Quadrennial and Warden Audit of CA Institution for Women, CA OIG, 2007
Download original document:
This text is machine-read, and may contain errors. Check the original document to verify accuracy.
Office of the Inspector General Matthew L. Cate, Inspector General The California Institution for Women Quadrennial and Warden Audit December 2007 State of California Contents Executive Summary .................................................................................................1 Institution Overview ................................................................................................4 Chapter 1: One-Year Evaluation of Warden Dawn S. Davison ..........................6 Objectives, Scope, and Methodology..........................................................6 Background of Warden ...............................................................................6 Discussion of Warden’s Strengths..............................................................7 Discussion of Criticisms...............................................................................9 Warden’s Response to Criticisms...............................................................11 Summary Discussion....................................................................................12 Chapter 2: Quadrennial Audit Findings and Recommendations .......................13 Objectives, Scope, and Methodology..........................................................13 Finding 1 .......................................................................................................15 The aging and overcrowded institution has fallen into disrepair, and many buildings have become inadequate, yet the institution still waits for overdue repair funds from department headquarters. Finding 2 .......................................................................................................19 The attendance rate is poor in education classes because of frequent cancellations and other factors. Finding 3 .......................................................................................................23 The California Institution for Women does not always assign inmates with low reading abilities to adult basic education classes. Finding 4 .......................................................................................................27 Inmates sent to off-site medical specialists do not always receive prompt followup medical care. Finding 5 .......................................................................................................29 The California Institution for Women does not complete its use-of-force incident packages within the required timelines. Finding 6 .......................................................................................................31 The visiting center staff does not consistently adhere to visiting policies and regulations, increasing the risk of visitors bringing banned materials into the institution. Finding 7 .......................................................................................................35 The California Institution for Women fails to ensure that staff members assigned to armed posts always meet their quarterly weapons qualifications requirements. California Department of Corrections and Rehabilitation’s Response ..............38 Executive Summary This report presents the results of an audit by the Office of the Inspector General (OIG) concerning the operations of the California Institution for Women (CIW) and the performance of its warden. The audit was performed under California Penal Code section 6126 (a)(2), which requires the Inspector General to audit each warden one year after his or her appointment, and to audit each correctional institution at least once every four years. Our team of inspectors examined CIW’s operations and programs to identify problem areas and recommend workable solutions. The institution, which houses 23 percent of California’s adult female inmates, gave our inspectors full access to its records, logs, and reports. In addition, site visits allowed us to observe CIW’s day-to-day operations. We also conducted interviews of various staff members and inmates, and we surveyed three distinct focus groups: institution management and staff, California Department of Corrections and Rehabilitation management, and key government and union stakeholders. In all, our inspectors made seven audit findings and 23 recommendations, which are detailed in Chapter 2 of this report. Overall, Warden Davison performs her duties well. As detailed in Chapter 1 of this report, we used surveys, personal interviews, and our audit findings to evaluate Warden Dawn S. Davison’s performance. Although Davison has numerous challenges ahead, her supporters describe her as a compassionate warden who is devoted to CIW’s mission, and she has made great strides in steering the institution in a positive direction. Since her appointment as CIW’s warden, Davison has implemented several innovative programs, and she brings a positive energy to the staff and inmates. We found that Davison is hard working and generally performs her duties well. However, she could improve by requiring a greater degree of compliance with department policy by her staff. Nonetheless, Davison is steadily improving the prison, and she should continue serving as warden at CIW. Challenges persist due to an aging, overcrowded facility. The warden is challenged by an aging, overcrowded facility that results in ongoing building maintenance problems. The institution was built over 50 years ago and suffers from a lack of preventive maintenance, caused in part by inadequate funding to repair or upgrade the aging facility. For example, the institution received only partial funding to renovate the support care unit after it found lead-based paint on the walls—even though the department approved the project, which has been on an “unfunded” list for the last seven years. Bureau of Audits and Investigations Office of the Inspector General Page 1 The California Institution for Women’s education department needs to improve its operations. While our evaluation of the warden’s performance was mostly positive, our audit of the institution’s programs in Chapter 2 uncovered a number of concerns in the education department. Most notably, attendance data showed that students in the education department’s academic and vocational programs attended class for only 42 percent of the total available classroom hours. Although absences caused by students and custody-related matters contributed to lost classroom time, we found other factors, such as no provision for substitute teachers and classrooms without air conditioning, caused the school to cancel 28 percent of available classroom time. Further, we found that students often miss class time without an approved excuse, and teachers sometimes fail to initiate disciplinary action against students for their missed time. We also found that CIW did not always identify and assign inmates who read below the ninth grade level to the academic program or, at the least, place them on a waiting list, a necessary step to comply with state law. Instead, the institution assigned many inmates with low reading abilities to its pre-forestry training program, fire camp program, or other institutional jobs. The inmate assignment errors occurred, in part, because CIW’s inmate assignment practices conflict with state law. The California Institution for Women needs to improve its adherence to established policies. During our review of CIW and its warden, we found several areas in which staff members deviated from accepted standards, regulations, and policies. In the area of medical care, the Division of Health Care Services requires that an inmate receiving a routine specialty service must receive follow-up medical care from her primary care physician within 14 days. We found, however, that CIW’s medical staff missed the 14-day standard in nearly half the files reviewed and that the delay averaged 12 days beyond the 14-day standard— potentially endangering the inmates’ health and jeopardizing the department’s compliance with the court-ordered quality-of-care standard. Similarly, over half the use-of-force incident packages (incident report and supplemental documents) prepared by CIW staff members are not submitted to headquarters within the 30-day time requirement. For 21 percent of those late packages, the use-of-force committee recommended further on-the-job training to address staff deficiencies; consequently, a delay in corrective training increases the possibility that the staff’s inappropriate use of force could reoccur. During our unannounced site visit, we found that the visiting center staff was unfamiliar with visiting procedures because they lacked training, and the staff was not consistently screening visitors to prevent them from bringing weapons or unapproved materials into the visiting center. In addition, despite a department requirement that only peace officers who have completed firearms training and Bureau of Audits and Investigations Office of the Inspector General Page 2 are currently qualified be assigned to armed posts, we found seven peace officers assigned to armed posts who did not participate in the last quarterly range qualification. Thus, more than three months elapsed between each of their qualifications. When peace officers do not maintain their proficiency with their firearms, they expose themselves and others to risk of unintentional injury. Bureau of Audits and Investigations Office of the Inspector General Page 3 Institution Overview CIW is one of 33 adult prisons operated by the California Department of Corrections and Rehabilitation. As of September 30, 2007, the department reported that it housed 10,993 female inmates, primarily in three facilities. With a design capacity of 1,325 inmates, CIW is home to 2,511 (23 percent) of California’s female inmates. Established in 1952, CIW’s primary mission is to provide a safe and secure environment while providing quality health care and institution programs geared to meet the special needs of female offenders. CIW also houses inmates with special needs, including maternity care, psychiatric care, methadone treatment, and medical problems such as HIV infection. Located in Corona in Riverside County, the institution accommodates all custody levels of female inmates and functions as a reception center for incoming female inmates. For fiscal year 2007-08, the institution’s operating budget is $101.6 million with 985.8 budgeted positions, of which 479.1 (48.6 percent) are custody staff. The table below compares CIW’s budgeted and filled positions as of November 15, 2007. Notably, CIW has filled more than 96 percent of its custody positions and almost 92 percent of its education positions. Overall, the institution filled 94.1 percent of its total budgeted positions. Staffing Levels at the California Institution for Women Position Filled Positions Budgeted Positions Percent Filled Custody Support Medical Education 462.9 203.7 226.8 34.0 479.1 216.0 253.7 37.0 96.6% 94.3% 89.4% 91.9% Total 927.4 985.8 94.1% Many programming opportunities exist for inmates at the California Institution for Women. CIW offers a variety of education and vocational programs designed to elevate inmates’ social awareness and personal responsibility. For example, the institution provides substance abuse programming, firefighting training, and a number of self-help groups and community improvement projects. In partnership with the Center for Children of Incarcerated Parents, one of the institution’s notable programs is the Family Reunification Program, which helps incarcerated mothers maintain or regain contact with their children. The California Institution for Women provides comprehensive care for inmates requiring mental health treatment. CIW provides inmates with mental health disorders different levels of treatment. The institution offers general population inmates outpatient mental health care through its Correctional Clinical Bureau of Audits and Investigations Office of the Inspector General Page 4 Case Management System. In addition, CIW has an Enhanced Outpatient Program for inmates needing more intensive mental health care, and the institution houses those inmates in its support care unit. CIW also recently opened a ten-cell psychiatric services unit, which it uses to house violent inmates who require an enhanced outpatient level of care. The institution continues to offer inmates brief inpatient care through its Correctional Treatment Center, where the mental health crisis beds are located. CIW transfers inmates who need long-term inpatient care (more than ten days) to Patton State Hospital for treatment and evaluation. The Prison Industry Authority introduced the nation’s first prison preapprenticeship carpentry program for women at the California Institution for Women. In August 2007, 11 female inmates graduated from the newly established pre-apprenticeship carpentry program that trains inmates in construction skills. As part of their training, the inmates renovated the California Department of Forestry and Fire Protection training facility located at the institution. Once inmates complete their training, they are eligible for placement in construction industry jobs. The Prison Industry Authority gives the inmates who complete the program the carpentry tools they need and provides employment assistance after release. The Prison Industry Authority also employs about 125 inmates in the institution’s textile factory. CIW’s textile factory produces numerous items for other California prisons. These items include men’s boxer shorts, sports shirts, food service shirts, potholders, and aprons. CIW reports that the factory’s annual revenue has been over $3 million in recent years. The institution indicated that most of the factory’s revenue comes from the sale of orange poplin work shirts and other apparel to the California Department of Transportation and fireretardant jackets and trousers to the California Department of Forestry and Fire Protection. According to CIW, the inmates assigned to work in the factory earn between $.30 and $.95 per hour and may receive certain privileges, such as paid state holidays, telephone calls, and reductions in their sentences as allowed by law. Bureau of Audits and Investigations Office of the Inspector General Page 5 Chapter 1: One-Year Evaluation of Warden Dawn S. Davison California Penal Code section 6126(a)(2) requires the OIG to audit each warden of an institution one year after his or her appointment, and to audit each correctional institution at least once every fours years. The OIG must fully comply with these requirements by July 2009. To satisfy this requirement for CIW, our inspectors audited the warden’s performance and the institution’s operations simultaneously. Objectives, Scope, and Methodology To understand how the staff and other stakeholders view the warden’s performance, we surveyed three distinct focus groups. Specifically, we sent surveys to 18 department officials and CIW managers. Of those surveys, we received 11 responses. We also delivered surveys to 176 CIW employees and received 35 responses. Finally, we sent surveys to 16 key stakeholders, including certain members of the Legislature, representatives of unions and associations, and a local district attorney. However, we received only one response. We toured CIW to gain insight into the environment where the warden must perform and we inspected various operational areas. These operational areas included, but were not limited to, the following areas: business services, inmate appeals, investigative services, litigation, labor relations, inmate records, plant operations, transportation services, education programs, inmate visiting, receiving and release, personnel assignment, and employee relations. During our site visits, we interviewed 52 individuals within the institution, including custody staff, executive management team members, labor union representatives, education and health care professionals, and representatives from the Women’s Advisory Committee, the Inmate Family Council, and the Citizens’ Advisory Committee. We also reviewed pertinent logs, reports, and other documents related to the warden’s performance over the past year, including the results of our institutional audit contained in Chapter 2. Background of Warden The Governor appointed Dawn S. Davison as the warden of CIW in November 2004. Davison began her career with the State of California in January 1980 as a Bureau of Audits and Investigations Office of the Inspector General Page 6 graduate student assistant at Lanterman Developmental Center. In 1986, Davison transferred to the department as a personnel supervisor at CIW. Over the next eight years, she advanced through various administrative classifications, which provided her with extensive personnel experience. In January 1994, Davison was promoted to business manager at Calipatria State Prison. In October 1997, Davison received a promotion to correctional administrator at California State Prison, Los Angeles County. In May 2000, she transferred to the California Rehabilitation Center in Norco, where she planned and directed the overall housing operations for approximately 4,000 level II inmates. Davison then served as the chief deputy warden at CIW from 2002 until she became warden in 2004. We evaluated Davison in October 2005 following the enactment of Penal Code section 6126(a)(2).1 Discussion of Warden’s Strengths Davison is one of the department’s more innovative wardens, specifically in dealing with female inmates. Davison is known to be a statewide expert in gender-specific correctional issues and has implemented gender-responsive strategies within the institution. At CIW, the warden focuses on the differences between male and female offenders in terms of the crimes they commit and the pathways to incarceration that bring them into the system, their risks and needs, and their roles in the community from which they have come and to which they will return. Several staff members noted gender responsiveness as one of Davison’s accomplishments. Davison also initiated California’s first in-prison nursery, the Bonding Mothers with Babies Program. This new program will allow inmates to deliver their babies while in prison and then care for the child for up to 15 months. This program falls under the institution’s Family Reunification Program. The warden believes that female offenders who maintain strong family ties during incarceration— specifically between a mother and child—have a greater chance of positive rehabilitation and have a lower risk of recidivism. According to the department, gender-specific rehabilitation programs such as this are one of many statewide efforts to reduce recidivism rates. In addition, Davison thinks “outside the box” by supporting inmate programs like the Chaffey College Program, the Prison Pup Program, and the Alpha Faith-Based Reentry Program. The Chaffey College Program is a state-funded educational program that offers academic support services to students who have experienced limited success in high school or college. The ultimate goal of the program is for 1 Warden Davison’s appointment in 2004 required Senate confirmation. Before she could be confirmed, that requirement was replaced by the warden evaluation process conducted by the Office of the Inspector General under Penal Code section 6126(a)(2). Bureau of Audits and Investigations Office of the Inspector General Page 7 the students to obtain associate degrees. The Prison Pup Program allows inmates to raise and train service dogs for mobility-impaired members of the community. The Alpha Faith-Based Reentry Program focuses on a curriculum of five core areas of instruction based on biblical principles: anger management, spiritual/values clarification, substance abuse relapse prevention, parenting/family relationships, and daily living skills development. Many staff members and inmates praise the warden for providing these opportunities to help inmates succeed once they leave the institution. Overall, Davison’s ability to initiate and operate these programs effectively, despite the overcrowding and infrastructure problems discussed in Chapter 2, is further indication of her strength as a warden. Those interviewed describe Davison as being honest, knowledgeable, compassionate, and committed to rehabilitation. Many said the warden is a person of integrity who is concerned about doing the right thing. An administrator told us that he often heard Davison say, “I don’t want you to allow me to lead us down the wrong road.” Staff members told us that Davison has an open-door policy and is very approachable; she often seeks opinions from her managers. She is viewed as a hard worker, and she genuinely cares about the institution’s success. Many staff members told us that the warden’s biggest accomplishments have been the implementation of the gender-responsive strategies, activation of the correctional treatment center, and planned activation of the Bonding Mothers with Babies Program. Inmates also praise Davison, stating that the warden is genuinely concerned about their future beyond prison. This concern is demonstrated by the large number of programs offered to the inmates. Several inmates told us that Davison and her management team members are receptive and supportive of their concerns. The executive body of the Women’s Advisory Committee, which is a committee that represents the inmates, meets with the warden and the associate wardens monthly to discuss any issues they may have. The inmates feel that they have direct access to the warden. Also, committee members describe the warden as an excellent crisis manager, as evidenced by her handling of the gastroenteritis virus outbreak, the transfer of inmates from the California Rehabilitation Center, and addressing the needs of an aging inmate population. Davison has made a positive impression on both the Inmate Family Council and the Citizens’ Advisory Committee, which are external organizations that support the inmates’ families and the community, respectively. Council and committee members told us that the warden is open to new ideas and is responsive to issues brought to her attention; they feel informed as to what is going on in the prison. Both organizations meet with Davison or her representatives every other month. Bureau of Audits and Investigations Office of the Inspector General Page 8 In summary, 46 of the 52 individuals interviewed provided an overall rating for Davison. Seventy-two percent of the individuals who provided an overall rating of the warden rated her either “very good” or “outstanding.” Institutional Staff’s Replies to the Question: “Rate the Warden’s Overall Performance” Rating Responses Percent Outstanding Very Good Satisfactory Improvement Needed Unacceptable 14 19 12 1 0 30% 42% 26% 2% 0% Total 46 100% Overall, the survey results were favorable. In addition to conducting face-toface interviews with staff members, we sent surveys to 34 individuals from the department’s headquarters, the institution’s management team, and external stakeholders. Twelve individuals responded to the survey, a 35 percent response rate. We asked respondents to rate the warden’s various management skills and qualities—from “outstanding” to “unacceptable.” In general, after we converted the ratings to a numerical score between 1 and 5, with 1 being “outstanding” and 5 being “unacceptable,” the results indicated a high opinion of the warden in all categories. Specifically, nearly 90 percent of all ratings were either “very good” or “outstanding.” Moreover, several respondents provided written comments that were quite positive. For example, one respondent stated that the warden “acts as a role model and mentor to other less senior wardens.” Another respondent stated that the warden is a “highly effective communicator.” We administered another survey to 176 institutional staff members. Thirty-five staff members responded to the survey, a 20 percent response rate. Respondents included custody staff and employees working in health care, plant operations, food service, administration, and education programs. One notable condition identified by the survey was that nearly 89 percent of the respondents indicated that they usually or always feel safe while in the institution. Additionally, over 94 percent of responding institution staff members indicated that they feel adequately trained to perform their job duties. Nearly 83 percent of the same staff members said the warden and her executive management team are ethical and emphasize an institution culture that calls for staff members to be highly ethical, professional, and honest. Finally, 77 percent of the respondents have no desire to transfer to another institution or resign within the next 12 months. Discussion of Criticisms Several staff members told our inspectors that communication between the management team and the custody staff needs improvement. Custody staff Bureau of Audits and Investigations Office of the Inspector General Page 9 members do not feel they are completely informed about institution changes or new programs being implemented. For example, some staff members expressed concerns about the Bonding Mothers with Babies Program, but after further discussions with them, most concerns resulted from the absence of information related to program details. In speaking with the administrators, they mentioned that the warden is trying new ways to improve communication among staff members. Davison recently held a town hall meeting where all staff members were invited. During this meeting, the warden and her management team members were available to answer staff members’ questions or concerns. Administrators told us that staff members appear to be receptive to the warden’s approach; therefore, the warden plans to regularly conduct town hall meetings in the future. Institution staff members say that Davison should spend more time walking around the institution and visiting the housing units. Some staff members told us they only see the warden when she is on her way to committee meetings. They said the warden appears to be more accessible to the inmates; therefore, they perceive her to be more supportive toward the inmates’ needs instead of staff members’ needs. The warden’s increased presence around the institution would provide staff members the opportunity to get to know her and to build better relationships with her. Such increased presence would also allow the warden to observe whether the staff is following her directives. Accountability may need to be addressed. Some of Davison’s critics do not view her to be enough of a disciplinarian. Several praised the working relationship between the prior chief deputy warden and Davison, saying their management styles complimented each other. The chief deputy warden focused on making sure the warden’s directives were carried out. However, since the chief deputy warden’s retirement, some staff members expressed concerns about whether the management team members will be held accountable. They said the warden needs to be more firm, and some fear that staff members may take advantage of her good nature. Some of the audit findings discussed in Chapter 2 support staff comments concerning whether the warden holds management team members accountable. For example, our audit found lapses in adherence to visiting policies, use-of-force incident requirements, and quarterly weapons qualification policies. In addition, the audit found weaknesses in the way teachers are utilized in the bridging program and in the methods used to identify and assign inmates to academic literacy programs. For each of these examples, an opportunity exists for the warden to hold institution managers more accountable. Our inspectors also noted a few areas of concern in the survey results. Thirtyfour percent of institutional staff respondents indicated that management seldom Bureau of Audits and Investigations Office of the Inspector General Page 10 or never listens to staff concerns or gives their concerns due consideration. Further, 46 percent of respondents said the warden seldom or never walks through the institution. Although we noted these minor concerns, the survey results were generally very positive and did not disclose any issues that were of significant concern to the OIG. Warden’s Response to Criticisms In her November 29, 2007, interview with the Inspector General, Davison noted that the focus of her job is to determine what measures or programs to implement that will address the inmates’ rehabilitative needs. Davison stated that she is genuinely concerned with providing the inmates with the tools and skills necessary for their success when they parole and to decrease California’s inmate recidivism rate. With that goal in mind, she researches, implements, and supports programs to allow as many inmates as possible to be successful in their transition to society, whether it be education, substance abuse treatment, vocational, or any of the other programs available at the institution. Communicating her vision to the staff and ensuring their support can be challenging, but she sees signs of progress each day. Davison conceded that her efforts to walk throughout the institution to talk with staff members informally have been insufficient. She noted that her temporary assignment at headquarters as an acting associate director took her away from the institution. However, she understands the importance of being more visible to all her staff, and she plans to make a concerted effort to walk the institution grounds more often. Davison also told us that her town hall meetings are very effective and are attended by many staff members. She has also placed a television monitor at the front entrance to inform the staff of current events at the institution, and she believes it has alleviated some of the prior communication complaints. Plus, she is working with her management team to help them become better communicators. She expects each member of her management team to communicate her message and direction to their respective staff members. Davison stated that this report characterized her accurately. She has worked hard to earn her reputation as an honest, hard-working leader with a passion to carry out her vision. She does not consider herself a disciplinarian, but she does believe in holding her managers accountable, and her style obtains her desired results. Davison cites that an increase in the number of staff disciplinary actions has occurred over the past few years—evidence that staff members are held accountable. Also, in selecting her new chief deputy warden, she looked for someone who would compliment her management style. Bureau of Audits and Investigations Office of the Inspector General Page 11 Davison accepted the criticism offered in her interview with the Inspector General and readily admitted her shortcomings. She showed great concern, as well as sincere appreciation for the criticism. She also expressed a commitment to continue implementing positive changes and improvements at CIW. Summary Discussion Davison has over 21 years of work experience at the California Department of Corrections and Rehabilitation. Despite the challenges every warden currently faces, our review found Davison is honest and hard working, and she brings a positive energy to the staff and inmates at the institution. She is devoted to the institution’s mission, and she believes that inmates need social, vocational, educational, and personal skills to become successful once they leave the institution. By most accounts, Davison passionately cares about CIW and demonstrates a personal commitment to carrying out its mission. The findings in this report, however, indicate a need for Davison to hold her management team accountable for enforcing critical policies and procedures. In addition, Davison can improve communication with staff by increasing her visibility to staff members and continuing her town hall meetings. In summary, Warden Dawn S. Davison appears to be performing her duties well and should continue serving as warden at the California Institution for Women while addressing the recommendations identified in this report. Bureau of Audits and Investigations Office of the Inspector General Page 12 Chapter 2: Quadrennial Audit Findings and Recommendations Objectives, Scope, and Methodology Our inspectors gained an understanding of the institution’s mission, safety and security procedures, and management practices by reviewing various laws, policies and procedures, and other criteria related to key facility systems, functions, and processes. As detailed in Chapter 1, we also inspected the institution, observed its general operations, and interviewed various staff members and inmates concurrently with the warden evaluation process. In addition, we surveyed key groups and reviewed statistical data reports that pertain to the institution’s population and programs. After assessing the institution’s operations and the survey results, we focused our audit on the following areas: Identifying infrastructure challenges Providing education programming to inmates Ensuring that inmates receive prompt follow-up medical care Submitting incident packages promptly Providing a safe and secure visiting environment Ensuring custody staff meets weapons proficiency requirements In conducting our work, we performed the following procedures: To identify the facility’s infrastructure challenges, we observed several infrastructure concerns during our site visits and interviewed staff members to obtain feedback regarding additional preventive maintenance issues. We then discussed the infrastructure concerns with facility management to determine what steps they have taken to address the concerns. To review the effectiveness of the institution’s education program at the El Prado Adult School, we studied state law and education policies and procedures, interviewed several education and management staff members, and consulted with the department’s Office of Correctional Education. We also reviewed student attendance reports and monthly summaries, which included the hours each student attended classes. Bureau of Audits and Investigations Office of the Inspector General Page 13 To determine whether inmates receive prompt follow-up medical care after they are sent to specialists, we interviewed staff members to gain an understanding of the medical care process, reviewed documents related to off-site medical transports, reviewed inmates’ medical records, and used information obtained from the Inmate Medical Services Scheduling and Tracking System. We did not review any other aspect of the prison’s medical program. To determine whether the institution promptly processes incident packages, including those involving use of force, we interviewed staff members responsible for monitoring and tracking incident packages, reviewed the incident log, and assessed whether CIW met the timeframes. To determine whether the institution provides a safe visiting environment, we reviewed policies and procedures for the inmate visiting center and conducted an unannounced site visit in June 2007, to observe the staff processing visitors during visiting hours. We also interviewed key staff members to understand their roles and responsibilities. To determine whether custody staff members in armed posts meet weapons proficiency requirements, we reviewed relevant policies and procedures, interviewed the institution’s training manager and individuals at the personnel assignment office, examined officer firearms qualifications and related training records, and obtained copies of employee rosters. Finally, we summarized the results of the above work and formulated our findings and recommendations. Bureau of Audits and Investigations Office of the Inspector General Page 14 Finding 1 The aging and overcrowded institution has fallen into disrepair, and many buildings have become inadequate, yet the institution still waits for overdue repair funds from department headquarters. Built over 50 years ago, CIW suffers from an overall lack of preventive maintenance, due in part to inadequate funding to repair or upgrade the aging facility. For example, many buildings need their roofs replaced, the perimeter security fence is rusty and deteriorating in some locations, and many windows in the inmate housing units are drafty because they do not properly open or close. In addition, the concrete and asphalt walkways and roads between institution buildings are cracked, uneven, and in such poor condition that they create a safety hazard for staff members and inmates. The deterioration, coupled with overcrowding, creates inhospitable living conditions for some inmates and jeopardizes the health and safety of staff and inmates. In many instances, CIW has received approval for special repair projects from the department’s headquarters, but the institution has only received limited funding to pay for the repairs because of department budget constraints. The institution submitted special repair project requests to headquarters, but years later, the projects have yet to be funded. Budget constraints have hindered CIW’s ability to address its many structural issues. For example, CIW submitted a capital outlay budget change proposal on December 19, 2000, to renovate and reroof the north and west wings of its support care unit. The department’s capital outlay unit approved this request, called a special repair project, on January 18, 2001, but seven years later, the department has still not funded the project. According to the associate warden for business services, CIW has received funding from the department for several projects, including replacing roofs on four inmate housing units and the medical clinic, and upgrading alarm and electrical equipment. However, the associate warden also noted that CIW has numerous approved but unfunded special repair projects that include: Renovating the support care unit. Repairing the inner perimeter fence. Repairing the roofs for the education buildings, administration building, and two of the six inmate housing units. Repairing asphalt roadways. The institution used its own funds to renovate the support care unit after it found lead-based paint on the walls. Although CIW requested funding nearly seven years ago to renovate its support care unit, the department approved the project but placed it on an “unfunded” list, where it still sits today. Bureau of Audits and Investigations Office of the Inspector General Page 15 Example of living unit cell prior to support care unit renovation. In early 2007, CIW discovered lead-based paint in the support care unit and subsequently moved the inmates from that unit, recognizing the critical need to address the problem due to the inmates’ poor living conditions. According to the associate warden, between May and June 2007, the institution abated the lead paint and received funding for the costs at year-end. In October 2007, CIW completed its renovation of the support care unit, using its own funding, and has submitted a request to headquarters for reimbursement. The two photographs illustrate the living conditions in the support care unit before and after the renovation. Overcrowded inmate living units cause 36 women to share one toilet and sink. Although the department does not have standards limiting the number of inmates who can share a toilet and sink, California does impose limitations on local jails. In dormitory settings, California regulations require local jails to provide one toilet and sink for every ten inmates. Living unit cell after renovation. To accommodate its increasing inmate population, CIW management converted the 700 square foot dayrooms and 500 square foot storage rooms in three of the six inmate housing units into dormitory housing. In each of these three housing units, up to 36 inmates occupy the converted spaces in double-bunk beds. Because these spaces were not designed to house inmates, there is only one toilet and sink for the inmates’ use. When possible, housing unit staff members make two additional toilets and sinks available by leaving two inmate cells unoccupied; however, both the inmates and officers told us that this is not a consistent practice among the three housing units. Institution management further told us that population pressures could partially Double bunks in storage area. explain why extra toilets and sinks are not always available. Nonetheless, because of the Bureau of Audits and Investigations Office of the Inspector General Page 16 lack of space and toilet facilities within these three housing units, tensions and frustration are increased among the inmates. Requiring 36 inmates to share one toilet and sink is unreasonable and should be unacceptable to the department. Several rooms in the education building lack adequate cooling. During summer Housing unit roof that needs repair. months, education classroom temperatures often exceed 89 degrees Fahrenheit. Once the temperatures exceed 89 degrees, potential health dangers for students taking certain medications cause the school administrators to dismiss all students in the affected education classrooms, resulting in lost education time. Most rooms in the education building have no air conditioning, or they have small portable air conditioning units that cannot provide sufficient cooling to keep the temperature below 90 degrees. In July 2007, the institution submitted an architectural and engineering request to the department for the installation of new air conditioning equipment in the education buildings. As discussed in detail in Example of cracked, rutted, and uneven roadway. Finding 2 of this report, students’ progress toward their education goals is delayed when classes are canceled because of heat. Other areas of the institution are also deteriorating. During visits to CIW, we noted numerous examples of deteriorating infrastructure at the institution. For example, many walkways and roadways between buildings are severely cracked or rutted, which can cause staff members or inmates to trip and fall and creates hazards as pedestrians and vehicles attempt to avoid ruts and potholes. In addition, the window opening and closing Water damage in education room caused by leaking roof. mechanisms are broken in many inmate living units, preventing windows from closing or opening properly and creating drafts or entry points for water. Similarly, many roofs have leaks that have caused water damage to the interior spaces of the buildings. Lastly, the perimeter fence has rusted in certain sections, posing a risk that an inmate could slip under the fence. Replacement of the fence was approved in December 2004, but similar to the institution’s request for funding to renovate Bureau of Audits and Investigations Office of the Inspector General Page 17 the support care unit, CIW is still waiting for department funding to replace the fence. During our interviews with staff members and inmates, we repeatedly heard complaints about the deteriorating condition of the buildings and surrounding grounds. The staff cited the lack of preventive maintenance, timely repairs, and sufficient maintenance staff necessary to maintain the aging structures as reasons for the continued deterioration. Rusted wire on perimeter fence. Recommendations To prevent further deterioration of the state’s prison facilities and to ensure that inmates are housed in decent living units, the Office of the Inspector General recommends that the California Department of Corrections and Rehabilitation take the following actions: Assemble an experienced team and conduct a thorough physical plant inspection of the California Institution for Women. Using the results of the inspection, identify all maintenance and safety problems and generate a corrective action plan. Using the corrective action plan, identify staffing requirements and resources necessary to complete repairs and maintain the institution’s infrastructure. Bureau of Audits and Investigations Office of the Inspector General Page 18 Finding 2 The attendance rate is poor in education classes because of frequent cancellations and other factors. Students in the CIW education department’s academic and vocational programs attended class for only 42 percent of the total available classroom hours. Although the education department emphasizes the many opportunities available to students, some factors, such as teacher absences and classrooms that are too hot, caused the school to cancel 28 percent of the available classroom time. Other contributing factors to low student attendance included class time lost because of custody-related matters and absences caused by the students themselves; these combined factors reduced attendance by another 30 percent. Consequently, students take longer to complete their remaining course objectives and may never complete their educational goals before they parole, thereby diminishing their chances for employment and increasing their chances for reoffending and returning to prison. Education programs reduce inmate recidivism rates. A January 2006 study by the Washington State Institute for Public Policy of ten basic adult and vocational education programs found that such programs reduce inmate recidivism. The study found that basic adult education programs reduced recidivism by an average of 5.1 percent and that vocational education programs reduced recidivism by an average of 12.6 percent.2 Students miss class more often than they attend class. CIW’s education department (known as the El Prado Adult School) operates a main education program that consists of academic and vocational programs, in addition to other educational programs, such as bridging, pre-forestry training, and an inmate library. According to the school’s Educational Staff Handbook, its mission “is to provide inmates with the educational, occupational, and social skills to help them better function in the institution; and upon their return, to society.” However, we found students were out of class more often than they attended. Based on our review of four months’ worth of academic and vocational attendance data for fiscal year 2006-07, students did not attend class 58 percent of the time, meaning they attended class only 42 percent of the time. The following chart summarizes our findings. As shown on the chart, we found that 24 percent of class time was lost because when teachers are absent, the school does not use other available teachers as substitutes. Another 4 percent of available class time was lost because classrooms lack adequate air conditioning. Custody-related reasons such as training, modified programming, and a lack of sufficient custody 2 Washington State Institute for Public Policy, “Evidence-Based Adult Corrections Programs: What Works and What Does Not,” January 2006. Bureau of Audits and Investigations Office of the Inspector General Page 19 officer coverage caused an additional 20 percent of lost classroom time. Finally, student absences for such reasons as illness, or voluntary unwillingness to attend class accounted for the remaining 10 percent of lost classroom time. Student Attendance and Class Closures for Sampled Months in Fiscal Year 2006-07 Custody-related Class Cancellations 20% Source: CIW’s student academic and vocational program attendance reports for August 2006, December 2006, January 2007, and April 2007. Attendance 42% Student Absences 10% Excessive Heat Class Cancellations 4% Teacher Absences Class Cancellations 24% Although the education department employs qualified teachers in its bridging program, it does not redirect any of them to the main education program when teachers there take time off. CIW’s main education program had an average of 15 academic and vocational teachers in fiscal year 2006-07 (through April 30, 2007); however, the program had no teachers assigned to act as substitutes. As a result, the school canceled classes when teachers became sick, took vacation, attended training, or participated in teacher work days. During the four months we reviewed, teacher absences forced class cancellations for 24 percent of the available class time and totaled over 41,000 student hours of lost classroom time out of a possible 173,000 student hours available. These closures equate to over 6,300 days of lost student time. We identified a potential source of substitute teachers within the school’s bridging program, which provides educational programming for inmates who cannot participate in regular academic and vocational programming—typically because the inmates reside in the prison’s reception center and are awaiting transfer to a permanent prison location. According to the acting vice principal, most of these teachers have the required credentials to act as substitute teachers for the main education program, and we found that the teachers are currently underutilized by the bridging program. Between July 2006 and April 2007, the school had seven bridging classes taught primarily by teachers holding teaching credentials similar to those of the teachers in the main academic education program. During that same period, the average student enrollment in the bridging program fell from 45 students to 26 students per class, indicating that bridging program teachers are Bureau of Audits and Investigations Office of the Inspector General Page 20 being increasingly underutilized. We estimated that from July 2006 through April 2007, approximately $163,400 in teacher salaries and benefits could have been more effectively used if the bridging teachers had been redirected as substitutes to avoid canceling academic and vocational classes. The department’s Office of Correctional Education told us that redirecting underutilized teachers to act as relief staff was well within the school management’s authority. We met with the institution’s warden, associate warden, labor relations officer, and acting vice principal to discuss consolidating the school’s half-filled bridging classes and redirecting teachers to substitute for the regular academic and vocational program classes when those teachers are absent. The prison’s officials could not think of any significant reasons why this solution could not be feasible. In fact, after bringing the issue to management’s attention, the acting principal told us that in August 2007 the education department began reassigning some of the bridging teachers to act as substitute teachers in the academic program. However, because these initial actions took place near the end of our field work, we did not verify the extent of their effectiveness. The school cancels many of its classes because some classrooms lack adequate air conditioning. The main education programming takes place primarily in two older buildings that have inadequate air conditioning. As a result, the school’s management releases all students in a class any time the inside temperature exceeds 89 degrees. We reviewed attendance records from August 2006 and found that excessive heat caused the institution to cancel class for 17 percent (over 7,700 hours) of the total available class time during that month. In addition, the school provided us documentation that identified 3,100 and 13,100 additional classroom hours lost because of excessive heat for the months of June and July 2006, respectively. Students’ absences also play a part in causing low attendance and lost classroom time. Our review found that students also contribute to lost classroom time. Ten percent of all available academic and vocational classroom time lost is attributable to students who do not attend class for either approved or unapproved reasons. Specifically, 7 percent of all classroom time is lost because students have approved absences for such reasons as illness or attorney visits. For the remaining 3 percent of the time, students are absent from class without proper authorization, and sometimes teachers do not initiate disciplinary action when students are habitually late or absent. For example, we selected six students whose unexcused absences generated high amounts of lost classroom hours, and we found that teachers had initiated discipline for only about 20 percent of the lost hours. It appears that the school’s management does not enforce the procedures contained in the Education Staff Handbook regarding situations in which a teacher must issue a minor rules violation or even a more serious rules violation disciplinary report when circumstances warrant. Although 3 percent is a small portion of the Bureau of Audits and Investigations Office of the Inspector General Page 21 overall classroom time, inconsistent student discipline sends a mixed message to students about the importance of their attendance and can interrupt their learning process. The institution cancels some of the classroom time because of custody-related matters. During the four months sampled from fiscal year 2006-07, we found that 20 percent of all available academic and vocational classroom time lost was directly attributable to custody-related reasons. The custody-related reasons are beyond the education program’s or the students’ control and can include custody staff training, modified programming, and custody staff shortages. In summary, when students miss classes for any of the reasons cited above, they take longer to complete their remaining course objectives. In some instances, they may never complete their educational goals before they parole. When this happens, students diminish their chances for employment and increase the likelihood they will reoffend and return to prison. Recommendations To minimize the number of lost classroom hours and increase student attendance, the Office of the Inspector General recommends that the California Institution for Women and the school’s management: Ensure that they effectively utilize all available teaching staff and redirect teachers as necessary. Ensure that the classrooms have adequate air conditioning by obtaining sufficient capital outlay funding to purchase and install appropriate air conditioning units. As part of the performance appraisal process, periodically review teacher files to ensure that teachers initiate disciplinary actions in accordance with the policies established in the Education Staff Handbook. Bureau of Audits and Investigations Office of the Inspector General Page 22 Finding 3 The California Institution for Women does not always assign inmates with low reading abilities to adult basic education classes. State law requires institutions to have literacy programs designed to ensure inmates read at the ninth grade level. However, we found that CIW did not always identify and assign inmates who read below the ninth grade level to an academic literacy program or, at the least, place them on a waiting list. Instead, the institution assigned many inmates with low reading abilities to other institutional jobs or its firefighting programs. The lack of policy adherence occurred, in part, because the institution’s inmate assignment practices conflicted with policies published by the department and with state law designed to ensure that inmates read at a ninth grade level upon parole. As a result of CIW placing inmates with low reading scores in programs other than education, the inmates miss an opportunity to increase their reading skills and their overall educational proficiency, thus diminishing their potential for success on the outside. The Legislature and the department consider education to be an important part of successful reentry into society. According to California Penal Code section 2053, the Legislature has found and declared “that there is a correlation between prisoners who are functionally literate and those who successfully reintegrate into society upon release.” Penal Code section 2053.1 requires that every state prison have a literacy program to ensure that, upon parole, inmates have a ninth grade reading ability. The department’s Operations Manual section 101010.1 similarly states that the goal of offering programs such as academic and vocational classes “is to provide inmates with educational, occupational and social skills to help them function better in the facility and upon return to society.” Contrary to its requirements, the July 12, 2007 - Job Assignments for institution assigned many inmates Students with Reading Scores Lower Than the Ninth Grade Level with low reading abilities to Number of programs other than its adult basic Job Assignment Inmates education program. Cooks, porters, other 74 We found that inmates with reading Fire camp or training 137 scores below ninth grade level were Total 211 assigned as cooks, porters, utility workers, sewing machine operators, firefighters, and fire camp trainees, rather than assigned to adult basic education literacy classes or placed on a waiting list. Specifically, based on information provided by CIW, we reviewed the reading scores for inmates assigned to various non-literacy programs as of July 12, 2007, and found 211 inmates with reading scores below the ninth grade level. These inmates included 74 inmates assigned to other institution jobs and 137 inmates Bureau of Audits and Investigations Office of the Inspector General Page 23 assigned to the firefighting program, which includes the fire camp or its prerequisite training programs. The institution’s assignment lieutenant could not give a reason why inmates with low reading abilities would have been assigned to non-firefighting program jobs such as cooks and porters instead of assigned to the education program or placed on a waiting list. But the assignment lieutenant speculated that because the inmate assignment process is sometimes chaotic, the education requirement was overlooked in these instances. With respect to firefighting, the assignment lieutenant and the chairman of the Unit Classification Committee stated that low reading levels do not disqualify inmates from being endorsed to firefighting programs. When the assignment lieutenant assigns firefighting-endorsed inmates to their initial firefighting training jobs, reading levels are not evaluated first to determine if the inmates should be recommended for reendorsement to CIW’s general population so that the inmates can be assigned to literacy classes. Both the Unit Classification Committee’s chairman and the Inmate Assignment Office’s lieutenant told us that they allowed the practice of assigning inmates with low reading skills to firefighting programs because they thought firefighting program endorsements had priority over education literacy requirements. However, we could find no approved policies and procedures to support this practice. When we interviewed CIW’s warden, the associate warden of custody operations, and the department’s classification services representative assigned to CIW, they all acknowledged that an inmate’s need to meet literacy reading requirements should have priority over firefighting program assignments. The OIG acknowledges that inmate firefighters provide valuable services to protect California’s citizens during wildfires and other state emergencies. Striking a proper balance between providing these important services and also providing literacy programs for inmates creates a potential conflict for the department. In resolving this conflict, the department should work with the Legislature so that the need to fulfill both important objectives does not conflict with state law. The institution excludes some inmates from educational literacy requirements if the inmate has a high school diploma or equivalent. Not only does the institution fail to assign inmates with low reading scores to literacy programs, but it also excludes from consideration inmates with low reading scores who have prior academic certifications, such as a high school diploma or a pass on the test of general education development (GED). According to the inmate assignment lieutenant, if an inmate possesses a high school diploma or a GED certificate, the inmate assignment office assumes the inmate reads at or above the ninth grade level, and as a result, the inmate is not assigned to academic education classes. Bureau of Audits and Investigations Office of the Inspector General Page 24 Our review of assignment office and education department records identified more than 100 inmates, in addition to the 74 discussed earlier, who were assigned to non-literacy programs yet still had reading scores below the ninth grade level even though the inmates reportedly had GED certificates or high school diplomas. This practice is inconsistent with California Penal Code section 2053.1, which requires that the institution have a program that ensures all inmates read at a ninth grade level. The Penal Code has no provisions to exclude inmates who have a high school diploma or its equivalent. Further, as illustrated during our review, having a high school diploma or equivalent does not assure that an inmate can read at the ninth grade level. The Penal Code and the department Operations Manual set different minimum standards. According to California Penal Code section 2053.1, every state prison must have a literacy program to ensure that, upon parole, inmates have at least a ninth grade reading ability. In contrast, the department’s Operations Manual section 101010.1 establishes a lower reading level standard than the Penal Code, requiring that inmates below a sixth grade reading level be assigned to adult basic education or English as a second language programs. Although both requirements are designed to improve the literacy of inmates, the department’s policy does not fully comply with the Penal Code. Until the department aligns its standard with the Penal Code, the institutions cannot develop their own inmate education procedures that are consistent with both the Penal Code and the department’s Operations Manual. Recommendations To ensure that the department’s policies to improve inmate literacy are consistent with the requirements in the California Penal Code, the Office of the Inspector General recommends that the department: Compare the inmate literacy requirements contained in its Operations Manual section 101010.1 with those of Penal Code section 2053.1 and change the department Operations Manual as necessary. For the inmate firefighting program, assess whether legislative exemptions are needed from current state laws related to inmate literacy, especially during dry years. To ensure that the prison assigns inmates with low reading abilities to appropriate education programming, the Office of the Inspector General recommends that the California Institution for Women: Bureau of Audits and Investigations Office of the Inspector General Page 25 Assign all inmates with reading scores below the ninth grade level to formal education programs regardless of their educational attainment. Develop written procedures that align with the department’s current education policies. Provide training to members of the Unit Classification Committee and the Inmate Assignment Office staff on the proper way to assess test scores before assigning inmates to education, forestry, and other programs at the institution. If exceptions to the written policies and procedures are necessary, written approval from an associate warden or higher should be placed in the inmate’s case file. Monitor the work of the Unit Classification Committee and the Inmate Assignment Office until the staff demonstrate that they consistently comply with the written policies and procedures. Bureau of Audits and Investigations Office of the Inspector General Page 26 Finding 4 Inmates sent to off-site medical specialists do not always receive prompt follow-up medical care. The Division of Health Care Services requires that an inmate receiving a routine specialty service (typically an off-site appointment) must receive follow-up medical care from her primary care physician within 14 days. However, we found that CIW medical staff members missed the 14-day standard in nearly half the files reviewed and that the delay averaged 12 days beyond the 14-day standard. Excessive delays in follow-up care by the primary care physician can endanger inmates’ health and jeopardize compliance with the court-ordered quality-of-care standard. Prison medical care is overseen by a federal court-appointed receiver and has been the subject of lawsuits. In 2001, the Prison Law Office, on behalf of various inmates, brought a class action lawsuit, Plata v. Schwarzenegger, against the State of California over the quality of medical care in the state’s prison system. In June 2005, the United States District Court appointed a receiver to oversee medical care in the prison system. Although inmates eventually received follow-up care, the care was delayed in nearly half the cases the OIG reviewed. According to the policies of the department’s Division of Correctional Health Care Services, the division is required to provide medically necessary specialty services to inmates. In order to do so, the division is to establish a diagnosis, make recommendations for a diagnostic work-up, provide therapy, and establish a treatment plan that includes follow-up visits with the specialist or the primary care physician. The division’s procedures require the patient to be seen by the primary care physician within 14 calendar days of a routine specialty service. Of the 20 inmate files we sampled, the follow-up care was delayed beyond the required 14 days for nine inmates. The average delay in providing follow-up visits for these nine inmates was 12 days beyond the 14-day requirement, and in one instance, the delay was 22 days. We selected seven of the nine instances in which follow-up care was delayed and reviewed the inmate medical files to identify the reason for the delay. No explanation for the delay was evident in five of the seven files, and the two remaining files were unavailable during our review. We asked the medical appeals coordinator at the institution if there were any reasons for these delays. She told us that she was unable to identify reasons for these specific cases, but that scheduling difficulties caused by too many inmates and too few doctors are a typical reason. During our exit interview at CIW, the health care manager stated that part of the problem was the failure by the health care administrative staff to schedule the appointments timely. Bureau of Audits and Investigations Office of the Inspector General Page 27 The requirement for a prompt follow-up visit ensures that the primary care physician or the specialist develop a treatment plan for each inmate without unreasonable delay. Delays in follow-up care can potentially have a negative effect on inmates’ health. Further, failure to follow the prescribed timeline for follow-up visits jeopardizes compliance with the federal court-ordered quality-ofcare standard. Recommendation The Office of the Inspector General recommends that the department’s Division of Health Care Services and the California Health Care Receivership assess the possible causes for the delays in providing inmates with prompt follow-up care, including the timely scheduling of appointments and whether there are too few doctors available to meet the 14-day requirement, and take appropriate corrective action. Bureau of Audits and Investigations Office of the Inspector General Page 28 Finding 5 The California Institution for Women does not complete its use-of-force incident packages within the required timelines. Over half the use-of-force incident packages prepared by CIW staff members are not submitted to headquarters within the 30-day time requirement. For 21 percent of those late packages, the use-of-force committee recommended further on-thejob training to address staff deficiencies. When use-of-force packages are not submitted on time, delays occur in corrective training, thereby increasing the possibility that the staff’s deficiencies in following use-of-force rules could reoccur. A use-of-force incident package consists of the incident report and other supplemental documents, such as the manager’s review, the incident commander’s review, the staff’s synopsis of the incident, and any reports of injury to staff members and inmates. Over half the use-of-force incident packages are submitted late. The California Institution for Women Department Operations Manual Supplement section 51030.1 states that packages on “all incidents involving UOF [use of force] need to be in the Associate Director Reception Centers Section3, Division of Adult Institutions office within 30 days.” To meet this requirement, the supplement sets the following time schedule: Week One Week Two Week Three Week Four Sergeant and Lieutenant review, 72 hours; Facility Captain review, three business days Associate Warden review, two business days; Use-of-Force Coordinator, four business days Use-of-Force Committee review, third Monday Associate Director Reception Centers Section, fourth Monday Of the 33 incidents at CIW that resulted in use of force from January 1, 2007, through May 13, 2007, the use-of-force coordinator did not receive 19 packages (58 percent) within 30 days of the occurrence date—a delay that rendered the packages overdue for submittal to headquarters even before CIW’s use-of-force committee review. The use-of-force coordinator received seven of the packages more than two months after the occurrence date, two of which were forwarded 3½ months after the incident date. Of the 19 late packages, the use-of-force committee concluded that four incidents required on-the-job staff training to address deficiencies in staff actions. The specific training areas included searching administrative segregation inmates before moving them, responding to alarms and emergencies, ensuring staff safety, and properly assessing threats. 3 Since the establishment of the CIW supplement, the responsibility has transitioned to the Associate Director, Female Offender Programs and Services. Bureau of Audits and Investigations Office of the Inspector General Page 29 Facility staff told our inspectors that the use-of-force packages are late mainly because the use-of-force coordinator is not tracking the packages, following up with report preparers to ensure on-time submittals, or alerting her supervisor of overdue reports. In addition, her supervisor, who works in the investigative services unit, does not have access to the automated use-of-force log, hindering his ability to obtain updated information when the use-of-force coordinator is not in the office. The use-of-force coordinator already keeps and updates a log via electronic spreadsheet that identifies the dates of incidents and other relevant information. The use-of-force coordinator could use the information contained in the log to provide staff reminders of due dates as deadlines approach and also quickly identify and follow up on late packages. The effects of late submissions are significant. When use-of-force incident packages are submitted late to the use-of-force committee, there are two potential effects. First, if the use-of-force committee recommends job training to prevent reoccurrence of a staff member’s improper use of force, then any delay increases the possibility of that staff member’s repeated improper use of force, which could lead to safety concerns as well as potential litigation. Second, unduly delayed packages erode the one-year time limit the department has to review the use-offorce committee findings, investigate possible excessive use of force, and initiate adverse action against sworn staff. Any delay in the investigation of an incident can lead to the degradation of evidence and the inability of staff members to recall the details of the incident. Recommendations The Office of the Inspector General recommends that the California Institution for Women: Use the current electronic use-of-force log as a tracking system to ensure the prompt follow-up on use-of-force incident packages submitted late. Immediately enforce its policy that all staff members are to forward their use-of-force incident packages to the use-of-force coordinator within stated timeframes. The institution should use performance appraisals and progressive discipline to hold staff members and the use-of-force coordinator accountable for their adherence to the policy. Bureau of Audits and Investigations Office of the Inspector General Page 30 Finding 6 The visiting center staff does not consistently adhere to visiting policies and regulations, increasing the risk of visitors bringing banned materials into the institution. The custody officers who staff the visiting center were unfamiliar with visiting procedures because they lacked training, and the staff was not properly screening visitors to prevent them from bringing weapons or unapproved materials into the visiting center. Also, none of the visiting center staff members monitored the visitors and inmates during their visits by actively roaming the visiting area to ensure they were adhering to the visiting rules and regulations. When staff members fail to properly screen or monitor inmates and their visitors, there is increased risk that banned substances, dangerous weapons, or prohibited clothing are allowed into the visiting center, potentially jeopardizing the safety and security of the visitors, inmates, and staff. Although the department considers inmate visits crucial for improving inmate morale and maintaining inmate and family connections, the visiting center is also a vulnerable entry point for contraband items, such as drugs and weapons. As such, existing visiting policies and regulations protect the safety of inmates, visitors, staff members, and the public. Not enforcing or adhering to the regulations places everyone at risk and diminishes the overall security of the institution. California Institution for Women Procedure #307 – Inmate Visiting (June 2006) requires that each visitor pass a metal detector test. Visitors who cannot clear the metal detector are subject to additional searches before they enter the visitor waiting room. Moreover, the California Visiting Rules and Regulations (May 2006), California Institution for Women Procedure #307 – Inmate Visiting (June 2006), and the California Code of Regulations, Title 15, section 3174, describe the rules and regulations visitors and inmates are to adhere to during visiting, including the clothing that visitors are prohibited from wearing. Some of the disallowed items are underwire bras, form-fitting clothing, and green or blue clothing. The staff does not consistently screen visitors for weapons, other contraband, or unapproved clothing. During our unannounced site visit in June 2007, we observed the visiting center staff allowing visitors to enter the facility who had not cleared the metal detector and who were wearing prohibited clothing. Rather than strictly enforcing existing policy, the visiting center staff relied on the visitors’ explanations of why they did not clear the metal detector. For example, one woman said it was probably her underwire bra that was setting off the metal detector, and another mentioned it was probably the tassels on her shorts. Despite Bureau of Audits and Investigations Office of the Inspector General Page 31 not clearing the metal detector, visiting center staff still allowed the visitors to enter the facility without using a handheld metal detector or performing other additional searches. Also, the metal detector’s sound option was turned off because the detector’s sensitivity causes it to sound off on every visitor. An indicator light on top of the detector also showed whether a visitor has cleared the metal detector, but only the tallest officer was able to see the light. In addition to not properly using the metal detector to screen visitors, some staff members allowed visitors into the visiting center with banned clothing. One visitor was told he could not visit wearing blue jeans, but when he returned, he was allowed to enter the visiting center wearing olive-green corduroy pants—a disallowed color and a shade of green that is similar to that used by the uniformed custody staff. The intent of specifying disallowed clothing is to ensure that visitors do not resemble inmates or custody staff. Poor screening of visitors increases the risk that weapons, drugs, or other contraband may be introduced into the institution. Even though staff members perform unclothed searches of the inmates before returning them to their housing units, contraband brought into the visiting area is still a threat to other visitors, inmates, and staff. This is because inmates and visitors can hide the contraband in the visiting area and arrange for the item to be retrieved by other inmates, or they can throw or place items over the fence for later retrieval. The staff does not monitor the inmates and visitors during their visits. During the four hours we observed the visiting area, none of the visiting center staff roamed the visiting area to monitor visitor and inmate activities to mitigate the exchange of contraband and to ensure that inmates and visitors adhered to the visiting rules and regulations. Instead, the visiting center staff stayed at the front counter. During standing count when all visitors are required to stay in the inside visiting room, staff members did not walk among the visitors, thereby increasing the potential for visitors to hide contraband for later retrieval by inmates. Because there are no video cameras installed in the visiting rooms, the staff’s ability to identify contraband exchanges is even further limited. Many visitors and inmates mentioned that the visiting center staff was not monitoring visits closely enough and that contraband can easily be brought into the institution. Having visitors notice and comment on the lack of monitoring is yet another sign of the institution’s vulnerability. We also observed that one inmate with a male visitor had moved two chairs to the perimeter fence, the furthest point from the visiting room and a violation of security procedures that state that visitors and inmates are to stay away from the fence. Allowing inmates and visitors to move furniture near the perimeter fence could enable inmates to climb the fence and escape. Bureau of Audits and Investigations Office of the Inspector General Page 32 Little or no training and high turnover contribute to lax enforcement of visiting policies and procedures. The visiting center staff members mentioned to us that they had not received any training related to inmate visiting, and only two of the six correctional officers knew how to operate the terminals used to verify visitor approval. The most senior staff member had only four months experience in visiting, and three others had four or fewer days experience. For one officer, the day of our visit was her first day as part of the visiting center staff, and she was reading the CIW visiting rules and regulations to familiarize herself with the visiting policy because no one provided her with any guidance on her responsibilities. In addition, the visiting center sergeant had been assigned to visiting for only three months. He acknowledged he had not provided any training to his staff, noting he also had not received any training on his duties and responsibilities. Not only had none of the visiting center staff members received formal or on-the-job training, but also none of the officers had signed the post orders.4 The Visiting Sergeant Post Orders, signed by the visiting center sergeant on April 7, 2007, require that the sergeant ensure he complies with all the visiting room procedures and regulations and that he provide his subordinates with the necessary on-the-job training. Improperly trained staff members jeopardize the safety and security of the facility by potentially endangering themselves, as well as other staff members, visitors, and inmates. Another factor contributing to the lax enforcement of visiting rules is the high turnover of visiting center staff. When we discussed our concerns with the visiting center sergeant, he noted that the different visiting hours on Saturday (8:30 a.m. to 3:00 p.m.) and Sunday (1:30 p.m. to 8:00 p.m.) do not appeal to officers when they select posts. This lack of appeal contributes to a high turnover rate for the visiting center officers. One more factor contributing to the lax enforcement of visiting rules may be an inadequate staffing level for CIW’s visiting center. Of the three adult female correctional institutions, CIW processes the most visitors yet has the fewest visiting center staff members. CIW’s visiting center staff consists of one correctional sergeant and six correctional officers, while the visiting center staff at the Central California Women’s Facility and the Valley State Prison for Women each consists of one correctional lieutenant, one correctional sergeant, and 12 correctional officers. The Central California Women’s Facility and the Valley 4 The department’s Operations Manual, sections 51040.1 to 51040.6.1, requires that each posted position in an institution have a post order that details the general functions and specific duty directives for that post. Employees under post orders are required to sign and date the post order, signifying they understand the duties and responsibilities of the post “when the employee is assigned to the post, when the post order has been revised, or upon returning from an extended absence.” Bureau of Audits and Investigations Office of the Inspector General Page 33 State Prison for Women have twice the number of visiting center staff members yet typically process fewer visitors per day than CIW. In addition to its comparatively low staffing levels, CIW’s visitor processing structure is located outdoors and is small—factors which may cause officers to rush security procedures during inclement weather and restrict officers’ ability to conduct private searches. According to the warden, CIW received $500,000 for a new modular building to replace the prison’s current outdoor visitor processing structure. Recommendations The Office of the Inspector General recommends that the California Institution for Women: Immediately provide training to all visiting center staff members regarding their responsibilities for enforcing the visiting rules and regulations. Provide adequate oversight of the visiting function to ensure the visiting center staff is enforcing all inmate visiting policies and regulations, terminating visiting for non-compliance with visiting regulations, and roaming the visiting areas. Use the sound option on the metal detector to prevent misinterpretation of the metal detector’s readings. Consider installing security cameras to provide an additional deterrent to the introduction of contraband. Implement measures to address the high turnover of custody staff assigned to the visiting area. The Office of the Inspector General also recommends that the California Department of Corrections and Rehabilitation perform an analysis of the visiting center staffing levels at the three adult women’s correctional facilities to determine whether appropriate staffing exists at each facility based on the average number of visitors each institution processes daily and the physical layout of each visiting facility. Bureau of Audits and Investigations Office of the Inspector General Page 34 Finding 7 The California Institution for Women fails to ensure that staff members assigned to armed posts always meet their quarterly weapons qualifications requirements. Despite a department requirement that only peace officers who have completed firearms training and are currently qualified be assigned to armed posts, we found seven peace officers assigned to armed posts who did not participate in the last quarterly range qualification session in April 2007. Therefore, more than three months elapsed between each of their qualifications. As a result, seven of the 58 employees tested who required quarterly weapons qualifications were not current with their quarterly requirements. A contributing factor is that training staff was not tracking compliance with the quarterly requirement. The department Operations Manual section 32010.19.7 requires that all department peace officers issued a department weapon as part of their regular or special assignment, such as armed posts, must complete a proficiency course on a quarterly basis before assuming the post. Title 15 of the California Code of Regulations section 3276(a), further stipulates that only peace officers who have satisfactorily completed firearms training and who are currently qualified to fire department firearms will be assigned to armed posts. Some staff members are not meeting quarterly weapons qualification requirements. Of the 58 employees tested who required quarterly weapons qualifications, seven peace officers (12 percent) were not current with their quarterly requirements. Two peace officers had actually qualified before they assumed their posts; however, because they did not qualify during the April 2007 range sessions, they allowed between four and six months to elapse between their qualifications. The remaining five peace officers did not qualify before they assumed their posts, and because they did not qualify in April 2007, they continued to be out of compliance. Although four of these five staff members qualified within the next quarter, the length of time between their qualifications ranged between seven and nine months. One of the five peace officers had not requalified as of June 30, 2007, and went on extended medical leave beginning July 1, 2007. As a result, the peace officer did not requalify during the July 2007 range sessions. An ineffective process is in place to track the quarterly requirement. The institution’s in-service training staff was not aware of the seven peace officers who had not qualified, but they agreed that the staff had not met the quarterly qualification requirements. The training staff incorrectly believed that a peace officer’s last annual qualification would be sufficient for the post assignment until the next quarterly qualification, even if that qualification occurred more than a Bureau of Audits and Investigations Office of the Inspector General Page 35 quarter ago. In such cases, the peace officers would simply attend the next quarter’s range qualification session to stay on track with the quarterly requirements instead of having them immediately attend a special session. On June 11, 2007, we identified the exceptions by comparing the peace officers’ names from two different lists: one that included the post assignments for all staff members and another that indicated who had successfully completed the range sessions held in April 2007. The training manager agreed that comparing the two lists periodically would help identify staff members who have yet to qualify during a particular period, including those staff members who did not qualify before assuming their posts. Furthermore, shortly after we discussed these exceptions with the training staff, the acting in-service training manager issued a memorandum on June 19, 2007, to all custody staff members emphasizing which posts required quarterly qualifications and reminding the custody staff that they needed to meet the quarterly requirements before assuming their posts. Danger exists when staff members are not adequately qualified. Regularly qualifying with a firearm helps to keep the staff’s weapons skills fresh in case they are ever needed. The importance of adequate weapons training is evidenced in the OIG’s Special Review into the Shooting of Inmate Daniel Provencio on January 16, 2005 at Wasco State Prison issued in June 2005. Inmate Provencio died after being struck in the head by a 40 mm launcher fired by an officer attempting to quell a fight between inmates. We reported that one of the contributing factors for the control booth officer’s inaccurate placement of the 40 mm projectile may have been inadequate training on the weapon with live rounds. Although the control booth officer participated in weapons training one month before the incident, we could not determine from the records whether the officer had actually fired a 40 mm round during this training or had simply handled the weapon. Without having demonstrated recent proficiency, staff members potentially place themselves and others at risk of injury and expose the state to litigation if they make a mistake with their firearms, such as shooting an unintended target. Thus, it is imperative that staff members demonstrate their proficiency at the required intervals. Recommendations The Office of the Inspector General recommends that the California Institution for Women: Ensure all staff members who are issued a department firearm as part of their regular or special assignment, such as armed posts, complete Bureau of Audits and Investigations Office of the Inspector General Page 36 a quarterly proficiency course before and after assuming the assignment. Set up a process to track adherence to the quarterly weapons requirement for peace officers who are issued a department firearm as part of their regular or special assignment. Bureau of Audits and Investigations Office of the Inspector General Page 37 California Department of Corrections and Rehabilitation’s Response Bureau of Audits and Investigations Office of the Inspector General Page 38