Score: +8 (15/23/7)

Ventura County Grand Jury • 2022-2023

Deaths in Ventura County Detention and Jail FacilitiesAddressing District-Based Representation for the Ojai City Council

Published: June 20, 2023 27 pages

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⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.

⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.

Findings and Recommendations 11 findings

F01

The Grand Jury finds that of the 13 deaths of detained persons reviewed, most were avoidable. (SF-01, SF-07, SF-12, SF-18, SF-29)

No recommendations for this finding

F02

The Grand Jury finds that in general, the public is not informed of the final results of the MCU and ME’s investigations of deaths of detained persons in the Ventura County jails. (SF-02, SF-03, SF-04)

No recommendations for this finding

F03

The Grand Jury finds that the current training regarding suicide prevention and response does not follow recommended best practices for consistent cross-training of deputies, SSTs, and Wellpath medical personnel. We did find that current practices are compliant with state law and BSCC requirements. (SF-05)

No recommendations for this finding

F04

The Grand Jury finds that between 2016 and 2022, the VCSO committed to implementing or strengthening primary, secondary and tertiary suicide prevention measures consistent with BSCC and NCCHC standards. Despite these efforts, detained persons committed suicide. (SF-06, SF-08, SF-09, SF-10, SF-14, SF-15, SF-16, SF-24)

No recommendations for this finding

F05

The Grand Jury finds that during incarceration, multiple factors can lead to a personal crisis after the initial screening. Communication and follow- up become key for suicide prevention. (SF-06, SF-10, SF-13)

No recommendations for this finding

F06

The Grand Jury finds that primary level intervention measures, including improvement of the orientation process and involvement of families, aid in the prevention of suicide. (SF-06, SF-11, SF-12, SF-13, SF-16)

No recommendations for this finding

F07

The Grand Jury finds that current incentives to surrender illicit substances and body searching protocols do not result in adequate detection and confiscation of increasingly dangerous drugs at PDTF and TRJ. (SF-17, SF- 18, SF-19, SF-22, SF-23)

No recommendations for this finding

F08

The Grand Jury finds that use of passive-alert drug detection dogs to discover illicit drugs is an effective methodology not fully utilized at the PTDF and TRJ facilities. (SF-19, SF-20, SF-21)

No recommendations for this finding

F09

The Grand Jury finds that historically, medical and behavioral health treatment in Ventura County’s jails often has been reactive rather than proactive, and has not included a robust “See Something, Say Something” protocol. (SF-06, SF-07, SF-25, SF-26, SF-29)

No recommendations for this finding

F10

The Grand Jury finds that the intake screening process and reassessments during incarceration do not always provide a complete evaluation of current medical and behavioral health, as outlined in the NCCHC Initial Health Assessment standard. (SF-26, SF-27, SF-28) Deaths in Ventura County Detention and Jail Facilities 13

Related Recommendations (1)

R10

The Grand Jury recommends that within ninety days, the VCSO implement a procedure to inform the public of the circumstances surrounding all jail deaths after the MCU investigation and/or independent review are completed. (F-02, F-11) RESPONSES Responses required from: The following elected officer : Ventura County Sheriff’s Office (F-01, F-02, F-03. F-04, F-05, F-06, F-07, F-08, F- 09, F-10, F-11, R-01, R-02, R-03, R-04, R-05, R-06, R-07, R-08, R-09, R-10) The following governing body : Ventura County Board of Supervisors (F-11, R-01, R-06, R-08) Deaths in Ventura County Detention and Jail Facilities 15 REFERENCES Ref-01. 9341. (2023, April 19). How to lower the high level of jail suicides. Brennan Center for Justice. https://www.brennancenter.org/our- work/analysis-opinion/how-lower-high-level-jail-suicides, Accessed 06/05/2023 Ref-02. Russo, J., Woods, D., Shaffer, J. S., & Jackson, B. A. (2017a, November 27). How to reduce mortality in correctional facilities. RAND Corporation. https://www.rand.org/pubs/research_reports/RR1967.html, Accessed 06/05/2023 Ref-03. Wiering, M., Christian, G., & Wooden, C. (2019, September 17). Suicide rate in prisons raises alarm, calls for change. Angelus News - Multimedia Catholic News. https://angelusnews.com/news/life- family/suicide-rate-in-prisons-raises-alarm-calls-for-change/, Accessed 06/05/2023 Ref-04. Initiative, P. P. (n.d.). Rise in jail deaths is especially troubling as jail populations become more rural and more female. Prison Policy Initiative. https://www.prisonpolicy.org/blog/2021/06/23/jail_mortality/, Accessed 06/05/2023 Ref-05. Special report: 2022 fatal overdoses - s31042.pcdn.co. (n.d.-f). https://s31042.pcdn.co/wp-content/uploads/2023/03/UPDATED-OD- Report-2022.pdf, Accessed 06/05/2023 Ref-06. Statutes, codes, and regulations. Legal research tools from Casetext. (n.d.). https://casetext.com/statute/california-codes/california-penal- code/part-2-of-criminal-procedure/title-4-grand-jury- proceedings/chapter-3-powers-and-duties-of-grand-jury/article-1- general-provisions/section-919-inquiry-into-case-of-person- imprisoned-but-not-indicted-condition-and-management-of-prisons- and-misconduct-in-office-of-public-officers, Accessed 06/05/2023 Ref-07. Inmate death from Ventura County Sheriff’s Office. Nixle. (n.d.). https://local.nixle.com/alert/9600254/, Accessed 06/05/2023 Ref-08. Grand Jury interviews Ref-09. County of Ventura Sheriff’s Office. (n.d.-d). https://s29762.pcdn.co/wp-content/uploads/2022/09/PUBLIC- Information-Plan-0722.pdf (pp. 153-156; 179-186; 325-339; 540- 545; 604-612; 656-660; 690-698; 699-712) https://s29762.pcdn.co/wp-content/uploads/2022/09/Divisional- Policy-Public-Redacted-090722.pdf, Accessed 06/05/2023 16 Deaths in Ventura County Detention and Jail Facilities Ref-10. Ventura County Sheriff’s Office confidential files and related documents reviewed by the Grand Jury Ref-11. San Diego County Sheriff’s department. Report 2021-109. (n.d.-a). Figure 2. https://www.auditor.ca.gov/reports/2021- 109/index.html#section3, Accessed 06/05/2023 Ref-12. Procedure in the event of an inmate death. National Commission on Correctional Health Care. (2022, May 16). https://www.ncchc.org/spotlight-on-the-standards/procedure-in-the- event-of-an-inmate-death/, Accessed 06/05/2023 Ref-13. H.R.1447 - Death In Custody Reporting Act of 2013 - congress.gov. (n.d.-f). https://www.congress.gov/bill/113th-congress/house- bill/1447, Accessed 06/05/2023 Ref-14. National Commission on Correctional Health Care. (n.d.-j). Project 2025 | American Foundation for Suicide Prevention. https://project2025.afsp.org/wp-content/uploads/2020/01/NCCHC- AFSP_Suicide_Prevention_Resource_Guide.pdf, Accessed 06/05/2023 Ref-15. Home - ventura county sheriff’s office. (n.d.-f). (pp. 153-155) https://s29762.pcdn.co/wp-content/uploads/2023/03/Divisional- Policy-Public-Redacted-011023.pdf, Accessed 06/05/2023 Ref-16. Guidelines for investigating deaths in custody. (n.d.-h). https://www.icrc.org/en/doc/assets/files/publications/icrc-002- 4126.pdf, Accessed 06/05/2023 Ref-17. Lester, D. (2019). Suicide and self-harm in prisons and jails (2nd ed.). Lexington Books. [pp. 2; 9-10; 15-37; 52-56; 61; 70; 81; 95-97; 112-113; 117-118; 165; 220-221; 224-227; 229] Ref-18. Spotlight on the standards. National Commission on Correctional Health Care. (2022c, May 17). https://www.ncchc.org/spotlight-on- the-standards/, Accessed 06/05/2023 Ref-19. Piper, S. (2022, July 20). 4 innovative approaches to inmate suicide prevention. Corrections1. https://www.corrections1.com/corrections- training/articles/4-innovative-approaches-to-inmate-suicide- prevention-KEWdUrajQPHmlHZ1/, Accessed 06/05/2023 Ref-20. State of California. (n.d.). Bscc.ca.gov. The Board of State and Community Corrections. https://bscc.ca.gov/wp- content/uploads/Adult-T15-Effective-1.1.2023-Full-Text.pdf, [pp. 18- 22, 26, 28-31, 34, 58, 61-62, 64], Accessed 06/05/2023 Deaths in Ventura County Detention and Jail Facilities 17 Ref-21. California Department of Corrections and Rehabilitation. (n.d.-b). The California Department of Corrections and Rehabilitation - CDCR. https://www.cdcr.ca.gov/regulations/wp- content/uploads/sites/171/2022/03/CDCR-DOM_2022.pdf, Accessed 06/05/2023 Ref-22. Jezierski, Abstract Some recent publications claim that the effectiveness of police canine drug detection is uncertain and likely minimal, Leitch, O., et.al. (2014a, February 7). Efficacy of drug detection by fully-trained police dogs varies by breed, training level, type of drug and search environment. Forensic Science International. https://www.sciencedirect.com/science/article/abs/pii/S037907381400 0371?via%3Dihub, Accessed 06/05/2023 Ref-23. Don Chaddock, I. C. editor. (2023, February 22). Meet the cen K-9 team: Arrow and Kendra. Inside CDCR. https://www.cdcr.ca.gov/insidecdcr/2023/02/16/meet-the-cen-k-9- team-arrow-and-kendra/, Accessed 06/05/2023 Ref-24. Dalton, N. (2023, April 3). Everything Drug Detection Dog gets up to in 24 hours - and human way they relax. mirror. https://www.mirror.co.uk/news/uk-news/everything-drug-detection- dog-gets-29616974.amp, Accessed 06/05/2023 Ref-25. Office of the Inspector General. (2023, January). Www.oig.ca.gov. https://www.oig.ca.gov/wp-content/uploads/2023/01/CDCR- Controlled-Substances-Contraband-Interdiction-Efforts-Audit.pdf, Accessed 06/05/2023 Ref-26. Burciaga, M., & Courtesy of Santa Barbara County Sheriff’s Office. (2019, December 17). Deputy’s dog is “kryptonite” for criminals: New K-9’s nose to help nab jailhouse narcotics. Santa Maria Times. https://santamariatimes.com/news/local/deputys-dog-is-kryptonite- for-criminals-new-k-9s-nose-to-help-nab-jailhouse- narcotics/article_0664c47a-65a4-515c-ab29-6836f0f553bf.html, Accessed 06/05/2023 Ref-27. Los Angeles County Sheriff’s Department. (n.d.). Canines help with keeping our LA county jails safe. Lasd.org - information detail. http://shq.lasdnews.net/pages/PageDetail.aspx?id=1408, Accessed 06/05/2023 Ref-28. Don Chaddock, I. C. editor. (2022a, December 5). K-9 CAMO takes Riverside Top Detection Honors. Inside CDCR. https://www.cdcr.ca.gov/insidecdcr/2022/11/30/k-9-camo-takes- riverside-top-detection-honors/, Accessed 06/05/2023 18 Deaths in Ventura County Detention and Jail Facilities Ref-29. Columbia Human Rights Review. (n.d.-c). Chapter 23 Y R Adequate Medical Care - Columbia University. https://jlm.law.columbia.edu/files/2017/05/35.-Ch.-23.pdf, Accessed 06/05/2023 Ref-30. American Civil Liberties Union. (2005, November). Know your rights - american civil liberties union. https://www.aclu.org/sites/default/files/images/asset_upload_file690_ 25743.pdf, Accessed 06/05/2023 Ref-31. Mendoza, L. (2020, December 9). CCR § 3350: Provision of medical care in California state prisons. foundations of law and society. https://foundationsoflawandsociety.wordpress.com/2020/12/08/15- ccr-3350-provision-of-medical-care-in-california-state-prisons/, Accessed 06/05/2023 Ref-32. Code section. Law section. (n.d.). https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?la wCode=PEN&sectionNum=4011, Accessed 06/05/2023 Ref-33. Item - Primegov Portal. (n.d.). BOS 6-21-22 Meeting Agenda, Item 76, Item Attachment, Exhibit 1, CMFG Medical Services Contract #8705, [Exhibits A – Sections K, Q & PP; and Exhibit D]. https://ventura.primegov.com/portal/item?id=232563, Accessed 06/05/2023 Ref-34. Wilson, K. (2022a, June 26). New contract promises Better Health Care in county jails. Ventura County Star. https://www.vcstar.com/story/news/2022/06/26/contract-promises- improved-mental-health-care-jails-ventura-county/7678721001/, Accessed 06/05/2023 Ref-35. Initial health assessment. National Commission on Correctional Health Care. (2022a, May 16). https://www.ncchc.org/spotlight-on-the- standards/initial-health-assessment/, Accessed 06/05/2023 Ref-36. MacDonald, R., Parsons, A., & Venters, H. (n.d.). The triple aims of Correctional Health: Patient Safety, population ... https://cochs.org/files/health-it-hie/triple-aim-in-corrections.pdf, Accessed 06/05/2023 Ref-37. Reingle Gonzalez, J. M., & Connell, N. M. (2014, December). Mental health of prisoners: Identifying barriers to mental health treatment and medication continuity. American journal of public health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4232131/, Accessed 06/05/2023 Deaths in Ventura County Detention and Jail Facilities 19 Ref-38. Brook-Eisen, L., & Nahra, A. (2023, May 9). The landscape of recent state and County Correctional Oversight EffortsLau. Brennan Center for Justice. https://www.brennancenter.org/our-work/research- reports/landscape-recent-state-and-county-correctional-oversight- efforts, Accessed 06/05/2023 Ref-39. 2022 California code :: Penal code - pen :: Part 3 - of imprisonment and the death penalty :: Title 7 - administration of the State Correctional System :: Chapter 5 - The Corrections Standards Authority :: Article 1 - General Provisions :: Section 6031.1. Justia Law. (n.d.-b). https://law.justia.com/codes/california/2022/code- pen/part-3/title-7/chapter-5/article-1/section-6031-1/, Accessed 06/05/2023 Ref-40. Statutes, codes, and regulations. Legal research tools from Casetext. (n.d.-a). https://casetext.com/statute/california-codes/california- welfare-and-institutions-code/division-2-children/part-1-delinquents- and-wards-of-the-juvenile-court/chapter-2-juvenile-court-law/article- 1-general-provisions/section-209-inspection-of-jails-juvenile-halls-or- special-purpose-juvenile-hall-facility-unsuitable-for-confinement-of- minors, Accessed 06/05/2023 Ref-41. Statutes, codes, and regulations. Legal research tools from Casetext. (n.d.-a). https://casetext.com/statute/california-codes/california- welfare-and-institutions-code/division-2-children/part-1-delinquents- and-wards-of-the-juvenile-court/chapter-2-juvenile-court-law/article- 24-wards-and-dependent-children-juvenile-homes-ranches-and- camps/section-885-standards-adopted-by-board-of-supervisors- inspection- reports?sort=relevance&type=case&tab=keyword&jxs=&resultsNav=fa lse, Accessed 06/05/2023 Ref-42. The Board of State and Community Corrections (BSCC), Biennial Inspection Records and Related Documents – Adult Detention Facilities – Ventura 09/22/2022 https://drive.google.com/drive/folders/1DW0At3nnjBIA5PvgtfiVKhVt7e YrqgLL, Accessed 06/05/2023 Ref-43. Statutes, codes, and regulations. Legal research tools from Casetext. (n.d.-a). https://casetext.com/statute/california-codes/california- health-and-safety-code/division-101-administration-of-public- health/part-3-local-health-departments/chapter-2-powers-and-duties- of-local-health-officers-and-local-health-departments/article-1-county- health-officers/section-101045-investigation-of-health-and-sanitary- conditions-in-detention- facility?sort=relevance&type=case&tab=keyword&jxs=&resultsNav=fal se,, Accessed 06/05/2023 20 Deaths in Ventura County Detention and Jail Facilities Ref-44. 2022 California code :: Penal code - pen :: Part 2 - of criminal procedure :: Title 4 - grand jury proceedings :: Chapter 3 - Powers and duties of grand jury :: Article 4 - Conduct of Investigations :: Section 939.9. Justia Law. (n.d.-b). https://law.justia.com/codes/california/2022/code-pen/part-2/title- 4/chapter-3/article-4/section-939-9/, Accessed 06/05/2023 Ref-45. Grand jury. Ventura County. (2020, April 9). https://www.ventura.org/grand-jury/, Accessed 06/05/2023 Ref-46. Bill text. Bill Text - AB-1185 County board of supervisors: sheriff oversight. (n.d.). https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=20 1920200AB1185, Accessed 06/05/2023 Ref-47. Diskin, M. (2019, April 18). Case documents reveal details, allegations in Ventura County jail inmate’s death. Ventura County Star. https://www.vcstar.com/story/news/local/communities/ventura/2019/ 04/18/detailcase-reveals-details-allegations-ventura-county-jail- inmates-deaths-allegations-emerge-jail-in/3455108002/, Accessed 06/05/2023 Ref-48. Butterfield, M., Al-Abri, S., Huntington, S., Carlson, T., Geller, R. J., & Olson, K. R. (2015b, September). Symptomatic exposures among California inmates 2011-2013. Journal of medical toxicology : official journal of the American College of Medical Toxicology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547960/, Accessed 06/05/2023 Ref-49. Naloxone in correctional facilities for the prevention of opioid overdose deaths (2020). National Commission on Correctional Health Care. (2023, February 2). https://www.ncchc.org/position- statements/naloxone-in-correctional-facilities-for-the-prevention-of- opioid-overdose-deaths-2020/, Accessed 06/05/2023 Ref-50. Brannon, M. (2020, October 8). Analysis reveals disparities among death rates in California County Jails. Dying Inside: Data shows gaps among California county jail death rates. https://www.redding.com/in- depth/news/local/2020/10/02/california-jails-inmate-deaths-shasta- county-mental-health-care/5539531002/, Accessed 06/05/2023 Ref-51. “see something, say something” - DPSS training. School of Nursing, University of Michigan. (n.d.). https://nursing.umich.edu/about/events-calendar/%E2%80%9Csee- something-say-something%E2%80%9D-dpss-training-190213, Accessed 06/05/2023 Deaths in Ventura County Detention and Jail Facilities 21 Ref-52 Mitchell, J. (2018, July 16). See something, say something. See Something, Say Something | Harvard Medical School. https://hms.harvard.edu/news/see-something-say-something, Accessed 06/05/2023 Ref-53. Nsiah, C., Siakwa, M., & Ninnoni, J. P. K. (2019, December 19). Barriers to practicing patient advocacy in healthcare setting. Nursing open. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7024610/, Accessed 06/05/2023 Ref-54. (OCR), O. for C. R. (2022, December 28). 505-when does the privacy rule allow covered entities to disclose information to law enforcement. HHS.gov. https://www.hhs.gov/hipaa/for-professionals/faq/505/what- does-the-privacy-rule-allow-covered-entities-to-disclose-to-law- enforcement-officials/index.html, Accessed 06/05/2023 Ref-55. Brannon, M. (2020a, October 7). With jail deaths on the rise, California counties look to improve. Dying Inside: California counties look for reforms as jail deaths rise. https://www.redding.com/in- depth/news/local/2020/10/07/shasta-county-jail-inmate-deaths- mental-health-california-reform-ideas/5621258002/, Accessed 06/05/2023 Ref-56. 7pillars. Ventura County Sheriff’s Office. (2023, February 8). https://www.venturasheriff.org/7pillars, Accessed 06/05/2023 22 Deaths in Ventura County Detention and Jail Facilities GLOSSARY TERM DEFINITION BOS Ventura County Board of Supervisors BSCC Board of State and Community Corrections DSD Detention Services Division MCU Major Crimes Unit ME Medical Examiner NCCHC National Commission on Correctional Healthcare PTDF Pre-Trial Detention Facility SST Sheriff’s Service Technicians TRJ Todd Road Jail VCSO Ventura County Sheriff’s Office ATTACHMENTS Att-01. Deaths in Ventura County jails since 2016 Att-02. Case studies Deaths in Ventura County Detention and Jail Facilities 23 Attachment-01 Source: Ref-10 24 Deaths in Ventura County Detention and Jail Facilities Attachment-02 CASE STUDIES Suicide: Case Study 1 – One attempted suicide involved a cell wall fixture that was not properly attached that provided the opportunity for hanging. Case Study 2 – One suicide involved a person with suicidal ideation of jumping to death being housed on second level with exposed railing. Overdose/Intoxication: Case Study 3 – Person was arrested for an outstanding warrant and no license plate after stopping at a convenience store. The person asked to go to the bathroom at the convenience store. After spending 14 minutes in the bathroom, the person was asked to come out of the bathroom by convenience store personnel. Paraphernalia found were found in the person’s belongings. A body scan at booking was done incorrectly. Specifically, the person’s hands were in a position behind his back which obscured any view of contraband hidden in the body cavity. The body scan was not redone. The detained person was found deceased 27.5 hours later. The cause of death, determined by the ME, was drug overdose. Medical: Case Study 4 – Person was booked symptomatic with signs and symptom of withdrawal, requiring intervention. Regular cell checks were not done according to VCSO’s Standard Operating Procedures. Person exhibited multiple incidents of vomiting & defecation over three days but refused fluids. No indication in case file that person was given emergency treatment in hospital setting. Case Study 5 – Person was booked under the influence. Screening process did not detect underlying medical condition (hypertensive cardiac disease, manifested by elevated blood pressure readings). There were gaps in verifying the person’s physical and mental health statements; 4.5 hours between last time seen alert and responsive in cell and time seen unresponsive in cell. Paramedics did not arrive to the jail until approximately thirty minutes had past when notified. Source: Ref-10 Deaths in Ventura County Detention and Jail Facilities 25

F11

The Grand Jury finds that involvement of the public and independent subject matter experts in the review of deaths in jail may reduce the risk of death, provide additional insight, justify additional resources and increase transparency. (SF-30, SF-31) RECOMMENDATIONS

Related Recommendations (1)

R11

R-02. The Grand Jury recommends that , the VCSO with Wellpath develop and implement a consistent in-service suicide prevention cross-training for all deputies, SSTs and Wellpath medical personnel. (F-03, F-04, F-09) R-03. The Grand Jury recommends that , the VCSO with Wellpath improve existing communication protocols for monitoring suicidal ideation and/or increased risk factors among detained persons. (F-03, F- 04, F-05, F-09) R-04. The Grand Jury recommends that , the VCSO develop and implement suicide and self-harm prevention protocols involving family input, including: • Placing Suicide Prevention Hotline Posters in visiting areas encouraging family members to contact a 24/7 number to report concerns about suicide or self-harm of a detained person. • An automated recording with the same hotline information at the beginning of each phone call to a detained person. (F-05, F-06) R-05. The Grand Jury recommends that , the VCSO’s Inmate Orientation include information explaining available resources for prevention of suicide, self-harm and overdose. (F-05, F-06, F-07, F-08) R-06. The Grand Jury recommends that within ninety days, the VCSO evaluate and report to the BOS the technical and financial feasibility of adding passive-alert drug detection dogs to each jail facility. (F-07, F-08) R-07. The Grand Jury recommends that , the VCSO implement a more robust protocol of “See Something, Say Something” that is reinforced by ongoing staff training and detained persons’ orientation. (F-

Agency Responses 4

Government agencies' official responses to this report's findings and recommendations. Click on a response to see the structured breakdown.

Board of Supervisors

September 27, 2023 • 29 pages • 17 responses • Score: +5 (+9, 4, -4) View Details ▾

PDF

17 responses to findings and recommendations

F01

The Grand Jury finds that of the 13 deaths of detained persons reviewed, most were avoidable. (SF-01, SF-07, SF-12, SF-18, SF-29)

Response: Agree Score: +1

agree with the Findings numbered: F-01, F-02, F-04, F-12, F-13, F-14 I (we) disagree wholly or partially with the Findings numbered: F-03, F-05, and F-06 thru F-10 (Attach a statement specifying any portions of the Findings that are disputed; include an explanation of the reasons.

R01

The Grand Jury recommends that , the Board of Supervisors (BOS) institute a review panel comprised of community members and independent subject matter experts to review jail deaths and support death prevention efforts by the VCSO. (F-01, F-02, F-09, F- 11)

Response: Will Not Implement

Score: -1

Recommendations numbered ____ will not be implemented because they are not warranted or are not reasonable. (Attach an explanation.) Signed: Mul Date: 9/12/2023 Title: Assistant County Executive Officer Number of pages attached: ____ 1 | Page Exhibit 2 Response to Grand Jury Report Form Report Title: Deaths in Ventura County Detention and Jail Facilities Report Date: June 20, 2023 Response By: Mike Pettit Title: Assistant County Executive Officer FINDINGS: F-11: Partially Disagree While we acknowledge the importance of involving the public and independent subject matter experts in vari...

F02

Response: Agree Score: +1

F03

Response: Agree Score: +1

F04

Response: Agree Score: +1

R04

The Grand Jury recommends that , the VCSO develop and implement suicide and self-harm prevention protocols involving family input, including: • Placing Suicide Prevention Hotline Posters in visiting areas encouraging family members to contact a 24/7 number to report concerns about suicide or self-harm of a detained person. • An automated recording with the same hotline information at the beginning of each phone call to a detained person. (F-05, F-06)

Response: Requires Analysis

Score: 0

Recommendations numbered _ require further analysis. (Attach an explanation to include: scope and parameters of the analysis or study and timeframe for the matter to be prepared for discussion with the agency or department head. The timeframe shall not exceed six months from the date of publication of the report.) R-04 Recommendations numbered will not be implemented because they are not warranted or are not reasonable. (Attach an explanation.) 8/16/2023 Date: Signed: Title: Director - Sheriff's Emergency Services Number of pages attached: ____2 Ventura County SHERIFF'S OFFICE OF SERVICE Ji...

F05

Response: Agree Score: +1

F06

Response: Agree Score: +1

R06

The Grand Jury recommends that within ninety days, the VCSO evaluate and report to the BOS the technical and financial feasibility of adding passive-alert drug detection dogs to each jail facility. (F-07, F-08)

Response: Will Not Implement

Score: -1

Recommendations numbered • ____require further analysis. (Attach an explanation to include: scope and parameters of the analysis or study and timeframe for the matter to be prepared for discussion with the agency or department head. The timeframe shall not exceed six months from the date of publication of the report.) R-01 Recommendations numbered ____ will not be implemented because they are not warranted or are not reasonable. (Attach an explanation.) Signed: Mul Date: 9/12/2023 Title: Assistant County Executive Officer Number of pages attached: ____ 1 | Page Exhibit 2 Response to Grand J...

F07

Response: Disagree Partially Score: 0

searching protocols do not result in adequate detection and confiscation of increasingly dangerous drugs at PDTF and TRJ. (SF-17, SF-18, SF-19, SF-22, SF-23) Response to the 2022-2023 Ventura County Grand Jury Report Page 6 of 12 Response: The Sheriff's Office disagrees wholly with this finding. The Sheriff's Office goes to great lengths to detect and confiscate illegal substances from entering any of our jail facilities. Arrestees are searched at least twice by arresting officers prior to booking. Detention Services deputies then conduct a third, and sometimes fourth physical search in booki...

R07

The Grand Jury recommends that , the VCSO implement a more robust protocol of “See Something, Say Something” that is reinforced by ongoing staff training and detained persons’ orientation. (F- 09) 14 Deaths in Ventura County Detention and Jail Facilities

Response: Will Not Implement

Score: -1

F08

The Grand Jury finds that use of passive-alert drug detection dogs to discover illicit drugs is an effective methodology not fully utilized at the PTDF and TRJ facilities. (SF-19, SF-20, SF-21)

Response: Disagree Partially Score: 0

Recommendations numbered ___ have not yet been implemented but will be implemented in the future. (Attach a summary indicating the timeframe for implementation.) R-06 Recommendations numbered • ____require further analysis. (Attach an explanation to include: scope and parameters of the analysis or study and timeframe for the matter to be prepared for discussion with the agency or department head. The timeframe shall not exceed six months from the date of publication of the report.) R-01 Recommendations numbered ____ will not be implemented because they are not warranted or are not reasonab...

R08

The Grand Jury recommends , and annually thereafter, the VCSO report to the BOS on the key performance metrics, the implementation of training and the suicide prevention program, per the terms and conditions of the Wellpath contract. (F-03, F-04, F-09, F-10)

Response: Will Implement

Score: +1

R-08 Recommendations numbered ___ have not yet been implemented but will be implemented in the future.

F09

Response: Disagree Partially Score: 0

I (we) partially agree with the Recommendation number R-04 Recommendation R-04: The Grand Jury recommends that the Ventura County Sheriff's OES develop a current contact list of water purveyors, updated at least once a year. Proudly Serving the County of Ventura Camarillo • Fillmore • Moorpark • Ojai • Thousand Oaks Response R-04: Partially Agree. Recommendation R-04 suggests Ventura County Sheriff's OES develop a contact list of all 150+ water purveyors and update that list annually. While not directly stated, it is our opinion that this recommendation also implies it is the responsibility o...

R09

The Grand Jury recommends that , the VCSO align its intake tool with NCCHC’s Initial Health Assessment standard. (F-10)

Response: Will Not Implement

Score: -1

F10

Response: Agree Score: +1

F11

Response: Agree Score: +1

agree with the Findings numbered: I (we) disagree wholly or partially with the Findings numbered: F-11 (Attach a statement specifying any portions of the Findings that are disputed; include an explanation of the reasons.

City of Ventura

September 07, 2023 • 15 pages • 20 responses • Score: +6 (+6, 12, 0) View Details ▾

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20 responses to findings and recommendations

F01

The Grand Jury finds that of the 13 deaths of detained persons reviewed, most were avoidable. (SF-01, SF-07, SF-12, SF-18, SF-29)

Response: Agree Score: +1

Agree. The City agrees that adequate supply of water is essential for suppressing wildfire in order to protect and preserve human life. F-02: The Grand Jury finds that the limited number of Fire Weather Watch (FWW) advisories amplifies the importance of establishing written procedures, protocols and training. (SF-01, SF-05, SF-07, SF-10)

R01

Response: Implemented

Score: 0

Recommendation numbered F-01 has been implemented. The City of Ventura has had in place a Red Flag PSPS Response Procedure. In this procedure, FWWs, RFWs, active fires and PSPS are treated as the same threat level with the same response. Staff is trained on the procedure upon hiring and the procedure is reviewed at the beginning of each event activation. The procedures were recently revised to update contact numbers. The updated version can be found in the provided Attachment. R-02: The Grand Jury recommends that water purveyors have emergency power on site for all critical water infrastructur...

F02

Response: Agree Score: +1

Agree. Additionally, the City feels that regardless of the number of FWW advisories, there is the importance of establishing written procedures, protocols and training. COUNTY of VENTURA 800 South Victoria Avenue Ventura, CA 93009 Tel (805) 477-1600 Fax (805) 658-4523 Grand Jury grandjury.countyofventura.org KEVIN G. DeNOCE JUDGE Response to 2022-2023 Ventura County Grand Jury Report Form (Please See California Penal Code Section 933.05) RECEIVED Report Title: Water Availability for Wildfires in Ventura County VENTURA COUNTY SUPERIOR COURT Responding Entity: Mayor Joe Schroeder, City o...

R02

The Grand Jury recommends that , the VCSO with Wellpath develop and implement a consistent in-service suicide prevention cross-training for all deputies, SSTs and Wellpath medical personnel. (F-03, F-04, F-09)

Response: Implemented

Score: 0

Recommendation numbered R-02 has been implemented. The City completed the Capital Improvement Project (CIP) for Emergency Generators in 2022. Every critical water site has backup generator power that powers the equipment and programming hardware and software, including SCADA systems. In addition to generator power, the SCADA servers are on UPS with at least 1.5 hours of battery backup. R-03: The Grand Jury recommends that water purveyors establish common communication protocols with adjoining water purveyors to coordinate needed actions, including water transfers during active fires (F-10).

F03

Response: Disagree Partially Score: 0

Partially disagree. The City does not have access to other County agency written procedures and cannot agree nor disagree with this finding or determine if they are lacking. The City believes that it has written procedures in place that are not lacking. F-04: The Grand Jury finds that the limited number of Red Flag Warning (RFW) events amplifies the importance of establishing written procedures, protocols, and training. (SF-01, SF-06, SF-07, SF-10)

R03

The Grand Jury recommends that , the VCSO with Wellpath improve existing communication protocols for monitoring suicidal ideation and/or increased risk factors among detained persons. (F-03, F- 04, F-05, F-09)

Response: Requires Analysis

Score: 0

Recommendation numbered R-03 will require further analysis. There are infrastructure limitations between agencies that may not make water transfers during active fires a possibility. Communication during an active event should take place at the County OES level to allow local agencies to focus on what their system demand is. The City of Ventura will attend OES Operations Training scheduled for August 8 and August 9, 2023 at the Ventura County Government Center. A recent partnership workshop was hosted by Calleguas Municipal Water District that broached the subject of emergency water supply. Wa...

F04

Response: Agree Score: +1

Agree. Additionally, the City feels that regardless of the number of RFW advisories there is the importance of establishing written procedures, protocols, and training. F-05: The Grand Jury finds that written procedures for actions taken by water purveyors during A Red Flag Warning event is a best practice that is lacking in Ventura County. (SF-01, SF-06, SF-07, SF-10)

R04

Response: Unknown

Score: 0

Abstain. The City of Ventura was not required to respond to recommendation numbered R-04. R-05: The Grand Jury recommends that water purveyors enroll their employees in the FCC Wireless Priority Service (WPS) providing cell phone priority in emergencies. (F-12) .

F05

Response: Disagree Partially Score: 0

Partially disagree. The City does not have access to other County agency written procedures and cannot agree nor disagree with this finding or determine if they are lacking. The City believes that it has written procedures in place that are not lacking. F-06: The Grand Jury finds that written procedures for actions taken by water purveyors during an active fire event is a best practice that is lacking in Ventura County. (SF-01, SF-08, SF-10)

R05

The Grand Jury recommends that , the VCSO’s Inmate Orientation include information explaining available resources for prevention of suicide, self-harm and overdose. (F-05, F-06, F-07, F-08)

Response: Will Implement

Due: Within 6 months Scheduled: within 6 months Score: +1

Recommendation numbered R-05 has not yet been implemented but will be implemented in the future. The City has submitted employee cell phone numbers to the FCC program and are awaiting verification into the program. It is anticipated that this will be complete within 6 months. R-06: The Grand jury recommends that water purveyors enroll in the Government Emergency Telecommunications System (GETS) providing cell phone landline phone priority in emergencies. (f-12)

F06

Response: Disagree Partially Score: 0

Partially disagree. The City does not have access to other County agency written procedures and cannot agree nor disagree with this finding or determine if they are lacking. The City believes that it has written procedures in place that are not lacking. F-07: The Grand Jury finds that written procedures for actions taken by water purveyors during Public Safety Power Shutoff (PSPS) events is a best practice that is lacking in Ventura County. (SF-01, SF-09, SF- 10)

R06

Response: Will Implement

Scheduled: within 6 months Score: +1

Recommendation numbered R-06 has not yet been implemented but will be implemented in the future. The City has submitted employee cell phone numbers to the GETS program and are awaiting verification into the program. It is anticipated that this will be complete within 6 months. R-07: The Grand Jury recommends that all water purveyors enroll in CalWARN, a network of water and wastewater agencies that can provide emergency resources. (F-13)

F07

Response: Disagree Partially Score: 0

Partially disagree. The City does not have access to other County agency written procedures and cannot agree nor disagree with this finding or determine if they are lacking. The City believes that it has written procedures in place that are not lacking. F-08: The Grand Jury finds that backup power to critical infrastructure is not always available. (SF-01, SF-11)

R07

Response: Implemented

Score: 0

Recommendation numbered R-07 has been implemented. The City has updated enrollment with CalWARN and provided new emergency contacts. R-08: The Grand Jury recommends that all water purveyors provide brush clearance around water tanks, water supply pumps, pump houses and related infrastructure. (F-14)

F08

The Grand Jury finds that use of passive-alert drug detection dogs to discover illicit drugs is an effective methodology not fully utilized at the PTDF and TRJ facilities. (SF-19, SF-20, SF-21)

Response: Disagree Partially Score: 0

Partially disagree. The City does not have access to other County agency critical infrastructure and cannot agree nor disagree with this finding or determine if backup power to other agency infrastructure is always available. The City has backup power available for all of its critical infrastructure. F-09: The Grand Jury finds that SCADA systems are not equipped with backup power in all instances. (SF-01, SF-12) .

R08

Response: Implemented

Score: 0

Recommendation numbered R-08 has been implemented. Fire abatement landscaping is required by June1st of each year per the City's landscape contracts. This is overseen by both the City's Parks Department and Ventura Water Department. R-09: The Grand Jury recommends that Ventura City Fire Department, Oxnard Fire Department, and Fillmore Fire Department adopt the Ventura County standard for brush clearance around water tanks, water supply pumps, pump houses and related infrastructure. (F-14)

F09

Response: Disagree Partially Score: 0

Partially disagree. The City does not have access to other County agency SCADA systems and cannot agree nor disagree with this finding. The City has backup power available for all of its critical infrastructure including SCADA. F-10: The Grand Jury finds that inadequate communication between adjoining water purveyors limits the ability to coordinate needed actions such as available water transfers. (SF-13, SF-14)

R09

The Grand Jury recommends that , the VCSO align its intake tool with NCCHC’s Initial Health Assessment standard. (F-10)

Response: Implemented

Score: 0

Recommendation numbered R-09 has been implemented. The Grand Jury recommendation the Ventura City Fire Department adopt the Ventura County Standard for "brush clearance around water tanks, water supply pumps, pump houses and related infrastructure" has been implemented and enforcing the same requirements through existing language in the San Buenaventura Municipal Code. The San Buenaventura Municipal Code states: Section 4907.1 General. Defensible space will be maintained around all buildings and structures in State Responsibility Area (SRA) as required in Public Resources Code 4290 and "SRA Fi...

F10

Response: Agree Score: +1

Agree. The City agrees that inadequate communication limits the ability to coordinate available water transfers. The City does have open communication with other water purveyors. In addition to communication there are infrastructure limitations of systems to be able to transfer water between purveyors. Water Systems are hydraulically designed to accommodate the community they service and not meant to allow for outside connections, to ensure the protection of water quality. The City receives water from Casitas Municipal Water District and is implementing the State Water Interconnection Project,...

F11

Response: Unknown Score: 0

Abstain. The City of Ventura is listed as an exception to this finding. F-12: The Grand Jury finds that enrolling in GETS and WPS would allow Ventura County water purveyors priority access to landline and cellular telephone networks in emergency situations. (SF-16, SF-17)

Ventura County Sheriff’s Office

August 18, 2023 • 12 pages • 6 responses • Score: -3 (+0, 3, -3) View Details ▾

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6 responses to findings and recommendations

F02

Response: Disagree Partially Score: 0

The Grand Jury finds that in general, the public is not informed of the final results of the MCU and ME's investigations of deaths of detained persons in the Ventura County jails. (SF-02, SF-03, SF-04) Response: The Sheriff's Office partially disagrees with this finding. Prior to January 1, 2023, there was no requirement to inform the public about the final results of an incarcerated person's death. On January 1, 2023, California Assembly Bill 2761 took effect which requires certain information be released to the public and updated after investigations are complete. The Sheriff's Office...

R02

Response: Will Not Implement

Score: -1

F07

Response: Disagree Partially Score: 0

searching protocols do not result in adequate detection and confiscation of increasingly dangerous drugs at PDTF and TRJ. (SF-17, SF-18, SF-19, SF-22, SF-23) Page 6 of 12 Response: The Sheriff's Office disagrees wholly with this finding. The Sheriff's Office goes to great lengths to detect and confiscate illegal substances from entering any of our jail facilities. Arrestees are searched at least twice by arresting officers prior to booking. Detention Services deputies then conduct a third, and sometimes fourth physical search in booking. When reasonable suspicion arises, and approved by the W...

R07

Response: Will Not Implement

Score: -1

F08

The Grand Jury finds that use of passive-alert drug detection dogs to discover illicit drugs is an effective methodology not fully utilized at the PTDF and TRJ facilities. (SF-19, SF-20, SF-21)

Response: Disagree Partially Score: 0

The Grand Jury finds that use of passive-alert drug detection dogs to discover illicit drugs is an effective methodology not fully utilized at the PTDF and TRJ facilities. (SF-19, SF-20, SF-21) Response: The Sheriff's Office disagrees wholly with this finding. The Ventura County Sheriff's Office currently has seven dogs in our Patrol Services Division. All seven of these dogs are trained in narcotics detection, which includes the ability to locate fentanyl using Scent Logix as the training aid. Our office has only been using Scent Logix (fentanyl) in training for the past year. Previous to tha...

R08

Response: Will Not Implement

Score: -1

Ventura County Sheriff’s Office

August 14, 2023 • 3 pages • 4 responses • Score: 0 (+0, 4, 0) View Details ▾

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4 responses to findings and recommendations

F01

The Grand Jury finds that of the 13 deaths of detained persons reviewed, most were avoidable. (SF-01, SF-07, SF-12, SF-18, SF-29)

Response: Disagree Partially Score: 0

agree with the Findings numbered: F-01 through F-14 RECOMMENDATIONS I (we) agree with the Recommendations numbered R-01 through R-03 and R-05 through R-09 I (we) partially agree with the Recommendation number R-04 Recommendation R-04: The Grand Jury recommends that the Ventura County Sheriff's OES develop a current contact list of water purveyors, updated at least once a year.

F04

Response: Disagree Partially Score: 0

Recommendations numbered _ require further analysis. (Attach an explanation to include: scope and parameters of the analysis or study and timeframe for the matter to be prepared for discussion with the agency or department head. The timeframe shall not exceed six months from the date of publication of the report.) R-04 Recommendations numbered will not be implemented because they are not warranted or are not reasonable. (Attach an explanation.) 8/16/2023 Date: Signed: Title: Director - Sheriff's Emergency Services Number of pages attached: 2 Ventura County SHERIFF'S OFFICE OF SERVICE Jim Fr...

R04

Response: Requires Analysis

Score: 0

Recommendations numbered _ require further analysis. (Attach an explanation to include: scope and parameters of the analysis or study and timeframe for the matter to be prepared for discussion with the agency or department head. The timeframe shall not exceed six months from the date of publication of the report.) R-04 Recommendations numbered will not be implemented because they are not warranted or are not reasonable. (Attach an explanation.) 8/16/2023 Date: Signed: Title: Director - Sheriff's Emergency Services Number of pages attached: 2 Ventura County SHERIFF'S OFFICE OF SERVICE Jim Fr...

F09

Response: Disagree Partially Score: 0