2015 Complete Grand Jury Report*

The Grand Jury finds that OES is sufficiently focused on updating the Plan while addressing the seriousness of an unprecedented drought and the extreme fire danger it poses. Commendation #1: The Grand Jury commends the OES for its attention to the Plan in the midst of the current drought crisis. Required Responses #1: None Implementation Monitoring The 2014-2015 Grand Jury Continuity Committee also reviewed and monitored items from previous grand juries. The Jury's continuity obligation was to review responses and follow-up to see if specific recommendations were adopted, and any process or procedure that required implementation was in fact completed. The 2012-2013 and 2013-2014 Grand Jury reports required implementation processes for the following investigated departments, agencies, or issues: Columbia Fire Protection District (CFPD), Tuolumne County Building Division, Columbia Union School District, Public Realignment AB 109 - Karpel Case Management (PBK), and Behavioral Health - 5150 Issue. Report #2 Columbia Fire Protection District Finding and Recommendations from the 2012-2013 Grand Jury DISCUSSION The 2014-2015 Grand Jury found a number of responses to previous grand juries' recommendations to be inadequate. The Grand Jury sent a letter dated September 17, 2014 to Columbia Fire Protection District requesting further clarification and information on Findings and Recommendations #5, #6, and #13 to the 2012-2013 Grand Jury report: 2012-2013 Finding and Recommendation #5: Finding -The hiring of administrative positions such as a Fire Chief, Administrative Captain or Captain are not subject to pre-employment background checks.

The Grand Jury finds that, according to CFPD, the Standard Operating Procedures have not been updated since 2003 and are outdated.

The Grand Jury finds that the terminology "local criminal background investigation," is vague, and current and updated criminal clearance checks have still not been completed for all employees and volunteers.

The Grand Jury finds that APS is meeting the current needs of the adult population of the County and is on track with its overall goal: “To wrap a safety-net around the adult person to support their aging in place,” but could benefit the community by having a formalized public education plan.

The Grand Jury finds that the current MOU described seems to be working well and as intended for the County. (See Attachment A) Commendation: The Grand Jury commends the County for the implementation of this MOU and for the excellent work Tuolumne County Behavioral Health does for the County. 2014 TUOLUMNE COUNTY 5150 EVALUATION AND RESPONSE PROTOCOL MULTIAGENCY AGREEMENT INTRODUCTION The purpose of this protocol is to provide for a coordinated response and shared understandings by all Tuolumne County stakeholders of the roles, accountabilities and systems guiding the care of patients who are being evaluated for a 5150. The ability to provide consistent care to those Tuolumne County residents most in need is a value shared by all. While we recognize that resources will continue to be in short supply, there is no shortage of possibilities when all community stakeholders come to the table with a single purpose to ensure the best care possible for our patients with mental illness. This document is intended to provide that community framework for care. DEFINITIONS a. Lanterman-Petris-Short Act (1972): This act, written in 1967 and signed into law in 1972, was intended to provide a system of care in each community for persons with severe and/or acute mental health issues. This Act spells out the parameters for providing both voluntary and involuntary mental health treatments. b. Welfare & Institutions Code 5150: This section of the W & I code states that a person who, as a result of a mental disorder, is a danger to self, a danger to others, or gravely disabled may be held up to 72 hours for observation in a 5150-designated facility. Related sections include 5151 – 5157. c. Receiving facility: This distinction applies to hospitals and other facilities who are equipped to provide medical clearance and other acute care services to a psychiatric patient in preparation for that patient's transfer to an inpatient psychiatric facility or discharge to outpatient care. d. California Forensic Medical Group (CFMG): The contract agency responsible for providing medical and psychiatric services to the inmates of the Tuolumne County jail and Juvenile Hall. e. Law enforcement: Includes those Tuolumne County sworn peace officers working for Municipal Police Departments, County Sheriff's Department, and the California Highway Patrol. f. Individuals designated to write 5150 applications in Tuolumne County: Pursuant to Welfare & Institutions Code Section 5150, the County Board of Supervisors has authorized the following persons and organizations to involuntarily detain individuals:▪ All sworn peace officers for the County and cities within Tuolumne County, including the California Highway Patrol. ▪ Licensed and/or designated crisis response personnel of Tuolumne County Behavioral Health. g. Medical clearance: The definition of 'medically cleared', as defined by this County, includes tests, screenings, and clinical observations that allow a medical professional to conclude that a patient is medically stable, does not require further inpatient acute care hospitalization, and is physically suitable for transfer for further psychiatric care (either on an inpatient or outpatient basis). h. Psychiatric hospitals: Hospitals licensed in California to provide in-patient psychiatric care. There are no psychiatric hospitals in Tuolumne County. i. CA Health and Safety Code 1799,111: States that a licensed acute care hospital that is not a designated facility is protected to hold a .5150 patient for up to 24 hours. j. Emergency Medical Treatment and Active Labor Act (EMTALA): Was enacted by Congress in 1986 to enhance access by all persons to emergency services and prohibit discrimination regardless of financial or insurance status. COMMUNITY PARTNERS a. Tuolumne County Board of Supervisors b. Tuolumne County Behavioral Health Department c. Sonora Regional Medical Center d. Tuolumne County Sheriff's Department e. Sonora Police Department f. California Highway Patrol g. Tuolumne County Correctional Facilities/Custody Detention Staff ASSUMPTIONS, GENERAL AGREEMENTS AND PRINCIPLES OF THIS COMMUNITY PROTOCOL 1. Mental health is a community responsibility. No single agency, organization or facility in the community has the resources, scope of services, or skill sets to address the challenges on their own. Tuolumne County puts a high value on the respectful and collaborative process used to develop this protocol and is committed to using that same process as this protocol is implemented and refined over time. 2. Our shared goals are to ensure patient access to the right care at the right time in the right place. This commitment to will allow care to be provided with the most respect for an individual's rights and capacity to choose. 3. We agree to leverage the competencies of our community partners and to share training and knowledge unique to each stakeholder for the benefit of the larger community. 4. We are committed to maintaining individual and community safety. At times, individuals may require voluntary or involuntary treatment in order to assure their safety and the safety of others. 5. We recognize that individuals who may be experiencing serious psychiatric crises and who also violate the law must be held legally accountable for their actions. 6. We recognize that individuals who may be experiencing serious psychiatric crises may also have acute physical conditions and stabilizing their physical/medical needs is a priority. 7. This 5150 protocol applies to Tuolumne County residents (Additional procedures are required when TCBH staff are involved in finding placement of residents of other counties). ROLES AND RESPONSIBILITIES: LAW ENFORCEMENT (SHERIFF'S DEPARTMENT, MUNICIPAL POLICE AGENCIES) 1. According to the Welfare & Institutions code, peace officers are authorized to complete a 5150 application and to take a person into custody for a mental health evaluation and assessment in a facility designated by the County and approved by the State Department of Mental Health. As there is no facility in Tuolumne County with the capabilities to provide the required mental health evaluation, assessment and/or treatment, peace officers in this County are authorized to take an individual into custody under this W & I code and transport them to the closest acute care hospital for medical clearance, assessment by a County-designated individual, and disposition to the appropriate inpatient or outpatient care centers. 2. Officer considerations and responsibilities ♦ Any officer responding to or handling a call involving a suspected or actual mentally disabled individual should carefully consider the following: ▪ Individual's need for emergency medical attention. ▪ Any available information which might assist in determining the cause/nature of the mental illness. ▪ Community resources which may be readily available to assist the individual. ▪ Services available by Tuolumne County Behavioral Health. 3. Transportation of 5150 patients who require no further law enforcement action ♦ If the person requires medical attention; ▪ Transportation is by ambulance per established Tuolumne County EMS policies. The officer will escort the patient into the facility and place that person in a treatment room or waiting area as directed by a hospital staff member. ♦ If the person does not require medical attention; ▪ Law enforcement may transport the individual directly to Sonora Regional Medical Center or call ambulance as per their department policies. ♦ Role of law enforcement after patient's arrival at the hospital: ▪ Law enforcement personnel will meet and confer with hospital staff to ensure a smooth transition and to discuss issues regarding safety risks and concerns. Law enforcement may remain with the patient in the hospital depending on necessity. If law enforcement leaves and the hospital determines law enforcement presence is required again for the safety of the patient, hospital staff and other hospital patients/visitors, there will be a request for called-back. 4. Patient elopements ♦ Coordination and communication between law enforcement agencies in regard to patients that leave against medical advice, elope, or that continue to be a risk following discharge is essential. ▪ Sonora Police Department and/or Tuolumne County Sheriff's Department and Tuolumne County Behavioral Health will be notified by Sonora Regional Medical Center of patient elopement if that patient has either been placed on a 5150 or is believed to be a danger to self or others or gravely disabled. Regardless of the law enforcement agency that transported the patient to the hospital, all will be involved, if needed. 5. Upon arrival at Sonora Regional Medical Center ▪ Patients accompanied by law enforcement personnel will be given priority after life & death, ambulance and other critically ill patients are cared for. ▪ The goal is to provide medical clearance and mental health evaluation within 60 minutes of arrival whenever possible. ▪ Hospital staff will notify Tuolumne County Behavioral Health regarding the need for a mental health evaluation when it is thought the patient will be medical cleared. ROLES AND RESPONSIBILITIES: SONORA REGIONAL MEDICAL CENTER 1. Medical clearance a. Medical evaluations of patients who are thought to be a danger to self, others or gravely disabled. ▪ Individuals who are experiencing a psychiatric crisis and who are placed on a 5150 hold by law enforcement or other County-designated personnel are brought to the closest appropriate hospital's Emergency Department (ED) for assessment, treatment and stabilization of their physical conditions. ▪ They are treated with the same medical evaluation, physical assessments, and triage principles as applied to any ED patient. ▪ Until referred to another venue of treatment or discharged, each patient is under the primary care of the ED physician, unless otherwise noted. ▪ For patients requiring transfer to an inpatient psychiatric facility, all require some level of medical clearance. The parameters of this clearance vary from facility to facility. b. Patients requiring hospital admission ▪ If a patient under a 5150 hold is admitted into the hospital based on their medical condition, the 5150 hold is suspended. ▪ When that patient is ready for discharge from the hospital, medical personnel will complete a medical clearance and then contact Tuolumne County Behavioral Health staff (TCBHS). ▪ TCBHS will respond within 1 hour or less whenever possible and re-assess the patient's mental health status. ▪ If TCBHS determine that the patient continues to meet criteria for a 5150 hold, TCBHS will write a new 5150 hold and coordinate admission of the patient into an appropriate designated psychiatric facility for a 72-hour treatment and evaluation. If, however, the criteria for a 5150 hold are no longer met, the patient and the 5150 hold will be discharged. c. Mental health evaluations of patients who may require a 5150 in the ED ▪ Upon completion of the medical clearance, ED nurse will notify TCBHS of the need for a mental health evaluation. ▪ TCBHS will respond in 30 minutes or less whenever possible. ▪ Patient transfers or referrals to designated inpatient psychiatric facilities or releases to outpatient services will be facilitated by TCBHS but remains the responsibility of the acute care hospital in accordance with EMTALA. d. Accounting for the 72-hour hold time ▪ It remains the designation of Tuolumne County and the findings of the W&I Code Section 5150 and 5151 that the 72-hour hold time begins upon admission to an appropriate psychiatric facility designated by the County, and not before. If a patient is medically cleared and awaiting psychiatric placement for longer than 72 hours, the 5150 hold will need to be reassessed and a new 5150 will be written by Behavioral Health crisis worker as necessary and appropriate. 2. Documentation/medical record ▪ Documentation will be done per hospital policy. ▪ Copies of the patient's medical record will be sent with the patient upon transfer to a designated inpatient psychiatric facility, including the original 5150 application. ▪ For patients released to outpatient services, the original 5150 application will remain in the patient's hospital medical record. 3. Arranging for transportation of patient to accepting psychiatric facility ♦ Transportation to an accepting psychiatric facility is the responsibility of the sending medical facility in accordance with EMTALA. 4. Patient elopement ♦ Sonora Police Department and/or Tuolumne County Sheriff's Department and Tuolumne County Behavioral Health will be notified by Sonora Regional Medical Center of patient elopement if that patient has either been placed on a 5150 or is believed to be a danger to self or others or gravely disabled. Regardless of the law enforcement agency that transported the patient to the hospital, all will be involved, if needed. ROLES AND RESPONSIBILITIES: TUOLUMNE COUNTY DEPARTMENT OF BEHAVIORAL HEALTH 1. Tuolumne County Department of Behavioral Health will complete 5150 evaluations and applications. 2. Psychiatric evaluations and other services ♦ Tuolumne County Behavioral Health designated staff have the ability to complete mental health crisis assessments, 5150 applications, crisis interventions, and other emergency interventions for persons in Tuolumne County as well as review, uphold and/or discontinue 5150 holds placed on individuals by other agencies. 3. Response times (hours of operation, response times) ♦ Tuolumne County Behavioral Health will respond to requests for crisis evaluations within 30 minutes of request of evaluation. Non-adherence to this standard might occur based on Tuolumne County Behavioral Health staff being currently engaged in another crisis evaluation. Tuolumne County Behavioral Health will track compliance to this standard and will work to ameliorate impediments as possible. ♦ Tuolumne County Behavioral Health can be contacted at 209-533-7000 4. Perform W & I code 5150 evaluation ♦ Complete mental health crisis assessment: ▪ In the course of completing the 5150 assessment, the TCBHS will complete a mental health crisis evaluation. ▪ TCBHS will consult with law enforcement and hospital staff, as appropriate, to provide additional information about a patient useful in the evaluation and subsequent treatment plan for the patient. ▪ A copy of the crisis evaluation form is provided to medical facility for inclusion in their medical record. ♦ To release an individual from a 5150 hold: ▪ If, after their assessment, the TCBHS determines that the individual does not meet the criteria for a 5150 application, they will discontinue the hold and inform patient regarding available community resources. ♦ If individual meets criteria for a 5150 hold: ▪ TCBHS will work to locate an appropriate inpatient psychiatric facility to accept the patient. ♦ Evaluation of hospital inpatients: ▪ When hospital staff requests a 5150 evaluation for those inpatients that are medically cleared and ready for discharge, TCBHS will respond to those requests in the same way that they do to an ED request. ♦ Arranging for transportation of patient to the accepting psychiatric facility: ▪ Tuolumne County Behavioral Health will identify an appropriate psychiatric facility and arrange for admission to the facility. Coordination of transportation of the patient remains the responsibility of the sending medical facility as per EMTALA. ♦ Consult with medical staff re: medical clearance evaluation: ▪ TCBHS will, as appropriate, consult with the hospital physicians in determining medical clearance as it applies to the ability to transfer the patient to an inpatient psychiatric unit. If the accepting facility's psychiatrist does not concur with the medical clearance, the treating hospital will maintain responsibility for the disposition of the patient until such time that the medical clearance is agreed upon. TCBHS may facilitate a physician-to-physician consultation. 5. Develop appropriate after-care plan for individuals who do not meet 5150 hold criteria ♦ Consult with individual/family members. ♦ Refer to appropriate outpatient treatment services (e.g. of Behavioral Health Services, private insurance providers, other social services agencies as appropriate). ♦ Consult with hospital staff. ♦ Documentation of criteria determined and after care plan. ROLES AND RESPONSIBILITIES: AMBULANCE SERVICES/COUNTY EMS 1. Transport of individuals to medical facilities Within Tuolumne County, this is consistent with Tuolumne County EMS Policies 2. Transport of individuals to in-patient psychiatric facilities Within Tuolumne County, this is consistent with Tuolumne County EMS Policies TRAINING 1. The community partners on this protocol agree to ensure that all agency personnel involved in carrying out the agreements shall be trained in this response protocol. 2. The community partners agree to establish a training plan/calendar for all agency personnel on issues dealing with this 5150 protocol and other related mental health issues and to share in the delivery of that training based on their respective areas of expertise. 3. In accordance with this community protocol, all parties shall verify and ensure that its employees and agents are in good standing with their boards of licensure or certification; shall verify and ensure that its employees and agents have the appropriate education, knowledge, experience and clinical competency, commensurate with their responsibilities and job duties. QUALITY REVIEW AND IMPROVEMENT PROCESSES 1. A Tuolumne County 5150 Work Group will be formed with representation from all community stakeholders and will agree to meet at least annually to address issues including, but not limited to, this protocol; process improvement opportunities; case study reviews for training purposes; and related mental health issues that arise in the community. TERMS OF AGREEMENT 1. This agreement shall be in effect from January 1, 2014 and shall remain in effect until revised. The terms of this agreement shall be reviewed at two year intervals. 2. This agreement may be amended or modified only if agreed upon by all parties. Such amendments or modifications shall become effective only after they have been submitted in writing and signed by all parties. SIGNATURES OF COMMUNITY PARTNERS TO THIS PROTOCOL County of Tuolumne: Evan Royce 4/15/14 Evan Royce, Chairperson (Date) Tuolumne County Board of Supervisors Sonora Regional Medical Center: Andrew Jahn 4/15/14 Andrew Jahn (Date) President Attest: Alicia James 4/15/14 Alicia James (Date) Deputy Clerk of the Board Approved as to Legal Form: Coyce 3/20/14 Christopher Schmidt (Date) Deputy County Counsel California Highway Patrol: Alicia James 3/25/14 Scott Clamp (Date) Lieutenant Commander Sonora Police Department: Mark Stinson 26 March 14 Mark Stinson (Date) Chief of Police Alicia James 3/20/14 Rita Austin, LCSW, Director (Date) Tuolumne County Department of Behavioral Health I hereby certify that according to the provisions of Government Code Section 25193, delivery of this document has been made. Ann Connolly 3/20/14 Ann McLe, Sheriff (Date) Tuolumne County Sheriff's Department ALICIA L. JAMAR Clerk of the Board By: Alicia James Ann Connolly 3/20/14 Ann Connolly, Director (Date) Tuolumne County Ambulance Bibliography Tuolumne County Grand Jury, Tuolumne County Grand Jury Report. Fiscal Year 2010-2011 Tuolumne County Grand Jury, Tuolumne County Grand Jury Report. Fiscal Year 2012-2013 Tuolumne County Grand Jury, Tuolumne County Grand Jury Report. Fiscal Year 2013-2014 SB-82 Investment in Mental Health Wellness Act of 2013 - website http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140SB82 ADULT PROTECTIVE SERVICES COMMITTEE REPORTS “Surfing the Silver Tsunami” INTRODUCTION The aging of baby boomers is creating a shift in the age of the U.S. population, and sadly, with a silver-haired population that is growing in numbers, the cases of elder abuse may be growing as well. It has been ten years since the last Adult Protective Services (APS) review, prompting the 2014-2015 Grand Jury to see how the County’s adult population is currently being served by APS and how they are handling elder abuse. After a thorough investigation, this committee produced reports about the merger of Child Welfare Services (CWS) and APS, case management technology, staff performance, planning for the future aging population, and public education. BACKGROUND The Aging Population According to the 2010 U.S. Census, adults over the age of 65 are the fastest growing demographic group in the United States. This group, known as “The Silver Tsunami,” will make up 20% of the US population by 2029; these are the baby boomers (born between 1946-1964), and there are 76 million of them. Tuolumne County has one of the three oldest populations in California with approximately 1/3 of its population over the age of 65, and that is not yet the crest of the wave, according to the California Department of Aging, (CDA), the elder population is projected to increase between 99% and 150% by 2020, and the unfortunate reality is, older people are more vulnerable to illness. Aging populations and chronic illnesses increase the vulnerability of older people. Studies indicate as we see more adults with Alzheimer's disease and other types of dementia, the likelihood of abuse increases as well. A study by the National Center on Elder Abuse (NCEA), found that Alzheimer's disease is expected to grow exponentially in the coming decades... from 5.3 million to 16 million cases in 2050. Communities need to be ready to care for this growing demographic and more importantly, need to be alert and educated for the potential of increased abuse. In Tuolumne County, Adult Protective Services helps our aging population by being a conduit of referral for many types of services. What is Adult Protective Services? Definition Adult Protective Services protects and intervenes for elder adults, and dependent adults, who are unable to protect themselves from harm or neglect. An "elder adult" is any person 65 years of age or older, a "dependent adult" is any person 18 through 64 years of age who has physical or mental limitations which restricts the ability to carry out normal daily activities. Services and Reporting Requirements APS is usually the first responders to reported or suspected abuse and are tasked to identify, investigate, and resolve abuse allegations. The client has the right to refuse services, if they so choose, as participation is voluntary and there are no income requirements to use their services. According to a 2011 Government Accountability Office survey, only 14 States require all citizens to report abuse, 32 states only require mandatory reporting of abuse by professionals, and 4, including the State of New York have no reporting requirement. California only requires professionals to report abuse, but other people may report suspected elder abuse as well. Any person with a reasonable concern about elder abuse may contact APS to file a report, and depending upon where the abuse takes place (for example, in the community versus in an institution), APS may not be the initial or only department to contact under California law. In California, the law recognizes two types of reporters: non-mandated reporters and mandated reporters. Non-mandated reporters are persons who are not licensed by the Department of Health and do not meet the requirements of a mandated reporter. They are encouraged to report their suspicions, and can do so anonymously, but there are no legal repercussions for not reporting. There are different rules for mandated reporters. According to the Welfare and Institutions Code Section 15630-15632, a mandated reporter is "Any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, clergy member, or employee of a county adult protective services agency or a local law enforcement agency, is a mandated reporter," but in the event of suspected financial abuse a mandated reporter also includes, "All officers and employees of financial institutions" [Welfare and Institutions Code Section 15630-15632]. Therefore when a mandated reporter has reason to suspect abuse they must make a direct telephone report to APS at (209) 533-5717 within two hours and follow up by filing the SOC 341 form within two days. (see Attachment A). Research on Abuse Research from the National Center on Elder Abuse (NCEA) tells us that... • 1 in 10 people will be subject to some kind of abuse at least once. • 90% of the perpetrators of abuse are trusted by the victim. They can be a primary caregiver (wife, husband, child, or sibling), an extended family member, a friend, a neighbor, a court-appointed guardian, or a health caregiver. • For every report of abuse, 5 incidents go unreported. That is why some call Elder Abuse the silent crime...it is under reported and there is a reluctance to report it. • APS is underfunded by federal as well as state governments. APS Partnerships APS, along with responding to abuse reports, also partners with a number of local organizations such as Meals on Wheels, Area 12, Catholic Charities, and Amador Tuolumne County Action Agency (ATCAA), that provide adult and senior services; these community partners may also refer clients to APS. Meetings with the partners are held on a monthly basis. Who Funds APS? The Grand Jury's research into types of funding provided to APS from state and federal governments revealed: 1. That there are no federal or state funding mandates. 2. County APS services are funded through state sales tax and vehicle license fees. In 2010 the Elder Justice Act was passed as part of the Affordable Care Act (ACA), commonly referred to as Obamacare. The grant funding from the ACA is to be directed to states and be used to test methods to improve APS. However, to date, no funding has been authorized by Congress; as a result, the federal government currently has no funding mandate to address detection, prevention, or treatment of elder abuse. State funding is low and, compared to other protective services, only receives a small slice of the funding pie. Tuolumne County Social Services has an annual budget of approximately $22 million, of which about $145,000, or less than 1%, has been allocated for APS services in the 2014-2015 fiscal year. The budget allows very little funding for technology support or system upgrades. Technology Tracking APS referrals is vital and having an automated system in place ensures that compiling and responding to cases of reported abuses is done in a timely manner. The Tuolumne County APS uses an existing computer software system from Oracle called People Soft. A number of County departments have used this system since 2000 which was designed so analysts could tailor-make modules to specifically meet the needs of the user. The APS program module was built so staff could take abuse reports over the phone while inputting data directly into the system. The reporting requirements include the type of abuse and facts about the victim and the person reporting the problem. The information gathered helps the APS worker develop and track interventions related to the reported concern. The system creates what is called an APS referral. When the details of a particular referral are completed in the system, they are placed in a pending status, prioritized, and then assigned to a caseworker by the supervisor, starting the work-flow time clock. All cases must be reviewed within 10 days. The system will time all cases starting from when the report of abuse is received until the case is closed manually by the caseworker assigned to the case; but unfortunately, sometimes during the course of a case, errors occur in the system. The case system software does create errors that are immediately apparent to the user. The user knows of an error as the system will send a duplicate email of the case to the supervisor. These errors are caused if a case is set-up in the system and data is not entered in sequential order. The Information Technology (IT) department is made aware of the error and works with the APS employee or case worker to correct these files. The data from the case management system is used for state reporting. Only one state mandated report is required to be submitted monthly to the State APS Department. It is called the SOC214 report. The SOC214 report is generated manually by the APS supervisor inputting specific data from the case management system into a Microsoft Excel spreadsheet. The APS system does not automatically generate the report. The data reported is for the previous month's activity and is reported at the following month's end. This means the April 2015 report is due to the State by the end of May 2015. It is forwarded to the California Health & Human Services Department and gives details, by county, all APS case load management information. It reports all cases carried forward, ages of cases, investigation findings as to if abuse was confirmed; inconclusive or unfounded; the types of abuse, Support Services provided – In-person (emergency shelter/in-home protection service); Information & Referral to service. This report is available to the public. To view a recent report in its entirety, it can be found on the State website at: http://www.cdss.ca.gov/research/rcs/pdf/soc242/2014/SOC242Nov14.pdf Staff Performance Although there are no specialized educational requirements, and on the job training is common, including working in both child and adult welfare services. Most APS personnel have a college degree and some hold advanced degrees in social work. The average number of years of work experience in the department is over ten years per person, and the APS staff is busy with a heavy case load. Figure 1: APS Process for Addressing Alleged Elder Abuse Source: GAO analysis of survey results and interviews from site victims. Investigations begin with a phone interview with the client, their family, or friends. APS will determine if abuse is present and what protective services are required. There are basic eligibility criteria to determine if the complaint needs to be investigated, such as: the type of abuse, the age of the victim, their mental capacity, and the victim's relationship to the perpetrator. If after screening, APS has found no abuse exists, but perhaps the client requires other services, they will be referred to specific services. If APS determines there is suspected abuse, the case is assigned to an APS social worker. THE INVESTIGATION This report was not initiated by any complaint. All county agencies should be evaluated minimally every few years and it had been ten years since the last APS review. This prolonged interval since last review prompted the 2014-2015 Grand Jury to see how well the County's adult population is currently being served by APS and how they are handling elder abuse. This report is based on multiple types of investigative techniques. To obtain the necessary information for this report, the Grand Jury conducted approximately 12 interviews while concurrently reviewing all policies, procedures, budgets, Memorandum Of Understanding contracts, use of credit cards, the Tuolumne County website, and any state and federal mandate requirements. In addition, the Grand Jury reviewed the case management methods and the case management computer system being used by department staff. ADULT PROTECTIVE SERVICES COMMITTEE REPORTS Report #1 The Merger DISCUSSION The 2011-2012 California budget called for a re-alignment of social services, moving control from Sacramento to each local county. The intent was to let counties decide what services to provide, based upon their demographic needs, with the goal of being more efficient while reducing costs. Implementation started in 2014 with a merger of two Tuolumne County agencies. In early 2014 Child Welfare Services (CWS) and Adult Protective Services merged offices into a central location on Cedar Road in Sonora. Prior to this merger, the agencies were two separate entities, in different locations, with separate staffing and budgets. At the time of the merger, additional social service programs came on line in the department as did the staffing of those services. Any cost savings of the merger were negated due to these additional services. Since there are very few dollars to support the agency on its own, this move extends the ability to provide services in a timely manner, and also increases the ability to train staff. The merger combined staffing so other social services staff can train and cross-train between protective services: APS and CWS. APS staff cross-trained with, and provides back-up to, CWS. It is not uncommon that a primary caregiver to a dependent or elder adult also is raising a family and may require some sort of services from both protective agencies. This allows protective services to bring the family together as a whole and work to get them the help they need. This merger was not the last restructuring of Protective Services. Due to an increase in staffing work load and lack of a full complement of CWS' staff, in mid-February 2015, Protective Services once again restructured. The staff that provided back up to APS has been re-assigned to CWS while CWS shifted staff to APS operations for training and back-up support. FINDINGS, RECOMMENDATIONS, COMMENDATIONS, and RESPONSES

Due to low staffing at the Building Code Division, building inspections take precedence over collection of penalty fees.

The Grand Jury finds that Information Technologists are trying to keep everything “up to date” and it is “progressing,” but, software upgrades are needed to make the Batch Permitting system more beneficial to both Building and Safety and permit owners.

The Grand Jury finds there are no intuitive reference questions on the County’s website for learning about proper Building and Safety Division permitting procedures and “Batching.”

The Grand Jury finds that applicants must telephone Building and Safety to learn of the daily inspection schedule, which wastes valuable time for both the staff and the applicant.

The Grand Jury finds that some customers have exhibited aggressive behavior and created a safety hazard by actually violating the workspace of Building and Safety employees due to the lack of physical protection at the DIC.

The Grand Jury commends a Permit Technician and the Senior Building Officials and Administration of CRA who gave the Jury a detailed and explanatory insight to the Development Information Center and Building Safety Division.

There is no secured room currently available for patients awaiting medical clearance and/or mental health evaluations.