Sacramento County Grand Jury
2014-2015
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 (10)
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Findings & Recommendations
4 findings
F1:
The Fire Department’s implementation of new computerized systems to replace manual inventory and tracking systems will greatly increase the accuracy and timeliness of information related to the purchase, storage, distribution and use of narcotics.
Related Recommendations (1)
R1:
The City of Sacramento Fire Department should continue implementing the City Auditor’s recommendations.
F2:
The Department’s implementation of coded access by authorized personnel provides better assurance that narcotics are only accessed by those with the proper and unique access codes, as referenced by the City Auditor’s report.
F3:
No evidence was discovered to indicate drug theft or tampering.
Related Recommendations (1)
R3:
In consultation with the City Attorney, the Fire Department should diligently pursue discussions with firefighter union representatives to institute a random drug testing program. RESPONSES Penal Code sections 933 and 933.05 require that the following officials submit specific responses to the findings and recommendations in this report to the Presiding Judge of the Sacramento County Superior Court by October 1, 2015: • The City of Sacramento Fire Department Chief - all Findings and all Recommendations Mail or hand-deliver a hard copy of the response to: Robert C. Hight, Presiding Judge Sacramento County Superior Court 720 9th Street, Department 47 Sacramento, California 95814 In addition, email the response to: Becky Castaneda, Grand Jury Coordinator at [email protected] 35
F4:
The Department’s publically stated willingness to consider random drug testing, as stated in the City Auditor’s report, is recognition of a proven program to create a safer work environment for fire personnel and to ensure better patient care.
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Findings & Recommendations
4 findings
F1:
The Fire Department’s implementation of new computerized systems to replace manual inventory and tracking systems will greatly increase the accuracy and timeliness of information related to the purchase, storage, distribution and use of narcotics.
Related Recommendations (1)
R1:
The City of Sacramento Fire Department should continue implementing the City Auditor’s recommendations.
F2:
The Department’s implementation of coded access by authorized personnel provides better assurance that narcotics are only accessed by those with the proper and unique access codes, as referenced by the City Auditor’s report.
F3:
No evidence was discovered to indicate drug theft or tampering.
Related Recommendations (1)
R3:
In consultation with the City Attorney, the Fire Department should diligently pursue discussions with firefighter union representatives to institute a random drug testing program. RESPONSES Penal Code sections 933 and 933.05 require that the following officials submit specific responses to the findings and recommendations in this report to the Presiding Judge of the Sacramento County Superior Court by October 1, 2015: • The City of Sacramento Fire Department Chief - all Findings and all Recommendations Mail or hand-deliver a hard copy of the response to: Robert C. Hight, Presiding Judge Sacramento County Superior Court 720 9th Street, Department 47 Sacramento, California 95814 In addition, email the response to: Becky Castaneda, Grand Jury Coordinator at [email protected] 35
F4:
The Department’s publically stated willingness to consider random drug testing, as stated in the City Auditor’s report, is recognition of a proven program to create a safer work environment for fire personnel and to ensure better patient care.
Findings & Recommendations
7 findings
F1:
Sacramento County has abdicated the provision of crisis services for the mentally ill. The current mental health crisis services in Sacramento County are inadequate, anti- therapeutic, costly and dangerous.
Related Recommendations (1)
R1:
Provide documentation that they are meeting all requirements for the provision of crisis and hospital services for the seriously mentally ill.
F2:
Sacramento County’s decision to close the Crisis Stabilization Unit to adult patients and to eliminate 50 beds from the Sacramento County Mental Health Treatment Center, as well as subsequent program decisions, has had widespread negative fiscal consequences.
Related Recommendations (1)
R2:
Establish a fully functional and available 23-hour intake and evaluation crisis unit (Crisis Stabilization Unit) or similar urgent care model.
F3:
Sacramento County’s shift of responsibility for crisis services has overwhelmed community hospital emergency rooms.
Related Recommendations (1)
R3:
Develop, expand and support outpatient programs that respond to and mitigate mental health crises before they escalate.
F4:
Sacramento County’s use of inpatient hospitals is dysfunctional and currently too expensive.
Related Recommendations (1)
R4:
Expand mobile crisis programs.
F5:
Sacramento County’s shift of responsibility for crisis services has adversely impacted area law enforcement agencies.
Related Recommendations (1)
R5:
Assure continuation of CIT (Crisis Intervention Training) opportunities for law enforcement by exploring all available funding options.
F6:
Sacramento County’s relationship with hospital providers and law enforcement is strained or conflictual.
Related Recommendations (1)
R6:
Expand crisis residential services, both acute and non-acute.
F7:
Sacramento County's use of long-term, non-acute 24-hour care utilization is inadequate, costly and fails to utilize more appropriate alternatives. 24
Related Recommendations (1)
R7:
Maximize reimbursable services utilizing funding sources including Prop 63 (MHSA), S.B. 82 (Mental Health Wellness Act), and Medi-Cal.
Additional Recommendations
8
Not linked to specific findings.
R8:
Clearly articulate the County’s budget for crisis and hospital services for non-Medi-Cal patients.
R9:
Involve the community in developing strategies regarding hospital bed availability, utilization and funding for patients requiring psychiatric inpatient care.
R10:
Cease the ongoing renovation project to convert the closed 50 beds at the SCMHTC and conduct an independent evaluation of cost-effective and highest use for this facility.
R11:
Use existing SCMHTC hospital beds for acute stays rather than for non-acute or administrative stays.
R12:
Consider additional 16-bed Psychiatric Health Facilities contingent on the analysis of an overall mental health crisis response plan.
R13:
Address the damaged relationships with community hospitals, law enforcement, and the mental health community at large.
R14:
Provide alternative longer-term 24-hour non-acute capacity that is less expensive than acute hospitalization.
R15:
Develop and implement programs for difficult to place patients. RESPONSES Penal Code sections 933 and 933.05 require that the following officials submit specific responses to the findings and recommendations in this report to the Presiding Judge of the Sacramento County Superior Court by October 1, 2015: • Sacramento County Board of Supervisors - All Recommendations, 1- 15 • Director, Sacramento County Department of Health and Human Services -
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Findings & Recommendations
7 findings
F1:
Sacramento County has abdicated the provision of crisis services for the mentally ill. The current mental health crisis services in Sacramento County are inadequate, anti- therapeutic, costly and dangerous.
Related Recommendations (1)
R1:
Provide documentation that they are meeting all requirements for the provision of crisis and hospital services for the seriously mentally ill.
F2:
Sacramento County’s decision to close the Crisis Stabilization Unit to adult patients and to eliminate 50 beds from the Sacramento County Mental Health Treatment Center, as well as subsequent program decisions, has had widespread negative fiscal consequences.
Related Recommendations (1)
R2:
Establish a fully functional and available 23-hour intake and evaluation crisis unit (Crisis Stabilization Unit) or similar urgent care model.
F3:
Sacramento County’s shift of responsibility for crisis services has overwhelmed community hospital emergency rooms.
Related Recommendations (1)
R3:
Develop, expand and support outpatient programs that respond to and mitigate mental health crises before they escalate.
F4:
Sacramento County’s use of inpatient hospitals is dysfunctional and currently too expensive.
Related Recommendations (1)
R4:
Expand mobile crisis programs.
F5:
Sacramento County’s shift of responsibility for crisis services has adversely impacted area law enforcement agencies.
Related Recommendations (1)
R5:
Assure continuation of CIT (Crisis Intervention Training) opportunities for law enforcement by exploring all available funding options.
F6:
Sacramento County’s relationship with hospital providers and law enforcement is strained or conflictual.
Related Recommendations (1)
R6:
Expand crisis residential services, both acute and non-acute.
F7:
Sacramento County's use of long-term, non-acute 24-hour care utilization is inadequate, costly and fails to utilize more appropriate alternatives. 24
Related Recommendations (1)
R7:
Maximize reimbursable services utilizing funding sources including Prop 63 (MHSA), S.B. 82 (Mental Health Wellness Act), and Medi-Cal.
Additional Recommendations
8
Not linked to specific findings.
R8:
Clearly articulate the County’s budget for crisis and hospital services for non-Medi-Cal patients.
R9:
Involve the community in developing strategies regarding hospital bed availability, utilization and funding for patients requiring psychiatric inpatient care.
R10:
Cease the ongoing renovation project to convert the closed 50 beds at the SCMHTC and conduct an independent evaluation of cost-effective and highest use for this facility.
R11:
Use existing SCMHTC hospital beds for acute stays rather than for non-acute or administrative stays.
R12:
Consider additional 16-bed Psychiatric Health Facilities contingent on the analysis of an overall mental health crisis response plan.
R13:
Address the damaged relationships with community hospitals, law enforcement, and the mental health community at large.
R14:
Provide alternative longer-term 24-hour non-acute capacity that is less expensive than acute hospitalization.
R15:
Develop and implement programs for difficult to place patients. RESPONSES Penal Code sections 933 and 933.05 require that the following officials submit specific responses to the findings and recommendations in this report to the Presiding Judge of the Sacramento County Superior Court by October 1, 2015: • Sacramento County Board of Supervisors - All Recommendations, 1- 15 • Director, Sacramento County Department of Health and Human Services -
Quick View
Full Details →
Findings & Recommendations
7 findings
F1:
Sacramento County has abdicated the provision of crisis services for the mentally ill. The current mental health crisis services in Sacramento County are inadequate, anti- therapeutic, costly and dangerous.
Related Recommendations (1)
R1:
Provide documentation that they are meeting all requirements for the provision of crisis and hospital services for the seriously mentally ill.
F2:
Sacramento County’s decision to close the Crisis Stabilization Unit to adult patients and to eliminate 50 beds from the Sacramento County Mental Health Treatment Center, as well as subsequent program decisions, has had widespread negative fiscal consequences.
Related Recommendations (1)
R2:
Establish a fully functional and available 23-hour intake and evaluation crisis unit (Crisis Stabilization Unit) or similar urgent care model.
F3:
Sacramento County’s shift of responsibility for crisis services has overwhelmed community hospital emergency rooms.
Related Recommendations (1)
R3:
Develop, expand and support outpatient programs that respond to and mitigate mental health crises before they escalate.
F4:
Sacramento County’s use of inpatient hospitals is dysfunctional and currently too expensive.
Related Recommendations (1)
R4:
Expand mobile crisis programs.
F5:
Sacramento County’s shift of responsibility for crisis services has adversely impacted area law enforcement agencies.
Related Recommendations (1)
R5:
Assure continuation of CIT (Crisis Intervention Training) opportunities for law enforcement by exploring all available funding options.
F6:
Sacramento County’s relationship with hospital providers and law enforcement is strained or conflictual.
Related Recommendations (1)
R6:
Expand crisis residential services, both acute and non-acute.
F7:
Sacramento County's use of long-term, non-acute 24-hour care utilization is inadequate, costly and fails to utilize more appropriate alternatives. 24
Related Recommendations (1)
R7:
Maximize reimbursable services utilizing funding sources including Prop 63 (MHSA), S.B. 82 (Mental Health Wellness Act), and Medi-Cal.
Additional Recommendations
8
Not linked to specific findings.
R8:
Clearly articulate the County’s budget for crisis and hospital services for non-Medi-Cal patients.
R9:
Involve the community in developing strategies regarding hospital bed availability, utilization and funding for patients requiring psychiatric inpatient care.
R10:
Cease the ongoing renovation project to convert the closed 50 beds at the SCMHTC and conduct an independent evaluation of cost-effective and highest use for this facility.
R11:
Use existing SCMHTC hospital beds for acute stays rather than for non-acute or administrative stays.
R12:
Consider additional 16-bed Psychiatric Health Facilities contingent on the analysis of an overall mental health crisis response plan.
R13:
Address the damaged relationships with community hospitals, law enforcement, and the mental health community at large.
R14:
Provide alternative longer-term 24-hour non-acute capacity that is less expensive than acute hospitalization.
R15:
Develop and implement programs for difficult to place patients. RESPONSES Penal Code sections 933 and 933.05 require that the following officials submit specific responses to the findings and recommendations in this report to the Presiding Judge of the Sacramento County Superior Court by October 1, 2015: • Sacramento County Board of Supervisors - All Recommendations, 1- 15 • Director, Sacramento County Department of Health and Human Services -
Findings & Recommendations
5 findings
F1:
Citrus Heights does not uphold its responsibility to operate and monitor its red light camera program.
Related Recommendations (1)
R1:
The CHPD should routinely produce and analyze actual traffic incident data. This information should then be used to judge the effectiveness of the program. This will allow informed decisions such as whether the cameras are placed at intersections that yield the most desired effect.
F2:
The CHPD routinely fails to follow its adopted policy and procedures on red light cameras.
Related Recommendations (1)
R2:
Citrus Heights Public Works should set the minimum timing for yellow lights at the minimum standard, in order to trigger the red flashing signal, indicating a problem with the timing.
F3:
The accident reduction data used to judge the effectiveness of the program by the CHPD is inconsistent and inaccurate in some instances.
Related Recommendations (1)
R3:
Citrus Heights should assign personnel to conduct an on-site physical timing of the yellow signal lights at each intersection where there is a red light camera. A written maintenance log should be kept. RESPONSES Penal Code sections 933 and 933.05 require that the following officials submit specific responses to the findings and recommendations in this report to the Presiding Judge of the Sacramento County Superior Court by October 1, 2015: • Citrus Heights Chief of Police - Findings 1, 2, 3 and Recommendations 1, 3 • Citrus Heights City Manager - Findings 1, 4, 5 and Recommendations 1, 2, 3 Mail or hand-deliver a hard copy of the response to: Robert C. Hight, Presiding Judge Sacramento County Superior Court 720 9th Street, Department 47 Sacramento, California 95814 In addition, email the response to: Becky Castaneda, Grand Jury Coordinator at [email protected] 39
F4:
The City has no process in place to be alerted when the yellow light sequencing falls below the minimum standard set by CA DOT and mandated by the CVC.
F5:
Citrus Heights has no reliable process in place to ensure that the timing of the yellow light sequencing is consistent. CHPD performs stopwatch audits of the yellow light sequencing using Redflex video, which is compressed and unreliable. 38
Findings & Recommendations
5 findings
F1:
Citrus Heights does not uphold its responsibility to operate and monitor its red light camera program.
Related Recommendations (1)
R1:
The CHPD should routinely produce and analyze actual traffic incident data. This information should then be used to judge the effectiveness of the program. This will allow informed decisions such as whether the cameras are placed at intersections that yield the most desired effect.
F2:
The CHPD routinely fails to follow its adopted policy and procedures on red light cameras.
Related Recommendations (1)
R2:
Citrus Heights Public Works should set the minimum timing for yellow lights at the minimum standard, in order to trigger the red flashing signal, indicating a problem with the timing.
F3:
The accident reduction data used to judge the effectiveness of the program by the CHPD is inconsistent and inaccurate in some instances.
Related Recommendations (1)
R3:
Citrus Heights should assign personnel to conduct an on-site physical timing of the yellow signal lights at each intersection where there is a red light camera. A written maintenance log should be kept. RESPONSES Penal Code sections 933 and 933.05 require that the following officials submit specific responses to the findings and recommendations in this report to the Presiding Judge of the Sacramento County Superior Court by October 1, 2015: • Citrus Heights Chief of Police - Findings 1, 2, 3 and Recommendations 1, 3 • Citrus Heights City Manager - Findings 1, 4, 5 and Recommendations 1, 2, 3 Mail or hand-deliver a hard copy of the response to: Robert C. Hight, Presiding Judge Sacramento County Superior Court 720 9th Street, Department 47 Sacramento, California 95814 In addition, email the response to: Becky Castaneda, Grand Jury Coordinator at [email protected] 39
F4:
The City has no process in place to be alerted when the yellow light sequencing falls below the minimum standard set by CA DOT and mandated by the CVC.
F5:
Citrus Heights has no reliable process in place to ensure that the timing of the yellow light sequencing is consistent. CHPD performs stopwatch audits of the yellow light sequencing using Redflex video, which is compressed and unreliable. 38
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Findings & Recommendations
5 findings
F1:
CFD has an ongoing lack of focus, priority and accountability in regard to inspections.
Related Recommendations (1)
R1:
Amend the job description for the Fire Marshal to include responsibility and accountability for California Fire Code required inspections. It is recommended that CFD implement scheduled rotation of all inspectors through all inspectable job classifications.
F2:
There is a lack of documentation of inspections and re-inspections.
Related Recommendations (1)
R2:
Establish and develop a training program for all applicable personnel and a staff of fully trained professionals to ensure continuity in the processing of the documents.
F3:
Previously purchased Image Trend software has not been fully implemented.
Related Recommendations (1)
R3:
Fully implement Image Trend software to improve documentation of inspections and re-inspections. The data system should include the ability to capture and identify violations, especially repetitive violations. Work with vendor on technical support.
F4:
Review of data received on high school re-inspections indicates 70% non-compliance.
Related Recommendations (1)
R4:
School administration needs to be actively involved in the remediation of noted violations.
F5:
There is no incentive for schools to resolve listed violations due to lack of CFD enforcement. Not correcting these violations increases the risk to children in Elk Grove and Galt school districts. 33
Related Recommendations (1)
R5:
CFD should process unresolved violations after re-inspections by issuance of citations.
Findings & Recommendations
5 findings
F1:
Larger boards such as the Board of Supervisors and city councils, which can afford consistent legal guidance at their meetings, usually follow Brown Act procedures.
Related Recommendations (1)
R1:
Jurisdictions must always follow Brown Act procedures.
F2:
There may be Brown Act violations that go unnoticed by staff, board members, and the public, especially in smaller jurisdictions.
Related Recommendations (1)
R2:
All jurisdictions should keep a log to ensure that board members and key staff receive training every two years, as required by Government Code 53235.1(c)(2)(b).
F3:
Awareness of such violations is often triggered by a controversial decision, and can cause great embarrassment. Rectifying violations can be very expensive and result in unplanned costs.
Related Recommendations (1)
R3:
Board members and staff should personally ensure that their training is adequate and current.
F4:
There are numerous opportunities to get professional Brown Act training. New board members and key employees appear to all receive training. It is unclear whether that training is reinforced every two years as required in Government Code 53234(d)(3).
Related Recommendations (1)
R4:
Jurisdictions should periodically schedule Brown Act training on a meeting agenda and invite members of the public to attend.
F5:
Since the general public has limited exposure to the Brown Act, strict adherence reduces the potential for procedural controversy.
Related Recommendations (1)
R5:
To ensure full transparency, jurisdictions should regularly review their meeting and posting procedures for compliance with the Brown Act. Further, jurisdictions can also consider reviewing all their public practices, including seeking a “District Transparency Certificate of Excellence”, which is offered by the Special District Leadership Foundation.
Additional Recommendations
1
Not linked to specific findings.
R6:
The Sacramento County Board of Supervisors and all cities within the County should ensure that their commissions, committees, boards and other bodies subject to the Brown Act, maintain records on their ethics and Brown Act training compliance. RESPONSES Penal Code sections 933 and 933.05 require that the following officials submit specific responses to the findings and recommendations in this report to the Presiding Judge of the Sacramento County Superior Court by October 1, 2015: • Sacramento County Board of Supervisors - all Findings and Recommendation 6. Mail or hand-deliver a hard copy of the response to: Robert C. Hight, Presiding Judge Sacramento County Superior Court 720 9th Street, Department 47 Sacramento, California 95814 In addition, email the response to: Becky Castaneda, Grand Jury Coordinator at [email protected] 46
Findings & Recommendations
5 findings
F1:
Larger boards such as the Board of Supervisors and city councils, which can afford consistent legal guidance at their meetings, usually follow Brown Act procedures.
Related Recommendations (1)
R1:
Jurisdictions must always follow Brown Act procedures.
F2:
There may be Brown Act violations that go unnoticed by staff, board members, and the public, especially in smaller jurisdictions.
Related Recommendations (1)
R2:
All jurisdictions should keep a log to ensure that board members and key staff receive training every two years, as required by Government Code 53235.1(c)(2)(b).
F3:
Awareness of such violations is often triggered by a controversial decision, and can cause great embarrassment. Rectifying violations can be very expensive and result in unplanned costs.
Related Recommendations (1)
R3:
Board members and staff should personally ensure that their training is adequate and current.
F4:
There are numerous opportunities to get professional Brown Act training. New board members and key employees appear to all receive training. It is unclear whether that training is reinforced every two years as required in Government Code 53234(d)(3).
Related Recommendations (1)
R4:
Jurisdictions should periodically schedule Brown Act training on a meeting agenda and invite members of the public to attend.
F5:
Since the general public has limited exposure to the Brown Act, strict adherence reduces the potential for procedural controversy.
Related Recommendations (1)
R5:
To ensure full transparency, jurisdictions should regularly review their meeting and posting procedures for compliance with the Brown Act. Further, jurisdictions can also consider reviewing all their public practices, including seeking a “District Transparency Certificate of Excellence”, which is offered by the Special District Leadership Foundation.
Additional Recommendations
1
Not linked to specific findings.
R6:
The Sacramento County Board of Supervisors and all cities within the County should ensure that their commissions, committees, boards and other bodies subject to the Brown Act, maintain records on their ethics and Brown Act training compliance. RESPONSES Penal Code sections 933 and 933.05 require that the following officials submit specific responses to the findings and recommendations in this report to the Presiding Judge of the Sacramento County Superior Court by October 1, 2015: • Sacramento County Board of Supervisors - all Findings and Recommendation 6. Mail or hand-deliver a hard copy of the response to: Robert C. Hight, Presiding Judge Sacramento County Superior Court 720 9th Street, Department 47 Sacramento, California 95814 In addition, email the response to: Becky Castaneda, Grand Jury Coordinator at [email protected] 46