Santa Cruz County Civil Grand Jury Rainbow the Reports

The County’s need for Outreach to raise awareness of passenger vehicle greenhouse gas (GHG) reduction goals is not being addressed by staff in significant ways.

Responsibility for the County’s Outreach efforts isn’t clearly defined. Even interested citizens have trouble finding updates.

The County Staff and the Commission on the Environment (COE) charged with reporting to superiors (i.e., Board of Supervisors) don’t stay current in publicly publishing their actions regarding the Climate Action and Adaptation Plan (CAAP).

Staff charged with instigating/tracking/coordinating efforts required by the CAAP do not consider public Outreach part of their task.

Money was spent to create progress trackers on the CAAP Storymap Website, but no one is updating the progress.

Money has been spent to create another interactive website (Resilient Santa Cruz) for the interested citizen, but that website is not being publicized, and the modest participation goals have not been met.

County web pages and social media specifically created for reporting to the public have been allowed to languish and are not populated with recent news items on CAAP goal progress. Climate Action Demands Outreach published June 2, 2025 10 Santa Cruz County Civil Grand Jury

The services of an Ombudsman could be utilized by tradespeople and homeowners to make the permitting process smoother and less costly.

The BFCA Board was disbanded, and the Appeals process, as currently constructed, is little known, not staffed by trade professionals, and therefore an ineffective means for resolving disputed decisions. Navigating the Building Permit Process published June 23, 2025 56 Santa Cruz County Civil Grand Jury

The DIYer and the small contractors need the support and/or instant answers they get from a knowledgeable staff person at the counter. However that service no longer exists.

Local nonprofit organizations have 24/7 hotline numbers that are staffed, and calls can be answered immediately or within minutes, greatly increasing the likelihood of contacting victims and providing assistance in real time. Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 99

There has been a lack of human trafficking presentations to law enforcement. Local law enforcement jurisdictions could request the no-cost training that is available from local human trafficking service providers. This can lead to officers learning to identify human trafficking victims and reduce further victim trauma.

Law enforcement task forces focused solely on human trafficking are very effective methods of detecting and preventing human trafficking activities. Such task forces could increase the rate of interdiction and the successful prosecution of human trafficking cases.

POST. January 1, 2020. “DE-ESCALATION Strategies & Techniques FOR CALIFORNIA LAW ENFORCEMENT.” POST. Accessed February 5, 2025. https://post.ca.gov/Portals/0/post_docs/publications/DeEscalation.pdf 51. Confidential Grand Jury interview. 52. Confidential Grand Jury interview. 53. Confidential Grand Jury interview. 54. California Commission on Peace Officer Standards and Training. December 31, 2020. “Deescalation Strategies and Techniques for California Law Enforcement.” POST Website. Accessed March 7, 2025. https://post.ca.gov/Portals/0/post_docs/publications/DeEscalation.pdf Handcuffing and Transport published June 18, 2025 78 . CalPERS. August 12, 2024. “Pension Reform Impacts.” CalPERS. Accessed February 26, 2025. https://www.calpers.ca.gov/employers/policies-and-procedures/pension-reform-i mpacts#:~:text=The%20California%20Public%20Employees'%20Pension,'%20R etirement%20Law%20(PERL). 56. Confidential Grand Jury interview. 57. Confidential Grand Jury interview. 58. National Testing Network. July 16, 2024. “Watsonville Police Department Job Information.” National Testing Network Website. Accessed February 26, 2025. https://nationaltestingnetwork.com/publicsafetyjobs/fullJobDetails.cfm?agencyjobi d=1192&jobid=1&agentid=745 59. County of Santa Cruz Personnel Department. February 26, 2025. “Santa Cruz County Government - Job Salary Schedule.” County of Santa Cruz Personnel Department. Accessed February 26, 2025. https://www2.santacruzcountyca.gov/personnel/salsched/OccCdDisp.asp?OccDe sc=LAW%20ENFORCEMENT%20*%20RELATED%20%20%20%20%20%20%2 0%20%20%20%20%20 60. San Jose Police Department Recruitment. January 1, 2025. “Salaries, Benefits, Pension.” San Jose Police Department Website. Accessed February 26, 2025. https://www.sjpdyou.com/for-applicants/additional-information/salary-benefits-pen sion#:~:text=Salary%20*%20Paid%20Academy%20training%20for%20Police,Pl us%202nd%20and%203rd%20watch%20shift%20differential. 61. Confidential Grand Jury interview. 62. Confidential Grand Jury interview. 63. Confidential Grand Jury interview. 64. Confidential Grand Jury interview. 65. Atlas of Surveillance. March 28, 2019. “Watsonville Police Department: Body-worn Cameras.” Electronic Frontier Foundation and the Reynolds School of Journalism at the University of Nevada, Reno. Accessed March 7, 2025. https://atlasofsurveillance.org/a/aos000151-watsonville-police-department-body- worn-cameras 66. Confidential Grand Jury interview. 67. Confidential Grand Jury interview. 68. Confidential Grand Jury interview. 69. WYSM. January 1, 2025. “From Duty to Desire. Leadership and empowerment training for first responders and the community..” WYSM (Why'd You Stop Me?) Website. Accessed February 21, 2025. https://wysm.org/ Handcuffing and Transport published June 18, 2025 2024-2025 Consolidated Final Report 79 70. Confidential Grand Jury interview. 71. Confidential Grand Jury interview. Websites https://post.ca.gov/ https://www.watsonville.gov/2324/Police https://shf.santacruzcountyca.gov/ Handcuffing and Transport published June 18, 2025 80 Santa Cruz County Civil Grand Jury Human Trafficking in Santa Cruz County Voices Unheard, Signs Unseen Summary Human trafficking is defined by the U.S. Department of Justice as a crime involving the exploitation of a person for labor, services, or commercial sex. The Grand Jury concluded that human trafficking goes largely unrecognized and unreported in Santa Cruz County. This report will show that there is a lack of training and prevention activities provided to youth, school administrators, teachers, and law enforcement. State and local mandates meant to curtail trafficking are often not enforced. Additionally, there is insufficient coordination among stakeholders to address the issue of human trafficking. The Grand Jury recommends actions that will increase collaboration among responsible agencies to better recognize and respond to human trafficking, coordinate handling of cases to support prosecutions, and secure additional funding while providing more effective support for prevention and increasing public awareness of the problem. Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 81 Table of Contents Summary 1 Background 3 Scope and Methodology 4 Investigation 4 What is Human Trafficking? 4 The Scope and Nature of the Problem 5 Vulnerable Populations in Santa Cruz County 5 Indicators of Trafficking Activity 8 What Resources are Available to Human Trafficking Victims? 8 State Laws Regarding Prevention and Support Services to Minors 9 SB 855 - Human Services Omnibus Trailer Bill for the 2014-15 Budget 9 AB 1227 - Human Trafficking Prevention Education and Training Act (2017) 10 State Laws and Local Ordinances Regarding Human Trafficking 10 Pending Legislation 10 Existing State Legislation 11 Local Ordinances 11 Why Are So Few Human Trafficking Cases Prosecuted? 12 Santa Cruz County - A Feeder for San Francisco Bay Area Trafficking 13 There is Room for Improvement 13 Conclusion 18 Findings 19 Recommendations 20 Required Responses 21 Invited Responses 22 Definitions 22 Sources 23 References 23 Websites 28 Site Visits 28 Reducing Human Trafficking published June 30, 2025 82 Santa Cruz County Civil Grand Jury Background Human trafficking is poorly understood, difficult to define, and therefore, acquiring solid data is scattered and fractured. Though the common perception is that human trafficking happens primarily in other countries, it is indeed a significant problem in the United States. California consistently reports a high volume of human trafficking calls in the US, according to data from the National Human Trafficking Hotline (National Hotline). California also ranks #8 per capita at 28.88 victims per 100,000 residents.[1] In 2023, California had approximately 1,128 reported cases involving 2,045 victims. Roughly 62% of these cases involved sex trafficking.[2] It is estimated by the National Institute of Justice (NIJ) that 85% of human trafficking cases go unreported. However, the NIJ also states that this 85% rate of underreporting is a minimum.[3] [4] This translates into potentially 5,000-10,000 cases per year in California. Young girls between the ages of 12-14 years old and boys between the ages of 11 and 13 years of age are especially vulnerable.[5] [6] ● One local service provider states that it gets 5-7 calls on average per week from victims and estimates that in any given week, there are 200 sex trafficking victims in Santa Cruz County. ● A different local service provider representative states that in the past three years, it has served approximately 20 human trafficking victims who were minors between the ages of 12 to 18. This is a significant number of cases considering that the agency serves victims of multiple types of crimes. ● Public presentations made by a third local service provider generate 8-10 human trafficking cases annually. ● The County Office of Education (COE) administration is aware of two reported cases of sex trafficking among their 800 at-risk students in the 2024-2025 school year and is aware of at least four other suspected cases within the past three to four years.[7] [8] However, other COE staff working with at-risk students reported being unaware of any cases of student human trafficking. The California Department of Justice determined that human trafficking, both sex and labor trafficking, is the fastest-growing criminal enterprise globally and is increasing in California. This is because human trafficking is a very lucrative business. Unlike drug sales, the commodity (sex or forced labor) can be sold over and over.[9] Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 83 Scope and Methodology In its investigation of human trafficking in the County, the Grand Jury (the Jury) set out to determine the following: ● The prevalence of human trafficking in the County of Santa Cruz. ● The level of education and outreach to youth and other vulnerable populations for the prevention of human trafficking. ● Law enforcement challenges in the prosecution of traffickers. ● Resources available to provide services to victims of human trafficking. The Jury’s investigation consisted of 19 interviews with County and various City law enforcement officers, non-profit agencies focusing on serving human trafficking victims, actual human trafficking survivors, school administrators, County administrators, administrators from a neighboring county, farmworker advocates, and homeless outreach workers. In addition, the Jury researched State and local laws and ordinances related to the prevention and monitoring of human trafficking and the funding for these activities. The Jury also surveyed a random selection of businesses in each of the County’s five supervisorial districts for compliance with signage requirements. Finally, Jurors did extensive research on websites related to human trafficking, attended local public events intended to raise public awareness, and obtained supporting documentation from interviewees as well as filed Public Records Act requests. Investigation What is Human Trafficking? The simplified US legal definition of human trafficking is: The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of involuntary servitude, peonage, debt bondage, or slavery. Or, for commercial sex acts in which the person induced to perform such acts is under 18 years of age or is forced, defrauded, or coerced.[10] The coercion can be subtle or overt, physical or psychological. Exploitation of a minor for commercial sex is human trafficking, regardless of whether any form of force, fraud, or coercion was used. [11] In Santa Cruz County, recruitment, harboring, and coercion are consistently reported in human trafficking cases. Reducing Human Trafficking published June 30, 2025 84 Santa Cruz County Civil Grand Jury The Scope and Nature of the Problem Human trafficking victims are often recruited via manipulation or coercion. They may be promised shelter, drugs, money, or romantic attention. Once lured in, they are commonly subjected to sexual exploitation, forced labor, coerced recruitment of others, violence, and trauma. Local survivors and frontline workers interviewed report that victims often do not recognize themselves as being trafficked. The result is a population that remains largely hidden and underserved. Human trafficking is a growing criminal enterprise nationwide and one of the most underreported crimes in California. Santa Cruz County is not immune. [12] [13] The Super Bowl and World Cup events scheduled for 2026 in Santa Clara County will impact the County of Santa Cruz directly with an influx of tourism and money, both of which increase the likelihood of human trafficking activity.[14] [15] Closer to home, the future development of a large year-round event center in the City of Santa Cruz Downtown Expansion Plan will potentially bring a heightened need for public awareness regarding human trafficking in our area.[16] [17] [18] Vulnerable Populations in Santa Cruz County According to the United Nations Office on Drugs and Crime, women and girls make up 71% of all detected trafficking victims worldwide. About 51% of all trafficked victims are adult women, and 20% are girls under the age of 18, typically between the ages of 12 and 14. Men make up 29% of victims, 21% of whom are adult men, and 8% are boys, typically between the ages of 11 and 13.[19] The illustration below shows some of the factors that leave victims vulnerable to traffickers’ seductive tactics. Figure 1: Pre-existing Factors Traffickers Take Advantage of[20] Source: Global Report on Trafficking in Persons, 2020 Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 85 In interviews with various service providers, law enforcement officers, and County administrators, several categories of vulnerable people who are disproportionately targeted by traffickers emerged. ● Youth in Foster Care: These minors are particularly vulnerable because most have come from dysfunctional homes. Many have suffered familial neglect and/or abuse. Traffickers target these youths, initially offering them the attention and nurturing they crave. They may be offered expensive gifts, drugs, or money. These youths may have been friended and groomed on social media - a medium traffickers are skilled at using to build trust with their contacts. Youths may be led to believe they are in a romantic relationship with their captors, making victims more likely to be compliant. ● School-aged Children: Young children are among the most vulnerable due to their age and dependency on adults for their care. Sexual exploitation of these young children is most commonly perpetrated by a family member or a close, trusted friend of the family. Being victimized by adults who are responsible for their care leaves them with fewer options to speak out. They also lack the resources, know-how, or courage to reach out for help and may have experienced sexual exploitation for so long that it has become normalized. ● Homeless and Runaway Youth: These youths lack shelter, food, and money. Traffickers can immediately fulfill these unmet needs. In exchange, youths are asked to repay their traffickers by submitting to acts of sexual exploitation and/or engaging in criminal activities on behalf of their traffickers. Homeless and runaway youths will often choose to stay in abusive trafficking situations because the dangers are known, and they believe they are better off than they were in the situation from which they came. ● Young Adults Aged 18-25 Experiencing Poverty, Addiction, or Homelessness: As with minors, traffickers are able to offer these adults housing, food, and relative safety from the dangers of living on the streets. Addicts are lured by the prospect of access to the source of drugs they need to feed their addiction or forestall withdrawals. ● Undocumented Agricultural Workers: Undocumented workers, including unaccompanied minors, often come into the US with only the items they carry with them, leaving them vulnerable to offers of assistance meant to lure them into servitude. They likely do not speak English well, and many will have a limited education. Complaining about their abuse can result in being blacklisted by employers. Reporting abuse can also bring them to the attention of law enforcement, with the subsequent risk of being deported, especially in the current political environment. Reducing Human Trafficking published June 30, 2025 86 Santa Cruz County Civil Grand Jury Another factor not shown above is the use of social media. All youth who are on social media are vulnerable to traffickers. Known as “sexploitation”, youth are increasingly coerced into posting nude photos of themselves on social media only to be later exploited and coerced by traffickers. Social media has created a platform for clever traffickers to lure and recruit youth of all socio-economic backgrounds. This practice continues to increase, and the nature of social media makes it difficult to detect and prevent. The three composite examples below demonstrate how vulnerable youth can be exploited. All three have elements of recruitment, harboring, and coercion. Details have been provided by local service providers and are taken from actual local trafficking cases. Sarah is a 15-year-old high school freshman who recently started dating John, a 17-year-old junior. Sarah believes she is in love with John and that their relationship is reciprocal. After two months of dating, John takes Sarah to a get-together with friends. He then asks her to have sex with his friend Mike. Sarah says, “But I don’t want to have sex with your friend. I love you.” John responds by saying, “If you loved me, you would do this for me.” Reluctantly, Sarah agrees to have sex with Mike. John has made an arrangement with Mike to pay John to have sex with Sarah. Sarah has unwittingly become a human trafficking victim. After hooking Sarah in, John goes on to traffic her to other boys and men at parties in exchange for money, drugs, or alcohol. He has nude pictures of Sarah that he posts online to solicit customers. Kathy is an 18-year-old who is invited to a party hosted by John, a trafficker. At the party, Kathy and her friends are provided alcohol and drugs. John offers Kathy what sounds like a great opportunity to make good money. He claims to be a professional photographer and offers her work as a model. He tells her a time and day to meet. After this meeting, Kathy decides to run away from home and drop out of school. John takes her on a shopping spree for the designer clothes she “needs” for modeling work. In exchange, she hands over her phone and identification. Kathy is now isolated, making it difficult for her to seek help. She is told that she now “owes” him for his gifts, and she must work off the debt. Soon, he is taking her from city to city, where she is forced into sex trafficking. Mary was six years old when her uncle Bill first took her for an outing that resulted in him sodomizing her. He warned her not to tell her parents, and that he would hurt her little brother if she did. Uncle Bill began to take her to parties at his friend’s house that always resulted in coerced sex acts she did not like, sometimes causing injury, and always involved other men who paid her uncle Bill with money, drugs, or alcohol. Sometimes, Uncle Bill would make videos of what she was forced to do with these men. She was afraid of her uncle’s continued threats and did not want to upset her parents. Over time, she began to regard his sexual demands as normal. Even though Mary did not like what her uncle demanded she do, she focused on the reward of good food and nice clothes she would not have otherwise. Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 87 Indicators of Trafficking Activity Signs of human trafficking are often masked by the presenting issues that bring victims to the attention of law enforcement or service providers. This means that most cases of human trafficking are unidentified, as many law enforcement officers are not properly trained to recognize cases of trafficking. While not an exhaustive list, these are some key red flags indicating a potential trafficking situation:[21] [22] Living conditions: ● Living with an employer ● Poor living conditions ● Multiple people in a cramped space Physical appearance: ● Signs of physical abuse ● Malnourishment or extreme hunger ● Suspicious tattoos or skin branding that is unexplained Working/school conditions: ● Employer is holding identity documents, ● Unpaid or paid very little ● Under 18 and in prostitution ● Truancy Suspicious Behavior: ● Inability to speak to the individual alone ● Answers appear to be scripted and rehearsed ● Submissive or fearful behavior What Resources are Available to Human Trafficking Victims? Below is a description of local providers of direct services to victims and their prevention activities. There are currently five such nonprofit service providers in the county. Links are provided for researching additional details on services provided by these organizations. Arukah Project: Arukah provides direct services to human trafficking victims who contact Arukah through their 24/7 hotline. Arukah supports survivors of sex trafficking and also provides survivor-led trainings to schools. Rising Worldwide: Rising is a Santa Cruz-based nonprofit dedicated to empowering survivors of human trafficking, gender-based violence, and extreme poverty. Rising provides free survivor-led training, mentorship, access to resources, and emergency financial support. Reducing Human Trafficking published June 30, 2025 88 Santa Cruz County Civil Grand Jury Monarch Services: Monarch is a County nonprofit that provides emergency shelter to survivors of domestic violence, sexual assault, and sexual trafficking. Other services include a 24-hour bilingual crisis line, legal advocacy, counseling, and support groups. Monarch also provides training. However, their trainers do not necessarily have any actual lived experience in human trafficking. The Coalition to End Human Trafficking in Santa Cruz and Monterey County: The Coalition has grown a collaboration of organizations, businesses, and individuals working to end human trafficking in Santa Cruz and Monterey counties through education, advocacy, policy change, services for survivors, and prosecution of offenders. Catholic Charities of Monterey Bay: Located in Watsonville, the agency serves migrant farm workers. Staff are trained to detect signs of trafficking among migrants and refer cases to appropriate local and state agencies for assistance, as well as providing trauma-focused bilingual care and counseling. State Laws Regarding Prevention and Support Services to Minors There are two State laws mandating enhanced prevention and support services for minor victims of human trafficking. Both of these laws provide for the allocation of funding to County child welfare agencies. This section gives an overview of these laws and their requirements. Compliance with these laws will be discussed in a later section of this report. SB 855 - Human Services Omnibus Trailer Bill for the 2014-15 Budget SB 855 created the Commercially Sexually Exploited Children (CSEC) Program and requires the State of California to collect data from counties related to human trafficking cases and services provided. The law mandates a collaborative approach involving child welfare, probation, mental health, public health, and other relevant agencies.[23] The County of Santa Cruz participates in the CSEC Program and receives funding from the California Department of Human Services. These funds are provided to support the identification, protection, and specialized care of children and youth who are victims of, or at risk of, sexual exploitation. Counties are required to report back to the State on the allocation of CSEC funds as part of their County Biennial Call Report. As the recipient of CSEC funds, Santa Cruz County’s Family & Child Services (previously known as Child Protective Services) is required to form a multidisciplinary team and hold regular meetings for case reviews of identified minor victims and at-risk youth. This team is required to have representatives from child welfare, probation, mental health, public health, juvenile courts, the Sheriff’s Office, and the County Office of Education.[24] Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 89 In the past five fiscal years, the County Human Services Department has received annual CSEC allocations ranging from $136,000 to $142,000, plus an additional $6,555 in Federal funding for fiscal year 2024-25. Funds are distributed to local service providers as shown in Figure 2. Total contract/purchase Fiscal order amount Year Grand Vendor 2021-22 2022-23 2023-24 2024-25 Total % Total Monarch $65,000 $65,000 $65,000 $61,750 $256,750 43.84% Rising Worldwide $25,000 $25,000 $25,000 $23,750 $98,750 16.86% Diversity Center $25,000 $25,000 $25,000 $23,750 $98,750 16.86% The Coalition $17,000 $17,000 $17,000 $16,150 $67,150 11.46% West Coast Children's Clinic $300 $14,000 $18,000 $12,000 $44,300 7.56% Encompass - Youth Advisory Board $10,000 $10,000 $0 $20,000 3.41% Grand Total $142,300 $156,000 $150,000 $137,400 $585,700 100.00% CSEC Allocation $139,370 $140,739 $135,860 $141,938 $557,907 95.25% Balance not spent/excess expenditures -$2,930 -$15,261 -$14,140 $4,538 -$27,793 -4.75% Figure 2: CSEC Fund Disbursement Detail by Fiscal Year Source: Department of Human Services, Santa Cruz County [25] AB 1227 - Human Trafficking Prevention Education and Training Act (2017) AB 1227 is an update to SB 855 and requires California public schools to include education on human trafficking prevention in sexual health education classes for middle and high school students. It mandates that instruction be age-appropriate, medically accurate, and include information on how to recognize and avoid exploitation. The bill also requires school staff to receive training on how to identify and respond to signs of human trafficking.[26] State Laws and Local Ordinances Regarding Human Trafficking Pending Legislation AB 379 Survivor Support and Demand Reduction Act: This bill passed the California Assembly with a unanimous vote of 74-0 on May 15, 2025, and at the time of publication of this report is under consideration in the State Senate. Reducing Human Trafficking published June 30, 2025 90 Santa Cruz County Civil Grand Jury If passed into law, a key provision of this new bill would create a grant program through the California Office of Emergency Services to support district attorneys. This funding could be used to create specialized units for the vertical prosecution of trafficking cases. Vertical prosecution refers to the process of the initial investigation of a case through final disposition, including trial and sentencing. Such a process would streamline prosecutions. AB 379 will also create a Survivor Support Fund, opening grant opportunities to community-based organizations that provide direct services and outreach to victims of sex trafficking and exploitation.[27] Existing State Legislation There are three existing critical California laws addressing the issue of sex and labor trafficking. The laws focus on public notice requirements and civil lawsuits against traffickers and those benefiting financially from trafficking. In brief: SB 1193 - Human Trafficking: Public Notice Requirements: Requires certain businesses (such as bars, massage businesses, and transit stations) to post a notice with information on how victims of human trafficking can seek help, including the National Human Trafficking Hotline. SB 1193 also requires farm labor contractors to post human trafficking signage, according to the State Department of Industrial Relations. SB 1193 was expanded by AB 260, which requires hotels, motels, and bed and breakfasts to post the same human trafficking public notice. It also requires that staff be trained to recognize and report human trafficking.[28] [29] SB 225 - Human Trafficking: Civil Actions: Allows victims of human trafficking to bring civil lawsuits against perpetrators and other responsible parties (such as businesses that benefited from the trafficking), even after criminal proceedings have ended.[30] The Jury learned somewhat late in the investigation that AB 2130 requires all new emergency medical responders licensed on or after July 1, 2024, to also receive training to recognize and respond to victims of human trafficking. [31] [32]. Well-trained medical responders are better positioned to identify human trafficking victims than are law enforcement officers because of their perceived neutrality and the fact that they deliver medical care, not citations. [33] [34] [35] The Jury was unable to verify compliance of local fire and emergency medical responders in the county, but acknowledges the importance of them being properly trained to recognize victims of human trafficking to potentially collaborate with local service providers. Local Ordinances In addition to California laws, there are also local ordinances in effect at the County level and in each city within the county. These regulations focus on massage businesses and vary between cities and the County. The codes for the Cities of Santa Cruz, Scotts Valley, and Watsonville are nearly identical. They each require massage businesses to be registered with the Chief of Police and require practitioners to be certified by the California Massage Therapy Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 91 Council (CAMTC).[36] The Chief of Police is responsible for enforcement and inspections in these jurisdictions. The County of Santa Cruz also requires certification with CAMTC, but in addition, restricts proximity to schools and playgrounds. The City of Capitola does not have any specific ordinances regarding massage businesses.[37] [38] [39] [40] [41] Why Are So Few Human Trafficking Cases Prosecuted? In interviews with representatives of the Sheriff’s Office, municipal police departments, and the District Attorney’s Office, the Jury was told that there are very few cases of human trafficking identified and fewer still that are prosecuted. There are several reasons for the low number of reported cases. ● Perpetrators force victims to commit crimes in their stead to shield themselves from prosecution. Therefore, victims are at risk of being prosecuted for these crimes.[42] [43] A common example is where a victim has been tasked with recruiting new victims and can herself be accused of trafficking. [44] ● Victims can be reluctant to report being trafficked because, unfortunately, they themselves have been sexually assaulted by police officers, or have heard from other victims of cases of such abuse. This was stated by both a law enforcement administrator and a trafficking survivor who has worked with multiple victims experiencing this abuse.[45] [46] ● Victims may come to the attention of police officers for incidents that are the result of being trafficked. [47] Law enforcement may respond to a case of domestic violence or a report of rape, both incidents that may have occurred because the person is being trafficked. If the victims are unwilling to declare being trafficked, an officer may cite them for prostitution, for example, an offense that will bar them from entry into any housing shelter in the future.[48] ● Victims can experience the Stockholm syndrome, where they identify with their captor and see that person as a protector or ,and so will not cooperate with police. Interviews revealed that even when a victim of trafficking is identified and presented to the police, there are barriers to apprehending and prosecuting the trafficker. ● Victims rarely remain in the jurisdiction of local law enforcement. Most victims are moved frequently by their captors to avoid detection. Law enforcement may begin an investigation when a victim is cooperating but must close the case when the victim refuses to cooperate or leaves the area.[48] Investigations require law enforcement time and resources, and these cases may never result in arrest or prosecution. Even in the event of a completed investigation, the prosecution process can take years to complete.[13] Reducing Human Trafficking published June 30, 2025 92 Santa Cruz County Civil Grand Jury ● Victims can initially be cooperative with law enforcement, but they frequently return to trafficking. This occurs because shelter and other long-term support services are often not available. Jurors were told that victims who succeed in escaping trafficking have returned to their captors multiple times before finally severing ties. Law enforcement agrees that human trafficking is a problem and does occur in the County. However, from their point of view, few cases of trafficking come to their attention. Other crimes are more easily identified, investigated, and prosecuted. [49] [50] It is of note that in Grand Jury interviews with law enforcement for this investigation, the Jury perceived that officers are sincere in their desire to address the human trafficking problem in our County, but acknowledge that the obstacles outlined here are difficult barriers to overcome.[51] [52] [53] Later in this report, suggestions will be offered to help in the successful prosecution of more cases. Santa Cruz County - A Feeder for San Francisco Bay Area Trafficking Despite its relatively small size, the proximity of the County to the San Francisco Bay Area serves as a driver for recruitment and a transit point, connecting traffickers and victims with broader Bay Area networks. As mentioned above, major public events in the Bay Area are natural incentives for human trafficking.[54] [55] New venues being built and upcoming large events may also result in increased human trafficking activities.[15] Planning for this growth has not been found in local agency documents. There is Room for Improvement In spite of obstacles to preventing, identifying, and prosecuting cases of human trafficking, there are areas where obstacles can be minimized or even overcome. Overcoming obstacles includes improving data collection, improving agency collaboration, enhancing prevention and awareness in school settings, among law enforcement agencies, and within the wider community, and complying with existing laws. Inconsistent Data: Except for County Family & Child Services reporting requirements, the Jury found no evidence of a countywide effort to collect human trafficking data. Although the Federal Bureau of Investigation (FBI) gathers data on a broad scale regarding the number of human trafficking cases and other crimes reported, the data does not align with statistics reported locally. The FBI data shows zero cases of human trafficking in Santa Cruz County over a ten year period, [56] yet a 2018 Santa Cruz County Sheriff Operations Training Bulletin reported 37 children, youth, and young adults were confirmed to have experienced CSEC in the Tri-County Region between January 1, 2015 to December 31, 2016 and 54 children, youth and young adults were Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 93 suspected to have experienced CSEC. That report also stated that 690 children, youth, and young adults were identified as at risk of experiencing CSEC in the Tri-County Region (Santa Cruz, San Benito, and Monterey counties) during the same time frame.[57] [58] [59] There are currently four human trafficking cases being prosecuted in Santa Cruz County Superior Court, all related to a single trafficker.[60] The Jury found that while local law enforcement agents interviewed relied on data from the Polaris Project, which sponsors the National Human Trafficking Hotline, there is no collaboration among the agencies responsible for oversight of vulnerable youth to share information. This includes data gathered by the County Sheriff staff from the Internet Crimes Against Children (ICAC), a national data-gathering agency. These data yield significant numbers of potential cases of exploitation monthly.[61] [62] [63] [64] Furthermore, the Tri-County collaboration has dwindled due to a lack of regularly scheduled interaction and informational sharing opportunities. Because human traffickers are very mobile, it is important that there be regularly scheduled information sharing. [65] [66]. Neither law enforcement, nor child welfare staff, nor community nonprofit organizations share data on this issue with each other on a regularly scheduled basis. There is a chasm between the figures shared with the Grand Jury from law enforcement and local nonprofit organizations on incidents of human trafficking cases they have encountered. ● A District Attorney’s Office representative reported only two cases over the past four years, neither of which was successfully prosecuted. ● Information from the Watsonville Police Department reported there were no recent cases of human trafficking. However, a follow-up document stated that numerous cases were being reported and investigated each year, including cases of child trafficking.[67] ● An administrator from the Santa Cruz Police Department was not able to cite the number of victims encountered since 2023, but guessed it’s a single-digit number. ● A representative of the Sheriff’s Office believes that there have only been two cases “in the last few months”. The representative couldn’t be more certain because data on crimes is categorized only by the Penal Code. On the other hand, the number of potential trafficking cases, stated earlier in this report as provided by local service providers, is much higher. Reducing Human Trafficking published June 30, 2025 94 Santa Cruz County Civil Grand Jury A starting point to address the problem of human trafficking would be to have solid data on the number of cases collected countywide, as well as other data points on human trafficking activity in Santa Cruz County. Lack of Local Community, Government, Law Enforcement, and Nonprofit Collaboration: The Sheriff’s Office and the District Attorney’s Office collaborate with Arukah Project and Monarch Services in some cases. However, this appears to be the limit of collaboration in our county. There is currently no countywide team of stakeholders joining forces that is meeting regularly to coordinate and facilitate training, prevention activities, support services, or interdiction efforts.[68] Such a group could collaborate to consolidate statistics and other data on human trafficking in Santa Cruz County. Quantifying the number of human trafficking cases, as well as collecting additional data on trafficking, would better enable the group to procure additional funding to address this problem. The CSEC multidisciplinary team and the tri-county steering committee’s goals are different. Multiple sources stated that the formation of law enforcement task forces specifically focused on human trafficking interdiction efforts would allow law enforcement to more directly and effectively address local human trafficking activity. Good data collected and consolidated by a human trafficking coalition could work toward procuring this funding.[69] The District Attorney’s Office did apply for grant funding, but was unsuccessful because it had only two cases that it had attempted to prosecute. If AB 379 is enacted into law, which appears likely, funding specifically designated for the District Attorney’s Office to support vertical prosecution of human trafficking cases will become available. The CSEC Program requires that a tri-county steering committee be established and hold quarterly meetings. The initial 35-member committee was chaired by the child welfare directors of the three counties. It included representatives from child welfare, juvenile probation, law enforcement, and other community partners.[70] [71] Meetings were disbanded in 2018 once protocols were established and the counties discontinued pooling CSEC funds for collaborative staff training. The child welfare directors from Santa Cruz, Monterey, and San Benito Counties continued to meet monthly, then quarterly, but have not held any meetings since May 2024. Training for Business, School Staff, and Students: Local nonprofits specializing in human trafficking prevention, as discussed earlier, are available to provide low or no-cost training to students and staff, law enforcement, government staff, businesses, and the general public. Classes are led or supplemented by trafficking survivors. It was reported to Jurors that classes that include survivors are much more impactful, especially on students, than those led by non-survivors. Unfortunately, the Jury has also learned that these services are underutilized.[72] AB 1227 requires trafficking awareness training in grades 7-12. It also requires school staff and counselor training. Despite mandates, some local school administrators and agency representatives interviewed were unaware of training resources or have failed to implement trafficking prevention education. Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 95 Multiple County Office of Education staff interviewed could not recall when they last received any training specifically on this topic, but believe it was likely covered briefly in their required online training.[73] [74] Staff working with high-risk student cases report that it has been at least five years since they had training that touched on human trafficking.[75] [76] The Coalition to End Human Trafficking reports that it provides human trafficking prevention training by trafficking survivors to students at Juvenile Hall. This training has been very well received by these high-risk students. Training of Law Enforcement: The Jury interviewed administrators and investigators in the District Attorney’s Office, the Sheriff’s Office, and Santa Cruz and Watsonville Police Departments regarding the depth and frequency of human trafficking training. The record of such training is spotty and, in some cases, can be improved. ● A representative from the District Attorney’s office reports that there is a mandatory training requirement for human trafficking, but believes that it is not in-depth enough to enable officers to identify human trafficking victims. ● The Sheriff’s Office is mandated by the State to provide sexual assault investigators with a weeklong training on a human trafficking component.[77] Documentation from the Sheriff’s Office shows that some staff have attended three different human trafficking related trainings since 2024. It is unknown how widely these trainings were attended. ● An administrator from the Santa Cruz Police Department believes that human trafficking training is provided in the Peace Officer Standards and Training in the police academy, but doesn’t believe that it is included in ongoing training.[78] ● The Watsonville Police Department received two hours of human trafficking training for detectives in 2019, but has no record of human trafficking training since that time.[79] Some local nonprofits discussed earlier in this report are available to provide low or no-cost training on human trafficking to law enforcement upon request. Convening of CSEC Meetings: SB 855 requires that recipients of CSEC funds convene regular multidisciplinary team meetings to review human trafficking cases focused on minors. A document received from County Family & Child Services states that the CSEC multidisciplinary team last met in November 2023.[68] When no new cases were reported, monthly meetings were cancelled. However, a public records request revealed that documentation submitted by the County to the State in February 2025 declares that among the duties that the CSEC Coordinator completes are “monthly or emergency multidisciplinary meetings”.[80] [81] Reducing Human Trafficking published June 30, 2025 96 Santa Cruz County Civil Grand Jury While these meetings are cancelled because there are no new cases to discuss, in comparison, the Monterey County multidisciplinary team meets monthly and has a caseload of 30-40 minors. When there are no new cases to discuss, their team meets anyway to discuss progress on existing cases.[82] Signage Compliance: In spite of SB 1193 and AB 260, two laws requiring signage postings in a prominent place, a sample survey of all businesses across cities and unincorporated areas of Santa Cruz County found that only about 7% of businesses mandated to post signage are in compliance. SB 1193 states that enforcement is typically handled by police or the Sheriff’s Office, and the County’s District Attorney representative conveyed that, as regards to signage requirements, their role is prosecution and not enforcement.[83] [84] The Jury was told by representatives of law enforcement that they believe human trafficking signage is important in raising overall public awareness and potentially providing help to victims of trafficking. Hotels/ Health Alcohol Hair/Nail Massage Metros/ Motels Clinics Retailers Salons Businesses Airports Total Posted/ Posted/ Posted/ Posted/ Posted/ Posted/ Surveyed Surveyed Surveyed Surveyed Surveyed Surveyed Posted Surveyed Santa Cruz 0/25 0/3 1/12 0/6 0/5 0/2 1 53 Scotts Valley 1/2 0/2 0/4 1/2 0/3 1/1 3 14 Watsonville 0/7 0/16 0/3 0/5 0/4 1/2 1 37 Capitola 2/2 1/2 0/2 0/5 0/3 0/0 3 14 Unincorporated* 0/3 0/1 0/13 0/6 1/2 1/1 2 26 Total 3/39 1/24 1/34 1/24 1/17 3/6 10 144 Compliance % 7.69% 4.17% 2.94% 4.17% 5.88% 50.00% 6.94% *Includes Aptos, San Lorenzo Valley, Live Oak, and Soquel Figure 3: Compliance with Human Trafficking Signage Requirement Source: Survey conducted by Santa Cruz County Grand Jury, Spring 2025[85] Under SB 1193, farm labor contractors are also among those businesses required to post signs regarding human trafficking. In the case of farm labor contractors, the Santa Cruz County Agricultural Commission is responsible for enforcing the signage requirement. In addition, a survey of farm labor contractor sites showed that where the required human trafficking signs were posted, they were not necessarily readily accessible to farm workers. Existing signs in both English and Spanish were faded, in small type, and generally in very poor condition. Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 97 The Jury also surveyed rest stops throughout the County and was unable to find any human trafficking signs. Rest stops are also required by SB 1193 to post human trafficking signs. Human trafficking signs are required to list the telephone number and text message for the National Hotline. Two Jurors called this number multiple times and experienced a 30-minute wait for a callback. They also tried the text number listed on the sign. They were put into a continuous phone tree loop. A victim reaching out to a hotline is unlikely to be available for a callback and may be calling on a public phone. It is important for callers to get immediate help. Two local nonprofit organizations, Arukah Project and Monarch Services, each have a 24-hour hotline. Because these organizations are local and can provide real-time services, they could be added to local signs for a much better chance of receiving timely assistance. These organizations are equipped to provide emotional support as well as help locate immediate shelter and other basic needs. Law Enforcement Compliance with Local Massage Business Ordinances: Local ordinances, including the County Code Section 5.08 regarding massage businesses, vary among jurisdictions. Consistency and coordination in enforcing and enhancing existing ordinances, or an overall County set of ordinances, could facilitate improved and consistent monitoring of human trafficking laws regarding massage businesses. One Sheriff’s Office representative admitted that historically, Santa Cruz County has been more lax than other counties in licensing and inspection of massage businesses. While most massage businesses are legitimate and do not engage in trafficking, local service providers are aware that some do. While conducting surveys for signage compliance, a few massage businesses visited by the Jury appeared to be suspicious. Regular inspections, enforcement of practitioner certification requirements, and compliance with signage requirements could result in curtailment of such activity. Conclusion Human trafficking does occur in Santa Cruz County, but goes largely unrecognized and unreported. Lack of data regarding human trafficking activity, lack of collaboration among stakeholders, insufficient training, and lack of compliance with state and local laws leave us in the dark as to the prevalence of human trafficking. As a result, the issue is not being adequately addressed, and the trafficking problem will continue unabated and possibly increase, unless proactive measures are taken. The Jury is hopeful that recommendations in this report to address the scourge of human trafficking in our community will be seriously considered and adopted. Reducing Human Trafficking published June 30, 2025 98 Santa Cruz County Civil Grand Jury Findings F1. There is currently no consolidated data being collected on Santa Cruz County human trafficking cases. This causes an understatement of the problem and makes it difficult for stakeholders to obtain additional funding. F2. The potential passage of AB 379 may provide grants for the District Attorney’s Office for the prosecution of traffickers and grants for community-based organizations for direct services and victim outreach. This could provide the resources necessary to ultimately reduce human trafficking and reduce the likelihood of victims returning to trafficking. F3. The tri-county CSEC steering committee for the prevention of human trafficking has not met for a full year as of the publication of this report. Therefore, there is no active body that could potentially monitor trafficking cases across the tri-county area. F4. The County Family & Child Services CSEC-required monthly multidisciplinary team meetings have not been held since November 2023, despite biennial reporting otherwise to the State Department of Social Services. Therefore, known cases of human trafficking have not been properly overseen. F5. Staff and administration of the County Office of Education report they are not adequately trained and do not receive regular training regarding human trafficking as required by AB 1227. This is in spite of the fact that free training is available from local providers that could bring COE into compliance if enforced. This deficiency can lead to a failure in the staff’s ability to identify cases of trafficking. F6. Very few businesses in Santa Cruz County are in compliance with SB 1193 signage requirements. This results in the reduction of community awareness of the problem and the likelihood that trafficking victims will be able to reach out for help. F7. Existing human trafficking signs at farm worker contractor sites are not readily accessible to farm workers and are in poor condition. This can result in farm workers being unaware of available resources and an inability to reach out for help. F8. The mix of County and local municipal ordinances regarding the licensing and inspection of massage businesses varies, possibly causing confusion and inconsistent enforcement of existing regulations. F9. Annual inspections are required of massage businesses in jurisdictions with massage business ordinances, but inspections are generally not being conducted. This can result in undetected human trafficking activity. F10. Calls to the National Human Trafficking Hotline on existing signs have unacceptably long wait times and can result in a lost opportunity to assist human trafficking victims. F11. Local nonprofit organizations have 24/7 hotline numbers that are staffed, and calls can be answered immediately or within minutes, greatly increasing the likelihood of contacting victims and providing assistance in real time. Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 99 F12. There has been a lack of human trafficking presentations to law enforcement. Local law enforcement jurisdictions could request the no-cost training that is available from local human trafficking service providers. This can lead to officers learning to identify human trafficking victims and reduce further victim trauma. F13. Law enforcement task forces focused solely on human trafficking are very effective methods of detecting and preventing human trafficking activities. Such task forces could increase the rate of interdiction and the successful prosecution of human trafficking cases. Recommendations R1. The Department of Human Services should designate a qualified staff member to take the lead in forming a countywide human trafficking coalition, including the District Attorney and the Sheriff’s Office. Members should include stakeholders discussed in this report who are involved in the prevention and interdiction of human trafficking. The focus should include the consolidation of human trafficking data and the procurement of additional funds, potentially to fund law enforcement task forces. This should be completed by December 31, 2025. (F1,F2,F13) R2. The Program Manager of Family & Child Services should coordinate with Monterey and San Benito County peers for the purpose of reconvening the tri-county Commercial Sexual Exploitation of Children steering committee. This team would meet regularly to review and track intercounty human trafficking cases and activity in our region and participate in regional prevention activities. This should be completed by December 31, 2025. (F3) R3. The Program Manager of County Family & Child Services should resume and maintain monthly multidisciplinary team meetings, required as a condition of receiving Commercial Sexual Exploitation of Children funding, to review ongoing human trafficking cases and discuss other potential cases involving high-risk youth. This should commence by August 31, 2025. (F4) R4. Each law enforcement agency in Santa Cruz County, including the Sheriff’s Office, Santa Cruz Police Department, Scotts Valley Police Department, Capitola Police Department, and Watsonville Police Department, should require law enforcement officers to receive an annual human trafficking awareness training, preferably led by human trafficking survivors. This should commence by December 31, 2025. (F12) R5. The County Office of Education should come into compliance with AB 1227, providing human trafficking-related training, led by survivors, to students and staff as required. This should be completed by February 28, 2026. (F5) R6. Santa Cruz County Board of Supervisors should adopt an umbrella countywide ordinance requiring human trafficking signage currently mandated by the State to be part of all existing permitting and licensing procedures for affected businesses. This should be completed by June 30, 2026. (F6) Reducing Human Trafficking published June 30, 2025 100 Santa Cruz County Civil Grand Jury R7. Santa Cruz County Board of Supervisors should require that county-specific human trafficking awareness and support signs include at least one 24/7 local hotline number, and staff should collaborate with local non-profits providing support to human trafficking victims to develop an effective sign for countywide posting and distribution. This should be completed by June 30, 2026. (F10, F11) R8. The Santa Cruz County Agricultural Commissioner should come into compliance with SB 1193 by ensuring that existing human trafficking signs are refreshed annually. In addition, it should require all farm labor contractors to include the SB 1193 sign in employee handbooks for easy accessibility. A review for compliance should be done on an annual basis. This should commence by September 30, 2025. (F7) R9. Santa Cruz County Board of Supervisors should adopt a countywide ordinance regulating the licensing, employee certification, and inspection requirements for massage businesses consistent with California Massage Therapy Council certification and licensing requirements. This should be completed by June 30, 2026. (F8) R10. Local law enforcement agencies, including the Sheriff’s Office, Santa Cruz Police Department, Scotts Valley Police Department, Capitola Police Department, and Watsonville Police Department, should enforce massage business licensing, certification, and inspection requirements. This should include compliance with SB 1193 signage requirements. Enforcement of existing ordinances should commence by September 30, 2025. However, if/when the Board of Supervisors agrees to the Jury’s recommendation to adopt a countywide ordinance, law enforcement should come into compliance with this new ordinance within 30 days of adoption. (F9) Required Responses Respond Within/ Respondent Findings Recommendations Respond By F1, F2, F3, F4, F6, Santa Cruz County R1, R2, R3, R6, R7, 90 Days / F7, F8, F10, F11, Board of Supervisors R8, R9 September 29, 2025 F13 Santa Cruz County F1, F2, F6, F9, F12, 60 Days / R1, R4, R6, R10 Sheriff F13 August 29, 2025 County 60 Days / Superintendent of F5 R5 August 29, 2025 Schools Santa Cruz County 60 Days / F1, F2, F13 R1 District Attorney August 29, 2025 Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 101 Invited Responses Respond Within/ Respondent Findings Recommendations Respond By Program Manager, 60 Days / County Family & F1, F2, F3, F4, F13 R1, R2, R3 August 29, 2025 Child Services Director, Santa Cruz 60 Days / County Human F1, F2, F3, F4, F13 R1, R2, R3 August 29, 2025 Services Department Santa Cruz County 60 Days / Agricultural F7 R8 August 29, 2025 Commissioner Police Chief, City of 60 Days / F6, F9, F12 R4, R6, R10 Santa Cruz August 29, 2025 Police Chief, City of 60 Days / F6, F9, F12 R4, R6, R10 Scotts Valley August 29, 2025 Police Chief, City of 60 Days / F6, F9, F12 R4, R6, R10 Watsonville August 29, 2025 Police Chief, City of 60 Days / F6, F9, F12 R4, R6, R10 Capitola August 29, 2025 Director, Arukah 60 Days / F10, F11 R7 Project August 29, 2025 Chief Executive 60 Days / Officer, Monarch F10, F11 R7 August 29, 2025 Services Definitions ● CAMTC: California Massage Therapy Council ● COE: County Office of Education ● CSEC: Commercially Sexually Exploited Children ● NIJ: National Institute of Justice Reducing Human Trafficking published June 30, 2025 102 Santa Cruz County Civil Grand Jury Sources References 1. January 1, 2025. “Which U.S. States Have Had the Most Human Trafficking Victims Over the Past 5 Years? Human Trafficking Statistics 2024.” Joclyn Law Firm. Accessed May 22, 2025. https://www.criminalattorneycolumbus.com/which-u-s-states-have-had-the-most- human-trafficking-victims-over-the-past-5-years 2. April 19, 2025. National Human Trafficking Hotline. Accessed April 19, 2025. https://humantraffickinghotline.org/en/statistics/california?utm_source=chatgpt.co m 3. National Institute of Justice. August 4, 2020. “Gaps in Reporting Human Trafficking Incidents Result in Significant Undercounting.” NIJ website. Accessed October 10, 2024. https://nij.ojp.gov/topics/articles/gaps-reporting-human-trafficking-incidents-result- significant-undercounting 4. Confidential Grand Jury interview. 5. January 1, 2025. UC Davis Continuing & Professional Education-Human Services. Accessed June 8, 2025. https://humanservices.ucdavis.edu/toolkits/csec 6. UC Davis Human Services Continuing Professional Development. January 1, 2025. “CSEC 101.” UC Davis-Human Services. Accessed June 12, 2025. https://humanservices.ucdavis.edu/toolkits/csec/training-resources 7. Confidential Grand Jury document. 8. Confidential Grand Jury interview. 9. Confidential Grand Jury interview. 10. January 1, 2025. “VICTIMS OF TRAFFICKING AND VIOLENCE PROTECTION ACT OF 2000.” Department of Justice. Accessed June 13, 2025. https://www.justice.gov/humantrafficking 11. July 1, 2020. CA Legislature. “CA Penal Code 236.1 & 236.2.” Accessed June 12, 2025. https://www.childwelfare.gov/resources/definitions-human-trafficking-california/#: ~:text=Citation:%20Penal%20Code%20%C2%A7%20236.1,or%20received%20b y%20any%20person. 12. City of Watsonville Ad Hoc Committee Report on Community Policing. April 12, 2021. Report on Community Policing, p. 90. Accessed March 11, 2025. https://www.watsonville.gov/DocumentCenter/View/16928/ADHOC_REPORT_DI GITAL 13. Confidential Grand Jury document. Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 103 14. Dept. of Homeland Security. September 20, 2024. HSI Prepares for 2025 Super Bowl by Hosting a Human Trafficking Awareness Workshop. Accessed May 27, 2025. https://www.ice.gov/news/releases/hsi-new-orleans-prepares-2025-super-bowl-h osting-human-trafficking-awareness 15. Confidential Grand Jury interview. 16. Confidential Grand Jury interview. 17. Confidential Grand Jury interview. 18. Confidential Grand Jury interview. 19. January 1, 2020. “UNODC Global Report 2020,” p. fig. 8. United Nations Office on Drugs and Crime (UNODC). Accessed May 5, 2025. https://www.un.org/sustainabledevelopment/blog/2016/12/report-majority-of-traffi cking-victims-are-women-and-girls-one-third-children/ 20. January 1, 2020. “GLOTiP_2020_15jan_web.pdf,” p. figure 1. United Nations Office on Drugs and Crime (UNODC). Accessed May 5, 2025. https://www.unodc.org/documents/data-and-analysis/tip/2021/GLOTiP_2020_15j an_web.pdf 21. U.S. Department of State. January 20, 2009. “Identify and Assist a Trafficking Victim.” U.S. Department of State Archived Content. Accessed May 7, 2025. https://2009-2017.state.gov/j/tip/id/index.htm?utm_source=chatgpt.com 22. Our Rescue.org. January 1, 2025. “Signs and symptoms of human trafficking.” Our Rescue.org. Accessed May 27, 2025. https://ourrescue.org/education/prevention-awareness/how-can-i-identify-human- trafficking 23. California Department of Social Services. January 26, 2015. California Department of Social Services. Accessed May 8, 2025. https://www.cwda.org/sites/main/files/file-attachments/csec-sb-855-language.pdf ?1441823795 24. Ivy Hammond, etal. July 13, 2023. evaluation for Ca. Dept of Social Services. Evaluating California's Efforts to Address the Commercial Sexual Exploitation of Children, p. 21. Accessed April 17, 2025. https://www.urban.org/sites/default/files/2023-07/Evaluating%20California%E2% 80%99s%20Efforts%20to%20Address%20the%20Commercial%20Sexual%20Ex ploitation%20of%20Children.pdf 25. County of Santa Cruz. April 4, 2025. Accessed May 15, 2025. https://docs.google.com/spreadsheets/d/1J48g8bgbMkQY3H9jxDc1h7w3p6uZ_4 yl/edit?gid=1152084097#gid=1152084097 26. October 9, 2017. CA legislature. “AB1227.” Accessed June 12, 205. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180AB1 227 Reducing Human Trafficking published June 30, 2025 104 . May 8, 2025. CA Legislative portal. Accessed June 12, 2025. https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202520260AB3 79 28. April 9, 2025. Dept. of Industrial Relations. “Human Trafficking Notice for FLCs.” Accessed June 12, 2025. https://legiscan.com/CA/text/SB1193/id/626694 29. October 9, 2017. CA Legislature. “AB260.” Accessed June 12, 2025. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180AB2 60 30. October 9, 2017. CA Legislature. “SB225.” Accessed June 12, 2025. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180SB2 25 31. Assemblymember Jordan Cunningham. February 20, 2022. San Luis Obispo Tribune. Accessed May 27, 2025. https://www.sanluisobispo.com/news/local/crime/article258585773.html 32. Assemblyman Jordan Cunningham. September 6, 2022. legiscan. “AB 2130.” Accessed May 27, 2025. https://legiscan.com/CA/text/AB2130/id/2597191 33. February 25, 2022. “Labor Trafficking and the Role of the EMS Provider.” Collegiate Emergency Medical Services. Accessed May 27, 2025. https://www.collegeems.com/labor-trafficking-and-the-role-of-the-ems-profession al/#:~:text=If%20the%20patient%20is%20a,%28Figure%202%29. 34. Kate Dernocoeur, NREMT. December 20, 2024. EMS1 Newsletter: How EMS Can Identify, Help Victims of Human Trafficking:by debunking Human Trafficking Myths, EMS Providers can Assist the Victims They Encounter in Their Own Communities.. Accessed May 27, 2025. https://www.ems1.com/ems-products/child-safety-education/articles/how-ems-ca n-identify-help-victims-of-human-trafficking-zLrBan82ifC3x7T3/ 35. Confidential Grand Jury interview. 36. California Massage Therapy Council. January 1, 2023. “CAMTC "About Us" webpage.” CAMTC website. Accessed April 10, 2025. https://www.camtc.org/information-about-camtc/about-camtc/ 37. City of Watsonville. November 9, 2024. City of Watsonville Code. Accessed February 28, 2025. https://www.codepublishing.com/CA/Watsonville/html/Watsonville05/Watsonville0 527.html 38. City of Santa Cruz. January 1, 2016. “City Code Chapter 5.78.” City of Santa Cruz. Accessed March 1, 2025. https://www.codepublishing.com/CA/SantaCruz/html/SantaCruz05/SantaCruz057 8.html#5.78.030 Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 105 39. County of Santa Cruz. January 1, 2019. “County Code Chapter 5.08.” County website. Accessed March 1, 2025. https://www.codepublishing.com/CA/SantaCruzCounty/html/SantaCruzCounty05/ SantaCruzCounty0508.html 40. City of Scotts Valley. November 7, 2018. “Code Chapter 5.10.” City of Scotts Valley website. Accessed March 1, 2025. https://library.municode.com/ca/scotts_valley/codes/code_of_ordinances?nodeId =TIT5BUTALIRE_CH5.10MAES_5.10.040EX 41. Confidential Grand Jury document. 42. Confidential Grand Jury interview. 43. Confidential Grand Jury interview. 44. Confidential Grand Jury interview. 45. Confidential Grand Jury interview. 46. Confidential Grand Jury interview. 47. Confidential Grand Jury interview. 48. Confidential Grand Jury document. 49. Confidential Grand Jury interview. 50. Confidential Grand Jury interview. 51. Confidential Grand Jury interview. 52. Confidential Grand Jury interview. 53. Confidential Grand Jury interview. 54. Confidential Grand Jury interview. 55. Confidential Grand Jury interview. 56. FBI using Uniform Crime Reporting statistics. January 1, 2025. “FBI Crime Explorer Tool.” FBI website. Accessed June 8, 2025. https://cde.ucr.cjis.gov/LATEST/webapp/#/pages/explorer/crime/crime-trend 57. January 15, 2025. FBI. Accessed June 5, 2025. https://cde.ucr.cjis.gov/LATEST/webapp/#/pages/explorer/crime/crime-trend 58. Confidential Grand Jury document. 59. Confidential Grand Jury document. 60. Confidential Grand Jury document. 61. Confidential Grand Jury interview. 62. Confidential Grand Jury interview. 63. Confidential Grand Jury interview. 64. Confidential Grand Jury document. Reducing Human Trafficking published June 30, 2025 106 . Confidential Grand Jury interview. 66. Confidential Grand Jury interview. 67. Confidential Grand Jury interview. 68. Confidential Grand Jury document. 69. Confidential Grand Jury interview. 70. August 4, 2015. “Santa Cruz County Board of Supervisor Resolution and Staff Report..” Santa Cruz County Board of Supervisor archive. Accessed May 21, 2025. https://www2.santacruzcountyca.gov/BDS/Govstream2/Bdsvdata/non_legacy_2. 0/Minutes/2015/20150804-665/PDF/052.pdf#:~:text=Under%20the%20leadershi p%20of%20the%20child%20welfare,counties%2C%20including%20child%20wel fare%2C%20juvenile%20court%20judges 71. Confidential Grand Jury document. 72. Confidential Grand Jury interview. 73. Confidential Grand Jury interview. 74. Confidential Grand Jury interview. 75. Confidential Grand Jury interview. 76. Confidential Grand Jury interview. 77. Confidential Grand Jury interview. 78. Confidential Grand Jury interview. 79. Confidential Grand Jury document. 80. Confidential Grand Jury document. 81. Confidential Grand Jury document. 82. Confidential Grand Jury interview. 83. January 1, 2025. “Prevention and Public Awareness Resources.” CFPIC.org. Accessed May 11, 2025. https://pact.cfpic.org/resources/the-child-welfare-response-to-labor-trafficking-in-c alifornia/prevention-public-awareness-resources/?utm_source=chatgpt.com 84. Office of California Attorney General. January 1, 2023. California Civil Rights. “CA Civil Code of Procedure 52.6.” Accessed June 12, 2025. https://codes.findlaw.com/ca/civil-code/civ-sect-52-6/#:~:text=(h)%20A%20busine ss%20or%20establishment,described%20in%20paragraph%20(1). 85. Confidential Grand Jury document. Reducing Human Trafficking published June 30, 2025 2024-2025 Consolidated Final Report 107 Websites https://humanservices.ucdavis.edu/toolkits/cesc https://humanservices.ucdavis.edu/toolkits/csec/training-resources https://humanservices.ucdavis.edu/toolkits/cesc/legislation-and-guidance https://polarisproject.org/resources/us-national-human-trafficking-hotline-statistics / https://polarisproject.org/myths-facts-and-statistics/ Site Visits Canvassing of all five County Supervisorial Districts for SB 1193 signage compliance. Visited public events that included Farmworker Reality Tours and Rising at the Rio. May 15, 2025 Monterey County Human Trafficking Symposium. Reducing Human Trafficking published June 30, 2025 108 Santa Cruz County Civil Grand Jury If You Can’t Measure It, You Can’t Manage It. The Challenges Facing the Management of High-Cost Beneficiaries in the Health Services Agency Summary For several years, the Santa Cruz County Health Services Agency has been made aware of deficiencies in tracking and reporting on their highest-cost clients. Since 2021, two external state-mandated reports recommended that the Health Services Agency develop a Level of Care tool for identifying and managing Behavioral Health and Substance Use Disorder patients. There is a large subset of these patients whose total cost of care is considerably above normal expectations. A recent accreditation report stated that 15% of clients account for 55% of the claimed services, clients who are labeled as high-cost beneficiaries by the external regulators. High-cost beneficiaries present a complex challenge for Santa Cruz County. Effective strategies to address their needs require improvements in three major areas: 1. the administration and coordination of programs and services; 2. increased financial support of programs and staff, and 3. an enhanced focus on the underlying clinical issues resulting from homelessness, physical, and mental health conditions. High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 109 Table of Contents Background 3 Scope and Methodology 4 Investigation 5 Funding Behavioral Health and Substance Use Disorder Services 5 Definition and Identification of High-Cost Beneficiaries 7 County Health Services Programs and Resources 7 Other Resources for the County 8 A Special Program and Partner: The Central California Alliance for Health 9 The County has Challenges 12 Continued Planning for CalAIM Initiatives 13 Frameworks for Establishing Administrative, Financial, and Clinical Coordination 13 The Jury’s Challenge to the HSA and the Alliance 15 The County’s Directive to HSA 16 Findings 16 Recommendations 18 Required Responses 19 Invited Responses 19 Definitions 20 Sources 21 References 21 Websites 23 High-Cost Beneficiaries published June 26, 2025 110 Santa Cruz County Civil Grand Jury Background In California, the government-funded healthcare program is referred to as Medi-Cal. Medi-Cal offers plans and pays for healthcare for low- or no-income individuals, with some enrolled in Medi-Cal Managed Care plans. These plans feature provider networks (doctors, pharmacies, etc.) and cover standard health benefits, plus prescription drugs, and behavioral health. The behavioral health program for Medi-Cal enrollees in Santa Cruz County (the County) is a shared financial responsibility between the County and two Medi-Cal Health Maintenance Organizations (HMO’s). Those two HMO’s are Kaiser Permanente (Kaiser) and the Central California Alliance for Health (the Alliance). The majority of Medi-Cal beneficiaries in the County are enrolled through the Alliance. Specifically with respect to behavioral healthcare treatment, California has split the financial responsibility: ● The County is financially responsible for any costs in excess of Medi-Cal payments for clients with severe behavioral health and/or substance use disorders. ● The Alliance and Kaiser are financially responsible for any costs in excess of Medi-Cal payments for clients with mild to moderate behavioral health issues. The Alliance and Kaiser are also financially responsible for the majority of other healthcare services to these clients, such as preventative care, specialist care, hospitalization, surgeries, radiology, lab, and pharmacy. The County’s Health Services Agency (HSA) provides services to County residents under four broad categories: Behavioral Health, Environmental Health, Health Centers, and Public Health. The Health Centers serve approximately 15,000 Medi-Cal residents annually, offering primary care, substance use disorder (SUD) and mild to moderate behavioral health services to these clients. The Behavioral Health division serves about 5,700 Medi-Cal residents annually, addressing SUD and moderate to severe behavioral health issues.[1] [2] About 15-20% of those 5,700 behavioral health Medi-Cal patients in the County use more than half (55%) of the health services provided by HSA.[3] [4] In Fiscal Year 2022-2023, one individual incurred costs of $1,574,102. In Fiscal Year 2023-2024, one individual incurred costs of $667,209.[2] These two patients, and others like them, are known as High-Cost Beneficiaries (HCB) or High-Cost Utilizers. The 2024-2025 Santa Cruz County Grand Jury (the Jury) will use the term HCB for the remainder of the report. HCBs are individuals who, due to frequent and repeated interactions with city and/or county agencies, incur substantial costs. These outliers are costly to the County not only when measured by dollars spent, but more importantly, the cost and time involved in managing HCBs strains the entire health care system. Such strains are cumulative and affect the availability of staff, bed space, and services. Every day, the needs of HCBs put pressure on the services and resources needed by the other clients. High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 111 While many of the services required by the State of California under Medi-Cal are paid through State and federal funding, that funding does not cover the total costs to the County. As a result, HSA’s 2023-2024 budget required an additional funding of $18.6 million from the County’s general fund.[5] Today, as Santa Cruz County faces an ever-shrinking budget while the need for services only increases, it is imperative that the County develop and implement cost-effective solutions to better manage their clients. In particular, the County needs to be able to better manage the cost burden of treating HCBs. They must be able to quickly identify these clients, understand the critical incidents that lead to any given patient becoming a high-cost client, and provide services that will improve patient outcomes. In the long run, better management will improve outcomes for all patients, control costs, and reduce the number of HCBs. The Jury found that the HSA does not regularly report on the number of clients they serve, the frequency of services, or the types of services their clients use. The HSA does not have data benchmarks such as a Level of Care (LOC) tool that can lead to a better understanding of costs and utilization of the services provided to all HSA clients. In addition to tracking and managing the HCB’s, the Jury found that the clinical operations of HSA need to prioritize reporting tools for all clients. Through improved reporting, the leadership can gain a greater understanding of costs, monitor clinical productivity, and establish both data integration and reporting protocols with subcontracted entities. Scope and Methodology The Jury sought to understand the reasons why so many services are needed by individuals which then result in them becoming high-cost beneficiaries. The Jury wondered: if the number of HCBs could be reduced, how might that impact the County’s general fund contribution to the HSA? How do various County and community agencies work with HCBs? How could Kaiser and the Alliance reduce the number of HCBs? The Jury interviewed people from different agencies, including HSA divisions and departments. The Jury spoke with law enforcement to help understand the scope and severity of community issues around HCBs. And the Jury talked with County contracted service providers. The Jury collected data on the costs incurred by HSA clients, reviewed documents that were prepared by external review agencies, and combed through data on websites including California’s Department of Health Care Services, the HSA, and the Alliance. Finally, the Jury reviewed the mandated responsibilities for the County HSA to provide Medi-Cal services. High-Cost Beneficiaries published June 26, 2025 112 Santa Cruz County Civil Grand Jury Investigation Funding Behavioral Health and Substance Use Disorder Services A substantial portion (95%) of the funding for Behavioral Health and Substance Use Disorders comes through Medi-Cal, which is a combination of Federal and State funds. Despite this, the operating costs of these services in Santa Cruz County exceed the Federal and State funding, which then requires a General Fund contribution from the County. General Funds paid towards Behavioral Health and SUD have been $40,302,996 for the past 3 years. The following is a summary: Unduplicated Total Program Total General Number of Costs (excludes Program Fund Behavioral Health allocations of Costs per Federal, State, General Support per and Substance Use HSD Patient per and Insurance Fund Patient per Fiscal Period Disorder Patients Administration) Year Funding Support Year 2021-22 5,750 $108,778,527 $18,918 $100,174,667 $8,603,860 $1,496 Actuals 2022-23 5,777 $129,052,424 $22,339 $111,128,635 $17,923,789 $3,103 Actuals 2023-24 Estimated 5,922 $137,940,711 $23,293 $124,165,364 $13,775,347 $2,326 Actuals Figure 1. Summary of Santa Cruz County Behavioral Health Services Division Revenues, Expenses, and Patient Volumes [2] [6] [7] As a result of the General Fund contributions to operate the program, the County is essentially the insurer or financial backstop for costs in excess of Federal and State funding. As an insurer, most healthcare organizations develop a number of tools and business models to manage the underlying risk. Those tools are put in place with identified benchmarks. As an example from the above figure, the Jury is unable to determine, because of a lack of benchmarks, if the level of expenditures or General Fund support was too much or too little per patient. The identified goal by the County HSA Director and County Executive Officer for FY 2026 is to significantly reduce the General Fund support.[8] When making decisions concerning the ongoing funding for services, the HSA should be providing industry benchmark data or trending targets to the general public, its Advisory Commissions, and the Board of Supervisors. One common management risk tool is the Pareto Principle, often referred to as the “80/20” rule. In the health care setting, this principle suggests that 80% of patient care costs and services are incurred by 20% of the clients. As a consequence, it is important as an insurer that the County and HSA have the mechanisms in place to effectively manage the high-cost beneficiary, approximately 20% of all clients. High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 113 In reviewing the program costs by service, the values on a “per patient per year” basis can be skewed, as some patients might access multiple programs. As an example, an “Access and Crisis” patient might also be included under “Substance Use Disorder” in the same year. Patients can receive care under multiple programs with varying funding sources and protocols. The total cost trends for the departments are shown below. As an observation, salaries and benefits represent about 25% of the program costs, with the majority of costs arising from contracted services. Consequently, managing the total costs of care requires an important alignment between the County (as the insurer) and its vendors. Organizations like the Alliance have a larger share of medical delivery costs as contracted services and have developed tools to more closely monitor costs as HCB outlier cases unfold. Program Costs as a % of Total County Behavioral Health Service 2025-26 2025-26 2024-25 2024-25 2024-25 2024-25 Proposed + Proposed + Behavioral Health Program Name Adopted Estimated Adopted Estimated Supplemental Supplemental Budget Actuals Budget Actuals Budget Budget Substance Use Disorder $44,486,031 $41,144,557 $46,490,753 24.41% 24.52% 25.79% Adult Mental Health $30,868,822 $28,282,402 $28,346,756 16.94% 16.86% 15.73% Behavioral Health Administration $30,429,499 $24,795,823 $26,683,073 16.69% 14.78% 14.80% Mental Health Managed Care $23,344,094 $23,305,588 $21,505,354 12.81% 13.89% 11.93% Children's Mental Health $18,761,775 $14,092,070 $22,235,806 10.29% 8.40% 12.34% Residential Mental Health $16,962,125 $17,832,894 $20,098,224 9.31% 10.63% 11.15% Access and Crisis $8,137,014 $6,818,499 $6,706,731 4.46% 4.06% 3.72% Behavioral Health Support $5,222,214 $5,834,318 $4,774,302 2.87% 3.48% 2.65% Quality Improvement $3,464,249 $3,617,496 $3,416,301 1.90% 2.16% 1.90% Specialty Mental Health $600,172 $2,047,275 -$4,458 0.33% 1.22% 0.00% Total Expenses $182,275,995 $167,770,922 $180,252,842 100.00% 100.00% 100.00% Salaries and Benefits as a % of Total 26% 24% 24% Services and Supplies as a % of Total 57% 57% 60% Figure 2. Expenses by Program Type Santa Cruz County Behavioral Services Division [2] [6] [7] High-Cost Beneficiaries published June 26, 2025 114 Santa Cruz County Civil Grand Jury The Jury sought to understand what mechanisms HSA has deployed to manage utilization and cost for patients seeking behavioral health and substance use disorder services. Those mechanisms could include the LOC tool that had been recommended in previous independent credentialing reviews. Definition and Identification of High-Cost Beneficiaries There is no standard definition of HCBs used by the County; the criteria vary from program to program.[9] [10] [11] There is, however, general agreement that HCBs incur much higher-than-average costs to the County. The Jury learned: ● Identification of HCBs occurs through various methods, including attempts to track individuals with severe mental illness, homelessness, and frequent emergency room use, as well as those involved with the justice system. [9] [12] [13] ● Common factors contributing to high utilization of services include co-occurring mental health and substance use disorders, homelessness, chronic health conditions, lack of support for seniors, and justice system involvement.[14] [15] ● HCBs comprise at least 15% of the members served by Behavioral Health in the County (compared to 4.5% statewide) and account for over 55% of the claimed services (compared to 34% statewide).[3] Identifying HCBs has proved elusive because there are no system-wide or cross-provider data collection and reporting standards for identifying potential and current HCBs, the services they use, and the overall cost to the County. County Health Services Programs and Resources In addition to County-run clinics and staff, HSA has programs available to serve and help manage HCBs, as does the Alliance and the Santa Cruz County Sheriff’s Office (Sheriff’s Office). The Jury finds that each program provides critical services to HCBs and, although they have overlapping goals and likely clientele, too, there is little to no coordination for tracking clients that receive services from one or more of the following programs: Integrated Housing and Recovery Team (IHART): An Integrated Housing and Recovery Team within the Behavioral Health Division that helps people experiencing homelessness and mental illness.[16] The 24/7 Mobile Crisis Response Team was launched by the County in December 2024. In the words of their website: Mobile Crisis Response Teams provide culturally responsive and clinically appropriate services in the community. We respond quickly to urgent behavioral health emergencies to help stabilize youth, support families and provide linkages to additional services. We help remove barriers to access by meeting individuals where they are, whether that’s a park, school, or other safe site like a faith-based location.[17] High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 115 Enhanced Care Management (ECM): This Alliance program targets Alliance clients who meet their internal HCB criteria and other high-risk clients. The program provides cross-disciplinary case management for an individual’s physical, mental, and social needs.[18] Focus Intervention Team (FIT): The Focus Intervention Team is a partnership between the Sheriff's Office and HSA that aims to provide services to individuals who are habitually arrested and also suffer from mental health or substance use disorders. This program aims to reduce recidivism by connecting individuals with necessary services, such as mental health treatment, substance use counseling, and housing assistance. FIT teams are staffed by deputy sheriffs and social workers who together identify each client’s particular needs and work one-on-one with the client to secure the services, whether it is a new ID or driver’s license, arranging medical appointments, or contacting a family member.[13] Care Alert: Launched January 2025, Care Alert is a voluntary registry that allows community members to share critical information about individuals with cognitive or behavioral challenges that may affect their safety, communication or conduct during interactions with 911, 988 (Suicide and Crisis Lifeline), or law enforcement. This is a proactive approach that can help ensure the individual receives appropriate care, minimize duplication of services, and potentially reduce health care costs. The Mental Health Advisory Board (MHAB) has recommended that Care Alert and the Mobile Crisis Response Team explore ways to share data.[19] Other Resources for the County Serving Communities Health Information Organization (SCHIO): Established in 1996 by local physicians, SCHIO is now a non-profit organization whose board includes members from the Alliance, HSA, both hospitals in the County, as well as other County health care providers and organizations. As a Health Information Organization, SCHIO facilitates the exchange of health information to improve care management, reduce redundancy, and enhance patient safety. The Jury believes the SCHIO partnership has not been adequately leveraged, especially for monitoring HCBs. The Jury strongly suggests that as a member of the SCHIO Board, HSA, together with the Alliance, establish data-sharing for all County HCBs. Mental Health Advisory Board: The MHAB provides advice to the Board of Supervisors (BoS) and the Behavioral Health Division. They are charged with reviewing and evaluating the community’s mental health needs, services, facilities, and special problems. According to the County’s website, MHAB provides oversight and monitoring of the local mental health system, as MHAB’s stated goals include: ● Advise the Behavioral Health Division on current and ongoing issues and potential solutions as they relate to the quality and effectiveness of Behavioral Health Services for the County. High-Cost Beneficiaries published June 26, 2025 116 Santa Cruz County Civil Grand Jury ● Develop skills, identify resources, and utilize best practices to maximize the effectiveness of the Santa Cruz County Mental Health Advisory Board. ● Increase community awareness on issues, services, and solutions related to Behavioral Health to ensure inclusion and dissemination of accurate and relevant information. MHAB’s goals align with the goals noted in the April 2025 report released by the Rand Corporation: Funding the Service Gap for Adult Outpatient Mental Health Services in California. The Jury believes the MHAB Board could be an advocate for improving coordination of care between the County and the Alliance and securing additional funding for County and Alliance programs. An initial step in this direction is MHAB’s written request that the BoS find ways to allow data sharing between the two Behavioral Health programs.[19] Central California Alliance for Health. The Governing Board of the Alliance includes a member of the County’s Board of Supervisors and the Director of the County’s Health Service Agency. The Alliance has been a contracted health care partner with the HSA since 1996, almost 30 years. As a County health services contractor, the Alliance has helped meet the County’s ever-increasing need for services by enrolling and insuring approximately 79,000 of the County’s 82,000 Medi-Cal patients.[20] [21] [22] [23] The Jury believes the County and the Alliance would both benefit from better integrated services, standards of care, and data sharing. The Jury also believes the Alliance is in a unique position to enhance funding of County behavioral health and substance abuse projects and programs. A Special Program and Partner: The Central California Alliance for Health The Alliance has an outsized and unique impact on County HSA services and HCBs because it has worked with the County for almost 30 years. The Alliance is a Managed Care Organization and insurer licensed to serve Medi-Cal clients. Since its inception in Santa Cruz County in 1996, the Alliance has grown to cover more than 440,000 Medi-Cal beneficiaries (99% of its members) in five central California counties: Mariposa, Merced, Monterey, San Benito, and Santa Cruz. HCB Data and Metrics at the Alliance. The Alliance uses internal metrics and reports to track and manage high-cost clients, including clients with complex medical and social needs.[24] Regular internal reports are generated, including monthly and quarterly reviews of utilization metrics and performance against strategic goals. Those tools and reports are appropriately directed towards healthcare services under the responsibility of the Alliance, but this does not include County responsibilities (like severe mental health or substance use disorders). High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 117 ● The Alliance defines high utilizers as individuals with two or more chronic conditions and either four Emergency Department visits or three inpatient admissions within a rolling 12-month period. ● Defining criteria for HCBs also includes 30-day readmission rates, post-discharge follow-ups, and Enhanced Care Management enrollees. ● Approximately 2% of County Alliance members meet the Alliance’s high utilizer criteria. ● An internal and confidential High Utilizer Dashboard provides the Alliance staff with detailed insights into demographics, chronic conditions, and care management for the Alliance’s HCBs. Behavioral Health Coordination with the County. The Alliance reports that it collaborates with the County’s Mental Health Plan (MHP) to ensure effective care coordination for members receiving behavioral health services. This partnership includes interdisciplinary team meetings and regular data sharing to address member needs. This collaboration needs to be strengthened. ● According to the most recent credentialing report, about 15% of the County Behavioral Health patients consume over 55% of the resources. ● Most of these same patients are likely receiving other healthcare through the Alliance. ● It seems logical that both the County MHP and the Alliance make stronger efforts to collaborate on a Level of Care tool, as recommended by the external credentialing report. The Alliance’s Finances. The State requires the Alliance to maintain financial reserves, which are called its “tangible net equity” (TNE). As of December 31, 2024, the required TNE for the Alliance was $76 million, and the actual TNE was $891 million. The Alliance has excess financial reserves that are $815 million, or 11 times the required minimum.[25] High-Cost Beneficiaries published June 26, 2025 118 Santa Cruz County Civil Grand Jury Figure 3. Financial Information (Excess Tangible Net Equity) for the Central California Alliance for Health as reported to the California Department of Managed Health Care[25] The governing board of the Alliance has established some guidelines on how the excess reserves shall be used. One of the opportunities that would be of mutual benefit to the Alliance and the County would be to leverage systems and tools to build a Level of Care tool, as recommended to the County during the most recent accreditation. The Challenge for the County and the Alliance. The Alliance has been a contracted health care partner with the HSA since 1996, almost 30 years. During that time, the HSA budget for health services has decreased. For the coming fiscal year, FY 2025-26, HSA expects yet another decrease despite growing demand and increased costs. This spiral exacerbates the HSA budget gap between service costs and Medi-Cal funding, thus increasing what the County needs from the General Fund. HCBs can have a significant impact on the HSA budget and staffing levels. In FY2023-2024 the HSA needed $18.6 million of County general funds to break even.[26] During this time, the Alliance has regularly increased its annual budget, expanded its in-house services, added staff, and built a healthy cash reserve – its Tangible Net Equity. At the close of FY 2024, the Alliance posted a TNE that is 11 times the required minimum.[25] Partner Engagement. The County and the Alliance share many patients. County efforts to work with the Alliance to develop tools to assist coordinated care have yet to produce shared data or standard reports.[9] [18] High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 119 This Jury strongly believes that both parties should sit down and begin leveraging their relationship with the goal of better serving the County and Alliance’s clients beyond these necessary financial exchanges. While challenges might arise concerning patient confidentiality, the parties could form appropriate contractual arrangements or management service agreements to coordinate the information. The Jury strongly suggests that the County and the Alliance agree to expand their relationship by together developing, with their in-house staffs and funding, a Level of Care (LOC) tool. The LOC tool can be the foundation for, first, managing shared HCBs and, eventually, used by the County for all of its Health Care clients. This tool could also be used by the Alliance to manage the almost half a million clients it serves throughout five Central California Counties. The County has Challenges The Jury finds that behavioral health and substance use disorder programs across the County operate in silos. Each administers its own programs or clinics. Each collects its own client data. Each is funded separately. At the same time, all rely on a variety of sometimes overlapping funding sources to serve ever-growing and sometimes overlapping populations. Fragmentation hinders collaboration on services, finances, and program administration.[14] [18] [27] [28] Administrative and Clinical Fragmentation. The County, the Alliance, the Sheriff's Office, and the County’s two hospitals often treat the same HCB clients but, there is little to no coordination between programs that would allow staff to provide the widest array of services without duplication. Minimizing duplication could reduce patient costs and improve patient outcomes.[29] [30] For example, an emergency room visit could automatically link a client to other needed services, such as a social worker or primary care provider visits, freeing the hospital social worker to meet with other patients. Data Fragmentation: There is no comprehensive public report detailing the number of HCBs, their service utilization, and their associated costs. Data is regularly collected, but the County does not have standard, regular reports to document services used or costs incurred at the individual level.[14] Throughout the review of the HSA, the Jury discovered that there are many reports prepared, but it is not clear what cost or utilization benchmarks the department was using to measure progress. As an example, a recently announced expansion of inpatient services, while laudable in addressing the impact of housing and behavioral health, does not have clear benchmarks to identify clinical or financial improvements. [31] Information Sharing Restrictions: Privacy laws, such as the Health Insurance Portability and Accountability Act (HIPAA) and Title 42 Code of Federal Regulations, limit the sharing of mental health and substance use disorder information among agencies and programs. SCHIO and the California Health Foundation have developed methods for sharing data that allow for better care and better outcomes. The County is not making use of these methods. High-Cost Beneficiaries published June 26, 2025 120 Santa Cruz County Civil Grand Jury Resource Constraints: Limited resources and staffing hinder the County’s ability to provide comprehensive services and address the complex needs of HCBs. The situation is exacerbated with the latest County budget for the HSA, which reduces funding from $313.1M in 2023-2024 to a proposed budget of $304.1M for 2025-2026, as well as the proposed elimination of 74 positions. A 2023-2024 Grand Jury report addressed many of the staffing issues.[26] [32] Homelessness and Housing: Homelessness is compounded by the high cost of housing and the housing shortage in the County. Both issues drive up the cost of services and also affect the County’s ability to place clients in less costly settings as their health issues improve.[27] [33] Continued Planning for CalAIM Initiatives California Advancing and Innovating Medi-Cal (CalAIM) is a long-term plan by the California Department of Health Care Services to transform California's Medi-Cal program. It aims to improve the health and well-being of Medi-Cal members by integrating health and social services, focusing on whole-person care, and reducing complexity in the system. There are several important initiatives under CalAIM that County leadership will be devoting resources to over the next two years, with some funding coming from the Behavioral Health Infrastructure Bond Act of 2024. No later than January 1, 2027, the County must combine the administration of specialty mental health and substance use disorders into a single integrated specialty behavioral health program. Under CalAIM, patient behavioral health services are reimbursed regardless of initial diagnosis. There is a ”no wrong door” policy that provides reimbursement for the initial diagnosis, even when patients later require other levels of care. Using CalAIM’s Enhanced Care Management framework will result in greater coordination of clients with co-occurring conditions, addressing both physical health and behavioral health needs for both HSA and the Alliance.[34] [35] Frameworks for Establishing Administrative, Financial, and Clinical Coordination In March 2022, the California Healthcare Foundation released a report titled, “How California Can Build On CalAIM to Better Integrate Physical and Behavioral Health Care.” Key components of the report that are relevant to the County and the Alliance for managing HCB’s include: ● Physical and behavioral health providers often do not receive information about the co-occurring needs or treatment plans of their patients and therefore, are constrained in how they can deliver whole-person care. This fragmented care then leads to higher costs — people with serious behavioral health conditions High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 121 incur greater spending on care, and these costs are largely attributable to increased physical health spending. For example, someone with a severe behavioral health condition may incur an injury that requires hospitalization. ● Efforts to improve physical-behavioral health integration must occur across various system functions, including financing, administration, and clinical care delivery. ● The building blocks of integration include: ○ Infrastructure such as data sharing and health information exchange. ○ A licensing and regulatory environment related to integrated care delivery. ○ Quality measurement that assesses outcomes across the full continuum of services. ○ Provider readiness supports for integrated care delivery. ○ Payment methods and financial incentives for integrated practices, including the development of Value Based Purchasing (VBP) models across physical and behavioral health. VBP models are a type of health care delivery model where providers are paid based on the quality and outcomes of the care they provide, rather than just the quantity of services rendered. VBP aims to improve quality, efficiency, and patient experience while reducing costs. In April 2025, the Rand Corporation released a comprehensive report: Funding the Service Gap for Adult Outpatient Mental Health Services in California. The report provides a detailed assessment of the discrepancy between existing mental health services available and what, financially and programmatically, is required to adequately serve the state’s population. The report points out that 1 in 26 Californians (approximately 1,500,000) live with serious mental illness. In the County, that translates to potentially just over 10,000 County residents. According to their data, a fully funded system capable of providing evidence-based outpatient mental health care for all eligible Californian adults who need services would be $12.7 billion. The report concludes that such an investment is unlikely. At the same time, it again points out the discrepancies and realities of the ongoing financial and service challenges the County faces. The report recommends that California improve mental health services by: ● developing care guidelines and training staff so the volume and scope of evidence-based care can be increased statewide. ● increasing outreach to ensure that all eligible individuals can receive the care they need. High-Cost Beneficiaries published June 26, 2025 122 Santa Cruz County Civil Grand Jury ● increasing funding across the mental health care system to ensure there is adequate workforce capacity to meet the needs of the 1 in 26 Californians who need mental and behavioral health services. Under Federal Regulation 42, each state must conduct independent, outside reviews of their managed care organizations. These reviews must report on the quality of care and the program operations of each County’s behavioral health and substance abuse programs. The FY2023-24 Medi-Cal Specialty Behavioral Health External Quality Review Santa Cruz County Final Report included these recommendations for improvement: ● Investigate reasons and determine service patterns related to HCBs and level of care; consider implementing an LOC tool for adults. ● Develop and implement strategies for increased Information Services and analytic support. ● Explore the needs of contract providers to ensure that the necessary service capacity is maintained. This includes the timely contracting in order to reimburse for services provided. These three reports offer a framework for the County HSA and the Alliance to collaborate. The reports also provide added evidence for the Jury’s findings that the County does not effectively track and manage what is a growing unmet need for mental and behavioral health services; that the current services are under-funded and under-staffed; and that the County cannot measure this need and is struggling to manage it. In addition to the above reports, these topic briefs published by the California Health Care Foundation provide additional examples and potential starting points for exploring coordination and integration of services, finances, and administrative functions. ● How California Can Build On CalAIM to Better Integrate Physical and Behavioral Health Care. ● How California’s 1115 Demonstration, BH-CONNECT, Will Impact Behavioral Health Care for Medi-Cal Members. ● Braiding Medicaid Funds to Support Person-Centered Care: Lessons from Medi-Cal. The Jury’s Challenge to the HSA and the Alliance The Jury has learned from confidential interviews and its own review of publicly available data, that designing and implementing processes and tools to improve outcomes for all HSA and Alliance clients, especially HCBs, could begin by using existing in-house expertise and collaborating with strategic partners such as the MHAB and SCHIO. High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 123 Therefore, the Jury challenges the HSA and the Alliance to develop an LOC and other tools that will prioritize the needs of HCBs by: ● improving administrative and clinical integration of behavioral and physical healthcare services. ● improving data sharing to reduce service overlaps. ● prioritizing housing for HCBs through increased capital funding from the Alliance. The County’s Directive to HSA As part of the financial and operational planning process presented to the Board of Supervisors on May 6, 2025, the County Executive Officer developed the following Operational Plan Objective #91: By December 2025, the Health Services Agency, in coordination with the County Executive, will establish a financial plan for the Santa Cruz County behavioral health system of care.[8] A critical step in the plan is for the HSA to: Provide clear documentation of the cost to offer core mandated and elective services and/or programs and any gap between that cost and available revenue. Based on confidential interviews, the 2024-2025 Santa Cruz County Grand Jury finds that the HSA reporting structure does include data that can help meet this directive. However, the HSA does not have administrative processes or reports in place that can be readily tapped to meet the directive requirements. A significant commitment of staff time and resources is needed to ensure that HSA can meet the December 31, 2025 due date. Findings F1. Data: The Health Services Agency has not developed and deployed analytic, data-driven reports to address the financial challenges in managing the Behavioral Health and Substance Use Disorder services, despite recommendations from accreditation reviews. Data driven tools and regular reporting are required for the County to manage High-Cost Beneficiaries as well as all Behavioral Health and Substance Use Disorder clients. High-Cost Beneficiaries published June 26, 2025 124 Santa Cruz County Civil Grand Jury F2. Administrative: The Jury finds that many programs, such as the Focus Intervention Team, Integrated Housing And Recovery Team, 24/7 Mobile Crisis Response Team, and Enhanced Care Management, provide critical services to High-Cost Beneficiaries. Although they have overlapping goals there is little to no coordination for tracking clients that receive services from one or more of these programs. The lack of coordination leads to higher costs in an era of shrinking resources. F3. Clinical: Santa Cruz County does not have a Level of Care Tool to track and manage High-Cost Beneficiaries. The Central California Alliance for Health does have a Level of Care Tool to track and manage High-Cost Beneficiaries. The parties are partners in the delivery of services and their resources could be leveraged to create a unified Level of Care tool. F4. Administrative: Santa Cruz County programs and resources for High-Cost Beneficiaries, and all Health Services Agency behavioral health and substance use disorder services, are siloed and fragmented across HSA departments and contract providers. For example, clinical, financial, and operational benchmarks are not being used to report the cost of services and track patient acuity. As new programs are being developed, the financial, operational, and administrative targets are not established in advance or integrated into operations. County and Alliance collaboration and coordination can pave the way to overcome fragmentation. F5. Data, Clinical & Administrative: The Central California Alliance for Health (Alliance) has substantial financial reserves, and Santa Cruz County has seats on the governing board of the Alliance. Clinical, financial and operational collaboration between these agencies, who are both insurers and providers, needs to be better coordinated and integrated at all levels to improve treatment and outcomes for all clients. F6. Administrative: The Jury finds that the Serving Communities Health Information Organization and the Mental Health Advisory Board partnerships with Santa Cruz County could be better leveraged to have greater impact on Behavioral Health. Failure to leverage these partnerships results in missed opportunities to coordinate programs and services. F7. Compassion: Throughout the Grand Jury investigation, the Jury found that the staff and leadership of the Health Services Agency, Santa Cruz County Sheriff’s Office, and the Central California Alliance for Health are compassionate in the treatment of people experiencing behavioral health or substance use disorder. Patients are treated with dignity and respect, despite sometimes difficult conditions. High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 125 Recommendations R1. Administrative Integration. The Board of Supervisors recently adopted Operational Plan #91 which calls for establishing a financial plan for the County behavioral Health system by December 31, 2025. Given the urgency of reduced funding, the Santa Cruz County Health Services Agency should provide a monthly progress report beginning August 1, 2025 to the Santa Cruz County Board of Supervisors on Operational Plan #91. R2. Ongoing External Reporting. Given the urgency of diminishing funding, the Santa Cruz County Health Services Agency should publish a monthly report on its public website no later than October 1, 2025. The website should summarize patient volumes, cost benchmarks, quality benchmarks, provider productivity, number of patients being tracked for high utilization, and number of patients enrolled in Enhanced Care Management (through the Alliance). An appropriate subset of reports specific to Behavioral Health and Substance Use Disorder should be provided to the Mental Health Advisory Board beginning October 1, 2025. R3. Ongoing External Reporting: In order to leverage their partnership with the Mental Health Advisory Board (MHAB) and raise public awareness around Behavioral Health in Santa Cruz County, the Health Services Agency and the Central California Alliance for Health should jointly report to the MHAB. Their reporting should occur at least bi-annually starting no later than June 30, 2026. Their report should discuss their collaborative efforts towards implementing a LoC tool, their progress towards developing value-based financing and should include Year-to-Date statistics on HCBs. R4. Ongoing External Reporting: At least bi-annually beginning no later than September 30, 2025, Health Services Agency (HSA) and the Central California Alliance for Health (Alliance) should meet jointly with Serving Communities Health Information Organization (SCHIO). The meeting agenda should include a review of the data HSA and the Alliance submit to SCHIO and the SCHIO data and reporting features that HSA and the Alliance use. The goal is to leverage their partnership and better integrate the dissemination of accurate information to health care professionals and law enforcement about the treatment and needs of their clients. The outcome of the meeting should be reported to the Mental Health Advisory Board. R5. Clinical Integration. Annually, beginning January 1, 2026, the Santa Cruz County Health Services Agency and the Central California Alliance for Health should review, align, and jointly publish their aligned clinical and program delivery methods and goals for all levels of Behavioral Health and Substance Use Disorder patients. R6. Administrative, Financial & Clinical. By July 1, 2026, the Santa Cruz Health Services Agency and the Central California Alliance for Health should have a shared database and shared criteria for identifying potential High-Cost High-Cost Beneficiaries published June 26, 2025 126 Santa Cruz County Civil Grand Jury Beneficiaries. This Level of Care tool should track costs, services, and outcomes for not only Behavioral Health and Substance Use Disorder High-Cost Beneficiaries, but for all clients. The following California Health Care Foundation brief provides a starting point for building a more integrated system of care over the long term: Better Integrate Physical and Behavioral Health Care. R7. Administrative Integration. The Santa Cruz County Health Services Agency and the Central California Alliance for Health should develop a seamless administrative process that uses standardized and shared data, reports and goals. No later than December 31, 2026, a report shall be submitted to the respective governing boards outlining the processes established to integrate network management, provider payment, and data collection and reporting. R8. Financial Integration. On or before July 1, 2027, the County Health Services Agency and the Central California Alliance for Health should report to their respective governing boards the steps they have taken towards financial integration of all behavioral health services and substance use services using a value based financing process. Braiding Medicaid Funds described in the August 2024 Brief from the California Health Care Foundation provides a framework for achieving this necessary integration. Required Responses Respond Within/ Respondent Findings Recommendations Respond By Santa Cruz County F1, F2, F3, F4, F5, R1, R2, R3, R4, R5, 90 Days / Board of Supervisors F6, F7 R6, R7, R8 September 24, 2025 Governing Board, R3, R4, R5, R6, R7, 90 Days / Central California F3, F5, F7 R8 September 24, 2025 Alliance for Health Invited Responses Respond Within/ Respondent Findings Recommendations Respond By Director, Santa Cruz 60 Days / F1, F2, F3, F4, F5, R1, R2, R3, R4, R5, County Health August 25, 2025 F6, F7 R6, R7, R8 Services Agency CEO, Central 60 Days / R3, R4, R5, R6, R7, California Alliance for F3, F5, F7 August 25, 2025 R8 Health High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 127 Definitions ● 24/7 Mobile Crisis Response Team: Provides culturally responsive and clinically appropriate services in the community 24 hours a day, seven days a week. ● 988: Suicide and Crisis Lifeline ● Alliance: Central California Alliance for Health, a regional Medi-Cal managed care plan that provides health insurance for children, adults, seniors, and people with disabilities. ● Behavioral Health: The Behavioral Health Division of the Health Services Agency provides a wide range of prevention and treatment options for Santa Cruz County adults, children, and their families. ● CalAIM: California Advancing and Innovating Medi-Cal is a multi-year initiative by the California Department of Health Care Services to transform and improve the Medi-Cal program, California's Medicaid system ● County: Santa Cruz County ● ECM: Enhanced Care Management targets Alliance clients that meet their internal HCB criteria and other high-risk clients. The program provides cross-disciplinary case management for an individual’s physical, mental, and social needs. ● FIT: The Focus Intervention Team is a partnership between the Sheriff's Office and the HSA that aims to provide services to individuals who are habitually arrested and also suffer from mental health or substance use disorders ● Fragmentation: The process or state of breaking or being broken into small or separate parts. ● FY: Fiscal Year ● HCB: High-cost beneficiaries ● HIPPA: Health Insurance Portability and Accountability Act ● HMO: Health Maintenance Organization ● HSA: Santa Cruz County Health Services Agency ● IHART: An integrated housing and recovery team within the Behavioral Health Division that helps people experiencing homelessness and mental illness ● Jury: The 2024-2025 Santa Cruz County Civil Grand Jury ● LOC: Level of Care ● Medicaid: A joint federal and state program that helps cover medical costs for some people with limited income and resources High-Cost Beneficiaries published June 26, 2025 128 Santa Cruz County Civil Grand Jury ● Medi-Cal: A public health insurance program which provides needed health care services for low-income individuals including families with children ● MCO: Managed Care Organization ● MHAB: The Mental Health Advisory Board reports to the Board of Supervisors. They are charged with reviewing and evaluating the community’s mental health needs, services, facilities, and special problems. According to the County’s website, MHAB provides oversight and monitoring of the local mental health system ● MHP: Mental Health Plan ● Pareto Principle: Also known as the 80/20 rule, is a concept that states that approximately 80% of consequences come from about 20% of the causes. ● SCHIO: Serving Communities Health Information Organization was established in 1996 by local physicians, SCHIO now is a non-profit whose board includes members from the Alliance, the HSA, hospitals, as well as County health care providers and organizations. As a Health information Organization, SCHIO facilitates the exchange of health information to improve care management, reduce redundancy and enhance patient safety. ● SUD: Substance Use Disorder ● TNE: Tangible Net Equity - State mandated financial reserves ● VBP: Value Based Purchasing, a payment model that incentivizes providers to deliver high-quality, cost-effective care and improve patient outcomes. It shifts the focus from fee-for-service to performance-based payments. Sources References 1. Confidential Grand Jury interview. 2. Confidential Grand Jury document. 3. Behavioral Health Concepts, Inc.. January 26, 2024. “FY 2023-24 MediCal Specialty Behavioral Health External Quality Review,” p. 60. FY 2023-24 MediCal Specialty Behavioral Health External Quality Review. Accessed June 5, 2025. https://www.santacruzhealth.org/Portals/7/Pdfs/QI/2024/Santa%20Cruz%20MH P%20FY%202023-24%20Final%20Report-26958112.pdf 4. Confidential Grand Jury interview. High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 129 5. Santa Cruz County. (no date). “Adopted Budget - Health Services Agency.” Santa Cruz County website. Accessed May 29, 2025. https://www2.santacruzcountyca.gov/CAO/StrategicPlan/Budget/2024-25/dept/ 24 6. Confidential Grand Jury document. 7. Santa Cruz County. (no date). Santa Cruz County. Accessed June 5, 2025. https://www2.santacruzcountyca.gov/CAO/StrategicPlan/Budget/2024-25/dept/ 24 8. County Executive Officer. May 6, 2025. “Highlights of Santa Cruz County Operational Plan 2025-2027, See Board of Supervisors May 6, 2025 Meeting for background Item #12: Consider the Santa Cruz County Operational Plan for Fiscal Years 2025-25, and take related actions (County Executive Office) . 9. Confidential Grand Jury interview. 10. Confidential Grand Jury interview. 11. Behavioral Health Concepts, Inc. January 26, 2024. “FY 2023-24 MEDI-CAL SPECIALTY BEHAVIORAL HEALTH EXTERNAL QUALITY REVIEW.” Behavioral Health Concepts, Inc. Accessed June 5, 2025. https://www.santacruzhealth.org/Portals/7/Pdfs/QI/2024/Santa%20Cruz%20MH P%20FY%202023-24%20Final%20Report-26958112.pdf 12. Confidential Grand Jury interview. 13. Confidential Grand Jury interview. 14. Confidential Grand Jury interview. 15. Confidential Grand Jury interview. 16. Health Services Agency (HSA) website. (no date). “Behavioral Health Bridge Housing.” Accessed May 31, 2025. https://www.santacruzhealth.org/HSAHome/HSADivisions/BehavioralHealth/Be havioralHealthBridgeHousing.aspx 17. Santa Cruz County Behavioral Health Services Agency. (no date). Santa Cruz County Behavioral Health Services Agency. Accessed June 6, 2025. https://www.santacruzhealth.org/HSAHome/HSADivisions/BehavioralHealth/Mo bileCrisisResponseTeam.aspx 18. Confidential Grand Jury interview. 19. Santa Cruz County Mental Health Advisory Board. March 25, 2025. “Chair, Mental Health Advisory Board,” p. 37. MHAB Agenda. Accessed June 3, 225. https://health.co.santa-cruz.ca.us/Portals/7/Pdfs/Local%20Mental%20Health%2 0Board/2024/04.17.25%20Agenda%20and%20Materials.pdf High-Cost Beneficiaries published June 26, 2025 129 . Tania Ortiz, Lookout Santa Cruz. May 13, 2025. “Proposed Medicaid changes could threaten care access for 80,000 in Santa Cruz County, health leaders warn.” Jen Herrera, assistant director of Santa Cruz County Health Services Agency.. Accessed June 3, 2025. https://lookout.co/proposed-medicaid-changes-could-threaten-care-access-for- 80000-in-santa-cruz-county-health-leaders-warn/story 21. Tyler Maldonado. March 28, 2025. Santa Cruz Local. Accessed June 6, 2025. https://santacruzlocal.org/2025/04/01/thousands-of-santa-cruz-county-residents -could-lose-health-care-with-medicaid-cuts/ 22. Central California Alliance for Health. April 23, 2025. “Santa Cruz – Monterey – Merced – San Benito –Mariposa Managed Medical Care Commission Meeting Agenda,” p. 120. 23. Department of Health Care Services. (no date). Department of Health Care Services. Accessed June 17, 2025. https://data.chhs.ca.gov/dataset/medi-cal-certified-eligibles-with-demographics- by-month/resource/29a8f949-5c12-4e42-92db-39fa5ea12b8e 24. Confidential Grand Jury document. 25. Department of Managed Healthcare. January 1, 2023. “Health Plan: Santa Cruz-Monterey-Merced-San Benito-Mariposa Managed Medical Care Commission, 2023-2025.” Accessed June 30, 2025. 26. Santa Cruz County. (no date). Santa Cruz County. Accessed June 5, 2025. https://www2.santacruzcountyca.gov/CAO/StrategicPlan/Budget/2024-25/dept/ 24 27. Confidential Grand Jury interview. 28. Confidential Grand Jury interview. 29. Confidential Grand Jury interview. 30. Confidential Grand Jury interview. 31. Confidential Grand Jury interview. 32. 2023-2024 Santa Cruz County Grand Jury Report. June 1, 2024. “County Behavioral Health Services – A State of Mind.” Santa Cruz County Grand Jury website. Accessed May 15, 2025. https://www.santacruzcountyca.gov/Portals/0/County/GrandJury/GJ2024_final/2 024-7_HSA_Report.pdf 33. Confidential Grand Jury interview. 34. Confidential Grand Jury interview. High-Cost Beneficiaries published June 26, 2025 2024-2025 Consolidated Final Report 131 35. Department of Health Care Services. (no date). “No Wrong Door for Mental Health Services and Co-Occurring Conditions.” Accessed May 31, 2025. https://www.dhcs.ca.gov/Pages/CalAIM-BH-Initiative-FAQ-No-Wrong-Door-And -Co-Occurring-Treatment.aspx Websites Behavior Health Bridge Housing Behavioral Health Concepts, FY 2023-24 Medi-Cal Specialty Behavioral Health External Quality Review Santa Cruz Final Report CalAIM California Health Care Foundation, How California’s 115 Demonstration, BH‑CONNECT, Will Impact Behavioral Health Care for Medi-Cal Members California Health Care Foundation, Braiding Medicaid to Support Person-Centered Care: Lessons from Medi-Cal California Health Care Foundation, How California Can Build On CalAIM to Better Integrate Physical and Behavioral Health Care Care Alert Physical and Behavioral Health Care Central California Alliance for Health Governing Board Central California Alliance for Health Central California Alliance for Health, Enhanced Care Management Central California Alliance for Health Statistics reported to the Department of Managed Health Care FIT HIPAA Privacy Rule High-Cost Beneficiaries published June 26, 2025 131 Santa Cruz County Civil Grand Jury Mental Health Advisory Board (MHAB) Medi-Cal Managed Care Mobile Crisis Response Team Rand Corporation Santa Cruz County Civil Grand Jury Report 2023-2024, County Behavioral Health Services – A State of Mind Focus. Fund. Save Serving Communities Health Information Organization (SCHIO) Title 42, Code of Federal Regulations High-Cost Beneficiaries published June 26, 2025