Sonoma County 2007-2008 - California Grand Jury Reports

February 13, 2009 — "Sonoma County Office of Education – An Overview" R1: Scoe must ensure that school districts do not sacrifice important*

2 pages 3 recommendations

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Additional Recommendations 3

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R1: SCOE must ensure that school districts do not sacrifice important programs or decrease the number of teacher's aides as a way to balance the budget. The Sonoma County Office of Education is in agreement with the Grand Jury's findings that projected State budget cuts of 10 percent will impact art and music programs and possibly reduce the number of teachers' aides. The Sonoma County Superintendent of Schools, acting as an intermediate agent between the state and the districts in the county, is responsible for the fiscal oversight of districts in the county. As the fiscal oversight agency, the county superintendent provides management assistance and progressive intervention to districts whose financial condition requires such assistance and intervention. The first level of fiscal oversight remains with the board of education and administration of each district. The assistance and intervention required by of the SCOE by the state does not allow the SCOE to prescribe or mandate the types of programs offered or staffing for any district in the county. It is at the district level that decisions are made on how to balance the district budget. Local school boards are accountable to the electorate in their district. Local school boards have the responsibility to determine what programs and staffing will best meet the needs of the students in the district.

R2: SCOE should explore the possibility of establishing an internship program for education majors at Sonoma State, Dominican college, and Santa Rosa Junior college to give student teachers classroom experience and allow them to assist teachers. The Beginning Teacher Support and Assessment (BTSA) program is currently working with institutions of higher education through a regional network that already provides opportunities for student teachers and paraprofessional program participants placing them in classrooms throughout a seven-county region. BTSA program participants do assist classroom teachers through the development, implementation and assessment of classroom curriculum. In addition, most institutions of higher education require at least forty (40) hours of field work observation prior to the actual student teaching assignment. This field work can and should be utilized to assist classroom teachers at school site not only to increase their knowledge of classroom instruction, but also to assist teachers who have experienced a decrease in or elimination of classroom teaching assistants. Representatives from all surrounding Institutions of Higher Education attend our quarterly Advisory Meetings through our Beginning Teachers Support and Assessment program and this recommendation on restructuring the field work experience will be placed on the agenda for discussion. 8/19/08 - ...- ...

R3: The Sonoma County Board of Education should explore options to increase its effectiveness. The board represents a wealth of knowledge and needs to seek ways to change the paradigm of its work and increase its influence. The Sonoma County Board of Education has always been vigilant with regard to its duties, responsibilities and effectiveness and better communicates this to the public. The Board is appreciative of the recognition by the Grand Jury of the knowledge base of the Sonoma County Board. The Board also appreciates the Grand Jury's vision of operational issues and the recommendation that would increase the role and influence of the County Board of Education. The County Board will continue its work with statewide educational groups and local legislators as one means to implement the recommendation to explore options to increase the role and effectiveness of the County Board. 8/19/08

October 23, 2008 — Palm Drive*

21 pages 16 recommendations

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Additional Recommendations 16

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R1: Under the direction of the Board Chair, Linda Johnson, beginning in June 2008 management incorporated training segments into the agenda of the monthly meetings of the Board of Directors. The training curriculum for the Board encompasses all aspects of their responsibilities, but at this time has a special focus on the financial aspects of hospital operations and capital financing. At the October 2008 meeting of the District Board, for example, training was conducted on hospital budgeting, including the purposes, formation, and implementation of both operations and capital budgets. Since the FY 2009 operating budget was a first for the Hospital in terms of implementing budgets at the department level, the Board was shown how the budget will assist operating departments to manage their costs, as well as to provide the Board with a tool for evaluating financial performance at the department level. Planned financial training segments include capital financing, Medicare and Medi-Cal reimbursement changes, and basic hospital accounting practices.

R2: A five year strategic plan, with benchmarks, should be developed annually. Palm Drive Hospital provides an annual strategic plan to the District Board of Directors. This plan was presented and adopted by the Board in February. Listed below are the plans for year 2008: I. INTRODUCTION/PURPOSE The purpose of the Plan for the Provision of Patient Care (PPPC) is to provide a framework for planning, directing, coordinating, providing, and improving the health care services available at the hospital to ensure we are responsive to community and patient needs and improve health outcomes. This document serves as a basis to: Identify existing and new patient care services. • Direct and integrate patient care and support services throughout the hospital. Implement and coordinate services among departments.

R3: The District has addressed the issue of physician support in two ways. First, the District created a 1206(d) licensed medical clinic to house primary care physicians that either do not have an established patient population, or have not wished to continue to operate a private practice. Under the 1206(d) exemption from the California Health Facilities code, which prohibits the corporate practice of medicine, the Hospital is permitted to operate a physician-staffed medical clinic as an outpatient department. This model helps insure that the Hospital and local community will have access to primary care physicians into the future. Currently, there are three physicians and one nurse practitioner working in the clinic, which is known as Palm Drive Medical Center. By the end of the current calendar year an additional physician is expected to join the clinic. A second approach created by the District is the provision of billing, collection, and practice management consultation to local physicians whom are experiencing difficulties. This assistance, available since early 2008, has had four physicians as clients so far. Owned and operated by the Palm Drive Health Care District PALM DRIVE 501 Petaluma Avenue, Sebastopol, CA 95472 WILL! 707-823-8511 Fax: 707-829-4141 www.palmdrivehospital.com HOSPITAL Caring for Community Caring for Life

R4: The District should increase efforts to improve the image of Palm Drive Hospital in order to attract quality physicians and avoid losing patients to competing hospitals. As part of Palm Drive Hospital's strategic plan cosmetic renovation of the facility is well underway. Starting in June of 2007 the Intensive Care Unit was refurbished with new flooring, paint, window treatments, flat screen televisions, new chairs, new beds, new bedside tables and nurses station. The best technological monitors were bought and installed. These monitors are able to assess the most intensive patients, providing feedback to the nurses and physicians. A RP7 Robot was leased and now provides 24/7 specialist coverage to the ICU, Medical Surgical Units and the Emergency Room. This robot provides the means for 7 different medical specialties to consult via telemedicine. Dr. Gude, the Intensive Care Medical Director plans on opening the School of Robotic Telemedicine at Palm Drive Hospital in February 2009. The public image of our ICU, and thus hospital, has changed in the past year from being "shuttered" to now providing cutting edge medicine. Beginning in February of 2008 every patient room was renovated. This included new flooring, window treatments, paint, fixtures, nurse communication boards, above bed lighting, cubicle curtains and linens. The public hallways were also painted, ceiling tiles repaired, hand rails installed and art hung. The Medical Surgical Nurses Station was re-furbished to washable, functional and beautiful surfaces. New signage has been placed throughout the patient areas. The waiting room for out-patient surgery and ICU was also refurbished. New paint, flooring, window treatments, flat screen television, lighting, art, furniture and a wall water fountain were installed. This area is relaxing, and meditative. This past week we have completely refurbished our Human Resources office. All new floors with both carpet and vinyl, ceiling tiles, window coverings, furniture, and signage have been installed. The Emergency waiting room has been repainted; floors burnished and sealed, new HIPPA compliant registration furniture and Triage areas are now in place. New signage has been installed to further help with navigating the facility. The Out Patient Surgical Unit has also been revamped with new flooring. paint, window treatments, lighting, cubicle curtains, furniture and cabinetry. In the next two months we will have completed the "TCU" area, and public hallways with new paint, floor coverings and signage. This phase will also include a remodel of our two public restrooms. Owned and operated by the Palm Drive Health Care District ------ PALM DRIVE 501 Petaluma Avenue, Sebastopol, CA 95472 707-823-8511 Fax: 707-829-4141 www.palmdrivehospital.com HOSPIT A L Caring for Community Caring for Life Our Phase III project will encompass the remodeling of our front lobby area, cafeteria and conference room. This project will involve obtaining an OSPHD permit prior to proceeding. Lastly, the outside of our facility: This past year we have had our entire parking lot resurfaced, new ADA parking spots installed and curbs painted. The community has worked together to build the only "green" helipad in the nation. This helipad is unique in maintaining and enhancing the natural environment, providing an area for learning, and the necessary technological needs for landing an aircraft. We have also received a donation of landscaping which included tree trimming, sprinkler repair and plant installation. The sidewalks have been spray cleaned and trim areas repaired and painted. Owned and operated by the Palm Drive Health Care District . . . . . . . . . . . . . . . . . . . . PALM DRIVE HOSPITAL Department: Human Resources Performance Evaluation Policy Pro#: HR Subject: Effective Date: Review Dates: 9/01,11/03 Revision/Approval Dates: 9/01, 06/08 Distribution: Purpose: To describe the purpose and process for performance evaluations and staff development planning. Policy: It is the policy of the hospital to evaluate employee performance formally in writing on an annual basis. The purpose of the annual "performance evaluation" is to: help an individual and his/her supervisor clarify performance expectations; describe any gaps between desired performance and actual performance; differentiate salary increases based upon individual performance contribution; and . develop plans for personal development and continuous improvement. . Procedure: Human Resources will notify department managers on a monthly basis, 2 months in advance, when individuals are due for an "annual" performance evaluation. Evaluations are due within 30 days after the date indicated. Evaluations are considered late beginning on the 31st day after the due date. Managers are to submit all performance evaluation documentation, including all formal written performance evaluations, to the Human Resources Department for inclusion in the employee's personnel file. The procedure for assessing Managers and Executive Management encompasses a 360 degree approach as follows: In reviewing a Manager's performance, the reviewer will seek input from at least one person selected from each of the categories below. For objectivity and consistency, the reviewer will provide each of the 360 degree evaluators with a copy of the standard Job Expectations Form which is associated with the position. Peer Subordinate Staff Person Senior Manager Other Customer Member of the Board (if applicable) Community Member (if applicable) The reviewer will then summarize the above inputs in writing without attributing any specific comments to the providers thereof, and use this information to finalize the Manager's review and assessment. Upon completion of this process, the reviewer and Manager will meet to establish goals and objectives for the forthcoming year. PART 1 JOB DESCRIPTION Today's Date Review Dates: Employee From: To: Date of Hire: Type of Appraisal: 3 Month (New Employee) Position Title ☐ Annual ☐ Other Chief Operating Officer Appraisal Given By: Last Evaluation Date: ☐ Supervisor ☐ Employee (self-evaluation) Position Reports To: Due Date: Department Administration Chief Executive Officer Past Due After: Job Summary (Purpose the Position Exists): Under general direction, assumes line responsibility and authority for the administrative direction, evaluation, and coordination of the functions and activities of assigned departments within the hospital organization to ensure operating objectives and results are in accord with overall hospital needs. In the absence of the CEO and/or as assigned, represents the CEO in the coordination of the entire or portions of the hospital organization, speaking and acting within the scope of objectives set forth in the practice and/or policy of the hospital. Education, Training and Licenses Required: Bachelor's Degree required, Master's Degree preferred. Experience Required: Knowledge of the healthcare field as well as refined managerial skills, including excellent presentation skills and a track record of establishing trust and rapport with a diversity of constituents. At least 10 years in a high-level hospital management position, preferably as a COO or equivalent Management scope. Knowledge/Skills/Abilities Required: Must have a thorough knowledge of fundamentals of organization and administration, standards and regulations of hospital and laws applicable to hospital operations. Must have working knowledge of personnel or business administration, merchandising, public relations, mechanics, dietetics, medicine, psychiatry, or nursing and functions of all departments. Is able to apply principles of personnel administration to selection, placement and transfer of employees. Proven ability to communicate effectively with stakeholders at all levels, e.g. staff, physicians, and members of the community. Equipment Knowledge Required: Ability to use office equipment with dexterity and A.V. equipment. Working Conditions (Noise, Environmental, Demands, Shift, Setting, Human Interface, etc.): Works in a clean, well-lit, well- ventilated, temperature controlled environment. Makes frequent visits to all hospital areas. Hours of duty are lengthy and irregular. The noise level in the work environment is usually moderate. Confidentiality Requirements: I understand that any and all information regarding hospital, patient, and employment matters are disclosed or learned by me in confidence. I agree that during and after my term of employment, I will not directly or indirectly disclose this information, other than to an authorized employee of Palm Drive Hospital. Safety Requirements: Employees are responsible for all aspects of the hospital safety and health program including compliance with safety rules and regulations, remedying unsafe working conditions, and for continuously practicing safety while performing duties. Physical Requirements: See "Description of Physical Demands" record in Human Resources. Supervisory Requirements (if applicable): This position supervises a staff of ___, including part time employees. I understand I will be reviewed on my competence as a supervisor, including but not limited to communication skills, delegation of tasks. prioritization of work, leadership, problem solving, budgeting and reviewing of my staff's performance. H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PART 2 JOB SPECIFIC EXPECTATIONS REVIEW This section reviews the position's essential or most important functions. Job specific expectations account for 50% of the performance evaluation rating. Self Evaluator's 4 = Substantially Exceeds 3 = Exceeds 2 = Meets 1 = Below Assessment | Assessment Chief Operating Officer Expectations 4 4 3 3 2 1 1 2 1. Provides administrative direction for the operations of assigned departments and appraises the performance of respective department heads, including authority to hire and fire subject to the veto of the CEO. 2. Communicates routinely with the CEO concerning policy recommendations and suggested courses of action pertinent to the efficient operation of assigned departments. Implements new policies and disseminates pertinent information following administrative directives. 3. Recommends improvement of hospital facilities in assigned areas, including construction or renovation of structures and purchase of new equipment. 4. Promotes complete involvement of department heads in the preparation of the department's budget and educates them in the importance of the budget, forecasting, and planning process. Advises and makes recommendations to the CEO concerning budgeting, cost, and financial matters. 5. Encourages and assists department heads in establishing a measure of performance, increased productivity, quality improvement, cost controls and maximum utilization of facilities. Advises CEO where executive action is necessary to accomplish these goals. Plans the activities of individual departments so as to obtain a better understanding of each other's problems. 6. Attends medical staff meetings and/or medical staff committee meetings as assigned or requested. Informs the CEO of proceedings at meetings attended and recommends action as necessary. Represents the hospital by membership in related professional associations. 7. Performs other duties as assigned by the CEO and/or PDHCD Board of Directors. Total # of 4's ___ x 4 = ___ Total # of 3's ___ x 3 = ___ Total # of 2's ___ x 2 = ___ Total # of 1's ___ x 1 = ___ Job Specific Expectations Total Points (sum of above) = _____ Divided by 7 = ____ (Job Specific Score) H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PART 3 CORE EXPECTATIONS REVIEW This section reviews Palm Drive Hospital's core expectations. Core expectations account for 15% of the performance evaluation rating. Self Evaluator's 4 = Substantially Exceeds 3 = Exceeds 2 = Meets 1 = Below Assessment Assessment Attendance and Punctuality 3 4 3 1 4 2 2 1 1. Adheres to Palm Drive Hospital policy governing absences and tardiness. Adheres to meal and rest breaks according to department policy/schedule. Records time worked according to hospital policy. Uses time clock and missed punch sheet when appropriate. Submits vacation requests in a timely manner. Attends mandatory staff meetings and inservice programs. Dress Code / Grooming Adheres to hospital/department dress code at all times. Adheres to hospital grooming, personal hygiene and cleanliness standards. Wears unobstructed name badge at all times while on duty. Compliance Adheres to hospital compliance policy and Code of Conduct. 7. Complies with regulatory requirements: attends annual training, fulfills annual PPD requirements, and maintains current licenses and certifications. Supports and adheres to Palm Drive Hospital's mission and vision statement. Adheres to Palm Drive Hospital confidentiality policy and HIPAA guidelines. Customer Service (Customers are identified as patients, visitors, employees, and any other person on the hospital premises.) Listens to customer concerns and needs; takes personal action to meet customer needs and resolve complaints; seeks management support if unable to meet customer needs; apologizes for delays and provides updates to customers. Practices telephone and paging courtesy. Works with the customer to identify available options to meet customer needs; demonstrates a positive, flexible attitude in seeking solutions to customer; uses knowledge of rules and regulations to find solutions; if rules are a barrier, works to identify an alternative. 11. Demonstrates a caring and concerned attitude; treats customer problems and concerns seriously; protects privacy and confidentiality of the customer. 12. Responds to customers as the primary priority; earns trust and confidence of customer by knowing what to do and doing it well; continually strives to improve services for the customer. Professional Conduct 13. Initiates and maintains working relationships that are characterized by mutual support. open communication, trust, and respect. 14. Keeps personal biases and private life separate from work. 15. Accepts constructive criticism without defensiveness. Communication Maintains open communication style with co-workers and managers. 17. Communicates in a manner that promotes cooperation, avoids antagonism, reduces or resolves conflict, and prevents undue patient and/or staff anxiety. Total # of 4's ___ x 4 = ___ Total # of 3's ___ x 3 = ___ Total # of 2's ___ x 2 = ___ Total # of 1's ___ x 1 = ___ Core Expectations Total Points (sum of above) = _____ Divided by 17 = ____ (Core Score) H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PART 4 MANAGERIAL EXPECTATIONS REVIEW This section reviews Palm Drive Hospital's managerial expectations. Managerial expectations account for 35% of the performance evaluation rating. Self Evaluator's 4 = Substantially Exceeds 3 = Exceeds 2 = Meets 1 = Below Assessment Assessment Performance Improvement / Regulatory Compliance 3 4 2 1 4 3 2 1 1. Is proficient in integrating the key elements of performance improvement into daily work activities. Demonstrates familiarity of department/service area-based performance improvement initiatives. Implements or participates in at least one performance improvement project within area(s) of responsibility. 2. Ensures ongoing compliance with all regulatory requirements in area of supervision. Attends all mandatory Quality Management meetings. Prepares and presents reports in a timely fashion. Budget and Financial Management 4. Submits budget requests in a timely manner. Determines and implements cost control procedures. 6. Operates department(s)/unit(s) within allocated budget; or, provides well-documented justification of workload/census demands requiring a budget adjustment; seeks out and utilizes benchmarking and comparative data. Human Resources Management 7. Conducts all performance evaluations in a timely manner in accordance with hospital policy. Annual evaluation compliance for 12 month period = #Due _____#Completed Note: 100% compliance = 4 Rating; Anything less than 100% = 1Rating. Keeps departmental competency assessment records up-to-date. Manages work performance and behavior of staff and implements performance improvement plans and/or takes corrective actions as needed. Ensures staff compliance with regulatory requirements (annual training, PPD, licenses and certification, etc.). Ensures staff complete department and hospital-wide orientation. 11. Ensures all employment decisions and disciplinary actions are in accordance with hospital policy. Leadership 12. Demonstrates commitment to Palm Drive Hospital mission and vision statement Demonstrates appreciation of workplace diversity. 14. Exhibits professionalism in evaluating and recognizing staff performance and promotes staff development. 15. Establishes clear two-way communication with all staff to ensure accountability and understanding of pertinent issues. 16. Meets regularly with staff to communicate organizational and departmental priorities. Displays initiative in creativity and problem solving. Recommends and suggests solutions to problems brought forward. Able to exercise appropriate decision-making skills. Professional Development 18. Seeks for continuos learning and improvement through all available resources (journals, publications, inservices, seminars, classes, meetings, etc.). Total # of 4's ____ x 4 = ____ Total # of 3's ___ x 3 = ____ Total # of 2's ___ x 2 = ____ Total # of 1's ___ x 1 = ___ Core Expectations Total Points (sum of above) = _____ Divided by 18 = ____ (Managerial Score) H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PART 5 OVERALL PERFORMANCE RATING To calculate the overall performance rating: Job Specific Expectations Score (from Part 2): (x .50) = ____ (x .15) = Core Expectations Score (from Part 3): (x .35) = Managerial Expectations Score (from Part 4): Final Numerical Rating (Add the Scores Above) = Check the appropriate rating below: 3.5 - 4.0 = Substantially Exceeds 2.5 - 3.4 = Exceeds _____ 1.5 - 2.4 = Meets _____ 1.4 -- 1.0 = Below PART 6 GOALS & OBJECTIVES REVIEW Review completion of Goals & Objectives agreed upon from last performance review. Have the Goals & Objectives been met? ☐ Yes ☐ No (If no, explain below) PART 7 DIRECTOR'S/MANAGER'S/SUPERVISOR'S STATEMENT H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PART 8 EMPLOYEE'S STATEMENT (Optional) PART 9 GOALS AND OBJECTIVES FOR NEXT REVIEW PERIOD (List areas and timelines for performance improvement) Goals & Objectives Target Date PART 10 EVALUATION ACKNOWLEDGEMENT Director/Manager/Supervisor Signature Date Employee Signature Date H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PALM DRIVE 501 Petaluma Avenue, Sebastopol, CA 95472 707-823-8511 Fax: 707-829-4141 www.palmdrivehospital.com HOSPITAL Caring for Community Caring for Life

R5: Palm Drive has participated in all aspects of the Joint Powers Authority (JPA) since its inception in 2007. A Palm Drive Healthcare District Board member, Stephen Murphy, is the Vice-Chair of the JPA. Among several key issues that have been addressed by the JPA is the issue of specialist physician availability for the four rural hospital members. A plan for development of a physician network that would include specialists is currently under development by the four CEOs. While completion and implementation of the plan will take time, the JPA is confident that specialist availability will improve via the network arrangements currently under consideration. A corollary development at Palm Drive is the development of a special program for its intensive care unit (ICU) involving the use of robotic telemetry. This program involves the use of a robot through which specialists can be brought to the beside in such a way as to permit two way visual and audio communication and the transmission of diagnostic information to the physician in real time, allowing the specialist to diagnose and order the provision of treatment to the patient. Since its inception, the robotic telemetry-assisted ICU program has resulted in an increase in the ICU census from zero to an average of 3 per day, and has generated over $800,000 in net income for the 14 months ending August 31, 2008. As an offshoot of this program, the District is planning to open a school of Robotic Telemetry in February 2009 for rural hospital clients nationwide.

R6: Attends medical staff meetings and/or medical staff committee meetings as assigned or requested. Informs the CEO of proceedings at meetings attended and recommends action as necessary. Represents the hospital by membership in related professional associations.

R7: The District is very mindful of the assistance provided by West County citizens, in the form of a parcel tax, which in 2008 will have provided over $3.5 million in assistance to the Hospital. There is intense interest in the financial position of the Hospital, which has been operating under Chapter 9 protection of the bankruptcy code since April 2007. In the first quarter of FY 2009, the Hospital, for the first time in a number of years, generated a positive bottom line. The second quarter proves to be even more promising, based upon current census activity. The District wants its constituents to be fully aware of its financial position and the improvements that have been taking place. A financial report is being considered for presentation to the West County community, so that they may be made aware of how their parcel taxes are being used to help the Hospital become financially self-sustaining. Owned and operated by the Palm Drive Health Care District PALM DRIVE 501 Petaluma Avenue, Sebastopol, CA 95472 707-823-8511 Fax: 707-829-4141 www.palmdrivehospital.com HOSPITAL Caring for Community Caring for Life Note that this activity is in addition to the publically disseminated financial statements and budgets, which are presented at District Board meetings, and which are also reviewed monthly by the District Board's Finance Committee, which includes members of the local community in addition to members of the Board. . . .

R8: - PDHCD should institute and manage an effective A/R collection program to enhance management- support practices. In response to R8, Palm Drive Hospital (PDH) is proactively engaged in a comprehensive review of all internal policies, procedures and work-steps required to successfully operate its Business Office. The billing component of this department is responsible for the charges and collection of revenues for all inpatient and outpatient services provided to patients residing within and beyond West County. As our hospital Business Office continues to be an environment challenged by revenue constraints, we are proactively engaged in the assessment of a fully, integrated model to increase and sustain cash, reduce costs and identify economies of scale to ensure that all future performance exceeds the accounts receivable (A/R) industry benchmarks. Through a collaborative alliance with Sonoma Valley Hospital (SVH), PDH is actively in the developmental phase of a Virtual Business Office (VBO) that will allow each facility to capture charges, code procedures and submit clean claims to healthcare payers through an electronic interface, accessible from PDH or remotely, off-site. To begin this assessment process, PDH has joined forces through its Joint Powers Authority (JPA) to evaluate PDH's aging A/R, its current resource allocation and the skill-level of staff responsible for registration, admitting, billing and cash posting. A comprehensive evaluation of each key position has identified PDH's strengths and where SVH can enhance our internal processes and overall operations through a knowledge-gain environment. The VBO will also enable us to leverage our ability to compete for improved contract rates and to share in the costs associated with information technology upgrades and enhancements. The VBO model consists of a number of phases that includes an Open Issues Log for each Phase to ensure that a new process is thoroughly documented and adopted by appropriate staff. Testing and training will follow with check-off points so that every employee is trained for a specialty function and cross-trained to assume other responsibilities as needed to fill open positions. Owned and operated by the Palm Drive Health Care District PALM DRIVE 501 Petaluma Avenue, Sebastopol, CA 95472 707-823-8511 Fax: 707-829-4141 www.palmdrivehospital.com S P I T A Н О Caring for Community Caring for Life Each phase of the VBO is comprised of numerous tasks assigned to SVH and/or PDH with a designated responsible action party and an estimated date for completion. The following table represents the major steps within the project management tool that is currently in progress to manage the VBO project: PDH / SVH VBO Model Assess and Design I. II. Build-Out Process Test and Train III. Implementation and Deployment IV. V. Activate - Transition to Ongoing Support and Service VI. Assess and Design VBO Model Upon completion of Step III, the overall program, including each completed step of the Open Issues Log will be submitted to each respective Chief Executive Officer for review and final approval. The implementation and deployment will begin upon approval and will be the first step in transitioning to the VBO model. Owned and operated by the Palm Drive Health Care District

R11: Demonstrates a caring and concerned attitude; treats customer problems and concerns seriously; protects privacy and confidentiality of the customer.

R12: Responds to customers as the primary priority; earns trust and confidence of customer by knowing what to do and doing it well; continually strives to improve services for the customer. Professional Conduct

R13: Initiates and maintains working relationships that are characterized by mutual support. open communication, trust, and respect.

R14: Keeps personal biases and private life separate from work.

R15: Accepts constructive criticism without defensiveness. Communication Maintains open communication style with co-workers and managers.

R16: Meets regularly with staff to communicate organizational and departmental priorities.

R17: Communicates in a manner that promotes cooperation, avoids antagonism, reduces or resolves conflict, and prevents undue patient and/or staff anxiety. Total # of 4's ___ x 4 = ___ Total # of 3's ___ x 3 = ___ Total # of 2's ___ x 2 = ___ Total # of 1's ___ x 1 = ___ Core Expectations Total Points (sum of above) = _____ Divided by 17 = ____ (Core Score) H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PART 4 MANAGERIAL EXPECTATIONS REVIEW This section reviews Palm Drive Hospital's managerial expectations. Managerial expectations account for 35% of the performance evaluation rating. Self Evaluator's 4 = Substantially Exceeds 3 = Exceeds 2 = Meets 1 = Below Assessment Assessment Performance Improvement / Regulatory Compliance 3 4 2 1 4 3 2 1

R18: Seeks for continuos learning and improvement through all available resources (journals, publications, inservices, seminars, classes, meetings, etc.). Total # of 4's ____ x 4 = ____ Total # of 3's ___ x 3 = ____ Total # of 2's ___ x 2 = ____ Total # of 1's ___ x 1 = ___ Core Expectations Total Points (sum of above) = _____ Divided by 18 = ____ (Managerial Score) H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PART 5 OVERALL PERFORMANCE RATING To calculate the overall performance rating: Job Specific Expectations Score (from Part 2): (x .50) = ____ (x .15) = Core Expectations Score (from Part 3): (x .35) = Managerial Expectations Score (from Part 4): Final Numerical Rating (Add the Scores Above) = Check the appropriate rating below: 3.5 - 4.0 = Substantially Exceeds 2.5 - 3.4 = Exceeds _____ 1.5 - 2.4 = Meets _____ 1.4 -- 1.0 = Below PART 6 GOALS & OBJECTIVES REVIEW Review completion of Goals & Objectives agreed upon from last performance review. Have the Goals & Objectives been met? ☐ Yes ☐ No (If no, explain below) PART 7 DIRECTOR'S/MANAGER'S/SUPERVISOR'S STATEMENT H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PART 8 EMPLOYEE'S STATEMENT (Optional) PART 9 GOALS AND OBJECTIVES FOR NEXT REVIEW PERIOD (List areas and timelines for performance improvement) Goals & Objectives Target Date PART 10 EVALUATION ACKNOWLEDGEMENT Director/Manager/Supervisor Signature Date Employee Signature Date H:\gmullins\My Documents\GRAND JURY\COO.doc Raoul PALM DRIVE 501 Petaluma Avenue, Sebastopol, CA 95472 707-823-8511 Fax: 707-829-4141 www.palmdrivehospital.com HOSPITAL Caring for Community Caring for Life R8 - PDHCD should institute and manage an effective A/R collection program to enhance management- support practices. In response to R8, Palm Drive Hospital (PDH) is proactively engaged in a comprehensive review of all internal policies, procedures and work-steps required to successfully operate its Business Office. The billing component of this department is responsible for the charges and collection of revenues for all inpatient and outpatient services provided to patients residing within and beyond West County. As our hospital Business Office continues to be an environment challenged by revenue constraints, we are proactively engaged in the assessment of a fully, integrated model to increase and sustain cash, reduce costs and identify economies of scale to ensure that all future performance exceeds the accounts receivable (A/R) industry benchmarks. Through a collaborative alliance with Sonoma Valley Hospital (SVH), PDH is actively in the developmental phase of a Virtual Business Office (VBO) that will allow each facility to capture charges, code procedures and submit clean claims to healthcare payers through an electronic interface, accessible from PDH or remotely, off-site. To begin this assessment process, PDH has joined forces through its Joint Powers Authority (JPA) to evaluate PDH's aging A/R, its current resource allocation and the skill-level of staff responsible for registration, admitting, billing and cash posting. A comprehensive evaluation of each key position has identified PDH's strengths and where SVH can enhance our internal processes and overall operations through a knowledge-gain environment. The VBO will also enable us to leverage our ability to compete for improved contract rates and to share in the costs associated with information technology upgrades and enhancements. The VBO model consists of a number of phases that includes an Open Issues Log for each Phase to ensure that a new process is thoroughly documented and adopted by appropriate staff. Testing and training will follow with check-off points so that every employee is trained for a specialty function and cross-trained to assume other responsibilities as needed to fill open positions. Owned and operated by the Palm Drive Health Care District PALM DRIVE 501 Petaluma Avenue, Sebastopol, CA 95472 707-823-8511 Fax: 707-829-4141 www.palmdrivehospital.com S P I T A Н О Caring for Community Caring for Life Each phase of the VBO is comprised of numerous tasks assigned to SVH and/or PDH with a designated responsible action party and an estimated date for completion. The following table represents the major steps within the project management tool that is currently in progress to manage the VBO project: PDH / SVH VBO Model Assess and Design I. II. Build-Out Process Test and Train III. Implementation and Deployment IV. V. Activate - Transition to Ongoing Support and Service VI. Assess and Design VBO Model Upon completion of Step III, the overall program, including each completed step of the Open Issues Log will be submitted to each respective Chief Executive Officer for review and final approval. The implementation and deployment will begin upon approval and will be the first step in transitioning to the VBO model. Owned and operated by the Palm Drive Health Care District

September 05, 2008 — Readannogrnsidered Sep 1 5 2008 Drate 9/16/05 By_ Excellence in Education*

3 pages 4 recommendations

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Additional Recommendations 4

Not linked to specific findings.

R5: Superintendents must require that each school develop a disaster emergency plan designed for their school, and assure that the principal has approved the plan. The Rincon Valley Union School District agrees with this recommendation, and it has been fully implemented. Each school has a disaster emergency plan, which was developed from the model plan created by the Redwood Empire Schools Insurance Group (RESIG). Each plan addresses the NIMS/SEMS guidelines and follows all State and Federal standards. The plans are updated and approved annually by the Board of Trustees and the School Site Council of each school. See attached Board minutes dated May 6, 2008 Item 9.1 (Safe School Plan)

R6: SCOE, Superintendents and Principals must consider disaster preparedness a top priority. The Rincon Valley Union School District agrees with this recommendation. Beginning in the 2007 school year, the Rincon Valley Union School District contracted with B4 Disaster Management and Consulting Services to provide additional direction in disaster emergency planning and implementation. The District purchased the "Integrated Crisis Response System" for each school. The Response System includes a 24"X36" fully laminated framed map for every office area and is placed in full view for parents, staff, students, and community members. In addition, an 81/2"X11" map is located on emergency kits in the classrooms. A CD with the map was distributed to the Sonoma County and City of Santa Rosa emergency response offices by RESIG. A state of the art emergency kit was placed in all classrooms and other areas where there could 1000 YULUPA AVENUE • SANTA ROSA, CALIFORNIA 95405 • (707) 542-7375 FAX (707) 542-9802 be numbers of children. The supplies are contained in bright yellow rolling hard cases, and each includes a sanitation system, basic first aid kit, 64 water pouches, food ration bars, survival blankets, and emergency lighting. The kits are sealed and are not to be opened unless there is a major disaster or serious emergency. The food ration bars and water have a five year shelf life. After five years the food and water rations are replaced by the vendor. In addition, a Response Packet hangs on each emergency kit. It has a current site map and holder, a simplified emergency response guide, color coded vests, and alert signage, name badges, and erasable markers. The Emergency Plan that will go into effect for the 2008-2009 school year will include a full implementation binder for each response team designated in the plan, as well as training for all personnel on their roles. For example, the Logistics Section Chief is responsible for his team assignments of communications, staffing, and supplies.

R7: All Schools must train their personnel in disaster preparedness The Rincon Valley Union School District agrees with this recommendation. This recommendation has been fully implemented on an annual basis. The schools hold monthly drills for fire and earthquake. For the 2008-2009 school year we are implementing a monthly lockdown drill. In addition, the Rincon Valley District holds a district-wide drill annually, with scenarios that have been scripted for the principals and each participating team member. Following the actual drill, each school debriefs on the success of the drill and problem-solves the areas in need of improvement. At the Administrative Council Meeting following the district wide drill, an evaluation of the district wide drill is completed. During the 2007-08 school year, the radio system was upgraded so that all schools would be able to communicate without failure to the district office in case of an emergency or disaster. Training on the system was done by John Evers of Precision Wireless Service. Each Friday, the Supervisor of Maintenance and Operations contacts every school via radio to ensure constant readiness by key personnel. First aid training, search and rescue training, CERT certification, etc. are ongoing, provided by the school nurses and RESIG staff.

R8: Annually, all schools must check emergency supplies to assure that they are adequate. Consumable supplies must be checked for freshness and safety. The Rincon Valley Union School district agrees with this recommendation. The Integrated Crisis Response System emergency kits are sealed, and the water and food ration bars have a shelf life of five years. Barring any unforeseen circumstances, the kits will not need to be replenished until 2012. At that time, the consulting firm will replenish them. I believe this addresses each of the recommendations that the Grand Jury Report requested of district superintendents. If you have any further questions or would like to review any of our materials or supplies, please notify me. nese Diane Moresi, Superintendent Rincon Valley Union School District 1000 Yulupa Ave. Santa Rosa, CA 95405 707-542-7375 dmoresi@rvusd.org . . . . . . . . . . . . . . . . . . . . . . . . .

August 27, 2008 — Read and Considered Date 9111/01 by Windson Unified School District*

2 pages 4 recommendations

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Additional Recommendations 4

Not linked to specific findings.

R5: The recommendation is currently in practice. The site principals maintain the plan and update annually. The Windsor Unified School District agrees with the finding. The Schools

R6: maintain regular fire, earthquake, and intruder drills as required by Education Code. Regular logs are maintained for mandated cost claim purposes. The District and select schools (varied) participate in local Office of Emergency Services Training Drills (October 24, 2007)

R7: The Windsor Unified School District agrees with the finding. The District provides training within established parameters and with the resources made available by its property, liability carrier, Redwood Empire Schools Insurance Group.

R8: The Windsor Unified School District agrees with this finding. As part of the District's Facilities Inspection Report, this review is completed annually. . . . . . . . . . . . . . . . . . . . . - -

August 26, 2008 — Read and Considered Date 9//2/05 by*

1 pages 4 recommendations

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Additional Recommendations 4

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R5: Our school takes emergency preparedness seriously. Over the past three years, we have worked to create a meaningful disaster preparedness plan. Using resources from SCOE, the Redwood Empire Insurance Group (RESIG), the California Charter Schools Association, and FEMA, we have put together a plan that addresses various scenarios that our community might face. The Executive Director of the school has been integrally involved with the plan and its implementation, and the written plan is currently being fully implemented.

R6: Disaster preparedness constitutes a priority for our school. We have created a budget line item for supplies and training and allocate the necessary personnel to ensure the plan is fully implemented.

R7: Our school carries out regular drills and training to ensure the success of our preparedness plan. In addition to fire and earthquake drills, we routinely conduct lock down drills, varied scenario drills, and tests of our emergency contact system. Our entire staff is fully current in first aid and CPR training, and we have our own SCOPE and CERT-trained Emergency Operations Team, made up of parents and staff members. The school's Director is also CERT trained and actively participates in planning and executing preparedness activities. These members work together on campus, as well as with other local emergency services providers, such as the police, fire department, and town officials.

R8: We have developed a time line to check our supplies, always ensuring they are current and adequate. Currently, we are creating brief monthly emergency planning meetings for our team so we can conduct training in a regular and meaningful way. Since it is difficult to ask busy professionals and parents to participate in day-long events, we are trying to make our training truly doable for those committed to ensuring the safety of our community by doing it in shorter stints whenever possible. Respectfully submitted, 1 1 1 Susan Olson Alysson Baker Executive Director Chairperson, Board of Directors P.O. Box 1170 200 South Main Street Sebastopol, California 95473 (707) 824-9700 fax (707) 824-1432 “Offering a Waldorf curriculum supporting academic excellence, creative thinking, and a love of the arts.”

August 21, 2008 — Read and Considered*

2 pages 3 recommendations

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Additional Recommendations 3

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R3: SCOE Should consider assigning personnel to be responsible for making sure our schools are in compliance with State regulations on school disaster preparedness. For many years, the Sonoma County Office of Education has assigned and funded a director for Safe Schools. This office provides two trainings a year open to all county schools on developing safe school plans and developing school crisis response plans. This position assists individual districts as requested. The California Education Code Section 32281 (a) does not require the Sonoma County Office of Education to ensure that school districts have safe school plans. This code section requires that each school district and county office develop safe school plans for the schools sites they respectively operate.

R4: SCOE should act as facilitator for disaster preparedness for schools within the Sonoma County Region. This role should include financial help in providing funding for substitute teachers so that classroom teachers can participate in training programs. During the three year period, 2004-05 through 2006-07, the Sonoma County Office of Education was the lead agency for a three year United States Department of Education project, SchoolGuard, which was designed to improve emergency preparedness and crisis response in Sonoma County Schools. The Sonoma County Office of Education worked cooperatively with the Redwood Empire Schools Insurance Group (RESIG) to accomplish the goals of the project. With the difficulties of the current State economy, SCOE is not in a position to provide financial assistance to districts for substitutes for classroom teacher training, nor is this a SCOE responsibility. As members of Redwood Empire School Insurance Group (RESIG) all districts are eligible to participate in the Emergency Services Program that RESIG provides. There is some funding available through the RESIG program for substitutes and/or overtime for any school employee to attend emergency preparedness training.

R6: SCOE, Superintendents and Principals must consider disaster preparedness a top priority. The Sonoma County Office of Education, district superintendents and principals do consider disaster preparedness a top priority. School campus safety and security is a top priority of school board members, administrators, teachers, and classified staff across Sonoma County, as it is for the parents of the students in our schools. As members of the Redwood Empire School Insurance Group (RESIG), in May 2007, Sonoma County School Districts voted unanimously to add a surcharge to each district's property and liability insurance premium to fund the coordination of emergency preparedness activities. These activities are being coordinated through RESIG for all districts in the county. 8/19/08

August 21, 2008 — Read and Considered Aug 2 6 2008 Date 8/27/00 by Sonoma County Office of Education*

1 pages 1 recommendations

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Additional Recommendations 1

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R3: Attached please find

Page 1

August 18, 2008 — California Forensic Medical Group billy ha*

8 pages 3 findings 5 recommendations

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Findings & Recommendations 3 findings

F4: A twice a day monitoring schedule is inadequate to monitor W class inmates for withdrawal symptoms. Medical checks at four-hour intervals are generally accepted as adequate in a hospital environment and in other detention environments. Requested Response to Finding #4 This Finding requires further evaluation. CFMG provides ambulatory outpatient care to those individuals incarcerated at the Main Adult Detention Facility. The medical environment at the Main Adult Detention Facility is not a hospital environment. CFMG's policy as well as the Sheriff's Department policy requires that inmates housed in the sobering cells be checked upon admission and every four hours. Once they are cleared to be housed in General Population, they are seen two times per day. The Sheriff's Department has designated specific housing locations for inmates who have the potential for withdrawal. This allows for increased monitoring of these individuals by both custody and medical staff.

Related Recommendations (1)

R4: The Sheriff's Department should require that CFMG consider the administration of widely held medication practices to AWS inmates as a seizure precaution. Requested Response to Recommendation #4 This Recommendation requires further evaluation. CFMG provides standard detoxification medication for the prevention of seizures and alcohol withdrawal. CFMG will again work with its Quality Assurance and Peer Review Committee, its external peer review consultants, and on the recommendations of a specialist in addiction medicine to address this recommendation.

F5: If a more frequent monitoring protocol were to be initiated in the first 48 hours of incarceration, it may be possible to deliver medication to prevent the onset of AWS, which would diminish the probability of potential fatal withdrawal incidents. Requested Response to Finding #5 CFMG disagrees with this Finding. CFMG does initiate monitoring protocols for those individuals who are identified as having alcohol and drug abuse habits, and who are potentially likely to go through withdrawal. CFMG has detox protocols for drugs as well as alcohol, which are initiated during the first 48 hours. As mentioned previously, the addition of the Alert system on the Criminal Justice computer allows for immediate identification of those patients who have been previously identified and/or treated for withdrawals.

Related Recommendations (1)

R5: Specific rounds procedures should be defined and followed by CO's for W class inmates until CFMG reviews AWS risk and determines that special attention is no longer necessary. The new W class procedure should require a verbal response from the inmate. Also that CO's must open the cell door and/or turn on the light to elicit response. Requested Response to Recommendation #5 This Recommendation requires further evaluation. California Forensic Medical Group will work with the Sheriff's Department and the custody division to address this recommendation.

F6: The primary responsibility for the medical welfare of an inmate resides with the medical staff. However, correctional officers observe inmates every half-hour. With the implementation of special observation criteria they could significantly diminish the risk of the most serious AWS candidates (opening the cell door and requiring a verbal response from high-risk inmates may be sufficient). Requested Response to Finding #6 This Finding requires further evaluation. Medical staff works closely with correctional staff to observe inmates who are placed in sobering cells. California Forensic Medical Group provides in-service training as part of custody staff's overall training on alcohol and drug-related conditions including signs and symptoms of drug and alcohol withdrawal. This frequency of this training has increased over the last year. As mentioned previously, the signs and symptoms of withdrawal are written on the "W" alert sign which is posted on the cell door. This will assist custody staff with the monitoring of these individuals. CFMG will continue to provide on-going training to both custody and medical staff regarding signs and symptoms of alcohol and drug withdrawal and will work collaboratively with the Sheriff's Department to make changes as necessary to increase the monitoring of these individuals. Finding#7 Two medical experts indicated that the high-risk inmates we identified would have benefited from blood alcohol testing prior to being placed in general population. Requested Response to Finding #7 CFMG partially disagrees with this Finding. CFMG would appreciate the opportunity to review the findings of the two medical experts who indicated that blood alcohol testing prior to being placed in general population is the standard of practice, and the rationale for it. CFMG is not aware of any detention facility that currently does this, but is certainly willing to explore that as a benefit to this population. . . . . .

Additional Recommendations 3

Not linked to specific findings.

R1: The Sheriff's Department should require that the CFMG alcohol withdrawal risk assessment procedure be modified to more closely follow the CIWA-Ar, including all the parameters and rating scales in the formal procedure. Requested Response to Recommendation #1 CFMG partially disagrees with this Recommendation. CFMG has invited an expert in drug and alcohol withdrawal to review their current assessment tools and address the Grand Jury's recommendation. CFMG is not averse to following this recommendation.

R2: The Sheriff's Department should require that CFMG's assessment protocols identify chronic alcoholics who arrive intoxicated and have a medical history of AWS as a special class of inmates needing closer monitoring. Reassessment of AWS risk is required when BAC concentrations drop below .1%. Requested Response to Recommendation #2 CFMG partially disagrees with this Recommendation. CFMG has an assessment protocol to identify chronic alcoholics and those who arrive with a medical history of Alcohol Withdrawal Syndrome. In addition, the "Alert" system which has recently been implemented will identify inmates with a history of CFMG has worked in conjunction with the Sheriff's Department to withdrawal. implement polices which provide closer monitoring of this high-risk population. CFMG will look into the finding of reassessment of Alcohol Withdrawal Syndrome when BAC concentrations drop below .1%

R3: The Sheriff's Department should require that CFMG monitor W class inmates at least once every four hours. Requested Response to Recommendation #3 This Recommendation requires further evaluation. California Forensic Medical Group does provide four-hour monitoring of individuals who are placed in sobering cells. There are many inmates who are transported to the local emergency room after medical staff has done an assessment and determined the inmate needed a higher level of care. CFMG will explore with the Sheriff's Department the possibility of increasing nursing staff to monitor individuals on "W" class more frequently...

August 14, 2008 — AUG 2 9 2008 Read and Considered Unionsch Date 9/3/01 by 5 Tnon Monte RIO Union School District*

1 pages 4 recommendations

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Additional Recommendations 4

Not linked to specific findings.

R5: Superintendents must require that each school develop a disaster emergency plan designed for their school, and assure that the principal has approved the plan. The District is in total agreement with this recommendation and has previously fully implemented the recommendation. The District requires that the school review the disaster plan at least once a year, and the District is participating in disaster preparedness training through Redwood Empire Self Insurance Group (RESIG).

R6: SCOE, Superintendents and Principals must consider disaster preparedness a top priority. The District agrees with this recommendation and has previously implemented steps to address disaster preparedness as part of the back-to-school trainings.

R7: All schools must train their personnel in disaster preparedness. The District agrees and has previously fully implemented this recommendation.

R8: Annually, all schools must check emergency supplies to assure that they are adequate. Consumable supplies must be checked for freshness and safety. The District agrees with this recommendation and has emergency supplies on hand and is in the process of acquiring additional emergency supplies. The above response to Grand Jury recommendations was adopted at a regular meeting of the Board of Trustees on August 14, 2008. Control of Section 1

August 12, 2008 — Guerneville School District Aug 1 8 2008*

1 pages 4 recommendations

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Additional Recommendations 4

Not linked to specific findings.

R5: Superintendents must require that each school develop a disaster emergency plan designed for their school, and assure that the principal has approved the plan. The District is in total agreement with this recommendation and has previously fully implemented the recommendation. The District requires that the school review the disaster plan at least once a year, and the District is participating in disaster preparedness training through Redwood Empire Self Insurance Group (RESIG).

R6: SCOE, Superintendents and Principals must consider disaster preparedness a top priority. The District agrees with this recommendation and has previously implemented steps to address disaster preparedness as part of the back-to-school trainings.

R7: All schools must train their personnel in disaster preparedness. The District agrees and has previously fully implemented this recommendation.

R8: Annually, all schools must check emergency supplies to assure that they are adequate. Consumable supplies must be checked for freshness and safety.

August 08, 2008 — AUG 1 1 2008 Geyserville Elementary School*

2 pages 4 recommendations

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Additional Recommendations 4

Not linked to specific findings.

R5: – Both school sites have an active Emergency Preparedness Plan. The plan has involved the staff and school principal. Emergency Preparedness is a standing item on each staffs monthly meeting agenda.

R6: – The Superintendent and Principals do consider Emergency Preparedness a high priority. All district administrators have attended numerous sessions conducted by Redwood Empire School Insurance participating in table top discussions and scenarios. In addition, one staff member at each site has been released once a month to participate in training and providing in- District Office 1300 Moody Lane, Geyserville, CA 95441 (707) 857-3592 ~The Valley of Distinguished Schools~ service to staff assigned various responsibilities. They report at each monthly staff meeting, and conduct drills on a scheduled basis.

R7: - Staff are continually trained, and encouraged to attend trainings. Training and discussions are conducted monthly at school faculty meetings. When it is time to re-charge fire extinguishers, drills are held each year to teach staff how to discharge fire extinguishers.

R8: – At the school site a staff member is responsible for emergency supplies. At Geyserville Educational Park a cargo container has been purchased for the storage of emergency supplies. Each coordinator submits an annual supply budget to develop an emergency supply inventory. If I can provide additional information, please contact me. Respectfully submitted, 1 carnatum Joseph Carnation Interim Superintendent Geyserville Unified School District District Office 1300 Moody Lane, Geyserville, CA 95441 (707) 857-3592 ~The Valley of Distinguished Schools~

August 04, 2008 — Read and Considered Date 8/1/08 By_*

3 pages 4 recommendations

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Additional Recommendations 4

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R5: Dunham School District has developed a disaster plan for our single school district that reflects our school needs. We are in the process of updating the existing plan to more effectively meet the needs of both the students and the staff here at Dunham. Our plan is not only written by the staff but also involves the School Site Council as well. It is approved annually by the Principal, who also happens to be the Superintendent.

R6: Disaster preparedness is a top priority both at the County and district levels. SCOE has offered several trainings to districts throughout the year and RESIG has also offered trainings. Just last year I met with the RESIG staff on multiple occasions to implement a better emergency preparedness plan. We at Dunham continue to work to make our school safe in case of an emergency.

R7: We have had the RESIG staff come to our school to help train the staff in the logistics of emergency plan implementation and will have assigned staff go for further trainings in the area of their assigned tasks. For example search and rescue teams will need different trainings from communications teams. The RESIG staff has been extremely helpful in providing us with trainings that we need. These trainings need to continue and be updated on a yearly basis, however.

R8: At Dunham students are required to bring an emergency kit for the year. This kit is added to the classroom emergency kit and is therefore fresh each year. (See attached District Emergency Kit note). I hope these responses are adequate and meet the needs of the Grand Jury. ..... ... ..... . .... . . . . . . . . . Sincerely, Kindu n. ulla Kimberlee M. Wilding Principal/Superintendent Dunham School District . - Dunham School District STUDENT EMERGENCY KITS..... As a precaution, we would like all Dunham students to have an emergency kit with food and a space blanket available for them. These kits will be stored at school for the duration of the school year and will be returned to you at the end of the term. They would be an absolute necessity if there was ever a disaster and your children had to spend the night at school. Please make sure you provide a kit for your child. While we hope to never need this emergency food supply, we also know how important it is to keep it on hand should the need arise. Please return your child's kit to his/her teacher as soon as possible. Please enclose the following items in a large zip locked bag clearly marked with your child's name and grade: • 2 cans of meat/fish/beans with a flip top opening (i.e. tuna, sausages, pork & beans, or some other protein food your child will eat) • 2 granola bars (not chocolate coated) • 2 fruit cups with a flip top opening • 2 cans or boxes of juice • 2 cheese and crackers (or a similar snack your child will eat) • 2 napkins and 2 plastic spoons A note from you to your child reassuring them that they will be cared for, that you love them, etc. and possibly a picture that will be comforting to them should an emergency ever occur. (Be sure you check the expiration date of these food items. They should not expire before June 10, 2009.) The PTA has provided Mylar space blankets for each child. You do not need to purchase an emergency blanket for your child. PLEASE LET THE OFFICE KNOW IF YOU ARE UNABLE TO SUPPLY AN EMERGENCY KIT FOR YOUR CHILD FOR ANY REASON. August 2008

July 29, 2008 — AUG - 5 2008 Read and Considered Date 8/6/08 by Sutter Medical Center*

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Findings and recommendations not yet extracted.

June 27, 2008 — Ensuring Fairness in Child-Support Services The Grand Jury investigated how child-support payments Investigative

6 pages 7 findings 7 recommendations

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Findings & Recommendations 7 findings

F1: DCSS did not previously have a The Grand Jury commends DCSS for system for clear documentation of establishing a more clean-cut tracking child-support payments. system for documenting child-support cases. In the past, the department offered

Related Recommendations (1)

R1: DCSS should educate clients on court

F2: DCSS did not accurately monitor employees classes in sensitivity training, responsibility of health insurance for and parenting classes for clients. It also the supported children. developed a non-custodial-parent training program to assist in understanding that the

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R2: DCSS should provide clear and

F3: DCSS was not monitoring to see that custodial and non-custodial parents are in a custody arrangements were not business-partner relationship. Additionally, violated. DCSS has improved its bilingual and cultural services. It is also commended for

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R3: DCSS should clarify and verify responsibility of health insurance for children involved in each case.

F4: DCSS did not previously accept and converting the child-support management review all pertinent documentation for system to a computerized database. support-payment cases.

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R4: To minimize disputes, DCSS should evaluate and monitor client understanding of and satisfaction with Previously, child-support services were its services. Client evaluations should under the jurisdiction of the DA. Once the occur after three months, nine months, responsibility transferred to DCSS, and annually thereafter. shortcomings of the child-support payment system received the attention

F5: DCSS clients are intimidated by the court system.

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R5: DCSS should appoint a neutral third- they required. While DCSS continues to party ombudsman to ensure a fair improve management of this system, process. This volunteer would ideally mechanisms are required to manage the have a background in child-support system more effectively, and to address issues. the concerns of parents. Recommendations, continued

F6: Some DCSS policies and procedures procedures and the workings of the were not clear to participants, nor child-support system. were they communicated effectively.

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R6: DCSS investigations should include written documentation or other corroborating evidence regarding disputed issues.

F7: Terminology that was offensive to thorough documentation of child-support some parents was dictated at the payments to all parties involved. State level; such terminology has since been modified or changed.

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R7: If budget constraints allow, DCSS should reinstate parenting classes. If this training cannot be funded, volunteer resources should be explored. Requested Responses to Recommendations Sonoma County Board of Supervisors: R1, R2, R3, R4, R5, R6, R7 Required Responses to Recommendations Sonoma County Department of Child Support Services: R1, R2, R3, R4, R5, R6, R7 44

June 27, 2008 — Sonoma County Administrator’s Office Managing a County in Transition Sometime in the last decade, Sonoma County

6 pages 10 findings 3 recommendations

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Findings & Recommendations 10 findings

F1: The Board of Supervisors is pleased with the County Administrator’s performance.

F2: The Board of Supervisors conducts an informal performance review of the County Administrator annually.

F3: County employees at all levels are generally satisfied with the performance of the CAO.

F4: The Board of Supervisors, County Administrator, and other department heads and managers in County government believe they are accessible to all County employees.

F5: Some County employees believe they are unable to share their concerns about the operation of their specific departments and County government in general with the County Administrator or the Board of Supervisors.

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R1: The Board of Supervisors and the County Administrator should ensure that Sonoma County residents and County employees have a way to get their concerns heard by the people who are deciding the County’s future.

F6: Some County workers believe morale has suffered in recent years because County management doesn’t address the problems that staff members bring to their attention.

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R1: The Board of Supervisors and the County Administrator should ensure that Sonoma County residents and County employees have a way to get their concerns heard by the people who are deciding the County’s future.

F7: The County Administrator is perceived by many County employees and managers as being less accessible than his predecessors in the position, and less likely to consider their suggestions.

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R1: The Board of Supervisors and the County Administrator should ensure that Sonoma County residents and County employees have a way to get their concerns heard by the people who are deciding the County’s future.

F8: The County Administrator exercises near-unilateral control over the agenda of the weekly Board of Supervisors meeting.

F9: In recent years, most open positions have been filled by external candidates rather than through internal transfers or promotions. This requires more spending for recruitment and often results in higher salaries being offered to attract the most qualified candidates. Since this often means an entire salary range has to be increased, existing staff members in those positions may also receive raises above what they would have merited otherwise.

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R2: The CAO should plan and implement programs to encourage career development for County employees. Grooming internal candidates for top management positions saves the County money in recruitment and helps control salaries and other personnel costs.

F10: The County's five-year strategic plan is expected to be finalized this summer. According to the County Administrator, it focuses on matters not currently being addressed adequately by County departments. The County Administrator indicates that the plan will focus on five areas: 1. Improving roads 2. Maintaining the criminal justice system 3. Enhancing the visibility of County agencies to the communities they serve 4. Adapting to demographic changes occurring in the County 5. Upgrading County facilities 64 Commendations The Grand Jury commends the CAO for devising and beginning the implementation of a strategic plan for the County. The office has also begun internal audits of County agencies in an attempt to make them more efficient. Conclusions The transitions now underway in the County have affected staff at every level. Some County employees believe there is no one to whom they can express their concerns about the problems they perceive in County operations. There is also concern about how well County employees are being prepared to assume greater responsibility through internal promotions. Relying on outside hires to fill department-head and other management positions as they open up increases salary ranges throughout the affected agencies at a time when salaries already account for a growing percentage of overall agency budgets. The County’s future is in the hands of the CAO. The office has made great strides in recent years toward developing and implementing a long-overdue strategic plan. The CAO has begun to remake the way County government operates. These changes can be difficult for County employees, as well as for the citizens they serve. It is imperative that during the transition the CAO make an extra effort to keep the lines of communication open with Sonoma County residents and all county workers.

Additional Recommendations 1

Not linked to specific findings.

R3: The CAO should continue to audit County agencies to help them operate more efficiently and identify ways to offer County residents more and higher-quality services during times of shrinking County budgets. Required Responses to Findings Board of Supervisors F5, F6, F8 County Administrator F5, F6, F7, F8, F9 Required Responses to Recommendations Board of Supervisors R1 County Administrator R1, R2, R3 65

June 27, 2008 — Sonoma County Office of Education Misuse of State Vocational Education Funds The people of Sonoma County trust and

5 pages 7 findings 7 recommendations

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Findings & Recommendations 7 findings

F1: Programs that qualified for funding through Carl F6 The SKILLSUSA program affords students in Perkins vocational-education grants were vocational/technical education programs the denied funding by SCOE, and programs and opportunity to compete for awards recognizing materials not allowed by the Carl Perkins Act excellence in job skills learned. were purchased with the grant money.

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R1: The SCOE Superintendent of Schools must The Grand Jury commends the staff of SCOE's ensure that all funds spent by the office are Alternative Education Programs for the many disbursed as intended. excellent opportunities they offer to students who, for a variety of reasons, are not able to attend and

F2: SCOE’s original 2006-2007 Carl Perkins Grant Alternative Education Program asked SCOE Application requested funds for: for Carl Perkins Funds to allow his/her students classified salaries ($7,941for guidance and to participate in a SKILLSUSA competition. counseling) employee benefits ($1,661for SCOE refused to allocate funds from the guidance and counseling) books and supplies program for this purpose, stating that it was ($3,605) services and other expenditures not an appropriate use of the funds. ($250).

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R2: SCOE must adhere to requirements for the function well in the County's comprehensive high disbursal of grant monies received for specific schools. The programs are tailored to meet the programs. needs of a variety of student difficulties. To succeed, these programs require staff with

F3: After the initial grant application, monies were testified that these funds can be used for removed from "classified salaries” and SKILLSUSA competition. “employee benefits" to "services and other expenditures," increasing the original budget in F9 A staff person requesting Carl Perkins Funds that category from $250 to $4,500. for SKILLSUSA questioned SCOE's use of the funds for SASix, and disagreed with SCOE's

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R3: SCOE must acknowledge that targeted funds are exceptional skills. The programs are a valuable to be used for designated programs, not as service to at-risk students, and to society in general. general funds.

F4: The revised expenditures reflecting the final refusal to allow funds to be used for distribution of 2006-2007 Carl Perkins Funds SKILLSUSA. This staff person, who is not the indicates an expenditure of $4,000 for the complainant, was subsequently reassigned SASix software-attendance program that is against his/her will. The timing of this used by the SCOE Technology Services Unit. reassignment suggests poor personnel SASix is a general education support program management at SCOE. Mismanagement of this not specific to vocational training. kind may affect the morale of staff and undermine the support needed to ensure the

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R4: SCOE programs receiving targeted funding must be audited to ensure that the funds are spent appropriately. As a result of a State

F5: The State Administrator of Carl Perkins Funds success of Alternative Education Programs. testified that the purchase of SASix software was an inappropriate use of Carl Perkins F10 As a result of a State Department of Education Funds. investigation, SCOE will be required to repay all or part of the 2006-2007 Carl Perkins Funds it was awarded. Conclusions SCOE has misused the 2006-2007 Carl Perkins Funds supplied by the State for use by the Alternative Education vocational/technical training program. This action and related inappropriate personnel decisions threaten to undermine the morale of the Alternative Education staff. In order to have a vibrant and effective program, staff must have confidence in the administration, and be able to work effectively with them. The working relationship of Alternative Education staff and SCOE managers could be eroded by such actions.

Related Recommendations (1)

R5: SCOE must include teachers and other staff Department of members in decisions concerning the application Education investigation, for and disbursement of funds that may be used in SCOE will be required program funding. to repay all or part of

F7: An award-winning teacher at the Youth Camp

Related Recommendations (1)

R7: The movement of personnel, when undertaken, awarded. must benefit the students affected rather than strictly be in the best interest of SCOE, as stated in present SCOE policy (SP 4135.00). Required Responses to Findings SCOE F1, F3, F4, F5, F7, F8, F9, F10 Required Responses to Recommendations SCOE R1, R2, R3, R4, R5, R6, R7 27

F8: The State Administrator of Carl Perkins Funds

Additional Recommendations 1

Not linked to specific findings.

R6: SCOE must ensure that reassignment of the 2006-2007 Carl personnel is not punitive. Perkins Funds it was

June 27, 2008 — Each year the Sonoma County Civil Grand Jury has the authority to examine the operation of any agency within the

8 pages 18 findings 3 recommendations

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Findings & Recommendations 18 findings

F1: The Sonoma County Office of Education (SCOE), under the leadership of the Superintendent of Schools, distributes funds from the State of California Office of Education to the individual school districts depending on the schools’ average daily attendance.

F2: The Sonoma County Superintendent of Schools, elected to a four-year term, has the primary responsibility of providing leadership, support, and fiscal and performance oversight to all the school districts in Sonoma County. In addition, he acts as the Chief Executive Officer (CEO) to SCOE.

F3: Sonoma County has 40 individual school districts serving approximately 71,000 students K-12. Each of these school districts has its own superintendent, board of education, teachers, and office and support staff. Findings, continued

F4: As an elected official, the Superintendent is accountable only to the electorate. The County Board of Education approves his salary, but his job performance is not subject to Board review.

F5: The County Board of Education is composed of seven members who are elected from designated areas within Sonoma County, each area includes more than one school district. Their responsibilities are to approve the budget set by the Superintendent, to provide policy direction and oversight for Alternative Education and the Regional Occupational Program, to review and rule on appeals for student transfers between districts, and to serve as an appeal board for district-level student expulsion decisions.

Related Recommendations (1)

R3: The Sonoma County Board of Education should explore options to increase its effectiveness. The Board represents a wealth of knowledge and needs to seek ways to change the paradigm of its work and increase its influence. Required Responses to Recommendations SCOE Superintendent of Schools R1, R2 Sonoma County Board of Education R3 60

F6: The County Board of Education has influence over Alternative Education and ROP, but these programs represent a small part of the budget. BOE certifies learning materials used in the classroom, oversees quarterly reports of Williams Law compliance, manages lease-space requirements, approves the selling of capital equipment, and is responsible for the approval of charter schools designed to serve students throughout the county. (The Williams Law requires frequent monitoring of credentialed teachers assignments to ensure that schools with low performance scores on standardized tests have competent teachers and adequate materials).

F7: SCOE, under the direction of the Superintendent, is responsible for fiscal and educational performance and oversight of school districts. It is required to report this information quarterly to the State Office of Education.

F8: The State can assume control over local school districts, or SCOE can fund and assign a fiscal advisor with “stay and rescind” authority to assist the district to achieve fiscal stability.

F9: The districts of Sonoma Valley and Healdsburg are subject to corrective administrative status after continued difficulties with the Federal Government’s guidelines for the “No Child Left Behind Act.” SCOE has assisted the Healdsburg School District with student performance and fiscal issues, and the State is reviewing the Sonoma Valley’s curriculum, testing, and teacher quality issues.

F10: The Superintendent negotiates with several unions as their contracts come up for renewal. These unions represent teachers and ancillary staff. They are the California Federation of Teachers (CFT), Service Employees International Union (SEIU), Association of Sonoma County Office of Education (ASCOE), and Regional Occupation Program Teachers Association (ROPTA).

F11: The Superintendent has a management team of Assistant Superintendents, Directors, and others in leadership roles. They assist and advise the Superintendent in developing and achieving the goals of SCOE, providing oversight and reporting quarterly, as mandated by the State of California. Findings, continued

F12: Projected State budget cuts of 10 percent will decrease or cut art and music programs and reduce the number of teacher’s aides. Special Education teacher aides are mostly supported by federal funds and not likely to be affected by state budget cuts.

Related Recommendations (1)

R1: SCOE must ensure that school districts do not sacrifice important programs or decrease the number of teachers’ aides as a way to balance the budget.

F13: SCOE, under the direction of the Superintendent, is increasing its support to the districts with some of the following services: o Performs Live Scan fingerprinting through the Department of Justice (DOJ) as a clearinghouse for prospective teachers, support staff, and volunteers to protect the security of students. o Assists Human Resources at the district level with up-to-date information on new laws and union procedures. o Conducts job searches, if requested by the districts, for superintendents and administrators at less cost than outside recruiters. o Offers a Beginning Teachers Support and Assessment (BTSA), a two-year program for new teachers. o Offers an Aspiring Administrator’s Academy, in conjunction with Sonoma State University and Dominican College in San Rafael, for teachers interested in careers in administration. o Provides a website and phone-based automated calling system for requesting and assigning substitute teachers and assistants who have registered and been accepted by SCOE. o Offers a mentor program for new principals to orient and assist them with their new responsibilities. o Assists some of the smaller districts with purchasing supplies in bulk to minimize costs. o Assists districts with efforts to close the “learning gap” between native English speakers and English language learners through the Aiming High program. o Provides a district assistance intervention team, when requested, to help in “No Child Left Behind” program improvement to address issues and thereby avoid corrective action. o Promotes the K-16 Career Development Strategic Plan to assist students to prepare for and obtain meaningful careers with an efficient approach. Findings, continued

F14: School and College Legal Services (SCLS) is a Joint Powers Authority that contracts with schools and colleges throughout California. SCLS provides legal services to SCOE on a monthly retainer. It counsels on employer-employee issues, grievances, collective bargaining, and other aspects of school law. SCOE has a contract with SCLS through which SCOE provides payroll services for SCLS.

F15: SCOE may support, under appropriate circumstances, teacher’s use of Education Code Section 44922. At age 55 until age 70, certificated, full-time personnel may switch to part-time, receive a pro-rated salary, and are allowed health benefits the same as in their full-time position. To qualify, they must have at least 10 years of certificated employment, with the last five being full- time, without a break in service. This is informally referred to as the “Willie Brown” provision, named for its author, former Speaker of the House in the California Legislature.

F16: SCOE does not support the practice referred to as “spiking”, a process where teachers can enhance their retirement benefits by working extra hours in the year before retirement, i.e. summer teaching.

F17: The issue of elected vs. appointed superintendents has been studied, at the request of SCOE, under the direction of the Superintendent, by a professor at Sonoma State, and previously, by the League of Women Voters in Alameda County. Neither study reached definite conclusions as to what would be the best for the counties involved.

F18: Unification of Sonoma County’s 40 school districts would address the duplication of effort and salaries of forty superintendents, district administrators and support staff. Conclusions • SCOE is doing an efficient job overseeing its responsibilities. The Superintendent has a background in education that has been beneficial to the organization and operations within SCOE. • The Superintendent includes the next level of management in decision-making. Referred to as the Superintendent’s Cabinet, this group meets regularly to discuss issues of oversight and reporting as mandated by the State of California. • The Superintendent delegates to his staff and has an open door policy to encourage communication. He is always visible and strives to attract and retain the best employees. Conclusions, continued • SCOE has a cohesive team based on cross training. Due to deadlines, different departments are busy at different times, and they support one another when downtime occurs. • Staff morale has been an issue in the past, but with the exception of the recent projected budget cutback, under the current management structure, a more positive environment has been incorporated into the workplace. • It is the Grand Jury’s opinion that appointing a Superintendent would increase the authority of the Board. The Board at present has no authority to evaluate the performance of the Superintendent but sets his salary and performs pro-forma duties. • An elected superintendent must take valuable time from his office to run for re- election and if opposed, there is no guarantee that the best-qualified person for the job wins. With a job search, the County Board of Education—or a committee chosen for that purpose—researches, interviews, and approves the candidates, and it is not a political process. Additionally, running for election is costly. • Historically, the unification of school districts in Sonoma County is a controversial issue. This matter has been studied and commented on since 1916, when there were 147 school districts in Sonoma County. Deep-seated issues of local control make this an emotionally-charged topic. Declining enrollment, changes in demographics, and monetary concerns will eventually reduce the number of districts. Commendations • The Grand Jury commends the Superintendent of Schools for his goal-oriented philosophy of leadership, fiscal oversight, and hiring of quality employees. • The Grand Jury commends SCOE for its mission to educate all children in Sonoma County with quality occupational programs, special education, performance monitoring, and the desire to expand services in assisting the school districts • The Grand Jury commends the Director of Human Resources for initiating, under the direction of the Superintendent, the recommendations of the 2006-2007 Grand Jury regarding fingerprinting and background checks for volunteers and others who are in contact with students. • The Grand Jury commends the Assistant Superintendent of Business Services for her grasp of the issues and enthusiasm for her work. • The Grand Jury commends the President of the County Board of Education for his knowledge of and desire to improve education in Sonoma County. 59

Additional Recommendations 1

Not linked to specific findings.

R2: SCOE should explore the possibility of establishing an internship program for education majors at Sonoma State, Dominican College, and Santa Rosa Junior College to give student teachers classroom experience and allow them to assist teachers.

June 27, 2008 — Santa Rosa Central Library at Risk The Santa Rosa Central Library has experienced a growing problem with the homeless

5 pages 9 findings 11 recommendations

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Findings & Recommendations 9 findings

F1: The homeless are the principal cause of F8 There has been a noticeable increase in disruption of normal library operations and complaints from the public and recorded thereby impact the appropriate and productive incidents requiring police intervention. use of the library by the general public.

Related Recommendations (1)

R1: Modify the Standards of Behavior to include strict, unequivocal consequences for disruptive behavior.

F2: The homeless are utilizing the library as a easy observation of objectionable material by shelter during daytime hours, since there is no patrons passing through the library main aisle. daytime drop-in shelter available in the Santa Rosa shelter system. F10 The addition of a security guard (September 2007) has had a positive impact on relations

Related Recommendations (1)

R2: Incorporate no-loitering provisions into the Standards of Behavior and provide library staff and security with the necessary support and training to enforce these rules.

F3: The homeless often bring in bundles, bedrolls, with the homeless community. bags of recyclables and possessions, all items that are difficult for library staff to control. F11 Outreach and coordination with key shelter management and county mental health

Related Recommendations (1)

R3: Enforce a smoke-free zone on all properties surrounding the library facilities.

F4: Smoking and large gatherings at the library personnel has been effective in mitigating entrance are intimidating for many patrons and many potential problems. can discourage access.

Related Recommendations (1)

R4: Modify and strictly enforce current standards to prohibit any patron from bringing into the Library bed rolls, bundles, and containers other than reasonably sized backpacks.

F5: The Library Standards of Behavior, adopted in in identifying and handling individuals September 2007 are less specific and direct with mental health problems or potential for than the earlier Code of Conduct established in violent behavior. 1997, relative to the consequences and action for non-compliance. F13 Library volume and usage have remained relatively unchanged in the past two years

Related Recommendations (1)

R5: Prohibit cell phone use within the confines of the library. Recommendations, continued

F6: Those in violation of the Standards of Behavior, despite the population increase. even after repetitive incidents, are rarely denied long-term use of the library. F14 The daytime shelter and outreach programs organized by the Committee for The

Related Recommendations (1)

R6: Rearrange and monitor computer access to limit unintended viewing and exposure to inappropriate material.

F7: There has been a general relaxation towards Shelterless (COTS) in Petaluma have been the enforcement of the Standards of successful in minimizing inappropriate use Behavior: Restrictions on food and beverages, of the library in that city. smoking, computer and cell phone use, and loitering. F15 All shelter management professionals strongly recommended to consistently enforce rigid standards of behavior as well as consequences for noncompliance. Conclusions There is a growing dissatisfaction among the general public regarding the changing environment at the Central Library facilities in Santa Rosa. The increasing presence and inappropriate behavior of homeless and transitional people are jeopardizing the traditionally safe, secure, and welcoming surroundings that are typical of this highly-valued institution. Library staff is called upon to spend an inordinate amount of time away from their normal duties to address behavioral problems. These issues often involve dealing with individuals who are substance abusers or mentally handicapped for which staff often have only limited training and experience. Although assistance is available from County Mental Health Division and shelter management personnel and library security, these incidents can escalate rapidly and necessitate police intervention. Issue of a revised Library Code of Conduct in September 2007 has not given the library staff and security the necessary tools to cope with a rising level of code violations. A “three strikes” approach needs to be taken to send a clear message that strict measures will be applied to preserve acceptable conditions for all patrons. Additionally, library staff must be ensured of a working environment free of intimidation and threat of verbal abuse and physical violence. In spite of the addition of library security and coordination with the mental health and shelter community, it is anticipated that the library environment will continue to be negatively impacted if an adequate daytime shelter is not provided within the general support area of Santa Rosa. Public support will be crucial in order to maintain a healthy library system that is capable of expanding to meet population and advanced technology. To achieve this, it is paramount that the library system continue to offer an experience worthy of the library staff commitment and dedication. Commendations The dedication and commitment of the library staff has The library environment been exemplary in spite of sometimes difficult situations will continue to be demanding their attention and intervention. negatively impacted if an The security guard at the Central Library has dealt with adequate daytime shelter disruptive individuals in a calm, respectful, and efficient is not provided within the way. His presence brought some reassurance for the patrons and staff. general support area of Santa Rosa. The shelter management and mental health crisis intervention personnel have made major commitments in spite of their limited staff and demanding schedules.

Related Recommendations (1)

R7: Make the Standards of Behavior more visible and proactively introduce it to all new arrivals in the library.

F9: Current locations of computer stations allow

Related Recommendations (1)

R9: Coordinate with the Santa Rosa Police Department to schedule random but regular visits inside the library.

F12: There has been minimal training of library staff

Additional Recommendations 3

Not linked to specific findings.

R8: Sonoma County Mental Health Division and shelter management personnel should expand their commitment to training and on-site intervention.

R10: The Library Commission, City of Santa Rosa, and the Community Development Commission should coordinate a task force to investigate the feasibility of alternative daytime venues for the homeless community.

R11: The Library Commission should take the “pulse of the public” by producing an annual report summarizing citizen complaints and action taken by the library. Required Responses to Recommendations Library Commission RI, R2, R3, R4, R5, R10, R11 Sonoma County Library Director R6, R7, R8, R9, City of Santa Rosa R3, R9, R10 Sonoma County Mental Health Services Director R8 Sonoma County Housing Authority, Community Development Commission R8, R10 Sonoma County Board of Supervisors R10 24

June 27, 2008 — Like other small community hospitals, Palm Drive Hospital in Sebastopol operates with declining reimbursements and

6 pages 8 findings 10 recommendations

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Findings & Recommendations 8 findings

F1: Hospital executives and Board Members did an inadequate job of evaluating and communicating the serious financial trends and looking for ways to resolve the situation.

Related Recommendations (1)

R1: All Board members should receive basic financial training. California Special District Association offers training for new board members. Financial institutions and auditors also offer financial training.

F2: Financial Data: Fiscal Year Ending June 30 2003 2004 2005 2006 2007 Net Revenues from Operations $17,052,090 $14,958,886 $15,930,615 $16,772,800 $15,104,279 Operating Income or (Loss) ($3,451,399) ($4,304,254) ($4,499,097) ($4,936,734) ($6,925,239) Tax Revenues $1,838,051 $1,859,911 $4,402,300 $3,687,385 $4,030,946 Source: Audited Financial Statements

Related Recommendations (1)

R2: A five-year strategic plan, with benchmarks, should be developed and reviewed annually.

F3: Audited financial statements indicate: • Declining net revenue from Operations • Growing losses in operating income caused in part by low insurance and reimbursement rates. • Poor Accounts Receivable procedures and collections. • Bad decisions, i.e., closing and reopening the Intensive Care Unit. Opening long-term nursing facility and then closing it due to necessary repairs.

Related Recommendations (1)

R3: PDHCD should create a management-support group for the doctor population.

F4: 2007 Auditor’s comments: “These conditions raise substantial doubt about the District’s ability to continue Hospital Operations in the future.”

Related Recommendations (1)

R4: The district should increase efforts to improve the image of Palm Drive Hospital in order to attract quality physicians and avoid losing patients to competing hospitals.

F5: Despite a County Healthcare budget in excess of $200 million, there were no county funds earmarked to assist the small hospitals in the county like Palm Drive.

Related Recommendations (1)

R5: As a member of the JPA, Palm Drive should investigate specialization in specific medical areas.

F6: The performance review process for the executive staff was ineffective.

Related Recommendations (1)

R6: The Board and Hospital Management should create job descriptions for all executive employees, emphasizing the importance of communications.

F7: A Joint Powers Agreement (JPA) was formed to allow hospitals to save money by coordinating purchasing, etc.

Related Recommendations (1)

R7: PDHCD should continue to keep taxpayers informed on financial matters.

F8: Most board members have limited experience in hospital operations and financial analysis; there has been considerable turnover of Board and key hospital operations personnel in the 2003-2007 periods. Conclusions As noted, there are several areas of improvement: Key Statistics Average 7-1- 2007 YTD 12-31- 2007 YTD Variance Hospital IP Census 8.4 10.9 30% ER Visits 20.9 21.4 2% Lab & X-ray 37.1 36.1 -3% IP & OP Surgeries 4.3 4.7 9% Other OP 2.6 3.7 42% Hospital Admits 524 708 35% Hospital Patient Days (Acute & Swing) 1,796 2,339 30% ICU Admits N/A 187 ICU Days N/A 472 ER Visits 4,484 4,593 2% Lab & X-ray 7,975 7,762 -3% IP & OP Surgeries 934 1,004 7% Other OP 555 795 43% • Higher reimbursement rates from insurance • Improved billing and collection procedures PROJECTIONS • Five- year projections show a continued need for parcel taxes and long-term debt. • An essential element of the Plan of Adjustment is for the District to issue Certificates of Participation (COP). COPs are similar to bonds in that they are used to finance debt. They are paid for by Measure “W” proceeds, and DO NOT require voter approval. A portion of the proceeds will be : o Used to create the “Plan Fund” to pay creditors who have allowed Claims filed with the Bankruptcy Court, o Used to repay the Operating Loan, o Applied by the district to finance future long-term capital and operating needs for the District, o Used to retire the approximately $9.2 million remaining in the 2001 bond issue. The amount of the COP is approximately $23 million. Commendations The District has been fortunate to have the leadership and financial acumen of Dan Smith, a concerned citizen whose financial generosity single-handedly kept the hospital doors open during dire times.

Related Recommendations (1)

R8: PDHCD should institute and manage an effective A/R collection program to enhance management-support practices.

Additional Recommendations 2

Not linked to specific findings.

R9: PDHCD should institute an effective performance-review program for management.

R10: Sonoma County should show financial interest and use of influence to aid smaller hospitals. The County, as stated in its mission statement, is committed to providing superior and courteous services to support, preserve, and enhance the health of Sonoma County citizens. Therefore, Palm Drive Hospital should be preserved. Required Responses to Re

May 14, 2008 — Reada Nde SNSIDIRTff ? ri ?fi{'f; Date 6,1.2/.4_g,{, $omoma Offce of Education

5 pages 9 findings 6 recommendations

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Findings & Recommendations 9 findings

F1: Respondendti sagreeps artiallyw ith this finding. Regardingth e statementth atq ualified programsw ere deniedf unding throughC arl Perkinsg rantsb y SCOE,t he only instancer elating to this finding of which we are awarep ertainst o the teacherm entionedi n the grandj ury report who askedS COEt o fund SkillsU SA with $2,500o f Perkinsm oney. At thatt ime,t he Skills USA programw as alreadyf ully fundedf or that budgety ear fiom non-SCOEn on-Perkins sources.T he teacherw ast old thath is requeswt ould be consideredd uringt he nextf unding cycle. However,t he Carl PerkinsA ct hasb eena mendeds ince2 006-2007a nd SCOE is not receivinga ny Perkinsf undingf or 2007-2008. The issuer egardingw hether" programsa nd materialsn ot allowed by the Carl PerkinsA ct were purchasedw ith the grantm oney" is presentlyp endingw ith the StateD epartmenot f Education. As discussedin the reportb y Loyal Carlon,c opy attachedS, COEe xpendedfu ndsf iom the Perkinsg rant in 2006-2007f or the benefito f vocationalp rogramsa t the Youth Camp and Adera Cal-Safe.A s such,S COEw asa n eligibler ecipiento f thesef unds. The PerkinsA ct in effectf or thatt ime perioda lsop rovidcda t $2355(c)t hat Perkinst undsm ay be used,a mongo thert hings,t o "providep rogramsfb r speciapl opulations"a ndf br "support services." Section2 301( 23) of the Act deflned" specialp opulationst"o includei ndividualsw ith disabilitiesi,n dividualsf rom economicallyd isadvantagefda milies,i ncludingf osterc hildren, individualsp reparingf or non-traditionatlr aininga nde mploymcnts, inglep arentsa. nd 'l'he individualsw ith otherb arrierst o educationaal chievement. vastm ajorityo f SCOEs tudents attendingit s courta ndc ommunitys choolsa rew ithin this defrnitiono f "specialp opulation." In the first paragrapho f its lbur year local performancep lan fbr 2000-2004( which was extended for the 2006-2007s chooly ear), SCOE advisedt he statet hat it was recluestingP erkinsl unds "to addressth e educationaal ndv ocationanl eedso f the speciapl opulationso f at-risks tudentsw" ith the programso ffered by the County office. The disputede xpenditurebse nefitedth eses peciapl opulationsb y, amongo thert hings,a dvising theses tudentso f possiblec areero ptionsa nd by assistingt heses tudentsin finding appropriate careerp athways. Therefore,t hesee xpendituresa ppeart o fall within the permissibleu se of Perkinsf undsa sp rovidedi n the Act. However,i n its letterd atedM arch2 8, 2008,t he StateD epartmenot f Educationa dvisedS COE on paget hreea t (4) that its attorneyd id not believet hat thesee xpensesw ere allowed undert he Act. While the expressl anguageo f the PerkinsA ct appearsto supporta contraryi nterpretation, SCOEd oesn ot believei t is productiveto continuet o spendt ime ande nergyc ontestingth is expenditureo f a relatively small sum of money,a ll of which was clearly spentf or educational purposesth at benefitedS COEs tudents.A ccordingly,S COEh asp roposeda compromise resolution;h owever,w e have not yet heardb ack from the stateo n this matter. 8/19 /08

F2: No responseis required.

F3: Respondenat greesw ith this finding.

F4: Respondendt isagreeps artiallyw ith this finding.S ASI (refenedt o as SASix in the Grand Jury Report) is a prog.u* that tracksg radesa nd creditsf or highly mobile studentsin ordert o maximizet heir ability to meetg raduationre quirementsT. his programw as discussedo n pagel 4 of SCOE'sf our yearl ocalp erfbrmancep lan fbr 2000-2004( whichw as extendedto the endo f the 20Oi schooly ear) that was submittedt o the statei n connectionw ith the requestf br Perkins funding. fne $+,OOOre ferredt o in the GrandJ ury report representsm oney spentb y SCOE to provide technicals upportf or the SASix program,w hich was utilized to supportn ot only the vocationalp rog.urn, at ttre Youth Camp and Adera,b ut alsot he programsb enefitingt he special populationia ttendingS COEc ourta ndc ommunitys chools.A s noteda bove,t he PerkinsA ct statest hat funds 1nuyb . providedt o benellt specialp opulationsa nd to provide supports ervices in connectionw ith this funding.

F5: Respondendt isagreeps artiallyw ith this finding.W e aren ot surew hat the state administiators aidi n his testimonyt o the GrandJ ury. In any event.t he SASix expenditurew as not lor the purchaseo f software.P leases eet he responseto F4 above.

F6: No responseis required.

F7: Respondendt isagreeps artiallyw ith this finding.T he teacherm entionedin the GrandJ ury reporta skedS COEt o fund Skills USA with $2,500o f Perkinsm oney. At thatt ime,t he Skills USA programw as alreadyf ully lundedf br that budgety earl iom non-SCOEn on-Perkins .o.,r".r. The teacherw ast old thath is requeswt ould be consideredd uringt hc next funding cycle. As noteda bove,S COEi s not receivinga ny Perkinsf unding1 br2 007-2008. Fg: Respondenatg reesw ith the undcrlyingb asisl br this finding.W e aren ot surew hat the state administratosr aidi n his testimonyt o the GrandJ ury. We believet hat Perkinsf undsm ay be usedf br Skills USA Programs.

F9: Respondendt isagreesw ith this finding. The GrandJ ury report doesn ot identify the name of the staff personm Jntionedi n this finding. The reassignmenot f the SCOE teacherw ho had askedf or perkinsf undsf br the Skills USA program( whichw asa lreadyf ully fundedf rom other non-SCOEn on-Perkinss ourcesw) ast he subjecto f a grievancew, hich assertedth att he reassignmenotf the teacherw as" punitive,d isciplinaryo r retaliatory."A hearingo n the grievincew as held beforea n impartiala rbitratoro n January2 3.2008. At the hearing.s worn t-estimonyw as takena nd many exhibitsw ere submittedr egardingt he proprietyo f the reassignment.O n May 14, 2008 the impartial arbitratorr uled that the grievancew as without merit. In particular,t he arbitrators tated: "Grievant's primary contentioni s that he was transferredb ecauseh e reporteda n allegedm isuseo f Carl Perkinsf unds to the Stateo f California. This contentioni s not supportedb y the evidence." A copy of the impartial arbitrator'so pinion (redacted)a nd awardi s attachedh ereto. A copy of the swornt estimony given at the arbitrationw ill be madea vailableu pon request' The GrandJ ury report doesn ot provide any informationt hat contradictst he evidencep resented at the hearingo n the grievance. We are therefores urprisedt hat the Grand Jury concludesb y this 8/19/08 finding and recommendationR 6 that the subjectr eassignmenwt as punitive when an impartial arbitratorh asr uled that it was not.

Related Recommendations (1)

R6: We agreew ith this recommendationw,h ich representesx istingS COEp olicy. However,t he reassignmentht at involvedt he "award-winningte acher"w ast he sub.iecotf a full evidentiary hearingb eforea n impartial arbitrator. As noteda bovei n responseto F9, the impartial arbitrator concludedth at the reassignmenwt asn ot punitive.

F10: Respondendt isagreesp artially with this finding. SCOE may be askedt o repaya portion of the Perkinsf unding. SCOE hasn ot beeni nformed of any final determinationb y the stateo n this issue. Pleases eet he responseto Fl above. 8/19 /08 Responseto Recommendations Rl: We agreew ith this recommendationw,h ich representesx istingS COEp ractice.

Related Recommendations (1)

R2: We agreew ith this recommendationw,h ich representesx istingS COEp ractice.

Additional Recommendations 4

Not linked to specific findings.

R3: We acknowledget hat "targetedf unds" shouldb e usedf or the purposesin tended.

R4: We agreew ith this recommendationw,h ich representesx istingS COEp olicy. The independenat uditorsr etainedb y SCOEs electa sampleo f programsto audite achy ear.I t is not feasiblet o audite verys inglep rograma nde xpenditure.

R5: We agreew ith this recommendatioant leastw herei t is feasibleto do so,w hich represents existingS COEp olicy

R7: This recommendatiorne quiresf urthera nalysis.W e agreet hat a key consideration regardingt he assignmenot f personneils whethert he assignrnenwt ill benefitt he students aff-ectedO. therf -actortsh at may needt o be consideredin cludes eniority,q ualifications, credentialsa ndt he overalle ducationanl eedso f the Countyo ffice. The operativep olicy onthis subjecta st o certificatedp ersonneils the CollectiveB argainingA greemenbt etweenS COEa nd the teachersu' nion. In particulars, ees ection1 6.6.1o l'the CollectiveB argainingA greemenot n this issue,c opy attached.T he Countyo ffice cannotu nilaterallym odify the Collective BargainingA greementa ndw e do not believea t this time that it would be prudentt o do so in the manners uggestedsi ncet o focuso n onei ssue- - albeita n importanto ne- - to the exclusiono f otherp otentiallyr elevanti ssuesc ouldr esulti n an undulyn arrowa pproachto assignments. Further,t his recommendatioanp pearsto be premisedo n the assumptionth at F9 is accurate.A s noteda bove,w e believeF 9 is incorrecta ndt hatt his erroneousta ctualf indingh asl ed the grand jury to make unwarranteda ssumptionsa nd recommendations. 8/t9t08

March 08, 2008 — Officer-involved Fatal-incident Reports The 2007-2008 Sonoma County Civil Grand Jury reviewed three Fatal-Incident

4 pages 5 findings 2 recommendations

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Findings & Recommendations 5 findings

F1: The Law Enforcement Employee-Involved Fatal Incident Protocol requires that investigations be conducted "free of conflicts of interest." For that reason, the investigations were conducted by a law- enforcement agency whose employees were not involved in the incidents. The District Attorney’s Office also participated in the investigations and had the authority to investigate separately.

F2: Upon completion of each incident investigation, the District Attorney’s Office reviewed the physical evidence, the transcribed witness interviews, photographs, and all other evidentiary material.

F3: Based on the evidence, the District Attorney’s Office reached its conclusions and issued fatal-incident reports for the cases. In each, the District Attorney’s Office concluded there was insufficient evidence of criminal liability.

F4: The agencies that employ the involved officers conducted their own Administrative investigation of each incident. Administrative investigations seek to determine whether the agency's policies and procedures were followed in the incident and whether there could be improvement in those policies and procedures. They also make a determination as to whether any disciplinary action should be imposed against a particular individual or individuals.

F5: Two of the incidents in this report involved the fatal shooting of mentally ill people. The Sonoma County Sheriff’s Department is committed to its Crisis Intervention Training Academy (CIT) and has obtained $360,000 in funding over the next five years from the Sonoma County Board of Supervisors to support the program. The initial 32-hour class was started on March 8, 2008. The Sheriff’s commitment to CIT will result in the training of 35 Sonoma County law-enforcement officers twice a year. The overall program goal is to train 350 Sonoma County law- enforcement officers over the next five years. This class deals directly with the problems that officers encounter when confronting a mentally ill person. Conclusions Two of these cases were truly tragic deaths because they involved mentally ill subjects. It needs to be said that in Sonoma County there is no viable crisis-intervention option for the families of these mentally ill subjects. As a result, some of the responsibility for these deaths may be placed on the Sonoma County mental health care system. A domestic violence call involving a mentally ill person is by far the most dangerous situation that a police officer will encounter. An officer is called to resolve this crisis when no one else can. The mentally ill subject is often irrational, experiencing delusions, and acting unpredictably. When there are weapons involved (as was the case here), the risk to the officer and everyone in the vicinity escalates dramatically. If your loved one is wielding a weapon or firing a gun, the consequences are predictable. Police officers are human beings with families who take a sworn oath to protect lives and preserve peace. When they are confronted with violence they are not trained to retreat. They will react and use the force necessary to diffuse a situation safely. In some cases, lethal force is a result of the escalation of events. Saving their own lives, as well as those they are charged with protecting, is their duty. In both of these cases non-lethal force was used, but had no affect on the mentally ill subjects. It was only after the failure of non-lethal force that lethal force was used to protect the lives of others. The Sonoma County District Attorney has concluded that all officer-involved protocols were followed and that no wrongdoing was found. After reviewing these fatal incidents, the Sonoma County Civil Grand Jury concurs with the District Attorney’s findings. The public is understandably shocked and dismayed when it hears about a mentally ill person being killed by a police officer. The thought that immediately comes to mind is that there must be a better way. Sonoma County law enforcement shares this concern. The new CIT program described in our findings is a giant step towards the achievement of a better outcome in these extreme situations. The course outline we reviewed should help our police officers understand and apply techniques to minimize the use of lethal force in these crisis situations.

Additional Recommendations 2

Not linked to specific findings.

R1: The Sonoma County Grand Jury recommends that the District Attorney continue to notify them as soon as a District Attorney R1, R2 fatal- incident protocol is initiated.

R2: The District Attorney should continue to supply the Grand Jury with a copy of the fatal-incident report status log in a timely fashion and on a monthly basis. 41 4422

November 19, 2007 — Local Involvement in Immigration and Customs Enforcement Illegal immigration is a contentious political issue in the

6 pages 2 findings

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Findings & Recommendations 2 findings

F1: If an illegal immigrant obeys local and state laws, he or she can report crimes and obtain police assistance without fear of I.C.E. involvement. The insulation from I.C.E. for innocent bystanders, complainants, and victims of crimes is not perfect but it is substantial.

F2: Criminal activity by an undocumented individual will dramatically increase the likelihood of deportation. Minor infractions and lesser misdemeanors will produce a small but significant risk. Major crimes and gang involvement will probably result in I.C.E. intervention and possible deportation. 30

September 30, 2007 — Death by Incarceration

4 pages 7 findings 5 recommendations

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Findings & Recommendations 7 findings

F1: The CFMG assessment protocol lacks the formality and specificity to detect inmates with high risk for AWS. For example; the absence of a point system, the omission of specific awareness questions and general brevity of the assessment makes one consider the degree to which the outcome depends on the skill, working conditions and attitude of the medical staff. The lack of formality leaves too much to the subjective interpretation of the RN. A more comprehensive assessment would also enhance the County’s and the Contractor’s position with regard to contingent liability.

Related Recommendations (1)

R1: The Sheriff’s Department should require that Sonoma County Sheriff the CFMG alcohol withdrawal risk assessment procedure should be modified to more closely – F1, F2, F3, F4, F5, F6, F7 follow the CIWA-Ar including all the parameters and the rating scale in the formal procedure. Requested Responses to Findings

F2: Lack of withdrawal symptoms prior to assignment to general population housing is not a valid criterion for those inmates who may still have significant blood alcohol concentrations at the time of assessment. Blood Alcohol Concentration (BAC) or a breathalyzer test would reveal the need to closely monitor the inmate and reassess the AWS dangers when the BAC is low enough for the evaluation to be medically valid.

Related Recommendations (1)

R2: The Sheriff’s Department should require that the CFMG assessment protocol should identify California Forensic Medical Group, Inc. chronic alcoholics, who arrive intoxicated and have a medical history of AWS, as a special – F1, F2, F3, F4, F5, F6, F7 class of inmates needing closer monitoring. Reassessment of AWS risk is required when BAC concentrations drop below .1%. Required Responses to Recommendations

F3: To protect high risk inmates (as defined here), the withdrawal and detoxification protocol in use should be mandatory, as opposed to, being at the discretion of the RN. Initially, the protocol must include frequent monitoring of the inmate

Related Recommendations (1)

R3: The Sheriff’s Department should require that CFMG should monitor W class inmates at Sonoma County Sheriff least once every four hours. – R1, R2, R3, R4, R5

F4: A twice-a-day monitoring schedule is inadequate to monitor W class inmates for withdrawal symptoms. Medical checks, at four-hour intervals, are generally accepted as adequate in a hospital environment and in other detention environments.

Related Recommendations (1)

R4: The Sheriff’s Department should require that CFMG should consider the administration of widely-held medication practices to AWS Requested Responses to inmates as a seizure precaution. Recommendations

F5: If a more frequent monitoring protocol were to be initiated in the first 48 hours of incarceration, it may be possible to deliver medication to prevent the onset of AWS which would diminish the probability of potentially fatal withdrawal incidents.

Related Recommendations (1)

R5: Specific Rounds procedures should be defined and followed by COs for W class inmates until California Forensic Medical Group, Inc. CFMG reviews AWS S ris o k n a o nd m de a te C rm o in u es n t t h y a t Gran d Jury special attention is no longer necessary. The – R1, R2, R3, R4, R5 new W class procedure should require a verbal response from the inmate. Also, COs must open the cell door and/or turn on the light to elicit a response. 9

F6: The primary responsibility for the medical welfare of inmates resides with the medical staff. However, correctional officers observe inmates every half hour. With the implementation of special observation criteria, they could significantly diminish the risk to the most serious AWS candidates. (Opening the cell door and requiring a verbal response from high risk inmates may be sufficient).

F7: Two medical experts indicated that the high-risk inmates we identified would have benefited from blood alcohol testing prior to being placed in general population. Conclusions It is difficult to determine AWS risk. Fatal incidents can occur any time from a few hours to several days after the cessation of alcohol use. It is generally accepted that the greatest risk of life threatening events, such as seizures and delirium tremens, occurs in the first 48 hours. The CIWA-Ar protocol has a well documented track record for the assessment and treatment of AWS. Shortcuts to the CIWA–Ar save little time and can lead to catastrophically inaccurate assessments. The formal protocol takes only five (5) minutes to administer, and the result is less prone to subjective medical errors in the jail environment. There is a class of very high-risk people who can be easily identified. They are chronic alcoholics with a recent, very large intake of alcohol. They have a history of previous detoxification incidents, such as delirium tremens, and/or they have previously been given medication to mitigate their withdrawal. All of the research reviewed by the Grand Jury indicates that four-hour observation intervals, along with the recording of vital signs, are the minimum requirements for a safe alcohol detoxification. Numerous published Documents and the opinions of three independent medical experts support this. Two observations a day are not good enough. During our investigation at least one inmate died on that reduced observation schedule. Every Medical expert we interviewed expressed the opinion that deaths from AWS are completely preventable. There are relatively inexpensive procedures that can be employed to protect these inmates. Our recommendations outline what is required. If high risk inmates were temporarily housed in the Medical module (I module) there would be little impact on the added labor required to do this closer monitoring. The County should take responsibility to treat these sick inmates in an environment that is appropriate for their condition. Conclusions (continued) Inmate health is at-risk because they are being treated for AWS in a jail environment. As noted in F7, the high risk inmates that we identified, would have benefited from blood alcohol testing (BAC) prior to their assignment to general population cells. The experts we cite each stated two reasons for this. One reason was that alcohol poisoning potential (a separate life threatening problem) can be detected in a chronic alcoholic who may not exhibit symptoms that would cause a casual drunk to lose consciousness. The second reason was to validate the risk- assessment protocol. People with a high BAC will not exhibit the symptoms used to indicate AWS risk. Several hours later however, symptoms that would put them in a hospital may be undetected while they are in their cell. The Grand Jury checked these opinions with a third medical expert who supervises detention medicine in another county. He concurred, but pointed out that BAC testing was not a common practice in detention facilities, including the one he works in. Commendations The Grand Jury must commend the medical experts we interviewed. They provided extensive resource material, personal experiences, medical documentation and countless hours of their time to assist us in formulating our hypothesis and validating our conclusions. Their input was invaluable.

September 30, 2007 — Death by Incarceration

4 pages 7 findings 5 recommendations

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Findings & Recommendations 7 findings

F1: The CFMG assessment protocol lacks the formality and specificity to detect inmates with high risk for AWS. For example; the absence of a point system, the omission of specific awareness questions and general brevity of the assessment makes one consider the degree to which the outcome depends on the skill, working conditions and attitude of the medical staff. The lack of formality leaves too much to the subjective interpretation of the RN. A more comprehensive assessment would also enhance the County’s and the Contractor’s position with regard to contingent liability.

Related Recommendations (1)

R1: The Sheriff’s Department should require that Sonoma County Sheriff the CFMG alcohol withdrawal risk assessment procedure should be modified to more closely – F1, F2, F3, F4, F5, F6, F7 follow the CIWA-Ar including all the parameters and the rating scale in the formal procedure. Requested Responses to Findings

F2: Lack of withdrawal symptoms prior to assignment to general population housing is not a valid criterion for those inmates who may still have significant blood alcohol concentrations at the time of assessment. Blood Alcohol Concentration (BAC) or a breathalyzer test would reveal the need to closely monitor the inmate and reassess the AWS dangers when the BAC is low enough for the evaluation to be medically valid.

Related Recommendations (1)

R2: The Sheriff’s Department should require that the CFMG assessment protocol should identify California Forensic Medical Group, Inc. chronic alcoholics, who arrive intoxicated and have a medical history of AWS, as a special – F1, F2, F3, F4, F5, F6, F7 class of inmates needing closer monitoring. Reassessment of AWS risk is required when BAC concentrations drop below .1%. Required Responses to Recommendations

F3: To protect high risk inmates (as defined here), the withdrawal and detoxification protocol in use should be mandatory, as opposed to, being at the discretion of the RN. Initially, the protocol must include frequent monitoring of the inmate

Related Recommendations (1)

R3: The Sheriff’s Department should require that CFMG should monitor W class inmates at Sonoma County Sheriff least once every four hours. – R1, R2, R3, R4, R5

F4: A twice-a-day monitoring schedule is inadequate to monitor W class inmates for withdrawal symptoms. Medical checks, at four-hour intervals, are generally accepted as adequate in a hospital environment and in other detention environments.

Related Recommendations (1)

R4: The Sheriff’s Department should require that CFMG should consider the administration of widely-held medication practices to AWS Requested Responses to inmates as a seizure precaution. Recommendations

F5: If a more frequent monitoring protocol were to be initiated in the first 48 hours of incarceration, it may be possible to deliver medication to prevent the onset of AWS which would diminish the probability of potentially fatal withdrawal incidents.

Related Recommendations (1)

R5: Specific Rounds procedures should be defined and followed by COs for W class inmates until California Forensic Medical Group, Inc. CFMG reviews AWS S ris o k n a o nd m de a te C rm o in u es n t t h y a t Gran d Jury special attention is no longer necessary. The – R1, R2, R3, R4, R5 new W class procedure should require a verbal response from the inmate. Also, COs must open the cell door and/or turn on the light to elicit a response. 9

F6: The primary responsibility for the medical welfare of inmates resides with the medical staff. However, correctional officers observe inmates every half hour. With the implementation of special observation criteria, they could significantly diminish the risk to the most serious AWS candidates. (Opening the cell door and requiring a verbal response from high risk inmates may be sufficient).

F7: Two medical experts indicated that the high-risk inmates we identified would have benefited from blood alcohol testing prior to being placed in general population. Conclusions It is difficult to determine AWS risk. Fatal incidents can occur any time from a few hours to several days after the cessation of alcohol use. It is generally accepted that the greatest risk of life threatening events, such as seizures and delirium tremens, occurs in the first 48 hours. The CIWA-Ar protocol has a well documented track record for the assessment and treatment of AWS. Shortcuts to the CIWA–Ar save little time and can lead to catastrophically inaccurate assessments. The formal protocol takes only five (5) minutes to administer, and the result is less prone to subjective medical errors in the jail environment. There is a class of very high-risk people who can be easily identified. They are chronic alcoholics with a recent, very large intake of alcohol. They have a history of previous detoxification incidents, such as delirium tremens, and/or they have previously been given medication to mitigate their withdrawal. All of the research reviewed by the Grand Jury indicates that four-hour observation intervals, along with the recording of vital signs, are the minimum requirements for a safe alcohol detoxification. Numerous published Documents and the opinions of three independent medical experts support this. Two observations a day are not good enough. During our investigation at least one inmate died on that reduced observation schedule. Every Medical expert we interviewed expressed the opinion that deaths from AWS are completely preventable. There are relatively inexpensive procedures that can be employed to protect these inmates. Our recommendations outline what is required. If high risk inmates were temporarily housed in the Medical module (I module) there would be little impact on the added labor required to do this closer monitoring. The County should take responsibility to treat these sick inmates in an environment that is appropriate for their condition. Conclusions (continued) Inmate health is at-risk because they are being treated for AWS in a jail environment. As noted in F7, the high risk inmates that we identified, would have benefited from blood alcohol testing (BAC) prior to their assignment to general population cells. The experts we cite each stated two reasons for this. One reason was that alcohol poisoning potential (a separate life threatening problem) can be detected in a chronic alcoholic who may not exhibit symptoms that would cause a casual drunk to lose consciousness. The second reason was to validate the risk- assessment protocol. People with a high BAC will not exhibit the symptoms used to indicate AWS risk. Several hours later however, symptoms that would put them in a hospital may be undetected while they are in their cell. The Grand Jury checked these opinions with a third medical expert who supervises detention medicine in another county. He concurred, but pointed out that BAC testing was not a common practice in detention facilities, including the one he works in. Commendations The Grand Jury must commend the medical experts we interviewed. They provided extensive resource material, personal experiences, medical documentation and countless hours of their time to assist us in formulating our hypothesis and validating our conclusions. Their input was invaluable.

June 26, 2007 — Sonoma County Employees – Waiting to Be Trained for Disaster*

5 pages 12 findings 6 recommendations

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Findings & Recommendations 12 findings

F1: Emergency preparedness, First Aid, Cardiopulmonary resuscitation (CPR), and Automated External Defibrillator (AED) training is not consistent for all Disaster Service Workers throughout the governmental entities1 of Sonoma County.

Related Recommendations (2)

R1: - All Sonoma County employees should receive emergency preparedness training with annual updates/refresher.

R2: – All Sonoma County employees should be provided the opportunity for First Aid, CPR, and AED training.

F2: Sonoma County employees, who are not first responders, want to attend Emergency and Disaster type training such as First Aid, CPR, AED, Emergency Preparedness, etc.

F3: Some Sonoma County employees, who are not first responders, have completed training on their own, such as First Aid and CPR.

F4: Sonoma County employees, who are not first responders, have expressed an interest to participate in and/or observe emergency/disaster drills and exercises as part of their training.

F5: Sonoma County employees, who are not first responders, are willing to provide assistance during an emergency and disaster event.

F6: All county employees must complete the National Incident Management System (NIMS) course by the end of calendar year 2007. As of March 29, 2007, there were 349 county employees that have completed NIMS training. The 349 employees represent approximately 7% of the total county employees of 4,850. (Note: About 2 to 3% of the total number of employees include retirees and extra-help employees who remain in the payroll system.)

Related Recommendations (1)

R4: - Develop, implement, and monitor a strategy and plan that ensures all County Employees complete the National Incident Management System course by the end of calendar year 2007.

F7: New employees of Sonoma County receive emergency/disaster training during employee orientation.

F8: Ten percent of Homeland Security Grant Funds, are designated for emergency exercises and training.

F9: Specialized training is provided to county employees to accomplish unique assignments during emergencies/disasters. For example, architects are trained to evaluate structural integrity of buildings to determine if access and occupancy is safe.

F10: Some county employees were not aware of their role during a disaster, unsure when and where to report during a disaster, and how to contact management for instructions and assignments if normal communication facilities were down and/or overloaded.

Related Recommendations (3)

R3: - On an annual basis ensure that all county employees know their assigned duties, reporting locations, and contact methods during an emergency and disaster event.

R5: – On an annual basis ensure that Department Heads, Agency Chairperson, and upper level managers of all Sonoma County entities fully participate in emergency/disaster training and the exercises/drills.

R6: - All Sonoma County employees should be made aware of how to contact management if normal communication facilities are down or overloaded. Required responses to Findings None Requested responses to Recommendations None Required responses to Recommendations Board of Supervisors – R1, R2, R3, R4, R5, R6 Sonoma County Department of Emergency Services - R4

F11: When a disaster does occur some county employees are needed to "keep the doors open" for the county government to continue serving its employees and the public.

F12: County employees want to be able to provide assistance to the public during emergencies but lack basic disaster training in First Aid, CPR, AED, emergency preparedness etc. Entities refer to Sonoma County departments, agencies, commissions, committees, services, grand juries, etc. where county employees are assigned. Conclusions Given the potential for a disastrous event of some kind in Sonoma County, the grand jury considers the county's innate responsibility for providing its citizens with emergency, medical and logistical services to be of utmost importance and priority. The functional implementation of such services is daunting, indeed. This sense of how overwhelming this task would be is what makes the necessity of dedicated, diligent and disciplined preparation on the part of Sonoma County and its cities ever more essential and urgent. The Department of Emergency Services has worked steadfastly in obtaining grant monies, making information available and providing guidance to all entities in the county. The notion that emergency preparedness plans and procedures exist is a necessary step in the process but, in fact, it is merely the beginning. The myriad of other county workers who are required to aid and reinforce in emergencies will also be central for other non-essential support services. These employees may prove to be just as vital as first responders when it comes to serving as liaisons to the community, whether that be the elderly, office workers, properly prepared families or those who inherently crater under the weight of the situation. All county citizens will need leadership and accurate information from emergency agencies in order to survive and reconstruct their family lives. We will count heavily on county employees to be available and knowledgeable about communication and other pivotal issues. The fact that employees of Sonoma County express an eagerness to assist the public during emergencies and are willing to spend the time and effort to attend training classes and participate in practice sessions is a positive and contributing step in the right direction. However, as of March 2007, close to 93% of the employees of Sonoma County had not completed their mandatory NIMS training. This is not a good indicator of diligent preparation. It will be another daunting challenge to have all employees trained by December as the Emergency Plan suggests. The jury concludes that desire and intent are not enough. Sonoma County upper level managers need to lead by example to obtain training, actively participating in exercises and drills, working to create a sense of urgency in times of tranquility and routine and making management calendars and budgets work to include valuable time for training and preparation courses for all Sonoma County employees. A specific and bona fide timetable for employee training and regular, programmatic updates needs to be established and adhered to or all the best intentions of the world could turn to ashes. Commendations The Sonoma County Grand Jury would like to thank those Sonoma County employees who assisted in providing valuable information toward this report. The Sonoma County Grand Jury was impressed with the quality and skills of county employees, and their willingness to assist the public during emergency and non-emergency periods. The Sonoma County Grand Jury found that the manager and staff of the Emergency Management Division of the Sonoma County Department of Emergency Services were professional, very knowledgeable, experienced, and helpful.

Review of Moses McDowall Fatal Incident On November 6, 2006, Moses McDowall died while in custody at the Sonoma County

7 pages 7 findings 6 recommendations

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Findings & Recommendations 7 findings

F1: The preponderance of forensic evidence and the Protocol specified that this investigation be led by a testimony of several witnesses suggest that Mr. division of the same law enforcement agency in which McDowall expired two to four hours before he was the fatal incident occurred (employer agency). The found dead at 8:18 a.m. on November 6, 2006. lead investigator was a former CO. The Grand Jury had to consider the obvious possibility that

Related Recommendations (1)

R1: The Sheriff’s Department should initiate another investigation of Mr. McDowall’s death. This investigation should be led by an outside law-enforcement agency. The focus of this investigation may be limited to the resolution of the issues (F1, F3, F4, F5) raised in this Grand Jury report.

F2: An independent forensic pathologist, consulted by the Grand Jury, concluded that the preponderance of discrepancies in the investigation may have been evidence indicates that Mr. McDowall died before intentionally overlooked. The appearance of, and possibly the actuality of, an impartial independent 6:00 a.m., and probably much earlier. investigation is destroyed by this exception to the

Related Recommendations (1)

R2: The Sheriff’s Department should develop a procedure to identify the COs performing rounds in MADF modules.

F3: The VCU/DA conclusion that Mr. McDowall was alive Fatal Incident Protocol. at breakfast (sometime after 6:00 a.m.) is

Related Recommendations (2)

R1: The Sheriff’s Department should initiate another investigation of Mr. McDowall’s death. This investigation should be led by an outside law-enforcement agency. The focus of this investigation may be limited to the resolution of the issues (F1, F3, F4, F5) raised in this Grand Jury report.

R3: The Sheriff’s Department should review the integrity of RATS and provide redundant storage of RATS data.

F4: The statement of one CO (no longer with the this critical time. The unlikelihood of a successful department) that slight movement was noticed at criminal prosecution was given as a justification for 6:56am is questionable in light of the inmate witness’s testimony, the testimony of other the lack of pursuit of these issues. Justifications aside, the Grand Jury found that the Deputy District employees, and the forensic expert’s estimated time Attorney did not identify any of the issues we raised. of death. The testimony (to VCU) by this same CO indicates that he first arrived in Module D at 5:45 a.m. on November 6, 2006. No documentary evidence F8 Our review discovered errors in the investigation, which resulted in false assumptions. Principal among these was provided to indicate his assignment to, or presence in, Module D before 6 a.m. that morning. If were miscalculation of Mr. McDowall’s time of death, the five earlier Module D rounds were done, evidence and a failure to properly investigate events prior to the presumed time of death. indicating which CO conducted those rounds and the nature of those checks is missing from the VCU investigation.

Related Recommendations (2)

R1: The Sheriff’s Department should initiate another investigation of Mr. McDowall’s death. This investigation should be led by an outside law-enforcement agency. The focus of this investigation may be limited to the resolution of the issues (F1, F3, F4, F5) raised in this Grand Jury report.

R4: The Sheriff’s Department Internal Affairs Unit should investigate independently what occurred in Module D during the time that Mr. McDowall was housed there, specifically findings F1, F3, F4 and F5. This investigation should determine: which COs were involved, if procedures were followed, and if procedures need to be revised. If warranted, recommendations for disciplinary action should be made.

F5: The Rounds Automatic Tracking System data files were lost due to hard-drive failure 17 days after the fatal incident and are unavailable to verify the paper documents indicating that rounds were completed in Modules C and D (Mr. McDowal l’s module) on the morning of November 6, 2006. The only available paper logs contradict statements of several COs interviewed. There is no reliable system available to identify who performed the rounds in Modules C and D that night. 14 \ Conclusions • The investigation of the in-custody death of Mr. McDowall represents a perfect example of “how not to do it” by all parties involved. Mr. McDowall’s demise was officially recorded in the autopsy as “Alcoholic Withdrawal Syndrome as a result of chronic alcoholism, a natural cause of death.” There is a viewpoint expressed by CO’s and staff in the Sheriff’s Department Detention Division that sick people die everywhere, including in jail. The Grand Jury disagrees with both the attitude and the assessment. Mr. McDowall‘s severe alcoholism had put his health at risk for many years. Until he was incarcerated, he was able to cope with the affliction in his own way. In jail, he does not have that option. It is the responsibility of the Sheriff’s Department to assess Mr. McDowall’s health and take the necessary measures to keep him alive. With appropriate attention and minimal effort, this death was preventable. Neither the initial VCU investigation nor the subsequent Grand Jury investigation indicate that the Sheriff’s Department lived up to its responsibility to sufficiently monitor an inmate whose health was at risk. The Fatal Incident Report sheds no light on the matter. • Mr. McDowall died sometime after he entered his cell at 3:15 am but before he was offered breakfast that morning. Our own research of the evidence and the independent assessment by a forensic pathologist concur. Usually the Coroner’s autopsy report includes no speculation as to time of death. The autopsy was normal in that respect. Several of the doctors we consulted, including the forensic pathologist, commented that the cause of death was unusually non-specific. • The VCU did not competently and impartially • The IA investigation relied on documentary investigate the Detention Division’s role in Mr. evidence from the flawed VCU investigation. No McDowall’s death. The interviews of involved independent interviews were conducted. The parties appeared to be prompted rather than presumption that a specific CO did rounds in interrogatory. The VCU investigator asked leading Module D before 6:00 a.m. on November 6, 2006, questions of the witnesses he interviewed. is unsupported by any documentary or testimonial Misinterpreted testimony led to the failure to evidence in either investigation. explore important issues. • The Law Enforcement Chiefs’ Association Fatal The Sheriff’s Department did not decide on its Incident Protocol generally provides for an own to lead the investigation of its own Detention impartial investigation free from the appearance of Division. That decision is mandated by the impropriety because the inquiry is led by a Association of Law Enforcement Chiefs’ Protocol. separate law-enforcement agency. The For that reason, the inference that the Sheriff’s association’s exemption for jail fatalities leaves Department wanted an in-house investigation for those investigations open to the suspicion of bias some clandestine purpose is not supported by and conspiracy. the Grand Jury. • Sonoma County correctional officers are • The District Attorney’s participation and review of confronted with over 12,000 bookings annually into the Fatal Incident Report was not adequate to a jail system with a constantly changing average conclude that there was no criminal act, unlawful population of 1,100 inmates. COs often view an act, or act of omission. The Deputy District inmate withdrawing from alcohol addiction as “just Attorney’s review of the VCU investigation should another drunk.” This indifference can result in have raised the same questions posed by the cursory security checks and missed opportunities Grand Jury. Several prosecutors indicate that it is for intervention in health crises. An inmate’s death very difficult to prevail in a case involving a may be the byproduct of such apathy. correctional officer. We do not presume that there was a criminal act. However, there could be criminal liability. The unlikelihood of a successful prosecution does not justify failure to investigate. 15

Related Recommendations (2)

R1: The Sheriff’s Department should initiate another investigation of Mr. McDowall’s death. This investigation should be led by an outside law-enforcement agency. The focus of this investigation may be limited to the resolution of the issues (F1, F3, F4, F5) raised in this Grand Jury report.

R5: The District Attorney should conduct a new investigation into Mr. McDowall’s death, either independently or in concert with the outside agency referred to in R1.

F6: The Association of Joint Chiefs’ Fatal Incident

Related Recommendations (1)

R6: The Law Enforcement Chiefs’ Association should amend the Law Enforcement Employee-Involved Fatal Incident Protocol to require that investigations of deaths in custody be led by an outside law-enforcement agency. The exceptions to the routine prohibition--that the employer agency not lead or directly participate in the investigation-- would be consistent with the procedures mandated for other law-enforcement employee-involved fatal incidents. Required Responses to Findings Requested Responses to Sheriff’s Department F1, F3, F4, F5 Recommendations District Attorney F7 District Attorney R1 Law Enforcement Chiefs’ Association F6 Required Responses to Recommendations Sheriff’s Department R1, R2, R3, R4 District Attorney R5 Law Enforcement Chiefs’ Association R6 16

F7: The District Attorney’s review of the VCU investigation unsupported by the testimony of the only inmate witness to the incident. This erroneous assumption concludes that no criminal acts, unlawful acts, or acts of omission occurred between 3:15 a.m. and 6:00 on the part of the lead investigator (a former CO) diverted and minimized the investigation of events a.m., which in all probability was when Mr. McDowall earlier that morning. Furthermore, this died. There is no clear evidence indicating which, if misinterpretation was an important premise of the IA any, CO performed the five required cell checks during this period. Any one of these security checks, if investigation. done, may have saved his life. The DA and the VCU investigation failed to look into what occurred during

Assignment of Health Care Access Agreement Sutter Medical Center of Santa Rosa

9 pages 22 findings 5 recommendations

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Findings & Recommendations 22 findings

F1: Sutter Medical Center has been operating with a significant financial loss since 2004. It has and will continue to require substantial subsidies from its parent company. In 2005, Sutter Medical Center had a net loss of $6,837,400 (see Table 10, , “A Preliminary study for Sonoma County Health Services").

F2: Santa Rosa Memorial Hospital has been operating with a stronger financial footing than Sutter Medical Center has, although its income is declining. In 2005, the SRMH had a net income of $16,212,500 (Table 10, , "A Preliminary study for Sonoma County Health Services").

F3: The financial resources of the community would be stressed to meet the $700 million, plus inflationary costs, in capital improvements required for seismic retrofit and updates to County medical facilities.

F4: Research indicates that consolidation of services into one hospital has the potential for improved quality of care due to increased volume and additional resources.

F5: The Family Medicine Residency Program, a three-year curriculum to train physicians for board certification, is not in jeopardy. The plan to transfer the program to a consortium existed prior to the letter of intent. The participants, UCSF, Sonoma County, Kaiser Permanente, SRMH, Sutter Medical Center (as an outpatient presence), and the Southwest Community Clinics had endorsed this plan.

F6: Santa Rosa Memorial Hospital is constrained by the “Ethical Directives for Catholic Healthcare” which affect the delivery of women’s reproductive health care and end- of-life care. These directives do not apply to secular hospital settings (June 2001; see reference list).

F7: The demand for cultural competency (knowledge of the language and cultural traditions of different ethnic groups) will increase with the transfer of patients from Sutter Medical Center to Santa Rosa Memorial. With an ethnically diverse patient population, lack of cultural understanding can be a barrier to in-patient-provider communication and health-care service.

F8: Santa Rosa Memorial does not have adequate beds for obstetrics, intensive care, and neonatal intensive care to guarantee a seamless transfer of services. The earliest estimate that these beds are likely to be available is Fall of 2009.

F9: The transfer would not significantly affect emergency services. Santa Rosa Memorial, the designated regional trauma center, is completing an expansion of its Emergency Department. Sutter Medical Center’s emergency services serve fewer patients, and those patients have less-acute conditions than those admitted to the trauma center at Santa Rosa Memorial. However, Sutter Medical Center’s services would be absorbed by development of other urgent-care facilities. Findings, continued

F10: Care of prisoners in the custody of the Sonoma County Sheriff’s Department would not be negatively affected.

F11: The Ethical Directives for Catholic Healthcare will not affect treatment of sexual assault victims mandated by California State Law.

F12: Most therapeutic abortions are safely performed under local anesthesia in the outpatient setting. However, access to pregnancy termination services under sedation or anesthesia must be addressed, as this could be a life-threatening implication for women who require hospitalization.

F13: The Ethical Directives for Catholic Healthcare prohibits birth control measures, i.e. tubal ligations for women and vasectomies for men.

F14: This transfer would not negatively affect care for government-financed health insurance patients, i.e. Medi-Cal, Medicare, Child Health and Disability Program (CHDP), Crippled Children Services (CCS), and the County Medical Supplement Program (CMSP).

F15: There are no measures to evaluate and monitor quality of care and compliance with contractual guidelines. The audit in the present agreement is for financial purposes only.

Related Recommendations (1)

R4: The Board of Supervisors should adopt a quality-of-care monitoring system to ensure existing standards are maintained and continuously improved. The monitoring of Health Employer Data Information Set (HEDIS) for outpatient care, and Core Measures required by the Joint Commission for Accreditation of Hospitals (JCAHO) is a baseline standard of performance. These performance measures, which are public information, are collected annually and should be reviewed by the Department of Health Services for compliance.

F16: There has been no evidence of declining quality of care at Sutter Medical Center during the process of negotiation.

F17: Santa Rosa Memorial Hospital's physical location and expansion plans, with helicopter transfers and neighborhood encroachment, are disturbing, inconvenient, and congested.

F18: Concern exists over maintaining an adequate complement of physicians in the community due to financial burdens, e.g. cost of housing and office space, and low reimbursement by Medi-Cal and Medicare, as the Federal Government classifies Sonoma County as a rural area.

Related Recommendations (1)

R6: The Board of Supervisors should make a concerted effort to guarantee a fair process for physicians who currently have hospital privileges only at Sutter Medical Center to apply and receive comparable privileges at Santa Rosa Memorial before any agreement is transferred. Reference list Sonoma County Board of Supervisors, Health Care Access Agreement www.sonoma-county.org August 1996 Sutter Medical Center Medical Center of Santa Rosa, Health Care Access Business Plan, www.sonoma-county.org (September 2004) Santa Rosa Memorial Hospital and Sutter Medical Center Medical Center of Santa Rosa, Letter of intent Sonoma County Department of Health Services, www.sonoma-county.org, (January 8, 2007) Preliminary Responses to Request for Information: Ensuring Quality, Safe and Affordable Health Care in Santa Rosa, www.sonoma-county.org (January 2007) Kawahara & Associates, Sonoma County Initiatives to Improve Access to Health Care, www.sonoma.edu/program/healthcrisis) (February 2007) Hall, E, and Johns, E. A Preliminary study for Sonoma County Department of Health Services, www.sonoma- county.org/health/admin/Sutter Medical Center.htm (April 2007) California Health Care Foundation Report: Financial Health of California Hospitals, (2007 Bamberg, Iversen, Cohill, Schultz and Ameen, Sonoma Medicine Delivering Hospital Care to the Uninsured, Volume 54, Number 4, www.sonic.net/~scma/magazine (Fall 2003) Scardaci, R, Sonoma Medicine, Impact of Sutter Medical Center Closure on the Uninsured, Volume 58, Number 3, www.sonic.net/~scma/magazine (Summer 2007) U.S Conference of Catholic Bishops, Inc, National Catholic Bioethics Center, The Ethical Directives for Catholic Health Care Services, 4th Edition, www.ncbcenter.org/C-D-C_directives.asp (June 2001) Arthur Jones, The National Catholic Reporter, Group Pushes for Reproductive Services in Catholic Hospitals, www.ncronline.org (June 20, 2003) Arthur Jones, The National Catholic Reporter, Public Battle Conscience: Catholic Agencies Face Challenges to Ethical Directives, www.ncronline.org (June 20, 2003) Thomas Schindler, U. S. Catholic, Unions shouldn’t be D.O.A. at Catholic hospitals, www.uscatholic.org (Feb 1, 2005) Catholics for a Free Choice: The Facts about Catholic Health Care in the United States, www.catholicsforchoice.org (September 2005) The Press Democrat, Trading Spaces: Memorial’s Remodel Leaves the Question: When Will Sutter Medical Center Close? www.pressdemocrat.com (January 8, 2008) The Press Democrat, Memorial Gears UP: SR Hospital Shows off New Wing as Part of Aggressive Expansion Plan in County, www.pressdemocrat.com (January 8, 2008) North Bay Business Journal Presentation, Health Care in Crisis. Is Reform Possible? www.busjml.com (November 6, 2007) 52 Reference list, continued Planning Group on Medi-Cal Managed Care, Report of the Planning Group on Medi-Cal Managed Care to the Sonoma County Department of Health Services, www.sonoma-county.org/health/ph/ mmc/index.htm (November 2006) Kaiser Permanente, Kaiser Permanente Gives $2.9 Million Grant to Santa Rosa Medicine Residency Consortium, www.kaisersantarosa.org (November 21, 2007) The Press Democrat, Treatment Crisis Feared: Memorial’s Psychiatric Unit Closure Alarms Mental Health Workers. www.pressdemocrat.com (February 16, 2008) Dartmouth Biomedical Libraries, Cultural Awareness in Healthcare, The Providers Guide to Quality and Culture, www.dartmouth.edu/~biomed/resources.htmld/culturalcomp.shtml#eight (October 26, 2006) 53

F19: Santa Rosa Memorial, as the only major hospital and trauma center in the County, would have a greater advantage negotiating with insurers. With no competition in the bargaining process, this could increase rates for employers and the insured. (Rates determine premiums paid by employers and individuals for insurance coverage.)

F20: Research shows that Catholic hospitals have not been favorable to the unionization of their employees, and the rate of pay is lower (see reference, February 2005). Findings, continued

F21: Lack of psychiatric beds for adults and adolescents has brought significant hardship to the citizens of Sonoma County and placed additional burdens on law enforcement. Twenty percent of adults at Sonoma County detention facilities are in need of mental health treatment.

Related Recommendations (1)

R5: The Board of Supervisors should explore options, negotiate a contract, and have a formalized arrangement with an inpatient adult and adolescent psychiatric provider.

F22: A comprehensive evaluation of Warrack Hospital beds should be completed before they are decommissioned. Commissioning hospital beds for use is an expensive, arduous task involving State and Federal permits and inspections. Warrack has the capability for mental health or psychiatric services, and environmental and seismic issues should not be a deterrent. Conclusions It is critical that the Board of Supervisors carefully review all elements of any proposed (cid:122) assumption of an access agreement, with guarantees that the same high standards of care be maintained if not improved. • Neither Sutter Medical Center nor Santa Rosa Memorial is on solid financial footing. The capital investment of $700 million required for expansion and seismic retrofitting, the growth of Kaiser Hospital, and the current national trends in medical economics make the presence of three hospitals financially unsound. The elimination of duplicate services could result in occupancy that is more efficient, increased delivery of services, and an overall higher standard of care that research shows is associated with larger facilities. • A number of problems exist with the proposed transfer agreement, primarily centering on issues related to the contrast of the secular community hospital of Sutter Medical Center and Santa Rosa Memorial Hospital, which is constrained in its provision of services by the Ethical Directives of Catholic Healthcare. Women’s reproductive services and end-of-life care are two important examples. • Creative solutions to preserve a secular and universal approach to women’s reproductive services are crucial to the success of this transfer of services. Currently, pregnancy terminations at Santa Rosa Memorial can be done only if the life of the mother is in imminent danger. However, sterilizations are performed when the physician is willing to claim extenuating circumstances. This policy is potentially reversible at any time by the local bishop and unacceptable when it is the only alternative for the general population. • The nationally recognized Family Medicine Residency Program is a most valuable asset for our community and is crucial to attracting and maintaining both primary care and specialty clinicians. Sonoma County’s unique combination of a high cost of living and a low rate of medical reimbursement make it difficult to replace physicians lost to retirement or relocation. The Residency Program represents our best stratagem against this dilemma. Plans are already under way to convert supervision of the program to a consortium of hospitals and clinics, which should serve to strengthen it. Conclusions, continued • While Kaiser Hospital serves 70% of the commercial health insurance in Sonoma County, government-insured programs such as Medi-Cal and Medicare cover 97% of Sutter Medical Center’s patients. This population would constitute the majority of new patients that Santa Rosa Memorial would gain by the transfer. Santa Rosa Memorial has a fine record in dealing with charity care, as is mandated in the access agreement, but it would be challenged to serve the patient volume that would result from this transfer. • Santa Rosa Memorial does not have the capacity at present to absorb Sutter Medical Center’s obstetrical patients, intensive care patients, or neonatal intensive care patients. The additional 80 new medical-surgical beds just completed at the hospital are not situated in the correct location to allow them to be adapted to the above needs. The most optimistic estimate of when adequate numbers of these beds will be available is late 2009. • Approximately 40% of the physicians that admit patients to Sutter Medical Center do not have privileges at Santa Rosa Memorial. Family practitioners who perform caesarean sections at Sutter Medical Center would not currently be able to obtain privileges for the same level of practice at Santa Rosa Memorial. • There would be a greater need for cultural competency at Santa Rosa Memorial due to the increase in a younger, less affluent, ethnically diverse, and medically less-informed patient population. • The service to the County for inpatient medical care of prisoners, treatment or quarantine of those with infectious diseases, HIV/AIDS, and residential alcohol programs that require acute services would not be affected. • An unconscionable lack of adult and adolescent psychiatric inpatient care has affected citizens, the local medical community, law enforcement, and County detentions facilities. • The percentage of inmates in Sonoma County jails and patients in health care facilities will increase with the recent departure of North Coast Psychiatric Center by Santa Rosa Memorial. Commendations The Grand Jury commends the Sonoma County Department of Health Services for its efforts to keep the public informed of the implications involved in this proposed transaction. The Grand Jury commends the Kaiser Permanente Foundation for its grant of $2.9 million to support the development of the Family Medicine Residency Consortium. The Grand Jury commends Sutter Medical Center for its excellent comprehensive women’s health care program and cardiovascular services program. The Grand Jury commends Santa Rosa Memorial for its excellent trauma care program. 50

Related Recommendations (1)

R3: R3 Sutter Medical Center should consider other options for the use of Warrack Hospital before the beds are decommissioned, as a possible source for delivery of broad based secular care and services.

Additional Recommendations 1

Not linked to specific findings.

R2: The Sonoma County Board of Supervisors should explore every