Santa Barbara County Civil Grand Jury Quiet

Conclusions 56

• CL1
  The Santa Barbara County Public Health Department has not developed proactive pathogen- specific disaster plans based upon evidence-based risk analysis.
• CL2
  The Santa Barbara County Public Health Department has not employed current, more comprehensive software for the early detection of potential epidemic risks.
• CL3
  The Sheriff’s Office did not comply with the Remedial Plan outlined in Murray v. Santa Barbara County because it did not provide enough beds at all necessary levels of clinical care and security to meet the needs of inmates with serious mental illnesses, as in CC’s case.
• CL4
  The Santa Barbara County Public Health Department has not established a process to assure effective communication between regional healthcare providers regarding local epidemic risks. The 2024-2025 Santa Barbara County Grand Jury recommends that:
• CL5
  The Santa Barbara County Public Health Department has not developed proactive pathogen- specific risk assessments based upon evidence-based risk analysis.
• CL6
  The Santa Barbara County Public Health Department has the obligation to ensure wastewater testing is carried out throughout Santa Barbara County but is not currently fulfilling its responsibility.
• CL7
  Even though bioterrorism is a growing threat, Santa Barbara County has not established effective channels of communication with federal, regional, and other stakeholders to learn of and apply threat assessment at the local level.
• CL8
  Rivers, Caitlin. Crisis Averted: The Hidden Science of Fighting Outbreaks. New York: Viking Press, 2024.
• CL9
  Pringle, Eleanor. “Disease forecasters are convinced there’s a 27% chance of another COVID-like pandemic within 10 years—but experts believe there’s a silver bullet.” Fortune Magazine, April 18, 2023. https://fortune.com/well/2023/04/18/disease-forecasters-predict- new-covid-like-pandemic-within-10-years/
• CL10
  Sinha, Michael S., Wendy E. Parmet, and Gregg S. Gonsalves. “Déjà Vu All Over Again— Refusing to Learn the Lessons of Covid-19.” New England Journal of Medicine 391, no. 6 (2024): 481–483. https://doi.org/10.1056/NEJMp2406427
• CL11
  Baker, Rachel E., et al. “Infectious Disease in an Era of Global Change.” Nature Reviews Microbiology 20, no. 4 (2022): 193–205. https://doi.org/10.1038/s41579-021-00639-z
• CL12
  Lim, Poh Lian. “Travel and the Globalization of Emerging Infections." Transactions of the Royal Society of Tropical Medicine and Hygiene 108, no. 6 (2014): 309–310. https://doi.org/10.1093/trstmh/tru051
• CL13
  McMichael, Celia. “Climate Change-Related Migration and Infectious Disease.” Virulence 6, no. 6 (2015): 548–553. https://doi.org/10.1080/21505594.2015.1021539
• CL14
  Casadevall, Arturo, and Michael J. Imperiale. “Risks and Benefits of Gain-of-Function Experiments with Pathogens of Pandemic Potential, Such as Influenza Virus: A Call for a Science-Based Discussion.” mBio 5, no. 4 (2014). https://doi.org/10.1128/mBio.01730-14
• CL15
  Shin, Gee Yen, and Rohini Manuel. “Covid-19 Laboratory Leak Hypothesis: How a Few Kept the Many from Considering Alternative Possibilities.” BMJ 374, no. 2003 (2021). https://doi.org/10.1136/bmj.n2003
• CL16
  Linder, Ann, and Dale Jamieson. "Blind Spots in Biodefense." Science 379, no. 6633 (2023):
• CL17
  Rathish, Balram., et al. “Comprehensive Review of Bioterrorism.” In StatPearls, StatPearls Publishing, 2023. https://www.ncbi.nlm.nih.gov/pubmed/34033376
• CL18
  Hwang, Kun. “Possible Bioterrorism by North Korea and South Korea’s Preparedness.” Infectious Chemotherapy 56, no. 3 (2024): 300–307. https://doi.org/10.3947/ic.2024.0068 -30-
• CL19
  Li, Ziqi, et al. “Reviewing the Progress of Infectious Disease Early Warning Systems and Planning for the Future.” BMC Public Health 24, no. 3080 (2024). https://doi.org/10.1186/s12889-024-20537-2
• CL20
  Tran, Bach Xuan, et al. “Global Mapping of Epidemic Risk Assessment Toolkits: A Scoping Review for COVID-19 and Future Epidemics Preparedness Implications.” PLOS ONE (2022). https://doi.org/10.1371/journal.pone.0272037
• CL21
  Shadbolt, Nigel, et al. “The Challenges of Data in Future Pandemics.” Epidemics 40, no. 100612 (2022). https://doi.org/10.1016/j.epidem.2022.100612
• CL22
  Turtle, James, et al. “Accurate Influenza Forecasts Using Type-Specific Incidence Data for Small Geographic Units.” PLOS Computational Biology 17, no. 7 (2021). https://doi.org/10.1371/journal.pcbi.1009230
• CL23
  Rosenfeld, Roni, and Ryan J. Tibshirani. “Epidemic Tracking and Forecasting: Lessons Learned from a Tumultuous Year.” Proceedings of the National Academy of Sciences 118, no. 51 (2021). https://doi.org/10.1073/pnas.2111456118
• CL24
  El Morr, Christo, et al. “AI-Based Epidemic and Pandemic Early Warning Systems: A Systematic Scoping Review.” Health Informatics Journal 30, no. 3 (2024). https://doi.org/10.1177/14604582241275844
• CL25
  MacIntyre, Chandini Raina, et al. “Artificial Intelligence in Public Health: The Potential of Epidemic Early Warning Systems.” Journal of International Medical Research 51, no. 3 (2023). https://doi.org/10.1177/03000605231159335
• CL26
  Singh, Surabhi, et al. “A Narrative Review of Wastewater Surveillance: Pathogens of Concern, Applications, Detection Methods, and Challenges.” Frontiers in Public Health 12 (2024). https://doi.org/10.3389/fpubh.2024.1445961
• CL27
  Mao, Kang, et al. “Biosensors for Wastewater-Based Epidemiology for Monitoring Public Health.” Water Research 191 (2021): 116787. https://doi.org/10.1016/j.watres.2020.116787
• CL28
  Girón-Guzmán, Inés, Gloria Sánchez, and Alba Pérez-Cataluña. "Tracking Epidemic Viruses in Wastewaters." Microbial Biotechnology 17, no. 10 (2024). https://doi.org/10.1111/1751- 7915.70020 -31-
• CL29
  Boehm, Alexandria B., et al. “Wastewater Concentrations of Human Influenza, Metapneumovirus, Parainfluenza, Respiratory Syncytial Virus, Rhinovirus, and Seasonal Coronavirus Nucleic-Acids During the COVID-19 Pandemic: A Surveillance Study.” Lancet Microbe 4 (2023): e340–e348. https://doi.org/10.1016/S2666-5247(22)00386-X
• CL30
  Gao, Tilei, Tiebing Li, and Peng Xu. “Risk Analysis and Assessment Method for Infectious Diseases Based on Information Entropy Theory.” Scientific Reports 14 (2024). https://doi.org/10.1038/s41598-024-67783-3
• CL31
  Dean, Brandon, et al. “Los Angeles County Department of Public Health's Health Hazard Assessment: Putting the 'Health' into Hazard Assessment.” Journal of Public Health Management and Practice 19, Suppl 2 (2013): S84–S90. https://doi.org/10.1097/PHH.0b013e3182928e63
• CL32
  World Health Organization. Strategic Toolkit for Assessing Risks: A Comprehensive Toolkit for All-Hazards Health Emergency Risk Assessment. Geneva: World Health Organization,
• CL33
  U.S. Environmental Protection Agency. “Human Health Risk Assessment.” U.S. Environmental Protection Agency. Last modified January 31, 2025. https://www.epa.gov/risk/human-health-risk-assessment
• CL34
  Centers for Disease Control and Prevention. “Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings.” Centers for Disease Control and Prevention. Published April 16, 2024. https://www.cdc.gov/healthcare-associated-infections/php/toolkit/icar.html
• CL35
  World Health Organization. WHO Guidance on Preparing for National Response to Health Emergencies and Disasters. Geneva: World Health Organization. Published December 20,
• CL36
  Centers for Disease Control and Prevention. “Bioterrorism Overview.” Centers for Disease Control and Prevention. Published February 28, 2006. https://stacks.cdc.gov/view/cdc/44106 -32- Page left intentionally blank DO VACCINATION RATES IN SANTA BARBARA COUNTY CREATE A PUBLIC HEALTH RISK? SUMMARY If our friends and neighbors are unvaccinated against childhood diseases for whatever reason, the entire community may be put at risk. Over past decades, there has been increasing public discourse about the potential risks of vaccines, which may help to explain why vaccination rates have decreased across the United States. Exacerbating this trend has been an unfortunate lack of information about the differences between the various vaccines, most importantly the significant difference between childhood vaccinations and others. This report focuses on vaccinations that protect against serious childhood diseases such as mumps, measles, and polio. The investigation examines the level of community protection in Santa Barbara County provided by vaccinations administered to children and adults. It also considers vaccination concerns in the county's juvenile detention facilities and adult jails, both of which are congregate settings from which a disease outbreak could quickly grow and impact the public. Santa Barbara County does an excellent job of assuring that children who attend public and private schools receive mandated vaccinations. However, there are no readily available data in Santa Barbara to determine the level of vaccination rates in adults, who make up over 75 percent of the County population. It is therefore unknown whether there are significant numbers of unvaccinated individuals in the County. If this is the case, there is a real risk of a resurgence of dangerous diseases in our community. The Grand Jury recommends studies to determine whether our County has reached a tipping point below which reduced vaccination levels pose a significant risk of an outbreak.
• CL37
  Drawing from these comprehensive tours and experiences throughout the year, the Grand Jury gained an invaluable understanding of the multifaceted operations that sustain Santa Barbara County's infrastructure, public safety, and essential services. From observing the democratic process during the November 2024 Presidential Election to examining the complexities of water security at desalination and treatment facilities, from understanding the delicate work of the Coroner's Office to witnessing the challenges within both adult and juvenile correctional systems, each visit reinforced the interconnected nature of County governance. The educational journey through these diverse facilities not only enriched the Jury's perspective on local government operations but also helped develop a deeper appreciation for the complexities and responsibilities inherent in public service, ultimately strengthening the ability to fulfill the Grand Jury’s oversight role with greater insight and understanding. -8-
• CL38
  Page left intentionally blank SANTA BARBARA COUNTY AGENCIES RESPOND TO 2023-24 GRAND JURY REPORTS SUMMARY The 2023-24 Santa Barbara County Grand Jury issued nine reports. The current 2024-25 Grand Jury has assembled the responses to the prior Jury’s reports. The following report is based on the responses that agree or disagree with the Jury’s findings and recommendations. This Response Report is also meant to allow the public to become more familiar with their local agencies by reading their answers to the Grand Jury’s reports, found on its website: www.sbcgj.org. Overall, Santa Barbara County agencies agreed with the 2023-24 Jury’s findings 46 times (64.8% of the time) and stated that they either have implemented or will implement the Jury’s recommendations 56 times (58.4% of the time). INTRODUCTION In California, each county grand jury writes reports after looking into the operations of various local government entities. These reports are sent to the local agencies, who then are required to write a response to the jury’s findings and recommendations that are addressed to them. The agencies can agree with the jury’s findings and recommendations, and this can lead to changes in how policies are implemented. Agencies can also disagree with the jury, which can happen just as often. In these cases, the agencies explain their position and their actions in their responses. Either way, the investigative process informs the public how our local government agencies work. While the agencies might not always agree with a grand jury, everyone is working together to improve their function in the community. This is, at its core, a collaborative effort. A grand jury is considered the watchdog for the public. Grand jury members are able to directly interview members of the government and private citizens and gather information that is not always available to the public. In this way, a grand jury has a unique ability to “shine the light” on our civic processes. The 2024-25 Santa Barbara County Grand Jury invites the public to contact it regarding areas of future investigations. A form to request an inquiry can be found on the Grand Jury website: www.sbcgj.org. Letters can be mailed to: Santa Barbara County Grand Jury, 1100 Anacapa Street, Santa Barbara, CA 93101. -9-
• CL39
  The 2023-2024 Santa Barbara County Grand Jury’s findings and recommendations endorsed many actions taking place in and among county agencies, serving to highlight positive changes. The Jury would like to acknowledge what it notes as a high degree of cooperation among agencies and the Jury in this past year. Overall, agencies agreed with the Jury’s findings 46 out of 71 times (64.8%), and over half of the Jury’s 96 recommendations either have been implemented or will be (31.3% Have Been Implemented and 27.1% Will Be Implemented). The Jury’s reports spotlight the agencies’ actions so that the citizens of the County can participate to best ensure that the changes are carried out in a timely manner. The Jury thanks the agencies and other local entities that provided their responses to the 2023-24 Jury’s reports in a timely manner. The Jury further commends them for their commitment to implementing the Jury’s recommendations and improving the services they provide to our local communities. FINDINGS AND RECOMMENDATIONS Finding 1: County agencies agreed with most of the 2023-24 Jury’s findings and implemented a majority of the 2023-24 Jury’s recommendations, which reflects an encouraging level of cooperation among local agencies and the Jury. This Response Report has no recommendations. REQUIREMENTS FOR RESPONSES This Response Report does not require a response from any governmental agency. -18-
• CL40
  Page left intentionally blank IS THE SANTA BARBARA COUNTY PUBLIC HEALTH DEPARTMENT PREPARED FOR THE NEXT EPIDEMIC? SUMMARY Another epidemic in Santa Barbara County is not merely a possibility—it is an inevitability. The emergence of new infectious agents that may cause devastating outbreaks is occurring at an alarming rate. The 2024-2025 Grand Jury has identified shortcomings in Santa Barbara County’s readiness for a new epidemic. Our County must adopt a proactive approach to preparedness. This includes utilizing up-to-date technologies, implementing proactive risk assessment and disaster planning strategies, strengthening early detection, and improving communication to prepare for bioterrorism threats. (References 1-3) The Santa Barbara County Public Health Department is the front line. While federal and state agencies may provide guidance, it is the County Public Health Department’s responsibility to plan for and respond to infectious epidemics that might occur in Santa Barbara County.
• CL41
  Vaccination rates against childhood diseases have decreased in many communities in the United States. As a result, there has been a disturbing trend of new outbreaks of dangerous diseases across the County. In the overall Santa Barbara County population, the vaccination rates against childhood diseases are unknown. If the numbers of vaccinated individuals have fallen below herd immunity thresholds, our County is also at risk of outbreaks. The Jury recommends that County Health carry out studies to determine childhood vaccination rates. These studies should focus upon adults, and be inclusive of diverse populations, including immigrants and migrant workers. In addition, the Jury recommends that two particular at-risk populations require special attention: children who are receiving home schooling, and inmates in the County jails.
• CL42
  Water continues to be a scarce resource in Santa Barbara County, one which must be managed if the needs of the County—residential, commercial, and agricultural—are to be met. The Jury investigated the current status of water management in the County and was pleased to learn that not only are the current, relatively abundant, water resources being well managed, but also that all of the agencies the Jury examined have solid plans in progress or ready for implementation for the next inevitable drought. Water agencies and districts in Santa Barbara County know and understand that the drought cycle is a fact of life. Recognizing this, water agencies and districts face challenges in providing water for residential, commercial, and agricultural needs as well as meeting state-mandated housing requirements. Nevertheless, each entity the Jury interviewed has plans in place to both meet fluctuating drought pressures as well as future demand due to population growth and development. Yet the people of Santa Barbara County, and the officials tasked with providing their water, should not be complacent in these good tidings. Appropriately meeting Santa Barbara County’s water needs in the future requires the maintenance of existing water treatment and distribution infrastructure and a continued insistence on water conservation. FINDINGS AND RECOMMENDATIONS Finding 1: Despite community concerns about water scarcity, all of the public entities the Jury investigated that provide and manage water in Santa Barbara County have made proactive plans to fortify against future droughts and provide sufficient water necessary to support future housing growth and commerce. Finding 2: Despite a 2016-17 Grand Jury finding that limitations existed in coordinating water management, the Jury finds that coordination among different water management entities in the County has improved significantly. Finding 3: The City of Santa Barbara has gone beyond the basic management of water resources for its residents by utilizing desalination to innovatively expand local water availability. 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. -67- 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 City of Santa Barbara – 90 Days Findings 1, 2, 3 Board of Directors, Santa Barbara County Water Agency – 90 Days Findings 1, 2 Goleta Water District – 90 Days Findings 1, 2 Carpinteria Valley Water District – 90 Days Findings 1, 2 Carpinteria Valley Groundwater Sustainability Agency – 90 Days Finding 1, 2 Santa Ynez River Water Conservation District – 90 Days Finding 1, 2 San Antonio Basin Water District – 90 Days Finding 1, 2 San Antonio Basin Groundwater Sustainability Agency – 90 Days Finding 1, 2 Santa Maria Valley Water Conservation District – 90 Days Finding 1, 2 Cuyama Basin Groundwater Sustainability Agency – 90 Days Finding 1, 2 -68- Page left intentionally blank
• CL43
  Page left intentionally blank CANNABIS TAXATION AND EXPENDITURES SUMMARY The 2024-25 Santa Barbara County Grand Jury (Jury) investigated the current Santa Barbara County cannabis tax revenue and expenditures and how they are reported. During its investigation, the Jury learned that Santa Barbara County’s (County) tax revenues from the cannabis industry have been declining steadily since cannabis was approved for recreational use in California in 2018. In this same period of time, the County’s expenditures in regulating the cannabis industry have increased. As a result, the expenditures covering the County's cannabis industry-related management and taxation operations (Cannabis Program) are on track to become a financial burden in the near future unless the County takes corrective measures. The Jury also found that a significant number of growers have left the Santa Barbara County cannabis industry due to high cost of operations, price collapse, and market oversupply in part due to black-market competition. Currently, budgeting, tax collection, and compliance activities are the responsibility of different agencies and departments in the County. Inefficiencies in the management and required reporting of the Cannabis Program can be mitigated by the creation of a centralized information database that tracks the budget, tax revenues, expenses, and administrative activities related to licensing and compliance. In addition, Cannabis Program spending can be reduced by allocating tax revenues to support only operating expenses directly related to it. Given the volatility of the cannabis market, the Jury further recommends that the County maintain the solvency of the Cannabis Program by ensuring that expenditures do not exceed cannabis tax revenues each year. This Grand Jury Report was based on an investigation conducted from August 2024 to May 2025. The Report was in the final stages of production on June 3, 2025, when the Santa Barbara County Board of Supervisors initiated significant changes to the County's Cannabis Program, many of which are consistent with the Findings and Recommendations in this Report. This Report was not altered or amended in any way following the Board's actions.
• CL44
  The Cannabis Program began with the expectation that it would provide a windfall of tax revenue to Santa Barbara County. However, those expectations are no longer being met due to changing market conditions. Cannabis tax revenue has been steadily declining in Santa Barbara County since fiscal year 2021-22. Current County expenditures from cannabis tax revenue on deferred maintenance and capital projects, licensing, monitoring, compliance, and enforcement are projected to become a financial burden to Santa Barbara County in the near future if the current cannabis tax structure and expenditures are not reviewed and revised to account for the continuing decline in cannabis tax revenue. -75- FINDINGS AND RECOMMENDATIONS Finding 1: Cannabis tax revenues have been declining due to market oversupply and price collapse, stressing the County’s operating expenditures for the Cannabis Program. Recommendation 1: The Grand Jury recommends that the Board of Supervisors ensure that the Cannabis Program’s annual operating expenditures do not exceed annual cannabis tax revenues. Finding 2: The County’s allocation for deferred maintenance and capital project expenses from cannabis tax revenue has not been adjusted to reflect the decline in tax revenue over the past five years. Recommendation 2: The Grand Jury recommends that the Board of Supervisors revisit its capital projects allocation to be funded by cannabis tax revenues, ensuring that such allocations do not exceed available funds. Finding 3: Current County budget projections indicate that Cannabis Program ongoing expenditures will exceed expected cannabis tax revenues by $1.1 million in fiscal year 2025-26, posing a burden on County taxpayers. Recommendation 3: The Grand Jury recommends that the Board of Supervisors prioritize covering the direct operating costs of the Cannabis Program so as to achieve more balanced budgets in the future. Finding 4: Currently Santa Barbara County’s budgeting, tracking, and reporting of cannabis- related revenue, expenses, and compliance violations are decentralized, making it difficult to provide comprehensive and detailed information on demand. Recommendation 4: The Grand Jury recommends that the Board of Supervisors direct the County Executive Officer to develop an automated and centralized information database to track and report the budget, revenues, expenses, and administrative activities related to licensing and compliance specific to the Cannabis Program. Finding 5: Despite declining illicit cannabis cultivation activity in the County, a significant portion of the County’s cannabis tax revenues continue to be allocated to combat this activity each fiscal year. Recommendation 5: The Grand Jury recommends that the Board of Supervisors annually re- evaluate the allocation of cannabis tax revenue for combating illicit cannabis cultivation activity in the County. -76- 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 Santa Barbara County Board of Supervisors - 90 days Findings 1, 2, 3, 4, 5 Recommendations 1, 2, 3, 4, 5 -77- Page left intentionally blank
• CL45
  Page left intentionally blank SANTA BARBARA COUNTY SOUTH COAST HOUSING CRISIS A CALL TO ACTION SUMMARY The housing shortage in Santa Barbara County’s South Coast, particularly for low- and moderate- income residents, is reaching crisis levels. This growing concern is now a frequent topic at public hearings, advocacy meetings, and in news reports. The root of the problem is a lack of new housing development for many years. The situation has been made worse by the rise in short-term rentals and an increasing number of second or third homes left vacant for much of the year. While the County has met its obligation under the California Regional Housing Needs Allocation (RHNA) to plan for increased housing supply, there are serious barriers to building this housing, particularly affordable and workforce housing. Numerous barriers continue to stand in the way of actual construction. These include high land and labor costs, development fees, restrictive zoning, and neighborhood opposition (commonly known as “Not In My Back Yard” or NIMBY). Complex regulations further delay or block projects. The many federal and state programs that offer subsidies for affordable housing are underfunded, oversubscribed, and beset with confusing rules and deadlines. Recent shifts in federal policy have cast uncertainty on the future of these programs. Although RHNA only mandates planning, not building, housing, the County and cities do have tools to directly facilitate construction. These include expanding ministerial approvals, using objective design standards for accessory dwelling units (ADUs), revising restrictive codes, and rezoning land specifically for affordable and workforce housing. The 2024-25 Santa Barbara County Grand Jury (Jury) observed that our local governments on the South Coast, local non-profit organizations, many developers, and some employers are striving to create more housing, but much more needs to be done. To truly address the South County’s housing needs and meet RHNA goals, local agencies must go beyond planning. They must commit meaningful resources to the actual development of this needed housing.
• CL46
  The affordable housing crisis on the South Coast remains a complex and urgent challenge, shaped by high land costs, state and local regulatory hurdles, and limited financial resources. The development process is often slow and fragmented, and affordable housing projects face competition for limited funding. Although the jurisdictions on the South Coast will meet the RHNA goals that require identification of suitable building sites, it is unlikely that the target of increasing the inventory of affordable and moderate-income housing on the South Coast will be realized by 2031. Ultimately, providing needed housing on the Santa Barbara South Coast will require sustained collaboration among local governments, developers, community stakeholders, and the broader public to build a more inclusive, affordable, and resilient housing landscape. FINDINGS AND RECOMMENDATIONS Finding 1: Santa Barbara County and the cities of Santa Barbara, Goleta, and Carpinteria own land that is surplus to their operational requirements, some of which could be used for affordable housing. Recommendation 1a: The Grand Jury recommends that the Santa Barbara County Board of Supervisors and City Councils of Santa Barbara, Goleta, and Carpinteria identify publicly owned properties within their jurisdiction that could be utilized for affordable housing. Recommendation 1b: The Grand Jury recommends that the Santa Barbara County Board of Supervisors and City Councils of Santa Barbara, Goleta, and Carpinteria invite public and private developers to work with them to build affordable housing on the publicly owned land identified as available. Finding 2: The process for issuance of a permit for affordable housing development projects in the County and the cities of Santa Barbara, Goleta and Carpinteria is costly, time consuming, and complicated. Recommendation 2a: The Grand Jury recommends that the Santa Barbara County Board of Supervisors and City Councils of Santa Barbara, Goleta, and Carpinteria each create a position to be staffed by a qualified person who can coordinate and facilitate the application and approval processes for affordable housing projects, with the authority to bring together all interested parties to arrive at an expeditious resolution of any issue. -86- Recommendation 2b: The Grand Jury recommends that the Santa Barbara County Board of Supervisors and City Councils of Santa Barbara, Goleta, and Carpinteria review their processes for development approvals to prioritize affordable housing projects. Recommendation 2c: The Grand Jury recommends that the Santa Barbara County Board of Supervisors and City Councils of Santa Barbara, Goleta, and Carpinteria apply the ministerial approval process to all development projects comprising seventy five percent or more of low- income housing. Recommendation 2d: The Grand Jury recommends that the Santa Barbara County Board of Supervisors and City Councils of Santa Barbara, Goleta, and Carpinteria conduct a review of all development and impact fees and find ways to waive, reduce or amortize fees for affordable housing projects. Finding 3: There are insufficient funds available to develop needed affordable housing. Recommendation 3a: The Grand Jury recommends that the City Councils of Goleta and Carpinteria establish dedicated housing trust funds, certified as Community Development Financial Institutions, to facilitate the building of affordable housing. Recommendation 3b: The Grand Jury recommends that the Santa Barbara County Board of Supervisors increase funding to the Housing Trust Fund of Santa Barbara County to facilitate the building of affordable housing. Recommendation 3c: The Grand Jury recommends that the Santa Barbara City Council further increase funding to the City of Santa Barbara Local Housing Trust Fund to facilitate the building of affordable housing. Recommendation 3d: The Grand Jury recommends that the Santa Barbara County Board of Supervisors and the City Councils of Santa Barbara, Goleta and Carpinteria promote contributions to their housing trust funds by other non-governmental organizations, the philanthropic community, and the public. 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. -87- 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 Santa Barbara County Board of Supervisors – 90 Days Findings 1, 2, 3 Recommendations 1a, 1b, 2a, 2b, 2c, 2d, 3b, 3d City of Santa Barbara – 90 Days Findings 1, 2, 3 Recommendations 1a, 1b, 2a, 2b, 2c, 2d, 3c, 3d City of Goleta – 90 Days Findings 1, 2, 3 Recommendations 1a, 1b, 2a, 2b, 2c, 2d, 3a, 3d City of Carpinteria – 90 Days Findings 1, 2, 3 Recommendations 1a, 1b, 2a, 2b, 2c, 2d, 3a, 3d -88-
• CL47
  The first 72 hours of an inmate’s arrival at jail is a time of particular sensitivity, requiring careful attention from medical staff and custody staff. In the course of this custody-related death investigation, the Jury identified a number of areas relating to the screening and observation of new arrivals at the County’s jails that require improvement. An incomplete master problem list in the electronic health record, which meant that medical staff could not accurately assess whether AAO needed alcohol withdrawal monitoring or not, encompasses important areas where AAO’s case demonstrates shortcomings in provided medical care at the County’s jails. Two Service Level Agreements in the County’s new contract with Wellpath demonstrate that the County is taking steps to correct these deficiencies. A lack of communication regarding withdrawal risk between medical staff and custody staff, or between their respective information systems, was also identified as an area of concern by the Jury. With increased oversight by County agencies over Wellpath’s operations at the County’s jails following the signing of the new contract in April 2025, the Jury is increasingly hopeful that the concerns it raises in this Report will result in system-wide improvements at the jails.
• CL48
  It is the Jury’s view that the MHPs exhibited integrity and compassion in treating CC given the inherent deficiencies discussed in this Report. Likewise, custody staff demonstrated dedication and sincerity in their mission of safeguarding inmates. But that should not end the discussion. The systems and infrastructure used to evaluate and treat inmates with severe mental health concerns have failed inmates and staff. They must be given the necessary resources to ensure the health and safety of inmates, especially those with mental health conditions, or more individuals will die. 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. -119- FINDINGS AND RECOMMENDATIONS Finding 1: CC should not have been transferred to an observation cell with a telephone cord. Recommendation 1a: The Grand Jury recommends that the Sheriff’s Office will not place an inmate deemed by mental health staff to have been recently suicidal in an observation cell that contains a telephone cord. To be implemented no later than January 1, 2026. Recommendation 1b: The Grand Jury recommends to the Sheriff’s Office that if no cordless mental health observation cells are available when stepping down a potentially suicidal inmate from a safety cell, a Jail mental health provider should seek to transfer that inmate to the closest facility that can offer adequate protection. To be implemented no later than January 1, 2026. Recommendation 1c: The Grand Jury recommends to the Sheriff’s Office that if no cordless mental health observation cells are available when stepping down a potentially suicidal inmate from a safety cell in the Main Jail, a Jail mental health provider must contact the County's psychiatric holding facility, the Crisis Stabilization Unit, a local hospital, and the Northern Branch Jail to determine if a bed offering an appropriate level of care is available. To be implemented no later than January 1, 2026. Recommendation 2c: Recommendation 1d: The Grand Jury recommends that the Board of Supervisors negotiate a memorandum of understanding with San Luis Obispo County, Ventura County, Los Angeles County, and other neighboring counties in California setting procedures for transferring and accepting inmates with severe mental health disease when no other safe housing options are available. To be implemented no later than January 1, 2026. Finding 2: Wellpath staff failed to comply with existing policy requiring a psychiatric assessment while housed in a safety cell. Recommendation 2: The Grand Jury recommends that while an inmate is housed in a safety cell, the Sheriff’s Office require a Wellpath psychiatrist conduct an evaluation of that inmate. Given that the recommendation is to follow existing policy, to be implemented immediately. Finding 3: A Jail psychiatrist failed to evaluate, diagnose, or treat CC’s severe psychiatric illnesses, which were serious shortcomings. Recommendation 3a: The Grand Jury recommends that if the on-duty psychiatrist is not available to conduct what Jail medical and mental health staff deem to be an urgent evaluation of an inmate, the Sheriff’s Office require Wellpath to designate another backup on-call psychiatrist to conduct such an evaluation. To be implemented no later than January 1, 2026. -120- Recommendation 3b: The Grand Jury recommends to the Sheriff’s Office that if a stepdown inmate refuses to participate in a psychiatric evaluation, the on-duty Jail psychiatrist be required to obtain and review the inmate’s mental health history. To be implemented no later than January 1, 2026. Finding 4: During CC’s first approximately 23-hour stay in Safey Cell 3, the Sheriff’s Office failed to ensure that Wellpath staff comply with policy requiring that the Mobile Crisis Unit be called after 12 hours in a safety cell. Recommendation 4: The Grand Jury recommends that after an inmate spends more than 12 hours in a safety cell, the Sheriff’s Office require that Wellpath staff always call the Mobile Crisis Unit to conduct an evaluation and document the call and its outcome in the Jail electronic health record. Given that the recommendation is to follow existing policy, to be implemented immediately. Finding 5: There was poor communication regarding CC’s mental health history between Jail mental health staff, Mobile Crisis Teams, and outside healthcare providers who treated her. Recommendation 5a: The Grand Jury recommends that the Sheriff’s Office require additional training for Wellpath mental health providers regarding HIPAA regulations concerning inmates, including defining under what circumstances a mental health provider may legally contact outside mental health providers about an inmate’s mental health history. To be implemented no later than January 1, 2026. Recommendation 5b: The Grand Jury recommends that the Sheriff’s Office require the on-duty registered nurses at the County’s jails to request every newly arriving inmate at the time of intake to sign a written authorization to release their medical and mental health records and information. To be implemented no later than January 1, 2026. Finding 6: Wellpath staff did not obtain critical health-related documentation from Cottage Hospital or Behavioral Wellness and therefore CC did not receive proper treatment in jail. Recommendation 6a: The Grand Jury recommends that the Sheriff’s Office require Wellpath staff to contact outside healthcare providers, such as hospitals, physicians, and clinics, to obtain inmates’ health records in a timely manner following intake. To be implemented by January 1, 2026. Recommendation 6b: The Grand Jury recommends that the Sheriff’s Office upgrade its electronic health record system to allow it to receive patient health information from outside providers via an industry-standard means of internet transmission. To be implemented by March 31, 2027. -121- Finding 7: The Sheriff’s Office did not comply with the Remedial Plan outlined in Murray v. Santa Barbara County because it did not provide enough beds at all necessary levels of clinical care and security to meet the needs of inmates with serious mental illnesses, as in CC’s case. Recommendation 7a: The Grand Jury recommends that the Sheriff’s Office provide and maintain safety and observation cells sufficient in number to meet ongoing demands. Recommendation 7b: The Grand Jury recommends that the Sheriff Office require custody staff to consider mental health staff’s clinical input when determining placement upon discharge from a safety cell and document the reasons when clinical input is not followed. This report was issued by the Grand Jury with the exception of a Grand Juror who wanted to avoid the perception of a conflict of interest. That Grand Juror was excluded from all parts of the investigation, including interviews, deliberations, and the writing and approval of this report. 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 Santa Barbara County Board of Supervisors – 90 days Findings 1, 2, 3, 4, 5, 6, 7 Recommendations 1a, 1b, 1c, 1d, 2, 3a, 3b, 4, 5a, 5b, 6a, 6b, 7a, 7b Santa Barbara County Sheriff’s Office – 60 days Findings 1, 2, 3, 4, 5, 6, 7 Recommendations 1a, 1b, 1c, 1d, 2, 3a, 3b, 4, 5a, 5b, 6a, 6b, 7a, 7b -122- Page left intentionally blank
• CL49
  Page left intentionally blank PREVENTABLE DEATH AT THE NORTHERN BRANCH JAIL A Death-in-Custody Investigation SUMMARY On the fifth day after her incarceration at the Santa Barbara County Northern Branch Jail on March 24, 2025, inmate CF, a 57-year-old woman, was found unresponsive in her cell and could not be successfully resuscitated. The autopsy report concluded that CF died because of peritonitis (infection in the abdominal cavity) caused by a perforated gastric ulcer. The 2024-25 Santa Barbara County Grand Jury investigated the facts and circumstances surrounding CF’s death at the Northern Branch Jail. The Jury found that CF had repeatedly complained of abdominal pain for the last two days of her incarceration. Moreover, the autopsy indicated that CF’s stomach had perforated days before her death. Throughout her incarceration, the medical care provided to CF did not meet numerous jail medical procedure requirements. For example, her complaints of pain were never appropriately evaluated, which meant that CF did not receive treatment. CF was never seen by a physician during her incarceration. Her requests for transfer to an emergency room were not documented nor acted upon by medical staff. As a result, a diagnosis of CF’s perforated stomach was never made. Had CF’s complaints been evaluated, she would have received treatment for her perforated ulcer, and her death could have been prevented. While the Sheriff's Office released a statement that CF's death was unavoidable, the Jury concludes that there were opportunities to prevent this death.
• CL50
  After five days of incarceration in the Santa Barbara Northern Branch Jail, inmate CF died because of an untreated perforated gastric ulcer. For at least two days during her jail stay, CF repeatedly complained of pain, yet her pain was never appropriately evaluated. While the jail had established tools and forms to evaluate inmates’ pain, these were never utilized, though their use was expected. Had an appropriate evaluation of CF’s pain occurred, with subsequent treatment rendered immediately, CF’s death could potentially have been avoided. FINDINGS AND RECOMMENDATIONS Finding 1: CF repeatedly complained of abdominal pain for at least two days prior to her death, but these complaints were not assessed by medical staff in accordance with jail medical policy, procedure, and protocol. Recommendation 1: The Grand Jury recommends that the Sheriff’s Office require that qualified medical professionals assess and treat pain according to accepted medical standards and in accordance with existing policy, procedure, and protocol when inmates in the County’s jails complain of pain. Finding 2: Nursing staff at the Northern Branch Jail did not follow an evidence-based process to evaluate or treat CF for her abdominal pain, though such pain assessment forms were available and their use expected. Recommendation 2: The Grand Jury recommends that the Sheriff’s Office instruct all medical staff at the County’s jails to utilize available evidence-based pain assessment forms to evaluate and document inmates’ pain complaints. -129- Finding 3: Inmate CF’s death might have been prevented if she had received appropriate medical assessment in jail. Recommendation 3a: The Grand Jury recommends that the Board of Supervisors direct County Health to thoroughly assess the medical care provided to CF by Wellpath. To be implemented by January 1, 2026. Recommendation 3b: Based on the investigation of the care provided to CF, the Grand Jury recommends that the Board of Supervisors direct County Health make public a report identifying opportunities for systemic improvements in the quality of medical care in the County’s jails. To be implemented by January 1, 2026. This report was issued by the Grand Jury with the exception of a Grand Juror who wanted to avoid the perception of a conflict of interest. That Grand Juror was excluded from all parts of the investigation, including interviews, deliberations, and the writing and approval of this report. 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 Santa Barbara County Board of Supervisors – 90 days Findings 1, 2, 3 Recommendations 3a, 3b Santa Barbara County Sheriff’s Office – 60 days Findings 1, 2, 3 Recommendations 1, 2 -130-
• CL51
  Page left intentionally blank E-BIKES IN SANTA BARBARA What Will It Take to Make Them Safe? SUMMARY Electric bicycles, or e-bikes, have become an increasingly common mode of transportation. Whether they are used by students going to school or adults traveling to work, they have become a part of our culture of being on the go. This is evident in Santa Barbara, where City officials have been redesigning City pathways to encourage bike, and now e-bike, traffic. However, the rapid rise of e-bike usage since the pandemic—particularly among younger riders—has led to increased frustrations and dangers for riders, pedestrians, and even automobile drivers. Public safety is at risk. The proliferation of e-bikes has presented significant challenges for Santa Barbara County’s South Coast, and especially the City of Santa Barbara, where State Street has become an e-bike promenade. City officials initially waited to determine appropriate traffic laws applied specifically to e-bikes and only recently enacted new laws in the spring of 2025 regarding unsafe e-bike riding. The question now is how the new ordinance will be enforced. It is with a sense of urgency that the 2024-25 Santa Barbara County Grand Jury studied the matter of e-bikes in the City of Santa Barbara. Numerous postings on social media by local citizens cite bad behavior and near accidents on the part of e-bike riders. Accidents have been verified by local police and hospital records. Riders and pedestrians are at risk of critical injuries and death. The advent of e-bikes marks a broad cultural shift in how the community interacts in shared spaces, and addressing this change will require a collective effort to educate the public on the City’s new e-bike ordinance.
• CL52
  Riding e-bikes has resulted in many serious injuries in Santa Barbara, particularly among riders 20 years and younger. Santa Barbara experienced its first e-bike-related fatality in May 2025. In February 2025, the City Council enacted a new e-bike ordinance to cut down on certain unsafe riding behaviors, and the Santa Barbara Police Department is rolling out enforcement. It remains to be seen if more robust actions need to be taken to assure compliance with the new laws and more publicity to make an impact on public awareness. FINDINGS AND RECOMMENDATIONS Finding 1: Since the City of Santa Barbara’s adoption of the new e-bike ordinance, Santa Barbara Police Department officers now have broad discretion in responding to unsafe behavior by e-bike riders, but, as a general principle, behavioral change requires a strategic and consistent approach. Recommendation 1a: The Grand Jury recommends that the Santa Barbara City Council encourage the Santa Barbara Police Department to establish a plan to strategically and consistently focus enforcement efforts in high-traffic areas so as to achieve high visibility and have the greatest impact on behavior in enforcement operations. To be implemented by December 1, 2025. Recommendation 1b: The Grand Jury recommends that the Santa Barbara City Council require the Santa Barbara Police Department to give the Council monthly reports on the number and severity of e-bike-involved accidents in the City of Santa Barbara, as well as the number of citations issued. To be implemented by December 1, 2025. Recommendation 1c: The Grand Jury recommends that the Santa Barbara City Council make available to the public these monthly reports on the number and severity of e-bike-involved 6 See Cal. Vehicle Code section 21214.5, subdivision (f), and section 21214.7, subdivision (e). -143- accidents in the City of Santa Barbara, as well as the number of citations issued. To be implemented by December 1, 2025. Finding 2: The Santa Barbara City Council has tasked the Police Department and its officers with additional responsibilities related to enforcement of the new e-bike ordinance but has not provided additional funding to support those purposes. Recommendation 2: The Grand Jury recommends that the Santa Barbara City Council conduct a study to determine how much new funding for this additional police work is needed. To be completed by April 1, 2026. Finding 3: The City of Santa Barbara has initiated only a limited public information campaign about the new e-bike ordinance now in effect, thus limiting awareness of the ordinance. Recommendation 3a: The Grand Jury recommends that the Santa Barbara City Council initiate an expanded and long-term public information campaign to inform and educate the public about the City’s new e-bike rules. To be implemented by December 1, 2025. Recommendation 3b: The Grand Jury recommends that the Santa Barbara City Council invite the cooperation and participation of secondary schools in the Santa Barbara Unified School District, private organizations that are involved in e-bike education, neighboring cities including Goleta, and local businesses for expanded public outreach on e-bike safety and laws now in effect. Finding 4: The Santa Barbara Police Department has recently expanded its outreach in Santa Barbara Unified School District to instruct students in e-bike safety and laws, which is a positive development. This report was issued by the Grand Jury with the exception of a Grand Juror who wanted to avoid the perception of a conflict of interest. That Grand Juror was excluded from all parts of the investigation, including interviews, deliberations, and the writing and approval of this report. 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 -144- - 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 City of Santa Barbara – 90 days Findings 1, 2, 3, 4 Recommendations 1a, 1b, 1c, 2, 3a, 3b -145- Page left intentionally blank
• CL53
  Page left intentionally blank UNPERMITTED STREET FOOD VENDORS IN SANTA BARBARA COUNTY SUMMARY Food vendors in Santa Barbara County are required to follow food safety laws to ensure the safety of their products. In recent years, however, the presence of unpermitted street food vendors—push carts, food trucks, and tented restaurants—operating in Santa Barbara County has become widespread. Their unprecedented growth threatens not only the economic vitality of permitted restaurants and food trucks in the region, but, most importantly, the health of customers from sales of food prepared under potentially unsanitary conditions. The 2024-25 Santa Barbara County Grand Jury (Jury) has found that the County has not been able to effectively enforce permitting requirements or routinely inspect mobile food vendors in Santa Barbara County, as the mobile nature of such food vendors poses barriers to effective enforcement and inspection on several fronts. The Jury recommends that the County allocate funds to hire inspectors sufficient in number to enforce existing food safety laws, and also that law enforcement work closely with inspection personnel to safeguard in-person enforcement and inspection efforts. To protect the public from food-borne illnesses and other harms posed by unpermitted food vendors, the County must meet the challenge with more effective enforcement strategies.
• CL54
  While their consequences may have been unintended, SB 946 and SB 972 triggered a surge in unpermitted food vending operations across Santa Barbara County, reaching a scale that now poses a threat to public health and safety. The County—specifically, the County of Santa Barbara Health Department—is mandated to enforce food safety regulations through permitting and routine inspections of food vendors. However, significant enforcement gaps have emerged, leaving residents and visitors alike vulnerable to health risks posed by unpermitted mobile food vendors who prepare potentially hazardous foods. Among these vendors, there is widespread disregard and defiance of governmental regulations designed to protect public health. With no foreseeable relief to come at the state level, local authorities must devise their own effective enforcement solutions. While multi-jurisdictional task forces show promising results, they must encompass the full range of appropriate agencies, and funding for inspectors who focus specifically on food safety violations must be prioritized. -153- FINDINGS AND RECOMMENDATIONS Finding 1: County Health’s ability to inspect mobile food vendors and enforce food safety regulations has been limited by the small number of inspection personnel currently employed in its Environmental Health Services Division. Recommendation 1: The Grand Jury recommends that the Board of Supervisors provide County Health with sufficient funding to hire additional inspectors to facilitate more frequent inspections of mobile food vendors and to enforce compliance with existing food safety laws if violations are discovered. To be implemented by July 1, 2026. Finding 2: There is no established process by which the public can report unpermitted mobile food vendors to County Health, thus making enforcement of food safety requirements more difficult. Recommendation 2: The Grand Jury recommends that the Board of Supervisors direct County Health to establish a tip line for the public to report information about mobile food vendors who are not permitted. To be implemented by January 1, 2026. Finding 3: County Health efforts to conduct inspections of mobile food vendors have been negatively impacted by safety concerns for inspection personnel. Recommendation 3a: The Grand Jury recommends that the Santa Barbara County Sheriff’s Office delegate deputies to accompany County Health inspectors so that the inspectors, with the support of law enforcement, can safely enforce permitting and inspecting in the unincorporated areas of Santa Barbara County and in incorporated areas where the Sheriff’s Office is contracted to provide services. To be implemented by January 1, 2026. Recommendation 3b: The Grand Jury recommends that the Board of Supervisors direct County Health to partner with municipal law enforcement agencies so that health inspectors, with the support of law enforcement, can safely enforce permitting and inspecting within incorporated municipalities. To be implemented by January 1, 2026. Finding 4: Food trucks and carts are often not located in proximity to restroom or handwashing facilities for staff and customers as legally required, which poses a significant public health risk. Recommendation 4: The Grand Jury recommends that the Board of Supervisors direct County Health to focus inspection and enforcement efforts on mobile food vendors who operate without proximity to appropriate restroom or handwashing facilities. To be implemented by January 1, 2026. -154- REQUEST FOR RESPONSE Pursuant to California Penal Code §933 and §933.05, the Grand Jury requests that each entity or individual named below 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 Santa Barbara County Board of Supervisors - 90 Days Findings 1, 2, 3, 4 Recommendations 1, 2, 3a, 3b, 4 Santa Barbara County Sheriff’s Office - 60 Days Finding 3 Recommendation 3a -155-
• CL55
  Page left intentionally blank FEMALE INMATES AT SANTA BARBARA COUNTY JAILS Making Better Choices SUMMARY There are two distinct populations in Santa Barbara County’s jails: male and female. The 2024-25 Santa Barbara County Grand Jury conducted an investigation into the living conditions for female inmates. As required by the Fourteenth Amendment of the Constitution of the United States, jail administration has the responsibility to ensure that female inmates receive the same consideration as male inmates. Female inmates only make up approximately 10 to 11 percent of the daily average population at both of the County's jails, and the Jury finds that this results in certain disparities in conditions for male and female inmates. Even minor changes in living conditions could have a remediating effect on female inmates’ physical and emotional welfare, extending beyond the jail.
• CL56
  Meeting with female inmates and hearing them express themselves was an experience that should be shared with administrative staff at the County’s jails, the Santa Barbara County Board of Supervisors, and the public. Paying attention to requests for more positive experiences in the jails, such as vocational and educational opportunities, could help these female inmates reach that awakening that we hope every inmate can have. The women at the County’s jails want to be heard and want to maintain their dignity. The Jury learned that female inmates want to improve some conditions that are bothersome, but, at the same time, that they want to assure staff and volunteers that their contributions are working. -163- FINDINGS AND RECOMMENDATIONS Finding 1: To their detriment, female inmates have fewer work opportunities than male inmates in preparing them for life outside jail. Recommendation 1: The Grand Jury recommends that the Sheriff’s Office provide work detail opportunities to female inmates at both of the County's jails in crews that allow for a more flexible number of women. To be implemented by January 1, 2026. Finding 2: College classes are not available at the Main Jail to the same extent that they are available at the Northern Branch Jail, depriving women at the Main Jail of equivalent educational opportunities. Recommendation 2: The Grand Jury recommends that the Sheriff's Office expand current educational and vocational course offerings at the Main Jail in cooperation with local colleges. To be implemented by January 1, 2026. Finding 3: Women inmates are receptive to therapy and self-improvement groups. While the Sheriff's Treatment Program is available at both of the County's jails, the activities provided by community organizations—such as yoga, book clubs, and mutual-support recovery groups—vary between the two facilities. Recommendation 3: The Grand Jury recommends that the Sheriff’s Office expand its efforts to make more community-provided self-improvement and therapy programs available to educate and motivate inmates at both jails, including the women. 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 -164- - 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 Santa Barbara County Sheriff’s Office – 60 days Findings 1, 2, 3 Recommendations 1, 2, 3 -165-

Commendations 4

• CM1
  The 2024-25 Santa Barbara County Grand Jury commends the County of Santa Barbara Health Department for its work in achieving high vaccination rates among children in public and private schools.
• CM2
  The 2024-25 Santa Barbara County Grand Jury commends the Santa Barbara County Probation Department for its work in monitoring and achieving high vaccination rates in incarcerated youths. -45- FINDINGS AND RECOMMENDATIONS Finding 1: The lack of County-wide childhood vaccination data for homeschooled children means that County Health knowledge of community immunity levels is incomplete.
• CM3
  The County has taken important steps to implement oversight mechanisms at the jails to improve Wellpath’s compliance with the new contract and the jails’ adherence to national care standards. The Jury commends the Santa Barbara County Board of Supervisors, the Sheriff’s Office, the County of Santa Barbara Health Department, the Santa Barbara County Department of Behavioral Wellness, and their staff for their recent work in these pursuits. -103- FINDINGS AND RECOMMENDATIONS Finding 1: Because of the lack of an accurate and comprehensive master problem list in AAO’s electronic health record, Wellpath medical staff did not make fully informed decisions regarding AAO’s health needs and risks when he came to the Northern Branch Jail on August 29, 2024. Recommendation 1a: The Grand Jury recommends that the Board of Supervisors instruct the County of Santa Barbara Health Department to conduct systematic audits of inmates’ charts in the electronic health record to determine the extent to which master problem lists maintained by Wellpath accurately and comprehensively reflect inmates’ known health problems. To be completed by July 1, 2026. Recommendation 1b: The Grand Jury recommends that if non-compliance is discovered in the form of incomplete or inaccurate master problem lists so as not to meet performance measures established by the Wellpath contract, the County exact monetary penalties pursuant to the Service Level Agreement (Area 5. Incarcerated Person Problem List) in the new contract. Finding 2: AAO’s known medical history at the jail provided clear indicators for serious alcohol withdrawal risk, but no such identification occurred. Recommendation 2a: The Grand Jury recommends that the Board of Supervisors instruct the County of Santa Barbara Health Department to conduct audits to determine if Wellpath staff are appropriately identifying, monitoring, and treating at-risk inmates consistent with the U.S. Department of Justice’s Guidelines for Managing Substance Withdrawal in Jails. To be completed by July 1, 2026. Recommendation 2b: The Grand Jury recommends that if non-compliance is discovered in the form of missed cases of withdrawal monitoring or treatment, or performance of monitoring or treatment duties inconsistent with the U.S. Department of Justice guidelines so as not to meet performance measures established by the Wellpath contract, the County exact monetary penalties pursuant to the Service Level Agreement (Area 1. Withdrawal Management). Finding 3: Custody staff were not aware that AAO had an alcohol withdrawal alert or history because it was not communicated to them by medical staff or by means of an alert in the Jail Management System, though such communication would have been valuable. Recommendation 3a: The Grand Jury recommends that the Sheriff’s Office require a standardized verbal communication process upon inmate handover from the registered nurse performing the health receiving screening to the relevant on-duty classification deputy, specifically -104- requiring the sharing of health-related findings or history insofar as necessary to provide for the health and safety of the inmate or others. To be implemented by January 1, 2026. Recommendation 3b: The Grand Jury recommends that the Sheriff’s Office develop a comprehensive and automatic system of shared health alerts between the healthcare contractor’s electronic health record and the Jail Management System so that critical health-related alerts appear automatically in the Jail Management System. To be implemented by January 1, 2026. This report was issued by the Grand Jury with the exception of a Grand Juror who wanted to avoid the perception of a conflict of interest. That Grand Juror was excluded from all parts of the investigation, including interviews, deliberations, and the writing and approval of this report. 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 Santa Barbara County Board of Supervisors – 90 days Findings 1, 2, 3 Recommendations 1a, 1b, 2a, 2b, 3b Santa Barbara County Sheriff’s Office – 60 days Findings 1, 2, 3 Recommendations 3a, 3b -105- Page left intentionally blank
• CM4
  Page left intentionally blank ANOTHER SUICIDE IN SANTA BARBARA COUNTY JAIL Inmate’s Death Should Have Been Prevented SUMMARY The 2024-2025 Santa Barbara County Grand Jury (Jury) investigated the in-custody death of a female inmate (CC) at Santa Barbara County’s Main Jail (Main Jail). On the afternoon of November 13, 2024, CC hung herself by the neck using a wall-mounted telephone cord in a mental health observation cell. Penal Code §919(b) requires the Grand Jury to examine the operation of the jails within the County. Based upon its investigation of CC’s death, the Jury finds that several systemic problems within the Main Jail limited the staff’s ability to safeguard CC’s well-being, including insufficient numbers of properly equipped mental health observation cells. These issues resulted in a series of breakdowns leading to CC’s placement in an observation cell with a telephone cord, which ultimately resulted in her death. The Grand Jury finds that her suicide could and should have been prevented. The Jury finds that the County’s jails need additional funding to solve the many deficiencies that limit or obstruct the humane treatment of the many mentally ill inmates who occupy that space. The Jury is pleased to report that on April 1, 2025, the Santa Barbara County Board of Supervisors approved funding for construction of an additional 348 beds at the Northern Branch Jail, including more mental health beds, and an additional 20 custody deputies. When the construction is completed in 2029, inmates in the Main Jail will be transferred to the Northern Branch Jail, and most of the Main Jail will be closed. This will be a major step toward addressing the issues outlined in this Report. However, improvements must be made before 2029. INTRODUCTION Inmate suicides have been a recurring problem at local jails and state and federal prisons throughout the country, including Santa Barbara County. Nationwide, from 2001 to 2019, the number of suicides increased 85% in state prisons, 61% in federal prisons, and 13% in local jails.1 Between 2010 and 2019, suffocation, including hanging and self-strangulation, accounted for nearly 90% of suicide deaths in local jails. 1 Bureau of Justice Statistics, Suicide in Local Jails and State and Federal Prisons, 2000–2019 Statistical Tables. See https://bjs.ojp.gov/library/publications/suicide-local-jails-and-state-and-federal-prisons-2000-2019-statistical-tables -106- CC was a 41-year-old mother who resided with her family in Santa Ynez, California. She had a history of significant mental disorders and suicide attempts. On November 8, 2024, CC was pulled over by a Santa Barbara County Deputy Sheriff for driving in a reckless manner. After attempting to evade law enforcement and using her car as a weapon, she was arrested. She was first taken to Santa Ynez Cottage Hospital and was then transferred to Santa Barbara Cottage Hospital for a psychiatric evaluation. While there, she was booked in absentia for felony evading police officers, assault with a deadly weapon (automobile), and driving under the influence. On November 9, 2024, CC was moved to the Main Jail while awaiting arraignment. In the days preceding CC’s death on November 13, 2024, she made several suicidal statements to mental health providers, who then assigned her to a safety cell on suicide watch.2 Five days into her incarceration, CC was moved to a holding cell where she committed suicide by hanging. The County Coroner’s pathologist later performed an autopsy, finding that the cause of death was a suicide. During her incarceration, the mental health staff at the Main Jail did not know that CC had previously been diagnosed and treated for severe mental illnesses, including bipolar disorder and psychoses. Nor did they attempt to obtain such history from any of CC’s private doctors and hospitals. Thus, she was not offered a level of care commensurate with her mental health needs. When an inmate is deemed suicidal by a mental health provider (MHP), there are several protective housing options available.3 Safety cells are the highest level of protective custody and typically reserved for inmates at high risk of self-harm. The Main Jail has four safety cells. Once MHPs determine an inmate no longer requires a safety cell, the individual is relocated to a holding cell (known as a “step-down”), a lower level of protective custody. There are seven holding cells (H- 1, H-2, H-5, H-6, H-7, H-8 and H-9) in the IRC. By practice, H-1, H-2, and H-9 were the holding cells that SBSO would prioritize using for mental health observation purposes before utilizing other holding or housing cells. Based on need and physical plant logistics, cells H-6 and H-7 were used regularly for observation purposes. Inmates in an observation cell must be monitored by custody deputies every 15 minutes. Because some observation cells are on occasion used to hold newly arrived inmates who are legally entitled to make phone calls, three of these observation cells contained wall-mounted telephones with cords at the time of CC’s death. 2 Pursuant to applicable policies at the County’s jails, safety cells are to be used to temporarily house inmates who pose a threat to themselves or others. Inmates placed in safety cells are stripped of their clothing and given a paper smock which cannot be used as a ligature. The policy requires the on-duty Shift Commander or designee to approve safety cell assignments prior to placement. Jail protocols require custody deputies to conduct and document direct visual observations of safety cell inmates twice every 30 minutes. 3 For purposes of this Report, the MHPs are master’s level mental health counselors employed by Wellpath. -107- At the time of CC’s suicide, MHPs generally knew that step-down patients had sometimes been placed in holding cells with telephone cords when the three cordless cells were unavailable. MHPs recognized the risk of placing a potentially suicidal inmate into a cell with a cord but were limited in recommending other options to the Deputies due to the limited number of observation cells.

Observations 2

• OB1
  The following section provides a chronology of the events leading up to and following CC’s death in the Main Jail. Related Incident Two Weeks Prior to Death On October 28, 2024, approximately two weeks prior to her suicide, CC was visited at her home by a deputy sheriff for a welfare check, and an ambulance was called given her level of agitation. She was taken to the emergency department at Santa Ynez Valley Cottage Hospital evidencing a panic attack, anxiety, and depression. CC was angry, agitated and delusional during the evaluation. -108- CC had a history of suicide attempts. She was diagnosed with psychosis, malingering, conversion, and depression with psychotic features.4 During the examination, CC’s alter ego “Patricia” was manifesting. Patricia was typically more agitated and ruder to people than she was. The Mobile Crisis Team, a unit within Behavioral Wellness tasked with performing psychiatric hold evaluations within the County, was called and found that she did not meet the criteria necessary to issue a Welfare and Institutions Code section 5150 (5150) 72-hour involuntary hold because she did not express suicidal ideations.5 She was discharged from the hospital the same day. November 8, 2024 On November 8, 2024, CC’s car was pulled over by a Santa Barbara County Deputy Sheriff for driving her vehicle in a reckless manner. Although she initially stopped when the deputy’s overhead lights were illuminated, she suddenly drove off despite being ordered to stop. She nearly collided with parked vehicles, ran through stop signs, and sped through an elementary school parking lot towards a nearby park. A patrol car performed a “PIT” maneuver causing CC’s car to stop. She then reversed and collided with her vehicle into an occupied patrol car, rendering her unconscious. Deputies suspected that CC was overdosing and administered Narcan. Following her arrest, she was then transferred to Santa Ynez Valley Cottage Hospital for further evaluation. She told hospital staff that she may have been diagnosed with bipolar disorder.6 During her brief stay in the Emergency Department, medical staff found her to be at a high risk of suicide. She believed she was the devil and must kill herself to save and protect her children. November 9, 2024 Still under arrest but not yet cleared for transfer to the jail, CC was next transported to Santa Barbara Cottage Hospital on the morning of November 9, 2024, for further psychiatric assessment of her suicidal ideations. While there, she was booked in absentia for evading police officers, assault with a deadly weapon (her car), and driving under the influence of drugs. She reported to 4 Malingering is the intentional production or display of false or exaggerated symptoms for a specific benefit or reward. Conversion disorder is a mental health condition that causes real, physical symptoms that a person cannot control. Psychosis is a term for symptoms that happen when a person has trouble telling the difference between what is real and what is not. 5 Pursuant to Section 5150, subdivision (a), “When a person, as a result of a mental health disorder, is a danger to others, or to themselves, or gravely disabled, a peace officer, professional person in charge of a facility designated by the county for evaluation and treatment, member of the attending staff, as defined by regulation, of a facility designated by the county for evaluation and treatment, designated members of a mobile crisis team, or professional person designated by the county may, upon probable cause, take, or cause to be taken, the person into custody for a period of up to 72 hours for assessment, evaluation, and crisis intervention ….” 6 Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings. These include emotional highs, also known as mania or hypomania, and lows, also known as depression. See https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955 -109- staff at the hospital that she tried to choke herself when visiting deceased relatives at a cemetery that day. She stated that she was taking Xanax but had stopped taking her other medications, including medications for bipolar disorder. CC told hospital staff she was suicidal. A member of the hospital’s mental health staff documented that CC needed psychiatric hospitalization. However, a few hours later, during her interview with a hospital psychiatrist, CC denied suicidal ideations and did not meet the criteria for a 5150 hold. CC was diagnosed with adjustment disorder with mixed disturbance of emotions and conduct and was discharged to the Sheriff’s Office’s (SBSO) custody.7 Later the same day, she was moved to the Main Jail. When entering the Main Jail’s Inmate Reception Center (IRC), there were no prior Jail medical records available to medical staff because she had not been recently incarcerated in a jail in the County. CC indicated that she suffered from bipolar disorder and depression, and mental health staff was notified accordingly. However, bipolar disorder was never diagnosed nor treated by any Jail mental health staff. During the intake interview, CC stated that she had attempted to choke herself the previous day but was no longer experiencing suicidal thoughts. At that time, she was assigned to a cell in the general population unit known as West 6. A psychiatric consultation was not sought. November 10, 2024 On the morning of November 10th, a deputy in West 6 asked a Jail MHP to assess CC because she was having problems with other inmates in her unit. More specifically, those female inmates confronted CC because she was hovering over them and violating their personal space. During the MHP’s discussion with CC, she appeared to have difficulty keeping her eyes open and was breathing very deeply as though she was about to hyperventilate. She then collapsed to the ground. Medical staff was called to the scene and reported that she was awake, shaking, and speaking nonsensical sentences. She stated that she deserved to die and made other suicidal statements. The MHP then ordered her transferred to Safety Cell 3 (on suicide watch) by wheelchair because she could not walk. In the safety cell, she stated that she needed a pregnancy test and that she loved her babies. She then attempted to choke herself.8 The Jury learned that some MHPs would routinely call the Mobile Crisis Team to assess all inmates placed in safety cells.9 If asked, the Mobile Crisis Team would usually come to the Main Jail within the hour. The Mobile Crisis Team would typically assess safety cell inmates during their routine 7 “Adjustment disorder with mixed disturbance of emotions and conduct” is defined as an extreme reaction to a stressful incident that impacts mental equilibrium and causes negative changes in behavior. See https://www.hopkinsmedicine.org/health/conditions-and-diseases/adjustment-disorders 8 Wellpath’s on-call psychiatrist was not called on November 10th because she did not work on weekends (November 10th was a Sunday). 9 The Mobile Crisis Team is called to assess inmates who need an assessment for an involuntary 72-hour hold. It is staffed by at least one Marriage and Family Treatment Counselor. -110- daily visits to the Main Jail. Here, however, the Mobile Crisis Team inexplicably did not evaluate CC until the evening of November 12th. November 11, 2024 During a safety cell round by medical staff on November 11th at 2:03 a.m., CC was very anxious and was having difficulty sleeping. CC was observably distressed and crying at the time. CC expressed delusional thoughts claiming the devil would harm her children. CC did not make any threats to herself or others. An antihistamine was prescribed to treat these behaviors. At 8:09 a.m. on November 11th, an MHP visited CC in Safety Cell 3. The MHP offered to speak confidentially with CC in a private room, which CC declined. Thus, the MHP briefly spoke with CC through the food slot in the cell door. CC stated that she was not suicidal and would not engage in a Collaborative Safety Plan (CSP).10 She appeared anxious, angry, and hostile and again noted she was concerned about being pregnant. The MHP concluded that CC no longer needed a safety cell and advised the Deputies to move her to an observation cell. Custody deputies then placed her in Holding Cell H-6, which had a wall-mounted telephone and 12-inch cord.11 November 12, 2014 On November 12th, while housed in cell H-6, CC stated that she wanted to kill herself by hanging. At approximately 8:00 a.m., CC told the MHP that prior to her arrest she had been seeing a psychiatrist at a health clinic, where she was prescribed Hydroxyzine and Xanax.12 The MHP did not document CC’s prior history of bipolar disease, nor her history of stopping her previously prescribed anti-psychotic medication. The MHP told CC that the Mobile Crisis Unit would assess her that evening and that she would again be placed in a safety cell in the interim. The MHP noted that CC had not yet been diagnosed but offered a provisional diagnosis of major depressive disorder. CC was then moved to Safety Cell 4. CC was evaluated by the Mobile Crisis Team at 10:30 p.m. on November 12th, which found that she did not qualify for a 5150 hold. The evaluator from the Mobile Crisis Team was not a licensed mental health worker. The Mobile Crisis Team did not document its denial of a 5150 hold in writing. CC was characterized as not volatile, and she denied any suicidal ideations during that encounter. However, the Mobile Crisis Team felt that CC exhibited bizarre behavior that necessitated further evaluation and treatment. Because there was no documentation of this 10 A CSP includes a series of questions used to determine warning signs, coping skills and the patient’s “reasons for living,” for example the extent of supportive family and friends. 11 According to SBSO policy, “the Classification Unit will assign appropriate housing with consideration to those inmates with physical and/or mental disabilities and/or special needs.” 12 Hydroxyzine is an antihistamine used to treat anxiety, tension, and allergic conditions. Xanax is used to help control anxiety and tension caused by nervous and emotional conditions. -111- assessment, the Jury cannot determine whether the Mobile Crisis Team knew of CC’s bipolar disorder or recommended a treatment plan. November 13, 2024 – Day of Suicide On November 13th, at approximately 8:46 a.m., an MHP spoke with CC in Safety Cell 4 for about five minutes. At the time, CC was not in any acute mental distress and stated she did not want to kill herself. She mentioned that her children provided her with a reason for living. CC was scheduled to be seen by a Jail psychiatrist later that morning. The MHP notified custody staff to step down CC from the safety cell to an observation cell. A custody deputy placed CC into cell H-6.13 That cell contained a wall-mounted telephone with a 12-inch cord. All three of the cordless mental health observation cells were occupied when CC was stepped down from the safety cell on November 13th. CC was never evaluated or diagnosed by a psychiatrist during her time in jail. For the first time, on November 13th at approximately 1:39 p.m., a Jail psychiatrist was scheduled to evaluate CC from a remote location via telehealth, but CC refused. She was never assessed by the psychiatrist. Instead, the psychiatrist merely prescribed Hydroxyzine and scheduled a follow up visit for a week later. The psychiatrist took no further actions to address CC’s refusal of that evaluation, made no inquiries of Jail MHPs, did not review any of CC’s prior mental history, did not know CC had been in safety cells for suicidal ideations twice in the previous three days, did not know she had been diagnosed with bipolar disorder, and did not prescribe antipsychotic medication. Jail staff conducted safety checks of CC throughout the day, including at 4:04 p.m., 4:19 p.m., and 4:31 p.m., all of which demonstrated no unusual circumstances. However, while performing rounds at approximately 4:48 p.m., a custody deputy observed CC hanging from a 12-inch telephone cord wrapped around her neck. The deputy radioed a request for additional Deputies to respond to H-6 due to a hanging. The Shift Commander called for an ambulance. Deputies and Jail medical staff continued to administer medical aid until paramedics arrived at approximately 4:57 p.m. At approximately 5:31 p.m., paramedics terminated resuscitation efforts, and CC was pronounced dead. An autopsy was later conducted by the Coroner’s Bureau, which concluded that the cause of death was suicide by hanging. After Death Events As noted above, two holding cells that contained telephones with 12-inch cords were regularly used as observation cells when other options without telephones were not available. Several days after CC’s death, Jail staff removed the telephone cords from cells H-6 and H-7. Since then, all 13 The custody records contain conflicting data regarding which observation cell CC was assigned to. -112- holding cells that contained a telephone with a 12-inch cord have had the phone cord removed. There are now seven holding cells that do not have any phone cords. Photos taken of cell H-6 after CC’s death revealed a wall-mounted telephone with a 12-inch cord emanating from the bottom of the telephone. Based upon the Jury’s research, several options on the market could have been installed to prevent inmate suicides using telephone cords, including telephones with six-inch cords, wireless speaker telephones, and a telephone cord that comes out of the top of the telephone housing, making it more difficult to use as a ligature. Board of Supervisors Hearing Regarding Jail Health Monitoring On March 11, 2025, a hearing was conducted by the Board of Supervisors to provide an update on Jail Health Monitoring activities. According to performance audits conducted by the County’s Health Department and Behavioral Wellness, of 29 combined quality assurance measures reflecting the adequacy of health coverage, the Main Jail was rated “noncompliant” in nine measures, and “persistently noncompliant” in five of the nine. For the Northern Branch Jail there were eight measures of noncompliance, five of which demonstrated “persistent noncompliance.” The measure that generated the most alarm from the County Supervisors was the extent to which Wellpath failed to meet its contractual obligation to medically assess inmates placed in safety cells every four hours, properly doing so as required only 13 percent of the time at the Northern Branch Jail and 73 percent of the time at the Main Jail. Likewise, MHPs failed to timely check on such inmates inside safety cells within 12 hours, as the contract requires, doing so properly only 67 percent of the time at the Northern Branch Jail and 80 percent of the time at the Main Jail. On April 1, 2025, the Board of Supervisors approved a new two-year contract with Wellpath.
• OB2
  The Female Inmate Perspective on Living Conditions The female inmates have common concerns and common complaints that vary only somewhat between the two facilities. The complaints ranged from choices for the little things in daily living to options for life-enhancing activities. One such concern was that men can join work crews and prepare meals in the kitchen, do the laundry, do maintenance, or clean the facility. There are enough men to fill a work crew, and if someone is sick, a replacement can be found. Women, on the other hand, are fewer in number. So, when a female inmate is sick, or does not feel like working, which can happen often, there are not enough women available to fill the crew. The result is that women have few work detail opportunities in the jails at this time. This loss of work opportunities affects the women in several ways. First, they lose the ability to do something, to be active. Some women are said to be so bored that they sleep all day. Additionally, they do not feel productive, which reduces their self-esteem. Women at both jails described this as a true lack of opportunity. Moreover, the loss of not being able to work is that they are not learning or practicing skills that they could use outside the jail to look for a job. Many do not have a strong support system, and leaving the jail without a job skill or recent experience worried them. Without a family, a social group, or a system to keep them afloat, the women were anxious about being released. The Sheriff’s Office is reconsidering the minimum number of women required for work crews in recognition of their ability and willingness to work. Custody management is looking into allowing fewer women to make a team for some tasks such as cleaning, and are also discussing how to incorporate women into work crews. -159- Classes in jail can also prepare inmates for release, especially if the classes train for some sort of job. At the NBJ, classes in installing solar panels are in demand. But the females could not join them, again because of not enough female inmates to reach the minimum of ten people to fill a class. The women are cut off from the one job skill preparation class that does exist. The Sheriff’s Office is discussing lowering the minimum required to eight people rather than ten. Other job training in the jail is not available at this time with the exception of a program offered at both jails, known as SERVSAFE, which trains for a Safe Food Handling certificate. At this time, however, only male inmates can practice this skill in the jail kitchen duty. Female inmates also directed the Jury’s attention to the commissary. The commissary vendor has reduced the number of options for women. As stated in the April 1, 2025, letter to the Board of Supervisors concerning the new contract for the vendor, the Sheriff’s Office wrote: Commissary services play a crucial role in the proper management of incarcerated individuals by providing access to items that can improve quality of life, such as snacks, better hygiene products, and other personal care items. Having the ability to choose and buy items helps mimic the out-side world’s consumer choices and can contribute to a sense of normalcy among inmates. The current vendor has reduced the number of options to one kind each for such basic items as shampoo and soap. As a result, shampoo and soap products favor the much larger male population. The vendor is further seen as providing additional items for men only such as aftershave, shaving gel, and shaving cream. For hair conditioner and body lotion, there is only a generic brand in small travel-sized bottles. There is no other choice as there had been with the previous vendor, which had a “feminine package” that included brands more used by women. Since they do not have these options, the women inmates feel robbed of their dignity. This vendor has a one-year contract, and the female inmates hope that the next vendor will provide them with more options. In addition, the Jury found that, in general, the women were frustrated by the lack of food choices. They were enthusiastic about a new food vendor last fall, but disappointment grew as food offerings became more limited. The initial welcome came with the addition of fruit and fresh vegetables with the new vendor. Unfortunately for the NBJ, while some of the women invented small pies with the fresh fruit, some men saw fruit as an opportunity to make homemade alcohol, causing the vendor to remove fruit from their offerings to both men and women. Women at the Main Jail complained less about the food as they still received fruit. This situation has been remedied, but then the main dinner course offering was reduced to beans and rice for a time, which female inmates criticized for lack of variety. The nutritional value of the food is questioned especially by women who want to keep their weight down, a difficult ambition given the lack of food variety and the lack of exercise available. -160- A prior disparity between men and women was mentioned for clothing. For a time, men were allowed to wear shorts; the women were not. When the men began to cut off their pants to make them shorts at the Main Jail, once again jail management had to disallow shorts for everyone. Also, there was some confusion over women not being allowed to wear their sweatshirts to classes at NBJ, but the men could. This was eventually resolved in the women’s favor, and they can wear the sweatshirts when they leave their unit for another activity. However, women at the Main Jail will have to wait indefinitely for a different disparity to be resolved: television. Only one channel can be shown at a time across all the televisions in the technologically-challenged Main Jail. Female inmates therefore “watch a lot of soccer” because the Deputies program what the male inmates want to watch. At NBJ, the women’s units can select their own choices in television shows and movies. When inmates have a complaint or a suggestion, the process requires them to file a grievance and get signatures of other inmates. Grand Jurors did not find an example of female inmates petitioning for change. However, when women convey a problem to the custody deputies, they quickly respond to fix it. “They’re cool,’ one inmate said; “They help.” How Women Benefit from Incarceration There are educational classes at NBJ provided by Allan Hancock College that have greatly uplifted the inmates, and the female inmates seem particularly aware of the personal growth attained. Hancock College typically teaches three to four credit classes per semester. In fact, the women at NBJ asked for more general education credit classes and expressed a desire to continue studying at the college once released. They are encouraged by Hancock’s Rising Scholar program that assists former justice-involved inmates with fitting in, giving them supplies, mentoring, and even loaner laptops. In June 2025, Allan Hancock College awarded certificates of completion to 55 inmates at NBJ; six of these were women. Additionally, the jurors learned of one woman who continued classes until she received a college degree. Allan Hancock College will also start computer classes for credit at the NBJ later in 2025. Educational offerings at the Main Jail in Santa Barbara have not come back to the pre-Covid level of offerings. Currently, two classes are offered by Santa Barbara City College on alternating semesters at the Main Jail, a stress management class and a “College Ready Study Skills” class. At one time, computer literacy classes were offered at the Main Jail, but now these classes will exist only at NBJ. The return of computer classes at the Main Jail would offer educational and vocational enrichment to this population that is so appreciative of opportunities to change. Classes are available on the personal tablets issued to each woman at the jails, but these classes are not always free. It would benefit the women at the jail to also have the stimulation of contact with teachers and other students. -161- The Public Defender’s Office has staff that meet with inmates as they enter the jail. Their intention is to get to know the inmate, find out what their needs are, and help expedite solutions for their release. The Public Defender’s holistic defense program is not as well developed in South County as it is in North County, so there exist fewer Public Defender staff members to direct female inmates to support programs in South County. The female inmates in the Main Jail expressed understanding: “Oh, they’re so overworked.” The Jury learned that the Sheriff’s Office is hoping to arrange a one-year pilot program to boost the Public Defender’s program in South County. If this effort succeeds, it will be an important step towards supporting female inmates after their release. The Sheriff’s Treatment Program (STP) has been a successful program for decades. Classes center around personal development and interpersonal skills. Especially noted are the STP classes in drug and alcohol education, criminal and addictive thinking, and anger management. The female inmates mentioned this program and its role in helping them endure incarceration. There are also occasional counseling groups and therapy sessions with volunteers outside the jail that the inmates can attend. In addition to the Sheriff’s Treatment Program, each jail has different opportunities provided by different community organizations: at NBJ women meet with Planned Parenthood and yoga groups, and the acclaimed Freedom to Choose program will begin. At the Main Jail, there is a book group for women, and one organization in particular was praised: GOGI, Getting Out by Going In. The emphasis on a better future life by knowing oneself encouraged the female inmates to look ahead, giving them a will to change behavior. Well known organizations such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) also help the inmates. At the moment, NA is not meeting in the Main Jail. The women at both jails appreciated their access to mental health services. They could request a visit from a mental health counselor, and one would come with no long delay. Counselors help them to help themselves. The Jury learned that one female inmate, who had attended required group counseling at another jail, stated that having to go to group sessions helped her and other inmates and gave them something to do. Medical care was less praised. The female inmates had to put in a lot of “kites,” or call slips, to see someone, and if it was a specialty doctor, there was a long wait time. There is only one full time doctor and only one dentist at the moment who spend their time helping incarcerated individuals. Thus, a request for care can seem to go unanswered for a long time. However, the women affirmed that health issues specific to women were not neglected. Santa Barbara County's new contract (signed April 1, 2025) with the existing healthcare provider at the jails adds more nurses and mental health aides to the jail, which will help to some degree, as there are many inmates inside the jails who need medical care. -162- Overall, what should be noted is that the female inmates see the jail staff as helping and see themselves as getting help. There are disadvantages that are inherent in being incarcerated. When asked what is bad about being in jail, one woman answered, “You are in jail.” All agreed. They also shared the opinion that the hardest aspect of that was being away from their family. There are annoyances such as not enough products for women in the commissary, the mail being extremely slow, and not being able to go outside often enough, but these facts are part of living within the cement walls of a detention facility. Some are grateful to have a bed, food, a shower, and shelter. The women who would be homeless outside the jail were especially relieved. As one said, “It’s humbling, but it’s a safe place.” Female inmates understand that they are there for a reason. The female inmates also seem to know that they are there for a purpose and recognize that they can change. The benefits of incarceration mentioned by these women were:  Getting healthier  Getting into a routine  Being off drugs and alcohol  Connecting with your higher power  Building a foundation  Learning patience and anger management  Having time to think  Getting to know yourself  Being with the girls While the women in jail can be frustrated by limited choices in daily living, they know that they can make better choices in life.

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