Final Report Santa Barbara County Courthouse

Conclusions 23

• CL1
  Disagree Wholly with an explanation
• CL2
  Disagree Partially with an explanation 2018-2019 Santa Barbara County Grand Jury 31 Responses to Recommendations shall be one of the following:
• CL3
  Has been implemented, with a brief summary of the implemented actions
• CL4
  Will be implemented, with an implementation schedule
• CL5
  Requires Further Analysis, with an explanation of the scope and parameters of an analysis or study and a completion date of less than 6 months after the issuance of this report
• CL6
  Will not be implemented because it is not warranted or reasonable, with an explanation CUYAMA JOINT UNIFIED SCHOOL DISTRICT BOARD OF TRUSTEES - 90 Days Findings: 1, 2, 3, 4, 5, 6, 7, 8
• CL7
  Disagree Wholly, with an explanation
• CL8
  Disagree Partially, with an explanation Responses to Recommendations shall be one of the following:
• CL9
  Requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a completion date that is not more than six (6) months after the issuance of this report
• CL10
  Will not be implemented because it is not warranted or is not reasonable, with an explanation. Santa Barbara County Sheriff/Coroner – 60 Days Findings 1, 2, 3
• CL11
  mend existing fences and erect new ones
• CL12
  remove overgrown foliage in the right-of-way area
• CL13
  improve security patrols by negotiating MOUs with local law enforcement
• CL14
  increase surveillance by installing video cameras to monitor pedestrian trespassing and transient/homeless encampments.
• CL15
  A collaboration between all stakeholders, including scheduling regular meetings, will improve railroad safety measures in the County. 11 www.OLI.org Minnesota Operation Lifesaver, Inc., last visited May 23, 2019 2018-2019 Santa Barbara County Grand Jury 42 Exhibit A Source: Sheriff/Coroner Data 2018-2019 Santa Barbara County Grand Jury 43 FINDINGS AND RECOMMENDATIONS Finding 1 Eighty-five percent of railroad-related deaths occurring in Santa Barbara County were pedestrian trespasser incidents that occurred in the High Fatality Zone One from Ortega Hill in Summerland to Milpas Street in Santa Barbara and High Fatality Zone Two from Patterson Avenue to Glen Annie Road in Goleta.
• CL16
  Disagree partially with an explanation Responses to recommendations shall be one of the following:
• CL17
  Has been implemented, with a brief, summary of the implementation actions taken
• CL18
  Requires Further Analysis, with an analysis completion date of less than six months after the issuance of the report
• CL19
  Will not be implemented with an explanation of why City of Goleta - 90 Days Findings 1, 2, 3, 4, 5, 6
• CL20
  Requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a completion date that is not more than 6 months after the issuance of this report
• CL21
  Will not be implemented because it is not warranted or is not reasonable, with an explanation
• CL22
  Will not be implemented because it is not warranted or reasonable, with an explanation of why SHERIFF–CORONER - 60 DAYS Findings 1, 2, 3, 4, 5, 6, 7, 8
• CL23
  The Jury has concluded from its inquiry into the circumstances surrounding HJA’s death in custody that all pertinent health rules, regulations and policies were followed by the Sheriff’s Department and that no further action is required. Accordingly, pursuant to California Penal Code §933.05, this Activity Report does not require an agency response. 2018-2019 Santa Barbara County Grand Jury 57 2018-2019 Santa Barbara County Grand Jury 58 SUICIDE IN CUSTODY SUMMARY Pursuant to California Penal Code section 919, subdivisions (a) and (b), “[t]he grand jury may inquire into the case of every person imprisoned in the jail of the county on a criminal charge and not indicted,” and “shall inquire into the condition and management of the public prisons within the county.” Under that statute, prior Santa Barbara County Grand Juries often have examined the circumstances surrounding inmate deaths at the Santa Barbara County Main Jail. Four inmates have died at the Jail since March 2018; they will be identified here by the initials HJA, AB, JC, and ER. There has not been sufficient time for the Jury to consider the two most recent deaths (JC and ER). Both of those deaths were reported in the local press, appear to have been due to natural causes, and will be forwarded to the 2019-2020 Jury to review as it sees fit. The 2018-2019 Jury reviewed the death of AB, who committed suicide in a cell in July 2018, and of HJA, who died from natural causes at a local hospital in March 2018. This Report examines the circumstances of the suicide death of AB. The death of HJA is the subject of a separate Jury report.

Observations 24

• OB1
  Member Units and SBCWA have expressed support for formal, quantitative methods of decision-making under uncertainty which can identify sources of disagreement, and thus facilitate compromise solutions.
• OB2
  Public understanding and effective operation of the Cachuma Project would be enhanced if key terms in the Contract were defined and used more precisely.
• OB3
  The roles and responsibilities of SBCWA and the Member Units are not clearly defined in the current Contract.
• OB4
  Provisions in the 2020 Contract will need more frequent updating than those in previous Contracts due to rapid climate change altering the natural conditions affecting water supply.
• OB5
  Under the 1995 Contract, Article 9(g), the required five-year meetings cannot result in increased water diversion to Member Units.
• OB6
  SBCWA and the Member Units agree that meetings of their technical staffs are valuable but disagree over the organizational concerns of past meetings, such as claims of infrequency, non-attendance, non- response and cancellation without notice.
• OB7
  The websites of the Member Units and SBCWA lack clarity and detail on the Cachuma Project.
• OB8
  The current Contract does not fully address future water management problems such as will arise from climate and other rapid environmental changes.
• OB9
  The current Water Year, October 1 to September 30, makes diversion recommendations and decisions difficult because it comes just before the rainy season, when the quantity of water in Cachuma for the next few months is highly unpredictable.
• OB10
  Strengthen the role of SBCWA, as the "lead agency." The 2016-2017 Grand Jury4 recommended one version of this proposal: grant SBCWA enforcement power over County water supplies. The responses from MUs, SBCWA, and the Board of Supervisors all rejected this as undesirable and legally impossible. A weaker version is for the new Contract to allow explicitly for SBCWA to add its own recommendation when sending the MUs’ Water Year request to the Bureau. The MUs’ objections apply to this version also. Several sources told the Jury that, despite the unanimity among the MUs or the strength of their arguments, the Bureau was almost sure to choose a recommendation from SBCWA because it is more familiar and represents the larger entity, which may seem more stable financially. However, SBCWA has "no water customers, water rights, or operational responsibilities with respect to the Cachuma Project."29 Local agencies understand their own needs, constraints and unique powers. They are also closer to the people they serve. Directors of four of the five MUs are elected specifically to manage water supply. The Santa Barbara MU's directors (the City Council) are elected on a range of issues, but water is a major one; these directors, and their appointed Water Commissioners, interact closely with their Water Resources Division. By contrast, SBCWA is a small part of the responsibilities of its elected directors (the Board of Supervisors); the Board will expect reports, but frequent visits and close supervision are unlikely, unless there appear to be urgent problems. Thus, SBCWA will be less sensitive to the concerns of Cachuma Project stakeholders.
• OB11
  Weaken the role of SBCWA. Apart from the arguments just listed, the Jury heard MUs’ claims that the County may be biased because higher Cachuma levels would benefit the Recreation Area, which is a source of County revenue. One suggestion was to restrict SBCWA explicitly to its minimum role in the 1995 Contract: to act as the MUs' agent and convey their requests to the Bureau. This had little support among the MU officials interviewed by the Jury. Another suggestion was for SBCWA to make
• OB12
  A seat at the table for the MUs. In their interviews with the Jury, the most frequent suggestion by MU officials was for MUs and SBCWA to work together; one arena would be the contract negotiation. MU officials understand the Bureau prefers to work with a single partner, but the MUs want that partner to be constantly aware of their concerns and the reasons for them, to represent the MUs' positions firmly. They expect SBCWA to be the sole local signatory, but believe they can make valuable contributions, whether participating in the discussion at the table or just being in the room and available for consultation. Another suggestion was regular meetings of technical staff of the MUs and SBCWA. This step was urged by officials from both the MUs and SBCWA. The letter from County Counsel29 expresses 2018-2019 Santa Barbara County Grand Jury 10 commitment to cooperative work with the MUs which "should occur primarily through staff-to-staff discussions."31 The Jury was told that such meetings had occurred in the recent past, but were sometimes hard to arrange, cancelled with little notice, or poorly attended. A well-organized schedule of meetings could include Bureau representatives from time to time. It was suggested that the new Contract could provide for a "Standard Operating Procedure" whereby the Bureau would agree to follow the recommendations of formal meetings between SBCWA and the MUs when possible, especially concerning diversions; and otherwise give reasons based on legal requirements or the Project's physical limitations. Article 3(b) of the 1995 Contract2 specifies these types of reasons but does not explicitly require the Bureau to give them. Article 9(g) calls for SBCWA, the Member Units, and the Bureau to meet during the Contract period to discuss "changes to the operations of the Project." This Article is not ideal for the next Contract. First, the meetings are to occur "not more frequently than every five years." This allows meetings to be more than five years apart, perhaps at the whim of a single participant. It also prohibits meetings less than five years apart, even though rapid environmental changes could require emergency responses. Second, these meetings are to "protect the environment and groundwater quality downstream …, conserve Project Water, and promote efficient water management," and they must not "reduce the Available Supply in any Water Year." This ignores the possibility that engineering innovations or better models could lead to increased diversions to MUs without harm to any other Project functions, despite temporarily reducing available supply. Third, the meetings are to be “an open, public process.” This is required by California’s “open meetings” laws, but as one MU official emphatically pointed out, such a setting does not encourage uninhibited exchange and discussion of information and ideas among technical staff. The official suggested—and the Jury concurs—that the 5-year meetings should be preceded by informal meetings of technical staff from the Bureau, SBCWA, and the Member Units. Those preliminary meetings of technical staff could give the decision-makers a better understanding of the problems to be addressed at their 5-year meetings, along with the most technically-sound options for resolving those problems.
• OB13
  More explicit use of quantitative methods. Formal quantitative methods can help clarify the reasons for disagreements. Quantitative methods are mathematical strategies for comparing management options, based on probabilities of future outcomes that can be given a numerical preference score. For example, an option might be a formula for deciding how much water to divert to MUs in each year for five years. The option's outcome depends on the rainfall pattern of the next five years, each possible pattern has a probability, and the outcome it produces could be scored based on the supplies diverted to the MUs and the quantity remaining in the Lake. In practice, there may be only a few management options, but many possible rainfall patterns, and outcomes might depend on the availability of alternative sources of water. Possible rainfall patterns and their probabilities might be estimated from past experience but might need to allow for climate change. Scoring would depend on trade-offs, such as between MU supplies and Cachuma reserves 2018-2019 Santa Barbara County Grand Jury 11 or between reliability and total quantity in MU supplies (e.g., is five years of 2,000 AF better than three years of 4000 AF and two years of zero?). These problems exist but are not insurmountable. The point of using this quantitative approach is not to micromanage engineers, but to clarify why their recommendations differ. It could be the rainfall patterns they believe most probable or their scores for outcomes. Knowing where the differences exist can make negotiation and compromise easier. Several sources suggested parts of this formal approach. One was the option of a sliding-scale formula based on the volume of water in Cachuma. Another was to display outcomes by plots showing quantities diverted and quantities remaining over time. Several MU interviewees called for such yield curves, as did the Board of Supervisors and SBCWA in their responses to the 2016- 2017 Grand Jury. A proposed scoring criterion was to keep enough water in Cachuma for the "dead pool" (a generally agreed essential minimum of 12,000 AF), downstream users and the fish, after allowing for evaporation and leaks. Outcomes missing this goal would get very low scores. 2018-2019 Santa Barbara County Grand Jury 12 Other Issues Some interviewees strongly suggested that the next Contract should be a new Contract rather than a renewal. Some issues such as terminology, the roles of SBCWA and the MUs, and their meetings with the Bureau, are mentioned above. Another is the need to address the challenge of rapid climate change. Droughts, storms, fires, and sea level rise can all affect water supply. A stress on flexibility and frequent review or adaptation is critically important. The Jury felt that the choice of words matters: a renewal suggests minor changes, but a new Contract implies the addition of new Articles and close scrutiny of existing ones. There are two other issues the Jury decided to report without recommendations. One is the allocation of losses due to evaporation. For example, if Cachuma loses ten percent of its volume to evaporation, should every use category (fish, MUs, etc.) be reduced by ten percent, or should some categories (dead pool, downstream users, fish) be exempt? In the latter case, to compensate for the exemptions, the other categories must be reduced by more. One of these categories is carryover water, left in Cachuma by a MU which did not take its full share at an earlier release. Reducing this category discourages conservation by creating a "use it or lose it" situation. The second issue is the fish releases. For example, the Winter 2019 issue of "ID No.1 News" says it must "budget hundreds of thousands of dollars to pay for fish studies, fish monitoring programs, habitat enhancements (oak tree restoration projects), and other related environmental programs, for less than 10 steelhead." A counter-argument is that this low count proves the steelhead are truly endangered. FINDINGS AND RECOMMENDATIONS Finding 1 The current Contract does not fully address future water management problems such as will arise from climate and other rapid environmental changes.
• OB14
  areas of damaged or nonexistent fencing
• OB15
  stretches of scrub brush and overgrown trees
• OB16
  high numbers of homeless encampments
• OB17
  located near residential neighborhoods
• OB18
  adjacent to Highway 101
• OB19
  infrequently patrolled by security personnel The high number of transient/homeless encampments plays a significant role in county railroad pedestrian deaths. Twelve of the 19 victims have been designated as transient/homeless. Deteriorating fences or no fencing at all provide easy access to the HFZs, while overgrown foliage provides the partial shelter and concealment that attract homeless encampments. As UPR employs few security personnel, the homeless encampments flourish in these zones. Railroad service providers have worked in cooperation with local city and county agencies elsewhere in California to create sealed corridors. A sealed corridor is an area designed to enhance the safety of trains, passengers, motorists, pedestrians, and neighboring land users within and along a railroad corridor. It employs appropriate safety measures to systematically reduce the opportunity for accidents at grade crossings or elsewhere within the corridor.9 An example of this is the City of Glendale, California, where officials from Metrolink and city agencies combined to make safety improvements including roadway and curb widening, new automatic vehicle exit gates, new sidewalks, new pedestrian gates and traffic signal advance preemption technology. Officials from Metrolink and city agencies refer to this as positive train control.10 The combination of these measures and others, such as additional fencing, removal of excess foliage and increased security observation, can work to limit pedestrian access to railroad right- of-way and create a sealed corridor. UPR and Amtrak, working in conjunction with local governmental agencies, could create a sealed corridor stretching from Ortega Hill to Glen Annie Road. Improvements should include the repair and replacement of fencing to eliminate access to the rights-of-way, clearing of overgrown foliage to eliminate shelter areas and working with local law enforcement to provide security and eliminate 9 www.DOT.CA.gov/hg/ctc/2006 Southern California Regional Rail Authority Board of Directors Report, “Metrolinks Sealed Corridor Project 2006,” last visited May 9, 2019 10 www.cvweekly.com Crescenta Valley Weekly, “Rail ‘Sealed Corridor Inaugurated,’” November 22, 2012, page 1, last visited May 12, 2019 2018-2019 Santa Barbara County Grand Jury 41 pedestrian trespassing. Another component adding strength to the proposed sealed corridor would be to increase the security presence within the right-of-way area. In parts of Ventura County, the Sheriff’s Department and UPR have adopted an MOU to provide security within the privately owned UPR right-of-way, and to investigate reports of pedestrian trespassing. If MOUs can be created with the Santa Barbara County Sheriff’s Department and the Santa Barbara Police Department, security will be vastly improved within the proposed sealed corridor. The introduction of video cameras within the HFZs can also act to seal the corridors. An eight-car passenger train traveling at 80 miles per hour needs about a mile to stop.11 If video surveillance cameras were installed on poles every mile within the HFZs, the increased observation of the zones could alert UPR staff to the existence of pedestrian trespassers and homeless encampments within the right-of-way. Since 90 percent of the fatalities have occurred between 11 a.m. and 7 p.m., the cameras would need to be monitored only during this period. The sealed corridor concept could reduce the “suicide by train” incidents. All of the 11 pedestrian suicides occurred in the HFZ1 and HFZ2 areas. Easy access to the right-of-way, the predictability of train arrivals, the overgrown foliage, and the secluded nature of the zones within populated neighborhoods make them likely places for suicide. While the Jury realizes that it would be impossible to prevent determined individuals from ending their lives, creating sealed corridors can reduce the likelihood of suicide by train.
• OB20
  A major role of the five-member elected Board of Trustees is to make policy. Board members interviewed indicated there was an internal indifference to updating Board Policy and Administrative Regulations (Policies). A district official stated that the Policies are out of date and a plan has been initiated to revise them. Each month the Board now reviews updates presented by the Superintendent, which, when approved, are incorporated into the Policies. During the staff interviews, the Jury was advised that the District has experienced a high rate of turnover at the Superintendent position. The current Superintendent assumed the position on July 1, 2018. He was preceded by five superintendents since 2006. The last three superintendents, two of whom were part-time, served a total of four years.3 The Chief Business Officer (CBO) has served since July 2006. During the interview process with the Business Office staff members, the Jury learned that a calendar of significant events, such as key reports and due dates, does not exist. In one instance, the SBAS administrator reminded the District that a report requesting supplemental funding was due and the District risked not receiving entitled funds. 2 https://www.cuyamaunified.org CJUSD Website, last visited 05/02/19 3 Cuyama Joint Unified School District Personnel Records 2018-2019 Santa Barbara County Grand Jury 28 Staff members in the DBO have requested additional training in the use and application of Escape, the integrated software program used by SBCEO, and in day-to-day duties. A SBAS staff member has been assigned to provide training on the software program. The Jury was informed that there is no cross-training of DBO employees to perform essential business office functions due to absences of any duration. When the Account Clerk (AC) abruptly resigned, the CBO assumed responsibility for the payment of invoices. The lack of knowledge in processing invoices resulted in substantial late fees. Job descriptions provided by the District for the CBO and AC were reviewed. The current CBO job description was adopted in 1993, while the current AC job description was adopted in 1992, and neither has been updated. The District also provided the duties currently performed in each position. The Jury found job descriptions out-of-date. In particular, some current CBO functions are unrelated to fiscal responsibilities. The Business Office staff members were also asked if annual performance evaluations had been performed and provided to them. Staff members stated they could not recall when their last performance reviews were conducted. A probationary employee in the DBO has not been evaluated since starting in July 2018. A review of the state-mandated annual financial audits for 2014-2018 revealed that the same negative audit findings recurred from year-to-year because they were not corrected.4 Examples include lack of proper documentation, not depositing funds on a timely basis, improper coding, inaccurate time cards, non-compliance with state mandates, and failure to provide annual teacher contracts. The staff stated they use the procedures outlined in the ASB Accounting Manual5 for the handling of cash from fundraising activities conducted by the Associated Student Body and other school site activities. In order to minimize the risk of future loss of District funds, the Superintendent modified the bank deposit process so that deposits occur more frequently.
• OB21
  Contraband finds its way into the nation’s jails in many ways. Typically, it is secreted somewhere on the person of inmates or visitors where it cannot be detected, mailed to inmates, including in the glue on stamps, or introduced by outside vendors or their employees. So too, unauthorized items of contraband can be fashioned within the facilities themselves from wood, metal or other readily available materials which are benign as originally intended but can be weaponized as well. Contraband items also can be smuggled undetected into a correctional facility by custody staff members. However, as far as the interviewees were aware, within recent memory there have been no reported incidents which involved attempts to introduce contraband other than by arrestees themselves or their visitors, including attempted mail contacts. In that respect, as well, an Agreement for Services contract entered into between the County and an independent contractor at the Jail, reviewed by the Jury, expressly included a protocol requiring the training of contractor employees in matters of security and prescribing measures prohibiting unescorted entry. Nevertheless, by whatever means it enters, contraband continues to find its way into the Jail. In August 2018, a substantial variety of illegal drugs and other contraband items were found on an incarcerated inmate’s person in a housing unit, including heroin, methamphetamines and prescription medications. That contraband had an estimated value of $15,000 to $20,000. Also, in the previous month a female arrestee temporarily detained in a holding cell in Lompoc was found to have hidden heroin and methamphetamines in a plastic bag in a body cavity. Clearly, but not unexpectedly, these incidents demonstrate that there is a continuing contraband problem which obviously commands constant law enforcement vigilance. In a further effort to gauge the current extent of the problem, the Jury obtained statistical data from the Sheriff’s Department which logs, on a monthly basis, the total number of discovered instances in which controlled dangerous substances or alcohol were attempted to be brought into the Jail, or later found there. Examination of this data revealed that for the 12-month period from January 1, 2018 through December 31, 2018, the number of such drug related incidents totaled 214. Ninety-six of these incidents involved actual possession of controlled substances, alcohol, or drugs within the Jail itself, as opposed to intercepting persons attempting to bring them for use, barter or sale. Statistics as to how many items of contraband still manage to be introduced into the Jail completely undetected despite existing preventative efforts obviously are difficult to estimate. The Jury also examined randomized sample incident reports from the past few years which described a variety of circumstances in which contraband was discovered. Most involved finding the contraband through unannounced cell searches, perimeter searches, personal observation, odor detection, information provided by other inmates, and by screening all mail received at the Jail intended for distribution to inmates. Examples of items found include postcards doused in methamphetamines, a syringe hidden in a pipe, and heroin found at a perimeter fence. 7 In addition, the Jury also reviewed 7 Main Jail Incident Report Nos. 17-9248, 16-17442, 16-2067, 15-16049, 13-2029 2018-2019 Santa Barbara County Grand Jury 34 recent minutes of the Medical Advisory (MAC) and Continuous Quality Improvement (CQI) committees which are composed of senior custody, health, contracted medical provider, Wellpath, and other relevant departmental representatives. The CQI minutes revealed that, in January 2019, there were two confirmed instances of drug overdoses. Both inmates were transported to Cottage Hospital for treatment, where they remained for multiple days. In one instance, Naloxone branded as NARCAN, which is indicated for use in an opioid overdose situation was administered to the inmate. However, since it is an opioid antagonist, and the inmate had ingested LSD and Ecstasy, which are not opioids, it was ineffective. The second inmate had self-administered two prescription medications later identified as a potentially fatal mixture of phenobarbital and Klonopin. Fortunately, both hospitalized inmates survived. Prompted by the particular circumstances of the two overdose incidents, the “Critical Clinical Events” section of the CQI minutes pointedly observed that discussion needs to be had on better pat-down of new arrestees, especially since one inmate still had over 30 pills on his person. The Jury concluded that the need to offer this corrective suggestion indicates that more drug detection training, not to mention enhanced scrutiny by custody personnel generally, should be given priority attention, especially at the intake stage where pat-down of arrestees takes place. While one drug-sniffing dog, Krypto, presently is being utilized for drug detection by the Sheriff’s Department, competing demands county wide for his unique abilities has made it impossible to station the animal at the Jail’s arrestee intake area on any sort of a regular, no less permanent basis. Although some correctional facilities nation-wide employ full body x-ray scanners identical or similar to those used at airports to discover contraband, the Jail does not. The Jury was advised by a senior custody officer that this was likely due to the high cost of purchasing such items. However, the Jury believes that their possible purchase should continue to be explored by the Sheriff’s Department and could be well worth the initial investment, given the potential beneficial results. Finally, the Jury was advised that the purchase of one full-body x-ray scanner for use at the Northern Branch Jail is planned. The Jury posits that the additional purchase of one or more such scanners would be helpful in meaningfully fostering staff and inmate safety and getting ahead of the curve in contraband deterrence efforts at the new facility.
• OB22
  Throughout the County, resources are available that offer information, education, and coping skills, such 2018-2019 Santa Barbara County Grand Jury 50 as the YouthWell Coalition, Family Service Agency, peer and parents’ support groups, and off-campus and school-based programs, such as Signs of Suicide. Despite the available community resources and efforts at crisis prevention, many people throughout the County are unaware of them. Thus, the first step that most families or caregivers usually take when their child is in crisis is either to call 911 or go to the closest Emergency Room (ER). However, many ERs “are not equipped to provide the calming and therapeutic environment needed to manage behavioral health crises.”18 When a child is in crisis, SAFTY offers a crisis hotline (1-888-334-2777) from 8 a.m. to 8 p.m. seven days a week. In response, staff first attempts to resolve the crisis on the phone. If a crisis demands more, a SAFTY counselor may be dispatched to the scene for a face-to-face, in-depth assessment and evaluation. After SAFTY hours, the DBW 24/7 ACCESS (1-888-868-1649) line staff takes over. In late 2018, a Co-Response Team19 consisting of a DBW crisis worker and a county deputy sheriff who has received Crisis Intervention Training became available to respond and resolve crises in the southern part of the County. The Jury learned that mental health workers value the safety of this approach. Although this program may be in jeopardy of being eliminated, program funding discussions are ongoing. During interviews with professionals, they stated that the Co-Response team can often reduce the time required to contain the crisis. Recently, the Jury was told that the Co-Response team approach may be expanded to include the City of Santa Barbara Police Department. Once the DBW response system is activated and the child in crisis is assessed and evaluated, there are several options for action. One is that the crisis is contained in the least restrictive way and the child safely remains at home or may be sheltered in another secure setting. The most restrictive option is for the crisis evaluator to write a California Welfare and Institutions Code §5585.50 hold that allows for an involuntary detainment of a minor in a psychiatric facility for up to 72 hours. The legal criteria for a 5585 hold are danger to self, danger to others, or gravely disabled. Under this code, a gravely disabled minor is “unable to use the elements of life that are essential to health, safety, and development, including food, clothing, and shelter, even though provided to the minor by others.”20 If a 5585 hold is instituted, the child must be transported by ambulance to an ER to be medically cleared before being accepted into an appropriate inpatient facility. At the ER, the attending psychiatrist, if certified to do so, may rescind the hold. However, if the 5585 hold is instituted, a psychiatric bed must be located. All children’s psychiatric hospitals are located out of County. If beds are available, children are transferred to Aurora Vista del Mar Hospital in Ventura. However, if not available, some children are transported as far away as San Francisco and San Diego. There is competition among California counties for these psychiatric beds. The Jury was unable to learn how many children have been sent to inpatient psychiatric facilities in recent years because it was told DBW does not have a computerized data record in place to track all 5585 holds and subsequent hospitalizations out of County, including the length of stay. The Jury interviewed parents of children who had been psychiatrically hospitalized out of County. The 18 www.archive.mhsoac.ca.gov. Overview of Crisis Stabilization Services: California, February 26, 2015, last visited April 15, 2019. 19 www.sbsheriff.org. Sheriff’s Roundup, 1st Quarter 2019 20 California Welfare and Institutions Code §5585.25 2018-2019 Santa Barbara County Grand Jury 51 stressors for children, parents and caregivers included the long distance from home and the difficulty communicating with both the child in the hospital and medical professionals attending to the child. The uncertainties of discharge planning added to the stress. Some of these stressors might have been alleviated if crisis respite shelters had been available locally. In the past, delays occurred when certified crisis workers were called to the ER to evaluate the child and determine if a 5585 hold was required. Recently, a new program has been implemented to mitigate some of these ER delays. Licensed psychiatrists at local hospitals are now certified to write or rescind 5585 holds. This new protocol is designed to expedite the process of getting the child to an inpatient psychiatric facility through a written 5585 hold, or to resolve the crisis, rescind the hold and permit the child to return home. In 2018, DBW was awarded a grant by the Mental Health Services Oversight and Accountability Commission of $800,000 to improve mental health services for children in crisis.21 This grant provides funding for the creation of two hospital-based Children’s Triage Program teams located in North and South County, each consists of a licensed clinician and a parent partner. At the time of this report, only the triage team at Marian Regional Medical Center in Santa Maria is in operation. The goal of the Children’s Triage Program is to assess the nature and severity of the mental health crisis, determine what treatment options best meet the needs of the child, and provide support and information to the parents and caregivers who are also present in the emergency room. The licensed practitioner and parent partner will work closely with the hospital staff, the child and the caregivers to de-escalate the crisis, develop safety plans and, if possible, rescind the hold. Additionally, the Children’s Triage Program team members will follow up to ensure effective community re-integration for children upon discharge, including assistance navigating the mental health system and providing linkages to services and supports. SAFTY also provides follow up, aftercare, referrals and linkage to mental health services in the community regardless of the child’s or caregiver’s health insurance. The Jury became aware of perceived difficulties in the delivery of current DBW crisis services. This systemic issue revolves around the need to respond in a timely and efficient way, in keeping with the important MHSA goal of “timely access to needed help, including in times of crisis.” The Jury received several reports that crisis calls made to both SAFTY and the DBW 24/7 ACCESS Team are not always answered or returned promptly and there are often long wait times for the on-scene arrival of SAFTY crisis workers or no on-scene responses at all. Some interviewees also mentioned SAFTY personnel often cannot write a 5585 hold without consulting their supervisor which causes an unacceptable delay in de-escalating the crisis. In fact, the Jury learned that SAFTY workers are no longer allowed to work in the Cottage ERs and UCSB medical services for this reason. DBW has allocated considerable resources to provide crisis facilities for adults in the County, but not for children. The continuum of care for adults in crisis ranges from the most restrictive to the least restrictive 21 www.mhsoac.ca.gov. Triage Grant Awards, April 26, 2018, last visited May 23, 2019 2018-2019 Santa Barbara County Grand Jury 52 setting. The most restrictive setting is the Psychiatric Health Facility, a 16-bed locked unit which accepts individuals 18 and older who have been placed on a 5150 involuntary hold, the adult equivalent of a 5585 hold. DBW also operates a Crisis Stabilization Unit (CSU), which offers adults an alternative to in- patient hospitalization, where they can stay up to 23 hours and receive evaluation, treatment, medications, and aftercare referrals. The DBW also contracts with outside providers to ensure those adults who require longer stabilization times can be placed in two crisis residential facilities in the County. At the present time, there is no CSU, acute psychiatric hospital, licensed crisis residential, Temporary Shelter Care Facility (TSCF)22 or any other crisis respite shelter for children and youth in the County. The Jury was informed that DBW determined a CSU facility for children and youth only would not be economically feasible. However, the Jury learned that DBW is exploring the possibility of establishing a licensed CSU that can accommodate adults, children and youth in the Santa Maria area where there is facility availability. There is another type of shelter that can provide safety and security for children in crisis. A licensed Temporary Shelter Care Facility is owned and operated by a county or on behalf of a county by a private, nonprofit agency and provides 24-hour non-medical care for up to 10 calendar days for children and youth under 18 years of age. TSCFs are safe and supportive places for recovery when more care is required than can be provided at home.
• OB23
  In 2017, HJA, a 60-year-old homeless male, was booked into the Santa Barbara County Jail (Main Jail). HJA’s medical history revealed a veritable plethora of serious ailments, HJA had been incarcerated in the Main Jail on several occasions prior to May 2017, during which periods he often was non-compliant with his plan of care. In early March 2018, after a custody deputy delivering HJA’s breakfast found the inmate lying on the floor of his cell, he was taken by ambulance to Cottage Hospital when he expired the following day. During its investigation the Jury reviewed jail and medical records to familiarize itself with HJA’s incarceration history. Specifically, the Jury learned that HJA was discovered lying naked and unconscious on the floor of his isolation cell by a custody deputy who was delivering his breakfast tray. Present were two untouched dinner trays and one untouched breakfast tray indicating that HJA had not eaten for nearly two days. Medical staff quickly were notified, and a nurse practitioner summoned to the scene tried but was unable to obtain a “good” blood pressure reading. HJA was carried from his cell and transported to Cottage Hospital. He was then transferred to “comfort care” having previously executed a Do Not Resuscitate (DNR) request at the Main Jail. HJA’s critical medical condition continued to decline rapidly and he passed away. An autopsy and toxicological tests later revealed that no foul play or trauma caused or contributed to HJA’S death and that it was due to natural causes.
• OB24
  The following are the essential facts surrounding AB’s death in custody. On the afternoon of July 5, 2018, AB was arrested by Sheriff patrol deputies outside his home. The deputies had been dispatched to the premises as the result of a 9-1-1 telephone call reporting that AB was acting aggressively toward another resident in the house. When apprehended in a neighbor’s backyard, AB appeared clearly to be under the influence of alcohol. Later, toxicology test results from a bodily fluid sample drawn at the autopsy on July 9, 2018, revealed AB had a blood alcohol level above the legal limit for driving while impaired. In addition, the presence of methamphetamines was detected. Following his arrest, AB was handcuffed and placed in the rear seat of one of four responding patrol cars. In the meantime, the deputies, two of whom were still within their probationary period, continued their investigation inside and around the house. A family member who was present told the Jury they had important information about AB’s mental health history but was not interviewed by the deputies. Left alone in the rear of the vehicle, AB became increasingly agitated. Although he began loudly to complain that he was thirsty, no one brought him water. As observed on the dashboard camera video, AB then became even more agitated and began purposely to strike his head violently against the vehicle's interior. California Welfare and Institutions Code §5150 provides that if a peace officer determines that probable cause exists to believe that a person has a mental health disorder creating a danger to himself or others (although not necessarily imminent), or is gravely disabled, the officer may take that person into custody 2018-2019 Santa Barbara County Grand Jury 60 to be brought to a designated mental health facility for an evaluation. In Santa Barbara County, unlike all other counties in California, it is the Sheriff’s Office policy that the arresting officer cannot make that preliminary judgment himself or herself and a mental health professional must first determine if the predicate exists. In this instance the deputy drove directly from AB’s home to the Jail and there is no indication that he made any effort to arrange for a “5150” evaluation. The patrol vehicle’s dashboard camera video revealed that, while in transit from his home to the Jail, AB kept calling out to God for help and continued to strike his head forcefully against the vehicle's interior, causing contusions to his forehead. As a result, the deputy radioed ahead to the Jail that the arrestee was "combative." Thus, several custody deputies were posted outside the Jail sally-port to await AB's arrival and be available to help subdue him if necessary. Although the medical provider policy manual requires that a registered nurse (RN) conduct an initial evaluation to “clear” an arrestee medically and mentally, in this instance the RN initially directed a licensed vocational nurse (LVN) to meet the patrol vehicle when it arrived and to check AB’s vital signs before he was escorted into the sally-port. When the patrol car arrived, the LVN, as instructed, went out to the vehicle where she took AB’s blood pressure. Then he was escorted into the sally-port where there is a separate small room expressly designed for use by the RN to privately interview an arrestee and evaluate his or her mental and medical condition. Importantly, a dedicated computer is located in that room on which prior medical/mental health records can be retrieved. Although video revealed that by then AB appeared to be compliant with directions and to pose no physical danger to the RN or others, the standard procedure for the RN to use that room was not followed. Rather, AB was escorted directly through the sally-port into the booking area, where the RN questioned him. In a “late entry” added to the computerized medical records after AB’s death, the RN stated that AB had refused to answer questions about his mental state when questioned at booking. That refusal, even without his record of a “5150” hold at the time of a prior arrest, should have triggered an immediate psychiatric evaluation. Yet, to this point, contrary to the medical provider’s policy, it does not appear that anyone made any effort to review computerized or any other records of AB’s mental health or arrest history or gave any consideration to whether a “5150” might be indicated. Even a quick review of available records would have revealed that AB was arrested in December 2015, at which time it was noted that AB engaged in “suicidal talk,” which triggered a “5150” hold and his transport to the Cottage Hospital Emergency Department. At this point in the booking process, according to a deputy whom the Jury interviewed, it appeared likely that AB would be treated as a "cite and release." This meant that he would not be classified for housing purposes since he would be detained at the Jail only long enough to "sleep it off." Thereafter, he would be released from custody and served with a citation to appear in court at a later date. Despite AB’s prior arrest record, which included a 5150 hold, and despite his palpable agitation, his anger, his apparent state of intoxication, and his repeated self-harming behavior while seated in the patrol car, at his home, and in transit to the Jail, none of the patrol or custody deputies, or the Wellpath nursing staff, recognized that AB potentially was suicidal. After AB was booked, several custody deputies escorted him from the booking desk intending to place him in a nearby cell. Initially, he was taken to Cell C-14 because it was unoccupied. However, since that cell had no toilet, and AB said that he had to use a toilet, he was taken past Cell C-14 and placed into Cell C-9, located in a short hallway further away. Neither cell is located on a main corridor. 2018-2019 Santa Barbara County Grand Jury 61 Although a video camera is suspended in a fixed position from the ceiling at one end of the short hallway where Cell C-9 is located, and is intended to provide a complete view of both the entire cell and the hallway, the camera does not provide a full view of the interior of the cell. Specifically, the upper portion of the left corner of the cell as one faces into it from the front cannot be seen on the video monitor. Video viewed by the Jury showed that, after AB entered Cell C-9 at 7:10 p.m., his handcuffs were removed. Since he had arrived at the Jail shirtless, clothed only in board shorts, he was directed to remove the shorts and custody personnel provided him with a white T-shirt and beltless blue pants. Approximately 15 minutes later, AB removed his T-shirt and, out of camera sight, he affixed it to the bars above a slightly elevated concrete sleeping area located in the cell’s front left corner, tied the T-shirt to the upper portion of the bars, and proceeded to hang himself using the shirt as a ligature. It was not until nearly nine minutes later, at 7:35 p.m., that a custody deputy walked by and discovered AB hanging in the cell. The deputy immediately radioed for “man down” assistance, other custody deputies quickly arrived, and AB was lowered down and cut free from the ligature. Life-saving measures were begun, unfortunately to no avail, death was pronounced at 8:02 p.m. His body was later removed from the cell and an autopsy was performed on July 9, 2019. The forensic pathologist who conducted the autopsy attributed AB’s death to asphyxiation. Based upon the Jury’s viewing of the video of the scene at Cell C-9 from the time life-saving measures were initiated to the time AB’s death was pronounced, approximately sixteen people responded to the “man down” announcement. Although some clearly were engaged in resuscitation procedures, others in and around the cell did not appear to be doing anything but watching. No one appeared to take control of the scene and dismiss unnecessary personnel, despite a medical provider policy requiring that a licensed professional take charge in that situation. The video also appeared to show a deputy removing a piece of evidence from the cell. The deputy told the Jury that the item was a towel; however, the Jury believes the item shown in the video was the T-shirt ligature, a potentially important piece of evidence. The T-shirt later reappeared inside a paper bag at the autopsy, as shown by autopsy photographs. However, the Sheriff’s Department told the Jury the T-shirt was then “thrown away” and not preserved as evidence. In viewing the video, the Jury also noted that Jail personnel did not appear to use emergency resuscitation equipment, such as suction apparatus to clear an airway. In investigating further, the Jury learned that, when AB was first discovered hanging in his cell, emergency resuscitation equipment could not be located, and when located, did not function properly. The Sheriff’s Department told the Jury that the malfunctioning resuscitation equipment had not been retained as evidence, and more importantly, that there was no log or other documentation showing that required inspections of the Jail’s life-saving equipment had occurred.

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