Sacramento County Grand Jury
2005-2006
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 (5)
Findings & Recommendations
1 findings
F1:
The August incident with the developmentally delayed juvenile raised a red flag at the CPS Dependent Intake Unit of CRH. It became apparent that CPS needed to have full responsibility for any child brought to its unit. They took corrective action necessary to accomplish that goal. They are to be commended for their resolve to change the procedure. This decision gives CPS better control over juveniles placed in its care.
Additional Recommendations
1
Not linked to specific findings.
R1:
The Grand Jury supports the change made to CPS intake procedures. This change was an appropriate and necessary step, and the Grand Jury recommends they keep the new requirement in place. Response Requirements Penal Code sections 933 and 933.05 require that specific responses to both the finding and recommendations contained in this report be submitted to the Presiding Judge of the Sacramento Superior Court by October 1, 2006 from: • Director of Health and Human Services • Child Protective Services 55
Findings & Recommendations
2 findings
F1:
In this case, the City of Citrus Heights Neighborhood Enhancement Department did not exercise adequate oversight of contract services, nor did it demonstrate adequate job completion follow up. No one from the City of Citrus Heights monitored the job in progress and there was no confirmation that all the debris had been removed from the site.
Related Recommendations (1)
R1:
The city should institute an effective system of monitoring and overseeing contracts. The final inspection should require more than a cursory check of the capping of utilities and water lines. The city should assign qualified staff to check on jobs in progress, and conduct thorough inspections of each job upon completion to confirm that the work was fully performed in accordance with the contract requirements.
F2:
Given the substantial quantity of the debris found on the site by the new owner, it is unreasonable to conclude that either the previous owner, or unknown parties, buried it there subsequent to the 2003 demolition and debris removal. When the situation was reported to the City of Citrus Heights Neighborhood Enhancement Department, it denied responsibility. Sacramento County Grand Jury June 30, 2006
Related Recommendations (1)
R2:
The City of Citrus Heights should assume accountability whenever a vendor with whom it contracts does not comply with the contract. Response Requirements Penal Code sections 933 and 933.05 require that specific responses to both the finding and recommendations contained in this report be submitted to the Presiding Judge of the Sacramento Superior Court by October 1, 2006 from: • Citrus Heights City Manager • City of Citrus Heights City Council
Findings & Recommendations
10 findings
F1:
The Flood Annex to the county’s All-Hazards Emergency Operations Plan is projected for completion by September 2006.
Related Recommendations (1)
R1:
The county must make the completion of the Flood Annex to its All- Hazards Emergency Operations Plan a matter of high priority.
F2:
The Sheriff’s Department has not fully developed standard operating procedures for a mass evacuation due to a flood disaster.
Related Recommendations (1)
R2:
The Sheriff’s Department should, by August 2006, complete the development of standard operating procedures for a mass evacuation due to a flood disaster. This should include plans for the evacuation of the medically or mentally infirm due to age or disability.
F3:
While the county has established a Geographic Information System that maps the location of nursing homes, assisted living and congregate care facilities within the county, it lacks adequate means of identifying and locating most of the special needs populations in the event of a flood disaster.
Related Recommendations (1)
R3:
The county should develop and maintain a comprehensive database for the location and telephone numbers of skilled nursing facilities, assisted living facilities, board and care facilities, home health care and hospice agencies, senior centers, veterans homes, group homes for the mentally ill, client providers for persons with identified special needs, and other congregate care facilities, including numerous state licensed small scale adult day health care centers, in order to facilitate emergency communication directly or through such agencies in the event of a flood. For this purpose, each such provider or facility should be required to maintain a current list of client telephone numbers and addresses.
F4:
The “Privacy Rule” component of the Health Insurance Portability and Accountability Act of 1996 is deemed by many to constitute a barrier to the sharing of lists of client names, locations and telephone numbers to county or other emergency officials under any circumstances.
Related Recommendations (1)
R4:
The county should secure and distribute to all pertinent public and private agencies a formal opinion of the Sacramento County Counsel and/or the Attorney General on the effect of HIPAA upon the sharing of lists of such information in the event of an imminent disaster. 37
F5:
The county has not established a full partnership of private care facilities and agencies for the evacuation of special needs clients in the event of a flood disaster.
Related Recommendations (1)
R5:
The county should require training for managers and staff of private care facilities and agencies, along with formalized agreements specifying the roles and responsibilities of such facilities and agencies in the event of a flood.
F6:
The county lacks adequate access to fully staffed emergency-ready specialized transportation vehicles, wheelchair and gurney capable, and fully supplied with oxygen, insulin and other essential medicines.
Related Recommendations (1)
R6:
The county should secure or contract for immediate access to a determined number of emergency ready, fully staffed and equipped specialized transportation vehicles, for the transportation of persons with special needs to appropriate shelters or in-kind facilities within the region.
F7:
The county has not fully identified the local hospital surge capacity under various circumstances of a flood disaster, which could impede access to one or more of those facilities.
Related Recommendations (1)
R7:
The county should identify the local hospital surge capacity under various circumstances of a flood disaster, and provide for alternate care sites for special needs persons who might otherwise require hospitalization.
F8:
While the county has provided for mass shelters for general population evacuees, these shelters would not have the ability to provide for special needs persons who are medically or mentally infirm due to age or disability.
Related Recommendations (1)
R8:
The county should provide, reserve, staff, and equip one or more shelters for the special needs of the medically or mentally infirm due to age or disability.
F9:
The county has not engaged in comprehensive pre-mobilization planning, training, or exercises for the participation of county, city and other local agency employees in mitigation and relief efforts in the event of a major emergency evacuation.
Related Recommendations (1)
R9:
County, city, and other local agency employees are designated by law as disaster services workers, and may be assigned to such efforts, including evacuation and care of the special needs populations, in the event of a major emergency evacuation. Those who are able and competent to do so should be identified, organized and trained in advance of a major emergency.
F10:
The county has not engaged in a comprehensive public education program for the promotion of effective personal, household, and neighborhood plans for self-help and mutual assistance, with particular regard to persons with special needs, in the event of a major emergency evacuation. 38
Related Recommendations (1)
R10:
The county should refocus its efforts on public awareness, education, and promotion of effective personal, household, and local community plans for self-help and mutual assistance that would include the designation of contact monitors for each person with special needs, in the event of a major emergency evacuation. Response Requirements Penal Code sections 933 and 933.05 require that specific responses to both the findings and recommendations contained in this report be submitted to the Presiding Judge of the Sacramento County Superior Court by October 1, 2006 from: • Sacramento County Executive, as to
Findings & Recommendations
3 findings
F1:
The Grand Jury finds repeated damage has occurred to the markers at the sites referred to in the original complaint. No evidence was found that this type of damage is widespread or common. Damage to the specific plots resulted from the following: • Nature of the materials used for the grave markers in question • Cemetery need for access to newly created gravesites, accessible only across areas of established graves • Equipment may scrape monuments and/or run over markers as maneuvered through narrow areas
Related Recommendations (1)
R1:
The Grand Jury recommends FOCD evaluate additional materials and strategies to prevent damage to markers, and to avoid the appearance of neglect while markers are being repaired. These strategies might include use of artificial turf or other soft materials to shield and protect the flat markers under plywood sheeting; prompt grading of ruts and trampled areas and installation of turf instead of waiting for new grass to grow; and rental (or purchase) of lightweight excavation equipment for access to congested areas. 14
F2:
Certain marker materials are only suitable for placement flush to the ground. They are susceptible to cracking or chipping when weight is placed upon them. These materials may be too thin to be converted to vertical monuments.
Related Recommendations (1)
R2:
When markers are damaged in the course of maintenance, FOCD should, with the permission of the families involved, explore replacing them with markers more suited to the maintenance issues faced in the area where they are placed. All future sales contracts should specify the use of suitable marker materials.
F3:
FOCD does not maintain a documented complaint file. FOCD deals with families under emotional stress and when problems arise, misunderstanding can occur.
Related Recommendations (1)
R3:
Rather than relying solely upon oral agreements to resolve problems, FOCD should continue its practice of personally resolving issues, while confirming and documenting such agreements. Copies of all correspondence should be retained. Response Requirements Penal Code sections 933 and 933.05 require that specific responses to both the finding and recommendations contained in this report be submitted to the Presiding Judge of the Sacramento Superior Court by October 1, 2006 from: (cid:131) FOCD Board of Directors 15
Findings & Recommendations
4 findings
F1:
Chronic understaffing of nurses has lead to an inability to consistently conduct nurse sick call Monday through Friday. This raises the likelihood that inmates who sign up for nurse sick call may not be seen for up to four days from the date of request to see a nurse. Since nurse sick call is the primary way for an inmate to be seen by a jail physician, this means that inmates who need to be seen by a physician have their care delayed, possibly leading to serious harm to the inmate.
Related Recommendations (1)
R1:
The 30% vacancy rate for nurses needs to be significantly lowered and the reliance on the Nurse Registry should be reduced.
F2:
Quality assurance and the overall collection of data about healthcare in the jail are conducted on an informal basis. This means there is an inability to measure success or failure and an inability to quantify the goals of the health care system. It also means that there can be limited oversight of the system, since it is difficult to determine exactly what is occurring.
Related Recommendations (1)
R2:
The jail should seek accreditation by the Institute for Medical Quality through their Corrections and Detentions Survey Program. This would provide measurable performance standards that permit the jail officials and the public to better assess the quality of health care delivery.
F3:
Several incidents in the past year highlight the risks to nurses during nurse sick call when they are alone while examining an inmate.
Related Recommendations (1)
R3:
A custody officer needs to be stationed outside the examination room during nurse sick call to ensure that, if an incident occurs, a response can occur within seconds.
F4:
The current system of dispensing medication is a manual system that increases the risk of incorrect medications being given, does not allow for the avoidance of medications being given that might dangerously interact, and does not allow for inventory control. While the jail staff has indicated for several years that the system is going to be replaced, there have been difficulties with the process, and delays have occurred. However, the latest schedule indicates a new system will be in place, at least in the jail, by the middle of 2006.
Related Recommendations (1)
R4:
Jail officials need to regularly keep this and successor Grand Juries updated on the progress of replacing the old manual system, including progress reports on the implementation and its utilization of the system. These updates should be provided on a quarterly basis. Response Requirements Penal Code sections 933 and 933.05 require that specific responses to both the finding and recommendations contained in this report be submitted to the Presiding Judge of the Sacramento Superior Court by October 1, 2006 from: (cid:131) Sheriff, County of Sacramento 8 ELK GROVE CITY COUNCIL THE HANDLING OF POLITICAL DISSENT Issue Do Councilman Michael P. Leary and other members of the Elk Grove City Council (EGCC) promote or allow the free expression of political dissent with respect to the activities or policies of the council? Reason for the Investigation The Grand Jury received complaints that Councilman Leary and other members of the EGCC engaged in conduct which, by its nature, was intended or designed to intimidate the free expression of political dissent with respect to the activities or policies of the council. Method of Investigation The Grand Jury received sworn testimony from the following: • Constituents and residents of the City of Elk Grove • Two members of the EGCC, including Councilman Leary The Grand Jury reviewed video tapes of public meetings of the EGCC, and the Code of Ethics adopted at the April 27, 2005 city council meeting. The Grand Jury obtained by, legal process, and reviewed an exchange of electronic mail between Councilman Leary and a constituent. The Grand Jury consulted California state and federal appellate and Supreme Court cases bearing upon the conduct of a city council. Background and Facts The Grand Jury received a complaint that EGCC Councilman Leary, at a meeting of the city council on April 27, 2005, threatened to deny grant funds to any organization whose members publicly criticized the council with respect to an unrelated matter. Councilman Leary did, in fact, threaten to withhold funding from an organization, one or more members of which had expressed disagreement with the EGCC, to wit: “I will be quite frank with a situation that grinds me the wrong way. Individuals in this community want to throw darts at this council and want to trash us and say things that are 9 inappropriate. And then on the other hand, want to come up with their hat in their hand asking for money for different programs they are involved with. I would like to say that I am not apt to fund things that those individuals sit on.” Mayor Daniel Briggs interjected that board members might be making comments outside the scope of their board membership, and that organizations that solicit funds from the city should take more care when selecting their board members. Councilman Leary continued: “Common sense would kick in and say, ‘On one hand, I am beating them up in the paper, and another time I am sitting here asking them for money.’ I am putting that particular person on notice about how I am feeling.” Other council members verbally indicated concurrence with Councilmen Leary and Briggs. At the May 11, 2005 EGCC meeting, one council member expressly disassociated herself from the remarks made at the April 27th meeting. In the Grand Jury’s view, Councilman Leary and concurring members, by these remarks, compromised their duty to predicate their decisions based upon the public good, rather than for the purpose of impairing political dissent. It has been held by the courts of this state: “Governing bodies of municipalities stand in a higher category, higher than that of mere employees and directors of a private corporation; whatever other functions they may be called upon to perform, members of a municipal council or other body are at all times trustees of the public welfare. Obviously, such trusteeship does not call for competition and strife between such bodies and the interested members of the public.” (Los Angeles County v. City Council of Lawndale (1962) 202 Cal. App. 2d 20, 24, Hubble v. City of Los Angeles (1956) 142 Cal. App. 2d 1, 5.) The Supreme Court of the United States also has held that a funding decision by a public agency cannot be aimed at suppressing criticism. (Legal Services Corp. v. Velazquez (2001) 531 U.S. 533, 548-549.) The EGCC, later in the same meeting of April 27, 2005, adopted an eleven point City Code of Ethics. This Code of Ethics was in response to a Sacramento County Grand Jury Report dated February 28, 2005 (www.sacgrandjury.org). One of these points states, “I treat my fellow city officials, staff, commission members and the public with patience, courtesy, civility and respect, even when we disagree on what is best for the community and its citizens.” The Grand Jury is also in receipt of a complaint relating to comments by electronic mail from EGCC Councilman Leary to a constituent in response to the constituent’s earlier email critical of Councilman Leary’s action at a meeting of the city council on June 16, 2004. In his response to this email and to the constituent’s ongoing criticism, which he viewed as “anti-law enforcement,” he threatened to publicly expose a past misdemeanor conviction of the constituent. At the time, Councilman Leary was employed as a Sergeant with the Sacramento County Sheriff’s Department, and made the threat through official law enforcement channels of communication. In the Grand Jury’s view, Councilman Leary’s attitude to political dissent by a constituent is inconsistent with our “…‘profound national commitment,’ to the principal that ‘debate on public issues should be uninhibited, robust, and wide open.’” (Boos v. Barry (1988) 485 U.S. 312, 318.) This profound national commitment, as applied to a city council, is codified in California in Government Code section 54954.3(c): “The legislative body of a local agency shall not prohibit public criticism of the policies, procedures, programs or services of the agency, or of the acts or omissions of the legislative body.” The threat was even more egregious because it was made through official law enforcement channels, giving it the color of law.
* This report's PDF did not contain easily extractable text and required Optical Character Recognition (OCR) for analysis. There may be minor errors in the extracted findings and recommendations due to OCR limitations with scanned documents.