Ventura County Grand Jury
2010-2011
From the annual report
The consolidated year-end volume. The individual investigations it contains are listed separately below.
📑 Year-End Report
The full consolidated volume; individual reports are listed below.
Individual reports (12)
Findings & Recommendations
24 findings
F01:
The Council did not violate the Brown Act with regard to the Special Meeting of May 13, 2010. (FA-03)
F02:
The Council acted within applicable law in its use of enterprise funds generated by the City Refuse Department. (FA-06 and FA-07)
F03:
The Council elected to accept a WWTP proposal that was $22 million higher and at a higher monthly cost to ratepayers than the competing proposal. This decision was made contrary to City Manager and staff recommendations. (FA-08 through FA-10, FA-12, FA-13, and FA-15)
F04:
The Council did not adequately or reasonably justify their decision in public to award the WWTP contract to the higher-cost vendor. Nor did the Council address the selection of a firm with substantially less experience in the design, construction, and operation of MBR type WWTPs. (FA-08 through FA-13)
F05:
The Council compelled itself to make the WWTP contract award decision on the deadline date set by the regulatory agency. (FA-14)
F06:
Council members complied with State of California and City requirements for completing campaign contribution disclosure forms. Allegations that Council votes were influenced by campaign contributions were not substantiated. (FA-17 through FA-20)
F07:
During the vote on the awarding of the City Refuse contract, some Council members did not announce their receipt of campaign contributions from one of the vendors. (FA-18, FA-19, FA-21, and FA-22)
F08:
Council members are inconsistent in complying with City requirements for prior approval of trips relating to City business. (FA-23 through FA-24)
F09:
No substantiation was found to support allegations of improper procedure in awarding the refuse contract to a private vendor. (FA-06) 6 Santa Paula City Council Recommendations
F10:
The staff report addressed the financing proposals of the competing vendors. Veolia’s proposal offered financing of the project with a short- term construction loan financed through private activity bonds, while helping the City secure a State allocation for tax-exempt debt. PERC offered to provide 30-year fixed-rate private financing. The staff report recommended the Veolia plan as it provided “. . . the best financial option to the City . . .” [Ref-02 and Ref-03]
F11:
The Council majority voiced concern with the uncertainty of the bond market associated with the Veolia proposal. They feared that the interest rates might rise, and adding another bond issue to the City’s indebtedness might lead to a lower City credit rating. [Ref-03]
F12:
The City Manager stated that, historically, rising bond rates should not present a significant risk. Under the Veolia proposal, bonds could be refinanced at a lower rate. [Ref-03]
F13:
PERC and Veolia each submitted a revised Best and Final Offer (BAFO) by the previous Thursday’s deadline. However, the Council allowed PERC to amend its BAFO verbally at the April 15, 2008 Council meeting. Veolia stated that it had met the deadline, stood by its proposal, and objected to the manner in which verbally revised BAFOs were presented at this meeting. [Ref-03]
F14:
The Council recognized that they were facing the deadline date of April 15, 2008 set by the regulatory agency. Fines of $10,000 per day were to be assessed if a decision to award the WWTP contract was not made in the time specified. [Ref-03]
F15:
On April 15, 2008, the Council awarded the WWTP contract to PERC, contrary to the recommendations of City staff and the City Manager. [Ref-02 and Ref-03]
F16:
In addition to the potential for alleged financial risk associated with the Veolia proposal, majority Council members offered the following reasons for awarding the WWTP contract to PERC, with insufficient or no supporting data to quantify and offset cost differences: • the Veolia design lacked redundancy for screens and grit removal 4 Santa Paula City Council • the Veolia plan consumed more electrical energy • the Veolia proposal would have resulted in added costs associated with the purchase of public bonds, including administrative costs and refinancing fees • the PERC design had a smaller footprint, providing more land for future use • the PERC design for the building was aesthetically superior • the PERC proposal offered a recreational vehicle dump station [Ref-03]
F17:
In order to ensure ethical behavior by public officials and to promote transparency in government, the California Political Reform Act of 1974 (PRA) mandates periodic reporting by public officials. Among the required reports are Statement of Economic Interests Form 700, and Recipient Committee Campaign Statement and Monetary Contributions Received Form 460. To administer this mandate, the law established the FPPC. [Ref-05 and Ref-13]
F18:
City Resolution No. 6697 certifies that the City adopted the FPPC Conflict of Interest Code in its Resolution dated September 20, 2010. Members of the Council are covered by this policy. [Ref-10]
F19:
The City regulations regarding conflicts of interest state, in part, “. . . public identification [financial interest in the decision] shall be made orally and shall be made part of the public record . . . [and] . . . the public identification shall be made . . . following the announcement of the agenda item to be discussed or voted on but before the discussion or vote commences. . . .” [Ref-10, and Ref-12]
F20:
Council members filed Forms 700 and Forms 460 as required by law. Review of Forms 700 and Forms 460 and comparison to voting records alone, disclosed no evidence to indicate that Council member votes were influenced by campaign contributions.
F21:
Two Council members’ Forms 460 showed monetary campaign contributions from a refuse disposal firm actively engaged in business with the City. One of these Council members cast his vote for a firm that contributed to his campaign and was competing for the refuse contract.
F22:
The public record did not reflect that Council members made any open disclosure of a possible conflict of interest during debates on the awarding of the City refuse contract, even though members received campaign contributions from one of the firms.
Related Recommendations (1)
R03:
The Council should annually place on its agenda a public discussion of its Conflict of Interest Code. This Code should be amended, as necessary, to specifically include a requirement that Council members acknowledge at each meeting any potential conflict of interest, including any campaign contributions or gifts received from any person or business entity having an agenda item before the City. (FI-07)
F23:
The Council operates under a conflict of interest code which is reviewed annually and supplements requirements of the PRA. Accountability is required by City policy regarding “gifts of travel.” City officials are required to obtain approval from the Council prior to any trips which may Santa Paula City Council 5 involve City affairs. Travel expenses paid by the City or by third persons require specific prior Council approval. [Ref-05, Ref-10, and Ref-11]
F24:
In November 2010, a Council member attended a conference in Washington, D.C. without prior approval at third party expense. At this conference, the member was recognized as a representative of the City and “City of Santa Paula” appeared on the list of conference participants. The event was attended by major industries and universities, as well as by local, state, and federal agencies. A record of the Council member’s expenses was reflected in his Form 700. Findings
Related Recommendations (1)
R04:
The Council should fully adhere to City regulations regarding Council approval of trips relating to City business. As policy requires, this approval must be requested in open session, prior to travel, even if expenses are to be paid by a third party. (FI-08) Responses Responses Required From: Santa Paula City Council (FI-03 through FI-05, FI-07, and FI-08) (R-01 through
Findings & Recommendations
17 findings
F01:
The Grand Jury found that, with respect to the processing of the criminal complaint of alleged embezzlement, the SVPD had acted on that complaint properly as to its policies and procedures and without political motivation or unusual delay. The initial assignment of detectives and the start of the investigation occurred within a normal period of time for this type of investigation. Given the complexity of the case, the investigation could not have been closed for many months beyond the election date. (FA-01 through FA-13)
F02:
The Grand Jury found no impropriety with respect to the questioned surveillance and discerned no improper political motivation. (FA-14 through FA-16)
F03:
The Grand Jury found that a lack of timely promised feedback to the EI complainant led to frustration and resulted in negative comments in the press. (FA-17) Recommendations
F04:
On October 19, 2010, a police report of an alleged major embezzlement ($500,000) from a law office, operated by two attorneys at the time of the alleged embezzlement, was entered into the RMS. [Ref-01 through Ref-05, Ref-09, and Ref-11 through Ref-13]
F05:
On October 25, 2010, pursuant to SVPD news media release of information policy, the SVPD—upon inquiry from the Star—confirmed to the Star that “. . . a crime report was filed . . .” with respect to the alleged embezzlement and that detectives would conduct an investigation. [Ref-09]
F06:
The Officers’ Association’s endorsed candidate for Mayor was associated with the alleged embezzler in law practice. [Ref-01 through Ref-04, Ref-07, and Ref-11 through Ref-13] Review of Select SVPD Processes 3
F07:
One week following the filing of the embezzlement complaint, on October 25, 2010, two detectives were assigned to work as a team on the embezzlement investigation (EI). The lead detective was the most experienced SVPD white-collar crime investigator and the second investigator was newly assigned to the detective division.
F08:
On November 21, 2010, the lead detective role for the EI case was re-assigned to the second investigator, with support from the prior lead detective who had been transferred to another detective division. [Ref-05]
F09:
RMS data reflects that, for the period from May 1, 2010 through October 28, 2010, the average (mean) time to assign a property report, such as embezzlement, to detectives was 7.04 days.
F10:
RMS data reflects that, for the period from May 1, 2010 through October 28, 2010, the average (mean) time to close a property case from the initial report was 29.09 days. The minimum number of days to closure for that same period was 0 (same day as assignment). The maximum number of days to closure for that same period was 268.
F11:
It was understood by the SVPD that this EI case would be time- consuming and complex. It was immediately understood by SVPD management that in a case involving a law office—where a specific attorney in a firm was accused of embezzlement—the complexity of the case would be extraordinary; among other things, it would require the appointment of a special master, to preview documents for the court to avoid disclosure of privileged information. [Ref-01, and Ref-03 through Ref-06]
F12:
SVPD management understood that, in an EI case, it was necessary to proceed cautiously and thoroughly under the purview of their most experienced white collar crime investigators. In this case—because of the requirement in embezzlement investigations of massive paper gathering efforts from protected bank and office records—there appeared little risk of evidence being destroyed; start time—though important—was not a critical factor. [Ref-05]
F13:
As of January 10, 2011, the RMS reflects a large number of entries for the EI case. These entries are indicative of the beginning of the volume of necessary evidence being acquired; as noted in FA-12, above. The EI, as of the date of this report, is still in process.
F14:
A criminal complaint was filed with the SVPD on August 31, 2010 with respect to campaign signs being vandalized at various locations in the City. [Ref-02]
F15:
In response to the complaint referred to in FA-14, above, surveillance was approved, before the fact, by SVPD management. The surveillance was conducted in a particular location where repeated vandalizing acts had occurred and, therefore, promised possible results. Review of Select SVPD Processes
F16:
A filed criminal complaint—such as that referred to in FA-14—could not be responsibly ignored by the SVPD. There is SVPD documented history of a similar campaign sign surveillance having been conducted several years prior to this surveillance.
F17:
Although there is no duty to inform the public, the media, or a complainant of the progress of a case, in this instance, there was a failure of the SVPD to provide timely promised feedback to the complainant on the status of the criminal embezzlement case. [Ref-01] Findings
Findings & Recommendations
18 findings
F01:
There is a lack of information available to the public and to the City Council to demonstrate that the City carefully and adequately considered the appropriateness, safety, and potential liabilities of entering into a temporary firing range agreement. (FA-06 and FA-07)
F02:
The introduction of the Agreement as a Consent Agenda item, the lack of a proposed agreement at the time of City Council approval, and the lack of any subsequent agreement executed through April 2011, demonstrates that the City Council and City staff considered this to be a casual action with little risk to the City. (FA-07, FA-08, and FA-11)
F03:
Whether using firing ranges leased from others or considering the construction and ownership of a permanent firing range, there are risks and potential liabilities associated with both actions that merit careful consideration. (FA-10 and FA-11)
F04:
There is a pattern of the City entering into arrangements for the use of firing range facilities for which the City staff has not done its due diligence to verify that the facilities are appropriately permitted and legally operated. (FA-04, FA-05, FA-07, FA-08, FA-13, and FA-14)
F05:
The City is now proceeding with due care and consideration in assessing whether or not the City should own and operate a permanent firing range and training facility. (FA-10 and FA-11) 4 Santa Paula Police Firing Range
F06:
By not having a written Agreement in place, immediately upon City Council approval, the City is unnecessarily and carelessly exposing itself to liability in using a live firing range. (FA-08, FA-11, and FA-16 through FA-18) Recommendations
F07:
There was no other staff report for Consent Agenda item 9.M. provided to the City Council that indicated there was any research regarding the appropriateness of the land for a firing range. Whether or not there were any environmental or safety concerns that had to be addressed, or what liabilities or responsibilities the City might have in using the firing range, 2 Santa Paula Police Firing Range were not addressed. There was no information provided in the public record for this agenda item regarding with whom the City was entering into the Agreement. There was no proposed Agreement either provided to, or requested by the City Council prior to their approving the action. [Ref-01]
F08:
On September 7, 2010, the City approved Consent Agenda item number 9.M. without City Council or public comment. As a matter of policy, agenda items are placed on the Consent Agenda because they are considered routine, non-controversial, and are routinely not discussed. [Ref-01]
F09:
The approval of Consent Agenda item number 9.M. “ . . . 1) authorize[d] the City Manager to enter into an agreement, in a form approved by the City Attorney, for the use of a temporary firing range facility; and 2) take such additional, related, action that may be appropriate.” [Ref-01]
F10:
On the regular agenda for the same September 7, 2010 City Council meeting, there was a presentation made by City staff titled “Long-Term Option for a Firing Range/Training Facility” (agenda item 10.D.) and a request for City Council guidance to staff on how to proceed. The agenda item 10.D. and presentation were heard after Consent Agenda item 9.M. Staff recognized that a permanent range facility was an option to meet the requirements of the Police Department, and eliminate the disadvantages of using temporary or out-of-area facilities for training. The presentation acknowledged some of the possible citizen concerns with a firing range at various potential sites. The presentation also addressed some safety considerations, the potential costs and revenues associated with building, owning, and operating a firing range, and other possible impacts. [Ref-01] (Att-01)
F11:
Live firing ranges have inherent operating dangers and associated liabilities that require careful consideration. Where adequate planning and compliant design and construction are used, and all applicable environmental and operating regulations are followed, these dangers and liabilities can be reasonably minimized.
F12:
Sometime after the approval of the temporary firing range, Consent Agenda item 9.M., complaints by citizens hearing gunfire were received in the latter months of 2010 and into February 2011 by the County Code Compliance Division of RMA and by the City. The temporary firing range is located in the vicinity of South Mountain. (Att-04 and Att-05)
F13:
The Code Compliance Division of RMA sent a letter, dated February 4, 2011, to the land owner and to the business providing use of the South Mountain firing range to the City. The letter stated that they had received complaints regarding shooting activities and that there was no CUP on the property to operate a firing range. In another letter from RMA, dated the same day, it was noted that a complaint alleged violations for lack of a CUP, structures and lights constructed on the Santa Paula Police Firing Range 3 property without permits or inspection, and grading of land without a permit. (Att-04 and Att-06)
Related Recommendations (1)
R03:
The City should cease using the South Mountain facility until the current County NOV is satisfactorily resolved and the facility is appropriately permitted for such use. (FI-04 and FI-06)
F14:
Subsequently, on February 25, 2011, the Code Compliance Division of RMA issued a letter for NOV and Notice of Impending Civil Administrative Penalties for confirmed violations of the Ventura County Building Code and/or Non-Coastal Zoning Ordinance. The letter was sent to the land owner and to the business providing the firing range to the City. (Att-07)
Related Recommendations (1)
R03:
The City should cease using the South Mountain facility until the current County NOV is satisfactorily resolved and the facility is appropriately permitted for such use. (FI-04 and FI-06)
F15:
The City acknowledged a citizen complaint in February 2011 and indicated that some mitigation measures were being taken to reduce firearm noise associated with training conducted for the City Police Department at the South Mountain firing range. (Att-05)
F16:
As of April 2011, the South Mountain firing range was still available to the City for live firing and other training.
F17:
As of May 3, 2011, the City had not entered into a written agreement as specified by the City Council.
Related Recommendations (1)
R04:
The City Council should require City staff to provide proposed written agreements, if not agreements already signed by the other party, for the City to execute upon City Council approval, and not allow activities to commence until the agreements are fully executed. (FI-01 and FI-06) Responses Responses Required From: City Council, City of Santa Paula (FI-01, FI-02, FI-04, and FI-06) (R-01 through
F18:
City staff has indicated that the City is in the process of entering into a Hold Harmless Agreement with the business that is providing the South Mountain firing range services to the City. This is approximately eight months after the City began using the firing range for live firing. Findings
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Findings & Recommendations
22 findings
F01:
Although the election officer training materials provide clear and in- depth documentation of the requirements for establishing polling places and conducting the election processes, violations of procedure and noncompliance to guidelines occurred. (FA-15 through FA-19)
F02:
The training materials provided to election workers are detailed and accurate, but the classes need improvement to emphasize the importance of laws pertaining to elections. (FA-15 through FA-18 and FA-20)
F03:
If VBM voters ensured that their ballots arrived at the ROV prior to Election Day, it would facilitate their ballots being processed earlier and ease the post-election workload. (FA-04 and FA-05)
F04:
The majority of voter signatures are not verified against voter registration rolls. (FA-06 and FA-14)
F05:
A violation of election code occurred at one receiving station when election workers were unaccompanied when dropping off ballots. (FA-15 and FA-18)
F06:
In violation of the Election Code Handbook, some polling places had few directional signs and in one case no signage. Other polling places did not place the voting booths so that voters had privacy. (FA-16, FA-17, and FA-19)
F07:
The benefits of countywide VBM as the sole electoral process are the following: • eliminates the need for precinct polling places • eliminates the need for precinct workers • eliminates the need for trainers and training classes • eliminates the need for Provisional Ballots • allows each signature to be verified • establishes an accurate Master Voters Roster by having VBM ballots returned when the name or address of a voter is wrong • increases the number of voters for all elections • reduces errors by having a single voting method • saves money (FA-01 through FA-04, FA-06, FA-09 through FA-11, FA-14, FA-21, and FA-22) 6 Election Process Recommendations
F08:
The ROV conducts a vote/no vote process to record the voting participation of each registered voter. This process also allows election officials to determine if a voter has attempted to vote more than once per election.
F09:
PBs are given to voters who want to vote at a precinct, but are not on that precinct’s Master Roster. PBs are also given to voters who receive a VBM ballot, but decide to vote in the precinct.
F10:
PBs increased almost two-fold since the 2006 November Gubernatorial Election. There were 5,888 PBs in the 2006 November Election and 10,912 in the 2010 November Election. (Att-01)
F11:
PBs are counted last. Only 7,343 PBs of 10,912 were counted as valid. A significant number of voters who used a PB (1,506) were disqualified because they were not registered voters. (Att-01)
F12:
The County has 549 precincts; 357 are regular precincts and 192 are VBM only precincts.
F13:
There were 155 different ballot types in the County and 332 candidates in the 2010 November Election. Candidates must be registered voters and have other qualifications as required by the offices they seek. The ROV must verify that candidates have those qualifications.
F14:
There is no identification required at the polls to assure that the voter is the person who registered.
F15:
California law states that after the polls are closed, “…sealed packages containing lists, papers and ballots shall be delivered by 4 Election Process two precinct officers without delay, unopened, to the Election Official or to a receiving station designated.” (Italics added) [Ref-01]
F16:
According to the Election Officer Handbook, “Voting booths should be set up with the opening facing a wall, so that voters have privacy while voting.” [Ref-02]
F17:
The Election Officers Handbook gives written guidelines to “Post the Polling Place Signs in visible areas to guide voters to your polling location.” [Ref-02]
F18:
On Election Day, at one receiving station, the Grand Jury observed eight instances of a single precinct officer dropping off ballots and equipment, unaccompanied by the required second precinct officer. [Ref-01]
Related Recommendations (1)
R06:
The ROV should enforce the legal requirement that precinct inspectors always assign an election officer to accompany them when delivering voted ballots. (FI-05) Responses Responses Required From: Ventura County Registrar of Voters (R-01 through R-06) Ventura County Board of Supervisors (R-01) References Ref-01. California Election Code, chapter 4: Closing of the Polls, section 14434. Ref-02. County of Ventura, Election Officer Handbook November 2, 2010 Gubernatorial Election, pp. 04, 54. Ref-03. State of Oregon, Five Years Later: A Re-Assessment of Oregon’s Vote By Mail Electoral Process. www.sos.or.us/electionsvbm/pdf_files/southwell.pdf, (accessed March 24, 2011). Ref-04. State of Oregon, Ballot Integrity and Voting By Mail: The Oregon Experience, www.sos.state.or.us/elections/vbm/carterbaker (accessed March 24, 2011). Ref-05. California Election Code section 15360 Election Process 7 Attachments Att-01. Provisional Statistics Att-02. Election Officers Class Schedule Att-03. Turnout Statistics Att-04. Five Years Later: A Re-Assessment of Oregon’s Vote By Mail Electoral Process pp. 1, 2 Bibliography Absentee Ballot and Mail In Voting Processes/ -2007 Orange County Grand Jury www.ocgrandjury.org 8 Election Process Glossary TERM DEFINITION APEX Signature Reader A machine used to scan signatures from Vote by Mail ballots BOS Ventura County Board of Supervisors Grand Jury 2010-2011 Ventura County Grand Jury PB Provisional Ballot ROV Ventura County Registrar of Voters VBM Vote By Mail Election Process 9 This page intentionally blank 10 Election Process Attachment 01 Provisional Statistics Election Process 11 This page intentionally blank 12 Election Process Election Process 13 This page intentionally blank 14 Election Process Attachment 02 Election Officer Class Schedule Election Process 15 This page intentionally blank 16 Election Process Election Process 17 18 Election Process Election Process 19 This page intentionally blank 20 Election Process Attachment 03 Turnout Statistics Election Process 21 This page intentionally blank 22 Election Process Election Process 23 This page intentionally blank 24 Election Process Attachment 04 Five Years Later: A Re-Assessment of Oregon’s Vote By Mail Electoral Process pp. 1, 2 Election Process 25 This page intentionally blank 26 Election Process Election Process 27 28 Election Process
F19:
On Election Day, the Grand Jury observed a number of polling place configurations not following the election handbook guidelines. Specific examples are: • some polling places failed to post the Voters Bill of Rights both inside and outside the polls • some polling places failed to post the Voter Register Log outside the polling places • some polling places failed to situate voting booths in positions that would provide privacy • some polling places had few directional signs and, in one case, no signage pointing to the poll location • some polling places had poor or nonexistent lighting to indicate their location after dark
Related Recommendations (1)
R05:
The ROV should require that roving inspectors carry extra directional signage and instruct precinct officers on the proper placement of voting booths. (FI-06)
F20:
During training classes, the Grand Jury observed some election trainees texting on cell phones or sleeping during the audio-visual portion of the training.
Related Recommendations (1)
R04:
The ROV should require that all precinct officers attend training classes. The handbook should be reviewed thoroughly with interactive discussion of major points and election codes, especially during the long audio-visual presentation. (FI-01 and FI-02)
F21:
In the November 2010 election, clerical errors were made which confused the types of ballots, resulting in a duplication of count. If there were only one type of ballot these errors would be avoided.
F22:
Oregon implemented statewide VBM as the only electoral process in 1998. In a survey conducted five years later, the voting participation of one-third of the electorate had increased. Other voting patterns remained unchanged. The state of Oregon reports one-third to one- half savings to the election budget were realized by switching to statewide VBM. [Ref-03 and Ref-04] (Att-04) Election Process 5 Findings
Related Recommendations (1)
R01:
The ROV and the BOS investigate the feasibility and economics of countywide VBM as the only voting system. (FI-04 through FI-07)
Findings & Recommendations
10 findings
F01:
The Prop 36 Courtroom has no adversarial counsel, since the DA’s office removed its representative in 2009, leaving only the Judge and the Public Defender to work with representatives of the Prop 36 program. (FA-04)
F02:
From the time an offender walks out of the Prop 36 Courtroom until treatment begins, many obstacles exist: long waiting lists for fewer affordable outpatient treatment centers; transportation difficulties; and heavy financial burdens on the enrollees. (FA-07, FA-09, and FA-10)
F03:
Most treatment programs are on an outpatient basis because they are less expensive, but they often lack consistency and continuity, thus contributing to a higher dropout rate. (FA-03 and FA-10)
F04:
If the offender has financial means, self-payment for an inpatient treatment facility is the best option. Presently, this enables those who are better off financially to have the best chance at rehabilitation. Prop 36 was designed to provide funds for successful treatment to all offenders who met the enrollment criteria, irrespective of financial means. (FA-03, FA-07, and FA-10)
F05:
The BOS has worked with both the VCBHD and the VCPA to find alternative sources of funding. (FA-02 and FA-08) 4 Under-Enrollment in Proposition 36 Recommendations
F06:
According to a long-term UCLA study researching Prop 36 since its inception, there was a $2.50 savings to State and local governments for every dollar spent on Prop 36 treatment. However, savings were mostly seen in prisons and jails that did not have to incarcerate this population. These savings did not go toward treatment programs. [Ref-03]
F07:
In 2008, UCLA released its last statement to the press on the Prop 36 study, noting that “. . . . Prop 36 . . . is being undermined by inadequate funding, participants dropping out of treatment, and increased arrests for drug and property crimes. The good news, however, is that the initiative has saved taxpayers millions of dollars. . . . Several promising new programs have the potential to improve Prop 36’s results, and violent crime arrests have decreased more in California than nationally since the proposition’s implementation.” [Ref-07]
F08:
Prop 36 is currently operating on a federal stimulus grant, along with additional funds from the Drug and Alcohol Division of the VCBHD. The grant was due to expire in March 2011. However, due to the Under-Enrollment in Proposition 36 3 commitment of the VCBHD and the VCPA, current funding will be extended through September 2011.
F09:
The VCBHD and the VCPA work in tandem both in and out of the Prop 36 Courtroom to assess and qualify offenders for enrollment in the Prop 36 program. The VCBHD assists in the determination of financial need and provides substance abuse treatment. The VCPA supervises offenders on probation.
F10:
There are two types of treatment within the VCBHD treatment program for Prop 36. The first is outpatient treatment, which often has long waiting lists due to a reduced number of affordable treatment sites. In the past there were other treatment centers operated by private contractors, but some were discontinued when funding diminished. Most offenders now utilize the few County- sponsored facilities. The resulting delay in treatment may contribute to increased dropout rates. The second is inpatient treatment, which, while more expensive than outpatient treatment, tends to double the chances of successful recovery. According to the UCLA report, only 11% of statewide offenders were enrolled in more costly, yet more effective, inpatient treatment. [Ref-03] Findings
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Findings & Recommendations
28 findings
F01:
School transportation systems have been studied extensively at the national level, and that information indicates that school buses are one of the safest modes of transportation. (FA-01 through FA-04)
F02:
Nationally, the majority of people killed in school transportation- related crashes are not school-age bus riders, but are occupants of other vehicles involved or pedestrians. Students are safer as passengers on school buses than they are as passengers in cars involved in crashes with school buses, or as pedestrians in school bus crashes. (FA-02)
F03:
Not all Districts maintain information on school bus safety statistics. Some Districts do not track this information at all, while others rely on their contracted bus companies to do so. (FA-10) School Bus Safety 7
F04:
Due to the lack of comparable, consistent school bus safety statistics provided by the Districts, it is not possible to determine objective measures of school bus safety, such as accident rates. Thus, it is difficult to conclude that school bus transportation in the County is safe, as previously demonstrated at the national level. It is only possible to infer that school bus transportation in the County is safe from the information provided by the Districts. (FA-03, FA-10 through FA-13)
F05:
School bus safety statistics, for Districts or for individual schools, are not readily available to the public. (FA-09, FA-15 and FA-16)
F06:
The efforts of the CHP, including certifying school bus drivers, investigating school bus accidents, and inspecting school buses, contribute significantly to ensuring school bus safety in California. However, the CHP does not collect information at the school district level. (FA-17 through FA-19)
F07:
The Grand Jury was unable to identify any single local agency responsible for collecting, collating, and reporting County school bus safety information on a countywide basis. (FA-14, FA-18, and FA-19)
F08:
It is unclear whether seat belts on school buses significantly increase school bus safety. (FA-21, FI-25 through FA-28) Recommendations
F09:
Information on school bus safety statistics is not available on District websites. Examination of a representative sample of individual school websites revealed that none contained such information.
F10:
The Grand Jury requested school bus-related data for the 2009-2010 school year from the Districts, including: the number of student school bus riders, the number of school bus-related accidents and injuries, and total school bus passenger miles. Many school districts responded with clear, thorough answers. Some responses appeared incomplete and some were ambiguous and difficult to understand. The information was not provided in a comparable, consistent manner. School Bus Safety Three school districts stated that they do not maintain passenger mile information. Two school districts said that they do not keep statistics on school bus accidents or injuries. One school district referred the Grand Jury to private, contracted school bus companies, to the VCOE, and to the CHP for information this district does not maintain.
Related Recommendations (2)
R02:
The VCOE should develop a standard form for the annual collection of school bus safety information from the Districts. This information should include: the total number of students who ride the bus to and from school on a daily basis; the total number of students who are transported for field trips, special events, or athletic events; total miles ridden by students; and total number of school bus- related accidents and injuries resulting from those accidents. (FI-04)
R03:
The Districts should use the VCOE standard form recommended in
F11:
The Grand Jury was only able to estimate the number of student school bus riders from the information provided by the Districts because of inconsistent reporting of data. For the 2009-2010 school year, the estimated average number of daily student bus riders in the County was 16,167.
F12:
The 20 County school districts that do keep information on school bus-related accidents and injuries recorded a total of 41 school bus accidents in the 2009-2010 school year, resulting in four injuries to student bus riders, the only injury statistic studied by the Grand Jury. Eleven school districts reported zero accidents during that school year.
F13:
The Grand Jury was unable to calculate a school bus accident rate, i.e., the number of accidents per passenger mile, for the 2009-2010 school year since mileage figures provided by the Districts were not comparable.
F14:
The VCOE stated that each District is a Local Educational Agency and a self-governing governmental entity. Therefore, the VCOE does not collect countywide school bus safety data. According to the VCOE, the only County school bus-related information they collect is financial in nature.
F15:
All public schools in the State are required to complete a Student Accountability Report Card annually containing information required by State and federal laws. Student Accountability Report Cards are intended to provide the public, including parents of school children, with important information about each public school and to communicate a school's progress in achieving its goals. Schools have the option to supplement the required data. However, school bus safety statistics are not a requirement. [Ref-10 and Ref-11]
F16:
An examination of a representative sample of Student Accountability Report Cards for schools within the County revealed that none contained information on school bus safety statistics.
F17:
In 1959, the State Legislature designated the CHP as the department responsible for supervision of the school pupil transportation industry. The CHP adopts and enforces rules and regulations relating to the equipment, maintenance, construction, design, color, and operation of school buses. School Bus Safety 5 Among CHP responsibilities are: • inspecting and certifying all school buses at least once each school year • inspecting and licensing private school bus contractors • inspecting driver records and school bus preventive maintenance and inspection records • investigating school bus accidents • administering written and driving tests for applicants seeking to renew or obtain school bus driver certificates • fingerprinting applicants for an original certificate to drive a school bus [Ref-12 and Ref-13]
F18:
The CHP Statewide Integrated Traffic Records System is a database that serves as a means to collect and process data from collision scenes. School bus-involved collision data is available by California county, but not by school district. [Ref-14] The data available for the County includes all school bus accidents occurring within the County, whether or not the school buses involved were County school buses or from other jurisdictions.
F19:
According to the CHP, it does not gather information on County school bus passenger miles.
F20:
Effective April 1, 1977, Federal Motor Vehicle Standard 222, “School Bus Passenger Seating and Crash Protection,” established occupant protection requirements for school bus passenger seating and restraining barriers. Standard 222 requires that: • all newly manufactured small buses (with a gross vehicle weight under 10,000 pounds) be equipped with lap belts • all newly manufactured large buses (with a gross vehicle weight over 10,000 pounds) be required to protect riders through compartmentalization, which utilizes higher, padded seat backs, narrow seat spacing, and stronger seat structure to protect passengers from crash impact [Ref-15 and Ref-16]
F21:
A 1989 TRB report concluded that the potential benefits of requiring seat belts on large school buses were insufficient to justify a federal requirement. [Ref-17]
F22:
In 2008, the NHTSA ruled that all new small school buses manufactured on or after September 1, 2011 be equipped with three-point, lap/shoulder belt systems. [Ref-15] 6 School Bus Safety
F23:
The California Vehicle Code requires three-point lap/shoulder belts on all school buses manufactured after July 1, 2005. [Ref-18]
F24:
The California Code of Regulations requires that all school bus passengers use seat belts, if provided, and that all pupils be taught how to use seat belts in an age-appropriate manner. [Ref-18]
F25:
State requirements for three-point lap/shoulder belts on small and large school buses exceed federal standards. No national consensus exists on the benefits of seat belts on all school buses. [Ref-15 through Ref-21]
F26:
Advocates of school bus seat belts, including the American Academy of Pediatrics and the National Coalition for School Bus Safety, recommend that all newly manufactured school buses be equipped with three-point lap/shoulder belts. They argue that seat belts would reduce injuries or deaths. They maintain that the use of seat belts would also improve student behavior, reduce bullying, and decrease behavior that might be a distraction to school bus drivers. [Ref-19 and Ref-20]
F27:
Other organizations, including the National Association of State Directors of Pupil Transportation Services and the National Association of School Transportation, assert that school buses are already the safest way for students to travel to and from school. They contend that seat belts on school buses would result in little or no improvement in school bus safety at significant expense. [Ref-20]
F28:
A 2010 Summary Report of a University Transportation Center for Alabama investigation into the implementation of seat belts on school buses reached the following conclusions: seat belt use on school buses is extremely variable, school bus seat belts reduce capacity, and the costs of school bus seat belts “far exceed” the benefits. [Ref-21] Findings
Findings & Recommendations
18 findings
F01:
The federal and state governments have acted to make emergency communications interoperability a priority in efforts to improve safety for first responders and to coordinate emergency response. (FA-01 through FA-03)
F02:
The Emergency Planning Council has been actively engaged in supporting emergency communications interoperability. The standing ETC has been charged with developing the TICP and with advising the Emergency Planning Council on its progress. (FA-06 and FA-07)
F03:
The ETC has completed initial preparation of the TICP. (FA-09) Emergency Communications Interoperability 5
F04:
Emergency first responders and support agencies are well represented on the ETC. (FA-12)
F05:
The OES has made important contributions to communications interoperability through its participation on the ETC and its assistance with grant funding, including funds to obtain a gap analysis for the TICP. (FA-13 and FA-14)
F06:
Significant progress has been made toward improving emergency communications interoperability in the County Operational Area. (FA-15)
F07:
A completed gap analysis will be important to the continued improvement and timely implementation of the TICP. (FA-16)
F08:
While communications interoperability training will be a major component of a May 2011 disaster exercise, coordinated, continuing, interoperability training has yet to be implemented for first responders. (FA-17 and FA-18) Recommendations
F09:
Documents provided by the ETC indicate that the Operational Area TICP was completed in October 2010 in conformance with a template provided by Homeland Security.
F10:
The TICP includes detailed inventories of the availability and capability of two-way radio equipment used and shared by all the participating agencies in the County. Instructions for accessing the equipment and contact information are also included. This equipment is also available for assignment to assisting agencies from outside the County.
Related Recommendations (1)
R01:
The Board of Supervisors, the Emergency Planning Council, the ETC, the OES, and all emergency response and support agencies should continue their support of improving emergency communications interoperability. (FI-02 through FI-07)
F11:
“Gateway devices” are those which make communication possible between emergency responders who do not share the same radio frequencies. These devices are part of the extensive TICP inventory.
Related Recommendations (1)
R01:
The Board of Supervisors, the Emergency Planning Council, the ETC, the OES, and all emergency response and support agencies should continue their support of improving emergency communications interoperability. (FI-02 through FI-07)
F12:
According to information provided by the ETC, the County and all cities in the County are represented on the committee. Some cities are directly represented and others are represented by the Sheriff’s Department and/or the County Fire Department. Committee Emergency Communications Interoperability 3 participants currently include the following agencies and organizations: • Amateur Radio Emergency Service • California Emergency Management Agency • California Highway Patrol • City of Fillmore Fire Department • City of Ojai • City of Oxnard Police and Fire Departments • City of Port Hueneme Police and Fire Departments • City of Santa Paula Fire Department • City of Simi Valley Police Department • City of Ventura Police and Fire Departments • County of Ventura • County of Ventura Fire Department • County of Ventura OES • County of Ventura Sheriff • United States Navy
Related Recommendations (1)
R01:
The Board of Supervisors, the Emergency Planning Council, the ETC, the OES, and all emergency response and support agencies should continue their support of improving emergency communications interoperability. (FI-02 through FI-07)
F13:
According to documents provided by the OES, that office administers two Homeland Security grant programs. Those programs are the Ventura County Homeland Security Grant Program, intended to enhance regional preparedness, and the Oxnard-Thousand Oaks Urban Area Security Initiative Grant Program, intended to provide regional preparedness in high-threat, high-density metropolitan areas.
Related Recommendations (1)
R01:
The Board of Supervisors, the Emergency Planning Council, the ETC, the OES, and all emergency response and support agencies should continue their support of improving emergency communications interoperability. (FI-02 through FI-07)
F14:
In fiscal year 2010, the County, through the OES, allocated $734,329 from the Urban Area Security Initiative Grant Program to enhance interoperable communications. These funds were directed to the following projects: • the purchase of radios for first responders and area hospitals • the licensing and installation of a countywide radio frequency and related equipment in dispatch centers to facilitate interoperable communications among users not sharing the same frequencies • an interoperable communications gap analysis
Related Recommendations (1)
R01:
The Board of Supervisors, the Emergency Planning Council, the ETC, the OES, and all emergency response and support agencies should continue their support of improving emergency communications interoperability. (FI-02 through FI-07)
F15:
According to documents provided by the ETC, the following improvements to emergency communications interoperability have been achieved in the County Operational Area: 4 Emergency Communications Interoperability • a TICP that complies with Homeland Security requirements has been prepared with the participation of all committee members • a Standardized Interoperable Field Operations Guide complying with Homeland Security requirements has been updated with current and appropriate information • a simulcast upgrade is underway that will provide 60% more wireless radio coverage and increased functionality for first responders • a narrowband radio upgrade, mandated by the Federal Communications Commission, is in process; it is tied to the simulcast project and will require the upgrade of all emergency radios in the County • a microwave upgrade that will increase microwave network sites from six to eighteen, to cover the entire County, is scheduled for completion in 2011 • radio traffic will run through the microwave network which will also handle current and future upgrades such as data and video transmissions
Related Recommendations (1)
R01:
The Board of Supervisors, the Emergency Planning Council, the ETC, the OES, and all emergency response and support agencies should continue their support of improving emergency communications interoperability. (FI-02 through FI-07)
F16:
The ETC has approved a Request for Proposal outlining the gap analysis requirements to be met by potential consultant contractors. The Request for Proposal has been approved by the County’s purchasing authority and is awaiting distribution. The analysis is intended to guide future efforts to implement the TICP by the target date of 2017, as imposed by the California State Communications Interoperability Plan.
Related Recommendations (1)
R01:
The Board of Supervisors, the Emergency Planning Council, the ETC, the OES, and all emergency response and support agencies should continue their support of improving emergency communications interoperability. (FI-02 through FI-07)
F17:
The OES has planned a countywide disaster exercise, scheduled for May 2011, that will, in part, stress communications interoperability.
Related Recommendations (1)
R01:
The Board of Supervisors, the Emergency Planning Council, the ETC, the OES, and all emergency response and support agencies should continue their support of improving emergency communications interoperability. (FI-02 through FI-07)
F18:
The Grand Jury was unable to locate evidence of a coordinated countywide effort to provide continuing interoperability training to first responders. Findings
Related Recommendations (1)
R01:
The Board of Supervisors, the Emergency Planning Council, the ETC, the OES, and all emergency response and support agencies should continue their support of improving emergency communications interoperability. (FI-02 through FI-07)
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Findings & Recommendations
37 findings
F01:
The Sheriff is mandated to establish institutional processes that meet legal standards. Attempting to avoid a statistically rare event, like a suicide, is a unique management challenge. It takes an institutional focus on this kind of issue to insure that despite the conflicting demands and budget priorities of day-to-day events, this issue is always part of the management process. Other than the Sheriff, there is no one individual formally responsible for suicide prevention in the County Jail. (FA-01 through FA-04)
F02:
The majority of those booked into County Jail return to private life in the community and some are sent to a state prison. Some individuals are booked into the County Jail and released on a regular basis. A statistically small number die in County Jail custody. Of the 28,045 bookings in 2010, three inmates have died. (FA-03 and FA-04, FA-06 through FA-11)
F03:
The Sheriff has instituted a set of processes to screen, monitor, respond, and evaluate inmate suicides. After review of the literature, the Grand Jury has determined that some of these processes are considered to be best practices (e.g., the 72-hour reception housing and the multi-stage screening). These processes involve not just the detention staff, but also the Major Crimes staff and contracted medical staff. The Sheriff has instituted a project to modify the County Jail based on lessons learned from past suicides. (FA-05, FA-14 through FA-16)
F04:
Institutionally, dealing with potentially suicidal inmates is a challenging problem. Collecting information from those inmates about suicidal factors is sometimes difficult. Some inmates withhold information from custody staff even when it is in their best interest to provide that information. Some inmates withhold information when it is not in the best interest of their cellmate. Sometimes families are not forthcoming with pertinent information until after the event. Some inmates make non-serious attempts at suicide, therefore compounding the suicide prevention problem. Some aspects of suicidal tendencies are associated with mental illness. (FA-13, FA-24 and FA-25)
F05:
When compared with nationwide data collected from the Justice Department, the County Jail ranks in the top 12 percent in experiencing inmate deaths for seven of the last eleven years. Its eleven-year suicide rate is less than the smallest jails nationally and greater than most of the largest jails in California. Both suicide and mortality rates in the County Jail have risen over the three-year period 2008 through 2010. There are many factors correlated with 10 Inmate Processing and Suicide Prevention suicides in a jail environment. When addressing a specific institution, the analysis of the two suicide events in 2010 does not provide enough data to make a credible evaluation of patterns, but does lead to an understanding of special factors, e.g., cell configuration. (FA-04, FA-06 through FA-12, and FA-36)
F06:
The VCSD Policies and Procedures track all of the elements of a suicide prevention program identified by the National Commission on Correctional Health Care. There is not a single “Plan” for the VCSD, but a program does exist. The suicide prevention program is not represented in a single document, but it meets Title 15 criteria. What is significant is that all of the written policies and procedures exist in a coherent framework and contain standard practices that are not only followed to the letter, but are followed with commitment as well. For example, the immediate institutional responses to the suicides of inmates A and B were timely and appropriate. The teamwork that was demonstrated in the institutional responses to these two suicides indicates the dedication that exists within the detention staff. (FA-14 through FA-19, FA-22 through FA-26, FA-28, and FA-30 through FA-34)
F07:
Despite the thoroughness and dedication of the VCSD Major Crimes investigators, the fact that the VCSD is investigating deaths in its own jail can be perceived as a lack of transparency. This can lead to a false perception as to the integrity of the investigative process and findings. (FA-23 and FA-28)
F08:
The participation of the VCSD, the Jail Work Group of the Ventura County Mental Health Board, and the VCBHD with regard to inmate release, has demonstrated an openness that allows for effective communications across the community. This kind of relationship can be considered a best practice. (FA-29)
F09:
There is a spectrum of personnel available to observe the potential suicidal inclinations of inmates. These include individual deputies, chaplains, and psychiatrists from the CFMG, religious volunteers, teachers, work supervisors, and maintenance personnel. The amount of training regarding suicidal issues in this spectrum is varied. (FA-30, FA-33, and FA-37)
F10:
Psychological Autopsies have not been an explicit element in the VCSD suicide assessment process. There are two institutional resources available to the VCSD with the technical capability to support custody staff in performing Psychological Autopsies: the CFMG and the VCBHD. The CFMG is a contractor to the VCSD with a clinical perspective; the VCBHD is an independent organization within the County with a community-based perspective. (FA-35) (Att-04)
Related Recommendations (2)
R03:
The Sheriff should solicit the Ventura County Health Care Agency for VCBHD’s participation with the VCSD legal unit in the analysis of suicides in order to provide an independent perspective. (FI-06, FI- 08, and FI-10)
R10:
The Sheriff should consider requesting the VCBHD and the CFMG to support the performance of Psychological Autopsies on inmates A and B. (FI-03 and FI-10)
F11:
The stoic culture of custody staff and inmates is an inhibiting factor in their requesting counseling services. This can preclude staff and Inmate Processing and Suicide Prevention 11 inmates from requesting counseling services even if those services could be beneficial. (FA-29) Recommendations
F12:
At least 80% of suicides in custody occurred in the inmate’s cell; time of day was not a factor. [Ref-06]
F13:
A definitive cause-effect relationship between risk factors and suicidal death cannot be established. Some inmates attempt suicide with no intention of ever completing the act, while others persist, using more lethal methods until successful. [Ref-07]
F14:
The VCSD systematic process for receiving, housing, and monitoring inmates is as follows: A Transporting Officer introduces the inmate to the facility. The booking process begins with completion of the initial Intake Health Screening Form. (Att-01) The inmate is then classified as to type of housing. Based on the results of this initial screening form, an immediate medical review may be undertaken; otherwise, the screening form is reviewed later in the booking process by medical staff. The classified inmate is then placed in a 72-hour Reception Housing Area for incoming inmates. The inmate is closely monitored prior to assignment to long-term housing. Before leaving Reception Housing and being assigned to long-term housing, the inmate is interviewed by medical staff and a Reception Housing Clearance, Reception Housing Bypass Form is completed. (Att-02) After being assigned to a cell and monitored hourly, any anomalies in the inmate’s situation may cause reassignment to a cell which is more intensively monitored. Depending on the type of cell to which the inmate is assigned, the inmate is monitored every 15 minutes (Safety/Suicide Watch cells and Sobering cells), every 30 minutes (Medical Housing and Suicide Precaution cells), or every hour (all other cells). Logs of monitoring activities are recorded electronically for every cell monitored hourly. Logs are recorded manually for the Safety, Sobering, and Medical housing cells. If an inmate emergency occurs, a critical response protocol is executed. Deputies secure the area and implement emergency procedures. Jail medical personnel respond with a higher level of care. When necessary, Emergency Medical Technicians assume medical responsibility and transport the inmate to the hospital. If a death ensues, the Medical Examiner performs an examination and issues a report. The VCSD Major Crimes unit investigates and issues an investigative report. If it is determined to be a suicide, these reports are reviewed by the Legal Sergeant on the staff of the head of detentions. Based on this review, the Legal Sergeant, in conjunction with other detention staff members, may recommend changes to detention policy, training, or facilities. [Ref-08] Inmate Processing and Suicide Prevention 5
F15:
Two parts of the screening process are conducted prior to the assignment of an inmate to long-term housing. The first screening is completed prior to the 72-hour Reception Housing process. This is done by booking deputies with support, as required, from the California Forensic Medical Group (CFMG) medical personnel. The completion of the first form may trigger an immediate interview with CFMG medical personnel. Otherwise, the form is reviewed by CFMG prior to the inmate leaving the booking floor. (Att-01) The second screening is completed and documented by CFMG after the 72-hour Reception Housing interval. These two forms capture the mental and physical health state of the inmate. While the Ventura County Justice Information System (VCJIS) is able to easily keep track of institutional data on inmates who have had multiple bookings, these two paper forms used in the screening process are not maintained electronically. (Att-02) A briefing paper developed by the California Corrections Standards Authority includes a screening form with data elements that are not included in the Ventura County forms. [Ref-09] (Att-03)
F16:
The sources of information about inmates are the inmates themselves, transportation officers, intake personnel, custodial personnel, fellow inmates, and medical staff. If the inmate is a client of the Ventura County Behavioral Health Department (VCBHD), VCBHD medication records are available. If the inmate was previously incarcerated, criminal history data is also available in VCJIS.
F17:
Besides uniformed VCSD personnel, there are other categories of people who can have direct access to inmates. They include ministers, teachers, adult literacy volunteers, and civilian supervisors of the kitchen and print shop, etc.
F18:
Inmate communications with family, friends, and the outside world are mail, telephone calls, and personal visits. Visitors enter a lobby area where there are posted regulations.
F19:
Staff supporting the County Jail for medical and psychiatric services is contracted through CFMG. This group has been under contract with Ventura County since 1987. [Ref-10]
F20:
A subsidiary of the California Medical Association, The Institute for Medical Quality (IMQ), has awarded the Ventura County Adult Correctional Facilities accreditation for demonstrating 100% compliance with the IMQ applicable Essential Standards. The accreditation period is September 2010 to September 2012. [Ref-11]
F21:
The suicide monitoring and response process is implicit in many aspects of County Jail operation, including management, Legal 6 Inmate Processing and Suicide Prevention Sergeant, custody staff, investigators, medical staff, and intake screening staff.
F22:
The County has a process improvement approach for organizational evaluation and review of its departments. The Sheriff has embraced this approach to organizational change. A part of this management approach is to identify and emulate best practices from any source. The Sheriff has reduced overhead in his administration. For example, Detention Services and Major Crimes now report to the same Assistant Sheriff.
F23:
In 2010, one inmate died of natural causes; two inmates, A and B, were suicides. Inmates A and B had prior incarcerations. Inmate B had been incarcerated on a frequent basis during the prior six years. The ages of the three were between 48 and 52. In the case of the suicides of inmates A and B, custody personnel responded quickly. Deputies and attending nurses performed emergency procedures until Emergency Medical Technicians arrived in a timely manner and transported the inmates to the hospital.
F24:
Inmate A left reception housing and was interviewed by a nurse three days after booking. Inmate A was transferred from the MJ to the TRJ eight days after booking. Inmate A was found hanged in his cell 104 days after booking. An after-death investigation identified that former cellmates stated they had observed two prior suicide attempts. The first attempt was reportedly one day after booking; the second was 96 days after booking. Both attempts were unknown to the custody staff prior to the suicide investigation. The first cellmate claimed to have had contact with an unsworn employee at the MJ about this incident. This contact was not substantiated. The second attempt at the TRJ was not communicated to VCSD personnel by the cellmate before the successful suicide.
F25:
Inmate B was interviewed by a nurse at the end of reception housing. He was transferred from the MJ to the TRJ four days after booking. Inmate B was found hanged in his cell eleven days after booking. Subsequent investigation indicated that some family members were aware that the inmate had a bipolar disorder, was under psychiatric care, and had exhibited suicidal behavior. This information was not communicated to custody personnel.
F26:
Based on the analysis of prior suicides, various modifications to cells were initiated to mitigate suicide. These included rounding of bunk railings to prevent attachment of a rope or sheet and installing clothing hooks that would not support the weight of an inmate without giving way. These modifications were observed in the MJ but, based on review of the Investigative Reports and Grand Jury visits, the bunk alterations were not yet completed in the cells of inmates A or B at the TRJ. Inmate Processing and Suicide Prevention 7
F27:
The VCSD investigates all deaths in the County Jail. The Medical Examiner determines the cause of death and notifies the family of the decedent. If a death is determined to be a homicide, the District Attorney is presented with the investigative results. Similarly, the District Attorney is presented with the results of all investigations of officer involved shootings. In the case of suicides, the District Attorney is not presented with investigative results.
F28:
The VCBHD currently participates with the Sheriff in a number of ways: A VCBHD employee works in the County Jail to facilitate discharge planning of inmates and works jointly with custody personnel in support of the Jail Workgroup of the Ventura County Mental Health Board (VCMHB). The VCBHD screens inmate lists in order to identify those inmates who are already being served by the VCBHD. Some medication record formats have been standardized between the County Jail and the VCBHD to allow smooth access to medication records. The VCBHD does not participate in the evaluation of suicides and attempted suicides within the County Jail. The VCBHD supports the quarterly Quality Assurance Reviews of the CFMG.
F29:
Dealing directly with suicides is stressful and challenging. Employees of the VCSD have the Employee Assistance Program (EAP) that provides stress counseling to members of the custody staff. Supervisors can encourage employees to avail themselves of this service. Custody personnel have acknowledged the stressful impact of suicide incidents and have, in some cases, declined suggested counseling. Chaplains and CFMG medical personnel provide a similar counseling role for inmates when requested. In the particular case of the suicide of inmate B, CFMG provided an unrequested psychiatric intervention to a cellmate who demonstrated a severe emotional reaction.
Related Recommendations (1)
R07:
The Sheriff should consider developing a supplemental Critical Incident Stress Debriefing protocol for staff and inmates who are involved with suicides. (FI-06 and FI-29)
F30:
The uniformed personnel in the County Jail are composed of Sheriff Deputies and Sheriff Service Technicians (SSTs). Deputies undergo a six-month VCSD Academy training program. County Jail SSTs undergo a 176-hour training program developed by the California Corrections Standards Authority. Both deputies and SSTs also attend an 80-hour Standards and Training for Corrections Course (STC). All uniformed custody personnel are trained and annually tested in twenty-four knowledge domains associated with specific custody situations.
F31:
Of the 80 hours of STC training, one hour is devoted to “Indicators of Suicide (In a Jail Setting).” [Ref-12] 8 Inmate Processing and Suicide Prevention
F32:
Counseling by chaplains is a key component in any suicide prevention program. Chaplains in the County Jail undergo specialized training developed by the International Conference of Police Chaplains (ICPC). Suicide prevention is part of the training. Two chaplains and a Catholic Services Representative coordinate the efforts of clerical volunteers from over 50 churches to provide religious support to the inmates. All three of these coordinators have had suicide prevention training.
F33:
There are approximately 350 volunteers and non-uniformed staff who provide a number of services to the inmates. These activities include vocational, adult literacy, religious, educational, family, and discharge planning services.
F34:
The National Institute of Corrections Library identifies a thirty-two hour instructional program on suicide prevention. [Ref-13]
F35:
In some organizations experiencing multiple suicides, the process of reviewing suicide deaths has involved the use of a procedure designated as a “Psychological Autopsy.” For example, Psychological Autopsy is considered by the Department of the Army as a key element in the assessment of suicides in its Suicide Prevention Program. [Ref-15] (Att-03)
F36:
Using the metrics developed by the U.S. Department of Justice and the average daily population and mortality data from the VCSD for the County Jail, over the eleven-year period from 2000 through 2010, the average annual suicide rate was 59 per 100,000 inmates and the average annual mortality rate was 170 per 100,000 inmates. When calculated over the eight-year period from 2000 through 2007, the annual suicide rate was 48 per 100,000 and the average annual mortality rate was 138 per 100,000. Over the three-year period 2008 through 2010, the suicide rate was 83 per 100,000 and the average annual mortality rate was 209 per 100,000.
F37:
A recent report from the National Institute of Corrections has indicated the following: a) Inmate suicide is no longer centralized in the first 24 hours of confinement and can occur at any time within the inmate’s confinement; b) All correctional, medical, and health personnel, as well as any staff who have regular contact with the inmates, should receive eight hours of initial suicide-prevention training and two hours of refresher training each year; c) The majority of inmates who committed suicide attended (or were scheduled to attend) a court hearing within two days of when they committed suicide; d) Every completed suicide as well as attempts that require hospitalization should be examined through a morbidity- mortality review process, ideally, coordinated by an outside agency. Inmate Processing and Suicide Prevention 9 A psychological autopsy is recommended as part of this process. [Ref-16] Findings
Findings & Recommendations
14 findings
F01:
Workplace bullying is occurring in the County workplace and there is no policy or employee training to preclude bullying. (FA-01 through FA-03, FA-09, FA-10)
F02:
Processes in place to report workplace behavior problems are not trusted by employees because the agency with the alleged bullying issue is allowed to investigate complaints using personnel within its own organization. This system risks the exposure of a complainant’s identity and reinforces employee perception that the investigation would not be conducted fairly. (FA-05, FA-06, FA-12)
F03:
The BOS does not receive detailed data that would identify bullying problems within County offices. (FA-13)
F04:
Forms used for employee disciplinary actions are not reviewed for content on a periodic basis by County Counsel. Since County Council has opined that the “Placement on Paid Administrative Leave Memorandum” form is improper, it is likely that other forms used for employee disciplinary actions may have legal issues. (FA-04, FA-11) 4 Bullying in the Workplace
F05:
A County policy against bullying, that includes descriptions of bullying behaviors, will educate employees on unacceptable workplace behaviors and encourage employees to report this type of workplace abuse. This will potentially reduce the numbers of employees leaving County service to escape bullying and save the County the costs of finding and training replacements. (FA-06 through FA-10) Recommendations
F06:
Employees left their County positions as a result of being bullied and declined to complain about their situations through the Employee Complaint Resolution Process or to the A-C Employee Fraud Hotline. These employees did not believe their complaints would be investigated fairly. They feared that the offending manager would become aware of their complaints and their identities, resulting in retaliatory behavior that would worsen their situations.
F07:
Bullying in the workplace impacts the physical and emotional health of employees who are the targets of a bully. Health problems, as a result of bullying, have led to legal claims.
F08:
The County incurs the cost for recruitment and training of replacement personnel when bullied employees leave their County positions. During the recruitment and training periods of replacement personnel, departments must distribute their workload among the remaining staff or delay tasks.
F09:
The County has no written policy specifically directed against bullying in the workplace. The County does have a written policy for workplace discrimination and harassment to comply with Title VII, United States Code (Civil Rights Act of 1964). One instance of that Bullying in the Workplace 3 policy is documented in Attachment 3 in a paragraph entitled “What is discrimination or harassment?” (Att-03)
F10:
The County has a written policy that defines causes for disciplinary actions. Some of the causes describe actions that might serve as a policy against bullying such as “intemperance,” “discourteous treatment of other employees,” and “failure of good behavior.” These descriptions do not clearly identify bullying behavior. Attachment 4, Causes for Disciplinary Action, contains the full list of actions. (Att-04)
F11:
Forms used in employee disciplinary actions are not formally reviewed by County Counsel for compliance to current law and for sound legal practice on a periodic basis.
F12:
Workplace behavior complaints filed through the CEO-HR or the A-C Employee Fraud Hotline were normally assigned to the agency against which the complaint was lodged to investigate the allegations internally.
F13:
Neither the CEO-HR, nor the A-C Employee Fraud Hotline provided detailed data on workplace behavioral complaints to the BOS. In some cases, data identifying workplace behavior complaints by category and department, along with trend statistics, were available, but were considered to be sensitive information. Since reports to the BOS are published on a County website for public information, the detailed data are not included in the reports.
F14:
The Grand Jury found samples of policies written specifically to address bullying behavior through Internet searches. (Att-05) Findings
Findings & Recommendations
27 findings
F01:
It is not possible to determine the actual cost of the ranger program through examination of the Budget. (FA-16)
F02:
All District properties fall within the jurisdiction of either the SVPD or the VCSD. These agencies have the duty to provide law enforcement and public safety at all District properties. Rangers patrolling 47 District parks and facilities distributed over a large area are superfluous and ineffective. (FA-05, FA-17 through FA-25)
F03:
The level of law enforcement provided by the SVPD on District properties and the few contacts from the rangers requesting SVPD assistance demonstrate the relative importance of the SVPD in serving park properties. (FA-22 through FA-25)
F04:
The expenditure of public funds for the Ranger Program should be called into question given the presence and jurisdiction of the SVPD and the VCSD. (FA-04, FA-09 and FA-10, FA-12 through 14, FA-19 through FA-25)
F05:
Public funds are being inappropriately used by employing armed, sworn peace officers as rangers to perform non-law enforcement tasks. (FA-15) Recommendations
F06:
The District is served by a park ranger program intended to provide public safety, enforcement of park rules and regulations, vandalism prevention, and public education. (Att-04)
F07:
All rangers are armed, sworn peace officers. (Att-04)
F08:
Rangers may issue warnings or citations to persons violating park rules or ordinances. (Att-04)
F09:
The Budget provides for one senior ranger and two ranger positions. (Att-05)
F10:
Full-time and eligible part-time rangers receive employee benefits including participation in the California Public Employee Retirement System. The costs of employee benefits are not clearly detailed in the Budget. The benefit costs for the one-half ranger position indicated on of the Budget under Fund 45-Special Zone Tax, can be interpreted to be approximately 30 percent of total salary and employee benefits. (Att-05) Rancho Simi Recreation and Park District Rangers 3
F11:
The District’s ranger program is, in fact, staffed by one full-time senior ranger, two full-time rangers, and ten part-time rangers.
F12:
The District operates and maintains five ranger vehicles.
F13:
Rangers are issued uniforms, guns, ammunition, cell phones, protective vests, night vision instruments, and other types of equipment.
F14:
Ranger wages, uniform, and supply expenditures in fiscal year 2009- 2010 were estimated by the District to have been $381,000.
F15:
Armed, sworn rangers perform such non-law enforcement tasks as locking and unlocking gates and rest rooms. According to statements made by District personnel, rangers also conduct education programs.
F16:
The Budget fails to provide clear and complete detail of ranger program personnel and support costs. [Ref-01]
F17:
Ranger staffing varies widely from day to day. On most days there is only one ranger on duty. Daily Ranger Activity Reports for the six- month period from April 1, 2010 through September 30, 2010 were analyzed to obtain a history of ranger staffing levels. Copies of the Park Ranger Activity Reports, filed daily, were provided by the District at the request of the Grand Jury. The daily schedule may include an early shift running from 8:00 a.m. to 4:30 p.m. and a late shift running from 3:30 p.m. to midnight. The analysis revealed the following information for both shifts over the 183-day (six-month) period as shown in the table below: Staffing Early Shift Late Shift (Days) (Days) No rangers on duty 68 2 One ranger on duty 98 97 Two or more rangers on duty 17 84 (
F18:
One or more additional rangers may be added to the day’s duty roster on holidays, some weekends, or for special park events or programs.
F19:
When confronted with law enforcement problems, rangers call upon the VCSD or the SVPD to assume responsibility.
F20:
All District parks and facilities located in the City of Simi Valley are within the jurisdiction of the SVPD. Rancho Simi Recreation and Park District Rangers
F21:
All District parks and facilities located in the unincorporated areas of the County, including the Oak Park community, are within the jurisdiction of the VCSD.
F22:
The SVPD responded to approximately 1,390 calls involving District parks and District facilities between September 1, 2009 and September 1, 2010.
F23:
Of the approximate 1,390 calls responded to by the SVPD to District properties, only 15 can be directly attributed to requests from District personnel.
F24:
Of the 1,390 responses to District parks and other District facilities, 492 were initiated by the SVPD.
F25:
The majority of remaining calls responded to by the SVPD are attributed to unknown callers, citizens, or 911 calls.
F26:
No definitive data on sources or numbers of responses to District parks or District facilities is available from the VCSD.
F27:
According to the District, it does not track its requests for SVPD or VCSD response. Findings
Findings and recommendations not yet extracted.
Findings & Recommendations
7 findings
F01:
Public access to information regarding Special Assessments would be improved if the information were available on the AC and T-TC websites. (FA-01 and FA-06)
F02:
Additions of Special Assessments to the Property Tax Bill are verified and approved by the AC. (FA-05 and FA-07) 2 Special Property Tax Assessments
F03:
The AC Helpline representatives are able to answer questions on Special Assessments or redirect taxpayers to another agency that can provide answers. (FA-03 and FA-04)
F04:
AC and T-TC would save labor and money by providing the public with internet access to Special Assessments information. Currently, this information is available only by telephone request. (FA-01 through FA-03, and FA-06) Recommendations
F05:
The Grand Jury requested and received from the AC documentation to verify the authorization for five of the approximately 250 Special Assessments. [Ref-01 through Ref-05]
F06:
The AC and T-TC websites do not provide information related to Special Assessments. [Ref-06 and Ref-07]
F07:
Ventura County Special Assessments financial audits are conducted by the AC. Financial audits of Independent Special Districts and remaining jurisdictions are conducted by independent auditors. Those reports are filed with, or available to, the AC. Findings