San Luis Obispo County Grand Jury
2019-2020
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 (6)
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Findings & Recommendations
1 findings
F1:
The use of PBIS with our incarcerated youth teaches them the criteria of demonstrating safe, responsible and considerate behavior as adults. COMMENDATIONS The SLOCJH and the SLOCOE are to be commended for their cooperative effort in implementing a research-based method of behavioral improvement into JH. This method has the long-term potential to positively impact the prosocial behavior and general culture of youth while in JH. REQUIRED RESPONSES “This is an information report. No responses are required.” Presiding Judge Grand Jury Presiding Judge Jacquelyn H. Duffy San Luis Obispo County Grand Jury Superior Court of California P.O. Box 4910 1035 Palm Street Room 355 San Luis Obispo, CA 93403 San Luis Obispo, CA 93408 2 019-2020 San Luis Obispo County Grand Jury Final Report 26 San Luis Obispo County Juvenile Hall Adopts Positive Behavior Methods APPENDICES, ATTACHMENTS, BIBLIOGRAPHY, GLOSSARY AND SUGGESTED READING Bradshaw, C.P. (2013). Preventing Bullying through Positive Behavioral Interventions and Supports (PBIS): A Multitiered Approach to Prevention and Integration, Theory Into Practice, 52:4, 288-295, DOI: 10.1080/00405841.2013.829732 Cook, Clayton R.; Frye, Megan; Slemrod, Tal; Lyon, Aaron R.; Renshaw, Tyler L. & Zhang, Yanchen (2015). An integrated approach to universal prevention: Independent and combined effects of PBIS and SEL on youths’ mental health. School Psychology Quarterly, Vol 30(2), 166- 183. Cooper, J.O., Heron, T.O. & Heward, W.L. (2019). Applied behavior analysis. Hoboken, NJ: Pearson. Horner, R. H., & Sugai, G. (2015). School-wide PBIS: An example of applied behavior analysis implemented at a scale of social importance. Behavior Analysis in Practice, 8(1), 80–85. https://doi.org/10.1007/s40617-015-0045-4 Simonson, B. & Sugai, G. (2013). PBIS as Prevention for High-Risk Youth in Alternative Education, Residential, and Juvenile Justice Settings. Education and Treatment of Children., Vol. 36, No. 3. Simonson, B., Britton, L., & Young, D. (2010). School-wide positive behavioral support in an alternative school setting: A case study. Journal of Positive Behavioral Interventions. Vol. 12, No. 3. 180-191. 2 019-2020 San Luis Obispo County Grand Jury Final Report 27 This page intentionally left blank. 2 019-2020 San Luis Obispo County Grand Jury Final Report 28 PSYCHIATRIC HEALTH FACILITY: A REVIEW OF BEHAVIOR PATTERNS INTRODUCTION/PURPOSE The State of California requires county grand juries to inspect all jails and prisons within their county on a yearly basis. Since incarcerated persons may be sent to the Psychiatric Health Facility (PHF), this facility is now routinely inspected. It is noted that the PHF is actually a medical facility and not a part of our county’s jail system. In this report, the 2019-2020 San Luis Obispo County Grand Jury documents the results of our inspection of the County’s PHF. AUTHORITY The issuance of this report is authorized under investigative powers of the Grand Jury pursuant to California Penal Codes § 919, 921 and 925. The San Luis Obispo County Psychiatric Health Facility (PHF) is a hospital facility licensed by the California State Department of Health Care Services (DHCS) and is located at the former San Luis Obispo County General Hospital complex. San Luis Obispo County Health Agency oversees the facility. The PHF is licensed to serve 16 patients at any one time from 72 hours to 14 days. The PHF serves: • Individuals who may be involuntarily detained due to indications of a mental disorder or indications they may be harmful to themselves or others. (Welfare and Institutions Code §5150); • Persons in custody of the county jail who are charged with a misdemeanor, but who have been determined to be incompetent to stand trial, are treated for restoration to competence so they can participate in legal proceedings. (Penal Code §1370); • Conserved individuals (gravely disabled and permanently housed elsewhere) who are in need of stabilization. 2 019-2020 San Luis Obispo County Grand Jury Final Report 29 Psychiatric Health Facility: A Review of Behavior Patterns SUMMARY The Grand Jury toured the PHF facility and interviewed staff members as part of its routine inspection. A primary staff concern was the transfer of inmates from the county jail (Penal Code §1370). It was reported that sheriff’s deputies transport these inmates to the PHF and leave after signing off. According to PHF staff, jail transfers may be violent and pose a security problem for PHF personnel who are not law-enforcement trained. During the inspection Grand Jurors inquired as to the general frequency of behavior problems. Grand Jury members learned of staff concerns regarding a variety of physical altercations among inmates, who are now patients, despite patient checks that occur every 15 minutes 24 hours per day. Data reflecting recorded behavior problems were solicited. These data are normally collected as part of standard procedure. The San Luis Obispo Board of Supervisors approved a contract (August, 2019) for additional security staff. The Grand Jury wanted to determine whether the additional personnel would positively impact the data reported for January - October, 2019, and requested follow-up data following the hiring of additional personnel. DEFINITIONS FOR THE FOLLOWING CHART • Assaulted: This would be categorized as an act by one person on another causing perceived injury. An example would be one person being struck on the left side of their head by another person with a right closed fist. • Assaultive: This would be an act by one person on another of physical contact, attempted physical contact or threat when the ability is credible that would lead to injury. An example would be a person picking up a chair and swinging it like a club toward another person. • Destructive/Vandalism: This would be any damage to property. An example would be a person breaking a fire sprinkler in the ceiling causing a flood leading to tens of thousands of dollars in damage to the building. • Staff Injury: A staff member experiences pain during an event. An example would be staff members physically contain an aggressive person who is attempting to hit others. During the containment, the employee suffers neck pain. 2 019-2020 San Luis Obispo County Grand Jury Final Report 30 Psychiatric Health Facility: A Review of Behavior Patterns • Penal Code (PC) §1370/Welfare and Institutions Code §4011 Clients: Clients who have been sent from the County Jail to PHF for stabilization. • All Other Clients: Clients who may be involuntarily detained due to indications of a mental disorder, or indications they may be harmful to themselves or others. Data reflecting altercations occurring between January and October, 2019 were as follows: Period 1 – Prior to additional security January – October, 2019 1370/4011 Clients Total All Other Clients Total All Clients Total Assaulted 0 Assaulted 2 Assaulted 2 Assaultive 6 Assaultive 10 Assaultive 16 Destructive/Vandal. Destructive/Vandal. Destructive/Vandal. Staff Injury 5 Staff Injury 2 Staff Injury 7 Total 14 18 32 Data reflecting altercations occurring between November, 2019 and July, 2020 were as follows: Period 2 – Following additional security November 15 - July 01, 2020 1370/4011 Clients Total All Other Clients Total All Clients Total Assaulted 2 Assaulted 4 Assaulted 6 Assaultive 11 Assaultive 17 Assaultive 28 Destructive/Vandal. Destructive/Vandal. Destructive/Vandal. Staff Injury 2 Staff Injury 1 Staff Injury 3 Total 20 30 50 2 019-2020 San Luis Obispo County Grand Jury Final Report 31 Psychiatric Health Facility: A Review of Behavior Patterns Given the different number of days in each period, incident data are most accurately reported as rate data, or number of incidents per day: Period 1: January – October, 2019: N Rate 303 days Assaulted 2 0.01 Assaultive 16 0.05 Destruction 7 0.02 Staff Injury 7 0.02 Total 32 0.11 Period 2: November, 2019 – June, 2020: N Rate 235 days Assaulted 6 0.03 Assaultive 28 0.12 Destruction 13 0.06 Staff Injury 3 0.01 Total 50 0.21 Rate data presented in graph form: Average Incident Rate Per Day 0.25 0.21 0.2 0.15 0.12 0.11 0.1 0.06 0.05 0.05 0.03 0.02 0.02 0.01 0.01 0 Assaulted Assaultive Property Staff Injury TOT Destruction Jan '19-Oct '19 Nov. '19-Jun -'20 This data indicates an increase in the rate of overall incidents from Period 1 (January, 2019) to Period 2 (November, 2019 - June, 2020) 2 019-2020 San Luis Obispo County Grand Jury Final Report 32 Psychiatric Health Facility: A Review of Behavior Patterns The following factor must be considered in interpreting this data and its accuracy: • Given the frequency of turnover in the PHF client population, the degree of variability in behavior of the clientele may vary considerably from one time period to the next, making direct comparisons difficult. For example, staff reported during November - December, 2019, two extremely violent individuals were on site, necessitating a disproportionate amount of staff involvement, and possibly affecting the data reported for that general time period. • Staff injuries decreased despite increased incidents in other areas. The accuracy of this data was confirmed by PHF at a subsequent interview with GJ members. The data appears to be an accurate reflection of behavior patterns during Period 2. This suggests the addition of an estimated 2.1 - 3.62 full-time equivalent (FTE) staff had minimal effect on overall reported behavior patterns. It was the expectation of PHF supervising personnel that four FTE security would be hired, trained, and on duty by late fall, 2019. PHF staff report that since January, 2020, at least two additional (FTE) additional security guards have been on duty, and as of the last interview with PHF staff (July, 2020) current strength was at 3.62 FTEs. Staff indicated there has been considerable turnover with the newly funded security guard positions since hiring began in October, 2019. The turnover in both staff and client population makes drawing any correlations between the effectiveness of additional staff and reported incidents problematic. FINDINGS
Additional Recommendations
6
Not linked to specific findings.
R1:
It is recommended that the PHF security staff be increased to 4.0 FTEs per the August 2019, authorization. 2 019-2020 San Luis Obispo County Grand Jury Final Report 33 Psychiatric Health Facility: A Review of Behavior Patterns
R2:
It is recommended the PHF staff continue to collect data and analyze the impact of additional security staff.
R3:
The County should develop a weed abatement ordinance that is consistent with the cities’ regulations. The BOS has indicated that this recommendation requires further analysis. As indicated in Recommendation 2, the BOS adopted Ordinance No.3386 to provide for the abatement of fire hazardous weeds and rubbish in County Service Area 10. In addition to this, a countywide ordinance has been considered and is being studied further.
R4:
The County and all city fire jurisdictions should offer a chipping program similar to Atascadero. Funds may be available through the Fire Safe Program. A plan for this should be accomplished by the end of the 2019-20 fiscal year. The BOS has adopted the response of the County Fire Chief for this recommendation and determined that it requires further analysis. The vast area covered by County Fire, the costs of such a program, the 2 019-2020 San Luis Obispo County Grand Jury Final Report 42 2019-20 Continuity Report availability of staff to conduct the work, and the need to purchase and maintain several chippers and vehicles must be evaluated along with a funding source(s). Analysis was to be completed by November 30, 2019. As of this date the Grand Jury has not received a follow up response from the BOS or County Fire. The San Luis Obispo City Fire Department has indicated that this recommendation requires further analysis as an option to community fuel reduction projects as part of the recently completed San Luis Obispo City Community Wildlife Protection Plan (CWPP). The Five Cities Fire Authority has indicated that this recommendation requires further analysis. They have requested special funding that was not available and the cost of this program would need to be weighed against other existing community priorities. The City of Morro Bay disagreed with this recommendation. As in all communities in San Luis Obispo County, Morro Bay’s weed abatement program and the green waste program through Morro Bay Garbage Service has proven to be sufficient for the lighter vegetation fuel load removal in that city. The City of Paso Robles disagreed with this recommendation. In lieu of a chipping program, Paso Robles Fire and Emergency Services has initiated two significant hazardous fuel reduction projects, the Fern Canyon Fuel Break and the Salinas Riverbed Hazardous Fuel Reduction Project.
R5:
The County should work with the cities in a concerted effort to educate the public on detailed and coordinated evacuation plans. Various ways to disseminate this information may include all types of County or city mail communications. Public Service Announcements, websites, and other forms of communication are also informative. The BOS adopted the response of the County Office of Emergency Services who has implemented this recommendation. Both agencies are currently working with all operational area partners in disseminating emergency planning and preparedness information.
R6:
Plans should be implemented to incorporate the PG&E siren warning system for any and all emergencies where evacuation is warranted. The BOS has adopted the response of the County Office of Emergency Services and the recommendation has been implemented. The San Luis Obispo County Early Warning System (EWS) sirens are incorporated into each of the County’s emergency response plans where protective actions may be directed. This includes nuclear power, tsunami, dam/levee, hazardous material, and fire response plans. 2 019-2020 San Luis Obispo County Grand Jury Final Report 43
Findings & Recommendations
8 findings
F1:
Budget forecasting errors and mismanaged spending by the administration, without adequate oversight by the board, were compounded over a minimum of three years, leading to a reduction of the district reserves below mandatory minimums.
F2:
The superintendent and his staff provided financial information to trustees that was neither accurate nor conducive to making sound financial decisions.
F3:
Based on state guidelines for allowable administrative budgets the 25.9 new positions added between 2015 and 2018 exceeded recommended levels and was a key contributor to the depletion of reserves.
F4:
Conflict of interest, nepotism, and cronyism, real or imagined, created distrust and suspicion. This also led to teacher morale issues as documented in two union sponsored surveys.
F5:
The superintendent was not eligible for a severance package when he resigned. However, the board extended a negotiated settlement without obligation to do so.
F6:
The majority of trustees failed to independently verify information provided to them prior to approving expenses.
F7:
Issues exist with the way trustees are prepared for their duties. Not all trustees take advantage of training opportunities to enhance their understanding of complex issues in school management and administration.
F8:
The County Office of Education’s ability to intervene in a timely manner is unduly limited. The County Superintendent’s inability to respond resulted in serious budgeting errors over the period of the 2016-2018. CHAPTER 2-THE DISTRICT RESERVES
Additional Recommendations
16
Not linked to specific findings.
R1:
District policy should be amended to prevent a school district superintendent from acting simultaneously as CBO.
R2:
The District shall require comprehensive training for new hires who are responsible for financial accounting and business operations.
R3:
The structure for board meetings should be revamped to provide a more reasonable and focused agenda. Targeting the focus of each meeting would allow effective action and increased accountability by trustees.
R4:
In order to maintain institutional history and knowledge, the district should develop a succession plan to ensure timely replacements for essential positions and time for appropriate training.
R5:
Both the School District and the District Board of Trustees Procedure Manuals should be reviewed and updated annually and made readily available on the district website.
R6:
By-laws should be amended so that all trustees are encouraged to participate in comprehensive training with emphasis on financial oversight as provided by SLOCOE and other sources.
R7:
The County Office of Education should revisit its policies to provide further clarification on conflict of interest. All employees and board members shall be required to disclose any potential conflict issues.
R8:
The Chief Business Officer should have the authority to independently report on the fiscal health of the school district to the Board of Trustees and the County Board of Education.
R9:
The County Board of Education should provide tighter controls and transparency over authorizations for overriding a school district’s approved budgets.
R10:
Prior to an election, school districts should publicize the financial responsibility of the Board of Trustees to facilitate the complex scope of their fiduciary duties if elected.
R11:
Trustees must establish and document standard minimum qualifications for a superintendent, which reflect the needs of the district including financial management.
R12:
Standardized financial and performance metrics and monthly reporting should be developed to provide the board of trustees with the tools necessary for effective decision- making and greater accountability related to specific goals and financial objectives.
R13:
Under the conditions that exist today, the district trustees and administration should determine if the aquatic complex is viable.
R14:
The PRJUSD should consider the possibility of collaborating with the city of Paso Robles to use purchased equipment to upgrade current municipal swim facilities.
R15:
There should be a comprehensive audit and report made available to the public of 4A Foundation funds that were dedicated to the aquatic complex construction.
R16:
There should be a current audit of Measure M Funds by the Oversight Committee and it should be made available to the public.
Findings & Recommendations
5 findings
F1:
The cities of Atascadero, Grover Beach, Paso Robles, Pismo Beach and San Luis Obispo who operate their own PSAPs, could benefit financially and operationally by contracting their dispatch operation with Cal Fire and the County Sheriff.
F2:
The County Sheriff and Cal Fire have demonstrated that they can provide cost effective and operational dispatch service that is equal or better to the smaller agencies in San Luis Obispo county through contracting.
F3:
The portion of the EOC building now allocated to County Sheriff Dispatch operations is insufficient to provide dispatch service to all seven cities.
F4:
A state-of-the-art dispatch center could be a benefit to the County Sheriff’s aging building inventory, but the real benefit for taxpayers and residents countywide is the financial and operational efficiencies of a joint agency dispatch service.
F6:
It is the observation of the Grand Jury that the space is inadequate and insufficient and needs to be addressed.
Additional Recommendations
10
Not linked to specific findings.
R1:
The Cities of Atascadero, Grover Beach, Paso Robles, Pismo Beach and San Luis Obispo, should each request a proposal from the San Luis Obispo County Sheriff and Cal Fire to provide contract dispatch services and present it as an option in future budgets.
R2:
The San Luis Obispo County Sheriff and Cal Fire should modify their contingency plans for dispatch to all seven cities into a viable alternative to the proposed co-dispatch center.
R3:
The San Luis Obispo County Board of Supervisors should require the San Luis Obispo County Sheriff to provide a clear, long-term pricing for dispatch service with and without the proposed co-dispatch center.
R4:
The San Luis Obispo County Board of Supervisors should include the reallocation of space in the EOC building for expanded dispatch operations in their current negotiations with PG&E regarding the closing of Diablo Canyon Nuclear Power Plant in 2025.
R5:
Health services a) How delivered b) Common medical problems c) Public health concerns
R6:
Injuries a) Injuries to inmates due to aggression/agitation b) Accidental injuries to inmates requiring medical attention greater than first aid 2019-2020 San Luis Obispo County Grand Jury Final Report 68 Inspection Report for San Luis Obispo County Law Enforcement and Detention Facilities c) Injuries to staff by inmates due to assault or managing inmate aggression/agitation
R7:
Suicide a) Suicide attempts/deaths b) Serious self-injury incidents requiring medical attention beyond first aid
R8:
Drugs a) Drug overdoses b) Drug deaths by overdose
R9:
Deaths a) Other deaths
R10:
Training (title, hours, and instructor credentials for each type) a) Managing inmate violence b) Handling mental health behaviors c) Responding to drug/alcohol related problems 2019-2020 San Luis Obispo County Grand Jury Final Report 69 JOINT AGENCY DISPATCH: BETTER TOGETHER?
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Findings & Recommendations
7 findings
F1:
There is no evidence of an increase in response time by Cal Fire, the Sheriff’s Department or San Luis Ambulance to the emergency needs of south county residents when incidents occur at the Oceano Dunes.
F2:
The primary reason for steady response times by Cal Fire Paramedics and San Luis Ambulance is their strategic repositioning and move–up strategies. These approaches effectively place resources in positions that minimize response times.
F3:
Although the Sheriff’s department plays a minor role in the day-to-day law enforcement at the Oceano Dunes, they play a vital role when major crimes occur.
F4:
The Oceano Dunes District State Park Rangers attribute the main cause of accidents at the SVRA to inexperience, inattentiveness and speed.
Related Recommendations (1)
R2:
The County of San Luis Obispo should actively promote public safety announcements encouraging safety at the Oceano Dunes: a. Be educated to your surroundings and vehicle b. Be attentive c. Be mindful of your speed
F5:
The County Jail, which is part of the Sheriff’s department, incurs expense for booking and housing individuals arrested at the Oceano Dunes. The County of San Luis Obispo bears the cost of prosecuting and defending individuals arrested at the Oceano Dunes.
F6:
Of those requiring ambulance transport service at the Oceano Dunes, 92.8% are from locations outside of San Luis Obispo County.
F7:
The county and the state receive financial benefit from camping, sales tax and registration fees. The direct safety support services provided by the County of San Luis Obispo to the Park Rangers for services rendered at the Oceano Dunes are not reimbursed by the State.
Related Recommendations (1)
R1:
The County of San Luis Obispo should explore cost recovery for county services. The nature of off-road activities on the Oceano Dunes/SVRA require a unique level of county support.
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Findings & Recommendations
2 findings
F13:
The PHF has made minor upgrades to its small, antiquated facility. Response: We disagree partially with the finding. The County has invested significant work and funding into updating the Psychiatric Health Facility over the past year. Updates include painting, updated lighting, updated security camera system and a secure sally-port entry to allow safe entry to the facility.
F14:
According to the Sheriff's office, placing a deputy at the PHF is not an option because of existing county policies and procedures. Response: We disagree partially with this finding. Placing a deputy in the PHF is not an option due to state rules and condition of our licensure. The Health Agency is in the process of securing unarmed security guards for the facility to increase the safety of both patients and staff.