Gran Jurado del Condado de Santa Barbara
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 (5)
Hallazgos & Recomendaciones
12 hallazgos
F1:
In-person learning is more effective than remote learning both academically and emotionally.
F1a:
The cities of Buellton, Carpinteria, Goleta, Guadalupe, Solvang and the County of Santa Barbara are at less potential pension plan solvency risk.
F1b:
The cities of Lompoc, Santa Barbara and Santa Maria are at higher potential pension plan solvency risk. 65
F1c:
Unfunded Accrued Liabilities have risen for all cities since 2016, and with the announced change in the Discount Rate, are expected to rise further, which could impact the cities’ ability to deliver expected services to residents.
F2:
For student achievement, especially for low performing students, in-person learning in small classes or small groups is preferable to larger classrooms.
F3:
Remote learning exposed the importance of outreach efforts to provide coaching to parents on creating a positive home learning environment.
F4:
Santa Barbara County school districts did not use one common test throughout Santa Barbara County, making it impossible to compare countywide testing results.
F5:
Students with the greatest learning loss will require a concentrated effort to bring them up to Federal and State grade level standards.
F6:
As the 2020-21 school year wore on, remote learning and teaching techniques and students’ computer skills improved.
F7:
Federal and State COVID relief funds cannot be counted on indefinitely.
F8:
Community organizations provided critical assistance to the Santa Barbara County school districts by expanding their efforts to bridge the learning gap between the home environment and school.
F9:
Internet services were critical to remote learning and, in most cases, Santa Barbara County school districts filled the gap for homes that did not have them.
Recomendaciones adicionales
15
No vinculadas a hallazgos específicos.
R1:
That the Santa Barbara County Board of Supervisors and all city councils within the County establish programs similar to Roomkey in both North and South County to continue to provide rooms, with appropriate services, for vulnerable elderly homeless with underlying health conditions.
R1a:
That the Santa Barbara County Sheriff’s Office initiate joint training with all deputies and Wellpath health professionals to foster more efficient sharing of medical information at all major points of contact with the arrestee, including arrest, transport, intake, booking, classification, housing, and follow-up processes.
R1b:
That the Santa Barbara County Sheriff’s Office develop a real-time, commonly accessible database that includes all information at all major points of contact with the arrestee, including arrest, transport, intake, booking, classification, housing, and follow-up processes.
R2:
That the Santa Barbara County Board of Supervisors instruct the Santa Barbara County Community Services Department to form an alliance with all city councils within the County to develop a roster of hotels and motels willing to participate in a Roomkey-type program.
R3:
That the Santa Barbara County Board of Supervisors and all city councils within the County identify possible Homekey sites including government owned properties in each jurisdiction.
R3a:
That the Santa Barbara City Council direct the City of Santa Barbara Community Development Department to issue a report to the Santa Barbara City Council reviewing the status of mitigation measures taken with regard to the food processing operations of the Company at the Location.
R3b:
That the Santa Barbara City Council direct the City Community Development Department to review the documentation and archiving of its zoning and permitting decisions and its manner of communicating with the public, appointed officials, and elected officials with the purpose of making those decisions more complete, clearer, and more accessible to the general public and to City officials at all levels.
R4:
That the Santa Barbara County school districts and the Santa Barbara County Education Office work together to develop a common summative testing program to be adopted for all Santa Barbara County school districts for the 2022-23 school year.
R5:
That Santa Barbara County Schools outline their plans to attain Federal and State grade level standards for math and English language arts.
R6:
That the Santa Barbara County Board of Supervisors direct the Santa Barbara County Public Health, Behavioral Wellness, and Social Services Departments, along with the Santa Barbara County Community Services Department, to explore options for funding for wraparound services.
R6a:
That the Board of Trustees of Allan Hancock College direct the administration to make more effective use of peer-review evaluation practices.
R6b:
That the Board of Trustees of Allan Hancock College commission a new survey of faculty and staff engagement, to be done by an independent external firm, focusing on questions of staff incentives, training, and internal communications with the results of the survey to be discussed in a public forum.
R7:
That the Santa Barbara County Education Office schedule a series of meetings prior to the 2022-23 school year with Santa Barbara County school districts to establish spending guidelines and review budgets’ post-COVID relief funds to ensure that mitigation efforts continue.
R8:
That each Santa Barbara County school district develop plans by the start of the 2022-23 school year to encourage community organizations to continue to provide critical academic and emotional support. 25
R9:
That each Santa Barbara County school district maintain adequate internet services for all students if distance learning or an emergency should again require remote learning.
Hallazgos & Recomendaciones
8 hallazgos
F1:
Ensuring critical cyber security tasks and activities are properly executed on a timely basis requires a designated individual to be accountable and responsible.
Recomendaciones relacionadas (1)
R1:
That each public entity within Santa Barbara County designate an individual to be accountable and responsible to oversee cyber security.
F2:
Most public entities within Santa Barbara County have an inadequate understanding of what communication and electronic systems they use and what data they maintain, and do not fully understand the risks, security issues and costs associated with the destruction of systems or loss of data.
Recomendaciones relacionadas (1)
R2:
That each public entity within Santa Barbara County complete a full inventory of their data, electronic and communication systems and determine the related security risks.
F3:
Some public entities within Santa Barbara County do not have a written cyber security plan.
Recomendaciones relacionadas (1)
R3:
That each public entity within Santa Barbara County establish a written cyber security plan. Wany Zhao and Gregory White, “A collaborative information sharing framework for community cyber security,” published in Homeland Security (HST), 2012 IEEE Conference on Technologies for Homeland Security (HST), November 13-15, 2012
F4:
Nationally, cyber-attacks on governmental organizations have been successful for many years and are occurring with more frequency and sophistication.
Recomendaciones relacionadas (1)
R4:
That each public entity within Santa Barbara County take substantial steps to protect data from internal and external attacks or threats.
F5:
Cyber-attackers use a number of methods to install malicious software on systems including access through backdoors, staff or employee carelessness, and known bugs in software.
Recomendaciones relacionadas (4)
R5a:
That each public entity within Santa Barbara County install and maintain current antivirus software to detect malware and other threats.
R5b:
That each public entity within Santa Barbara County install and update all operating software regularly.
R5c:
That each public entity within Santa Barbara County periodically train employees and then test their cyber security awareness.
R5d:
That each public entity within Santa Barbara County periodically ensure electronic system-related contractors have been trained for cyber security awareness.
F6:
If data is lost or compromised for any reason, including cyber-attack, mechanical failure or error, the most cost effective and expedient way to recover is to have current data backups and a plan to reinstall it.
Recomendaciones relacionadas (2)
R6a:
That each public entity within Santa Barbara County create and implement a full backup and recovery plan.
R6b:
That each public entity within Santa Barbara County regularly update and test their backup and recovery plan.
F7:
Some public entities within Santa Barbara County do not have any, or adequate, cyber insurance.
Recomendaciones relacionadas (1)
R7:
That each public entity within Santa Barbara County secure adequate cyber insurance.
F8:
A cost-effective method to address cyber risks and concerns is to form an information sharing and learning consortium.
Recomendaciones relacionadas (1)
R8:
That each public entity within Santa Barbara County that is unable to allocate adequate funds for cyber security develop a cybersecurity working group to establish best practices and share costs for education, expertise, and insurance.
Hallazgos & Recomendaciones
6 hallazgos
F1:
Eighty-five percent of railroad-related deaths occurring in Santa Barbara County were pedestrian trespasser incidents that occurred in the High Fatality Zone One from Ortega Hill in Summerland to Milpas Street in Santa Barbara and High Fatality Zone Two from Patterson Avenue to Glen Annie Road in Goleta.
F2:
A sealed corridor has been used effectively to enhance railroad safety.
F3:
There is a need for increased security presence to reduce trespassing within the High Fatality Zones, and in other communities this has been achieved through Memoranda of Understanding between Union Pacific Railroad and local law enforcement.
F4:
Fencing along the railroad right-of-way in the High Fatality Zones is inadequate or nonexistent.
F5:
Overgrown foliage and trees provide a natural shelter for homeless encampments.
F6:
Video surveillance cameras provide increased observation of activity by pedestrian trespassers and homeless encampments within the Union Pacific Railroad right-of-way.
Recomendaciones adicionales
7
No vinculadas a hallazgos específicos.
R1:
That the Cities of Santa Barbara and Goleta, the County of Santa Barbara and Santa Barbara County Association of Governments meet regularly with Union Pacific Railroad to create a safety plan to reduce trespasser deaths in High Fatality Zones.
R2:
That the Cities of Santa Barbara and Goleta, the County of Santa Barbara, and Santa Barbara County Association of Governments collaborate with Union Pacific Railroad to develop a sealed corridor from Ortega Hill in Summerland to Glen Annie Road in Goleta.
R3:
That the Santa Barbara County Sheriff and City of Santa Barbara Police Department negotiate Memoranda of Understanding with Union Pacific Railroad to provide enhanced security within their respective High Fatality Zones.
R4:
That the Cities of Santa Barbara and Goleta, the County of Santa Barbara, and Santa Barbara County Association of Governments collaborate with Union Pacific Railroad to repair and install fencing, to prevent easy access to the Union Pacific Railroad right-of-way in the High Fatality Zones.
R5:
That the County of Santa Barbara and the Cities of Santa Barbara and Goleta encourage Union Pacific Railroad to cut back or remove overgrown trees and foliage within the Union Pacific Railroad right-of- way in the High Fatality Zones.
R6a:
That the Cities of Santa Barbara and Goleta, the County of Santa Barbara, and Santa Barbara County Association of Governments encourage Union Pacific Railroad to install and monitor video surveillance cameras on poles every mile within the High Fatality Zone.
R6b:
That County of Santa Barbara and the Cities of Santa Barbara and Goleta, together with Union Pacific Railroad, establish a schedule to monitor the video surveillance cameras between 11 a.m. and 7 p.m.
Hallazgos & Recomendaciones
9 hallazgos
F1:
There are no Crisis Stabilization Units for children and youth in Santa Barbara County as an alternative to out-of-county hospitalizations.
F2:
There are no licensed Temporary Shelter Care Facilities for children and youth in Santa Barbara County as an alternative to out-of-county hospitalizations.
F3:
The crisis call-in phone service and mobile crisis staff of both the contracted provider SAFTY and the Department of Behavioral Wellness’ ACCESS 24/7 Mobile Crisis teams often do not respond to the scene of a crisis or return phone calls in a timely manner.
F4:
The SAFTY mobile crisis workers do not write 5585 holds in a timely manner because they lack authority to do so without first consulting a supervisor.
F5:
The Department of Behavioral Wellness does not keep readily accessible data on the numbers of children on 5585 holds hospitalized out of County, where they are sent, their length of stay in each facility, and the cost of their treatment.
F6:
The Children’s Triage Program staff interacts with children and youth in crisis and their families in the Emergency Rooms and works to ensure community re-integration and linkage to behavioral health services upon discharge from the ER or psychiatric hospitals.
F7:
On-line, comprehensive information on mental health services, community supports and resources for children and youth who are experiencing a crisis in Santa Barbara County is not readily available on a central website.
F8:
Wellpath medical staff and Sheriff custody staff responding to the “man down” announcement was unaware of the location of life-saving resuscitation equipment and that it was not functional.
F9:
The Jail is operating without National Commission on Correctional Heath Care (NCCHC) accreditation, contrary to the contract requirement.
Recomendaciones adicionales
14
No vinculadas a hallazgos específicos.
R1:
That the Board of Supervisors direct the Department of Behavioral Wellness to pursue the establishment of a licensed Crisis Stabilization Unit that can accommodate adults, children and youth in Santa Maria.
R2:
That the Board of Supervisors direct the Department of Behavioral Wellness to explore partnerships with community agencies to sponsor and maintain licensed Temporary Shelter Care Facilities for children and youth in Santa Barbara County.
R3:
That the Sheriff require the current contract health care provider, Wellpath, to assure that its staff adhere to all policies, procedures, and contractual obligations regarding the assessment of the medical/mental health status of arrestees upon their arrival at the Jail.
R3a:
That the Board of Supervisors direct the Department of Behavioral Wellness to establish and implement measurable response times, and to track and evaluate the efficacy of their crisis response services.
R3b:
That the Board of Supervisors direct the Department of Behavioral Wellness to require its contracted partner SAFTY to respond in the field for face-to-face evaluations more quickly and frequently.
R4:
That the Board of Supervisors direct the Department of Behavioral Wellness to require the crisis response staff of their contracted partner, SAFTY, to receive more training to acquire the authority to write 5585 holds independently and in a timely manner.
R5:
That the Board of Supervisors direct the Department of Behavioral Wellness to design and implement a computerized record of the 5585 holds that are written, where the children are hospitalized out of County, their length of stay in each facility, and the cost of their treatment.
R6:
That the Sheriff require custody staff to receive continued training regarding policies and procedures to be followed in a “man down” situation, particularly to assure proper management and control of the scene and to release personnel no longer needed there.
R6a:
That the Board of Supervisors direct the Department of Behavioral Wellness to evaluate the efficacy of the new Crisis Triage Program by keeping statistics on the number of children served and process outcomes.
R6b:
That the Board of Supervisors direct the Department of Behavioral Wellness to continue to pursue the full implementation of the Children’s Triage Program in South County.
R6c:
That the Board of Supervisors direct the Department of Behavioral Wellness to integrate the funding of the Children’s Triage Program into the Department of Behavioral Wellness budget on an ongoing basis.
R7:
That the Board of Supervisors direct the Department of Behavioral Wellness to design, post and keep current an on-line dashboard that provides comprehensive contact information on mental health services and community resources for children and youth in all geographic areas of Santa Barbara County, and publicize this resource to the community at large.
R8:
That the Sheriff require Wellpath to inspect, repair and replace emergency life-saving equipment on a regular schedule; maintain a service log; and train custody staff regarding the location of life-saving equipment.
R9:
That the Board of Supervisors closely examine the provisions of the existing medical provider contract and enforce all of the current provider’s obligations, especially with regard to the continuing failure to obtain National Commission on Correctional Heath Care (NCCHC) accreditation for the Jail.
Hallazgos & Recomendaciones
8 hallazgos
F1:
B1 was accepted into the Main Jail despite his potentially life-threatening condition and inability to walk.
Recomendaciones relacionadas (1)
R1:
That the Santa Barbara County Sheriff enforce the policy regarding not admitting inmates to the Main Jail with life threatening medical conditions.
F2:
When the on-call physician was unable to be reached on April 12, 2019, at 2:30 p.m., the inmate was not transferred to the local hospital emergency room.
Recomendaciones relacionadas (1)
R2:
That the Santa Barbara County Sheriff require all medical staff be instructed to transfer inmates to the local hospital emergency room when there is an emergency that is a life threatening or serious injury or illness and the on-call physician does not respond.
F3:
When the blood sugar level was determined to be 587mg/dl at 5:00 p.m., and the on-call physician did not respond, the inmate was not sent to the emergency room.
Recomendaciones relacionadas (1)
R3:
That the Santa Barbara County Sheriff ensure that medical staff follow policy and procedures when the on-call physician does not respond.
F4:
When Wellpath personnel responded to a man down emergency, they did not bring an emergency kit to the scene.
Recomendaciones relacionadas (1)
R4:
That the Santa Barbara County Sheriff ensure that Wellpath personnel bring an emergency kit whenever they respond to a man down notification. 3.0 C1 Death in Custody June 25, 2019 C1 was arrested and booked at the Santa Barbara County Main Jail on April 10, 2018. C1 remained in custody and unsentenced while his court date was continued 25 times. The Jury questioned why C1 was held 14 months awaiting trial. The 6th amendment of the United States Constitution guarantees a speedy trial and California Penal Code Section 1382 dictates that unless waived a person charged with a felony be brought to trial within 60 days. The date of arrest on both the Sheriff’s letter to the Jury and the Coroner’s report incorrectly state 2019, giving the false impression that his incarceration was two months rather than fourteen months. C1 had a decades-long history of prior arrests, detention, and mental health issues with suicidal ideations. C1 was evaluated by a Wellpath psychiatrist in August of 2018, diagnosed with schizophrenia, and prescribed antipsychotic medications. Within five days, C1 was noncompliant and stopped taking prescribed medications, and there was no follow-up. A January 2019 assault at the Main Jail resulted in orbital and nasal fractures. It was reported to the custody deputies on June 25, 2019, that C1 was accused by fellow inmates of being a child molester, which he denied. On the same day at approximately 1:00 p.m., C1 was removed from his cell by a custody deputy after arguments among inmates. He was handcuffed, removed from his housing unit and displayed combative behavior toward a neighboring inmate. He was placed in the temporary cell Front Central C-14 at 1:11 p.m. The handcuffs were removed. The video provided to the Jury shows C1 began pacing in the cell. C1 requested to be assigned to a cell alone for permanent placement. C1 was advised Wellpath mental health (MH) would be contacted to meet with him prior to rehousing. The Custody Deputy stated he contacted MH and informed the clinician of his conversation with C1. Later that day at 1:34 p.m., C1 asked a MH clinician walking by his cell for help with housing and stated he would kill himself if he did not get a cell alone. At the end of their conversation, C1 denied any suicidal or homicidal intention. The same MH clinician determined C1 was not a danger to himself. This MH clinician, the last person to speak with C1 minutes prior to his hanging, stated in an interview that they are not required to inform a supervisor or custody personnel upon hearing a patient make a suicidal statement. Shortly thereafter, at 1:51 p.m., C1 took off his T-shirt and is shown on video experimenting by tying it at varying heights on the bars of his cell. At 1:59 p.m. C1 was standing normally in his cell, with the T-shirt tied to the bar, as a Custody Deputy walked by. At 2:01 p.m., C1 secured the T-shirt, tied at chest height, around his neck. At 2:13 p.m., C1 was discovered hanging by a Custody Deputy. He was cut down and life-saving measures were initiated. No carotid pulse or vital signs were detected. CPR was administered and the AED indicated no shock was needed, as a pulse was detected. AMR and Fire Department personnel arrived at approximately 2:23 p.m., and C1 was removed at 2:30 p.m. on a backboard and taken to Cottage Hospital. On June 30, 2019, C1 was removed from life-support equipment at Cottage Hospital with his family at his bedside. In its investigation the Jury discovered that 28 of 48 interviews regarding C1’s hanging in his cell omitted the date and time the witness was interviewed. Some interviews occurred in September, more than two months after the event.
F5:
An inmate suicide threat was not reported to a supervisor.
Recomendaciones relacionadas (1)
R5:
That the Santa Barbara County Sheriff ensure that all detention facility personnel inform their supervisor of any threats of suicide.
F6:
C1’s mental illness was not reevaluated for the ten months prior to his suicide.
Recomendaciones relacionadas (1)
R6:
That Santa Barbara County Board of Supervisors provide psychiatric services to better serve mentally ill inmates in detention. 4.0 D1 Death in Custody October 31, 2019 D1 was arrested on October 19, 2019 by the Lompoc Police Department on a violation of felony probation charge. On October 20, 2019 D1 was booked into the Main Jail and the medical intake screening was completed. D1 claimed to be suffering from mood disorders, anxiety and Post Traumatic Stress Disorder (PTSD), but claimed no drug or alcohol use. The records provided to the Jury did not show whether his previous booking records were reviewed. A thorough review of prior booking assessments would have revealed a history of drug use and suicidal ideations. An initial mental health assessment was attempted, but D1 refused services and no referral to a psychiatrist was made. D1 complained of withdrawal symptoms to the custody staff on October 23, 2019. The Jury learned custody staff later referred him to the medical staff where he was assessed and placed on a Benzodiazepine protocol. Later, he refused monitoring and appropriate medications. On October 23, 2019, D1 attempted to exit the facility by attempting multiple times to walk past Custody Deputies as they were serving meals. He was medically evaluated and cleared. He was then rehoused to cell IRC100-113 which contained a wall phone that had a long cord to the receiver. D1 was referred to Mental Health for evaluation because of demonstrated bizarre behavior. He was not seen that day and placed on “welfare check” for the next day by Mental Health. On October 31, 2019 at approximately 11:15 a.m., D1 committed suicide in his cell by wrapping a phone cord around his neck and dropping his feet out from under his body. When D1 was discovered, a custody deputy placed the pads from an AED device on D1’s chest. An RN arrived and checked for breathing and pulse and found none. CPR was then administered by several deputies, pausing only to allow the AED to check the patient. The deputies reported that the AED never gave the order to administer a shock. At 11:28 a.m., medics from the Santa Barbara County Fire Department arrived and took over CPR. At 11:50 a.m., D1 was pronounced dead. The required Responder Defibrillator Report was not found in the files provided to the Jury. In addition, during the incident one of the medical staff heard a Code 33 on the radio, thus knowing that this was an emergency but not knowing what type of emergency.
F7:
The radio call of Code 33 did not identify the nature of the emergency.
Recomendaciones relacionadas (1)
R7:
That the Santa Barbara County Sheriff direct all radio calls for medical emergencies be in plain language, including details of the symptoms encountered such as suicide by hanging, bleeding wounds, suspected overdose, etc.
F8:
The required Responder Defibrillator (AED) Report was not found in the files provided to the Jury.
Recomendaciones relacionadas (1)
R8:
That the Santa Barbara County Sheriff ensure that Wellpath test all AEDs monthly and after each use and keep logs of the dates of these checks.