Sacramento County Grand Jury
2002-2003
From the annual report
The consolidated year-end volume. The individual investigations it contains are listed separately below.
📑 Year-End Report
The full consolidated volume; individual reports are listed below.
Individual reports (13)
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Findings & Recommendations
16 findings
F1:
Death investigation historically has been folded into law enforcement duties. This combination is inappropriate in the face of advanced medical knowledge in the diagnosis of 10 unnatural and violent deaths. Death investigation is a medical science and should be performed by medically qualified people. Death certification is a healthcare issue.
Related Recommendations (1)
R1:
The citizens of Sacramento County should be served by a medical examiner system headed by a board certified forensic pathologist appointed by the governing board. The Office of the Medical Examiner is autonomous, independently funded, and responds only to the Board of Supervisors.
F2:
In the United States there has been a trend in large population centers to convert to a medical examiner system of death investigation. Such a system now serves 48 percent of the population of the United States and 40 percent in California.
F3:
Coroners with few exceptions are administrators and/or peace officers with no medical qualifications or training. Very few are physicians. Medical Examiners are licensed physicians who have completed medical school, four to six years of postgraduate training in pathology, including forensic pathology fellowship. They are board certified in anatomic, clinical, and forensic pathology.
Related Recommendations (1)
R3:
The Chief Medical Examiner should be selected by a search committee of medical experts utilizing non-political and strictly professional criteria, including prior administrative experience. All staff pathologists should be board certified in forensic pathology. They can be contractual or county employees.
F4:
Death investigation should be performed by an independently funded, autonomous office unrelated to law enforcement or prosecutorial agencies, answering only to the governing board of the jurisdiction. There should be clear separation of scientific medical decisions from non-qualified individuals, agencies and political interests.
F5:
The performance of death investigation does not require law enforcement background. Forensic pathology fellowship includes this training, and forensic board certification requires this knowledge.
F6:
There is no legal impediment to a medical examiner discharging all functions of death investigation. In Sacramento County the authority for death investigation would be conveyed by creation of the Office of Medical Examiner.
F7:
In Sacramento County the Office of the Coroner is within the Public Protection Agency and operates under the administrator of that agency and the county executive. It is defined as an administrative position with no formal medical qualifications required. It is frequently combined with other county positions.
Related Recommendations (1)
R1:
The citizens of Sacramento County should be served by a medical examiner system headed by a board certified forensic pathologist appointed by the governing board. The Office of the Medical Examiner is autonomous, independently funded, and responds only to the Board of Supervisors.
F8:
In Sacramento County, on an annual basis, a deputy coroner with no formal medical qualifications authorizes the signature of death certificates in approximately 4500 reportable deaths without consultation or knowledge of the department forensic pathologists. The assistant coroner, also with no formal medical training, is empowered to determine the extent of death investigation and the final manner of death and cause of death of the approximately 1400 decedents transported to the office for evaluation. This provision can include overruling the judgment of the pathologist. The compromise of medical autonomy is not just theoretical; cases confirming have been documented.
Related Recommendations (1)
R1:
The citizens of Sacramento County should be served by a medical examiner system headed by a board certified forensic pathologist appointed by the governing board. The Office of the Medical Examiner is autonomous, independently funded, and responds only to the Board of Supervisors.
F9:
On September 11, 2001 the Board of Supervisors authorized change in the coroner’s office from contractual pathology and morgue services to county employees, further compromising medical autonomy and discharging a pathology group that by all accounts was professionally excellent. The transition may have created problems with respect to recruitment 11 of pathologists and homicide testimony. The decision was made despite significant opposing written advice and testimony from the local medical community. The chief forensic pathologist continues to be a contractual employee.
F10:
On December 11, 2001 the Board of Supervisors created a conflict of interest in the investigation of in-custody deaths by placing the coroner in charge of correctional health. This conflict was in place at a time of intense scrutiny regarding inmate deaths/suicides. There is pending litigation. The conflict was only partially resolved by an autopsy contract with San Joaquin County and the very recent transfer of correctional health to the Sheriff ‘s Department. This action was also the subject of major objection in the medical community. Investigation of in-custody deaths by an independent medical examiner’s office in concert with a district attorney’s investigator will resolve this conflict.
Related Recommendations (1)
R5:
The investigation of in-custody deaths should be separate from correctional health and the Sheriff’s Department. It should be performed by an independent medical examiner and district attorney investigator.
F11:
Coroner and Medical Examiner systems operate outside the usual medical oversight and control. There are no national standards or guidelines. Therefore voluntary review and certification by organizations such as NAME and ABMDI are desirable. Affiliation with the UCD Department of Pathology would facilitate subspecialty consultation, development of policy and quality assurance.
Related Recommendations (2)
R3:
The Chief Medical Examiner should be selected by a search committee of medical experts utilizing non-political and strictly professional criteria, including prior administrative experience. All staff pathologists should be board certified in forensic pathology. They can be contractual or county employees.
R4:
The Medical Examiner System of Sacramento County should establish a strong relationship with the UCD Medical Center for development of lines of consultation, quality assurance and continuing education programs. The system should utilize professional organizations for review, certification and guidelines of operation. There should be medical emphasis in the recruitment and continuing education of staff. A forensic pathologist should supervise each reported decedent investigation and sign the death certificate of all those studied in the medical examiners office. A pathologist should supervise all morgue functions.
F12:
With the above review and affiliation, the excellent physical plant already in place and conversion to a medical examiner system assuring medical autonomy, Sacramento County will attract excellent forensic pathologists and be in position to develop a state of the art death investigation program.
F13:
Conversion to a medical examiner system would not be difficult from an operational standpoint. The coroner’s staff would not have to be replaced and would adapt quickly to medical emphasis and supervision.
F14:
A financial analysis of the transition has been reviewed by the jury and thought to be neutral, with no additional funding necessary for the operation of a medical examiner system.
F15:
Change to a medical examiner system requires a charter amendment and electorate participation.
Related Recommendations (1)
R2:
To establish this office the Board of Supervisors should propose and place on the ballot a charter amendment to abolish the Office of Coroner and replace it with the 12 Office of Medical Examiner. Failing that, the board should propose and place on the ballot a charter amendment to require the coroner to be a forensic pathologist. Failing that, the board should appoint a forensic pathologist to be coroner at the earliest opportunity.
F16:
There have been complaints of inappropriate pressure by deputy coroners placed upon attending physicians to certify deaths when the physicians had inadequate knowledge as to the cause of death. This problem appears resolved.
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Findings & Recommendations
1 findings
F1:
The School Resource Officer is essential to the safety of students at school.
Related Recommendations (1)
R1:
That all comprehensive high schools which serve Sacramento County students have on campus a school resource officer.
Additional Recommendations
5
Not linked to specific findings.
R2:
That intermediate schools have a school resource officer.
R3:
That continuation high schools have access to a school resource officer.
R4:
That the safety of students be recognized by including the school resource officers program in the budgets of the Sheriff’s Department and the school districts serving the unincorporated areas of the county for 2003-2004.
R5:
That the safety of students be recognized by including the school resource officers program in the budgets of the Sacramento Police Department and the Sacramento Unified School District for 2003-2004.
R6:
That the safety of students be recognized by including the school resource officers program in the budgets of the San Juan Unified School District, the Elk Grove Unified School District and the Center Unified School District for 2003-2004. Commendation The Sheriff’s Department’s fiscal support of the SRO program in 2002-2003 in the unincorporated areas is recognized as positive and necessary.
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Findings & Recommendations
1 findings
F1:
The City of Folsom is in compliance with existing laws when the L&L District uses its assessment authority. When a surplus occurs, credits are applied to the tax rolls generated from the County Auditor. The credit is not specifically noted on the tax bill, and as such, is not necessarily clear to property owners.
Related Recommendations (1)
R1:
The City of Folsom should explain to property owners how assessments are made and why credits are given rather than lowering assessments. The L&L District and the City Council should continue their efforts to keep property owners informed about the assessment and billing process. Response Requirements Penal Code sections 933 and 933.05 require that specific responses to both the
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Findings & Recommendations
4 findings
F1:
It could find no evidence that relatives were hired by SITOA, or of discrimination based on religious, national or racial issues.
F2:
There was no evidence that SITOA was initially handling applications inappropriately.
Related Recommendations (1)
R2:
Airport staff should ensure that taxi contractors follow the procedures, protocols and requirements agreed to by it and the Sacramento County Counsel’s Office. 14
F3:
The County Airports Office failed to provide oversight of SITOA’s hiring procedures prior to the complaints by applicants. However, the County Counsel now has the assignment to ensure compliance of the rules and to research future contracts.
Related Recommendations (1)
R3:
County Counsel should continue to oversee the County contract between taxi contractors and the Airport.
F4:
The Airport had no way of ensuring that the appropriate fees were being paid to the Airport. The Airport indicates that transponders have now been installed in all of the cabs to record each trip. This will provide a way to track the fees due to the Airport by the drivers.
Related Recommendations (1)
R4:
The Airport should continue to have an assigned employee oversee all taxicab issues, provide periodic public reports on the taxicab services of the airport, and act on problems in a timely manner. Response Requirements Penal Code sections 933 and 933.05 require that specific responses to both the
Findings and recommendations not yet extracted.
Findings & Recommendations
5 findings
F1:
In the past the Environmental Health Division has been very lax in its responsibility to provide mandated food inspections in a timely manner. In comparison, San Diego and Los Angeles both have established risk-based programs, which led to more inspections where extensive food preparation occurs and could be potentially hazardous. Sacramento inspectors have to waste time trying to track down mobile food carts who list only their main distribution address but not their site location, causing a backlog of these inspections.
F2:
The Environmental Health Division needs more staff devoted to food preparation inspections and needs to allocate tasks to maximize the staff they have.
F3:
The Environmental Health Division is not disseminating its inspection results effectively to the public.
F4:
The county Environmental Health Specialists (inspectors) displayed a high degree of professionalism during inspections. The inspectors took time to explain violations and to train restaurant employees.
F5:
The Environmental Health Division does not provide sufficient penalties for food service establishments to improve.
Additional Recommendations
12
Not linked to specific findings.
R1:
Risk-based Inspection Frequency—Base the frequency of inspection on the type and amount of food being handled (level of risk associated with same).
R1a:
Give priority to inspections based on risk assessment, putting resources to work where the risk is highest. Increase inspections to 2 or 3 per year for full food service establishments with complex menus where large amounts of food are prepared.
R1b:
Require owners of mobile food carts to come to the County office for their inspections during a single month of the year, e.g., January. Schedule them all during that month.
R2:
Staff should be increased from 11 to at least 22 full time inspectors. Each inspector should be provided personal digital assistant devices (palm pilots) to enter timely results of their inspections. All inspectors should have access to the automated database. Increased inspection fees from risk-based inspections and mandatory re-inspection fees should cover the cost of increased staffing.
R3:
Enforcement—Develop aggressive enforcement activities at facilities with continuous and repeat violations.
R3a:
Give the public what it wants and issue letter grades to restaurants inspections, which must be prominently displayed. Certificates or awards of excellence could also be given to restaurants consistently receiving a letter grade of A over 3 consecutive inspections.
R3b:
The county Environmental Health Division should establish its own Web site to post all food inspections results including grades, enforcement or closure actions, follow-up inspections, and complaint remedies.
R4:
Public Notification—Improve methods used to notify public of food facility inspection results. The first three areas of food program enhancements received almost 100 percent of consumer and industry support. The fourth received over 90 percent consumer support for notification either by letter grading or the onsite posting of the full inspection report. Industry did not support grading but favored giving an “Award for Excellence” to facilities found to be consistently in compliance with the regulations. At the March 11, 2003 meeting of the Board of Supervisors, the Environmental Health Division requested the following changes in the food inspection program: · To change and prioritize the frequency of inspections for most food facilities from 1 per year to 2 or 3 per year · To hire additional health inspectors and increase fees · To require operators with numerous health code violations to attend “food school” · Beginning July 1, 2003, to publicly display entire health inspection reports 31 Sacramento County Grand Jury June 30, 2003 The Board of Supervisors unanimously approved the changes. There was little opposition to the first three recommendations. However, industry representatives opposed the public display of health inspection reports objecting to a grade based on a single inspection. A comparison of Sacramento County to San Diego and Los Angeles Counties: Sacramento County San Diego County Los Angeles County Inspection Goal Non risk-based Risk-based Risk-based Goal 1/yr for full service 4/yr for full service High risk—3/yr restaurants restaurants Moderate risk—2/yr Low risk—1/yr Repetitive problems -- +1/yr Prioritizing No prioritizing Extensive food Based on risk preparation, potentially assessment hazardous inspected more frequently Grading System No grading system A,B,C A,B,C Considering “award of 200-point grading 3 consecutive A’s excellence” system receives “Certificate of Excellence” Public Satisfaction Public is not aware of Public is aware of Public is aware and inspection results grading system participates by calling Limited access through Restaurants quickly hotline The Sacramento Bee correct violations and Most recognized website request/pay for program in health immediate re-inspection services Facilities 5,000 food preparation 7,000 full service 37,000 retail food businesses restaurants/limited food establishments preparation Staffing 15 positions, 11 full time 63 positions, 33 staff 283 field inspectors equivalents years 37,000/283= 131/ 5000/11 = 454/inspector 7000/33 = 212/inspector inspector 32 Sacramento County Grand Jury June 30, 2003
R4a:
The county Environmental Health Division should encourage inspection staff development by allowing staff to attend training programs sponsored by government agencies and leaders in the food safety industry. Sacramento County Grand Jury June 30, 2003
R4b:
The County Environmental Health Division should consider establishing an apprenticeship program to encourage recent college graduates to enter the field. Such a program would allow these individuals to move up to staff positions after they become registered Environmental Health Specialist.
R5a:
Enforcement actions with severe implications should require immediate closure of the facility and mandatory re-inspections, paid for by the violator. Increase education for minor violations.
R5b:
Increased enforcement should lead to administrative hearings for repeat violators with ultimate license revocation.
Findings and recommendations not yet extracted.
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Findings & Recommendations
4 findings
F1:
The EGUSD gave insider information to a real estate agent which allowed the agent to make a profit in excess of $2 million on school site #8.
F2:
The EGUSD failed its fiduciary responsibility to the taxpayers by paying $2.4 million more than the fair market value for school site #8.
F3:
The EGUSD failed to perform due diligence in the search for school site #8.
F4:
The EGUSD refuses to admit a mistake was made and to take responsibility for its actions.
Additional Recommendations
6
Not linked to specific findings.
R1a:
The EGUSD should take immediate disciplinary action against responsible staff.
R1b:
The Superintendent and Board of Education should provide oversight to the staff responsible for the purchase of school sites.
R2a:
The district should require staff members responsible for the purchase of property, supplies, or services to sign a fiduciary responsibility statement. District staff should also be accountable under the EGUSD conflict of interest policy.
R2b:
The district should develop policies and procedures for the purchase of school sites that protect the financial interests of taxpayers.
R3:
The district should require staff to do their own research on potential school sites and not rely solely on agents and developers.
R4:
The district should take responsibility for its actions and implement policies and procedures to make sure this situation never happens again. Sacramento County Grand Jury June 30, 2003 TO THE CITIZENS IN THE ELK GROVE UNIFIED SCHOOL DISTRICT: The Elk Grove Unified School District is accountable to you. Apparently they do not agree. The Grand Jury can investigate, write a report, and receive an inadequate reply year after year. The EGUSD can obfuscate, delay, and refuse to talk without a subpoena, hoping to drag out the process long enough so that we will go away. This process cannot work for them if you, the good citizens in the Elk Grove Unified School District, demand better leadership from your elected officials.
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Findings and recommendations not yet extracted.
Findings and recommendations not yet extracted.
Findings & Recommendations
1 findings
F1:
District staff members exhibited a very careless attitude toward their fiscal responsibilities when negotiating the purchase of property. The Grand Jury also concluded that had the District been more diligent in its search for school property, it might have purchased the property for a price closer to the lower appraised value of $4,350,000. The Elk Grove Unified School District failed in its fiduciary responsiblity to taxpayers in the purchase of property located 22
Additional Recommendations
1
Not linked to specific findings.
R1:
The Elk Grove Unified School District should: a. develop formal policies and procedures for the purchase of school site property that protect financial interests of the taxpayers and eliminate the appearance of favoritism to any landowner, land developer or real estate agent; b. publish in a newspaper of general record an official notice of any decision by the District to establish a new school or seek a new site location. An offical notice should also be delivered to the local Board of Realtors; c. direct staff to use all available resources for the selection of property for school construction including physical inspection of properties for sale within the area of interest as well as Multiple Listing and newspaper ads.
Findings and recommendations not yet extracted.