REPORT OF SITE VISIT AND AUDIT OF THE SEXUAL BEHAVIOR
TREATMENT PROGRAM
PREPARED FOR
DONNA BRORBY, SPECIAL MASTER, FARRELL v. TILTON
--------CALIFORNIA DEPARTMENT OF CORRECTION AND REHABILITATIONDIVISION OF JUVENILE JUSTICE
BY
Barbara Schwartz Ph.D.
Sexual Behavior Treatment Expert
August 2007

Introduction:
I conducted site visits at four facilities. The first site visit and audit was conducted at two
CDCR-DJJ facilities located in Stockton, California on May 24 and 25. I was accompanied
and assisted by Monitor Cathleen Beltz. On the first day of the visit I interviewed staff,
observed a therapy group, met with the Personnel Department and reviewed files at O.H.
Close. The second day was spent at Chaderjian where I met with staff and residents,
observed a group and reviewed files. Exit interviews were conducted at both facilities.
The second visit occurred on July 26, 2007 at the Southern Reception Center and on July
27, 2007 at Stark. Present during the visits were Monitor Cathleen Beltz assisted me with
the gathering of documentation and with interviews of staff and youths. Also present were
Dr. Fred Martin, Dr. Paul Woodward, Barbara Edgar, Katie Riley and Rebeka Lachear.
May 24, 2007: Stockton Complex (O.H. Close and N.A. Chaderjian)
On this day myself and Monitor Beltz met with Drs. Stevens, Bowlds and Dr. Martin.
There ensued a discussion of the proposed moves that have been postponed. Remodeling of
the Humboldt Unit at Close and moving of the SBTP from the Feather Unit at Chaderjian
have been delayed due to recent legislation and the Governor’s budget. The Sex Offender
Task Force continues to meet and will be convening in June, 2007.
The following issues emerged at the Humboldt Unit:
•

There is still no organization chart for the SBTP and the staff still doesn’t know
whether SBTP will be under Mental Health, which was Dr. Martin’s impression, or
the Behavioral Program which was the impression of the Personnel Department.

•

60 staff attended CCOSO in San Diego within the past month. This included most
of the staff working with the SBTP and represents exceptional support for training.

•

Currently there are two psychologists working at Feather and next week Dr. Bowlds
will be the only psychologist at Humboldt. Additionally she is being called out of
the Program to sit on various committees and to supplement the Mental Health staff
at DeWitt.

•

Polices and procedures were being developed but the process was stopped in order
to make sure that all DJJ policies were uniform and did not conflict.

•

Legal issues on Informed Consent and Confidentiality have not been clarified.

•

Dr. Bowlds is using a form that tracks the stages of the program for the Humboldt
Unit. However, the form does not correspond to the specifics that exist in the
curriculum. The form that the Task Force was developing has not been completed
or implemented.

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August 2007

2

•

Only 55% of the 60 program participants are in resource groups.

•

Both process and resource groups are very small (4 to 6 participants). More
program participants could be in resource groups if the groups were larger.

•

The scheduling of groups is still vague. I attended a group that was theoretically
supposed to run between 10am and 2:00pm. This group actually meets between one
and two hours a session. This is not an optimal way to run groups. Traditionally
groups are run on a set schedule of 90 to 120 minutes.

•

The DJJ files remain inconsistent across facilities and confusing because documents
are in four to five different files. Some staff keep soft files, which allow the
therapist to document progress, file relevant assignments and do treatment planning.
I recommend that DJJ create one SBTP file containing all information needed for
effective treatment.

•

I observed a group of four youths conducted by Dr. Herskovic. Three of the
participants were relatively new in the program. They discussed personal issues but
there was little discussion of sex offender specific issues although the participants
did appear to be doing related homework.

The following issues were discussed with the Personnel Department:
•

Dr. Martin is not in the loop regarding filling positions and has not been asked to sit
in on hiring panels even for SBTP positions. Additionally he was not aware of how
many vacancies exist in the SBTP, or that positions in his program were being
allocated to general mental health duties. As just mentioned, the newly filled SBTP
have been reassigned to Mental Health. I met with the psychologists at Humbodlt
and Chad. I know all of these individuals and was repeatedly assured that these four
psychologists were the only ones functioning in the program as per the date of the
audit. I was also told by Dr. Martin, Dr. Bowlds, and two employees of the
Personnel Department that psychologists including one who had begun to work for
the SOTP were reassigned to Mental Health. No psychologists from Mental Health
were reassigned to work for the SOTP.

•

Salaries for psychologists have been increased, and this has resulted in an increase
in applicants.

•

Applications are delayed because live scans take 2 to 3 months in DJJ vs. a reported
10 days in the adult system.

•

The post and bid system continues to present a challenge to the training and
retention of Youth Counselors who are interested in working with this population.
This is particularly concerning since they provide the bulk of the SBTP therapy and

Report of Sexual Behavior Treatment Expert
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3

they generally have little relevant education or previous training when they first
come to work in the SBTP units.
May 25, 2007: N.A. Chaderjian
The visit to the Feather Unit revealed the following issues:
•

Staff reports that the violence that once characterized Chaderjian has been
transferred to DeWitt. The SBTP participants at Chad can now go to school without
being in physical danger.

•

Staff feels marginalized. In the process of renovating the Feather Unit, the youths
were moved to a different housing unit. The SBTP staff reported that received no
notification of this move and only found out about it when the youths informed
them.

•

The post and bid process has significantly impacted treatment. There have been
instances where staff that were qualified, interested and experienced have been
replaced with staff that were unfamiliar with program operations and had little
interest in working with this challenging population.

•

One of the majors (Steve Gardner) has been particularly supportive of treatment.

•

Moving Parole Violators into the Mojave Unit which adjoins Feather has
necessitated conducting educational classes for this population in a shared dining
room which has windowed doors into both the SBTP living unit and group room.
Residents from Mojave routinely peer through these windows and harass SBTP
residents. The group room has become a hall through which staff routinely walk,
disrupting the group in the process. Teachers have frequently interrupted groups
including stopping to talk to group participants just as another group member was
about to make a critical disclosure. This situation would have been corrected if the
SBTP could have been moved as planned but the construction process has been
delayed.

•

A resource group on substance abuse was observed. Dr. Kirkwood was running this
group although YCCs are supposed to conduct these groups. Dr Kirkwood told me
that he felt this group was too important to leave to an untrained individual who
would be relying on a set of handouts. The YCC who sat in this group was on a
computer at least half of the group that made a statement to the group members
about how much the group was valued.

•

In the Individual Change Plan the only reference to treatment goals relating to their
inappropriate sexual behavior was the statement, “I am a sex offender.” Not only
does this statement challenge the philosophy that these youths are more than their

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4

inappropriate sexual conduct but it is not helpful to treatment planning as it does not
identify the specifics of the problem or indicate remedial plans.
•

Documentation of individual participation:
o E’s group notes indicate that he participated in two hours of SBTP group per
week with individual therapy one hour a week and three resource groups, at
least two of which were not l related to the SBTP.
o J’s record shows that he attended four different resource groups in a week,
at least two of which were not SBTP-related (IMPACT and Restorative
Justice). He also attended 30 minutes of individual treatment. Between May
1 and May 24, 2007 he attended one 60 minute SBTP. In April he attended
two 120 minute SBTP groups.
o T’s record showed attendance at five groups between 1/4/07 and 5/3/07
although four additional groups had been documented in May with the notes
being completed on May 24, 2007.

•

Youth 1 was interviewed as a program participant who has done well in the
program. He would have been rated as a high risk offender. He initially was in
Humboldt Unit but admitted to not participating seriously in the program. He was
transferred to Preston where he participated in an informal program and was
transferred to Chaderjian eleven months ago. He does show good comprehension of
relapse prevention and was able to describe his high risk situations and his cognitive
distortions. This youth appears to have benefited from the program.

•

Youth 2 was ordered by the court to complete “sex offender treatment.” He was
sent to O.H. Close for three months in 11/04 and then to Preston where he was in an
informal program that met once a month. He was then told that he would not
receive credit for his participation in the Preston program, and his sentence was
extended. He had been writing DJJ administrators to transfer him into a recognized
program. Since his transfer, it appears that he is being rushed through the program
to make up for the delay in his treatment. He has been rated at Stage 8 of the
program but has little realistic idea of his high-risk situations. He sees no need to
continue sex offender treatment. Youth 2 is at very high risk to re-offend sexually
and/or violently. He is being rated as having almost completed the SBTP but shows
little understanding of behavior or of risky situations. I am commenting on this as it
reflects on the need for a clear policy on what “completion” of the program means
and what is the process for deciding when one has or has not finished the SBTP.

July 26, 2007: Southern Youth Correctional Reception Center and Clinic
Initially we met with the above mentioned staff from Central Office as well as Dr. P.
Courelli, Dr. D. Leong, E. Mejia, and Ted Bonzon at the Southern Youth Correctional
Center and Clinic in Norwalk, CA. Our initial meeting focused on updating personnel
issues for the SBTP. Encouragingly, six psychologists have been offered positions at
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5

Close and Chad. Staff at Southern described how the youths were on a 30 day summer
break and that 36 of the 49 youths in the SBTP were participating in a Leadership School.
The staff believes that the decision has been made not to move the SBTP, at least in the
near future. We attended a presentation prepared by the participants in the SBTP which
included a description of a number of other institutional programs. It was a pleasure to
see the young men looking very handsome in the clothing provided to them through the
Dress for Success Program which focuses on improving the youth’s self concept by
teaching them hygiene, grooming, job interview skills, etc and provides them with
appropriate dress clothing. The youths also gave a presentation on the California Cadet
Corps and the Restorative Justice projects which have been done on Sutter Unit (SBTP).
The residents of the program gave presentations demonstrated a knowledge of basic
treatment concepts such as their cycles. One participant presented a poem he had written
on thinking errors. The presentation lasted for several hours.
In the afternoon staff and youths were interviewed by Monitor Beltz. She was given a list
of questions and interviewed youths which were chosen by me, recording their verbatim
responses which I reviewed. This was done because an inordinate amount of time at
SYCRCC was taken up with a formal presentation by the youths which dealt primarily
with generic programs such as the “Dress for Success” Program, the Cadet Program, and
Restorative Justice program. Consequently there was not time to interview both
individual youths and attend groups. Additionally I chose to observe a family therapy
session in which a youth and his family agreed to a Section 1800 being filed and not to
challenge this in court.
The results of the interview reflected positive views towards the staff and the program. It
also as mentioned below reflected mixed opinions about whether youths knew how they
might be terminated or suspended from the program. Respnses to questions about relapse
prevention varied depending upon the stage of the program the participant was in..
I attended a family therapy session that included a youth, his mother and his
grandparents, Dr. Courelli and Ted Bonzon.
The following issues were noted:
•

I observed a family therapy group that involved a young man who had done quite
well in treatment and because he was doing well in treatment, he revealed that his
inappropriate behavior had been more extensive than he had previously admitted.
He had revealed that he had initially had not been completely candid with his
treatment team or his family. It should be noted that this is completely
predictable and is the pattern for almost all sex offenders in treatment. He was
due to be released to a very caring family. However, Dr. Courelli and Mr.
Bonzon recommended that this young man agree with the filing of an 1800
petition that would extend his commitment for up to two years. While additional
offenses or additional victims should necessitate some revision of his previous
work, it should not require two years of additional work. I am commenting on
this as it reflects on the need for a clear policy on what “completion” of the

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6

program means and what is the process for deciding when one has or has not
finished the SBTP. While at a northern facility I observed a ward being rushed
through the treatment program so that his time would not be extended, here was a
youth who is doing well in treatment being recommended for a Section 1800.
•

A review of records indicated that YCCs and psychologists are co-leading groups
that is good. However, both individuals do notes on the groups and each files
his/her group notes in different files. Therefore not only is this a duplication of
efforts but the files may not be identical and may even contradict each other.
Additionally psychologists record their notes on the WIN system but these are
not copied and filed in the UHR per DJJ policy as there is no clerical staff to
perform this function.

•

YCC group notes were reviewed and the following average length of groups over
the past three months were noted:
o
o
o
o
o

YCC #1=114 minutes/week
YCC#2=128 minutes/week
YCC#3=106 minutes/week
YCC#4=108 minutes/week
YCC#5=106 minutes/week

•

The plan indicates that SBTP participants are to receive 180 minutes of group
therapy per week. Mr. Bonzon stated that the program counts “prep time,
briefing, face-to-face, debriefing.” It is my opinion that this was not the intent of
the plan which I believe calls for 180 minutes of actual group therapy.

•

In June the following number of wards participated in the following resource
groups:
o
o
o
o
o

Gang Awareness=4-6
Substance Abuse=7-8
Relapse Prevention=7 to 8
Stress Management =16
Criminal Thinking=7-8

•

Some of these youths are participating in more than one of the above listed
groups. Some of these groups are offered to all youths in a facility such as Gang
Awareness, and it is not clear how generic all of these groups are. For example,
stress management could be based on a curriculum designed for antisocial youth
in general rather than specifically designed for individuals who manage stress by
behaving in sexually inappropriate ways. The youth also participate in generic
groups such as the Cadet Program, and Dress for Success.

•

One of the most significant concerns is that although the staff that I observed
appeared to be enthusiastic, devoted and skilled, they each appeared to be “doing

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their own thing.” For example, Dr. Courelli is offering a Multi-systemic
Approach to working with families; it appears that this is limited to the families
of the youth that she is treating rather than being something that has been adopted
by the program as a whole. There was no documentation between staff
suggesting that psychologists cross-refer youths to each other.
•

Because the psychologists and the YCCs work under different departments, it is
not clear who is providing leadership at the different SBTP sites. Therefore it is
not clear who has the authority to form a uniform program. It is not even clear
whether Dr. Martin has the authority to insist that YCCs and psychologists offer
the amount of treatment required by the plan. When an organizational chart is
provided, this should clear up the matter.

July 27, 2007: Heman G. Stark Youth Correctional Facility
We visited the Heman G. Stark Youth Correctional Center in Chino, California. We met
with Drs. Poncin and Barrington, Ms. Hetherton and Mock. Files were reviewed, youths
and staff were interviewed. I sat in on a group for special needs youth and later on in the
afternoon on a resource group.
The following issues were noted:
•

Reportedly all the positions on the SBTP have been filled with the exception of
one position which is either YCC position or a parole agent position. The staff
was not sure.

•

It was reported that each YCC does two resource groups and four casework
groups. The resource groups reportedly run two to four months with five to six
members.

•

In the files completed by the YCCs, there is no uniform notation of whether a
note refers to a group or an individual session and rarely was there
documentation of length of session.

•

Psychologists were conducting groups that lasted on the average about one hour a
week. Dr. Barrigan has directed them to provide three hours a week in two 90
minute sessions.

•

Ms. Hetherton has developed curriculum for 17 classes as well as an extensive
collection of experiential exercises. This would be a valuable tool for the whole
program, provided that copyright issues can be resolved.

System Issues:

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8

•

Director of SBTP should be a Chief Psychologist position as it involves supervision
psychologist staff in several institutions. These individuals may also be supervised
by Chief Psychologists at their respective institutions and the Director of SBTP
should be at a comparable level.

•

The plan requires that the treatment be offered by “qualified staff.” That could be
mean mental health professionals who have specialized training in sex offenders. It
could also mean that all staff have relevant college degrees with additional training
in treating youth with inappropriate sexual behavior. It could also mean that
whatever educational level, the staff has comprehensive specialized training and
their duties are structured, based on carefully developed and approved curriculum
and they receive appropriate supervision as outlined in the plan. Those staff that
were interviewed indicated that they had college degrees with some training in
dealing with sexually inappropriate youths. Because educational background and
training records were not provided, it is not possible to determine if all staff that are
providing treatment are qualified to do so.

•

While attendance at conferences is one way of receiving training and the effort and
expenditure to send 60 staff to a statewide conference is very commendable,
adequate training must include at minimum a written training plan which outlines
an initial training period for new staff and a plan for yearly in-service trainings.

•

The SBTP Task Force is being expanded to include representatives from Parole and
Education. Staff have mixed feelings about this, being concerned that there may be
a lack of consistency with these representatives and this would hold up decisionmaking processes. I concur that unless consistent attendance by assigned
professionals can be insured that it might confuse and delay decision-making
processes

•

Use of interns---Dr. Herskovic is transferring to a position supervising interns who
are to rotate through different programs. This may prove to be a valuable recruiting
venue for filling SBTP slots.

•

Files continue to lack standardization needed to facilitate both the provision and the
monitoring of treatment. In some facilities both YCCs and psychologists both do
notes on the same group that are filed in different files. This is a duplication of
effort and may be confusing as groups may not be similar. Also a lack of clerical
staff has limited transferring notes from the WIN system to the UHR.

•

Dr. Cellini has begun meeting with the Task Force, has completed most of the
Healthy Living Curriculum which I saw and has scheduled its piloting. I also
observed during this visit and had previously been aware that the portions of the
curriculum written by DJJ were not uniform in style with the rest of the curriculum.
In fact, one module was simply downloaded from the Internet. Thus these will need
to be rewritten. I met with Dr. Cellini on July 28, and we held a conference call
with Dr. Martin where the Healthy Living curriculum was discussed.

Report of Sexual Behavior Treatment Expert
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9

•

Personnel Issues
o A rise in salaries has resulted in more applicants for psychologist positions.
o Although it is not clear, there initially appeared to be between 8 and 10 open
psychologists positions in the SBTP. Dr. Martin reports that all but possibly
one casework supervisor or parole officer position have been offered to
qualified individuals.
o Several SBTP positions have been filled but then transferred to fill mental
health positions. This was confirmed by two personnel staff members in
Stockton.
o Dr. Martin had not been included in the hiring panels for SBTP positions.
This appears to have been corrected.
o The YCC positions can be filled by anyone who has one year experience as
a correctional officer with no degree required. These individuals are
supposed to provide the bulk of the SBTP treatment. DJJ is unable to
provide YCC qualifications to the expert. Those interviewed did report
academic qualifications beyond the minimum. This standard could also be
met if evidence can be provided that YCCs are only providing treatment as
supervised co-leaders of groups and only teach resource groups where a
structured, approved curriculum is provided.

•

There are reportedly treatment programs for youths with inappropriate sexual
behavior being offered at other but these programs are not included in the SBTP.
These programs should either by included under the SBTP jurisdiction, or their
function clarified.

•

The SBTP Task Force had not developed a form that outlines progress in the
established treatment program. Dr. Martin has now provided me with a Treatment
Matrix which is now ready to be implemented.

Conclusion:
This audit initially addressed the two northern facilities where SBTP is offered
(Close and Chaderjian). The southern facilities were audited in July, 2007. Dr. Cellini
was met with in July as well. Formal audits have been delayed in hopes that contract
issues affecting Dr. Cellini’s retention would be resolved, and that the program regained
the progress that was made in 2005. Dr. Cellini is now back on board and working on
finalizing the Healthy Sexuality curriculum and will begin work on either the Residential
or Outpatient curriculum thereafter. It is my recommendation that the Residential
curriculum be developed next for two reasons. It would be relatively easy to abbreviate
the Residential curriculum, choosing the most relevant sections to use as the Outpatient
curriculum. Additionally the Residential Programs are currently in existent but in
desperate need of standardization. A program director has been hired. DJJ has sent
several SBTP staff to a national conference and more recently sent 60 staff members to a
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10

statewide conference. At the time of the first part of this audit, the Task Force had
continued to meet regularly, projects such as contracting for training in the J-SOAP,
development of a form to track treatment progress and development of policies and
procedure had not progressed. However, the staff have now been trained on the J-SOAP
and the treatment matrix has been finalized although not as yet implemented.
The planned move that would consolidate two of the four programs seriously
impacted the morale of both the staff and the participants. The uncertainty of this major
change continues to impact the program. Though persistent vacancies in psychologist
positions undermined the program for some time, psychologist salaries were increased
and it would appear that most of these positions have now been filled. Dr. Martin had not
been involved in the hiring process for the SBTP positions but now he is. However, the
designation of his position as a Senior Psychologist as opposed to a Chief Psychologist
places him at a disadvantage in supervising staff that may also be taking orders from the
Chief Psychologists at their respective institutions. Dr. Martin needed to be involved in
the hiring of all of SBTP clinical positions, and the Personnel Department has agreed.
This has happened.
The problems with the program are exemplified by the situation at O. H. Close
that was previously the flagship of the SBTP with the strong leadership of Rosa Rivera,
three psychologists and strong YCC staff. Ms. Rivera has retired and two of the three
psychologists will have left by June 2007. As of the time of the site visit in May 2007,
this left the entire program to be operated by Dr. Bowlds who was frequently called away
in the middle of therapy sessions to cover other institutions. Were she to leave, the
program would collapse.
The SBTP needs standardization in its operation as well as documentation. This
requires uniform policies and procedures, formal training on assessment and treatment
techniques as well as a comprehensive curriculum. A training program for psychologists
and YCCs working within the SBTP would bring all of the current and future staff onto
the same page regarding the treatment model. A comprehensive training plan for SBTP
and other facility staff needs to be developed which would not only include hours of
training as well as who is responsible at each facility but also the curriculum including
pre- and post testing. Materials for resource groups could be standardized by adopting
curriculums that have already been developed across institutions. For example, The
Prepare Curriculum by Arnold Goldstein, which is a collection of detailed coursed for
teaching pro-social skills to adolescents, could be implemented across institutions for less
than $125.
The J-SOAP and the Treatment Matrix need to be implemented. Ethical issues
such as Informed Consent and Confidentiality need to be clarified. The issue of the
records remains unresolved; an effective treatment program can only be conducted and
monitored if the records are accessible and useable. In general, SBTP has an excellent
staff that are committed and enthusiastic but are working without direction, which results
in inconsistency in approaches and an inability to spread the ideas and innovations of one
staff to the program in general. The fact that the SBTP team works under different
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11

organizational divisions creates a lack of communication, duplication of efforts and a
failure to have a workable method of recording treatment progress and issues. However,
SBTP has made some definite progress over the past several months.
September, 2007

Report of Sexual Behavior Treatment Expert
August 2007

_________________________________
Barbara Schwartz, Ph.D.
Farrell Sexual Behavior Treatment Expert

12

Standard

Title

1

Policies and
Procedures Which
Establish and
Govern the
Administration of
the Sexual
Behavior
Treatment
Program

2

Treatment Model

Description

Audit Criteria

Compliance Rate

Compliance Goal:
Written and officially approved a) The expert will review
Approved/Disapproved
policies and procedures will be
the Program Manual
included in a Program Manual
and all policies and
Rating: Disapproved
that describes in detail the
procedures to insure
implementation of the Sexual
adequacy.
The policies and procedures were
Behavior Treatment Program
started but DJJ has deferred them
until all policies and procedures can
be consistent This is preventing the
SBTP from implementing uniform
approaches, even on issues which
would not impact other programs.
Specific treatment programs
are established to address a
variety of special needs of
youths with sexual behavior.

a) Expert will review
group notes that
document the
existence of therapy
groups directed at
different risk levels
and special needs
participants. While

1

* Indicates that this was observed on the visit to the northern facilities.
** Indicates that this was observed in visit to southern facilities.
1

Compliance Goal: 95%
Rating: Partial
1

*While there are no special groups
for special needs offenders, there
are groups for Spanish-speaking
offenders
** A group for special needs youths
was observed at HGS. SRC reports
that one Spanish-speaking youth
was assigned to a caseload of a
Spanish-speaking YCC. However,
the groups are not conducted in
Spanish and this youth actually
speaks English well, according to

Standard

Title

Description

Audit Criteria

Compliance Rate
Dr. Uliani. She stated that he would
benefit more from a special needs
group but there are none available.
Some youth with co-morbid
conditions are receiving individual
therapy for these issues.

2

Standard
3

Title
Screening and
Assessment

Description

Audit Criteria

Appropriate screening and
assessment tools are used to
evaluate risk and treatment
needs initially and on an
ongoing basis. Included in the
assessment protocol will be an
evaluation of a participant’s
substance abuse history. These
screening and assessment tools
have demonstrated reliability
and validity.

a) Expert will review the
protocol for the
development and/or
selection and
administration of
appropriate screening
and assessment tools

Compliance Rate
Compliance Goal: Approved/Not
Rating: Not Approved
*DJJ is continuing to use the SORD
and this was present in all of the
cases reviewed. The staff has
reviewed an assessment instrument
but this instrument does not meet
the needs of the SBTP.
** DJJ-SBTP has scheduled
training on the J-SOAP to be
conducted in the middle of August.
** Despite the fact that Paul
Woodward stated that SORD scores
are emailed to all facilities with the
intent that scores be placed in the
youth’s file, no SORD scores could
be found at SRC.
**At HGS eight of the nine files
reviewed had both the SORD score
as well as the SORD instrument.

3

Standard

4

Title

Multi-modal
Treatment
Model-Residential
Component

Description

Audit Criteria

The treatment program
provides a multi-modal, multidisciplinary and offensespecific model, which is
responsive to the evolving
research on treatment efficacy
in the field of treating youths
with sexual behavior. The
residential program will be
presented at OH Close YCF,
NA Chaderjian YCF, Southern
Youth Correctional Center
Clinic, and Heman G. HGS
YCF.

4

Compliance Rate

b) The expert will access
10% of the records of
program participants
who have been in the
program for three
months and review for
the presence of
assessments that
follow the established
protocol.

Compliance Goal: 95%

a) The expert will review
10% of files for the
presence and
appropriate-ness of
group notes
documenting
individual progress in
at least three hours of
core group therapy per
week.

Compliance Goal: 95%

Rating: 50%
This rating reflects the fact that
psychological assessments were
present in some of the files but they
were not part of a consistent
assessment approach that is utilized
throughout the SBTP.

Rating: Partial
*Neither O.H.Close nor Chaderjian
are offering three hours of core
group therapy a week. They appear
to offering an average of two hours
a week (See Narrative)
** Neither SRC nor Stark are
offering three hours of core group
therapy. They are currently offering
less than two hours of core group
therapy. However, Dr. Barrigan at
HGS has instructed the
psychologists to begin doing two 90
minute groups a week.

Standard

Title

Description

Audit Criteria
b) The expert will review
10% of individual
treatment notes
documenting that each
program participant
receives individual
work including Case
Conferences and
individuals sessions
with treatment staff
for at least three hours
a week.

5

Compliance Rate
Compliance Goal: 95%
Rating: Partial
The records reflect that all of the
records had evidence of case
conferences but none of the
participants are receiving individual
therapy three times a week.

Standard

Title

Description

Audit Criteria
c) The expert will review
for presence and
appropriateness of the
resource group notes
documenting that at
least eight difference
groups are offered on
a ten-week schedule.
The expert will review
resource group
schedule and lists of
participants.

Compliance Rate
Compliance Goal: 95%2
Rating: 30%
*There are 9 Resource groups being
offered at Close but only 21 out of
55 youths are participating in them,
At Chad, 41 out of 49 youths were
participating in at least one resource
group but the majority of these
groups were offered to all
institutional residents and not
operated by the SBTP.
** At SRC six resource groups were
reported. However, some of these
are generic groups which are
offered to all of the facility residents
and are not related to SBTP. at least
one group was clearly related to
SBTP but only accommodated 7-8
youths.

6

**I observed a resource group at
HGS but it is not possible to tell
from the records which youth are in
resources groups and which have
completed resource groups. The
notes co not consistently identify
what they are about. Ms. Heatherton
agreed to have the YCC’s document
in a title what the note is about.
Several residents had certificates of
completion in their files others did
not. Notes on one resident indicated
that he had completed 8 resource
groups but there were no
certificates.

Standard

Title

Description

Audit Criteria

Compliance Rate

d) The expert will review
10% records for the
presence and
appropriateness of
special resource group
notes documenting
that at least two
different special
resource groups
offered on a ten week
schedule

Compliance Goal: 95%

e) The expert will review
documentation
reflecting an effort to
involve relevant
family members in the
treatment program in
Stages Three, Six and
Nine.

Compliance Goal: 95%

Rating: Partial
There were no group notes
documenting special resource
groups. These groups may be being
conducted but there was no way to
determine this from the records.

Rating: Partial
*There is some work being done
with families but there is little
documentation of family sessions or
attempts to contact families.
** SRC maintains a family contact
log and contact with families was
documented in 5 of 7 files.
**HGS does not document family
involvement.

7

Standard

Title

Description

Audit Criteria
f) The expert will review
for presence and
appropriateness of
relevant
documentation of
meetings with family
members.

Compliance Rate
Compliance Goal: 95%
Rating: Partial
* There were no notes documenting
this.
**I observed a family group being
conducted at SRC. I presume that
will be documented in the mental
health record.
**Staff at HGS report that they
regularly attempt to contact
families; however, they report little
success in involving families in
youth treatment often are unable to
reach youth families at all.

g) The expert will review Compliance Goal: 95%
10% of records for
Rating:0 %
presence and
There are no maintenance groups
appropriate-ness of
group notes on
maintenance groups
for all program
participants having
completed Stage 10
documenting at least
one hour of treatment
a week following
completion of
residential treatment.
8

Standard
5

Title
Multi-model
Treatment ModelOutpatient
Component

Description

Audit Criteria

The treatment program
a) The expert will review
provides a multi-modal, multi10% of records for
disciplinary and offensepresence and
specific model, which is
adequacy of group
responsive to the evolving
notes documenting
research on treatment efficacy
individual progress in
in the field of treating youths
at least two hours of
with sexual behavior. This
group therapy per
program will be provided at all
week.
facilities to medium risk youths
b) The expert will review
with sexual behavior.
10% of records for the
presence and
adequacy of individual
treatment notes
documenting that each
ward receives
individual work
including Case
Conference and
individuals sessions
with treatment staff
for at least one hour
every two weeks

9

Compliance Rate
Compliance Goal: 95%
Rating: 0%
There are no outpatient groups as
described in the master plan.

Compliance Goal: 95%

Standard

Title

Description

Audit Criteria

Compliance Rate

c) The expert will review Compliance Goal: 95%
10 % of records for
resource group notes
documenting that at
least one resource
group is offered on a
ten-week schedule.
d) The expert will review Compliance Goal: 95%
documentation
reflecting an effort to
involve relevant
family members in the
treatment program in
Stages Three, Six and
Nine.
e) The expert will review Compliance Goal: 95%
for presence and
appropriate-ness
relevant
documentation of
meetings with family
members

10

Standard

Title

Description

Audit Criteria

Compliance Rate

f) The expert will review
10% of files for the
presence and
adequacy of group
notes from
maintenance groups
conducted for all
wards having
completed Stage 10.
6

Milieu Therapy in
Residential
Treatment

The SBTP residential
component will be offered in a
modified therapeutic
community/milieu therapy
model in which youths are
provided with opportunities to
learn appropriate social
behaviors and are encouraged
to exercise responsibility for
themselves and others.

11

a) The expert will review
for presence and
adequacy the notes of
residential large group
minutes documenting
that such two groups
are held per week for
a total of four hours
per week.

Compliance Goal: Present/Not
present
Rating: Not present
No documentation. While the staff
of SYRCC reportedly gave the audit
team a packet containing the
signatures of youth participating in
weekly Therapeutic Community
groups, this was in the packet I
received.

Standard

Title

Description

Audit Criteria

Compliance Rate

b) The expert will review Compliance Goal: 85%
committee and large
Rating: 0%
group notes to
No documentation
ascertain whether
program participants
are participating in a
variety of committees
related to the
operation of the
residential treatment
program
7

Individuation of
Treatment

The treatment of program
participants with problematic
sexual behavior is
individualized through the
provision of specialized groups
and referral for ancillary
therapeutic experiences.

a) Expert will review a
random selection of
records of program
participants who have
been identified with
special needs and
evaluate
documentation that
specialized services
have been provided.
b) Expert will review
rosters of specialized
resource groups and
other therapeutic
experiences.

12

Compliance Goal: 95%
Rating: Partial
* Northern programs did not have
specialized groups **HGS did have
a specialized groups.
All of the programs provide some
degree of individual therapy which
can address special programs

Standard
8

Title
Treatment Plans
with Objective
Goals

Description

Audit Criteria

All program participants will
have written treatment plans
that are revised quarterly with
clearly stated objective goals.

a) Expert will review a
10% of records for
documentation of
objective behavioral
goals that are prepared
and updated quarterly
for all participants

Compliance Rate
Compliance Goal: 95%
RATING: 40%
There are periodic treatment plans
at all facilities but they are not
coordinated with the levels of the
SBTP. Dr. Martin has now provided
me with a copy of the treatment
matrix which will be used to do this.

b) Expert will review
Compliance Goal: 95%
those same clinical
records for evidence
that appropriate
therapeutic
interventions have
been provided to assist
the youth in meeting
the behavioral goals.
9

Victim Outreach

The treatment program
coordinates with treatment
programs and therapists of
individual victims as well as
agencies that address sexual
abuse in the community to
combat the problem of sexual
assault.

a) The expert will review Compliance Goals: Present/Not
the file of
Present
correspondence with
community therapists.
b) The expert will review Rating: Not present
documentation of
outreach to victims’
agencies

13

Standard
10

11

Title
Staff Qualifications

Staff Training

Description

Audit Criteria

Compliance Rate

The program employs a) Expert will
staff who are qualified
review the
and competent to work
number and
with youth with sexual
professional
behavior in a sufficient
qualifications of
number to insure
SBTP staff.
adequate treatment and
supervision as well as
a diversity of relevant
skills.

Compliance Goal: 100%

Staff is provided with
relevant initial
orientation and
ongoing in-service
training as outlined in
the program plan as
well as opportunities
to attend professional
conferences.

Compliance Goal: 95%

a) Expert will
review training
records of the
SBTP staff.

Rating: 50%
All psychologists have
academic qualifications.
The expert was not provided
with qualifications of YCC
staff although interviews with a
sampling of this staff showed
that most had educational
qualifications above the
minimum required.
Rating: 50%
DJJ sent 60 staff members to a
conference but there is neither
a training plan nor consistent
or ongoing training in the
SBTP approach.
** SRC provided evidence of
an “all day team meeting and
training” Training records were
provided.
**HGS also provided staff
training records.

12

Staff Supervision

The program provides
regularly scheduled
14

a) The expert will
review a log of

Compliance Goal: 95%
Rating: Not reviewed

Standard

Title

Description
supervision for all
staff working directly
with wards.

13

14

Multi-disciplinary Team
Reviews

Ethics

Audit Criteria

Compliance Rate

supervision
meeting. No log
of supervised
with provided.

The program uses
multidisciplinary
teams which conduct
quarterly treatment
reviews regarding
client information

a) The expert will
review minutes
of the multidisciplinary
teams.

Compliance Goal: 95%

The program insures
that treatment is
offered in a way that
respects the ethical
principles of the
involved professions
as well as insuring that

a) The expert will
review written
procedures
regarding
confidentiality
and informed
consent

Compliance Goal: 100%

15

Rating: 95%
There are minutes of Multidisciplinary team reviews,
which focus on the overall
program with few specific
references to progress in
SBTP.
Rating: 0%
Legal has been consistently
requested to clarify DJJ’s
stance on various ethical issues
but this has never been
responded to.

Standard

Title

Description

Audit Criteria

Compliance Rate

confidentiality,
b) Audit will review Compliance Goal: 100%
informed consent and
10% of randomly
Rating: 0%
due process are
selected files for
insured. All
documents
participants are
signed by
informed and sign
program
documents reflecting
participants
an understanding of
informing them
the limits of
of these policies
confidentiality,
informed consent to
treatment and their due
process rights.
15

Program Completion

Completion of the
program reflects the
completion of
competency-based
goals.

16

a) The expert will
review 10% of
clinical files of
program
completers for
evidence that
program
completion was
based on the
completion of
competencybased goals.

Compliance Goal: 95%
Rating: 0%
It was noted that the absence of
this contributed to one youth
having a Section 1800 filed

Standard
16

Title
Suspension/Termination
from SPTP

Description

Audit Criteria

Suspension or
termination for the
SBTP are based on
written policies which
prescribe that the
reasons for such
measures are clearly
documented, that staff
undertakes proactive
intervention when
program completion is
at jeopardy and that
the principles of due
process including
impartial hearings and
an appeal procedure
are in place.

a) The expert will
review 10 % of
clinical records
for documents
reflecting
program
participants’
understanding of
program rules
related to
suspension and
termination.

Compliance Goal: 95%
Rating: 0%
** Selected youth at SRC were
interviewed and were not
uniformly aware of what would
get them suspended or
terminated. No documentation
in the records indicate that
youth receive the orientation
that the facility indicate that
they receive.

b) Audit will review Compliance Goal: 95%
20% of records
Rating: Not Rated
of terminated or
suspended
participants to
insure the they
comply with
policy
c)

17

Compliance Rate

Standard
17

Title
Pre-release

Description

Audit Criteria

The pre-release
a) The expert will
process will be
review 20% of
implemented 60 days
files of program
before discharge and
participants who
will include evaluation
have completed
of proposed residence
the pre-release
as well as the
program for
preparation of a predocumentation
release package.
that the program
Efforts will be made
participants
by the SBYP to help
proposed
the program
residence has
participants develop an
been evaluated
appropriate support
and that the pregroup, containment
release package
group or relapse
was complete at
prevention group.
the time of
release

18

Compliance Rate
Compliance Goal: 95%
Rating: Not Reviewed

Standard

Title

Description

Audit Criteria

Compliance Rate

b) The expert will
Compliance Goal: 95%
review 10% of
Rating: Not Reviewed
records of
program
participants who
have completed
the pre-release
process for
documentation
(phone logs,
records, etc) that
efforts have been
made to assist the
program
participant in
acquiring an
appropriate
support group
18

Aftercare

CYA will contract
with community
vendors to provide
aftercare treatment.
Additionally efforts
will be made to
develop parole as an
extension of treatment

19

a) The expert will
review monthly
reports from
community
vendors to insure
that they are in
compliance with
provisions of the
contract.

Compliance Goal: 95%
Rating: Not Reviewed

Standard

Title

Description
and informed
supervision

19

Program Evaluation

Audit Criteria

Compliance Rate

b) The expert will
review
documentation
that the SBTP
has been
involved in the
training of parole
personnel.

Compliance Goal: Present/Not
Present

CYA will conduct an a) The expert will
evaluation of the
review written
SBTP, which will
proposal for the
assess basic
evaluation
demographic factors,
project and
progress in treatment
compliance with
and treatment outcome
agreed upon
including recidivism
deadlines
rates and their possible
correlation with the
above. If possible, a
control group shall be
identified and
followed with the
same variables.

20

Compliance Goal Present/Not
Present

Standard
20

21

22.

23.

Title
Program Materials

SBTP Program Coordinator

Vocational Training

Physical Facilities

Description

Audit Criteria

CYA will contract with
a publisher to produce a
standardized set of
workbooks/journals for
the SBTP to include
specialized materials
for developmentally
disabled, females and
Spanish-speakers.
These materials will be
culturally sensitive.

a) Audit will review
written contract with
publisher for
compliance with
contract

Compliance Rate
Compliance Goal:
Present/Not Present
Rating: Partially Present:
this is presently being done
partially by Dr. Cellni

CYA will retain a full
a) The expert will
time program
evaluate whether this
coordinator of the
position has been
SBTP who will
filled.
orchestrate the
establishment and
ongoing operation of all
facets of the SBTP

Compliance Goal:

The CYA will make
a) The expert will
vocational opportunities
evaluated vocational
available for youths
training opportunities
with sexual behavior.
for youth with sexual
behavior.

Compliance Goal:
Present/Not Present

CYA will insure that
adequate and
appropriate physical
facilities for available

Compliance Goal:
Present/Not Present

21

a) The expert will
inspect the physical
facilities to insure
that they are

Achieved/Not Achieved
Rating: Achieved

Rating: Not Evaluated

Rating: Partial

Standard

Title

Description
for both the residential
and outpatient
programs.

24

26

Behavioral Management System

Healthy Sexuality Programs for all
wards

Audit Criteria
appropriate for
conducting a
therapeutic program.

Compliance Rate
The current facility at
Chad is inadequate. The
space is tiny and is used as
a corridor. Facilities at
other institutions are
adequate.

SBTP will develop a
behavioral management
system based upon the
latest research on
effective approaches
which will reward
prosocial behavior and
provide reasonable
consequences for
antisocial behaviors

a) The expert will
Compliance Goal: 95%
review 10% of all
Rating: Not Rated
records for
documentation, which
supports the use of
such a system.

CYA will establish
Healthy Sexuality
Programs for all wards
of CYA.

a) The expert will
Compliance Goal: 95%
review records, which
Rating: 50%
document existence
I went to Dr. Cellini’s
of such programs.
office and he showed me
the Healthy Sexuality
curriculum, which appears
to be completed. The
program will then need to
be piloted, staff trained and

22

b) The expert will
review 10% of files
containing
disciplinary reports
for documentation,
which supports use of
such a system.

Compliance Goal: 95%
Rating: Not Rated

Standard

Title

Description

Audit Criteria

Compliance Rate
the program implemented.
.

27

Training of Adjunct Staff in Needs
of Youths with Sexual Behavior

SPTP staff will provide
training to educational,
medical, recreational
and security staffs on
the needs of youths
with sexual behavior.

a) The expert will
review training
records documenting
that adjunct staff of
CYA facilities have
been trained in the
needs of youths with
sexual behavior.

Compliance Goal:
Present/not Present

b) The expert will
review the content of
training materials to
insure that quality
training is being
provided is suitable.

Compliance Goal: Present
/not present

In addition to review records, the expert will directly observe these activities and facilities.

23

Rating: Partial
At Chad, this training was
being conducted. This
item was not monitored
for at other facilities

Rating: Not present