2023-2024 Santa Barbara County Grand Jury Consolidated Report

Conclusions 49

• CL1
  Lompoc City Council has not directed Visit Lompoc to request, conduct, or complete an independent audit of its Financial Statements.
• CL2
  Lompoc does not have an adequate system of checks and balances to confirm that Visit Lompoc’s accounting methods are accurate and complete.
• CL3
  Other than the reference in the Agreement to the Resolution and District Management Plan there are no specific guidelines concerning how Visit Lompoc LLC shall expend its funds.
• CL4
  SP, who had clearly expressed an intention to harm himself in any way that he could, was nonetheless placed in a cell located in a two-level housing unit, which provided SP with easy access and the means to jump to his death from the second level of the unit.
• CL5
  The Public Defender’s Office currently conducts an entry interview to establish a connection with newly incarcerated persons booked into the Northern Branch Jail, which continues until the incarcerated persons are discharged.
• CL6
  The Grand Jury investigations of deaths in custody rely heavily on information provided by the Santa Barbara County Sheriff’s Office. Completion of the investigations was impeded greatly by a lack of timely cooperation by the Sheriff’s Office.
• CL7
  Five of the six deaths in this report occurred within the first three days of entering the jail. The main factors for jail deaths involved issues of inconsistent and inadequate observation.
• CL8
  For the time period 2018 through 2022 the analysis conducted by Lompoc and Visit Lompoc’s accountants of the Visit Lompoc’s financial records confirmed the >$500,000 discrepancy in unspent funds versus reported carryover values.
• CL9
  The Annual Reports submitted by Visit Lompoc to the City of Lompoc did not include all amounts that should be publicly disclosed.
• CL10
  When heavy rain is forecast and materializes, the persons in encampments along creeks and riverbeds are at high risk for loss of life, personal property, and living quarters.
• CL11
  Lompoc City Council has not directed Visit Lompoc to request, conduct, or complete an independent audit of its Annual Reports.
• CL12
  Ongoing renovations and upgrades within the IRC 300 housing unit had resulted in the in-cell intercom system, certain video surveillance systems, and the electronic locking mechanisms being non-operational at the time of SP’s death, causing delayed response times by custody and medical staff.
• CL13
  There was a failure to initiate a collaborative safety plan with SP prior to his release from the mental health observation cell which is intended to provide support and decrease the chance of self-harm during a critical period of time.
• CL14
  There were only 11 Custody Deputies on shift at the time of SPs’ death. The level of safety inside jail facilities is directly affected by the number of Custody Deputies on duty. If more than one critical incident were to occur at the same time, it could be extremely difficult to manage.
• CL15
  Santa Barbara Sheriff/Coroner’s Bureau
• CL16
  Isla Vista Foot Patrol Substation - holding cell closed
• CL17
  Lompoc Sheriff’s Substation
• CL18
  Lompoc Holding Facility
• CL19
  New Cuyama Substation/Holding Facility - new holding facility
• CL20
  Santa Barbara Court Holding Facility
• CL21
  Northern Branch Jail
• CL22
  Santa Maria Court Holding Facility
• CL23
  Santa Maria Substation - holding cell closed
• CL24
  Solvang Substation - holding cell closed Santa Barbara County Probation Department
• CL25
  Los Prietos Boys Camp - closed
• CL26
  Susan J. Gionfriddo Juvenile Justice Center Municipal Police Jails and Holding Facilities
• CL27
  Lompoc Police Department
• CL28
  Santa Maria Police Department
• CL29
  Santa Barbara Police Department
• CL30
  Guadalupe “Secure Bench” - closed
• CL31
  The recommendation has been implemented with a summary regarding the implemented action
• CL32
  The recommendation has not been implemented but will be implemented in the future with a time frame for implementation
• CL33
  The recommendation requires further analysis with an explanation, parameters of an analysis or study, and a time frame (which shall not exceed 6 months from the date of report publication)
• CL34
  The recommendation will not be implemented because it is not warranted or not reasonable with an explanation thereof The Grand Jury believes it is important for future Grand Juries to continue to review these responses and to be vigilant in seeing that recommendations are implemented. Special attention should be paid to those responses providing implementation within specified time frames. In this manner, the commitment and hard work of past and future Grand Juries will result in positive changes for the citizens of Santa Barbara County. The Responses to the 2022-2023 Grand Jury reports are posted on the Grand Jury Website in their entirety and can be viewed at: https://sbcgj.org/general-information/final-reports-responses-2022/ COMMITMENT REVIEW Report title: A Death in Custody – Lessons Learned The Santa Barbara County Sheriff responded to the Grand Jury that three (3) recommendations associated with this report required further analysis and one (1) recommendation would be implemented by January 2024. The Jury found that, after further analysis, the Sheriff’s Office will be partially implementing one of the Grand Jury’s recommendations and will not be implementing the other three. The entirety of the Sheriff’s response can be found at the following link: Santa Barbara County Sheriff's Office response Report title: Every Death In Custody Is A Failure The Santa Barbara County Sheriff responded to the Grand Jury that one (1) recommendation associated with this report required further analysis. The Jury found that, after further analysis, the Sheriff’s Office will not be implementing the
• CL35
  Disagree with partial explanation Response to Recommendations shall be one of the following:
• CL36
  Has been implemented, with brief summary of implementation actions taken
• CL37
  Will be implemented, with implementation schedule
• CL38
  Requires further analysis, with analysis completion date of no more than six months after the issuance of the report
• CL39
  Will not be implemented, with an explanation of why 10 homeless encampments in santa barbara county: becoming part of the community again HOMELESS ENCAMPMENTS IN SANTA BARBARA COUNTY Becoming Part of the Community Again SUMMARY In 2021 the Santa Barbara County Board of Supervisors approved the Homeless Encampment Resolution Strategy, a three-year plan to transition persons from encampments to housing. The 2023-24 Santa Barbara County Grand Jury studied the issues surrounding encampments and the progress made as the Strategy approaches the end of its first phase in mid-2024. The Jury found that the Encampment Resolution Strategy energized several departments and agencies to address homelessness in new ways, generating collaboration among them, which has led to positive and helpful contact with unhoused people in the encampments. Many placements in housing were made and encampments were “resolved,” or removed. Yet, many encampments continue to have negative impacts on neighborhoods. Heightened health, safety, mental health issues, substance abuse, along with environmental harm, remain concerns for everyone. Our local agencies are still handicapped by lack of affordable housing availability, impeding movement from encampments. Local economic challenges detract from the success of the Encampment Resolution Strategy, as more people are becoming unhoused than those being housed. These multiple social problems would require unparalleled resources were it not for the enhanced collaboration among government and community agencies fostered by the Homeless Encampment Resolution Strategy. Ideally, the next phase of the Strategy will find more ways to ensure that collaboration is thoroughly planned, enacted, and funded.
• CL40
  Disagree partially with an explanation Responses to Recommendations shall be one of the following:
• CL41
  Will be implemented, with an implementation schedule
• CL42
  Requires further analysis, with analysis completion date of no more than six months after the issuance of the report
• CL43
  Will not be implemented, with an explanation of why Santa Barbara County Board of Supervisors - 90 days Findings 1, 2, 3, 4, 5, 6, 7
• CL44
  The City of Lompoc does not have an adequate system of checks and balances to administer its Agreement with VLI. Transparency in the reporting of funds collected from Lompoc businesses for tourism enhancement should clearly show how these funds are being used to promote Lompoc. Accounting is not a disappearing act and neither cash nor accrual methods cause year-over-year carryover discrepancies of this magnitude. The Jury advocates for a mutual agreement between the City of Lompoc and VLI that results in ongoing third-party audits of the 2018-2029 agreement. These recommendations will enable a transparent relationship benefitting all parties including the businesses, residents, and tourists of Lompoc. FINDINGS AND RECOMMENDATIONS Finding 1: Lompoc City Council has not directed Visit Lompoc to request, conduct, or complete an independent audit of its Annual Reports. Recommendation 1a: Lompoc City Council shall instruct Visit Lompoc to have an independent audit performed of their Annual Reports and present the findings to the Council no later than mid- 2024. Recommendation 1b: Visit Lompoc shall use excess funds under its control to fund this audit. Finding 2: Lompoc City Council has not directed Visit Lompoc to request, conduct, or complete an independent audit of its Financial Statements. Recommendation 2a: Lompoc City Council shall instruct Visit Lompoc to have an independent audit performed of their financial records and present the findings to the Council no later than mid- 2024. Recommendation 2b: Visit Lompoc shall use excess funds under its control to fund this audit. Finding 3: For the time period 2018 through 2022 the analysis conducted by Lompoc and Visit Lompoc’s accountants of the Visit Lompoc’s financial records confirmed the >$500,000 discrepancy in unspent funds versus reported carryover values. Recommendation 3: Lompoc City Council shall address the accounting discrepancies by amending the Agreement and holding Visit Lompoc accountable for reporting all funds (including any excess) or mandating that all excess funds (less an approved contingency amount) be utilized for purposes related to enhancing tourism. Finding 4: Lompoc does not have an adequate system of checks and balances to confirm that Visit Lompoc’s accounting methods are accurate and complete. Recommendation 4: Lompoc City Council shall formally establish a review process to ensure there is no inaccurate or incomplete reporting on behalf of Visit Lompoc before the submittal of the 2024 annual report. Finding 5: Other than the reference in the Agreement to the Resolution and District Management Plan there are no specific guidelines concerning how Visit Lompoc LLC shall expend its funds. Recommendation 5a: By the end of 2024, Lompoc City Council shall re-evaluate the terms of the Agreement to ascertain whether the 3% fee assessed on hotel customers is achieving its intended objectives. Recommendation 5b: By the end of 2024, Lompoc City Council shall determine whether it should have a greater ability to direct unused funds for tourism enhancement projects. Recommendation 5c: By the end of 2024, Lompoc City Council and Visit Lompoc shall create a joint ad hoc committee potentially including private citizens and other business owners within Lompoc to develop and implement projects utilizing excess funds to further enhance tourism in Lompoc. Finding 6: The Annual Reports submitted by Visit Lompoc to the City of Lompoc did not include all amounts that should be publicly disclosed. Recommendation 6: Lompoc City Council shall mandate Visit Lompoc to account for all Lompoc-provided funds under its control via its required annual reports beginning with the submittal of the 2024 annual report (i.e.; zero-based budgeting methodology). REQUIREMENTS FOR RESPONSES Pursuant to California Penal Code §933 and §933.05, the Grand Jury requests each entity or individual named below to respond to the Findings and Recommendations within the specified statutory time limit. Responses to Findings shall be either: - Agree - Disagree with an explanation - Disagree partially with an explanation Responses to Recommendations shall be one of the following: - Has been implemented, with a summary of the implementation actions taken - Will be implemented, with an implementation schedule - Requires further analysis, with an analysis completion date of fewer than 6 months after the issuance of the report - It will not be implemented with an explanation of why Lompoc City Council: 90 Days Finding(s): All Recommendation(s): All 2 potential perceived conflict of interest for death in custody investigations POTENTIAL PERCEIVED CONFLICT OF INTEREST FOR DEATH IN CUSTODY INVESTIGATIONS SUMMARY The potential liability to Santa Barbara County for in-custody deaths is significant and is comparable to any law enforcement-involved death. Mandating the participation of independent criminal investigators and medical examination teams would aid greatly in mitigating this risk. Based on the 2023-24 Santa Barbara County Civil Grand Jury findings, the cost to achieve this recommendation would be minimal when compared to either the overall budget of the Sheriff’s Office or possible liability caused by lack of transparency and potential conflict of interest. INTRODUCTION Santa Barbara County (SB) is one of 47 counties within the State of California with a Sheriff/Coroner system. Five counties have a Coroner system separate from the Sheriff and six have Medical Examiner departments. California (pop. >19 million) is one of three states by law that does not mandate the separation of the Sheriff and Coroner offices. The other states are Montana (pop. >800,000) and Nevada (pop. >400,000). The 2023-24 Santa Barbara County Civil Grand Jury (Jury) elected to compare and contrast two neighboring counties, Ventura and San Luis Obispo (SLO), to SB concerning how their Coroners’ responsibilities are organized and executed. SLO has the same type of Sheriff/Coroner organization as SB, but the pathology work is outsourced to a San Diego firm, NAAG Forensic. NAAG performs the required procedures in SLO at a county-provided facility. Since 1984, the Ventura’s Medical Examiner Department (ME) has been separate from the Ventura County Sheriff. Ventura employs its own certified pathologists and forensic investigators within the ME Department. The SB County Coroner Bureau is led by the Sheriff/Coroner. The Bureau is managed by a Sergeant and a staff of four Sheriff detectives along with a Forensic Pathologist, Pathology Technicians, and Administrative Support.
• CL45
  The inherent risk and potential liability to the County are significant when Deaths-in-Custody occur and those numbers are rising. These conditions are exacerbated when the Sheriff’s own Criminal Investigation Department is sometimes reluctant to engage in DIC investigations. Utilization of existing independent resources is readily available and easily implemented. These low-cost resources are a viable means to eliminate or significantly mitigate these risks and liabilities. FINDINGS AND RECOMMENDATIONS Finding 1: There is a real or perceived conflict of interest in investigating and conducting pathological exams related to deaths in custody that can be avoided or mitigated by having a separate Medical Examiner's office (inclusive of a separate investigative detective unit) or outsourcing those specific cases to an independent agency. Recommendation 1a: To avoid a potential conflict of interest in having the Sheriff/Coroner’s office conduct deaths in custody investigations, the Sheriff/Coroner’s office shall request another Santa Barbara County agency to conduct either an independent or parallel investigation for all deaths in custody events. This could be implemented immediately. Recommendation 1b: All deaths in custody pathology investigations shall be conducted using an independent medical examination team. This policy shall be implemented no later than the end of December 2024. Finding 2: The Sheriff/Coroner’s office has no current succession plan to replace or train new staff if either or both are no longer available to provide the required support. Recommendation 2: The Sheriff/Coroner shall develop and implement a succession plan for pathology technicians (including identification of potential candidates and ensuring training budget is available) following current California Department of Health standards, with a specific timeline by the end of September 2024. Requirements for Responses: Pursuant to California Penal Code §933 and §933.05, the Grand Jury requests each entity or individual named below to respond to the Findings and Recommendations within the specified statutory time limit. Elected Official: - Santa Barbara County Sheriff/Coroner - 60 Days Finding(s): 1, 2 Recommendation(s): 1a, 1b, 2 Responses to Findings shall be either: - Agree - Disagree with an explanation - Disagree partially with an explanation Responses to Recommendations shall be one of the following: - Has been implemented, with a summary of the implementation actions taken - Will be implemented, with an implementation schedule - Requires further analysis, with an analysis completion date of fewer than 6 months after the issuance of the report - It will not be implemented with an explanation of why EXHIBIT A Potential Pricing for Independent Medical Examinations
• CL46
  3 Wellpath contract services provided to santa barbara county and the sheriff’s office WELLPATH CONTRACT SERVICES PROVIDED TO SANTA BARBARA COUNTY AND THE SHERIFF’S OFFICE Summary The County of Santa Barbara with the Sheriff’s Office has a contractual agreement with California Forensic Medical Group/Wellpath, a privately held corporate correctional healthcare provider. Along with positive qualities within the Wellpath organization, shortcomings exist. Contractual variances, lack of staff, and inadequate reporting systems call for corrective measures. Additionally, the lack of Sheriff’s Office oversight allows contractual financial deficiencies to persist. Recognizing and correcting these shortcomings would facilitate the delivery of improved and more cost-effective healthcare in the Santa Barbara County jails.
• CL47
  Ensuring access to timely and appropriate healthcare for all detainees and inmates in the County jails is a fundamental human right. Adherence to accepted standards within the framework of the correctional system can effectively deliver such care. Wellpath, the privately held corporate healthcare provider, and their staff work collaboratively with the Sheriff’s Office staff. Both entities maintain a positive working relationship and jointly strive to meet or exceed established standards, but they sometimes fall short of achieving all contractual requirements. The Jury’s recommendations are intended to assist in the formulation of and compliance with an improved contract among the chosen healthcare provider, the Sheriff, and the County Board of Supervisors.
• CL48
  The daily compensation (per diem) for members of the Civil Grand Jury of Santa Barbara County is currently set at $25 per day for any day that the Jury member works for at least one hour. Santa Barbara Superior Court has traditionally estimated that Jury members will work a minimum of 20 hours each week. This time frame is supposed to adequately cover the duties of the members of the Grand Jury during their one-year term of service. The $25 stipend Jury members receive for their hour plus of daily work has not increased in at least 25 years. This report shows clearly how inflation has changed the value of the dollar and both the minimum wage and the cost of living. This Jury’s goal is to expand the number of Jury applicants and balance the demographics of Grand Jury membership to more fairly represent the population of Santa Barbara County. To reach this goal, Santa Barbara County should reconsider increasing the per diem pay in relation to the time commitment expected of the Grand Jury. Santa Barbara County is required to support a Civil Grand Jury with 19 jurors. When the Jury loses so many members that it exhausts not only the pool of alternates but also must ask former members to return, Santa Barbara County has a problem. The recommended changes this Grand Jury proposes will help Santa Barbara County better reach its goal of maintaining a viable and diverse Civil Grand Jury to better represent the citizens of the County. FINDINGS AND RECOMMENDATIONS Finding 1: The Santa Barbara County Grand Jury per diem of $25 has not increased in more than 25 years. Recommendation 1: The Board of Supervisors should increase the Santa Barbara County Grand Jury per diem to $50, effective January 1, 2025. Finding 2: The second highest budgeted cost associated with the Grand Jury is mileage reimbursement. Most of this cost is associated with Jury members who commute from North County because dedicated space and equipment are only available in Santa Barbara. Recommendation 2a: The Board of Supervisors in conjunction with the Superior Court will make available for the sole use of the Grand Jury for a minimum of one day per week a room in Santa Maria with the capacity to support 19 members of the Grand Jury with equivalent communication, printing, photocopy, kitchenette, restroom access, and parking capabilities as is available in the Santa Barbara County Courthouse facility. Recommendation 2b: The Board of Supervisors in conjunction with the Superior Court will make available for three to four (3-4) days per week a room in Santa Maria with video conferencing capabilities, access to restrooms, adequate parking and the capacity to support up to 10 members of the Grand Jury for ad hoc use. Requirements for Responses: Pursuant to California Penal Code §933 and §933.05, the Grand Jury requests each entity or individual named below to respond to the Findings and Recommendations within the specified statutory time limit. Elected Official: Santa Barbara County Board of Supervisors – 90 Days Finding(s): 1, 2 Recommendation(s): 1, 2a, 2b Responses to Findings shall be either: - Agree - Disagree with an explanation - Disagree partially with an explanation Responses to Recommendations shall be one of the following: - Has been implemented, with a summary of the implementation actions taken - Will be implemented, with an implementation schedule - Requires further analysis, with an analysis completion date of fewer than 6 months after the issuance of the report - It will not be implemented with an explanation of why 6 santa barbara county coroner facility and equipment SANTA BARBARA COUNTY CORONER FACILITY AND EQUIPMENT A Hazardous Environment SUMMARY The existing, outdated, and deteriorating Coroner facility is a detriment to the profession and poses a significant health risk to the members of the Coroner’s Bureau. The Sheriff’s Office and General Services Department have been remiss in their oversight and willingness to provide upgrades to this property, even though alerted to the substandard conditions for more than a decade. Major upgrades and repairs are necessary to make this workplace environmentally safe and efficient. A total rebuild of the facility is essential to establish a safe workplace for the Sheriff’s Coroner Bureau to avoid what has been a band-aid approach in the past. INTRODUCTION Prior Santa Barbara County Grand Jury (Jury) reports in 2013 and 2015 recommended multiple capital improvements. Almost none of the recommendations have been implemented. The 2020 Grand Jury report also highlights several of the ongoing facility and personnel needs of the Coroner Bureau. The Coroner Bureau facility was constructed in the early 1970s by an inmate labor crew and has had minimal capital upgrades since then. The modular office structure was added at a later date. Other than a negative pressure ventilation system installed in 2016, no other Jury recommendations have been funded or implemented by the Sheriff or Board of Supervisors. Due to the limited space and a single autopsy room, some autopsies are being conducted in open-air conditions when necessary. New equipment is on order (rapid toxicology), but the Jury’s inspection of the facility indicated the building is still in need of significant additional upgrades, modernization, or replacement.
• CL49
  Two overdoses, two suicides, and two medically complicated incidents. These deaths in custody occurred in part due to insufficient observation, occasional lack of effective and timely communications between jail Custody Deputies and healthcare staff, and inadequate resources. In order to help those who enter the jail experiencing medical or mental health issues, there needs to be more custody officers, more healthcare attendants, and better housing and equipment. These improvements are difficult to obtain given the current job market and the burdened County budget. The Sheriff’s Office and the jails can develop solutions by combining resources with other County departments. Behavioral Wellness, the Public Defender’s Office, and Public Health are poised to be collaborative partners in observing, tending, and caring for those inside the jails. Santa Barbara County jails have the opportunity to create a better model for the County’s principal mental health institutions, drug treatment centers, and healthcare centers that we call jails. If you're having thoughts of suicide, please call the National Suicide Prevention Lifeline at 1-800-273-8255, or call or text 988 (Crisis and Suicide Lifeline). They have caring people available 24/7 to provide free and confidential support. FINDINGS AND RECOMMENDATIONS Finding 1 Being placed in a prone position while restrained contributed to JG’s death. Recommendation 1 The Sheriff’s Office should review and reevaluate the use of prone restraint position with obese individuals. Finding 2 The arresting officers failed to inform the intake staff that JG had complained of back and chest pain. This lack of communication was a missed opportunity to ascertain whether JG needed timely and appropriate medical care. Recommendation 2 The Grand Jury recommends that the Sheriff's Office implement a mandatory communication protocol between arresting officers and jail medical intake staff. This protocol should ensure that arresting officers consistently relay all potentially relevant medical information to intake nurses, including any complaints of pain or existing medical conditions. Finding 3 Custody Deputies removed JG from the medical intake screening process before it was completed. The failure to prioritize JG's medical needs at intake raises serious concerns about the potential for harm to individuals in custody. Recommendation 3a The Grand Jury recommends that custody and medical staff develop improved communication protocols. This collaboration should ensure that medical intake screenings are consistently completed before individuals are removed from the process. Recommendation 3b The Grand Jury recommends revising the medical screening questionnaire to prioritize the most critical information. Specifically, a question like "Are you currently experiencing any pain or are you suffering from an acute condition?" should be placed as the first question on the questionnaire. This simple change could ensure that individuals with immediate medical needs are identified and addressed promptly. Finding 4 LR's physical injuries and cognitive abilities worsened during his three days of incarceration at the Main Jail. An admitted alcoholic, he was not treated for alcohol withdrawal symptoms when examined by mental health or medical personnel. Recommendation 4 Any incarcerated person who has admitted to prolonged and excessive alcohol consumption and begins exhibiting symptoms consistent with alcohol withdrawal must immediately be treated in a manner to reduce symptoms and monitored for continued physical and/or cognitive degradation. Finding 5 When the Public Health Medical Advisor position has been filled, this medical professional will be working with Wellpath staff at the jails. Recommendation 5 The Public Health Medical Advisor shall help oversee and advise treatment for medically compromised individuals entering the jails, especially during the critical first week of incarceration. Finding 6 RU and DL suffered from drug addiction and died within two days of entering the jails. Recommendation 6a The Sheriff’s Office should contract with Behavioral Wellness for a number of beds in the recently reopened Crisis Stabilization Unit next to the Main Jail, where arrestees can be consistently monitored. Recommendation 6b The Sheriff’s Office shall direct medical staff at the Northern Branch Jail to hold a number of beds in the medical unit for those arrestees entering the jail who exhibit withdrawal symptoms. Recommendation 6c The Sheriff’s Office shall work with Public Health and Behavioral Wellness to increase staffing of the Medically Assisted Treatment program at both jails. Finding 7 SP spent over 12 hours confined in a safety cell without a mental health evaluation being conducted by a C.A.R.E.S. Mobile Crisis Unit during that time. Recommendation 7a To comply with its current policy, the Sheriff's Office should review and revise its protocols to ensure that timely mental health evaluations are conducted by a C.A.R.E.S. Mobile Crisis Unit for individuals retained in safety cells over the initial 12-hour limit. Recommendation 7b The Jury recommends that all procedures that are mandated by policy to be performed prior to the removal of an occupant from a safety or observation cell be incorporated as a checklist into the posted observation logs. A custody supervisor shall review the observation logs together with the checklist to ensure that each required step has been completed and upon such verification, the custody supervisor’s signature releases the occupant. Finding 8 There was a failure to initiate a collaborative safety plan with SP prior to his release from the mental health observation cell which is intended to provide support and decrease the chance of self-harm during a critical period of time. Recommendation 8a The Sheriff’s Office shall ensure that the procedures outlined within its policy and its contract with Wellpath be completed prior to the removal of an occupant from a safety or observation cell. Recommendation 8b The Jury recommends that all procedures that are mandated by policy to be performed prior to the removal of an occupant from a safety or observation cell be incorporated as a checklist into the posted observation logs. A custody supervisor shall review the observation logs together with the checklist to ensure that each required step has been completed and upon such verification, the custody supervisor’s signature releases the occupant. Finding 9 Ongoing renovations and upgrades within the IRC 300 housing unit had resulted in the in-cell intercom system, certain video surveillance systems, and the electronic locking mechanisms being non-operational at the time of SP’s death, causing delayed response times by custody and medical staff. Recommendation 9 The Sheriff’s Office should develop and implement more effective alternatives for visually monitoring incarcerated individuals and enabling emergency communication when the electronic surveillance and intercom systems are not functioning properly, including relocating incarcerated persons to other holding locations within the County jail system, increasing the frequency and duration of in-person safety checks and cell inspections by custody staff when electronic monitoring is unavailable, and stationing custody personnel within the housing unit to enhance direct supervision. Finding 10 There were only 11 Custody Deputies on shift at the time of SPs’ death. The level of safety inside jail facilities is directly affected by the number of Custody Deputies on duty. If more than one critical incident were to occur at the same time, it could be extremely difficult to manage. Recommendation 10 The Sheriff’s Office shall review its minimum staffing levels in the jail facilities. Finding 11 SP, who had clearly expressed an intention to harm himself in any way that he could, was nonetheless placed in a cell located in a two-level housing unit, which provided SP with easy access and the means to jump to his death from the second level of the unit. Recommendation 11a The Grand Jury recommends that the Santa Barbara County Sheriff’s Office immediately review and revise its incarcerated housing and classification placement protocols. Going forward, the Sheriff’s Office must ensure that individuals who have made suicidal statements or exhibit a desire to harm themselves are never assigned to cells or housing units that offer ready access to methods of self-harm such as elevated areas from which an incarcerated individual could jump. Recommendation 11b To help mitigate the risk of incarcerated persons jumping or falling from elevated housing areas, the Grand Jury recommends that the Sheriff’s Office explore the feasibility of installing physical barriers, such as safety netting or higher railings, in those locations. Finding 12 The Public Defender’s Office currently conducts an entry interview to establish a connection with newly incarcerated persons booked into the Northern Branch Jail, which continues until the incarcerated persons are discharged. Recommendation 12 The Sheriff’s Office shall work with the Public Defender’s Office to initiate a similar program at the Main Jail. Finding 13 The Grand Jury investigations of deaths in custody rely heavily on information provided by the Santa Barbara County Sheriff’s Office. Completion of the investigations was impeded greatly by a lack of timely cooperation by the Sheriff’s Office. Recommendation 13 The Sheriff’s Office shall promptly provide information to the Grand Jury. Finding 14 Five of the six deaths in this report occurred within the first three days of entering the jail. The main factors for jail deaths involved issues of inconsistent and inadequate observation. Recommendation 14 The Sheriff’s Office, working in conjunction with Wellpath, Behavioral Wellness and Public Health, shall have procedures in place to more closely monitor at-risk incarcerated persons when they enter the jails. Request for Response Santa Barbara County Sheriff’s Office – 60 days Findings 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 Recommendations 1, 2, 3a 3b, 4, 5, 6a, 6b, 6c, 7a, 7b, 8a, 8b, 9, 10, 11a, 11b, 12, 13, 14 Santa Barbara County Board of Supervisors – 90 days Findings 5, 6, 12, 14 Recommendations 5, 6,c, 12, 14 Requirements for Responses: Pursuant to California Penal Code §933 and §933.05, the Grand Jury requests each entity or individual named below to respond to the Findings and Recommendations within the specified statutory time limit. Responses to Findings shall be either: Agree ⦁ Disagree with an explanation ⦁ Disagree partially with an explanation ⦁ Responses to Recommendations shall be one of the following: Has been implemented, with a summary of the implementation actions taken ⦁ Will be implemented, with an implementation schedule ⦁ Requires further analysis, with an analysis completion date of fewer than 6 months after the issuance of the report ⦁ It will not be implemented with an explanation of why ⦁

Commendations 10

• CM1
  Disagree with an explanation
• CM2
  Has been implemented, with a summary of the implementation actions taken
• CM3
  Requires further analysis, with an analysis completion date of fewer than 6 months after the issuance of the report
• CM4
  It will not be implemented with an explanation of why 4 2023-2024 santa barbara county grand jury response report 2023-24 SANTA BARBARA COUNTY GRAND JURY RESPONSE REPORT INTRODUCTION The Santa Barbara County Civil Grand Jury (Grand Jury) is empaneled annually to act on the public’s behalf, conducting investigations and reporting to the community on areas of concern as requested. This Status Report by the 2023-24 Grand Jury assesses the adequacy of the responses to the seven Investigative Reports issued by the 2022-23 Grand Jury. Each investigative report required responses from one or more government agencies. California Penal Code sections 933 and 933.05, specifies the response form and the statutory time limit to respond. All Grand Jury reports and the responses to each report are posted on the Grand Jury’s website. The Jury’s objective is to increase transparency and operating efficiency. The 2023-2024 Grand Jury collected and reviewed the required responses to each report. The 2022-2023 Grand Jury issued seven (7) reports that include 35 findings and 51
• CM5
  Agree • Has been implemented with a summary of the
• CM6
  Disagree wholly implementation actions taken
• CM7
  Disagree partially with an explanation • Will be implemented with an implementation schedule
• CM8
  Requires further analysis, with a time frame that shall not exceed six months from the report's publication date
• CM9
  Will not be implemented, with an explanation of why SUMMARY OF RESPONSES Total # of Total # of Findings Agreed Findings Disagreed Findings Partially reports Findings With With Agreed With 7 35 19 2 14 Total # of Already Will Be Requires Further Will Not Be
• CM10
  Stereotyping individuals without housing by labeling them as “the homeless” or “the mentally ill” can lead to misconceptions about unhoused persons as somehow different. The Grand Jury commends our community leaders, service agencies, and news media for using appropriate language when referring to our unhoused citizens. This fosters greater compassion and empathy, empowering society to better address the needs of those without housing.

Observations 12

• OB1
  Attending weekly plenary meetings and at least three committee meetings. Meetings are typically 1-3 hours in length
• OB2
  Evaluating and researching all submitted Requests for Investigations, along with corresponding witness interviews
• OB3
  Researching, reviewing, writing, and working independently
• OB4
  Reviewing and investigating, as needed, all the deaths in custody that occur during the Grand Jury’s term of service
• OB5
  Completing a series of County facility tours to educate and inform Jury members on how they function
• OB6
  Performing a series of facility inspections in Santa Barbara County
• OB7
  Writing formal reports about the results of its investigations including findings and
• OB8
  The day the Jury visited, 33 incarcerated persons were or had been in holding cells awaiting their court appearance. No incarcerated persons are ever held there overnight. They are only detained there for their court appearance, and then as soon as possible they are returned to either the Main Jail or NBJ. The Jury entered the holding location on the driveway to the east side of the Superior Court Figueroa building. The entrance leads into the basement of the building, and the driveway adjacent to the entrance serves as the most direct point of entry and exit for incarcerated persons. The entry structure is a painted metal enclosure (sally port). Even though there is a drainage system in the sally port as well as the corridor, during a severe rainstorm this year the sally port and the corridor were flooded. The drains were subsequently cleaned out. Along the length of the entry corridor are nine sturdy single person cells that are now only used if there is an overflow of incarcerated persons or if certain incarcerated persons must be held separately from the others. The cells are about 7 feet tall by 32 inches square and are equipped with a very small, attached metal corner seat. To the left of the single cells, there are holding cells of different sizes, some hold one inmate, some two or three. There are larger cells that hold up to 12 incarcerated persons. At the end of the corridor is the operational center. The hallway continued down a very narrow passageway where there are more holding cells. The operation/observation center is located at the corner of the two hallways. There is an area outside the center where deputies can sit while they wait to escort incarcerated persons. The center is a cramped room with an alcove where the cell videos are monitored. Files, desks, and counters take up a good deal of the limited space. Although it serves its purpose, the general condition of the Superior Court holding area is outdated, small, and crowded. Furthermore, the air in the basement was warm and muggy. The staff is, to some extent, inured to the air quality condition although there have been some maintenance repairs to correct the problem. But not enough has been done due to old equipment and outdated structural systems. There needs to be a major overhaul of the facility, preferably an expansion in every aspect of the operation. Everything needs to be upgraded. But first and foremost, the air circulation must be improved. The State of California has budgeted for a new facility, which is currently earmarked to be initiated in fiscal year 2026-27. Main Jail With the opening of the NBJ, there are now only three areas currently in use at the Main Jail. The original section of the Main Jail was opened in 1971; the Northwest Wing was built in 1987-88; the Inmate Reception Center (IRC) was added in 1992. There are three types of populations: general, protected, and restricted. Prior to the opening of the NBJ, the Main Jail was often cited for overcrowding. Floor sleeping was common. It was rated for 819 incarcerated persons and often the population exceeded that. Now there are half that number of incarcerated persons at the Main Jail. With over 200 incarcerated persons transferred to the NBJ, this has allowed the closure of several wings at the Main Jail. There are two safety cells in use in the main area. Each safety cell is a cement box lined with impact absorbing material. There is a hole in the floor instead of a toilet, and there is no water available. The safety cells are for those who are actively combative or suicidal. The incarcerated persons inside are checked every 15 minutes. Their stay is normally scheduled for 12 hours maximum. There are also two holding cells for medical or mental health incarcerated persons. These have a concrete bed, toilet, and mirror. The staff makes rounds every 15 minutes and maintains an observation log based on what is seen through the glass window in the door. The American with Disabilities Act (ADA) dormitory had 17 incarcerated persons on the day of the Jury’s inspection. This room is a large space filled with beds and a few tables with benches. There was one wall of opaque glass for natural light. The bathrooms have recently been remodeled to accommodate incarcerated persons with disabilities. The older group cells in the Main Jail have a compact front space filled with tables and benches, plus a TV. Sleeping bunks occupy a back room. There are four housing units in the Northwest module. These units previously separated different gang members. They are now used for behavioral health incarcerated persons and inmate workers. A deputy is assigned to each Behavioral Health Unit (BHU). The BHUs have been remodeled. They are considered step-up units compared to the former restrictive single cell units. These units have cells on two floors and a central day room. Depending on their level of behavior, the number of incarcerated persons allowed in the central dayroom may vary. This area has tables and benches, a rug, couches, a TV, and a phone. Incarcerated persons tend to respond better when in these units with more open space. Incarcerated persons with behavioral health issues are housed in one unit and are considered incompetent to stand trial (IST). They take a class for jail-based competency to stand trial. Usually these individuals stay for six (6) months to be restored to competency so that they can participate in the court process; this used to take years. Before this program, they were in restrictive housing, which is harsher and less conducive to developing competency. This jail program restored 130 people last year. The daily per capita cost for an inmate is $344 at the Main Jail and $280 at the NBJ. Based on the design of the NBJ, a lower number of custody officers is required. The three housing areas of the Main Jail should be staffed by a minimum of 19 custody officers. Because of staff shortages, there are generally 10-14 officers working. They are scheduled for 12- hour shifts and mandatory overtime is common. The overtime requirement is cited as the major reason custody officers stop working at the Santa Barbara County jails, Main and NBJ. Because of the high cost of living in Santa Barbara County, most custody officers assigned to the Main Jail live in other parts of the County and even out of the County. Some custody officers who have a long commute use the former Medium Security Facility, on the Main Jail campus, to sleep between shifts. This part of the jail, which once held about 200 incarcerated persons, has been closed and is no longer used. Cameras throughout the jail are being upgraded. They will offer a wider and clearer view of the residential areas. Monitoring the cameras will be consolidated in one room with two officers for greater efficiency. Other infrastructure systems can be harder to renovate. The Northwest and the IRC wings have their own heating system; the original Main Jail has an older system that is harder to regulate. The jail’s remedy has been to issue sweaters to incarcerated persons. There are several outside areas. In the general population area, one large outdoor yard can hold up to 25 incarcerated persons at one time. The incarcerated persons must be escorted there, different groups at a time. The Jail is in the process of purchasing more correctional-grade recreation equipment. The other housing units in the Northwest branch have smaller open areas. All the outdoor yards are concrete with meshing over the top. Besides the TV and the scheduled time in the outside yard, all incarcerated persons are issued an Android tablet to help occupy their time. The incarcerated persons are able to access emails, photos, legal research, music, games, and programs on the tablets. Santa Barbara City College classes are available. The jail now has a full-time person who works with the community programs. By participating in these programs, the incarcerated persons will earn milestone credits toward release. There are six Wellpath nurses’ offices in the building. While the nursing positions are fully staffed at the moment, it is not always easy to get incarcerated persons to medical appointments because a custody officer must accompany the inmate to the office. This takes an officer away from other duties. Visits from family, friends, and lawyers also demand that a custody officer accompany the inmate to the visitation booths. The jail is working on additional safety measures for the incarcerated persons. They have begun removing structural elements that could aid suicide attempts. This includes any prominent feature that could be used in hangings. Since a recent suicide by jumping from the second story of a housing unit, there have been discussions for the installation of mesh or some sort of fall protection. Meals are prepared on site. There is a dietician to assist with special requirements and restrictions. All incarcerated persons are provided basic necessities. There is also a commissary, from which incarcerated persons can get a variety of food items, including coffee. Incarcerated persons can use a type of personal payment system to obtain more items from the commissary. This can be viewed as a reward by the incarcerated persons. Although there have been modifications to the Main Jail, the future of the facility remains static. When asked if the building can be remodeled, answers from administration and custody staff have stated that for this building there is no current plan or funding to make this happen. In the meantime, staff continue to make any possible improvements. Northern Branch Jail The Santa Barbara County Northern Branch Jail (NBJ) is a Type II facility (typically referred to as County Jails) and has a Board of State and Community Corrections (BSCC) rating of 344 beds and an operating capacity of 376 beds. At the time of the inspection, the jail had a population of 300 male and 40 female incarcerated individuals. The NBJ was opened for occupancy in January of 2022. This well-designed facility is a model for new jail construction. It sits on over 50 acres and includes housing for incarcerated persons, administrative offices, and medical and mental health beds in a specialized and well-equipped unit. The jail is comprised of interconnected housing pods with small outdoor recreation yards. This correctional facility was designed as a predominantly direct-supervision facility. Custody Deputies supervise incarcerated persons while working within the housing unit twenty-four hours a day. Additionally, centralized electronic monitoring stations are staffed by custody deputies and sheriff’s service technicians. Incarcerated persons may access classrooms for continued education, behavioral counseling, or yoga instruction. There is an on-site warehouse and a central plant for maintenance, including painting and groundskeeping. An outdoor area is also designated for occupational training facilities. There is a fully functioning, professional-style kitchen where volunteer incarcerated persons help prepare meals. A laundry facility, also staffed by volunteer incarcerated persons, cleans jail clothing and bedding. Medical, dental, and psychological care is administered by Wellpath, a contracted provider. The Jail has an area designated for restrictive housing and two Behavioral Health Units, one serving males and one serving females. This Jury found the NBJ to be clean, bright, and quiet with a well-maintained physical plant. The staff was professional and engaging to the Jury members and to those who were incarcerated. While the NBJ faces chronic short staffing, the Jury recognizes this as emblematic of the crisis in law enforcement staffing across the nation. It should be noted that the administration at the Northern Branch Jail, in conjunction with the Sheriff’s Human Resources Bureau, works diligently to attract qualified custody deputies. Santa Maria Court Holding Facility The Santa Maria Court Compound (SMCC) has 12 holding cells. Each cell can accommodate 4- 28 incarcerated persons. The facility capacity is 113. The staff is comprised of 50 officers who work 10-hour shifts. The incarcerated persons are held as long as court/trial is in session. The facility has not exceeded capacity since its last inspection. There have been no suicides, no attempted suicides, no deaths from other causes, nor have there been any escapes since last inspected. There is no medical team on staff. If there is a medical emergency, American Medical Response (AMR) is called immediately. The staff is well aware of the medical conditions of the incarcerated persons, including any allergies. Cold meals are prepared including special diets and packed by NBJ staff daily. The meals are transported to the compound for the incarcerated persons and refrigerated in the small, clean kitchen area. The facility is in compliance with the Americans with Disabilities Act. In case of fire or other emergency there is an escape route/plan in place. The control room is located in the middle of the holding cells with multiple cameras present and well-staffed. Santa Maria Substation- holding cell closed Solvang Substation – holding cell closed Los Prietos Boys Camp - closed Susan J. Gionfriddo Juvenile Justice Center, Santa Maria The Juvenile Justice Center (JJC) is managed by the Santa Barbara County Probation Department and is the only 24-hour maximum security facility for juvenile offenders in Santa Barbara County. The JJC is adjacent to the Juvenile Court building, making it efficient for the youth to attend court. Juveniles (aka “wards”) housed at the JJC include both males and females. They are directed to the facility from the juvenile justice system and may be serving a sentence or awaiting transportation to placement. The JJC has a total capacity of 120. At the time of the Jury’s inspection, the population included 34 males and three (3) females. Of these incarcerated youths, six (6) were considered “high risk.” The number of wards has been declining because of changes in California State laws. Fewer youths are sentenced to incarceration but instead may be part of the home detention program alternatives. These alternatives include but are not limited to electronic monitoring, house arrest, or home supervision. The JJC offers incarcerated juveniles many services. Juveniles who have not earned a high school diploma must attend classes while in the JJC. College credits can be earned through local junior college courses available in the facility’s classroom setting. All juveniles are medically cared for and undergo a Behavioral Wellness Health screening. Substance abuse rehabilitation is offered through the Council on Alcoholism and Drug Abuse (CADA) program. Counseling and support are offered to wards who may have suffered sexual exploitation. All wards are offered coaching through Courage to Change. This is a program designed to help offenders recognize areas that present risk and how to make better choices for long-term success. The staff administers an effective performance program based on rewards for good behavior. The establishment of the Trust Unit gives wards an opportunity to be housed in a more relaxed environment with more daily choices. Housing in the Trust Unit is dependent upon ongoing good behavior. Both physical and mental health care continue throughout their stay. The onsite mental health staff consists of licensed professionals provided by Wellpath. These professionals describe their team as cohesive, long-term, and committed to helping the population they serve. A mental health care professional is available Monday through Friday and holidays from 8:00 a.m. to 6:00 p.m. This staff deals in crisis management, ongoing mental health support, and “warm hand-off” care for those who are being released. Surveillance cameras are placed throughout the JJC, although they do not face the cells. A staff member watches the videos from the central monitoring room. The outdoor exercise facilities are available and are being developed. At the time of the Grand Jury visit the large open yard was being updated. There are limited recidivism statistics due to the confidential nature of juvenile files and information. Evidence of the effectiveness of the JJC in reducing recidivism is lacking because juvenile records are sealed after the probation period terminates. One area of concern for the Jury was food services. The current contract with a food catering service seems to be universally disliked by all the residents. It not only provides less food than adolescents need and want but also the food is sometimes found to be unpalatable to adolescent tastebuds. Staff reports that it is difficult to find companies willing to bid on the food contracts because of the 7 days a week / 52 weeks a year meal requirement the facility must meet. There are no commercial kitchen facilities available in the building, so in-house preparation is not an option. Overall, the Grand Jury found the JJC clean and well-maintained. Those currently in charge of the facility work to not only meet but surpass California state operational requirements. The staff was extremely courteous and professional and demonstrated a high level of dedication toward the juveniles. Lompoc Police Department The facility has seven cells in total. Three general population male cells hold four incarcerated persons each for a total of 12; one general population female cell holds four, one protective custody cell can hold three (but usually is limited to one), one male sobering cell holds four, and one female sobering cell holds four. There are seven total cells with a maximum capacity of 27. It is staffed by the Jail Supervisor and three sworn jail employees. The control center, which has cameras covering the entire facility, is staffed whenever incarcerated persons are present. The Jury felt that the facility was old but adequate, well-maintained, and staffed appropriately. Santa Maria Police Department The facility is utilized for the initial processing of detainees and interviewing prior to the subject being cited and released or transported to the NBJ. Subjects are under the supervision of a Police Officer at all times. A video observation office observes and records activity in the area at all times. Ordinarily, subjects are in the facility for no more than thirty minutes. Santa Barbara Police Department Holding Cell The Santa Barbara Police has two holding cells in its facility. The cells appear to be in good condition, and the area adjacent to the cells is organized and clean. Directly across the hall from the holding cell room is an interrogation room. No one is ever left in the cells overnight. Most arrestees are taken directly to the Main Jail for immediate booking. The only exception for holding an arrestee at the Santa Barbara Police Department would be when a capital crime has occurred that would necessitate immediate interrogations requiring the arrested individual to remain at the Police Department for an extended period. The Police Department building on East Figueroa constructed in 1959 is outdated and in need of many infrastructure upgrades. In 2022, the decision was finalized to build a new Police Department Structure at the corner of Cota and Santa Barbara Streets. The new three-story, 65,000 square-foot headquarters with 236 parking spaces is estimated to cost approximately $95 million and is projected to be completed in 2026. A rendering of the proposed new Santa Barbara police station at the corner of Santa Barbara and Cota streets downtown. (Courtesy Rendering / Cearnal Collective) Guadalupe Police Department “Secured Bench” The Secured Bench is no longer being used. Both adults and juveniles are now held at the Guadalupe Police Department for 45 minutes or less. The adults are cited and released or transferred to NBJ. The juveniles are cited and then immediately released to their parents.
• OB9
  Discrepancies in VLI’s Annual Report VLI is required to submit annual reports to Lompoc per the Property and Business Improvement District (PBID) Law of 1994. However, while the Agreement mandates the reports shall be provided to Lompoc within two months after the end of a calendar year, VLI has never been able to achieve that goal. The PBID law does not require such reports to be submitted in that time frame. The Jury acquired the annual reports from Lompoc for the calendar years (CY) 2018 through 2023 as submitted by VLI to Lompoc. An analysis of the financial data from those reports yielded the following information: Annual Report Analysis The analysis took information directly from the reports and compared the calculated balance versus the carryover values. The balance for each year was determined by adding the prior year's carryover to the current collections and subtracting the actual expenses. The carryover value is the amount reported by VLI in their annual report. The discrepancy value results from the calculated balance less the carryover numbers published by VLI. Starting in CY2020 there is a difference in the balance of funds as compared to the reported value of carryover. The rolling cumulative value of those annual discrepancies exceeds $500,000. There is no mention of these potential accounting discrepancies in the annual report for CY2020 or any subsequent reports. At a meeting of the Lompoc City Council, a representative of the VLI Board volunteered to have an independent audit conducted of their financial records. The Jury was not able to find any evidence that such an audit had been requested or completed. Review of VLI Financial Records The Jury requested and received financial statements directly from VLI. Discrepancies similar to those indicated above were discovered in the Jury’s analysis of these records. There are differences in some of these numbers when compared to those reflected in the annual reports. Most of those differences are relatively small in value and could potentially be related to earned interest. The Jury’s analysis of the financial data from those reports yielded the following information: Grand Jury Financial Statement Analysis The analysis shown in the above table reflects the differences in the calculated savings/loss amount as opposed to the reported values. The Jury calculated savings/loss as the sum of the carryover and income, less expenses. There are minor accounting differences between the profit and loss (P&L) savings from the financial records and the VLI annual reported savings. There is a significant difference between the Jury’s calculated savings and the reported savings. This discrepancy appears to be directly related to the annual carryover values not being included in VLI’s profit and loss record keeping. The starting and ending balances shown above reflect the beginning and ending cash balances for VLI’s checking account. The Jury also discovered a total of $800,000 that VLI transferred out of their checking account and into a separate Money Market account. The Money Market account funds are not reported in the annual reports submitted to Lompoc. Analysis of VLI Financial Records by Lompoc The Jury provided Lompoc with the financial records submitted by VLI and the Jury’s analysis of those financial statements. The Jury also provided the Lompoc administration with its analysis of the Annual Reports submitted to Lompoc for the years 2018-2022. Lompoc agreed to conduct a review of those financial records and provide the Jury with a summary of the results. Lompoc discovered an accounting anomaly due to the different accounting methods used (accrual vs. cash). That difference amounted to $9,450. Additionally, as a result of its analysis, Lompoc also discovered the >$500,000 cumulative difference in savings/loss versus reported carryover but only stated that VLI accounts for that value differently. Summary of Lompoc’s Financial Statement Analysis Calendar Year 2021 Calendar Year 2022 Analysis of Records by VLI’s Financial Services Firm When members of VLI’s board were interviewed by the Jury, they neither concurred nor disagreed with the Jury’s findings of Lompoc’s analysis. VLI did agree to have the firm that manages their accounts review the data reflecting the discrepancies. After conducting such a review, the analysis performed by VLI’s financial services firm yielded similar numbers as those calculated by the Jury (see below). The primary difference is that the financial services firm did not include in its analysis the annual reports submitted to Lompoc, since the firm is not responsible for preparing them. The carryover from 2022 calculated by the firm is $555,575 higher than the estimated carryover reflected in VLI’s 2023 annual report. While the calculations from the Jury, Lompoc, and VLI’s financial services firm vary, the difference between the carryover value reported annually and the actual savings/loss amounts are all more than $500,000. Financial Services Firm Financial Statement Analysis Annual Reporting VLI utilizes local financial services and accounting firms to manage its bookkeeping and tax reporting requirements. Additionally, VLI contracts with a third-party firm to prepare and submit the mandatory annual reports required for a Tourism Business Improvement District and by the Agreement. The financial services company provides its bookkeeping data to the accounting firm and they, in turn, provide data to the consulting firm for the annual report. VLI works with Civitas Advisors, a consulting firm offering legal and technical assistance to non- profits, as that third link in the reporting chain. Civitas aided VLI in establishing its non-profit organization and has worked with them in preparing and submitting the required annual reports. VLI does not have a multi-year contract with Civitas to perform this service and has been contracting with them on an annual basis. Even though VLI’s agreement with Lompoc requires the submittal of the annual report within 60 days after calendar year-end, VLI typically does not reach out to Civitas for assistance until after that deadline has passed. Each year VLI contacts Civitas to request their services helping prepare an annual report. Civitas standardly commits to providing this report within 30 days of receiving all the required information from VLI. Specifically, in 2023 the financial information provided by VLI to Civitas had several issues that prevented Civitas from completing the financial section of the report. Due to those issues, Civitas did not complete the financial section of the report and told VLI they could not do so without that information. The Jury was unable to determine what the specific issues were. Each year Civitas submits the annual report directly to Lompoc, as requested by VLI. The Jury was not able to determine if anyone from VLI reviews or approves the report before that submittal. $800,000 in Money Market Funds As indicated in the financial analysis data above, VLI has recently transferred $800,000 out of its regular checking account into a Money Market account. At the end of 2022, $700,000 was transferred (VLI’s total budget for 2022 was $734,000) and an additional $100,000 was transferred in May/June of 2023. The transfer of funds at the end of 2022 is not reflected in the annual report submitted by VLI in 2023. The 2023 contingency budget reported by VLI for unexpected expenses is only $54,000 and that amount currently resides in a Money Market account. Approximately $712,000 resides in a separate Certificate Account with no indication of any interest income. VLI is not required to provide Lompoc with its financial statements but Lompoc is allowed access to that information per the Agreement. When a member of VLI’s board was questioned by the Jury regarding the $800,000, the individual confirmed the transfer of funds and the value in the Money Market account. The same individual had no explanation as to why those funds were not declared in the annual reports submitted to Lompoc. Potential conflict of interest The Jury investigated whether there was any potential conflict of interest between member(s) of the Lompoc City Council and VLI. Based on the evidence presented to the Jury and the subsequent investigation, the Jury could not confirm whether a specific conflict exists. While it was evident that a perceived conflict may exist, Lompoc does account for this possibility by adjusting its consent calendar when necessary and ensuring applicable recusals are effected when appropriate.
• OB10
  Deaths in Custody and Resultant Medical Examinations Per the California Department of Justice, the total number of Deaths in Custody (DICs) in SB County from 2006-2020 was 24 (https://www.bsa.ca.gov/reports/2021-109/supplemental.html). The total number of DICs from the beginning of 2021 through the end of 2023 in SB County has been 10. The information for post-2020 was requested and received from the California State Attorney General’s office and was current at the time of the request (December 2023). The table below highlights the DICs in SB, Ventura, and SLO for comparative purposes: Deaths in Custody Pre and Post 2020 County Name 2006-2020 Post 2020 San Luis Obispo County 20 1 Santa Barbara County 24 10 Ventura County 47 7 One hundred percent of the DICs reported in those other counties resulted in autopsies being performed. The sole exception is when an inmate dies because of known natural causes (i.e.; pre- diagnosed terminal cancer). All of the DICs in SB had autopsies authorized by the Coroner’s Bureau. In SB, a member of the Coroner's Detective Staff, in conjunction with the pathologist, decides whether to conduct an autopsy. It is not at the sole discretion of the pathologist. In each of the other counties, the medical staff decides whether to perform the autopsy or not. Certification and Training of Staff Ventura and SLO counties mandate their pathologists be certified per the American Board of Medicolegal Death Investigators (ABMDI) standards and their facilities and equipment meet the standards set by the National Association of Medical Examiners (NAME). Neither the medical staff nor the facilities of the SB County Coroner’s Bureau are certified to these standards. It should be noted that these standards are recommended by the U.S. Department of Justice but are not mandatory. The Jury discovered that in SB both Pathology Technicians are retired Law Enforcement Officers, and, while they have had the required training to perform their jobs, there is no succession plan to fill those positions when needed. The training required for Medical Laboratory Technicians (aka Pathology Technicians) is listed on the California Department of Public Health website (https://www.cdph.ca.gov/). Cross County Cooperation The Jury discovered that other counties collaborate on DIC investigations or request independent reviews/medical services for those cases. For example, Monterey County uses SLO’s pathology group for DIC autopsies. However, SB does not seek the assistance of other counties. The Jury learned that SB does not request independent assistance with any DICs or other death investigations. The company that provides forensic pathology services for SLO, NAAG Forensic, charges $2,200- $2,700/autopsy (not including toxicology), and they are willing to provide support to SB for DICs (see Exhibit A). Ventura also provides autopsy services to the public, and they charge $5,000/case. It is not yet known whether they would be willing to provide this service to SB for DICs and mitigate any potential or perceived conflict of interest. In-Custody Death Investigations (California Senate Bill (SB) 519) The SB County Sheriff/Coroner organization has a specific protocol that mandates a multiple discipline investigation for all DICs. Members of the Custody, Criminal, and Coroner investigator departments must participate jointly in every DIC occurrence. In some cases, there has been reluctance on behalf of the Criminal Investigation Department to participate in these reviews. This was the case in December 2023 when an inmate committed suicide at the County Main Jail. As a result, the Sheriff has specifically ordered that all departments comply with this policy with no exceptions. In 2023, Governor Newsom signed Senate Bill 519 which will be effective July 1, 2024. This measure: (1) requires public disclosure of records relating to investigations conducted into local in-custody deaths, as specified; and, (2) establishes within the Board of State and Community Corrections (BSCC) the position of Director of In-Custody Death Review. That new position will be responsible for reviewing investigations of any death incident occurring within a local detention facility. All Coroner facilities and staff will be facing additional scrutiny regarding these incidents. With an increasing level of DICs, SB County may alert the recently appointed Director for an in- depth process review. Coroner’s Budget In the SB County Coroner Bureau budget for FY 2023-24, total expenditures are budgeted at $2,480,900, comprised of $1,979,600 in employee total compensation, $312,000 in services and supplies (e.g., primarily removal/disposal costs, communications, operating supplies), and $189,300 in other charges (liability insurance, motor pool charges, and utility costs). The Coroner Bureau is predominantly (95%+) funded by the SB County General Fund, as well as a small amount of fees for services. Potential Perceived Conflict of Interest There is a potential perceived conflict of interest for the Sheriff/Coroner to perform investigations and autopsies for DICs. Since Ventura’s ME is a separate department, the perceived potential conflict of interest becomes a moot point. In SLO, while the investigative team remains under the direction of the Sheriff, any medical decisions associated with a DIC are made by the forensic pathologist. As previously mentioned, in SB the Coroner Detective Staff makes the medical decisions as to when to conduct autopsies, in conjunction with the Forensic Pathologist. Furthermore, SLO assists its neighbor to the north, Monterey, by performing autopsies for most or all their DIC cases. California Government Code §27491.55, specifies the conditions when an independent medical examination or, in the instance of a potential criminal case involving a DIC, an investigation could be performed: §27491.55. In any case where a coroner is required to inquire into a death pursuant to Section 27491, the coroner may delegate his or her jurisdiction over the death to an agency of another county or the federal government when all of the following conditions have been met: (a) The other agency has either requested the delegation of jurisdiction, or has agreed to take jurisdiction at the request of the coroner (b) The other agency has the authority to perform the functions being delegated. (c) When both the coroner and the other agency have a jurisdictional interest or involvement in the death. The Jury was unable to uncover any instances where the Coroner staff had requested an independent investigative or medical exam from an outside source.
• OB11
  Coroner Facility In 2020, the SB Coroner Bureau staff were doing an average of five (5) autopsies per month. In 2023, they were presented with approximately 8-10 deaths per day while conducting an average of 4-5 autopsies per month. All of these have been performed in a substandard physical plant. The SB Pathology facility is housed in an old building and needs new equipment and other updates. There have been three Grand Jury reports in the last 10 years highlighting the age and substandard status of the facility and its related equipment. The Sheriff’s Office has made minimal capital improvements over that time frame, and the ongoing deferred maintenance has now reached a critical level. The prior Grand Jury reports highlighting the deficiencies with the Coroner Facility are as follows: 2012-13 “SHERIFF-CORONER’S BUREAU: The Manner of Death - A Final Diagnosis” 2014-15 “SANTA BARBARA SHERIFF-CORONER’S BUREAU: Still an Unhealthy Environment” 2019-20 “SANTA BARBARA COUNTY CORONER’S BUREAU: Still a Substandard Facility” In its response to the 2014-15 Grand Jury report, the Board of Supervisors stated that after the air systems were upgraded, “General Services (GS) will work with the CEO and Sheriff’s departments to develop a Capital Improvement Project (CIP) for the refurbishment of an existing facility or the construction of a new facility.” The CIP would also address the Coroner’s needs, recommend a location, and estimate the construction and ongoing maintenance costs. The Jury found no evidence supporting any follow-through on this. The Jury conducted a tour and inspection of the Coroner's Facility as part of its investigation. Two buildings comprise the facility. The front building (Bldg. 1) houses the administrative staff, autopsy suite, cold storage facility, and relevant equipment. The rear building (Bldg. 2) houses the detective staff and the pathologist. There is an empty space between the two buildings which is, in effect, the second autopsy suite when needed. Photo of Second Autopsy Suite Empty Lot between Bldg. 1 and Bldg. 2 In cases when a severely decomposed body is delivered to the Coroner facility, a temporary, outdoor autopsy site must be set up behind the building to avoid cross-contamination and to manage the emanating odors (see photo above). An enclosed second autopsy suite has been requested by the Coroner’s Bureau but has not been approved by the Sheriff or Board of Supervisors. The Jury was informed the roof of the front building requires replacement; however, only the section above the bathroom was approved for repair after the inspector fell through an existing hole. The hole was repaired, but the job was only partially done and there remains a large opening in the ceiling. Multiple requests to replace the entire roof have been denied. In addition, there is visible evidence of termite damage in the eaves and roof line and probable wood rot. Photos of Coroner Facility – Building 1 Termite damage and wood rot (Bldg. 1) View of the bathroom ceiling in Bldg. 1 Another view of the bathroom in Bldg. 1 During the Jury’s investigation, it also learned that the detective’s office area in the Coroner’s building is in deplorable condition. There is visible evidence of water intrusion, possible mold, and significant wood rot. Photos of Coroner Facility – Building 2 Rotted handrail outside Bldg. 2 Evidence of water intrusion and possible mold in Bldg.2 More evidence of water intrusion and possible mold in Bldg.2 A History of Remission and Deferred Maintenance The Facilities Maintenance Division of General Services is responsible for the maintenance, both preventative and repairs, of the Coroner Bureau’s facility. GS has a significant backlog of deferred maintenance across the County, with an estimated cost of $200 million. The Jury was provided with the GS deferred project list and discovered records of attempted repairs. There were multiple requests from the Coroner Bureau to repair gutter systems, roof leaks, and mold. Some of these requests were completed and others were denied. The Jury also discovered requests to replace the roof on both the main and modular buildings. The Jury learned this effort is out for bid a second time, but no date has been set for these projects. While the Coroner Bureau has requested multiple repairs, very few have been completed by the Facilities Maintenance Division (including the rejection of the roof replacement stated above). This Division is directly responsible for the Coroner’s facility and is also empowered to correct unsafe conditions. The Division is also aware of the possibility of mold/mildew/water intrusion and the deteriorated handrail outside Building 2. Instead of testing for mold or replacing the handrail, a rain gutter was installed on one side of the building. GS does not have a Safety Officer or any specific safety inspection schedule. The Jury also learned that no independent safety inspections had been conducted. Even though GS employees are encouraged to look for and report safety concerns, GS is almost totally reliant on other County employees to notify them of issues and concerns. Coroner’s Equipment The main cold storage located inside the building is the original unit installed 50 years ago and has had air conditioning failures requiring the use of the excess capacity trailer located in the front parking lot. This extra equipment was donated to the Coroner Bureau. The primary storage unit is frequently at capacity which requires constant coordination with various mortuaries and funeral homes to retrieve bodies and manage the available space. Another factor impacting the turnover time for Coroner investigations is the long lead time for toxicology. The Coroner’s staff has addressed this complication with the order of new rapid toxicology equipment. In addition to the existing rapid DNA capability, new rapid toxicology equipment is on order. The costs of sending samples for toxicology tests to an outside facility outweigh the price of the new equipment. The equipment will provide a return on investment (ROI) in approximately one (1) year once it is fully operational. The Jury was informed the Coroner staff conducted a benchmark comparison with Riverside County and has crafted a calibration schedule that requires a minimum of 6 months of parallel tests to ensure accuracy. Once the new equipment is set up and calibrated, it will provide the Coroner staff the ability to obtain results in approximately 17 minutes versus having to send out samples and wait weeks or months to get results. There is a cold storage unit located outside the building that is used for after-hours deliveries of badly decomposed bodies. Due to the unit being outdoors, it is subjected to the elements and there is evidence of decay on the equipment. The scale utilized to measure the gross weight of incoming bodies was originally installed 50 years ago, is also located outdoors, and can no longer be calibrated with confidence. There is no lifting equipment available for the staff to move excessively large bodies, so that task must be performed manually at the potential cost of physical injury to personnel.
• OB12
  Behavioral Wellness BWell has mobile crisis teams which are trained, designated, and empowered to issue the 5150 holds in Santa Barbara County. In most instances BWell endeavors to rapidly respond, de-escalate and stabilize individuals with mental disorders that pose serious risks. Their intervention often reduces the danger to the person and the community, avoids unnecessary emergency department care, and lessens or circumvents law enforcement involvement. In many responses, the individual of concern is stabilized on site, sometimes agreeing to a voluntary admission into a mental health facility, and therefore no involuntary hold is required. Beginning January 2024, BWell no longer relies exclusively on a phone assessment in requests for their mobile crisis response services. Staff must respond in person within 60 minutes. The usual response time is now 20-40 minutes. BWell is currently faced with a shortage of qualified personnel to fully staff their mobile crisis services and the Co-Response Teams, which often leads to delays in attending each mental health related request 24/7/365. Weekends and nights are of particular concern especially when absences occur due to staff vacations and sick leaves. In the fiscal year 2022-2023 there were 425 involuntary 5150 holds written by BWell in Santa Barbara County. Police Departments There are eight incorporated cities within Santa Barbara County. Santa Barbara, Santa Maria, and Lompoc have independent police departments; the others contract with the Santa Barbara County Sheriff’s Office for law enforcement. Santa Barbara and Santa Maria City Police Departments and the Sheriff’s Office have Co-Response Teams. The LPS Act allows for a law enforcement officer to respond to an undetermined 911 call to determine whether to issue a 5150 involuntary hold. The Co-Response Team model includes a qualified BWell clinician responding with law enforcement when dispatched to a suspected or clearly defined mental health crisis. In times of urgency, if a BWell clinician is not available, peace officers should not hesitate to issue a 5150. Law enforcement officers are often the first on the scene for most, if not all, crisis concerns reported to 911. Data suggests that 7-10% of law enforcement calls are in response to individuals displaying moderate to severe mental illness behaviors. All California police academies have a 40-hour course in Crisis Intervention Training (CIT) which is included in their basic Police Officer Standards and Training curriculum. Furthermore, the Sheriff’s Office currently has a clinician who instructs law enforcement officers in CIT and the proper procedures for 5150 issuances. This is in direct response to the need for some officers to receive supplemental training to ensure competency when responding to individuals in mental health crises. The Santa Barbara County Sheriff’s Office launched a pilot program allowing its officers, under highly specific circumstances, to issue 5150 holds. In 2023 only one such 5150 hold had been issued. This low number has been cited to rebut widespread concerns among emergency department doctors and mental health care administrators that their facilities would be overrun by enabling law enforcement to issue 5150 holds. The intent has never been to issue more 5150 holds, but rather to have law enforcement officers fully trained to evaluate, stabilize or refer mentally ill persons to a Crisis Stabilization Unit (CSU), PHF, emergency department, or available alternative and social services. This change would help guarantee future protection of individual civil rights and assist in providing the right treatment at the right time to those in need. The County Sheriff deputies, along with the Santa Barbara and Santa Maria City police officers, participated in CIT training and were authorized to make 5150 holds. It was stated to the Jury that the Sheriff’s Office has issued only two 5150 referrals through February 2024. Holding Facility Capacity A critical concern in the discussion of which agency or department is authorized to issue 5150s focuses on the number of available beds in the PHF run by BWell. Under federal and state medical guidelines, to be eligible for Medi-Cal and Medicare reimbursements, the County is permitted one PHF with a 16-bed maximum. There are preliminary plans, based on updated State allowances, for the PHF to be expanded to 19 beds by 2026. It has been estimated that for Santa Barbara County’s population the number of beds should be closer to 40, and even that number is considered a low estimate when compared to the guidelines established by the State. The 16-bed limitation often begs the following question: Who is the gatekeeper for patients that require the services provided in the 72-hour hold in the PHF? The answer to this question is subject to some dispute. Community-based mental health advocates and social watchdog groups state that simply claiming a lack of available beds does not properly address the urgent needs of those in their time of crisis. Mentally distraught patients who are a danger to themselves or others are entitled to the same medical services as for any other emergency. When the local PHF is at capacity, new patients who require an involuntary detention can be sent to an out of county psychiatric facility. The experience at the Marian Medical Center’s Crisis Stabilization Unit (CSU) in Santa Maria, opened in 2022, has demonstrated that 70% of the admitted patients stabilize within the 24-hour timeframe. By receiving de-escalation, social services, and medications, patients are often released to family members, caregivers, or into the general population. An added benefit is that the CSU diverts these patients from entering the emergency department, which can be overburdened, sometimes chaotic, and therefore not an altogether safe environment for someone with serious mental issues. In July of 2024, a Crisis Stabilization Unit is slated to open in Santa Barbara with an eight-bed locked facility admitting patients for detentions of up to 24-hours. Santa Barbara Cottage Hospital has a locked psychiatric ward. The Emergency Department Physician can place an individual on a California Health and Safety Code 1799.111 hold to detain the person for 24 hours until a designated professional is able to evaluate the patient for a 5150 hold. All patients presented to the Emergency Department (ED) for psychiatric assessment will be registered as an ED patient and seen per ED protocol. Because Cottage Hospital is not an LPS Act designated holding facility, efforts to secure placement for each patient placed on a 5150 hold will begin immediately upon admission.

No Responses Found 1

Government entities assigned to respond to this report. No response documents have been linked in our database.