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San Luis Obispo County Jail Conditions Violate Eighth and Fourteenth Amendments

by Keith Sanders

On August 31, 2021, the Department of Justice (DOJ) Civil Rights Division released a report detailing its investigation concerning the conditions inside San Luis Obispo County Jail.

The findings of the report, conducted pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA), 42, U.S.C. § 1997, Title II of the American Disabilities Act (ADA), and 42 U.S.C. § 12132, established reasonable cause that the California jail violated the Eighth and Fourteenth Amendments and the ADA. The United States District Attorney’s Office of the Central District of California advised Wade Horton, San Luis Obispo County Administration Officer, and Sheriff Ian Parkinson that the Attorney General could file suit under CRIPA against them within 49 days to remedy the alleged conditions inside the jail.

The investigation was initiated in October 2018 to examine the jail’s treatment of disabled prisoners and the level of medical and mental health care it provided. A relatively high percentage of prisoners in the county jail, roughly 40%, suffer from mental illness at any given time, most of whom are taking psychotropic medications. The jail estimated, according to the report, that over “90% of prisoners have substance abuse issues,” with many of them temporarily housed in “sobering cells” where they withdraw from alcohol or drugs.

Prisoners who pose a danger to themselves or others, or who are found incompetent to stand trial, are typically transferred to either the County’s Psychiatric Health Facility, the Atascadero State Hospital, or to the Jail-Based Competency Treatment Unit established at the jail in July 2019.

Overall, the investigation found that the jail failed to provide essential and adequate mental health care to prisoners in its custody. The jail “engaged in a pattern or practice” of not providing prisoners with such care. The report concluded those patterns or practices violated the Eighth Amendment protection against cruel and unusual punishment.

Because the jail houses both sentenced prisoners and pretrial detainees, the report also noted that the jail violated the Fourteenth Amendment, which guarantees the rights of pretrial detainees equal to those rights under the Eighth Amendment.

The investigation found myriad other violations as well. Among other issues, prisoners were subjected to significant delays in medical care; the jail failed to adequately treat prisoners with chronic medical conditions, like diabetes, HIV, Hepatitis C, and hypertension; the jail did not provide adequate medical screening; and it failed to provide access to medical care because its “medical forms and health care grievances did not function properly.”

All these factors contributed to the jail’s failure to provide adequate medical and mental health care, which in some cases ended in a prisoner’s death.

The report identified sixteen prisoner deaths at the jail from January 2012 to June 2020, with three more dying during the investigation. For instance, in January 2017, a 36-year-old schizophrenic “died after spending 46 consecutive hours strapped to a restraint chair,” the investigation discovered. Technically, he died of a pulmonary embolism, a condition that causes “blood clots that form in the extremities, which can occur as a result of lack of mobility.” According to the investigation, “He spent his last minutes writhing on the floor of a cell while deputies watched him through the clear glass cell door.”

Another prisoner died in April 2017 of hypertension after the jail failed to provide the 60-year-old prisoner with a “comprehensive medical evaluation when he entered custody, performed no tests or laboratory examination or otherwise monitored his condition, and prescribed him high doses of Ibuprofen, a drug the FDA has warned can lead to heart attacks in people with high blood pressure.”

In February 2019, while the DOJ investigation was ongoing, the San Luis Obispo County Jail contracted with Wellpath LLC, the largest healthcare provider for prisons in the U.S., to administer medical and mental health care to the jail’s prisoners.

Moreover, in May 2019, the county jail constructed the Jail-Based Competency Treatment unit, as well as several housing units more appropriate to prisoners with medical and mental health care needs.

Nonetheless, the DOJ’s investigation cited Wellpath and its staff for not taking “seriously prisoner grievances or the grievance process as a mechanism for prisoners to raise legitimate medical concerns.”

Wellpath did not resolve the issues at the jail. The report noted that the healthcare provider was chronically understaffed, did not review the quality of care it provided, and there was no mechanism for the County to remedy deficiencies in Wellpath’s care.

The DOJ investigation discovered that jail officials had been aware of the medical deficiencies for years and were actually put on notice with the death of the schizophrenic prisoner in 2017.

“By disregarding the obvious risks to prisoner health and safety, officials at the jail evince a deliberate indifference to prisoners’ constitutional rights to adequate medical care,” the report concluded.

The report also heavily criticized the jail for using Restrictive Housing to manage and house prisoners with mental health issues. Despite a lack of documentation of disciplinary notice, hearing or adjudication, prisoners suffering from mental health crises were p1aced in Restrictive Housing for “discip1inary reasons” with limited out-of-cell time. Citing Graves v. Arpaio, 48 F.Supp. 3d 1315 (D. Ariz. 2014), the DOJ report pointed out that holding “inmates with serious mental illness in prolonged isolated confinement may cause serious illness and needless suffering in violation of the Eighth Amendment.”

The report concluded by listing twenty minimal remedial measures for medical care, eighteen measures for mental health care, six measures regarding the usa of Restrictive Housing, eighteen measures to modify the Jail’s use of force policies, and three measures to comply with the ADA.

Editor’s Note: The DOJ investigation in San Luis Obispo appeared to have rippling effects. According to reporting from, nearby Ventura County supervisors noted the Civil Rights Division’s findings upon authorizing $2.5 million in September 2021 for their Sheriff Bill Ayub to hire more nurses, therapists and other health care staff for county prisoners there. 


Source: “Investigation of the San Luis Obispo County Jail,” report by DOJ Civil Rights Division

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