Santa Cruz County Grand Jury
2016-2017
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 (17)
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Findings & Recommendations
30 findings
F1:
The Santa Cruz City Schools Comprehensive School Safety Plans provide a best practice and is a useful resource for parents and the public.
Related Recommendations (1)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
F2:
The Naval Postgraduate School’s Center for Homeland Defense and Security provides an excellent resource for school administration with its K-12 school shooting database.
Related Recommendations (2)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R19:
The Board of Supervisors should require the CAO to appoint a county Risk Manager, by December 31, 2020. The Risk Manager should report to the CAO, who will be responsible for ongoing identification, analysis, quantification, and remediation planning of all fire risks across the County. This role should be considered as a service to all four cities in the County as well. (F2, F3, F24)
F3:
The Pajaro Valley Unified School District can improve its oversight and communications by following the The California League of Bond Oversight Committees (CaLBOC) Best Practices document on School Bond Oversight Committee Operations Standards.
Related Recommendations (3)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R19:
The Board of Supervisors should require the CAO to appoint a county Risk Manager, by December 31, 2020. The Risk Manager should report to the CAO, who will be responsible for ongoing identification, analysis, quantification, and remediation planning of all fire risks across the County. This role should be considered as a service to all four cities in the County as well. (F2, F3, F24)
R22:
The Santa Cruz County Administrative Office should develop and sign a Memorandum of Understanding between the County and PG&E, to require that PG&E share and update quarterly the location of their aging and high risk equipment. This should include coverage of the four cities in the County and should be done by December 31, 2020. (F3)
F4:
City employees do not feel supported and protected by the City Manager and Human Resources.
Related Recommendations (2)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R23:
Santa Cruz County and Cities should invest in an ALERTWildfire Imaging Surveillance system. Cameras should be purchased, installed, and tested to achieve full coverage of the County by the beginning of the 2021 fire season. (F4)
F5:
There are disagreements and a lack of transparency on how the City Council meeting agendas are set.
Related Recommendations (1)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
F6:
Failures to amend City Council Policy 6.9 resulted in a lack of comprehensive guidelines to address interactions between City Council and City Staff.
Related Recommendations (3)
R13:
The City Council should re-establish a working group to update the Council Policy 6.9, to more clearly define interactions between City Council and City Staff when making requests, and should do so by December 31, 2020. (F6)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R25:
The County Board of Supervisors should explain to the public why the Proposition 218 information on response times is inconsistent with the response time data available from County Fire by December 31, 2020. (F6, F8, F30)
F7:
Lack of a well-defined social media policy leads to confusion about the appropriate use of social media.
Related Recommendations (2)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R16:
Santa Cruz County Board of Supervisors should request the Santa Cruz County Administrative Officer investigate and report on the viability of converting the underutilized County Juvenile Hall campus, located at 3650 Graham Hill Rd, Felton, CA into a facility focused on fulfilling crucial homeless, mental health and substance abuse needs by December 31, 2020. (F7)
F8:
The public has lost confidence in the City Leadership’s ability to function effectively.
Related Recommendations (2)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R25:
The County Board of Supervisors should explain to the public why the Proposition 218 information on response times is inconsistent with the response time data available from County Fire by December 31, 2020. (F6, F8, F30)
F9:
The Assistant City Manager and City Manager do not manage to key performance indicators and measures of success.
Related Recommendations (1)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
F10:
The designation of a City Council position as part-time, with insufficient compensation, may limit the candidate pool and negatively affect City Council performance.
Related Recommendations (1)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
F11:
The City does not have an elected mayor position which limits the ability of voters to assign accountability when City government is dysfunctional and ineffective. Published June 25, 2020 192 Santa Cruz County Civil Grand Jury
Related Recommendations (2)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R21:
County emergency planners at all levels should provide notification of evacuation routes and/or shelter-in-place options by March 31, 2021. Notification plans should be provided for when power is out and dissemination of information by wireless or internet is difficult or impossible. (F11, F14, F15, F17, F18, F27)
F12:
Lack of a formal intern policy for Councilmembers has caused confusion, disruption and a burden on City Staff.
Related Recommendations (1)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
F13:
Lack of trust among City Councilmembers impedes constructive discourse and decision making.
Related Recommendations (3)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R18:
Santa Cruz County should create a 24-hour mobile crisis response unit that includes medical staff and an experienced crisis worker to respond to emergency 911 calls and non-emergency police calls that do not involve legal issues or threats of violence. The Santa Cruz County Board of Supervisors should work with the County’s law enforcement agencies to identify funds in their budgets that could be allocated to this program. The Grand Jury recommends the County consider using CAHOOTS (Crisis Assistance Helping Out On The Streets) in Eugene, Oregon as a model. (F13)
R20:
The County Office of Emergency Services should inventory, designate, and publish locations by December 31, 2020 for assembly and refuge in high risk communities, designating shelter in place locations in case of threatening wildfire when evacuation from the area might not be possible. (F13–F15, F27)
F14:
The Conflict Resolution Center (CRC) contract lacks performance criteria, making it difficult to determine whether conflict resolution was successful. The CRC engagement also failed to address conflicts between City Council and City Staff.
Related Recommendations (3)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R20:
The County Office of Emergency Services should inventory, designate, and publish locations by December 31, 2020 for assembly and refuge in high risk communities, designating shelter in place locations in case of threatening wildfire when evacuation from the area might not be possible. (F13–F15, F27)
R21:
County emergency planners at all levels should provide notification of evacuation routes and/or shelter-in-place options by March 31, 2021. Notification plans should be provided for when power is out and dissemination of information by wireless or internet is difficult or impossible. (F11, F14, F15, F17, F18, F27)
F15:
Major conflicts and dysfunctions were recognized by City Staff, City Council, and the public in February 2019, but there was a failure to seek remediation for those conflicts until October 2019.
Related Recommendations (4)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R20:
The County Office of Emergency Services should inventory, designate, and publish locations by December 31, 2020 for assembly and refuge in high risk communities, designating shelter in place locations in case of threatening wildfire when evacuation from the area might not be possible. (F13–F15, F27)
R21:
County emergency planners at all levels should provide notification of evacuation routes and/or shelter-in-place options by March 31, 2021. Notification plans should be provided for when power is out and dissemination of information by wireless or internet is difficult or impossible. (F11, F14, F15, F17, F18, F27)
R24:
The County Board of Supervisors should update regulations to require evacuation routes be kept clear for fire prevention, not just for line of sight, but also for access by fire engines and other emergency equipment by the beginning of the 2021 fire season. (F15–F18, F27) Published July 3, 2020 61 of 97 382 Santa Cruz County Civil Grand Jury
F16:
Without a current, detailed strategic plan, the City Staff and City Council goals and objectives are unclear.
Related Recommendations (2)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R24:
The County Board of Supervisors should update regulations to require evacuation routes be kept clear for fire prevention, not just for line of sight, but also for access by fire engines and other emergency equipment by the beginning of the 2021 fire season. (F15–F18, F27) Published July 3, 2020 61 of 97 382 Santa Cruz County Civil Grand Jury
F17:
Poor performance and antagonism at City Hall resulted in lost opportunities and could impair the City's ability to raise money.
Related Recommendations (3)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R21:
County emergency planners at all levels should provide notification of evacuation routes and/or shelter-in-place options by March 31, 2021. Notification plans should be provided for when power is out and dissemination of information by wireless or internet is difficult or impossible. (F11, F14, F15, F17, F18, F27)
R24:
The County Board of Supervisors should update regulations to require evacuation routes be kept clear for fire prevention, not just for line of sight, but also for access by fire engines and other emergency equipment by the beginning of the 2021 fire season. (F15–F18, F27) Published July 3, 2020 61 of 97 382 Santa Cruz County Civil Grand Jury
F18:
The City Council’s inability to control disruptive behavior during meetings increases meeting length and inhibits a representative cross-section of the public from participating.
Related Recommendations (3)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
R21:
County emergency planners at all levels should provide notification of evacuation routes and/or shelter-in-place options by March 31, 2021. Notification plans should be provided for when power is out and dissemination of information by wireless or internet is difficult or impossible. (F11, F14, F15, F17, F18, F27)
R24:
The County Board of Supervisors should update regulations to require evacuation routes be kept clear for fire prevention, not just for line of sight, but also for access by fire engines and other emergency equipment by the beginning of the 2021 fire season. (F15–F18, F27) Published July 3, 2020 61 of 97 382 Santa Cruz County Civil Grand Jury
F19:
The employee engagement survey methodology is flawed, and may not accurately represent employee sentiment. The survey does not have the ability to present results per City department and thus the interpretation of results and
Related Recommendations (1)
R15:
The City Manager and City Council should independently make public acknowledgments of the difficulties and dysfunctions that have plagued the City for the last 18 months, and make commitments which are consistent with the implementation of the Grand Jury’s recommendations by December 31, 2020. (F1–19)
F20:
There are tools available, such as Santa Clara County’s “Silicon Valley Triage Tool," that could be applied to Santa Cruz County to allow the County to better understand the true cost of homelessness enabling the County to use public resources more efficiently.
F21:
If underutilized parcels of land throughout Santa Cruz County were identified, such as the area near Coral Street in Santa Cruz, and the parcel adjacent to the County Government Mental Health Building in Watsonville, these parcels could potentially be used to increase the number of beds and services to support the homeless.
Related Recommendations (1)
R17:
By December 31, 2020, Santa Cruz County Planning Department should evaluate whether using the parcel of land adjacent to the County Mental Health Building to provide more temporary or permanent housing for the homeless would be a viable option, and report the results to the Board of Supervisors by December 31, 2020. (F21) Published June 30, 2020 284 Santa Cruz County Civil Grand Jury
F22:
The information provided in the ADU section of the Santa Cruz County Planning Department’s website is not user friendly, and therefore not as encouraging as it could be to homeowners looking to build much needed housing for the County. Published June 30, 2020 282 Santa Cruz County Civil Grand Jury
F23:
No single organization in the County is assuming a leadership role in Fire Hazard Mitigation. It is not clear whose responsibility it is to minimize this County wide risk.
F24:
The annual report to the County Board of Supervisors and the County Administrative Office by County Fire/CAL FIRE does not provide data or analysis of resources, response times, code enforcement, inspection, or education. This information is necessary to show what gaps exist between current performance and community needs in order for informed budget decisions to be made. Without adequate background information, the Board of Supervisors is unable to hold CAL FIRE accountable for the specific responsibilities specified in their contract.
Related Recommendations (1)
R19:
The Board of Supervisors should require the CAO to appoint a county Risk Manager, by December 31, 2020. The Risk Manager should report to the CAO, who will be responsible for ongoing identification, analysis, quantification, and remediation planning of all fire risks across the County. This role should be considered as a service to all four cities in the County as well. (F2, F3, F24)
F25:
The four fire protection districts in the San Lorenzo Valley would benefit by further aligning their policies and procedures in anticipation of future consolidation. Published July 3, 2020 58 of 97 2019–2020 Consolidated Final Report 379
F26:
Reporting data, statistics, and formats utilized by fire agencies throughout the County are highly inconsistent, uncoordinated, and therefore not readily evaluated and compared. The standard Insurance Services Office (ISO) rating system would be useful to adopt. Response time data are not well described or consistently reported by the jurisdictions, making accurate assessment difficult, especially by other agencies or by the public.
F27:
The 2015 County of Santa Cruz Emergency Operations Management plan does not adequately address evacuation, and references data too outdated to be useful, such as a population density map from the 2000 census.
Related Recommendations (3)
R20:
The County Office of Emergency Services should inventory, designate, and publish locations by December 31, 2020 for assembly and refuge in high risk communities, designating shelter in place locations in case of threatening wildfire when evacuation from the area might not be possible. (F13–F15, F27)
R21:
County emergency planners at all levels should provide notification of evacuation routes and/or shelter-in-place options by March 31, 2021. Notification plans should be provided for when power is out and dissemination of information by wireless or internet is difficult or impossible. (F11, F14, F15, F17, F18, F27)
R24:
The County Board of Supervisors should update regulations to require evacuation routes be kept clear for fire prevention, not just for line of sight, but also for access by fire engines and other emergency equipment by the beginning of the 2021 fire season. (F15–F18, F27) Published July 3, 2020 61 of 97 382 Santa Cruz County Civil Grand Jury
F28:
The 2016 LAFCO Municipal Service Review of Fire Districts report and its 2006 predecessor do not adequately address district performance in the areas of Fire Risk Reduction (specifically: inspections, vegetation management, and education).
F29:
The Grand Jury finds that formally specified baseline and target performance statements, in alignment with the Center for Public Safety Excellence Assessment Process, neither currently exist nor are they reported by fire departments in the County as required by best practice standards. There are no goals set or measures made of progress for review by the Board of Supervisors regarding County Fire/CAL FIRE performance. Other fire districts in the County are similarly remiss in reporting to their governing bodies. Appropriate goals would include progress on response times, vegetation management, and code inspection progress, all of which are necessary to properly quantify the budget and resources required for full-time, volunteer, and prison inmate workforces, in appropriate, affordable proportions.
F30:
Due to the inconsistent reporting of response times provided by CAL FIRE in Proposition 218, conflict with information supplied by document request to the Grand Jury, and due to lack of performance standards for response times, voters may have been ill-informed when voting on the proposition.
Related Recommendations (1)
R25:
The County Board of Supervisors should explain to the public why the Proposition 218 information on response times is inconsistent with the response time data available from County Fire by December 31, 2020. (F6, F8, F30)
Additional Recommendations
13
Not linked to specific findings.
R1:
Continue to be proactive in evaluating voting systems that are safe, efficient, and available. The County Clerk responded to R1 with a pledge of future implementation: As new systems become available, we will participate in evaluating them. After 2018 and the implementation of the Vote Center model in a few counties in California, Santa Cruz will need to determine if we want to pursue a Vote Center model or the current polling place model. The type of voting model will impact our voting system needs. We anticipate putting together a voter advisory group in 2018 to assist us as we evaluate our options.
R2:
Once USB drives or other equipment have been connected to the County network, do not reattach to the offline vote counting systems. Published June 19, 2020 2019–2020 Consolidated Final Report 113 The County Clerk’s response affirmed that this recommendation already was implemented for future use: We have purchased additional USB drives and now have procedures in place to use a USB drive only once when taking data from our vote counting system and loading it onto the county network. Recommendation made to the Santa Cruz County Board of Supervisors:
R3:
Identify and budget requisite funds for replacement of outdated election equipment once it has been certified (state certified, federally qualified). The Board of Supervisors responded to R3 with a pledge of future implementation, adding “The Board understands the need for election equipment upgrades.” 2020 Status Update: Were commitments fulfilled? In October 2019, the County Clerk’s Office visited the Grand Jury to explain the new voting system operation and discuss various aspects of the election cycle - a presentation similar to several offered to the public at large to acquaint them with the new system. More recently, answering the Grand Jury’s request for a 2020 status update, Respondents provided the following additional information on improvements to Santa Cruz County election equipment and procedures: ● Two federally qualified and state certified systems were offered to the County by the California Secretary of State.[23] [24] ● A Decision Group was formed, consisting of members from County Counsel, General Services, and Voter Accessibility Advisory Committee.[25] ● Formation of the Voter Advisory Group (originally planned for 2018) was delayed; the Elections Department plans to assemble the promised Citizen Advisory Group in 2021.[26] ● Of the two systems approved by the Secretary of State, Dominion Voting Systems was chosen, based largely on the long-established relationship of trust with the vendor.[27] ● A Staff Memo written by the County Clerk, and with approval recommended by County Administrative Officer, was presented to the Board of Supervisors at a regular public meeting on June 25, 2019.[28] ● June 25, 2019 Minutes indicate that the Board of Supervisors unanimously approved the voting system lease agreement.[29] [30] ● Deciding to opt out of the Vote Center model, the Elections Department instead developed a hybrid model of traditional polling sites plus ten Voter Service centers - the hybrid system functioned smoothly and efficiently in the March primary election.[31] ● Some modifications and refinements to this hybrid model are anticipated to further improve efficiency and accessibility for voters.[32] Published June 19, 2020 114 Santa Cruz County Civil Grand Jury In its update, the County Administrative Office (responding on behalf of the Board of Supervisors) simply confirmed that “New election equipment has been certified, leased, and deployed for use during the March 2020 Presidential Primary Election”,[33] providing a link to the Elections Department website “votescount.com” for more information.[34] In conclusion, we find that three recommendations were made, and three responsive commitments were fulfilled. Based on the Decision Group evaluation of voting system options, the memo and presentation by the County Clerk, and the County Administrator’s recommendation, the Board of Supervisors approved the new contract and service agreement for the new voting system. The County Clerk completed all actions promised by immediately correcting a USB drive security vulnerability, and by evaluating available voting systems and efficiently transitioning to the updated system, successfully implementing its use in the Countywide primary election of March 2020. Report Title: Assessing the Threat of Violence in our Public Schools The 2016-17 Santa Cruz County Grand Jury investigated the readiness of our 10 public school districts, the County’s alternative education sites, and their respective law enforcement agencies to respond effectively to threats of targeted school violence. State law requires all public school districts and county offices of education to develop a comprehensive school safety plan. 2020 Status Update: Were Commitments Fulfilled? The Grand Jury reports and responses of 2016-2017 has been the primary source of information used to examine whether or not the respective agencies fulfilled their commitments to implement recommended actions.[35] In addition, a Santa Cruz County Grand Jury report was issued in 2018[36] to review and confirm the first step: the development and documentation of a comprehensive Countywide threat plan (‘The Plan’).[37] In that report, additional information about the Plan and the training was provided by the County Office of Education (COE). The 2018 investigation only looked at the COE and the Santa Cruz County Sheriff’s Office (CSO)’s compliance with their responses and the development of the threat assessment plan. It did not analyze or evaluate the agencies’ plans or preparations for physically securing school sites in a threat situation. This report takes that step. We reviewed the Offices of Education websites for publicly available information and documentation, and requested documentation from the boards and law enforcement agencies to confirm actions taken as outlined in the plans. Training materials were reviewed as well as training roster attendance. As one benchmark with which to compare, the similar report made by the San Diego County Grand Jury was reviewed for best practices and opportunities to further improve. Published June 19, 2020 2019–2020 Consolidated Final Report 115 In reviewing the 2019 report of the San Diego County Grand Jury ”School Safety in San Diego County - How Prepared Are We for Another Active School Shooting?”[38] we extract these key
R4:
The BoS should allocate funds for a permanent budget for the SSP to function as mandated per SSP Policy and Procedures. 2016-17 response: BoS: Requires further analysis 2019-20 updated response: BoS: Has been implemented[61] Notes: The BoS felt it was necessary to evaluate funding opportunities before committing in 2017. By February 2019, SSP was re-organized under the Communicable Diseases Unit of the Public Health Division (PHD) which allowed a new staffing structure for SSP.[62] It continues to explore ways to access and utilize state funds allocated to address the opioid crisis.
R5:
The HSA should devote more time and resources to community outreach to promote rehabilitation and counselling of SSP clients. 2016-17 response: HSA and BoS: Has been implemented 2019-20 updated response: none provided. However, in the 2019 biennial report HSA recommended that SSP be incorporated into the Homeless Persons Health Project clinical field services.[63] Published June 19, 2020 2019–2020 Consolidated Final Report 121
R6:
The HSA should implement a mobile needle exchange unit to increase access to SSP services. 2016-17 responses: HSA and BoS: Requires further analysis 2019-20 updated responses: BoS: Requires further analysis[64] HSA: On 6/11/2019 presented their biennial report to BoS and presented recommended actions for Board direction in response to the Grand Jury report. In addition to the recommendation that SSP be incorporated into the Homeless Persons Health Project, HSA recommended a mobile exchange unit program to reach out to clients in the field.[65] SSP will return to BoS at a later date with a plan for review.
R7:
The HSA should post hazardous waste signs with a single contact number for advice or reporting, available 24/7, in areas where syringes are commonly found. 2016-17 responses: BoS and HSA: Requires further analysis 2019-20 updated responses: BoS: Requires further analysis[66] HSA: On 6/11/19, the BoS directed that the HSA collaborate with the California Department of Public Health (CDPH) to complete a study of syringe litter. HSA to return with a proposed plan for a possible pilot program that could include using the County’s Citizen Connect mobile app to provide information about and reporting syringes. Further, HSA’s PHD is working with the CDPH office of AIDS to evaluate syringe disposal practices in the community, including where syringes are most commonly found. HSA will continue to explore ways to educate and inform the community.[67]
R8:
The HSA should install and maintain Sharps containers in bathrooms in high needle-use public areas. 2016-17 responses: HSA and BoS: Requires further analysis 2019-20 updated responses: BoS: Will not be implemented[68] HSA: As Sharps containers in public bathrooms have been vandalized, HSA is focusing on placement of public kiosks in county & city jurisdictions. On 6/11/19, BoS directed the Board Chair to write a letter to local jurisdictions to work with them to install kiosks at HSA expense. HSA reached out to all local jurisdictions in the County to offer the installation and maintenance of public Sharps Containers and continues to work with partner jurisdictions to identify safe Published June 19, 2020 122 Santa Cruz County Civil Grand Jury disposal sites. Also, the City of Santa Cruz formally offered willingness to coordinate with the County for placement of four additional disposal kiosks in the city.[69]
R9:
The SSP should coordinate specific clean-up events throughout the county on a regular basis and report such efforts in their biennial and annual reports. 2016-17 responses: HSA and BoS: Requires further analysis 2019-20 updated responses: BoS: Will not be implemented[70] HSA: The HSA is using models that include more frequent clean-up; partnering with the County Department of Public Works, HSA provides $40,000 annually to Save Our Shores, Downtown Streets Team, and a private vendor for needle disposal as a part of these groups’ existing work. Also, HSA has a $10,000 contract with a private vendor for enhanced syringe clean-up focusing on the Emeline neighborhood. Once the results of the syringe litter study are analyzed (as described in R7), HSA will focus syringe disposal resources to the areas which data shows are most impacted by discarded needles. Disposal collection data will be included in future biennial reports.[71] The HSA has continued to include the Grand Jury's "Sharper Solutions" recommendations in its monthly progress reports to the BoS , including as recently as December 10, 2019 (as of this writing). SSP has been directed to return to the BoS in June of 2020 with recommendations to improve syringe litter reporting and response.[72] Report Title: Santa Cruz Metropolitan Transit District - The Bus Stops Here The 2016-2017 Grand Jury investigation led to 15 findings resulting in 16 separate recommendations. Responses were required from both the METRO Board of Directors (Board) and the METRO Chief Executive Officer (CEO). Overall, answers provided by the Board matched those given by its CEO. Explanations were required for partial or full disagreement with any finding, and for all responses to the recommendations. Of the 16 recommendations, METRO had stated that four “required further analysis”, while one recommendation “has not been implemented but will be implemented in the future”. 2020 Status Update - Were Commitments Fulfilled? In November 2019, the METRO CEO provided updates[73] to the 2017 report responses.
R10:
Metro should improve cleanliness at transit facilities.
R11:
Metro should improve maintenance at transit facilities. 2017 response: CEO: requires further analysis. 2019 updated response: Metro has made three significant accomplishments relative to these recommendations: ● In FY17, the METRO Board authorized one additional Custodial Service Worker. ● In compliance with the Federal Transit Administration’s requirement that all agencies receiving federal funds develop a Transit Asset Management Plan, METRO met the federal deadline and now has a plan in place that recognizes ● all assets valued at $50,000 or greater and establishes a remaining life for the asset and a Preventative Maintenance Program for the proper maintenance of the assets. Such a program now helps METRO regularly maintain the assets, facilitating the asset replacement program set forth in the Capital Improvement Plan. ● Over the past year METRO invested over $35,000 at Pacific Station remediating water damage and attempting to make the facility water-tight.
R12:
Metro should establish overnight parking at the Scotts Valley Cavallero Transit Center for riders. 2017 response: CEO: Requires further analysis 2019 updated response: METRO has posted the Cavallero Transit Center with signs reflecting overnight parking by permit only. Paper permits can be obtained at the Pacific Station customer service booth at a cost of $5 per day. METRO is also investigating a smartphone application that could eventually replace the paper permits.
R14:
METRO should use easily cleanable materials for bus seats. 2017 response: CEO: Has not been implemented; will be implemented in future. Published June 19, 2020 124 updated response: Upon further investigation, METRO discovered that the problem has nothing to do with padded seats. Since the 2017 Grand Jury report, METRO has received five new Gillig buses and will receive four new zero emissions Porterra electric buses next year. All of these buses have been specified with a different seat insert which has an impermeable vinyl cover. The current Grand Jury commends the METRO CEO, staff, and Board for ongoing efforts to improve and modernize service delivery. Based on our review, METRO has been consistent in fulfilling the commitments made in response to the Grand Jury report. The CEO’s 2020 Spring Message[74] affirms METRO’s ongoing commitment to improving services. Further, the Grand Jury commends METRO for the implementation of smartphone apps for more efficient ticketing and the anticipated Summer 2020 rollout of Automatic Vehicle Location, which will dramatically improve rider experience.[75] Kudos also for METRO’s excellent and comprehensive “Headways Bus Rider’s Guide,”[76] available in English, Spanish, Large Print, also online and via CRS (California Relay Service) for hearing/speech assist.
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Findings & Recommendations
7 findings
F1:
Elections in Santa Cruz County are run fairly and conscientiously, with numerous procedures and safeguards that minimize the likelihood of fraud or systemic errors. Although minor problems occurred, we consider these inevitable given the number of people and the complexity of the process, and they were detected or reported and remedied expeditiously.
F2:
Most equipment used to conduct the election is old, much of it nearing or past its useful life. This includes voting machines and electronic and mechanical vote counting systems. Spare parts are increasingly hard to find.
Related Recommendations (2)
R1:
The Elections Department should continue to be proactive in evaluating voting systems that are safe, efficient, and available. (F2–F5, F7)
R3:
The Board of Supervisors should begin the process of identifying and budgeting the requisite funds for replacement of election equipment once it is certified. (F2–F5)
F3:
Santa Cruz County uses a state certified system that meets state standards. Beyond keeping some key systems offline, this equipment does not implement adequate computer security measures.
Related Recommendations (2)
R1:
The Elections Department should continue to be proactive in evaluating voting systems that are safe, efficient, and available. (F2–F5, F7)
R3:
The Board of Supervisors should begin the process of identifying and budgeting the requisite funds for replacement of election equipment once it is certified. (F2–F5)
F4:
Santa Cruz County limits physical access to the ballots and the machinery used to process the ballots and conducts comprehensive audits both before and after every election.
Related Recommendations (2)
R1:
The Elections Department should continue to be proactive in evaluating voting systems that are safe, efficient, and available. (F2–F5, F7)
R3:
The Board of Supervisors should begin the process of identifying and budgeting the requisite funds for replacement of election equipment once it is certified. (F2–F5)
F5:
Voting equipment that the county would select to replace its aging infrastructure has not yet been certified. When the certified replacement equipment becomes available, it is not clear when funds might be provided.
Related Recommendations (2)
R1:
The Elections Department should continue to be proactive in evaluating voting systems that are safe, efficient, and available. (F2–F5, F7)
R3:
The Board of Supervisors should begin the process of identifying and budgeting the requisite funds for replacement of election equipment once it is certified. (F2–F5)
F6:
Re-use of USB drives on the offline vote collection systems, after being attached to an internet-connected system, is a possible avenue to compromise the offline systems.
Related Recommendations (1)
R2:
In order to protect the integrity of the count, once USB drives or other equipment have been connected to the county network, they should never be reattached to the offline vote counting systems. (F6)
F7:
While currently not being considered in Santa Cruz County, the future possibility of internet voting is a concern due to the inability to ensure the security and anonymity of the vote. Published May 17, 2017 24 Santa Cruz County Grand Jury
Related Recommendations (1)
R1:
The Elections Department should continue to be proactive in evaluating voting systems that are safe, efficient, and available. (F2–F5, F7)
Findings & Recommendations
16 findings
F1:
Metro experienced an anticipated revenue reduction of $26 million from 2008–2014 and had to use its reserves to fill the shortfall. This is not sustainable.
Related Recommendations (2)
R1:
Metro should conduct a limited study to determine if reduced fares would generate additional revenue through increased ridership. (F1, F4, F7)
R7:
Metro should adopt and adhere to a budget that does not deplete reserves for operating expenses. (F1)
F2:
Metro grant writing has been insufficient and ineffective.
Related Recommendations (2)
R5:
Metro should identify and secure additional funding sources. (F2, F8, F9, F10)
R6:
Metro should expand their grant writing program. (F2)
F3:
Many Metro Board members lack transit management knowledge of best practices or business experience, leaving them ill-equipped to address Metro's declining revenues.
Related Recommendations (1)
R3:
The Metro Board should include members who have marketing, business management, or finance experience. (F3, F5, F6)
F4:
Metro use of Bus Rapid Transit (BRT) industry best practices is limited.
Related Recommendations (2)
R1:
Metro should conduct a limited study to determine if reduced fares would generate additional revenue through increased ridership. (F1, F4, F7)
R16:
Metro should provide WiFi connection on more buses. (F4)
F5:
There are no experience qualifications for Metro Board members in its bylaws, and the Board lacks the range of experience or training necessary to improve Metro’s performance.
Related Recommendations (2)
R3:
The Metro Board should include members who have marketing, business management, or finance experience. (F3, F5, F6)
R4:
The Metro Board, Metro management, and the Metro Advisory Committee should meet jointly on a regular basis. (F5, F6)
F6:
Metro does not have joint meetings that include the Board, Metro management, and the Metro Advisory Committee. Better and more frequent communication and coordination between these bodies could improve decision making.
Related Recommendations (2)
R3:
The Metro Board should include members who have marketing, business management, or finance experience. (F3, F5, F6)
R4:
The Metro Board, Metro management, and the Metro Advisory Committee should meet jointly on a regular basis. (F5, F6)
F7:
Manual collection of route performance data does not allow for optimal use of the HASTUS system. Published June 29, 2017 2016–2017 Consolidated Final Report 101
Related Recommendations (2)
R1:
Metro should conduct a limited study to determine if reduced fares would generate additional revenue through increased ridership. (F1, F4, F7)
R15:
Metro should conduct a limited trial using AVL and HASTUS to explore bus route efficiency. (F7)
F8:
Metro partnerships with UCSC and Cabrillo College have contributed significantly to Metro revenues, and Metro would benefit from additional community partnerships.
Related Recommendations (2)
R5:
Metro should identify and secure additional funding sources. (F2, F8, F9, F10)
R8:
Metro should consider pursuing additional private and government partnership programs, such as those with UCSC and Cabrillo College. (F8) Published June 29, 2017 102 Santa Cruz County Grand Jury
F9:
Metro marketing functions are handled inefficiently, in significant part due to an unfilled marketing manager position. Marketing must be more than just selling advertising on buses.
Related Recommendations (2)
R2:
Metro should redefine the Marketing Manager position as Director of Business Development and fund it. (F9, F10)
R5:
Metro should identify and secure additional funding sources. (F2, F8, F9, F10)
F10:
Metro lacks a business development manager. Currently, business development responsibilities are distributed across the organization, and are not implemented or effective.
Related Recommendations (2)
R2:
Metro should redefine the Marketing Manager position as Director of Business Development and fund it. (F9, F10)
R5:
Metro should identify and secure additional funding sources. (F2, F8, F9, F10)
F11:
Metro design standards for bus stops and shelters have not been consistently implemented, which may negatively impact ridership.
Related Recommendations (1)
R9:
Metro should create a bus stop sponsorship program that underwrites construction of bus stops in accordance with Metro’s design standards. (F11)
F12:
Metro bus seats are difficult to clean and sanitize, which may negatively impact ridership.
Related Recommendations (3)
R10:
Metro should improve cleanliness at transit facilities. (F12, F16)
R11:
Metro should improve maintenance at transit facilities. (F12, F15, F16)
R14:
Metro should use easily cleanable materials for bus seats. (F12)
F13:
The lack of overnight parking at bus facilities may be a deterrent to potential riders.
Related Recommendations (1)
R12:
Metro should establish overnight parking at the Scotts Valley Cavallaro Transit Center for riders. (F13)
F14:
Metro’s CNG bus engines break down sooner than expected, resulting in accelerated expenses.
Related Recommendations (1)
R13:
Metro should evaluate cost-effective alternatives to the CNG bus powertrain. (F14)
F15:
Metro transit centers are deteriorating and in disrepair, which may negatively impact ridership.
Related Recommendations (1)
R11:
Metro should improve maintenance at transit facilities. (F12, F15, F16)
F16:
Metro transit centers are not clean, which may negatively impact ridership.
Related Recommendations (2)
R10:
Metro should improve cleanliness at transit facilities. (F12, F16)
R11:
Metro should improve maintenance at transit facilities. (F12, F15, F16)
Findings & Recommendations
10 findings
F1:
In a threat situation, timely and specific communication from the school to the community can reduce fear, anxiety, anger, and frustration.
Related Recommendations (1)
R1:
The County Superintendent of Schools should advocate school districts inform parents and guardians on how and when they will be contacted in the event of a threat. (F1)
F2:
Confusion over the disclosure of protected information regarding juveniles has been a barrier to the timely exchange of vital information between school districts and law enforcement, although FERPA permits disclosure of juvenile student information to law enforcement without parental consent.
Related Recommendations (1)
R2:
The County Office of Education (COE) and the County Sheriff's Office (CSO) should advocate that the threat assessment plan for each school district has a written agreement with law enforcement in which restricted information may be exchanged during the investigation of a threat. (F2)
F3:
Threat assessment is a necessary part of the comprehensive school safety plan, but very little direct guidance has been provided to school districts in how to go about doing it.
Related Recommendations (1)
R3:
The COE and the CSO should collaborate to develop a plan in which all school districts are prepared and capable of assessing a threat of targeted school violence. (F3, F5–F7)
F4:
Investigating a threat may involve actions that can only be done by law enforcement, necessitating coordination and collaboration in formulating and implementing a threat assessment plan.
Related Recommendations (1)
R4:
The County Sheriff and the County Superintendent of Schools should act as boundary spanners to facilitate collaboration between the school districts and law enforcement in assessing threats. (F4)
F5:
Seven of the ten districts have a specific threat assessment plan; those districts without a plan are less able to respond effectively to threats. All of these reported that local law enforcement was aware of their plan.
Related Recommendations (1)
R3:
The COE and the CSO should collaborate to develop a plan in which all school districts are prepared and capable of assessing a threat of targeted school violence. (F3, F5–F7)
F6:
Only one school district had a threat assessment plan that was created with the help of law enforcement, leaving all other districts at a disadvantage in addressing threats. Published June 13, 2017 52 Santa Cruz County Grand Jury
Related Recommendations (2)
R3:
The COE and the CSO should collaborate to develop a plan in which all school districts are prepared and capable of assessing a threat of targeted school violence. (F3, F5–F7)
R5:
The CSO and Chiefs of Police should ensure a law enforcement representative, preferably a School Resource Officer, be made available to school districts drafting or revising a threat assessment plan. (F6, F8)
F7:
Three of the four districts with a single school lack the personnel to adequately assemble a threat assessment team.
Related Recommendations (2)
R3:
The COE and the CSO should collaborate to develop a plan in which all school districts are prepared and capable of assessing a threat of targeted school violence. (F3, F5–F7)
R7:
The COE should advocate each school district either has or has access to a multidisciplinary threat assessment team, including a representative from law enforcement. (F7, F9)
F8:
All threat assessment teams had training in the 2015-16 school year, but not all districts attended a professional threat assessment training held in the spring of 2017.
Related Recommendations (2)
R5:
The CSO and Chiefs of Police should ensure a law enforcement representative, preferably a School Resource Officer, be made available to school districts drafting or revising a threat assessment plan. (F6, F8)
R6:
The County Superintendent of Schools should advocate each school district receives periodic training in assessing threats of targeted school violence. (F8)
F9:
Countywide, only two of 11 SROs were included as members of a threat assessment team.
Related Recommendations (1)
R7:
The COE should advocate each school district either has or has access to a multidisciplinary threat assessment team, including a representative from law enforcement. (F7, F9)
F10:
Not all local law enforcement agencies have personnel trained in assessing threats of school violence, leaving them less able to assist schools.
Related Recommendations (1)
R8:
The County Sheriff and the Chiefs of Police should ensure their respective law enforcement agencies attend periodic training in assessing threats of targeted school violence. (F10) Published June 13, 2017 2016–2017 Consolidated Final Report 53
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Findings & Recommendations
12 findings
F1:
The current SSP Advisory Group is composed of city and county employees as well as those working in the drug and rehabilitation community, with no members from the general public who can add a community perspective.
Related Recommendations (1)
R1:
The SSP Advisory Group should include members of the general public, including at least one rehabilitated injection drug user. (F1)
F2:
The SSP leadership creates an atmosphere of poor communication and a lack of transparency by not holding public meetings or forums for community input.
Related Recommendations (1)
R2:
The SSP should hold public meetings or forums to encourage dialog and address community concerns. (F2, F3) Published on June 27, 2017 74 Santa Cruz County Grand Jury
F3:
The SSP provides an abundance of information on its webpage but does not have an avenue for public dialog.
Related Recommendations (1)
R2:
The SSP should hold public meetings or forums to encourage dialog and address community concerns. (F2, F3) Published on June 27, 2017 74 Santa Cruz County Grand Jury
F4:
The SSP currently operates without a budget or permanent staff, which hinders the success of program goals.
Related Recommendations (1)
R4:
The Board of Supervisors should allocate funds for a permanent budget for the SSP to function as mandated per SSP Policy and Procedures. (F4)
F5:
The SSP needle exchange site on Emeline Street is a confined shared space, making it difficult to provide all services to those in need.
Related Recommendations (1)
R5:
The HSA should devote more time and resources to community outreach to promote rehabilitation and counselling of SSP clients. (F5, F6)
F6:
Limited hours, space, and staff hamper referrals to counseling, treatment, and support programs, reducing the number of people receiving assistance.
Related Recommendations (1)
R5:
The HSA should devote more time and resources to community outreach to promote rehabilitation and counselling of SSP clients. (F5, F6)
F7:
The strict one-to-one needle exchange policy can’t be followed as the SSP policy prohibits the actual physical counting of syringes.
Related Recommendations (1)
R3:
The SSP should stop using the “one-to-one” terminology to describe their needle exchange policy. (F7)
F8:
Some injection drug users don’t travel to SSP exchange sites, thus preventing them from receiving assistance from other health programs.
Related Recommendations (1)
R6:
The HSA should implement a mobile needle exchange unit to increase access to SSP services. (F8, F9)
F9:
The community is at risk with syringes found in public and private spaces throughout the county.
Related Recommendations (4)
R6:
The HSA should implement a mobile needle exchange unit to increase access to SSP services. (F8, F9)
R7:
The HSA should post hazardous waste signs with a single contact number for advice or reporting, available 24/7, in areas where syringes are commonly found. (F9, F10)
R8:
The HSA should install and maintain Sharps containers in bathrooms in high needle-use public areas. (F9, F11)
R9:
The SSP should coordinate specific clean-up events throughout the county on a regular basis and report such efforts in their biennial and annual reports. (F9, F12)
F10:
Without posted signage explaining how to report hazardous waste, the public is confused as to whom to notify or what action to take about found, discarded syringes.
Related Recommendations (1)
R7:
The HSA should post hazardous waste signs with a single contact number for advice or reporting, available 24/7, in areas where syringes are commonly found. (F9, F10)
F11:
There are only three county syringe disposal kiosks, limiting access to proper disposal.
Related Recommendations (1)
R8:
The HSA should install and maintain Sharps containers in bathrooms in high needle-use public areas. (F9, F11)
F12:
There is no combined syringe clean-up effort between local agencies to protect the public.
Related Recommendations (1)
R9:
The SSP should coordinate specific clean-up events throughout the county on a regular basis and report such efforts in their biennial and annual reports. (F9, F12)
Findings & Recommendations
11 findings
F1:
The lack of a complete, comprehensive, and updated list of all Measure L projects planned, completed, or approved by the Trustees, makes it impossible for the public to be informed.
Related Recommendations (1)
R1:
The District, under the direction of the Trustees, should regularly provide the public and the COC a project list showing original and amended Measure L projects. (F1, F10)
F2:
The COC has not presented to the Trustees in public session a complete Annual Report for Measure L as of May 2017, in violation of state law.
Related Recommendations (1)
R2:
The COC should comply with California Education Code section 15280(b) and deliver annual reports to the Trustees at public meetings. (F2)
F3:
The COC has not received adequate training or information to fulfill its role.
Related Recommendations (2)
R4:
The District Trustees should provide the COC a comprehensive orientation program for new members and annual updates for returning members. (F3)
R5:
The District should provide COC members a Measure L handbook detailing committee procedures, protocols, and responsibilities. (F3)
F4:
The District's Maintenance, Operations & Facilities Department has not provided other district departments, school sites, the COC, or Trustees updated scheduling reports that meet industry standards for any project, leading to system inefficiency.
Related Recommendations (1)
R6:
The District should provide the COC and Trustees a scheduling report of all Measure L activities depicting project milestones and sequential activity dependencies. (F4)
F5:
The District has not presented the COC or Trustees a composite change order list with a cumulative total cost for each site and project, leaving them unable to properly oversee the bond.
Related Recommendations (1)
R7:
The District should provide the Trustees and COC a cumulative, quarterly change order list, including budget impacts by project and by site. (F5)
F6:
The COC and Trustees are unable to oversee the bond due to the District’s failure to provide a timely financial summary of the bond’s status by site, or a cumulative total cost for Measure L projects.
Related Recommendations (1)
R3:
The District should comply with California Education Code section 15278 by providing to the Trustees and COC a comprehensive Measure L financial report, updated quarterly, and including it in their Annual Report. (F6, F7, F9, F10)
F7:
The COC and the District have had no discussion about cost savings with those designing and implementing Measure L projects, limiting the COC’s oversight.
Related Recommendations (2)
R3:
The District should comply with California Education Code section 15278 by providing to the Trustees and COC a comprehensive Measure L financial report, updated quarterly, and including it in their Annual Report. (F6, F7, F9, F10)
R8:
The COC and the Trustees should meet at least quarterly to discuss recommendations for reducing costs in accordance with COC bylaws and the California Education Code section 15278(b). (F7)
F8:
The COC in its official capacity has visited only two project sites in the past four years to inspect Measure L work progress, failing to adequately inform itself about the status of the projects.
Related Recommendations (1)
R9:
The COC should regularly make on-site inspections of Measure L projects. (F8)
F9:
Trustees and the COC cannot properly manage the bond because they do not know how much money remains to finish Measure L projects.
Related Recommendations (1)
R3:
The District should comply with California Education Code section 15278 by providing to the Trustees and COC a comprehensive Measure L financial report, updated quarterly, and including it in their Annual Report. (F6, F7, F9, F10)
F10:
The COC is not informed of all changes to the projects listed in the voter’s pamphlet, undermining their oversight and reporting responsibilities. Published on June 13, 2017 2016–2017 Consolidated Final Report 65
Related Recommendations (2)
R1:
The District, under the direction of the Trustees, should regularly provide the public and the COC a project list showing original and amended Measure L projects. (F1, F10)
R3:
The District should comply with California Education Code section 15278 by providing to the Trustees and COC a comprehensive Measure L financial report, updated quarterly, and including it in their Annual Report. (F6, F7, F9, F10)
F11:
Bond reporting may be greatly improved once the District’s new accounting and business software is implemented.
Findings and recommendations not yet extracted.
Findings & Recommendations
5 findings
F1:
Felton Fire is in violation of California Government Code §50569 which requires each government agency to annually inventory their property and make available to the public a description of excess property.
Related Recommendations (1)
R1:
An annual inventory of Districtowned real estate and surplus property should be publicly available. (F1)
F2:
Felton Fire violated California Government Code §§5422054233 and §65402 which govern the manner by which Special Districts must conduct sales of surplus properties and which require confirmation that proposed uses conform with the county’s general plan.
Related Recommendations (2)
R2:
All proposed sales of surplus property should be publicly advertised in a manner that reaches and informs the general public. This may include signage posted on the property, listing in online forums (such as the MLS and other classified advertisers), and notices on the District’s website. (F2, F3)
R3:
The Board should comply with the law and adopt policies and procedures for acquiring, managing, and disposing of surplus property. All policies and procedures should be posted on their website. (F2, F4)
F3:
By not openly advertising the Subject Property or obtaining an independent appraisal of the property’s value, the Board did not establish market value and may not have obtained the highest price for the district.
Related Recommendations (1)
R2:
All proposed sales of surplus property should be publicly advertised in a manner that reaches and informs the general public. This may include signage posted on the property, listing in online forums (such as the MLS and other classified advertisers), and notices on the District’s website. (F2, F3)
F4:
Felton Fire did not maintain impartiality by permitting the Fire Chief to transact the sale with a colleague.
Related Recommendations (1)
R3:
The Board should comply with the law and adopt policies and procedures for acquiring, managing, and disposing of surplus property. All policies and procedures should be posted on their website. (F2, F4)
F5:
The Board did not account for the value of all of the District’s land holdings on its balance sheet, denying its constituents a full accounting of the District’s assets and liabilities.
Related Recommendations (1)
R4:
All of the District’s assets should be included on its balance sheet. (F5)
Findings & Recommendations
5 findings
F1:
All schools had a plan. However, not all schools were current with the required yearly updates.
Related Recommendations (2)
R1:
All schools should have a plan that is reviewed and updated yearly. (F1)
R6:
County Office of Education should require a yearly report from each district superintendent certifying the existence and annual update of each school’s safety plan. (F1)
F2:
Few schools had any reference to a Safety Preparedness Plan on their websites.
Related Recommendations (1)
R2:
Publicly available school safety plans should be on all school websites. The location of this information should be prominently and uniformly displayed on the homepage of each school’s website. (F2)
F3:
Most schools had insufficient emergency supplies.
Related Recommendations (1)
R3:
The County Office of Education should ensure that schools have sufficient and appropriate emergency supplies. (F3)
F4:
At some district offices the existence of the safety plan was unknown, at other district offices the location of the plan was unknown.
Related Recommendations (1)
R5:
All district and school staff members should know about the existence of the safety plan and should know the exact location of their printed safety plan. (F4)
F5:
Some district offices had only online versions of their schools’ plans and no printed copies.
Related Recommendations (1)
R4:
All schools and district offices should have a printed copy of the school safety plan readily available. (F5)
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Findings & Recommendations
5 findings
F1:
The Domestic Violence Commission has not met since 2013.
Related Recommendations (2)
R1:
Domestic Violence Commission meetings should be held monthly during the first six months with the commission determining the ongoing meeting times and schedule. (F1)
R4:
The Domestic Violence Commission should report to the Board of Supervisors quarterly for the first year and annually thereafter. (F1)
F2:
A quorum was not reached at the majority of the 2013 meetings.
Related Recommendations (1)
R2:
The Board of Supervisors should reduce the Domestic Violence Commission membership from 28 to a workable number. (F2, F3)
F3:
The mandated 24–28 person membership is too large.
Related Recommendations (1)
R2:
The Board of Supervisors should reduce the Domestic Violence Commission membership from 28 to a workable number. (F2, F3)
F4:
The District Attorney’s Office has appointed a leader to organize the new Domestic Violence Commission.
Related Recommendations (1)
R3:
The District Attorney (or their designee) should be the Domestic Violence Commission’s chair for at least the first year. (F4)
F5:
There was universal concern that the dedicated Domestic Violence Court had been abandoned.
Related Recommendations (1)
R5:
The Board of Supervisors should direct the Domestic Violence Commission to investigate the reestablishment of the Domestic Violence Court. (F5)
Findings & Recommendations
6 findings
F1:
The District Attorney's Office does not currently provide an annual summary of the disposition of civil asset forfeitures.
Related Recommendations (2)
R1:
The Santa Cruz County District Attorney’s Office should include an annual summary of civil asset forfeitures on their website. (F1)
R2:
Such a report should include a chart similar to the table 2014 Civil Asset Forfeiture Process Summary above. (F1)
F2:
The Sheriff and prosecuting authorities are following the letter and spirit of the law.
F3:
The District Attorney’s Office and the Sheriff’s Office are following strict accounting procedures in managing the process.
F4:
Property due to be returned was released in a timely and fair manner.
F5:
Proper escrow procedures were followed.
F6:
There is no incentive to abuse the program to supplement salaries and benefits, since none of the retained funds are used for salaries or benefits in the Santa Cruz County Sheriff’s Office.
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Findings & Recommendations
8 findings
F1:
The Grand Jury finds that the Board has violated the Brown Act on at least two occasions. These violations were due to the lack of open session discussion regarding the superintendent's contract and incomplete reporting of closed session decisions.
Related Recommendations (1)
R1:
The Board must follow the state law and their District policies by adopting practices that will inform the public of the details of their decisions and their decision process. As noted in the report the Brown act provides a baseline for public disclosure. Debating and giving reasoned explanations for their decisions in open meetings will improve public support and participation. (F1, F3, F4)
F2:
The Board chose to add the superintendent's expenses to his annual salary. While this is contrary to the spirit of the California Public Employees’ Pension Reform Act adopted in 2012, the practice is commonplace for superintendents hired before 2013.
Related Recommendations (1)
R2:
If the Board chooses to grant the Superintendent a salary raise in excess of the percentage granted to District Bargaining Units, they should announce the amount together with the Superintendent’s annual performance goals and discuss the increase in a public meeting. (F2, F3)
F3:
There is history of poor communication and mistrust of the Board and District administration by the public they serve.
Related Recommendations (7)
R1:
The Board must follow the state law and their District policies by adopting practices that will inform the public of the details of their decisions and their decision process. As noted in the report the Brown act provides a baseline for public disclosure. Debating and giving reasoned explanations for their decisions in open meetings will improve public support and participation. (F1, F3, F4)
R2:
If the Board chooses to grant the Superintendent a salary raise in excess of the percentage granted to District Bargaining Units, they should announce the amount together with the Superintendent’s annual performance goals and discuss the increase in a public meeting. (F2, F3)
R4:
Soquel Union Elementary School District should make available on their website an easily filed complaint form with guidelines. (F3, F4)
R5:
The Board should include a summary of complaint topics received since their last meeting in the meeting minutes. All complaint topics should be summarized, including Williams Uniform Complaint Procedure, Uniform Complaint Process, Freedom Of Information Act, email, etc. (F3, F4)
R6:
The District administration should provide accounting reports to the HSCs in accordance with mutually agreed content and frequency. (F3, F6, F7)
R7:
The Board should include public recognition, recorded in meeting minutes, of all financial contributions from HSCs and other contributors of funds to the District. (F3, F6)
R8:
At the beginning of each school year and after consulting with the school principal, a proposed budget should be prepared by each HSC outlining the plans for donations in excess of $500. The plan should be submitted to the District for final approval. (F3, F6, F7)
F4:
The lack of an adequate, posted complaint procedure and problem resolution process contributes to the mistrust of the District and Board.
Related Recommendations (3)
R1:
The Board must follow the state law and their District policies by adopting practices that will inform the public of the details of their decisions and their decision process. As noted in the report the Brown act provides a baseline for public disclosure. Debating and giving reasoned explanations for their decisions in open meetings will improve public support and participation. (F1, F3, F4)
R4:
Soquel Union Elementary School District should make available on their website an easily filed complaint form with guidelines. (F3, F4)
R5:
The Board should include a summary of complaint topics received since their last meeting in the meeting minutes. All complaint topics should be summarized, including Williams Uniform Complaint Procedure, Uniform Complaint Process, Freedom Of Information Act, email, etc. (F3, F4)
F5:
The Board has failed to adequately develop and report performance standards for the superintendent.
Related Recommendations (1)
R3:
The Board should include in the Superintendent’s performance standard a goal of reaching an agreement between the District and the HSCs that specifies accounting report content and frequency. (F5, F7)
F6:
Although HSC contributions are a significant part of the discretionary budget for schools in the District, they are not well managed and they do not receive adequate public recognition.
Related Recommendations (3)
R6:
The District administration should provide accounting reports to the HSCs in accordance with mutually agreed content and frequency. (F3, F6, F7)
R7:
The Board should include public recognition, recorded in meeting minutes, of all financial contributions from HSCs and other contributors of funds to the District. (F3, F6)
R8:
At the beginning of each school year and after consulting with the school principal, a proposed budget should be prepared by each HSC outlining the plans for donations in excess of $500. The plan should be submitted to the District for final approval. (F3, F6, F7)
F7:
There is no policy in place to reconcile HSC donations with District expenditures. The proposed contract policy between the District and contributors of donations in excess of $500 is intended to address this issue.
Related Recommendations (3)
R3:
The Board should include in the Superintendent’s performance standard a goal of reaching an agreement between the District and the HSCs that specifies accounting report content and frequency. (F5, F7)
R6:
The District administration should provide accounting reports to the HSCs in accordance with mutually agreed content and frequency. (F3, F6, F7)
R8:
At the beginning of each school year and after consulting with the school principal, a proposed budget should be prepared by each HSC outlining the plans for donations in excess of $500. The plan should be submitted to the District for final approval. (F3, F6, F7)
F8:
Because HSC contributions for teacher supplies are combined with contributions from other sources, accounting to individual donors for each teacher's expenses is impractical.
Related Recommendations (1)
R9:
The District should assume all responsibility for funding and managing teacher supply accounts and/or define a clear donation policy for contributions to teacher accounts. (F8)
Findings & Recommendations
8 findings
F1:
The Mental Health Advisory Board had not followed the recommendations of the 2013–2014 Grand Jury report and instead was less communicative and less effective.
Related Recommendations (1)
R1:
The appointed member of the Board of Supervisors should be an advocate for the Mental Health Advisory Board, meeting regularly with the Chair to establish goals, identify problem areas, suggest possible solutions, and should personally attend the monthly meetings. (F1–F3, F6)
F2:
The Mental Health Advisory Board is not meeting the requirements of the Mental Health Services Act or achieving its own goals to advocate for persons with mental illness and to increase community awareness on issues related to mental health.
Related Recommendations (1)
R1:
The appointed member of the Board of Supervisors should be an advocate for the Mental Health Advisory Board, meeting regularly with the Chair to establish goals, identify problem areas, suggest possible solutions, and should personally attend the monthly meetings. (F1–F3, F6)
F3:
The Board of Supervisors is providing little or no direction, no specific goals and objectives, and no comprehensive training on how to be an effective advisory board.
Related Recommendations (2)
R1:
The appointed member of the Board of Supervisors should be an advocate for the Mental Health Advisory Board, meeting regularly with the Chair to establish goals, identify problem areas, suggest possible solutions, and should personally attend the monthly meetings. (F1–F3, F6)
R2:
The Board of Supervisors should make every effort to fill Mental Health Advisory Board vacancies immediately, provide training for new appointees, and provide annual professional training for all members on how to serve effectively on an advisory board. (F3, F4)
F4:
The apparent lapses of direct communication between the Advisory Board, HSA[Health Services Agency], and the Board of Supervisors impedes the Advisory Board’s goals of effective advocacy for clients and advising HSA concerning Prop 63 funded mental health programs.
Related Recommendations (4)
R2:
The Board of Supervisors should make every effort to fill Mental Health Advisory Board vacancies immediately, provide training for new appointees, and provide annual professional training for all members on how to serve effectively on an advisory board. (F3, F4)
R3:
The chair of the Mental Health Advisory Board should immediately notify the Board of Supervisors and the Clerk of the Board of vacancies. (F4)
R4:
HSA should regularly attend the Mental Health Advisory Board meetings and should respond directly to the concerns raised. (F4)
R5:
The Mental Health Advisory Board should quickly and clearly communicate to HSA all issues that come before the Board. (F4)
F5:
The Mental Health Advisory Board takes no responsibility for investigation or possible action on issues raised at their meetings, and there is no general process available for the public to raise concerns.
Related Recommendations (1)
R6:
Monthly meetings of the Mental Health Advisory Board should be conducted according to County Code Chapter 2.104. In addition, they should be scheduled well in advance with times and locations made available to the public, conducted according to parliamentary procedure, physically arranged to invite public participation, and recorded in complete and accurate minutes that include discussion, decisions, actions, and public comments. (F5, F7, F8)
F6:
Five vacancies on the 11member Advisory Board left it ineffective for months during our investigation. 2013–2014 Recommendations
Related Recommendations (2)
R1:
The appointed member of the Board of Supervisors should be an advocate for the Mental Health Advisory Board, meeting regularly with the Chair to establish goals, identify problem areas, suggest possible solutions, and should personally attend the monthly meetings. (F1–F3, F6)
R7:
The Board of Supervisors should fill all Advisory Board vacancies in a timely manner. (F6) The Santa Cruz County Board of Supervisors (BOS) and the Santa Cruz County Health Services Agency (HSA) responded to that Grand Jury report, but the Mental Health Advisory Board (MHAB) did not. The California Welfare and Institutions Code § 5604.2[3] and Santa Cruz County Code Title 2, Chapter 2.104[4] provide for the establishment of a local mental health board as the advisory body to the local Mental Health Director and BOS for county mental health programs and policies. The following is a description of the MHAB on the County of Santa Cruz HSA website:[5] SCCMHB [Santa Cruz County Mental Health Advisory Board] provides advice to the governing body (Board of Supervisors) and the local mental health director. They provide oversight and monitoring of the local mental health system as well as advocate for persons with mental illness. A primary responsibility of the Local Mental Health Board (LMHB) is to review and evaluate the community’s mental health needs, services, facilities, and special problems. Printed on each MHAB Meeting Agenda[6] is a mission statement and list of goals: Mission Statement: To obtain the highest quality and most effective mental health services for the county. SCCMHB Goals: 1) Advise the Mental Health Department on Current and ongoing Issues as they relate to the Quality and Effectiveness Of Mental Health Services for the County 2) Develop skills and procedures to maximize the effectiveness of the SCCMHB 3) Increase community awareness on issues related to mental health to Ensure Inclusion and Dissemination of Accurate Information Scope The 2015–2016 Grand Jury inquired into whether the prior jury recommendations concerning the MHAB were implemented, and examined the board’s current functioning and effectiveness. Investigation We began our investigation by reviewing related documents and published literature, including text of the original Proposition 63 passed in 2004[7], and subsequent amendments to the law now known as the Mental Health Services Act (MHSA)[8]. The MHSA requires that mental health consumers and community members participate in the local advisory board. In Santa Cruz County the BOS appoints eleven members, one of whom is a County Supervisor. The other ten members are to include current or former clients of mental health services, their relatives, and others with relevant knowledge and experience. Jurors observed four of the monthly public MHAB meetings held between August and December, 2015. During this period at least three of the ten appointed positions were vacant, which combined with member absences prevented a quorum. According to MHAB attendance records, the Supervisor did not attend four of the eleven meetings in 2015, and sent an assistant as a representative. Two of the eleven meetings had no attendance record in the 2014–2015 MHAB biennial report; see
F7:
The Mental Health Advisory Board receives a great deal of information from local mental health agencies and professionals on available programs and services, but there is no mechanism to circulate and share the information with the community and to keep local mental health professionals up to date.
Related Recommendations (2)
R6:
Monthly meetings of the Mental Health Advisory Board should be conducted according to County Code Chapter 2.104. In addition, they should be scheduled well in advance with times and locations made available to the public, conducted according to parliamentary procedure, physically arranged to invite public participation, and recorded in complete and accurate minutes that include discussion, decisions, actions, and public comments. (F5, F7, F8)
R8:
The Mental Health Advisory Board should increase efforts to raise community awareness of mental health issues through public announcements, publications, speaking engagements, and other forms of community outreach. (F7)
F8:
The Grand Jury’s involvement has resulted in an increased recognition that an effective Mental Health Advisory Board is important to the community and that more positive steps are needed for continuing improvement.
Related Recommendations (1)
R6:
Monthly meetings of the Mental Health Advisory Board should be conducted according to County Code Chapter 2.104. In addition, they should be scheduled well in advance with times and locations made available to the public, conducted according to parliamentary procedure, physically arranged to invite public participation, and recorded in complete and accurate minutes that include discussion, decisions, actions, and public comments. (F5, F7, F8)
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Findings & Recommendations
1 findings
F1:
The public has not received a clear, understandable accounting of the County of Santa Cruz’s total annual retirement costs and obligations in a single summary document.
Related Recommendations (1)
R1:
The Board of Supervisors should direct the County Administrative Office to provide an annual summary of all retirement costs and obligations starting in FY 2016/17.
Additional Recommendations
1
Not linked to specific findings.
R2:
The annual summary of the total retirement costs and obligations should be identified in the county budget in clear and understandable language.
Findings & Recommendations
8 findings
F1:
The Facility Risk Report, which is generated from the Crisis Intervention Team meeting, lacks specific recommendations.
Related Recommendations (1)
R1:
The Grand Jury recommends the Crisis Intervention Team’s Facility Risk Report include written concerns and recommendations for inmates identified as atrisk. (F1)
F2:
The Crisis Intervention Team only meets on weekdays, creating potential communication problems by not meeting on weekends and holidays.
Related Recommendations (1)
R2:
The Grand Jury recommends the Crisis Intervention Team meet seven days a week. (F2)
F3:
The Observation Unit does not meet the standard definition of an infirmary.
Related Recommendations (2)
R3:
The Grand Jury recommends that the Observation Unit be upgraded to an infirmary or that the Sheriff’s Office stop referring to the area as an infirmary. (F3)
R4:
This Grand Jury has concerns about the usage of space in the Observation Unit and the Medical Unit and recommends working with a space planner to redesign the physical access between these two units. (F3–F5)
F4:
There are two holding cells in the Medical Unit which can be put to better use for inmate medical needs.
Related Recommendations (1)
R4:
This Grand Jury has concerns about the usage of space in the Observation Unit and the Medical Unit and recommends working with a space planner to redesign the physical access between these two units. (F3–F5)
F5:
The Medical Unit (which houses the nurse’s station) is several doors away from the Observation Unit contributing to lessthanoptimal medical care.
Related Recommendations (1)
R4:
This Grand Jury has concerns about the usage of space in the Observation Unit and the Medical Unit and recommends working with a space planner to redesign the physical access between these two units. (F3–F5)
F6:
Current policy allows 72 hours before an atrisk inmate is seen by a doctor, which we feel is too long for atrisk inmates.
Related Recommendations (1)
R5:
The Grand Jury recommends that atrisk inmates be seen within four hours by medical personnel. (F6)
F7:
The window for cell 13 in the Observation Unit is too small for adequate observation.
Related Recommendations (1)
R6:
The Grand Jury recommends that the window for cell 13 in the Observation Unit be enlarged to at least the same size as the other cells. (F7)
F8:
The Main Jail’s unsecured kitchen back door is a security risk.
Related Recommendations (1)
R7:
The Grand Jury recommends a fence be built within this year to enclose the unrestricted area outside the kitchen back door. Until it is completed, a temporary solution should be installed immediately and inmates should be personally escorted. (F8)
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Findings & Recommendations
11 findings
F1:
There is no publicly available comprehensive report identifying the cause of Krista DeLuca’s death, the activities of the SheriffCoroner’s Office, and the activities of the medical services provider related to her death.
Related Recommendations (2)
R1:
The SheriffCoroner should designate qualified personnel to oversee the medical services contract provisions and compliance with standards. Response: Will not be implemented [with explanation].
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
F2:
There is no independent county oversight, by a qualified medical professional, of both the medical services provider (CFMG) and the contract.
Related Recommendations (2)
R2:
The SheriffCoroner should obtain independent oversight of its jail medical services by medically qualified personnel. Response: Will not be implemented [with explanation].
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
F3:
The 2012–2016 contract does not allow the Sheriff’s Office to retain additional independent medical providers but the Watch Commander can override the medical service provider’s decision and escalate to a higher level of medical care in lifethreatening emergency circumstances.
Related Recommendations (2)
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
R4:
The SheriffCoroner should revise the medical services contract to allow an independently retained medical provider to escalate medical care under lifethreatening emergency circumstances. (F3)
F4:
The 2012–2016 contract requirement that the jail medical services provider pay up to $15,000 per inmate admitted to a hospital may be a deterrent to admitting inmates in need of hospital medical care.
Related Recommendations (1)
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
F5:
The Health Services Agency completed the required 2015 annual Title 15 inspection of the Main Jail but did not identify if the facility was in compliance with the Detoxification Treatment requirements (Title 15, Section 1213).
Related Recommendations (3)
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
R5:
The SheriffCoroner should require, at the time of contract renewal, that the jail medical services provider obtain and maintain California Medical AssociationInstitute for Medical Quality accreditation for the Main Jail, Blaine Street and Rountree detention facilities. Response: Requires further analysis [with explanation]. We find the Sheriff’s responses unsatisfying. There have been six deaths in the Main Jail since October 2012. The sixth and most recent death occurred on September 29, 2015. It is important to note that not all of the six inmates died while under the direct medical care of CFMG. Santa Cruz Main Jail InCustody Deaths from October 2012 through March 2016 Name Age Date of Death Reported Cause of Death Richard Prichard 59 10/06/12 Heart attack Brant Monnett 47 11/20/12 Narcotic overdose Bradley Dreher 47 1/13/13 Asphyxiation by hanging Amanda Sloan 30 7/17/13 Asphyxiation by hanging Sharyon Gibbs 65 11/5/14 Natural causes Aspiration pneumonia, dehydration from Krista DeLuca 23 9/29/15 opiate withdrawal Sources: Five Deaths in Santa Cruz[3] in 2014, Medical Services at the Jails[4] in 2015, and the autopsy report for Krista DeLuca.[6] Two of those deaths have been related to the withdrawal or detoxification from controlled substances (opiates) while under the medical care of CFMG. The Grand Jury has the authority to evaluate the Sheriff’s Office, the detention facilities, the policies and procedures reviewed and approved by the Sheriff’s Office, and the contract between the Sheriff'’s Office and CFMG. The Grand Jury does not have the authority to investigate the California Forensic Medical Group, Inc., a forprofit company. Death rates for jails are collected by the U.S. Bureau of Justice Statistics. For the years 2000–2013 death rates at local jails have ranged from 123 to 151 per 100,000 inmates per year.[7] During this 13 year period, 82% of local jails had zero deaths recorded.[7] The Santa Cruz County jail population is roughly 500.[8] Therefore, we could expect at most three deaths in our jails in four years; there have been more than twice that number of deaths in the four years under the 2012–2016 contract. Jail inmates are a medically vulnerable population, whether due to poor health habits, poverty, old age, lack of medical care or, as in the case of Krista DeLuca, drug or alcohol addiction. The Sheriff’s Office is responsible for the health care of inmates and our investigation made note of the efforts taken by Corrections Officers in providing humane assistance and care to these fragile inmates. What the Grand Jury found to be so disturbing in Ms. DeLuca's case was that she was under medical care during the fourday period in which she slowly died. Ms. DeLuca did not die from a drug overdose; this 23yearold woman died from complications from an ostensibly medically supervised drug withdrawal. Six inmate deaths have occurred at the Main Jail since October 2012, two of which were related to opiate withdrawals or detoxification while under the medical care of CFMG. Scope The focus of this report is to review three issues: the most recent death in the jail, the medical policies and procedures reviewed and approved by the Sheriff’s Office related to that death, and the existing medical services contract between Santa Cruz County and California Forensic Medical Group, Inc. The following documents were examined: ● The contract between the SheriffCoroner and CFMG[2] ● Four medical policies approved by the Sheriff’s Office related to the death: ○ PreDetention Medical Evaluation/Intake Health Screening ○ Chronic Care ○ Chemically Dependent Inmates ○ Reporting InCustody Deaths ● The 2013–2014[3] and 2014–2015[4] Grand Jury reports ● The autopsy report[6] for Krista DeLuca ● Title 15 Inspection of the Main Jail by the Health Services Agency, April and May 2015[9] ● The Federal Bureau of Prisons, Clinical Practice Guidelines, Detoxification of Chemically Dependent Inmates, February 2014[10] Interviews were conducted and the Grand Jury toured and inspected the Main Jail. The Grand Jury does not have the authority to investigate the California Forensic Medical Group, Inc., a forprofit company. Investigation Death Krista DeLuca was taken into custody on September 25, 2015, and died four days later in the County Main Jail on September 29, 2015. The autopsy stated the cause of death was: Acute aspiration pneumonia, dehydration and probable electrolyte imbalance due to protracted vomiting associated with opiate withdrawal and opiate dependence from chronic heroin abuse.[6] In common terms, this says in part that Ms. DeLuca died after four days of vomiting, depleting her body of essential minerals and hydration, ultimately inhaling her own vomit and developing pneumonia. As an inmate of the County Main Jail, Ms. DeLuca was under the medical care of CFMG. For a chronology of the four days of events leading to her death see Appendix A. After reviewing the records from the jail and conducting interviews, the Grand Jury found that the Corrections Officers at the facility followed their policies and procedures and provided both professional and compassionate care to Krista DeLuca. The Grand Jury has jurisdiction to investigate the SheriffCoroner’s oversight of the CFMG contract, but the Grand Jury does not have authority to investigate CFMG directly. The Sheriff's Office has not issued a public report on Ms. DeLuca's death and the actions or inactions of CFMG. Medical Policies and Procedures Approved by the SheriffCoroner As part of the contract between CFMG and the SheriffCoroner, the Medical and Mental Health Care Procedure Manual is reviewed and approved by the Sheriff’s Office prior to its implementation. Four policies were reviewed by the Grand Jury for compliance to California Title 15 requirements for adult detention facilities: 1. PreDetention Medical Evaluation/Intake Health Screening This policy meets the requirements of Title 15.[11] 2. Chronic Care This policy meets the requirements of Title 15. 3. Chemically Dependent Inmate Policy This policy does not meet the requirements of the Title 15, Section 1213, which states in part: The responsible physician shall develop written medical policies on detoxification which shall include a statement as to whether detoxification will be provided within the facility or require transfer to a licensed medical facility. The facility detoxification protocol shall include procedures and symptoms necessitating immediate transfer to a hospital or other medical facility. The Grand Jury found that the Chemically Dependent Inmates Policy does not specify what symptoms necessitate immediate transfer to a hospital or other medical facility. The policy does not address how chemically dependent inmates are identified other than self report or staff report. Also missing from this policy is the use of an objective opiate withdrawal screening tool such as the Clinical Opiate Withdrawal Scale (COWS).[12] This simple 11 item questionnaire provides an objective measurement of the stage and severity of an inmate’s opiate withdrawal and helps staff with treatment decision making. 4. Reporting InCustody Deaths This policy meets the requirements of Title 15. The Grand Jury reviewed the Detoxification of Chemically Dependent Inmates, Federal Bureau of Prisons Clinical Practice Guidelines, February 2014.[10] The document provides guidelines for the medical management of withdrawal from addictive substances for federal inmates. The Grand Jury recommends this document be reviewed and evaluated by the SheriffCoroner and the applicable guidelines be incorporated into the Sheriff's Office policies and procedures. Why did CFMG medical staff not transfer Krista DeLuca to a hospital? The Grand Jury can not investigate this because actions by a forprofit contractor are not within our jurisdiction. Contract between the SheriffCoroner and CFMG The Grand Jury reviewed the existing contract between the SheriffCoroner and CFMG, which expires on September 16, 2016. Five areas of concern were noted: 1. Responsibility for Health Care Services The contract states ( ) the following regarding responsibility: Final medical judgements rest with the Medical Director of CFMG, or designee. The SheriffCoroner, who is ultimately responsible for emergency and basic health care services to all inmates, should have the ability to retain additional independent medical assessment for lifethreatening or emergency circumstances. 2. Compliance with CMAIMQ Accreditation Standards[13] The contract states ( ) the following regarding compliance with standards: All health care services will comply with Title 15, the CMAIMQ Accreditation Standards for Adult Correction Facilities and all other applicable laws, regulations, codes and guidelines relating to health care services and programs in adult correction facilities in the State of California. The contract does not specifically state CFMG must seek and obtain CMAIMQ accreditation, only that they must comply with the accreditation standards. The Grand Jury found no documentation that the medical services at detention facilities under CFMG’s management were compliant with CMAIMQ accreditation standards. 3. Detoxification Treatment The contract states ( 0186) the following relating to detoxification treatment: Inmates who are unresponsive and/or whose condition is deemed by CFMG health services staff as unsuitable for housing in the jail will be transported to either Dominican Hospital or Watsonville Community Hospital for treatment. CFMG medical staff did not transfer Krista DeLuca to a hospital. The Grand Jury can not investigate this because actions by a forprofit contractor are not within our jurisdiction. 4. Emergency and Catastrophic Costs The contract states ( ) the following relating to emergency and catastrophic costs: CFMG will pay all hospital emergency/catastrophic medical care costs up to $15,000 per inmate for each medical/surgical inpatient episode. The Grand Jury believes this is a disincentive to admit inmates to a hospital for necessary medical treatment, and recommends removing this clause from the contract, an action currently being considered by the Sheriff's Office. The Board of Supervisors and the SheriffCoroner should thoroughly review and revise the existing medical services contract and critically evaluate the performance of the 2012–2016 medical services provider. 5. Outside Review of Contract and the Medical Services Contractor There is no ongoing independent county medical oversight of the detention facility medical services provider or contract compliance related to medical issues. The Grand Jury believes retaining medically qualified personnel familiar with medical services within institutions and contract compliance is necessary to ensure basic health care for all inmates. Investigative Facts Summary 1. The SheriffCoroner has the responsibility to ensure provision of emergency and basic health care services to all inmates in Santa Cruz County detention facilities, even when contracting with a medical services provider for jail health care services. 2. The 2012–2016 contract with CFMG for medical services at the county detention facilities began on September 17, 2012, and ends on September 16, 2016. 3. There have been six inmate deaths in the Main Jail since October 2012. 4. The Santa Cruz County detention facilities are not accredited by the California Medical AssociationInstitute for Medical Quality. The contract states that all health care services will comply with the California Medical AssociationInstitute for Medical Quality standards, but there is no specific requirement for accreditation. 5. The Sheriff’s Office and Board of Supervisors have the option of continuing with a private contractor for jail medical services or returning to the Santa Cruz County Health Services Agency. 6. The Sheriff’s Office at times refers to placing atrisk inmates in the infirmary, when in fact they are placed in the Observation Unit. The Observation Unit is not an infirmary. 7. The most recent Title 15 annual inspection for detention facilities conducted by the Santa Cruz County Health Services Agency in April and May 2015 shows that compliance with the detoxification treatment requirements (Title 15, Section 1213) was marked as “not applicable.” 8. The SheriffCoroner declined to implement most recommendations in the 2013–2014 and 2014–2015 Grand Jury Reports. 9. SheriffCoroner Watch Commanders have the authority to override the medical service provider’s decision and escalate to a higher level of medical care in lifethreatening emergency circumstances.
R6:
The Health Services Agency should complete the annual 2016 Title 15 inspection and identify if the facility is in compliance with the Detoxification Treatment requirements (Title 15, Section 1213), as required by state law. (F5)
F6:
There is no documentation that the Santa Cruz County facilities have been evaluated for compliance with the CMAIMQ medical accreditation standards for detention facilities.
Related Recommendations (2)
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
R7:
The SheriffCoroner and Board of Supervisors should require in the contract that the medical services provider for detention facilities obtain and maintain accreditation from the California Medical AssociationInstitute for Medical Quality for adult detention facilities. (F6)
F7:
The Chemically Dependent Inmate Policy lacks objective measurement tools for assisting the medical staff with their clinical decision making and determination of when a patient requires a higher level of medical care.
Related Recommendations (2)
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
R8:
The SheriffCoroner should require that the Chemically Dependent Inmate Policy include the use of objective measurements of opiate detoxification stages, such as the Clinical Opiate Withdrawal Scale (COWS), to assist the medical staff in making more objective decisions regarding treatment. (F7)
F8:
The Chemically Dependent Inmate Policy does not include procedures and symptoms necessitating immediate transfer to a hospital or other medical facility.
Related Recommendations (2)
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
R9:
The SheriffCoroner should work with the medical services provider to revise the Chemically Dependent Inmate Policy to comply with California Code of Regulations, Title 15, Section 1213, regarding procedures and symptoms necessitating immediate transfer to a hospital or other medical facility. (F8)
F9:
The Chemically Dependent Inmate Policy and the Sheriff’s Medical and Mental Health Care Procedure Manual lack guidance for when an inmate should be transferred to a hospital for a higher level of care or when an inmate should be placed on IV hydration.
Related Recommendations (2)
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
R10:
Clear guidelines need to be established in the Sheriff’s Medical and Mental Health Care Procedure Manual for when an inmate should be given a higher level care such as IV hydration or transfer to a hospital. (F9)
F10:
The Detoxification of Chemically Dependent Inmates, Federal Bureau of Prisons Clinical Practice Guidelines, February 2014, contains useful information related to recommended standards for the medical management of withdrawal from addictive substances.
Related Recommendations (2)
R3:
Prior to approving a new medical services contract, the SheriffCoroner and Board of Supervisors should thoroughly review the existing contract and evaluate the performance of the 2012–2016 medical services provider with the assistance of qualified medical personnel. (F1–10)
R11:
The SheriffCoroner should review Detoxification of Chemically Dependent Inmates, Federal Bureau of Prisons Clinical Practice Guidelines, February 2014, and revise applicable Sheriff's policies and procedures to meet or exceed federal guidelines. (F10)
F11:
The Sheriff’s Office at times refers to placing atrisk inmates in the infirmary, when in fact they are placed in the Observation Unit. The Observation Unit is not an infirmary. The Grand Jury finds this misnomer to be misleading to the public and endangering of the public trust.
Related Recommendations (1)
R12:
The SheriffCoroner should stop referring to the Observation Unit as an infirmary unless major steps are taken to improve the medical services provided in this unit. Continuing to refer to this group of observation cells as an infirmary is misleading to the public and does a disservice to the public trust. (F11) Commendation C1. In this entire unfortunate situation, there is but one bright spot. The Corrections Officers who watched over Krista DeLuca during her last hours carried out their duties with professionalism and compassion for their charge by making small but meaningful efforts to preserve her dignity during her last hours. The Corrections Officer who was working at the booking desk was concerned for Ms. DeLuca’s safety and kept her in booking so he could keep a closer watch on her. Corrections Officers in the Observation Unit made efforts to provide water and assistance while performing their required duties.
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Findings & Recommendations
11 findings
F1:
Inmates are kept at Water Street Jail for medical reasons alone when they are otherwise eligible for the increased services and programming at Rountree. This denies programming to an otherwise-eligible inmate that may increase their ability to succeed upon community reentry.
Related Recommendations (1)
R1:
The Sheriff’s Office should make the necessary changes to allow inmates with chronic medical problems to be housed at Rountree. (F1)
F2:
The Crisis Intervention Team keeps notes in inmate records, but not minutes of meetings or a summary of daily record changes. Without a meeting summary, there is no documentation of continuum of care and context for decision making.
Related Recommendations (1)
R2:
The Crisis Intervention Team should produce and review minutes of their meetings. (F2)
F3:
The Sheriff’s Custody Manual includes a general description of a safety cell’s allowable use. This results in the inappropriate housing of inmates in cell O13.
Related Recommendations (1)
R3:
The Sheriff’s Custody Manual Policy sections 517.1 and 517.2 should be modified to avoid inappropriate housing of inmates in detox or medically at risk. (F3)
F4:
Long term inmates at Water Street may suffer from Vitamin D deficiencies due to lack of exposure to natural sunlight. Medical staff have not tested inmates for possible Vitamin D deficiencies.
Related Recommendations (1)
R4:
The Sheriff’s Office should test whether any long-term or at-risk inmates at Water Street are Vitamin D deficient. (F4)
F5:
Water Street, a maximum security facility, has no means of detecting non-metal contraband other than physically searching an inmate. This increases the chance of dangerous items being brought into the facility.
Related Recommendations (1)
R5:
The Sheriff’s Office should review and implement current technology available for contraband detection. (F5)
F6:
The empty Blaine Street facility indicates a lack of long-range facility planning and coordination.
Related Recommendations (1)
R6:
The Sheriff’s Office should create a strategic long-range facilities management plan, including management of multiple funding sources. (F6)
F7:
When asked about program effectiveness and measurements of success locally, staff were unable to provide scorecards, analytics, or follow-up information on recidivism or success. This impacts their programs and future funding.
Related Recommendations (1)
R7:
Law enforcement should create, use, and publish scorecards to measure the local success of inmate programs. (F7)
F8:
AB109 prison realignment is making it difficult to maintain adequate firefighting crews at Ben Lomond Conservation Camp.
Related Recommendations (1)
R8:
The Sheriff needs to be proactive with placing Boarders, qualified inmates from the county jail system, at the fire camp when appropriate. (F8, F9)
F9:
The county “Boarder Program” at the Ben Lomond Conservation Camp is less costly to the county than housing inmates in the county jail system.
Related Recommendations (1)
R8:
The Sheriff needs to be proactive with placing Boarders, qualified inmates from the county jail system, at the fire camp when appropriate. (F8, F9)
F10:
There is significantly less programming at Ben Lomond Conservation Camp than in the other facilities that we visited, which may impact inmates’ post-release success.
Related Recommendations (1)
R9:
CDCR should provide in-person help with GED studies to benefit Ben Lomond Fire Camp inmates. (F10)
F11:
The remote location of the Ben Lomond Conservation Camp impacts emergency medical services for inmates and staff. Current county medical protocol does not allow staff on site to store or administer Narcan or Epinephrine. Published June 27, 2017 90 Santa Cruz County Grand Jury
Related Recommendations (1)
R10:
Narcan nasal spray and epinephrine auto-injectors should be available, along with training on when and how to use them. (F11)