Santa Barbara County Grand Jury
2023-2024
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 (8)
Findings & Recommendations
1 findings
F1:
The Jury finds that increased implementation of the 5150 holds by trained law enforcement officers and more Behavioral Wellness clinicians would benefit all citizens of Santa Barbara County.
Related Recommendations (2)
R1a:
The Jury recommends that the Board of Supervisors direct Behavioral Wellness to increase the number of clinicians available for Co-Response Teams.
R1b:
The Jury recommends that all County and City law enforcement officers who are trained in crisis intervention, in accordance with State guidelines, be encouraged to fully exercise the issuance of 5150 holds in appropriate circumstances.
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Findings & Recommendations
7 findings
F1:
Use of a team approach has made engagement with community services more acceptable to those who live in encampments.
F2:
The negative effects of encampment sweeps can be mitigated when a variety of community resources are present at the time of the clean-up.
Related Recommendations (1)
R2:
The County and the cities shall ensure that all sweeps occur utilizing a multi-disciplinary approach.
F3:
Encampments lack basic sanitation services.
Related Recommendations (1)
R3:
The County and the cities shall make trash cans, porta-potties, resources for handwashing, and sharps containers for safe disposal of needles and other hazardous waste available near encampment sites.
F4:
Encampment residents are reluctant to transition to housing with strict rules of conduct.
Related Recommendations (1)
R4:
The County shall encourage the creation of more units that continue the Housing First model, providing a home first, and offering supportive services as the individual learns to cope in socially accepted ways.
F5:
State funding for helping people without housing is becoming less available.
Related Recommendations (1)
R5:
The Board of Supervisors shall instruct the County Community Services Department to work with community partners in addition to Continuum of Care members to pursue funding opportunities beyond those coming from the State or the encampment resolution.
F6:
Most state encampment funding cannot be applied to environmental restoration.
Related Recommendations (1)
R6:
The Board of Supervisors shall instruct the Community Services Department to invite environmental non-profits into its multi-disciplinary teams.
F7:
When heavy rain is forecast and materializes, the persons in encampments along creeks and riverbeds are at high risk for loss of life, personal property, and living quarters.
Related Recommendations (2)
R7a:
The Santa Barbara County Sheriff's Office and the Office of Emergency Management, using mapping technology, shall continue to refine and share comprehensive locations of encampment sites among all concerned agencies.
R7b:
The Santa Barbara County Sheriff's Office and the Office of Emergency Management shall develop and formalize a multi-modal warning system to relocate persons when there are looming credible threats.
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Findings & Recommendations
14 findings
F1:
Being placed in a prone position while restrained contributed to JG’s death.
Related Recommendations (1)
R1:
The Sheriff’s Office should review and reevaluate the use of prone restraint position with obese individuals.
F2:
The arresting officers failed to inform the intake staff that JG had complained of back and chest pain. This lack of communication was a missed opportunity to ascertain whether JG needed timely and appropriate medical care.
Related Recommendations (1)
R2:
The Grand Jury recommends that the Sheriff's Office implement a mandatory communication protocol between arresting officers and jail medical intake staff. This protocol should ensure that arresting officers consistently relay all potentially relevant medical information to intake nurses, including any complaints of pain or existing medical conditions.
F3:
Custody Deputies removed JG from the medical intake screening process before it was completed. The failure to prioritize JG's medical needs at intake raises serious concerns about the potential for harm to individuals in custody.
Related Recommendations (2)
R3a:
The Grand Jury recommends that custody and medical staff develop improved communication protocols. This collaboration should ensure that medical intake screenings are consistently completed before individuals are removed from the process.
R3b:
The Grand Jury recommends revising the medical screening questionnaire to prioritize the most critical information. Specifically, a question like "Are you currently experiencing any pain or are you suffering from an acute condition?" should be placed as the first question on the questionnaire. This simple change could ensure that individuals with immediate medical needs are identified and addressed promptly.
F4:
LR's physical injuries and cognitive abilities worsened during his three days of incarceration at the Main Jail. An admitted alcoholic, he was not treated for alcohol withdrawal symptoms when examined by mental health or medical personnel.
Related Recommendations (1)
R4:
Any incarcerated person who has admitted to prolonged and excessive alcohol consumption and begins exhibiting symptoms consistent with alcohol withdrawal must immediately be treated in a manner to reduce symptoms and monitored for continued physical and/or cognitive degradation.
F5:
When the Public Health Medical Advisor position has been filled, this medical professional will be working with Wellpath staff at the jails.
Related Recommendations (1)
R5:
The Public Health Medical Advisor shall help oversee and advise treatment for medically compromised individuals entering the jails, especially during the critical first week of incarceration.
F6:
RU and DL suffered from drug addiction and died within two days of entering the jails.
Related Recommendations (3)
R6a:
The Sheriff’s Office should contract with Behavioral Wellness for a number of beds in the recently reopened Crisis Stabilization Unit next to the Main Jail, where arrestees can be consistently monitored.
R6b:
The Sheriff’s Office shall direct medical staff at the Northern Branch Jail to hold a number of beds in the medical unit for those arrestees entering the jail who exhibit withdrawal symptoms.
R6c:
The Sheriff’s Office shall work with Public Health and Behavioral Wellness to increase staffing of the Medically Assisted Treatment program at both jails.
F7:
SP spent over 12 hours confined in a safety cell without a mental health evaluation being conducted by a C.A.R.E.S. Mobile Crisis Unit during that time.
Related Recommendations (2)
R7a:
To comply with its current policy, the Sheriff's Office should review and revise its protocols to ensure that timely mental health evaluations are conducted by a C.A.R.E.S. Mobile Crisis Unit for individuals retained in safety cells over the initial 12-hour limit.
R7b:
The Jury recommends that all procedures that are mandated by policy to be performed prior to the removal of an occupant from a safety or observation cell be incorporated as a checklist into the posted observation logs. A custody supervisor shall review the observation logs together with the checklist to ensure that each required step has been completed and upon such verification, the custody supervisor’s signature releases the occupant.
F8:
There was a failure to initiate a collaborative safety plan with SP prior to his release from the mental health observation cell which is intended to provide support and decrease the chance of self-harm during a critical period of time.
Related Recommendations (2)
R8a:
The Sheriff’s Office shall ensure that the procedures outlined within its policy and its contract with Wellpath be completed prior to the removal of an occupant from a safety or observation cell.
R8b:
The Jury recommends that all procedures that are mandated by policy to be performed prior to the removal of an occupant from a safety or observation cell be incorporated as a checklist into the posted observation logs. A custody supervisor shall review the observation logs together with the checklist to ensure that each required step has been completed and upon such verification, the custody supervisor’s signature releases the occupant.
F9:
Ongoing renovations and upgrades within the IRC 300 housing unit had resulted in the in-cell intercom system, certain video surveillance systems, and the electronic locking mechanisms being non-operational at the time of SP’s death, causing delayed response times by custody and medical staff.
Related Recommendations (1)
R9:
The Sheriff’s Office should develop and implement more effective alternatives for visually monitoring incarcerated individuals and enabling emergency communication when the electronic surveillance and intercom systems are not functioning properly, including relocating incarcerated persons to other holding locations within the County jail system, increasing the frequency and duration of in-person safety checks and cell inspections by custody staff when electronic monitoring is unavailable, and stationing custody personnel within the housing unit to enhance direct supervision.
F10:
There were only 11 Custody Deputies on shift at the time of SPs’ death. The level of safety inside jail facilities is directly affected by the number of Custody Deputies on duty. If more than one critical incident were to occur at the same time, it could be extremely difficult to manage.
Related Recommendations (1)
R10:
The Sheriff’s Office shall review its minimum staffing levels in the jail facilities.
F11:
SP, who had clearly expressed an intention to harm himself in any way that he could, was nonetheless placed in a cell located in a two-level housing unit, which provided SP with easy access and the means to jump to his death from the second level of the unit.
Related Recommendations (2)
R11a:
The Grand Jury recommends that the Santa Barbara County Sheriff’s Office immediately review and revise its incarcerated housing and classification placement protocols. Going forward, the Sheriff’s Office must ensure that individuals who have made suicidal statements or exhibit a desire to harm themselves are never assigned to cells or housing units that offer ready access to methods of self-harm such as elevated areas from which an incarcerated individual could jump.
R11b:
To help mitigate the risk of incarcerated persons jumping or falling from elevated housing areas, the Grand Jury recommends that the Sheriff’s Office explore the feasibility of installing physical barriers, such as safety netting or higher railings, in those locations.
F12:
The Public Defender’s Office currently conducts an entry interview to establish a connection with newly incarcerated persons booked into the Northern Branch Jail, which continues until the incarcerated persons are discharged.
Related Recommendations (1)
R12:
The Sheriff’s Office shall work with the Public Defender’s Office to initiate a similar program at the Main Jail.
F13:
The Grand Jury investigations of deaths in custody rely heavily on information provided by the Santa Barbara County Sheriff’s Office. Completion of the investigations was impeded greatly by a lack of timely cooperation by the Sheriff’s Office.
Related Recommendations (1)
R13:
The Sheriff’s Office shall promptly provide information to the Grand Jury.
F14:
Five of the six deaths in this report occurred within the first three days of entering the jail. The main factors for jail deaths involved issues of inconsistent and inadequate observation.
Related Recommendations (1)
R14:
The Sheriff’s Office, working in conjunction with Wellpath, Behavioral Wellness and Public Health, shall have procedures in place to more closely monitor at-risk incarcerated persons when they enter the jails.
Findings & Recommendations
3 findings
F1:
The new Cuyama Sheriff’s Substation / Holding Facility cell is unable to get certified due to an incorrect installation of the cell door.
Related Recommendations (1)
R1:
The Sheriff's Office should request the repair of the cell door so it will meet the certification standard.
F2:
The Santa Barbara Superior Court Figueroa Building holding facility’s metal cells in the entrance hallway are used only when overflow conditions require it.
Related Recommendations (1)
R2:
The Sheriff's Office should remove the metal cells.
F3:
The Santa Barbara Superior Court Figueroa Building holding facility’s air quality in the basement facility is poor.
Related Recommendations (1)
R3:
The Sheriff's Office should request a complete overhaul of the air circulation system in the basement facility. Elected Official: Santa Barbara County Sheriff - 60 Days
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Findings & Recommendations
4 findings
F1:
The buildings that the Coroner Bureau occupies are dangerous to the health and safety of the Coroner Bureau staff; they present an ongoing health hazard to everyone who works there.
Related Recommendations (5)
R1a:
The Jury recommends the installation of new roofing, including the replacement of accompanying support beams as needed, by a licensed roofing contractor, and not by handyman employees or janitorial staff from the Sheriff’s Office or General Services. Repairs shall be completed by the end of the third quarter of calendar year 2024 or sooner.
R1b:
The Jury recommends a licensed professional mold abatement contractor be hired to assess whether there is active mold and, as necessary, conduct all required eradication efforts. Repairs shall be completed by the end of the third quarter of calendar year 2024 or sooner.
R1c:
The Jury recommends a licensed professional exterminator be hired to assess whether there is active termite infestation and, as necessary, tent both structures. Additionally, the exterminator must perform all required sectional work to repair or replace all the termite-damaged areas. Repairs shall be completed by the end of the third quarter of calendar year 2024 or sooner.
R1d:
The Jury recommends the installation of a state-of-the-art ventilation system in the front autopsy building. This shall be completed by the end of calendar year 2025.
R1e:
The Jury recommends the entire Coroner’s facility shall be demolished and rebuilt. The Sheriff’s Office shall request, and the Board of Supervisors shall allocate, funding to implement a design and a timeline to replace this antiquated facility with one that ensures the safety of its employees and visitors by the end of calendar year 2024.
F2:
There have been no independent safety or health inspections or audits conducted at the Coroner’s facility.
Related Recommendations (2)
R2a:
An inspection of the Coroner’s facility by OSHA or Cal-OSHA, whoever is available first, shall be requested immediately. 9
R2b:
In the event that neither OSHA nor Cal-OSHA are available within 60 days, the SB County Public Health Department shall contract with an independent, accredited entity to conduct an inspection.
F3:
It will be beneficial to conduct parallel testing to confirm that the new rapid toxicology equipment on order is calibrated accurately and produces accurate results.
Related Recommendations (1)
R3:
The Coroner Bureau shall conduct parallel toxicology testing for a minimum of 6 months based on the success of the model used by the Riverside County Coroner's office.
F4:
The Facilities Maintenance Division of General Services does not have a Safety Officer.
Related Recommendations (3)
R4a:
General Services shall develop a job description for a General Services Safety Officer and identify or recruit an individual to function as the Safety Officer.
R4b:
The Safety Officer will conduct annual, at a minimum, safety inspections of the Coroner Bureau’s facility.
R4c:
The Safety Officer shall generate reports of their findings to the Board of Supervisors. Requirements for Responses: Pursuant to California Penal Code §933 and §933.05, the Grand Jury requests each entity or individual named below to respond to the Findings and Recommendations within the specified statutory time limit. Elected Official: Santa Barbara County Sheriff/Coroner - 60 Days
Findings & Recommendations
2 findings
F1:
The Santa Barbara County Grand Jury per diem of $25 has not increased in more than 25 years.
Related Recommendations (1)
R1:
The Board of Supervisors should increase the Santa Barbara County Grand Jury per diem to $50, effective January 1, 2025.
F2:
The second highest budgeted cost associated with the Grand Jury is mileage reimbursement. Most of this cost is associated with Jury members who commute from North County because dedicated space and equipment are only available in Santa Barbara.
Related Recommendations (2)
R2a:
The Board of Supervisors in conjunction with the Superior Court will make available for the sole use of the Grand Jury for a minimum of one day per week a room in Santa Maria with the capacity to support 19 members of the Grand Jury with equivalent communication, printing, photocopy, kitchenette, restroom access, and parking capabilities as is available in the Santa Barbara County Courthouse facility.
R2b:
The Board of Supervisors in conjunction with the Superior Court will make available for three to four (3-4) days per week a room in Santa Maria with video conferencing capabilities, access to restrooms, adequate parking and the capacity to support up to 10 members of the Grand Jury for ad hoc use. Requirements for Responses: Pursuant to California Penal Code §933 and §933.05, the Grand Jury requests each entity or individual named below to respond to the Findings and Recommendations within the specified statutory time limit. Elected Official: Santa Barbara County Board of Supervisors – 90 Days
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Findings & Recommendations
6 findings
F1:
Lompoc City Council has not directed Visit Lompoc to request, conduct, or complete an independent audit of its Annual Reports.
Related Recommendations (2)
R1a:
Lompoc City Council shall instruct Visit Lompoc to have an independent audit performed of their Annual Reports and present the findings to the Council no later than mid- 2024.
R1b:
Visit Lompoc shall use excess funds under its control to fund this audit.
F2:
Lompoc City Council has not directed Visit Lompoc to request, conduct, or complete an independent audit of its Financial Statements.
Related Recommendations (2)
R2a:
Lompoc City Council shall instruct Visit Lompoc to have an independent audit performed of their financial records and present the findings to the Council no later than mid- 2024.
R2b:
Visit Lompoc shall use excess funds under its control to fund this audit.
F3:
For the time period 2018 through 2022 the analysis conducted by Lompoc and Visit Lompoc’s accountants of the Visit Lompoc’s financial records confirmed the >$500,000 discrepancy in unspent funds versus reported carryover values.
Related Recommendations (1)
R3:
Lompoc City Council shall address the accounting discrepancies by amending the Agreement and holding Visit Lompoc accountable for reporting all funds (including any excess) or mandating that all excess funds (less an approved contingency amount) be utilized for purposes related to enhancing tourism.
F4:
Lompoc does not have an adequate system of checks and balances to confirm that Visit Lompoc’s accounting methods are accurate and complete.
Related Recommendations (1)
R4:
Lompoc City Council shall formally establish a review process to ensure there is no inaccurate or incomplete reporting on behalf of Visit Lompoc before the submittal of the 2024 annual report.
F5:
Other than the reference in the Agreement to the Resolution and District Management Plan there are no specific guidelines concerning how Visit Lompoc LLC shall expend its funds.
Related Recommendations (3)
R5a:
By the end of 2024, Lompoc City Council shall re-evaluate the terms of the Agreement to ascertain whether the 3% fee assessed on hotel customers is achieving its intended objectives.
R5b:
By the end of 2024, Lompoc City Council shall determine whether it should have a greater ability to direct unused funds for tourism enhancement projects.
R5c:
By the end of 2024, Lompoc City Council and Visit Lompoc shall create a joint ad hoc committee potentially including private citizens and other business owners within Lompoc to develop and implement projects utilizing excess funds to further enhance tourism in Lompoc.
F6:
The Annual Reports submitted by Visit Lompoc to the City of Lompoc did not include all amounts that should be publicly disclosed.
Related Recommendations (1)
R6:
Lompoc City Council shall mandate Visit Lompoc to account for all Lompoc-provided funds under its control via its required annual reports beginning with the submittal of the 2024 annual report (i.e.; zero-based budgeting methodology).
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