Score: -5 (4/13/9)
Alameda County Grand Jury • 2021-2022

Alameda County’s Mental Health System

Published: ∼ December 01, 2022 182 pages Consolidated Report
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Note: Missing finding numbers detected: F14

Findings 66 findings

F1 Page 26
A county-wide needs/gaps assessment (broader than what the Mental Health Services Act mandates) has not been completed since 2015. A current strategic plan for Alameda County Behavioral Health is missing. 26
F2 Page 27
Alameda County mental health data is not well developed, organized, shared, or distributed by Alameda County Behavioral Health Care Services. Outside of mandatory Mental Health Services Act annual and three-year plans required by the state, integrated data is unavailable to the general public and local advocates. Because of this lack of transparency, Alameda County Behavioral Health outsiders suspect that funds are not properly directed to community service gaps and needs.
F3 Page 27
Alameda County Behavioral Health service contracts are inflexible. Alameda County Behavioral Health’s switch to fee-for-service contracts from performance-based contracts has likely resulted in reduced services available to Alameda County residents.
F4 Page 27
The mental health record systems of county mental health service providers cannot connect with each other. Lack of interoperability of medical records for Mental Health Services Act providers limits needed communication and consistent information capacity between service providers.
F5 Page 27
Most Alameda County residents have limited knowledge of the ACCESS phone line and its role.
F6 Page 27
Although there is a phone line answered by a volunteer from a local mental health provider during hours when ACCESS is not staffed, emergency mental health services for low-income seriously mentally ill individuals are not offered 24-7. There is no crisis referral line or alternative to jail or 5150 for immediate care for the seriously mentally ill when ACCESS is closed.
F7 Page 27
Behavioral Health Court works. That’s the unanimous verdict of the Grand Jury’s witnesses. But it’s not adequately supported and funded. Alameda County Behavioral Health and the courts have not provided adequate data to determine that the well-regarded Behavioral Health Court is effective and is racially and geographically equitable so it can attract more funding.
F8 Page 27
The Mental Health Advisory Board, which has strong, knowledgeable, and experienced members and generates excellent ideas, is not used effectively by the Board of Supervisors. 27
F9 Page 44
The Oakland City Clerk’s office is not meeting the minimum requirements of the Filing Officer under the Political Reform Act. The issues of non-compliance with the rules regarding Form 700s are long-standing and structural, resulting from inadequate funding, an inefficient system of communication of critical information to the Filing Officer, and limited staffing.
F10 Page 44
A transfer of the Form 700 filing duties from the Oakland City Clerk’s office to the Public Ethics Commission would require hiring an additional employee; an amendment of the City Ethics Act to identify the Public Ethics Commission as the Filing Officer for Form 700s; and the transfer of the function and payment of the City’s contract with the online filing provider, NetFile, from the City Clerk’s office to the Public Ethics Commission.
F11 Page 44
Grant funding has been used to fund staffing to support critical services in the City of Oakland. 44
F12 Page 45
The city of Oakland’s shared electronic Human Resources platform is not used in the Form 700 process but could be customized to assist in the sharing of information between departments.
F13 Page 45
The city of Oakland’s new employee checklist does not include Form 700 filing requirements to the employee.
F15 Page 71
The Public Defender’s probate conservatorship unit is severely understaffed and overworked, meaning that proposed conservatees with means receive a far higher level of service than the indigent.
F16 Page 71
The failure of the Public Defender to gather data on conservatorship case outcomes, implement formal training procedures, and establish a formal grievance process for clients, in addition to its reliance on paper files, hampers its ability to identify trends, stay up to date on best practices, and learn from past experience.
F17 Page 71
The lack of a contract between Alameda County and its conservatorship defense providers that outlines the expected scope of representation means that not all proposed conservatees receive the same level of service and raises the risk of litigation against the county.
F18 Page 71
Involuntary conservatorship proceedings can quickly drain proposed conservatees’ estates, which would not occur under a recorder’s fee- or grant-funded model.
F19 Page 104
High-risk safety code violations exist within the Santa Rita Jail. These include: • High-voltage electrical wiring not installed in accordance with code. • Obstruction of access to emergency safety equipment. • Emergency safety equipment for which testing and maintenance are out of date. • Unlabeled emergency-stop controls on industrial equipment. • Inconsistent signage on hazardous waste disposal containers. • Instances of missing temperature-monitoring data for food storage refrigerators.
F20 Page 104
The absence of periodic, proactive reviews of the Santa Rita Jail facility’s condition increases the risk that critical issues will be undetected and unaddressed until they result in an injury or operational disruption.
F21 Page 104
Inspections of the Santa Rita Jail facility conducted by the Board of State and Community Corrections do not include participation of Alameda County General Services Agency staff responsible for the condition and maintenance of the jail facility, resulting in a missed opportunity for valuable exchange between inspectors and county staff and potentially unnecessary delays in addressing issues identified during inspections.
F22 Page 104
Controls to protect against weapons, drugs, and other contraband being brought into Santa Rita Jail by staff and administrative visitors are weak, placing staff and detainees at risk. Detainment Conditions
F23 Page 104
Access to the outdoors for detainees at Santa Rita Jail is severely limited, with most inmates having a single one-hour opportunity per week, weather permitting, for access to fresh air and sunlight.
F24 Page 104
Safety and sobering cells at Santa Rita Jail are not universally cleaned and sanitized after each use, indicating a systemic issue with maintaining cleanliness standards. 104
F25 Page 105
The level of cleanliness in common areas and recreation yards at Santa Rita Jail is highly variable across housing units, with jail staff disavowing responsibility for ensuring a minimal standard of hygiene in areas cleaned by inmates.
F26 Page 105
The level of engagement and oversight by the Alameda County Sheriff’s Office of Wellpath’s operational activities is insufficient to ensure that health care is being delivered in a timely manner with high quality. COVID-19 Management
F27 Page 105
COVID-19 screening procedures at points of entry at Santa Rita Jail are inconsistent with both stated Alameda County Sheriff’s Office policy and current recommended best practices.
F28 Page 105
The Alameda County Sheriff’s Office has failed to follow local and national recommendations that all staff working at correctional facilities be vaccinated for COVID-19, posing an unnecessary hazard to detainees.
F29 Page 105
The rate of COVID-19 vaccination among Santa Rita Jail staff is materially below the community average.
F30 Page 105
The consequences for Alameda County Sheriff’s Office staff who are not in compliance with COVID-19 test mandates are insufficient to ensure that up-to-date testing is performed.
F31 Page 105
The Alameda County Sheriff’s Office fails to provide full transparency by including weekly staff COVID-19 vaccination statistics on its website alongside detainee vaccination data and staff/detainee testing data.
F32 Page 105
The Alameda County Sheriff’s Office does not ensure that Santa Rita staff consistently adhere to Alameda County’s indoor mask mandate, placing both staff and detainees at greater risk of COVID-19 infection.
F33 Page 105
The Alameda County Sheriff’s Office’s efforts to promote detainee COVID-19 vaccination have been unsuccessful in materially improving the rate of vaccination in the detainee population. Grievance Process
F34 Page 106
The Santa Rita Jail Grievance Unit has failed to provide an electronic grievance submission system that eliminates the need for detainees to engage with the local housing unit deputy.
F35 Page 106
Medical issues raised by detainees at Santa Rita Jail through the grievance process are not investigated and resolved in a timely manner.
F36 Page 106
The current grievance process at Santa Rita Jail inadequately tracks and follows up on the status of investigations transferred to other departments, leaving grievances open for extended time periods and forgoing the opportunity to learn from patterns and trends.
F37 Page 106
The Santa Rita Jail Grievance Unit fails to take advantage of the opportunity to analyze grievance submission data to identify trends in complaints, root causes, and resolutions.
F38 Page 106
The current grievance process at Santa Rita Jail is a suboptimal mechanism for addressing facility safety and maintenance issues identified by detainees.
F39 Page 106
The grievance process at Santa Rita Jail inappropriately disqualifies and denies grievances in which a third-party observes and is impacted by the treatment of another detainee.
F40 Page 106
The current grievance investigation process at Santa Rita Jail fails to adequately engage the grievance submitter in the investigative process.
F41 Page 131
BART’s board and management interfered with the Office of the Inspector General’s performance of its duties.
F42 Page 131
BART’s board and general manager hampered the approval and implementation of a charter for the Office of the Inspector General, resulting in a lack of understanding within the organization that the Inspector General is independent.
F43 Page 131
BART’s board and management supported the labor unions representing BART employees to try to limit the independence of the Office of the Inspector General investigations by setting unreasonable conditions for engagement of employee witnesses or complainants.
F44 Page 131
BART’s Office of the Inspector General does not have access to independent counsel, administrative staff, and records storage systems as is considered best practice nationally.
F45 Page 131
BART’s Office of the Inspector General’s budget, set at an initial $1 million per year in 2018 by PUC Section 28842, is much lower than the budgets of comparable transit agencies’ Office of Inspector Generals adjusted for size. A mechanism for increasing the budget annually in the enabling legislation has not been used.
F46 Page 131
A potential serious conflict of interest exists between a BART senior manager and a construction management firm now under contract that employs the manager’s spouse and sibling. 131
F47 Page 144
The Oakland City Council has no written plan or timetable for holding Oakland Fire Department accountable to annually complete all state-mandated fire inspections.
F48 Page 144
The Oakland Fire Department does not have an up-to-date inventory of buildings that require state-mandated inspections.
F49 Page 144
The slow, uncoordinated, and incomplete implementation of Accela, throughout Oakland’s city departments including, but not limited to the Oakland Fire Department, has greatly reduced the ability of the Fire Prevention Bureau to complete state-mandated fire inspections.
F50 Page 144
Historically, the Oakland Fire Department has not provided sufficient training for fire inspectors.
F51 Page 144
The city of Oakland presents a uniquely challenging environment for inspections which has resulted in high turnover of inspectors.
F52 Page 144
The city of Oakland’s slow and inefficient recruitment process results in hiring delays and fails to hire candidates with relevant experience.
F53 Page 144
The Oakland Fire Department has not used the citation process for fire safety violations in a manner that results in immediate and substantive improvements to fire safety.
F54 Page 144
The Oakland Fire Department does not have sufficient administrative staff support for fire inspectors to aid in the citation process.
F55 Page 144
The city of Oakland does not have fire inspection information readily available on its website for public review. 144
F56 Page 159
The system in place for authorizing, assigning, checking, and verifying reported overtime for expedited plan checks in Oakland’s Department of Planning and Building is ineffective.
F57 Page 159
The extended vacancy of the deputy director/chief building official position in Oakland’s Department of Planning and Building contributes to the undermanagement of the expedited plan check service. 159
F58 Page 160
The fees currently charged by Oakland for expedited service of plan checks are likely inconsistent with the requirements of Proposition 26.
F59 Page 160
The plan check function in Oakland’s Department of Planning and Building does not actively monitor productivity within the plan check team and currently does not collect data on hours worked by project to enable this analysis.
F60 Page 160
Supply of plan checking resources in Oakland’s Department of Planning and building is not aligned with demand for those resources in part because there is no attempt to forecast anticipated supply and demand and provide decision makers with the information with sufficient lead time to address anticipated gaps.
F61 Page 160
Exclusive reliance on internal resources for providing plan check services in Oakland’s Department of Planning and Building limits the ability of the Planning and Building Department to ensure service commitments to applicants are consistently achieved.
F62 Page 172
McKenney-Vento liaisons face significant time restraints fulfilling their duty to assist homeless students in Alameda County.
F63 Page 172
McKenney-Vento liaisons lack visibility within their organizations to effectively impact school districts’ service for homeless students.
F64 Page 172
Teachers in Alameda County are not required to be trained or certified to identify homeless students.
F65 Page 172
Efforts to identify homeless students throughout Alameda County are inconsistent from district to district, including differences as to which school district employees receive training on identifying homeless students and how they are trained.
F66 Page 172
Wrap-around services provided at a single geographical location, such as those provided at the Union City Family Center, offer tremendous value to homeless students and their families and are a critical component in assisting with the difficulties associated with homelessness. 172
F67 Page 173
Partnerships with Community-Based Organizations are an effective way for school districts and schools to overcome funding deficiencies for the provision of services for homeless students.

Recommendations 65

Conclusions 18

Commendations 1

Agency Responses 3

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No Responses Found 1

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