Madera County Grand Jury

2018-2019

25 reports

From the annual report
The consolidated year-end volume. The individual investigations it contains are listed separately below.
📑 Year-End Report
The full consolidated volume; individual reports are listed below.
Individual reports (25)
Findings & Recommendations 4 findings
F1: Both MUSD and GVUSD are in compliance with Education Code 39831.5 (a) (A,B,C,D, and E) (2), the "Annual Student Bus Safety Document" requirements.
Related Recommendations (1)
R1: The MCGJ recommends that MUSD and GVUSD must continue staying in compliance with Education Code 39831.5 (a) (A,B,C,D, and E) (2), the "Annual Student Bus Safety Document" requirements each year to ensure that the most complete and accurate information is provided to drivers. . Response: Ed Code 39831.5 (a) (1) (A,B,C,D, and E) states: (a) All pupils in prekindergarten, kindergarten, and grades 1 to 12, inclusive, in public or private school who are transported in a school bus or school pupil activity bus shall receive instruction in school bus emergency procedures and passenger safety. The county superintendent of schools, superintendent of the school district, or owner operator of a private school, as applicable, shall ensure that the instruction is provided as follows: (1) Upon registration, the parents or guardians of all pupils not previously transported in a school bus or school pupil activity bus and who are in prekindergarten, kindergarten, and grades 1 to 6, inclusive, shall be provided with written information on school bus safety. The information shall include, but not be limited to, all of the following: MADERA UNIFIED SCHOOL DISTRICT Board of Trustees: 1902 Howard Road, Madera, California 93637 MADER Ray G. Seibert, President (559) 675-4500 Ruben Mendoza, Clerk FAX: (559) 675-1186 Trustees: www.madera.k12.ca.us Brent Fernandes, Joetta Fleak Ed McIntyre, Lucy Salazar Superintendent: Todd Lile (A) A list of school bus stops near each pupil's home. (B) General rules of conduct at school bus loading zones. (C) Red light crossing instructions. (D) School bus danger zone. (E) Walking to and from school bus stops. (2) At least once in each school year, all pupils in prekindergarten, kindergarten, and grades 1 to 8, inclusive, who receive home-to-school transportation shall receive safety instruction that includes, but is not limited to, proper loading and unloading procedures, including escorting by the driver, how to safely cross the street, highway, or private road, instruction on the use of passenger restraint systems, as described in paragraph (3), proper passenger conduct, bus evacuation, and location of emergency equipment. Instruction also may include responsibilities of passengers seated next to an emergency exit. As part of the instruction, pupils shall evacuate the school bus through emergency exit doors. The district will continue to provide this information to parents through several avenues and to the families of all students enrolled in our district. School bus stops are posted on the district website and a flier is provided to each school site listing the bus stops for each of our bus routes organized by school of attendance. These routes are developed annually based on student enrollment and the location of student residences. Written information on general rules of conduct, red light crossing instructions, and school bus danger zones are included in the district handbook that is provided to all students at the beginning of every school year. Students will continue to participate in annual bus safety drills conducted by district drivers as required by Ed Code.
F5: The MCGJ finds that the traffic conditions are dangerous at Alpha Elementary School and John Adams Elementary.
Related Recommendations (1)
R5: The MCGJ recommends MUSD senior District leaders immediately meet with senior City of Madera Law Enforcement and the City of Madera Traffic Engineer in order to mitigate all traffic congestion at Alpha School and John Adams School. Response: On July 16, 2019, MUSD leaders, City of Madera Police Chief, City of Madera Police Commander, and City of Madera Traffic Engineer met to discuss the MCGJ findings regarding traffic around district schools. Alpha Elementary and John Adams Elementary were discussed in great detail. MADERA UNIFIED SCHOOL DISTRICT Board of Trustees: 1902 Howard Road, Madera, California 93637 Ray G. Seibert, President (559) 675-4500 Ruben Mendoza, Clerk FAX: (559) 675-1186 Trustees: www.madera.k12.ca.us Brent Fernandes, Joetta Fleak Ed McIntyre, Lucy Salazar Superintendent: Todd Lile It was determined that the City of Madera would install traffic delineators in areas on Stadium Road that would prohibit left turns out of the parent pick up/drop off driveway at Alpha Elementary as well as the exit out of Madera South High School. MUSD was also informed that Stadium Road would be included in a traffic study the City will conduct as part of an analysis of extending Almond Ave. from Pine St. to Stadium Road. MUSD was also informed that a future "HAWK signal light" would be installed on the corner of Stadium Road and Gary Lane. It was recommended that MUSD ask parents traveling east towards John Adams to drop off/pick up students on National Ave, and parents traveling west towards John Adams to drop off/pick up students on Third Street. The intent is to eliminate students crossing those roadways in front of vehicular traffic.
F6: Many drivers are either uninformed or disregard traffic safety procedures at Alpha Elementary School and John Adams Elementary School causing additional traffic congestion and unsafe conditions for students.
Related Recommendations (1)
R6: The MCGJ recommends, by the beginning of the 2019-2020 school year, MUSD must begin using social media platforms, such as Aeries, Facebook, Twitter, and the school website, to publicize existing traffic hazards and expose problems in order to improve the behavior of drivers. Response: Madera Unified has established a standard procedure for all school sites to follow in order to better communicate traffic patterns at school sites. This procedure is currently in implementation stages and is expected to be followed at all school sites. School maps with clearly identified student drop off/pick up areas are in development. These maps will be posted on school websites and distributed to parents through emails and social media platforms. School sites have already sent messages via robo-phone calls to parents at the beginning of the school year. Madera Police Department has also provided communication through social media and coordinated their messages with the district. MUSD and Madera PD are continuing to visit and monitor all district school sites to review traffic patterns and make recommendations for improvement.
F7: Senior staff at both MUSD and Madera City Police Department are not collaborating to solve traffic safety issues throughout the district.
Related Recommendations (1)
R7: The MCGJ recommends MUSD senior leadership immediately begin to collaborate with senior managers of the City of Madera Police Department and the City of Madera Traffic Engineer to review the traffic flow plan on each school in Madera Unified. MADERA UNIFIED SCHOOL DISTRICT Board of Trustees: 1902 Howard Road, Madera, California 93637 Ray G. Seibert, President (559) 675-4500 Ruben Mendoza, Clerk FAX: (559) 675-1186 Trustees: www.madera.k12.ca.us Brent Fernandes, Joetta Fleak Ed McIntyre, Lucy Salazar Superintendent: Todd Lile Response: On July 16, 2019 the following District and City staff met to discuss the MCGJ findings (MUSD Superintendent, MUSD Deputy Superintendent, MUSD Area Assistant Superintendents, City of Madera Chief of Police, City of Madera Police Commander, and City of Madera Traffic Engineer. A second meeting was held on August 1, 2019. Meetings between the District, Madera Police Department, and City of Madera Traffic Engineer will be held every other month for the purpose of addressing traffic safety issues around school sites. Madera Police Department has provided additional resources to our school sites during morning drop off and afternoon pick up times and have provided "media blasts" to parents regarding enforcement of traffic laws around school sites. MUSD and Madera PD have also established satellite offices on the campuses of both Madera High School and Madera South High School for traffic patrol officers. This will provide increased traffic enforcement around the high schools as well as Stadium Road. Madera Unified would like to thank the Madera County Grand Jury for their diligence and thoughtful recommendations in making our community and specifically our schools safer. Respectfully, Todd Lile Ray Siebert Superintendent President Madera Unified School District Madera Unified Board of Trustees . į. . Add to Grand Jury Website 9-5-19 Responses to Final Report 1819-03 Community Action Partnership of Madera County Inc. 1819-05 Student Safety: Why Are They Turning the Wrong Way? .

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Findings & Recommendations 5 findings
F1: The MCGJ finds that the property within CSA-21, that contains the Cascadel Clubhouse, on four lots within three parcels of land, is owned by the County of Madera.
Related Recommendations (1)
R1: It is recommended that, within the next year, the property owners within Cascadel Woods (CSA 21), begin to form a legal association, to start the process of returning all properties to their ownership, control, and responsibility, as well as the use of the property at the owners own expense.
F2: The MCGJ finds that the County of Madera is currently responsible for upkeep, maintenance, insurance (both property and liability), for those properties noted in
Related Recommendations (1)
R2: It is recommended that the County continue to maintain and insure the subject properties until the transfer of ownership is complete.
F4: The MCGJ finds that currently there is not a multi-year contract in effect between the County and a contractor for mowing and maintenance of the properties.
Related Recommendations (1)
R4: It is recommended that, when all CSA 21 properties are relinquished from the County of Madera, it would be the responsibility of the new legal association contract, as they find necessary, for all upkeep, mowing, maintenance, and insurance.
F5: The MCGJ finds that the area around and adjacent to the Clubhouse, including the land parcels, are a designated “Shelter in Place” zone for the residents in the event of fire blocking egress from Cascadel Woods.
Related Recommendations (1)
R5: It is recommended that the area around and adjacent to the Cascadel Clubhouse, must remain accessible and maintained as a “Shelter in Place” zone.
F6: The MCGJ finds that the amount collected from property owners is insufficient to cover the cost of maintenance and expenses currently paid by the County.
Related Recommendations (1)
R6: It is recommended that Madera County find a solution to fund the financial shortage within the next fiscal year.
Additional Recommendations 1

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R3: It is recommended that Cascadel Woods continue to maintain control of road maintenance.
Findings & Recommendations 7 findings
F1: The MCGJ finds that community knowledge of CAPMC services is severely limited to primarily word of mouth.
Related Recommendations (1)
R1: By January 1, 2020, the MCGJ recommends that CAPMC promote services through various forms of social media and other community venues throughout the County.
F2: The MCGJ finds that the Resource Guide is outdated in style, information, and format for the entire County of Madera.
Related Recommendations (1)
R2: The MCGJ recommends, by January 1, 2020, CAPMC update their Resource Guide to reflect style, social media outlets, and include all areas of the county.
F3: The MCGJ finds that elimination of the Gang Task Force resulted in increased violent gang activity.
Related Recommendations (1)
R3: The MCGJ recommends, by January 1, 2020, that CAPMC reestablish the Gang Task Force in conjunction with other community agencies.
F4: The MCGJ finds staff members and witnesses experience intimidation during court appearances.
Related Recommendations (1)
R4: The MCGJ recommends, by January 1, 2020, CAPMC coordinate a plan to work with law enforcement and the Courts for training staff on how to recognize and defuse gang intimidation.
F5: The MCGJ finds that the number of victims of sexual assault have increased dramatically.
Related Recommendations (1)
R5: The MCGJ recommends, by January 1, 2020, CAPMC increase efforts to address the community issues for the needs of victims of sexual assault and human trafficking by reviewing and creating new strategies for victim prevention and assistance.
F6: The MCGJ finds that CAPMC does not have dedicated funding specifically related to CFIT activity.
Related Recommendations (1)
R6: The MCGJ recommends, by July 1, 2020-2021 budget, CAPMC secure funds and include a line item for expenses attributed specifically related to CFIT activity.
F7: The MCGJ finds that DSS and CAPMC work well together.
Related Recommendations (1)
R7: The MCGJ recommends that CAPMC and DSS continue to have a positive relationship.
Findings & Recommendations 10 findings
F1: The City of Madera does not have a written code of ethics for senior officials or elected members.
Related Recommendations (1)
R1: By September 30, 2019, the MCGJ recommends that the City of Madera create and follow a code of ethics for all senior officials and elected members, and display the code of ethics in a public place.
F2: The senior officials and elected members do not have adequate follow-up training on ethics.
Related Recommendations (1)
R2: By September 30, 2019, the MCGJ recommends that the City of Madera create and contract for follow-up ethical training for senior officials and elected members to attend annually.
F3: The general public does not know how to access the City Council meeting agenda and comment on agenda items including the consent calendar.
Related Recommendations (1)
R3: By September 30, 2019, the MCGJ recommends that City Council make clarifications regarding the access to Agenda and Consent Calendar for the public.
F4: Speakers during Public Comment at City Council meetings are intimidated by the requirement to provide their personal address.
Related Recommendations (1)
R4: By September 30, 2019, the MCGJ recommends that those addressing the City Council during Public Comment not be required to provide their street address.
F5: The Agendas for the City Council Meetings are difficult for the general public to understand.
Related Recommendations (1)
R5: By September 30, 2019, the MCGJ recommends that City Council make clarifications which enable the public’s understanding of all Agenda items.
F6: The City Council of Madera did not provide the MCGJ with requested documentation in a timely and orderly manner.
Related Recommendations (1)
R6: By September 30, 2019, the MCGJ recommends the City of Madera officials implement training for their department heads and employees on how to respond in a timely and orderly manner, within ten days, to inquiries made by the MCGJ.
F7: City administration violated the MCGJ’s admonition of secrecy.
Related Recommendations (1)
R7: The MCGJ recommends the City of Madera officials immediately take steps to understand the importance and necessity of the MCGJ’s admonition of secrecy.
F8: The City of Madera does not follow its Purchasing-Central Supply Mission Statement regarding conflicts of interest.
Related Recommendations (1)
R8: The MCGJ recommends the Madera City Council and the Madera City officials immediately review and follow its Purchasing-Central Supply Mission Statement regarding Conflicts of Interest.
F9: City administrators and elected officials are doing personal business with the City as private individuals.
Related Recommendations (1)
R9: The MCGJ recommends that City administrators and elected officials immediately cease doing personal business with the City of Madera.
F10: The City of Madera shows a lack of transparency towards residents of the City of Madera and the Madera County Grand Jury.
Related Recommendations (1)
R10: The MCGJ recommends that the City of Madera immediately take steps to restore the trust of the citizens by being more forthcoming and transparent in their cooperation and communication with residents of Madera.
Findings & Recommendations 8 findings
F1: Because senior management of MUSD and GVUSD was unaware of the requirement to provide written bus safety information for drivers, there is a potential violation of Education Code §39831.S (a) (A, B, C, D, and E) (2).
Related Recommendations (1)
R1: The MCGJ recommends that MUSD and GVUSD must continue staying in compliance with Education Code §39831.S (a) (A, B, C, D, and E) (2), the Annual Student Bus Safety Document requirements each year to ensure that the most complete and accurate information is provided to drivers. RECOMMENDATIONS: GVUSD
F2: Because the findings of the study done in 2014 and 2015 regarding Webster Elementary School have not been implemented, congestion problems continue and unsafe conditions persist.
Related Recommendations (1)
R2: The MCGJ recommends that by September 2020, GVUSD must secure funding for implementing the Webster Elementary School Master Plan for redirecting the entrance to Webster Elementary School in order to reduce vehicle congestion and improve student safety.
F3: There is a need for a crossing guard on Ruth Avenue at Webster Elementary School to enhance student safety.
Related Recommendations (1)
R3: The MCGJ recommends, by the beginning of the 2019-2020 school year, GVUSD must begin using social media platforms, such as Aeries, Facebook, Twitter, and school website to post existing traffic hazards to illustrate problems and improve the education of drivers.
F4: GVUSD presented a job announcement searching for a volunteer crossing guard for Webster Elementary School, but this position remains unfilled as of the writing of this report. (see Exhibit C) FINDINGS FOR MADERA UNIFIED SCHOOL DISTRICT:
Related Recommendations (1)
R4: The MCGJ recommends, by the start of the 2019-2020, Webster Elementary School must complete the implementation of a paid Crossing Guard Service to ensure, enhances, and maximize student and driver safety. RECOMMENDATIONS: MADERA UNIFIED SCHOOL DISTRICT
F5: The MCGJ finds that the traffic conditions are dangerous at Alpha Elementary School and John Adams Elementary.
Related Recommendations (1)
R5: The MCGJ recommends MUSD senior District leaders immediately meet with senior City of Madera Law Enforcement and the City of Madera Traffic Engineer in order to mitigate all traffic congestion at Alpha School and John Adams School.
F6: Many drivers are either uninformed or disregard traffic safety procedures at Alpha Elementary School and John Adams Elementary School causing additional traffic congestion and unsafe conditions for students.
Related Recommendations (1)
R6: The MCGJ recommends, by the beginning of the 2019-2020 school year, MUSD must begin using social media platforms, such as Aeries, Facebook, Twitter, and the school website, to publicize existing traffic hazards and expose problems in order to improve the behavior of drivers.
F7: Drivers turning left out of Alpha Elementary School onto Stadium Road create congestion problems and dangerous conditions for pedestrians.
Related Recommendations (1)
R7: The MCGJ recommends MUSD senior leadership immediately begin to collaborate with senior managers of the City of Madera Police Department and the City of Madera Traffic Engineer to review the traffic flow plan of each school in Madera Unified.
F8: Drivers turning left into Alpha Elementary School from Stadium Road create congestion problems and dangerous conditions for pedestrians. METHODOLOGY: For the purposes of continuity, the 2018-2019 MCGJ reviewed the Madera County Grand Jury Final Report 1718-06 School Transportation Safety and all of the responses received from the school districts and the Motor Carrier Specialist I of the California Highway Patrol. After reviewing the responses, the current MCGJ investigated the following:  MCGJ members visited both John Adams Elementary School and Alpha Elementary School in the MUSD and Webster Elementary School in GVUSD multiple times to witness traffic congestion during student arrival and dismissal times.  At the request of the MCGJ, the superintendents of MUSD and GVUSD observed student arrival and dismissal times at their respective schools.  Subsequent to the superintendents’ observations at their respective schools, the superintendents were interviewed by the MCGJ.  The MCGJ requested the City of Madera Chief of Police personally observe the traffic congestion during the arrival and dismissal times for the students at both Alpha and John Adams Elementary Schools.  Subsequent to his observation, the MCGJ interviewed the City of Madera Chief of Police.  MCGJ interviewed senior school administrators, senior school transportation personnel, senior City of Madera administration, and senior City of Madera law enforcement personnel.  MCGJ reviewed the Webster Elementary School Master Plan.  MCGJ reviewed the newly revised MUSD transportation manual and other internal documents related to school transportation. DISCUSSION Madera Unified School District and GVUSD provided MCGJ the revised transportation documents. These documents included school bus emergency procedures, passenger safety, and walking routes. The same documentation should be provided annually to both students and those who transport students. In response to the 2017-2018 Report Finding 1 (F1), the MCGJ obtained a revised policy and procedures manual. Distribution of this document to impacted individuals cures the potential violation of Education Code §39831.S (a) (A, B, C, D, and E) (2). Many students are transported by private vehicles. The drivers of these private vehicles create unsafe traffic conditions. In some instances, drivers were observed following a consistent and organized process, while other drivers were making erratic and unsafe driving choices. The traffic congestion and unsafe drop-off and pick-up conditions may not improve at Webster Elementary School until the GVUSD is successful in finding funds to implement the Master Plan. This plan, once implemented, will improve traffic flow on Ruth Avenue. In addition, there is a need for a crossing guard on Ruth Avenue. On the Webster Elementary School website, there is a “Student Pick Up & Drop Off.pdf” with a description of how drivers need to drop-off and pick-up students to lessen the traffic congestion and increase safety of both students and drivers (Exhibit B). Until adequate funds are obtained, the GVUSD must try to reduce the traffic congestion and the unsafe conditions by continuing to educate drivers. Webster Elementary School provides printed handouts to students for the drivers to read, and has information available on their website. However, given the ease and wide use of social media, it is surprising that schools have not been taking advantage of platforms such as Aeries, Facebook, Twitter, or even their own website to inform drivers of the proper drop-off and pick-up procedures. The use of social media platforms informs the public through a contemporary method familiar, accessible, and acceptable to most drivers. If schools are to keep pace with the changing nature of methods of communication in today’s world, they should be open to exploring new ideas. Stadium Road in Madera not only connects a football stadium but two high schools, and two elementary schools. Traffic is extremely congested during school start and end times for nine months each year. Traffic is exacerbated when drivers disregard the faded, unofficial "No Left Turn" sign exiting the Alpha Elementary School parking lot. Drivers traveling north on Stadium Road and turning left, across traffic, into Alpha Elementary School parking lot adds danger to the congestion. The congestion on Stadium Road is well known to both the City of Madera and the MUSD. Permanent electronic traffic controls have been considered; however, the controls are quite expensive for the length of time they would be used. These types of electronic traffic controls would be needed only during the school year, twice a day, during arrival and dismissal times, or approximately 30 minutes twice a day. John Adams Elementary School has designed and implemented a designated safe area on the north side of the school, on National Avenue, for buses, drivers, and students walking to school. However, drivers were witnessed double parking and blocking traffic while dropping off or waiting for students at the intersection of National Avenue and Accornero Street. Moreover, drivers were witnessed letting students out of vehicles in the middle of the street, allowing students to weave through cars causing increased danger. Third Street, on the South side of John Adams Elementary School, is quite narrow and becomes extremely congested and dangerous during drop-off and pick-up times. John Adams Elementary School currently has almost three times the number of students, teachers, staff, and employee cars as the school was originally designed to accommodate. Many employees and residents compete for parking on the street. Parked cars, double parked cars, and the large number of drivers dropping off and picking up students, limits the traffic flow to one direction and creates an extremely dangerous situation. Recently, the City of Madera has taken steps to increase safety for students walking to John Adams Elementary School. At the time of this writing, sidewalks, on the south, east, and north side of the school, are being constructed. The intent of this plan includes requesting drivers to drop students off on Williams Avenue instead of Third Street, and placing a staff person in the area to monitor drivers and students. Madera Unified School District staff met with local police officers assigned to Madera High School Campus to try to design a safe and appropriate traffic flow of drivers dropping off and picking up students at each schools in MUSD. That effort was notable, but student safety issues could be vastly improved with complete coordination between the senior staff of MUSD and the senior staff of the City of Madera Police Department. FINDINGS: Finding for both Madera Unified School District and Golden Valley Unified School District:
Findings & Recommendations 12 findings
F1: The MCGJ finds there are no established and consistent testing, security, or maintenance
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Related Recommendations (1)
R1: The MCGJ recommends that, by September 1, 2019, the Public Works Director implement
F2: The MCGJ reports the chlorine residual tests results filed with the state of California Water
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R2: The MCGJ recommends that, by September 1, 2019, the Public Works Director implement a
F3: The MCGJ observed chlorine residual testing kits are not readily available in each vehicle for
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R3: The MCGJ recommends that, by September 1, 2019, the Public Works Director be
F4: The MCGJ found the chlorine residual testing at sample site #14 was leaking, dirty, and not
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R4: The MCGJ recommends that, by September1, 2019, the Public Works Director will assure
F5: The MCGJ observed during the chlorine testing procedure, the outcome was forced to
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R5: The MCGJ recommends the Public Works Director immediately adopt and implement a
F6: The MCGJ observed the equipment door was open, not locked or secured at well site #14.
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R6: The MCGJ recommends the Public Works Director immediately secure all equipment room
F7: The MCGJ observed sample test site #14 was not secured despite a designated mesh ring
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R7: The MCGJ recommends the Public Works Director immediately secure all sample sites to
F8: The MCGJ found from 2013-2017, the valve exercise program was not completed on a
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R8: The MCGJ recommends, by September 1, 2019, the Public Works Director implement and
F9: The MCGJ found the supporting documentation used to populate the state of California
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R9: The MCGJ recommends, by September 1, 2019, the Public Works Director implement and
F10: The MCGJ found the flush line bracket leading to the catch basin at well site #14 was
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R10: The MCGJ recommends the Public Works Director immediately direct staff to address the
F11: The MCGJ found no labeling of water supply or drain lines to equipment at well site #14.
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R11: The MCGJ recommends, by September 1, 2019, the Public Works Director implement a
F12: The City of Chowchilla’s Personnel Rules and Regulations as well as the Public Works
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R12: The MCGJ recommends, by September 1, 2019, the Public Works Director develop, adopt,
Findings & Recommendations 2 findings
F1: The MCGJ’s examination of the County accounts and reports failed to disclose any malfeasance or negligence by the County of Madera.
Related Recommendations (1)
R1: The MCGJ recommends that the County of Madera continue to use appropriate accounting practices and policies consistent with national accounting standards for all County Service Areas managed by the County.
F2: The MCGJ found a lack of good communication between County of Madera and the residents of Rolling Hills, which resulted in misunderstanding and frustration on both sides.
Related Recommendations (1)
R2: The MCGJ recommends the County of Madera communicate in writing or meeting in person with County Service Areas and Special Districts to provide the financial health of those entities to them on an annual basis. REQUIRED RESPONSES Pursuant to Penal Code sections 933 and 933.05, the grand jury requests responses as follows: From the following elected and appointed county officials within 60 days: Supervisor District 1 County of Madera 200 W. 4th St., Madera, CA 93637 Chief Administrative Officer, County of Madera 200 W. 4th St., Madera, CA93637 Reports issued by the Grand Jury do not identify individuals interviewed. Penal Code section 929 requires that reports of the Grand Jury not contain the name of any person or facts leading to the identity of any person who provides information to the Grand Jury.

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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.