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Cripa Los Angeles County Ca Probation Camps Investigation Findings 10-31-08

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U.S. Department of Justice
Civil Rights Division

Assistant Attorney General
950 Pennsylvania Avenue, NW - RFK
Washington, DC 20530

October 31, 2008


Yvonne B. Burke, Chairperson
Angeles County Board of Supervisors
West Temple Street, Suite 856
Angeles, CA 90012

Investigation of the Los Angeles County Probation Camps

Dear Ms. Burke:
I write to report the findings of the Civil Rights
Division’s investigation of conditions at the Los Angeles County
Probation Camps (“the Camps”). On November 9, 2006, we notified
you of our intent to conduct an investigation of the Camps
pursuant to the Civil Rights of Institutionalized Persons Act,
42 U.S.C. § 1997 (“CRIPA”), and the Violent Crime Control and Law
Enforcement Act of 1994, 42 U.S.C. § 14141 (“Section 14141"). We
informed you that our investigation of the Camps would focus on
whether youth were adequately protected from harm. As we noted,
both CRIPA and Section 14141 give the Department of Justice
(“the Department”) authority to seek a remedy for a pattern or
practice of conduct that violates the constitutional or federal
statutory rights of youth in juvenile justice institutions.
Prior to the investigatory tours, the Department and Los
Angeles County (“the County”) agreed that the Department would
tour a sample of the Camps, and that the Department’s inspection
of the sample would stand as representative of all of the Camps.1
On January 22-26, February 5-8, and March 5-8, 2007, we conducted
on-site inspections of Camp Vernon Kilpatrick (“Camp
Kilpatrick”), Camp Joseph Scott (“Camp Scott”), and Camp Karl
Holton (“Camp Holton”), as well as five of the camps at the
Challenger Memorial Youth Center (“Challenger” or “the Challenger
Camps”). We toured with expert consultants in juvenile justice


The Los Angeles County Probation Camps include 19
juvenile justice facilities. The Department toured eight of

-2administration and, at the Challenger Camps, an expert consultant
in mental health. Before, during, and after our visit, we
reviewed an extensive number of documents including, but not
limited to, policies and procedures, incident reports, housing
logs, and orientation materials. However, the County refused to
provide us access to all child abuse investigations and to some
medical records and logs.2 Additionally, in conducting our onsite investigations, we interviewed administrators,
professionals, staff, and youth. We observed the youth in a
variety of settings, including on their living units, while
dining, in classrooms, and during recreation.
Consistent with our commitment to provide technical
assistance and conduct a transparent investigation, we conducted
exit conferences at each facility we visited upon the conclusion
of the tour, during which our expert consultants conveyed their
initial impressions and concerns.
Under the leadership of Robert Taylor, Chief Probation
Officer of the Los Angeles County Probation Department
(“Probation Department”), the County has unequivocally indicated
its clear desire to improve the facilities. We commend the
Probation Department staff for their helpful, courteous, and
professional conduct throughout the course of this investigation.
We hope to continue to work with the County and facility staff in
the same cooperative manner going forward.
Consistent with our statutory obligation under CRIPA, we set
forth below the findings of our investigation, the facts
supporting them, and the minimum remedial steps that are
necessary to address the deficiencies we have identified. As
described below, we conclude that youth confined at the Los
Angeles Juvenile Camps suffer harm or the risk of harm from
constitutional deficiencies, specifically in the areas of
protection from harm and mental health care. Notwithstanding the


By law, our investigation must proceed regardless of
whether County officials choose to cooperate fully. Indeed, when
CRIPA was enacted, lawmakers considered the possibility that
State and local officials might not cooperate in our federal
investigations. See H.R. Conf. Rep. 96-897, at 12 (1980),
reprinted in 1980 U.S.S.C.A.N. 832, 836. As we informed the
County’s attorney, the County’s decision to deny us access to
these records permits us to draw negative inferences about their
contents. We have drawn negative inferences with respect to the
adequacy of abuse investigations and the adequacy of the
discipline for staff who violate the rights of youth.

-3foregoing, we are pleased that the County informed us of some
preliminary steps it intends to take to remedy deficiencies we
reported during our exit conferences.


Description of the Facilities

The Los Angeles County Probation Department operates 19
detention camps. Approximately 2,200 post-adjudicated youth are
housed in the Camps, which provide an intermediate sanction
between community supervision and detention in the secure
facilities operated by the California Department of Corrections
and Rehabilitation, Division of Juvenile Justice. The Probation
Department also operates the Los Angeles County Juvenile Halls
(“Juvenile Halls”), which house approximately 1,500 to 1,800
youth who generally range in age from 11 to 19 and are awaiting
adjudication.3 Many youth from the Halls are transferred to the
Camps following adjudication.


The Challenger Camps are six separate camps located on 44
acres in the town of Lancaster in Los Angeles County’s Antelope
Valley. In January 2007, one of the six camps, Camp Onizuka,
which housed girls, was closed. The remaining five camps Jarvis, McNair, Resnick, Scobee and Smith - have the capacity to
house 110 youth each.
Each camp is a large, concrete, single-story facility,
configured in a semi-circle, divided in half by a continuous line
of classrooms. The classrooms divide the facility into two
identical halves, each with a large grass field area in its
center. There are three camps on each side of the facility’s
divide. Although all youth in each camp move to school and to
outdoor recreation together, programming and meals are conducted
separately in the dayrooms of each side of each camp.
Youth housed at the Challenger Camps tend to include those
with histories of violence and/or escape. All youth with medical
and mental health needs are housed in the Challenger Camps. A
significant percentage of the population is prescribed

On August 26, 2004, the Department, Los Angeles County,
and the Los Angeles County Office of Education entered into an
agreement to resolve the Department’s investigation regarding
conditions of confinement at the Juvenile Halls.

-4psychotropic medication. Youth housed at the Challenger Camps
range in age from 14 to 18 and most are fulfilling commitments of
three, six, or nine months.
There is also a 60-bed disciplinary unit called a Special
Housing Unit (“SHU”) that operates as a separate program at the
Challenger Camps. The SHU also serves as a local detention
facility for up to 10 youth arrested by police in the community
immediately surrounding the Challenger Camps.


Camp Scott is a secure facility for girls located in the
rural Santa Clarita community of Los Angeles County. Camp Scott
is configured as a semi-circle of single story buildings. Camp
Scott has a rated capacity of 125 youth, although the population
on the first day of our visit was 79 youth. The girls, who range
in age from 12 to 18, sleep in a single dorm designed to house up
to 113 youth. Girls are generally committed to Camp Scott for
periods of three, six, or nine months. The newest building on
the campus is an Assessment Center (which also functions as a
disciplinary housing unit), with a capacity of 12 youth housed in
single cells. All of the camp’s buildings open onto the main
grass field and recreation area. Girls are able to walk the
short distances from their dorm to the school, culinary unit,
administration building, assessment center, and other buildings
on the campus.


Camp Holton is located in the rural Sylmar community of Los
Angeles County. This secure, all male facility is constructed
largely of cinderblock with a single dorm used as living quarters
for all youth. Although the facility can house up to 119 youth,
77 were assigned to the facility on the first day of our tour.
Youth are typically committed to the camp for three, six, or nine
months, with an average length of stay reported to be
approximately 90 days. The single dorm is divided into four
sections, each with approximately 25 bunks. The sections are
separated by a low, cinderblock wall running down the center of
the dorm with a control center located in the middle of the dorm.
Youth ages 13 and under tend to be housed in one quadrant of the
dorm while honors youth occupy another and general population
youth occupy the remaining two quadrants.4 The various buildings

At the time of our visit, it appears that the youngest
youth housed in the camps we toured was 12 years old.

-5that make up the facility - - the school, administrative area,
culinary unit, Special Housing Unit and a gym - - are arranged in
a fully enclosed, semi-circle around a large, open area with
basketball courts, a track, and a grass field for recreation.
Youth walk the relatively short distances from building to


Camp Kilpatrick is a secure facility for boys built in 1964
in the hills of Los Angeles County’s Malibu community. The
facility is unique among the Camps because of its focus on
sports; Kilpatrick is a certified high school and its sports
teams compete with area high schools in football, basketball,
baseball, and soccer, at both the junior varsity and varsity
levels. Built mostly of cinderblock, the facility is in a
general state of physical and cosmetic disrepair. For example,
the gymnasium was rendered structurally unsound after an
earthquake in 1994 and has not been usable since.
Kilpatrick is configured in a fully enclosed, semi-circular
fashion around a large dirt field and basketball courts. The
facility’s rated capacity is 112 youth, although only 91 were
assigned on the first day of our tour. The youth ranged in age
from 13 to 18 years old. Youth are assigned to one of two
identical dorms, based largely on programming preferences. Each
dorm houses approximately 45 youth in single bunks arranged in
four rows with a control center in the middle of each dorm. The
various buildings that make up the facility - - the school,
culinary unit, administration building, and Special Housing Unit
- - open on to the field and recreational space and each is
within easy walking distance to the dorms. Youth at Kilpatrick
are typically committed for periods of three, six, or nine
months, with three-month commitments being the most common. Camp
Kilpatrick is next to Camp Miller, with which it shares kitchen
facilities and its Special Housing Unit, although the camps
operate as two separate and distinct camp programs.

Legal Background

CRIPA gives the Department of Justice authority to
investigate and take appropriate action to enforce the
constitutional rights and the federal statutory rights of
juveniles in juvenile justice facilities. 42 U.S.C. § 1997.
Section 14141 of the Violent Crime Control and Law Enforcement
Act of 1994, 42 U.S.C. § 14141, makes it unlawful for any
governmental authority with responsibility for the incarceration
of juveniles to engage in a pattern or practice of conduct that

-6deprives incarcerated juveniles of constitutional or federal
statutory rights. Section 14141 grants the Attorney General
authority to file a civil action to eliminate the pattern or
The Due Process clause of the Fourteenth Amendment to the
U.S. Constitution governs the standards for conditions of
confinement of juvenile offenders who have not been convicted of
a crime. Gary H. v. Hegstrom, 831 F.2d 1430, 1432 (9th Cir.
1987); Jones v. Blanas, 393 F.3d 918, 931 (9th Cir. 2004).
Confinement of youth in conditions that amount to punishment, or
in conditions that represent a substantial departure from
generally accepted professional standards, violates the Due
Process clause. Youngberg v. Romeo, 457 U.S. 307 (1982); Bell v.
Wolfish, 441 U.S. 520 (1979); Alexander S. v. Boyd, 876 F. Supp.
773, 796-799 (D.S.C. 1995), aff’d in part and rev’d in part on
other grounds, 113 F.3d 1373 (4th Cir. 1997). The Fourteenth
Amendment prohibits imposing on incarcerated persons who have not
been convicted of crimes conditions or practices not reasonably
related to the legitimate governmental objectives of safety,
order, and security. Bell v. Wolfish, 441 U.S. at 539-540.
The County has an obligation to assure the reasonable
health, safety, and freedom from undue restraint of the youth in
its custody. See Youngberg v. Romeo, 457 U.S. 307 (1982); Gary
H. v. Hegstrom, 831 F.2d 1430 (9th Cir. 1987); Alexander S. v.
Boyd, 876 F. Supp. at 786-7; Santana v. Collazo, 793 F.2d 41
(1st Cir. 1984); D.B. v. Tewksbury, 545 F. Supp. 896 (D. Or.
1982). Confined juveniles must receive adequate medical
treatment, including adequate mental health treatment and suicide
prevention measures. See Youngberg, 457 U.S. at 323-24 & n.30;
Oregon Advocacy Ctr. v. Mink, 322 F.3d 1101, 1120 (9th Cir.
2003); Gibson v. County of Washoe, 290 F.3d 1175, 1187 (9th Cir.
2002); Carnell v. Grimm, 74 F.3d 977, 978-79 (9th Cir. 1996);
Cabrales v. County of Los Angeles, 864 F.2d 1454 (9th Cir. 1988),
vacated and remanded, 490 U.S. 1087 (1989), reinstated, 886 F.2d
235 (9th Cir. 1989); Horn v. Madison County Fiscal Court, 22 F.3d
653, 660 (6th Cir. 1994); Gordon v. Kidd, 971 F.2d 1087, 1094
(4th Cir. 1992).


Youth residing in Los Angeles County’s Camps are not
adequately protected from harm. Further, the County fails to
provide adequate suicide prevention and mental health care to


Failure to Protect Youth From Harm

Youth housed at the Camps are subjected to harm and risk of
harm as a result of the following failures by the County:
(1) failure to protect youth from harm by staff, including
failure to protect youth from use of excessive force by staff,
excessive and inappropriate use of Oleoresin Capsicum (“OC”)
spray, and staff misconduct at Camp Holton; (2) failure to
protect youth from harm by other youth; (3) failure to provide
adequate staffing; (4) failure to provide adequate staff
training; (5) failure to adequately investigate allegations of
abuse; (6) failure to provide an adequate classification system;
and (7) failure to provide an adequate grievance process.

Failure to Protect Youth From Harm by Staff

Use of Excessive Force by Staff

Youth at the Camps have a right to be free from unnecessary
restraint and the use of excessive force. Youngberg, 457 U.S. at
315-16. With the noteworthy exception of Camp Kilpatrick, our
investigation uncovered systemic physical abuse of youth by
staff. We found a disturbing consistency in the youth’s accounts
of the use of unnecessary physical restraint and excessive force
by staff at the Camps. Most of the youth we interviewed reported
staff abuse they had received themselves or had witnessed. Youth
repeatedly corroborated each other’s allegations in separate
interviews, with no opportunity to discuss the allegations
between interviews. In each instance, we attempted to track down
whether the abuse had been reported (by reviewing the Suspected
Child Abuse Report (“SCAR”) forms we received from the County),
or a grievance had been filed. Some allegations had been
reported to or discovered by the County. Others, for various
reasons, were reported to us in the first instance, suggesting
both that youth lack trust in the County to report abuse and that
the County systemically fails to detect abuse occurring at the

The Five Challenger Camps

At the Challenger Camps, many of the youth we interviewed
reported several allegations of mistreatment at the hands of
staff. Other youth witnesses corroborated the original youth’s
accounts of these events. In two instances that we describe
below, staff knew about the incidents, yet did not take the
required steps to report them to the Los Angeles Department of
Children and Family Services (“DCFS”) or initiate an

-8investigation. Generally, we found that staff did not understand
their responsibilities as mandatory child abuse reporters or know
what procedures to follow when receiving an allegation of abuse.
As a result, the protections that would have been afforded by
DCFS involvement were never accessed, and youth reported that
they did not feel safe enough to voice their concerns about
mistreatment directly to staff. Consider the following
illustrative examples:

B.P.5 reported that a Camp McNair probation officer,
while attempting to restrain L.N., slammed L.N. to the
ground and dislocated the youth’s shoulder. L.N.
reported that the incident occurred in December 2006 in
the dining hall after another youth threatened to spit
in his food. He stated that he got mad and started
fighting the youth. L.N. reported that staff ordered
the youth to stop fighting and that L.N. complied by
backing away from the other youth. Nevertheless, the
officer grabbed him and slammed him to the floor on his
shoulder.6 (We observed a bone sticking out of L.N.’s
shoulder. He told us that he was seen by camp medical
staff and told that he would have to see a bone


One youth described being given what he believed was a
new jacket by a member of the staff, but learned later
that the jacket actually belonged to another youth in
the camp. The other youth demanded that his jacket be
returned. The reporting youth refused. The two youth
fought soon thereafter. The staff member who had given


The initials used to refer to youth are pseudonyms to
protect their privacy. We will provide a key to the youth’s real
names to the County under separate cover.

Youth reported that staff “slam” youth in the following
manner: Youth are either slammed against the wall, or staff grab
youth, lift them in the air, and forcibly take them to the
ground. In some cases, officers land on top of youth, injuring
both the youth and the officers involved in the process. As
discussed below, staff at all of the Camps consistently reported
to us that the Probation Department did not have a use of force
continuum and that staff had received no additional training on
use of force techniques after their initial new hire training.
Abusive practices such as “slamming” are the predictable
consequences of a systemic lack of adequate training on the use
of force.

-9the jacket to the first youth intervened by physically
taking one youth to the ground. The youth reported
that, during this contact, he suffered a broken jaw.
Facility administrators reported that although staff
knew about this incident, they had not investigated the
veracity of any complaints of excessive force or that
the staff had purposefully instigated the incident.
With our urging, the Probation Department’s Special
Investigations Unit (“SIU”) was notified of this

V.T. reportedly observed staff physically restrain a
youth in the dining hall because the youth continued to
talk after being instructed to be quiet. After the
restraint, V.T. reported that he observed the youth
with a bloody mouth and a “knot” on his forehead.


A.K. reported that two Camp Resnick probation officers
allegedly punched, kicked, and sprayed a youth with OC
while he was handcuffed.

Youth reported the following incidents at Camp Smith:

L.O. alleged that he was grabbed, slammed, and dragged
across the control center steps in Camp Smith because
he refused to exercise with the dorm.


Youth reported observing staff break a youth’s jaw and
beat him while restraining him (the youth purportedly
suffered a broken jaw after staff allegedly “slammed”
the youth to the ground).


C.R. reported that he observed staff beat a youth who
had assumed the “OC [Oleoresin Capsicum spray]
position”7 on the ground.

We received additional noteworthy reports of staff-on-youth
assaults at Camp McNair, such as the following:


Staff order youth to assume the “OC position” as a
means of gaining control of the youth, meaning that the youth
must immediately lie down on the floor in the prone position with
his eyes shut.


N.T. alleged that in December 2006, a Camp McNair
probation officer caught two youth “locking legs.”8
officer “slammed them,” sprayed them with OC, and
kicked them.



J.I. allegedly witnessed staff members using excessive
force on V.T. J.I. observed that, following the use of
force, V.T. had a bloody mouth and a big knot on his


F.D. alleged that he was physically assaulted by staff
for no reason. The youth is visibly physically
disabled, and of short stature. He reported suffering
from a bone weakening disease that causes his bones to
be fragile and undeveloped. Staff allegedly dragged
F.D. across the recreation field, causing severe injury
to his knee. The County began an investigation of this
incident after we brought it to the County’s attention.
The County preliminarily reported after our exit
conference that F.D. was suspected of drug possession.
The County agreed, however, that regardless of the
youth’s offense, the staff should have handled the
incident differently.

The allegations described above had indicia of credibility
and we did not receive any documents refuting these accounts.
More generally, allegations like these, both founded and
unfounded, are not uncommon in secure facilities such as the
Camps. It is therefore essential, for the protection of the
youth and the staff, that such allegations be promptly and
properly reported, and thoroughly investigated. For this to
occur, staff must understand their legal obligations in this
regard and must know the formal steps required to properly report
incidents of alleged child abuse.
ii.	 Camp Holton
We also uncovered abusive practices at Camp Holton. Youth
reported that some staff verbally and physically mistreated youth
when their drill performance fell below expectations. Youth

“Locking legs” is a discreet method of fighting where
youth sit on the ground or on a bunk facing each other and
interlock their legs at the knee so only a few inches separate
them. They then begin to hit each other. The loser is
determined, in part, by which youth first “unlocks” his or her
legs and moves away.

-11revealed that some staff become agitated and impatient with youth
when “facing movements” (a method of lining up youth in formation
and moving them safely and efficiently from building to building)
and when other required regimens are not carried out in a swift
and organized manner.
Additionally, we uncovered a number of disturbing
allegations of staff assault. These allegations include:

One 15-year-old youth stated that staff kicked him
twice in the ribs during his first week at Camp Holton.
He explained that while he was in the dorm during
shower time, staff allegedly directed him and others to
line up. Because he did not line up quickly enough,
staff allegedly directed him to come to the control
center area. Upon arriving at the control area, which
is a slightly elevated staff observation area
surrounded by a wall standing approximately four feet
in height, staff directed the youth to sit in a chair
against the wall. This positioning made it difficult
for other youth in the dorm or the video surveillance
system to observe the youth. While seated, the youth
reported that a staff member kicked him twice in the
ribs and slapped him once on the back of his head with
an open hand.


Another youth reported that in February 2007, a staff
member reportedly told him, “I can do whatever I want,”
and pushed him with both hands on the youth’s chest,
tackled him to the concrete floor, and twisted his arm
and leg behind his back.


K.Z. reported that in January 2007, after an argument
with staff, staff bumped into the youth but claimed
that the youth hit the staff. Using this as cause to
restrain the youth, staff reportedly grabbed the
youth’s arm and foot, causing the youth to fall
forward. Once on the ground, staff pushed the youth’s
head to the floor. Another youth corroborated this
incident and stated that he heard the youth scream.
The following day, the Director reported this incident
to law enforcement; two days later, a deputy responded
to the facility to interview the youth involved. We do
not know the results of the investigation.


D.B. reported that staff pushed him against a wall and
put his arm behind his back in a painful hammer lock
allegedly because he was moving too slowly. He

-12reported that staff then placed him on the floor and
put their knees to his head and against his ribs. He
suffered scratches on his leg and neck and swelling
around his eye as a result of this incident. Another
youth corroborated this story, stating that the alleged
victim told him he had been beaten up by staff.
Although a mental health professional completed a
Suspected Child Abuse Report (“SCAR”) about the alleged
incident, the incident was not reported to DCFS or law
enforcement at that time. The Camp Director filed a
report with law enforcement four days later, on January
21, 2007, but law enforcement had yet to respond at the
time of our initial tour.

Another youth, whose arm was in a sling as a result of
a fractured clavicle, reported that, in December 2006,
two staff who had been escorting him had taken him
forcefully to the ground.9 He further reported that one
of the officers drove his knee into the youth’s
shoulder and pulled the youth’s arm up behind his back,
causing considerable pain and aggravating the fracture.
The youth reported that the officers then lifted him to
his feet and slammed him into the wall twice. He
complained about excessive pain to his injured arm but
reported that medical staff did not see him until the
following day. He reported the incident
to his case manager, who had him complete an affidavit.
A police report was filed, but staff from the SIU
interviewed the youth. We do not know the results of
the SIU’s investigation.10

Additionally, youth reported that Holton staff order youth
to go to the Command Center (“CC”) and assume the “bob sled
position” (meaning that youth are made to sit on the ground with
their knees close to their chests and their arms interlocked
around their knees). Youth reported that by “assuming the bob
sled position” in the CC, “no one can see what is happening to
you.” One youth reported that staff also turn the lights off and
kick the youth when they are forced to assume the bob sled
position. The youth reported that this practice occurs as often


We believe that the youth’s clavicle was broken prior
to the incident, but we cannot confirm or deny this belief
because we were denied access to the youth’s medical files.

As discussed later in the report, the County refused to
provide us with any of their child abuse investigations.

-13as two to three times per week. S.C. reported that he had been
forced to assume the bob sled position twice. P.S. reported that
youth sit in the bob sled position out of camera range where
“staff can slap and yell at you.”
iii. Camp Scott
Youth at Camp Scott repeatedly reported that staff twist
youth’s arms behind their backs to control their behavior, and
one staff person in particular was mentioned repeatedly as using
inappropriate force by tackling youth, twisting their arms behind
their backs, and slamming them to the ground.
Staff at Camp Scott also lack of knowledge of both the
proper thresholds for reporting allegations of abuse and the
authorities to whom to report such allegations. These
inadequacies are clearly evident in the way in which recent
allegations of staff abuse have been handled. Although
supervisors and administrators took some action in most of the
situations described later in this letter, their actions stopped
far short of a formal report to the proper authority, and fell
substantially below generally accepted professional standards.
iv.	 Camp Kilpatrick
We are very pleased to report that we did not uncover any
reports of staff abuse at Camp Kilpatrick. Although staff
training on the use of force is inadequate at all of the Camps,
including Kilpatrick (as discussed below), youth interviews and
documents consistently indicated that staff at Camp Kilpatrick
exercise a continuum of non-physical interventions prior to using
physical force. Moreover, although proper medical documentation
was not available for review, the documents we did review
indicated that staff intervention in altercations did not cause
or exacerbate injuries to youth. Youth at Camp Kilpatrick also
consistently reported that they could talk to staff about their
problems or concerns without fear of retaliation.

Excessive and Inappropriate Use of OC Spray
at Challenger

Probation officers throughout the Challenger Camps are using
OC spray excessively. See Alexander S. v. Boyd, 876 F. Supp. at
786 (finding that the use of CS gas (a form of tear gas) in a
juvenile justice facility for purposes other than the protection
of staff or other juveniles, or where there is a threat of
serious bodily harm, is unconstitutional). Probation Department
policy on the use of chemical agents in the Camps appropriately

-14requires that such agents be used only as a last resort. The
policy requires that staff follow a use of force continuum and
attempt to de-escalate a situation before deploying OC spray.
The Probation Department fails to comply with this policy.
For example, N.T. reported that a probation officer at Camp
McNair (one of the Challenger Camps) slams youth into a prone
position on the ground, sprays them with OC spray, and then kicks
them. A number of youth similarly reported excessive uses of OC
spray at Camp Smith. L.O. allegedly observed a youth sprayed
with OC while the youth was restrained on the ground. C.R.
reportedly observed a youth sprayed in the face for no apparent
reason as he entered the dorm. At Camp Resnick, J.I. alleged
that he observed a probation officer empty a can of OC spray on
two youth who had been fighting but had complied with his order
to get on the ground. As previously mentioned, A.K. alleged that
probation officers punched, kicked, and sprayed a handcuffed
juvenile at Camp Resnick.
Further, a probation officer told us about an incident in
which OC spray was used in the SHU in April 2006. Allegedly,
several Camp McNair youth were sent to the SHU after a
disturbance. Many of the youth were yelling and banging on their
cell doors for hours. Another supervisor identified a couple of
youth who were banging especially hard. That supervisor and an
officer moved to one of the cells and opened the door. They gave
a verbal OC warning. The youth jumped back in what the officers
perceived to be a threatening manner. A probation officer then
sprayed the youth and quickly closed and locked the door to the
youth’s cell. The probation officer and the supervisor then
moved to two other cells, where they sprayed one of the two youth
Probation Department policy also appropriately prohibits the
use of OC spray on youth who suffer from medical or respiratory
conditions such as asthma, youth who are on psychotropic
medication, obese youth, and youth with mental health disorders.
As a mental health director reported, nearly half the youth
at the Challenger Camps are being actively seen by mental health
staff, and roughly one-third are on at least one psychotropic
medication. We were repeatedly told during our tours that youth
with mental health needs, and particularly troubled youth, are
sent to one of the Challenger Camps. Yet, we were told that the
Challenger Camps are, paradoxically, the only camps at which
staff are authorized to carry OC spray. One supervisor told us
that he believed that allowing staff to carry and use OC spray
made sense given the “mental health population” at the Challenger

-15Camps. This rationale not only contradicts policy, but also
generally accepted professional standards.
In addition to adequate policies, the County must also have
clear procedures guiding the use of OC spray to ensure that youth
who have the disqualifying conditions listed above are not
sprayed. The probation officers with whom we spoke alleged that
they were not provided with this information. Indeed, we
received varying answers from staff regarding the types of youth
on whom it is impermissible to use OC spray. When asked,
probation officers were unable to identify the conditions that
should prevent the use of OC spray, except for asthma or some
other respiratory disorder. Some staff could list a few youth
who had asthma, but most answered our inquiries about who could
be sprayed by saying, “I assume that all of them can.” Further,
officers offered a variety of explanations as to precisely how
they would identify a youth as having one or more of the
disqualifying conditions. Some officers stated that they simply
have no way of knowing whether a youth should not be sprayed,
others reported that youth with excluded conditions wear green
t-shirts bearing the letters “MED,” while others told us that
different colored wrist bands were used to indicate the
prohibited condition status of a youth.
We interviewed several youth who had been sprayed with OC in
the three months prior to our tour; several of them reportedly
had one of the disqualifying conditions listed above. For

W.G. reported having asthma. Although he reported to
us that he was not on any psychotropic medications, he
reported earlier spending two months at the Dorothy
Kirby Center (the County’s psychiatric residential
treatment center), suggesting that he has a mental
health diagnosis that would prohibit him from being


G.R. was sprayed in mid-January 2007 and reported
having been sprayed on at least one other occasion.
reported taking psychotropic medications.



E.V. was sprayed in January 2007 after he and two other
youth were involved in a fight over a chair in the
dorm. He reported taking psychotropic medication.

Failing to inform staff about which youth have disqualifying
conditions for the use of OC spray is not only negligent, but

-16also amounts to a gross deviation from generally accepted
professional standards.
Further, no one at the Challenger Camps or in the leadership
ranks of the Probation Department has recognized that the use of
OC spray at the Challenger Camps is a problem. The
Superintendent at the Challenger Camps reported that she had
heard of improper uses of OC spray in the past, but believed that
these had occurred “a long time ago.”
Finally, the facilities do not have adequate procedures and
documentation governing the issuance of OC spray canisters to
officers, nor do they have any procedures to weigh OC canisters
on a regular basis to detect the unauthorized discharge of spray.
After our tour, the Probation Department started to establish a
“Use of Force Review” to assess the extent to which policies
surrounding the use of OC spray have been followed. Although we
have not had an opportunity to assess the implementation and
adequacy of this reform, it is evident that the use of force
review will not be meaningful until these policies are clearly
articulated and staff have been adequately trained on them.

Inappropriate Staff Conduct at Camp Holton

We found the treatment of youth at Camp Holton by some of
the staff who work there particularly troubling. We conducted a
second, follow-up tour on March 7 and 8, 2007, to investigate
newly arising allegations of mistreatment and intimidation of
youth by Camp Holton staff, as well as reports that some staff
maintained and consumed alcohol on the facility premises during
the course of their 56-hour shifts. The implications of these
allegations were so troubling that we modified our previously
established plans and revisited Camp Holton to interview youth,
staff, and Camp administrators, and to re-tour portions of the
Youth reported on our follow-up tour that during our initial
visit in January 2007, staff allegedly warned them not to
“embarrass” staff by reporting mistreatment. We also learned of
alleged remarks by staff during our second tour that were clearly
intended to intimidate youth and prevent them from reporting
staff misbehavior to us. A number of youth reported that one
evening after we conducted interviews, staff purportedly made
comments like, “We’re going to have cheese sent up from the
kitchen for the rats.” Or, “C Dorm is still waiting for cheese
from the kitchen.” We heard numerous and serious allegations of
staff physically mistreating youth and intimidating them by
threatening physical harm or administrative sanctions if youth

-17cooperated with our investigation. Youth repeatedly named three
staff and one former staff member as staff who threatened,
intimidated, and put their hands on youth in a violent manner.
Additionally, on our second visit to Camp Holton, we
discovered two bottles of alcoholic beverages in some of the
staff’s sleeping quarters.11 The use or possession of alcoholic
beverages by staff while on shift is expressly forbidden in
policy, and foments a serious and unnecessary risk of harm to
youth and staff in a secure institutionalized setting. It is
also our understanding that Camp Holton leadership may allegedly
have been aware of allegations of mistreatment and alcohol
consumption by some of these staff.
We commend the County for taking immediate steps to address
the serious concerns raised as a result of this tour by ensuring
that the youth and staff who spoke with us were protected, and
conducting an extensive follow up investigation. We understand
that the County is also discussing this matter with the Probation
Officers’ union. We do not know the current status of the
investigation or the discussions, but believe that appropriate
initial measures had been taken when we raised our concerns at
exit interviews.

Failure to Protect Youth from Harm by Other Youth

The high incidence of youth-on-youth assaults, particularly
at the Challenger Camps and at Camp Scott, evidences another
failure of the County to keep youth safe. At the Challenger
Camps, youth reported that fights occur daily in the dorms. A
review of the logbooks confirmed these reports. Youth reported
that movement from the five camps to school - where groups of 90
or more youth are escorted by approximately seven staff - was
perhaps the most likely time for a fight to break out. The
combination of large numbers of youth and relatively few staff
was cited by several youth as being a factor in fights occurring
during movement. We learned that fights occur not only within
the staff’s field of supervision, but many occur out of staff’s
line of sight, in places that could not be well supervised given
the small number of staff.
Youth are aware of the severe shortage of staff and describe
two primary “types” of fights - those that occur in the open and
are seen and responded to by staff, and those that are conducted



Staff who are in the sleeping quarters are still on

-18in a more discreet fashion without staff becoming aware. The
more discreet method of fighting is called “locking legs,” as
described above. This form of fighting generally occurs in the
back of the dorm room where large fans obscure the sound, and
other youth obscure the vision of officers. At Camp Scott, girls
reported “locking legs” in the back of the dorm area and stated
that such fights occur daily. Although youth reported that staff
seldom noticed these fights, some youth believed that staff were
aware of the fights and allowed them to take place.
At Camp Scott, fights also typically occur undetected in the
laundry room and shower area. For example, two youth fought
undetected in the laundry room of the dorm. Staff did not see
them until after the fight had ended, when a staff person noticed
that one of the girls appeared to be injured. The girl required
emergency medical treatment for a concussion sustained when the
other girl repeatedly shoved her head against the wall. Another
girl, H.N., alleged that she was repeatedly punched and stomped
in the face and head in the laundry room. A third girl had to
intervene to stop the fight because staff were not around. H.N.
alleged that she had to be taken to the hospital as a result of
her injuries and was purportedly told by a probation officer that
if the officer gets into trouble due to the incident, “I’m filing
a ‘triple-seven’12 on both of you.” In another incident of
youth-on-youth assault, two girls engaged in a premeditated fight
outdoors, out of the view of staff. Later, while the girls were
working on kitchen duty, kitchen staff noticed their injuries as
the girls washed their blood away in the sink.
Fights that occur in full view of staff are referred to as
“going live.”13 Youth know that when they “go live” they will
probably be caught and punished. Some youth alleged that staff
have encouraged youth occasionally to “go live.”
Fights are not the only evidence of the County’s failure to
adequately protect youth from harm. Many youth at the Challenger
Camps also reported being “stressed” about other youth tampering


A "777" refers to a formal probation violation filed
with the judge who retains jurisdiction in a youth’s case. Such
filings can and, according to both staff and youth, often do,
result in additional time in custody for the subject youth.

Many of the fights that occur at the Camps are
concealed, i.e., youth lock legs or fight in some other manner
that is undetected by staff. “Going live” means that caution is
abandoned and the fight occurs in plain view of staff and others.

-19with their food, stealing their personal property, spitting on
their beds, filling neoprene gloves with urine and throwing them,
filling soap cups in the shower with urine, as well as engaging
in gang-related conflicts. In several interviews, youth noted
that their stress levels interfered with their ability to sleep
and that they had sought and received medication to aid them in
this area. Several youth expressed fear that they would not be
able to “make it” at the Challenger Camps.
Each of these concerns from youth point, in part, to a need
for enhanced staff supervision. Youth described the common
practice of staff congregating for long periods in the command
center area of the dorms, rather than circulating through the
dorms as required. Some staff believed that other staff,
particularly new staff, were afraid of the youth. This fear of
the youth by some staff reportedly resulted in those staff either
turning a blind eye to inappropriate activities or in a tendency
to keep their distance from youth, typically remaining in the
units’ command center areas.
Increasing staff-to-youth ratios and ensuring that the youth
remain under supervision at all times would likely reduce youth’s
stress, decrease staff apprehension, and lessen youth-on-youth
violence at all of the Camps.
Additionally, the lack of an adequate behavior management
system at the Camps contributes to youth-on-youth violence and
the staff’s inability to keep youth safe. If staff had a range
of options with youth rather than either, generally, the threat
of a “triple-seven” or sending the youth to the SHU for an
infraction, and were provided with clear guidelines on the use of
positive as well as negative incentives, the level of safety in
the Camps would increase.

Inadequate Staffing

The biggest factor preventing the Camps from keeping youth
safe is the lack of sufficient staff to adequately supervise
youth. Without adequate numbers of trained staff, it is
impossible to respond in a safe and timely manner when violence
and other crises occur. Staff themselves discussed the stress
they experience when a violent altercation breaks out in their
dorm, and they must choose between intervening in a fight or
ensuring that other youth do not become involved in it.
Moreover, without adequate numbers of qualified staff, probation
officers do not have the time to build the relationships with

-20youth that are necessary to identify potential conflicts, prevent
incidents from occurring, and engage youth in meaningful
Adequate numbers of staff must be deployed to supervise
youth during waking and sleeping hours in order to protect youth
from harm. The number of staff available to supervise youth is
directly relevant to nearly all of the measures designed to
protect youth from harm. For example, each housing unit is
staffed with a combination of supervisory and line probation
officers. Although seven staff may be assigned to a dorm holding
100 youth, at any given time, only four of them are assigned
primary supervision duties, with two on one side of the dorm, and
two on the other side of the dorm. The requirement that they
attend to the needs of so many youth prevents staff from being
able to de-escalate tensions effectively. This has serious
repercussions as some staff purportedly may not intervene in
fights immediately, choosing instead to await the arrival of
backup staff, which creates the potential for youth to inflict
more serious injuries during physical altercations.
Because staff at the Camps work 56-hour shifts (16 hours on,
eight hours off, 16 hours on, eight hours off, and a final eight
hours on shift before departing for four days off), they are
given regular breaks throughout each of these stretches on duty.
We observed several meal periods during which only two staff were
present to supervise approximately 50 youth lining up, receiving
food, sitting down to eat, and cleaning up. The other staff were
either on break or doing casework (e.g., preparing court reports,
contacting the youth’s families, etc.). When the youth were on
the housing unit, only two line staff were assigned to each side,
resulting in a 1:27 ratio, at best. All staff assigned to the
unit are deployed to assist with movement to and from school,
which may bring the ratio down to 1:15 if seven staff are
assigned to the dorm. When interviewed, however, staff indicated
that they are frequently required to operate with fewer than
seven staff.14 In any event, a ratio of 1:15 during waking hours
substantially departs from the generally accepted professional
standard, which is 1:8/10 during the day.


The definition of “direct care staff” is inconsistent
across the Camps’ facility administrators and Probation
Department policy. The generally accepted practice is to count
only those staff whose primary duty is youth supervision, and to
exclude those who are assigned as administrative, supervisory,
and office staff.


Challenger Camps

Inadequate staffing during school hours at the Challenger
Camps is a major concern. The youth in each camp are distributed
across five classrooms allocated to that camp (youth from various
camps do not mix in the school setting, except in special
education classes). During school hours, only one staff from
each camp was assigned as the School Liaison, which translates to
a dangerous 1:110 ratio during the school day. The School
Liaison sits in “the bubble” (the equivalent of a control center
at the school) and watches a monitor which, when functioning,
provides a three-second glimpse of each classroom in rotation.
Each classroom has a telephone and a stationary panic button that
the teachers are to use when an incident begins. Over the six
months prior to our tour, the panic buttons were inoperable for
long stretches of time, resulting in one instance where a teacher
was unable to summon help when several students assaulted him in
his classroom. Although other staff assigned to the dorm
reportedly will respond when the School Liaison summons them on
the radio, those staff are often coming from far across campus
and therefore are not immediately available to assist. Teachers
also complained that the phone was often busy when they tried to
call the bubble to request assistance from the assigned officer.
The Superintendent at the Challenger Camps stated that the School
Liaison is required to patrol the corridor outside the classrooms
and to check in on each class periodically. Neither teachers nor
probation officers reported that this occurs with any regularity.
The Probation Department’s Regional Director indicated that
the Challenger Camps had recently received additional staffing,
sufficient to bring the waking hours ratio in all camps but
Jarvis up to generally accepted standards. Although 62 new
positions had been funded, 47 of these were vacant and the
remainder were in pre-service training. Thus, the enriched
staffing had yet to be put into place within the Camps during our
tour. In addition, the facility had 18 staff on worker’s
compensation leave, meaning that they were on leave after having
been injured on the job. Moreover, the filling of vacancies in
the recent past reportedly came, at least in part, at the expense
of filled case worker positions. According to the Regional
Director, 70% of case workers have returned to line staff
positions, leaving significant vacancies in the case worker
The failure to meet generally accepted staffing levels at
the Challenger Camps results in significant and tangible harm to
youth. As discussed earlier, physical altercations between youth
are very common. As detailed above, some of these fights

-22occurred within the staff’s field of supervision but many
occurred out of the line of sight, in places that could not be
well supervised given the small number of staff.
At the Challenger Camps, directors and the Superintendent
were seldom observed circulating in the dorms or other common
areas where youth could see them. Youth commonly said that they
did not know who the Camp Directors were. The lack of a
high-level staff presence at the Challenger Camps seems
particularly unwise given the camps’ large number of new staff
and generally challenging population.

Camp Holton

Camp Holton also lacks sufficient staff to adequately
protect youth housed there. Exacerbating the risk of harm
presented to youth by chronic understaffing at Camp Holton is an
apparent lack of oversight and supervision. As previously
mentioned, youth repeatedly identified a specific group of staff
as particularly abusive. Also as noted, the leadership at Camp
Holton allegedly was aware of some of the allegations concerning
abuse, threats, intimidation, and alcohol, and we could not find
evidence that adequate steps had been taken to address these
serious allegations. For example, during our January 2007 tour,
we expressed concern regarding the presence of alcohol at the
camp. In response to this concern, the Camp Director reportedly
issued a memorandum to all staff regarding the bringing of
contraband items into the camp. Nonetheless, when we returned to
Camp Holton in March 2007, we found alcohol on site.

Camp Scott

We also found inadequate staffing at Camp Scott. A review
of staff schedules revealed that overtime is used extensively,
but the lack of staff greatly affected facility operations. In
February 2007, for example, the facility could not find
additional overtime staff to cover several shifts. A review of
the supervisor’s log revealed that, on one night, staffing fell
dangerously low, to only two staff from 10pm to 6am for
populations of 76 and 106 youth, respectively.
Inadequate staffing has led to staff being pulled from the
orientation/isolation unit (the Assessment Unit (“AU”)) at Camp
Scott. A minimum of two staff is needed to keep this unit
operational. When the staffing complement is insufficient, the
unit is closed. A review of this unit’s Movement Log revealed
that the unit was closed on 10 of 63 days between January 1 and
March 4, 2007, because of staff shortages. Thus, the essential

-23functions of new resident orientation, small group counseling,
and disciplinary isolation were not available on those days.
Many youth corroborated that they either did not receive
orientation or were not sent to isolation as a result of the lack
of staff. In fact, during the several weeks prior to our visit,
new girls moved almost immediately into the dorms without
receiving the benefit of proper camp orientation. One girl we
interviewed had been at Camp Scott for one week without having
had orientation and without having been assigned to a caseworker.
As a result of not having been assigned a case worker, she was at
a loss for how to access mental health services, gain access to
personal items that family members brought to the facility for
her, file a grievance, access medical care, or become familiar
with the behavior management system. She reported feeling
depressed and wanting to speak to someone from mental health, but
she did not know how to access mental health services, believing
all girls were expected to make such requests through their
caseworker. Camp staff and administrators informed us that the
chronic staffing shortages have forced them to rely on youth who
fill “leadership” positions to perform orientation and other
duties more appropriately performed by staff.

Camp Kilpatrick

Camp Kilpatrick also suffers from the lack of adequate
staff. At the time of our visit, seven assigned staff were
unable to report to work because of worker’s compensation leave,
family leave, or sick leave. Two other staff positions were
vacant. These nine slots accounted for about one-quarter of the
facility’s 38 line staff positions. Although extra staff have
been budgeted to ease some of this difficulty (i.e., staffing
relief factor), the significant number of staff who are unable to
report to work presents a significant burden for remaining staff.
During our initial tour of Camp Kilpatrick, we entered a
housing unit at approximately 6:00 pm where only one staff person
was present, providing supervision from a position in the command
center. At the time, approximately 35 youth were involved in
varying activities the dorm. Camp Kilpatrick’s staff-to-youth
ratios often fell below generally accepted standards. The
disparity was particularly notable on the night shift, when a
single staff member was commonly assigned to dorms housing as
many as 56 youth. During our visit, the ratio was approximately
1:45. The generally accepted standard for staff-to-youth ratios
at night is 1:16/20.


Inadequate Staff Training

Not only must the facilities have an adequate number of
staff, but these staff must also be well trained to manage youth
behavior appropriately, to de-escalate tensions and intervene
effectively in crises, and to use force appropriately when less
restrictive means have failed. The gross lack of staff training
exacerbates all of the problems associated with the lack of
staffing at the Camps with respect to keeping youth safe. The
gross lack of training available to staff, coupled with the lack
of adequate staff, means that staff are ill-equipped to ensure
that fights between youth are stopped quickly, appropriately, and
The County has no policy regarding staff training, when it
is required, its content, or how staff skills and knowledge will
be assessed. Staff at the Camps do not receive adequate training
to perform critical job functions such as protecting youth from
harm. For example, staff at the Challenger Camps reported that
they do not receive sufficient guidance, either through formal
training or on-the-job mentoring and supervision, on how to
properly restrain youth.
The lack of staff training is particularly problematic at
the Challenger Camps. Given the characteristics of these camps’
population as described by the facility Superintendent -- that
is, youth who are on various forms of medication for mental
health reasons, who have violent offense histories, who have
medical concerns, and who are generally considered to be “high
risk” -- staff training is essential to the safe operation of
these facilities. This training is sorely lacking in all
critical areas, and was noted by many staff as being among the
greatest unmet needs at the Challenger Camps. One supervisor
noted that this is particularly important given the large number
of new staff at the facilities. This supervisor noted that some
staff lacked basic knowledge about how to perform their jobs and
conduct themselves in a safe and professional manner.
Specifically, the supervisor mentioned staff understanding of
proper use of force techniques, as well as a wide range of
unprofessional conduct, including staff use of foul language and
talking on cell phones while on duty, as priority training areas.
Training on the use of force should have, as its foundation,
a set of detailed policies governing the use of physical,
mechanical, and chemical restraints. The paucity of information
in formal policy relevant to the use of force and the lack of a
Probation Department-approved use of force curriculum illustrate
the lack of standardization and attention to this issue.

-25Training documentation revealed that only 14% of Challenger staff
had received formal training in the use of force since January
2006, while an additional 20% had received training at some point
earlier in their careers. At Holton, only 10% had received
training in the use of force since January 2006, and 24%, at some
point earlier in their careers. At Camp Kilpatrick, only 9%
percent of staff had received formal training in the use of force
since January 2006, and only an additional 9% had such training
at some point earlier in their careers. Two-thirds of staff at
both Challenger (66%) and Camp Holton (67%), had never received
formal training in the safe use of physical restraint measures;
more than three-quarters of Camp Kilpatrick staff (82%) had never
had formal training in such techniques. Undoubtedly related to
this gross lack of training, as detailed above, youth uniformly
reported the widespread use of slamming and other inappropriate
uses of force by staff at virtually all the Camps.
Staff interviews at all of the camps that we toured
confirmed that no Probation Department-approved use of force
continuum exists, nor could staff name or demonstrate any
specific physical restraint techniques that were approved for
use. Except for two individuals who were recently hired or
recently transferred to the Challenger Camps from one of the
County’s Juvenile Halls, none of the staff had received any
training in the use of force since their initial training after
being hired. For some staff, this meant that they had not
received any use of force training in more than 10 years.
Several staff indicated that they were not paid to attend
training that was scheduled outside of their normal shifts, and
they therefore refused to attend.
Staff’s lack of knowledge and the lack of a standardized
curriculum was highlighted in the incident reports we reviewed,
nearly all of which lacked details about the specific ways in
which staff intervened in fights between youth, what restraint
was used, and which staff participated in the restraint. Most
often, the incident report indicated that the youth was “assisted
to the ground” or “placed on the ground,” but no details were
given as to how this was accomplished. (Emphasis added).
It is critical that training in the proper use of physical
restraint to break up a fight between youth be given to Camp
staff. Youth and staff consistently reported a high number of
youth-on-youth assaults throughout the Camps. Many youth
reportedly sustained injuries during these fights (although the
rate of injury could not be determined because the County denied
us access to the youth’s medical charts despite our repeated
requests). Youth and staff also reported a high number of staff

-26injuries as a result of attempts to intervene in the fights. The
lack of training available to staff, coupled with the lack of
adequate numbers of staff discussed previously, mean that staff
are ill-equipped to ensure that fights between youth are stopped
quickly, appropriately, and safely. Of the 47 staff injured on
the job in 2006, nearly half (48%) were injured during the course
of a restraint.
Further, our observations and reports from youth demonstrate
that staff are not properly trained to de-escalate conflict
between youth. Rather than using the typical methods of
de-escalation (e.g., calm tone of voice, clear directions,
providing opportunities for youth to express themselves), some
staff reportedly instigate, antagonize, and otherwise encourage
youth to assault each other. For instance, one youth reported
that in response to a brewing altercation between him and another
youth, the staff allegedly said, “Come on, you motherfuckers, I
haven’t seen anyone ‘go live’ in months.” These, and other
statements like them reported by several youth, escalate, rather
than de-escalate, conflict. Many youth described unprofessional
behavior by staff and offered graphic examples of improper uses
of force. Youth described staff provoking youth, ridiculing
youth in front of their peers, swearing at youth, calling them
stupid, using sexual innuendos, fostering racial tension among
youth, punishing large numbers of youth for the behavior of one,
and using excessive force. Youth also stated that some staff
even engaged in “gang talk” with them. A youth from Camp Resnick
(a Challenger Camp) indicated that a staff refused to let another
youth use the restroom after the youth stated that he felt ill.
The youth, in fact, vomited and the staff antagonized the youth
by saying, “Stop acting like a bitch! Suck it up! Stop being a
pussy!” The reporting youth filed a grievance regarding this
incident and received a response two weeks later, stating that
the youth and staff had been “counseled.”
Staff also are inadequately trained on procedures and safe
practices regarding the use of OC spray. The County’s OC Spray
policy fails to include a use of force continuum that would serve
as a guide to its officers on when it is appropriate to use OC
spray. The policy also does not comment on the training and
certification requirements for staff. We were also told that the
training officers received upon hiring was inconsistent regarding
the proper use of OC spray, and that Challenger staff received a
separate training on the topic from a member of the Challenger
staff who also maintained all staff training records on this
topic. We were unable to verify this because, according to the
Superintendent, the training records were lost. Although we were
informed that efforts were underway to re-establish both OC spray

-27training and a record system to track the training, we were
provided with no documents reflecting the status of these

Inadequate Investigation of Abuse Allegations

Failure to Report Abuse

When an allegation of abuse is made, it must be reported to
the proper authorities to investigate the veracity of the
allegation. Generally accepted professional standards require
that all staff working at a juvenile justice facility be mandated
child abuse reporters. As such, they must report all instances
of alleged abuse, no matter how credible, to the state Child
Protective Services agency. The allegations or information must
be reported without filtering or making subjective decisions
about which are serious or credible enough to be reported.
Disturbingly, most of the staff we interviewed at the Camps were
unaware of their duties to report.
At all of the Camps, three separate agencies have been
designated to handle allegations of abuse - the Department of
Child and Family Services (“DCFS”), local law enforcement, and
the SIU. Staff uniformly reported that they were responsible for
reporting allegations they received to their supervisors, but had
no knowledge of their responsibility to make an independent
report to any agency. Indeed, none of the administrators or
Probation Department officials knew what the staff’s obligations
were in this regard.
At Camp Holton, two of four abuse allegations that were
reported to staff in the six months prior to our tour were not
passed on to DCFS in a timely manner. In November 2006, a youth
made an allegation of abuse to an officer and to a member of the
mental health staff. Neither of these individuals made a DCFS
Suspected Child Abuse Report (SCAR), choosing instead to wait for
the Camp Director to return from vacation two weeks later to find
out how to handle the allegation. In January 2007, another youth
reported an allegation to a member of the mental health staff,
yet that staff person also failed to make a SCAR report. The
Camp Director made the report four days later. The failure to
make a SCAR report is of great concern and severely threatens the
integrity of the process for protecting youth from harm by staff.
It does not appear that any of these staff were held accountable
for their failure to take required suspected child abuse
reporting actions.

-28Staff at the Camps reported that they had not received any
training on child abuse reporting in the previous year prior to
our tour. Training documentation revealed that only 16% of
Challenger staff had received formal training in child abuse
reporting since January 2006. An additional 38% had received
this training at some point earlier in their career. None of
Camp Holton’s staff had received formal training in child abuse
reporting since January 2006, but two-thirds (67%) had received
training at some point earlier in their careers. Only 4% of Camp
Scott staff had received formal training in child abuse
prevention and reporting since January 2006; 49% had received
such training at some point earlier in their careers.
Alarmingly, nearly half (46%) of Challenger staff had never
received formal training in child abuse reporting. One-third
(33%) of Camp Holton staff had never received formal training in
child abuse reporting, and nearly one-half of Camp Scott staff
(47%) have never received any kind of training in child abuse
At Camp Scott, the lack of knowledge surrounding the proper
thresholds and authorities for reporting allegations of abuse is
apparent in the way in which allegations of abuse have been
handled. Although supervisors and administrators took some
action in most situations, their actions stopped short of a
formal report to the proper authority. For example:

In November 2006, a youth provided a written statement
recounting an event that had allegedly occurred in
August 2006: “[staff] pushed me down on the control
center and literally put his knee on top of my chest,
holding my breath out/in, while his other hand was
around my neck choking me for at least 5-10 seconds. I
black [sic] out for about 2 seconds and woke up.” The
youth stated that she told the Administrator on Duty
who replied that the staff was doing his job and that
the youth needed to calm herself down. The Licensed
Clinical Social Worker (“LCSW”) receiving this
complaint, completed a written report, and gave it to
the Camp Director. The Camp Director, however, failed
to report the allegation to the appropriate


A youth alleged an inappropriate relationship between
another youth and a staff member at Camp Scott in
January 2006. Although the youth’s statement named the
staff member, the facility never reported the alleged
inappropriate relationship to DCFS. The facility

-29administrator reported to us that the SIU had
investigated this matter, but stated that she did not
have a copy of the resulting report. Of particular
concern, the same staff person involved in this
incident was implicated in two other allegations of
misconduct in August and December 2005. Even if the
staff member’s behavior had not amounted to “abuse,” it
certainly should have been evaluated for compliance
with the Probation Department’s policies surrounding
appropriate professional boundaries.

In November 2006, a youth’s written statement clearly
alleged excessive force and verbal abuse by a staff
person: “[staff] grabbed my thumb and bent it back”
and also called her a derogatory name. This youth’s
statement was never reported to or investigated by any
of the three agencies (DCFS, law enforcement, or SIU).

Camp Scott’s failure to promptly report allegations of abuse
to the proper authorities substantially departs from generally
accepted practice and the Probation Department’s own regulations.
At Camp Kilpatrick, although there have been complaints of
verbal abuse, there had been no allegations of physical abuse or
mistreatment in the six months prior to our visit. Nevertheless,
it is of concern that staff reported they had not received any
training in child abuse reporting, and some were not aware of
their duties in this regard. Training documentation revealed
that none of Camp Kilpatrick’s staff have received child abuse
training since January 2006. Approximately two-thirds (68%) had
received training at some point earlier in their careers. About
one-third (32%) had never received formal training in child abuse

Failure to Take Adequate Investigatory
Actions Once Abuse is Reported

Once an allegation of abuse has been made, proper
investigation is required to protect youth from staff abuse by
collecting evidence to verify or disprove the allegation. These
investigations are essential to identify staff in need of
training and/or termination, as well as to clear staff who have
been wrongfully accused. The investigation process must have
reasonable integrity, preserve all physical evidence (e.g.,
videotape footage, documentation and photographs of injuries,
clothing, etc.), obtain statements from all youth and staff
involved in the incident and those who witnessed the incident,
and utilize other sources of information to corroborate or refute

-30the allegation (e.g., logbooks, other sources of facility

Failure to document medical treatment
following a use of force

The integrity of the investigative process includes
documenting the youth’s injuries. Generally accepted
professional standards require that youth subject to a use of
force be seen and treated, if necessary, by a medical
professional. Medical staff can also be an avenue for youth to
report abuse or mistreatment. Further, even when youth do not
report abuse or mistreatment, under generally accepted
professional standards, medical staff are mandated reporters of
child abuse if abuse is suspected. Oftentimes, the nature of a
youth’s injury would lead a medical professional to suspect
Staff and County officials repeatedly claimed that if
medical attention was received, it would be documented on the
incident report. The documentation provided by the County did
not suggest that medical attention is automatically provided to
youth involved in uses of force. At Camp Holton, the medical
portion of the incident reports we reviewed was left blank in
nearly all instances; only two of the 30 incident reports
included any documentation by a medical professional. Thus, in
the event that the youth actually did receive treatment and the
error was one of documentation, we requested access to the
medical charts of the youth involved in the undocumented
incidents. This request was denied, and therefore no evidence
was provided that indicated youth receive medical treatment by
licensed medical staff following their involvement in a use of
At Camp Scott, the available documentation also did not
substantiate that medical attention was automatically given to
youth involved in uses of force. Of the 27 incident reports
reviewed, 18 recounted events that required some form of medical
attention (e.g., fights, uses of force, suicide gestures, etc.).
Of these 18, only five provided evidence to verify that the youth
involved received prompt medical attention. Several others
provided documentation for only one of the youth involved, and
several revealed long delays in obtaining medical attention, even
during times when the nurse was at the facility.15 Six incident


At some of the Camps, nurses are not on duty after
certain hours or on weekends.

-31reports did not include any documentation that the youth had been
seen by a nurse following his involvement in the incident. Once
again, we were unable to review the medical files to determine if
this was simply a failure of documentation or practice.
Efforts should also be made to increase the involvement of
medical staff as an avenue to uncover information about youth
mistreatment. The nurses can conduct confidential interviews
with the youth to gather information about the incidents.
ii. 	 Failure to take adequate action
following an allegation of staff abuse
Youth we interviewed reported several allegations of
mistreatment at the hands of staff. Pending the outcome of the
investigation of these allegations, generally accepted
professional standards require that these staff be placed in
non-contact positions. Most of the staff we interviewed reported
that accused staff are “usually” moved to security, where they
are deployed to the key room, office, or other positions where
they do not have contact with youth. However, staff were also
aware of other accused staff who continued to work directly with
youth. One staff reported that he, himself, had been accused of
mistreating a youth, but was simply transferred to another unit,
rather than to a non-contact position. By moving accused staff
to a position in which they do not have direct contact with
youth, the facility protects youth from the risk of harm and
protects itself from liability if the staff person were to commit
additional misconduct pending the outcome of the initial
Obviously, because some allegations are unfounded, it is
vital that child abuse investigations be completed in a timely
manner so that wrongly accused staff can be can return to their
normal post. All of the Challenger Camp staff with whom we spoke
voiced a concern regarding the length of time required for the
investigation process to clear staff, if the allegation was not
substantiated. Reports of investigations pending for over a year
were not uncommon. The length of time required for this process
contributes to the generally low morale reported by many staff,
who feel unsupported in doing their work.
At Camp Scott, the Director stated that accused staff are
assigned to non-contact positions at Camp Headquarters pending
the outcome of the investigation. However, as discussed above,
several of the allegations of abuse occurring over the past 12
months were administratively screened out and not reported to the
proper authorities. In one of the cases discussed above, the

-32same individual was implicated in three separate incidents (all
alleged misconduct). None of the accused staff were removed from
direct supervision. Failures to report allegations of abuse and
to move staff into non-contact positions place youth at Camp
Scott at significant risk of harm.
According to Camp Holton’s Director, staff at the camp are
not automatically placed in non-contact positions pending the
outcome of an abuse investigation. The reasons for this practice
are not clear, although it is likely influenced by the impact on
facility staffing levels. Indeed, a total of 11 staff were
involved in child abuse allegations from November 2006 to the
time of our tours, representing approximately one-quarter of the
facility’s staff. If all were to be placed on non-contact
status, the facility would have a very difficult time covering
each shift. Although difficult operationally, the responsibility
to protect youth from harm is paramount, and thus transfer to
non-contact status is essential. The SCARs discussed above,
along with several other youth and one staff, made repeated
references to a small core group of staff at Camp Holton who
allegedly abuse and terrorize youth. Indeed, these are the same
staff who the youth we spoke with described as being heavy-handed
during the course of restraint. Camp Holton’s failure to place
these staff on non-contact status at the first allegation of
abuse not only created an opportunity for additional allegations
of abuse to occur, but also led to the sentiment among both staff
and youth that staff are not held accountable for their behavior.
This lack of accountability leads directly to the culture of fear
and intimidation that pervades youth’s experiences at Camp
Normally, our site inspection protocol includes a careful
review of the investigations of each allegation of abuse
occurring over the past 12 months. However, we were denied
access to these documents. The reason for the denial provided by
the County was the staff’s right to privacy. This was despite
our repeated offers to ensure confidentiality and privacy,
including our offer to sign a confidentiality agreement. Without
these documents, we are unable to verify that the County
adequately protects youth from abuse by staff because we are
unable to make any finding regarding the actual existence of such
investigations or their quality. Accordingly, we draw negative
inferences and find that the investigations are inadequate.
Our site inspection protocol also includes a review of all
disciplinary action taken against staff found to be guilty of
misconduct or abuse. We were also denied access to these
records, and therefore cannot verify that the County protects

-33youth from abuse by appropriately disciplining staff.
Accordingly, we draw a negative inference and find that
discipline of staff who violate the rights of youth is

Failure to Provide Safe Avenues to Report Threats and
Intimidation at Camp Holton

Avenues for youth to report abuse at Camp Holton are
ineffective due to the culture of fear that pervades the facility
and the failure to hold staff accountable for mistreating youth.
As previously mentioned, of great concern during both tours at
Camp Holton were reports that youth were threatened and
intimidated by staff in an effort to prevent youth from speaking
with us. During the first tour, we had difficulty locating
several youth who were supposed to have been confined at Camp
Holton. These youth, it turned out, had been recently
transferred to Barry J. Nidorf Juvenile Hall (“Barry J.”).
Facility staff were not able to tell us the time of return to
Camp Holton so that they could be interviewed by members of our
team. Our subsequent efforts to contact some of these youth at
Barry J. were unsuccessful because, by the time we visited Barry
J., they had been transferred back to Camp Holton. Additionally,
as previously mentioned, during our second tour, youth reported
that staff made public announcements suggesting that the youth
who cooperated with our interviews were “rats.” Other youth
reported that staff warned youth “not to embarrass [them]” by
talking candidly with our team. The various avenues for youth to
report mistreatment, no matter how well designed, are rendered
ineffective in a facility that permits staff to threaten and
intimidate youth to prevent them from exercising their right to
discuss their conditions of confinement with federal

Inadequate Classification System

The absence of an adequate classification system also
contributes to the County’s inability to keep youth safe.
Generally accepted professional standards require that youth be
housed and supervised based on a reliable classification system
which includes the following considerations: a youth’s age,
charged offense, history of violence and escape, gang membership
or affiliation, health and mental health concerns, and
institutional history.
The youth at the Camps are, at best, classified in an ad hoc
manner, rendering it impossible to safely house youth.
Compounding the problem of inadequate placement criteria is the

-34physical structure of the housing units and lack of adequate
numbers of staff. At the Challenger Camps, the facility
Superintendent indicated that initial camp placements are loosely
based on the programmatic focus at the camp. However, we did not
find this to be the case. The Challenger Camps do not utilize a
structured decision-making tool to make housing decisions within
each camp. Instead, they rely on the subjective assessments of
staff, none of whom have received classification training. Youth
who are considered to be “at risk” are reportedly assigned bunks
in the front of each dorm. However, staff were not consistent in
their definition of “at risk.” Most often, youth were judged to
be at risk due to a particular medical condition. None of the
staff included youth who were vulnerable (due to age, size,
etc.), had serious mental health issues, or who were at risk of
self-harming behavior. Occasionally, staff discussed the need to
separate members of rival gangs, but there was no method for
doing so.
Similar to the practice at the Challenger Camps, at Camp
Holton, youth who are considered “at risk” are reportedly
assigned bunks close to the command center. However, this
practice appeared to be applied with questionable consistency.
At Camp Holton, our findings rest almost exclusively on reports
from staff and administrators. We were unable to verify whether,
in fact, at risk youth are placed in beds closer to the command
center because they did not maintain adequate records of bed
assignments. We requested the bed charts for one of the dorms
for 20 randomly selected days, but staff were able to produce
only four of them. Not only are these records important to
determine whether any classification system has been properly
implemented, but they are essential when investigating serious
incidents or child abuse allegations that occur in the dorm.
At Camp Kilpatrick, youth are separated into two dorms, with
one dorm reserved for those participating in the sports program
and the other dorm housing everyone else. Youth considered by
staff to be “at risk” are assigned bunks closest to the control
center within each dorm. But we found no definition of the term
“at risk,” and staff are left to interpret its meaning. Youth
who misbehave as well as vulnerable youth and youth with medical
conditions are all considered at risk at Camp Kilpatrick.
Although an at-risk determination certainly is appropriate for
each of these groups, not separating violent and non-violent
youth is contrary to generally accepted practice.
The primary form of classification at Camp Scott is to place
youth into one of four platoons: one for dorm leadership, one
for youth with jobs, one for recently admitted youth, and one for

-35general population. These distinctions bear little relationship
to protecting youth from harm or improving outcomes for youth in
the facility, which are the intended purposes of classification.
The platoon assignments do not account for a youth’s particular
vulnerabilities, interpersonal conflicts, or past involvement in
institutional misconduct. Similarly, the concentration of those
holding leadership positions into a single platoon limits the
ability of these youth to serve effectively as role models for
other youth, which was noted by staff and administrators as being
a primary role of leadership.
One of the problems plaguing Camp Scott on an episodic basis
is the involvement of youth in consensual sexual activity. A
review of relevant incident reports indicate that, although staff
attempt to note and address the behavior from a variety of
angles, the use of a formal classification strategy was not among
them. Youth found to be involved in this type of behavior are
often assigned to the bunks farthest from the control center, and
have opportunities to manipulate the environment to provide cover
for their activities. The use of a structured classification
system to guide housing decisions would accurately identify youth
involved in these behaviors.
The current classification process in the Camps does not
adequately address known risk factors for institutional
misconduct, and could lead to the proximal housing of youth who
should be separated in order to adequately protect them from
harm. The Regional Director for the Camps reports that each of
the Camps will have an entirely different focus as a result of
Camp Redesign, an ongoing 14-point project aimed at a variety of
improvements throughout the Camps.16 In the meantime, however,
the Camps’ method of classification does not ensure that youth
are protected from harm, and substantially departs from generally
accepted professional standards.

Inadequate Grievance Process

Youth at the Camps are not provided with adequate access to
a grievance system designed to address their complaints regarding
their treatment at the facilities. Generally accepted
professional standards mandate that youth should have readily
available access to a grievance process. Where courts have
considered this, they have uniformly found that detained youth
have a constitutional right to file grievances with facility


The project is protected to continue at least through
the end of 2008, if not far beyond.

-36administrators regarding their treatment. Bradley v. Hall, 64
F.3d 1276, 1279 (9th Cir. 1995); D.B. v. Tewksbury, 545 F. Supp.
896, 905 (D. Or. 1982); Morales v. Turman, 364 F. Supp. 166, 175
(E.D. Tex. 1973). An objective grievance system should be well
known and easily accessible. Grievances also provide an
important quality-control mechanism by which camp administrators
can monitor whether facility staff are adhering to policies and
Youth at the Challenger Camps knew of the existence of a
grievance process, but very few had pursued it as a remedy for
concerns or complaints. Most youth interviewed had no confidence
in the grievance process as a useful avenue for addressing
concerns about staff or camp conditions. Of the relatively few
youth who had raised issues regarding staff directly with
supervisors or via the grievance process, it was reported that
such actions resulted in staff calling them “snitches.” During
the tours of all the facilities, we noticed grievance forms and
boxes in the housing units. Staff reported that the boxes had
been installed just prior to our visit. The procedure previously
had inappropriately required youth to submit their completed
grievance forms to a staff member. The availability of the
submission boxes appropriately increases the confidentiality
afforded to youth.
Although they did not have great confidence in the grievance
system, youth did use it to address some of their concerns about
their treatment at the Challenger Camps. We reviewed
approximately 75 grievances from all five Challenger Camps
between January 2006 and January 2007. Approximately 20 of the
grievances complained about food, maintenance issues, and
personal products. Approximately 25 grievances complained about
the denial of medical care or tensions between staff and youth.
Approximately 15 grievances alleged verbal abuse or mistreatment
by staff. For example, a youth from Camp Resnick alleged that a
staff had cursed at the youth repeatedly and made fun of him for
being gay. This grievance was never responded to or resolved. A
large number of other grievances alleged mistreatment by this
same staff person.
Approximately six of the grievances alleged physical abuse
or the excessive use of force by staff. For example:

In June 2006, a youth from Camp McNair alleged that a
staff used OC spray on him without cause, stating that
he (the youth) had assumed the “OC position” to
indicate he was not involved in the incident. The

-37response to the grievance was only:
[the staff] about the incident.”

“I will speak to


In January 2006, a youth from Camp Resnick alleged that
he was physically restrained by a staff for five or 10
minutes after an incident occurred. The disposition on
the grievance form inappropriately concluded that the
grievance was “resolved” because the youth was
transferred to another camp. It does not appear that
the youth requested the transfer.


In June 2006, another Camp Resnick youth alleged that
he was threatened by a staff who later grabbed the
youth by the neck and pushed his face into the ground.
Again, the grievance was “resolved” when the youth was
transferred to another camp.


In June 2006, a youth from Camp Scobee alleged that a
teacher kicked him. There was no response or apparent
resolution of the grievance.

Although a few of the grievances pertaining to maintenance,
hygiene, and access to medical care appear to have been
appropriately resolved, in many situations, releasing the youth
to the community or transferring him to another camp led to the
determination that an issue had been “resolve[d].” All of these
complaints were about conditions at the facilities that would not
change in any meaningful way simply because the youth was no
longer there. Although the youth made the effort to address the
issue, the staff responsible for resolving the matter chose not
to do so. Further, many of the grievances took an inordinate
amount of time to resolve, and many others did not have a date of
receipt or date of resolution written on them, making their
compliance with required timelines impossible to ascertain. One
youth marked his grievance “urgent” and went on to explain his
desire to be placed in protective custody. After 16 days, the
grievance was considered “resolved” because the youth had been
transferred to another camp.
Thus, although a grievance system exists at the Challenger
Camps, it lacks many of the components needed for it to be a
viable avenue for youth to state their concerns. For the
grievance system to meet generally accepted standards, the
timeliness and thoroughness of the responses must be improved and
those indicating mistreatment or abuse by staff must follow the
required procedures for child abuse reporting. Finally, whether
or not the youth is transferred to another camp or released to

-38the community, the underlying issues for all grievances must be
appropriately addressed.
The grievance system at Camps Holton and Scott is similarly
inadequate. At Camp Holton, only two grievances had been
submitted between approximately July 2006 and January 2007. One
alleged abuse by staff and was properly reported to DCFS, but not
before the receiving staff member replied: “Denied. If you
followed instructions and did not resist, nothing would have
happened.” The other protested a disciplinary write-up, and was
resolved in the youth’s favor. The system lacks a set of local
policies to identify responsible parties, timelines, and required
investigatory procedures. Further, contrary to policy, no
grievance log is maintained at either Camp Holton or Camp Scott.
At Camp Scott, a new staff had been appointed to serve as
the Grievance Coordinator. In this new role, the Grievance
Coordinator noted that he checks the grievance boxes daily and
tries to respond to each grievance within 48 hours, and to
resolve each within five working days. These efforts to
strengthen the grievance process, however, have yet to take root.
Most of the youth interviewed were familiar with the grievance
process, but the process is used very rarely. Although under
development, the system as it currently exists lacks a clear set
of policies to identify responsible parties, timelines, and
required investigatory procedures. The absence of a consistent
and fully developed orientation program, during which new youth
should be adequately informed of the grievance process, may also
contribute to the limited usage of the grievance system. Some of
the girls interviewed acknowledged using the grievance system, or
at least considering it as one means of formally expressing a
complaint. Others expressed a total lack of confidence in the
system, stating that they had complained previously about broken
windows and clogged air vents in the dorm, to no avail.

Inadequate Suicide Prevention and Mental Health Care

The Constitution requires that confined juveniles receive
adequate medical treatment, including adequate mental health
treatment and suicide prevention measures. See Youngberg, 457
U.S. at 323-24 & n.30; Oregon Advocacy Ctr. v. Mink, 322 F.3d
1101, 1120 (9th Cir. 2003); Gibson v. County of Washoe, 290 F.3d
1175, 1187 (9th Cir. 2002); Carnell v. Grimm, 74 F.3d 977, 978-79
(9th Cir. 1996); Cabrales v. County of Los Angeles, 864 F.2d 1454
(9th Cir. 1988) vacated and remanded, 490 U.S. 1087 (1989),
reinstated, 886 F.2d 235 (9th Cir. 1989); Horn v. Madison County
Fiscal Court, 22 F.3d 653, 660 (6th Cir. 1994); Gordon v. Kidd,
971 F.2d 1087, 1094 (4th Cir. 1992). The Camps fail to meet

-39these constitutionally minimal standards. Below, we describe
deficiencies in the areas of suicide and self-harm prevention;
mental health screening and identification; clinical assessment,
treatment planning, and case management; medication management
practices; mental health counseling and other rehabilitative
services; and quality assurance programs.

Inadequate Suicide Prevention Plan

Juvenile institutions are required to adequately protect
youth from self harm. Generally accepted professional standards
require juvenile facilities to have a well-established suicide
prevention plan. The plan should be implemented on a systematic
basis and all staff members should understand it. The plan
should include procedures for the placement of youth under
varying levels of enhanced supervision, immediate evaluation by a
mental health professional, and, if necessary, safe transfer to a
psychiatric facility better capable of handling a psychiatric
emergency. Staff members must be well trained on an ongoing
basis in identifying and preventing youth suicides, and the
facility should have a system for providing ongoing follow up to
youth who have expressed suicidal ideations while in detention.
The Camps fail to protect youth from self harm in the following
ways: (i) staff fail to adequately assess youth for risk of
suicide; (ii) the Camps fail to provide sufficient mental health
services to youth on suicide precautions; (iii) staff fail to
supervise youth on suicide precautions and in seclusion
sufficiently; and (iv) staff lack preparation and training to
respond appropriately to suicide attempts.
As an initial matter, it is critical to note that Camps
Kilpatrick, Scott, and Holton have absolutely no formal suicide
prevention plan in place. And the Challenger Camps’ policies,
practices, and training regarding suicide prevention are grossly
inadequate. These deficiencies at all of the Camps place youth
at grave risk of harm.

Insufficient Suicide Risk Assessment

A formal screening for suicide risk is necessary for all
youth upon entry to the Camps. This screening should be
conducted using a validated suicide risk assessment instrument.
Contrary to these generally accepted practices, the Camps fail to
adequately assess youth’s risk for suicide upon admission,
thereby exposing youth to grave risk of harm.
Not one of the Camps has procedures in place to screen youth
for suicide risk upon admission. Nor does any Camp actually

-40provide such screening. Instead, staff and administrators
reported that youth are screened at the Juvenile Halls, prior to
their arrival at the Camps. The lack of screening upon entry to
the Camps is troubling for a variety of reasons. First, the
screening at Juvenile Halls may take place months prior to a
youth’s arrival at one of the Camps. A youth’s risk of self harm
could drastically change during that time, particularly in light
of the stress and change the youth experiences as he or she
transitions from the Juvenile Halls to the Camps. Second, a
youth’s mental health case file often does not accompany him/her
from the Juvenile Halls, so relevant historical indicators and
even suicide attempts may go unnoticed. Finally, the screening
conducted at the Juvenile Halls provides no protection for youth
transferred to the Camps from other facilities or from an
extended stay elsewhere.

Insufficient Mental Health Services for Youth
on Suicide Precautions

Youth on suicide precautions should receive appropriate
follow-up care from mental health staff to assess the need for
ongoing restrictions associated with such precautions and to
provide treatment. In addition, a qualified mental health
professional must be available for consultation during hours when
staff are not scheduled to be at the facility, and this
professional should be able to respond promptly when a youth
requires crisis evaluation. The Camps fail to provide sufficient
mental health services to youth on suicide precautions, exposing
youth to grave risk of harm.
When a youth is transported to a Special Housing Unit
(“SHU”) on suicide precautions, the generally accepted practice
is to place him on the highest level of supervision, one-to-one,
until a qualified mental health professional can make an adequate
risk assessment and assign an appropriate level of supervision.
Contrary to this generally accepted practice, at the Challenger
Camps, when youth are transported to the SHU, non-mental health
professionals - individuals who are not trained in conducting
such assessments - make the initial determinations of risk level
and required level of supervision. For example, we encountered
one youth whose level of supervision changed frequently,
apparently as a result of determinations of risk assessment by
line staff. Troublingly, this youth was never seen by mental
health staff while in the SHU. In general, the role of mental
health professionals in addressing the risk of self harm among
youth was largely unknown to line staff.

-41At the Challenger Camps, we encountered numerous instances
where youth at obvious risk of self harm were not seen by mental
health staff within a reasonable time. For example:

One youth was referred to mental health on 11/30/06.
He was seen 11 days later, on 12/11/06. The day after
he was seen, the youth made a self-harm gesture.
Contrary to stated policy and practice, the youth was
not transported to the SHU following this gesture.
And, he was not seen by mental health staff for another
three days.


Another youth was referred to mental health on 9/23/06
and again three days later. He was not seen until
10/9/06 – more than two weeks later. Just over a month
later, the youth made a suicidal gesture and was placed
in the SHU. He was not seen by mental health staff at
all while he was in the SHU. And, he was not seen by
mental health again until 12/27/06 - more than seven
weeks after his self-harm gesture.


Another youth, who had a history of self-harming
behavior while in a Juvenile Hall, was referred to
mental health at a Challenger Camp on 12/8/06. He was
not seen by mental health until 12/28/06 –- a troubling
20 days after his initial referral, and 22 hours after
he had engaged in another self-harming behavior at the
Challenger Camp.


Another youth was sent to the SHU at 9:30 a.m. on
2/4/07, after he had cut his wrist during the night
with a piece of metal from his wristband. Another
youth on the unit had alerted the nurse to this
behavior. The troubled youth was sent to the SHU with
a notation indicating “recent cutting, verbalizes SI
[suicidal ideation].” The youth was not seen by a
mental health or a medical professional until 7:30 a.m.
the following day - 22 hours after he had been sent to
the SHU.


In another incident, two youth who were brought to the
SHU the previous evening on suicide precautions were
not seen the next morning. When we asked mental health
staff why the youth had received no mental health care,
the psychiatrist stated “I forgot.”

Once placed on suicide precautions, youth at the Challenger
Camps receive inconsistent follow-up care. Despite a Probation

-42Department policy requiring that youth on suicide precautions be
seen daily by mental health staff for the first five days, as
previously noted, youth often spend days in the SHU without the
benefit of regular clinical contact. Moreover, none of the staff
with whom we spoke knew the requirements for monitoring youth
pending an assessment by a mental health professional. Staff at
the Challenger Camps also do not help youth learn skills to
reduce their suicidal ideations or behaviors.
Like the Challenger Camps, Camps Kilpatrick, Holton, and
Scott fail to provide adequate mental health services to youth on
suicide precautions. As noted above, none of these camps has a
formal suicide prevention plan in place. Instead, staff are
simply instructed to send youth either back to a Juvenile Hall,
to a psychiatric hospital, and/or to the Challenger Camps if a
chronic condition persists or a risk of self-harm develops. In
the interim, however, not one of these camps has formal
procedures in place to protect youth from self-harm as they await
transfer to a more appropriate setting. Procedures appear to be
ad-hoc in nature and not guided by formal policy and procedures.
Moreover, although staff at Camps Holton, Kilpatrick, and
Scott stated that they would fill out a mental health assessment
form if they felt a youth was particularly vulnerable, we found
the benefits of filling out such a form to be questionable at
best. At Camp Holton, the time frame within which the form would
be received and a mental health professional would see the youth
was unknown. At Camp Kilpatrick, as noted above, the
psychologist is available only part-time and is assigned to at
least two other facilities; he therefore cannot be relied upon
for timely availability to youth. And, although Scott appeared
to have a good practice for referring, monitoring, and
transferring vulnerable youth so they could obtain mental health
services, the camp does not document this practice, so it could
not be verified.
c. 	 Inadequate Supervision of Youth on Suicide
Precautions and in Seclusion
Generally accepted professional standards require adequate
supervision of youth on suicide precautions and in disciplinary
seclusion. Staff who conduct periodic checks of such youth
should document their observations and the times of their checks.
Safety checks should be conducted at random intervals at least
four times per hour for lower risk youth, and more often for
youth at higher risk. Per the Camps’ policy, a sheet is to be
displayed on the door of each occupied cell with a notation of
the time the youth was last visibly observed, along with the

-43initials of the staff member who conducted the observation. In
addition, prior to their admission to the unit, youth and the
room in which they will be placed should be searched to ensure
that no hazards or other materials that could be used in a self
harm attempt are available.
We observed a number of disturbing practices regarding
supervision of youth on suicide precautions and in seclusion;
these practices expose youth to grave risk of harm. Of
particular concern was the falsification of Observation Forms and
logs - critical papers that document the facility’s supervision
(or lack thereof) of youth who have been placed in the SHU and
may be at risk of self harm. Specifically, at the Challenger
Camps, we observed that staff certified on forms that they had
conducted checks at times that had not yet arrived (for example,
noting at 9:30 a.m. that a check had been done at 10:15 a.m.).
We observed a similar practice on at least one form at Camp
Scott. Moreover, at both the Challenger Camps and at Camp
Holton, we observed logs that had times pre-printed on them;
staff thus again were failing to record the actual times when
safety checks had occurred. At the Challenger Camps, we also
observed staff filling in the logs by writing in observation
times after we noticed that the log was blank or had not included
an observation time within the last hour.
Because these forms are to be completed when an actual
visual check has been conducted, pre-completed forms suggest that
staff assigned to these high-risk youth are actually not
monitoring them in accordance with safe practices. This
falsification of records calls into question the reliability of
supervision for youth on such special security status, and
suggests that supervision is insufficient to ensure that staff
uphold these serious responsibilities. Moreover, pre-printing of
set times on forms does not allow for checks of youth at random
times, as dictated by generally accepted professional standards.
Despite questions about the validity of the Observation
Forms in light of the disturbing falsification we observed, we
requested random samplings of Observation Forms for youth in the
SHU at the Challenger Camps, Camp Holton, and Camp Kilpatrick,
and the Assessment Unit log for youth at Scott. At the
Challenger Camps, Camp Holton, and Camp Kilpatrick, only a
handful of the forms we requested could even be located. Our
review of the forms revealed multiple additional failures to
follow generally accepted practices to protect youth on suicide
precautions or in disciplinary seclusion from self harm.
Deficiencies included the following:


Safety checks were not being conducted randomly at
least four times per hour (the Challenger Camps, Camp
Scott, Camps Kilpatrick).


Many of the forms revealed gaps of 30 minutes to
several hours during which youth were not monitored at
all (Camp Holton).


Forms contained no documentation of visits by medical
or mental health staff (Camp Holton, Camp Kilpatrick).
At both camps, youth reported having seen the nurse,
but said they did not see mental health staff.


Instead of using individual forms for each youth,
checks were documented for the entire hall on a single
sheet (Challenger Camps, Camp Scott).


Staff did not document the condition of the youth at
the time of observation (e.g., sleeping, crying,
eating, etc.) (Challenger Camps).


The forms did not evidence any supervisory review
(Challenger Camps, Camp Scott).


The location (Dorm or Assessment Unit) was not marked
(Camp Scott).


The length of time in confinement indicated in the
Observation Logs did not match the time in confinement
indicated in the movement log (Camp Holton).

Apart from the serious issues evidenced in our review of the
Observation Forms and Assessment Unit logs, at the Challenger
Camps, we observed multiple additional troubling instances where
staff failed to adequately supervise youth in the SHU, in direct
contravention to Probation Department policies. For example,
although Probation Department policy requires that the level of
enhanced monitoring be gradually decreased over time as the
youth’s level of risk of self-harm decreases, we found three
separate instances where youth were returned from the SHU to the
general population without any gradual decrease in supervision.
Moreover, direct care staff had placed one of these youth in a
room providing only supervision by camera upon his entry to the
SHU, in direct contravention of the policy prohibiting the camera
room from substituting for direct care staff observation.
Although the youth was later placed on one-to-one supervision
after a mental health assessment, one-to-one supervision should
have been the default level upon his placement in the SHU. In

-45another instance, a staff member providing one-to-one supervision
to a youth did not have any information as to what behavior
prompted the high level of supervision; the staff member reported
being told only to make sure the youth’s hands were visible at
all times. Yet another staff member was performing one-to-one
supervision while he had a novel on the chair next to him. It is
inappropriate for staff to do anything other than observe a youth
who is placed on one-to-one supervision. Such failures to
supervise youth in the SHU put already vulnerable youth at risk
of grave harm.
Finally, the Camps fail to adequately supervise youth at the
outset of their placement in the SHU. At the Challenger Camps,
although youth’s general population clothes are shaken out and
youth are required to put on a SHU uniform, youth are not
routinely searched prior to placement in the SHU. Similarly,
youth are not routinely searched prior to admission to Holton’s
SHU. A youth thus could conceal a weapon or other contraband on
his or her person and bring it to the SHU. Indeed, at Camp
Scott, a youth gave herself a tattoo while confined to that
camp’s assessment unit. This strongly suggests that search
procedures prior to her admission were inadequate. Moreover, the
Challenger Camps require a youth to search his own SHU room to
ensure that the youth is not unfairly accused of property damage
in the room. Staff - not youth - should be responsible for all
searches so that the Camps can ensure that youth do not have
access to contraband and potential self-harm items.
d. 	 Lack of Preparedness for Suicide Attempts and
Other Self Harm
Staff training in suicide prevention measures at the Camps
also departs from generally accepted professional standards.
Because the risk for suicide may be present at admission or may
develop during incarceration, it is critical at each juncture
that staff who interact with potentially suicidal youth be
trained to detect, assess, and if necessary, intervene to prevent
a suicide. The generally accepted practice is for all staff to
receive suicide prevention training as part of both pre-service
and annual training. The Camps fail in this regard, exposing
youth to grave risk of harm.
The Camps’ training statistics are alarming. Half of all
staff at Camp Kilpatrick, and one-third or more of all staff at
the Challenger Camps, Camp Holton, and Camp Scott have never
received formal training in suicide prevention. Yet, these staff
are responsible for the safety of vulnerable, potentially
suicidal youth on a daily basis.

-46Annual suicide prevention training at the Camps is nearly
non-existent. As of our visits in early 2007, since January
2006, no staff at Camp Holton had received refresher suicide
prevention training; only 5% had received it at Camp Kilpatrick;
just 18% had received such training at the Challenger Camps; and
only 33% at Camp Scott. Even when the training statistics are
expanded to encompass the entire course of a staff member’s
career, the numbers continue to paint a dismal picture: only an
additional 33% of Scott staff had ever received suicide
prevention training, only an additional 45% had received it at
Camp Kilpatrick and the Challenger Camps, and just an additional
67% had received training at Camp Holton.
Based on the training statistics, it is not surprising that
staff at all of the Camps lack knowledge and strategies for
de-escalating youth who engage in self-harming behaviors. For
example, at the Challenger Camps, even staff assigned to monitor
youth on the highest level of suicide precautions have no
guidance as to how to respond to youth who make statements
indicating they are considering self harm. Indeed, Challenger
staff gave widely conflicting accounts as to the Camps’ policy
and practice for safely managing youth who exhibit suicidal
ideations. In one of the most egregious examples, one staff
member stated that OC spray should be used to stop a suicide
attempt in progress.
Additionally, at all of the Camps, many staff were
frighteningly unaware of how to intervene appropriately in the
event of an actual suicide attempt. For example, staff did not
know how to relieve pressure on the neck in the event of a
hanging or how to use the cut-down tool. In fact, at the
Challenger Camps, although most staff were aware that cut-down
tools had recently been placed in a lockbox in the control center
of each dorm, none had received any training or instruction on
how to use the tool. Indeed, when asked to open the box and
remove the cut-down tool, the supervisor of the SHU was unable to
do so; his key did not appear to fit the lock. At Camp Scott,
staff also had received no formal training in the proper use of
the cut-down tool.
Staff at Camp Holton also were unaware of any formal
criteria used to determine the appropriate level of monitoring by
staff (e.g., 15-minute checks versus constant observation), or
even of any formal procedures for notifying mental health staff
or anyone else in the event a youth expressed suicidality. Staff
at Camp Scott likewise were unaware of procedures for monitoring
youth who had expressed intent to harm themselves. In addition,
at both Camp Scott and Camp Kilpatrick, staff lacked awareness of

-47the ways in which depression manifests itself in adolescents
(e.g., fighting, failing to follow instructions, or letting
others take advantage of them).
Finally, we found that emergency intervention measures at
the Challenger Camps were wholly inadequate. For example, first
aid kits and rescue tools (e.g., blades to cut ligature from
around a hanging victim’s neck) were not available. These
failures to have emergency equipment readily available to trained
staff can mean the difference between life and death to youth at
the Camps.

Inadequate Mental Health Care

Because youth who have the most serious mental health needs
are sent to the Challenger Camps, those camps are largely the
focus of the mental health care deficiencies in this letter.
Nonetheless, it is important to note that none of the Camps
provides adequate mental health services to youth. The Camps’
deficiencies include: (1) inadequate mental health screening and
identification; (2) inadequate clinical assessment, treatment
planning, and case management; (3) inadequate medication
management practices; (4) inadequate mental health counseling and
other rehabilitative services; and (5) inadequate quality
assurance programs.
As an initial matter, many of the deficiencies described
below are attributable to staffing shortages. Specifically, the
Challenger Camps have only one full-time psychiatrist, and a new
part-time psychiatrist. In addition, they have three full-time
clinicians, two half-time clinicians and two interns (who are
present on Fridays and Saturdays), along with two primarily
administrative positions of Clinical Program Manager and Clinical
Supervisor. Having only five and a half full-time equivalent
clinicians for a population of more than 400 youth with serious
mental health needs is clearly inadequate.
Of similar concern is the lack of adequate mental health
staffing at Camp Kilpatrick. Camp Kilpatrick’s licensed
psychologist - the camp’s only mental health professional valiantly divides his time between Camp Kilpatrick and at least
two other facilities. In doing so, he keeps no set schedule;
rather, he sets his time at the facility based on staff referrals
of youth to him. Indeed, none of the youth on the psychologist’s
caseload were self-referred, and he is not notified about youth
placed in the Special Housing Unit in any systematic way.
Moreover, he has not even been provided office space on site;
consequently, he is forced to carry his notes and files with him

-48at all times and is at the mercy of other staff and the
facility’s schedule when he needs to find suitable private spaces
where he can meet with youth. In the psychologist’s professional
opinion, the youth at Camp Kilpatrick are not being served
properly with regard to mental health treatment. At Camp
Kilpatrick (and at the Challenger Camps), interventions consist
of “crisis management,” where the psychologist acts more like a
social worker than a psychologist. Camp Kilpatrick’s
psychologist sees individual youth for approximately eight hours
per week, a length of time he believes is insufficient to meet
their needs. He sees about 10 youth at the camp on a regular
basis, but stated that, because of staffing constraints, he is
unable to provide ongoing psychotherapy. He also is unable
systematically to contact family members of youth to engage
family in support of treatment. Although he has attempted to
enlist the assistance of interns to expand mental health access
at the camp, administrative obstacles have prevented him from
being able to do so.
These staffing limitations inevitably affect the quality of
mental health care and place these already vulnerable youth at
significant risk of harm.

Inadequate Intake Screening and Identification

Generally accepted professional standards require that all
youth entering secure facilities receive a reliable, valid, and
confidential initial screening and assessment to identify
psychiatric, medical, substance abuse, developmental, and
learning disorders, as well as suicide risks as discussed above.
The assessment should include assessment of suicide and homicide
risk factors and past behaviors. Based on this screening and
assessment, staff should refer youth for any required care. To
do this, staff must gather available information, such as a
youth’s previous records from past admissions, and gather
important information needed to care for and treat the youth.
The information must be communicated to appropriate personnel so
that each youth’s needs are appropriately and timely addressed.
We find the efforts to identify youth with mental health
disorders at the Challenger Camps significantly lacking. Not
only do the Challenger Camps fail to screen youth for suicide
risk, as described above, but they also fail to screen youth for
other mental health issues at intake and fail to review youth’s
previous records. As with suicide risk screening, to the extent
any mental health screening is performed, it is done only at the
time the youth is admitted to the Juvenile Halls. Of additional
concern, there is no protocol to ensure that mental health charts

-49and information are transmitted from the Juvenile Halls to the
Challenger Camps. Thus, mental health screening information
generated at the Juvenile Halls often does not follow a youth to
the Challenger Camps. Consequently, the mental health team at
the Challenger Camps often has no way of knowing a youth’s mental
health history and current medication needs or history. If
documentation does not follow the youth to the Challenger Camps,
and a current mental health screening is not performed upon a
youth’s arrival, it is impossible to identify and appropriately
address a youth’s mental health needs.
The intake process at the Challenger Camps consists merely
of noting in a youth’s medical chart those youth who come in on
psychotropic medication and then scheduling a future appointment
with the psychiatrist. Our observations, interviews with youth,
and the facilities’ own documentation indicate that a significant
number of youth who manifest mental health disorders are not
being identified, and thus are not being treated. These failures
expose youth to significant risk of harm.
Moreover, the records provided to us reveal that the
facilities have no reliable documentation system in place to
actually identify youth who are receiving mental health services.
At the time of our visit, the population roster listed 432 youth
as living at the Challenger Camps. The mental health services
roster of youth currently on the mental health caseload, however,
indicated that 433 youth - a number one greater than the
then-current population - were receiving mental health services.
As reported to us, this suggested that every youth at the
Challenger Camps was on the mental health caseload. When we
cross-referenced the mental health services roster with the
population roster, however, we discovered that only 192 names fewer than half - matched. Even more disturbing, the mental
health staff for the Challenger Camps identified 86 youth who
were currently receiving psychotropic medications; of them, seven
were not on the population roster and another eight were not on
the mental health roster.
Based upon these conflicting figures, it is readily apparent
that the Challenger Camps lack any uniform tracking system to
identify youth currently at the facilities, youth receiving
mental health services, and youth on psychotropic medications.
If we rely upon the figures provided, it appears that only 46% of
the total population at all of the Challenger Camps is receiving
mental health treatment (192 youth plus the additional seven
youth receiving psychotropic medications who are not on the
mental health caseload). This statistic suggests that the
facilities are not identifying and treating all the youth in need

-50of mental health services, particularly in light of the fact that
all youth who have mental health needs are sent to the Challenger
Camps and that, statistically, as many as 65-75% of youth in
juvenile facilities have a diagnosable psychiatric disorder.17
The failure of the Challenger Camps to adequately identify youth
who have significant mental health disorders is a substantial
departure from generally accepted professional standards.
In short, the initial screening and assessment process fails
to achieve all of its primary goals: the process does not
identify youth who need immediate services, refer them for
services in a timely manner, screen out youth who should be
hospitalized rather than admitted to the Camps, or gather and
disseminate necessary information to share with staff caring for
the youth.

Inadequate Clinical Assessments, Treatment
Plans, and Case Management

Generally accepted professional standards require timely
specialized clinical assessments of youth who have potential
mental health needs, development of treatment plans to guide
youth’s care, and implementation of those plans. The Challenger
Camps fail to provide adequate clinical assessments, treatment
plans, and case management.

Inadequate Clinical Assessments

Youth who are identified at intake as exhibiting behaviors
associated with mental illness and/or substance abuse disorders
must receive a timely assessment that includes the gathering of
prior assessments, treatment history, and other information to
confirm a diagnosis and determine an effective course of
intervention. This process does not occur at the Challenger
Camps, and the consequence for youth is haphazard, uncoordinated,
and inadequate care.
As a result, some youth with serious immediate needs slip
through the cracks and receive services far too late, or never,
because of poor documentation and insufficient staffing levels.

Los Angeles County Juvenile Justice Coordinating
Council, Comprehensive Multi-Agency Juvenile Justice Plan, at 57
(Mar. 20, 2001) (stating that both the National Mental Health
Association and federal studies generally estimate that as many
as 65-75% of incarcerated youth have a mental health disorder,
and 20% have a severe disorder).

-51Other youth who are in need of an assessment are missed entirely
because of the lack of screening. And, as described more fully
in the medication management section below, even where youth are
referred to mental health, they do not consistently receive an
Moreover, as a general practice at the facilities, it is our
understanding that neither the psychiatrist nor any other member
of the mental health staff reviews prior treatment records or
contacts community therapists, parents, or probation officers for
critical developmental and treatment histories. This is not

Inadequate Treatment Planning

In order for youth to receive adequate mental health
treatment, they must be provided adequate treatment plans that
guide their care. Treatment planning requires the identification
of symptoms and behaviors that need intervention, and the
development of strategies to address them. Such planning is a
critical part of generally accepted professional standards and is
critical for effective treatment of serious mental illness,
ensuring that youth are receiving appropriate services, and
allowing for the tracking of the youth’s progress.
The Challenger Camps lack any kind of formal treatment
planning. Although recommendations for services are listed as
part of initial assessments (to the extent such assessments occur
at all), no treatment plans are identified. Although case
workers write documents called “treatment plans,” these are, in
reality, generally uniform sets of exercises designed to help
youth develop insights about their delinquent acts, their
behavior, and their future plans. They are wholly unrelated to
mental health treatment planning.
Moreover, we found that, to the extent the Challenger Camps
have any unofficial treatment planning, that planning fails to
target specific symptoms or articulate meaningful strategies;
does not involve important contributors, such as family members,
previous therapists or psychiatrists, or any other system of care
in which the youth may be treated; and fails to provide for
measuring whether the plan is working. The treatment planning
also rarely identifies co-occurring substance abuse disorders as
primary goals of treatment, even though effective treatment of
mentally ill youth with substance abuse disorders must address
these issues simultaneously. Particularly troubling, the
Challenger Camps have no substance abuse treatment programming,
even though staff estimate that 70% of youth at the facilities

-52meet the criteria for a substance abuse disorder. The lack of
such a treatment program grossly departs from generally accepted
professional standards. In addition, the Challenger Camps have
no system for establishing individual treatment plans or
behavioral plans for youth frequently placed in the Special
Housing Unit.
The Challenger Camps also fail to adequately involve
families in any kind of treatment planning, despite the fact that
families are an extremely important source of clinical
information and that it is not possible to conduct an adequate
overall functional mental health assessment without including
current and historical information from families. Challenger
staff reported that family meetings/therapy cannot be conducted
on a regular basis because no clinicians are available on
Sundays, which is the day families are permitted to visit. The
resulting lack of assessment of family, social, and developmental
history and the lack of family involvement can handicap
clinicians in creating appropriate treatment plans.
iii. Inadequate Case Management
Case managers should communicate treatment plans for
mentally ill youth to all staff involved in the management of
youth in a juvenile justice facility, and should coordinate
implementation of the plans. Although all youth at the
Challenger Camps are assigned case workers in their residential
units, these case workers have no mental health training, and
serve as liaisons between the facilities and the probation
officer, rather than coordinating care at the facilities for
mentally ill youth. As described above, they write documents
called “treatment plans,” but these documents have nothing to do
with mental health treatment.
Moreover, staff who come in daily contact with youth must
have sufficient information about youth’s mental health symptoms
so that they can understand and respond appropriately when youth
manifest such symptoms. Communication between mental health
staff, health staff, custody staff, case managers, teachers,
community probation officers, and parents regarding the treatment
of youth at the Challenger Camps is grossly inadequate. Mental
health staff do not share appropriate information with other
personnel who need this information to supervise youth safely and
meet their needs. For example, custody staff do not receive
guidance about the behaviors that mentally ill youth display that
stem from their mental illnesses. As a result, custody staff
misconstrue psychiatric symptoms as intentional behaviors, and
inappropriately apply ineffective discipline in an attempt to

-53reduce the troubling behavior. In addition, youth often target
other youth who exhibit mental health problems, thereby
exacerbating their symptoms.
Further, contrary to generally accepted professional
standards of care, the Challenger Camps do not provide aftercare
planning discharge summaries to facilitate treatment in future
placements. Our review of 31 mental health records revealed that
only seven contained some level of aftercare planning, and none
were adequate. Although staff reported that aftercare planning
is an important part of a youth’s stay at the Challenger Camps
and begins at the time of admission, we saw no evidence or
documentation of such planning in the records we reviewed. The
failure to communicate the goals, successes, and failures of
treatments tried at the Camps may compromise future attempts at
treatment for youth in other settings.
c. 	 Inadequate Psychotropic Medication Management
Generally accepted professional standards include, where
appropriate, the use of psychotropic medications to augment a
mental health treatment plan. The care of youth on psychotropic
medications requires proper assessment and management by a
psychiatrist. Medications prescribed should have a known benefit
to treat the symptoms identified, based on a valid diagnosis and
understanding of the root causes of the illness, and medication
changes should follow documented monitoring of the effects of
previous medication choices and reasons for abandoning a previous
approach. Youth and their parents or guardians should be
informed about the benefits and risks of medications and give
informed consent for their use. Careful monitoring through
laboratory tests is necessary to ensure that youth do not
experience harmful side effects of many psychotropic medications.
Based on our review, the Challenger Camps have serious
deficiencies in these areas, exposing youth to risk of grave
harm. First, we noted lengthy delays in the initial psychiatric
review of youth on psychotropic medications. For example:

A youth arrived on 11/24/06 with a notation in his
chart that he had been taking medications prior to his
arrival at the Challenger Camps, and an “ASAP” request
for a psychiatric evaluation. No response was noted in
his chart. Two more requests for a psychiatric
evaluation followed on 12/7/06 and 12/18/06, both also
marked “ASAP,” and both had no response noted. The
psychiatrist did not see the youth until 12/29/06 more than a month after the youth arrived at the camp.


Another youth arrived at a Challenger camp on 1/3/07,
and a request for medication evaluation for him was
similarly marked “ASAP.” Again, no response was noted.
Shortly thereafter, the youth’s mental health services
were terminated as a result of his “asking for things
and getting angry.” Ironically, it appears that the
youth was denied mental health treatment because he was
exhibiting possible signs of a mental health disorder.

Instead of promptly evaluating youth who have been
prescribed psychotropic medications prior to their admission, the
mental health staff at the Challenger Camps automatically
continue youth on those medications until they are seen by a
facility psychiatrist. This means that rather than verifying the
medication and obtaining a verbal order from the camps’
psychiatrist (thus sanctioning the use of the medication until
the youth can be seen for an in-person evaluation), medical staff
assume that the youth is taking the medication pursuant to a
valid prescription, and that the medication is being prescribed
for the appropriate reasons. This practice is particularly
dangerous because, as discussed above, in many cases, the mental
health records do not accompany the youth to the Challenger
Camps. We saw many cases where admitted youth had a history of
taking psychotropic medications, but had no records to document
diagnosis, side effects, or past efficacy of treatment efforts.
These youth nonetheless were continued on their medications.
Moreover, as described above, we identified seven youth who were
prescribed psychotropic medications but were not being seen by
mental health staff because they did not appear on the mental
health caseload.
For youth who did not enter the facilities already on
psychotropic medications, the provision of such medications to
youth at the Challenger Camps who need them is inconsistent at
best. Some youth are prescribed psychotropic medications without
the benefit of appropriate evaluations or systematic
physiological monitoring. Other youth are not provided with
medications to treat their symptoms at all. Still other youth
are referred for psychiatric evaluation for “urgent” medication
evaluations because of side effects from the medications or other
mental health concerns and either are never seen by the
psychiatrist or are seen weeks after the request for referral.
Moreover, where youth are placed or continued on
psychotropic medications, the Challenger Camps have no protocols
for providing monitoring or periodic reassessment. Specifically,
although many of the medications youth at the Challenger Camps
are taking require laboratory tests prior to and during the

-55course of the treatment, we found no protocols for the
administration of appropriate tests to monitor the efficacy and
side effects of psychotropic medications in accordance with
professional medical standards. Additionally, the frequency of
psychiatric follow-up depends, in many cases, upon when the
psychiatrist has time to evaluate the youth. Often, such
evaluation does not occur for months after the youth’s arrival.
We found a wide range of follow-up frequency, from several weeks
to more than 60 days. For example:

One youth’s chart contained an “ASAP” request for
medication evaluation dated 1/20/07, as well as a
second request on 2/3/07. Despite these repeated
urgent requests, as of our tour on 3/7/07, the youth’s
chart contained no documentation indicating that a
psychiatric evaluation had occurred.


Another youth was referred from another camp on 9/26/06
for an “urgent” medication evaluation because he had
been having “severe headaches” and was “very irritable”
since stopping his medications. Although he denied
suicidal ideation, he made the statement, “I can’t make
it.” He was housed in the Special Housing Unit pending
a psychiatric evaluation, which he did not receive for
more than a week.

In addition, although the case files reviewed all included
signed consent forms for treatment, it does not appear that the
Challenger Camps involve families in youth’s therapy and
treatment, including when the treatment includes psychotropic
medications. Families should be involved, where possible.
Finally, as discussed above, youth at the Challenger Camps
are discharged from the facilities without aftercare planning,
including medication or prescriptions, thus making it likely that
their medications will be discontinued precipitously. This can
be dangerous. See, e.g., Wakefield v. Thompson, 177 F.3d 1160,
1164 (9th Cir. 1999) (in the context of a prisoner who was
receiving psychotropic medication while incarcerated, holding
that the State “must provide an outgoing prisoner who is
receiving and continues to require medication with a supply
sufficient to ensure that he has that medication available during
the period of time reasonably necessary to permit him to consult
a doctor and obtain a new supply.”).


Inadequate Mental Health Counseling and Other
Rehabilitative Services

Generally accepted professional standards require that
mental health counseling be provided frequently and consistently
enough to provide meaningful interventions for youth. Treatment
should utilize approaches that generally accepted practices have
determined are effective. Youth with mental illness should
receive treatment in settings appropriate to their needs.
We have noted previously the lack of adequate mental health
counseling and rehabilitative treatment at Camp Kilpatrick. At
the Challenger Camps, mental health counseling is also inadequate
to meet the needs of mentally ill youth both in frequency and in
content. The limited counseling records that exist do not
evidence adequate use of effective treatment strategies. Despite
the presence of some caring, dedicated counselors, interventions
are not structured toward specific goals and do not adequately
involve approaches accepted as effective. As discussed above,
many youth are prescribed psychotropic medications to manage
their behavior, but receive no counseling whatsoever. Indeed, as
noted above, the youth with mental health needs are housed at the
Challenger Camps; yet, as the Director of Mental Health Services
at the Challenger Camps explained to us, mental health services
at the Challenger Camps consist of “mostly crisis intervention.”
Troublingly, the Challenger Camps fail to provide adequate
individual and group therapies. Both types of therapy are
critical to effective treatment in detention settings and are
required by generally accepted professional standards of
Of equal concern is the lack of a substance abuse treatment
program. Staff generally do not examine individual patterns of
use, abuse, addiction, or motivation, nor do they instruct youth
in alternative stress management or abstinence support
techniques. We found similar deficiencies in this area at Camp
Holton, as well.
Recordkeeping also is inadequate. Mental health staff must
keep records in a manner that allows both mental health and
non-mental health staff at the facility, as well as future
providers, to track treatment previously provided. Records of
prior interventions are critical to guide staff regarding
effective methods of crisis intervention. Counseling records at
the Challenger Camps are incomplete, as evidenced by the failure
to document follow-up to mental health referrals, including those
involving requests for treatment, medication side effects,

-57discontinuation of psychotropic medications, and suicidal
The lack of family involvement in treatment is concerning.
Counseling staff fail to adequately involve youth’s families in
therapy and treatment interventions, thus reducing the
effectiveness of any attempt at rehabilitation for youth who plan
to return to their families following detention.
Additionally, generally accepted professional standards
require juvenile facilities to provide opportunities for
rehabilitation that include effective behavior management
systems. Effective behavior management systems generally involve
incentive-based programs for promoting appropriate behaviors
throughout the day, and clearly defined guidelines that are
consistently applied across each institution. For youth
identified as having behavioral health problems, behavior
management programs need to be coordinated with a treatment plan.
Appropriate rehabilitative programs for youth confined in
juvenile justice facilities include programs that address family
conflict, substance abuse, anger management, gang affiliation,
and other issues youth in a juvenile justice system typically
Contrary to these generally accepted professional standards,
the Challenger Camps do not have an adequate behavioral
management system in place. As a result, the goals of custody
staff and mental health providers are not coordinated, and youth
do not benefit from the little mental health treatment that is

Inadequate Quality Assurance Program

Generally accepted professional standards require juvenile
facilities to establish a quality assurance program to
continuously evaluate the processes and efficacy of mental health
treatment. The Challenger Camps lack any such program. Indeed,
they do not even conduct internal audits; at most, the Los
Angeles County Department of Mental Health conducts yearly
audits. The risk of inadequate treatment without accountability
or oversight is extremely high. The lapses in care discussed
above should not have to be discovered by outside auditors or
agencies. And, they would be less likely to occur in the first
instance if adequate internal review processes were in place.



In order to rectify the identified deficiencies and protect
the constitutional rights of the youth confined at the Camps,
the County should implement, at a minimum, the following
A. 	 Protection of Youth From Harm
1. 	 Ensure that youth are adequately protected from staff
abuse and abusive institutional practices such as
“slamming,” or “assuming the bob sled position.”

Develop and implement a use of force policy that
provides clear guidelines and appropriate limits on
the use of force, including OC spray. Ensure that OC
spray is used only where there is an imminent risk of
serious bodily harm and no other less intrusive
restraint is available, and that policies regarding
disqualifying conditions for use of OC spray are
developed and followed. Ensure that all uses of OC
spray or chemical restraints are well-documented and
reviewed in a timely manner by senior administrators.


Ensure that staff neither threaten or intimidate youth
from reporting abuse or mistreatment, nor maintain or
consume alcohol at the Camps.

4. 	 Ensure that the facilities maintain sufficient levels
of adequately trained direct care staff to supervise
youth safely. Provide sufficient staff supervision to
keep youth safe from youth-on-youth violence and allow
rehabilitative activities to occur successfully in
accordance with generally accepted professional
5. 	 Improve orientation to communicate important
information to new residents, such as how to access
the grievance system, medical care, and mental health
6. 	 Ensure that there is an adequate, appropriate, and
effective behavior management system in place, and
that the system is regularly reviewed and modified in
accordance with evidence-based principles.

Provide adequate training and supervision to staff in
all areas necessary for the safe and effective

-59performance of job duties, including training in child
abuse reporting and training in the safe and
appropriate use of force and physical restraint, the
use of force continuum, and de-escalation techniques.
Routinely provide refresher training as required by
generally accepted standards.
8. 	 Ensure that all allegations of child abuse and
mistreatment are promptly referred to the appropriate

Ensure that serious incidents, allegations of abuse,
and allegations of staff misconduct are adequately and
timely investigated.

10. 	 Ensure that the facilities provide adequate
protections for youth once abuse has been reported,
and safe avenues through which youth may report
11. 	 Ensure that the facilities develop and implement an
adequate objective housing classification system to
ensure safe and appropriate housing assignments.
12.	 Ensure that the facilities develop and maintain an
adequate youth grievance system that ensures youth
access to a functional and responsive grievance

Suicide Prevention and Mental Health Care

Develop and implement an adequate formal suicide
prevention policy, procedure, and protocol.

2. 	 Develop policies and procedures to reduce the risk of
self harm and suicidal behaviors, to include adequate
suicide risk assessments in accordance with generally
accepted professional standards.

Develop and adhere to specific protocols for mental
health involvement for all youth identified as being
at risk of suicide.


Adequately and effectively monitor all youth who are
placed on suicide precautions in accordance with
generally accepted professional standards in order to
reduce the risk of self harm, and accurately document
the frequency of all safety checks.


Create and implement a procedure for enacting suicide
precautions pending transfer to another facility for


Provide staff with adequate training to identify and
supervise youth at risk for suicide, including
training on suicide prevention measures such as the
proper use of cut down tools, and re-train staff
annually to refresh their skills and knowledge of
suicide prevention procedures.

7. 	 Provide and maintain adequate mental health care
8. 	 Provide an adequate, comprehensive, reliable mental
health screening and assessment at intake.

Develop and implement policies, practices, and
procedures for identifying youth receiving mental
health services and youth on psychotropic medications.

10.	 Maintain accurate and complete mental health records;
ensure that all relevant records are forwarded from
the Juvenile Halls in a timely manner.
11.	 Provide ongoing training, proper supervision, and
reasonable accountability for mental health clinicians
in accordance with generally accepted professional
12. 	 Provide timely evaluations to youth referred for
mental health services.
13. 	 Establish and maintain adequate formal treatment
planning in accordance with generally accepted
professional standards.
14. 	 Establish and maintain adequate mental health
programming, including substance abuse programming,
and the case management thereof.
15. 	 Establish and maintain protocols to monitor youth who
are on psychotropic medications in accordance with
generally accepted professional standards.
16. 	 Provide aftercare planning discharge summaries to
facilitate treatment in future placements.

-6117.	 Establish and maintain an effective quality assurance
program consisting of established policies and
procedures by which to judge the quality and success
of treatment.
* * * * *
Please note that this findings letter is a public document.
It will be posted on the Civil Rights Division’s website. While
we will provide a copy of this letter to any individual or
entity upon request, as a matter of courtesy, we will not post
this letter on the Civil Rights Division’s website until 10
calendar days from the date of this letter.
The collaborative approach the parties have taken thus far
has been productive. We hope to continue working with the
County in an amicable and cooperative fashion to resolve our
outstanding concerns with regard to the Camps. Provided that
our cooperative relationship continues, we will forward our
expert consultants’ reports under separate cover. These reports
are not public documents. Although our expert consultants’
reports are their work – and do not necessarily represent the
official conclusions of the Department of Justice – their
observations, analyses, and recommendations provide further
elaboration of the issues discussed in this letter and offer
practical, technical assistance in addressing them. We hope
that you will give this information careful consideration and
that it will assist in your efforts at prompt remediation.
We are obligated by statute to advise you that, in the
unexpected event that we are unable to reach a resolution
regarding our concerns, within 49 days after your receipt of
this letter, the Attorney General is authorized to initiate a
lawsuit pursuant to CRIPA, to correct deficiencies of the kind
identified in this letter. See 42 U.S.C. § 1997b(a)(1). We
would very much prefer, however, to resolve this matter by
working cooperatively with you.

-62Accordingly, the lawyers assigned to this matter will be
contacting your attorney to discuss next steps in further
detail. If you have any questions regarding this letter, please
call Shanetta Y. Cutlar, Chief of the Civil Rights Division’s
Special Litigation Section, at (202) 514-0195.
/s Grace Chung Becker
Grace Chung Becker
Acting Assistant Attorney General
cc:	 Robert Taylor
Chief Probation Officer
Raymond G. Fortner, Jr.

County Counsel

Gordon Trask

Principal Deputy County Counsel

Law Enforcement Services Division

Leon Bass, Director

Camp Clinton B. Afflerbaugh

Edward Anhalt, Director

Camp David Gonzales

Lynn Duke, Director

Camp Karl Holton

Harold Soloman, Director

Camp Gregory Jarvis

Craig Levy, Director

Camp Vernon Kilpatrick

Mike Varela, Director

Dorothy Kirby Center

Luis Domiguez, Director

Camp Ronald McNair

Gary Thomas, Director

Camp William Mendenhall

-63Alex Williams, Director
Camp Fred Miller
Daniel Moreno, Director
Camp John Munz
Randy Herbon, Director
Camp Joseph Paige
Trenier Woodland, Director
Camp Judith Resnick
Eduardo Silva, Director
Camp Glenn Rockey
Charlie Trask, Director
Camp Louis Routh
Jennifer Owen, Director
Camp Scott
Walter Mann, Director
Camp Francis Scobee
Michelle Guybon, Director
Camp Kenyon Scudder
Walter Mann, Director
Camp Michael Smith
The Honorable Thomas P. O’Brien
United States Attorney for the
Central District of California