Fresno County 2024-2025 - California Grand Jury Reports

July 29, 2025 — County of Fresno Oscar J. Garcia, Cpa Auditor-Controller/Treasurer-Tax Collector*

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F8: division have a different perception as to the timing of reimbursements into the County's general fund. County's Response The Auditor's Office agrees with the finding. There were differing perceptions as to the timing of reimbursements to the County's general fund. We have met with DBH Finance/Accounting staff within the past five months to address this matter.

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R10: meetings with the County Auditor/Controller's Office to timely resolve any accounting issues by December 31, 2025. (F8) County's Response The recommendation will be implemented. The Auditor's Office is willing to meet with DBH staff on a quarterly basis, monthly if needed, to review and assist with resolving AUDITOR-CONTROLLER/TREASURER-TAX COLLECTOR 2281 Tulare Street, Room 105 / Fresno, California 93721 / (559) 600-3496 / FAX (559) 600-1444 Equal Employment Opportunity Employer July 29, 2025 The Honorable Judge Houry A. Sanderson, Presiding Judge Fresno County Superior Court Grand July Finding Reporting No. 2 any accounting issues. The Director of Behavioral Health should develop a clear written procedure regarding

R11: the timing of reimbursement from DBH to the County general fund by December 31, 2025. (F8) County's Response The recommendation will be implemented. The Auditor's Office will discuss and review procedures with DBH staff during the first quarterly meeting. This concludes the Fresno County Auditor-Controller/Treasurer-Tax Collector's responses to the findings and recommendations of the 2024-25 Fresno County Grand Jury Report No.3. Sincerely, Oscar J. Garcia, CPA Auditor-Cont Auditor-Controller/Treasurer-Tax Collector cc: Susan Holt, Director of Behavioral Health and Public Guardian Amy Ryals, Senior Administrative Analyst 13(3) AUG 114 2025 STOPS RUBERLOWSKI OF CALIFORNS S COUNTY OF LABORATE

July 29, 2025 — Grand Jury Report No. 3 Fresno County Department of Behavioral Health: Will the

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F1: Funding is sensitive as it comes from Federal and State sources (Medi-Cal and grants), yet there is no contingency plan defining how spending will be cut at DBH in the event of funding cuts. Response: The Department partially disagrees with the finding. DBH agrees that the funding is sensitive and complex, however, stating the Department does not have a contingency plan is not completely accurate. DBH has developed a menu of potential changes and a mechanism to make those decisions, including bringing forth recommendations for cuts to the budget, when appropriate, to the Board of Supervisors, as the Board is ultimately responsible for setting County policy and approving the budget. In addition, DBH has maximized the Mental Health Services Act (MHSA) Prudent Reserve as allowable by regulations to prepare for changes to MHSA funding, and this is outlined in the MHSA Plan, which is updated annually and approved by the Board of Supervisors. The DBH Finance Division Manager has a standing item on the Department’s leadership team meeting agenda for monthly fiscal updates to all Division Managers, Deputy Directors, and the Director; this item provides a continuous opportunity to review key funding and budgetary matters and for all leadership team members to assist in planning. The Director and Deputy Directors meet monthly with the DBH Finance Division for routine fiscal reporting and planning, as well adjustments, as needed and within budgetary authority. Additionally, each division has a quarterly fiscal check-in meeting with the DBH Finance Division, Deputy Directors, and the Director for fiscal monitoring and planning purposes. Most of the funding sources which support Department services and operations are dynamic, not static. The current regulatory environment in the California public behavioral health environment is rapidly evolving. Preparedness for funding changes is an ongoing process, as the Department continuously updates projections of revenue increases or declines and adjusts expenditures based on actual changes in revenue where authorized in the approved departmental budget. Decisions on adjustments are made in alignment with the Department’s vision, mission, and goals and the overall County mission, always with focus on preservation of core services to the public. The Director of DBH provides frequent updates to the County Administrative Officer regarding any threats to DBH funding and would return to the Board of Supervisors with formal recommendations in the event of significant external cuts to funding. While contingency planning is regular and ongoing, DBH acknowledges that there is not a written departmental policy or document outlining the process by which we review and plan for overall funding changes and we are in the process of creating such a policy.

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R1: The Director of Behavioral Health should create a written contingency plan to define cuts in service in the event there are cuts in funding by January 31, 2026. (F1) Response: DBH will not implement this recommendation because as it is written in the Civil Grand Jury Report, it is not reasonable; however, DBH offers alternative solutions that the Director believes satisfy the intent of R1. DBH is developing a written policy that outlines the behavioral health financial review process, including review of potential funding threats and contingency planning, and specifies the process by which recommendations for formal cuts to the budget would be prepared for consideration by the Board of Supervisors in the event of external cuts in funding. This policy will be written by January 31, 2026. It is important to note that, pursuant to the passage of Proposition 1 in March 2024, effective July 1, 2026, all DBH funding sources will be incorporated into an Integrated Plan that must be approved by the Board of Supervisors, submitted to the California Department of Health Care Services by June 30, 2026, and updated annually. Additionally, any significant changes to funding require an update to the Integrated Plan. In effect, this Integrated Plan reflects ongoing contingency planning, in writing, for all funding sources. As stated in response to F1, funding and operations are dynamic, not static, so the Director of DBH does not support creating a plan which defines predetermined specific cuts in services, as the most prudent business practice is to have ongoing analysis and planning to support the Board of Supervisors in decision-making for the budget in alignment with the Board’s priorities. The combination of the new statutorily required Integrated Plan and an internal departmental written policy related to financial review and planning process is believed to satisfy the Department’s understanding of the intent of the R1.

F2: There is no formal system of vertical communication for DBH employees to ask questions or make suggestions and have a guaranteed response from upper management. Response: The Department disagrees with this finding. There are numerous opportunities for DBH employees to communicate with upper management and have a guaranteed response. The Director of DBH conducts a live YouTube broadcast every month to all DBH employees, which includes a standard question-and-answer segment at the end. Employees may ask questions in real time by emailing the DBH Executive Assistant who relays them to the Director live, or by asking anonymously through YouTube’s live chat feature. During the YouTube broadcast, the Director answers all questions in real time if answers are known and for any questions that cannot be answered live, the Director commits to address them by email or subsequent presentation. This broadcast date/time is typically the third Thursday of every month and the meeting invitation is sent by Outlook to all employees for their calendar. If rescheduling is required, all employees are notified by email. Employees who cannot view the broadcast live can watch the recording; the DBH Executive Assistant sends the link to the recording by email following the broadcast and employees may send in questions via email for follow up. The Department also hosts one or more annual All Staff Meetings, during which a question- and-answer section is included. The December 2024 All Staff Meeting was fully dedicated to questions and answers with invited guest, County Administrative Officer, Paul Nerland; during that meeting both Mr. Nerland and the DBH Director, Susan Holt, addressed questions directly asked by DBH employees. For calendar year 2025, two in-person All Staff Meetings are planned. Additionally, the DBH Director holds a monthly All Supervisors meeting where every supervisor in the Department is expected to attend. During these All Supervisors meetings, supervisors are encouraged to ask questions and make suggestions. Division Managers schedule quarterly meetings with their division to provide information, address questions, hear concerns and suggestions, and focus on teambuilding. As schedules permit, Deputy Directors are invited to participate in divisional meetings. Division Managers routinely provide feedback from their employees to Deputy Directors and the Director. DBH teams have regular meetings with their supervisors and Division Managers visit their teams on a regular basis, giving staff the opportunity to ask questions, seek clarification, and provide suggestions. Supervisors are encouraged to meet regularly with their managers who, in turn, are expected to communicate employee and supervisor feedback with a member of the DBH Executive Leadership Team. Supervisors are also recommended to regularly schedule one-on-one meetings with their individual team members. At all levels, team members are welcome to share information. Deputy Directors and DBH Human Resources representatives meet often with bargaining units and document all concerns and suggestions for follow up. DBH leaders circle back in subsequent meetings to share the outcome of follow up with bargaining unit representatives and employees who participate in the labor-management meetings. Team members are reminded during the bargaining unit meetings of the availability of the chain-of-command and inclusion of DBH Human Resources and encouraged to escalate any questions, suggestions, or concerns. Employees are encouraged to ask questions of the DBH Director, Deputy Directors and Division Managers via email, Teams chats, or by setting up appointments for a meeting. Deputy Directors routinely visit programs, work areas, and staff meetings specifically to hear from employees in their areas of responsibility. The Director has utilized the DBH Quality Management team (formerly known as Quality Improvement Team) to facilitate focus groups to further illicit input, perspectives, and suggestions from DBH employees. Employees working in the field have County-issued cellular phones to communicate with their supervisor or a designated supervisor or manager who may be covering in the event of the supervisor’s absence. All Division Managers are accessible by cell phone during business hours. The expectation for multidirectional sharing of information, suggestions, and questions has been communicated numerous times and in different formats in DBH. The Director, Deputy Directors, and Division Managers regularly communicate with DBH employees, responding to questions and suggestions in various formats, which have been supported and encouraged by these leaders including, but not limited to, the live Director’s Update broadcast, standing meetings, direct email, by-appointment, one-on-one meetings, labor- management bargaining unit meetings, and employee focus groups. While the Director acknowledges that communication in any organization can always improve, the Director believes that there are numerous formal and informal mechanisms for vertical communication.

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R2: The Director of Behavioral Health or his/her designee should create a vertical communication system enabling field level staff to communicate concerns and suggestions to the Deputy Director / Director level of management by December 31, 2025. (F2) Response: This recommendation will not be implemented because it is not warranted. As described in response to F2, DBH has numerous existing formal and informal mechanisms for vertical communication by all levels of staff.

F3: The transition to SmartCare Electronic Health Record (EHR) software system has created more issues for DBH than anticipated. Response: The Department disagrees with this finding. Stating that the transition has created more issues than anticipated is not accurate, as DBH anticipated the transition would include numerous challenging issues. DBH was aware of the ambitious timeline to implement the new software, but the transition date was, by design, aligned with California’s historical behavioral health payment reform. This decision was strategically executed in order to minimize the number of changes that staff would have to make to accommodate payment reform. Implementation challenges are inherent in any transition of a healthcare system’s electronic health record; thus, DBH was proactive to prepare for and develop processes to swiftly address transition challenges as they surfaced. There are numerous employees identified as Subject Matter Experts (SME) and Expert Users throughout the Department in specialized areas and these employees received enhanced SmartCare training to serve as the first point of contact within their teams. Another layer of expertise was established in the form of Super Users, which includes representatives from DBH Compliance, Information Technology, a few Division Managers and a select few Expert Users. Throughout implementation, this group would discuss questions and determine answers, address real-time issues, and post validated information and instruction in a Teams chat with all the Expert Users. An example of a specialized Expert Users group in DBH is a group of SMEs called the Clinical Expert Users. This group was formed before SmartCare go-live and met weekly before and after go-live. Each team had their Clinical Supervisor and one other team member who were identified to serve as the SME Expert Users for their team. Although DBH is now well beyond the initial transition support needs, the Clinical Expert Users group continues to meet monthly to this day for ongoing EHR support. Other groups of classification or function-based Expert Users also met regularly throughout DBH’s preparation for and implementation of SmartCare. The Teams chat for all Expert Users is still currently maintained and accessible for any support or immediate answers which may be needed. Each DBH team maintains an identified Expert User representative who is expected to troubleshoot, train, share information with their team and to the other expert users. Both contracted and county staff participate in this process. Clinicians in the Planning and Quality Management (PQM) Division are also SMEs and provide additional support to staff when needed. PQM conducts a hands-on training for new staff who are onboarding into the EHR as new users of the system. This training, called SmartCare Onboarding for Full EHR Users, is an in-person monthly training for new hires. New hires in DBH are automatically enrolled in this training. Prior to the SmartCare go-live date, DBH Staff Development created a SmartCare training plan with links to all online trainings related to the EHR. This training plan was celebrated as an example for the rest of the counties in many cross-county meetings hosted by the Joint Powers Authority as well as the California Mental Health Services Authority (CalMHSA), which serves as the overall System Administrator of the semi-statewide SmartCare EHR. SmartCare is a semi-statewide EHR for participating county behavioral health plans and, as such, DBH participates in regular Technical Assistance calls with CalMHSA SmartCare System Administration to raise issues and to facilitate development of supports and solutions in the EHR.

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R3: An employee proficient in SmartCare should be identified by the Director of Behavioral Health as the subject matter expert (SME) to provide as needed training or assistance to all DBH Employees by December 31, 2025. (F3) Response: This recommendation will not be implemented because it is not warranted nor reasonable. The Department believes it is not advisable to have one singular SME to provide training and assistance to all DBH employees. As outlined in response to F3, there are already numerous employees identified as SMEs throughout the Department based on their specialized areas. Having one person who would serve as a singular SME across all areas, including having a meaningful understanding of the functions and implications of the EHR for diverse areas such as Finance, Clinical, Medical, Plan Administration, and Information Technology is not feasible and may introduce unintended risk to the Department. The existing system of SME by functional areas of the Department is a more effective mechanism. To ensure all areas have clarity on the existing Expert User and training system, DBH will include a presentation and discussion at a DBH All Supervisors meeting by December 31, 2025 regarding how to access training on SmartCare; provide clarity on the role of Expert Users; remind all staff to reach out to their expert users when having any EHR issues; and to ensure all Department supervisors are clear on how to share updates from their Expert Users with the DBH leads for SmartCare. The Department believes that this level-setting presentation, including time for questions and discussion, will ensure that all Department teams retain awareness of how to access training and Expert User support. Following this presentation and discussion, the DBH Health Information Technology and Privacy Management Division will send department-wide communication reminding all SmartCare Users to contact their Expert User and/or their direct supervisor when experiencing any challenges related to the EHR. The Department believes this alternative recommendation is the most prudent business decision to address concerns identified in F3.

F4: DBH Field Clinicians lack sufficient training to enhance their safety and effectiveness. Response: The Department partially disagrees with this finding. New hires are required to take trainings relevant to their professional category (whether clinical or administrative) and supervisors ensure that their staff are signed up for all appropriate trainings through DBH Staff Development, Relias Learning Management System (LMS), or Neogov (County’s electronic LMS). When training needs are identified, the DBH Training Committee and/or the DBH Staff Development team (with support from management) propose solutions to address the needs. Solutions have included bringing in external trainers, utilizing internal team members to provide training, and developing a training series specific to a professional classification. For clinicians and other clinical staff, Clinical Supervisors also provide trainings in their staff meetings and in one-to-one supervision related to targeted case management, psychosocial rehabilitation, crisis intervention, documentation and other relative topics. The Clinical Supervisor Onboarding Training Guideline supports Clinical Supervisors to onboard new clinical staff and includes safety and de-escalation training. This guideline was developed through a DBH Training Committee workgroup in July 2022 and was last updated on April 16, 2024. Although this document was shared with Clinical Supervisors, it is possible that not all Clinical Supervisors have a current copy. To mitigate that risk moving forward, Staff Development will assign this training guideline to all new Clinical Supervisors through the Relias LMS and assign a Relias LMS module for all existing Clinical Supervisors on an annual basis. DBH has invested in numerous clinical training modalities and supports evidence-based practice consultation groups for specific modalities (e.g., treatment of eating disorders). Additionally, all pre-licensure clinicians receive up to three hours of clinical mentoring from experienced licensed clinicians, in addition to the training and supervision provided by their Clinical Supervisor. Clinical mentoring provides a direct process for clinical guidance, support, and coaching by a licensed clinician, which can include a wide range of clinical topics including, but not limited to, evidence-based practices, diagnostics, specific treatment interventions, and clinical management of persons who present with complex behaviors. DBH is also in the process of formalizing a written training plan for all team members, which will include safety, clinical trainings, and clear protocols for field-based service delivery for all clinical staff. Related to safety, in early 2023, the Department conducted an assessment to reinstitute Crisis Prevention Institute (CPI) Nonviolent Crisis Intervention (NCI) trainings for all DBH staff, which was previously paused due to COVID-19 and the lack of certified trainers. NCI is a certified training in nonviolent crisis intervention that teaches staff how to prevent, recognize, and respond to challenging behaviors; prioritize safety; and use physical interventions as a last resort. The training includes risk assessment, verbal and non-verbal de-escalation skills, disengagement tactics and techniques to physically intervene if other options have been exhausted. The certification training supports staff to identify stages of increasing behaviors, use evidence-based approaches with individuals presenting with crisis behaviors, and prepares staff to minimize physical interventions by using safe and advanced disengagement techniques. While the Department prepared to relaunch the NCI training, it identified and implemented other safety trainings through the Relias LMS. For example, on March 20, 2023, the Department assigned two safety trainings to all staff: 1) Strategies for Preventing and De- escalating Hostile Situations, and 2) Facing Confrontation in Customer Service. In June 2023, the Department met with a CPI representative to explore a direct delivery training model. While the Department continued efforts to create a plan for in-person NCI training, DBH Staff Development identified other trainings in the Relias learning management system. On June 30, 2023, the Department emailed all staff of the availability of safety focused trainings: 1) First Aid, 2) Safety in the Field, and 3) The Basics of Workplace Safety, and included instructions on the process for enrollment. On July 25, 2024, DBH Staff Development submitted a proposal to resume in-person NCI training, whereby the Department funds three County Human Resources (HR) Staff Development members to become CPI NCI trainers via a train-the-trainer process. The goal of DBH was to invest in an approach for training in NCI that could support all of DBH as well as other county departments who could benefit from this valuable training. County HR committed to provide 25 NCI training sessions to train over 500 staff over a span of 18 months. In February 2025, NCI training was reinstituted and offered twice per month for DBH staff. The Department’s goal is to ensure all clinical staff are trained first and after that, the NCI training will be expanded to non-clinical positions. As of June 2025, a total of 180 staff have received NCI training.

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R4: The Director of Behavioral Health or his/her designee should develop a formal training program for all new hires based on their administrative or professional category by March 31, 2026. (F4) Response: The recommendation has not yet been implemented but will be by March 31, 2026. Although the Department already has a training program for new hires based on their administrative or professional category, the Department agrees that this is an opportunity for improvement and expansion and had already planned to enhance and improve our process, which aligns well with this recommendation. The DBH Staff Development unit will ensure updated training guidelines exist for all classifications and will assign those guidelines to all new supervisors through the Relias LMS. DBH Staff Development will assign a Relias LMS module for all existing supervisors on an annual basis. DBH will finalize formal written training plans for all employee classifications by March 31, 2026, and these plans will be updated no less than annually thereafter. In addition to trainings specific to classifications (e.g., clinicians, accountants, staff analysts), DBH Staff Development will ensure that for any classifications providing field-based services, training plans will include clear protocols and safety training for field-based service delivery.

R5: The Director of Behavioral Health or his/her designee should develop a formal training for all field clinicians, with annual refresher training based on current needs, including a hands-on self defense course and make it available to all field staff who encounter clients by March 31, 2026. (F4) Response: The first component of this recommendation (“a formal training for all field clinicians”) has not yet been implemented but will be by March 31, 2026. The Department is implementing a formal training plan for all employees, including field clinicians, as noted above in R4. A formal NCI training for all staff, prioritizing clinical staff first, has already been implemented and this training includes a hands-on physical intervention component. The second part of this recommendation (“with annual refresher training based on current needs”) requires further analysis as to operational needs and a sustainable refresher training cadence and format. As the Department updates and finalizes formal training plans for all classifications, by March 31, 2026, the Department will ensure that the plans include the frequency with which employees will take a refresher course.

F5: DBH’s Field Clinicians have no current information regarding known violent tendencies or criminal history of their patients prior to meeting with them. Response: The Department partially disagrees with this finding. With respect to persons previously known to the Department or referred through the justice system, information is available to clinical staff, including field staff. As a common clinical assessment practice, information related to a person’s criminal history or violent behavior, when disclosed or otherwise made available, would be documented and available in the clinical record. Thus, for persons having received a past service from the Department, a new team member who is to meet with a person for the first time has access to those records. For individuals who are specifically referred to the Department by the criminal justice system, those referrals typically come with details of criminal history. The Department agrees that for persons who are accessing our system of care for the first time, information related to potential for violence and criminal history is not available ahead of time. Risk assessment is a standard clinical procedure in every initial assessment for those accessing the system of care for the first time and in every reassessment for persons returning to services after a hiatus.

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R6: The Director of Behavioral Health or his/her designee should create a flag in the Smart Care System which identifies known violent tendencies and criminal history of the clients by March 31, 2026. (F5) Response: The Department will not implement this recommendation because it is not reasonable. The Department offers an alternative solution to address concerns identified in F5. There are over 60 different flags in SmartCare, and one of them is Safety Risk. This flag can already be added to a person’s health record and configured as a pop-up or an icon near the person’s name when the person is selected by the EHR user. Training is provided in EHR onboarding on how to add and remove flags to charts. By March 31, 2026, the Department will update EHR guidance in the form of a policy on how and when to add a safety risk flag on a chart, including how often flags should be reviewed and when they should be removed. A factor to be considered in said guidance is “flag fatigue,” a phenomenon by which staff become desensitized to flags and come to ignore them due to the sheer amount of them and high frequency with which flags are present in health records. If most persons have a flag on their health record, then flags would tend to be ignored; thus, most EHR professionals advise a cautious use of flags to minimize flag fatigue, so that utility of flags to serve as an alert is not diminished. Another factor for DBH to consider in developing policy guidance, which will need to be monitored, is the potential for disproportionate use of flags in certain populations due to implicit bias. Having a specific flag related to criminal history will not be implemented as it is not clinically useful and risks introducing stigma and bias in care delivery. A better process is to support clinical staff to conduct a thorough and comprehensive individualized clinical assessment at the first intake. For subsequent treating professionals beyond the initial assessing professional, best practice is to review the existing health record and build on clinical information in the record throughout the course of a person’s care with the Department in ongoing reassessment. Clinical assessments (including reassessments) should document relevant history including danger to self; danger to others; and relevant involvement with the other systems and services such as child welfare, the justice system, physical health care, and other systems. DBH employees will continue to receive safety trainings as any member of the public could potentially pose a threat to safety and DBH remains committed to training our employees to be mindful of workplace safety.

F6: There are insufficient or outdated supplies provided to DBH clinicians working in environments outside of the office including complete first aid kits and Narcan. Response: The Department agrees with this finding.

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R7: The Director of Behavioral Health or his/her designee should implement a resupply system that ensures all first aid kits in DBH vehicles are fully stocked and updated by January 31, 2026. (F6) Response: The recommendation has not yet been implemented but will be implemented in the future. Although the Department already has a written protocol for County vehicles to have adequate first aid supplies (e.g., checklist for County vehicles, a How-to-Guide, and a procedure for vehicle check-out), the Department has learned that not all staff are following these guidelines. Thus, DBH is revisiting and updating the process, standardizing protocols, implementing training for staff on the updated process, and will bolster monitoring procedures to ensure that first aid kits are kept fully supplied with non-expired, required items. The revised written and standardized protocols, with training, will be implemented no later than January 31, 2026.

R8: The Director of Behavioral Health should require that field staff be provided with Narcan, based on the potential Fentanyl and Opioid exposure in the field by January 31, 2026. (F6) Response: The recommendation requires further analysis because a new requirement imposed on represented employees requires DBH to consult County Labor Relations and Meet and Confer with employees’ bargaining units. Narcan is a brand name of Naloxone, a medication that can rapidly reverse the effects of an opioid overdose. Clinical staff members’ incidental exposure to Fentanyl and other Opioids in the course of their duties is exceptionally low, and DBH team members will be far more likely to administer Naloxone to community members than to themselves in the course of their duties. The Department supports having Naloxone available to staff who are trained to administer it and, in fact, has had Naloxone in some DBH clinics for several years. Naloxone is available in a separate compartment that is placed adjacent to first aid kits in DBH clinical buildings. The DBH Safety Committee members in those areas are responsible to check the fire extinguishers, first aid kits and Naloxone monthly to determine any necessary replacement/replenishment. DBH Safety Committee member information is posted in the building breakrooms. The Department supports expanding the practice of having Naloxone available to other sites as well as to team members providing field-based services. The Department intends to prepare a plan for field staff to be provided with Naloxone and to notice Labor Relations before December 31, 2025. Naloxone training is already mandatory for all DBH employees in medical classifications (i.e., Licensed Vocational Nurse, Psychiatric Technician, and Mental Health Nurse) and voluntary training is available for non-medical staff who express interest and willingness to voluntarily administer Naloxone. The training in how to administer Naloxone is encouraged for all DBH employees. Preliminary analysis has resulted in draft plans to create “field kits” for staff to take when providing services in the field. As Naloxone is a medication which should be maintained between 59 - 86 degrees Fahrenheit, and weather conditions of Fresno County can go below 59 and exceed 86 for most months out of the year, storing Narcan in vehicle’s first aid kits is not viable. Therefore, the Department is in the process of creating field kits for staff who go into the field and these kits will include Naloxone. By December 31, 2025, DBH will offer these field kits to employees voluntarily. To carry a field kit, employees must complete a DBH-approved training on how to administer Naloxone. DBH will explore whether carrying Naloxone will be a requirement for all DBH employee classifications. As noted above, for some employee classifications, this would be subject to a Meet and Confer process with employees’ bargaining units.

F7: DBH is not maintaining the most current information on its website as reports located on the website are aged and require updating. Response: The Department agrees with this finding.

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R9: The Director of Behavioral Health or his/her designee should conduct a yearly audit of each link and button on the DBH website to ensure reports and information contained on the website are up to date by January 31, 2026. (F7) Response: The recommendation has not yet been implemented but will be by January 31, 2026. To ensure accuracy of information available to the public, DBH will establish a protocol to do a full review and audit of its website, including all pages within and each link and button at least annually. DBH is currently in the process of streamlining information on its website so that information is easier to track and more accessible and actionable for the public. Team members are actively reviewing all links and buttons. Materials that are no longer current are being archived. The Director will also review the Department’s current communications strategies to consider additional recommendations for improvement. Streamlining the existing information on the DBH website and the first full audit of each link and button will be completed no later than January 31, 2026.

F8: The Auditor - Controller / Treasurer-Tax Collector’s office and DBH Finance/Accounting division have a different perception as to the timing of reimbursements into the County’s general fund. Response: The Department partially disagrees with this finding. In July 2023, a new county behavioral health payment method was implemented by California, commonly known as “payment reform.” This historic reform completely changed the process by which counties are paid for specialty mental health services from a cost-based reimbursement methodology, subject to retrospective cost settlement often up to ten years in arrears, to a fee-for-service methodology with an intergovernmental transfer process. DBH notified Assistant CAO, Greg Reinke and Deputy Auditor, Enedina Garcia of the upcoming change in FY 2022-23. However, DBH agrees that there was some confusion between the departments in FY 2023- 24, as the entire process was new to both DBH and the Auditor-Controller/Treasurer-Tax Collector’s (ACTTC) offices. DBH, the County Administrative Office, and the ACTTC held recurring meetings in FY 2023-24 to address this. As of the publication of the Civil Grand Jury Report, the offices of DBH and ACTTC had long since resolved the initial confusion on timing of reimbursements. Nonetheless, DBH acknowledges the complexities of payment reform and the initial confusion that resulted across departments. The Civil Grand Jury report erroneously stated that at one point, DBH owed the County general fund over $200 million. DBH records confirm that while there were limited and isolated months of high dollars due to the general fund, the Department’s portion never exceeded $200 million, and most months were significantly lower than that figure.

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R10: The Director of Behavioral Health or his/her designee should schedule monthly meetings with the County Auditor/Controller’s Office to timely resolve any accounting issues by December 31, 2025. (F8) Response: The recommendation will not be implemented because it is not reasonable. The Director of DBH and the ACTTC have established a working relationship that affords each of our respective teams the opportunity for escalation and access to both Department Heads for swift dispute resolution if and when needed. As such, with clear lines of communication already established and for the sake of efficient use of resources, it is believed that a standing quarterly meeting is sufficient for routine executive level meetings. Meetings can be scheduled more often if determined necessary by either department. Additionally, the Director of DBH and the ACTTC will seek to include the County Budget Director, representing the County Administrative Office, in the quarterly meetings to ensure that all three parties are on the same page moving forward.

R11: The Director of Behavioral Health should develop a clear written procedure regarding the timing of reimbursement from DBH to the County general fund by December 31, 2025. (F8) Response: The recommendation has not yet been implemented but will be by December 31, 2025. Although timing of reimbursement is dependent upon processes controlled by the State, and the County nor DBH can dictate State policy, DBH will develop a written procedure of how its claiming to the State is completed and timelines for transfers to the general fund. This written procedure will be completed no later than December 31, 2025. On behalf of DBH, thank you for the opportunity to review and respond to the findings and recommendations of the FY 2024-25 Civil Grand Jury Report No. 3. Sincerely, Susan Holt (Jul 29, 2025 15:02:58 PDT) Susan L. Holt Director of Behavioral Health and Public Guardian cc: Paul Nerland, County Administrative Officer Oscar J. Garcia, CPA, Auditor-Controller/Treasurer-Tax Collector

July 23, 2025 — County of Fresno*

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F1: tax bills; however, bill complexity has increased with a corresponding decrease in transparency as more special assessments appear on property tax bills. The Auditor's Office partially agrees with this finding, acknowledging that the

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R1: and acquire a new software system that will replace the COBOL-based system currently used. The software should be acquired by June 30, 2026. (F1 - F3, F9) The Auditor's Office has implemented this recommendation. On June 27, 2025,

R6: modify the new and subsequently printed versions of 'County of Fresno Tax Rate Book' to include 'Dollar Amount,' and 'Maturity Date' columns and associated data in both the secured and unsecured tax rate tables to improve transparency. The new information should be included in the tables by November 1, 2025. (F1,

F2: Fresno County Assessor and the Fresno County Auditor-Controller / Treasurer- Tax Collector as well as school districts that have levied taxes on voter-approved bonds.

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F3: problem of maintaining and coding the Fresno County legacy property tax program will only increase over time. The Auditor's Office is aware of this issue regarding the declining number of

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R2: Treasurer-Tax Collector's Office should implement the following additions to Fresno County property tax bills: 1) Columns and associated data for 'Start Date,' 'Dollar Amount,' and 'Maturity Date' should be added for all special assessment line items. 2) Internet address printed on bill stock directing property owners to a functional 'Sample Tax Bills and Notices' webpage at the Fresno County Auditor- [July 23, 2025] The Honorable Judge Houry A. Sanderson, Presiding Judge Fresno County Superior Court Grand July Finding Reporting No. Controller / Treasurer-Tax Collector's Office website. These changes to the Fresno County property tax bill should be implemented by December 1, 2025. (F3, F6) The Auditor's Office will not be implementing this recommendation because it

F4: provide specific information on special assessments to property owners because they can't understand the titles placed on the property tax bill by the Fresno County Auditor-Controller / Treasurer-Tax Collector's Office. The Auditor's Office cannot agree or disagree with this finding, as we do not

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R5: provide a key / legend for the special assessment codes appearing on property tax bills to all school districts levying taxes for bond obligations that will assist school district contact personnel in providing information to property owners. This key / legend should be made available by October 1, 2025. (F4) The Auditor's Office has not yet implemented this recommendation but will

F5: property tax owners with questions about special assessments are sometimes non- functional. The Auditor's Office agrees with this finding. The Auditor's Office would like

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R3: repair and update the website (Auditor-Controller/Treasurer-Tax Collector - County of Fresno) to provide better transparency for property owners. Repairs and updates should at the minimum include: 1) A webpage or partial webpage that provides information about special assessments that is also linked to a functional 'Sample Tax Bills and Notices' webpage. 2) A question / answer on the 'Frequently Asked Questions' webpage relative to special assessments, noting where to find more information. 3) A functioning link to the 'Auditor-Controller / Treasurer-Tax Collector document library for public resources' (ACTTC Publications - County of Fresno). 4) A functioning link to the current County of Fresno Tax Rate Book. These repairs and updates should be completed no later than October 1, 2025. (F1,

R4: examine and update annually the contact phone numbers of all 5000 series tax code entities on the Fresno County property tax bill and in the County of Fresno Tax Rate Book. These examinations and updates should be completed by November 1, 2025. (F5) The Auditor's Office will not be implementing the recommendation because it is

F6: Office offers no searchable link to 'special assessment' when queried, and several pages of the website have remained non-functional throughout the duration of this investigation. The Auditor's Office agrees with this finding. On the property tax bill, bonds

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F7: Auditor-Controller / Treasurer-Tax Collector's Office, provides a complete and properly titled listing of all outstanding bond obligations for Fresno County school districts. [July 23, 2025] The Honorable Judge Houry A. Sanderson, Presiding Judge Fresno County Superior Court Grand July Finding Reporting No. The Auditor's Office agrees with this finding. The County of Fresno Tax Rate

F8: to Fresno County property owners at the time of the property tax bill issuance, and was still unavailable at the end of April 2025. The Auditor's Office agrees with this finding. Annually, the County of Fresno

F9: Controller / Treasurer-Tax Collector are collaborating to identify an appropriate vendor to supply a client-based software system that will replace the COBOL- based legacy program. The Auditor's Office agrees with this finding. The Auditor's Office and the

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F10: that additional information (dollar amount of bond, year of bond maturity) could be easily inserted into the tax rate tables for voter-approved bond obligations. The Auditor's Office partially agrees with this finding. We concur that the

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∼ June 30, 2025 — How is the City of Fowler addressing Water Contamination? Fresno County

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Hallazgos & Recomendaciones 6 hallazgos

F1: Not all City of Fowler Public Works, Water Department operators knew written procedures and/or checklists existed for their day to day operation tasks as the procedures were recently developed for the department by the new Public Works Director.

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R1: Training for all Public Works, Water Department operators, including written procedures and/or checklists, should be disseminated and implemented for ease of access, continuity and succession planning by the City of Fowler’s Public Works Director by March 31, 2026. (F1)

F2: The City of Fowler’s water reports are submitted occasionally late to SWRCB due to the absence of the report deadline checklists to remind users.

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R2: The City of Fowler’s Public Works Director should develop a process and or procedure to ensure required water board reports are completed and returned on time to the California State Water Resources Board by October 31, 2025. (F2)

F3: The City of Fowler Public Works, Water Department website information is not organized in a user friendly, searchable format and is outdated, with the most recent reports not being added in a timely period.

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R3: The City of Fowler Public Works, Water Department webpage should be improved making it more user friendly, accessible and straightforward to easily find all water information and important links to enhance transparency by the City of Fowler’s Public Works Director by March 31, 2026. (F3)

F4: A maintenance and budget plan for the ongoing operation of the soon to be installed GAC filtration system in the City of Fowler has not been developed.

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R4: A maintenance and budget plan for the ongoing operation of the soon to be installed GAC filtration system should be developed by the City of Fowler’s Public Works Director by March 31, 2026. (F4)

F5: While only one of the City of Fowler’s six wells is above the CA-MCL for TCP, all wells, including the TCP contaminated well, must be utilized to satisfy consumer demands and fire protection requirements.

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R5: The City of Fowler Public Works, Water Department should proactively develop plans to increase water system capacity and fire protection needs through new well development, distribution interconnectivity and above ground storage facilities that would assist in providing potable water to Fowler citizens if TCP contamination extends to another City of Fowler water well by March 31, 2026. (F5, F6)

R6: The City of Fowler Public Works, Water Department should identify and establish a water sampling location(s) within the distribution system (apart from well sources mandated by SWRCB) and use the location(s) to begin compiling water quality data from quarterly water samples by September 30, 2025. (F5) 10

F6: The City of Fowler has been aware of elevated TCP levels in Well #7 since 2018; however, funding to mitigate TCP contamination was delayed because of litigation. 9

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June 25, 2025 — County Superintendent*

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Hallazgos & Recomendaciones 5 hallazgos

F1: Presently serving elected school board members were uncertain whether Brown Act/Ethics training was a requirement as a board member. In fulfilling its duties and roles, the County Superintendent's office has not surveyed presently- serving elected school board members regarding this issue, and does not have knowledge of the contents of the testimony given to the Grand Jury in the preparation of the Report, and is therefore not equipped to opine on this finding, or make broad generalizations regarding the unique and varied board members serving across Fresno County. Accordingly, the County Superintendent must disagree with the finding. The Honorable Houry A. Sanderson June 25, 2025

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R1: The Fresno County Superintendent of Schools should provide no later than September 1, 2025, a courtesy notification to the governing boards of all Fresno County school districts to indicate the following: 1) AB 2158 mandates two hours of public service ethics laws training every two years for all elected school board members. 2) All elected school board members must complete AB 1234 training by December 31, 2025 unless their term of office ends before January 1, 2026. 3) That records pertaining to AB 1234 training of The Honorable Houry A. Sanderson June 25, 2025 elected school board members are public records, and subject to disclosure under the California Public Records Act. (F1 - F4) The County Superintendent's office has already implemented this recommendation by transmitting a courtesy notification to all governing boards of all Fresno County school districts including the recommended information, in addition to extra relevant details and resources. Please find a copy of that memorandum enclosed.

F2: Presently serving elected school board members were unaware of the consequences which could arise from violating the Brown Act. In fulfilling its duties and roles, the County Superintendent's office has not surveyed presently- serving elected school board members regarding this issue, and does not have knowledge of the contents of the testimony given to the Grand Jury in the preparation of the Report, and is therefore not equipped to opine on this finding, or make broad generalizations regarding the unique and varied board members serving across Fresno County. Accordingly, the County Superintendent must disagree with the finding.

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F3: Brown Act training is among the core content topics required in any curriculum to satisfy AB 1234 training requirements. Agree.

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F4: As per requirements of AB 2158, local school districts are responsible to provide an AB 1234 training curriculum to the elected school board members that includes all core content topics identified in Fair Political Practices Commission Regulation 18371. Disagree partially, as to what school districts are specifically required to "provide." Pursuant to Government Code, section 53235, subd. (f), "A local agency shall provide information on training available to meet the requirements of this article to its local officials at least once annually." While school districts should use every reasonable effort to inform and encourage its board members to complete the state-mandated training - and are required to provide information on training available - the school district itself is not required to become a provider of the mandated training course or curricula. Within Fresno County, presently serving elected school board members were

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F5: receptive to developing an onboarding checklist to assist in identifying when state- mandated training requirements are completed by newly elected board members. In fulfilling its duties and roles, the County Superintendent's office has not surveyed presently- serving elected school board members regarding this issue, and does not have knowledge of the contents of the testimony given to the Grand Jury in the preparation of the Report, and is therefore not equipped to opine on this finding, or make broad generalizations regarding the unique and varied board members serving across Fresno County. Accordingly, the County Superintendent must disagree with the finding.

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R3: The Fresno County Superintendent of Schools should provide no later than September 1, 2025, a courtesy notification advocating that Fresno County school districts each develop and implement an onboarding checklist for newly elected board members to identify and monitor state-mandated training requirements. (F5) The County Superintendent's office has already implemented this recommendation by transmitting a courtesy notification to all governing boards of all Fresno County school districts including the recommended information, in addition to extra relevant details and resources. Please find a copy of that memorandum enclosed. The County Superintendent's office again thanks the Grand Jury for raising the issues of Brown Act compliance among school districts within Fresno County and the state-mandated ethics training requirements applicable to school board members, and providing this opportunity to highlight the work of the County Superintendent's office in this area. Sincerely, Meoph Michele Cantwell-Copher Fresno County Superintendent of Schools Enclosure Courtesy Notification Regarding State-Mandated Ethics Training and Onboarding New Board Members 4925-3190-6893, v. Fresno County Superintendent of Schools Dr. Michele Cantwell-Copher, Superintendent MEMORANDUM To: Members of the Board of Trustees c/o District Superintendents All Fresno County School Districts From: Benjamin C. Rosenbaum, Legal Counsel Date: June 25, 2025 Courtesy Notification Regarding State-Mandated Ethics Training and Re: Onboarding New Board Members This memorandum is sent on behalf of the Fresno County Superintendent of Schools Michele Copher, On May 9, 2025, the Fresno County Grand Jury released its Report No. 1, "The Brown Is it being taken seriously by Fresno County school districts?" available at: Act. https://www.fresno.courts.ca.gov/system/files/general/report-1-brown-act-it-being-taken- seriously-fresno-county-school-districts.pdf In the Report the Grand Jury examined issues related to compliance with the Ralph M. Brown Act among school districts within Fresno County, as well as state-mandated ethics training requirements applicable to school board members. The Report recommended that this office provide courtesy notification to the governing boards of all school districts within the County regarding these issues and the onboarding of new board members, and this office is providing this memorandum to implement those recommendations. Please remember that pursuant to Government Code, sections 53234 through 53235.2: (1) it is mandated that each school board member "shall receive at least two hours of training in general ethics principles and ethics laws relevant to the official's public service every two years"; (2) each school board member "who, as of January 1, 2025, is a member of the governing board of a school district, . . . except for officials whose term of office ends before January 1, 2026, shall receive the training required . . . before January 1, 2026"; (3) your district is required to "provide information on training available to meet the requirements" to each board member at least once annually; and (4) your district is required to maintain records indicating the date of each member's training and the entity that provided the training for at least five years, and the records are public records subject to disclosure under the California Public Records Act. Fresno County Office of Education 1111 Van Ness Avenue • Fresno, California 93721 (559) 265-3000 · www.fcoe.org Re: Courtesy Notification Regarding State-Mandated Ethics Training and Onboarding New Board Members June 25, 2025 The Fair Political Practices Commission maintains and makes available a free on-demand online course to satisfy the requirements of this state-mandated training, which is available at: https://localethics.fppc.ca.gov/login.aspx mandated training must satisfy the Government Code requirements and be developed in consultation with the Fair Political Practices Commission and the Attorney General regarding its sufficiency and accuracy. Following the Grand Jury's recommendation, it also is worth considering developing and implementing an onboarding checklist for new school board members to identify and monitor state-mandated training requirements, in addition to topics your board feels may be beneficial for new members. My office will continue to highlight and offer updates on related legal developments and learning opportunities for board members and district staff. If you have any questions regarding the training requirements or ethics laws applicable to your board, please consult with your legal counsel. 4909-4829-4477, v. SUPERIOR COURT OF CALIFORNIA COUNTY OF THE PARC

May 22, 2025 — Fresno County Department of Behavioral Health: Will the Department be able to meet current and future

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Hallazgos & Recomendaciones 8 hallazgos

F1: Funding is sensitive as it comes from Federal and State sources (Medi-Cal and grants), yet there is no contingency plan defining how spending will be cut at DBH in the event of funding cuts.

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R1: The Director of Behavioral Health should create a written contingency plan to define cuts in service in the event there are cuts in funding by January 31, 2026. (F1)

F2: There is no formal system of vertical communication for DBH employees to ask questions or make suggestions and have a guaranteed response from upper management.

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F3: The transition to SmartCare Electronic Health Record (EHR) software system has created more issues for DBH than anticipated. 3 https://www.fresnocountyca.gov/Departments/Behavioral-Health/For-Professionals/Quality-Improvement/ Annual-Beneficiary-Grievance-Appeal-Reports 7

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F4: DBH Field Clinicians lack sufficient training to enhance their safety and effectiveness.

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R4: The Director of Behavioral Health or his/her designee should develop a formal training program for all new hires based on their administrative or professional category by March 31, 2026. (F4) 8

F5: DBH’s Field Clinicians have no current information regarding known violent tendencies or criminal history of their patients prior to meeting with them.

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F6: There are insufficient or outdated supplies provided to DBH clinicians working in environments outside of the office including complete first aid kits and Narcan.

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R7: The Director of Behavioral Health or his/her designee should implement a resupply system that ensures all first aid kits in DBH vehicles are fully stocked and updated by January 31, 2026. (F6)

R8: The Director of Behavioral Health should require that field staff be provided with Narcan, based on the potential Fentanyl and Opioid exposure in the field by January 31, 2026. (F6)

F7: DBH is not maintaining the most current information on its website as reports located on the website are aged and require updating.

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F8: The Auditor - Controller / Treasurer-Tax Collector’s office and DBH Finance/Accounting division have a different perception as to the timing of reimbursements into the County’s general fund.

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R11: The Director of Behavioral Health should develop a clear written procedure regarding the timing of reimbursement from DBH to the County general fund by December 31, 2025. (F8) 9

May 13, 2025 — Special assessment transparency on the Fresno County property tax bill: How can it be improved?

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F1: Over the last 30 years, many changes have been made to Fresno County property tax bills; however, bill complexity has increased with a corresponding decrease in transparency as more special assessments appear on property tax bills.

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R1: The Fresno County Auditor-Controller / Treasurer-Tax Collector should prioritize and acquire a new software system that will replace the COBOL-based system currently used. The software should be acquired by June 30, 2026. (F1 - F3, F9)

R3: The Fresno County Auditor-Controller / Treasurer-Tax Collector's Office should repair and update the website ( Auditor-Controller/Treasurer-Tax Collector - County of Fresno ) to 10 provide better transparency for property owners. Repairs and updates should at the minimum include: 1) A webpage or partial webpage that provides information about special assessments that is also linked to a functional ‘Sample Tax Bills and Notices’ webpage. 2) A question / answer on the ‘Frequently Asked Questions’ webpage relative to special assessments, noting where to find more information. 3) A functioning link to the ‘ Auditor-Controller / Treasurer-Tax Collector document library for public resources ’ ( A CTTC Publications - County of Fresno ). 4) A functioning link to the current County of Fresno Tax Rate Book. These repairs and updates should be completed no later than October 1, 2025. (F1, F6)

R6: The Fresno County Auditor-Controller / Treasurer-Tax Collector's Office should modify the new and subsequently printed versions of ‘County of Fresno Tax Rate Book’ to include ‘Dollar Amount,’ and ‘Maturity Date’ columns and associated data in both the secured and unsecured tax rate tables to improve transparency. The new information should be included in the tables by November 1, 2025. (F1, F7, F8, F10) 11

F2: Preparation of property tax bills requires coordination between the offices of the Fresno County Assessor and the Fresno County Auditor-Controller / Treasurer-Tax Collector as well as school districts that have levied taxes on voter-approved bonds.

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F3: Due to the declining number of educational institutions teaching COBOL, the problem of maintaining and coding the Fresno County legacy property tax program will only increase over time.

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R2: As a measure to improve transparency, the Fresno County Auditor-Controller / Treasurer-Tax Collector's Office should implement the following additions to Fresno County property tax bills: 1) Columns and associated data for ‘Start Date,’ ‘Dollar Amount,’ and ‘Maturity Date’ should be added for all special assessment line items. 2) Internet address printed on bill stock directing property owners to a functional ‘Sample Tax Bills and Notices’ webpage at the Fresno County Auditor-Controller / Treasurer-Tax Collector's Office website. These changes to the Fresno County property tax bill should be implemented by December 1, 2025. (F3, F6)

F4: Personnel listed for informational contact on property tax bills are unable to provide specific information on special assessments to property owners because they can’t understand the titles placed on the property tax bill by the Fresno County Auditor-Controller / Treasurer-Tax Collector’s Office.

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R5: The Fresno County Auditor-Controller / Treasurer-Tax Collector's Office should provide a key / legend for the special assessment codes appearing on property tax bills to all school districts levying taxes for bond obligations that will assist school district contact personnel in providing information to property owners. This key / legend should be made available by October 1, 2025. (F4)

F5: Informational contact phone numbers placed on property tax bills to assist property tax owners with questions about special assessments are sometimes non-functional.

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R4: The Fresno County Auditor-Controller / Treasurer-Tax Collector's Office should examine and update annually the contact phone numbers of all 5000 series tax code entities on the Fresno County property tax bill and in the County of Fresno Tax Rate Book. These examinations and updates should be completed by November 1, 2025. (F5)

F6: The website of the Fresno County Auditor-Controller / Treasurer-Tax Collector’s Office offers no searchable link to ‘special assessment’ when queried, and several pages of the website have remained non-functional throughout the duration of this investigation.

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F7: The ‘County of Fresno Tax Rate Book,’ compiled annually by the Fresno County Auditor-Controller / Treasurer-Tax Collector’s Office, provides a complete and properly titled listing of all outstanding bond obligations for Fresno County school districts. 9

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F8: The 2024 - 2025 version of the ‘County of Fresno Tax Rate Book’ was unavailable to Fresno County property owners at the time of the property tax bill issuance, and was still unavailable at the end of April 2025.

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F9: The offices of the Fresno County Assessor and the Fresno County Auditor-Controller / Treasurer-Tax Collector are collaborating to identify an appropriate vendor to supply a client-based software system that will replace the COBOL-based legacy program.

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F10: The 2023-2024 ‘County of Fresno Tax Rate Book’ is compiled in a manner such that additional information (dollar amount of bond, year of bond maturity) could be easily inserted into the tax rate tables for voter-approved bond obligations.

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March 26, 2025 — The Brown Act. Is it being taken seriously by Fresno County school districts?

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Hallazgos & Recomendaciones 5 hallazgos

F1: Presently serving elected school board members were uncertain whether Brown Act/Ethics training was a requirement as a board member.

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F2: Presently serving elected school board members were unaware of the consequences which could arise from violating the Brown Act.

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F3: Brown Act training is among the core content topics required in any curriculum to satisfy AB 1234 training requirements.

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R2: The Fresno Unified School District Board of Education should ensure no later than September 31, 2025, that curricula developed or utilized to comply with AB 1234 training for their elected school board members contain all the core content topics identified in Fair Political Practices Commission Regulation 18371. (F3, F4)

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F5: Within Fresno County, presently serving elected school board members were receptive to developing an onboarding checklist to assist in identifying when state-mandated training requirements are completed by newly elected board members.

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* This report's PDF did not contain easily extractable text and required Optical Character Recognition (OCR) for analysis. There may be minor errors in the extracted findings and recommendations due to OCR limitations with scanned documents.