Santa Cruz County 2007-2008 - California Grand Jury Reports

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F1: Conclusions 2. Since the most pressing concern today is from where the money will come to maintain Medicare and Medicaid services for those who qualify under today’s system, extending it to include low-income families is not being discussed. 3. Santa Cruz County public, non-profit, and for-profit medical resources have worked together to make health care more accessible to low-income families. Commendation 1. The Human Services Department and the Health Services Agency are to be commended for ongoing focus on the delivery of adequate health care services to Santa Cruz County residents. Health Insurance Coverage 2000-2001 Grand Jury Recommendation 3: The Healthy Families Program should include parents in its coverage. Premiums should be set at more affordable levels in order to accelerate enrollment of families without insurance. Coverage should be maintained during short periods of seasonal unemployment. The Central Coast Alliance for Health should approach local employers to continue premium payments for families during short periods of seasonal unemployment to keep insurance coverage from lapsing. It should continue to expand the participation of specialists in its programs. County Response: This recommendation has been implemented. 2007-2008 Grand Jury Findings 12. The Healthy Families Program does not include parents in its coverage. Healthy Families insurance premiums vary depending on the health plan selected. Families receive a discounted premium if they select the local Community Provider Plan, which is the Central Coast Alliance for Health (the Alliance) in Santa Cruz County. The Alliance’s maximum monthly premium for a family with three or more children is $36 (or $108 per quarter). 13. Recent local funding contributions to the Healthy Kids program, which came primarily from Sutter Santa Cruz and Dominican Hospital, will allow the Alliance to move 295 children off the waiting list and into enrollment. 14. Seasonal unemployment only affects the eligibility of adults in a family receiving Medi-Cal. The Alliance reports that their Medi-Cal membership fluctuates by about five percent each year according to the growing season and migration of Medi-Cal recipients out of the area. Typically, a seasonal employee becomes eligible for Medi- Cal when the work season ends or slows down because the worker’s income A Promise Kept 29 decreases. When an individual’s work hours increase again, Medi-Cal eligibility could be lost due to the corresponding increase in income. Thus, an individual may qualify during periods of little work or unemployment but no longer qualify for Medi- Cal when working full-time. 15. Medi-Cal has no provision for continued eligibility if an adult no longer meets the criteria. However, children can maintain Medi-Cal eligibility for 12 months even if the adults in the family are terminated due to an increase in income or assets. 16. Although families pay no premiums for the Medi-Cal program, there are premiums associated with the Healthy Families and Healthy Kids programs. However, regardless of changes in family income, once a child is deemed eligible for Healthy Families or Healthy Kids, that child remains eligible for 12 months unless he or she becomes eligible for no-cost Medi-Cal, is covered by other health insurance, or turns 19. Children also lose Healthy Kids eligibility and coverage when they move out of Santa Cruz County. 17. In 2000, the Santa Cruz County population was 255,602. In 2007, the population increased slightly to an estimated 264,125 (3.3 percent). But the supply of health care specialists for Alliance programs has increased by almost 30 percent since that year. In 2000, the Alliance had an average of 499 specialists available to serve Santa Cruz County residents. As of March 2008, 697 specialists are available. 18. The Alliance collaborates with over 60 community coalitions and organizations to promote its programs, including the Santa Cruz County Human Services Department. It also promotes health care resources to the public at events, such as farmers’ markets, health fairs, community block parties, and other festivals. In addition, the Alliance publishes a provider bulletin in which providers are urged to encourage their Healthy Families and Healthy Kids patients to stay enrolled and thereby continue their health care coverage. 19. In March 2008, at California’s annual Medi-Cal Quality Conference, Central Coast Alliance for Health tied for first place with Health Plan of San Francisco, winning the Gold Award for the highest rate of preventive care services among all 39 Medi-Cal health plans in California. The Alliance also won a second place Silver Award for member satisfaction. Conclusions 4. Because Healthy Families is a state and federally funded health plan, Santa Cruz County cannot change the eligibility requirements for the program. 5. The 2000-2001 report recommended, “Coverage should be maintained during short periods of seasonal unemployment.” But, in fact, qualifying seasonal workers are covered while unemployed. They risk losing coverage when employed because their income may exceed guidelines. That issue has not been addressed by Medi-Cal or any county agency. 6. A public/private partnership exists in the county to provide affordable access to health care for low-income individuals and families. A Promise Kept

F2: County code violations do not always result in enforcement action. • The Planning Department documents some violations but does not enforce them, for example, violations of residential property fence height limits. Response from the County: PARTIALLY AGREES. In certain, limited situations such as side or rear yard fences that are slightly over the maximum height, no enforcement action is taken due to workload/caseload issues. Enforcement action for other minor violations may be limited to the issuance of a Notice of Violation (Red-tag) and recordation of the Notice of Violation on the property title. The Notice of Violation must be addressed when the property is sold or refinanced or when a permit is required for something else. • Some enforcement decisions are based upon Board of Supervisors’ policy, such as the 2002 board policy specifying that structures built pre-1980 without permit will not be subject to enforcement. Response from the County: PARTIALLY AGREES. This policy directive is followed, but pertains solely to non-habitable structures. • “No enforcement” is one complaint classification category in HANSEN®. Between March 29, 2007, and February 7, 2008, 11 percent of “no enforcement” decisions were based on policy adopted by the board; the remaining 89 percent were decided within the Planning Department without clear policy guidelines. Response from the County: DISAGREES. A portion of these “no enforcement” designations were open Service Requests (complaints) that had not yet been resolved. The Code Compliance staff initially selected “no enforcement” in the Hansen system for complaints that did not immediately result in the issuance of a Notice of Violation. It is common for a Code Compliance Investigator to conduct a site inspection and need to perform additional review of office records before determining whether, in fact, a violation exists. The remainder of the Service Requests referred to were actually resolved, with no further action, using the “no enforcement” designation. During the deliberations that ultimately led to adoption of the policy regarding structures built without permits prior to 1980, the Planning Department informed the Board that there is a category of violations that are so minor that no enforcement action on the part of the County is warranted. Planning Department management staff is involved in the decision-making process for each of the Service Requests that result in resolution using the “no enforcement action” coding. Examples of these determinations include side or rear yard fences that are a few inches over height, or a minor setback encroachment of a deck that would not otherwise require a Building Permit. Code Compliance Enforcement 3

F3: There is no formal policy requiring county building inspectors or code compliance investigators to report code violations they might chance upon. • The City of Watsonville requires home maintenance compliance, and its inspectors report violations they happen to see. • The City of Santa Cruz expects its staff to report obvious violations it encounters as a matter of policy. Response from the County: DISAGREES. The Planning Department Procedures Manual contains a Section related to the reporting of code violations by staff. That procedure, established in 2006, requires that certain types of violations be reported to the Code Compliance Section if encountered by any departmental employee during the course of their work. These include obvious and serious health and/or safety violations, significant environmental violations, and construction in-progress. The procedure contains specific definitions to provide further guidance to staff related to filing a code compliance complaint.

F4: After a party files a complaint and receives an initial acknowledgement letter, the complainant is responsible for future contact with the Planning Department to determine the status of the violation.

F5: It appears to be technically feasible to access the public information contained in the code violation database and there is a plan to implement public online INCOMING COMPLAINTS (by type) access before the end of 2009. 50.0% Currently, members of the public wishing to learn the status of a code violation must telephone or visit the 40.0% Planning Department. Response from the County: AGREES. 30.0%

F6: The code compliance staff fields roughly 750 incoming complaints 20.0% annually. About 300 of the complaints require continuing 10.0% extensive investigation and action. These represent approximately 40 percent of the total; the other 60 0.0% BUILDING ZONING VIOLATIONS ENVIRONMENTAL REFERRALS percent are either found to be invalid VIOLATIONS VIOLATIONS or are referred to another agency for appropriate action.

F7: Each of the four full-time and one half-time code compliance investigators averages 66 new complaint investigations per year (not including those classified as “no violation,” “no enforcement action,” or “referred to other agency”), or fewer than two each week.

F8: The code compliance group has positions for one typist/clerk, one planning technician, five code compliance investigators, and a principal planner. Additional assistance may also be provided by county financial and legal staff. Code Compliance Enforcement

F9: Earlier this year one investigator worked half time assisting the Planning Department’s understaffed fiscal section.

F10: One additional investigator position has been funded but will not be filled during 2008; funding for this position for 2009 is not guaranteed.

F11: Staff responsible for data entry works part time performing Planning Department receptionist duties.

F12: To help reduce the overall workload, follow-up with complainants is generally limited to a single written acknowledgment that the complaint has been received. Also the Planning Department does not take any enforcement action against some low-priority violations or investigate anonymous complaints. Response from the County: PARTIALLY AGREES. In addition to the written acknowledgment of the complaint, code enforcement staff frequently answer questions from complainants about the status of a case throughout the enforcement process. In addition, our Compliance-by-Mail Program requires the original complainant to verify that a violation has been in fact been resolved following receipt of a declaration from the property owner stating that the violation has been corrected. Planning staff makes contact with the complainant to verify resolution. Staff is also investigating whether it will be possible, within the Hansen system, to allow complainants to access the status of their code complaints on-line.

F13: Compliance-by-mail form letters are sent to violators asking for voluntary cooperation in correcting some low-priority violations. Violators comply by returning a signed Declaration and Affidavit of Correction. Investigators may subsequently perform an inspection to confirm compliance. Violations currently handled this way include illegally inhabited mobile homes or campers, or people keeping too many cats or dogs. Compliance-by-mail was used in two percent of the complaints reviewed by the Grand Jury.

F14: Despite two requests, the Grand Jury was not provided with precise data describing the size of the backlog of unresolved code compliance complaints or the rate at which this backlog is growing. One estimate provided was that for every 100 complaints entering the system 80 were being resolved, leaving 20 to accrue to the existing backlog. Based on this estimate and the annual number of complaints, the backlog of unresolved complaints would grow by about 150 a year. Response from the County: DISAGREES. We believe that the Department has now provided all information requested by the Grand Jury related to their investigation. There was an initial misunderstanding as to whether such a request was related to code compliance cases that reside in the older, ALUS system or in Hansen. Information on this topic of the backlog does exist for both systems and has since been provided to the Grand Jury. There has been a dramatic reduction in the number of unresolved cases since the beginning of 2008 due, in large part, to the audit of the department’s records related to the transition to the Hansen system. In addition, the department has implemented a systematic strategy for addressing the backlog and is confident that further reductions will occur. Code Compliance Enforcement 5

F15: There are many rules built into the current code violation resolution system that allow violators to delay complying with code requirements. Examples: • It may take six weeks or more to get on the calendar for a protest hearing. • Once the hearing is scheduled, the violator has the right to delay the hearing once. • During the hearing, a violator may request a continuance, which the judge will usually grant.

F16: In 2003, the Planning Department committed to the Board of Supervisors to develop written procedures for using the HANSEN® system. The code compliance group has established process mileposts and created a detailed flow chart, but there is no employee procedures manual for handling complaints. Response from the County: DISAGREES. The Grand Jury was provided with a high level summary page that represents the milestone flow within the Code Violation case type. This summary page was excerpted from a detailed user’s manual that guides users through each milestone of a code case, from intake to completion. This manual, over 120 pages in length, was developed in July of 2007 and was distributed to each of the Code Compliance staff to assist them in their transition to using the Hansen system.

F17: Except for a single summary report, the HANSEN® system was not generating data management reports as of March 1, 2008.

F18: The Planning Department has requested at least 12 data management reports. As of April 11, 2008, only six of the reports originally requested the previous December were completed. Response from the County: PARTIALLY AGREES. Initially, the development of management and other system reports was a joint undertaking by the Planning Department and the County Information Services Department. However, after several months, it became clear that the development of these reports required a stronger technical background, and the Information Services Department took the lead in getting these reports into production. This resulted in some delays, but that has since changed. The Planning Department has been working closely with the Information Services Department on the development of numerous reports utilizing the information contained within the Hansen system. These reports fall into three categories: letters and forms generated by the system, information related to Service Requests, and information related to Cases. To date, seventeen of these reports have been developed and are in use. Of these, nine fall into the category of “data management reports.” The remaining reports will be completed by Fall of 2008. In addition to these programmed reports, a great deal of management information can be generated on- demand using Hansen’s search and reporting function that are built into the software.

F19: The Planning Department has not asked for a routinely-generated report listing unresolved cases chronologically, with the oldest first. Code Compliance Enforcement Response from the County: DISAGREES. It is true that the department does not get a listing of unresolved cases by the age of the case, because that is not how the caseload is managed: the oldest cases are not necessarily the most important. The department does track cases to ensure that appropriate actions are taken at the various stages of the enforcement process. The Planning Department receives reports for various milestones within the Hansen system to ensure that cases are moving forward according to their established business practices. The department receives reports listing unresolved Service Requests to ensure that new complaints do not remain open ended. The department has requested a report listing cases where a red tag has been issued and the Notice of Violation has not been recorded on the property title within 35 days of the mailing of that Notice. Similarly, the department has requested a notification report when 60 days have elapsed since recordation of the Notice of Violation and that, if the violation has not been corrected, a stipulation must be developed and sent to the property owner specifying required compliance periods and penalties. Finally, the department has requested a report indicating the current milestone of all cases and number of days spent in that milestone. The report will be able to be sorted in any number of ways, including chronologically.

F20: The Grand Jury reviewed 100 consecutively numbered complaints (spanning entry dates between August 10 and September 27, 2007) and found the following: • Almost 30 percent of them were incorrectly coded. • Nearly 18 percent of the complaints had activity dates earlier than the entry date. These differences mean that work was performed on the complaints before their entry into the HANSEN® system. The largest discrepancy between entry date and the activity date was more than two months. • The Planning Department received more code violations than it resolved. After six months, unresolved complaints outnumbered resolved complaints by 50 percent.

F21: In April and May of 2008, the Planning Department presented several code change proposals to the Board of Supervisors. Some were approved and others were tabled for further study and discussion. While major focus of the changes was on rules for building second units, among the approved changes were several that are intended to reduce the burden on code enforcement by eliminating requirements judged unnecessary. For example, the County now intends to • exclude most demolition from requiring Coastal Commission approval. • allow installation of solar energy systems in the coastal zone without a discretionary permit. Conclusions

F22: Although with careful scrutiny the whistleblower program link can eventually be located, many people have difficulty finding it on the county’s website. Typing “whistleblower hotline” into the search box results in “no matches.”

F23: The budget for fiscal year was $403,000. First 5 funded $300,000, and the Coalition hopes to receive the additional $103,000 from Medi-Cal Administrative Activities.

F24: The County works as a middleman for both sources of Coalition funding. Medi-Cal Administrative Activities

F25: During the month of September, the Coalition completes a “time survey” to establish the annual cost of outreach activities in excess of what First 5 already pays. The federal government agency Medi-Cal Administrative Activities is billed that excess cost. The turnaround for payment is generally about three years.

F26: The County supports various organizations associated with the Coalition throughout the year and receives the money from Medi-Cal Administrative Activities. Many 32 A Promise Kept variables determine what work is being done and how it is being claimed. On average, the Coalition received approximately 75 percent of what they predicted in their budget from Medi-Cal Administrative Activities. The County then funds the remaining budget. First 5 California

F27: The State of California retains 20 percent of the money First 5 receives, and 80 percent is distributed to the 58 counties throughout California based on the number of children born in the county. Santa Cruz receives approximately $2,700,000 annually.

F28: makes no distinction between Regional Occupational Program classes and Watsonville Adult Education classes. They are operated by two distinct entities. Watsonville Adult Education is a Pajaro Valley Unified School District function and the Regional Occupational Program is a County Office of Education function. ROP can offer only Career Technical Education courses under California Education Code. By law, ROP does not offer skill-building classes. All classes at Rountree, with the exception of Auto Body and Computer Applications are under the jurisdiction of Watsonville Adult Education. Of the two ROP instructors at the facility, the Auto Body instructor is a native Spanish- speaker. The Computer Applications instructor is semi-fluent in speaking and fully fluent in understanding Spanish. All ROP teachers are trained in Sheltered Instruction under the requirements of the State of California as part of their credential process. ROP does not employ teachers’ aides. ROP will, of course, make every effort to provide instruction in dual languages. 29. Minimum security inmates can walk away from the facility, and it happens about four times a year. Those who walk away are generally rearrested within 24 hours. They are then likely to be held at the Main Jail for the remainder of their sentences, and new charges can result. 30. Due to the lack of fencing around the facility, Rountree has had problems with unauthorized persons entering the grounds. This has enabled contraband to be dropped off in the parking lot area which can be picked up by inmates working in the area and brought into the facility. The Grand Jury has been informed the Sheriff’s office has secured $72,000 to install fencing around the front of the facility. The automatic gates into the facility would be controlled from the control Rountree 71 room located in the medium security section of Rountree. The Sheriff’s Office is waiting for the General Services Department (GSD) to put this project out to bid. Response from the County: AGREES. 31. Exercise and recreational options are adequate and include basketball, weight lifting, horseshoes, volleyball, baseball, soccer and ping pong. 32. The County has provided $48,000 in funding to repair and replace the shower posts, flooring and support walls at the Jail Farm. This was reported to be a problem in the Environmental Health Report. Funding has been secured for this project. Rountree staff is still awaiting GSD to put the project out to bid. Conclusions 1. Correctional officers and civilian workers at Rountree Detention Center appear to be respectful of inmate rights, experienced in dealing with inmates, and well trained in security procedures. 2. Inmate visits in both facilities are well managed and beneficial to both the inmates and their families. 3. The maintenance and cleanliness of all areas of both facilities is good. 4. There are a commendable variety of constructive activities and skill building classes for inmates although few are conducted by Spanish-speaking teachers. 5. Because the Rountree jail inmate populations are consistently under capacity, the facilities could be better utilized to relieve the overcrowding at the Main Jail. 6. The staffing of the facilities is inadequate to properly oversee, protect, and transport the inmate population. 7. Onsite medical care is currently available 40 hours a week. The newly approved nursing weekend hours are needed to assure that medical problems are properly assessed and expeditiously treated. This weekend coverage will allow qualified inmates who need mental health maintenance medications to be transferred from the Main Jail to Rountree. 8. The video surveillance system has been noted to be inadequate in earlier Grand Jury reports, but it has still not been improved. 9. Installation of fencing around the facility would prohibit the public from entering the facility without permission and would deter contraband from entering the facility. 10. The Grand Jury agrees with the Environmental Health Report that the shower posts, flooring and support walls at the Jail Farm are in need of repair and replacement.

F29: First 5 reimburses the County for payments made to community agencies for contracted services.

F30: In the fall of 2008, First 5 will create a new three-year strategic plan. This may or may not result in continued funds for the Coalition for Health Care Outreach. Conclusion

F31: While there are no outside windows in the inmate housing units, the front of each has windows facing a central area where the correctional officers are located. The central command area has dimmed red lighting so the officers can see into each of the well- lighted housing units. Food trays and medicine are dispensed from this central area through openings in the main door of each unit. This type of detention facility in which no correctional officers are located within the inmate housing areas is called a “podular design” system. Such a configuration contrasts with a direct supervision detention facility in which the correctional officers are located directly in the inmate housing areas.

F32: In 2005, a computerized program was established to monitor inmate classification, housing movements and disciplinary actions. The Sheriff’s Office Detention Bureau hopes to replace that system with a comprehensive jail management system in the next two years that will integrate the current classification system with medical, commissary, food, and inmate records management (currently located across the street in the county building). To date no funding has been secured for this project.

F33: Department 11 of the Santa Cruz Superior Court handles the drug cases and is now located at the Main Jail. Fifty to 100 inmates are taken from their cells to court each week in shackles and chains. Having drug court located at the Main Jail has eliminated the need for transport to the county court house on Ocean Street and has facilitated a more efficient handling of drug cases.

F34: Policies and procedures are in place to ensure the facility’s security, but it is an ongoing concern for the staff. Last year, two inmates attempted unsuccessfully to escape. Main Jail Inmate Services

F35: Inmates may see visitors in one of the five visiting rooms during visiting hours. All visits are audio recorded. Inmates and visitors are separated by a wire and plexiglass barrier. Inmates must complete a visitor request form before any visits will be allowed. Staff must pre-approve all visitors before they are scheduled. The inmate’s visitor lists can be updated only once every 30 days from the date the original list was completed.

F36: Professional interview rooms are available 24 hours a day for the inmates and their attorneys or the clergy. To preserve client confidentiality, no recordings are made in these rooms.

F37: Each of the housing units has a secure outdoor area for basketball, handball and exercise. Board games, cards and puzzles are also available. Newly released movies are rented from Swank distribution for monthly movie viewing.

F38: Other services available include television (both Spanish and English from 7 a.m. to 11 p.m.) and a limited selection of paperback books. Inmates may purchase any book or periodical accepted for distribution by the U.S. Post Office. A law library is available to provide legal research assistance for inmates and UCSC Women’s Center Inside-Out offers writing workshops.

F39: Inmates are served three meals per day (at 6:00 a.m., 11:30 a.m. and 5:00 p.m.). A maximum of 30 minutes is allowed for consumption and/or disposal of a meal. The county nutritionist plans the meals according to the standards set forth in the California Code of Regulations. The inmates receive a total of 2,600 calories a day according to Title 15 standards. The kitchen area was originally built to serve 90 inmates. The kitchen passed the 2007 State Standards review even though it is outdated and extremely small for the current jail population.

F40: Once a week, inmates have access to a commissary. They may purchase from a pre- approved list of items, such as snacks, canvas shoes, nail clippers, cosmetic items. Inmates must use money placed in their individual accounts to purchase commissary items. Upon their request, inmates with less than $3 in their accounts may be given the following items once each week: six sheets of paper, two stamped envelopes, two shampoo packets, a pencil, a toothbrush, toothpaste, and a comb.

F41: Friends Outside, a program provided by Volunteer Center of Santa Cruz County, helps maintain outside contacts, and assists inmates in conducting basic and necessary transactions, such as banking and paying bills. They also provide reading glasses.

F42: The jail chaplain provides religious services while several local churches of numerous denominations provide Bible studies, communion services and prayer groups.

F43: Drug counseling is provided by Alto and Janus of Santa Cruz. Programs are also offered by Alcoholic Anonymous (AA) and Narcotics Anonymous (NA), Dual Diagnosis Group, and Criminal Gangs Anonymous.

F44: The Mental Health and Substance Abuse Services (Division), a division of the Santa Cruz County Health Services Agency, works with and through many groups to offer a wide range of mental health care services including emergency shelter, transitional housing, supported housing, dual diagnosis treatment, crisis intervention, case management, and peer support. Other services available to clients are assessment, counseling, medication support, and referrals. Spanish translation is offered, as is an Appeal Resolution Process for anyone who is denied assistance. The following is a partial list of these resources. Adult residential treatment is offered at • Transition House, 10 beds • Paloma House, 12 beds • Pioneer House, eight beds • Opal Cliffs, 15 beds • El Dorado Center, 16 beds • Darwin House, 15 beds 38 A Promise Kept • Front St., Inc., 11 beds • River Street Shelter, 20 beds reserved for people referred by County Mental Health Outpatient treatment and/or social rehabilitation are available at • North County Mental Health Center • South County Clinic • Community Support Services • Dominican Hospital Behavioral Health • Pioneer House Dual Diagnosis Day Program • Community Connection Academy • Front Street Day Rehabilitation Program Self help resources include • Mental Health Client Action Network • Mariposa Activity Center • Community Connection Mental Health Resource Center and Career Services • Community Support Services Community Organizers Program Ongoing services for the protection of low-income mentally ill residents include • Advocacy, Inc. (Patient Rights) • Public Guardian’s Office

F45: It is hard to retain staff; therefore, continual training programs are necessary. Many new employees come from the Cabrillo College Health Science/Community Health programs.

F46: Various federal, state, county and private agencies fund mental health treatment in our county. Mental health has made effective use of these grants and programs. Some of these sources (known as funding streams) are designated for specific and limited uses. Clients often present with a variety of issues and staff sometimes has difficulty matching funds to the specific needs of the client. Services offered to individuals and families will be further restricted by potential state and county budget cuts in the coming year.

F47: Training in cultural sensitivity is emphasized and employees are trained within their department as well as by outside resources.

F48: Some families have difficulty acknowledging the existence of a mental health problem. This can be a cultural issue or a matter of pride. Successful mental health outreach and education programs have worked as a part of the network of general health services.

F49: Access to services is difficult for South County residents because most service sites are located in Santa Cruz. Public transit offers only a few routes and limited hours of operation. The Division is attempting to expand county services and to create more partnerships with community agencies in South County.

F50: The Division works with Senior Network Services but does not yet have an early intervention program for seniors. A Promise Kept 39

F51: Among the ongoing concerns of the Division is the ever-present worry of patients exhibiting unexpected antisocial behavior. Conclusions

F52: The Main Jail now has a full-time medical director. This position was recently changed from 16 hours per week to full-time. The doctor is also available on call as needed. Every inmate admitted to the jail for 14 days or longer is examined by the staff doctor.

F53: Title 15 requires a minimum number of medical staff to be on duty for each shift. Substitute nurses fill in when full-time staff take vacation. It has been difficult to recruit substitutes because they receive lower wages and no benefits. Nurses lose accrued vacation time because of substitute shortages.

F54: Currently the Main Jail employs three registered nurses during the day, two in the evening and one at night. A nurse practitioner works 20 hours per week and is on call when off duty. All these positions are currently filled. Gynecological services are provided 2 to 3 hours once a week. Main Jail

F55: Every morning, the Crisis Intervention Team meets to review risk management problems and any new admits in the last 24 hours. The team consists of medical and mental health staff, lieutenants, sergeants, and booking staff.

F56: Currently the medical staff provides services for HIV, hepatitis, prenatal care, lacerations, pain management, gynecological and internal medicine. If an injury is minor, the medical staff can provide the necessary care. Inmates with serious injuries are transported to Dominican Hospital. The jail has no X-ray services; inmates are sent to outside medical facilities for MRI/CT scans and procedures requiring specialists. Tuberculosis testing of all inmates is mandatory and must be completed within three days of admittance.

F57: The Main Jail has two automated external defibrillators (AEDs), and correctional officers and medical personnel are trained in their use. They are also trained to administer CPR.

F58: Ill or injured inmates must fill out medical request forms (blue slip). The medical staff receives approximately 200 blue slips per month. Nurses pick up these slips twice daily when they distribute medicine. The nurse on duty reviews each complaint and determines if it can be handled by a nurse or if the inmate needs to be put on the sick call list. The list is given to the nurse practitioner, who reviews and triages the needs. Some action must be taken on each blue slip within 24 hours. In case of emergency correctional officers contact medical personnel.

F59: A blue slip must be completed for every medical problem, creating a backlog of slips. Many inmates reported having to wait up to three weeks to be seen. Requests range from simple medical needs, such as antibacterial ointment, to more serious medical services. Inmates said the medical treatment is very good once they receive it.

F60: Currently Santa Cruz County uses eight nearby counties in salary surveys: Monterey, Santa Clara, Alameda, Napa, Sonoma, Marin, Solano and San Mateo. For the most part, these are more similar to Santa Cruz than the nine counties formerly used in that they are not strictly agricultural and have living costs comparable to Santa Cruz.

F61: Recruiting and retaining physicians and other medical professionals is uniquely difficult in Santa Cruz County because it is labeled by Medicare as a rural county. The Medicare reimbursement rate is the same as Butte, Imperial and other counties with a much lower cost of living.

F62: The county health programs must compete with Dominican and Sutter for physicians and other medical professionals. Hospitals are in a unique position to pay higher salaries as their Medicare reimbursements are based on actual costs. A national Medicare study released in 2007 shows hospitals in Santa Cruz County have the highest labor costs in the country, which local health officials say means higher medical costs and insurance premiums for patients. This situation creates a difficult challenge when it comes to recruiting medical professionals.

F63: Salaries and working conditions for physicians and other medical professionals employed by the County are negotiated with the respective unions. Conclusions

F64: The O Unit is the medical observation unit that includes individual rooms where physically or mentally ill inmates are monitored by medical staff and by a video monitoring system. Seven rooms have video monitoring. In addition, a “padded room” houses inmates who are a danger to themselves or others. This room also has video surveillance and physically inspected every 15 minutes. New linoleum has recently been installed over the concrete floors throughout the O Unit This new flooring can be more effectively cleaned and sanitized.

F65: A 5150 hold is a provision of the state’s Welfare and Institutions Code whereby people can be held for 72 hours if, as result of mental disorder, they pose a danger to themselves or others or are gravely disabled. Dominican Hospital is the only facility in the county licensed to care for 5150 patients. Those on 5150 hold and suspected of committing felonies are not accepted in Dominican’s Behavioral Health Unit and instead are booked into the Main Jail. Those with psychiatric problems need to be separated from the rest of the inmate population. If after the 72-hour hold, an inmate is still incapacitated and no licensed outside placement can be located, he or she remains in isolation in the medical unit. The jail does not have the resources to provide adequate psychiatric services, nor is it licensed to provide ongoing support services to these inmates. Response from the County: PARTIALLY AGREES. The Main Jail at 259 Water does not have cooling in the inmate housing area. The heating system was designed with an occupancy load for a much lower population. To meet the current air changes for the increased population, more outside air needs to be introduced to the facility that will in turn create a higher heating load for the building. The existing equipment was not designed to maintain the increased load which results in heating inconsistencies in the building. As for the response time, the work order data base shows that General Services responded either the same day or the next working day to reported problems.

F66: The jail provides on-site dental work two half days per month and serves about 18 inmates per month. The dental staff pulls teeth but does not provide fillings or more extensive dental work. Inmates must turn in a blue slip to request dental services. The jail dentist receives about 25 blue slip requests per month. Many inmates cancel their requests prior to their dental appointment. Recent legislation provides for more extensive dental work to be performed off-site if necessary and if approved by the correctional officers. This service is not extended to inmates sentenced to six months or less. Minimum security inmates are eligible to go to their own outside dentist. Medium and maximum security inmates are eligible to see an outside dentist if approved by the correctional officers. Anyone under administrative segregation for disciplinary reasons is not eligible to see an outside dentist. No provisions are being considered to address the dental needs of inmates incarcerated for longer than one 60 Main Jail year (about five percent of the population) and who also are not approved to see an outside dentist.

F67: The medical records of all present and past inmates are kept in paper files. The 2006 - 2007 Grand Jury found inmate records stored in the medical corridor, in violation of Health Insurance Portability and Accountability Act (HIPAA) security and privacy requirements. The medical unit has recently installed a $25,000 mechanized file sorter, which provides complete security for each inmate’s medical folder and resolves previous security and confidentiality concerns.

F68: Inmates sleep on two-inch thick, fireproof, foam mattresses placed on concrete blocks. Due to limited supply, each inmate is issued only a single mattress. The State fire marshal and Bureau of Home Furnishings and Thermal Insulation mandate the mattress’s overall length and width but not the thickness. To receive an additional mattress, an inmate must be housed in the Medical Observation Unit and the request approved by a doctor.

F69: The current medical budget is $3 million per year. Outside emergency medical visits for inmates account for $400,000 of that. Because Medi-Cal and most other insurance providers will not cover a person who is incarcerated, the jail is billed full hospital fees for inmate treatment at Dominican Hospital. The County is not offered a reduced rate. Overcrowding

F70: The average daily population (ADP) of the Main Jail continues to exceed the State- rated capacity of 311. The ADP for the first six months of 2007 was 358 (318 men and 40 women). The 2007 state inspection report identified overcrowding as a significant area of non-compliance.

F71: Triple bunks and/or boats (boat-shaped plastic beds that sit directly on the floor) are sometimes situated in the dayrooms, reducing space for daytime activities. The bunks and boats allow the jail to accommodate 422 beds even though its rated capacity is only 311.

F72: When a housing module becomes too crowded the inmates in that module can be traded to a larger module holding a smaller group of inmates.

F73: The maximum sentence a person can receive for a misdemeanor is one year, which can be shortened with time off for good behavior. However, if a person is convicted of several misdemeanors, the judge can order sentences to be served consecutively. In that case, an inmate could end up serving several years in the Mail Jail, adding to the total inmate population.

F74: Inmates doing “soft time” contribute to the overcrowded conditions. At any given time, the jail has 16 to 24 inmates charged with very serious crimes who are doing soft time awaiting appeal of their cases.

F75: The Sheriff’s Office offers a work release program for eligible inmates, which helps reduce overcrowding. The inmate pays a fee and does community work in lieu of serving time. Main Jail 61

F76: A representative from the Sheriff’s Office chairs the Jail Overcrowding Committee, which consists of representatives from each of the following groups: law enforcement, the judiciary, prosecutors, probation, public defenders, county supervisors, county administrative office, health services and community service providers. It meets quarterly to examine methods of reducing overcrowding without jeopardizing public safety.

F77: The overcrowding committee has developed a set of strategies to reduce jail crowding, primarily at the Main Jail. The results of these efforts have been significant. The average monthly population in 2004 was 408. The 2007 average population was 347. The current average monthly population is down 15 percent compared to 2004.

F78: The overcrowding committee continues its efforts on a number of fronts that include • dedicating sufficient personnel to classifying inmates. • exploring options for expanding the use of the Rountree and Blaine Street facilities. • securing funding through the Mentally Ill Offender Crime Reduction Grant Program in conjunction with the Probation Department and the Health Services Agency. This grant provides for an out-of-custody program from a Community Corrections Center to be located on Water Street.

F79: A jail population control officer was appointed to monitor overcrowding at the Main Jail until a new classification system was completed. This position was discontinued at the beginning of fiscal year 2007 - 2008 and rolled into a classification supervisor position. The new position, along with the new classification system, allows more appropriate distribution of the county inmate population, which should then reduce the Main Jail population.

F80: The Board of Supervisors approved a medical staffing increase, which began in March of 2008 at the Rountree facility. As a result, an additional five to seven inmates a day may be transferred from the Main Jail to the Rountree facility.

F81: The Probation Department has implemented a number of alternative programs and added personnel to address jail crowding. These include • expanded pretrial services, such as release on one’s own recognizance with or without conditions. • a supervised release, which includes phone checks, field supervision, with conditions such as drug and alcohol testing. • intensive supervision, which includes field supervision, electronic monitoring and individualized conditions. These supervised and intensely supervised programs account for an average jail population reduction of 30 jail beds per day.

F82: The Community Action Board, a local nonprofit agency, also provides a community service alternative to jail with its Community Restoration Program. This program provides supervised work crews in county parks and, together with Habitat for Humanity, builds low income housing. This alternative to jail served 54 individuals and saved an estimated 1,785 bed days in 2007. Main Jail

F83: In Partnership with Community Action Board’s Gemma program the Probation Department is reducing the recidivism of females who typically are incarcerated for nonviolent offenses related to substance abuse. The women’s jail sentences are reduced contingent on participation in the residential component of the program. The program offers day treatment and skill-building classes for women.

F84: The Warrant Reduction Advocacy Program (WRAP) is designed to avert the issuance of probation bench warrants for individuals who have not maintained contact with their probation officers. Friends Outside provides a three-quarter time warrant reduction specialist to make contact with probationers and reconnect them to their probation officers. This program saves an estimated 40 jail bed days for each warrant averted.

F85: While all the jail reduction strategies are working as planned and the population has declined since 2005, the Main Jail is still above rated capacity. The daily jail population is the result of two variables: the number of individuals placed in jail and how long the inmates stay in jail. Had the recent measures not been put into place, the projected Main Jail population would have been 416 rather than the actual average population for 2007, which was 347. Classification and Discipline

F86: The jail uses the National Council of Crime and Delinquency (NCCD) classification system to determine an inmate’s housing assignment. This system considers ten different factors that either increase or decrease points for an inmate. Within 24 hours, the inmate is classified as minimum, medium or maximum security depending on total points. Gang affiliation, medical needs, escape risk, level of violence, crimes committed, charges pending, and behavior while in custody are all factors used in the classification system.

F87: Inmates are classified by a formal process. The booking supervisor is the first person to consider an inmate’s classification within the facility. There are two classification correctional officers (working alternate shifts) who interview every new inmate, review the booking supervisor’s preclassification, and ultimately determine the inmate’s classification and housing placement within the facility. These two officers are supervised by the classification supervisor, a position added at the beginning of fiscal year 2007-2008.

F88: Inmates requiring disciplinary measures are monitored by two disciplinary correctional officers working alternating shifts. The disciplinary officers report to the classification supervisor.

F89: For safety reasons there are times when groups of inmates in a given housing module cannot get along with one another. In an effort to quell potential problems these groups of inmates can be “racked” (allowed out of their cells and into the dayrooms for a minimum of four hours per day).

F90: Privileges can be withheld if an inmate breaks the rules. According to Title 15, the degree of punitive actions taken by the disciplinary officer needs to be directly related to the severity of the rule infraction. The Main Jail has a four-point discipline system. A minor infraction could result in a verbal warning. A second minor infraction could Main Jail 63 result in a loss of visiting or commissary privileges or confinement to a cell for four hours. A maximum infraction, such as injury to someone, could result in administrative segregation (ad seg) lasting from ten to 60 days.

F91: Inmates unable to get along with others for any reason, such as gang affiliation, race hatred, or antisocial behavior, are assigned to ad seg, defined by Title 15 as separated from the general population. Inmates may request ad seg if they fear for their own safety. They can request a reclassification and/or change in housing assignment every 30 days.

F92: Some ad seg inmates are held in disciplinary isolation (lock-down), and confined to cells 23 hours a day with only one hour outside to eat, shower, exercise, watch TV, make phone calls, and talk with others. While locked down, they have no access to any type of religious services or addiction therapy support groups. They can turn in a green slip to talk with the chaplain or a blue slip to see medical personnel. They can also receive books from the book cart. Title 15 states no inmate can be in lock-down beyond 30 consecutive days without review by the facility manager. The jail complies with this Title 15 requirement.

F93: Title 15 states food is not to be used as a disciplinary measure. In the ad seg unit, food (mostly snacks) may be withheld as an incentive to improve behavior. Inmates always receive at least the state-required calories. After major violations of institution rules, inmates may be subjected to a disciplinary isolation diet in accordance with Title 15. Every 72 hours, the facility manager must approve the continuation of this diet. Reportedly the isolation diet has only been implemented on rare occasions. Conclusions

Recomendaciones adicionales 42

No vinculadas a hallazgos específicos.

R1: The Planning Department should • remove responsibilities other than code enforcement from existing code compliance staff. Response from the County: HAS BEEN IMPLEMENTED. The temporary reassignment of one of our Code Investigators to assist in the training of a new fiscal person was the result of unprecedented turnover in our fiscal division and the need to train incoming accounting personnel to support the Code program. This training has been completed and the individual has returned full time to Code Investigations. In addition, all of the Planning Technicians in the Department, including the two staff presently assigned to our Code Program, assist in staffing the General Information Desk that is an integral part of our public counter operation. This time commitment ranges from 2-10 hours a week. While this assignment does divert a few hours away from the Code Program, it also ensures that Code staff are kept aware of all of the ongoing changes at our building and zoning counters, and also places them in a position to suggest operational changes that improve the interactions between code staff, counter staff, and property owners trying to resolve their violation(s). This arrangement will remain in place for the foreseeable future. • recruit and train volunteers to assist the code compliance group. Response from the County: WILL NOT BE IMPLEMENTED. With the reassignment of an additional Planning Technician to the Code Compliance Section, sufficient staff resources are in place to assist the existing Investigators with caseload management. Two Planning Technicians assist the Investigators with in-office research and preparation of draft stipulated agreements and case hearing packets. It would not be appropriate to use volunteers to act as Code Investigators due to the technical training and expertise that is required to perform the job. • consider expanding the compliance-by-mail program to include additional low- priority violations. Response from the County: REQUIRES FURTHER ANALYSIS. The compliance-by-mail program is used for violations that do not require issuance of a permit or a field investigation to verify the existence of a violation. In addition, correction of the violation must be able to be verified by the complainant. Initially, the Program was limited to illegal occupation of trailers and RV’s. In the last year, it was expanded to include certain animal keeping violations. We are currently evaluating whether this approach to code enforcement can be further expanded and will implement this expansion, if deemed appropriate, no later that the end of the 2008 calendar year. Code Compliance Enforcement • create a list of code violations not currently being enforced and determine if any of the most commonly received complaints represent violations that can be added to the list. Response from the County: REQUIRES FURTHER ANALYSIS. Certain minor code violations may not warrant enforcement action. Quite often, factors specific to the particular situation are taken into account when making a determination as to whether or not enforcement action will be taken. The Department will evaluate the range of minor violations that it encounters to determine whether, regardless of other factors, any of them qualify for such treatment. This evaluation will be completed in early

R2: The Civil Service Commission should periodically review individual provisional appointments to ensure the system is not being abused. Response from the County: HAS BEEN IMPLEMENTED. Response from the Civil Service Commission: HAS BEEN IMPLEMENTED. The first provisional appointment report was initiated by the Commission and received at their July 2008 quarterly meeting. The Commission directed staff to provide provisional appointment reports at each quarterly meeting. The first report on provisional appointments was issued to the Commission at its July 17, 2008 quarterly meeting. The Commission will now receive these reports quarterly. Nepotism and Favoritism

R3: To create consistency among code compliance staff, Planning Department management should provide a detailed, written procedures manual, including targets for the amount of time allowed for each step in the complaint resolution process. Response from the County: HAS BEEN IMPLEMENTED.

R4: The Civil Service Commission should permanently create a standing committee consisting of two commissioners to hear and investigate personnel and hiring practice complaints. Upon conclusion of each of its investigations, this committee should report its findings and recommendations to the full commission. Response from both the County and from the Civil Service Commission: WILL NOT BE IMPLEMENTED. In 2007 the Civil Service Commission created a temporary ad hoc committee, consisting of two commissioners, to hear complaints from SEIU members. Handpicked for the Job? 17 The Brown Act (Government Code Section 54952), County Code (2.46.060), and Civil Service rules (Section 130 I. 1. A.) restrict the Civil Service Commission’s ability to create a standing committee and still maintain a confidential forum for county employee complaints. The meetings of a standing committee composed of less than a quorum of the commission would be subject to the notice, agenda, and public participation requirements of the Ralph M. Brown Act. It is not possible under the Brown Act to set up a permanent standing committee that could accomplish a confidential forum for complaints of County employees. Whistleblower Program

R5: If First 5 no longer supports it, the Coalition for Health Care Outreach should be supported in the budget of the Health Services Agency. Response from the County: WILL NOT BE IMPLEMENTED. Although the Coalition for Health Care Outreach is very important, unless funding is identified to replace the $300,000 First Five contribution, such support cannot be guaranteed due to other competing high priority needs. Clinic Hours 2000-2001 Grand Jury Recommendation 6: Additional sessions in the evening and through the lunch hour would be a great advantage for family members who now must lose time at work to attend the clinics. Response from the County: This recommendation requires further analysis. 2007-2008 Grand Jury Findings 31. Three community clinics were visited in 2000, Salud Para La Gente in Watsonville, Santa Cruz Women’s Health Center, and Dientes Community Dental Clinic in Santa A Promise Kept 33 Cruz. The current Grand Jury has confirmed the following hours with employees at each clinic. All three clinics are closed Sundays and specified holidays. • Salud Para La Gente: • Monday through Friday, 9:00 a.m. to 7:00 p.m. • Saturday, 8:00 a.m. to 4:30 p.m. • Santa Cruz Women’s Health Center: • Monday, 8:30 a.m. to 5:00 p.m. • Tuesdays and Thursdays, 8:20 a.m. to 8:00 p.m. • Wednesday, 12:20 to 5:00 p.m. • Friday, 8:20 a.m. to 5:00 p.m. • Saturday, 8:00 a.m. to noon • Dientes Community Dental Care: • Monday though Thursday, 8:30 a.m. to 5:00 p.m. (closed 12:30 to 1:30 p.m.) • Friday, 7:30 a.m. to noon, and 1:00 to 4:00 p.m. (closed noon to 1:00 p.m.) • Saturday, 8:30 a.m. to 2:30 p.m. 32. Some discrepancies exist between the clinic hours posted on websites and the hours provided in email and telephone communication.

R6: The Health Services Agency should encourage community clinics to accurately communicate clinic hours to the public. Response from the County: HAS BEEN IMPLEMENTED and will continue to be coordinated with the Safety Net Clinic Coalition. Dental Health Programs 2000-2001 Grand Jury Recommendation 7: Full-service dental health programs should be launched in county and community clinics. County Response: This recommendation has been and will continue to be implemented through the county’s community partners.

R7: Preliminary results of whistleblower investigations should be required within 60 days of the original complaint. Response from the County: HAS BEEN IMPLEMENTED. This requirement is in effect for reports received after August 15, 2008. Response from the Santa Cruz County Auditor-Controller: HAS BEEN IMPLEMENTED.

R8: The Board of Supervisors is encouraged to create a body independent of county government to serve as the first point of contact for all whistleblower complaints; from there they can be forwarded to the appropriate entity for investigation and resolution. Response from the County: REQUIRES FURTHER ANALYSIS. The Auditor-Controller will review suggestions for modifying the Whistleblower Hotline and will make appropriate recommendations to the Board. Handpicked for the Job?

R9: Clinic operations are no longer confined to daytime hours. The three clinics each offer some lunchtime and/or evening hours. All offer Saturday appointments as well.

R10: The inconsistencies of the posted clinic hours confuse and possibly inconvenience patients. Recommendation

R11: The Grand Jury recommends that the Health Services Agency continue to build the network of mental health services countywide. Response from the County: HAS BEEN IMPLEMENTED.

R12: Staff development, including improved training and new methods for reviewing program results, would increase the effectiveness of the Health Services Agency. Response from the County: HAS BEEN IMPLEMENTED. HSA will further expand staff development as additional funding becomes available.

R13: The Grand Jury recommends that the Board of Supervisors support coordination of the various funding streams by the Health Services Agency so that available funds can be used to match the diverse needs of the clients. A Promise Kept Response from the County: HAS BEEN IMPLEMENTED. HSA will continue efforts to coordinate and increase various funding streams to meet the needs of our clients.

R14: The Board of Supervisors should ensure adequate funding for patients’ employment services, which play an important part in mental health treatment. Response from the County: HAS BEEN IMPLEMENTED. The Board of Supervisors restored $50,000 for employment services in the 2008-09 budget.

R15: It would be beneficial for the Health Services Agency to continue developing mental health outreach and education programs to provide even more community social support for recovering patients, so they can feel welcome in their communities. Support resources can include churches and neighborhood organizations. Response from the County: HAS BEEN IMPLEMENTED. HSA will continue developing outreach and educational programs as funding becomes available. Commendation

R16: The Grand Jury urges the Health Services Agency to continue to seek grants and other alternative sources for funds to pay competitive salaries to health professionals. Response from the County: HAS BEEN IMPLEMENTED and will continue to be a high priority for the Health Services Department.

R17: The Grand Jury recommends that library management consult with the City of Watsonville to establish a location for a drive-up book drop at the Main Library. Response from Watsonville Library Director: WILL NOT BE IMPLEMENTED. During the building phase of the library and the Civic Center Plaza, all possible locations for a drive-up book deposit were explored. There are no viable locations which can be used for this service.

R20: Since Medi-Cal and Healthy Families reimbursement rates are set by state and federal government agencies, the County of Santa Cruz has no authority to revise them.

R21: Congressman Sam Farr, the California Medical Association (CMA), and others have called the reimbursement fee schedules for county doctors inequitable and continue to work to require that the U.S. Department of Health and Human Services fix a system viewed as unfair to local qualified participants. Conclusion

R22: In June of 2001 the Packard Foundation grant expired. In 2007-2008, funding for the Coalition for Health Care Outreach (Coalition) came from two sources, First 5 California (First 5) and Medi-Cal Administrative Activities.

R23: The budget for fiscal year was $403,000. First 5 funded $300,000, and the Coalition hopes to receive the additional $103,000 from Medi-Cal Administrative Activities.

R24: The County works as a middleman for both sources of Coalition funding. Medi-Cal Administrative Activities

R25: During the month of September, the Coalition completes a “time survey” to establish the annual cost of outreach activities in excess of what First 5 already pays. The federal government agency Medi-Cal Administrative Activities is billed that excess cost. The turnaround for payment is generally about three years.

R26: The County supports various organizations associated with the Coalition throughout the year and receives the money from Medi-Cal Administrative Activities. Many 32 A Promise Kept variables determine what work is being done and how it is being claimed. On average, the Coalition received approximately 75 percent of what they predicted in their budget from Medi-Cal Administrative Activities. The County then funds the remaining budget. First 5 California

R27: The State of California retains 20 percent of the money First 5 receives, and 80 percent is distributed to the 58 counties throughout California based on the number of children born in the county. Santa Cruz receives approximately $2,700,000 annually.

R28: First 5 has three established goals: healthy children, children learning and ready for school, and healthy families. Allowing for local decision-making, the First 5 Santa Cruz County Commission determines how to distribute funds based on a three-year strategic plan and annual contracts. Money provided to the Coalition by First Five has been designated as outreach funds.

R29: First 5 reimburses the County for payments made to community agencies for contracted services.

R30: In the fall of 2008, First 5 will create a new three-year strategic plan. This may or may not result in continued funds for the Coalition for Health Care Outreach. Conclusion

R31: Three community clinics were visited in 2000, Salud Para La Gente in Watsonville, Santa Cruz Women’s Health Center, and Dientes Community Dental Clinic in Santa A Promise Kept 33 Cruz. The current Grand Jury has confirmed the following hours with employees at each clinic. All three clinics are closed Sundays and specified holidays. • Salud Para La Gente: • Monday through Friday, 9:00 a.m. to 7:00 p.m. • Saturday, 8:00 a.m. to 4:30 p.m. • Santa Cruz Women’s Health Center: • Monday, 8:30 a.m. to 5:00 p.m. • Tuesdays and Thursdays, 8:20 a.m. to 8:00 p.m. • Wednesday, 12:20 to 5:00 p.m. • Friday, 8:20 a.m. to 5:00 p.m. • Saturday, 8:00 a.m. to noon • Dientes Community Dental Care: • Monday though Thursday, 8:30 a.m. to 5:00 p.m. (closed 12:30 to 1:30 p.m.) • Friday, 7:30 a.m. to noon, and 1:00 to 4:00 p.m. (closed noon to 1:00 p.m.) • Saturday, 8:30 a.m. to 2:30 p.m.

R32: Some discrepancies exist between the clinic hours posted on websites and the hours provided in email and telephone communication. Conclusions

R52: In the County of Santa Cruz, “safety net clinics,” (i.e., county or nonprofit clinics), take patients that are uninsured regardless of their ability to pay.

R53: Current public and non-profit clinics, as a whole, have not been reconfigured to family-oriented and preventative care, but rather each clinic has an area or multiple areas of concentration which are listed below. Santa Cruz Clinics A Promise Kept 41 Santa Cruz Women’s Health • Primary Care for Women and Children • Family Planning • Health Benefits Advocacy • Illness Prevention and Health Promotion • Gynecology and Prenatal Care • Pediatrics • Acupuncture, Chiropractic, Naturopathy Westside Health Center (Planned Parenthood) • Primary Care Services • Family Planning • Health Benefits Advocacy • Illness Prevention and Health Promotion • Obstetrics and Gynecology • Pediatrics • Abortion Services Emeline Clinic • Primary Care Services • Walk-in Immunizations • Health Benefits Advocacy • Pediatrics • Child Health and Disability Prevention • Orthopedics • Family Planning • Laboratory, Radiology, and Pharmacy Coral Street Clinic • Urgent Care and Primary Care • Integrated Case Management • Mental Health and Substance Abuse • Health Benefits Advocacy • Counseling Beach Flats Clinic • Primary Care Services • Women’s Health • Pediatrics • Family Planning • Dental Care • HIV Testing • Obstetrics and Gynecology Dientes Community Dental Care • Emergency Dental Care • Full Range of Dental Services 42 A Promise Kept • Oral Health Advocacy Dominican Pediatric Clinic • Pediatric Services Elderday Adult Day Health (Salud Para La Gente) • Adult Day Health Watsonville Clinics Salud Para La Gente • Primary Care Services • Family Planning • Dental Care • Eye Clinic / Optometry • Health Prevention and Promotion • Health Benefits Agency • Pediatrics • Obstetrics and Gynecology Diabetes Health Center • Diabetes Self-Management • Medical Nutrition Therapy • Group Classes • Insulin Training • Glucometer Training Clinica del Valle Del Pajaro • Primary Care Services • Dental Care • Family Planning • Women’s Health • Pediatrics • Child Health and Disability Prevention • Obstetrics and Gynecology South County Clinic • Primary Care Services • Immunizations • Health Benefits Advocacy • Pediatrics • Child Health and Disability Prevention • HIV Prevention • Laboratory • Radiology • Breast Cancer Early Detection Programs • Family Planning A Promise Kept 43 Clinic Mariposa (Planned Parenthood Mar Monte) • Primary Care Services • Family Planning • Health Benefits Advocacy • Pediatrics • Obstetrics and Gynecology • Illness Prevention and Health Promotion Children’s Resource Center • Pediatrics • Child Health and Disability Prevention • Dental Care Green Valley Clinic • Obstetrics and Gynecology • Women’s Health

R54: Santa Cruz Women’s Health and Planned Parenthood specialize in women’s health, family care, and reproductive health.

R55: Specialists are available when necessary, usually through Sutter Maternity & Surgery Center, which provides some free services to the community.

R56: The County of Santa Cruz currently employs 20 full-time doctors: five primary care physicians (including two pediatricians), and 15 psychiatrists, four of which are bilingual.

R57: The recruitment of allied health practitioners and full-time county physicians is often a challenge. Response from the County: AGREES. The Health Services Agency and the Personnel Department have developed a number of successful initiatives to increase the County’s ability to recruit for various classes of health practitioners and physicians.

R58: The high cost of housing in Santa Cruz County makes recruiting primary care physicians difficult.

R59: Psychiatry has only one vacant position, and nurse practitioner positions are filled through a “feeder program” from San Jose State University. Conclusions

R60: Currently Santa Cruz County uses eight nearby counties in salary surveys: Monterey, Santa Clara, Alameda, Napa, Sonoma, Marin, Solano and San Mateo. For the most part, these are more similar to Santa Cruz than the nine counties formerly used in that they are not strictly agricultural and have living costs comparable to Santa Cruz.

R61: Recruiting and retaining physicians and other medical professionals is uniquely difficult in Santa Cruz County because it is labeled by Medicare as a rural county. The Medicare reimbursement rate is the same as Butte, Imperial and other counties with a much lower cost of living.

R62: The county health programs must compete with Dominican and Sutter for physicians and other medical professionals. Hospitals are in a unique position to pay higher salaries as their Medicare reimbursements are based on actual costs. A national Medicare study released in 2007 shows hospitals in Santa Cruz County have the highest labor costs in the country, which local health officials say means higher medical costs and insurance premiums for patients. This situation creates a difficult challenge when it comes to recruiting medical professionals.

R63: Salaries and working conditions for physicians and other medical professionals employed by the County are negotiated with the respective unions. Conclusions

📋January 26, 2009 — In 2000, the United Way Community Assessment Project estimated that: 41. Seventeen percent of county residents had no