Alameda County Grand Jury
2021-2022
Findings & Recommendations
8 findings
F1:
A county-wide needs/gaps assessment (broader than what the Mental Health Services Act mandates) has not been completed since 2015. A current strategic plan for Alameda County Behavioral Health is missing. 26 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
F2:
Alameda County mental health data is not well developed, organized, shared, or distributed by Alameda County Behavioral Health Care Services. Outside of mandatory Mental Health Services Act annual and three-year plans required by the state, integrated data is unavailable to the general public and local advocates. Because of this lack of transparency, Alameda County Behavioral Health outsiders suspect that funds are not properly directed to community service gaps and needs.
F3:
Alameda County Behavioral Health service contracts are inflexible. Alameda County Behavioral Health’s switch to fee-for-service contracts from performance-based contracts has likely resulted in reduced services available to Alameda County residents.
F4:
The mental health record systems of county mental health service providers cannot connect with each other. Lack of interoperability of medical records for Mental Health Services Act providers limits needed communication and consistent information capacity between service providers.
F5:
Most Alameda County residents have limited knowledge of the ACCESS phone line and its role.
F6:
Although there is a phone line answered by a volunteer from a local mental health provider during hours when ACCESS is not staffed, emergency mental health services for low-income seriously mentally ill individuals are not offered 24-7. There is no crisis referral line or alternative to jail or 5150 for immediate care for the seriously mentally ill when ACCESS is closed.
F7:
Behavioral Health Court works. That’s the unanimous verdict of the Grand Jury’s witnesses. But it’s not adequately supported and funded. Alameda County Behavioral Health and the courts have not provided adequate data to determine that the well-regarded Behavioral Health Court is effective and is racially and geographically equitable so it can attract more funding.
F8:
The Mental Health Advisory Board, which has strong, knowledgeable, and experienced members and generates excellent ideas, is not used effectively by the Board of Supervisors. 27 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
Additional Recommendations
14
Not linked to specific findings.
R1:
Alameda County Behavioral Health should develop a community-wide needs/gaps assessment, beyond the scope of what the Mental Health Services Act requires, to guide funding and ensure equity in service delivery. This can help Alameda County Behavioral Health develop a strategic plan to ensure that Alameda County’s current approach to mental health services and funding is fully in sync with “Care First, Jail Last” and Alameda County’s current needs.
R2:
Alameda County Behavioral Health should invest in and improve its data development, organization, sharing, and distribution capabilities. Accurate and complete data-driven analysis and evaluation should direct Alameda County mental health service and funding choices.
R3:
Alameda County Behavioral Health should lift contract caps for providers who are over- serving their contracts, or at least provide clear protocols for how and when to lift those caps during contract negotiations with service providers.
R4:
Alameda County Behavioral Health must develop technology that allows uniform interoperability between multiple provider agencies for sharing of medical records.
R5:
Alameda County Behavioral Health should add outreach in multiple ways, languages, and venues, including directing materials to law enforcement, health care, social services, and to the general public to instruct them appropriately about ACCESS as both a resource line and a referral line.
R6:
The ACCESS number should be more widely distributed by Alameda County Behavioral Health to the professional and consumer communities. If the ACCESS line is an information and referral line, there should be corresponding easily accessible resource information about mental health programs on ACBH’s website and outside of the website, available to the public.
R7:
Alameda County Behavioral Health should provide a mental health support/crisis line that is staffed 24-7 as a referral alternative to jail or psychiatric holds. 28 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
R8:
Alameda County Behavioral Health must develop enough program slots to meet current needs.
R9:
Alameda County Behavioral Health must improve/expand upon its coordination between service providers and ACCESS staff regarding available slots for service by developing appropriate technology to assess available program slots in real time.
R10:
Alameda County Behavioral Health must provide more transparency in its reporting on Behavioral Health Court and make results of Behavioral Health Court available, including graduation rates, recidivism, and reasons for lack of completion.
R11:
Alameda County Behavioral Health, in collaboration with the courts, should increase the capacity of Behavioral Health Court, based on findings above, to support the “Care First, Jails Last” Board of Supervisors resolution.
R12:
Alameda County Behavioral Health, in collaboration with the courts, needs to provide data that ensures that Behavioral Health Court is racially and geographically equitable.
R13:
The Alameda County Board of Supervisors should better utilize the expertise and skills of the Mental Health Advisory Board. Regular, scheduled Advisory Board presentations to the Board of Supervisors would be useful.
R14:
The Alameda County Board of Supervisors should fill the vacant Mental Health Advisory Board positions that the Board of Supervisors is supposed to appoint. 29 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
Findings & Recommendations
6 findings
F41:
BART’s board and management interfered with the Office of the Inspector General’s performance of its duties.
F42:
BART’s board and general manager hampered the approval and implementation of a charter for the Office of the Inspector General, resulting in a lack of understanding within the organization that the Inspector General is independent.
F43:
BART’s board and management supported the labor unions representing BART employees to try to limit the independence of the Office of the Inspector General investigations by setting unreasonable conditions for engagement of employee witnesses or complainants.
F44:
BART’s Office of the Inspector General does not have access to independent counsel, administrative staff, and records storage systems as is considered best practice nationally.
F45:
BART’s Office of the Inspector General’s budget, set at an initial $1 million per year in 2018 by PUC Section 28842, is much lower than the budgets of comparable transit agencies’ Office of Inspector Generals adjusted for size. A mechanism for increasing the budget annually in the enabling legislation has not been used.
F46:
A potential serious conflict of interest exists between a BART senior manager and a construction management firm now under contract that employs the manager’s spouse and sibling. 131 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
Additional Recommendations
6
Not linked to specific findings.
R56:
BART’s Board of Directors must adopt written policies that acknowledge California Government Code 1236 and require compliance with standards prescribed by the Institute of Internal Auditors or the Government Auditing Standards issued by the Comptroller General of the United States (known as the “Yellow Book.”).
R57:
BART’s Board of Directors must adopt an Office of the Inspector General charter that expands on the spare language of PUC 28840 – 28845 such that the independence of the Inspector General is clearly acknowledged, and the roles and relationships are clearly defined between the Inspector General and senior BART staff such as general manager, general counsel, treasurer/controller, and internal auditor.
R58:
BART’s Board of Directors must give the Office of the Inspector General unencumbered and confidential access to all of BART’s resources, information, and employees, while respecting the “Weingarten” right of employees to representation during an investigatory interview if requested by the employee.
R59:
BART’s Board of Directors must provide the Office of the Inspector General independent access to counsel, administrative staff, and records storage systems.
R60:
BART’s Board of Directors must increase funding for the Office of the Inspector General to the level of peer transit agencies such as LA Metro and WMATA, expressed as a percentage of overall operating budget.
R61:
BART’s Board of Directors must update BART’s Code of Conduct, last revised in 2013, to make reporting of potential conflicts of interest more internally consistent and aligned with federal and state regulations. 132 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
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Findings & Recommendations
6 findings
F62:
McKenney-Vento liaisons face significant time restraints fulfilling their duty to assist homeless students in Alameda County.
F63:
McKenney-Vento liaisons lack visibility within their organizations to effectively impact school districts’ service for homeless students.
F64:
Teachers in Alameda County are not required to be trained or certified to identify homeless students.
F65:
Efforts to identify homeless students throughout Alameda County are inconsistent from district to district, including differences as to which school district employees receive training on identifying homeless students and how they are trained.
F66:
Wrap-around services provided at a single geographical location, such as those provided at the Union City Family Center, offer tremendous value to homeless students and their families and are a critical component in assisting with the difficulties associated with homelessness. 172 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
F67:
Partnerships with Community-Based Organizations are an effective way for school districts and schools to overcome funding deficiencies for the provision of services for homeless students.
Additional Recommendations
6
Not linked to specific findings.
R90:
The Alameda County Office of Education should identify strategies for reducing the workloads for McKenney-Vento liaisons in Alameda County to provide greater focus on homeless student service provision.
R91:
The Alameda County Office of Education should work with school districts to increase visibility for McKenney-Vento liaisons within their organizations, including making MKV liaisons cabinet-level positions for district superintendents.
R92:
The Alameda County Office of Education should require, to the extent possible, that Alameda County teachers be certified that they have completed training on identifying homeless students.
R93:
The Alameda County Office of Education should develop standards to identify which district/school personnel should complete training related to homeless students, as well as how that training should be conducted.
R94:
The Alameda County Office of Education should assist districts within the county as to possibilities for wrap-around service centers and which services could be offered at such centers.
R95:
The Alameda County Office of Education should create a clearinghouse to identify potential partnerships for districts in the county with appropriate Community-Based Organizations as well as assist districts in how to establish these partnerships. 173 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
Findings & Recommendations
9 findings
F47:
The Oakland City Council has no written plan or timetable for holding Oakland Fire Department accountable to annually complete all state-mandated fire inspections.
F48:
The Oakland Fire Department does not have an up-to-date inventory of buildings that require state-mandated inspections.
F49:
The slow, uncoordinated, and incomplete implementation of Accela, throughout Oakland’s city departments including, but not limited to the Oakland Fire Department, has greatly reduced the ability of the Fire Prevention Bureau to complete state-mandated fire inspections.
F50:
Historically, the Oakland Fire Department has not provided sufficient training for fire inspectors.
F51:
The city of Oakland presents a uniquely challenging environment for inspections which has resulted in high turnover of inspectors.
F52:
The city of Oakland’s slow and inefficient recruitment process results in hiring delays and fails to hire candidates with relevant experience.
F53:
The Oakland Fire Department has not used the citation process for fire safety violations in a manner that results in immediate and substantive improvements to fire safety.
F54:
The Oakland Fire Department does not have sufficient administrative staff support for fire inspectors to aid in the citation process.
F55:
The city of Oakland does not have fire inspection information readily available on its website for public review. 144 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
Additional Recommendations
17
Not linked to specific findings.
R62:
The Oakland Fire Department shall report the status of state-mandated fire inspections to the Oakland City Council’s Public Safety Committee quarterly for review and evaluation.
R63:
Oakland’s mayor must meet monthly with the Oakland Fire Department chief focusing on progress toward the goal of 100% compliance with state-mandated fire inspections.
R64:
The city of Oakland must develop a dependable, cross-agency, up-to-date inventory of buildings needing state-mandated fire inspections.
R65:
The Oakland Fire Department, in partnership with the Accela Task Force, must evaluate the Oakland Fire Department team and the work plan for the Oakland Fire Department’s Accela implementation, including the possible addition of administrative permission for the Oakland Fire Department to allow the Oakland Fire Department Accela liaison to make direct changes to the Accela interface.
R66:
The Oakland Fire Department executive staff must meet regularly with the Oakland Fire Department Accela liaison to evaluate the status of Accela implementation within the department, including the status of Accela’s performance in aiding inspections.
R67:
The Oakland Fire Chief must evaluate personnel assignments to ensure the appropriate liaison with systems and operational knowledge is in place for the critical implementation of Accela.
R68:
The Oakland Fire Chief must evaluate the implementation of Accela support and training available for state-mandated inspectors.
R69:
The Oakland Fire Department must assess its Accela working group to ensure that the fire department’s automated needs in the Accela program are being met. This should include an automated online system for documenting all state-mandated inspections, the ability to document all follow-up inspections, and the ability to access data for statistical analysis of inspection results. 145 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
R70:
The Oakland Fire Department must ensure that all fire inspection training meets or exceeds the standards provided by the California Office of the Fire Marshal, and that a sufficient number of staff are cross-trained to ensure that fire inspections are completed.
R71:
The Oakland Fire Department must create a clear career path for professional advancement of fire inspectors.
R72:
Oakland Fire Department leadership must work to raise the status of the Fire Prevention Bureau, so it is on par with the status and esteem afforded firefighters within the department.
R73:
The Oakland Fire Department must establish clear expectations for the number of completed inspections on a daily/weekly basis to reach the 100% inspection goal.
R74:
The Oakland Fire Chief must authorize a salary and job study to determine the placement of Fire Prevention Bureau personnel in comparison to other large cities. Results should be shared with the mayor, city council, and Oakland’s human resources department.
R75:
The city of Oakland must reform its hiring process to allow for more rapid filling of open positions in order to hire more experienced fire inspectors.
R76:
The Oakland Fire Chief and Fire Prevention Bureau Fire Marshal must provide all inspectors with sufficient training that includes clear guidelines on how and when to cite violators. This must include a written policy that outlines specific actions and inspectors’ authority when citing.
R77:
The Oakland Fire Department must provide the Fire Prevention Bureau with administrative staff to support the fire inspectors to process noncompliance citations and prepare for court appearances if necessary.
R78:
State-mandated fire inspection data should be easily accessible on the city of Oakland’s public information web page. 146 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
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Findings & Recommendations
6 findings
F56:
The system in place for authorizing, assigning, checking, and verifying reported overtime for expedited plan checks in Oakland’s Department of Planning and Building is ineffective.
F57:
The extended vacancy of the deputy director/chief building official position in Oakland’s Department of Planning and Building contributes to the undermanagement of the expedited plan check service. 159 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
F58:
The fees currently charged by Oakland for expedited service of plan checks are likely inconsistent with the requirements of Proposition 26.
F59:
The plan check function in Oakland’s Department of Planning and Building does not actively monitor productivity within the plan check team and currently does not collect data on hours worked by project to enable this analysis.
F60:
Supply of plan checking resources in Oakland’s Department of Planning and building is not aligned with demand for those resources in part because there is no attempt to forecast anticipated supply and demand and provide decision makers with the information with sufficient lead time to address anticipated gaps.
F61:
Exclusive reliance on internal resources for providing plan check services in Oakland’s Department of Planning and Building limits the ability of the Planning and Building Department to ensure service commitments to applicants are consistently achieved.
Additional Recommendations
16
Not linked to specific findings.
R1:
Overtime authorizations are routed to payroll without supervisor approval.
R2:
Overtime authorizations are not kept in a retrievable format and cannot be checked against timecards.
R3:
There is no process for comparing overtime hours authorized to overtime hours reported.
R4:
There is no systemic reconciliation of hours reported for expedited service billing and hours reported for expedited service overtime compensation.
R5:
There is no limit to the amount of overtime an individual can work by day, week, or year. Investigation of an Irregularity In 2019, a plan check manager within the Building Bureau noticed a material discrepancy between the overtime hours reported by an engineer to payroll and that same engineer’s report of hours worked on expedited services that were billed to applicants. The net impact of this discrepancy was that many fewer hours were billed to applicants than were paid to the engineer in their overtime compensation. The Grand Jury learned the manager failed to take immediate steps to investigate, waiting at least several months before asking the engineer for an explanation and nearly a year before escalating to their supervisor. 156 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ As of April 2022, the internal investigation into this discrepancy has been underway for over two years and the Grand Jury understands that the investigation remains open. Despite a written acknowledgement by the engineer of intentionally misreporting hours worked for an extended period, the Grand Jury was unable to find any evidence that disciplinary actions were taken or that efforts were made to recover funds that might have been owed to the city from applicants for work performed that went unbilled or for overtime compensation that might have been paid but not earned. Through its investigation, It is the Grand Jury’s understanding that despite this recent example the Grand of a control gap which could result in applicants receiving expedited Jury learned there was an service without paying the mandated fees and/or engineers receiving absence of a overtime compensation for hours not actually worked, PBD has not yet common implemented a control to ensure matching entries in the compensation understanding and applicant billing systems. among PBD staff of the policies and Management and Senior Leadership Engagement procedures for providing the Through its investigation, the Grand Jury learned there was an absence expedited of a common understanding among PBD staff of the policies and service for procedures for providing the expedited service for plan checks. The plan checks. Grand Jury further learned that there was limited visibility of the economics and operational dynamics of this service outside of the Building Bureau. The Grand Jury observed that management expressed little concern about the extended time frame required to complete plan checks as well as a lack of engagement on the underlying dynamics that were leading to a plan check engineer being frequently one of the city’s highest paid employees. The Grand Jury noted a lack of urgency and accountability in PBD management’s investigation into the discrepancy between overtime hours paid and the hours billed to applicants for expedited service that was described earlier in this report. The Grand Jury learned that several management positions within PBD have been vacant or filled on an acting basis for extended periods, and acting managers are often tasked with performing multiple jobs during their acting role period, which may limit their ability to be effective at either job. In particular, the Grand Jury is concerned that the role of chief building official, who serves as the primary interface between PBD senior leadership and the Building Bureau, has remained vacant since the end of 2020. The Grand Jury believes that the combination of inadequate process controls and insufficient management engagement have contributed to creating an environment around plan checks where poor service levels are accepted as the norm and identified financial risks go unaddressed. 157 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ The Grand Jury views stronger leadership around these issues by senior executives within the Building Bureau and PBD as essential for improving the current situation. Reasonableness of Fees Local governments in California are empowered to establish and collect fees for certain services subject to the requirements of California Proposition 26 which states: the local government bears the burden of proving by a preponderance of the evidence that a levy, charge, or other exaction is not a tax, that the amount is not more than necessary to cover the reasonable costs of governmental activity, and that the manner in which those costs are allocated to a payor bear a fair or reasonable relationship to the payor’s burdens on, or benefits received from the governmental activity. A common method for meeting this burden is through the commission of an independent analysis to estimate the government’s cost to provide services. The study used in setting Oakland’s current fee for expedited service processing was completed in 2015. This study’s recommendations were documented in a 69-page report that addressed a broad range of services provided by PBD. The city council adopted the study’s proposed recommendations for fee levels and incorporated them into the city’s Master Fee Schedule. Applicants requesting expedited plan checks at the time of this report are charged a fee of $465 per hour of plan checker time engaged on their project. This hourly cost represents the fee of $375 per hour recommended in the 2015 Cost Study with periodic increases for inflation and 14.75% in additional charges to support records management and technology enhancements. The Grand Jury’s analysis of the study used to set the fee for expedited service on plan checks identified several areas of analytical concern that when considered together represent strong evidence, in the Grand Jury’s opinion, that the fee is likely not fully compliant with the requirements of Proposition 26. Specifically, the Grand Jury notes:
R79:
Oakland’s Planning and Building Department shall integrate a comprehensive set of process controls to protect against the risk of fraud in the reporting of overtime.
R80:
Oakland’s Planning and Building Department shall establish and enforce a limit on the maximum annual number of hours of overtime for that can be worked by each plan checker.
R81:
Oakland’s Planning and Building Department shall establish a process for regularly reconciling Authorized Overtime, Paid Overtime, and Expediting Fees charged to applicants.
R82:
Oakland’s Planning and Building Department shall fill the currently vacant post of Deputy Director/Chief Building Official.
R83:
Once the chief building official is hired, the director of Oakland’s Planning and Building Department shall direct the chief building official to provide updates to Planning and Building Department senior leadership on the state of the plan check function and progress on implementing these recommendations on a quarterly basis during their first year in the role. 160 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
R84:
In the next update to the Planning and Building Department cost study, Oakland’s Planning and Building Department shall direct the independent consultants to address or respond to the cost estimate methodological issues identified in this report.
R85:
With the next amendment to Oakland’s Master Fee Schedule, the city council shall ensure the cost estimate methodological issues and the Proposition 26 compliance issues identified in this report have been addressed in fees set for expedited plan checks.
R86:
Oakland’s Planning and Building Department shall extend the practice of tracking plan checker activity to all projects not just those for which expedited Service has been requested.
R87:
Oakland’s Planning and Building Department shall establish and maintain forecasting models for plan checker supply and demand.
R88:
Oakland’s Planning and Building Department shall make use of forecast models of plan checker supply and demand in resource planning.
R89:
Oakland’s Planning and Building Department shall establish contracts with on-demand resources, such as third-party plan checkers, that can be utilized during periods in which internal resources are inadequate to meet applicant demand. 161 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
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Findings & Recommendations
6 findings
F9:
The Oakland City Clerk’s office is not meeting the minimum requirements of the Filing Officer under the Political Reform Act. The issues of non-compliance with the rules regarding Form 700s are long-standing and structural, resulting from inadequate funding, an inefficient system of communication of critical information to the Filing Officer, and limited staffing.
F10:
A transfer of the Form 700 filing duties from the Oakland City Clerk’s office to the Public Ethics Commission would require hiring an additional employee; an amendment of the City Ethics Act to identify the Public Ethics Commission as the Filing Officer for Form 700s; and the transfer of the function and payment of the City’s contract with the online filing provider, NetFile, from the City Clerk’s office to the Public Ethics Commission.
F11:
Grant funding has been used to fund staffing to support critical services in the City of Oakland. 44 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
F12:
The city of Oakland’s shared electronic Human Resources platform is not used in the Form 700 process but could be customized to assist in the sharing of information between departments.
F13:
The city of Oakland’s new employee checklist does not include Form 700 filing requirements to the employee.
F14:
The Grand Jury commends the hard work of those individuals within the Oakland City Clerk’s office who are responsible for the Form 700 process. The problems with the Form 700 process are the result of structural limitations, limited staffing, and inadequate interdepartmental communication.
Additional Recommendations
5
Not linked to specific findings.
R15:
The city of Oakland should transfer the Form 700 Filing Officer responsibility to the Public Ethics Commission.
R16:
The city of Oakland should hire an experienced grant writer with knowledge of state and local funding streams to secure funding for Form 700 services.
R17:
On its shared electronic Human Resources platform, the city of Oakland should add a field to the employee information section that indicates whether the employee is a required Form 700 filer and require that the field be updated upon hiring, promotion, demotion, or separation.
R18:
The City of Oakland should ensure that the Filing Officer is able to access a current list of Form 700 designated employees through the shared electronic Human Resources platform.
R19:
The City of Oakland should add the notification of Form 700 status on the new employee checklist. 45 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
Findings & Recommendations
4 findings
F15:
The Public Defender’s probate conservatorship unit is severely understaffed and overworked, meaning that proposed conservatees with means receive a far higher level of service than the indigent.
F16:
The failure of the Public Defender to gather data on conservatorship case outcomes, implement formal training procedures, and establish a formal grievance process for clients, in addition to its reliance on paper files, hampers its ability to identify trends, stay up to date on best practices, and learn from past experience.
F17:
The lack of a contract between Alameda County and its conservatorship defense providers that outlines the expected scope of representation means that not all proposed conservatees receive the same level of service and raises the risk of litigation against the county.
F18:
Involuntary conservatorship proceedings can quickly drain proposed conservatees’ estates, which would not occur under a recorder’s fee- or grant-funded model.
Additional Recommendations
8
Not linked to specific findings.
R20:
The Alameda County Board of Supervisors must transfer responsibility for conservatorship defense from the Alameda County Public Defender’s Office to a separate agency.
R21:
The Alameda County Board of Supervisors must establish a written contract with its conservatorship defense provider(s) outlining the standards to be met in order to receive county funding, as set forth in Recommendation 22.
R22:
The Alameda County Board of Supervisors must include the following provisions in the written contract(s) named in Recommendation 21: a. actions required to establish zealous advocacy, including 71 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ i. arranging an evaluation of proposed conservatees by a licensed medical professional and/or a social worker, ii. working with regional centers to review individualized program plans (IPPs) for (proposed) conservatees who are regional center clients, to determine whether a less-restrictive alternative is available, and iii. implementing a procedure to follow up with court investigators to ensure thorough and timely investigations, b. the length of time an attorney or support staff must perform affirmative outreach after letters of conservatorship are issued, c. requirements that the conservatorship defense provider i. establish written attorney training procedures, ii. establish annual attorney performance evaluation procedures, iii. review each case after the conservatorship ends and conduct an “exit interview” or survey with interested parties, and iv. maintain a database of case outcomes.
R23:
The Alameda County Board of Supervisors must select a neutral third party to conduct an annual audit of a random sample of conservatorship defense cases to assess attorney performance and determine compliance with probate rules.
R24:
Unless and until there has been a determination as to a new funding model, the Alameda County Board of Supervisors must approve funding for one experienced full-time attorney to be assigned exclusively to the Alameda County Public Defender’s probate conservatorship unit. If the Alameda County Board of Supervisors finds it unmanageable to follow
R25:
The Alameda County Board of Supervisors must direct the Alameda County Public Defender to subscribe to an attorney training service upon hire and for continuing education in the area of probate conservatorship.
R26:
The Alameda County Board of Supervisors must direct the Alameda County Public Defender to establish annual performance evaluation procedures for conservatorship attorneys. 72 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
R27:
The Alameda County Board of Supervisors must direct the Alameda County Public Defender and Legal Assistance for Seniors to arrange for each client to be evaluated by a licensed medical professional and/or a social worker.
Findings & Recommendations
26 findings
F1:
facility infrastructure,
F2:
detainment conditions,
F3:
COVID-19 management, and
F4:
the grievance process. The Grand Jury concludes that many of these findings present continuing risks to the health and safety of the staff and detainees who occupy the facility as well as a financial risk to Alameda County, which is ultimately responsible for the damages that may arise from conditions at the jail. The Grand Jury gratefully acknowledges the support and assistance of the many Santa Rita staff members who accompanied jurors on their inspections, located documents and data, and explained processes and procedures. While not all personnel interactions were positive, the few instances in which staff engaged in a manner that the Grand Jury experienced as adversarial or unprofessional were addressed during the investigation and did not impair the completeness or accuracy of this report. 103 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ FINDINGS Facility Safety Finding 19: High-risk safety code violations exist within the Santa Rita Jail. These include: • High-voltage electrical wiring not installed in accordance with code. • Obstruction of access to emergency safety equipment. • Emergency safety equipment for which testing and maintenance are out of date. • Unlabeled emergency-stop controls on industrial equipment. • Inconsistent signage on hazardous waste disposal containers. • Instances of missing temperature-monitoring data for food storage refrigerators. Finding 20: The absence of periodic, proactive reviews of the Santa Rita Jail facility’s condition increases the risk that critical issues will be undetected and unaddressed until they result in an injury or operational disruption. Finding 21: Inspections of the Santa Rita Jail facility conducted by the Board of State and Community Corrections do not include participation of Alameda County General Services Agency staff responsible for the condition and maintenance of the jail facility, resulting in a missed opportunity for valuable exchange between inspectors and county staff and potentially unnecessary delays in addressing issues identified during inspections. Finding 22: Controls to protect against weapons, drugs, and other contraband being brought into Santa Rita Jail by staff and administrative visitors are weak, placing staff and detainees at risk. Detainment Conditions Finding 23: Access to the outdoors for detainees at Santa Rita Jail is severely limited, with most inmates having a single one-hour opportunity per week, weather permitting, for access to fresh air and sunlight. Finding 24: Safety and sobering cells at Santa Rita Jail are not universally cleaned and sanitized after each use, indicating a systemic issue with maintaining cleanliness standards. 104 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ Finding 25: The level of cleanliness in common areas and recreation yards at Santa Rita Jail is highly variable across housing units, with jail staff disavowing responsibility for ensuring a minimal standard of hygiene in areas cleaned by inmates. Finding 26: The level of engagement and oversight by the Alameda County Sheriff’s Office of Wellpath’s operational activities is insufficient to ensure that health care is being delivered in a timely manner with high quality. COVID-19 Management Finding 27: COVID-19 screening procedures at points of entry at Santa Rita Jail are inconsistent with both stated Alameda County Sheriff’s Office policy and current recommended best practices. Finding 28: The Alameda County Sheriff’s Office has failed to follow local and national recommendations that all staff working at correctional facilities be vaccinated for COVID-19, posing an unnecessary hazard to detainees. Finding 29: The rate of COVID-19 vaccination among Santa Rita Jail staff is materially below the community average. Finding 30: The consequences for Alameda County Sheriff’s Office staff who are not in compliance with COVID-19 test mandates are insufficient to ensure that up-to-date testing is performed. Finding 31: The Alameda County Sheriff’s Office fails to provide full transparency by including weekly staff COVID-19 vaccination statistics on its website alongside detainee vaccination data and staff/detainee testing data. Finding 32: The Alameda County Sheriff’s Office does not ensure that Santa Rita staff consistently adhere to Alameda County’s indoor mask mandate, placing both staff and detainees at greater risk of COVID-19 infection. Finding 33: The Alameda County Sheriff’s Office’s efforts to promote detainee COVID-19 vaccination have been unsuccessful in materially improving the rate of vaccination in the detainee population. 105 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ Grievance Process Finding 34: The Santa Rita Jail Grievance Unit has failed to provide an electronic grievance submission system that eliminates the need for detainees to engage with the local housing unit deputy. Finding 35: Medical issues raised by detainees at Santa Rita Jail through the grievance process are not investigated and resolved in a timely manner. Finding 36: The current grievance process at Santa Rita Jail inadequately tracks and follows up on the status of investigations transferred to other departments, leaving grievances open for extended time periods and forgoing the opportunity to learn from patterns and trends. Finding 37: The Santa Rita Jail Grievance Unit fails to take advantage of the opportunity to analyze grievance submission data to identify trends in complaints, root causes, and resolutions. Finding 38: The current grievance process at Santa Rita Jail is a suboptimal mechanism for addressing facility safety and maintenance issues identified by detainees. Finding 39: The grievance process at Santa Rita Jail inappropriately disqualifies and denies grievances in which a third-party observes and is impacted by the treatment of another detainee. Finding 40: The current grievance investigation process at Santa Rita Jail fails to adequately engage the grievance submitter in the investigative process.
F19:
High-risk safety code violations exist within the Santa Rita Jail. These include: • High-voltage electrical wiring not installed in accordance with code. • Obstruction of access to emergency safety equipment. • Emergency safety equipment for which testing and maintenance are out of date. • Unlabeled emergency-stop controls on industrial equipment. • Inconsistent signage on hazardous waste disposal containers. • Instances of missing temperature-monitoring data for food storage refrigerators.
F20:
The absence of periodic, proactive reviews of the Santa Rita Jail facility’s condition increases the risk that critical issues will be undetected and unaddressed until they result in an injury or operational disruption.
F21:
Inspections of the Santa Rita Jail facility conducted by the Board of State and Community Corrections do not include participation of Alameda County General Services Agency staff responsible for the condition and maintenance of the jail facility, resulting in a missed opportunity for valuable exchange between inspectors and county staff and potentially unnecessary delays in addressing issues identified during inspections.
F22:
Controls to protect against weapons, drugs, and other contraband being brought into Santa Rita Jail by staff and administrative visitors are weak, placing staff and detainees at risk. Detainment Conditions
F23:
Access to the outdoors for detainees at Santa Rita Jail is severely limited, with most inmates having a single one-hour opportunity per week, weather permitting, for access to fresh air and sunlight.
F24:
Safety and sobering cells at Santa Rita Jail are not universally cleaned and sanitized after each use, indicating a systemic issue with maintaining cleanliness standards. 104 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
F25:
The level of cleanliness in common areas and recreation yards at Santa Rita Jail is highly variable across housing units, with jail staff disavowing responsibility for ensuring a minimal standard of hygiene in areas cleaned by inmates.
F26:
The level of engagement and oversight by the Alameda County Sheriff’s Office of Wellpath’s operational activities is insufficient to ensure that health care is being delivered in a timely manner with high quality. COVID-19 Management
F27:
COVID-19 screening procedures at points of entry at Santa Rita Jail are inconsistent with both stated Alameda County Sheriff’s Office policy and current recommended best practices.
F28:
The Alameda County Sheriff’s Office has failed to follow local and national recommendations that all staff working at correctional facilities be vaccinated for COVID-19, posing an unnecessary hazard to detainees.
F29:
The rate of COVID-19 vaccination among Santa Rita Jail staff is materially below the community average.
F30:
The consequences for Alameda County Sheriff’s Office staff who are not in compliance with COVID-19 test mandates are insufficient to ensure that up-to-date testing is performed.
F31:
The Alameda County Sheriff’s Office fails to provide full transparency by including weekly staff COVID-19 vaccination statistics on its website alongside detainee vaccination data and staff/detainee testing data.
F32:
The Alameda County Sheriff’s Office does not ensure that Santa Rita staff consistently adhere to Alameda County’s indoor mask mandate, placing both staff and detainees at greater risk of COVID-19 infection.
F33:
The Alameda County Sheriff’s Office’s efforts to promote detainee COVID-19 vaccination have been unsuccessful in materially improving the rate of vaccination in the detainee population. 105 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ Grievance Process
F34:
The Santa Rita Jail Grievance Unit has failed to provide an electronic grievance submission system that eliminates the need for detainees to engage with the local housing unit deputy.
F35:
Medical issues raised by detainees at Santa Rita Jail through the grievance process are not investigated and resolved in a timely manner.
F36:
The current grievance process at Santa Rita Jail inadequately tracks and follows up on the status of investigations transferred to other departments, leaving grievances open for extended time periods and forgoing the opportunity to learn from patterns and trends.
F37:
The Santa Rita Jail Grievance Unit fails to take advantage of the opportunity to analyze grievance submission data to identify trends in complaints, root causes, and resolutions.
F38:
The current grievance process at Santa Rita Jail is a suboptimal mechanism for addressing facility safety and maintenance issues identified by detainees.
F39:
The grievance process at Santa Rita Jail inappropriately disqualifies and denies grievances in which a third-party observes and is impacted by the treatment of another detainee.
F40:
The current grievance investigation process at Santa Rita Jail fails to adequately engage the grievance submitter in the investigative process.
Additional Recommendations
31
Not linked to specific findings.
R1:
Standard grievances, used to report problems in detainment conditions.
R2:
Emergency grievances, used to report harassment or sexual assault in accordance with the Prison Rape Elimination Act of 2003 (PREA). Standard grievances may be submitted either on paper or electronically via jail-issued tablet. When filing on paper, detainees must request an official grievance form and a grievance tracking number from a deputy. While there is no limit on the number of paper grievances a detainee may file, electronic grievances are limited to four per detainee per month. In an effort to streamline the grievance process and provide detainees with a way to submit grievances without needing to engage with a deputy who may be the subject of a grievance, Santa Rita introduced the electronic submission option in 2019. Although many detainees successfully submit electronic grievances, others reported that filing electronically is confusing and does not work as intended. Staff appeared unaware of the problems detainees were experiencing with tablet-based submissions. 96 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ Overview of the Grievance Filing and Investigation Process Submission Intake Review Investigation Appeal Excess Manager force? review Conclusion only, no details Internal Yes Affairs Tablet Gri U ev n a it nce No Yes: misconduct External Yes : other Wellpath In r s e p v e ie c w tor investigation? No t R o e G su ri l e ts v a p n ro ce v i U de n d it Obtain Tracking # and Submit to GSA Grievance Referred for Unit Investigation No Locally Resolved? Paper Review Yes Grievance Unit Decision after with Conducts Investigation deputy Investigation Appeal CLOSED Inmate review (Per policy should Notification be submitted to (if in custody) Grievance Unit for filing) Yes Appealed? No CLOSED One critical issue highlighted by detainees involves the continued need to engage with a deputy to obtain a grievance tracking number for electronic submissions. While staff had informed the Grand Jury that this was not a required step for tablet submissions, detainees demonstrated to the Grand Jury that the tablet submission form shows the tracking number field as “required,” warns users about consequences for submissions with inaccurate information and displays an error message on attempts to submit grievances with the field unfilled. The Grievance Unit’s response to these observations was that the requirement for including an accurate grievance tracking number had previously been eliminated and detainees could insert any number into that field to enable a submission. The detainees with whom the Grand Jury spoke were unaware of this authorized bypass and, given the limited number of submissions permitted per month and the warnings about consequences for inaccurate submissions, were understandably reluctant to follow the suggested work-around. 97 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ Further complicating the use of placeholder tracking numbers is that detainees who used this approach reported inconsistency in receiving confirmation that their grievance was successfully submitted and delays in being notified of the actual tracking number once assigned. The Grand Jury believes that the implementation of a tablet-based option for grievance submissions improved the mechanism through which detainees can draw attention to concerns about detainment conditions. However, the flawed software implementation and inconsistent communication with detainees significantly reduce the value of this tool. A blank electronic grievance form. The field labeled “Enter the grievance number provided by the deputy” is marked as mandatory by a red asterisk. The default text states: “If the grievance number does not match our records, the grievance will be denied.” Emergency Grievances Emergency grievances are intended primarily for reporting sexual assault or harassment, in accordance with PREA requirements. Given the nature of these issues, the jail provides each housing unit with a lockbox to allow confidential and third-party submissions. By policy, lockboxes are checked daily, and the Grievance Unit assigns emergency grievances a high priority. The Grand Jury observed the presence of a lockbox in each housing unit visited and confirmed that, consistent with policy, the on-duty deputy did not have the ability to unlock the box. 98 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ An emergency grievance box in a minimum/medium-security housing unit. Grievance Investigations The first attempt to resolve a standard grievance occurs before it is formally submitted. By policy, when a detainee approaches a deputy to request a tracking number, the deputy attempts to resolve the issue directly. If the complaint is not resolved on the spot, the deputy obtains a tracking number from Grievance Unit staff, adds that information to the detainee’s completed form, gives the detainee a copy, and submits the original to the Grievance Unit through internal mail. The Grievance Unit is staffed by three deputies and three non-sworn technicians who are responsible for the initial investigation of all grievances. On receipt, paper grievances are scanned and converted into an electronic record, as all the Grievance Unit’s work is managed through an online case management system. Each day, a technician reviews that day’s newly filed grievances and assigns them to the investigators. Investigations typically involve interviewing staff members named in the grievance, reviewing jail policies, and viewing bodycam footage as appropriate. The Grand Jury learned that detainees are not routinely contacted as part of the investigation of their grievance, and several reported receiving no update on the status for weeks after submission. 99 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ The Grievance Unit refers and transfers investigation responsibility for several categories of grievances to other departments or contracted service providers. These include medical grievances, which are forwarded to Wellpath; facility issues, which are forwarded to GSA; and investigations of certain excessive use of force claims, which are forwarded to Internal Affairs (IA). These referrals are deemed necessary because the Grievance Unit has no access to detainee medical records, does not have the expertise required to address facility issues, and is prohibited from investigating the conduct of jail staff. Grievances alleging excessive use of force by a deputy are initially reviewed by the Grievance Unit manager to determine whether a full investigation is warranted by IA. If the manager does not believe the grievance warrants IA review, it is typically concluded with a finding of “Denied.” When a grievance has been referred to another department within the jail for investigation, the Grievance Unit suspends its tracking of investigation activities, as these steps are now being performed by a different department. As a result, some investigation steps conducted by other departments are not routinely captured in the case management system, and the Grievance Unit effectively cedes responsibility for the timely investigation of the grievance to the other department. The Grand Jury learned that once a grievance is referred to another department, the Grievance Unit awaits direction from that department before taking further action. There does not appear to be a consistent process within the Grievance Unit for checking the status of referred grievances that remain open for an extended period of time, nor is there regular reporting on open grievance investigations that have exceeded target turnaround times. The Grand Jury noted that many detainee complaints about the grievance process involved extended timelines for investigations and that referred investigations take, on average, longer to reach determination that those handled entirely within the Grievance Unit.
R3:
COVID-19 management, and
R4:
the grievance process. The Grand Jury concludes that many of these findings present continuing risks to the health and safety of the staff and detainees who occupy the facility as well as a financial risk to Alameda County, which is ultimately responsible for the damages that may arise from conditions at the jail. The Grand Jury gratefully acknowledges the support and assistance of the many Santa Rita staff members who accompanied jurors on their inspections, located documents and data, and explained processes and procedures. While not all personnel interactions were positive, the few instances in which staff engaged in a manner that the Grand Jury experienced as adversarial or unprofessional were addressed during the investigation and did not impair the completeness or accuracy of this report. 103 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
R28:
The Alameda County Sheriff’s Office must remediate the following issues and verify full compliance with applicable codes: • Electrical connection to ovens and tablet-charging stations within housing units. • Provide permanent floor marking to demarcate area that must be kept clear around eyewash station in kitchen. 106 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ • Bring current the testing and maintenance for eyewash station in kitchen and incorporate the necessary periodic reviews into preventive maintenance scheduling system. • Ensure presence and readability of all emergency-stop controls in kitchen. • Attach signage for PPE/hazardous waste disposal to disposal containers.
R29:
The Alameda County Sheriff’s Office must conduct a facility-wide audit for health and safety code issues to be led by a subject matter expert and review results with the jail commander and the Alameda County General Services Agency (GSA) manager on completion.
R30:
The Alameda County Sheriff’s Office must incorporate into the Santa Rita Jail facility operation procedures a requirement for a semiannual facility-wide safety inspection to include the jail commander, the GSA facility manager, and a facility health and safety code expert. Document these results in a written report and add any issues identified to the facility’s maintenance issue tracking system.
R31:
The Alameda County Sheriff’s Office must inform GSA of all Santa Rita Jail inspections by the Board of State and Community Corrections or any other third-party entities.
R32:
The Alameda County General Services Agency must require a GSA facility manager be present during all Board of State and Community Corrections and other Santa Rita Jail facility inspections.
R33:
The Alameda County Sheriff’s Office must ensure that all entrants into the secure portion of the Santa Rita Jail facility are positively identified via government-issued identification in advance of entry.
R34:
The Alameda County Sheriff’s Office must implement access control procedures to reduce the risk of contraband being introduced into Santa Rita Jail by staff and administrative visitors. Controls should, at a minimum, place limits on the nature and number of personal effects that may be brought into the secure perimeter and establish protocols for screening those permitted personal effects for contraband. 107 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________ Detainment Conditions
R35:
The Alameda County Sheriff’s Office must establish policies and procedures to ensure that each Santa Rita Jail detainee is provided an opportunity for access to outdoor space on at least three days per week for at least one hour per opportunity.
R36:
The Alameda County Sheriff’s Office must establish policies and procedures to ensure that each temporary access cell at Santa Rita Jail is removed from service until it is cleaned and sanitized.
R37:
The Alameda County Sheriff’s Office must establish policies and procedures that codify both the minimum acceptable levels of cleanliness at Santa Rita Jail in areas designated as being the cleaning responsibility of detainees and the responsibility of jail staff when those minimum levels are not maintained.
R38:
The Alameda County Sheriff’s Office must augment existing quality reviews to incorporate assessment of the timeliness of health care delivery at Santa Rita Jail.
R39:
The Alameda County Sheriff’s Office must institute monthly senior-level meetings of Santa Rita leadership, the on-site medical director, and Wellpath’s service delivery leadership to review quality assessment reporting and any emerging operational issues related to health care delivery at Santa Rita Jail.
R40:
During the next amendment to the Wellpath contract, the Alameda County Sheriff’s Office must negotiate for the addition of jail-specific provisions requiring that the Sheriff’s Office be allowed to explicitly consent to personnel changes in key roles proposed by Wellpath. COVID-19 Management
R41:
The Alameda County sheriff’s Office must implement a visitor screening procedure for Santa Rita Jail that is consistent with current Alameda County Public Health Department and the Centers for Disease Control (CDC) guidance for congregate settings. 108 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
R42:
The Alameda County Sheriff’s Office must adopt a requirement that all Santa Rita employees be fully up to date with state and CDC-recommended COVID-19 vaccinations within congregate settings.
R43:
The Alameda County Sheriff’s Office must implement a procedure for discipline, up to and including removal, for employees who do not fully comply with Alameda County’s COVID-19 protocols for county employees.
R44:
The Alameda County Sheriff’s Office must provide and maintain accurate weekly reporting of staff COVID-19 vaccination statistics on the Sheriff’s Office website.
R45:
The Alameda County Sheriff’s Office must direct all Santa Rita staff (both Sheriff’s Office employees and contractors) to fully comply with Alameda County’s indoor masking recommendations.
R46:
The Alameda County Sheriff’s Office must develop a program that supplements COVID-19 education with targeted and compelling incentives for Santa Rita Jail detainees to become vaccinated. Grievance Process
R47:
The Alameda County Sheriff’s Office must inform Santa Rita Jail detainees, in writing, that electronic grievances may be submitted by using a placeholder tracking number.
R48:
The Alameda County Sheriff’s Office must update the electronic grievance submission system at Santa Rita Jail to make clear to all users that there is no requirement for deputy involvement in a grievance submission.
R49:
The Alameda County Sheriff’s Office must modify procedures for the review, referral, and management of medical-related grievances at Santa Rita Jail to achieve a target of 100% engagement with medical grievance submitters within 72 hours, and resolution of 95% of medical-related grievance within seven days of submission. 109 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________
R50:
The Alameda County Sheriff’s Office must implement policy and procedure changes necessary to ensure that the Santa Rita Jail Grievance Unit actively tracks the status of grievances referred to all external departments and contracted service providers, and that these changes include a mechanism for follow-up and escalation should a grievance not be resolved within a predefined period of time. Recommendations 51: The Alameda County Sheriff’s Office must complete an analytical review of grievances received over the preceding 12 months that name individual Santa Rita Jail deputies.
R52:
The Alameda County Sheriff’s Office must adopt procedures that result in the delivery of a holistic analysis of grievance submission data on a quarterly schedule to the Santa Rita Jail commander.
R53:
The Alameda County Sheriff’s Office must adopt a mechanism for Santa Rita Jail detainees to alert jail administration to building safety and maintenance issues in a manner that is distinct from the filing of personal grievances.
R54:
The Alameda County Sheriff’s Office must adopt policies to acknowledge that the observation or knowledge of abuse or mistreatment of other detainees at Santa Rita Jail represents a potential grievance-qualifying harm requiring investigation.
R55:
The Alameda County Sheriff’s Office must modify Grievance Unit policies at Santa Rita Jail to acknowledge the value of seeking clarifications and direct testimony from submitters as an integral step in the investigative process. 110 2021-2022 Alameda County Civil Grand Jury Final Report _______________________________________________________________________________________