1 DONALD SPECTER (SBN 83925)
2 dspecter@prisonlaw.com SARA NORMAN (SBN 189536)
3 snorman@prisonlaw.com
4 PRISON LAW OFFICE 1917 Fifth Street
5 Berkeley, California 94710
6 Telephone: (510) 280-2621 Fax: (510) 280-2704
7

8 SHAWN HANSON (SBN 109321)

shanson@akingump.com 9 AMIT KURLEKAR (SBN 244230)

10 akurlekar@akingump.com

11

ANYA FREEDMAN (SBN 275213) afreedman@akingump.com

12 AKIN GUMP STRAUSS HAUER

13

& FELD LLP 580 California Street, Suite 1500

14 San Francisco, CA 94104-1036

15

Telephone: (415) 765-9500 Fax: (415) 765-9501

16

17

Attorneys for Plaintiffs Quinton Gray, Angela Patterson, and Stanley Kujansky

18

19
UNITED STATES DISTRICT COURT
20
FOR THE CENTRAL DISTRICT OF CALIFORNIA
21

22 QUINTON GRAY, ANGELA

23 PATTERSON, and STANLEY

24

KUJANSKY, on behalf of themselves and all others similarly situated,

25
26 v.

Plaintiffs,

27 COUNTY OF RIVERSIDE,

28 Defendant.

Case No. CLASS ACTION
CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

NATURE OF THE ACTION

2

1. Riverside County has one of the largest jail systems in California, with

3 nearly 4,000 men and women held in five detention facilities (“Riverside jails”).

4 This population consists of both pretrial detainees and people serving sentences in

5 local custody (collectively referred to herein as “prisoners”).

6

2. The thousands of men and women locked up in Riverside’s jails face

7 cruel and inhumane deficits in medical and mental health care. Defendant has

8 known for years that its inadequate health care delivery system places prisoners

9 entering the jails at a serious risk of harm but has failed to take the necessary steps

10 to mitigate the risk. As a result, prisoners in the Riverside jails are subjected to

11 policies and practices that systematically deprive them of their constitutional right to

12 basic life-saving care.

13

JURISDICTION

14

3. The jurisdiction of this Court is invoked pursuant to 28 U.S.C. §§ 1331,

15 1343, and 1367. Plaintiffs seek declaratory and injunctive relief under 28 U.S.C. §§

16 1343, 2201, and 2202; and 42 U.S.C. § 1983.

17

VENUE

18

4. Venue is proper in the Central District of California under 28 U.S.C. §

19 1391(b) because Plaintiffs’ claims for relief arose in this district and Defendant is

20 located in the district.

21

PARTIES

22 Plaintiffs

23

5. Plaintiff Quinton Gray is a prisoner in the Riverside jails in custody of

24 Defendant Riverside County. He has multiple chronic medical and mental health

25 conditions, including seizures, high blood pressure, severe arthritis, and visual and

26 auditory hallucinations and depression. He has experienced and continues to

27 experience repeated treatment failures, including delays in adjusting medication

28
1
CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 regimens, lack of appropriate laboratory monitoring and frequent missed doses. His

2 initial intake form, similar to other Riverside files, documented “no” to all questions

3 (including history of seizures and high blood pressure)—demonstrating inadequate

4 intake procedures. Even when Mr. Gray has been seen, he has not received adequate

5 basic primary care: for example, he was not screened for high cholesterol or

6 diabetes, despite his chronic high blood pressure.

7

6. Further, Mr. Gray was placed on potent psychotropic medication

8 without appropriate evaluation by a mental health professional with an utter failure

9 to monitor serious and possibly life-threatening side effects. Medications were

10 either suddenly discontinued or multiple doses missed, placing him at serious risk of

11 serious side effects and psychiatric decompensation. He in fact experienced and

12 continues to experience significant, injurious side effects from his medication

13 mismanagement and treatment failures. Mr. Gray has exhausted his administrative

14 remedies.

15

7. Plaintiff Angela Patterson is a prisoner in the Riverside jails in custody

16 of Defendant Riverside County. After sustaining severe injuries in a car accident in

17 June 2009, Ms. Patterson had a temporary filter placed in her inferior vena cava

18 (IVC), the blood vessel supplying the heart, to prevent blood clots. She was booked

19 into the Riverside jails shortly thereafter, where she was subjected to multiple

20 delays, cancellations, appointment mix-ups, and failures to provide appropriate

21 follow-up regarding safe removal of the temporary filter. Nearly a year later, when

22 she was finally taken for surgery, it was found that the filter could not be removed

23 due to the build-up of scar tissue. As a result, Ms. Patterson is now condemned to a

24 lifetime of daily anticoagulation medications and frequent laboratory monitoring,

25 with significant risk of fatal bleeds and other complications. She is 26 years old. If

26 physicians had appropriately obtained and reviewed her records, and made efforts to

27

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 refer her for IVC filter removal in a timely fashion, it is likely that the filter could

2 have been removed and Ms. Patterson would need no further treatment.

3

8. In addition, she has experienced multiple delays in follow-up with the

4 orthopedic and vascular surgery clinics as well as in the work-up of a scalp mass.

5 She has also not had timely and effective medication monitoring and administration,

6 resulting in frequent stretches of time where her anticoagulation levels are too low

7 or too high, placing her at risk for further complications. Ms. Patterson has

8 exhausted her administrative remedies.

9

9. Plaintiff Stanley Kujansky1 is a prisoner in the Riverside jails in

10 custody of Defendant Riverside County. He has been subjected to substandard care

11 while in Defendant’s custody, with inadequate medication administration and

12 treatment of his blood pressure and multiple delays in the work-up and diagnosis of

13 his chronic neck pain. As a result, he has suffered and continues to suffer

14 unnecessary pain and Defendant’s treatment has endangered his cardiovascular

15 health. Mr. Kujansky has exhausted his administrative remedies.

16 Defendant

17

10. Defendant County of Riverside operates five jails -- the Robert Presley

18 Detention Facility, the Smith Correctional Facility, the Indio Jail, the Southwest

19 Detention Center, and the Blythe Jail – that incarcerate nearly 4,000 prisoners. The

20 County is responsible for providing a constitutional level of health care for those in

21 its custody, including the funding, oversight, and corrective action to ensure

22 adequate conditions.

23

24

25

26 1 Due to a clerical error, Mr. Kujansky is referred to as Stanley Kwawsky or 27 Kujawsky in the Riverside jail records.

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

FACTUAL ALLEGATIONS

2 I. Riverside County exhibits systemic failures in the provision of basic

3

health care to prisoners in its jails.

4

11. Defendant, by policy and practice, maintains and runs a health care

5 system that lacks basic elements necessary to provide constitutional care: it

6 systematically fails to identify and diagnose serious conditions, to provide timely

7 care, to administer appropriate medications, to employ adequate staff to meet

8 prisoners’ basic needs, to maintain records that allow informed treatment decisions,

9 to establish legally required confidentiality, and to identify and correct its own

10 failings.

11

12. Prisoners’ access to health care is so inadequate at all the Riverside

12 jails as to constitute deliberate indifference to their serious medical and mental

13 health needs. Further, Defendant is deliberately indifferent to the fact that these

14 systemic failures result in significant injury and a substantial risk of serious harm.

15

A. Delays in and denial of access to care

16

13. Defendant has a policy and practice of failing to provide timely access

17 to necessary health care and is deliberately indifferent to the risk of harm and injury

18 to prisoners that results from this systemic failure. Care is often delayed or denied

19 entirely, causing unnecessary pain and suffering as well as physical injury to the

20 patients. The two basic mechanisms to alert health care staff to prisoners’ needs --

21 intake screening and sick call – are inadequate in both policy and practice.

22

1. Intake screening

23

14. Riverside’s jail screening and intake process fails to adequately identify

24

and treat the medical and mental health care problems of newly arriving prisoners.

25

15. Insufficient numbers of nursing staff are available to identify and

26

evaluate medical conditions on intake, resulting in dangerous delays in treatment.

27

Prisoners are rarely assessed for communicable diseases when they arrive at the

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 jails, and medically high-risk prisoners do not have histories taken, physical

2 assessments, or treatment plans.

3

16. Plaintiff Quinton Gray arrived at the Riverside jails with a chronic

4 seizure disorder and high blood pressure. His initial intake form nonetheless has

5 “no” marked for every question about health care needs, including those that should

6 clearly be marked “yes.” Numerous other prisoners with longstanding chronic

7 conditions have intake forms with the same deficiencies, demonstrating an

8 inadequate intake screening process.

9

17. As a result, prisoners are placed at serious risk of harm. For example,

10 one woman who regularly takes medication for her chronic severe high blood

11 pressure entered the Riverside jails on September 9, 2011. She received no

12 medication or, indeed, any recorded medical screening or attention until she suffered

13 chest pain and hypertensive emergency nearly three weeks later. At that time, she

14 was sent to the emergency room at Riverside County Regional Medical Center

15 (RCRMC) and found to have blood pressure of 230/140 -- high enough to cause a

16 stroke, vision loss, or a heart attack.

17

18. Another woman with multiple serious medical conditions, including

18 hypothyroidism, diabetes, and a recent history of gastric bypass surgery, had no

19 record of any of these crucial health factors on her booking form, in which every

20 question regarding the presence of health care needs was marked “no.” Treatment

21 for her serious chronic conditions was delayed, resulting in significant health risks.

22

19. Another patient who arrived in the Riverside jails with multiple

23 longstanding chronic conditions -- a seizure disorder, asthma, psoriasis, and

24 Hepatitis C -- had “no” marked for every question on his booking form regarding

25 medical history. As a result, he did not receive all of his necessary medications for

26 several weeks.

27

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1

20. Initial mental health screening at the jails is faulty because it is

2 performed by untrained custody staff, a practice that Riverside Sheriff Stanley Sniff

3 knows is inadequate and dangerous because, as he states, “correctional officers may

4 not recognize hidden medical and/or mental health problems that could be best

5 observed by a medical/mental health expert. This could result in delaying needed

6 treatment.” Appropriate screening is particularly important since, according to the

7 Sheriff, “the time period immediately following admission to a jail is the most

8 dangerous time for an inmate, and over half of in-custody deaths occurred within

9 one month of admissions, with 24% of deaths occurring within two days of

10 admission.”

11

21. One man admitted to the Smith Jail had no recorded intake or screening

12 at all. He was eventually placed in a suicide watch “safety cell” and given

13 psychotropic medications (Zoloft and Trazodone). His medical records contain no

14 diagnosis, medical administration records, review of symptoms, psychiatric history,

15 social history, review of current medications, allergies, mental status examinations,

16 vital signs, risk assessments or treatment goals.

17

22. Another prisoner’s intake note is extremely brief and illegible. It does

18 not contain an adequate diagnosis, review of symptoms, social and psychiatric

19 history, allergies, mental status examination, vital signs, risk assessment, or

20 treatment goals. The patient was given multiple psychotropic medications,

21 including antipsychotics, with no subsequent recorded clinical notes describing

22 symptoms, ongoing examinations, or diagnoses. The inadequate screening and

23 diagnostic process placed him at risk for dangerous unmonitored side effects,

24 contraindicated medications, and untreated mental illness.

25

23. Another patient was prescribed Trazodone, Risperdal and Zoloft

26 without any associated documentation indicating he was first assessed by a mental

27 health professional and provided a treatment plan outlining a rationale for these

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 medications. There was no documentation of informed consent, which in his case is

2 particularly important since he had a pre-existing seizure disorder and type-II

3 diabetes. Risperdal lowers the seizure threshold and can worsen type-II diabetes.

4 On the day he was prescribed Risperdal, Trazodone and Zoloft, he submitted a

5 health needs request stating he had a seizure in his cell. Risperdal should be

6 attempted to be lowered or discontinued if patients are having uncontrolled seizures

7 prior to starting or on the medication. There is no documentation of screening for

8 active seizures prior to initiating Risperdal and no documentation addressing co-

9 management of his seizure disorder and use of Risperdal with a neurology specialist.

10

2. Sick call and access to care

11

24. Even if their serious medical concerns are flagged at intake, patients are

12 often unable to obtain care because the sick call system is inadequate. Outside

13 monitors have repeatedly found the Riverside jails incapable of providing the daily

14 sick call that state law requires. These conditions harm prisoners, who experience

15 extreme difficulty in obtaining necessary medical and mental health appointments.

16 In the absence of a functioning sick call system they must either obtain a court order

17 from the criminal court or file repeated blue slips (health needs requests, or HNRs)

18 and grievances. Plaintiff Quinton Gray has never seen a Riverside jail doctor

19 without an order from the Superior Court for care. He has received three orders: in

20 late 2011, in June 2012, and in September 2012. Plaintiff Stanley Kujansky

21 similarly has had to obtain court orders to see a doctor in the Riverside jails.

22

25. Court orders, blue slips, and grievances regarding health care are

23 routinely ignored. The County maintains an extensive computerized list of court-

24 ordered appointments that notes how long the prisoners have been waiting; delays of

25 one, two, or three months are common. One prisoner obtained a court order on

26 November 21, 2011, that orders her “to see medical doctor within 48 hours to be

27 evaluated for severe pain due to hernia on back. Court recommends medication

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 treatment to control pain.” After waiting several weeks, the prisoner filed a

2 grievance asking that the order be honored. The response, dated December 23,

3 2011, acknowledged the court order and the month-long delay and stated that

4 “nurses confirmed they are waiting for the doctor to show up to see the court

5 orders.” Plaintiff Stanley Kujansky was prescribed pain medication without ever

6 seeing a doctor in the jails; he received a court order on November 22, 2011, to see a

7 doctor for his pain, but was not actually seen until January 25, 2012.

8

26. Some prisoners who request medical attention are told that doctors are

9 only seeing patients with court orders for care.

10

27. Prisoners also file repeated blue slips without any result except a $3

11 charge exacted for each request. As a result, they are placed at serious risk of harm.

12 For example, one patient filed numerous blue slips complaining of serious stomach

13 pain but was never seen by a doctor. After three months of such complaints, he

14 submitted a blue slip stating that he was vomiting blood, a symptom that can

15 indicate an emergency leading to death and which is at minimum is concerning for

16 gastric disease such as peptic ulcers or cancer. The patient should have seen a

17 physician immediately, had his vital signs and blood counts checked, and possibly

18 even have been referred to an emergency room or gastroenterologist for further

19 evaluation. None of this was done. He was not even referred to see a doctor for

20 another month.

21

28. Compounding the problem, prisoners often have extreme difficulty

22 grieving inadequate access to care since they must request grievance forms from

23 sheriffs’ deputies, who often refuse to provide them. Plaintiff Quinton Gray filed a

24 grievance in September 2012 noting serious ongoing problems with access to

25 medical and mental health care, and stating that he had to get a grievance form from

26 “an outside agency” because of custody staff’s refusal to provide him with a form

27 and their interference with access to adequate health care.

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

29. As a result of these policies and procedures, prisoners experience

2 dangerous delays in access to both primary and specialty care.

3

30. One woman entered the Presley jail with Stage Four colon cancer in

4 late July 2011. In early August, she was seen for abdominal pain, nausea and

5 vomiting, similar to the colon cancer symptoms she had experienced on first

6 diagnosis. Her outside medical records, obtained at that time by the County,

7 documented chemotherapy in 2009 for colon and ovarian cancer and a recent CT

8 scan showing possible recurrence. With these strong indicators that her cancer had

9 returned, she should have received a colonoscopy and referral to an oncologist

10 within a very few weeks. Although both referrals were made on August 3, neither

11 was completed by the time she was released from custody in December 2011. For

12 more than four months, County medical providers demonstrated gross incompetence

13 and negligence, with unexplained delays, apparently lost referrals, and a botched

14 attempt at a colonoscopy, for which she was not given a basic bowel preparatory

15 procedure – an elementary mistake. Throughout this time, the patient repeatedly

16 complained of abdominal pain and rectal and vaginal pressure. The lack of care for

17 her malignancy possibly allowed it to progress to a point where she was no longer a

18 candidate for further treatment, shortening her life expectancy. The inadequate

19 treatment for her symptoms forced her to endure unnecessary pain and suffering.

20

31. Another woman with a breast tumor suffered significant delays in care:

21 she was denied timely appointments with a physician; multiple specialty

22 appointments were not scheduled or were skipped, despite physician referrals; and

23 she was frequently not notified of important test results such as biopsies, when

24 standard practice is to notify patients of results within one to two weeks. Nearly

25 every time her complaints were addressed by medical staff was in response to a

26 court order. Her tumor was found to be benign; had it been malignant, these

27 cumulative delays could have been life-threatening. Although she received some

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 medications to treat her ovarian cyst-related pain, she continued to have pain and

2 physicians failed to order a repeat vaginal ultrasound or refer her to gynecology for

3 further evaluation and management, as the standard of care requires.

4

32. Plaintiff Angela Patterson arrived at the Riverside jails following

5 surgery to place a temporary filter in a major blood vessel supplying her heart. She

6 was discharged directly from the RCRMC hospital to the jail. Despite the fact that

7 such filters should be removed within three months, there was no acknowledgment

8 of the existence of the filter in her jail medical records for over a month. Ms.

9 Patterson then endured many months of delays, cancellations, and scheduling mix-

10 ups in specialty care, as well as repeated medication administration failures. For

11 nearly six months, medical staff documented confusion over whether the IVC filter

12 was temporary or permanent; they did not resolve the matter until March 2010, nine

13 months after the filter was placed in her body. She was not seen in surgery until

14 June 25, 2010, at which point it was discovered that the filter could not be safely

15 removed because of the accumulation of scar tissue.

16

33. Following the surgery, a Riverside jail doctor discontinued Ms.

17 Patterson’s anticoagulation medication because of “filter removal,” despite the fact

18 that it was still in her body and there was a note in her medical records from two

19 days earlier reporting that the filter had not been removed. In August 2010, she was

20 placed on life-long anticoagulation therapy. Anticoagulation therapy has significant

21 risks, including the risk of fatal bleeds, and requires daily medication and frequent

22 laboratory monitoring -- a weighty burden, particularly for Ms. Patterson, who is 26

23 years old. If physicians had appropriately obtained and reviewed her records and

24 made efforts to refer her for IVC filter removal in a timely fashion (within a few

25 months of placement), it is likely that the filter could have been removed and Ms.

26 Patterson would need no further anticoagulant therapy, with all the risks that entails.

27

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

34. A patient with chronic high blood pressure was inadequately screened

2 on intake, as described above, which resulted in an emergency room visit and

3 dangerously high blood pressure. Subsequent months in custody saw no

4 improvement in her care, as Riverside County medical staff failed utterly to monitor

5 her chronic condition. Her care was repeatedly delayed, prescribed medications

6 repeatedly not offered, and the sub-par care led to multiple episodes of uncontrolled

7 hypertension and preventable emergency room visits.

8

35. A patient experiencing uncontrolled seizures and multiple emergency

9 room visits was not given a neurology referral for more than three months after his

10 arrival in the Riverside jails. After the referral was made, he waited for two more

11 months to actually see a neurologist, although he was having seizures two to three

12 times per week, often sustaining head trauma and other injuries, and although

13 managing his condition was clearly beyond the scope of a general medicine

14 practitioner. The neurologist recommended an EEG, which was never performed.

15 The patient continued to have uncontrolled seizures and emergency room visits; he

16 had another neurologist appointment two months later, at which point the EEG was

17 re-ordered. The patient was never referred to an epilepsy specialist, despite the clear

18 indication that his medication regime was ineffective and such a consultation was

19 needed. Continued, untreated generalized seizures place patients at high risk for

20 immediate injury (such as he repeatedly sustained) as well as worsening long-term

21 cognitive impairment, decreased function, and diminished quality of life.

22

36. Another patient arrived in jail with a lap-band that had been surgically

23 inserted into his stomach for weight loss. He soon began to demonstrate symptoms

24 of a esophageal obstruction (a known complication of such surgery), including

25 significant weight loss, nausea, vomiting, and extreme hunger. Despite numerous

26 requests for help, he experienced unnecessary delays in diagnosis and treatment and

27 failure to respond to his multiple health complaints. For example, after two

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 episodes of loss of consciousness, a documented 17-pound weight loss in 30 days,

2 complaints of inability to tolerate any food or liquid intake, and a blood pressure of

3 90/60, he was merely referred for a medical appointment more than a week in the

4 future. The delays in diagnosis of his obstruction put him at risk for serious health

5 complications due to rapid weight loss and deprivation of essential nutrients.

6

37. Access to mental health care is no better. Defendant’s deficient system

7 forces mentally ill prisoners to wait weeks or months for mental health assessment

8 and evaluation by clinical staff, during which time they are denied essential

9 psychotropic medications and other treatment. The Sheriff admitted this problem in

10 July 2011, acknowledging that “such delays may impact an inmate’s mental

11 stability.” As with medical care, many mental health patients must file repeated

12 blue slips or grievances to get seen; others are only seen by clinicians after the

13 judges in their criminal cases have ordered care. Patients experience a range of

14 symptoms, from auditory hallucinations to severe depression, while enduring these

15 lengthy delays.

16

38. Patients with serious dental care needs suffer from the same pattern and

17 practice of injurious delays. Patients in severe pain wait for months to see a dentist

18 and face significant pain and suffering as a result. For example, one patient with

19 only two functioning teeth lost more than 20 pounds in the six months he has been

20 incarcerated because he is unable to eat much of the food he is served and he cannot

21 afford to buy his own. He has submitted blue slips to see a dentist to get dentures

22 without success.

23

39. Another patient experienced serious delays in care: her complaints of

24 tooth pain were first documented in her health records in December 2011. On

25 March 17, 2012, a progress note in her file simply reads “Back upper Rt tooth broke

26 and gum swollen.” This one-line progress note, with no medical history, duration of

27 symptoms, or full exam, is inconsistent with accepted medical standards of care. In

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 addition, the patient was prescribed penicillin and motrin for her symptoms without

2 any mention of a dental referral or evaluation.

3

40. Another patient filed a request complaining of a broken tooth and

4 requesting a dental referral on September 21, 2011. He submitted a repeat request a

5 month later also requesting a dental referral. He was not seen for these complaints

6 until November 1, 2011, at which time medical staff noted that he had decayed teeth

7 and referred him to dental staff without any mention of his ability to eat or whether

8 the tooth looked infected. In the many months he has been waiting, he has

9 experienced intermittent severe pain in his teeth that makes him unable to eat

10 several times a week.

11

3. Specialty referrals

12

41. The Riverside jails lack adequate policies and procedures to provide

13 patients with needed referrals for specialty medical consultations and procedures.

14 For example, a patient with colon cancer was referred for a colonoscopy and to an

15 oncologist on August 3, 2011, but neither was completed by the time she was

16 released from custody in December 2011. Given that her cancer was Stage IV, she

17 should have been seen in a very few weeks.

18

42. As discussed above, Plaintiff Angela Patterson experienced numerous

19 delays and cancellations in specialty referrals, which likely led to build-up of scar

20 tissue on a temporary filter in a blood vessel near her heart. As a result, she will live

21 the rest of her life with this filter in her chest and suffer a lifetime of serious

22 anticoagulation medication with related health risks and the burden of frequent

23 monitoring.

24

43. Another man with uncontrolled seizures and multiple emergency room

25 visits was not given a neurology referral for more than three months after his arrival

26 in the Riverside jails. After the referral was made, he waited for two more months

27

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 to actually see a neurologist, although he was having seizures two to three times per

2 week.

3

44. A man who had experienced severe recent head injuries was ordered an

4 ENT consultation by a Riverside jail doctor but it did not take place and had to be

5 re-ordered one month later. When the ENT consultation finally took place, he was

6 not sent with his crucial records and the appointment was of limited use. He was

7 referred for surgery on September 30, 2011, but did not receive it, and despite

8 repeated complaints of pain and two more court orders for care, he was not seen

9 again until November 8, 2011, when the surgery was re-ordered “ASAP.”

10

45. A patient with multiple chronic conditions -- a seizure disorder, asthma,

11 psoriasis, and Hepatitis C -- experienced multiple delays in obtaining timely

12 referrals, even after ordered by physicians, as well as follow-up, resulting in sub-

13 standard care.

14

4. Denials of care

15

46. Some prisoners face outright denials of basic and necessary medical

16 care. Plaintiff Quinton Gray was prescribed Dilantin on his arrival at the jail, but

17 even after two emergency room readings taken over the next few days showed that

18 the Dilantin level in his blood was far below the therapeutic level, jail medical staff

19 did nothing for well over a year.

20

47. A prisoner with thyroid disease was denied medication for nearly three

21 months. Although her initial screening form missed the condition, it was noted

22 repeatedly on her charts for several months by medical staff before she was finally

23 prescribed medication. Missed doses of thyroid medication for a prolonged period

24 put patients at risk for severe fatigue, slow heart rates, weight gain, constipation,

25 hair loss, edema, and eventually coma. The same patient also has a history of

26 gastric bypass surgery; the jail doctor refused her any dietary supplements to ensure

27 proper nutrition throughout her jail stay, despite repeated requests. Patients are at

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1 risk for malnutrition following bypass surgery and require life-long vitamin

2 supplementation. In addition, no tests were ordered to assess any nutritional

3 deficiencies, another violation of the standard of care.

4

48. Another prisoner fell and hurt his back at Presley in November 2010

5 and again in March 2011. He was provided inadequate neurologic exams after his

6 falls, several-month delays for scheduling of x-rays and consultations (even when

7 ordered “as soon as possible”), and inadequate trial of physical therapy; his back

8 pain went essentially untreated. Two clinic appointments were cancelled due to

9 “too many ad-segs” and one was cancelled because a wheelchair van was not

10 available.

11

B. Substandard medication management and administration

12

49. Reliable and systematic medication delivery is an essential element to a

13 constitutional health care system. Defendant has a policy and practice of failing to

14 prescribe, provide, and properly manage medication, and of providing incorrect,

15 interrupted, or incomplete dosages. As a result, prisoners with serious health care

16 conditions are placed at substantial risk of harm and are in fact harmed.

17

50. Many patients are provided substandard care because there is

18 inadequate staff to distribute medications. (Staffing deficiencies are described in

19 more detail in the following section.) Medication deliveries are often skipped

20 entirely, leaving patients without essential treatment. Plaintiffs Quinton Gray,

21 Angela Patterson, and Stanley Kujansky have experienced numerous skipped

22 medication dosages at various Riverside jail facilities, placing Mr. Gray at serious

23 risk for heart attack, stroke, and seizures; exposing Ms. Patterson to an increased

24 risk of recurrent thrombus; and endangering Mr. Kujansky’s cardiovascular health.

25

51. Other prisoners face the same problems. One patient who is prescribed

26 medications for his chronic high blood pressure has experienced a dangerous

27 number of missed doses: for example, in April 2011 he was not given nine doses of

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 both of his medications, and in September 2011 staff did not administer 14 doses of

2 one and eight doses of the other medication. Another patient who has been

3 prescribed medications for his diabetes has experienced numerous missed

4 medication doses – 21 missed doses in one month alone.

5

52. In practice, medication distribution in the jails takes place only once or

6 at most twice daily, leaving patients who require multiple daily dosages, or bedtime

7 delivery, unserved. Since the Smith facility is so large, nurses start evening pill call

8 at approximately 2 p.m. to allow them to deliver medications throughout the

9 institution. This includes sleep medications: some patients receive their pills in the

10 middle of the afternoon and fall asleep within a few hours. Pill call is erratic for

11 many prisoners, and evening pills might arrive any time from 3 to 10 p.m., if at all,

12 which is particularly dangerous for diabetics, many of whom must receive

13 medications at regular intervals, coordinated with meal times. Plaintiff Angela

14 Patterson has had her medications switched by jail staff from morning to evening,

15 despite the fact that the medication should be taken at the same time daily, likely

16 affecting her treatment stability.

17

53. Defendant’s policy and practice is to require patients to alert staff when

18 their medications run out. As a result, some prisoners’ prescriptions are not

19 renewed until they file multiple health care requests or grievances, resulting in

20 significant treatment interruptions with resulting, predictable harm to the patients.

21 For example, a patient at Southwest Detention Center has experienced several one-

22 month gaps between refills of his psychiatric medications, including Paxil. Paxil

23 has a well-documented discontinuation syndrome: the lengthy lapses in medication

24 delivery place him at serious risk for severe discontinuation symptoms including

25 flu-like symptoms, nausea, vomiting, and headaches. A Presley patient prescribed

26 pain medications for his severe back pain is frequently deprived of the medications

27

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 when the prescriptions run out and refills are not provided; doctors also renew his

2 medications without assessing their efficacy.

3

54. Another man held in the Presley facility experienced significant lapses,

4 without explanation, in receiving medication for his bipolar disorder: his Zoloft was

5 not renewed for nearly one month, and his Topomax was not renewed for nearly

6 three months. Further, neither medication was appropriately titrated on being

7 restarted. Sudden discontinuation of these medications can cause manic episodes

8 and seizures as well as physical symptoms such as nausea, vomiting, and headaches;

9 sudden resumption after a significant gap in time can also cause damaging side

10 effects. The patient in fact experienced depression and severe mood swings due to

11 the medication mismanagement.

12

55. Plaintiff Stanley Kujansky has been denied medications on the days he

13 goes to court for hearings in his criminal case as well as on the days he goes to see

14 outside specialists for medical care. These deprivations are pursuant to policy and

15 practice: numerous other prisoners are denied medications altogether when they

16 attend court hearings or are transported to outside appointments. Some prisoners

17 regularly miss medications in the morning because they are asleep and staff

18 routinely fail to announce medication delivery effectively.

19

56. Riverside also has a policy and practice of failing to monitor the effects

20 of medication to determine whether dosages are correct or medications should be

21 changed. Plaintiffs Quinton Gray, Angela Patterson, and Stanley Kujansky have

22 suffered from inadequately monitored medication regimens which have serious

23 endangered their health and forced them to endure unnecessary pain and suffering.

24 Their problems are typical of those experienced by medical and mental health

25 patients in the Riverside jails. For example, one man with high blood pressure has

26 been given two medications to treat his condition, but on occasion, without

27 explanation, he has been abruptly discontinued from one of the medications. No

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 monitoring of his condition is documented in his medical records, suggesting that

2 either such documentation is missing or it was never charted -- either way, lack of

3 proper documentation can be dangerous for patient care and signifies a concerning

4 level of disorganization within the medical department.

5

57. The same patient’s file lacks any progress notes documenting any

6 blood pressure, history, physical exam or lab tests during the duration of treatment.

7 In general, when starting or changing blood pressure regimens, patients’ blood

8 pressures should be checked to ensure that they are not over-medicated or given low

9 blood pressure, which can be dangerous. In addition, without monitoring blood

10 pressure, there is no way to know if the patient was actually adequately controlled --

11 high blood pressure could put him at risk for strokes, brain bleeds and heart attacks.

12 Further, because one of his medications can be associated with electrolyte

13 abnormalities, the standard of care requires physicians to check basic blood tests for

14 sodium, potassium and kidney function levels either prior to or shortly after starting

15 such agents. None of this was done.

16

58. A diabetic man who entered the Riverside jails with an elevated blood

17 sugar count was prescribed medications and ordered glucose checks twice daily for

18 two weeks and then weekly thereafter, as well as various blood work. These orders

19 were apparently ignored, however, along with two subsequent orders for weekly

20 blood sugar checks: his health records show only two glucose checks over the next

21 several months and no evidence that he ever had the blood work performed. This

22 failure to monitor his condition placed him at serious risk of harm, particularly since

23 one of the medications he was prescribed, Glipizide, can make patients

24 hypoglycemic.

25

59. Psychotropic medications also are not monitored to determine whether

26 they are effective or whether they cause severe side effects.

27

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1

60. Patients face serious consequences from the denial of appropriate

2 medications. For example, one man experienced uncontrolled seizures resulting in

3 serious injuries. His medication regimen was clearly ineffective, but he was merely

4 prescribed increases in his existing medication, contrary to the standard of care. He

5 continued to suffer from frequent seizures and resulting physical injuries.

6

61. Another patient fell in his cell and hurt his hand (he uses a cane due to

7 leg injuries, but is only allowed it to ambulate longer distances). He was sent to the

8 emergency room one day later with increasing pain in his hand. He was found to

9 have suffered a fracture and prescribed Vicodin and Ibuprofen for the pain. He was

10 never given these medications on his return to the jail, and suffered unnecessary

11 pain as a result.

12

62. Medication lapses can be particularly devastating in the mental health

13 realm. According to Sheriff Sniff, “continuity in delivery of mental health

14 medications may affect the stability of an inmate’s mental health and is critical to

15 inmate care.” More specifically, delays in administering psychotropic medications

16 to mental health patients can result in serious harm. Such harm is occurring in the

17 Riverside jails: prisoners experience frequent gaps in medication delivery, as the

18 Sheriff has admitted. Sometimes psychotropic medications are not distributed at all

19 in entire housing units, since nurses are simply overwhelmed. At other times,

20 patients’ medications are abruptly changed with no examination and no explanation.

21 These interruptions harm prisoners. Over many months in the Indio, Presley, and

22 Smith jails, Plaintiff Quinton Gray had his powerful psychotropic medications either

23 suddenly discontinued or multiple doses missed. Similarly, a patient at Smith had

24 his psychotropic medications and dosages changed repeatedly over two years,

25 including the abrupt and unexplained cessation of his antipsychotic medications. A

26 Presley patient also had psychotropic medications abruptly started, stopped, and

27 renewed over several years with little or no evaluation or assessment. This pattern

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 and practice of medication mismanagement places these patients at serious risk for

2 decompensation, untreated mental illness, and severe side effects.

3

C. Severe staffing deficits

4

63. Many of the deficits described herein stem from the inadequate health

5 care staffing levels maintained by Defendant in the jails. There are simply not

6 enough doctors, nurses, mental health providers, pharmacists, or medical records

7 staff to meet the needs of the population.

8

64. Defendant’s policy and practice of severely understaffing health care

9 positions in the jails is long standing and has been repeatedly censured by the county

10 Grand Jury. In 2010, the Grand Jury found that “[m]ental health staff is not

11 available in any county jail facility in sufficient numbers to identify and treat in an

12 individualized manner those treatable inmates suffering from serious mental

13 disorders.” The Grand Jury Report released on June 14, 2012, states the problem in

14 clear terms:

15

In July, 2011, DMH was advised. . . .that the medical/mental health

16

staffing levels in county jails needed to be restored to 2007 levels, in

17

order to be in compliance with [state law]. As of this writing, the

18

Grand Jury learned through sworn testimony that during the eight

19

months following the 2010-2011 Grand Jury report, DMH staffing

20

levels were allowed to decrease even further.

21

65. Medical care is no better: according to the independent Inmate Medical

22 Quality evaluators, invited by Sheriff Sniff to identify deficiencies in jail health

23 care, “[t]he request for medical care exceeds the capability of the staff to meet the

24 demands.” The Detention Health Services administrator agreed, admitting that “the

25 demand exceeds the resources available to provide the requested services.”

26

66. Long-term medical vacancies are endemic, particularly given the

27 competition with the higher salaries offered by the state prison system. For

28

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 example, at the beginning of 2011, there were only three physicians for well over

2 3,000 prisoners in the five jails. Two doctors subsequently resigned and for at least

3 several months, there was not a single physician, physician assistant, or nurse

4 practitioner working in the Riverside jails – only a “Chief of Medical Specialty”

5 who rarely saw patients. Only two of the five full-time physician positions in the

6 jails were filled as of May 31, 2012.

7

67. Other medical staffing is also deficient. As of May 2012, the county

8 had multiple vacancies for nurses and nurse supervisors, and only 65 of 101 total

9 Detention Health Services positions were filled. Further, according to the CSA,

10 “there is no budget for overtime and no staff available to provide services in the

11 event of illness, injury, or vacation.”

12

68. Defendant lacks the staff necessary to provide minimally adequate

13 dental care. By the County’s own assessment, two full-time dentists and two full-

14 time dental assistants are required to offer basic dental care to the nearly 4,000

15 prisoners. As of May 2011, only one dentist and one dental assistant were working

16 in the jails.

17

69. A patient at the Smith Jail with chronic high blood pressure filed a

18 grievance complaining that although the doctor had ordered blood pressure checks

19 every three days, he had only received them twice in the preceding 23 days. The

20 grievance response from Senior Corporal Diaz confirms that the patient “is still not

21 having his blood pressure checked. When he asked the nursing staff they stated they

22 do not have the time.”

23

D. Violations of patients’ confidentiality rights

24

70. According to the Grand Jury, Riverside “has no confidential self-

25 referral system by which inmates can request mental health care without revealing

26 the nature of their request to correctional officers,” as required by federal and state

27 law. See 45 C.F.R. §§ 164.500 et seq.; Cal. Civil Code §§ 56.10 et seq. Requests

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 for medical care are also not confidential, since they too are delivered to medical

2 staff by custody staff. Prisoners are directed to give blue slips requesting health

3 care directly to custody staff; many believe that they must provide as much detail as

4 possible about their health care needs in order to increase their chances to be seen.

5 Many prisoners, including Plaintiffs Gray and Kujansky, also must file grievances in

6 order to be seen by clinicians. To get grievance forms, they must persuade custody

7 staff that their concerns are significant. The grievances are then heard by custody

8 staff, who make the determination whether to involve health care staff.

9

71. Examination space at Southwest Detention Center is not confidential:

10 patients can overhear other patients’ examinations through an open door, as they

11 wait in the hallway for their own treatment.

12

E. Poor records administration

13

72. Adequate health care cannot be provided in the absence of adequate

14 health records: clinicians must know their patients’ medical histories, past diagnoses

15 and treatment, and for psychiatric patients, a history of suicidal thinking or attempts.

16

73. Riverside’s medical records system is profoundly disorganized and

17 incomplete. Some psychiatric patients have no diagnosis recorded, despite the

18 prescription of psychotropic medications. Some patients are prescribed medications

19 but lack any record of medication administration in their file, or any record that the

20 effects of the medication were tracked and reviewed. All three Plaintiffs’ health

21 care records demonstrate Riverside’s failures in this area.

22

74. It is not surprising that record-keeping is inadequate: as of December 6,

23 2011, the entire medical records staff for five jails and well over three thousand

24 prisoners was three medical records technicians and no medical clerks.

25

75. The record-keeping gaps impact patient care. One psychiatric patient

26 had no legible diagnosis, review of symptoms, psychiatric history, mental status

27 examination, or risk assessment. He was nonetheless prescribed antipsychotics with

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 no reference to any ongoing mental status exams or data on symptoms, even when

2 doses or medications are changed, as was done repeatedly over a two-year period.

3 At one point, the patient’s antipsychotics were stopped abruptly with no explanation

4 in the records.

5

76. Another patient was placed in a safety cell on suicide watch with no

6 recorded reason. The order to discontinue the watch is similarly bereft of any

7 explanation as to why he is no longer a danger to himself, or any risk assessment.

8

F. Inadequate quality assurance

9

77. Not surprisingly, given the paucity or records and severe staffing

10 shortages, Riverside officials lack the ability to identify and correct the problems

11 described herein. Health care staff do not systematically correct identified

12 deficiencies, and there is inadequate staff for oversight and review of care.

13 II. Even If Prisoners See Health Care Providers, They Do Not Receive Constitutionally Adequate Medical or Mental Health Care
14
78. As detailed in the previous section, Riverside’s lack of the basic
15
elements of a health care delivery system -- policies and procedures to ensure timely
16
access to appropriate care, medication management, adequate staffing, patient
17
confidentiality, medical records, and quality assurance – harms Plaintiffs and
18
members of the plaintiff class. Even when they are able to see health care providers,
19
prisoners are by policy and practice denied adequate medical and mental health care
20
in the Riverside jails: they experience gross treatment failures, inadequate
21
examinations, and the failure to provide necessary specialty appointments and
22
diagnostic tests.
23

24

25

A. Substandard medical care

26

79. Plaintiffs Gray, Patterson, and Kujansky, on behalf of themselves, the

27 plaintiff class, and the medical subclass, assert the following.

28

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

80. Prisoners – even those with serious medical conditions -- rarely see

2 physicians, and health care records demonstrate a paucity of appropriate follow-up,

3 monitoring, and specialty referrals, as well as improper care.

4

81. Plaintiff Quinton Gray has chronic high blood pressure that has been

5 inadequately monitored and controlled by Riverside jail medical staff. He has

6 experienced multiple elevated blood pressure measurements without any assessment

7 of the efficacy of his medications and dosages. He has twice gone without blood

8 pressure check for more than four months, despite his history of elevated readings

9 and despite the fact that regular readings had been ordered by physicians. In

10 addition, he is frequently not provided his medications at all, thus increasing his risk

11 of poorly controlled blood pressure. Uncontrolled blood pressure can cause heart

12 attacks, heart failure and strokes.

13

82. Mr. Gray’s seizure disorder has also been inadequately treated. He was

14 prescribed Dilantin on his arrival at the jail, but two emergency room readings taken

15 over the next few days showed that the Dilantin level in his blood was far below the

16 therapeutic level. Jail medical staff did nothing for well over a year, at which point

17 a Dilantin level check was ordered, then re-ordered after it was not performed.

18 Moreover, Mr. Gray is frequently not provided his Dilantin at all, placing him at

19 serious risk for seizures, which he has experienced in the jails.

20

83. Plaintiff Angela Patterson has experienced significant and damaging

21 sub-standard health care, as described above, which has likely caused her permanent

22 injury.

23

84. Plaintiff Stanley Kujansky has chronic high blood pressure. Sub-

24 standard care in the Riverside jails has endangered his cardiovascular health. First,

25 multiple dosages of his blood pressure medication have not been administered as

26 prescribed. In particular, he is denied medications on the days he appears in court as

27 well as the days he has specialty care appointments in the Riverside county hospital,

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 in part because there are no medical staff on duty at the Presley jail who could

2 deliver the medications on his return, after 6 p.m. As a result of these missed

3 dosages of blood pressure medication, Mr. Kujansky has suffered from abrupt and

4 repeated fluctuation in blood pressure.

5

85. Mr. Kujansky has filed repeated grievances on this denial of

6 medications, notably on June 15, 2012; July 15, 2012; and August 15, 2012. These

7 grievances have either been granted or ignored, but the problem has not been solved.

8

86. Further, the blood pressure medication Mr. Kujansky has been

9 prescribed in the jails -- Clonidine -- is usually a last-resort drug to control blood

10 pressure since it can cause severe dizziness and low blood pressure and in particular

11 can cause rebound tachycardia (an elevated heart rate) if doses are missed. It should

12 not be prescribed unless a patient can take it consistently and reliably, which is

13 clearly not the case in the Riverside jails, as medical staff should well know and as

14 is amply demonstrated by the medication administration record showing repeated

15 missed doses of his medications. Moreover, the frequent use of Ibuprofen, as

16 prescribed to Mr. Kujansky, can also elevate blood pressure, which likely

17 contributed to some of his high readings.

18

87. Other patients experience similarly inadequate and at times life-

19 threatening medical care. For example, one patient arrived in the Riverside jails

20 after having been assaulted with a crowbar just three weeks earlier. He had spent

21 two of those weeks in the hospital and had undergone surgery to repair his jaw and

22 implant hardware. Despite obvious facial injuries and blood noted in his ear on his

23 arrival at the jail, he was not seen by a doctor for three weeks, and not until he

24 received a court order for treatment. At that time, his severe recent head trauma was

25 noted and the doctor ordered an ENT consultation. However, it did not take place,

26 and the consultation had to be re-ordered one month later. Following a second

27 court-ordered doctor’s appointment, the patient’s implanted hardware was found to

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 be coming out of his jaw. He was diagnosed in the emergency room with a

2 fractured dental plate. He was again referred for an ENT consultation, which finally

3 took place a week later. Because he was not sent with his crucial records, however,

4 the appointment was of limited use. He was referred for surgery on September 30,

5 2011, but did not receive it; despite repeated complaints of pain and two more court

6 orders for care, he was not seen again until November 8, when the surgery was re-

7 ordered “ASAP.” Throughout, the patient was never seen except in response to a

8 court order. Repeated warning signs – complaints of incontinence, evidence of

9 memory loss and confusion – were ignored, and there are no documented attempts

10 to determine whether he was experiencing brain trauma symptoms or displaying

11 underlying dementia, psychiatric disease, or cognitive deficits. Had the patient

12 been evaluated when he was first noted to have his injuries at the time of booking,

13 with records requested sooner and a more timely evaluation and appointment in both

14 the ENT clinic and the oral and maxillofacial surgery clinic, his serious

15 complications could have been minimized and they certainly would have been

16 treated earlier, likely reducing the unnecessary pain and suffering that he endured.

17

88. A patient at the Smith jail was seen by a nurse for ear pain on August 2,

18 2011. The doctor did not examine him, but prescribed medication over the

19 telephone. Five days later he was seen again by a nurse for worsening pain and

20 redness of the ear; the doctor, again over the telephone, referred him to the

21 emergency room at RCRMC. Following that visit, the same doctor prescribed

22 antibiotics over the telephone, which he never received. Two weeks later, he had

23 another emergency room visit and was again prescribed the same antiobiotic by the

24 same doctor by telephone. Three weeks after that, on September 15, the patient

25 underwent tympanoplasty and mastoidectomy at RCRMC. On his return to the jail

26 after the surgery, he was prescribed Vicodin and antibiotics over the telephone but

27 never received them. On September 22, he reported blood coming from the ear but

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 was only seen by the nurse and not a doctor; the doctor ordered medications over the

2 telephone. He again reported bleeding on October 1 to the nurse but was not seen

3 by a doctor. He was finally seen on October 5, 2011, by a specialist at RCRMC and

4 was noted to have pus in his ear. Throughout the entire ordeal, he never once saw a

5 doctor at the jail.

6

89. Another patient with a long history of seizures endured many months

7 during which he was denied all seizure medications. Jail medical staff were aware

8 of his seizure disorder on November 8, 2011, but despite multiple blue slips

9 requesting care, he was not prescribed seizure medications until April 9, 2012. He

10 suffered several seizures in custody which would likely have been prevented if he

11 had been evaluated by a physician sooner and continued on his stable, home anti-

12 seizure medication regimen.

13

90. Another patient was seen, pursuant to court order, for ovarian cyst-

14 related pain. She was given some medication but continued to have pain. Jail

15 physicians failed to order a repeat vaginal ultrasound or refer her to gynecology for

16 further evaluation and management, as the standard of care requires.

17

91. Even when prisoners get to see the doctor, the examinations are often

18 ludicrously inadequate. Patients at Presley are “examined” in the non-contact

19 attorney visiting booth. However, instead of sitting on the well-lighted attorney side

20 of the booth facing the patient behind glass, the doctor places himself outside of the

21 booth, where the deputies ordinarily sit, visible only through a slot for passing

22 documents. No meaningful physical examination is possible under such conditions.

23 Without meaningful physical examinations, the standard of care cannot be met.

24

25

26

B. Substandard mental health care

27

28

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

92. Plaintiff Gray, on behalf of himself, the plaintiff class, and the mental

2 health subclass, asserts the following.

3

93. Riverside County lacks an adequate system to provide a basic level of

4 constitutional mental health care. In the absence of such a system, the County fails

5 utterly to provide appropriate, informed diagnoses and treatment plans, ensure

6 continuity of psychotropic medication, monitor prisoners prescribed such

7 medication, make available medications that are effective in treating serious mental

8 disorders, or provide necessary therapeutic treatment.

9

94. Many prisoners do not get the right medications, the right dosages, or

10 appropriate ongoing care: the Grand Jury found that “[i]nmates with assessed

11 moderate mental health problems such as neuroses, phobias, panic disorders, etc.,

12 are not always offered appropriate mediation and counseling by qualified staff to get

13 and maintain them in a stable condition.” As a result, they suffer severe side effects

14 and decompensation.

15

95. Mentally ill prisoners are regularly started on powerful psychotropic

16 medications with no record of any evaluation, diagnosis, or treatment plan. This

17 practice is dangerous because it does not allow subsequent monitoring or review,

18 and places patients at serious risk of harm through lack of treatment or inappropriate

19 treatment for their mental illness.

20

96. Even prisoners prescribed appropriate medications face frequent

21 disruptions in medication delivery, including abrupt cessation and missed pill

22 deliveries, which cause serious suffering for these mentally ill patients, as described

23 in more detail in the prior section on medication administration.

24

97. No tracking is done of patients’ symptoms and any reaction they might

25 have to the medication, except for a cursory, non-confidential questioning at their

26 cell doors. The monitoring of vital signs such as weight, cholesterol, and glucose

27

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 levels, which is essential to ensure the patients are not suffering adverse effects from

2 psychotropic drugs, is absent. Dosages are changed abruptly, with no explanation.

3

98. On arrival in the Riverside jails, Plaintiff Quinton Gray was prescribed

4 several powerful psychotropic medications with no evaluation, diagnosis, or

5 assessment by a mental health professional, and no baseline laboratory test to

6 monitor known risky side effects of the medications.

7

99. One of his medications, Geodon, must be taken with food or much of it

8 is not absorbed. Mr. Gray was not ordered to be given his Geodon with food, which

9 placed him at risk for varying blood levels and varying side effects and efficacy. He

10 was also started on the maximum dose, which increases the risk of severe side

11 effects such as acute muscle stiffness and tremors. Several months later, Mr. Gray’s

12 medications were discontinued suddenly without appropriate taper of maximum

13 dose of Geodon, which placed him at risk for rebound tardive dyskinesia, seizures,

14 discontinuation syndrome (flu-like illness) and decompensation of psychiatric

15 symptoms (paranoia, hallucinations, and thought disorganization).

16

100. Months later, Mr. Gray was started on a second antipsychotic while

17 also on Geodon, despite the lack of clinical evidence that treating schizophrenic

18 patients with two antipsychotics provides better efficacy or treatment outcomes, and

19 despite the increased risk of side effects and drug-drug interactions. When

20 prescribed together, Mr. Gray’s two medications increase the risk of tardive

21 dyskinesia (such as tongue-biting), acute muscle stiffness and tremors, and cardiac

22 events (arrhythmias). Both medications also lower the seizure threshold and when

23 given together in a patient with a history of seizure disorder, could cause increased

24 seizure events.

25

101. In July 2012, Mr. Gray was started on Benadryl and Cogentin at the

26 same time, with no documented explanation in his health care records. There is

27

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 never a need to treat a patient with both of these medications at the same time, and

2 they have multiple side effects including constipation and delirium.

3

102. Multiple doses of Mr. Grey’s medications have not been administered

4 to him during his stay in the jails. Missed doses can alter blood levels in a way that

5 increases side effects (including worsening of tardive dyskinesia), variably changes

6 seizure thresholds and can cause decompensation of psychiatric symptoms.

7

103. As a result of Defendant’s failed mental health delivery system, Mr.

8 Gray has in fact experienced twitching, tongue-biting, increased seizures and tongue

9 swelling, all predictable side effects from taking near maximum dose of these two

10 antipsychotic medications. He lives with racing thoughts, disorientation,

11 depression, and chronic sleep loss. He has not been appropriately monitored or

12 treated for these damaging side effects and signs of the inefficacy of his medication

13 regimen.

14

104. These failures are typical of the policies and practices that produce

15 substandard mental health care generally for patients in the Riverside jails. For

16 example, one Southwest Detention Center patient has no noted psychiatric/mental

17 health progress notes in his chart to indicate he was ever evaluated by a medical

18 doctor regarding his psychiatric condition, treatment plan or consent to medication

19 changes. He was maintained on Paxil, an antidepressant with an extremely short-

20 half life that can lead to a severe discontinuation syndrome if the dose is missed

21 even for 24 hours. He has experienced multiple incidences of missing days of

22 medications as well as not having his medications renewed for one month periods,

23 placing him at risk for severe discontinuation symptoms as well as decompensation.

24 There are no medication monitoring standards set in place, particularly to monitor

25 for weight gain on Paxil. His medications were repeatedly renewed without

26 evidence of evaluation.

27

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1

105. Another patient housed in Presley was started on multiple

2 antipsychotic, anti-depressant, and bipolar disorder medications without any record

3 of an appropriate assessment of her mental illness, the indications for the

4 medications, or informed consent. Most notes by the clinician in her file are

5 illegible and they contain no assessment or plan regarding her treatment. Multiple

6 times her medications were renewed, stopped, started or changed without any

7 documentation or assessment: in particular, her medications were renewed

8 repeatedly for more than two years without any indication of ever being evaluated

9 by a medical doctor; during this period two new medications were started without a

10 medical evaluation or documentation of informed consent; and once her medications

11 were not renewed for an entire month. Sudden discontinuation of medications puts

12 patients at risk for severe side effects and decompensation of psychiatric illnesses.

13 She was also started on multiple medications at high doses without appropriate

14 titration, resulting in severe side effects, and subjected to the abrupt discontinuation

15 of medications that might have been helpful for her symptoms. Further, she was

16 placed on safety-cell observation but was never evaluated by a medical doctor

17 despite this being a psychiatric emergency.

18

106. Another Presley patient was prescribed multiple psychotropic

19 medications with no documentation of ever being evaluated by a mental health

20 professional for ongoing psychiatric care. This is of particular concern in her case,

21 since two of her medications are relatively contraindicated and should have had

22 clear documented psychiatric necessity for concomitant use including special

23 monitoring for side effects.

24

107. Further, the patient was started and stopped on multiple medications

25 and had doses changed without any documentation of evaluation for efficacy, side

26 effects or informed consent. Such reviews were essential for this patient, since she

27 was placed on Thioridazine, a drug used to treat psychosis, anxiety and insomnia,

28

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CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 that with long-term use can cause tardive dyskinesia, a highly distressing and

2 uncomfortable phenomenon consisting of involuntary movements. There is no

3 documentation she was ever evaluated for such side effects.

4

108. In addition, she had significant periods of not receiving her medications

5 as well as frequent missed delivery of individual doses, placing her at risk for

6 discontinuation syndrome including intense anxiety, flu-like symptoms, headache,

7 nausea/vomiting, and parasthesias as well as rapid decompensation of mental illness.

8 Moreover, despite missing significant periods of medications, the medications were

9 suddenly restarted or given again at their regular doses rather than appropriately re-

10 titrated. One of her medications, Lamotrigine, can result in a life-threatening rash if

11 it is suddenly started after stopping it for several days, as happened in her case.

12 Sudden starting of Paroxetine, another of her medications, can lead to severe gastro-

13 intestinal upset, sedation and anxiety.

14

109. A patient at Smith was started on numerous psychotropic medications

15 without any documentation he was evaluated by a mental health professional, given

16 informed consent prior to initiation, or monitored for efficacy or side effects. He

17 experienced significant lapses in medication administration, placing him at risk for

18 discontinuation syndrome associated with his medications, including severe

19 headache, nausea, vomiting, flu-like symptoms, agitation and anxiety.

20

110. One reason for this inadequate care might be the abysmally poor

21 communication with clinical staff that some prisoners experience. For example, one

22 Smith prisoner described his interview as taking place in a non-contact attorney

23 visiting booth, with glass separating doctor from patient. He answered some

24 questions from the psychiatrist, who then held up a piece of paper on which he

25 wrote words such as “mood swings” and “voices.” The patient nodded in response.

26 No history was taken – he is a disabled veteran with severe anxiety and PTSD – and

27 there was no discussion of medication side effects. The entire session lasted 15-20

28

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1 minutes. The psychiatrist then briefly held up a piece of paper with information

2 about medications, but the patient did not have a chance to read it. The psychiatrist

3 handed the paper to a deputy, who gave it to the patient and rushed him to sign it.

4 When the patient asked, “can I read it?” the deputy responded: “just sign it.” The

5 patient did not find out the names of the medications he was prescribed for three

6 days after he started taking them. For the first two days, when he asked the nurses

7 the names of the pills, they would respond but he could not understand. When he

8 requested clarification, they would say “next person” and rush him through.

9

111. Another prisoner arrived at the Smith jail with a list of her prescribed

10 psychotropic medications, which was placed in her property. She waited two weeks

11 to see a psychiatrist, but could not recall for him which medications she had taken

12 and did not have the list to consult. He told her he would prescribe medications and

13 when she asked for her diagnosis, and he responded “That is not important right

14 now, just go ahead and take your medications.” A week later, the pills arrived and

15 she took them without knowing what they were. Within three days, she experienced

16 a severe reduction in her ability to function and could not walk unassisted. She

17 stopped taking the pills. A week later, her mother spoke to a sergeant and told him

18 that the medication list should be retrieved from her property. He assured her it

19 would be done and the proper pills would be dispensed. The following day, new

20 pills arrived, which again made her feel “woozy” and “dizzy.” She again stopped

21 taking them.

22

112. A crucial element of an adequate mental health care delivery system is

23 an appropriate means to assess and monitor patients who exhibit or contemplate

24 self-harming behavior. Here, too, Riverside’s practices fall far short of acceptable

25 mental health care procedures. Prisoners believed to be suicidal or self-harming are

26 placed in a barren cell with only a rough smock to wear and a hole in the ground to

27 relieve themselves. The so-called “safety cells” are often filthy and stink of the

28

33

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 urine and feces that is visible on the walls and floor. Patients are left in the cells for

2 many days, with inadequate monitoring or supervision, under lights that are never

3 turned off. Plaintiff Quinton Gray was forced to endure these conditions for 48

4 hours simply because he told custody staff on entering the jail that he needed

5 psychiatric medications. Another man was placed in a safety cell and removed more

6 than a day later with no risk assessment, explanation, or criteria for removal – a

7 gross departure from the standard of care.

8
9 III.
10

Defendant has known for years of the significant risk of harm from its inadequate jail health care system and has failed to take reasonable steps to mitigate the risk to prisoners

11

113. Defendant Riverside County has for many years woefully underfunded

12 detention health care. The lack of infrastructure and staff to deliver life-saving care

13 has resulted, as Sheriff Stanley Sniff has told the Board of Supervisors, in a “crisis

14 in the jail system.”

15

114. The County’s own Grand Jury as well as several independent auditors

16 have come to the same conclusion: dangerous deficits in health care services at the

17 jails threaten the lives and health of the thousands of men and women they hold.

18

115. The severe deficiencies in health care services in Riverside’s jails are

19 thus well established by admissions from Sheriff Sniff and reports from state and

20 county watchdogs and independent auditors. Defendant has long been aware of the

21 harm its deficient system causes to patients with serious health care needs through

22 these reports as well as numerous grievances and health needs requests from

23 prisoners. Defendant’s failure to take action to ameliorate the conditions constitutes

24 deliberate indifference to Plaintiffs’ serious health care needs.

25

116. Several 2011 reports documented extensive health care violations in the

26 jails. The 2010-11 Grand Jury Report: Riverside County Detention Health Care

27 Administration found systemic failures in treatment, medication management,

28

34

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 record-keeping, and administration of forced medications, among other areas. On

2 July 5, 2011, the Sheriff responded that he “generally concurs with the findings of

3 the Grand Jury and has been outspoken on the need to remedy these issues over the

4 last two years.”

5

117. The Grand Jury’s report on mental health care deficiencies, 2010-11

6 Grand Jury Report: Mental Health Detention Services, noted serious health care

7 staffing deficiencies. Again, the Sheriff agreed with this assessment. The Grand

8 Jury released an updated report in June 2012, noting that mental health staffing has

9 in fact decreased since its prior year’s report.

10

118. The Sheriff invited the state’s Corrections Standards Authority (CSA),

11 a body with statutory duty to regularly inspect county facilities, to perform an

12 additional inspection in January 2011. The CSA found numerous violations of state

13 law, including a widespread failure to provide daily sick call and insufficient

14 oversight of prisoners on suicide watch. They also found serious deficits in

15 medication administration: missed pill calls, night-time medications administered

16 between 4 and 6 p.m., and prisoners going to court denied medications entirely.

17

119. At the CSA’s recommendation, Sheriff Sniff contracted with the

18 independent Inmate Medical Quality (IMQ) to identify deficits and make

19 recommendations. IMQ performed their evaluation May 2-5, 2011, and reported

20 significant and potentially harmful systemic deficiencies in staffing, screening, sick

21 call, quality assurance, medical records, management of communicable diseases,

22 medication management, and use of restraints and safety cells for suicidal or self-

23 harming prisoners. As with both of the Grand Jury reports, the Sheriff accepted

24 these findings as requiring immediate and drastic attention.

25

120. The health care deficiencies in the Riverside jails, and Defendant’s

26 awareness of them, predate the 2011 reports and stem in part from years of drastic

27 cost-cutting measures. As Sheriff Sniff has explained, the County made “deep cuts

28

35

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 to medical personnel staffing levels” in fiscal year 2008-09, which “unacceptably

2 impacted the delivery of medical services. . . and other jail operations.” Instead of

3 correcting the problem, the County made another 20% reduction in medical and

4 mental health care staff as of July 1, 2010.

5

121. On January 12, 2012, Plaintiffs’ counsel sent Defendant officials a

6 sixteen-page letter detailing the systemic problems set forth in this Complaint.

7 Defendant did not make any substantive response to the specific concerns described

8 in the letter.

9

122. The County’s systemic failures, as outlined in this Complaint, in

10 Plaintiffs’ January 2012 letter, and in the numerous reports of independent auditors,

11 result in significant injury and the unnecessary and wanton infliction of pain in

12 violation of the Eighth and Fourteenth Amendments. The injuries, as described

13 above, include drastically inadequate cancer treatment that may have significantly

14 decreased one patient’s life expectancy; severe and unnecessary pain;

15 unconstitutional conditions on suicide watch; exacerbated mental illness from

16 failure to provide appropriate screening and medications; and severe reactions from

17 inadequate and frequently interrupted medication delivery.

18

CLASS ACTION ALLEGATIONS

19 Plaintiff class

20

123. Plaintiffs bring this action on their own behalf and, pursuant to Rule

21 23(a), b(1), and (b)(2) of the Federal Rules of Civil Procedure, on behalf of all adult

22 men and women who are now, or will be in the future, in the custody of Riverside

23 County and who are now, or will be in the future, subject to an unreasonable risk of

24 harm due to Defendant’s policies and practices of denying prisoners minimally

25 adequate medical care and minimally adequate mental health care.

26

124. The class is so numerous that joinder of all members is impracticable.

27 There are currently nearly 4,000 people incarcerated in the five Riverside jails, all of

28

36

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 whom are entirely dependent on Defendant for medical and mental health care. All

2 prisoners are at risk of developing serious medical and mental health conditions

3 while in the Riverside jails. Due to Defendant’s policies and practices, all Riverside

4 jail prisoners receive or are at risk of receiving inadequate health care while in the

5 Riverside jails.

6

125. There are questions of law and fact common to the class including

7 whether the failure to provide minimally adequate medical and mental health care

8 violates the Due Process Clause of the Fourteenth Amendment and the Cruel and

9 Unusual Punishment Clause of the Eighth Amendment to the United States

10 Constitution and whether Defendant has been deliberately indifferent to the serious

11 health care needs of class members. Defendant is expected to raise common

12 defenses to these claims.

13

126. Since there are several thousand class members, separate actions by

14 individuals would in all likelihood result in inconsistent and varying decisions,

15 which in turn would result in conflicting and incompatible standards of conduct for

16 the defendants.

17

127. Defendant has acted and failed to act on grounds that apply generally to

18 the class, so that final injunctive or corresponding declaratory relief is appropriate

19 respecting the class as a whole.

20

128. The claims of the named Plaintiffs are typical of the claims of the class

21 and subclasses, since their claims arise from the same policies, practices, and

22 courses of conduct and their claims are based on the same theory of law as the

23 class’s claims.

24

129. The named Plaintiffs, through counsel, will fairly and adequately

25 protect the interests of the class. Plaintiffs do not have any interests antagonistic to

26 the plaintiff class. Plaintiffs, as well as the Plaintiff class members, seek to enjoin

27 the unlawful acts and omissions of Defendant. Further, Plaintiffs are represented by

28

37

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 counsel experienced in civil rights litigation, prisoners’ rights litigation, and

2 complex class action litigation.

3 Medical Subclass

4

130. Plaintiffs Gray, Patterson, and Kujansky bring this action on their own

5 behalf and, pursuant to Rule 23(a), b(1), and (b)(2) of the Federal Rules of Civil

6 Procedure, on behalf of a subclass of prisoners (hereinafter “Medical Subclass”)

7 who are now, or will in the future be, subjected to the medical care policies and

8 practices of the Riverside jails.

9

131. The Medical Subclass is so numerous that joinder of all members is

10 impracticable. There are currently nearly 4,000 people incarcerated in the five

11 Riverside jails. All prisoners are at risk of developing serious medical conditions

12 while in the Riverside jails. Due to Defendant’s policies and practices, all Riverside

13 jail prisoners receive or are at risk of receiving inadequate medical care while in the

14 Riverside jails.

15

132. There are questions of law and fact common to the Medical Subclass

16 including whether the failure to provide minimally adequate medical care violates

17 the Due Process Clause of the Fourteenth Amendment and the Cruel and Unusual

18 Punishment Clause of the Eighth Amendment to the United States Constitution and

19 whether Defendant has been deliberately indifferent to the serious health care needs

20 of Medical Subclass members. Defendant is expected to raise common defenses to

21 these claims.

22

133. Since there are several thousand Medical Subclass members, separate

23 actions by individuals would in all likelihood result in inconsistent and varying

24 decisions, which in turn would result in conflicting and incompatible standards of

25 conduct for the Defendant.

26

27

28

38

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

134. Defendant has acted and failed to act on grounds that apply generally to

2 the Medical Subclass, so that final injunctive or corresponding declaratory relief is

3 appropriate respecting the Medical Subclass as a whole.

4

135. The claims of the named Plaintiffs are typical of the claims of the

5 Medical Subclass, since their claims arise from the same policies, practices, and

6 courses of conduct and their claims are based on the same theory of law as the

7 Medical Subclass’s claims.

8

136. The named Plaintiffs, through counsel, will fairly and adequately

9 protect the interests of the Medical Subclass. Plaintiffs do not have any interests

10 antagonistic to the Medical Subclass. Plaintiffs, as well as the Plaintiff class

11 members, seek to enjoin the unlawful acts and omissions of Defendant. Further,

12 Plaintiffs are represented by counsel experienced in civil rights litigation, prisoners’

13 rights litigation, and complex class action litigation.

14 Mental Health Subclass

15

137. Plaintiff Gray brings this action on his own behalf and, pursuant to

16 Rule 23(a), b(1), and (b)(2) of the Federal Rules of Civil Procedure, on behalf of a

17 subclass of prisoners (hereinafter “Mental Health Subclass”) who are now, or will in

18 the future be, subjected to the mental health care policies and practices of the

19 Riverside jails.

20

138. The Mental Health Subclass is so numerous that joinder of all members

21 is impracticable. There are currently nearly 4,000 people incarcerated in the five

22 Riverside jails. All prisoners are at risk of developing serious mental health

23 conditions while in the Riverside jails. Due to Defendant’s policies and practices,

24 all Riverside jail prisoners receive or are at risk of receiving inadequate mental

25 health care while in the Riverside jails.

26

139. There are questions of law and fact common to the Mental Health

27 Subclass including whether the failure to provide minimally adequate mental health

28

39

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 care violates the Due Process Clause of the Fourteenth Amendment and the Cruel

2 and Unusual Punishment Clause of the Eighth Amendment to the United States

3 Constitution and whether Defendant has been deliberately indifferent to the serious

4 health care needs of Mental Health Subclass members. Defendant is expected to

5 raise common defenses to these claims.

6

140. Since there are several thousand Mental Health Subclass members,

7 separate actions by individuals would in all likelihood result in inconsistent and

8 varying decisions, which in turn would result in conflicting and incompatible

9 standards of conduct for the Defendant.

10

141. Defendant has acted and failed to act on grounds that apply generally to

11 the Mental Health Subclass, so that final injunctive or corresponding declaratory

12 relief is appropriate respecting the Mental Health Subclass as a whole.

13

142. The claims of Plaintiff Gray are typical of the claims of the Mental

14 Health Subclass, since his claims arise from the same policies, practices, and

15 courses of conduct and his claims are based on the same theory of law as the Mental

16 Health Subclass’s claims.

17

143. Plaintiff Gray, through counsel, will fairly and adequately protect the

18 interests of the Mental Health Subclass. Plaintiff does not have any interests

19 antagonistic to the Mental Health Subclass. Plaintiff Gray, as well as the Mental

20 Health Subclass members, seeks to enjoin the unlawful acts and omissions of

21 Defendant. Further, Plaintiff is represented by counsel experienced in civil rights

22 litigation, prisoners’ rights litigation, and complex class action litigation.

23
CLAIMS FOR RELIEF
24

25

First Cause of Action

26

(Plaintiffs Gray, Patterson, and Kujansky and the plaintiff class

v. Defendant County of Riverside)
27

(Eighth Amendment; 42 U.S.C. § 1983)

28

40

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

144. By its policies and practices described in paragraphs 1 through 143,

2 Defendant subjects Plaintiffs and the Plaintiff class to an unreasonable risk of harm

3 and injury from inadequate health care. These policies and practices have been and

4 continue to be implemented by Defendant and its agents or employees in their

5 official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff class’s

6 ongoing deprivation of rights secured by the United States Constitution under the

7 Eighth Amendment.

8

145. Defendant has been and is aware of all of the deprivations complained

9 of herein, and has condoned or been deliberately indifferent to such conduct.

10

11

Second Cause of Action

(Plaintiffs Gray, Patterson, and Kujansky and the plaintiff class
12
v. Defendant County of Riverside)
13
(Fourteenth Amendment; 42 U.S. C. § 1983)

14

146. By its policies and practices described in paragraphs 1 through 143,
15

Defendant subjects Plaintiffs and the Plaintiff class to an unreasonable risk of harm
16

and injury from inadequate health care. These policies and practices have been and
17

continue to be implemented by Defendant and its agents or employees in their
18

official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff class’s
19

ongoing deprivation of rights secured by the United States Constitution under the
20

Fourteenth Amendment.
21

147. Defendant has been and is aware of all of the deprivations complained
22

of herein, and has condoned or been deliberately indifferent to such conduct.

23

Third Cause of Action

24

(Plaintiffs Gray, Patterson, and Kujansky and the Medical Subclass

25

v. Defendant County of Riverside)

26

(Eighth Amendment; 42 U.S.C. § 1983)

27

28

41

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

148. By its policies and practices described in paragraphs 1 through 143

2 Defendant subjects Plaintiffs and the Medical Subclass to an unreasonable risk of

3 harm and injury from inadequate medical care. These policies and practices have

4 been and continue to be implemented by Defendant and its agents or employees in

5 their official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff

6 class’s ongoing deprivation of rights secured by the United States Constitution

7 under the Eighth Amendment.

8

149. Defendant has been and is aware of all of the deprivations complained

9 of herein, and has condoned or been deliberately indifferent to such conduct.

10

11

Fourth Cause of Action

(Plaintiffs Gray, Patterson, and Kujansky and the Medical Subclass
12
v. Defendant County of Riverside)
13
(Fourteenth Amendment; 42 U.S. C. § 1983)

14

150. By its policies and practices described in paragraphs 1 through 143,
15

Defendant subjects Plaintiffs and the Medical Subclass to an unreasonable risk of
16

harm and injury from inadequate medical care. These policies and practices have
17

been and continue to be implemented by Defendant and its agents or employees in
18

their official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff
19

class’s ongoing deprivation of rights secured by the United States Constitution
20

under the Fourteenth Amendment.
21

151. Defendant has been and is aware of all of the deprivations complained
22

of herein, and has condoned or been deliberately indifferent to such conduct.
23

24

Fifth Cause of Action

25

(Plaintiff Gray and the Mental Health Subclass v. Defendant County of

26

Riverside)

27

(Eighth Amendment; 42 U.S.C. § 1983)

28

42

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

152. By its policies and practices described in paragraphs 1 through 143,

2 Defendant subjects Plaintiffs and the Mental Health Subclass to an unreasonable

3 risk of harm and injury from inadequate mental health care. These policies and

4 practices have been and continue to be implemented by Defendant and its agents or

5 employees in their official capacities, and are the proximate cause of Plaintiff’s and

6 the Plaintiff class’s ongoing deprivation of rights secured by the United States

7 Constitution under the Eighth Amendment.

8

153. Defendant has been and is aware of all of the deprivations complained

9 of herein, and has condoned or been deliberately indifferent to such conduct.

10

11

Sixth Cause of Action

(Plaintiff Gray and the Mental Health Subclass v. Defendant County of

12

Riverside)

13

(Fourteenth Amendment; 42 U.S. C. § 1983)

14

154. By its policies and practices described in paragraphs 1 through 143,

15 Defendant subjects Plaintiffs and the Mental Health Subclass to an unreasonable

16 risk of harm and injury from inadequate mental health care. These policies and

17 practices have been and continue to be implemented by Defendant and its agents or

18 employees in their official capacities, and are the proximate cause of Plaintiff’s and

19 the Plaintiff class’s ongoing deprivation of rights secured by the United States

20 Constitution under the Fourteenth Amendment.

21

155. Defendant has been and is aware of all of the deprivations complained

22 of herein, and has condoned or been deliberately indifferent to such conduct.

23

PRAYER FOR RELIEF

24

156. Plaintiffs and the class they represent have no adequate remedy at law

25 to redress the wrongs suffered as set forth in this complaint. Plaintiffs have suffered

26 and will continue to suffer irreparable injury as a result of the unlawful acts,

27 omissions, policies, and practices of the Defendant as alleged herein, unless

28

43

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1 Plaintiffs are granted the relief they request. The need for relief is critical because

2 the rights at issue are paramount under the Constitution of the United States.

3

157. WHEREFORE, Plaintiffs, on behalf of themselves and the class they

4 represent, request that this Court grant them the following relief:

5

A. Declare the suit is maintainable as a class action pursuant to Federal Rule

6 of Civil procedure 23(a) and 23(b)(1) and (2);

7

B. Adjudge and declare that the conditions, acts, omissions, policies, and

8 practices of Defendant and its agents, officials, and employees are in violation of the

9 rights of Plaintiffs and the class they represent under the Eighth and Fourteenth

10 Amendments to the U.S. Constitution;

11

C. Order Defendant, its agents, officials, employees, and all persons acting

12 in concert with them under color of state law or otherwise, to develop and

13 implement, as soon as practical, a plan to eliminate the substantial risk of serious

14 harm that Plaintiffs and members of the Plaintiff class suffer due to Defendant’s

15 inadequate medical and mental health care. Defendant’s plan shall include at a

16 minimum the following:

17
1. Staffing: Staffing shall be sufficient to provide Plaintiffs and the Plaintiff
18
class with timely access to qualified and competent clinicians who can provide
19
routine, urgent, emergent, and specialty health care;
20

21

2. Access: Policies and practices that provide timely access to health care;

22

3. Screening: Policies and practices that reliably screen for medical and

23 mental health conditions that need treatment;

24

4. Emergency response: Timely and competent responses to health care

25 emergencies;

26

27

5. Medication and supplies: Timely prescription and distribution of

28

medications and supplies necessary for medically adequate care;
44

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

1

6. Chronic care: Timely access to competent care for chronic illnesses;

2

7. Mental health treatment: Timely access to necessary treatment for serious

3 mental illness, including medication, therapy, inpatient treatment, suicide

4 prevention, and suicide watch; and

5

8. Quality assurance: A regular assessment of health care staff, services,

6 procedures, and activities designed to improve outcomes, and to identify and correct

7 errors or systemic deficiencies.

8
D. Enjoin Defendant, its agents, officials, employees, and all persons acting
9
in concert with them under color of state law or otherwise, from continuing the
10
unlawful acts, conditions, and practices described in this Complaint and from failing
11
to provide minimally adequate health care;
12

13

E. Award Plaintiffs, pursuant to 42 U.S.C. § 1988, the costs of this suit and

14 reasonable attorneys’ fees and litigation expenses;

15

F. Retain jurisdiction of this case until Defendant has fully complied with the

16 orders of this Court, and there is a reasonable assurance that Defendant will continue

17 to comply in the future absent continuing jurisdiction; and

18

G. Award such other and further relief as the Court deems just and proper.

19

20

21

22

23

24

25

26

27

28

45

CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

 
 Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 1 of 49 Page ID #:76

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 2 of 49 Page ID #:77

1

NATURE OF THE ACTION

2

1. Riverside County has one of the largest jail systems in California, with

3 nearly 4,000 men and women held in five detention facilities (“Riverside jails”).

4 This population consists of both pretrial detainees and people serving sentences in

5 local custody (collectively referred to herein as “prisoners”).

6

2. The thousands of men and women locked up in Riverside’s jails face

7 cruel and inhumane deficits in medical and mental health care. Defendant has

8 known for years that its inadequate health care delivery system places prisoners

9 entering the jails at a serious risk of harm but has failed to take the necessary steps

10 to mitigate the risk. As a result, prisoners in the Riverside jails are subjected to

11 policies and practices that systematically deprive them of their constitutional right to

12 basic life-saving care.

13

JURISDICTION

14

3. The jurisdiction of this Court is invoked pursuant to 28 U.S.C. § 1331,

15 1343, and 1367. Plaintiffs seek declaratory and injunctive relief under 28 U.S.C. §

16 1343, 2201, and 2202; and 42 U.S.C. § 1983.

17

VENUE

18

4. Venue is proper in the Central District of California under 28 U.S.C. §

19 1391(b) because Plaintiffs’ claims for relief arose in this district and Defendantis

20 located in the district.

21

PARTIES

22 Plaintiffs

23

5. Plaintiff Quinton Gray is a prisoner in the Riverside jails in custody of

24 Defendant Riverside County. He has multiple chronic medical and mental health

25 conditions, including seizures, high blood pressure, severe arthritis, and visual and

26 auditory hallucinations and depression. He has experienced and continues to

27 experience repeated treatment failures, including delays in adjusting medication

28
1
FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 3 of 49 Page ID #:78

1 regimens, lack of appropriate laboratory monitoring and frequent missed doses. His 2 initial intake form, similar to other Riverside files, documented “no” to all questions 3 (including history of seizures and high blood pressure)—demonstrating inadequate

4 intake procedures. Even when Mr. Gray has been seen, he has not received adequate 5 basic primary care: for example, he was not screened for high cholesterol or

6 diabetes, despite his chronic high blood pressure.

7

6. Further, Mr. Gray was placed on potent psychotropic medication

8 without appropriate evaluation by a mental health professional with an utter failure

9 to monitor serious and possibly life-threatening side effects. Medications were

10 either suddenly discontinued or multiple doses missed, placing him at serious risk of 11 serious side effects and psychiatric decompensation. He in fact experienced and

12 continues to experience significant, injurious side effects from his medication

13 mismanagement and treatment failures. Mr. Gray has exhausted his administrative

14 remedies.

15

7. At the time of the filing of the original Complaint in this case, Plaintiff

16 Angela Patterson was a prisoner in the Riverside jails in custody of Defendant

17 Riverside County. After sustaining severe injuries in a car accident in June 2009,

18 Ms. Patterson had a temporary filter placed in her inferior vena cava (IVC), the

19 blood vessel supplying the heart, to prevent blood clots. She was booked into the

20 Riverside jails shortly thereafter, where she was subjected to multiple delays,

21 cancellations, appointment mix-ups, and failures to provide appropriate follow-up

22 regarding safe removal of the temporary filter. Nearly a year later, when she was

23 finally taken for surgery, it was found that the filter could not be removed due to the

24 build-up of scar tissue. As a result, Ms. Patterson is now condemned to a lifetime of

25 daily anticoagulation medications and frequent laboratory monitoring, with

26 significant risk of fatal bleeds and other complications. She is 26 years old. If

27 physicians had appropriately obtained and reviewed her records, and made efforts to

28
2
FIRST AMENDED CLASS ACTION COMPLAINT FOR INNCIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 4 of 49 Page ID #:79

1 refer her for IVC filter removal in a timely fashion, it is likely that the filter could

2 have been removed and Ms. Patterson would need no further treatment.

3

8. In addition, she has experienced multiple delays in follow-up with the

4 orthopedic and vascular surgery clinics. As of late 2012, she still had not had a

5 follow-up CT scan of her head to determine whether a growth on her scalp was a

6 slow-growing tumor, more than a year after it was ordered to be performed. Since

7 being placed on anti-coagulant therapy and for the duration of her stay in the

8 Riverside jails, she has also not had timely and effective medication monitoring and

9 administration, resulting in frequent stretches of time throughout her time in the jails

10 where her anticoagulation levels are too low or too high, placing her at risk for

11 further complications. Ms. Patterson has exhausted her administrative remedies.

12

9. At the time of the filing of the original Complaint in this case, Plaintiff

13 Stanley K1 ujawsky was a prisoner in the Riverside jails in custody of Defendant

14 Riverside County. He has been subjected to substandard care while in Defendant’s

15 custody, with inadequate medication administration and treatment of his high blood

16 pressure and multiple delays in the work-up and diagnosis of his chronic neck pain.

17 As a result, he has suffered and continues to suffer unnecessary pain and

18 Defendant’s treatment has endangered his cardiovascular health. Mr. Kujawsky has

19 exhausted his administrative remedies.

20

10. Plaintiff John Rosson III is a prisoner in the Riverside jails in custody

21 of Defendant Riverside County. Mr. Rosson suffers from bipolar affective disorder

22 and has received and continues to receive substandard mental health care while in

23 the jails that has endangered his health and safety. While in the Riverside jails, he

24 has been prescribed major psychotropic medications without any meaningful

25
26 1 Due to a clerical error, Mr. Kujawsky is referred to as Stanley Kwawsky or 27 Kujansky in the Riverside jail records.
28 3
FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 5 of 49 Page ID #:80

1 assessment by a mental health professional and without informed consent. His

2 medications have repeatedly been renewed without any regular assessment of his

3 progress, side effects, and co-existing medical issues, a clear violation of the

4 standard of care and particularly dangerous given his history of diabetes and

5 hyperlipidemia, which can be worsened by the psychotropic medications he takes.

6 Acute psychiatric symptoms, such as hearing voices, have been ignored by

7 Riverside jail mental health treatment staff. He suffers frequent lapses in

8 medication delivery: after one such episode in early 2013, when he was denied his

9 necessary psychotropic medications for more than two weeks, he became actively

10 self-harming and cut himself. As a result, he was placed in a filthy “safety cell”

11 with blood and feces on the wall and subsequently in the county hospital for several

12 days. He continues to experience medical delivery interruptions to this day. Mr.

13 Rosson has exhausted his administrative remedies.

14 Defendant

15

11. Defendant County of Riverside operates five jails -- the Robert Presley

16 Detention Facility, the Smith Correctional Facility, the Indio Jail, the Southwest

17 Detention Center, and the Blythe Jail — that incarcerate nearly 4,000 prisoners. The

18 County is responsible for providing a constitutional level of health care for those in

19 its custody, including the funding, oversight, and corrective action to ensure

20 adequate conditions.

21

FACTUAL ALLEGATIONS

22

Riverside County exhibits systemic failures in the provision of basic

23

health care to prisoners in its jails.

24

12. Defendant, by policy and practice, maintains and runs a health éare

25 system that lacks basic elements necessary to provide constitutional care: it

26 systematically fails to identify and diagnose serious conditions, to provide timely

27 care, to administer appropriate medications, to employ adequate staff to meet

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1 prisoners’ basic needs, to maintain records that allow informed treatment decisions, 2 to establish legally required confidentiality, and to identify and correct its own

3 failings.

4

13. Prisoners’ access to health care is so inadequate at all the Riverside

5 jails as to constitute deliberate indifference to their serious medical and mental

6 health needs. Further, Defendant is deliberately indifferent to the fact that these

7 systemic failures result in significant injury and a substantial risk of serious harm.

8

A. Delays in and denial of access to care

9

14. Defendant has a policy and practice of failing to provide timely access

10 to necessary health care and is deliberately indifferent to the risk of harm and injury 11 to prisoners that results from this systemic failure. Care is often delayed or denied

12 entirely, causing unnecessary pain and suffering as well as physical injury to the

13 patients. The two basic mechanisms to alert health care staff to prisoners’ needs -14 intake screening and sick call — are inadequate in both policy and practice.

15

1. Intake screening

16

15. Riverside’s jail screening and intake process fails to adequately identify

17 and treat the medical and mental health care problems of newly arriving prisoners.

18

16. Insufficient numbers of nursing staff are available to identify and

19 evaluate medical conditions on intake, resulting in dangerous delays in treatment.

20 Prisoners are rarely assessed for communicable diseases when they arrive at the

21 jails, and medically high-risk prisoners do not have histories taken, physical

22 assessments, or treatment plans.

23

17. Plaintiff Quinton Gray arrived at the Riverside jails with a chronic

24 seizure disorder and high blood pressure. His initial intake form nonetheless has

25 “no” marked for every question about health care needs, including those that should

26 clearly be marked “yes.” Numerous other prisoners with longstanding chronic

27

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1 conditions have intake forms with the same deficiencies, demonstrating an

2 inadequate intake screening process.

3

18. As a result, prisoners are placed at serious risk of harm. For example,

4 one woman who regularly takes medication for her chronic severe high blood

5 pressure entered the Riverside jails on September 9, 2011. She received no

6 medication or, indeed, any recorded medical screening or attention until she suffered

7 chest pain and hypertensive emergency nearly three weeks later. At that time, she

8 was sent to the emergency room at Riverside County Regional Medical Center

9 (RCRMC) and found to have blood pressure of 230/140 -- high enough to cause a

10 stroke, vision loss, or a heart attack.

11

19. Another woman with multiple serious medical conditions, including

12 hypothyroidism, diabetes, and a recent history of gastric bypass surgery, had no

13 record of any of these crucial health factors on her booking form, in which every

14 question regarding the presence of health care needs was marked “no.” Treatment

15 for her serious chronic conditions was delayed, resulting in significant health risks.

16

20. Another patient who arrived in the Riverside jails with multiple

17 longstanding chronic conditions -- a seizure disorder, asthma, psoriasis, and

18 Hepatitis C -- had “no” marked for every question on his booking form regarding

19 medical history. As a result, he did not receive all of his necessary medications for

20 several weeks.

21

21. Initial mental health screening at the jails is faulty because it is

22 performed by untrained custody staff, a practice that Riverside Sheriff Stanley Sniff

23 knows is inadequate and dangerous because, as he states, “correctional officers may

24 not recognize hidden medical and/or mental health problems that could be best

25 observed by a medical/mental health expert. This could result in delaying needed

26 treatment.” Appropriate screening is particularly important since, according to the

27 Sheriff, “the time period immediately following admission to a jail is the most

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1 dangerous time for an inmate, and over half of in-custody deaths occurred within 2 one month of admissions, with 24% of deaths occurring within two days of

3 admission.”

4

22. One man admitted to the Smith Jail had no recorded intake or screening

5 at all. He was eventually placed in a suicide watch “safety cell” and given

6 psychotropic medications (Zoloft and Trazodone). His medical records contain no

7 diagnosis, medical administration records, review of symptoms, psychiatric history, 8 social history, review of current medications, allergies, mental status examinations, 9 vital signs, risk assessments or treatment goals.

10

23. Plaintiff John Rosson III was started on psychotropic medications

11 including Risperdal, Trileptal, Trazodone and Prozac with no recorded evaluation,

12 diagnosis, or rationale, despite the fact that he had a noted history of diabetes and

13 hyperlipidemia and Risperdal can worsen these conditions.

14

24. Another prisoner’s intake note does not contain an adequate diagnosis,

15 review of symptoms, social and psychiatric history, allergies, mental status

16 examination, vital signs, risk assessment, or treatment goals. The patient was given 17 multiple psychotropic medications, including antipsychotics, with no subsequent

18 recorded clinical notes describing symptoms, ongoing examinations, or diagnoses. 19 The inadequate screening and diagnostic process placed him at risk for dangerous

20 unmonitored side effects, contraindicated medications, and untreated mental illness.

21

25. Another patient was prescribed Trazodone, Risperdal and Zoloft

22 without any associated documentation indicating he was first assessed by a mental

23 health professional and provided a treatment plan outlining a rationale for these

24 medications. There was no documentation of informed consent, which in his case is

25 particularly important since he had a pre-existing seizure disorder and type-IT

26 diabetes. Risperdal lowers the seizure threshold and can worsen type-IT diabetes.

27 On the day he was prescribed Risperdal, Trazodone and Zoloft, he submitted a

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1 health needs request stating he had a seizure in his cell. Risperdal should be

2 attempted to be lowered or discontinued if patients are having uncontrolled seizures

3 prior to starting or on the medication. There is no documentation of screening for

4 active seizures prior to initiating Risperdal and no documentation addressing co

5 management of his seizure disorder and use of Risperdal with a neurology specialist.

6

2. Sick call and access to care

7

26. Even if their serious medical concerns are flagged at intake, patients are

8 often unable to obtain care because the sick call system is inadequate. Outside

9 monitors have repeatedly found the Riverside jails incapable of providing the daily

10 sick call that state law requires. These conditions harm prisoners, who experience

11 extreme difficulty in obtaining necessary medical and mental health appointments.

12 In the absence of a functioning sick call system they must either obtain a court order

13 from the criminal court or file repeated blue slips (health needs requests, or HNRs)

14 and grievances. Plaintiff Quinton Gray has never seen a Riverside jail doctor

15 without an order from the Superior Court for care. He has received three orders: in

16 late 2011, in June 2012, and in September 2012. Plaintiff Stanley Kujawsky

17 similarly has had to obtain court orders to see a doctor in the Riverside jails.

18

27. Court orders, blue slips, and grievances regarding health care are

19 routinely ignored. The County maintains an extensive computerized list of court-

20 ordered appointments that notes how long the prisoners have been waiting; delays of

21 one, two, or three months are common. One prisoner obtained a court order on

22 November 21, 2011, that orders her “to see medical doctor within 48 hours to be

23 evaluated for severe pain due to hernia on back. Court recommends medication

24 treatment to control pain.” After waiting several weeks, the prisoner filed a

25 grievance asking that the order be honored. The response, dated December 23,

26 2011, acknowledged the court order and the month-long delay and stated that

27 “nurses confirmed they are waiting for the doctor to show up to see the court

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1 orders.” Plaintiff Stanley Kujawsky was prescribed pain medication without ever

2 seeing a doctor in the jails; he received a court order on November 22, 2011, to see a

3 doctor for his pain, but was not actually seen until January 25, 2012.

4

28. Some prisoners who request medical attention are told that doctors are

5 only seeing patients with court orders for care.

6

29. Prisoners also file repeated blue slips without any result except a $3

7 charge exacted for each request. As a result, they are placed at serious risk of harm.

8 For example, one patient filed numerous blue slips complaining of serious stomach

9 pain but was never seen by a doctor. After three months of such complaints, he

10 submitted a blue slip stating that he was vomiting blood, a symptom that can

11 indicate an emergency leading to death and which is at minimum is concerning for

12 gastric disease such as peptic ulcers or cancer. The patient should have seen a

13 physician immediately, had his vital signs and blood counts checked, and possibly

14 even have been referred to an emergency room or gastroenterologist for further

15 evaluation. None of this was done. He was not even referred to see a doctor for

16 another month.

17

30. Compounding the problem, prisoners often have extreme difficulty

18 grieving inadequate access to care since they must request grievance forms from

19 sheriffs’ deputies, who often refuse to provide them. Plaintiff Quinton Gray filed a

20 grievance in September 2012 noting serious ongoing problems with access to

21 medical and mental health care, and stating that he had to get a grievance form from

22 “an outside agency” because of custody staff’s refusal to provide him with a form

23 and their interference with access to adequate health care.

24

31. As a result of these policies and procedures, prisoners experience

25 dangerous delays in access to both primary and specialty care.

26

32. One woman entered the Presley jail with Stage Four colon cancer in

27 late July 2011. In early August, she was seen for abdominal pain, nausea and

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1 vomiting, similar to the colon cancer symptoms she had experienced on first

2 diagnosis. Her outside medical records, obtained at that time by the County,

3 documented chemotherapy in 2009 for colon and ovarian cancer and a recent CT

4 scan showing possible recurrence. With these strong indicators that her cancer had

5 returned, she should have received a colonoscopy and referral to an oncologist

6 within a very few weeks. Although both referrals were made on August 3, neither

7 was completed by the time she was released from custody in December 2011. For

8 more than four months, County medical providers demonstrated gross incompetence

9 and negligence, with unexplained delays, apparently lost referrals, and a botched

10 attempt at a colonoscopy, for which she was not given a basic bowel preparatory

11 procedure — an elementary mistake. Throughout this time, the patient repeatedly

12 complained of abdominal pain and rectal and vaginal pressure. The lack of care for

13 her malignancy possibly allowed it to progress to a point where she was no longer a

14 candidate for further treatment, shortening her life expectancy. The inadequate

15 treatment for her symptoms forced her to endure unnecessary pain and suffering.

16

33. Another woman with a breast tumor suffered significant delays in care:

17 she was denied timely appointments with a physician; multiple specialty

18 appointments were not scheduled or were skipped, despite physician referrals; and

19 she was frequently not notified of important test results such as biopsies, when

20 standard practice is to notify patients of results within one to two weeks. Nearly

21 every time her complaints were addressed by medical staff was in response to a

22 court order. Her tumor was found to be benign; had it been malignant, these

23 cumulative delays could have been life-threatening. Although she received some

24 medications to treat her ovarian cyst-related pain, she continued to have pain and

25 physicians failed to order a repeat vaginal ultrasound or refer her to gynecology for

26 further evaluation and management, as the standard of care requires.

27

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1

34. Plaintiff Angela Patterson arrived at the Riverside jails following

2 surgery to place a temporary filter in a major blood vessel supplying her heart. She

3 was discharged directly from the RCRMC hospital to the jail. Despite the fact that

4 such filters should be removed within three months, there was no acknowledgment

5 of the existence of the filter in her jail medical records for over a month. Ms.

6 Patterson then endured many months of delays, cancellations, and scheduling mix-

7 ups in specialty care, as well as repeated medication administration failures that

8 have continued throughout her time in the Riverside jails. For nearly six months,

9 medical staff documented confusion over whether the IVC filter was temporary or

10 permanent; they did not resolve the matter until March 2010, nine months after the

11 filter was placed in her body. She was not seen in surgery until June 25, 2010, at

12 which point it was discovered that the filter could not be safely removed because of

13 the accumulation of scar tissue.

14

35. Following the surgery, a Riverside jail doctor discontinued Ms.

15 Patterson’s anticoagulation medication because of “filter removal,” despite the fact

16 that it was still in her body and there was a note in her medical records from two

17 days earlier reporting that the filter had not been removed. In August 2010, she was

18 placed on life-long anticoagulation therapy. Anticoagulation therapy has significant

19 risks, including the risk of fatal bleeds, and requires daily medication and frequent

20 laboratory monitoring -- a weighty burden, particularly for Ms. Patterson, who is 26

21 years old. If physicians had appropriately obtained and reviewed her records and

22 made efforts to refer her for IVC filter removal in a timely fashion (within a few

23 months of placement), it is likely that the filter could have been removed and Ms.

24 Patterson would need no further anticoagulant therapy, with all the risks that entails.

25 The risks are significantly enhanced by the repeated medication administration

26 failures she has continued to suffer throughout her time in the Riverside jails: the

27

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1 frequent missed dosages, switched dosage times, and inadequate monitoring have

2 resulted in blood anti-coagulation levels so low as to put her at risk for blood clots.

3

36. A patient with chronic high blood pressure was inadequately screened

4 on intake, as described above, which resulted in an emergency room visit and

5 dangerously high blood pressure. Subsequent months in custody saw no

6 improvement in her care, as Riverside County medical staff failed utterly to monitor

7 her chronic condition. Her care was repeatedly delayed, prescribed medications

8 repeatedly not offered, and the sub-par care led to multiple episodes of uncontrolled

9 hypertension and preventable emergency room visits.

10

37. A patient experiencing uncontrolled seizures and multiple emergency

11 room visits was not given a neurology referral for more than three months after his

12 arrival in the Riverside jails. After the referral was made, he waited for two more

13 months to actually see a neurologist, although he was having seizures two to three

14 times per week, often sustaining head trauma and other injuries, and although

15 managing his condition was clearly beyond the scope of a general medicine

16 practitioner. The neurologist recommended an EEG, which was never performed.

17 The patient continued to have uncontrolled seizures and emergency room visits; he

18 had another neurologist appointment two months later, at which point the EEG was

19 re-ordered. The patient was never referred to an epilepsy specialist, despite the clear

20 indication that his medication regime was ineffective and such a consultation was

21 needed. Continued, untreated generalized seizures place patients at high risk for

22 immediate injury (such as he repeatedly sustained) as well as worsening long-term

23 cognitive impairment, decreased function, and diminished quality of life.

24

38. Another patient arrived in jail with a lap-band that had been surgically

25 inserted into his stomach for weight loss. He soon began to demonstrate symptoms

26 of a esophageal obstruction (a known complication of such surgery), including

27 significant weight loss, nausea, vomiting, and extreme hunger. Despite numerous

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1 requests for help, he experienced unnecessary delays in diagnosis and treatment and

2 failure to respond to his multiple health complaints. For example, after two

3 episodes of loss of consciousness, a documented 17-pound weight loss in 30 days, 4 complaints of inability to tolerate any food or liquid intake, and a blood pressure of

5 90/60, he was merely referred for a medical appointment more than a week in the 6 future. The delays in diagnosis of his obstruction put him at risk for serious health

7 complications due to rapid weight loss and deprivation of essential nutrients.

8

39. Access to mental health care is no better. Defendant’s deficient system

9 forces mentally ill prisoners to wait weeks or months for mental health assessment

10 and evaluation by clinical staff, during which time they are denied essential

11 psychotropic medications and other treatment. The Sheriff admitted this problem in 12 July 2011, acknowledging that “such delays may impact an inmate’s mental

13 stability.” As with medical care, many mental health patients must file repeated

14 blue slips or grievances to get seen; others are only seen by clinicians after the

15 judges in their criminal cases have ordered care. Patients experience a range of

16 symptoms, from auditory hallucinations to severe depression, while enduring these

17 lengthy delays.

18

40. Patients with serious dental care needs suffer from the same pattern and

19 practice of injurious delays. Patients in severe pain wait for months to see a dentist

20 and face significant pain and suffering as a result. For example, one patient with

21 only two functioning teeth lost more than 20 pounds in the six months he has been

22 incarcerated because he is unable to eat much of the food he is served and he cannot

23 afford to buy his own. He has submitted blue slips to see a dentist to get dentures

24 without success.

25

41. Another patient experienced serious delays in care: her complaints of

26 tooth pain were first documented in her health records in December 2011. On

27 March 17, 2012, a progress note in her file simply reads “Back upper Rt tooth broke

28
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1 and gum swollen.” This one-line progress note, with no medical history, duration of

2 symptoms, or full exam, is inconsistent with accepted medical standards of care. In

3 addition, the patient was prescribed penicillin and motrin for her symptoms without

4 any mention of a dental referral or evaluation.

5

42. Another patient filed a request complaining of a broken tooth and

6 requesting a dental referral on September 21, 2011. He submitted a repeat request a

7 month later also requesting’ a dental referral. He was not seen for these complaints

8 ‘until November 1, 2011, at which time medical staff noted that he had decayed teeth

9 and referred him to dental staff without any mention of his ability to eat or whether

10 the tooth looked infected. In the many months he has been waiting, he has

11 experienced intermittent severe pain in his teeth that makes him unable to eat

12 several times a week.

13

3. ,Specialty referrals

14

43. The Riverside jails lack adequate policies and procedures to provide

15 patients with needed referrals for specialty medical consultations and procedures.

16 For example, a patient with colon cancer was referred for a colonoscopy and to an

17 oncologist on August 3, 2011, but neither was completed by the time she was

18 released from custody in December 2011. Given that her cancer was Stage IV, she

19 should have been seen in a very few weeks.

20

44. As discussed above, Plaintiff Angela Patterson experienced numerous

21 delays and cancellations in specialty referrals, which likely led to build-up of scar

22 tissue on a temporary filter in a blood vessel near her heart. As a result, she will live

23 the rest of her life with this filter in her chest and suffer a lifetime of serious

24 anticoagulation medication with related health risks and the burden of frequent

25 monitoring. In addition, a CT scan was ordered in January 2011 to be performed in

26 six months to rule out a possible slow-growing tumor on her scalp. As of January

27 2013, it had not yet been performed — well over a year late.

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1

45. Another man with uncontrolled seizures and multiple emergency room

2 visits was not given a neurology referral for more than three months after his arrival

3 in the Riverside jails. After the referral was made, he waited for two more months

4 to actually see a neurologist, although he was having seizures two to three times per

5 week.

6

46. A man who had experienced severe recent head injuries wa ordered an

7 ENT consultation by a Riverside jail doctor but it did not take place and had to be

8 re-ordered one month later. When the ENT consultation finally took place, he was

9 not sent with his crucial records and the appointment was of limited use. He was

10 referred for surgery on September 30, 2011, but did not receive it, and despite

11 repeated complaints of pain and two more court orders for care, he was not seen

12 again until November 8, 2011, when the surgery was re-ordered “ASAP.”

13

47. A patient with multiple chronic conditions -- a seizure disorder, asthma,

14 psoriasis, and Hepatitis C -- experienced multiple delays in obtaining timely

15 referrals, even after ordered by physicians, as well as follow-up, resulting in sub-

16 standard care.

17

4. Denials of care

18

48. Some prisoners face outright denials of basic and necessary medical

19 care. Plaintiff Quinton Gray was prescribed Dilantin on his arrival at the jail, but

20 even after two emergency room readings taken over the next few days showed that

21 the Dilantin level in his blood was far below the therapeutic level, jail medical staff

22 did nothing for well over a year.

23

49. A prisoner with thyroid disease was denied medication for nearly three

24 months. Although her initial screening form missed the condition, it was noted

25 repeatedly on her charts for several months by medical staff before she was finally

26 prescribed medication. Missed doses of thyroid medication for a prolonged period

27 put patients at risk for severe fatigue, slow heart rates, weight gain, constipation,

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1 hair loss, edema, and eventually coma. The same patient also has a history of

2 gastric bypass surgery; the jail doctor refused her any dietary supplements to ensure

3 proper nutrition throughout her jail stay, despite repeated requests. Patients are at

4 risk for maLnutrition following bypass surgery and require life-long vitamin

5 supplementation. In addition, no tests were ordered to assess any nutritional

6 deficiencies, another violation of the standard of care.

7

50. Another prisoner fell and hurt his back at Presley in November 2010

8 and again in March 2011. He was provided inadequate neurologic exams after his

9 falls, several-month delays for scheduling of x-rays and consultations (even when

10 ordered “as soon as possible”), and inadequate trial of physical therapy; his back

11 pain went essentially untreated. Two clinic appointments were cancelled due to

12 “too many ad-segs” and one was cancelled because a wheelchair van was not

13 available.

14

B. Substandard medication management and administration

15

51. Reliable and systematic medication delivery is an essential element to a

16 constitutional health care system. Defendant has a policy and practice of failing to

17 prescribe, provide, and properly manage medication, and of providing incorrect,

18 interrupted, or incomplete dosages. As a result, prisoners with serious health care

19 conditions are placed at substantial risk of harm and are in fact harmed.

20

52. Many patients are provided substandard care because there is

21 inadequate staff to distribute medications. (Staffing deficiencies are described in

22 more detail in the following section.) Medication deliveries are often skipped

23 entirely, leaving patients without essential treatment. Plaintiffs Quinton Gray,

24 Angela Patterson, Stanley Kujawsky, and John Rosson III have experienced

25 numerous skipped medication dosages at various Riverside jail facilities, placing

26 Mr. Gray at serious risk for heart attack, stroke, and seizures; exposing Ms.

27 Patterson to an increased risk of recurrent thrombus; endangering Mr. Kujawsky’s

28
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1 cardiovascular health, and seriously endangering Mr. Rosson’s mental health and

2 risk of self-harm.

3

53. Other prisoners face the same problems. One patient who is prescribed

4 medications for his chronic high blood pressure has experienced a dangerous

5 number of missed doses: for example, in April 2011 he was not given nine doses of

6 both of his medications, and in September 2011 staff did not administer 14 doses of

7 one and eight, doses of the other medication. Another patient who has been

8 prescribed medications for his diabetes has experienced numerous missed

9 medication doses —21 missed doses in one month alone.

10

54. In practice, medication distribution in the jails takes place only once or

11 at most twice daily, leaving patients who require multiple daily dosages, or bedtime

12 delivery, unserved. Since the Smith facility is so large, nurses start evening pill call

13 at approximately 2 p.m. to allow them to deliver medications throughout the

14 institution. This includes sleep medications: some patients receive their pills in the

15 middle of the afternoon and fall asleep within a few hours. Pill call is erratic for

16 many prisoners, and evening pills might arrive any time from 3 to 10 p.m., if at all,

17 which is particularly dangerous for diabetics, many of whom must receive

18 medications at regular intervals, coordinated with meal times. Throughout 2012 and

19 2013, Plaintiff Angela Patterson has had her medications delivered at inconsistent

20 times, including being switched by jail staff from morning to evening, despite the

21 fact that the medication should be taken at the same time daily, likely affecting her

22 treatment stability.

23

55. Defendant’s policy and practice is to require patients to alert staff when

24 their medications run out. As a result, some prisoners’ prescriptions are not

25 renewed until they file multiple health care requests or grievances, resulting in

26 significant treatment interruptions with resulting, predictable harm to the patients.

27 For example, a patient at Southwest Detention Center has experienced several one

28
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1 month gaps between refills of his psychiatric medications, including Paxil. Paxil

2 has a well-documented discontinuation syndrome: the lengthy lapses in medication

3 delivery place him at serious risk for severe discontinuation symptoms including

4 flu-like symptoms, nausea, vomiting, and headaches. A Presley patient prescribed

5 pain medications for his severe back pain is frequently deprived of the medications

6 when the prescriptions run out and refills are not provided; doctors also renew his

7 medications without assessing their efficacy.

8

56. Plaintiff Stanley Kujawsky has been denied medications on the days he

9 goes to court for hearings in his criminal case as well as on the days he goes to see

10 outside specialists for medical care. These deprivations are pursuant to policy and

11 practice: numerous other prisoners are denied medications altogether when they

12 attend court hearings or are transported to outside appointments. Some prisoners

13 regularly miss medications in the morning because they are asleep and staff

14 routinely fail to announce medication delivery effectively.

15

57. Riverside also has a policy and practice of failing to monitor the effects

16 of medication to determine whether dosages are correct or medications should be

17 changed. Plaintiffs Quinton Gray, Angela Patterson, Stanley Kujawsky, and John

18 Rosson III have suffered from inadequately monitored medication regimens which

19 have seriously eridangered their health and forced them to endure unnecessary pain

20 and suffering. Their problems are typical of those experienced by medical and

21 mental health patients in the Riverside jails. For example, one man with high blood

22 pressure has been given two medications to treat his condition, but on occasion,

23 without explanation, he has been abruptly discontinued from one of the medications.

24 No monitoring of his condition is documented in his medical records, suggesting

25 that either such documentation is missing or it was never charted -- either way, lack

26 of proper documentation can be dangerous for patient care and signifies a

27 concerning level of disorganization within the medical department.

28
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1

58. The same patient’s file lacks any progress notes documenting any

2 blood pressure, history, physical exam or lab tests during the duration of treatment.

3 In general, when starting or changing blood pressure regimens, patients’ blood

4 pressures should be checked to ensure that they are not over-medicated or given low

5 blood pressure, which can be dangerous. In addition, without monitoring blood

6 pressure, there is no way to. know if the patient was actually adequately controlled --

7 high blood pressure could put him at risk for strokes, brain bleeds and heart attacks.

8 Further, because one of his medications can be associated with electrolyte

9 abnormalities, the standard of care requires physicians to check basic blood tests for 10 sodium, potassium and kidney function levels either prior to or shortly after starting 11 such agents. None of this was done.

12

59. A diabetic man who entered the Riverside jails with an elevated blood

13 sugar count was prescribed medications and ordered glucose checks twice daily for

14 two weeks and then weekly thereafter, as well as various blood work. These orders

15 were apparently ignored, however, along with two subsequent orders for weekly

16 blood sugar checks: his health records show only two glucose checks over the next 17 several months and no evidence that he ever had the blood work performed. This 18 failure to monitor his condition placed him at serious risk of harm, particularly since 19 one of the medications he was prescribed, Glipizide, can make patients

20 hypoglycemic.

21

60. Psychotropic medications also are not monitored to determine whether

22 they are effective or whether they cause severe side effects.

23

61. Patients face serious consequences from the denial of appropriate

24 medications. For example, one man experienced uncontrolled seizures resulting in

25 serious injuries. His medication regimen was clearly ineffective, but he was merely

26 prescribed increases in his existing medication, contrary to the standard of care. He

27 continued to suffer from frequent seizures and resulting physical injuries.

28

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1

62. Another patient fell in his cell and hurt his hand (he uses a cane due to

2 leg injuries, but is only allowed it to ambulate longer distances). He was sent to the

3 emergency room one day later with increasing pain in his hand. He was found to

4 have suffered a fracture and prescribed Vicodin and Ibuprofen for the pain. He was

5 never given these medications on his return to the jail, and suffered unnecessary

6 pain as a result.

7

63. Medication lapses can be particularly devastating in the mental health

8 realm. According to Sheriff Sniff, “continuity in delivery of mental health

9 medications may affect thestability of an inmate’s mental health and is critical to

10 inmate care.” More specifically, delays in administering psychotropic medications

11 to mental health patients can result in serious harm. Such harm is occurring in the

12 Riverside jails: prisoners experience frequent gaps in medication delivery, as the

13 Sheriff has admitted. Sometimes psychotropic medications are not distributed at all

14 in entire housing units, since nurses are simpiy overwhelmed. At other times,

15 patients’ medications are abruptly changed with no examination and .no explanation.

16

64. These interruptions harm prisoners. Plaintiff John Rosson III recently

17 experienced a lapse of more than two weeks in medication delivery, despite filing a

18 blue slip and speaking tO a doctor about his need for the medications. As a result, he

19 became despondent and self-harming, cutting his arm and leg. He was placed in a

20 filthy safety cell and the county hospital, where his medications were final

21 stabilized. The medication failures have been of long standing: Mr. Rosson has

22 filed repeated grievances over the last several years regarding mediation failures, but

23 these attempts to obtain appropriate care have been unsuccessful.

24

65. Similarly, over many months in the Indio, Presley, and Smith jails,

25 Plaintiff Quinton Gray had his powerful psychotropic medications either suddenly

26 discontinued or multiple doses missed. Another man held in the Presley facility

27 experienced significant lapses, without explanation, in receiving medication for his

28
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1 bipolar disorder: his Zoloft was not renewed for nearly one month, and his Topomax

2 was not renewed for nearly three months. Further, neither medication was

3 appropriately titrated on being restarted. Sudden discontinuation of these

4 medications can cause manic episodes and seizures as well as physical symptoms

5 such as nausea, vomiting, and headaches; sudden resumption after a significant gap

6 in time can also cause damaging side effects. The patient in fact experienced

7 depression and severe mood swings due to the medication mismanagement.

8

66. Similarly, a patient at Smith had his psychotropic medications and

9 dosages changed repeatedly over two years, including the abrupt and unexplained

10 cessation of his antipsychotic medications. A Presley patient also had psychotropic

11 medications abruptly started, stopped, and renewed over several years with little or

12 no evaluation or assessment. This pattern and practice of medication

13 mismanagement places these patients at serious risk for decompensation, untreated

14 mental illness, and severe side effects.

15

C. Severe staffing deficits

16

67. Many of the deficits described herein stem from the inadequate health

17 care staffing levels maintained by Defendant in the jails. There are simply not

18 enough doctors, nurses, mental health providers, pharmacists, or medical records

19 staff to meet the needs of the population.

20

68. Defendant’s policy and practice of severely understaffing health care

21 positions in the jails is long standing and has been repeatedly censured by the county

22 Grand Jury. In 2010, the Grand Jury found that “[mjental health staff is not

23 available in any county jail facility in sufficient numbers to identify and treat in an

24 individualized manner those treatable inmates suffering from serious mental

25 disorders.” The Grand Jury Report released on June 14, 2012, states the problem in

26 clear terms:

27

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1

In July, 2011, DMH was advised. .. .that the medical/mental health

2

staffing levels in county jails needed to be restored to 2007 levels, in

3

order to be in compliance with [state lawJ. As of this writing, the

4

Grand Jury learned through sworn testimony that during the eight

5

months following the 2010-2011 Grand Jury report, DIvIH staffing

6

levels were allowed to decrease even further.

7

69. Medical care is no better: according to the independent Inmate Medical

8 Quality evaluators, invited by Sheriff Sniff to identify deficiencies in jail health

9 care, “[t]he request for medical care exceeds the capability of the staff to meet the

10 demands.” The Detention Health Services administrator agreed, admitting that “the

11 demand exceeds the resources available to provide the requested services.”

12

70. Long-term medical vacancies are endemic, particularly given the

13 competition with the higher salaries offered by the state prison system. For

14 example, at the beginning of 2011, there were only three physicians for well over

15 3,000 prisoners in the five jails. Two doctors subsequently resigned and for at least

16 several months, there was not a single physician, physician assistant, or nurse

17 practitioner working in the Riverside jails — only a “Chief of Medical Specialty”

18 who rarely saw patients. Only two of the five full-time physician positions in the

19 jails were filled as of May 31, 2012.

20

71. Other medical staffing is alsO deficient. As of May 2012, the county

21 had multiple vacancies for nurses and nurse supervisors, and only 65 of 101 total

22 Detention Health Services positions were filled. Further, according to the CSA,

23 “there is no budget for overtime and no staff available to provide services in the

24 event of illness, injury, or vacation.”

25

72. Defendant lacks the staff necessary to provide minimally adequate

26 dental care. By the County’s own assessment, two full-time dentists and two full

27 time dental assistants are required to offer basic dental care to the nearly 4,000

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1 prisoners. As of May 2011, only one dentist and one dental assistant were working

2 in the jails.

3

73. A patient at the Smith Jail with chronic high blood pressure filed a

4 grievance complaining that although the doctor had ordered blood pressure checks

5 every three days, he had only received them twice in the preceding 23 days. The

6 grievance response from Senior Corporal Diaz confirms that the patient “is still not

7 having his blood pressure checked. When he asked the nursing staff they stated they

8 do not have the time.”

9

D. Violations of patients’ confidentiality rights

10

74. According to the Grand Jury, Riverside “has no confidential self

11 referral system by which inmates can request mental health care without revealing

12 the nature of their request to correctional officers,” as required by federal and state

13 law. See 45 C.F.R. § 164.500 et seq.; Cal. Civil Code § 56.10 et seq. Requests
14 for medical care are also not confidential, since they too are delivered to medical

15 staff by custody staff. Prisoners are directed to give blue slips requesting health

16 care directly to custody staff; many believe that they must provide as much detail as

17 possible about their health care needs in order to increase their chances to be seen.

18 Many prisoners, including Plaintiffs Gray and Kujawsky, also must file grievances

19 in order to be seen by clinicians. To get grievance forms, they must persuade

20 custody staff that their concerns are significant. The grievances are then heard by

21 custody staff, who make the determination whether to involve health care staff.

22

75. Examination space at Southwest Detention Center is not confidential:

23 patients can overhear other patients’ examinations through an open door, as they

24 wait in the hallway for their own treatment.

25

E. Poor records administration

26

27

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1

76. Adequate health care cannot be provided in the absence of adequate

2 health records: clinicians must know. their patients’ medical histories, past diagnoses

3 and treatment, and for psychiatric patients, a history of suicidal thinking or attempts.

4

77. Riverside’s medical records system is profoundly disorganized and

5 incomplete. Some psychiatric patients have no diagnosis recorded, despite the

6 prescription of psychotropic medications. Some patients are prescribed medications

7 but lack any record of medication administration in their file, or any record that the

8 effects of the medication were tracked and reviewed. All three Plaintiffs’ health

9 care records demonstrate Riverside’s failures in this area.

10

78. It is not surprising that record-keeping is ihadequate: as of December 6,

11 2011, the entire medical records staff for five jails and well over three thousand

12 prisoners was three medical records technicians and no medical clerks.

13

79. The record-keeping gaps impact patient care. One psychiatric patient

14 had no legible diagnosis, review of symptoms, psychiatric history, mental status

15 examination, or risk assessment. He was nonetheless prescribed antipsychotics with

16 no reference to any ongoing mental status exams or data on symptoms, even when

17 doses or medications are changed, as was done repeatedly over a two-year period.

18 At one point, the patient’s antipsychotics were stopped abruptly with no explanation

19 in the records.

20

80. Another patient was placed in a safety cell on suicide watch with no

21 recorded reason. The order to discontinue the watch is similarly bereft of any

22 explanation as tp why he is no longer a danger to himself, or any risk assessment.

23

F. Inadequate quality assurance

24

81. Not surprisingly, given the paucity or records and severe staffing

25 shortages, Riverside officials lack the ability to identify and correct the problems

26 described herein. Health care staff do not systematically correct identified

27 deficiencies, and there is inadequate staff for oversight and review of care.

28
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1 IL 2

Even If Prisoners See Health Care Providers Constitutionally Adequate Medical or Mental

They Do Not Health Care

Receive

82. As detailed in the previous section, Riverside’s lack of the basic

3 elements of a health care delivery system -- policies and procedures to ensure timely

4 access to appropriate care, medication management, adequate staffing, patient

5 confidentiality, medical records, and quality assurance — harms Plaintiffs and

6 members of the plaintiff class. Even when they are able to see health care providers,

7 prisoners are by policy and practice denied adequate medical and mental health care

8 in the Riverside jails: they experience gross treatment failures, inadequate

9 examinations, and the failure to provide necessary specialty appointments and

10 diagnostic tests.

11

A. Substandard medical care

12

83. Plaintiffs Gray, Patterson, and Kujawsky, on behalf of themselves, the

13 plaintiff class, and the medical subclass, assert the following.

14

84. Prisoners — even those with serious medical conditions -- rarely see

15 physicians, and health care records demonstrate a paucity of appropriate follow-up,

16 monitoring, and specialty referrals, as well as improper care.

17

85. Plaintiff Quinton Gray has chronic high blood pressure that has been

18 inadequately monitored and controlled by Riverside jail medical staff. He has

19 experienced multiple elevated blood pressure measurements without any assessment

20 of the efficacy of his medications and dosages. He has twice gone without blood

21 pressure check for more than four months, despite his history of elevated readings

22 and despite the fact that regular readings had been ordered by physicians. In

23 addition, he is frequently not provided his medications at all, thus increasing his risk

24 of poorly controlled blood pressure. Uncontrolled blood pressure can cause heart

25 attacks, heart failure and strokes.

26

86. Mr. Gray’s seizure disorder has also been inadequately treated. He was

27 prescribed Dilantin on his arrival at the jail, but two emergency room readings taken

28

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1 over the next few days showed that the Dilantin level in his blood was far below the

2 therapeutic level. Jail medical staff did nothing for well over a year, at which point

3 a Dilantin level check was ordered, then re-ordered after it was not performed.

4 Moreover, Mr. Gray is frequently not provided his Dilantin at all, placing him at

5 serious risk for seizures, which he has experienced in the jails.

6

87. Plaintiff Angela Patterson has experienced significant and damaging

7 sub-standard health care, as described above, which has likely caused her. permanent

8 injury.

9

88. Plaintiff Stanley Kujawsky has chronic high blood pressure. Sub-

10 standard care in the Riverside jails has endangered his cardiovascular health. First,

11 multiple dosages of his blood pressure medication have not been administered as

12 prescribed at several different jails. He has been denied his long-prescribed

13 medications on his transfer to different jails in the Riverside system and has been

14 denied medications when jail staff allow the prescriptions to run out without

15 refilling them. He is also denied medications on the days he appears in court as well

16 as the days he has specialty care appointments in the Riverside county hospital, in

17 part because there are no medical staff on duty at the Presley jail who could deliver

18 the medications on his return, after 6 p.m. As a result of these missed dosages of

19 blood pressure medication, Mr. Kujawsky has suffered from abrupt and repeated

20 fluctuations in his blood pressure.

21

89. Mr. Kujawsky has filed repeated grievances on this denial of

22 medications, notably on June 15, 2012; July 15, 2012; August 15, 2012; and January

23 30, 2013. These grievances have either been granted or ignored, but the problem

24 has not been solved.

25

90. Further, the blood pressure medication Mr. Kujawsky has been

26 prescribed in the jails -- Clonidine -- is usually a last-resort drug to control blood

27 pressure since it can cause severe dizziness and low blood pressure and in particular

28
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1 can cause rebound tachycardia (an elevated heart rate) if doses are missed. It should

2 not be prescribed unless a patient can take it consistently and reliably, which is

3 clearly not the case in the Riverside jails, as medical staff should well know and as

4 is amply demonstrated by the medication administration record showing repeated

5 missed doses of his medications. Moreover, the frequent use of Ibuprofen, as

6 prescribed to Mr. Kujawsky, can also elevate blood pressure, which has likely

7 contributed to some of his high readings.

8

91. Other patients experience similarly inadequate and at times life-

9 threatening medical care. For example, one patient arrived in the Riverside jails

10 after having been assaulted with a crowbar just three weeks earlier. He had spent

11 two of those weeks in the hospital and had undergone surgery to repair his jaw and

12 implant hardware. Despite obvious facial injuries and blood noted in his ear on his

13 arrival at the jail, he was not seen by a doctor for three weeks, and not until he

14 received a court order for treatment. At that time, his severe recent head trauma was

15 noted and the doctor ordered an ENT consultation. However, it did not take place,

16 and the consultation had to be re-ordered one month later. Following a second

17 court-ordered doctor’s appointment, the patient’s implanted hardware was found to

18 be coming out of his jaw. He was diagnosed in the emergency room with a

19 fractured dental plate. He was again referred for an ENT consultation, which finally

20 took place a week later. Because he was not sent with his crucial records, however,

21 the appointment was of limited use. He was referred for surgery on September 30,

22 2011, but did not receive it; despite repeated complaints of pain and two more court

23 orders for care, he was not seen again until November 8, when the surgery was re

24 ordered “ASAP.” Throughout, the patient was never seen except in response to a

25 court order. Repeated warning signs — complaints of incontinence, evidence of

26 memory loss and confusion — were ignored, and there are no documented attempts

27 to determine whether he was experiencing brain trauma symptoms or displaying

28

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1 underlying dementia, psychiatric disease, or cognitive deficits. Had the patient

2 been evaluated when he was first noted to have his injuries at the time of booking,

3 with records requested sooner and a more timely evaluation and appointment in both

4 the ENT clinic and the oral. and maxillofacial surgery clinic, his serious

5 complications could have been minimized and they certainly would have been

6 treated earlier, likely reducing the unnecessary pain and suffering that he endured.

7

92. A patient at the Smith jail was seen by a nurse for ear pain on August 2,

8 2011. The doctor did not examine him, but prescribed medication over the

9 telephone. Five days later he was seen again by a nurse for worsening pain and

10 redness of the ear; the doctor, again over the telephone, referred him to the

11 emergency room at RCRMC. Following that visit, the same doctor prescribed

12 antibiotics over the telephone, which he never received. Two weeks later, he had

13 another emergency room visit and was again prescribed the same antibiotic by the

14 same doctor by telephone. Three weeks after that, on September 15, the patient

15 underwent tympanoplasty and mastoidectomy at RCRMC. On his return to the jail

16 after the surgery, he was prescribed Vicodin and antibiotics over the telephone but

17 never received them. On September 22, he reported blood coming from the ear but

18 was only seen by the nurse and not a doctor; the doctor ordered medications over the

19 telephone. He again reported bleeding on October 1 to the nurse but was not seen

20 by a doctor. He was finally seen on October 5, 2011, by a specialist at RCRMC and

21 was noted to have pus in his ear. Throughout the entire ordeal, he never once saw a

22 doctor at the jail.

23

93. Another patient with a long history of seizures endured many months

24 during which he was denied all seizure medications. Jail medical staff were aware

25 of his seizure disorder on November 8, 2011, but despite multiple blue slips

26 requesting care, he was not prescribed seizure medications until April 9, 2012. He

27 suffered several seizures in custody which would likely have been prevented if he

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1 had been evaluated by a physician sooner and continued on his stable, home anti-

2 seizure medication regimen.

3

94. Another patient was seen, pursuant to court order, for ovarian cyst-

4 related pain. She was given some medication but continued to have pain. Jail

5 physicians failed to order a repeat vaginal ultrasound or refer her to gynecology for

6 further evaluation and management, as the standard of care requires.

7

95. Even when prisoners get to see the doctor,. the examinations are often

8 ludicrously inadequate. Patients at Presley are “examined” in the non-contact

9 attorney visiting booth. However, instead of sitting on the well-lighted attorney side

10 of the booth facing the patient behind glass, the doctor places himself outside of the

11 booth, where the deputies ordinarily sit, visible only through a slot for passing

12 documents. No meaningful physical examination is possible under such conditions.

13 Without meaningful physical examinations, the standard of care cannot be met.

14

B. Substandard mental health care

15

96. Plaintiffs Gray and Rosson, on behalf of themselves, the plaintiff class,

16 and the mental health subclass, assert the following.

17

97. Riverside County lacks an adequate system to provide a basic level of

18 constitutional mental health care. In the absence of such a system, the County fails

19 utterly to provide appropriate, informed diagnoses and treatment plans, ensure

20 continuity of psychotropic medication, monitor prisoners prescribed such

21 medication, make available medications that are effective in treating serious mental

22 disorders, or provide necessary therapeutic treatment.

23

98. Many prisoners do not get the right medications, the right dosages, or

24 appropriate ongoing care: the Grand Jury found that “[ijnmates with assessed

25 moderate mental health problems such as neuroses, phobias, panic disorders, etc.,

26 are not always offered appropriate mediation and counseling by qualified staff to get

27

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1 and maintain them in a stable condition.” As a result, they suffer severe side effects

2 and decompensation.

3

99. Mentally ill prisoners are regularly started on powerful psychotropic

4 medications with no record Of any evaluation, diagnosis, or treatment plan. This

5 practice is dangerous because it does not allow subsequent monitoring or review,

6 and places patients at serious risk of harm through lack of treatment or inappropriate

7 treatment for their mental illness.

8

100. Even prisoners prescribed appropriate medications face frequent

9 disruptions in medication delivery, including abrupt cessation and missed pill

10 deliveries, which cause serious suffering for these mentally ill patients, as described

11 in more detail in the prior section on medication administration.

12

101. No tracking is done of patients’ symptoms and any reaction they might

13 have to the medication, except for a cursory, non-confidential questioning at their

14 cell doors. The monitoring of vital signs such as weight, cholesterol, and glucose

15 levels, which is essential to ensure the patients are not suffering adverse effects from

16 psychotropic drugs, is absent. Dosages are changed abruptly, with no explanation.

17

102. On arrival in the Riverside jails, Plaintiff Quinton Gray was prescribed

18 several powerful psychotropic medications with no evaluation, diagnosis, or

19 assessment by a mental health professional, and no baseline laboratory test to

20 monitor known risky side effects of the medications.

21

103. One of his medications, Geodon, must be taken with food or much of it

22 is not absorbed. Mr. Gray was not ordered to be given his Geodon with food, which

23 placed him at risk for varying blood levels and varying side effects and efficacy. He

24 was also started on the maximum dose, which increases the risk of severe side

25 effects such as acute muscle stiffness and tremors. Several months later, Mr. Gray’s

26 medications were discontinued suddenly without appropriate taper of maximum

27 dose of Geodon, which placed him at risk for rebound tardive dyskinesia, seizures,

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1 discontinuation syndrome (flu-like illness) and decompensation of psychiatric 2 symptoms (paranoia, hallucinations, and thought disorganization).

3

104. Months later, Mr. Gray was started on a second antipsychotic while

4 also on Geodon, despite the lack of clinical evidence that treating schizophrenic

5 patients with two antipsychotics provides better efficacy or treatment outcomes, and

6 despite the increased risk of side effects and drug-drug interactions. When

7 prescribed together, Mr. Gray’s two medications increase the risk of tardive

8 dyskinesia (such as tongue-biting), acute muscle stiffness and tremors, and cardiac

9 events (arrhythmias). Both medications also lower the seizure threshold and when

10 given together in a patient with a history of seizure disorder, could cause increased

11 seizure events.

12

105. In July 2012, Mr. Gray was started on Benadryl and Cogentin at the

13 same time, with no documented explanation in his health care records. There is

14 never a need to treat a patient with both of these medications at the same time, and

15 they have multiple side effects including constipation and delirium.

16

106. Multiple doses of Mr. Grey’s medications have not been administered

17 to him during his stay in the jails. Missed doses can alter blood levels in a way that

18 increases side effects (including worsening of tardive dyskinesia), variably changes

19 seizure thresholds and can cause decompensation of psychiatric symptoms.

20

107. As a result of Defendant’s failed mental health delivery system, Mr.

21 Gray has in fact experienced twitching, tongue-biting, increased seizures and tongue

22 swelling, all predictable side effects from taking near maximum dose of these two

23 antipsychotic medications. He lives with racing thoughts, disorientation,

24 depression, and chronic sleep loss. He has not been appropriately monitored or

25 treated for these damaging side effects and signs of the inefficacy of his medication

26 regimen.

27

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1

108. Plaintiff John Rosson III, as described above, has experienced repeated

2 failures to adequately treat and monitor his serious mental illness, culminating in a

3 recent extended deprivation of his long-term psychotropic medications. As a result,

4 he decompensated and exhibited symptoms of self-harm serious enough to warrant

5 hospitalization.

6

109. These failures are typical of the policies and practices that produce

7 substandard mental health care generally for patients in the Riverside jails. For

8 example, one Southwest Detention Center patient has no noted psychiatric/mental

9 health progress notes in his’ chart to indicate he was ever evaluated by a medical’

10 doctor regarding his psychiatric condition, treatment plan or consent to medication

11 changes. He was maintained on Paxil, an antidepressant with an extremely short-

12 half life that can lead to a severe discontinuation syndrome if the dose is missed

13 even for 24 hours. He has experienced multiple incidences of missing days of

14 medications as well as not having his medications renewed for one month periods,

15 placing him at risk for severe discontinuation symptoms as well as decompensation.

16 There are no medication monitoring standards set in place, particularly to monitor

17 for weight gain on Paxil. His medications were repeatedly renewed without

18 evidence of evaluation.

19

110. Another patient housed in Presley was started on multiple

20 antipsychotic, anti-depressant, and bipolar disorder medications without any record

21 of an appropriate assessment of her mental illness, the indications for the

22 medications, or informed consent. Most notes by the clinician in her file are

23 illegible and they contain no assessment or plan regarding her treatment. Multiple

24 times her medications were renewed, stopped, started or changed without any

25 documentation or assessment: in particular, her medications were renewed

26 repeatedly for more than two years without any indication of ever being evaluated

27 by a medical doctor; during this period two new medications were started without a

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1 medical evaluation or documentation of informed consent; and once her medications

2 were not renewed for an entire month. Sudden discontinuation of medications puts

3 patients at risk for severe side effects and decompensation of psychiatric illnesses.

4 She was also started on multiple medications at high doses without appropriate

5 titration, resulting in severe side effects, and subjected to the abrupt discontinuation

6 of medications that might have been helpful for her symptoms. Further, she was

7 placed on safety-cell observation but was never evaluated by a medical doctor

8 despite this being a psychiatric emergency.

9

111. Another Presley patient was prescribed multiple psychotropic

10 medications with no documentation of ever being evaluated by a mental health

11 professional for ongoing psychiatric care. This is of particular concern in her case,

12 since two of her medications are relatively contraindicated and should have had

13 clear documented psychiatric necessity for concomitant use including special

14 monitoring for side effects.

15

112. Further, the patient was started and stopped on multiple medications

16 and had doses changed without any documentation of evaluation for efficacy, side

17 effects or informed consent. Such reviews were essential for this patient, since she

18 was placed on Thioridazine, a drug used to treat psychosis, anxiety and insomnia,

19 that with long-term use can cause tardive dyskinesia, a highly distressing and

20 uncomfortable phenomenon consisting of involuntary movements. There is no

21 documentation she was ever evaluated for such side effects.

22

113. In addition, she had significant periods of not receiving her medications

23 as well as frequent missed delivery of individual doses, placing her at risk for

24 discontinuation syndrome including intense anxiety, flu-like symptoms, headache,

25 nausea/vomiting, and parasthesias as well as rapid decompensation of mental illness.

26 Moreover, despite missing significant periods of medications, the medications were

27 suddenly restarted or given again at their regular doses rather than appropriately re

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1 titrated. One of her medications, Lamotrigine, can result in a life-threatening rash if

2 it is suddenly started after stopping it for several days, as happened in her case.

3 Sudden starting of Paroxetine, another of her medications, can lead to severe gastro

4 intestinal upset, sedation and anxiety.

5

114. A patient at Smith was started on numerous psychotropic medications

6 without any documentation he was evaluated by a mental health professional, given

7 informed consent prior to initiation, or monitored for efficacy or side effects. He

8 experienced significant lapses in medication administration, placing him at risk for

9 discontinuation syndrome associated with his medications, including severe

10 headache, nausea, vomiting, flu-like symptoms, agitation and anxiety.

11

115. One reason for this inadequate care might be the abysmally poor

12 communication with clinical staff that some prisoners experience. For example, one

13 Smith prisoner described his interview as taking place in a non-contact attorney

14 visiting booth, with glass separating doctor from patient. He answered some

15 questions from the psychiatrist, who then held up a piece of paper on which he

16 wrote words such as “mood swings” and “voices.” The patient nodded in response.

17 No history was taken — he is a disabled veteran with severe anxiety and PTSD — and

18 there was no discussion of medication side effects. The entire session lasted 15-20

19 minutes. The psychiatrist then briefly held up a piece of paper with information

20 about medications, but the patient did not have a chance to read it. The psychiatrist

21 handed the paper to a deputy, who gave it to the patient and rushed him to sign it.

22 When the patient asked, “can I read it?” the deputy responded: “just sign it.” The

23 patient did not find out fhe names of the medications he was prescribed for three

24 days after he started taking them. For the first two days, when he asked the nurses

25 the names of the pills, they would respond but he could not understand. When he

26 requested clarification, they would say “next person” and rush him through.

27

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1

116. Another prisoner arrived at the Smith jail with a list of her prescribed

2 psychotropic medications, which was placed in her property. She waited two weeks

3 to see a psychiatrist, but could not recall for him which medications she had taken

4 and did not have the list to consult. He told her he would prescribe medications and

5 when she asked for her diagnosis, and he responded “That is not important right

6 now, just go ahead and take your medications.” A week later, the pills arrived and

7 she took them without knowing what they were. Within three days, she experienced

8 a severe reduction in her ability to function and could not walk unassisted. She

9 stopped taking the pills. A week later, her mother spoke to a sergeant and told him

10 that the medication list should be retrieved from her property. He assured her it

11 would be done and the proper pills would be dispensed. The following day, new

12 pills arrived, which again made her feel “woozy” and “dizzy.” She again stopped

13 taking them.

14

117. A crucial element of an adequate mental health care delivery system is

15 an appropriate means to assess and monitor patients who exhibit or contemplate

16 self-harming behavior. Here, too, Riverside’s practices fall far short of acceptable

17 mental health care procedures. Prisoners believed to be suicidal or self-harming are

18 placed in a barren cell with only a rough smock to wear and a hole in the ground to

19 relieve themselves. The so-called “safety cells” are often filthy and stink of the

20 urine and feces that is visible on the walls and floor. Patients are left in the cells for

21 many days, with inadequate monitoring or supervision, under lights that are never

22 turned off. Plaintiff Quinton Gray was forced to endure these conditions for 48

23 hours simply because he told custody staff on entering the jail that he needed

24 psychiatric medications. Another man was placed in a safety cell and removed more

25 than a day later with no risk assessment, explanation, or criteria for removal — a

26 gross departure from the standard of care.

27

28
35
FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

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1 III. Defendant has known for years of the significant risk of harm from its

inadequate jail health care system and has failed to take reasonable steps

2

to mitigate the risk to prisoners

118. Defendant Riverside County has for many years woefully underfunded
detention health care. The lack of infrastructure and staff to deliver life-saving care
has resulted, as Sheriff Stanley Sniff has told the Board of Supervisors, in a “crisis 6 in the jail system.”

119. The County’s own Grand Jury as well as several independent auditors 8 have come to the same conclusion: dangerous deficits in health care services at the

jails threaten the lives and health of the thousands of men and women they hold.

10

120. The severe deficiencies in health care services in Riverside’s jails are

thus well established by admissions from Sheriff Sniff and reports from state and

12 county watchdogs and independent auditors. Defendant has long been aware of the

13 harm its deficient system causes to patients with serious health care needs through

14 these reports as well as numerous grievances and health needs requests from

15 prisoners. Defendant’s failure to take action to ameliorate the conditions constitutes

16 deliberate indifference to Plaintiffs’ serious health care needs.

17

121. Several 2011 reports documented extensive health care violations in the

18 jails. The 2010-11 Grand Jury Report: Riverside County Detention Health Care

19 Administration found systemic failures in treatment, medication management,

20 record-keeping, and administration of forced medications, among other areas. On

21 July 5, 2011, the Sheriff responded that he “generally concurs with the findings of

22 the Grand Jury and has been outspoken on the need to remedy these issues over the

23 last two years.”

24

122. The Grand Jury’s report on mental health care deficiencies, 2010-11

25 Grand Jury Report: Mental Health Detention Services, noted serious health care

26 staffing deficiencies. Again, the Sheriff agreed with this assessment. The Grand

27

28
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FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 38 of 49 Page ID #:113

1 Jury released an updated report in June 2012, noting that mental health staffing has 2 in fact decreased since its prior year’s report.

3

123. The Sheriff invited the state’s Corrections Standards Authority (CSA),

4 a body with statutory duty to regularly inspect county facilities, to perform an

5 additional inspection in January 2011. The CSA found numerous violations of state 6 law, including a widespread failure to provide daily sick call and insufficient

7 oversight of prisoners on suicide watch. They also found serious deficits in

8 medication administration: missed pill calls, night-time medications administered

9 between 4 and 6 p.m., and prisoners going to court denied medications entirely.

10

124. At the CSA’s recommendation, Sheriff Sniff contracted with the

11 independent Inmate Medical Quality (IMQ) to identify deficits and make

12 recommendations. IMQ performed their evaluation May 2-5, 2011, and reported 13 significant and potentially harmful systemic deficiencies in staffing, screening, sick 14 call, quality assurance, medical records, management of communicable diseases,

15 medication management, and use of restraints and safety cells for suicidal or self16 harming prisoners. As with both of the Grand Jury reports, the Sheriff accepted

17 these findings as requiring immediate and drastic attention.

18

125. The health care deficiencies in the Riverside jails, and Defendant’s

19 awareness of them, predate the 2011 reports and stem in part from years of drastic

20 cost-cutting measures. As Sheriff Sniff has explained, the County made “deep cuts

21 to medical personnel staffing levels” in fiscal year 2008-09, which “unacceptably

22 impacted the delivery of medical services. . . and other jail operations.” Instead of

23 correcting the problem, the County made another 20% reduction in medical and

24 mental health care staff as of July 1, 2010.

25

126. On January 12, 2012, Plaintiffs’ counsel sent Defendant officials a

26 sixteen-page letter detailing the systemic problems set forth in this Complaint. 27

28
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FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCHVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 39 of 49 Page ID #:114

1 Defendant did not make any substantive response to the specific concerns described

2 in the letter.

3

127. The County’s systemic failures, as outlined in this Complaint, in

4 Plaintiffs’ January 2012 letter, and in the numerous reports of independent auditors,

5 result in significant injury and the unnecessary and wanton infliction of pain in

6 violation of the Eighth and ,Fourteenth Amendments. The injuries, as described

7 above, include drastically inadequate cancer treatment that may have significantly

8 decreased one patient’s life expectancy; severe and unnecessary pain;

9 unconstitutional conditions on suicide watch; exacerbated mental illness from

10 failure to provide appropriate screening and medications; and severe reactions from

11 inadequate and frequently interrupted medication delivery.

12

CLASS ACTION ALLEGATIONS

13 Plaintiff class

14

128. Plaintiffs bring this action on their own behalf and, pursuant to Rule

15 23(a), b(1), and (b)(2) of the Federal Rules of Civil Procedure, on behalf of all adult

16 men and women who are now, or will be in the future, in the custody of Riverside

17 County and who are now, or will be in the future, subject to an unreasonable risk of

18 harm due to Defendant’s policies and practices of denying prisoners minimally

19 adequate medical care and minimally adequate mental health care.

20

129. The class is so numerous that joinder of all members is impracticable.

21 There are currently nearly 4,000 people incarcerated in the five Riverside jails, all of

22 whom are entirely dependent on Defendant for medical and mental health care. All

23 prisoners are at risk of developing serious medical and mental health conditions

24 while in the Riverside jails. Due to Defendant’s policies and practices, all Riverside

25 jail prisoners receive or are at risk of receiving inadequate health care while in the

26 Riverside jails.

27

28
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FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

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1

130. There are questions of law and fact common to the class including

2 whether the failure to provide minimally adequate medical and mental health care

3 violates the Due Process Clause of the Fourteenth Amendment and the Cruel and

4 Unusual Punishment Clause of the Eighth Amendment to the United States

5 Constitution and whether Defendant has been deliberately indifferent to the serious

6 health care needs of class members. Defendant is expected to raise common

7 defenses to these claims.

8

131. Since there are several thousand class members, separate actions by

9 individuals would in all likelihood result in inconsistent and varying decisions,

10 which in turn would result in conflicting and incompatible standards of conduct for

11 the defendants.

12

132. Defendant has acted and failed to act on grounds that apply generally to

13 the class, so that final injunctive or corresponding declaratory relief is appropriate

14 respecting the class as a whole.

15

133. The claims of the named Plaintiffs are typical of the claims of the class

16 and subclasses, since their claims arise from the same policies, practices, and

17 courses of conduct and their claims are based on the same theory of law as the

18 class’s claims.

19

134. The named Plaintiffs, through counsel, will fairly and adequately

20 protect the interests of the class. Plaintiffs do not have any interests antagonistic to

21 the plaintiff class. Plaintiffs, as well as the Plaintiff class members, seek to enjoin

22 the unlawful acts and omissions of Defendant. Further, Plaintiffs are represented by

23 counsel experienced in civil rights litigation, prisoners’ rights litigation, and

24 complex class action litigation.

25 Medical Subclass

26

135. Plaintiffs Gray, Patterson, and Kujawsky bring this action on their own

27 behalf and, pursuant to Rule 23(a), b(1), and (b)(2) of the Federal Rules of Civil

28
39
FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 41 of 49 Page ID #:116

1 Procedure, on behalf of a subclass of prisoners (hereinafter “Medical Subclass”)

2 who are now, or will in the future be, subjected to the medical care policies and

3 practices of the Riverside jails.

4

136. The Medical Subclass is so numerous that joinder of all members is

5 impracticable. There are currently nearly 4,000 people incarcerated in the five

6 Riverside jails. All prisoners are at risk of developing serious medical conditions

7 while in the Riverside jails Due to Defendant’s policies and practices, all Riverside

8 jail prisoners receive or are at risk of receiving inadequate medical care while in the

9 Riverside jails.

10

137. There are questions of law and fact common to the Medical Subclass

11 including whether the failure to provide minimally adequate medical care violates

12 the Due Process Clause of the Fourteenth Amendment and the Cruel and Unusual

13 Punishment Clause of the Eighth Amendment to the United States Constitution and

14 whether Defendant has been deliberately indifferent to the serious health care needs

15 of Medical Subclass members. Defendant is expected to raise common defenses to

16 these claims.

17

138. Since there are several thousand Medical Subclass members, separate

18 actions by individuals would in all likelihood result in inconsistent and varying

19 decisions, which in turn would result in conflicting and incompatible standards of

20 conduct for the Defendant.

21

139. Defendant has acted and failed to act on grounds that apply generally to

22 the Medical Subclass, so that final injunctive or corresponding declaratory relief is

23 appropriate respecting the Medical Subclass as a whole.

24

140. The claims of the named Plaintiffs are typical of the claims of the

25 Medical Subclass, since their claims arise from the same policies, practices, and

26 courses of conduct and their claims are based on the same theory of law as the

27 Medical Subclass’s claims.

28
40
FIRST AMENDED CLASS ACTION COMPLAINT FOR iNJUNCTIVE AND DECLARATORY RELIEF

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1

141. The named Plaintiffs, through counsel, will fairly and adequately

2 protect the interests of the Medical Subclass. Plaintiffs do not have any interests

3 antagonistic to the Medical Subclass. Plaintiffs, as well as the Plaintiff class

4 members, seek to enjoin the unlawful acts and omissions of Defendant. Further,

5 Plaintiffs are represented by counsel experienced in civil rights litigation, prisoners’

6 rights litigation, and complex class action litigation.

7 Mental Health Subclass

8

142. Plaintiffs Gray and Rosson bring this action on their own behalf and,

9 pursuant to Rule 23(a), b(1), and (b)(2) of the Federal Rules of Civil Procedure, on

10 behalf of a subclass of prisoners (hereinafter “Mental Health Subclass”) who are

11 now, or will in the future be, subjected to the mental health care policies and

12 practices of the Riverside jails.

13

143. The Mental Health Subclass is so numerous that joinder of all members

14 is impracticable. There are currently nearly 4,000 people incarcerated in the five

15 Riverside jails. All prisoners are at risk of developing serious mental health

16 conditions while in the Riverside jails. Due to Defendant’s policies and practices,

17 all Riverside jail prisoners receive or are at risk of receiving inadequate mental

18 health care while in the Riverside jails.

19

144. There are questions of law and fact common to the Mental Health

20 Subclass including whether the failure to provide minimally adequate mental health

21 care violates the Due Process Clause of the Fourteenth Amendment and the Cruel

22 and Unusual Punishment Clause of the Eighth Amendment to the United States

23 Constitution and whether Defendant has been deliberately indifferent to the serious

24 health care needs of Mental Health Subclass members. Defendant is expected to

25 raise common defenses to these claims.

26

145. Since there are several thousand Mental Health Subclass members,

27 separate actions by individuals would in all likelihood result in inconsistent and

28
41
FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

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1 varying decisions, which in turn would result in conflicting and incompatible 2 standards of conduct for the Defendant.

3

146. Defendant has acted and failed to act on grounds that apply generally to

4 the Mental Health Subclass, so that final injunctive or corresponding declaratory

5 relief is appropriate respecting the Mental Health Subclass as a whole.

6

147. The claims of Plaintiffs Gray and Rosson are typical of the claims of

7 the Mental Health Subclass, since their claims arise from the same policies,

8 practices, and courses of conduct and their claims are based on the same theory of 9 law as the Mental Health Subclass’s claims.

10

148. Plaintiffs Gray and Rosson, through counsel, will fairly and adequately

11 protect the interests of the Mental Health Subclass. Plaintiffs do not have any

12 interests antagonistic to the Mental Health Subclass. Plaintiffs Gray and Rosson, as

13 well as the Mental Health Subclass members, seek to enjoin the unlawful acts and

14 omissions of Defendant. Further, Plaintiffs are represented by counsel experienced

15 in civil rights litigation, prisoners’ rights litigation, and complex class action

16 litigation.

17

CLAIMS FOR RELIEF

18

First Cause of Action

19 (Plaintiffs Gray, Patterson, Kujawsky, and Rosson and the plaintiff class

20

v. Defendant County of Riverside)

21

(Eighth Amendment; 42 U.S.C. § 1983)

22

149. By its policies and practices described in paragraphs 1 through 148,

23 Defendant subjects Plaintiffs and the Plaintiff class to an unreasonable risk of harm

24 and injury from inadequate health care. These policies and practices have been and

25 continue to be implemented by Defendant and its agents or employees in their

26 official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff class’s

27

28
42
FIRST AMENDED CLASS AC1ON COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 44 of 49 Page ID #:119

1 ongoing deprivation of rights secured by the United States Constitution under the 2 Eighth Amendment.

3

150. Defendant has been and is aware of all of the deprivations complained

4 of herein, and has condoned or been deliberately indifferent to such conduct.

5

Second Cause of Action

6 (Plaintiffs Gray, Patterson, Kujawsky, and Rosson and the plaintiff class

7

v. Defendant County of Riverside)

8

(Fourteenth Amendment; 42 U.S. C. § 1983)

9

151. By its policies and practices described in paragraphs 1 through 148,

10 Defendant subjects Plaintiffs and the Plaintiff class to an unreasonable risk of harm

11 and injury from inadequate, health care. These policies and practices have been and

12 continue to be implemented by Defendant and its agents or employees in their

13 official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff class’s

14 ongoing deprivation of rights secured by the United States Constitution under the

15 Fourteenth Amendment.

16

152. Defendant has been and is aware of all of the deprivations complained

17 of herein, and has condoned or been deliberately indifferent to such conduct.

18

Third Cause of Action

19

(Plaintiffs Gray, Patterson, and Kujawsky and the Medical Subclass

20

v. Defendant County of Riverside)

21

(Eighth Amendment; 42 U.S.C. § 1983)

22

153. By its policies and practices described in paragraphs 1 through 148

23 Defendant subjects Plaintiffs and the Medical Subclass to an unreasonable risk of 24 harm and injury from inadequate medical care. These policies and practices have 25 been and continue to be implemented by Defendant and its agents or employees in 26 their official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff

27

28
43
FIRST AMENDED CLASS ACfION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 45 of 49 Page ID #:120

1 class’s ongoing deprivation of rights secured by the United States Constitution 2 under the Eighth Amendment.

3

154. Defendant has been and is aware of all of the deprivations complained

4 of herein, and has condoned or been deliberately indifferent to such conduct.

5

Fourth Cause of Action

6

(Plaintiffs Gray, Patterson, and Kujawsky and the Medical Subclass

7

v. Defendant County of Riverside)

8

(Fourteenth Amendment; 42 U.S. C. § 1983)

9

155. By its policies and practices described in paragraphs 1 through 148,

10 Defendant subjects Plaintiffs and the Medical Subclass to an unreasonable risk of

11 harm and injury from inadequate medical care. These policies and practices have

12 been and continue to be implemented by Defendant and its agents or employees in

13 their official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff

14 class’s ongoing deprivation of rights secured by the United States Constitution

15 under the Fourteenth Amendment.

16

156. Defendant has been and is aware of all of the deprivations complained

17 of herein, and has condoned or been deliberately indifferent to such conduct.

18

Fifth Cause of Action

19 (Plaintiffs Gray and Rosson and the Mental Health Subclass v. Defendant

20

County of Riverside)

21

(Eighth Amendment; 42 U.S.C. § 1983)

22

157. By its policies and practices described in paragraphs 1 through 148,

23 Defendant subjects Plaintiffs and the Mental Health Subclass to an unreasonable

24 risk of harm and injury from inadequate mental health care. These policies and

25 practices have been and continue to be implemented by Defendant and its agents or

26 employees in their official capacities, and are the proximate cause of Plaintiff’s and

27

28
44
FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 46 of 49 Page ID #:121

1 the Plaintiff class’s ongoing deprivation of rights secured by the United States

2 Constitution under the Eighth Amendment.

3

158. Defendant has been and is aware of all of the deprivations complained

4 of herein, and has condoned or been deliberately indifferent to such conduct.

5

Sixth Cause of Action

6 (Plaintiffs Gray and Rosson and the Mental Health Subclass v. Defendant

7

County of Riverside)

8

(Fourteenth Amendment; 42 U.S. C. § 1983)

9

159. By its policies and practices described in paragraphs 1 through 148,

10 Defendant subjects Plaintiffs and the Mental Health Subclass to an unreasonable

1 risk of harm and injury from inadequate mental health care. These policies and

12 practices have been and continue to be implemented by Defendant and its agents or

13 employees in their official capacities, and are the proximate cause of Plaintiff’s and

14 the Plaintiff class’s ongoing deprivation of rights secured by the United States

15 Constitution under the Fourteenth Amendment.

16

160. Defendant has been and is aware of all of the deprivations complained

17 of herein, and has condoned or been deliberately indifferent to such conduct.

18

PRAYER FOR RELIEF

19

161. Plaintiffs and the class they represent have no adequate remedy at law

20 to redress the wrongs suffered as set forth in this complaint. Plaintiffs have suffered

21 and will continue to suffer irreparable injury as a result of the unlawful acts,

22 omissions, policies, and practices of the Defendant as alleged herein, unless

23 Plaintiffs are granted the relief they request. The need for relief is critical because

24 the rights at issue are paramount under the Constitution of the United States.

25

162. WHEREFORE, Plaintiffs, on behalf of themselves and the class they

26 represent, request that this Court grant them the following relief:

27

A. Declare the suit is maintainable as a class action pursuant to Federal Rule

28
45
FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 47 of 49 Page ID #:122

1 of Civil procedure 23(a) and 23(b)(1) and (2);

2

B. Adjudge and declare that the conditions, acts, omissions, policies, and

3 practices of Defendant and its agents, officials, and employees are in violation of the

4 rights of Plaintiffs and the class they represent under the Eighth and Fourteenth

5 Amendments to the U.S. Constitution;

6

C. Order Defendant, its agents, officials, employees, and all persons acting

in concert with them under color of state law or otherwise, to develop and 8 implement, as soon as practical, a plan to eliminate the substantial risk of serious

harm that Plaintiffs and members of the Plaintiff class suffer due to Defendant’s 10 inadequate medical and mental health care. Defendant’s plan shall include at a

minimum the following:

12 1. Staffing: Staffing shall be sufficient to provide Plaintiffs and the Plaintiff
13 class with timely access to qualified and competent clinicians who can provide
14
routine, urgent, emergent, and specialty health care; 15

16

2. Access: Policies and practices that provide timely access to health care;

17

3. Screening: Policies and practices that reliably screen for medical and

18 mental health conditions that need treatment;

19

4. Emergency response: Timely and competent responses to health care

20 emergencies;

21

5. Medication and supplies: Timely prescription and distribution of 22

medications and supplies necessary for medically adequate care; 23

24

6. Chronic care: Timely access to competent care for chronic illnesses;

25

7. Mental health treatment: Timely access to necessary treatment for serious

26 mental illness, including medication, therapy, inpatient treatment, suicide

27 prevention, and suicide watch; and

28
46
FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 48 of 49 Page ID #:123

8. Quality assurance: A regular assessment of health care staff, services,
2 procedures, and activities designed to improve outcomes, and to identifr and correct errors or systemic deficiencies.

4

D. Enjoin Defendant, its agents, officials, employees, and all persons acting

5 in concert with them under color of state law or otherwise, from continuing the

6 unlawful acts, conditions, and practices described in this Complaint and from failing

7 to provide minimally adequate health care;

8

E. Award Plaintiffs, pursuant to 42 U.S.C. § 1988, the costs of this suit and

reasonable attorneys’ fees and litigation expenses; 10
F. Retain jurisdiction of this case until Defendant has fully complied with the

orders of this Court, and there is a reasonable assurance that Defendant will continue 12
to comply in the future absent continuing jurisdiction; and 13

14

G. Award such other and further relief as the Court deems just and proper.

15

Dated:

16

17

Apnl 29, 2013 PRISON LAW OFFICE

18

By: 4 wrtv

19

DONALD SPECTER SARA NORMAN

20

Attorneys for Plaintiffs

21

22

AKIN GUMP STRAUSS HAUER

& FELD LLP

23

24
25 •
26 27 28

By: SHAWN HAON AMIT KURLEKAR KELSEY MORRIS ANYA FREEDMAN Attorneys for Plaintiffs
47
FIRST AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 8 Filed 04/30/13 Page 49 of 49 Page ID #:124

1

PROOF OF SERVICE

2

STATE OF CALIFORMA, COUNTY OF LOS ANGELES

3

I am employed in the County of Los Angeles, State of California. I am over the

age of 18 and not a party to the within action; my business address is: 2029 Century

4 Park East, Los Angeles, California 90067. On April 30, 2013, I served the foregoing

document(s) described as: FIRST AMENDED COMPLAINT on the interested

5 party(ies) below, using the following means:

6

Arthur K. Cunningham, Esq.

7

Lewis Brisbois Bisgaard & Smith LLP

650 East Hospitality Lane, Suite 600

8

San Bernardino, CA 92408

9

akcatty@lbbslaw. corn

Attorney for Defendant, Riverside County

10

Christopher D. Lockwood, Esq.

11

Arias & Lockwood

12

225 West Hospitality Lane, Suite 314

San Bernardino, CA 92408

13

Christopher.lockwoodariaslockwood.com

14

Attorney for Defendant, Riverside County

15

Michael Stock, Esq.

County of Riverside

16

4080 Lemon Street, Floor

17

Riverside, CA 92502

rnstock@rc-hr. corn

18

Attorney for Defendant, Riverside County

19

BY UNITED STATES MAIL I enclosed the documents in a sealed envelope or package

20

addressed to the respective address(es) of the party(ies) stated above and placed the envelope(s) for collection and mailing, following our ordinary business practices. I am

21

readily familiar with the firm’s practice of collection and processing correspondence for mailing. On the same day that correspondence is placed tor collection and m2 ailing it is

22 deposited in the ordinary course of business with the United States Postal Service, in a

23

(FEDERAL) I declare that I am employed in the office of a member of the bar of this court at whose direction the service was made.

24

Executed on April 30, 2013at Los Angeles, California.

25

26

Mararetha Avers
Print Name of Person Executing Proof]

27

28

Proof of Service

 
 Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 1 of 56 Page ID #:16251

PRISON LAW OFFICE

1 DONALD SPECTER (SBN 83925)

SARA NORMAN (SBN 189536)

2 WARREN GEORGE (SBN 53588)

1917 Fifth Street

3 Berkeley, California 94710

Telephone: (510) 280-2621

4 Fax: (510) 280-2704

Email: dspecter@prisonlaw.com

5

snorman@prisonlaw.com

6

7

AKIN GUMP STRAUSS HAUER & FELD LLP SHAWN HANSON (SBN 109321)

8

DANIELLE CROCKETT (SBN 261809) NICHOLAS GREGORY (SBN 275582)

9

KELSEY MORRIS (SBN 277859) SAURISH BHATTACHARJEE (SBN 286264)

10

580 California Street, Suite 1500 San Francisco, CA 94104-1036

11

Telephone: (415) 765-9500 Fax: (415) 765-9501

12

Email: shanson@akingump.com, dcrockett@akingump.com ngregory@akingump.com, kmorris@akingump.com,

13

sbhattacharjee@akingump.com

14 Attorneys for Plaintiffs

15

UNITED STATES DISTRICT COURT

16

FOR THE CENTRAL DISTRICT OF CALIFORNIA

17

EASTERN DIVISION -- RIVERSIDE

18

19 QUINTON GRAY, ANGELA 20 PATTERSON, STANLEY
KUJAWSKY, JOHN ROSSON III, 21 BRANDY MCCLELLAN, JULIE 22 MILLER, AND MICHAEL
WOHLFEIL on behalf of themselves 23 and all others similarly situated,

24

Plaintiffs,

25 v.

26 COUNTY OF RIVERSIDE,

Defendant.
27

Case No. EDCV13-0444 VAP (OP) PROPOSED CLASS ACTION
SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

28

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 2 of 56 Page ID #:16252

1

NATURE OF THE ACTION

2

1. Riverside County has one of the largest jail systems in California, with

3 nearly 4,000 men and women held in five detention facilities (“Riverside jails”).

4 This population consists of both pretrial detainees and people serving sentences in

5 local custody (collectively referred to herein as “prisoners”).

6

2. The thousands of men and women locked up in Riverside’s jails face

7 cruel and inhumane deficits in medical and mental health care. Defendant has

8 known for years that its inadequate health care delivery system places prisoners

9 entering the jails at a serious risk of harm but has failed to take the necessary steps

10 to mitigate the risk. As a result, prisoners in the Riverside jails are subjected to

11 policies and practices that systematically deprive them of their constitutional right to

12 basic life-saving care.

13

JURISDICTION

14

3. The jurisdiction of this Court is invoked pursuant to 28 U.S.C. §§ 1331,

15 1343, and 1367. Plaintiffs seek declaratory and injunctive relief under 28 U.S.C. §§

16 1343, 2201, and 2202; and 42 U.S.C. § 1983.

17

VENUE

18

4. Venue is proper in the Central District of California under 28 U.S.C. §

19 1391(b) because Plaintiffs’ claims for relief arose in this district and Defendant is

20 located in the district.

21

PARTIES

22 Plaintiffs

23

5. At the time of the filing of the Complaint and the First Amended

24 Complaint in the Case, Plaintiff Quinton Gray was a prisoner in the Riverside jails

25 in custody of Defendant Riverside County. He has multiple chronic medical and

26 mental health conditions, including seizures, high blood pressure, severe arthritis,

27 and visual and auditory hallucinations and depression. He has experienced repeated

28
1
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Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 3 of 56 Page ID #:16253

1 treatment failures, including delays in adjusting medication regimens, lack of

2 appropriate laboratory monitoring and frequent missed doses. His initial intake

3 form, similar to other Riverside files, documented “no” to all questions (including

4 history of seizures and high blood pressure)—demonstrating inadequate intake

5 procedures. Even when Mr. Gray has been seen, he has not received adequate basic

6 primary care: for example, he was not screened for high cholesterol or diabetes,

7 despite his chronic high blood pressure.

8

6. Further, Mr. Gray was placed on potent psychotropic medications

9 which were either suddenly discontinued or multiple doses missed, placing him at

10 serious risk of serious side effects and psychiatric decompensation. He in fact

11 experienced significant, injurious side effects from his medication mismanagement

12 and treatment failures. Mr. Gray has exhausted his administrative remedies.

13

7. At the time of the filing of the original Complaint in this case, Plaintiff

14 Angela Patterson was a prisoner in the Riverside jails in custody of Defendant

15 Riverside County. After sustaining severe injuries in a car accident in June 2009,

16 Ms. Patterson had a temporary filter placed in her inferior vena cava (IVC), the

17 blood vessel supplying the heart, to prevent blood clots. She was booked into the

18 Riverside jails shortly thereafter, where she was subjected to multiple delays,

19 cancellations, appointment mix-ups, and failures to provide appropriate follow-up

20 regarding safe removal of the temporary filter. Nearly a year later, when she was

21 finally taken for surgery, it was found that the filter could not be removed due to the

22 build-up of scar tissue. As a result, Ms. Patterson is now condemned to a lifetime of

23 daily anticoagulation medications and frequent laboratory monitoring, with

24 significant risk of fatal bleeds and other complications. She is 27 years old. If

25 physicians had appropriately obtained and reviewed her records, and made efforts to

26 refer her for IVC filter removal in a timely fashion, it is likely that the filter could

27 have been removed and Ms. Patterson would need no further treatment.

28

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1

8. In addition, she has experienced multiple delays in follow-up with the

2 orthopedic and vascular surgery clinics. As of late 2012, she still had not had a

3 follow-up CT scan of her head to determine whether a growth on her scalp was a

4 slow-growing tumor, more than a year after it was ordered to be performed. Since

5 being placed on anti-coagulant therapy and for the duration of her stay in the

6 Riverside jails, she has also not had timely and effective medication monitoring and

7 administration, resulting in frequent stretches of time throughout her time in the jails

8 where her anticoagulation levels are too low or too high, placing her at risk for

9 further complications. Ms. Patterson has exhausted her administrative remedies.

10

9. At the time of the filing of the original Complaint in this case, Plaintiff

11 Stanley Kujawsky1 was a prisoner in the Riverside jails in custody of Defendant

12 Riverside County. He has been subjected to substandard care while in Defendant’s

13 custody, with inadequate medication administration and treatment of his high blood

14 pressure and multiple delays in the work-up and diagnosis of his chronic neck pain.

15 As a result, he has suffered and continues to suffer unnecessary pain and

16 Defendant’s treatment has endangered his cardiovascular health. Mr. Kujawsky has

17 exhausted his administrative remedies.

18

10. Plaintiff John Rosson III is a prisoner in the Riverside jails in custody

19 of Defendant Riverside County. Mr. Rosson suffers from bipolar affective disorder

20 and has received and continues to receive substandard mental health care while in

21 the jails that has endangered his health and safety. While in the Riverside jails, he

22 has been prescribed major psychotropic medications which have repeatedly been

23 renewed without any regular assessment of his progress, side effects, and co-

24 existing medical issues, a clear violation of the standard of care and particularly

25

26 1 Due to a clerical error, Mr. Kujawsky is referred to as Stanley Kwawsky or 27 Kujansky in the Riverside jail records.

28

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1 dangerous given his history of diabetes and hyperlipidemia, which can be worsened

2 by the psychotropic medications he takes. Acute psychiatric symptoms, such as

3 hearing voices, have been ignored by Riverside jail mental health treatment staff.

4 He suffers frequent lapses in medication delivery: after one such episode in early

5 2013, when he was denied his necessary psychotropic medications for more than

6 two weeks, he became actively self-harming and cut himself. As a result, he was

7 placed in a filthy “safety cell” with blood and feces on the wall and subsequently in

8 the county hospital for several days. He continues to experience medical delivery

9 interruptions to this day. Mr. Rosson has exhausted his administrative remedies.

10

11. Plaintiff Brandy McClellan is a prisoner in the Riverside jails in the

11 custody of Defendant Riverside County. She experienced a dangerous and entirely

12 predictable and avoidable side effect of the psychotropic medications she was

13 prescribed, resulting in her hospitalization after she nearly collapsed and had serious

14 cardiac complications. Nonetheless, in order to get any attention from mental health

15 staff after returning from the hospital she had to file a health care request form

16 (“blue slip”) and wait several weeks to be seen by a psychiatrist. During this time,

17 the medications she had been misprescribed and which caused her hospitalization

18 continued to be presented to her at pill call. If she had not had the presence of mind

19 to refuse them, she could have been in serious danger. The treating psychiatrist was

20 not made aware of her hospitalization until she told him. Ms. McClellan has

21 exhausted her administrative remedies.

22

12. Plaintiff Julie Miller is a prisoner in the Riverside jails in the custody of

23 Defendant Riverside County. She is a chronic care patient with major depression

24 and suspected bipolar disorder. She is given Norvir for her medical condition in the

25 jails. In February 2013, Ms. Miller was prescribed Paxil and Trazodone. Norvir

26 inhibits the metabolism of both of these drugs and as a result, can increase blood

27 levels of the drugs to dangerous levels. Increased blood levels of Trazodone and

28

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1 Paxil can be associated with more side effects, including dry mouth, sedation,

2 dizziness, and weight gain, which she has experienced. Also, both drugs increase

3 serotonin blood levels, placing Ms. Miller at higher risk of serotonin syndrome -- a

4 potentially life-threatening condition consisting of altered mental status, muscle

5 contractions, fever and autonomic instability. There is no notation in her medical

6 file to indicate that she was regularly assessed for possible side effects from these

7 medications, nor is there documentation that those medications were given at lower

8 doses while she was on Norvir. She has never been told about possible side effects

9 of new medications or monitored to determine their effects. Ms. Miller has

10 exhausted her administrative remedies.

11

13. Plaintiff Michael Wohlfeil is a prisoner in the Riverside jails in the

12 custody of Defendant Riverside County. Since early 2011 Mr. Wohlfeil has

13 suffered from chronic daily diarrhea and has lost more than 30 pounds. Given this

14 history, he should have been promptly evaluated for possible colon cancer. But

15 after an initial referral in 2011, it took more than two years for Mr. Wohlfeil to be

16 seen by a gastroenterology clinic and finally receive a recommendation for an upper

17 endoscopy and a colonoscopy.

18

14. Early in his confinement in Defendant’s custody, Mr. Wohlfeil

19 complained of lumps on his skin; these tumors subsequently grew in number to

20 cover much of his body. Despite the knowledge of the tumors by Jail medical staff,

21 however, no biopsies were done until October 2013. Had they been malignant, Mr.

22 Wohlfeil might not have survived Defendant's substandard medical care and

23 attention. Mr. Wohlfeil also reported lower extremity weakness and severe back

24 pain to Defendant’s staff in 2011. Although an MRI was ordered for him multiple

25 times, he did not receive one for two and a half years. Mr. Wohlfeil also reported a

26 history of Hepatitis C on his intake form in 2011, and was recommended for testing

27 for this disease in May 2011. Even though failure to conduct this testing put Mr.

28

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1 Wohlfeil at risk for liver scarring and possible liver failure, he has never been tested

2 for Hepatitis C while in Defendant's custody. To get assistance from medical staff,

3 he has had to file grievances and obtain a court order. Mr. Wohlfeil has exhausted

4 his administrative remedies.

5 Defendant

6

15. Defendant County of Riverside operates five jails -- the Robert Presley

7 Detention Facility, the Smith Correctional Facility, the Indio Jail, the Southwest

8 Detention Center, and the Blythe Jail – that incarcerate nearly 4,000 prisoners. The

9 County is responsible for providing a constitutional level of health care for those in

10 its custody, including the funding, oversight, and corrective action to ensure

11 adequate conditions.

12
FACTUAL ALLEGATIONS
13

14 I. Riverside County exhibits systemic failures in the provision of basic health care to prisoners in its jails.
15
16. Defendant, by policy and practice, maintains and runs a health care
16
system that lacks basic elements necessary to provide constitutional care: it
17
systematically fails to identify and diagnose serious conditions, to provide timely
18
care, to administer appropriate medications, to employ adequate staff to meet
19
prisoners’ basic needs, to maintain records that allow informed treatment decisions,
20
to establish legally required confidentiality, and to identify and correct its own
21
failings.
22
17. Prisoners’ access to health care is so inadequate at all the Riverside
23
jails as to constitute deliberate indifference to their serious medical and mental
24
health needs. Further, Defendant is deliberately indifferent to the fact that these
25
systemic failures result in significant injury and a substantial risk of serious harm.
26
A. Delays in and denial of access to care
27

28

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1

18. Defendant has a policy and practice of failing to provide timely access

2 to necessary health care and is deliberately indifferent to the risk of harm and injury

3 to prisoners that results from this systemic failure. Care is often delayed or denied

4 entirely, causing unnecessary pain and suffering as well as physical injury to the

5 patients. The two basic mechanisms to alert health care staff to prisoners’ needs --

6 intake screening and sick call – are inadequate in both policy and practice.

7
1. Intake screening and treatment planning
8
19. Riverside’s jail screening and intake process fails to adequately identify
9
and treat the medical and mental health care problems of newly arriving prisoners.
10
20. Insufficient numbers of nursing staff are available to identify and
11
evaluate medical conditions on intake, resulting in dangerous delays in treatment.
12
Prisoners are rarely assessed for communicable diseases when they arrive at the
13
jails, and medically high-risk prisoners do not have histories taken, physical
14
assessments, or treatment plans.
15
21. Plaintiff Quinton Gray arrived at the Riverside jails with a chronic
16
seizure disorder and high blood pressure. His initial intake form nonetheless has
17
“no” marked for every question about health care needs, including those that should
18
clearly be marked “yes.” Numerous other prisoners with longstanding chronic
19
conditions have intake forms with the same deficiencies, demonstrating an
20
inadequate intake screening process.
21
22. As a result, prisoners are placed at serious risk of harm. For example,
22
one woman who regularly takes medication for her chronic severe high blood
23
pressure entered the Riverside jails on September 9, 2011. She received no
24
medication or, indeed, any recorded medical screening or attention until she suffered
25
chest pain and hypertensive emergency nearly three weeks later. At that time, she
26
was sent to the emergency room at Riverside County Regional Medical Center
27

28

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1 (RCRMC) and found to have blood pressure of 230/140 -- high enough to cause a

2 stroke, vision loss, or a heart attack.

3

23. Another woman with multiple serious medical conditions, including

4 hypothyroidism, diabetes, and a recent history of gastric bypass surgery, had no

5 record of any of these crucial health factors on her booking form, in which every

6 question regarding the presence of health care needs was marked “no.” Treatment

7 for her serious chronic conditions was delayed, resulting in significant health risks.

8

24. Another patient who arrived in the Riverside jails with multiple

9 longstanding chronic conditions -- a seizure disorder, asthma, psoriasis, and

10 Hepatitis C -- had “no” marked for every question on his booking form regarding

11 medical history. As a result, he did not receive all of his necessary medications for

12 several weeks.

13

25. Another prisoner with a clear prior history of diabetes, glaucoma,

14 and arthritis has a booking form from August 2012 noting no chronic conditions and

15 no medications. It is unlikely, from subsequent records, that he failed to report his

16 conditions: his records show that he informed nurses at pill call five days later of the

17 conditions and he subsequently filed grievances and obtained court orders for care.

18

26. Plaintiff Julie Miller had to get court order to get her chronic care

19 medications started five months after her arrival in the Riverside jails.

20

27. Initial mental health screening at the jails is faulty because it is

21 performed by untrained custody staff, a practice that Riverside Sheriff Stanley Sniff

22 knows is inadequate and dangerous because, as he states, “correctional officers may

23 not recognize hidden medical and/or mental health problems that could be best

24 observed by a medical/mental health expert. This could result in delaying needed

25 treatment.” Appropriate screening is particularly important since, according to the

26 Sheriff, “the time period immediately following admission to a jail is the most

27 dangerous time for an inmate, and over half of in-custody deaths occurred within

28

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1 one month of admissions, with 24% of deaths occurring within two days of

2 admission.”

3

28. One man admitted to the Smith Jail had no recorded intake or screening

4 at all. He was eventually placed in a suicide watch “safety cell” and given

5 psychotropic medications (Zoloft and Trazodone). His medical records contain no

6 diagnosis, medical administration records, review of symptoms, psychiatric history,

7 social history, review of current medications, allergies, mental status examinations,

8 vital signs, risk assessments or treatment goals.

9

29. Plaintiff John Rosson was started on psychotropic medications

10 including Risperdal, Trileptal, Trazodone and Prozac with no recorded evaluation

11 for his underlying medical conditions, despite the fact that he had a noted history of

12 diabetes and hyperlipidemia and Risperdal can worsen these conditions.

13

30. Plaintiffs Quentin Gray, Julie Miller, and Brandy McClellan were

14 similarly prescribed powerful psychotropic medications with inadequate assessment

15 and treatment planning regarding medication interactions, safety, and efficacy.

16

31. Another patient was prescribed Trazodone, Risperdal and Zoloft

17 although he had a pre-existing seizure disorder and type-II diabetes. Risperdal

18 lowers the seizure threshold and can worsen type-II diabetes. On the day he was

19 prescribed Risperdal, Trazodone and Zoloft, he submitted a health needs request

20 stating he had a seizure in his cell. Risperdal should be attempted to be lowered or

21 discontinued if patients are having uncontrolled seizures prior to starting or on the

22 medication. There is no documentation of screening for active seizures prior to

23 initiating Risperdal and no documentation addressing co-management of his seizure

24 disorder and use of Risperdal with a neurology specialist.

25

2. Sick call and access to care

26

32. Even if their serious medical concerns are flagged at intake, patients are

27 often unable to obtain care because the sick call system is inadequate. Outside

28

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1 monitors have repeatedly found the Riverside jails incapable of providing the daily

2 sick call that state law requires. These conditions harm prisoners, who experience

3 extreme difficulty in obtaining necessary medical and mental health appointments.

4 In the absence of a functioning sick call system they must either obtain a court order

5 from the criminal court or file repeated blue slips (health care request forms) and

6 grievances. Plaintiff Quinton Gray has never seen a Riverside jail doctor without

7 an order from the Superior Court for care. He has received three orders: in late

8 2011, in June 2012, and in September 2012. Plaintiffs Stanley Kujawsky and

9 Michael Wohlfeil similarly have had to obtain court orders to see a doctor in the

10 Riverside jails.

11

33. Court orders, blue slips, and grievances regarding health care are

12 routinely ignored. The County maintains an extensive computerized list of court-

13 ordered appointments that notes how long the prisoners have been waiting; delays of

14 one, two, or three months are common. One prisoner obtained a court order on

15 November 21, 2011, that orders her “to see medical doctor within 48 hours to be

16 evaluated for severe pain due to hernia on back. Court recommends medication

17 treatment to control pain.” After waiting several weeks, the prisoner filed a

18 grievance asking that the order be honored. The response, dated December 23,

19 2011, acknowledged the court order and the month-long delay and stated that

20 “nurses confirmed they are waiting for the doctor to show up to see the court

21 orders.” Plaintiff Stanley Kujawsky was prescribed pain medication without ever

22 seeing a doctor in the jails; he received a court order on November 22, 2011, to see a

23 doctor for his pain, but was not actually seen until January 25, 2012.

24

34. Some prisoners who request medical attention are told that doctors are

25 only seeing patients with court orders for care.

26

35. Prisoners also file repeated blue slips without any result except a $3

27 charge exacted for each request. As a result, they are placed at serious risk of harm.

28

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1 For example, one patient filed numerous blue slips complaining of serious stomach

2 pain but was never seen by a doctor. After three months of such complaints, he

3 submitted a blue slip stating that he was vomiting blood, a symptom that can

4 indicate an emergency leading to death and which is at minimum is concerning for

5 gastric disease such as peptic ulcers or cancer. The patient should have seen a

6 physician immediately, had his vital signs and blood counts checked, and possibly

7 even have been referred to an emergency room or gastroenterologist for further

8 evaluation. None of this was done. He was not even referred to see a doctor for

9 another month.

10

36. Compounding the problem, prisoners often have extreme difficulty

11 grieving inadequate access to care since they must request grievance forms from

12 sheriffs’ deputies, who often refuse to provide them. Plaintiff Quinton Gray filed a

13 grievance in September 2012 noting serious ongoing problems with access to

14 medical and mental health care, and stating that he had to get a grievance form from

15 “an outside agency” because of custody staff’s refusal to provide him with a form

16 and their interference with access to adequate health care.

17

37. As a result of these policies and procedures, prisoners experience

18 dangerous delays in access to both primary and specialty care.

19

38. One woman entered the Presley jail with Stage Four colon cancer in

20 late July 2011. In early August, she was seen for abdominal pain, nausea and

21 vomiting, similar to the colon cancer symptoms she had experienced on first

22 diagnosis. Her outside medical records, obtained at that time by the County,

23 documented chemotherapy in 2009 for colon and ovarian cancer and a recent CT

24 scan showing possible recurrence. With these strong indicators that her cancer had

25 returned, she should have received a colonoscopy and referral to an oncologist

26 within a very few weeks. Although both referrals were made on August 3, neither

27 was completed by the time she was released from custody in December 2011. For

28

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1 more than four months, County medical providers demonstrated gross incompetence

2 and negligence, with unexplained delays, apparently lost referrals, and a botched

3 attempt at a colonoscopy, for which she was not given a basic bowel preparatory

4 procedure – an elementary mistake. Throughout this time, the patient repeatedly

5 complained of abdominal pain and rectal and vaginal pressure. The lack of care for

6 her malignancy possibly allowed it to progress to a point where she was no longer a

7 candidate for further treatment, shortening her life expectancy. The inadequate

8 treatment for her symptoms forced her to endure unnecessary pain and suffering.

9

39. Another woman with a breast tumor suffered significant delays in care:

10 she was denied timely appointments with a physician; multiple specialty

11 appointments were not scheduled or were skipped, despite physician referrals; and

12 she was frequently not notified of important test results such as biopsies, when

13 standard practice is to notify patients of results within one to two weeks. Nearly

14 every time her complaints were addressed by medical staff was in response to a

15 court order. Her tumor was found to be benign; had it been malignant, these

16 cumulative delays could have been life-threatening. Although she received some

17 medications to treat her ovarian cyst-related pain, she continued to have pain and

18 physicians failed to order a repeat vaginal ultrasound or refer her to gynecology for

19 further evaluation and management, as the standard of care requires.

20

40. Plaintiff Angela Patterson arrived at the Riverside jails following

21 surgery to place a temporary filter in a major blood vessel supplying her heart. She

22 was discharged directly from the RCRMC hospital to the jail. Despite the fact that

23 such filters should be removed within three months, there was no acknowledgment

24 of the existence of the filter in her jail medical records for over a month. Ms.

25 Patterson then endured many months of delays, cancellations, and scheduling mix-

26 ups in specialty care, as well as repeated medication administration failures that

27 have continued throughout her time in the Riverside jails. For nearly six months,

28

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1 medical staff documented confusion over whether the IVC filter was temporary or

2 permanent; they did not resolve the matter until March 2010, nine months after the

3 filter was placed in her body. She was not seen in surgery until June 25, 2010, at

4 which point it was discovered that the filter could not be safely removed because of

5 the accumulation of scar tissue.

6

41. Following the surgery, a Riverside jail doctor discontinued Ms.

7 Patterson’s anticoagulation medication because of “filter removal,” despite the fact

8 that it was still in her body and there was a note in her medical records from two

9 days earlier reporting that the filter had not been removed. In August 2010, she was

10 placed on life-long anticoagulation therapy. Anticoagulation therapy has significant

11 risks, including the risk of fatal bleeds, and requires daily medication and frequent

12 laboratory monitoring -- a weighty burden, particularly for Ms. Patterson, who is 26

13 years old. If physicians had appropriately obtained and reviewed her records and

14 made efforts to refer her for IVC filter removal in a timely fashion (within a few

15 months of placement), it is likely that the filter could have been removed and Ms.

16 Patterson would need no further anticoagulant therapy, with all the risks that entails.

17 The risks are significantly enhanced by the repeated medication administration

18 failures she continued to suffer throughout her time in the Riverside jails: the

19 frequent missed dosages, switched dosage times, and inadequate monitoring have

20 resulted in blood anti-coagulation levels so low as to put her at risk for blood clots.

21

42. A patient with chronic high blood pressure was inadequately screened

22 on intake, as described above, which resulted in an emergency room visit and

23 dangerously high blood pressure. Subsequent months in custody saw no

24 improvement in her care, as Riverside County medical staff failed utterly to monitor

25 her chronic condition. Her care was repeatedly delayed, prescribed medications

26 repeatedly not offered, and the sub-par care led to multiple episodes of uncontrolled

27 hypertension and preventable emergency room visits.

28

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1

43. A patient experiencing uncontrolled seizures and multiple emergency

2 room visits was not given a neurology referral for more than three months after his

3 arrival in the Riverside jails. After the referral was made, he waited for two more

4 months to actually see a neurologist, although he was having seizures two to three

5 times per week, often sustaining head trauma and other injuries, and although

6 managing his condition was clearly beyond the scope of a general medicine

7 practitioner. The neurologist recommended an EEG, which was never performed.

8 The patient continued to have uncontrolled seizures and emergency room visits; he

9 had another neurologist appointment two months later, at which point the EEG was

10 re-ordered. The patient was never referred to an epilepsy specialist, despite the clear

11 indication that his medication regime was ineffective and such a consultation was

12 needed. Continued, untreated generalized seizures place patients at high risk for

13 immediate injury (such as he repeatedly sustained) as well as worsening long-term

14 cognitive impairment, decreased function, and diminished quality of life.

15

44. Another patient arrived in jail with a lap-band that had been surgically

16 inserted into his stomach for weight loss. He soon began to demonstrate symptoms

17 of a esophageal obstruction (a known complication of such surgery), including

18 significant weight loss, nausea, vomiting, and extreme hunger. Despite numerous

19 requests for help, he experienced unnecessary delays in diagnosis and treatment and

20 failure to respond to his multiple health complaints. For example, after two

21 episodes of loss of consciousness, a documented 17-pound weight loss in 30 days,

22 complaints of inability to tolerate any food or liquid intake, and a blood pressure of

23 90/60, he was merely referred for a medical appointment more than a week in the

24 future. The delays in diagnosis of his obstruction put him at risk for serious health

25 complications due to rapid weight loss and deprivation of essential nutrients.

26

45. A prisoner who filed blue slips complaining of a head injury in

27 October 2012, after an assault, was given only Tylenol and not assessed for serious

28

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1 injuries for several days, despite repeated complaints of pain in his head and right

2 side, which are indicators of potential brain injury. When he was finally sent to the

3 emergency room, he was given a CT scan that showed a brain bleed. Fortunately,

4 the brain bleed was small; if he had suffered a more serious injury, the delay could

5 have been fatal.

6

46. Plaintiff Michael Wohlfeil experienced delays of more than two years

7 in getting even basic diagnostic tests to determine appropriate treatment for his

8 numerous tumors and his chronic diarrhea and weight loss.

9

47. Access to mental health care is no better. Defendant’s deficient system

10 forces mentally ill prisoners to wait weeks or months for mental health assessment

11 and evaluation by clinical staff, during which time they are denied essential

12 psychotropic medications and other treatment. The Sheriff admitted this problem in

13 July 2011, acknowledging that “such delays may impact an inmate’s mental

14 stability.” As with medical care, many mental health patients must file repeated

15 blue slips or grievances to get seen; others are only seen by clinicians after the

16 judges in their criminal cases have ordered care. Patients experience a range of

17 symptoms, from auditory hallucinations to severe depression, while enduring these

18 lengthy delays.

19

48. Plaintiffs Quinton Gray, John Rosson, Brandy McClellan, and Julie

20 Miller have all experienced significant delays in access to care. Instead of receiving

21 the appropriate oversight that standard of care demands for patients with their

22 significant mental health conditions, they have been forced to file blue slips and

23 grievances, get court orders, and seek help from outside advocates in order to

24 receive basic care and attention from mental health staff in the jails.

25

49. Patients with serious dental care needs suffer from the same pattern and

26 practice of injurious delays. Patients in severe pain wait for months to see a dentist

27 and face significant pain and suffering as a result. For example, one patient with

28

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1 only two functioning teeth lost more than 20 pounds in the six months he has been

2 incarcerated because he is unable to eat much of the food he is served and he cannot

3 afford to buy his own. He has submitted blue slips to see a dentist to get dentures

4 without success.

5

50. Another patient experienced serious delays in care: her complaints of

6 tooth pain were first documented in her health records in December 2011. On

7 March 17, 2012, a progress note in her file simply reads “Back upper Rt tooth broke

8 and gum swollen.” This one-line progress note, with no medical history, duration of

9 symptoms, or full exam, is inconsistent with accepted medical standards of care. In

10 addition, the patient was prescribed penicillin and motrin for her symptoms without

11 any mention of a dental referral or evaluation.

12

51. Another patient filed a request complaining of a broken tooth and

13 requesting a dental referral on September 21, 2011. He submitted a repeat request a

14 month later also requesting a dental referral. He was not seen for these complaints

15 until November 1, 2011, at which time medical staff noted that he had decayed teeth

16 and referred him to dental staff without any mention of his ability to eat or whether

17 the tooth looked infected. In the many months he has been waiting, he has

18 experienced intermittent severe pain in his teeth that makes him unable to eat

19 several times a week.

20

52. Plaintiff Michael Wohlfeil has suffered from chronic tooth pain caused

21 by cavities. He has had twelve teeth pulled in the last three years. In all but one

22 case, the dentist could not or would not provide Mr. Wohlfeil with a filling and told

23 him that he was only able to pull the teeth.

24

3. Specialty referrals and diagnostic tests

25

53. The Riverside jails lack adequate policies and procedures to provide

26 patients with needed referrals for specialty medical consultations and procedures.

27 For example, a patient with colon cancer was referred for a colonoscopy and to an

28

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1 oncologist on August 3, 2011, but neither was completed by the time she was

2 released from custody in December 2011. Given that her cancer was Stage IV, she

3 should have been seen in a very few weeks.

4

54. As discussed above, Plaintiff Angela Patterson experienced numerous

5 delays and cancellations in specialty referrals, which likely led to build-up of scar

6 tissue on a temporary filter in a blood vessel near her heart. As a result, she will live

7 the rest of her life with this filter in her chest and suffer a lifetime of serious

8 anticoagulation medication with related health risks and the burden of frequent

9 monitoring. In addition, a CT scan was ordered in January 2011 to be performed in

10 six months to rule out a possible slow-growing tumor on her scalp. As of January

11 2013, it had not yet been performed – well over a year late.

12

55. As discussed above, Plaintiff Michael Wohlfeil spent more than two

13 years waiting for specialty care and tests to diagnose and develop a treatment plan

14 for his chronic, debilitating diarrhea and the dozens of tumors that cover his body.

15 He still has not been tested for Hepatitis C, despite reporting a history of the disease.

16 These unacceptable delays exposed him to serious risk of harm.

17

56. Another man with uncontrolled seizures and multiple emergency room

18 visits was not given a neurology referral for more than three months after his arrival

19 in the Riverside jails. After the referral was made, he waited for two more months

20 to actually see a neurologist, although he was having seizures two to three times per

21 week.

22

57. A man who had experienced severe recent head injuries was ordered an

23 ENT consultation by a Riverside jail doctor but it did not take place and had to be

24 re-ordered one month later. When the ENT consultation finally took place, he was

25 not sent with his crucial records and the appointment was of limited use. He was

26 referred for surgery on September 30, 2011, but did not receive it, and despite

27

28

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1 repeated complaints of pain and two more court orders for care, he was not seen

2 again until November 8, 2011, when the surgery was re-ordered “ASAP.”

3

58. A patient with multiple chronic conditions -- a seizure disorder, asthma,

4 psoriasis, and Hepatitis C -- experienced multiple delays in obtaining timely

5 referrals, even after ordered by physicians, as well as follow-up, resulting in sub-

6 standard care.

7

59. One prisoner who complained of a tumor on his neck in September

8 2012 was referred for an ultrasound but it was not done for nearly six weeks, and the

9 results – which were atypical -- were not communicated to the prison for two weeks.

10 After the results were finally reviewed, he was ordered a CT scan and a surgery

11 referral “ASAP.” Despite this order and his complaints of worsening pain, he was

12 not seen in surgery for more than four weeks, at which time the CT scan was re-

13 ordered. The CT scan results showed some abnormalities, and a follow-up CT scan

14 and surgery consultation were ordered in December 2012, but the CT scan was not

15 done and the patient was not seen in surgery until March 2013, more than three

16 months after the referral.

17

60. The March 2013 appointment was of limited value because the

18 patient’s medical records from a previous surgery (ordered three months earlier) had

19 never been obtained. As it was, he was scheduled for surgery on April 3, but the jail

20 did not bring him to the surgery and it had to be rescheduled for several weeks later.

21 If this patient’s abnormal mass had proven to be cancerous, these delays could have

22 been deadly.

23

61. A diabetic prisoner was given substandard care for his chronic

24 condition. Hemoglobin A1c tests are standard monitoring mechanisms given to

25 diabetics every three months. Despite repeated orders, there are no hemoglobin A1c

26 test results in his records from his arrival in August 2012 through February 2013, a

27 failure that places him at serious risk for inadequate care. In the same time period,

28

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1 he was never given a foot exam, a standard annual precaution for diabetics to assess

2 for neuropathy, despite the fact that he was being medicated for peripheral

3 neuropathy.

4

4. Denials of care

5

62. Some prisoners face outright denials of basic and necessary medical

6 care. Plaintiff Quinton Gray was prescribed Dilantin on his arrival at the jail, but

7 even after two emergency room readings taken over the next few days showed that

8 the Dilantin level in his blood was far below the therapeutic level, jail medical staff

9 did nothing for well over a year. Plaintiff Michael Wohlfeil reported a history of

10 Hepatitis C on his arrival at the jail in 2011, and was recommended for testing, but

11 has not received it, placing him at risk for liver damage or failure.

12

63. A prisoner with thyroid disease was denied medication for nearly three

13 months. Although her initial screening form missed the condition, it was noted

14 repeatedly on her charts for several months by medical staff before she was finally

15 prescribed medication. Missed doses of thyroid medication for a prolonged period

16 put patients at risk for severe fatigue, slow heart rates, weight gain, constipation,

17 hair loss, edema, and eventually coma. The same patient also has a history of

18 gastric bypass surgery; the jail doctor refused her any dietary supplements to ensure

19 proper nutrition throughout her jail stay, despite repeated requests. Patients are at

20 risk for malnutrition following bypass surgery and require life-long vitamin

21 supplementation. In addition, no tests were ordered to assess any nutritional

22 deficiencies, another violation of the standard of care.

23

64. Another prisoner fell and hurt his back at Presley in November 2010

24 and again in March 2011. He was provided inadequate neurologic exams after his

25 falls, several-month delays for scheduling of x-rays and consultations (even when

26 ordered “as soon as possible”), and inadequate trial of physical therapy; his back

27 pain went essentially untreated. Two clinic appointments were cancelled due to

28

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1 “too many ad-segs” and one was cancelled because a wheelchair van was not

2 available.

3

65. A patient with high blood pressure and a history of coronary artery

4 disease complained to staff of an irregular heartbeat and chest pain in July 2012. He

5 was told simply to tell staff if it happened again, which is dangerously inappropriate

6 due to the serious risk of heart attack this patient presents. Five weeks later, he was

7 found unresponsive, pale, and sweaty, with high blood pressure and a heart flutter.

8 There is no indication in his medical records that any tests were done or vital signs

9 taken at the jail; he was subsequently hospitalized for several days. A month later,

10 in September 2012, the jail doctor ordered a regime of blood pressure checks (daily

11 for five days, weekly for two weeks, and then monthly) as well as a follow-up

12 appointment; the blood pressure checks were not done and the appointment never

13 took place. In November 2012, his blood pressure was found to be high, but he was

14 not seen by a doctor.

15

66. The same patient has records from July 2012 noting that he has

16 Hepatitis C, but there is no further follow-up regarding this condition in his medical

17 record, a clear violation of the standard of care, which requires a determination of

18 whether he has cirrhosis or is a candidate for treatment.

19

B. Substandard medication management and administration

20

67. Reliable and systematic medication delivery is an essential element to a

21 constitutional health care system. Defendant has a policy and practice of failing to

22 prescribe, provide, and properly manage medication, and of providing incorrect,

23 interrupted, or incomplete dosages. As a result, prisoners with serious health care

24 conditions are placed at substantial risk of harm and are in fact harmed.

25

68. Many patients are provided substandard care because there is

26 inadequate staff to distribute medications. (Staffing deficiencies are described in

27 more detail in the following section.) Medication deliveries are often skipped

28

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1 entirely, leaving patients without essential treatment. Plaintiffs Quinton Gray,

2 Angela Patterson, Stanley Kujawsky, and John Rosson have experienced numerous

3 skipped medication dosages at various Riverside jail facilities, placing Mr. Gray at

4 serious risk for heart attack, stroke, and seizures; exposing Ms. Patterson to an

5 increased risk of recurrent thrombosis; endangering Mr. Kujawsky’s cardiovascular

6 health, and seriously endangering Mr. Rosson’s mental health and risk of self-harm.

7

69. Other prisoners face the same problems. One patient who is prescribed

8 medications for his chronic high blood pressure has experienced a dangerous

9 number of missed doses: for example, in April 2011 he was not given nine doses of

10 both of his medications, and in September 2011 staff did not administer 14 doses of

11 one and eight doses of the other medication. Another patient who has been

12 prescribed medications for his diabetes has experienced numerous missed

13 medication doses – 21 missed doses in one month alone.

14

70. One patient with a fractured foot was prescribed pain medications but

15 repeatedly denied scheduled doses of his medications throughout the second half of

16 2012, despite his frequent requests.

17

71. In practice, medication distribution in the jails takes place only once or

18 at most twice daily, leaving patients who require multiple daily dosages, or bedtime

19 delivery, unserved. Since the Smith facility is so large, nurses start evening pill call

20 at approximately 2 p.m. to allow them to deliver medications throughout the

21 institution. This includes sleep medications: some patients receive their pills in the

22 middle of the afternoon and fall asleep within a few hours. Pill call is erratic for

23 many prisoners, and evening pills might arrive any time from 3 to 11 p.m., if at all,

24 which is particularly dangerous for diabetics, many of whom must receive

25 medications at regular intervals, coordinated with meal times. Plaintiffs Julie

26 Miller, Brandy McClellan, and John Rosson have experienced and continue to

27 experience these fluctuating medication delivery times to their detriment.

28

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1 Throughout 2012 and 2013, Plaintiff Angela Patterson has had her medications

2 delivered at inconsistent times, including being switched by jail staff from morning

3 to evening, despite the fact that the medication should be taken at the same time

4 daily, likely affecting her treatment stability.

5

72. Defendant’s policy and practice is to require patients to alert staff when

6 their medications run out. As a result, some prisoners’ prescriptions are not

7 renewed until they file multiple health care requests or grievances, resulting in

8 significant treatment interruptions with resulting, predictable harm to the patients.

9 Plaintiffs John Rosson and Julie Miller are two of the many prisoners who suffer

10 from this policy and practice. In another example, a patient at Southwest Detention

11 Center has experienced several one-month gaps between refills of his psychiatric

12 medications, including Paxil. Paxil has a well-documented discontinuation

13 syndrome: the lengthy lapses in medication delivery place him at serious risk for

14 severe discontinuation symptoms including flu-like symptoms, nausea, vomiting,

15 and headaches. A Presley patient prescribed pain medications for his severe back

16 pain is frequently deprived of the medications when the prescriptions run out and

17 refills are not provided; doctors also renew his medications without assessing their

18 efficacy.

19

73. Plaintiff Stanley Kujawsky has been denied medications on the days he

20 goes to court for hearings in his criminal case as well as on the days he goes to see

21 outside specialists for medical care. These deprivations are pursuant to policy and

22 practice: numerous other prisoners are denied medications altogether when they

23 attend court hearings or are transported to outside appointments. Some prisoners

24 regularly miss medications in the morning because they are asleep and staff

25 routinely fail to announce medication delivery effectively.

26

74. Riverside also has a policy and practice of failing to monitor the effects

27 of medication to determine whether dosages are correct or medications should be

28

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1 changed. Plaintiffs Quinton Gray, Angela Patterson, Stanley Kujawsky, Brandy

2 McClellan, Julie Miller, and John Rosson have suffered from inadequately

3 monitored medication regimens which have seriously endangered their health and

4 forced them to endure unnecessary pain and suffering. Their problems are typical of

5 those experienced by medical and mental health patients in the Riverside jails.

6

75. For example, one man with high blood pressure has been given two

7 medications to treat his condition, but on occasion, without explanation, he has been

8 abruptly discontinued from one of the medications. No monitoring of his condition

9 is documented in his medical records, suggesting that either such documentation is

10 missing or it was never charted -- either way, lack of proper documentation can be

11 dangerous for patient care and signifies a concerning level of disorganization within

12 the medical department.

13

76. The same patient’s file lacks any progress notes documenting any

14 blood pressure, history, physical exam or lab tests during the duration of treatment.

15 In general, when starting or changing blood pressure regimens, patients’ blood

16 pressures should be checked to ensure that they are not over-medicated or given low

17 blood pressure, which can be dangerous. In addition, without monitoring blood

18 pressure, there is no way to know if the patient was actually adequately controlled --

19 high blood pressure could put him at risk for strokes, brain bleeds and heart attacks.

20 Further, because one of his medications can be associated with electrolyte

21 abnormalities, the standard of care requires physicians to check basic blood tests for

22 sodium, potassium and kidney function levels either prior to or shortly after starting

23 such agents. None of this was done.

24

77. A diabetic man who entered the Riverside jails with an elevated blood

25 sugar count was prescribed medications and ordered glucose checks twice daily for

26 two weeks and then weekly thereafter, as well as various blood work. These orders

27 were apparently ignored, however, along with two subsequent orders for weekly

28

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1 blood sugar checks: his health records show only two glucose checks over the next

2 several months and no evidence that he ever had the blood work performed. This

3 failure to monitor his condition placed him at serious risk of harm, particularly since

4 one of the medications he was prescribed, Glipizide, can make patients

5 hypoglycemic.

6

78. In one of the most disturbing events of medication mismanagement, a

7 patient who was clearly documented as allergic to Dilantin was repeatedly

8 prescribed the medication, placing him at serious risk of medical complications. He

9 had to repeatedly refuse doses of the medication in June 2012.

10

79. Psychotropic medications also are not monitored to determine whether

11 they are effective or whether they cause severe side effects. Quinton Gray, Julie

12 Miller, and Brandy McClellan all experienced distressing and painful side effects

13 (including involuntary muscle contractions and incontinence for Mr. Gray,

14 significant weight gain for Ms. Miller, and severe cardiac complications for Ms.

15 McClellan) that could have been avoided or ameliorated with oversight, monitoring,

16 and treatment adjustment that met the community standard of care.

17

80. Patients face serious consequences from the denial of appropriate

18 medications. For example, one man experienced uncontrolled seizures resulting in

19 serious injuries. His medication regimen was clearly ineffective, but he was merely

20 prescribed increases in his existing medication, contrary to the standard of care. He

21 continued to suffer from frequent seizures and resulting physical injuries.

22

81. Another patient fell in his cell and hurt his hand (he uses a cane due to

23 leg injuries, but is only allowed it to ambulate longer distances). He was sent to the

24 emergency room one day later with increasing pain in his hand. He was found to

25 have suffered a fracture and prescribed Vicodin and Ibuprofen for the pain. He was

26 never given these medications on his return to the jail, and suffered unnecessary

27 pain as a result.

28

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1

82. Medication lapses can be particularly devastating in the mental health

2 realm. According to Sheriff Sniff, “continuity in delivery of mental health

3 medications may affect the stability of an inmate’s mental health and is critical to

4 inmate care.” More specifically, delays in administering psychotropic medications

5 to mental health patients can result in serious harm. Such harm is occurring in the

6 Riverside jails: prisoners experience frequent gaps in medication delivery, as the

7 Sheriff has admitted. Sometimes psychotropic medications are not distributed at all

8 in entire housing units, since nurses are simply overwhelmed. At other times,

9 patients’ medications are abruptly changed with no examination and no explanation.

10

83. These interruptions harm prisoners. Plaintiff John Rosson experienced

11 a lapse of more than two weeks in medication delivery, despite filing a blue slip and

12 speaking to a doctor about his need for the medications. As a result, he became

13 despondent and self-harming, cutting his arm and leg. He was placed in a filthy

14 safety cell and the county hospital, where his medications were final stabilized. The

15 medication failures have been of long standing: Mr. Rosson has filed repeated

16 grievances over the last several years regarding medication failures, but these

17 attempts to obtain appropriate care have been unsuccessful.

18

84. Similarly, over many months in the Indio, Presley, and Smith jails,

19 Plaintiff Quinton Gray had his powerful psychotropic medications either suddenly

20 discontinued or multiple doses missed. Another man held in the Presley facility

21 experienced significant lapses, without explanation, in receiving medication for his

22 bipolar disorder: his Zoloft was not renewed for nearly one month, and his Topomax

23 was not renewed for nearly three months. Further, neither medication was

24 appropriately titrated on being restarted. Sudden discontinuation of these

25 medications can cause manic episodes and seizures as well as physical symptoms

26 such as nausea, vomiting, and headaches; sudden resumption after a significant gap

27

28

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1 in time can also cause damaging side effects. The patient in fact experienced

2 depression and severe mood swings due to the medication mismanagement.

3

85. Similarly, a patient at Smith had his psychotropic medications and

4 dosages changed repeatedly over two years, including the abrupt and unexplained

5 cessation of his antipsychotic medications. A Presley patient also had psychotropic

6 medications abruptly started, stopped, and renewed over several years with little or

7 no evaluation or assessment. This pattern and practice of medication

8 mismanagement places these patients at serious risk for decompensation, untreated

9 mental illness, and severe side effects.

10

86. Another patient arrived at the jails with a diagnosis of bipolar disorder,

11 on psychiatric medications, and with a reported history of prior suicide attempts.

12 Bipolar disorder has one of the highest rates of suicide for any psychiatric condition,

13 20 to 30% higher than the suicide rate of the general population. He was prescribed

14 Lithium and Depakote, medications typically used for bipolar disorder. He had

15 multiple documented suicide attempts while in jail, and multiple visits to safety

16 cells. Despite severe and life-threatening suicide attempts there is no documentation

17 of any psychiatric intervention, including psychiatric hospitalization, assessment or

18 change in medications. Even after repeated attempts at self-hanging he continued to

19 have access to implements by which he could attempt to hang himself again. When

20 he did receive medications, they were not given as directed and were given

21 inconsistently.

22

87. Another prisoner has a history of high blood pressure treated with the

23 medication Norvasc. He was started on the drug Olanazapine. A patient with this

24 history should have had baseline labs done prior to initiation of Olanazapine,

25 including a lipid panel and HbA1C levels, because Olanazapine can cause weight

26 gain, hyperlipidemia and metabolic syndrome, which would place him at higher risk

27 of cardiac and metabolic complications. No such baseline assessment was done.

28

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1 This patient's medical administration records indicate that on multiple occasions he

2 was not given Risperdal. Missing doses of Risperdal can cause discontinuation

3 symptoms of nausea, sweating, dizziness and dyskinesias.

4

88. Another prisoner was prescribed Thorazine and Prozac. This patient's

5 medications were renewed late, doses were not delivered, and his medications were

6 abruptly discontinued, with no indication that he was assessed prior to

7 discontinuation and no rationale given for discontinuation. This left the prisoner at

8 risk for rebound tardive dyskinesias, extrapyramidal symptoms, and worsening

9 psychiatric symptoms.

10

89. Another prisoner with a history of schizophrenia was prescribed a high

11 dose of Thorazine, which was suddenly discontinued in October 2012. Sudden

12 discontinuation of Thorazine can lead to rapid decompensation of psychotic

13 symptoms (e.g., voices, paranoia). His antipsychotic was restarted two months later

14 but at a much lower dose. The two-month period without an anti-psychotic

15 medication left him at risk for worsening psychiatric symptoms. Two weeks later he

16 attempted suicide by cutting his neck and wrists and was hospitalized.

17

C. Severe staffing deficits

18

90. Many of the deficits described herein stem from the inadequate health

19 care staffing levels maintained by Defendant in the jails. There are simply not

20 enough doctors, nurses, mental health providers, pharmacists, or medical records

21 staff to meet the needs of the population.

22

91. Defendant’s policy and practice of severely understaffing health care

23 positions in the jails is long standing and has been repeatedly censured by the county

24 Grand Jury. In 2010, the Grand Jury found that “[m]ental health staff is not

25 available in any county jail facility in sufficient numbers to identify and treat in an

26 individualized manner those treatable inmates suffering from serious mental

27

28

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1 disorders.” The Grand Jury Report released on June 14, 2012, states the problem in

2 clear terms:

3

In July, 2011, DMH was advised. . . .that the medical/mental health

4

staffing levels in county jails needed to be restored to 2007 levels, in

5

order to be in compliance with [state law]. As of this writing, the

6

Grand Jury learned through sworn testimony that during the eight

7

months following the 2010-2011 Grand Jury report, DMH staffing

8

levels were allowed to decrease even further.

9

92. Medical care is no better: according to the independent Inmate Medical

10 Quality evaluators, invited by Sheriff Sniff to identify deficiencies in jail health

11 care, “[t]he request for medical care exceeds the capability of the staff to meet the

12 demands.” The Detention Health Services administrator agreed, admitting that “the

13 demand exceeds the resources available to provide the requested services.”

14

93. Long-term medical vacancies are endemic, particularly given the

15 competition with the higher salaries offered by the state prison system. For

16 example, at the beginning of 2011, there were only three physicians for well over

17 3,000 prisoners in the five jails. Two doctors subsequently resigned and for at least

18 several months, there was not a single physician, physician assistant, or nurse

19 practitioner working in the Riverside jails – only a “Chief of Medical Specialty”

20 who rarely saw patients. Only two of the five full-time physician positions in the

21 jails were filled as of May 31, 2012.

22

94. Other medical staffing is also deficient. As of May 2012, the County

23 had multiple vacancies for nurses and nurse supervisors, and only 65 of 101 total

24 Detention Health Services positions were filled. Further, according to the state’s

25 Corrections Standards Authority (CSA), a body with statutory duty to regularly

26 inspect county facilities, “there is no budget for overtime and no staff available to

27 provide services in the event of illness, injury, or vacation.”

28

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1

95. Staffing has not improved meaningfully since that time. As of

2 September 2013, the County had only a 63% fill rate for medical staff in the jails,

3 including three of five physician slots vacant; all three nurse practitioner slots

4 vacant; and 22 of 57 institutional nurse slots vacant. County records from October

5 7, 2013, show similar severe deficiencies: three of five physician slots are still

6 empty and the sole physician’s assistant position is also empty. The October 2013

7 records further show 28 out of 73 institutional nurse positions vacant (including

8 senior and supervisor positions, and excluding positions at the juvenile halls) and 16

9 out of 42 licensed vocational nurse positions vacant (excluding positions at the

10 juvenile halls).

11

96. Defendant lacks the staff necessary to provide minimally adequate

12 dental care. By the County’s own assessment, two full-time dentists and two full-

13 time dental assistants are required to offer basic dental care to the nearly 4,000

14 prisoners. As of May 2011, only one dentist and one dental assistant were working

15 in the jails. As of October 2013, there were still just one chief of dentistry and one

16 dental assistant working in the jails.

17

97. A patient at the Smith Jail with chronic high blood pressure filed a

18 grievance complaining that although the doctor had ordered blood pressure checks

19 every three days, he had only received them twice in the preceding 23 days. The

20 grievance response from Senior Corporal Diaz confirms that the patient “is still not

21 having his blood pressure checked. When he asked the nursing staff they stated they

22 do not have the time.”

23

D. Violations of patients’ confidentiality rights

24

98. According to the Grand Jury, Riverside “has no confidential self-

25 referral system by which inmates can request mental health care without revealing

26 the nature of their request to correctional officers,” as required by federal and state

27 law. See 45 C.F.R. §§ 164.500 et seq.; Cal. Civil Code §§ 56.10 et seq. Requests

28

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1 for medical care have historically not been confidential, since they too have been

2 delivered to medical staff by custody staff. Prisoners were until recently directed to

3 give blue slips requesting health care directly to custody staff; many believe that

4 they must provide as much detail as possible about their health care needs in order

5 to increase their chances to be seen. It remains to be seen whether the policies,

6 changed on paper, result in improved privacy. Further, many prisoners, including

7 Plaintiffs Gray and Kujawsky, also must file grievances in order to be seen by

8 clinicians. To get grievance forms, they must persuade custody staff that their

9 concerns are significant. The grievances are then heard by custody staff, who make

10 the determination whether to involve health care staff.

11

99. Examination space at Southwest Detention Center is not confidential:

12 patients can overhear other patients’ examinations through an open door, as they

13 wait in the hallway for their own treatment.

14

100. In addition, mental health care encounters are often held in the

15 presence of custody staff and even other prisoners. Such violations of privacy do

16 not allow for effective treatment, since they reduce the likelihood that patients will

17 provide a thorough account of their concerns and needs. Plaintiffs Miller, Rosson,

18 and Gray have all experienced such substandard mental health encounters.

19

E. Poor records administration

20

101. Adequate health care cannot be provided in the absence of adequate

21 health records: clinicians must know their patients’ medical histories, past diagnoses

22 and treatment, and for psychiatric patients, a history of suicidal thinking or attempts.

23

102. Riverside’s medical records system is profoundly disorganized and

24 incomplete. Some psychiatric patients have no diagnosis recorded, despite the

25 prescription of psychotropic medications. Some patients are prescribed medications

26 but lack any record of medication administration in their file, or any record that the

27

28

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1 effects of the medication were tracked and reviewed. All three Plaintiffs’ health

2 care records demonstrate Riverside’s failures in this area.

3

103. It is not surprising that record-keeping is inadequate: as of December 6,

4 2011, the entire medical records staff for five jails and well over three thousand

5 prisoners was three medical records technicians and no medical clerks.

6

104. The record-keeping gaps impact patient care because clinicians and

7 nurses will be unable to track physician’s orders, medication administration records,

8 and general patient care.

9

F. Inadequate quality assurance

10

105. Not surprisingly, given the paucity or records and severe staffing

11 shortages, Riverside officials lack the ability to identify and correct the problems

12 described herein. Health care staff do not systematically correct identified

13 deficiencies, and there is inadequate staff for oversight and review of care.

14 II. Even If Prisoners See Health Care Providers, They Do Not Receive Constitutionally Adequate Medical or Mental Health Care
15
106. As detailed in the previous section, Riverside’s lack of the basic
16
elements of a health care delivery system -- policies and procedures to ensure timely
17
access to appropriate care, medication management, adequate staffing, patient
18
confidentiality, medical records, and quality assurance – harms Plaintiffs and
19
members of the plaintiff class. Even when they are able to see health care providers,
20
prisoners are by policy and practice denied adequate medical and mental health care
21
in the Riverside jails: they experience gross treatment failures, inadequate
22
examinations, and the failure to provide necessary specialty appointments and
23
diagnostic tests.
24
A. Substandard medical care
25
107. Plaintiffs Gray, Patterson, Kujawsky, and Wohlfeil, on behalf of
26
themselves, the plaintiff class, and the medical subclass, assert the following.
27

28

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1

108. Prisoners – even those with serious medical conditions -- rarely see

2 physicians, and health care records demonstrate a paucity of appropriate follow-up,

3 monitoring, and specialty referrals, as well as improper care.

4

109. Plaintiff Quinton Gray has chronic high blood pressure that has been

5 inadequately monitored and controlled by Riverside jail medical staff. He has

6 experienced multiple elevated blood pressure measurements without any assessment

7 of the efficacy of his medications and dosages. He has twice gone without blood

8 pressure check for more than four months, despite his history of elevated readings

9 and despite the fact that regular readings had been ordered by physicians. In

10 addition, he is frequently not provided his medications at all, thus increasing his risk

11 of poorly controlled blood pressure. Uncontrolled blood pressure can cause heart

12 attacks, heart failure and strokes.

13

110. Mr. Gray’s seizure disorder has also been inadequately treated. He was

14 prescribed Dilantin on his arrival at the jail, but two emergency room readings taken

15 over the next few days showed that the Dilantin level in his blood was far below the

16 therapeutic level. Jail medical staff did nothing for well over a year, at which point

17 a Dilantin level check was ordered, then re-ordered after it was not performed.

18 Moreover, Mr. Gray is frequently not provided his Dilantin at all, placing him at

19 serious risk for seizures, which he has experienced in the jails.

20

111. Plaintiff Angela Patterson has experienced significant and damaging

21 sub-standard health care, as described above, which has likely caused her permanent

22 injury.

23

112. Plaintiff Stanley Kujawsky has chronic high blood pressure. Sub-

24 standard care in the Riverside jails has endangered his cardiovascular health. First,

25 multiple dosages of his blood pressure medication have not been administered as

26 prescribed at several different jails. He has been denied his long-prescribed

27 medications on his transfer to different jails in the Riverside system and has been

28

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1 denied medications when jail staff allow the prescriptions to run out without

2 refilling them. He is also denied medications on the days he appears in court as well

3 as the days he has specialty care appointments in the Riverside county hospital, in

4 part because there are no medical staff on duty at the Presley jail who could deliver

5 the medications on his return, after 6 p.m. As a result of these missed dosages of

6 blood pressure medication, Mr. Kujawsky has suffered from abrupt and repeated

7 fluctuations in his blood pressure.

8

113. Mr. Kujawsky has filed repeated grievances on this denial of

9 medications, notably on June 15, 2012; July 15, 2012; August 15, 2012; and January

10 30, 2013. These grievances have either been granted or ignored, but the problem

11 has not been solved.

12

114. Further, the blood pressure medication Mr. Kujawsky has been

13 prescribed in the jails -- Clonidine -- is usually a last-resort drug to control blood

14 pressure since it can cause severe dizziness and low blood pressure and in particular

15 can cause rebound tachycardia (an elevated heart rate) if doses are missed. It should

16 not be prescribed unless a patient can take it consistently and reliably, which is

17 clearly not the case in the Riverside jails, as medical staff should well know and as

18 is amply demonstrated by the medication administration record showing repeated

19 missed doses of his medications. Moreover, the frequent use of Ibuprofen, as

20 prescribed to Mr. Kujawsky, can also elevate blood pressure, which has likely

21 contributed to some of his high readings.

22

115. Plaintiff Michael Wohlfeil has experienced significant and damaging

23 sub-standard health care, as described above, which has placed him at serious risk of

24 harm.

25

116. Other patients experience similarly inadequate and at times life-

26 threatening medical care. For example, one patient arrived in the Riverside jails

27 after having been assaulted with a crowbar just three weeks earlier. He had spent

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1 two of those weeks in the hospital and had undergone surgery to repair his jaw and

2 implant hardware. Despite obvious facial injuries and blood noted in his ear on his

3 arrival at the jail, he was not seen by a doctor for three weeks, and not until he

4 received a court order for treatment. At that time, his severe recent head trauma was

5 noted and the doctor ordered an ENT consultation. However, it did not take place,

6 and the consultation had to be re-ordered one month later. Following a second

7 court-ordered doctor’s appointment, the patient’s implanted hardware was found to

8 be coming out of his jaw. He was diagnosed in the emergency room with a

9 fractured dental plate. He was again referred for an ENT consultation, which finally

10 took place a week later. Because he was not sent with his crucial records, however,

11 the appointment was of limited use. He was referred for surgery on September 30,

12 2011, but did not receive it; despite repeated complaints of pain and two more court

13 orders for care, he was not seen again until November 8, when the surgery was re-

14 ordered “ASAP.” Throughout, the patient was never seen except in response to a

15 court order. Repeated warning signs – complaints of incontinence, evidence of

16 memory loss and confusion – were ignored, and there are no documented attempts

17 to determine whether he was experiencing brain trauma symptoms or displaying

18 underlying dementia, psychiatric disease, or cognitive deficits. Had the patient

19 been evaluated when he was first noted to have his injuries at the time of booking,

20 with records requested sooner and a more timely evaluation and appointment in both

21 the ENT clinic and the oral and maxillofacial surgery clinic, his serious

22 complications could have been minimized and they certainly would have been

23 treated earlier, likely reducing the unnecessary pain and suffering that he endured.

24

117. A patient at the Smith jail was seen by a nurse for ear pain on August 2,

25 2011. The doctor did not examine him, but prescribed medication over the

26 telephone. Five days later he was seen again by a nurse for worsening pain and

27 redness of the ear; the doctor, again over the telephone, referred him to the

28

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1 emergency room at RCRMC. Following that visit, the same doctor prescribed

2 antibiotics over the telephone, which he never received. Two weeks later, he had

3 another emergency room visit and was again prescribed the same antiobiotic by the

4 same doctor by telephone. Three weeks after that, on September 15, the patient

5 underwent tympanoplasty and mastoidectomy at RCRMC. On his return to the jail

6 after the surgery, he was prescribed Vicodin and antibiotics over the telephone but

7 never received them. On September 22, he reported blood coming from the ear but

8 was only seen by the nurse and not a doctor; the doctor ordered medications over the

9 telephone. He again reported bleeding on October 1 to the nurse but was not seen

10 by a doctor. He was finally seen on October 5, 2011, by a specialist at RCRMC and

11 was noted to have pus in his ear. Throughout the entire ordeal, he never once saw a

12 doctor at the jail.

13

118. Another patient with a long history of seizures endured many months

14 during which he was denied all seizure medications. Jail medical staff were aware

15 of his seizure disorder on November 8, 2011, but despite multiple blue slips

16 requesting care, he was not prescribed seizure medications until April 9, 2012. He

17 suffered several seizures in custody which would likely have been prevented if he

18 had been evaluated by a physician sooner and continued on his stable, home anti-

19 seizure medication regimen.

20

119. Another patient was seen, pursuant to court order, for ovarian cyst-

21 related pain. She was given some medication but continued to have pain. Jail

22 physicians failed to order a repeat vaginal ultrasound or refer her to gynecology for

23 further evaluation and management, as the standard of care requires.

24

120. Even when prisoners get to see the doctor, the examinations are often

25 ludicrously inadequate. Patients at Presley are “examined” in the non-contact

26 attorney visiting booth. However, instead of sitting on the well-lighted attorney side

27 of the booth facing the patient behind glass, the doctor places himself outside of the

28

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1 booth, where the deputies ordinarily sit, visible only through a slot for passing

2 documents. No meaningful physical examination is possible under such conditions.

3 Without meaningful physical examinations, the standard of care cannot be met.

4

B. Substandard mental health care

5

121. Plaintiffs Gray, Rosson, McClellan, and Miller, on behalf of

6 themselves, the plaintiff class, and the mental health subclass, assert the following.

7

122. Riverside County lacks an adequate system to provide a basic level of

8 constitutional mental health care. In the absence of such a system, the County fails

9 utterly to provide appropriate, informed diagnoses and treatment plans, ensure

10 continuity of psychotropic medication, monitor prisoners prescribed such

11 medication, make available medications that are effective in treating serious mental

12 disorders, or provide necessary therapeutic treatment.

13

123. Many prisoners do not get the right medications, the right dosages, or

14 appropriate ongoing care: the Grand Jury found that “[i]nmates with assessed

15 moderate mental health problems such as neuroses, phobias, panic disorders, etc.,

16 are not always offered appropriate mediation and counseling by qualified staff to get

17 and maintain them in a stable condition.” As a result, they suffer severe side effects

18 and decompensation.

19

124. Mentally ill prisoners are regularly started on powerful psychotropic

20 medications with no record of any evaluation or treatment plan that takes into

21 account medication interactions and underlying medical conditions. This practice is

22 dangerous because it does not allow subsequent monitoring or review, and places

23 patients at serious risk of harm through lack of treatment or inappropriate treatment

24 for their mental illness.

25

125. Even prisoners prescribed appropriate medications face frequent

26 disruptions in medication delivery, including abrupt cessation and missed pill

27

28

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1 deliveries, which cause serious suffering for these mentally ill patients, as described

2 in more detail in the prior section on medication administration.

3

126. No tracking is done of patients’ symptoms and any reaction they might

4 have to the medication, except for a cursory, non-confidential questioning at their

5 cell doors. The monitoring of vital signs such as weight, cholesterol, and glucose

6 levels, which is essential to ensure the patients are not suffering adverse effects from

7 psychotropic drugs, is absent. Dosages are changed abruptly, with no explanation.

8

127. On arrival in the Riverside jails, Plaintiff Quinton Gray was prescribed

9 several powerful psychotropic medications with no evaluation or assessment by a

10 mental health professional regarding his underlying physical condition and medical

11 treatment needs, and no baseline laboratory test to monitor known risky side effects

12 of the medications.

13

128. One of his medications, Geodon, must be taken with food or much of it

14 is not absorbed. Mr. Gray was not ordered to be given his Geodon with food, which

15 placed him at risk for varying blood levels and varying side effects and efficacy. He

16 was also started on the maximum dose, which increases the risk of severe side

17 effects such as acute muscle stiffness and tremors. Several months later, Mr. Gray’s

18 medications were discontinued suddenly without appropriate tapering off of the

19 maximum dose of Geodon, which placed him at risk for rebound tardive dyskinesia,

20 seizures, discontinuation syndrome (flu-like illness) and decompensation of

21 psychiatric symptoms (paranoia, hallucinations, and thought disorganization).

22

129. Months later, Mr. Gray was started on a second antipsychotic while

23 also on Geodon, despite the lack of clinical evidence that treating schizophrenic

24 patients with two antipsychotics provides better efficacy or treatment outcomes, and

25 despite the increased risk of side effects and drug-drug interactions. When

26 prescribed together, Mr. Gray’s two medications increase the risk of tardive

27 dyskinesia (such as tongue-biting), acute muscle stiffness and tremors, and cardiac

28

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1 events (arrhythmias). Both medications also lower the seizure threshold and when

2 given together in a patient with a history of seizure disorder, could cause increased

3 seizure events.

4

130. In July 2012, Mr. Gray was started on Benadryl and Cogentin at the

5 same time, with no documented explanation in his health care records. There is

6 never a need to treat a patient with both of these medications at the same time, and

7 they have multiple side effects including constipation and delirium.

8

131. Multiple doses of Mr. Gray’s medications have not been administered

9 to him during his stay in the jails. Missed doses can alter blood levels in a way that

10 increases side effects (including worsening of tardive dyskinesia), variably changes

11 seizure thresholds and can cause decompensation of psychiatric symptoms.

12

132. As a result of Defendant’s failed mental health delivery system, Mr.

13 Gray has in fact experienced twitching, tongue-biting, increased seizures and tongue

14 swelling, all predictable side effects from taking near maximum dose of these two

15 antipsychotic medications. He lives with racing thoughts, disorientation,

16 depression, and chronic sleep loss. He has not been appropriately monitored or

17 treated for these damaging side effects and signs of the inefficacy of his medication

18 regimen.

19

133. Plaintiff John Rosson, as described above, has experienced repeated

20 failures to adequately treat and monitor his serious mental illness, culminating in an

21 extended deprivation of his long-term psychotropic medications. As a result, he

22 decompensated and exhibited symptoms of self-harm serious enough to warrant

23 hospitalization.

24

134. Plaintiff Brandy McClellan experienced medication mismanagement

25 that severely endangered her health when she was started on Thorazine, an outdated

26 antipsychotic medication far from the standard of care in a modern mental health

27 delivery system, along with Vistaril, a medication with overly sedating effects that may

28

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1 impair a patient’s ability to realize there is a problem. Thorazine presents an

2 unacceptable risk of sudden death due to cardiac arrhythmia and in fact, Ms.

3 McClellan experienced a cardiac event serious enough to land her in the hospital.

4 Riverside mental health staff not only failed to monitor her when she was placed on this

5 dangerous combination of medications, but they were unaware of the dangerous effect she

6 experienced, and the medications continued to be offered to Ms. McClellan daily at pill

7 call for weeks after her hospitalization. They were not changed until she herself notified

8 mental health staff. This event demonstrates dangerous indifference to patient care.

9

135. Plaintiff Julie Miller has also been placed at serious risk by substandard

10 care in the Riverside jails. She has been prescribed multiple psychotropic

11 medications that have the potential to interact dangerously with each other and with

12 one of her physical medications, with no adjustments or monitoring of her condition

13 to assure her safety and the efficacy of her mental health care.

14

136. These failures are typical of the policies and practices that produce

15 substandard mental health care generally for patients in the Riverside jails. For

16 example, one Southwest Detention Center patient was maintained on Paxil, an

17 antidepressant with an extremely short-half life that can lead to a severe

18 discontinuation syndrome if the dose is missed even for 24 hours. He has

19 experienced multiple incidences of missing days of medications as well as not

20 having his medications renewed for one month periods, placing him at risk for

21 severe discontinuation symptoms as well as decompensation. There are no

22 medication monitoring standards set in place, particularly to monitor for weight gain

23 on Paxil. His medications were repeatedly renewed without evidence of evaluation.

24

137. Another patient housed in Presley was started on multiple

25 antipsychotic, anti-depressant, and bipolar disorder medications. Multiple times her

26 medications were renewed, stopped, started or changed without any documentation

27 or assessment: in particular, her medications were renewed repeatedly for more than

28

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1 two years without any indication of ever being evaluated by a medical doctor;

2 during this period two new medications were started without a medical evaluation or

3 documentation of informed consent; and once her medications were not renewed for

4 an entire month. Sudden discontinuation of medications puts patients at risk for

5 severe side effects and decompensation of psychiatric illnesses. She was also

6 started on multiple medications at high doses without appropriate titration, resulting

7 in severe side effects, and subjected to the abrupt discontinuation of medications

8 that might have been helpful for her symptoms. Further, she was placed on safety-

9 cell observation but was never evaluated by a medical doctor despite this being a

10 psychiatric emergency.

11

138. Another Presley patient was prescribed multiple psychotropic

12 medications, two of which are relatively contraindicated and should have had clear

13 documented psychiatric necessity for concomitant use including special monitoring

14 for side effects. There was none in her records.

15

139. Further, the patient was started and stopped on multiple medications

16 and had doses changed without any documentation of evaluation for efficacy, side

17 effects or informed consent. Such reviews were essential for this patient, since she

18 was placed on Thioridazine, a drug used to treat psychosis, anxiety and insomnia,

19 that with long-term use can cause tardive dyskinesia, a highly distressing and

20 uncomfortable phenomenon consisting of involuntary movements. There is no

21 documentation she was ever evaluated for such side effects.

22

140. In addition, she had significant periods of not receiving her medications

23 as well as frequent missed delivery of individual doses, placing her at risk for

24 discontinuation syndrome including intense anxiety, flu-like symptoms, headache,

25 nausea/vomiting, and parasthesias as well as rapid decompensation of mental illness.

26 Moreover, despite missing significant periods of medications, the medications were

27 suddenly restarted or given again at their regular doses rather than appropriately re-

28

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1 titrated. One of her medications, Lamotrigine, can result in a life-threatening rash if

2 it is suddenly started after stopping it for several days, as happened in her case.

3 Sudden starting of Paroxetine, another of her medications, can lead to severe gastro-

4 intestinal upset, sedation and anxiety.

5

141. A patient at Smith was started on numerous psychotropic medications

6 without any documentation he was monitored for efficacy or side effects. He

7 experienced significant lapses in medication administration, placing him at risk for

8 discontinuation syndrome associated with his medications, including severe

9 headache, nausea, vomiting, flu-like symptoms, agitation and anxiety.

10

142. One reason for this inadequate care might be the abysmally poor

11 communication with clinical staff that some prisoners experience. For example, one

12 Smith prisoner described his interview as taking place in a non-contact attorney

13 visiting booth, with glass separating doctor from patient. He answered some

14 questions from the psychiatrist, who then held up a piece of paper on which he

15 wrote words such as “mood swings” and “voices.” The patient nodded in response.

16 No history was taken – he is a disabled veteran with severe anxiety and PTSD – and

17 there was no discussion of medication side effects. The entire session lasted 15-20

18 minutes. The psychiatrist then briefly held up a piece of paper with information

19 about medications, but the patient did not have a chance to read it. The psychiatrist

20 handed the paper to a deputy, who gave it to the patient and rushed him to sign it.

21 When the patient asked, “can I read it?” the deputy responded: “just sign it.” The

22 patient did not find out the names of the medications he was prescribed for three

23 days after he started taking them. For the first two days, when he asked the nurses

24 the names of the pills, they would respond but he could not understand. When he

25 requested clarification, they would say “next person” and rush him through.

26

143. Another prisoner arrived at the Smith jail with a list of her prescribed

27 psychotropic medications, which was placed in her property. She waited two weeks

28

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1 to see a psychiatrist, but could not recall for him which medications she had taken

2 and did not have the list to consult. He told her he would prescribe medications and

3 when she asked for her diagnosis, and he responded “That is not important right

4 now, just go ahead and take your medications.” A week later, the pills arrived and

5 she took them without knowing what they were. Within three days, she experienced

6 a severe reduction in her ability to function and could not walk unassisted. She

7 stopped taking the pills. A week later, her mother spoke to a sergeant and told him

8 that the medication list should be retrieved from her property. He assured her it

9 would be done and the proper pills would be dispensed. The following day, new

10 pills arrived, which again made her feel “woozy” and “dizzy.” She again stopped

11 taking them.

12

144. A crucial element of an adequate mental health care delivery system is

13 an appropriate means to assess and monitor patients who exhibit or contemplate

14 self-harming behavior. Here, too, Riverside’s practices fall far short of acceptable

15 mental health care procedures. Prisoners believed to be suicidal or self-harming are

16 placed in a barren cell with only a rough smock to wear and a hole in the ground to

17 relieve themselves. The so-called “safety cells” are often filthy and stink of the

18 urine and feces that is visible on the walls and floor. Patients are left in the cells for

19 many days, with inadequate monitoring or supervision and no meaningful treatment,

20 under lights that are never turned off. Plaintiff Quinton Gray was forced to endure

21 these conditions for 48 hours simply because he told custody staff on entering the

22 jail that he needed psychiatric medications. John Rosson has also experienced the

23 damaging conditions and treatment deprivations in safety cells and, like many other

24 Riverside patients, has been moved in and out of the regional medical center for

25 suicidality to little effect. Another man was placed in a safety cell and removed

26 more than a day later with no risk assessment, explanation, or criteria for removal –

27 a gross departure from the standard of care.

28

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1

145. Riverside’s current practices concerning use of safety cells and safety

2 “restraint chairs” are ineffective and potentially dangerous. Deputies routinely log

3 that prisoners are placed in safety cells for “destroying jail property” or for being

4 “combative with jail staff.” Using the safety cell as a punitive measure exceeds the

5 proper use of such placements, which is to protect and treat patients who exhibit or

6 contemplate imminent self-harming behavior. It also makes it less likely that

7 patients will report serious emotional distress or suicidal ideation. People placed in

8 Riverside’s safety cells sometimes go more than 10 or 20 hours without offers of

9 food, and 10 hours or more without offers of water.

10

146. In some cases, when placing a prisoner in the safety cell, deputies also

11 strap his or her arms and legs to a restraint chair, completely immobilizing that

12 person for hours or even days at a time. These placements are often disciplinary as

13 well, such as for “destruction of jail property.” These chairs are dangerous: as

14 reported in the national press, they have caused the death of people subjected to

15 their use in other jurisdictions, some who suffered from seizures and choked to

16 death on their own vomit and others who developed blood clots from the

17 immobilization and died as they were released from the chair. Even without causing

18 death, the improper use of these chairs can exacerbate patients’ injuries while

19 preventing them from demonstrating the need for immediate medical care.

20 Riverside’s logs of restraint chair use are limited to documenting the time that the

21 chair is used and do not indicate why the chair was used or why the duration of its

22 use was appropriate; the logs also demonstrate frequent failures in provided

23 necessary checks on the restrained person’s welfare. These practices remove

24 accountability and depart from the standard of care required for mental health

25 treatment.

26
27 III.
28

Defendant has known for years of the significant risk of harm from its inadequate jail health care system and has failed to take reasonable steps
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1

to mitigate the risk to prisoners

2

147. Defendant Riverside County has for many years woefully underfunded

3 detention health care. The lack of infrastructure and staff to deliver life-saving care

4 has resulted, as Sheriff Stanley Sniff has told the Board of Supervisors, in a “crisis

5 in the jail system.”

6

148. The County’s own Grand Jury as well as several independent auditors

7 have come to the same conclusion: dangerous deficits in health care services at the

8 jails threaten the lives and health of the thousands of men and women they hold.

9

149. The severe deficiencies in health care services in Riverside’s jails are

10 thus well established by admissions from Sheriff Sniff and reports from state and

11 county watchdogs and independent auditors. Defendant has long been aware of the 12 harm its deficient system causes to patients with serious health care needs through

13 these reports as well as numerous grievances and health needs requests from

14 prisoners. Defendant’s failure to take action to ameliorate the conditions constitutes 15 deliberate indifference to Plaintiffs’ serious health care needs.

16

150. Several 2011 reports documented extensive health care violations in the

17 jails. The 2010-11 Grand Jury Report: Riverside County Detention Health Care 18 Administration found systemic failures in treatment, medication management,

19 record-keeping, and administration of forced medications, among other areas. On 20 July 5, 2011, the Sheriff responded that he “generally concurs with the findings of 21 the Grand Jury and has been outspoken on the need to remedy these issues over the

22 last two years.”

23

151. The Grand Jury’s report on mental health care deficiencies, 2010-11

24 Grand Jury Report: Mental Health Detention Services, noted serious health care

25 staffing deficiencies. Again, the Sheriff agreed with this assessment. The Grand 26 Jury released an updated report in June 2012, noting that mental health staffing has 27 in fact decreased since its prior year’s report.

28

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1

152. The Sheriff invited the state’s Corrections Standards Authority (CSA),

2 a body with statutory duty to regularly inspect county facilities, to perform an

3 additional inspection in January 2011. The CSA found numerous violations of state

4 law, including a widespread failure to provide daily sick call and insufficient

5 oversight of prisoners on suicide watch. They also found serious deficits in

6 medication administration: missed pill calls, night-time medications administered

7 between 4 and 6 p.m., and prisoners going to court denied medications entirely.

8

153. At the CSA’s recommendation, Sheriff Sniff contracted with the

9 independent Inmate Medical Quality (IMQ) to identify deficits and make

10 recommendations. IMQ performed their evaluation May 2-5, 2011, and reported

11 significant and potentially harmful systemic deficiencies in staffing, screening, sick

12 call, quality assurance, medical records, management of communicable diseases,

13 medication management, and use of restraints and safety cells for suicidal or self-

14 harming prisoners. As with both of the Grand Jury reports, the Sheriff accepted

15 these findings as requiring immediate and drastic attention.

16

154. The health care deficiencies in the Riverside jails, and Defendant’s

17 awareness of them, predate the 2011 reports and stem in part from years of drastic

18 cost-cutting measures. As Sheriff Sniff has explained, the County made “deep cuts

19 to medical personnel staffing levels” in fiscal year 2008-09, which “unacceptably

20 impacted the delivery of medical services. . . and other jail operations.” Instead of

21 correcting the problem, the County made another 20% reduction in medical and

22 mental health care staff as of July 1, 2010.

23

155. On January 12, 2012, Plaintiffs’ counsel sent Defendant officials a

24 sixteen-page letter detailing the systemic problems set forth in this Complaint.

25 Defendant did not make any substantive response to the specific concerns described

26 in the letter.

27

28

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1

156. The County’s systemic failures, as outlined in this Complaint, in

2 Plaintiffs’ January 2012 letter, and in the numerous reports of independent auditors,

3 result in significant injury and the unnecessary and wanton infliction of pain in

4 violation of the Eighth and Fourteenth Amendments. The injuries, as described

5 above, include drastically inadequate cancer treatment that may have significantly

6 decreased one patient’s life expectancy; severe and unnecessary pain;

7 unconstitutional conditions on suicide watch; exacerbated mental illness from

8 failure to provide appropriate screening and medications; and severe reactions from

9 inadequate and frequently interrupted medication delivery.

10

CLASS ACTION ALLEGATIONS

11 Plaintiff class

12

157. Plaintiffs bring this action on their own behalf and, pursuant to Rule

13 23(a), b(1), and (b)(2) of the Federal Rules of Civil Procedure, on behalf of all adult

14 men and women who are now, or will be in the future, in the custody of Riverside

15 County and who are now, or will be in the future, subject to an unreasonable risk of

16 harm due to Defendant’s policies and practices of denying prisoners minimally

17 adequate medical care and minimally adequate mental health care.

18

158. The class is so numerous that joinder of all members is impracticable.

19 There are currently nearly 4,000 people incarcerated in the five Riverside jails, all of

20 whom are entirely dependent on Defendant for medical and mental health care. All

21 prisoners are at risk of developing serious medical and mental health conditions

22 while in the Riverside jails. Due to Defendant’s policies and practices, all Riverside

23 jail prisoners receive or are at risk of receiving inadequate health care while in the

24 Riverside jails.

25

159. There are questions of law and fact common to the class including

26 whether the failure to provide minimally adequate medical and mental health care

27 violates the Due Process Clause of the Fourteenth Amendment and the Cruel and

28

46

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 48 of 56 Page ID #:16298

1 Unusual Punishment Clause of the Eighth Amendment to the United States

2 Constitution and whether Defendant has been deliberately indifferent to the serious

3 health care needs of class members. Defendant is expected to raise common

4 defenses to these claims.

5

160. Since there are several thousand class members, separate actions by

6 individuals would in all likelihood result in inconsistent and varying decisions,

7 which in turn would result in conflicting and incompatible standards of conduct for

8 Defendant.

9

161. Defendant has acted and failed to act on grounds that apply generally to

10 the class, so that final injunctive or corresponding declaratory relief is appropriate

11 respecting the class as a whole.

12

162. The claims of the named Plaintiffs are typical of the claims of the class

13 and subclasses, since their claims arise from the same policies, practices, and

14 courses of conduct and their claims are based on the same theory of law as the

15 class’s claims.

16

163. The named Plaintiffs, through counsel, will fairly and adequately

17 protect the interests of the class. Plaintiffs do not have any interests antagonistic to

18 the plaintiff class. Plaintiffs, as well as the Plaintiff class members, seek to enjoin

19 the unlawful acts and omissions of Defendant. Further, Plaintiffs are represented by

20 counsel experienced in civil rights litigation, prisoners’ rights litigation, and

21 complex class action litigation.

22 Medical Subclass

23

164. Plaintiffs Gray, Patterson, Kujawsky, and Wohlfeil bring this action on

24 their own behalf and, pursuant to Rule 23(a), b(1), and (b)(2) of the Federal Rules of

25 Civil Procedure, on behalf of a subclass of prisoners (hereinafter “Medical

26 Subclass”) who are now, or will in the future be, subjected to the medical care

27 policies and practices of the Riverside jails.

28

47

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 49 of 56 Page ID #:16299

1

165. The Medical Subclass is so numerous that joinder of all members is

2 impracticable. There are currently nearly 4,000 people incarcerated in the five

3 Riverside jails. All prisoners are at risk of developing serious medical conditions

4 while in the Riverside jails. Due to Defendant’s policies and practices, all Riverside

5 jail prisoners receive or are at risk of receiving inadequate medical care while in the

6 Riverside jails.

7

166. There are questions of law and fact common to the Medical Subclass

8 including whether the failure to provide minimally adequate medical care violates

9 the Due Process Clause of the Fourteenth Amendment and the Cruel and Unusual

10 Punishment Clause of the Eighth Amendment to the United States Constitution and

11 whether Defendant has been deliberately indifferent to the serious health care needs

12 of Medical Subclass members. Defendant is expected to raise common defenses to

13 these claims.

14

167. Since there are several thousand Medical Subclass members, separate

15 actions by individuals would in all likelihood result in inconsistent and varying

16 decisions, which in turn would result in conflicting and incompatible standards of

17 conduct for the Defendant.

18

168. Defendant has acted and failed to act on grounds that apply generally to

19 the Medical Subclass, so that final injunctive or corresponding declaratory relief is

20 appropriate respecting the Medical Subclass as a whole.

21

169. The claims of the named Plaintiffs are typical of the claims of the

22 Medical Subclass, since their claims arise from the same policies, practices, and

23 courses of conduct and their claims are based on the same theory of law as the

24 Medical Subclass’s claims.

25

170. The named Plaintiffs, through counsel, will fairly and adequately

26 protect the interests of the Medical Subclass. Plaintiffs do not have any interests

27 antagonistic to the Medical Subclass. Plaintiffs, as well as the Plaintiff class

28

48

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 50 of 56 Page ID #:16300

1 members, seek to enjoin the unlawful acts and omissions of Defendant. Further,

2 Plaintiffs are represented by counsel experienced in civil rights litigation, prisoners’

3 rights litigation, and complex class action litigation.

4 Mental Health Subclass

5

171. Plaintiffs Gray, Rosson, McClellan, and Miller bring this action on

6 their own behalf and, pursuant to Rule 23(a), b(1), and (b)(2) of the Federal Rules of

7 Civil Procedure, on behalf of a subclass of prisoners (hereinafter “Mental Health

8 Subclass”) who are now, or will in the future be, subjected to the mental health care

9 policies and practices of the Riverside jails.

10

172. The Mental Health Subclass is so numerous that joinder of all members

11 is impracticable. There are currently nearly 4,000 people incarcerated in the five

12 Riverside jails. All prisoners are at risk of developing serious mental health

13 conditions while in the Riverside jails. Due to Defendant’s policies and practices,

14 all Riverside jail prisoners receive or are at risk of receiving inadequate mental

15 health care while in the Riverside jails.

16

173. There are questions of law and fact common to the Mental Health

17 Subclass including whether the failure to provide minimally adequate mental health

18 care violates the Due Process Clause of the Fourteenth Amendment and the Cruel

19 and Unusual Punishment Clause of the Eighth Amendment to the United States

20 Constitution and whether Defendant has been deliberately indifferent to the serious

21 health care needs of Mental Health Subclass members. Defendant is expected to

22 raise common defenses to these claims.

23

174. Since there are several thousand Mental Health Subclass members,

24 separate actions by individuals would in all likelihood result in inconsistent and

25 varying decisions, which in turn would result in conflicting and incompatible

26 standards of conduct for the Defendant.

27

28

49

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 51 of 56 Page ID #:16301

1

175. Defendant has acted and failed to act on grounds that apply generally to

2 the Mental Health Subclass, so that final injunctive or corresponding declaratory

3 relief is appropriate respecting the Mental Health Subclass as a whole.

4

176. The claims of the named plaintiffs are typical of the claims of the

5 Mental Health Subclass, since their claims arise from the same policies, practices,

6 and courses of conduct and their claims are based on the same theory of law as the

7 Mental Health Subclass’s claims.

8

177. The named plaintiffs, through counsel, will fairly and adequately

9 protect the interests of the Mental Health Subclass. Plaintiffs do not have any

10 interests antagonistic to the Mental Health Subclass. Plaintiffs, as well as the

11 Mental Health Subclass members, seek to enjoin the unlawful acts and omissions of

12 Defendant. Further, Plaintiffs are represented by counsel experienced in civil rights

13 litigation, prisoners’ rights litigation, and complex class action litigation.

14
CLAIMS FOR RELIEF
15

16

First Cause of Action

17

(Plaintiffs Gray, Patterson, Kujawsky, Rosson, McClellan, Miller, and Wohlfeil and the plaintiff class

18

v. Defendant County of Riverside)

19

(Eighth Amendment; 42 U.S.C. § 1983)

20

178. By its policies and practices described in paragraphs 1 through 156,

21 Defendant subjects Plaintiffs and the Plaintiff class to an unreasonable risk of harm

22 and injury from inadequate health care. These policies and practices have been and

23 continue to be implemented by Defendant and its agents or employees in their

24 official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff class’s

25 ongoing deprivation of rights secured by the United States Constitution under the

26 Eighth Amendment.

27

28

50

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 52 of 56 Page ID #:16302

1

179. Defendant has been and is aware of all of the deprivations complained

2 of herein, and has condoned or been deliberately indifferent to such conduct.

3

4

Second Cause of Action

(Plaintiffs Gray, Patterson, Kujawsky, Rosson, McClellan, Miller, and Wohlfeil

5

and the plaintiff class

6

v. Defendant County of Riverside)

7

(Fourteenth Amendment; 42 U.S. C. § 1983)

8

180. By its policies and practices described in paragraphs 1 through 156,

9 Defendant subjects Plaintiffs and the Plaintiff class to an unreasonable risk of harm

10 and injury from inadequate health care. These policies and practices have been and

11 continue to be implemented by Defendant and its agents or employees in their

12 official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff class’s

13 ongoing deprivation of rights secured by the United States Constitution under the

14 Fourteenth Amendment.

15

181. Defendant has been and is aware of all of the deprivations complained

16 of herein, and has condoned or been deliberately indifferent to such conduct.

17

Third Cause of Action

18 (Plaintiffs Gray, Patterson, Kujawsky, and Wohlfeil and the Medical Subclass

19

v. Defendant County of Riverside)

20

(Eighth Amendment; 42 U.S.C. § 1983)

21

182. By its policies and practices described in paragraphs 1 through 156,

22 Defendant subjects Plaintiffs and the Medical Subclass to an unreasonable risk of

23 harm and injury from inadequate medical care. These policies and practices have

24 been and continue to be implemented by Defendant and its agents or employees in

25 their official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff

26 class’s ongoing deprivation of rights secured by the United States Constitution

27 under the Eighth Amendment.

28

51

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 53 of 56 Page ID #:16303

1

183. Defendant has been and is aware of all of the deprivations complained

2 of herein, and has condoned or been deliberately indifferent to such conduct.

3

4

Fourth Cause of Action

(Plaintiffs Gray, Patterson, Kujawsky, and Wohlfeil and the Medical Subclass
5
v. Defendant County of Riverside)
6
(Fourteenth Amendment; 42 U.S. C. § 1983)

7

184. By its policies and practices described in paragraphs 1 through 156,
8

Defendant subjects Plaintiffs and the Medical Subclass to an unreasonable risk of
9

harm and injury from inadequate medical care. These policies and practices have
10

been and continue to be implemented by Defendant and its agents or employees in
11

their official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff
12

class’s ongoing deprivation of rights secured by the United States Constitution
13

under the Fourteenth Amendment.
14

185. Defendant has been and is aware of all of the deprivations complained
15

of herein, and has condoned or been deliberately indifferent to such conduct.
16

17

Fifth Cause of Action

18 (Plaintiffs Gray, Rosson, McClellan, Miller, and the Mental Health Subclass v.

19

Defendant County of Riverside)

20

(Eighth Amendment; 42 U.S.C. § 1983)

21

186. By its policies and practices described in paragraphs 1 through 156,

22 Defendant subjects Plaintiffs and the Mental Health Subclass to an unreasonable

23 risk of harm and injury from inadequate mental health care. These policies and

24 practices have been and continue to be implemented by Defendant and its agents or

25 employees in their official capacities, and are the proximate cause of Plaintiff’s and

26 the Plaintiff class’s ongoing deprivation of rights secured by the United States

27 Constitution under the Eighth Amendment.

28

52

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 54 of 56 Page ID #:16304

1

187. Defendant has been and is aware of all of the deprivations complained

2 of herein, and has condoned or been deliberately indifferent to such conduct.

3

4

Sixth Cause of Action

(Plaintiffs Gray, Rosson, McClellan, Miller, and the Mental Health Subclass v.

5

Defendant County of Riverside)

6

(Fourteenth Amendment; 42 U.S. C. § 1983)

7

188. By its policies and practices described in paragraphs 1 through 156,

8 Defendant subjects Plaintiffs and the Mental Health Subclass to an unreasonable

9 risk of harm and injury from inadequate mental health care. These policies and

10 practices have been and continue to be implemented by Defendant and its agents or

11 employees in their official capacities, and are the proximate cause of Plaintiff’s and

12 the Plaintiff class’s ongoing deprivation of rights secured by the United States

13 Constitution under the Fourteenth Amendment.

14

189. Defendant has been and is aware of all of the deprivations complained

15 of herein, and has condoned or been deliberately indifferent to such conduct.

16

PRAYER FOR RELIEF

17

190. Plaintiffs and the class they represent have no adequate remedy at law

18 to redress the wrongs suffered as set forth in this complaint. Plaintiffs have suffered

19 and will continue to suffer irreparable injury as a result of the unlawful acts,

20 omissions, policies, and practices of the Defendant as alleged herein, unless

21 Plaintiffs are granted the relief they request. The need for relief is critical because

22 the rights at issue are paramount under the Constitution of the United States.

23

191. WHEREFORE, Plaintiffs, on behalf of themselves and the class they

24 represent, request that this Court grant them the following relief:

25

A. Declare the suit is maintainable as a class action pursuant to Federal Rule

26 of Civil procedure 23(a) and 23(b)(1) and (2);

27
B. Adjudge and declare that the conditions, acts, omissions, policies, and

28

53

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 55 of 56 Page ID #:16305

1 practices of Defendant and its agents, officials, and employees are in violation of the 2 rights of Plaintiffs and the class they represent under the Eighth and Fourteenth 3 Amendments to the U.S. Constitution;

4

C. Order Defendant, its agents, officials, employees, and all persons acting

5 in concert with them under color of state law or otherwise, to develop and

6 implement, as soon as practical, a plan to eliminate the substantial risk of serious

7 harm that Plaintiffs and members of the Plaintiff class suffer due to Defendant’s

8 inadequate medical and mental health care. Defendant’s plan shall include at a

9 minimum the following:

10

1. Staffing: Staffing shall be sufficient to provide Plaintiffs and the Plaintiff

11 class with timely access to qualified and competent clinicians who can provide

12 routine, urgent, emergent, and specialty health care;

13
2. Access: Policies and practices that provide timely access to health care;
14

15

3. Screening: Policies and practices that reliably screen for medical and

16 mental health conditions that need treatment;

17

4. Emergency response: Timely and competent responses to health care

18 emergencies;

19

5. Medication and supplies: Timely prescription and distribution of

20 medications and supplies necessary for medically adequate care;

21

6. Chronic care: Timely access to competent care for chronic illnesses;
22

23

7. Mental health treatment: Timely access to necessary treatment for serious

24 mental illness, including medication, therapy, inpatient treatment, suicide

25 prevention, and suicide watch; and

26

8. Quality assurance: A regular assessment of health care staff, services,

27 procedures, and activities designed to improve outcomes, and to identify and correct

28

54

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 129 Filed 08/20/14 Page 56 of 56 Page ID #:16306

1 errors or systemic deficiencies.

2

D. Enjoin Defendant, its agents, officials, employees, and all persons acting

3 in concert with them under color of state law or otherwise, from continuing the

4 unlawful acts, conditions, and practices described in this Complaint and from failing

5 to provide minimally adequate health care;

6

E. Award Plaintiffs, pursuant to 42 U.S.C. § 1988, the costs of this suit and

7 reasonable attorneys’ fees and litigation expenses;

8
F. Retain jurisdiction of this case until Defendant has fully complied with the
9
orders of this Court, and there is a reasonable assurance that Defendant will continue
10
to comply in the future absent continuing jurisdiction; and
11

12

G. Award such other and further relief as the Court deems just and proper.

13

14

Dated: June 23, 2014 PRISON LAW OFFICE

15

16

By: ___/s/ Sara Norman_________

17

DONALD SPECTER

WARREN GEORGE

18

SARA NORMAN

19

Attorneys for Plaintiffs

20
AKIN GUMP STRAUSS HAUER

21

& FELD LLP

22

23

By: ___/s/ Danielle Crockett_____

SHAWN HANSON

24

DANIELLE CROCKETT

25

NICHOLAS GREGORY

KELSEY MORRIS

26

SAURISH BHATTACHARJEE

27

Attorneys for Plaintiffs

28

55

SECOND AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

 
 Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 1 of 116 Page ID #:16320

1

2

3

4

5

6

7

8

9

UNITED STATES DISTRICT COURT

10

CENTRAL DISTRICT OF CALIFORNIA

11

12 QUINTON GRAY, ANGELA )

PATTERSON, AND STANLEY )

13 KUJANSKY, ON BEHALF OF )

THEMSELVES AND ALL

)

14 OTHERS SIMILARLY

)

SITUATED,

)

15

)

Plaintiffs, )

16

)

v.

)

17

)

COUNTY OF RIVERSIDE, )

18

)

Defendant. )

19 ________________________

Case No. EDCV 13-00444-VAP (OPx)
ORDER GRANTING PLAINTIFFS' MOTION FOR CLASS CERTIFICATION; DENYING DEFENDANT'S MOTION TO DISMISS
Motions filed on April 14, 2014 and August 4, 2014

20 Before the Court is Plaintiffs' Motion for Class
21 Certification ("Mot." or "Motion") (Doc. No. 28) and
22 Defendant's Motion to Dismiss Portions of the Second
23 Amended Complaint (Doc. No. 126). The Motion for Class
24 Certification came before the Court for hearing on July
25 21, 2014. The Motion to Dismiss is appropriate for
26 resolution without a hearing and the Court VACATES the
27 hearing set for this matter on September 8, 2014, at 2:00
28 p.m. See Fed. R. Civ. P. 78; L.R. 7-15.

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 2 of 116 Page ID #:16321

1 After consideration of the papers filed in support of,

2 and in opposition to, the Motions, the Court GRANTS

3 Plaintiffs' Motion for Class Certification and DENIES

4 Defendant's Motion to Dismiss.

5

6

I. BACKGROUND

7

The County of Riverside ("Defendant" or "County")

8 operates five county jails: the Robert Presley Detention

9 Facility ("Presley"), the Smith Correctional Facility

10 ("Smith"), the Indio Jail ("Indio"), the Southwest

11 Detention Center ("Southwest"), and the Blythe Jail

12 ("Blythe") (collectively, "Riverside Jails"). (SAC ¶

13 15.) In total, the Riverside Jails incarcerate

14 approximately 3,500 prisoners. (Id.) Three departments

15 within the County share responsibility for providing

16 medical and mental health care to inmates within the

17 Riverside Jails: the Riverside County Sheriff's

18 Department ("Sheriff's Department"); Riverside County

19 Regional Medical Center - Detention Health Services

20 ("Detention Health Services"); and the Riverside County

21 Regional Medical Center - Detention Mental Health

22 Services ("Detention Mental Health Services"). (Ex. 13

23 to Crockett Decl., Riverside County Interagency Adult

24 Detention Healthcare Memorandum of Agreement ("MOU")

25 (Doc. No. 32).)

26

27

28

2

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 3 of 116 Page ID #:16322

1

Quinton Gray, Angela Patterson, Stanley Kujawsky,

2 John Rosson III, Brandy McClellan, Julie Miller, and

3 Michael Wohlfeil (collectively, "Plaintiffs") are current

4 and former inmates in the Riverside Jails. On March 8,

5 2013, Plaintiffs filed this action on behalf of all

6 current and future inmates who are in the custody of the

7 County. Plaintiffs allege systemic inadequacies in the

8 County's provision of medical and mental health care

9 expose inmates in the Riverside Jails to a substantial

10 risk of serious harm. Plaintiffs allege that the County

11 has acted with deliberate indifference in the provision

12 of medical and mental health care and that the County's

13 failure to provide adequate medical and mental health

14 care to inmates in their custody violates the Eighth and

15 Fourteenth Amendments. Plaintiffs seek declaratory and

16 injunctive relief.

17

18

On April 14, 2014, Plaintiffs filed this Motion to

19 certify the Class and two Subclasses. On June 9, 2014,

20 after the Class Certification Motion was filed,

21 Plaintiffs filed a Motion to file a Second Amended

22 Complaint ("SAC") and on July 18, 2014, the Court granted

23 Plaintiffs' Motion. (See Order Granting Motion to File a

24 Second Amended Complaint (Doc. No. 118).) Accordingly,

25 the Court addresses certification based on the factual

26 allegations and named Plaintiffs in the SAC.

27

28

3

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 4 of 116 Page ID #:16323

1

Defendant filed its Opposition to the Motion for

2 Class Certification on June 16, 2014 ("Opp'n.") (Doc. No.

3 52), and Plaintiffs filed their Reply on June 30, 2014

4 ("Reply") (Doc. No. 75). Defendant filed a Response to

5 Plaintiffs' Reply on July 11, 2014 ("Def.'s Response")

6 (Doc. No. 115).

7

8

Plaintiffs seek certification of a Class and two

9 Subclasses. The proposed Class definition is, "all adult

10 men and women who are now, or will be in the future, in

11 the custody of Riverside County and who are now, or will

12 be in the future, subject to an unreasonable risk of harm

13 due to Defendant's policies and practices of denying

14 prisoners minimally adequate medical care and minimally

15 adequate mental health care." (SAC ¶ 157.) The proposed

16 "Medical Subclass" definition is "prisoners who are now,

17 or will in the future be, subjected to the medical care

18 policies and practices of the Riverside jails." (Id. ¶

19 164.) The proposed Medical Subclass representatives are

20 Gray, Patterson, Kujawsky, and Wohlfeil. (Id.) The

21 proposed "Mental Health Subclass" definition is

22 "prisoners who are now, or will in the future be,

23 subjected to the mental health care policies and

24 practices of the Riverside jails." (Id. ¶ 171.) The

25 proposed Mental Health Subclass representatives are Gray,

26 Rosson, McClellan, and Miller. (Id.)

27

28

4

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 5 of 116 Page ID #:16324

1

The motion for class certification came before the

2 Court for hearing on July 21, 2014. On August 4, 2014,

3 Defendant filed a Motion to Dismiss Portions of the

4 Second Amended Complaint ("MTD") (Doc. No. 126).

5 Plaintiffs filed an Opposition to the Motion to Dismiss

6 on August 18, 2014 ("MTD Opp'n") (Doc. No. 128) and

7 Defendant filed its Reply on August 22, 2014 ("MTD

8 Reply") (Doc. No. 130).

9

10

II. FACTUAL ALLEGATIONS

11

Plaintiffs allege that Defendant maintains and runs a

12 health care system that "lacks basic elements necessary

13 to provide constitutional care" and fails to identify and

14 diagnose serious conditions, provide timely care,

15 administer appropriate medications, employ adequate

16 staff, maintain records, maintain inmate confidentiality,

17 and identify and correct its own failings. (SAC ¶ 16.)

18 Plaintiffs allege that, as a system, the Defendant's

19 policies and prisoners' access to health care are so

20 inadequate they constitute deliberate indifference to

21 serious medical and mental health needs. (Id. ¶ 17.)

22 Plaintiffs identify several inadequate policies and

23 procedures related to delays in access to care and the

24 provision of inadequate care at the Riverside Jails.

25

26

To begin, Plaintiffs allege that Defendant has a

27 policy and practice of severely understaffing health care

28

5

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 6 of 116 Page ID #:16325

1 positions in the jails. (Id. ¶ 90.) As a result, there

2 are not enough doctors, dentists, nurses, mental health

3 providers, pharmacists, or medical records staff to serve

4 the needs of the population. (Id.) As of September of

5 2013, only 63 percent of medical staff positions in the

6 jails were filled. (Id. ¶ 95.)

7

8

Plaintiffs also allege the intake process and

9 procedures are inadequate and result in delayed or denied

10 medical care. (SAC ¶ 18.) The intake procedures are not

11 sufficiently staffed with nurses who can identify and

12 evaluate medical and mental health conditions. (Id. ¶

13 20.) Furthermore, the intake procedures do not

14 adequately identify medical and mental health conditions

15 because they are performed by custody staff without

16 medical or mental health training. (Id. ¶ 27.) As a

17 result of this policy, inmates may receive delayed or

18 inappropriate treatment of medical and mental health

19 conditions. For example, Plaintiff Gray entered the

20 Riverside Jails with a chronic seizure disorder and high

21 blood pressure. His intake form has "no" marked for

22 every question about health care needs, including those

23 that should be marked "yes." (Id. ¶ 21.)

24

25

Plaintiffs allege that the Defendant maintains a non-

26 functioning sick call system that is incapable of

27 providing daily sick call. (SAC ¶ 32.) The lack of a

28

6

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 7 of 116 Page ID #:16326

1 functioning sick call system puts prisoners at a risk of

2 serious harm because they must rely on other means to

3 obtain care. Prisoners may either obtain a court order

4 from the criminal court, file repeated health care

5 request forms ("blue slips"), or file grievances in order

6 to receive access to primary and specialty care. (Id. ¶¶

7 32, 37.) In addition, the County maintains a policy that

8 makes it difficult for prisoners to file a grievance

9 about inadequate access to medical care. As a result,

10 the prisoners experience dangerous delays in accessing

11 medical care, creating a serious risk of additional harm

12 and suffering from untreated medical conditions. (Id. ¶

13 38.)

14

15

For example, Plaintiff Gray alleges he has only seen

16 Riverside Jail doctors when required by court order.

17 (Id. ¶ 32.) Other named Plaintiffs also received court

18 orders to see doctors in the Riverside Jails. (Id.)

19 Furthermore, court orders are often not honored. (Id. ¶

20 33.) For example, in November 2011, the Superior Court

21 ordered an inmate to be seen by a medical doctor within

22 48 hours. A few weeks later, despite this directive, the

23 inmate filed a grievance because he still had not

24 received treatment. (Id.)

25

26

Delays in access to care result in serious harm. For

27 example, Plaintiff Patterson arrived at the Riverside

28

7

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 8 of 116 Page ID #:16327

1 Jails following heart surgery that placed a temporary

2 filter in a major blood vessel supplying her heart. (SAC

3 ¶ 40.) The filter was supposed to have been removed

4 within three months, but this was not reflected in the

5 jail medical records. (Id.) As a result, there was

6 delay and confusion as to whether the filter was

7 temporary or permanent. Nine months later she went in

8 for surgery, but by that time the filter could no longer

9 be removed safely because of the accumulation of scar

10 tissue. (Id.) As a result, Patterson will require life-

11 long anticoagulation therapy, which carries significant

12 risks of fatal blood clotting and requires daily

13 medication and monitoring. (Id. ¶ 41.)

14

15

Plaintiffs allege that Defendant lacks adequate

16 policies and procedures to provide inmates with referrals

17 for specialists. (SAC ¶¶ 53-61.) For example, Plaintiff

18 Wohlfeil spent more than two years waiting for speciality

19 care to diagnose and develop a treatment plan for his

20 chronic diarrhea and dozens of tumors. (Id. ¶ 55.)

21

22

As a result of inadequate access to care, many

23 inmates are completely denied care while in Riverside

24 Jails. For example, an inmate with high blood pressure

25 and a history of coronary artery disease complained of an

26 irregular heartbeat and chest pain. He was not evaluated

27 or given any treatment, and only instructed to let staff

28

8

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 9 of 116 Page ID #:16328

1 know if he experienced those symptoms again. Five weeks

2 later he was found unresponsive, pale, and sweaty with

3 high blood pressure and a heart flutter. (Id. ¶ 65.)

4

5

Plaintiffs allege that Defendant has a policy and

6 practice of failing to prescribe, provide, and properly

7 manage medication. In addition, Defendant provides

8 incorrect, interrupted, or incomplete dosages, which puts

9 prisoners at a serious risk of harm. (Id. ¶ 67.)

10 Defendant maintains a policy of inadequate staffing to

11 distribute medications. (Id. ¶ 68.) As a result,

12 prisoners are often forced to skip doses of medication;

13 placing them at risk of harm. In addition, as a result

14 of understaffing, the delivery of medication is erratic

15 and the time of delivery fluctuates greatly. (SAC ¶ 71.)

16 A prisoner who requires multiple daily dosages may

17 receive his or her evening dose in the middle of the day.

18 Plaintiffs Gray, Patterson, Kujawsky, and Rosson have

19 each experienced skipped medication dosages and

20 fluctuating medication delivery times. (Id. ¶¶ 68, 71.)

21

22

Defendant's policies require inmates to alert staff

23 when a medication refill is required. (Id. ¶ 72.) As a

24 result of this policy, there are often significant

25 interruptions in treatment because a prescription may not

26 be renewed until the prisoners file multiple health care

27 requests or grievances. (Id.) In addition, the

28

9

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1 Defendant maintains a policy of denying prisoners

2 medications when they attend court hearings or are

3 transported to outside appointments. (Id. ¶ 73.) Lapses

4 in the delivery of psychotropic medications are

5 particularly detrimental to the prisoners. (Id. ¶ 83.)

6 For example, Plaintiff Gray has suffered harm from lapsed

7 dosages of his psychotropic medications that treat him

8 for bipolar disorder. (Id. ¶ 84.)

9

10

Defendant also has a practice of failing to monitor

11 the effects of medication to determine whether dosages

12 are correct or whether medications should be changed.

13 (SAC ¶ 74.) Failure to monitor medication dosages

14 exposes prisoners to serious risks to their health and

15 unnecessary pain and suffering. (Id.) For example, a

16 prisoner with a documented allergy to Dilantin was

17 repeatedly prescribed the medication and offered it

18 during pill call, placing him at serious risk of harm.

19 (Id. ¶ 78.)

20

21

Plaintiffs allege that mental health "encounters" are

22 often held in the presence of custody staff and other

23 prisoners. The lack of confidentiality reduces the

24 likelihood that inmates will feel comfortable speaking

25 candidly about their conditions, and thus may inhibit the

26 provision of effective mental health care. (Id. ¶ 100.)

27 Plaintiffs Miller, Rosson, and Gray have all experienced

28

10

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1 mental health encounters that were not confidential.

2 (Id.)

3

4

Plaintiffs allege that due to understaffing, the

5 Defendant's medical records system is disorganized and

6 incomplete, thus increasing the serious risk that

7 prisoners will receive inadequate healthcare. (Id. ¶¶

8 102, 104.)

9

10

Finally, when inmates are treated by jail physicians,

11 the inmates often do not receive sufficient follow-up,

12 monitoring, specialty referrals, or proper care. (SAC ¶

13 108.) In regard to mental health, Plaintiffs allege

14 there are no appropriate means to assess and monitor

15 inmates who exhibit or contemplate self-harming behavior.

16 (Id. ¶ 144.) Inmates who require mental health treatment

17 are often put into safety cells, where they are not

18 monitored and do not receive treatment. (Id.) Current

19 practices concerning the use of safety cells and safety

20 "restraint chairs" are ineffective and potentially

21 dangerous. (Id. ¶ 145.) The Riverside Jails' logs

22 reveal improper use and failure to monitor inmates in

23 safety cells and restraint chairs. (Id. ¶ 146.)

24 Plaintiffs Gray and Rosson have experienced placement in

25 safety cells without proper monitoring or treatment.

26 (Id. ¶ 144.)

27

28

11

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1

Plaintiffs allege that Riverside officials lack the

2 ability to identify and correct the systemic problems in

3 their policies and practices. As a result, they do not

4 remedy the deficiencies. (SAC ¶ 105.)

5

6

Plaintiffs allege that inadequacies in Defendant's

7 health policies are well-documented, including multiple

8 Grand Jury reports, a report by the Corrections Standards

9 Authority, and a report by Inmate Medical Quality. These

10 reports all document systemic deficiencies in staffing,

11 screening, sick call, quality management, medical

12 records, medication management, and the use of restraint

13 chairs and safety cells. (Id. ¶¶ 148-154.) In 2011, the

14 Sheriff accepted the findings of these reports as

15 requiring immediate and drastic action, but has failed to

16 take reasonable steps to mitigate the risk of serious

17 harm to inmates.

18

19

III. LEGAL STANDARD

20 A. Motion to Dismiss

21

Federal Rule of Civil Procedure 12(b)(6) allows a

22 party to bring a motion to dismiss for failure to state a

23 claim upon which relief can be granted. Rule 12(b)(6) is

24 read along with Rule 8(a), which requires a short, plain

25 statement upon which a pleading shows entitlement to

26 relief. Fed. R. Civ. P. 8(a)(2); Conley v. Gibson, 355

27 U.S. 41, 47 (1957) (holding that the Federal Rules

28

12

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1 require a plaintiff to provide "'a short and plain

2 statement of the claim' that will give the defendant fair

3 notice of what the plaintiff's claim is and the grounds

4 upon which it rests." (quoting Fed. R. Civ. P. 8(a)(2)));

5 Bell Atl. Corp. v Twombly, 550 U.S. 544, 555 (2007).

6 When evaluating a Rule 12(b)(6) motion, a court must

7 accept all material allegations in the complaint — as

8 well as any reasonable inferences to be drawn from them —

9 as true and construe them in the light most favorable to

10 the non-moving party. See Doe v. United States, 419 F.3d

11 1058, 1062 (9th Cir. 2005); ARC Ecology v. U.S. Dep't of

12 Air Force, 411 F.3d 1092, 1096 (9th Cir. 2005); Moyo v.

13 Gomez, 32 F.3d 1382, 1384 (9th Cir. 1994).

14

15

"While a complaint attacked by a Rule 12(b)(6) motion

16 to dismiss does not need detailed factual allegations, a

17 plaintiff's obligation to provide the 'grounds' of his

18 'entitlement to relief' requires more than labels and

19 conclusions, and a formulaic recitation of the elements

20 of a cause of action will not do." Twombly, 550 U.S. at

21 555 (citations omitted). Rather, the allegations in the

22 complaint "must be enough to raise a right to relief

23 above the speculative level." Id.

24

25

To survive a motion to dismiss, a plaintiff must

26 allege "enough facts to state a claim to relief that is

27 plausible on its face." Twombly, 550 U.S. at 570;

28

13

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1 Ashcroft v. Iqbal, 556 U.S. 662, 129 S. Ct. 1937, 1949

2 (2009). "The plausibility standard is not akin to a

3 'probability requirement,' but it asks for more than a

4 sheer possibility that a defendant has acted unlawfully.

5 Where a complaint pleads facts that are 'merely

6 consistent with' a defendant's liability, it stops short

7 of the line between possibility and plausibility of

8 'entitlement to relief.'" Iqbal, 129 S. Ct. at 1949

9 (quoting Twombly, 550 U.S. at 556).

10

11

The Ninth Circuit has clarified that (1) a complaint

12 must "contain sufficient allegations of underlying facts

13 to give fair notice and to enable the opposing party to

14 defend itself effectively" and (2) "the factual

15 allegations that are taken as true must plausibly suggest

16 an entitlement to relief, such that it is not unfair to

17 require the opposing party to be subjected to the expense

18 of discovery and continued litigation." Starr v. Baca,

19 652 F. 3d 1202, 1216 (9th Cir. 2011).

20

21 B. Class Certification

22

Federal Rule of Civil Procedure 23 governs class

23 actions. Fed. R. Civ. P. 23. Under Rule 23(a), a party

24 seeking class certification must demonstrate the

25 following prerequisites: (1) numerosity of plaintiffs;

26 (2) common questions of law or fact; (3) typicality of

27 named plaintiff's claims; and (4) ability of the named

28

14

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1 plaintiff to protect the interests of the class

2 adequately. See Ellis v. Costco Wholesale Corp., 657

3 F.3d 970, 980 (9th Cir. 2011) (citing Fed. R. Civ. P.

4 23(a)). The party seeking certification bears the burden

5 of demonstrating it has met each of the four requirements

6 of Rule 23(a). Id. Although not mentioned in Rule

7 23(a), the moving party must also demonstrate that the

8 class is ascertainable. Keegan v. Am. Honda Motor Co.,

9 Inc., 284 F.R.D. 504, 521 (C.D. Cal. 2012); Rodmakers,

10 Inc. v. Newport Adhesives & Composites, Inc., 209 F.R.D.

11 159, 163 (C.D. Cal. 2002) ("Prior to class certification,

12 plaintiffs must first define an ascertainable and

13 identifiable class.").

14

15

After satisfying the five prerequisites of

16 numerosity, commonality, typicality, adequacy, and

17 ascertainability, a party must also demonstrate that it

18 meets at least one of the prerequisites in Rule 23(b).

19 Under 23(b), class certification is appropriate if (1)

20 there is a risk that separate actions would create

21 incompatible standards of conduct for the defendant or

22 prejudice individual class members not parties to the

23 action; or (2) the defendant has treated the members of

24 the class as a class, making appropriate injunctive or

25 declaratory relief with respect to the class as a whole;

26 or (3) common questions of law or fact predominate over

27 questions affecting individual members and that a class

28

15

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1 action is a superior method for fairly and efficiently

2 adjudicating the action. Fed. R. Civ. P. 23(b)(1–3).

3

4

The decision to grant or deny a motion for class

5 certification is committed to the trial court's broad

6 discretion. Bateman v. American Multi–Cinema, Inc., 623

7 F.3d 708, 712 (9th Cir. 2010). A party seeking class

8 certification must affirmatively demonstrate compliance

9 with Rule 23 — that is, the party must be prepared to

10 prove that there are in fact sufficiently numerous

11 parties and common questions of law or fact. Wal–Mart

12 Stores, Inc. v. Dukes, —— U.S. ——, 131 S. Ct. 2541, 2550,

13 2551 (2011). This requires a district court to conduct a

14 "rigorous analysis" that frequently "will entail some

15 overlap with the merits of the plaintiff's underlying

16 claim." Id.

17

18 C. Denial of Adequate Medical and Mental Health Care

19

Plaintiffs claim the policies and practices of the

20 Riverside Jails subject inmates to an unreasonable risk

21 of harm and injury from inadequate medical and mental

22 health care. Plaintiffs bring their claims under the

23 Eighth and Fourteenth Amendments because the Riverside

24 Jails house both pre-conviction and post-conviction

25 inmates. The Fourteenth Amendment applies before

26 conviction and the Eighth Amendment applies after

27 conviction, but the standards are equivalent in regard to

28

16

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1 medical care. See City of Revere v. Massachusetts Gen.

2 Hosp., 463 U.S. 239, 244 (1983) (In regard to medical

3 care "the due process rights of a person [before trial]

4 are at least as great as the Eighth Amendment protections

5 available to a convicted prisoner."). Under the Eighth

6 Amendment, prison officials must provide for inmates'

7 basic human needs while in custody, including "food,

8 clothing, shelter, medical care, and reasonable safety."

9 Helling v. McKinney, 509 U.S. 25, 32 (1993). Medical

10 care includes both mental and physical health. See

11 Hoptowit v. Ray, 682 F.2d 1237, 1253 (9th Cir. 1982).

12

13

To prevail on their claims under the Eighth and

14 Fourteenth Amendments, Plaintiffs must show Defendant

15 acted with "deliberate indifference to serious medical

16 needs." Jett v. Penner, 439 F.3d 1091, 1096 (9th Cir.

17 2006) (citing Estelle v. Gamble, 429 U.S. 97, 104

18 (1976)). There are two prongs to the deliberate

19 indifference analysis. Id. First, under an objective

20 analysis, the prisoner must show a "serious medical need

21 by demonstrating that failure to treat a prisoner's

22 condition could result in further significant injury or

23 the unnecessary and wanton infliction of pain." Id.

24 (internal quotations and citations omitted).

25

26

Second, under a subjective analysis, the prisoner

27 must show that the defendant's response to that need was

28

17

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1 deliberately indifferent. Id. The state of mind

2 required for deliberate indifference is "subjective

3 recklessness." Snow v. McDaniel, 681 F.3d 978, 985-86

4 (9th Cir. 2012) overruled on other grounds by Peralta v.

5 Dillard, 744 F.3d 1076 (9th Cir. 2014). The deliberate

6 indifference standard is "less stringent in cases

7 involving a prisoner's medical needs . . . because 'the

8 State's responsibility to provide inmates with medical

9 care ordinarily does not conflict with competing

10 administrative concerns.'" McGuckin v. Smith, 974 F.2d

11 1050, 1060 (9th Cir. 1992) overruled on other grounds by

12 WMX Technologies, Inc. v. Miller, 104 F.3d 1133 (9th Cir.

13 1997).

14

15

The deliberate indifference prong is met if (1) there

16 is a purposeful act or failure to respond; and (2) the

17 plaintiff demonstrates there was harm caused by the

18 indifference. Id. A prisoner may meet the harm

19 requirement by demonstrating that the defendant's actions

20 expose the prisoner to a "substantial risk for serious

21 harm." Parsons v. Ryan, 754 F.3d 657, 677 (9th Cir.

22 2014) ("Parsons II"). It is not necessary for a prisoner

23 to "await a tragic event" before seeking a remedy.

24 Farmer, 511 U.S. at 828. Deliberate indifference to

25 serious medical needs may be established by showing that

26 there are "systemic and gross deficiencies in staffing,

27 facilities, equipment, or procedures that the inmate

28

18

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 19 of 116 Page ID #:16338

1 population is effectively denied access to adequate

2 medical care." Madrid v. Gomez, 889 F. Supp. 1146, 1256

3 (N.D. Cal. 1995) (citing Wellman v. Faulkner, 715 F.2d

4 269, 272 (7th Cir. 1983); see also Wilson v. Seiter, 501

5 U.S. 294, 304 (1991) (Approving Wellman and recognizing

6 that "[s]ome conditions of confinement may establish an

7 Eighth Amendment violation "in combination" when each

8 would not do so alone, but only when they have a mutually

9 enforcing effect that produces the deprivation of a

10 single, identifiable human need such as food, warmth, or

11 exercise—for example, a low cell temperature at night

12 combined with a failure to issue blankets.").

13

14

IV. MOTION TO DISMISS

15

Defendant moves to dismiss portions of Plaintiffs'

16 SAC related to intake procedures, privacy procedures, and

17 the use of safety cells and restraint chairs as a

18 disciplinary measures on the basis that allegations

19 related to these policies fail to state a claim upon

20 which relief may be granted.

21

22

In Opposition, Plaintiffs argue that each of these

23 alleged policies expose inmates in the Riverside Jails to

24 a substantial risk of serious harm in violation of the

25 Eighth and Fourteenth Amendments. In addition,

26 Plaintiffs correctly assert that they have not alleged a

27 separate claim arising out of each specific policy;

28

19

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1 rather, the factual allegations of the SAC support

2 Plaintiffs' six claims that the health care system in the

3 Riverside Jails subjects Plaintiffs in the Medical and

4 Mental Health subclasses to an unreasonable risk of harm

5 and injury from inadequate health care. See Wilson, 501

6 U.S. at 304; Madrid, 889 F. Supp. at 1256 (N.D. Cal.

7 1995).

8

9 A. Intake Procedures

10

Defendant moves to dismiss all allegations related to

11 intake procedures in the SAC. (SAC ¶¶ 19-25, 27; Prayer

12 at 54:15-16.) As explained above, Plaintiffs allege that

13 the intake procedures in the Riverside Jails are

14 inadequate because they are conducted by untrained

15 custody staff, and there are insufficient numbers of

16 nursing staff available to evaluate medical and mental

17 health conditions on intake. As a result, the "inmates

18 are rarely assessed for communicable diseases when they

19 arrive at the jails and medically high-risk prisoners do

20 not have histories taken, physical assessments, or

21 treatment plans." (SAC ¶ 20.) Plaintiffs have

22 sufficiently alleged the intake procedures fail to screen

23 inmates adequately for medical and mental health

24 procedures. For example, Plaintiff Gray's intake form

25 has "no" marked for every question about health care

26 needs, including those that should be marked "yes." (Id.

27 ¶ 21.) The SAC also includes allegations of similar

28

20

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1 deficiencies in the intake screening process for unnamed

2 plaintiffs.

3

4

Defendant moves to dismiss these allegations on the

5 basis that the intake policy alleged in the SAC is not

6 constitutionally inadequate. In addition, Defendant

7 claims that the specific allegations related to Gray's

8 intake do not rise to the level of deliberate

9 indifference. (MTD at 4-5.)

10

11

An adequate intake screening assessment is a

12 recognized component of a constitutionally adequate

13 health care delivery system. See Madrid, 889 F. Supp. at

14 1258 (deficient intake screening method part of

15 constitutionally inadequate health care system which

16 failed to provide access to medical and mental health

17 care); Carty v. Farrelly, 957 F. Supp. 727, 738 (D.V.I.

18 1997) (Inadequate intake health evaluations also

19 contribute to constitutionally inadequate medical and

20 mental health care); see also Lareau v. Manson, 651 F.2d

21 96, 109 (2d Cir. 1981) (inadequate screening of

22 communicable diseases at intake is inadequate medical

23 practice that violates Eighth Amendment). Defendant

24 argues the alleged intake policy is not constitutionally

25 deficient because inmates are not entitled to better

26 health care than members of the public, and that members

27 of the public are only treated for medical conditions

28

21

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1 that they disclose and seek treatment for. In addition,

2 Defendant also argues that there is no requirement under

3 federal law that medical or mental health staff, rather

4 than officers, conduct intake screening and that there is

5 no "federal Constitutional right to have information

6 recorded on forms." (MTD at 5.) Plaintiffs do not

7 allege that intake conducted by officers is per se

8 constitutionally inadequate; rather, they claim that in

9 Riverside Jails, intake is conducted by untrained custody

10 staff who do not have specialized training to conduct

11 mental health screenings and fail to identify health

12 concerns or accurately record medical issues on booking

13 forms. Plaintiffs allege that this policy exposes

14 inmates to a substantial risk of serious harm because

15 medical and mental health conditions may not be

16 recognized at intake. The intake policy is one policy in

17 an alleged system of delivering health care that is

18 constitutionally deficient under the Eighth and

19 Fourteenth Amendments.

20

21

Next, the Court turns to Defendant's claim that the

22 allegations related to Gray's intake experience are

23 insufficient to state a claim for a constitutional

24 violation. Defendant would likely succeed on its Motion

25 if Gray had filed a Complaint as an individual inmate,

26 alleging that his individual intake experience amounted

27 to constitutional violation. See Boncher ex rel. Boncher

28

22

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 23 of 116 Page ID #:16342
1 v. Brown Cnty., 272 F.3d 484, 487 (7th Cir. 2001) 2 (inadequacy of intake checklist form and training of the 3 intake officer insufficient to constitute constitutional 4 violation where intake officer believed suicidal inmate 5 was joking about committing suicide); McCaster v. 6 Clausen, 684 F.3d 740, 747 (8th Cir. 2012) (nurse who 7 conducted intake exam was not deliberately indifferent 8 when serious medical need was not obvious). The SAC, 9 however, only includes Gray’s experience as evidence of 10 the existence of an allegedly deficient intake policy 11 that exposes inmates to a substantial risk of serious 12 harm. Moreover, Plaintiffs allege that the intake policy 13 combines with other policies to create a health care 14 system that is constitutionally inadequate and subjects 15 inmates to a substantial risk of serious harm. Thus, 16 there is no "claim" that may be dismissed based on the 17 constitutional adequacy of Gray's individual intake 18 experience. See Brown v. Plata, —— U.S. ——, 131 S.Ct. 19 1910, 1925 n.3 (2011)("Because plaintiffs do not base 20 their case on deficiencies in care provided on any one 21 occasion, this Court has no occasion to consider whether 22 these instances of delay - or any other particular 23 deficiency in medical care complained of by the 24 plaintiffs - would violate the Constitution"); Parsons 25 II, 754 F.3d at 678 ("Although a presently existing risk 26 may ultimately result in different future harm for 27 different inmates — ranging from no harm at all to death 28
23

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 24 of 116 Page ID #:16343

1 — every inmate suffers exactly the same constitutional

2 injury when he is exposed to a single statewide ADC 3 policy or practice that creates a substantial risk of 4 serious harm."). Whether Gray's individual exposure to 5 the policy amounts to a constitutional violation does not

6 alter the alleged injury suffered by the class, which is

7 a substantial risk of serious harm. Thus, Plaintiffs' 8 allegations regarding the Riverside Jails' intake 9 policies are sufficient to survive a motion to dismiss 10

11 B. Privacy Allegations

12

Defendant seeks to dismiss all allegations in the SAC

13 related to inmate privacy. (See SAC ¶¶ 98-100.)

14 Plaintiffs allege that until recently the Riverside Jails

15 did not have a confidential self-referral system by which

16 inmates could request mental health care without

17 revealing the nature of their request to correctional 18 officers. (SAC ¶ 98.) Under the old policy inmates 19 would give blue slips requesting health care directly to 20 custody staff, who would then determine whether the

21 requests should be passed to medical staff. (Id.) This

22 policy was in violation of HIPAA and California state 23 law. (Id.) Currently, inmates give any blue slips 24 directly to medical staff. The SAC alleges that, even 25 under the current policies, if an inmate would like a

26 grievance form in order to complain about delays or

27 inadequacies in receiving medical treatment that inmate 28

24

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must persuade custody staff that their concerns are 1
significant. In addition, the SAC alleges that many 2
mental health encounters are held in the presence of 3
other custody staff and prisoners, which does not allow 4
for effective treatment because the patients are not 5
comfortable disclosing their mental health issues or 6
needs in a non-confidential setting. (SAC ¶ 100.) 7
Plaintiffs Miller, Rosson, and Gray have all experienced 8
non-confidential mental health encounters. (Id. ¶ 100.) 9
10 Defendant moves to dismiss these allegations on the
11 basis that inmates do not have a right to privacy or
12 confidentiality of their medical records. (Mot. at 13-
13 16.) Defendant is correct that an inmate does not have
14 an absolute constitutional right to confidential medical
15 records. See Seaton v. Mayberg, 610 F.3d 530, 534 (9th
16 Cir. 2010) (recognizing general principle that whatever
17 right to privacy an inmate has may be "overridden for
18 legitimate penological reasons"). Furthermore,
19 violations of HIPPA or California state law regarding
20 medical records do not necessarily rise to the level of a
21 constitutional violation. But, the factual allegations
22 in the SAC regarding privacy are not alleged in support
23 of a claim that the County violated inmates' right to
24 privacy. Rather, Plaintiffs allege that Defendant's
25 practice of conducting mental health interviews in non-
26 confidential environments and involving custody staff in
27 the process of obtaining medical care exposes inmates to
28
25

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a substantial risk of serious harm because the inmates 1
are less likely to disclose mental health issues in a 2
non-confidential setting. These practices are one of 3
several deficient practices that Plaintiffs allege form a 4
healthcare system that fails to provide adequate access 5
to medical and mental health care. Thus, Defendant's 6
arguments regarding the lack of a right to privacy are 7
unavailing as that is not the right Plaintiffs allege is 8
being violated. Plaintiffs’ allegations regarding 9
privacy are sufficient to survive a motion to dismiss. 10
11 C. Use of Safety Cells and Restraint Chairs for
12 Discipline
13 Lastly, Defendant moves to dismiss allegations
14 related to the use of safety cells and restraint chairs
15 for disciplinary purposes. (See SAC ¶ 145.) The SAC
16 alleges that the County routinely places inmates in
17 safety cells as a punitive measure for actions such as
18 "destroying jail property" or "being combative with jail
19 staff." (Id.) Plaintiffs allege that using the safety
20 cells as a punitive measure exceeds the proper use of the
21 placements, and exposes patients to a substantial risk of
22 serious harm because it makes it less likely that
23 patients will report serious emotional distress or
24 suicidal ideation. (Id.)
25
26 The County moves to dismiss these allegations on the
27 basis that it is constitutional to use safety cells and
28
26

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restraint chairs as a disciplinary measure. Defendant is 1
correct that the use of safety cells and restraint chairs 2
"to control violent or self-destructive inmates" is not a 3
per se constitutional violation. Anderson v. Cnty. of 4
Kern, 45 F.3d 1310, 1315 opinion amended on denial of 5
reh'g, 75 F.3d 448 (9th Cir. 1995) (policy of using 6
safety cells for suicidal and mentally disturbed inmates 7
was not unconstitutional). The use of safety cells for 8
purely punitive purposes, however, may rise to the level 9
of a constitutional violation. Id. 10
11 Plaintiffs do not allege that any use of safety cells
12 and restraint chairs to restrain suicidal or violent
13 inmates is unconstitutional. Rather, Plaintiffs allege
14 that Riverside Jails' deficient practice of using safety
15 cells for disciplinary and punitive purposes exposes
16 inmates to a substantial risk of serious harm because the
17 inmates are less likely to report serious emotional
18 distress out of fear they will be placed in a safety
19 cell. Plaintiffs allege this practice is one of many
20 allegedly deficient policies that creates a healthcare
21 system that provides inadequate medical and mental health
22 care. Thus, Plaintiffs’ allegations regarding the use of
23 safety cells for disciplinary purposes survive
24 Defendant's Motion.
25
26
27
28
27

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V. STANDING 1
Defendant challenges Plaintiffs' standing in its 2
Motion to Dismiss and its opposition to the Motion for 3
Class Certification. In the opposition to the Motion for 4
Class Certification, Defendant argues that the named 5
Plaintiffs do not have Article III standing to bring 6
claims related to any injury they themselves did not 7
suffer. (Opp'n. at 10-13.) Specifically, Defendant 8
contends that no named Plaintiff suffered any injury as a 9
result of inadequate intake procedures, inadequate dental 10
or vision care1, or inadequate suicide prevention 11
policies2, and thus claims related to these alleged 12
policies may not proceed. In addition, Defendant argues 13
that the majority of people in the proposed Subclasses do 14
not have standing. In the Motion to Dismiss, Defendant 15
16 1It is unclear from the Motion and the Second Amended
17 Complaint whether Plaintiffs claim Defendant's policies related to dental or vision care are inadequate. The
18 allegations concerning dental care largely relate to the timeliness of such care, but Plaintiffs do not identify a
19 specific policy or practice for which they seek certification. Accordingly, the Court does not address
20 the policies regarding the provision of dental or vision care in any detail.
21 2At the hearing Defendant argued that no named
22 Plaintiff has suffered any injury as a result of inadequate suicide prevention policies because no named
23 Plaintiff has committed suicide. The Court rejects Defendant's suggestion that only an inmate who
24 successfully commits suicide has standing to challenge inadequate suicide prevention policies. See Helling v.
25 McKinney, 509 U.S. 25, 33 (1993) (It would be odd to deny an injunction to inmates who plainly proved an unsafe,
26 life-threatening condition in their prison on the ground that nothing yet had happened to them.").
27
28
28

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 29 of 116 Page ID #:16348
also submits that Plaintiffs lack standing to assert 1
claims related to the use of safety cells as a 2
disciplinary measure. 3
4 Defendant asserts lack of standing on three bases.
5 First, many inmates are only in the Riverside Jails for a
6 short period of time - a few hours or a few days - and
7 thus never need any medical or mental health care.
8 Second, inmates who receive medical or mental health care
9 that meets community standards; e.g., the "large portion
10 of the inmates [that] receive better care in jail than
11 outside of jail," do not have standing. (Opp'n. at 10.)
12 Third, inmates who are satisfied with the medical and
13 mental health care they receive have no standing.
14
15 Article III standing requires a plaintiff to
16 demonstrate "an "invasion of a legally protected interest
17 which is (a) concrete and particularized, and (b) actual
18 or imminent, not conjectural or hypothetical." D'Lil v.
19 Best W. Encina Lodge & Suites, 538 F.3d 1031, 1036 (9th
20 Cir. 2008) (citing Lujan v. Defenders of Wildlife, 504
21 U.S. 555, 560–61 (1992)). In the context of claims
22 arising from prison conditions, an inmate who is claiming
23 that the defendant fails to prevent harm must show that
24 he is incarcerated under conditions "posing a substantial
25 risk of serious harm." Brown, 131 S.Ct. at 1926 n. 3 (no
26 consideration of whether specific instances of care
27 violate the Constitution, because Plaintiffs rely on
28
29

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 30 of 116 Page ID #:16349
systemwide deficiencies that, taken as a whole, subject 1
sick and mentally ill prisoners to a substantial risk of 2
serious harm.) (citing Farmer v. Brennan, 511 U.S. 825, 3
834 (1994)). When seeking only injunctive relief, a 4
plaintiff need not wait until he suffers an actual injury 5
because the constitutional injury is the exposure to the 6
risk of harm. Parsons II,754 F.3d at 678; Parsons v. 7
Ryan, 289 F.R.D. 513, 521 (D. Ariz. 2013) ("Parsons I"); 8
see also Chief Goes Out v. Missoula Cnty., 2013 WL 9
139938, at *5 (D. Mont. Jan. 10, 2013) (injury suffered 10
is the "deprivation itself, not just the negative effects 11
resulting from the deprivation."); Rosas v. Baca, 2012 WL 12
2061694, at *3 (C.D. Cal. June 7, 2012) (class 13
certification appropriate where all inmates were at 14
significant risk of excessive violence at the hands of 15
deputies, even if they had not been personally subject to 16
excessive force). Indeed, the United States Supreme 17
Court has commented that "it would be odd to deny an 18
injunction to inmates who plainly proved an unsafe, life19
threatening condition in their prison on the ground that 20
nothing yet had happened to them." Helling v. McKinney, 21
509 U.S. 25, 33 (1993). 22
23 Defendant argues that the named Plaintiffs lack
24 standing to raise allegations related to the intake
25 procedures. The gravamen of the County's argument is
26 that because Gray's individual intake experience does not
27 amount to a constitutional violation, Plaintiffs may not
28
30

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 31 of 116 Page ID #:16350
allege any facts related to the intake policies. As 1
discussed above, whether an individual Plaintiff's 2
exposure to the policy amounts to a constitutional 3
violation does not affect whether the class as a whole, 4
or that specific individual, is subject to a substantial 5
risk of serious harm. Gray has alleged direct exposure 6
to the intake procedures, one of the policies that forms 7
the basis for Plaintiffs' claim of unconstitutional 8
healthcare. His exposure is sufficient to support 9
Plaintiffs standing to bring their claim that they suffer 10
a substantial risk of serious harm as a result of the 11
deficient intake policy. 12
13 The County also asserts that Plaintiffs lack standing
14 to challenge the Riverside Jails' alleged practice of
15 improperly using safety cells and restraint chairs for
16 disciplinary purposes because no named Plaintiff was
17 exposed to this policy or asserts any specific injury.
18 The Court addresses this issue in relation to its
19 commonality analysis, and finds that Plaintiffs have
20 failed to submit sufficient evidence to support the
21 existence of an unofficial policy of using safety cells
22 for purely punitive or disciplinary purposes.
23 Accordingly, the Court does not reach the question of
24 Plaintiffs' standing as to this specific policy.
25
26
27
28
31

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 32 of 116 Page ID #:16351
Thus, in regard to Defendant's argument regarding the 1
named Plaintiffs,3 the Court finds that the Plaintiffs 2
have sufficiently alleged that a named Plaintiff has 3
suffered a "serious risk of substantial harm" as a result 4
of each of the alleged inadequate healthcare policies 5
that are appropriate for certification. Although support 6
for these allegations is not necessarily provided in each 7
named Plaintiff's declaration, other evidence submitted 8
in support of certification describes inadequacies in the 9
named Plaintiffs' intake forms and Mr. Rosson's treatment 10
for self-harming behavior and suicidal ideation. 11
12 The unnamed members of the proposed Subclasses are
13 "highly likely to require medical [or] mental health . .
14 . care" and thus face a "substantial risk of serious harm
15 resulting from exposure to the defendant's policies and
16 practices governing healthcare." See Parsons II, 754
17 F.3d at 686. An inmate may require medical or mental
18 health care regardless of the length of time he or she is
19 in the Riverside Jails, indeed; the first 24 hours of
20
21
22
23 3Both Gray and Patterson are no longer inmates in the
24 Riverside Jails. The Court determines standing based on "whether the elements of Article III standing . . . were
25 satisfied at the time the complaint was filed." Haro v. Sebelius, 747 F.3d 1099, 1108 (9th Cir. 2014) (citing
26 Cnty. of Riverside v. McLaughlin, 500 U.S. 44, 51 (1991)). Gray and Patterson were inmates at the time
27 Plaintiffs' initial complaint was filed. Accordingly, they maintain standing to bring this suit.
28
32

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 33 of 116 Page ID #:16352
confinement may be the most dangerous.4 (Stewart Decl. 1
(Doc. No. 29) ¶ 19.) That an inmate is satisfied with 2
his care, or may have received even worse care outside of 3
jail, does not eliminate his exposure to a substantial 4
risk of serious harm. It is the exposure to a risk of 5
serious harm, and not the actual medical or mental health 6
care received, that constitutes the injury suffered by 7
the inmates in this action. Each member of the proposed 8
Subclasses is alleged to be subject to a "substantial 9
risk of serious harm" as a result of each of the alleged 10
policies in the SAC. These allegations are sufficient to 11
confer Article III standing on the unnamed class members. 12
13 VI. CLASS CERTIFICATION
14 A. Rule 23(a)
15 1. Ascertainability
16 Defendant contends that the proposed Class definition
17 of "all adult men and women who are now, or will be in
18
19 4At the hearing, Defendant argued that Riverside
20 Jails are distinguishable from Parsons because this action involves jails where as Parsons involved prisons,
21 where inmates were likely to stay for much longer periods of time while serving their sentence. The Court is not
22 persuaded by this distinction. Although the average stay within a Riverside County Jail may be shorter than in a
23 prison, every inmate who enters a Riverside County Jail is allegedly exposed to a risk of serious harm as a
24 result of inadequate healthcare policies. This is true even if that risk does not materialize into physical harm
25 due to the short period of detention. See Parsons II, 754 F.3d at 678 ("any one of them [prisoners] could
26 easily fall ill, be injured, need to fill a prescription, require emergency or specialist care, crack a tooth, or
27 require mental health treatment").
28
33

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 34 of 116 Page ID #:16353
the future, in the custody of Riverside County and who 1
are now, or will be in the future, subject to an 2
unreasonable risk of harm due to Defendant's policies and 3
practices of denying prisoners minimally adequate medical 4
care and minimally adequate mental health care" is a 5
"fail safe" class that is not ascertainable. A proposed 6
class is ascertainable if it is "administratively 7
feasible for the court to determine whether a particular 8
individual is a member." Keegan, 284 F.R.D. at 521 9
(quoting O'Connor v. Boeing N. Am., Inc., 184 F.R.D. 311, 10
319 (C.D. Cal. 1998).) Defendant argues it is not 11
administratively feasible to determine the members of the 12
proposed Class because it would require a specific 13
factual inquiry into whether each inmate was "subject to 14
an unreasonable risk of harm" or received "adequate" 15
medical care. (Opp'n. at 4.) A class is "fail safe" if 16
the definition of the class shields the class members 17
from adverse judgment. Randleman v. Fid. Nat. Title Ins. 18
Co., 646 F.3d 347, 352 (6th Cir. 2011) ("the class itself 19
is defined in a way that precludes membership unless the 20
liability of the defendant is established."). Either 21
"the class members win or, by virtue of losing, they are 22
not in the class and, therefore, not bound by the 23
judgment." Id.; Kamar v. RadioShack Corp., 375 F. App'x 24
734, 736 (9th Cir. 2010) ("the class itself is defined in 25
a way that precludes membership unless the liability of 26
the defendant is established."). 27
28
34

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 35 of 116 Page ID #:16354
In Reply, Plaintiffs propose a new Class definition: 1
"all prisoners who are now, or will be in the future, 2
subjected to the healthcare policies and practices of 3
Riverside County." (Reply at 21.) This Class definition 4
is almost identical to the definition approved in 5
Parsons, and is similar to the definitions of the 6
Subclasses, which Defendant concedes are ascertainable. 7
(Opp'n. at 8.); see Parsons I, 289 F.R.D. at 525 8
(certifying class of "all prisoners who are now, or will 9
in the future be, subjected to the medical, mental 10
health, and dental care policies and practices of the 11
ADC"). In addition, this modification resolves 12
Defendant's contention that the original Class definition 13
is "fail safe." Accordingly, the Court will proceed to 14
analyze the Rule 23(a) factors using the Plaintiffs' 15
revised Class definition, modified to use the term 16
"medical and mental health" rather than "healthcare" 17
policies. See Wolph v. Acer Am. Corp., 272 F.R.D. 477, 18
483 (N.D. Cal. 2011) (the Court has broad discretion to 19
modify a class definition); Chief Goes Out, 2013 WL 20
139938, at *3 (modifying class definition in class 21
certification order); Morrow v. Washington, 277 F.R.D. 22
172, 189 (E.D. Tex. 2011) (modifying class definition in 23
certification order to ensure ascertainable class). 24
25 2. Numerosity
26 Rule 23(a)(1) requires the class be so numerous that
27 joinder of individual class members is impracticable.
28
35

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 36 of 116 Page ID #:16355

See Fed. R. Civ. P. 23(a)(1). There is no "precise 1
threshold," but Courts have routinely found the 2
numerosity requirement is met when a proposed class 3
comprises "40 or more members." Berry v. Baca, 226 4
F.R.D. 398, 403 (C.D. Cal. 2005). Here, the Riverside 5
Jails have custody over approximately 3,500 inmates, and 6
approximately 50,000 inmates pass through the jails each 7
year. (See Ex. 153 to Crockett Decl., U.S. Dept. of 8
Justice, Office of Justice Program, Bureau of Justice 9
Statistics, "Jail Prisoners at Midyear 2010 - Statistical 10
Tables (June 28, 2011), at 2170; Ex. 154 to Crockett 11
Decl., Defendant's October 10, 2013 Response to 12
Plaintiffs' Request for Production.) Accordingly, the 13
proposed Class and Subclasses meet the numerosity 14
requirement. 15

16 3. Commonality
17 Commonality requires Plaintiffs to demonstrate there
18 are "questions of law or fact common to the class." Fed.
19 R. Civ. P. 23(a)(2). Plaintiffs must demonstrate
20 "significant proof"5 that members of the class have
21

22

5In Parsons II the Ninth Circuit noted that courts

23

have taken different views as to whether the "significant proof" standard articulated in Wal-Mart applies to claims

24

outside of the employment discrimination context. See 754 F.3d at 684 n.29. It then declined to decide the

25 issue because it found that Plaintiffs had met their burden under either a significant proof or lesser

26

standard. This Court assumes without deciding that the higher, "significant proof" standard applies in this

27

action. This approach is consistent with other district courts in the Ninth Circuit that have applied the

28

(continued...)

36

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 37 of 116 Page ID #:16356

suffered the same injury, and not merely that they have 1
suffered violations of the same provision of law." 2
Wal-Mart, 131 S. Ct. at 2551. Plaintiffs' claims must 3
depend on a "common contention" and "[t]hat common 4
contention . . . must be of such a nature that it is 5
capable of classwide resolution — which means that 6
determination of its truth or falsity will resolve an 7
issue that is central to the validity of each one of the 8
claims in one stroke." Id. "Plaintiffs need not show 9
that every question in the case, or even a preponderance 10
of questions, is capable of classwide resolution. So 11
long as there is 'even a single common question' a 12
would-be class can satisfy the commonality requirement of 13
Rule 23(a)(2)." Wang v. Chinese Daily News, Inc., 737 14
F.3d 538, 544 (9th Cir. 2013) (quoting Wal-Mart, 131 S. 15
Ct. at 2556.) Thus, commonality exists even "[w]here the 16
circumstances of each particular class member vary but 17
retain a common core of factual or legal issues with the 18
rest of the class." Evon v. Law Offices of Sidney 19
Mickell, 688 F.3d 1015, 1029 (9th Cir. 2012) (quoting 20
Parra v. Bashas', Inc., 536 F.3d 975, 978–79 (9th Cir. 21
2008).) In a civil rights class action, "commonality is 22
satisfied where the lawsuit challenges a system-wide 23
practice or policy that affects all of the putative class 24

25

26

5(...continued)

"significant proof" standard to classes of prisoners

27 seeking injunctive relief. See Parsons I, 289 F.R.D. at

522; Amador v. Baca, 2014 WL 1679013, at *3 (C.D. Cal.

28 Mar. 12, 2014).

37

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 38 of 116 Page ID #:16357
members." Armstrong v. Davis, 275 F.3d 849, 868 (9th 1
Cir. 2001). 2
3 In this action, the crucial question is whether the
4 Plaintiffs have submitted "sufficient evidence of
5 systemic and centralized policies or practices in a
6 prison system that allegedly expose all inmates in that
7 system to a substantial risk of serious future harm."
8 Parsons II, 754 F.3d at 684. Plaintiffs must provide
9 more than conclusory or "threadbare" allegations that
10 systemic policies and practices exist. Id. at 48.
11 Rather, proof that there are "in fact . . . common
12 questions of law or fact" is required. Wal-Mart, 131 S.
13 Ct. at 2551. In this analysis, "a district court must
14 consider the merits if they overlap with the Rule 23(a)
15 requirements." Ellis, 657 F.3d at 981. Thus, it may be
16 necessary for the Court to "probe behind the pleadings"
17 in evaluating proof of systemic policies and practices.
18 Comcast Corp. v. Behrend, 133 S. Ct. 1426, 1432 (2013).
19 The Court, however, may examine the underlying claims of
20 the Plaintiff only for the purposes of determining
21 whether common questions exist; it may not conduct a
22 "mini-trial on the merits" prior to certification.
23 Ellis, 657 F.3d at 983 (citing Wal-Mart, 131 S. Ct. at
24 2552 n. 6); see also Amgen Inc. v. Connecticut Ret. Plans
25 & Trust Funds, —— U.S. ——, 133 S. Ct. 1184, 1194-95
26 (2013) ("Rule 23 grants courts no license to engage in
27 free-ranging merits inquiries at the certification stage.
28
38

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 39 of 116 Page ID #:16358
Merits questions may be considered to the extent - but 1
only to the extent - that they are relevant to 2
determining whether the Rule 23 prerequisites for class 3
certification are satisfied."); Messner v. Northshore 4
Univ. HealthSystem, 669 F.3d 802, 811 (7th Cir. 2012) 5
("the court should not turn the class certification 6
proceedings into a dress rehearsal for the trial on the 7
merits."). 8
9 i. Evidence Submitted in Support of and in
10 Opposition to the Existence of Commonality
11 In support of their Motion, Plaintiffs submitted
12 extensive evidence, including: (1) declarations of the
13 named Plaintiffs; (2) expert opinions of Dr. Wilcox and
14 Dr. Stewart; (3) Riverside County jail records, such as
15 autopsy reports of inmates who have died, safety cell
16 logs, and inmate grievances; (4) official County
17 documents related to mental health staffing at the jails,
18 standards and policies for medical and mental health care
19 at the jails, and depositions of county employees; and
20 (5) the 2010-2011 and 2011-2012 Grand Jury Reports and
21 related documents.6 In their Reply, Plaintiffs submitted
22 the County's records of court orders issued from
23 Riverside County Superior Courts to Riverside Jails from
24
25 6Both parties filed all documents related to the
26 medical and jail records of all inmates who are not named Plaintiffs in this action under seal pursuant to the
27 protective order issued in this action. (See Doc. No. 19.) To the extent possible, the parties filed redacted
28 versions of the evidence submitted to the Court.
39

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 40 of 116 Page ID #:16359

2011-2014 ("court orders"), statistical analysis of those 1
court orders, and the supplemental declarations of Dr. 2
Wilcox and Dr. Stewart.7 3

4

7Defendant objects to the court orders, Lynch's

5 analysis of the court orders, and the supplemental declarations of Dr. Wilcox and Dr. Stewart on the basis

6

that it is improper to submit new factual or legal arguments for the first time in reply. (See Def.'s

7

Response.) Generally, "reply briefs are limited in scope to matters either raised by the opposition or unforeseen

8 at the time of the original motion." Burnham v. City of Rohnert Park, 1992 WL 672965, at *1 n. 2 (N.D. Cal. May

9

18, 1992) (citing Lujan v. National Wildlife Federation, 497 U.S. 871 (1990).) "New evidence submitted as part of

10

a reply is improper" because it does not allow the Defendant an adequate opportunity to respond. Morris v.

11 Guetta, 2013 WL 440127, *8 (C.D. Cal. Feb. 4, 2013). For this reason, the district court may decline to consider

12

new evidence or arguments raised in reply, and generally "should not consider the new evidence without giving the

13

non-movant an opportunity to respond." Provenz v. Miller, 102 F.3d 1478, 1483 (9th Cir. 1996); Deirmenjian

14 v. Deutsche Bank, A.G., 2006 WL 4749756, at *6 n.52 (C.D. Cal. Sept. 25, 2006). The opportunity for rebuttal,

15

however, need not be in writing; an opportunity for oral rebuttal may be sufficient. See Smith v. Microsoft

16 Corp., 2013 WL 6497073, at *2 (S.D. Cal. Dec. 10, 2013) (considering new evidence in a reply for a motion for

17 class certification); Jones v. ConAgra Foods, Inc., 2014 WL 2702726, at *22 (N.D. Cal. June 13, 2014) (considering

18

new evidence in reply brief in support of class certification). Here, the court orders were referred to

19 in Plaintiffs' Motion and the actual records of the court orders were supplied by the Defendant to Plaintiffs in

20 discovery. (See Mot. at 8.) Thus, it is debatable whether this evidence raises "new matters." See Gambra

21

v. Int'l Lease Fin. Corp., 377 F. Supp. 2d 810, 827 (C.D. Cal. 2005) ("The Court finds that defendants' reply brief

22 and supporting materials do not raise new matters and should not be stricken."). Assuming the court orders and

23

the accompanying analysis are new evidence, the Defendant has submitted substantial written objections to all of

24

the "new" material. (See Def.'s Objs. to Pls.'s Ex. A-E (Doc. No. 116); Wilcox Reply Evid. Objs. (Doc. No. 113);

25 Stewart Reply Evid. Objs. (Doc. No. 114).) Thus, the Court will consider the evidence Plaintiffs' submitted in

26

Reply, as well as Defendant's written objections and any oral arguments at the hearing. See Provenz, 102 F.3d at

27

1483 (suggesting the district court erred in considering the moving party's new evidence submitted in reply and

28

(continued...)

40

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 41 of 116 Page ID #:16360

In opposition to the Motion, Defendant submitted the 1
declarations of 14 County employees; the declaration of 2
the Chief Executive Officer for Inland Empire Health 3
Plan; the expert opinions of four physicians; and 4
hundreds of pages of Riverside County jail records, 5
inmate mental health and medical records, and transcripts 6
of deposition testimony. In addition, the Defendant 7
submitted over 1,000 evidentiary objections to 8
Plaintiffs' evidence. As the Court details below, the 9
majority of these objections are challenges to the 10
credibility of the named Plaintiffs and proposed class 11
members, catalogued disagreements with the opinions of 12
Plaintiffs' experts, disputes over the interpretation of 13
facts and evidence, and repetitive objections that are 14
often obviously inapplicable. Defendant's misguided 15
objections are largely inappropriate at the class 16
certification stage as the Court is limited in its 17
ability to resolve factual disputes and may not hold a 18
mini-trial on the merits. 19

20 ii. Commonality Evidentiary Standard
21 "At the class certification stage, the Court makes no
22 findings of fact, nor any ultimate conclusions on
23 Plaintiffs' claims." Velazquez v. Costco Wholesale
24 Corp., 2011 WL 4891027, at *2 (C.D. Cal. Oct. 11, 2011).
25

26

27

7(...continued)

not considering the non-moving party's supplemental

28 declaration in response).

41

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 42 of 116 Page ID #:16361
Accordingly, "evidentiary rules unrelated to expert 1
testimony are not applied with rigor in deciding motions 2
for class certification." Cholakyan v. Mercedes-Benz, 3
USA, LLC, 281 F.R.D. 534, 550 (C.D. Cal. 2012); 4
Velazquez, 2011 WL 4891027, at *2 (("[T]o the extent the 5
Court relies on evidence to which the parties object, the 6
Court overrules the objections. This is because at the 7
class certification stage, the Court makes no findings of 8
fact, nor any ultimate conclusions on Plaintiffs' claims, 9
and the Court may consider inadmissible evidence."); 10
Keilholtz v. Lennox Hearth Prods., 268 F.R.D. 330, 337 n. 11
3 (N.D. Cal. 2010) ("On a motion for class certification 12
. . . the Federal Rules of Evidence take on a 13
substantially reduced significance, as compared to a 14
typical evidentiary hearing or trial"); Parkinson v. 15
Hyundai Motor Am., 258 F.R.D. 580, 599 (C.D. Cal. 2008) 16
("[A] motion for class certification ... need not be 17
supported by admissible evidence."). 18
19 The Court applies a more rigorous evidentiary
20 standard in regard to expert testimony, even at the class
21 certification stage. See Wal-Mart, 131 S.Ct. at 2554
22 (expressing "doubt" that expert testimony is admissible
23 in evaluating a class action without a Daubert analysis);
24 Ellis, 657 F.3d at 982 (in a class certification motion
25 "the district court correctly applied the evidentiary
26 standard set forth in Daubert"); Cholakyan, 281 F.R.D. at
27 541-42 (applying Daubert analysis to expert testimony in
28
42

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 43 of 116 Page ID #:16362
class certification motion). Rule 702 of the Federal 1
Rules of Evidence permits admission of "scientific, 2
technical or other specialized knowledge" by a qualified 3
expert if it will "assist the trier of fact to understand 4
the evidence or to determine a fact in issue." Fed. R. 5
Evid. 702. A trial judge has a "gatekeeping" obligation 6
with respect to opinion testimony of experts. Daubert v. 7
Merrell Dow Pharmaceuticals, 509 U.S. 579, 589 (1993). 8
"[T]he trial judge must "ensure that any and all 9
scientific testimony or evidence admitted is not only 10
relevant, but reliable." Id. All forms of expert 11
testimony, not just scientific testimony, are subject to 12
the trial court's gatekeeping role. Kumho Tire Co. v. 13
Carmichael, 526 U.S. 137, 147-149 (1999); White v. Ford 14
Motor Co., 312 F.3d 990, 1007 (9th Cir. 2002) (finding 15
that the trial judge is required to "apply his 16
gatekeeping role . . . to all forms of expert testimony, 17
not just scientific testimony."). Under Daubert, the 18
court must make "a preliminary assessment of whether the 19
reasoning or methodology underlying the testimony is 20
scientifically valid and of whether that reasoning or 21
methodology properly can be applied to the facts in 22
issue." Daubert, 509 U.S. at 543. 23
24 The Court has reviewed all of evidence submitted in
25 support, and in opposition to, the existence of
26 commonality for the Class and the Subclasses, and
27 summarizes the evidence presented below.
28
43

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iii.

Declarations

1

In support of their Motion, Plaintiffs filed 2

declarations from nearly all named Plaintiffs.8 (See Ex. 3

1 to Crockett Decl. (Doc. No. 32) ("Gray Decl.); Ex. 2 to 4

Crockett Decl. ("McClellan Decl."); Ex. 3 to Crockett 5

Decl. ("Miller Decl."); Ex. 4 to Crockett Decl. ("Rosson 6

Decl."); Ex. 155 to Crockett Decl. ("Wohlfeil Decl."); 7

Ex. 157 to Crockett Decl. ("Patterson Decl.").) 8

Defendant filed evidentiary objections to all of the 9

named Plaintiffs' Declarations. ("Evid. Objs. to Pls.' 10

Decl. (Doc. No. 85).) Plaintiffs responded to all of 11

Defendant's objections. (See Doc. Nos. 95, 98, 106, 107, 12

108, 109.) 13

14 Defendant submitted lengthy evidentiary objections to
15 all named Plaintiffs' declarations. Most commonly,
16 Defendant objects that a statement in the Plaintiff's
17 declaration "misstates the evidence." These objections
18 are supported by citations to jail medical records, which
19 Defendant argues contradict Plaintiffs' statement either
20 because there is no evidence in the jail medical record
21 supporting the statement, or, the record appears to
22 contradict the statement.9 All of the Plaintiffs'
23

24

8Although many of the experts in this case reviewed

25

the medical records of Plaintiff Kujawsky, the Plaintiffs only filed an excerpt from Kujawsky's deposition. (See

26 Ex. 7 to Crockett Decl. ("Kujawsky Dep.").)

27

9See, e.g., Ex. A to Evid. Objs. to Pls.' Decl. Obj.

11 (Gray declares he slept on the floor because he was

28

(continued...)

44

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 45 of 116 Page ID #:16364

declarations are based on personal knowledge and signed 1
under penalty of perjury. The existence of discrepancies 2
between Plaintiffs' versions and what is documented in 3
the jail records does not render the Plaintiffs' 4
declarations inadmissible, or even unreliable. This is 5
especially so given the Plaintiffs' contention that the 6
County maintains grossly inadequate inmate records that 7
are incomplete and unreliable. 8

9 Defendant raises numerous other evidentiary
10 objections to the declarations such as: (1) unqualified
11 expert opinion and improper opinion;10 (2) lacks
12

13

14

9(...continued)

afraid of falling out of bed; Defendant objects that

15

misstates the evidence because medical records indicate Gray was approved for a low tier, low bunk cell

16 assignment); Obj. 17 (Gray declares that some of his medications cause episodes of tardive dyskinesia;

17

Defendant objects because the jail medical records do not indicate he suffered from that condition); Ex. F to Evid.

18

Objs. to Pls.' Decl. Obj. 12 (Wolfheil states that he waited a year for his lumps to be biopsied; Defendant

19 argues this misstates the evidence because the records state that Wohlfeil repeatedly refused treatment); Ex. C

20

to Evid. Objs. to Pls.' Decl. Obj. ¶ 14 (Miller declares she submitted numerous blue slips requesting blood work;

21

Defendant objects this assumes facts contrary to evidence because the records only show one blue slip); Ex. B to

22

Evid. Objs. to Pls.' Decl. Obj. 3 (McClellan states he took the medication Trazodone and Visatril; Defendant

23 objects that this assumes facts not in evidence).

24

10See, e.g., Ex. E to Evid. Objs. to Pls.' Decl. ¶ 2

(Rosson states that he wants to make a difference for

25 others by improving medical and mental health care for all prisoners in Riverside County jail; Defendant objects

26

that this is improper opinion by a lay witness because the evidence actually shows that inmates receive adequate

27

medical and mental healthcare); Ex. C to Evid. Objs. to Pls.' Decl. ¶ 6 (Miller states that she had trouble

28

(continued...)

45

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 46 of 116 Page ID #:16365

foundation;11 (3) vague;12 and (4) irrelevant.13 At the 1
class certification stage, the Court makes no findings of 2
fact, or any ultimate conclusions on Plaintiffs' claims. 3
Thus, it is not necessary to resolve every evidentiary 4
issue raised by the Defendant, especially when the 5
majority lack merit and are raised on objectionable 6
grounds. See Cholakyan, 281 F.R.D. at 550; Jimenez v. 7
Domino's Pizza, Inc., 238 F.R.D. 241, 246 (C.D. Cal. 8
2006) ("a strategy of blunderbuss, repetitive, blanket 9
objections" is "an unhelpful diversion."). Accordingly, 10
to the extent the Court considers any statement in the 11
Declarations to which Defendant objects, the Court 12
overrules the objection. 13

14

15

16 10(...continued)
17 adjusting and felt depressed when her medications were changed; Defendant objects this is improper expert
18 opinion because she is not qualified to opine on whether other medications would have been more effective).
19 11See, e.g., Ex. E to Evid. Objs. to Pls.' Decl. ¶ 10
20 (Rosson states that he did not get his night time pills at regular times at Presley; Defendant objects "lacks
21 foundation").

22

12See, e.g., Ex. A to Evid. Objs. to Pls.' Decl. Obj.

16 ("Gray states it "got so bad I had to be put in the

23 hospital"; Defendant objects that "got so bad" is vague).

24

13Ex. F to Evid. Objs. to Pls.' Decl. Obj. 31

(Wolfeil states that dental care is very bad; Defendant

25 objects that is irrelevant because no Plaintiff has

standing to raise dental issues); Ex. D to Evid. Objs. to

26 Pls.' Decl. ¶ 17 (relevance objection to Patterson's

statement because treatment cited occurred before January

27 1, 2013); Ex. C to Evid. Objs. to Pls.' Decl. ¶ 5

(relevance objection to Miller's statement because events

28 occurred before 2013).

46

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 47 of 116 Page ID #:16366
a. Quinton Gray 1
Plaintiff Gray is a former prisoner of the Riverside 2
Jails. (Gray Decl. ¶ 2.) He suffers from multiple 3
chronic medical and mental health conditions, including 4
seizures, high blood pressure, severe arthritis, and 5
visual and auditory hallucinations and depression. (Id. 6
¶ 2.) While he was in the Riverside Jails, Gray only 7
received his medications after he "went to Court." (Id. 8
¶ 6.) He has encountered difficulties getting his 9
medications at the appropriate times: pill call was often 10
cancelled, his medicine was not timed to be taken with 11
meals, and he did not receive medication when he went to 12
court. (Id. ¶ 14.) In addition, it was very difficult 13
for Gray to renew his medications; he had to file 14
multiple blue slips and grievance forms before it was 15
renewed, resulting in gaps in administration of the 16
pills. (Id. ¶¶ 15, 16.) Gray was placed in a safety 17
cell five times during his imprisonment.14 (Id. ¶ 28.) 18
The conditions in the safety cells were filthy, and there 19
were feces on the walls. (Id. ¶ 29.) While he was in 20
the cells he did not receive any treatment and was given 21
22 14At the hearing, Defendant argued that Gray's
23 Declaration was not credible because Riverside Jail records indicated that he was only placed in a safety
24 cells once. The Court does not find this discrepancy sufficient to disregard Gray's Declaration, and it would
25 be inappropriate to make a credibility determination as to the number of times that Gray was placed in a safety
26 cell at the class certification stage. Moreover, finding that Gray had only been placed in a safety cell once
27 would not defeat commonality as to alleged deficiencies in Defendant’s safety cell policies; the issue only goes
28 to credibility of Gray’s Declaration.
47

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 48 of 116 Page ID #:16367
very little food and water. (Id.) Gray was once held in 1
a restraint chair and while restrained he soiled himself 2
and was provided no food or water. (Id. ¶ 31.) In order 3
to avoid the safety cell, Gray would not tell custody 4
staff if he was feeling very depressed or hearing voices. 5
(Id. ¶ 32.) Gray felt uncomfortable speaking about his 6
mental health problems with nursing staff because the 7
custody officers were present and could hear what he was 8
saying. In addition, he knew the custody staff reviewed 9
all medical grievances. (Id. ¶¶ 34-35.) Finally, Gray 10
suffered repeated seizures while he was in prison. 11
Despite his seizure condition, he was not assigned to a 12
lower tier, and thus was forced to take the stairs 13
despite the danger he might be injured. (Id. ¶ 3.) He 14
fell once and hit his teeth on the stairs. (Id.) 15
16 b. Brandy McClellan
17 McClellan has been in the custody of the Riverside
18 Jails since early November 2013. (McClellan Decl. ¶ 1.)
19 When McClellan arrived at Presley the custody staff asked
20 her whether she was on "psych meds," if she had been
21 suicidal in the past, and whether she felt like hurting
22 herself or others, and she answered "no" to all of these
23 questions. (Id. ¶ 3.) After requesting to see a
24 psychiatrist, she was prescribed Trazodone and Vistaril
25 to treat her anxiety and mood swings. (Id. ¶ 5.) After
26 taking the medication for a short time, she had to be
27 transported to the emergency room because she began
28
48

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 49 of 116 Page ID #:16368
feeling dizzy, foaming at the mouth, and slurring her 1
speech. (Id. ¶¶ 8-9.) When McClellan returned to the 2
hospital, the nurse continued to provide her with the 3
same combination of medication, but she refused to take 4
it. (Id. ¶ 9.) After refusing the medication, McClellan 5
filed a blue slip requesting a change in medication, but 6
did not see a psychiatrist again until several weeks 7
later. (Id. ¶ 9.) McClellan's medication was changed 8
and she is now supposed to take some of her medicine in 9
the morning and some at night; however, the evening pill 10
call often happens between 3:00 and 4:00 p.m. (Id. ¶ 11
10.) 12
13 c. Julie Miller
14 Miller has been in the custody of Riverside Jails
15 since May 2011. (Miller Decl. ¶ 1.) When Miller first
16 arrived she submitted numerous blue slips requesting
17 blood work and to see the infectious disease clinic, but
18 her requests were ignored until five months later when a
19 judge issued a court order regarding the requested
20 treatment. (Id. ¶ 14.) Miller did not receive
21 medication to manage her manic depression and attention-
22 deficit hyperactivity disorder until several months after
23 she entered the jail. (Id. ¶ 5.) Her medications have
24 been changed several different times while in jail, and
25 each time she has not been informed of the side effects
26 of the medicine or monitored to see if the medications
27 are working. (Id. ¶ 6.) She gained 60 pounds as a side
28
49

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 50 of 116 Page ID #:16369

effect of one medication she was prescribed.15 She does 1
not receive her sleeping medication at the appropriate 2
time because the medication delivery happens anytime 3
between 3:00 p.m. and 8:00 p.m. (Id. ¶ 9.) When her 4
prescription runs out, she must file a blue slip to get 5
it renewed, which sometimes takes a long time and results 6
in time without any medication. (Id. ¶ 10.) When Miller 7
meets with mental health staff it is in the attorney 8
visiting non-contact booth, and there is darkened glass 9
between her and the staff. (Id. ¶ 12.) Her meetings 10
with mental health staff are often overheard by custody 11
staff. (Id. ¶ 13.) 12

13 d. John Rosson III
14 Rosson has been in the custody of Riverside Jails
15 since September 2008. (Rosson Decl. ¶ 1.) Rosson
16 suffers from a history of hyperlipidemia, non-insulin
17 dependent diabetes, hypertension, deep vein thrombosis,
18 recurrent cellulitis, anxiety, paranoia, depression, and
19 is bipolar and has a personality disorder. Rosson was
20 given multiple medications, including psychotropic
21

22

23

15At the hearing Defendant argued that jail records

indicate that Miller actually lost weight during her time

24 in custody, and thus her declaration lacks credibility

and should not be considered. Plaintiffs argued that

25 Defendant's conclusion is drawn from an interpretation of

jail records from the wrong period of time. This is

26 another example of a factual dispute that is not resolved

appropriately at the class certification stage.

27 Furthermore, the existence of a factual dispute is not

sufficient to disregard the Miller's Declaration as

28 lacking credibility.

50

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 51 of 116 Page ID #:16370
medications, to treat these conditions, but staff did not 1
monitor whether medication for one condition would have a 2
negative effect on a different condition. (Id. ¶ 6.) In 3
addition, he did not get his nighttime pills at a regular 4
time, and would sometimes receive them as early as 2:00 5
or 3:00 p.m. (Id. ¶ 10.) There were many times when 6
Rosson's medications were not renewed on time, and 7
without his medications he suffered anxiety, depression, 8
paranoia, began to hear voices, and sometimes tried to 9
harm himself. (Id. ¶ 6.) The times Rosson was placed in 10
the safety cells the cells were dirty, sometimes with wet 11
blood and feces stains on the floor. (Id. ¶ 7.) When 12
Rosson's condition did not stabilize in the safety cell 13
he was sent to Riverside County Regional Medical Center 14
for an evaluation. (Id.) Rosson has had difficulties 15
seeing mental health staff; often waiting for weeks. 16
(Id. ¶ 11.) Any meetings with the psychiatrist always 17
happen at his cell door where other inmates can overhear 18
the conversation. (Id. ¶ 12.) 19
20 e. Michael Wohlfeil
21 Wohlfeil has been in the custody of Riverside Jails
22 since January 2011. (Wohlfeil Decl. ¶ 1.) He suffers
23 from hypothyroidism, Hepatitis C, back pain, and "foot
24 drop." (Id. ¶ 4.) Shortly before Wohlfeil entered jail,
25 his doctor told him he needed to be tested for colon
26 cancer. Once in jail, he began developing lumps on his
27 body, losing weight, and suffering diarrhea attacks five
28
51

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 52 of 116 Page ID #:16371
or six times a day. (Id. ¶ 5.) He filed a blue slip to 1
see a doctor for his thyroid medication, but did not get 2
a prescription until the judge in his case issued a court 3
order. (Id. ¶ 6.) Wohlfeil did not see a doctor about 4
his other medical conditions for five months, and after 5
he saw the doctor it was over a year before his tumors 6
were biopsied. (Id. ¶ 8.) The tumors were not 7
cancerous, and he had surgery to remove the two largest 8
ones. (Id. ¶ 10.) He did not receive an MRI for his 9
back pain until October 2013, and after the MRI he was 10
prescribed pain medication. He saw a gastroenterology 11
specialist for his diarrhea in July 2013, but could not 12
complete the procedures ordered by the specialist because 13
he was not given appropriate pre-procedure instructions. 14
(Id. ¶ 12.) He has experienced lapses in medication due 15
to delays in renewing his prescriptions. 16
17 f. Angela Patterson
18 Patterson was an inmate in the Riverside Jails from
19 July 2009 to March 2013. (Patterson Decl. ¶ 1.) In June
20 2009, doctors placed a temporary filter in her inferior
21 vena cava (IVC) to prevent blood clots in her legs from
22 traveling to her heart. (Id. ¶ 4.) The filter was
23 intended to be in place for three months, and during this
24 time Patterson was prescribed blood-thinners. Patterson
25 was transferred directly from the hospital to Presley,
26 and she released her medical records to the County and
27 informed the County jail staff of her medical conditions
28
52

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 53 of 116 Page ID #:16372
and the IVC filter when she arrived. (Id. ¶ 7-8.) 1
Surgery to remove the filter was not scheduled until June 2
2010, and when it did occur, the surgery was unsuccessful 3
because too much scar tissue attached to the IVC. As a 4
result, the IVC filter is now permanent and Patterson 5
must remain on blood thinning medication for the rest of 6
her life. In addition, daily doses of medication were 7
often not delivered because of understaffing; pills were 8
delivered at different hours throughout the day; she did 9
not receive medication when she went to court; and she 10
does not receive regular blood testing or monitoring. 11
(Id. ¶¶ 20-22.) Finally, she never received follow-up 12
treatment for a lump on her scalp. (Id. ¶ 23.) 13
14 iv. Plaintiffs' Expert Opinions
15 Plaintiffs filed the expert opinions of Dr. Pablo
16 Stewart and Dr. Thomas Wilcox in support of their Motion.
17 (See Stewart Decl. (Doc. No. 29); Stewart Reply Decl.
18 (Doc. No. 103); Wilcox Decl. (Doc. No. 35-1); Wilcox
19 Reply Decl. (Doc. No. 104).) Defendant filed voluminous
20 evidentiary objections to both expert opinions.
21
22 a. Dr. Pablo Stewart
23 Defendant filed 418 evidentiary objections to Dr.
24 Stewart's 42 page Declaration (Stewart Evid. Objs. (Doc.
25 No. 79)); as well as additional, separate, objections to
26 Dr. Stewart's analysis of the medical care individual
27 Plaintiffs and inmates received. (See Stewart Inmate
28
53

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 54 of 116 Page ID #:16373

Evid. Objs. (Doc. No. 81).) Defendant also filed an 1
additional 136 evidentiary objections to Dr. Stewart's 2
Reply Declaration. ("Stewart Evid. Objs. 2" (Doc. No. 3
114).) Plaintiffs filed responses to all of Defendant's 4
objections to the first Declaration.16 See Pls. Resp. 5
Def.'s Objs. (Doc. Nos. 96, 98, 99, 100, 101, 106, 107, 6
108, 109.) Defendant's objections to Dr. Stewart's first 7
declaration boil down to the argument that Dr. Stewart is 8
not qualified to render an expert opinion because he 9
relies on sources, namely inmate declarations and 10
grievances, that are not reasonably relied on by experts 11
in the field. (Stewart Evid. Objs. at 3.) Accordingly, 12
Defendant objects that all of his opinions are "ipse 13
dixit conclusions"; his declaration lacks foundation; and 14
all references to medical records are inadmissible 15
hearsay.17 16

17

16After submitting approximately 500 evidentiary

18

objections to Dr. Stewart's Declaration, Defendant has the audacity to suggest that, under Federal Rule of

19 Evidence 103, Plaintiffs are not permitted to respond to these objections because there is no procedural basis for

20

Plaintiffs to file any kind of response. (See Def.'s Response at 7-11.) Federal Rule of Evidence 103 governs

21

rulings on evidence, and after reviewing the Rule, the Court finds no basis for Defendant's contention. In a

22

reply, it is perfectly appropriate for the moving party to respond to issues in raised by the non-moving party in

23

opposition. Accordingly, the Court will consider the Plaintiffs' response to Defendant's objections to Dr.

24

Stewart's Declaration, as well as Plaintiffs' response to the hundreds of other evidentiary objections Defendant

25 submitted in opposition.

26

17Defendant also objects on the basis that the

medical records that Dr. Stewart reviewed in forming his

27

opinion were not submitted to the Court, and therefore are hearsay. The medical records described in Dr.

28

(continued...)

54

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 55 of 116 Page ID #:16374

Dr. Stewart is a psychiatrist and Clinical Professor 1
in the Department of Psychiatry of the University of 2
California, San Francisco. He has experience managing, 3
monitoring, and reforming correctional mental health 4
systems, and previously served as a Director of Forensic 5
Psychiatric Services for the City and County of San 6
Francisco. (Stewart Decl. ¶¶ 1-4.) Dr. Stewart has 7
served as a psychiatric expert to federal courts and 8
other organizations implementing remedial decrees or 9
inspecting facilities regarding the provision of mental 10
heath care in correctional institutions, including the 11
United States Department of Justice, the State of New 12
Mexico, and federal courts in the Eastern District of 13
California. (Id. ¶ 3.) 14

15 Dr. Stewart reviewed healthcare records from current
16 and former Riverside prisoners, Riverside jail health
17 care policies, prisoner declarations and grievances,
18 death reports, autopsy reports, safety cell and restraint
19 chair logs, audits and reports regarding health care
20

21

22

17(...continued)

Stewart's declaration are not offered for the truth of

23 the matter asserted. Rather, they are illustrations of

the reasons for Dr. Stewart's opinion. As the Ninth

24 Circuit case cited by the Defendant states, "Rule 703

merely permits such hearsay, or other inadmissible

25 evidence, upon which an expert properly relies, to be

admitted to explain the basis of the expert's opinion."

26 Paddack v. Dave Christensen, Inc., 745 F.2d 1254, 1261

(9th Cir. 1984). Accordingly, the Court may consider the

27 medical records in the context of Dr. Stewart's opinion,

but they are not being considered, at this stage, for

28 their truth.

55

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 56 of 116 Page ID #:16375
delivery in the Riverside jails, and budget and staffing 1
information. (Id. ¶ 5.) In addition, Dr. Stewart 2
submitted a reply declaration after reviewing the 3
declarations of the County employees, the declarations of 4
Defendant's physicians, and the County's records of court 5
orders. (Stewart Reply Decl. ¶ 1.) Dr. Stewart has not 6
yet visited the Riverside Jails or spoken to staff or 7
prisoners; however, he offers his preliminary opinion 8
that the County fails to deliver adequate and appropriate 9
mental health care to inmates in its jails. (Id. ¶¶ 710
8.) 11
12 Defendant does not contest Dr. Stewart's training or
13 experience. Rather, Defendant argues that his opinion is
14 inadmissible because it is based on information on which
15 reasonable experts in the field would not rely. (Stewart
16 Evid. Objs. at 3; Opp'n. at 14-15.) Specifically,
17 Defendant criticizes Stewart's consideration of inmates'
18 grievances on the basis that the grievances are
19 contradicted by jail records, and many recent grievances
20 were "created by inmates at the direction of counsel for
21 Plaintiffs'." (Opp'n. at 15.) In addition, Defendant
22 argues that inmates often lie, so a grievance or a
23 declaration written by an inmate is not reliable. (Id.
24 at 14-15; see, e.g., Ex. B to Stewart Inmate Evid. Objs.
25 at 7 ("Hearsay . . . No reasonable expert would rely on
26 the declaration of an inmate as a sole source of
27 information.").) Defendant's criticism is supported by
28
56

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 57 of 116 Page ID #:16376
Defendant's expert Dr. Gislason, who criticizes Dr. 1
Stewart's consideration of Gray's and Rosson's 2
declarations because he finds the declarations 3
untrustworthy. (Gislason Decl. ¶¶ 28-29, 70.) 4
5 The Court notes that Dr. Gislason does not challenge
6 the type of information, i.e., inmate grievances and
7 declarations. Rather, Dr. Gislason challenges the
8 specific declarations of Rosson and Gray on the basis
9 that he believes they are not credible. After reviewing
10 the testimony and qualifications of Dr. Stewart, and the
11 declaration of Dr. Gislason, the Court finds that Dr.
12 Stewart's consideration of the inmates' declarations and
13 grievances as one of several sources informing his
14 opinion is a valid methodology and does not render his
15 opinion inadmissible.
16
17 Aside from Defendant's objections to Dr. Stewart's
18 methodology, a large number of Defendant's other
19 "objections" are simply catalogued disagreements with Dr.
20 Stewart's opinions. (See, e.g., Stewart Evid. Obj. 34
21 (Objection because Defendant's Expert, Dr. Gilbert,
22 reached a different conclusion regarding adequacy of
23 County's core patient treatment processes and policies).)
24 Other common objections include "lack of standing," lack
25 of foundation, hearsay, reliance on documents dated prior
26 to 2013, and "misstates the evidence." (See generally
27 Stewart Evid. Objs.; Stewart Inmate Evid. Objs.) The
28
57

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Court has reviewed Defendant's objections that Dr. 1
Stewart's opinion misstates facts in the record and finds 2
that the "misstated facts" are more accurately cast as 3
differences in opinion. Similarly, Defendant's 4
"relevance" objections to Dr. Stewart's opinions are 5
largely disagreements about how to interpret facts in the 6
record. (See, e.g., Ex. A to Stewart Inmate Evid. Objs. 7
("Dr. Stewart unnecessarily and unreasonably criticizes 8
the County for complying with the statute.").) 9
Accordingly, to the extent the Court has relied on any 10
portions of Dr. Stewart's declaration to which Defendant 11
objects, Defendant's objection to Dr. Stewart's testimony 12
is overruled.18 13

14

15

16

17

18Defendant's objections to Stewart's Supplemental

Declaration are largely similar, with the addition of the

18 following objections: (1) new evidence in reply; (2)

improper expert argument under United States v. Cano, 289

19 F.3d 1354, 1363 (11th Cir. 2002); (3) best evidence rule;

and (4) improper summary to prove content (Fed. R. Evid.

20 1006). (See generally Def.'s Objs. to Stewart Reply

Decl.) It is not necessary for the Court to address

21 these objections for the purposes of this Motion,

especially since many are raised on questionable grounds.

22 Defendant asserts the "new evidence in argument in reply"

objections when Dr. Stewart opines on information

23 submitted by the Plaintiffs in Reply, and even when he

opines on declarations submitted by the Defendant in

24 Opposition. (See, e.g., id. at Obj. 111.) Cano

addresses a lay witness delivering a "jury argument from

25 the witness stand"; it does not address an expert's

opinions. See 289 F.3d at 1363. Finally, the best

26 evidence and "improper summary to prove content"

objections do not apply to Dr. Stewart's descriptions of

27 the court orders because the references are made only for

the purpose of Dr. Stewart explaining the basis for his

28 expert opinion.

58

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In his Declarations, Dr. Stewart evaluated a variety 1
of sources. In regard to his opinions regarding suicide 2
prevention, Dr. Stewart discusses three inmates who 3
committed suicide while held in Riverside Jails. The 4
first was a 24-year-old war veteran who suffered 5
posttraumatic stress disorder and bipolar disorder. When 6
he was booked, he attempted to stab himself with a pen, 7
and was placed in a safety cell. Once in the safety cell 8
he admitted to previous suicide attempts. He was removed 9
from the safety cell after Mr. Matloff, a marriage and 10
family therapist, interviewed him through the pill slot 11
in the door and determined he was no longer suicidal. 12
(Stewart Reply Decl. ¶ 7.) He was then placed by himself 13
in a cell that contained a telephone with a cord. 14
(Stewart Decl. ¶ 81.) An hour later he was found 15
unconscious with the cord wrapped around his neck, and he 16
later died. (Id.) Dr. Stewart opines that Mr. Matloff 17
was unqualified to assess whether the inmate was 18
suicidal, it was inadequate to conduct such an interview 19
through the pill slot, and that the inmate's death could 20
have been prevented with proper placement and monitoring 21
of his condition. (Id.; Stewart Reply Decl. ¶ 7.) 22
23 Another inmate admitted to suicidal thoughts at
24 intake, was placed in a safety cell, and then six hours
25 later was cleared for release from the safety cell. A
26 day later he committed suicide by fashioning a noose from
27 a bed sheet and hanging himself from a bookshelf. Dr.
28
59

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 60 of 116 Page ID #:16379

Stewart opines that he was inadequately monitored, and 1
that his suicide was preventable. (Id. ¶ 82.) A third 2
case of suicide involved an inmate who had entered the 3
Riverside Jails based on allegations of sexual acts with 4
a child. He committed suicide by hanging himself with a 5
bed sheet attached to the top bunk of the bed in his cell 6
during a 90 minute period in which he was unobserved. 7
Dr. Stewart opines that he should have been monitored for 8
self-harming behavior due to the nature of his alleged 9
crime. (Id. ¶ 83.) 10

11 Dr. Stewart concludes that the County "clearly
12 intends the Riverside jails to operate according to
13 system-wide policies, but that does not mean those
14 policies are adequate." (Stewart Decl. ¶ 12.) Dr.
15 Stewart identifies the following deficiencies in
16 Defendant's mental health policies and procedures:
17

18 • Chronic staffing shortages19 (¶¶ 28, 29).
19 • Inadequate intake polices and procedures,
20 including reliance on intake officers with no
21 specialized training to conduct mental health
22

23

24

25

19Dr. Stewart acknowledges that the staffing

shortages have improved since 2011 and that the County is

26 currently staffed at or near their own desired staffing

levels, but questions whether the desired levels of

27 staffing are adequate given his assessment that the

amount of mental heath care provided is insufficient.

28 (Stewart Decl. ¶ 29.)

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Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 61 of 116 Page ID #:16380
screenings during intake procedures (¶¶ 18, 301
37; Reply Decl. ¶ 12).20 2
• Failure to provide timely access to mental 3
health care (¶¶ 51, 58; Reply Decl. ¶ 13). 4
• Failure to manage medication administration (¶¶ 5
66, 75), including prescribing medication (¶¶ 6
39, 43, 49), monitoring side effects and track 7
dangerous drug interactions (¶¶ 39-42), relying 8
on inmates to initiate refills of medication, 9
including psychotropic medication (¶ 75); and 10
failing to distribute medication at proper times 11
and in proper doses (¶¶ 39, 73, 76). 12
• Inadequate suicide prevention policies, 13
including delegating decisions regarding removal 14
from safety cells to unqualified mental health 15
staff and conducting evaluations of inmates in 16
safety cells through the pill slot (¶¶ 78, 79, 17
Reply Decl. ¶ 7). 18
• Misuse of safety cells and restraint chairs as 19
disciplinary measures (¶ 94). 20
• Failure to care for inmates in safety cells and 21
restraint chairs, including failure to monitor 22
restrained inmates, perform regular motion 23
24 20Dr. Stewart notes that the County's written policy
25 now provides that a registered nurse will do a follow-up health screening with all inmates, but finds that this
26 policy is still inadequate because it does not provide a time frame for the screening except that it has to be
27 done prior to the inmate being housed in the jail population and does not require the nurse to have any
28 mental health training. (Stewart Decl. ¶ 19, n.3.)
61

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checks, administer mental health treatment, or 1
provide food and water. In addition, there is a 2
pattern of inmates being removed from safety 3
cells before the internal 48 hour time limit and 4
then being returned to the cell shortly after 5
(¶¶ 88, 90. 92, 93, 95, 97, 98; Reply Decl. ¶ 6 6
n.1). 7
• Failure to clean safety cells (¶ 88). 8
• Failure to ensure appropriate record-keeping (¶ 9
100). 10
• Use of custody staff to enter health requests 11
into medical records system which violates 12
inmates's privacy and inhibits mentally ill 13
inmates from seeking help they need (Reply Decl. 14
¶ 3). 15
16 b. Dr. Todd Wilcox
17 Defendant submitted 291 objections to the 37 page
18 Declaration of Dr. Wilcox, and 185 to Dr. Wilcox's Reply
19 Declaration.21 (Wilcox Evid. Objs. (Doc. No. 82); Wilcox
20 Reply Evid. Objs.) Plaintiffs filed a response to all of
21 Defendant's objections to Dr. Wilcox's first Declaration.
22 (Doc. No. 97.)
23
24
25 21Defendant's objections to Dr. Wilcox's Reply
26 Declaration are largely similar, if not identical, to the objections submitted to Dr. Stewart's Reply Declaration.
27 Accordingly, the Court declines to rule on these objections for the reasons stated above in regard to the
28 objections to Dr. Stewart's Reply Declaration.
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Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 63 of 116 Page ID #:16382
Dr. Wilcox is a physician who has worked in jail and 1
prison environments for 18 years. (Wilcox Decl. ¶ 1.) 2
He is currently the Medical Director of the Salt Lake 3
County Jail System. (Id.) He has assisted facilities 4
and organizations around the country, such as the 5
California Department of Corrections and Rehabilitation, 6
the Mississippi Department of Corrections, Pima County 7
Department of Institutional Health, the National 8
Institutes of Corrections, the American Jail Association, 9
and the American Correctional Association, in improving 10
their delivery of care. (Id.) Dr. Wilcox's opinion is 11
based on his "extensive experience studying and 12
researching correctional systems," his experience in the 13
field, his experience as an expert and monitor in prison 14
and jail condition cases, and a review of depositions of 15
county employees, the declarations of named Plaintiffs, 16
and inmates' medical files and records. (Decl. ¶ 3.) In 17
addition, Dr. Wilcox submitted a reply declaration after 18
reviewing the declarations of the County employees, the 19
declarations of Defendant's physicians, and documents 20
related to the County's court order tracking system. Dr. 21
Wilcox has not yet visited the Riverside Jails or spoken 22
to staff or prisoners. (Id. ¶ 4.) 23
24 Defendant does not challenge Dr. Wilcox's
25 credentials, instead it objects to Dr. Wilcox's expert
26 opinion on the same grounds it objects to Dr. Stewart's,
27 i.e., Dr. Wilcox's reliance on inmates' declarations and
28
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grievances. For the reasons stated above in relation to 1
Dr. Stewart's declaration, the Court finds that Dr. 2
Wilcox has employed reliable methodologies and is 3
qualified to give an expert opinion on the medical and 4
mental health care provided by Defendant in the Riverside 5
Jails. Defendant also objects to Dr. Wilcox's opinions 6
on the basis they are improper expert testimony, lack 7
foundation because the practices did not result in harm, 8
consist of "ipse dixit conclusions," improperly rely on 9
pre-2013 jail conditions, and are substantively 10
incorrect. Again, the Court need not resolve all of 11
these evidentiary objections for the purposes of class 12
certification, especially since many of the objections 13
are repetitive and based on questionable grounds. See 14
Cholakyan, 281 F.R.D. at 550. 15
16 Dr. Wilcox opines that there is "widespread,
17 pervasive, and systemic neglect throughout the critical
18 systems of the healthcare delivery model" and that the
19 "severe deficiencies" within the jail system are best
20 corrected through a common remedy. (Wilcox Decl. ¶¶ 5,
21 6.) In his Declarations, Dr. Wilcox identifies the
22 following deficiencies in Defendant's policies and
23 procedures:
24
25 • A system-wide practice of not following or
26 implementing the policies and procedures
27
28
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governing the provision of health care to 1
prisoners (¶ 12). 2
• Grossly inadequate medical records system and 3
note taking that deviates from written policies 4
(¶¶ 13, 95, 96, 119). 5
• Reliance on court orders to spur provision of 6
medical care (¶¶ 14, 38, 39; Reply Decl. ¶¶ 67
15). 8
• Inadequate staffing and reliance on temporary 9
staff (¶¶ 22, 27-29, 96, 114; Reply Decl. ¶ 19). 10
• Ineffective intake screening performed by 11
untrained custody staff who fail to identify 12
health concerns and accurately record medical 13
issues on booking forms (¶¶ 31, 32, 115). 14
• Failure to provide timely care (¶¶ 39, 49, 51, 15
55, 59). 16
• Lack of adequate policies and procedures to 17
provide for specialty medical consultations and 18
procedures (¶¶ 63, 67). 19
• Deficient procedures in the distribution and 20
refill of medications, including delivery of 21
evening pills in the early afternoon (¶¶ 79, 81, 22
94, 115). 23
• Defendant's medical and mental health grievance 24
policy inappropriately involves custody staff 25
26
27
28
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Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 66 of 116 Page ID #:16385
and violates inmates' privacy (¶ 73, Reply Decl. 1
¶ 18).22 2
• Inadequate policies to ensure quality assurance, 3
including insufficient use of outside mechanism 4
to ensure quality (¶¶ 102-105, 120). 5
6 v. Court Orders
7 In their Reply, Plaintiffs organized and submitted
8 the County's records of court orders issued from
9 Riverside County Superior Courts to Riverside County
10 jails from 2011-2014 ("court orders")23 into five
11 exhibits. (See Exs. A-E to the Decl. of Megan Lynch
12 ("Lynch Decl.") (Doc. No. 92.) Ms. Lynch, with the
13 assistance of John Bonacorsi, organized the court orders
14 by year and then catalogued the court orders within that
15 year based on several different categories. Exhibit A
16 organizes records of all of the court orders issued in
17
18
19 22Dr. Wilcox acknowledges that Defendant changed its
20 policy so that requests for healthcare are provided directly to nursing staff instead of being screened by
21 custodial staff, but opines that the new policy continues to violate inmates' privacy, and thus create a risk of
22 harm, because the deputy is responsible for inputting the request into the system and is aware of contents of the
23 request. As a result, prisoners remain in the "awkward position of relaying sensitive information to those who
24 monitor their behavior on a daily basis." (Wilcox Reply Decl. ¶ 18.)
25 23The documents submitted are the records of the
26 court orders and not copies of each individual court order issued. For ease of reference, the Court refers to
27 the individual entries as "court orders." Defendant provided Plaintiffs with the records of the court orders
28 in discovery.
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2011 into eight "sheets"24: (1) Court Orders 2011; (2) 1
JIMS Court Order Key; (3) Court Order History 201125; (4) 2
Medical; (5) Mental Health26; (6) Unique Medical and 3
Mental Health27; (7) Urgent28; and (8) Annual Statistics. 4

5

6

24"Sheet" is a term of art used by Excel, the brand

of software Defendant used to create records of the court

7 orders turned over to Plaintiffs. Plaintiffs also used

Excel in producing the Exhibits submitted to the Court.

8 (Lynch Decl. ¶ 4.)

9

25Sheet one includes: the prisoner's booking number,

the issue date of the court order, the category assigned

10 to the order by the County, and other identifying

information. (Lynch Decl. ¶ 6.) This sheet is a

11 modified version of Joint Trial Exhibit 4377, which was

produced by Defendant. Sheet two contains a key that

12 explains the codes used in the other sheets. (Lynch

Decl. ¶ 6.) This sheet is a modified version of Joint

13 Trial Exhibit 4377, which was produced by Defendant.

Sheet three "appears" to contain notes regarding the

14 County's responses to the court orders. (Id.) This

sheet is a modified version of Joint Trial Exhibit 4377,

15 which was produced by Defendant.

16

26Sheet four lists all the court orders from 2011

that pertain to medical treatment. (Lynch Decl. ¶¶ 16-

17 21.) Lynch created this sheet by using the County's

code, as provided in sheet two, to identify all the

18 orders that had been marked by the County as relating to

medical needs. Sheet five lists all the court orders

19 from 2011 that pertain to mental health treatment.

(Lynch Decl. ¶¶ 16-21.) Lynch created this sheet by

20 using the County's code to identify all the orders that

had been marked as the County as relating to mental

21 health. Lynch then manually reviewed these records and

removed entries "clearly not related to mental health

22 treatment in jails." (Id. ¶ 23.)

23

27Sheet six lists the booking number of each prisoner

who received a medical or mental health care court order

24 during 2011. (Lynch Decl. ¶¶ 24-28.) This sheet was

created by Bonacorsi at Lynch's direction.

25

28Sheet seven lists all "urgent" medical and mental

26 health orders for 2011. This list was complied by

conducting a search of all court orders using the terms:

27 A.S.A.P, before, day, emergency, forthwith, hours, hrs.,

immediately, today, tomorrow, urgent, w/in, week, and

28 within. (Lynch Decl. ¶¶ 29-30.)

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The court orders from 2012 (Ex. B), 2013 (Ex. C), and 1
2014 (Ex D), were organized in the same manner. Exhibit 2
E compiles all the information from Exhibits A-D and 3
provides a statistical analysis of the court orders 4
issued in 2011-2014. 5
6 Defendant objects to Lynch's analysis on the basis
7 that neither Lynch or Bonacorsi are experts, they are not
8 qualified to determine whether a court order pertains to
9 medical or mental health care based on "allegedly
10 disputed system-wide policies"; they are not qualified to
11 assess whether the county's codes relate to medical or
12 mental health care allegedly based on one of the disputed
13 system-wide policies; they are not qualified to determine
14 whether a court order is irrelevant to medical or mental
15 health treatment in jails; and they are not qualified to
16 determine whether a particular court order is "urgent."
17 (Def.'s Objs. to Pls.'s Ex. A-E.) In addition, Defendant
18 objects that the records of the court orders do not
19 reflect court orders for medical and mental health care
20 that was allegedly denied as a result of one of
21 Defendant's policies. (Id.)
22
23 Federal Rule of Evidence 1006 provides that "[t]he
24 contents of voluminous writings, recordings, or
25 photographs which cannot conveniently be examined in
26 court may be presented in the form of a chart, summary or
27 calculation." Fed. R. Evid. 1006. When a chart or
28
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summary of evidence "does not contain complicated 1
calculations requiring the need of an expert for 2
accuracy, no special expertise is required in presenting 3
the chart," and thus a lay witness may establish the 4
foundation for admission of the summary evidence under 5
Rule 1006. Terry v. City of San Diego, 2011 WL 1897491, 6
*7 (S.D. Cal. May 18, 2011) (quoting U.S. v. Jennings, 7
724 F.2d 436, 442 (5th Cir. 1984)). The process Lynch 8
and Bonacorsi used is explained in detail in her 9
declaration. After reviewing the Lynch Declaration and 10
the exhibits, the Court is satisfied that her methodology 11
of categorizing the court orders is sufficiently reliable 12
and that the level of data analysis performed does 13
require specialized expertise or training.29 Furthermore, 14
the Court notes that the court orders were organized 15
based on Defendant's coding system, and recognizes that 16
the court orders do not represent medical or mental 17
health that was denied based on one of the Defendant's 18

19

20

29The methods used consist of sorting the court

orders using the County's coding labels, applying the

21 "remove duplicate" function of Excel, and using the "find

and replace" and "keyword search" function of Excel. To

22 the extent some discretion was exercised, it was in

manually deleting orders not related to mental or medical

23 health care treatment at the jails, such as orders

related to releases of medical information, competency

24 evaluations and attorney access to records. Defendant

argues it is impossible to make such decisions without

25 the original court orders and that Lynch is not qualified

to do so. After reviewing the records the Court finds

26 they provide sufficient detail such that Ms. Lynch could

exclude non-relevant records. Moreover, Defendant has

27 not identified any specific court orders that is disputes

being classified as "medical health care" or "mental

28 health care."

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alleged health care policies. Accordingly, the Court 1
overrules these objections and will consider the Exhibits 2
for the purposes of this Motion. 3

4 According to Lynch's analysis, a total of 9,316 court
5 orders relating to medical or mental health treatment
6 were issued between January 1, 2011 and March 10, 2014.
7 During this time period, a little over 4,000 different
8 prisoners received court orders related to healthcare.
9 (See Ex. E to Lynch Decl. at 766).30 1,737 of the court
10 orders during this period related to what Plaintiffs
11 classified as "urgent" medical needs. (See Ex. E to
12 Lynch Decl. at p. 766.) For example, an order issued on
13 November 6, 2013, states "Deft to be seen immediately
14 following court by jail mental health staff." (Ex. E to
15 Lynch Decl. at 521; see, e.g., December 11, 2013 Court
16 Order, "Crt Ord. Deft. be seen by jail physician regard
17 med. cond. and meds within 24H" (Id. at 389); May 2, 2012
18 Order, "Def to be seen by jail medical staff ASAP" (Id.
19 at 232); August 3, 2011 Order, "Inmate to be seen by
20 medical staff within 48 hours." (Id. at 114)).
21

22 Some of the court orders appear to reflect a poor
23 record of compliance by the Defendant with previous court
24

25

26

30In 2011, 2,892 court orders issued; in 2012, 2,998

court orders issued; in 2013, 2,870 court orders issued,

27 and as of May 14, 2014, 556 court orders issued. (See

Ex. A to Lynch Decl. at 504, Ex. B at 489, Ex. C at 416,

28 Ex. D at 238.)

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orders. (Wilcox Reply Decl. ¶ 11; Stewart Reply Decl. ¶ 1
18.) In addition, some of the orders relate to what 2
appear to be serious medical conditions, such as brain 3
tumors and heart conditions. (Wilcox Reply Decl. ¶ 9; 4
Stewart Reply Decl. ¶ 15.) After reviewing the court 5
orders, Dr. Stewart opined that in a well-functioning 6
health care delivery system, there would be no need for 7
inmates to raise health care concerns with the judges 8
presiding in their criminal cases and no need for the 9
judge to take action. (Stewart Reply Decl. ¶ 14.) Dr. 10
Stewart was "astounded" by this practice, and opined that 11
the "sheer scope" of the orders demanded accounting. 12
(Stewart Reply Decl. ¶¶ 14, 17.) Similarly, Dr. Wilcox 13
concluded that in his experience, he has "never seen 14
courts involved in the minutia of the day-to-day health 15
care of prisoners as I see here." (Wilcox Reply Decl. ¶ 16
15.) Both Dr. Wilcox and Dr. Stewart agree that although 17
the court orders are not proof that the medical care 18
ordered was necessarily needed or had previously been 19
denied, the "extraordinary numbers and nature of the 20
court orders" support the existence of a systemic policy 21
of failing to provide timely medical care. (Wilcox Reply 22
Decl. ¶ 7; Stewart Reply Decl. ¶ 13.) Indeed, Dr. Wilcox 23
concludes that "the most egregious constraint on timely 24
access to healthcare is that routine healthcare is 25
accessed via court orders mandating that healthcare 26
providers see and treat patients." (Wilcox Decl. ¶ 61.) 27
28
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In opposition, Defendant submitted the Declaration of 1
Jerry Gutierrez, the Correctional Chief Deputy. (See Ex. 2
D to Decl. of Cnty Personnel (Doc. No. 86). ) Mr. 3
Gutierrez explains that the court orders are completely 4
ex parte procedures, and the court "never" inquires as to 5
whether the inmate has sought medical care through the 6
regular procedures before requesting a court order.31 7
(Id. ¶ 22.) On many occasions, the inmate did not make a 8
request through regular procedures, the inmate did not 9
file a grievance before requesting the court order, the 10
medical or mental health care was already scheduled, or 11
the medical or mental health care was not medically 12
appropriate. (Id.) Mr. Gutierrez met with some of the 13
criminal judges on the Superior Court to request they 14
inquire as to whether the inmate has sought medical care 15
through the regular procedures before issuing a court 16
order. (Id. ¶ 24.) 17
18 vi. Grand Jury Reports
19 In California, the Grand Jury has the responsibility
20 to review the operations of all local governments within
21 that jury's county. (Ex. 150 to Crockett Decl., ("The
22 California Grand Jury System") at 2104.) Under
23
24 31As Correctional Chief Deputy, Mr. Gutierrez is
25 responsible for "corrections support" and ensuring compliance with policies and procedures in the Riverside
26 Jails. (Gutierrez Decl. ¶¶ 2, 4.) Mr. Gutierrez offers no explanation as to how he has knowledge of what occurs
27 during Superior Court proceedings, or the practices of the Superior Court judges when issuing orders regarding
28 medical and mental health care.
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California Penal Code section 919(b), the Grand Jury is 1
required to inquire into the condition and management of 2
public prisons within the County. (Id. at 2118; Cal. 3
Penal Code § 919(b).) In 2010-2011, the Grand Jury 4
issues two reports concerning conditions in Riverside 5
Jails: 2010-2011 Mental Health Detention Services Grand 6
Jury Report (Ex. 15 to Crockett Decl., ("2011 Mental 7
Health Grand Jury Report")) and the 2010-2011 Riverside 8
County Detention Health Care Administration Grand Jury 9
Report (Ex. 149 to Crockett Decl., ("2011 Medical Grand 10
Jury Report")). 11
12 The 2011 Mental Health Grand Jury Report identified
13 several deficiencies in the provision of mental health
14 care in Riverside Jails and made numerous recommendations
15 to the County, including: (1) mental health personnel
16 should be assigned to each jail and should screen inmates
17 during the intake proceeding for possible mental illness
18 using a validated mental health screening tool; (2) a
19 mental health evaluation should be conducted for any
20 inmate who screens positively for possible mental illness
21 within 24 hours of booking; and a qualified medical
22 professional should complete and document a mental health
23 evaluation within two weeks of booking; (3) medications
24 should be distributed and administered properly with
25 trained health care personnel monitoring for side
26 effects; (4) mental health staffing should be available
27 on a 24-hour basis; (5) a confidential self-referral
28
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system for inmates should be developed; and (6) a 1
computer system should be implemented to allow prompt, 2
up-to-date access to inmates' medical and mental health 3
records. (See 2011 Mental Health Grand Jury Report at 4
307-10.) 5
6 Similarly, the 2011 Medical Grand Jury Report
7 identified serious deficiencies in the staffing and
8 provision of medical care in Riverside Jails, including
9 violations of California law in regard to the provision
10 of medical care and the medical assessment of inmates
11 held in physical restraint chairs and safety rooms.32
12 (2011 Medical Grand Jury Report at 2093-98.)
13
14 In response to the 2011 Grand Jury reports, the
15 Sheriff's Department acknowledged that "budget and
16 medical personnel staffing cuts had . . . unacceptably
17 impacted the delivery of medical services," and there was
18 a "need to remedy these issues." (Ex. 125 to Crockett
19 Decl. ("Sheriff's Response to 2011 Medical Grand Jury
20 Report") at 1799, 1802; Ex. 16 to Crockett Decl.
21 ("Sheriff's Response to 2011 Mental Health Grand Jury
22 Report") at 316.) The Sheriff's Department requested the
23
24 32A key Grand Jury recommendation was that all health
25 care administration authority be transferred back to the Riverside County Sheriff. It appears that the provision
26 of health care has been affected by a division between the "legal authority" of the Sheriff's Department and the
27 "practical authority" of the Riverside County Regional Medical Center ("RCRMC"). (Sheriff's Response to 2011
28 Medical Grand Jury Report at 1802.)
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Corrections Standards Authority ("CSA") assess whether 1
the Riverside Jails were compliant with California law, 2
and also contracted with Inmate Medical Quality ("IMQ") 3
to conduct an expert analysis on staffing at the 4
Riverside Jails. (Sheriff's Response to 2011 Mental 5
Health Grand Jury Report at 316.) The CSA Report found 6
that the provision of medical and mental health care in 7
the Riverside Jails did not comply with the intent of 8
California law33 in several areas, including medication 9
delivery, access to medical and mental health care staff, 10
use of safety cells and restraint chairs, and the inmate 11
grievance processes. (Ex. 18 to Crockett Decl. ("2011 12
CSA Report").) The IMQ Report found medical and mental 13
health staffing at the Riverside Jails was inadequate, 14
and that as a result of inadequate staffing there were 15
deficiencies in many areas, including the evaluation of 16
inmates at booking, distribution of medications, and 17
medical evaluations of inmates held in safety cells and 18
restraint chairs. (Ex. 14 to Crockett Decl. ("2011 IMQ 19
Report").) 20
21 Finally, the Sheriff's Department, Detention Mental
22 Health Services, and Detention Health Services entered
23 into a Memorandum of Understanding to provide adequate
24 services and personnel for Riverside Jail inmates in need
25
26 33California law does not apply to this action. The
27 Court only recites the facts related to the Grand Jury reports and subsequent state actions as evidence of
28 commonality.
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of mental and medical health care in 2011. (Ex. 13 to 1
Crockett Decl. ("MOU").) The MOU includes an agreement 2
as to minimum staffing patterns and levels, as well as 3
the need to implement policies in compliance with 4
California law. It also provides specific policies 5
governing various aspects of the delivery of medical and 6
mental health care, including intake, that are intended 7
to bring in the policies in compliance with California 8
law. 9
10 In 2012, the Grand Jury issued a second report
11 concerning mental health care in the Riverside Jails.
12 (Ex. 148 to Crockett Decl., ("2012 Mental Health Grand
13 Jury Report")). The Report noted that despite the MOU,
14 staffing levels actually had decreased and that there
15 were a large number of vacancies in mental health
16 staffing. In response, Mental Health Detention Services
17 contended that, due to the use of per diem clinical
18 therapists and overtime for mental health employees, its
19 current level of staffing was at 91 percent. (Ex. 17 to
20 Crockett Decl., ("Response to 2012 Mental Health Grand
21 Jury Report").)
22
23
24
25
26
27
28
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vii.

Defendant's Evidence in Opposition to

1

Commonality 2

Defendant submitted extensive evidence in Opposition, 3

including the declarations of 14 County employees,34 four 4

physicians35, and Bradley Gilbert, the Chief Executive 5

Officer for the Inland Empire Health Plan. Defendant 6

offers this evidence in support of its two main arguments 7

against commonality. First, Defendant argues that 8

although there may have been issues in regard to the 9

policies and provision of medical and mental health care 10

in the past, any issues have been resolved. (See Opp'n. 11

at 40 ("Plaintiffs' motion is based largely on a 12

13 34Arnisa Adewumni, Institutional Supervising Nurse at
14 Smith and Twin Pines Ranch Juvenile Center ("Adewumni Decl."); Allison Apgar, Mental Health Clinical Therapist
15 II ("Apgar Decl."); Lt. Edward Delgado, Lieutenant at Presley ("Delgado Decl."); Jerry Gutierrez, Correctional
16 Chief Deputy ("Gutierrez Decl.); Deborah Johnson, Deputy Director of Forensics at the Riverside County Department
17 of Mental Health ("Johnson Decl."); Victor Laus, Chief of Medical Speciality, Detention Health Services ("Laus
18 Decl."); Daniel Matloff, Clinical Therapist II at Banning ("Matloff Decl."); Espergene Manalo, Nurse ("Manalo
19 Decl."); Gregory Prouty, Pharmacy Director of Riverside County Health System and Riverside County Regional
20 Medical Center ("Prouty Decl."); Rhonda Reeves, Supervising Institutional Nurse at Southwest Detention
21 Center ("Reeves Decl."); Leticia Stillwell, Institutional Supervising Nurse at Presley ("Stillwell Decl."); Carl
22 Strong, Mental Health Services Supervisor at Southwest Detention Center ("Strong Decl."); William Wilson,
23 Assistant Hospital Administrator and Director of Detention Health Services ("Wilson Decl."); Joseph
24 McNamara, Correctional Captain ("McNamara Decl.") (See Doc. No. 86.)
25 35Dr. Lee Gislason, Psychiatrist ("Gislason Decl.");
26 Dr. William Klein, Internist ("Klein Decl."); Dr. Kendall Wagner, Orthopedic Surgeon ("Wagner Decl."); James
27 Lineback, Internist with experience providing medical care to inmates in the Los Angeles County jail system
28 ("Lineback Decl.") (See Doc. No. 88.)

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purported medical and mental health care system which 1
does not currently exist.").) Defendant disputes any 2
evidence relating to conditions before January 1, 2013, 3
and argues that in light of the current policies and 4
practices at the Riverside Jails, any deficiencies in 5
care are simply isolated deviations and do not suffice to 6
support a finding of commonality. Second, Defendant 7
offers extensive evidence in support of its contention 8
that the specific medical and mental health care received 9
by the named Plaintiffs, as well as other individual 10
inmates described in Plaintiffs' evidence, was 11
constitutionally adequate. In addition, Defendant offers 12
evidence that its policies are constitutionally adequate 13
because they are equal to the "community standards" for 14
Medi-Cal recipients under the Inland Empire Health Plan. 15
16 a. Current Conditions
17 As the Court detailed above in regard to the Grand
18 Jury reports, in 2009 and 2010, the County made
19 significant cuts to the budgets for medical and mental
20 health care in the Riverside Jails. As a result of these
21 cuts, as well as an influx of inmates from the California
22 state prison system, the Riverside Jails were confronted
23 with a decrease in medical and mental health staffing and
24 an increase in medical and mental health needs.
25 Defendant contends that any deficiencies in the provision
26 of health care caused by those unique circumstances have
27 been remedied, and thus Plaintiffs' complaints are either
28
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moot, or reflect isolated deviations from the County's 1
policies. Defendant identifies the policies it contends 2
currently apply, including: 3
4 • Staffing: Increases in levels of staffing and
5 coverage of vacancies in permanent positions
6 through per diem employees, county temporary
7 employees, overtime work, and registry
8 employees. (Wilson Decl. ¶¶ 7,8; Johnson Decl.
9 ¶ 6.)
10 • Intake: Some inmates are screened by nurses
11 during the intake process. (Adewunmi Decl. ¶
12 4.) Those who are not screened by nurses are
13 interviewed by trained correctional officers
14 regarding the inmate's medical and mental health
15 history and needs. (Reeves Decl. ¶ 8.) If an
16 inmate identifies a need for medical or mental
17 health services, or the correctional officer
18 observes such a need, the inmate is referred for
19 treatment. (Delgado Decl. ¶¶ 8-10; Adewunmi
20 Decl. ¶ 4.) Before an inmate is placed in the
21 general population a "classification deputy"
22 interviews the inmate to determine housing, and
23 can also refer the inmate for medical or mental
24 health treatment. (Adewunmi Decl. ¶ 4; Reeves
25 Decl. ¶ 8, Delgado Decl. ¶ 13; Strong Decl. ¶ 5;
26 McNamara Decl. ¶ 4.)
27
28
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• Access to Medical Care: Recently, Defendant 1
changed its policy regarding medical and mental 2
health request slips, which are also known as 3
"blue slips." Inmates now hand the blue slips 4
directly to a nurse or other medical staff and 5
the requests are no longer handled by the 6
correctional officers. All requests for medical 7
care are entered into the Jail Information 8
Management System ("JIMS") by a deputy. 9
(Delgado Decl. ¶ 15; Reeves Decl. ¶¶ 8, 10.) 10
The response to the request is tracked, and the 11
goal is to triage all requests in 24 hours and 12
provide a response within five days. (Reeves 13
Decl. ¶¶ 11-12.) JIMS automatically prints out 14
a list of any inmate not seen within five days 15
and the sergeant assigned to that area is 16
responsible for ensuring that inmate is seen. 17
(Delgado Decl. ¶ 17.) 18
• Medication: The Pharmacy Director for the 19
Riverside County Medical Center pharmacy uses a 20
program, CIPS, to address potential drug 21
interactions. (Prouty Decl. ¶ 4.) A nurse 22
provides twice daily pill call. Inmates may 23
refuse their medications. (Reeves Decl. ¶ 27.) 24
Medications which require more frequent 25
administration may either be kept on the 26
inmate's person or administered by a nurse. 27
(Reeves Decl. ¶ 29.) 28
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• Prescription Renewals: if the medication is non1
essential, the inmate must request a renewal. 2
If the medication is for an essential medical 3
issue, the medication will be renewed by the 4
medical staff without any action by the inmate. 5
(Reeves Decl. ¶ 25.) 6
• Inmates have a right to obtain outside care at 7
their own expense. (Gutierrez Decl. ¶ 16.) 8
• Court Orders: Riverside Jails do not rely on 9
court orders to provide medical or mental health 10
care. Inmates often request a court order 11
before seeking the care through a request or 12
grievance, and the judges issue the orders 13
without inquiring as to whether the inmate has 14
sought other means of getting the care needed. 15
(Gutierrez Decl. ¶ 22.) 16
• Safety Cells: It is the County's policy to clean 17
the safety cells after every use. (Delgado 18
Decl. ¶ 23.) A Detention Health Services nurse 19
assesses the inmate shortly after the inmate is 20
placed in the safety cell.36 (Adewunmi Decl. ¶ 21
25; Reeves Decl. ¶ 30.) Medical staff check on 22
the inmate at least every eight hours after the 23
initial assessment, and the policy requires a 24

25

26

36It is unclear whether this policy only applies to

suicidal inmates. Strong states that if an inmate is

27 placed in a safety cell for reasons other than potential

suicide, a psychiatrist will see the inmate within 24

28 hours. (Strong Decl. ¶ 17.)

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Mental Health employee see the inmate at least 1
every 24 hours. (Adewunmi Decl. ¶ 25; Reeves 2
Decl. ¶ 30; Strong ¶ 15.) All the safety cells 3
are monitored by camera, and there is a visual 4
check of any inmate in the safety cell every 30 5
minutes. (Delgado Decl. ¶ 19.) An inmate may 6
not be kept in a safety cell for more than 48 7
hours. (Delgado Decl. ¶ 19.) If an inmate was 8
placed in a safety cell because he is 9
potentially suicidal or self-harming, he may 10
only be released after authorization by a Mental 11
Health employee. (Delgado Decl. ¶ 21.) If the 12
inmate is can not be released after 48 hours he 13
is transferred to an outside mental health 14
facility. (Delgado Decl. ¶ 22.) 15
• Restraint Chairs: Inmates in restraint chairs 16
are evaluated by Detention Health Services staff 17
directly after placement and then at least every 18
four hours. (Reeves Decl. ¶ 31.) Inmates may 19
not be kept in a restraint chair for more than 20
six hours. (Delgado Decl. ¶ 24.) A sergeant 21
reviews whether continued placement is necessary 22
every two hours. (Id.) Restraint chairs are 23
monitored by camera and the policy requires 24
visual checks every two hours and allowances for 25
range of motion every thirty minutes. Before 26
the increase in staffing, medical and mental 27
health staff did not have time to accurately 28
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record all of the contacts with inmates in 1
safety cells, and presumably in restraint 2
chairs. (See Delgado Decl. ¶ 22.) 3

4 b. Adequate Medical Care
5 Defendant argues the evidence it submitted
6 demonstrates that the care the named Plaintiffs, as well
7 as various other inmates, received, was adequate.37 For
8 example, Dr. Wagner reviewed the medical records of each
9 named Plaintiff and found that the care provided meets or
10 exceeds the applicable standard of care. He also
11 provides a detailed analysis regarding Plaintiff
12 Kujawsky. (See generally Wagner Decl.) Dr. Gislason
13 disagrees with Plaintiffs' expert, Dr. Stewart, regarding
14 whether the named Plaintiffs, as well as many of the
15 unnamed inmates described in Dr. Stewart's report,
16 received adequate care, and whether the policies are
17 adequate. (Gislason Decl. ¶ 7 ("In sum . . . I disagree
18 with Dr. Stewart's assertions regarding mental health
19 care in the Riverside County Jails.")). Similarly, Dr.
20 Lineback opines that it was within the standard of care
21

22

23

37In their Reply, Plaintiffs do not challenge the

qualifications of any of Defendant's experts. The Court

24 has reviewed the qualifications of these doctors and

notes that only Dr. Lineback has any experience working

25 in prisons. The Court has some doubts as to the ability

of these experts to opine on the adequacy of medical and

26 mental health policies and procedures in the prison

context. At this stage, the Court has not relied on

27 these experts' opinions regarding the adequacy of the

policies and thus it is not necessary to perform a full

28 Daubert analysis as to their qualifications.

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to leave Patterson's IVC filter in place; and that Gray 1
did not actually suffer a seizure, and instead suffered 2
an episode of syncope (passing out) as a side effect of 3
his medication. (Lineback Decl. ¶¶ 9-11; 16-18.) 4
Similarly, Dr. Klein disagrees with Plaintiffs' expert, 5
Dr. Wilcox, and opines, based on review of the medical 6
records of individual Plaintiffs and inmates, that the 7
combinations of drugs prescribed were appropriate. (See, 8
e.g., Klein Decl. ¶¶ 8, 9.) 9
10 In regard to the adequacy of the Defendant's
11 policies, Defendant submits the Declaration of Dr.
12 Gilbert, who is the CEO of the Inland Empire Health Plan
13 ("IEHP"). ("Gilbert Decl.") (Doc. No. 56.) IEHP is an
14 agency of Riverside and San Bernardino Counties and
15 serves as the Local Initiative Medi-Cal Managed Care Plan
16 for both counties. Dr. Gilbert reviewed the allegations
17 in Plaintiffs' complaint and compared the alleged
18 policies to the "community standard for Medi-Cal
19 members," on the basis that the majority of jail inmates
20 were eligible for Medi-Cal before incarceration and will
21 continue to be eligible after they are released. (Id. ¶
22 69.) For example, Dr. Gilbert concludes that the ability
23 for an inmate to choose to pay for a private provider is
24 comparable to an IEHP member choosing to go to an out-of-
25 network doctor. (Id. ¶ 34.) Dr. Gilbert even opines
26 that the standard of care in Riverside Jails is actually
27 higher than the community standard in certain respects;
28
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e.g., inmates receive a twice daily reminder to take 1
their medication, but members in the community do not 2
receive an equivalent "summons." (Id. ¶ 51.) Dr. 3
Gilbert concludes that the medical and mental health care 4
standards in the Riverside Jails are "comparable" to the 5
standard of care members in IEHP should receive. (Id. ¶ 6
71.) 7
8 viii. Commonality Analysis
9 Plaintiffs contend, based on the above evidence, that
10 the question common to all members in the Class and the
11 Subclasses is whether Defendant's systemic practices
12 constitute deliberate indifference to the medical and
13 mental health care needs of inmates and place inmates a
14 substantial risk of serious harm in violation of the
15 Fourteenth and Eighth Amendments. Furthermore, they
16 contend that the common question may generate common
17 answers that are capable of resolving the litigation "in
18 one stroke." Reply at 3 (quoting Wal-Mart, 131 S. Ct. at
19 2551).
20
21 Defendant argues the commonality requirement for the
22 Class and Subclasses has not been satisfied here because:
23 (1) Plaintiffs have not met their burden of demonstrating
24 "significant proof" of the existence of any systemic
25 policies; (2) Defendant's evidence refutes all of
26 Plaintiffs' contentions and accurately portrays current
27 conditions and policies regarding medical and mental
28
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health care; (3) any claim that an inmate receives 1
inadequate medical or mental health care requires an 2
individual determination and may not be resolved on a 3
class-wide basis; and (4) even as alleged by Plaintiffs, 4
the policies are comparable to community standards and 5
all named Plaintiffs and inmates referenced in the papers 6
received adequate care. As discussed below, these 7
arguments are unavailing. 8
9 Defendant's contention that an individual inquiry is
10 required to determine whether each member of the proposed
11 class receives inadequate medical or mental health, and
12 thus suffered an injury, is misplaced. As in Parsons II,
13 Plaintiffs' injury is that Defendant's alleged policies
14 expose each inmate to a "substantial risk of serious
15 harm." 754 F.3d at 678 ("What all members of the
16 putative class and subclass have in common is their
17 alleged exposure, as a result of specified statewide ADC
18 policies and practices that govern the overall conditions
19 of health care services and confinement, to a substantial
20 risk of serious future harm to which the defendants are
21 allegedly deliberately indifferent."). Thus, an
22 individual determination is not required because it is
23 the exposure to the policy that constitutes the harm;
24 courts have routinely held that "many inmates can
25 simultaneously be endangered by a single policy." Id.
26 (collecting cases).
27
28
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Plaintiffs challenge numerous policies and practices 1
of the Defendant. Some of these policies are written, 2
official policies of the Riverside Jails; for these it is 3
clear that commonality exists.38 See Parsons II, 754 F.3d 4
at 664. In regard to Plaintiff's claims that Defendant 5
has policies and practices that deviate from the written 6
policies,39 the key question before the Court is whether 7
there is "sufficient evidence of systemic issues in the 8
provision" of medical and mental health care or whether 9
"Plaintiffs' allegations are simply many examples of 10
isolated instances of deliberate indifference." Parsons 11
I, 289 F.R.D. at 521. A policy or practice may be 12
inferred from a widespread practice or evidence of 13
repeated constitutional violations for which the errant 14
officials are not reprimanded. Menotti v. City of 15
Seattle, 409 F.3d 1113, 1147 (9th Cir. 2005) (citing 16

17

18

38These include: (1) the medical and mental health

staffing levels and reliance on temporary and per diem

19 employees to fill vacancies; (2) using custody staff to

conduct intake interviews and screen for medical and

20 mental health issues; (3) requiring inmates to request

renewals of non-essential prescriptions; (4) using

21 custody staff to enter data regarding medical and mental

health blue slips and grievances into JIMS; (5) allowing

22 mental health staff qualified as marriage and family

therapists to make decisions regarding release from

23 safety cells for potentially suicidal inmates; and (6)

performing mental health treatment and counseling for

24 inmates in safety cells through the pill slot.

25

39Such as (1) failure to provide timely care and

instead relying on court orders; (2) failure to adhere to

26 medical records policies and note taking requirements;

(3) failure to monitor inmates for dangerous drug

27 interactions and refill medications in a timely manner;

and (4) failure to monitor inmates in safety cells and

28 restraint chairs.

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Nadell v. Las Vegas Metro. Police Dep't., 268 F.3d 924, 1
929 (9th Cir. 2001)). When examining liability for an 2
improper custom or practice, courts should look at 3
whether the practice at issue reflects "isolated or 4
sporadic incidents" or is one of sufficient duration, 5
frequency, and consistency such that the alleged conduct 6
may be the "traditional method of carrying out policy." 7
Trevino v. Gates, 99 F.3d 911, 918 (9th Cir. 1996); see 8
Parsons I, 289 F.R.D. at 521. 9
10 Plaintiffs have provided "significant proof," at the
11 class certification stage, of the existence of systemic
12 policies governing the provision of medical and mental
13 health care that deviate from the written policies.
14 Unlike cases cited by Defendant, Plaintiffs have
15 identified specific systemic policies relating to (1) the
16 timeliness of treatment; (2) administration of
17 medication; (3) maintenance of medical and mental health
18 records; and (4) the use of safety cells and restraint
19 chairs and monitoring of inmates held in restraint, that
20 differ from the County's written policies. See Stevens
21 v. Harper, 213 F.R.D. 358, 382 (E.D. Cal. 2002) (alleging
22 that the provision of mental health care is inadequate
23 without identifying specific policies); Mathis v. GEO
24 Grp., Inc., 2012 WL 600865, at *6 (E.D.N.C. Feb. 23,
25 2012) (no commonality where plaintiff failed to specify
26 any specific policy and instead alleged a "constellation
27 of unspecified "organizations, systems, policies,
28
88

Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 89 of 116 Page ID #:16408
procedures, practices, acts, and omissions."). 1
Plaintiffs have supported the existence of the alleged 2
inadequacies in the written and unwritten systemic 3
policies with declarations illustrating the impact of 4
these deficiencies on individual inmates, including named 5
Plaintiffs.40 This is not the extent of Plaintiffs' 6
proof, however. Unlike the cases cited by the Defendant, 7
Plaintiffs have offered more than a collection of 8
isolated instances. See e.g. Lewis v. Casey, 518 U.S. 9
343, 359 (1996) (factual findings consisting of only two 10
instances of lack of access to law library was a 11
"patently inadequate basis for a conclusion of systemwide 12
violation and imposition of systemwide relief."); Amador 13
v. Baca, 2014 WL 1679013, at *5-8 (C.D. Cal. Mar. 12, 14
2014) (156 declarations, without any additional evidence, 15
was not sufficient evidence to demonstrate a common 16
practice or policy that deviated from the written 17
policy). 18
19 40Defendant argues that Plaintiffs must demonstrate
20 systemic deficiencies by providing statistical evidence of the percentage of prisoners who suffered harm as a
21 result of an unwritten policy, i.e., the number of documented instances where prisoners were not provided
22 their medications in proportion to the total number of prisoners in the jail. Applying this methodology,
23 Defendant argues Plaintiffs rely on anecdotal evidence from 59 inmates that occurred over a three-period of
24 time. (Opp'n. at 16.) The Court agrees that this evidence, on its own, is not significant proof of the
25 existence of practices that deviate from the official policies. Nevertheless, Plaintiffs have offered other
26 evidence, including expert opinion and the County's own records, that support their claims. The anecdotes are
27 mere illustrations of the impact of the these policies, and are not offered as statistical proof of their
28 existence. (See Reply at 20 n.5.)
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In addition to the declarations, Plaintiffs provided 1
the expert opinions of Dr. Stewart and Dr. Wilcox, who, 2
based on their review of the safety cell logs, 3
grievances, records of court orders, and inmates' medical 4
records, each identified several systemic deficiencies in 5
Defendant's medical and mental health policies, including 6
deviations from the County's written policies. 7
Furthermore, in support of the alleged policy that 8
Defendant fails to provide timely access to medical and 9
mental care, Plaintiffs submitted records of over 9,000 10
court orders regarding medical and mental health care. 11
Some of these court orders appear to concern routine 12
medical issues such as prescriptions and doctor visits, 13
and others appear to instruct urgent action and concern 14
serious medical and mental conditions. The Court 15
recognizes the limits of these records, and does not 16
interpret the records as suggesting that each order 17
necessarily reflects an instance of failure to provide 18
timely care. Nevertheless, the sheer volume of the 19
records, as well as Dr. Stewart's and Dr. Wilcox's 20
interpretation of the court orders, strongly suggest that 21
there are systemic deficiencies in access to care that go 22
beyond the isolated experiences of the named Plaintiffs 23
in this action. 24
25 Finally, the Grand Jury reports and the related
26 correspondence lend additional support to Plaintiffs'
27 contention that the policies are designed and implemented
28
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at a systemic level, and thus are best suited for class 1
wide resolution. See Parsons I, 289 F.R.D. at 521 (court 2
found that a cure notification to the contractor 3
responsible for providing medical care to prisoners "tips 4
the balance" in favor of commonality). In particular, 5
the Grand Jury reports note deficiencies in the 6
Defendant's policies related to several areas, including 7
intake, staffing, access to care, safety cells, and 8
restraint chairs, health care requests, medical records, 9
and recommended actions the Defendant take to remedy the 10
identified issues. These reports support a finding of 11
commonality, and suggest that questions regarding the 12
adequacy of Defendant's policies are best addressed on a 13
class-wide basis. 14
15 Defendant seeks to distinguish this case from Parsons
16 II by submitting extensive rebuttal evidence and
17 evidentiary objections in support of its Opposition.
18 Indeed, in Parsons II, the Ninth Circuit noted with
19 seeming dismay that the defendants:
20
21 [R]elied on a few declarations by some ADC
22 officials in which those officials summarized
23 formal ADC policies — several of which had been
24 modified mere days before the defendants filed
25 their brief in the district court. The
26 defendants did not submit rebuttal expert
27 declarations, nor did they offer evidence that
28
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the newly revised written statements of ADC 1
policy reflected the actual policy and practice 2
of the ADC facilities. Further, the defendants 3
did not address the individual policies and 4
practices complained of by the plaintiffs nor 5
present evidence meant to deny their existence. 6
Rather, the defendants argued in a general 7
fashion that ADC written policies are the only 8
statewide policies and practices. 9
754 F.3d at 663-64. 10
11 The voluminous evidence submitted in opposition to
12 Plaintiffs' Motion does not undermine the existence of
13 commonality. Rather, Defendant has succeeded in
14 identifying multiple triable issues of fact as to whether
15 the common policies and practices identified constitute
16 deliberate indifference. For example, the Defendant's
17 experts disagree with the Plaintiffs' experts regarding
18 whether Defendant's policies and treatment of specific
19 inmates were adequate.41 Defendant has provided new
20 statistics regarding staffing, and Plaintiffs' experts
21 opine that the staffing levels remain inadequate.
22 Defendant submits declarations stating that the intake
23
24 41The Court notes that any trial in this action will
25 not involve adjudication of the quality of treatment rendered to each individual plaintiff, or named
26 Plaintiff. Any disputes over the quality of care provided to an individual inmate goes to the question of
27 whether that inmate's experience is an example of the serious harm that may result as a consequence of
28 Defendant's medical and mental health policies.
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deputies are properly trained and qualified to screen for 1
medical and mental health conditions, and Plaintiffs' 2
experts opine they are not. At the hearing, Defendant 3
argued that the Court must resolve each of these factual 4
disputes prior to class certification and determine not 5
only whether the materials relied on by Plaintiffs' 6
experts were reliable, but also decide whether the 7
information contained within the materials is credible. 8
For example, whether to credit a named Plaintiff's 9
declaration that he was given certain medicine or the 10
Riverside Jails records which do not have a record of 11
that medicine being administrated. As Defendant's 12
argument suggests, at the class certification stage, the 13
Court cannot resolve questions as to the adequacy of the 14
policies identified without engaging in an assessment of 15
the merits that goes well beyond what is required in 16
order to determine commonality. 17
18 To the extent the Court makes any findings as to the
19 merits, it is limited to what is required to determine
20 commonality. In this regard, the Court finds the
21 Defendant's explanation of the 9,000 court orders is not
22 sufficiently credible to support a finding that these
23 records must be disregarded in considering whether
24 commonality exists. Similarly, Defendant's explanation
25 of the missing entries in the safety cell and restraint
26 chair logs does not convince the Court it should
27 disregard this proof of the County's deviation from
28
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written policy. Moreover, the Court may not, at this 1
stage in the proceedings, make a blanket credibility 2
determination as to all inmate grievances and 3
declarations based merely on Defendant's contention that 4
an inmate is an inherently untrustworthy person. 5

6 Finally, Defendant contends that the evidence it
7 submitted demonstrates "current" conditions in the
8 Riverside Jails, and that any allegations or evidence of
9 conditions or policies before January 1, 2013 are
10 irrelevant. Given current conditions and policies,
11 Defendant argues that Plaintiffs have failed to
12 demonstrate significant proof of any ongoing deficiencies
13 in the provision of health care. (Opp'n. at 17-19.) In
14 support for this argument, Defendant relies on cases
15 where it was undisputed that remedial measures were in
16 place, and the defendant moved for judgment as a matter
17 of law.42 See Kress v. CCA of Tennessee, LLC, 694 F.3d
18 890, 893-94 (7th Cir. 2012) (court granted summary
19 judgment in favor of the defendant on injunctive and
20 declaratory relief claims after jail warden testified
21

22

23

42Defendant also relies on cases where courts held

that individuals do have standing to seek class wide

24 injunctive relief solely on the basis of isolated

constitutional violations, such as a single illegal stop

25 or single illegal chokehold. See City of Los Angeles v.

Lyons, 461 U.S. 95, 105, 103 (1983); Hodgers-Durgin v. de

26 la Vina, 199 F.3d 1037, 1044 (9th Cir. 1999). These

cases are not applicable to the present action, where

27 named Plaintiffs and class members continue to be subject

to the Defendant's policies, and exposure in and of

28 itself constitutes an injury.

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that all inadequacies in prison conditions had been 1
resolved and plaintiff did not contest that the remedial 2
measures were taken). 3
4 The Court has reviewed all of the declarations and
5 documents submitted by the Defendant, and has noted where
6 there have been recent changes to the policies at issue
7 in the action. Plaintiffs' experts have also reviewed
8 the policies and opine that they remain constitutionally
9 inadequate despite the modifications. In addition,
10 Plaintiffs' proof of unofficial practices extends to 2013
11 and 2014. The County's declarations flatly refuting
12 these unofficial practices and its expert opinions
13 disputing the adequacy of specific instances of care does
14 not, in light of Plaintiffs' proof, undermine a finding
15 of commonality.
16
17 Moreover, in regard to the Defendant's intake
18 policies, the declarations of the County employees
19 confirm that actual intake practices differ from the
20 written policies. Under the MOU, "prior to any newly
21 booked inmate being housed in the jail population, a
22 follow-up intake health screening and assessment will be
23 completed on the inmate by a registered nurse." (MOU at
24 261.) The declarations of several county employees state
25 that an inmate is interviewed by a "classifications
26 deputy" before he is placed into general housing. (See
27 Adewunmi Decl. ¶ 4; Delgado Decl. ¶ 13; Reeves Decl. ¶ 8;
28
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Case 5:13-cv-00444-VAP-OP Document 131 Filed 09/02/14 Page 96 of 116 Page ID #:16415
Strong Decl. ¶ 5; McNamara Decl. ¶ 4.) An inmate is 1
referred to a medical or mental health staff only if he 2
or she discloses medical or mental health issues, or the 3
classifications deputy observes medical or mental health 4
issues. (See Adewunmi Decl. ¶ 4; Delgado Decl. ¶ 13; 5
Reeves Decl. ¶ 8; Strong Decl. ¶ 5; Wilson Decl. ¶ 20; 6
McNamara Decl. ¶ 4.) 7
8 In sum, Defendant's evidence and extensive
9 evidentiary objections confirm that there exist common
10 questions regarding the Defendant's systemic medical and
11 mental health care policies and practices.
12
13 ix. Commonality Conclusion
14 The Court has considered all evidence submitted in
15 support of, and in opposition to, the Motion, and finds
16 commonality exists as to the allegations that the
17 following systemic policies constitute deliberate
18 indifference to a substantial risk of serious harm. The
19 Court has included citations to where named Plaintiffs'
20 have alleged direct exposure to the policies43:
21
22
23
24
25 43The Court notes that none of the named Plaintiffs
26 specifically alleged that they were denied care as a result of inadequate medical staffing; however, several
27 Plaintiffs alleged delays in the distribution of medication that Plaintiffs’ experts attribute to
28 understaffing.
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a. Medical Care Subclass 1
• Inadequate medical staffing and reliance on 2
temporary staff (Wilcox Decl. ¶¶ 22, 27-29, 96, 3
114; Wilcox Reply Decl. ¶ 19). 4
• Ineffective intake screening performed by 5
untrained custody staff who fail to identify 6
health concerns and accurately record medical 7
issues on booking forms (Wilcox Decl. ¶¶ 31, 32, 8
115; Patterson Decl. ¶¶ 7-8; McClellan Decl. ¶ 9
3; Miller Decl. ¶ 14). 10
• Inadequate medical records system and note 11
taking practices that deviate from written 12
policies (Wilcox Decl. ¶¶ 13, 95, 96, 119; 13
Patterson Decl. ¶ 9). 14
• Failure to provide timely medical care (Wilcox 15
Decl. ¶¶ 39, 49, 51, 55, 59; Wohlfeil Decl. ¶¶ 16
4-6, 8-12; Patterson Decl. ¶¶ 10-12; Rosson 17
Decl. ¶ 5). 18
• Reliance on court orders to spur provision of 19
medical care (Wilcox Decl. ¶¶ 14, 38, 39; Wilcox 20
Reply Decl. ¶¶ 6-15; Wohlfeil Decl. ¶ 6; Gray 21
Decl. ¶ 10; Kujawsky Dep. at 43-45). 22
• Lack of adequate policies and procedures to 23
provide for specialty medical consultations and 24
procedures (Wilcox Decl. ¶¶ 63, 67; Wohlfeil 25
Decl. ¶ 7; Patterson Decl. ¶¶ 23-24). 26
• Deficient procedures in the distribution and 27
refill of medications, including delivery of 28
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evening pills in the early afternoon (Wilcox 1
Decl. ¶¶ 79, 81, 94, 115; Wohlfeil Decl. ¶ 13; 2
Patterson Decl. ¶¶ 13, 18-22; Gray Decl. ¶ 12; 3
Miller Decl. ¶ 9; Kujawsky Dep. at 49). 4
• Medical request and grievance policy that 5
inappropriately involves custody staff (Wilcox 6
Decl. ¶ 73, Reply Decl. ¶ 18; Gray Decl. ¶¶ 237
25). 8
9 b. Mental Health Care Subclass
10 • Inadequate mental health staffing and chronic
11 staffing shortages (Stewart Decl. ¶¶ 28, 29).
12 • Inadequate intake polices and procedures,
13 including reliance on intake officers with no
14 specialized training to conduct mental health
15 screenings during intake procedures (Stewart
16 Decl. ¶¶ 18, 30-37; Stewart Reply Decl. ¶ 12;
17 Miller Decl. ¶ 14).
18 • Inadequate mental health record-keeping system
19 (Stewart Decl. ¶ 100; McClellan Decl. ¶ 9).
20 • Failure to provide timely access to mental
21 health care, including reliance on court orders
22 (Stewart Decl. ¶¶ 51, 58; Stewart Reply Decl. ¶
23 13; Gray Decl. ¶ 16; McClellan Decl. ¶ 11;
24 Miller Decl. ¶¶ 5, 7-10; Rosson Decl. ¶ 12).
25 • Failure to manage mental health medication
26 administration (Stewart Decl. ¶¶ 66, 75),
27 including prescribing medication (Id. ¶¶ 39, 43,
28
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49), monitoring side effects and tracking 1
dangerous drug interactions (Id. ¶¶ 39-42), 2
relying on inmates to initiate refills of 3
medication, including psychotropic medication 4
(Id. ¶ 75); and failing to distribute medication 5
at proper times and in proper doses (Id. ¶¶ 39, 6
73, 76) (see Gray Decl. ¶¶ 6, 12, 14; McClellan 7
Decl. ¶¶ 7, 9, 10; Rosson Decl. ¶ 5, 6, 10). 8
• Inadequate suicide prevention policies, 9
including delegating decisions regarding removal 10
from safety cells to unqualified mental health 11
staff and conducting evaluations of inmates in 12
safety cells through the pill slot (Stewart 13
Decl. ¶¶ 78, 79, Stewart Reply Decl. ¶ 7; Gray 14
Decl. ¶ 22). 15
• Failure to care for inmates in safety cells and 16
restraint chairs, including failure to monitor 17
restrained inmates, perform regular motion 18
checks, administer mental health treatment, or 19
provide food and water. In addition, there is a 20
pattern of inmates being removed from safety 21
cells before the internal 48 hour time limit and 22
then being returned to the cell shortly after 23
(Stewart ¶¶ 88, 90, 92, 93, 95, 97, 98; Stewart 24
Reply Decl. ¶ 6 n.1; Gray Decl. ¶¶ 28-33; Rosson 25
Decl. ¶ 7). 26
• Failure to provide mental health treatment in a 27
confidential setting and grievance policy which 28
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inappropriately involves custody staff and 1
mental health practices (Stewart Reply Decl. ¶ 2
3; Gray Decl. ¶¶ 7, 8, 25-27, 35; Miller Decl. ¶ 3
13, 15, 16; Rosson Decl. ¶ 13). 4

5 The Court does not find commonality exists as to the
6 following alleged practices: unsanitary safety cells,44
7 inadequate facilities to conduct inmate interviews and
8 deliver medical treatment,45 quality assurance, and the
9 use of safety or restraint chairs for purely punitive or
10 disciplinary purposes.
11

12 3. Typicality
13 "The commonality and typicality requirements of Rule
14 23(a) tend to merge." Wal-Mart, 131 S. Ct. at 2555 n.1.
15 "The purpose of the typicality requirement is to assure
16 that the interest of the named representative aligns with
17 the interests of the class." Wolin v. Jaguar Land Rover
18 North Am., LLC, 617 F.3d 1168, 1175 (9th Cir. 2010).
19

20
44Dr. Stewart opines that the safety cells are often 21 filthy, but the only evidence he appears to rely on for
this conclusion are the declarations of two named 22 Plaintiffs. Defendant submitted a declaration from a
County employee stating that it is the County's policy to 23 clean the safety cells after every use, and any failure
to clean is a deviation from that policy. Evidence of 24 two instances of deviation from the policy is not
sufficient to demonstrate commonality. See Amador, 2014 25 WL 1679013, at *6 ("In light of these declarations,
plaintiffs' 168 declarations fall short of the 26 "significant proof" required to show that defendants had
a pattern and practice of strip searching CRDF inmates on 27 an unsanitary floor.").

28

45The allegations related to this alleged policy

appear to be limited to one of the five Riverside Jails.

(SAC ¶ 142.)

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"The test of typicality 'is whether other members have 1
the same or similar injury, whether the action is based 2
on conduct which is not unique to the named plaintiffs, 3
and whether other class members have been injured by the 4
same course of conduct.'" Ellis, 657 F.3d at 984 5
(quoting Hanon v. Dataproducts Corp., 976 F.2d 497, 508 6
(9th Cir. 1992). Thus, typicality is satisfied if the 7
plaintiff's claims are "reasonably co-extensive with 8
those of absent class members; they need not be 9
substantially identical." Id. 10
11 As discussed in regard to Defendant's argument
12 regarding standing, the alleged injury among the class
13 members is that the Defendant's medical and mental health
14 policies result in exposure to a substantial risk of
15 serious harm. Any differences in the named Plaintiffs'
16 specific medical or mental needs do not defeat
17 typicality. Accordingly, Plaintiffs have satisfied the
18 typicality factor.
19
20 4. Adequate Class Representation
21 Finally, under Rule 23(a)(4), the named plaintiffs
22 must be deemed capable of adequately representing the
23 interests of the entire class, including absent class
24 members. See Fed. R. Civ. P. 23(a)(4) (requiring
25 "representative parties [who] will fairly and adequately
26 protect the interests of the class"). The adequacy
27 inquiry turns on: (1) whether the named plaintiff and
28 class counsel have any conflicts of interest with other
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class members and (2) whether the representative 1
plaintiff and class counsel can vigorously prosecute the 2
action on behalf of the class. See Ellis, 657 F.3d at 3
985. 4

5 Defendant does not challenge the adequacy of any of
6 the named Plaintiffs as representatives. The Court notes
7 that two of the named Plaintiffs, Gray and Patterson, are
8 no longer subject to the custody of Riverside Jails and
9 are currently being held in state prison. That Gray's
10 and Patterson's individual claims have been rendered moot
11 does not render them, as proposed representatives of the
12 injunctive relief class, inadequate. See Cnty. of
13 Riverside v. McLaughlin, 500 U.S. 44, 52 (1991) ("That
14 the class was not certified until after the named
15 plaintiffs' claims had become moot does not deprive us of
16 jurisdiction."); Amador, 2014 WL 1679013, at *8. Thus,
17 the Court is satisfied that the named Plaintiffs do not
18 have any interests antagonistic to the remainder of the
19 class, nor does Plaintiffs' counsel have any conflicts
20 with the putative class. The named Plaintiffs have
21 actively participated in the litigation thus far, and
22 express an interest and commitment to responding to the
23 requests of class counsel and other parties in the
24 litigation. Accordingly, the named Plaintiffs are
25 adequate representatives.
26

27 D.
28

Rule 23(b) Since Plaintiffs have demonstrated they meet the

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requirements of Rule 23(a), the Court turns to Rule 1
23(b). Of the three basis for certification under Rule 2
23(b), Plaintiffs seek certification under Rule 23(b)(1) 3
and Rule 23(b)(2). 4
5 1. 23(b)(2)
6 Plaintiffs seek certification under Rule 23(b)(2).
7 Certification is appropriate under Rule 23(b)(2) when
8 "the party opposing the class has acted or refused to act
9 on grounds that apply generally to the class, so that
10 final injunctive relief or corresponding declaratory
11 relief is appropriate respecting the class as a whole."
12 Fed. R. Civ. P. 23(b)(2); Amchem Products, Inc. v.
13 Windsor, 521 U.S. 591, 614 (2009). "Rule 23(b)(2)
14 applies only when a single injunction or declaratory
15 judgment would provide relief to each member of the
16 class. It does not authorize class certification when
17 each individual class member would be entitled to a
18 different injunction or declaratory judgment against the
19 defendant." Wal-Mart, 131 S. Ct. at 2557. The "primary
20 role" of a 23(b)(2) action is to allow civil rights
21 actions seeking injunctive and declaratory relief to be
22 brought on a class wide basis. See Parsons II, 754 F.3d
23 at 686; Walters v. Reno, 145 F.3d 1032, 1047 (9th Cir.
24 1998) ("Rule 23(b)(2) was adopted in order to permit the
25 prosecution of civil rights actions."); Baby Neal for &
26 by Kanter v. Casey, 43 F.3d 48, 63 (3d Cir. 1994) ("The
27 writers of Rule 23 intended that subsection (b)(2) foster
28 institutional reform by facilitating suits that challenge
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widespread rights violations of people who are 1
individually unable to vindicate their own rights."); 2
Parsons I, 289 F.R.D. at 524 ("injunctive relief stemming 3
from allegedly unconstitutional conditions of confinement 4
are the quintessential type of claims that Rule 23(b)(2) 5
was meant to address."). 6
7 Plaintiffs contend that certification under Rule
8 23(b) is appropriate because the deficiencies in
9 Defendant's medical and mental health policies apply to
10 all members of the class, and thus injunctive and
11 declaratory relief are appropriate remedies. Plaintiffs
12 seek (1) a declaration that Defendant's acts, omissions,
13 and policies of the Defendant are in violation of the
14 rights of Plaintiffs under the Eighth and Fourteenth
15 Amendments; and (2) an injunction ordering Defendant to
16 "develop and implement, as soon as practical, a plan to
17 eliminate the substantial risk of serious harm that
18 Plaintiffs and members of the Plaintiff class suffer due
19 to Defendant's inadequate medical and mental care" that
20 addresses staffing, access, screening, emergency
21 responses, medication and supplies, chronic care, mental
22 health treatment, and quality assurance. (SAC ¶ 191.)
23 Defendant argues certification under 23(b)(2) is not
24 appropriate because Plaintiffs have failed to demonstrate
25 commonality and the proposed injunctive relief fails to
26 satisfy Rule 65(d). (Opp'n. at 35-38.)
27
28
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As discussed above, Plaintiffs demonstrated 1
commonality. Plaintiffs challenge alleged systemic 2
inadequacies in Defendant's medical and mental health 3
care policies, which are applicable to the proposed class 4
as a whole. If Plaintiffs succeed on their claims, 5
injunctive and declaratory relief will provide relief to 6
all members of the proposed class. See Parsons II, 754 7
F.3d at 686-87 (certifying 23(b)(2) class of prison 8
inmates challenging prison healthcare policies); Ashker 9
v. Governor of State of California, 2014 WL 2465191, at 10
*7 (N.D. Cal. June 2, 2014) (certifying 23(b)(2) class of 11
inmates at state prison challenging secured housing unit 12
confinement policy); Rosas, 2012 WL 2061694, at *5 13
(certifying 23(b)(2) class of prisoners challenging 14
policy of deliberate indifference to unlawful violence); 15
Amador, 2014 WL 1679013, at *8 (certifying 23(b)(2) class 16
of prisoners challenging prison strip search policy). 17
18 Defendant contends that class certification must be
19 denied because the request for relief is at a
20 "stratospheric level of abstraction" and fails to comply
21 with Rule 65(f). (See Opp'n. at 38 (citing Shook v. Bd.
22 of Cnty. Commissioners of Cnty. of El Paso, 543 F.3d 597,
23 604 (10th Cir. 2008))).46 Under Rule 65(f), an injunction
24
25 46In Shook the Tenth Circuit Court of Appeals
26 affirmed a district court's denial of class certification on the basis that the injunctive relief requested was too
27 vague. In Parsons II, the Ninth Circuit rejected reliance on Shook as out of circuit precedent, and then
28 reasoned that certification was proper even under the Shook standard because plaintiffs had described their (continued...)
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must state its terms specifically and describe in 1
reasonable detail — and not by referring to the complaint 2
or other document — the act or acts restrained or 3
required. Fed. R. Civ. P. 65(f). 4

5 In evaluating a proposed injunction at the class
6 certification stage in a prison conditions case, the
7 Ninth Circuit recently clarified that the district court
8 should assess whether the proposed relief is "is
9 appropriate respecting the class as a whole." Parsons
10 II, 754 F.3d at 689; Ashker, 2014 WL 2465191, at *7
11 ("numerous courts have expressly held that plaintiffs are
12 not required to satisfy Rule 65(d) in order to obtain
13 class certification."). This requirement is satisfied
14 where plaintiffs have described the "general contours of
15 an injunction that would provide relief to the whole
16 class, that is more specific than a bare injunction to
17 follow the law, and that can be given greater substance
18 and specificity at an appropriate stage in the litigation
19 through fact-finding, negotiations, and expert
20 testimony." Id. In a prison conditions case, it is not
21 feasible at the class certification stage to propose
22 specific remedies as any injunction must "closely track
23 the violations established by the evidence at trial,"
24 comply with the Prison Litigation Reform Act, account for
25

26

27

46(...continued)

injunction in sufficiently specific terms by submitting 28 expert testimony outlining the alleged policy

deficiencies and potential remedies. 754 F.3d at 689

n.35.

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changing conditions in prisons, and involve prison 1
officials in the process of determining an appropriate 2
remedy. Id. 3
4 In Parsons II, the Ninth Circuit affirmed
5 certification of a 23(b)(2) class of prisoners
6 challenging medical and mental health policies on the
7 basis that the injunctive relief proposed was based on
8 expert reports that explained how the challenged policies
9 were deficient and the sorts of policies remedies that
10 could alleviate the alleged violations. Id. Here, as in
11 Parsons II, Plaintiffs have provided the "general
12 contours" of the proposed injunctive relief by submitting
13 expert reports that identify specific deficiencies and
14 possible remedies. Accordingly, certification under
15 23(b)(2) is appropriate.
16
17 2. 23(b)(1)
18 Plaintiffs also seek certification under Rule
19 23(b)(1)(A) and 23(b)(1)(B). Under 23(b)(1)(A), class
20 certification is appropriate if the prosecution of
21 separate actions by individual members of the class would
22 create the risk of "inconsistent or varying adjudications
23 with respect to individual members of the class which
24 would establish incompatible standards of conduct for the
25 party opposing the class." Fed. R. Civ. P. 23(b)(1)(A).
26 A "core example" of an action under 23(b)(1)(A) is the
27 "situation in which many individuals, all challenging a
28 single government policy, bring separate suits for
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injunctive relief." Newberg on Class Actions § 4:11 (5th 1
ed.) Thus, certification is appropriate under 2
23(b)(1)(A) because if each member of the proposed class 3
litigated their claims individually there would be a risk 4
of that each individual case would impose a different 5
standard on the County. See Ashker, 2014 WL 2465191, at 6
*7 (certifying class of inmates claiming prison policy 7
violated the Eighth Amendment pursuant to 23(b)(1)(A)). 8
Accordingly, the requirements for certification under 9
23(b)(1)(A) are met. 10
11 An action under 23(b)(1)(B) is appropriate when
12 prosecuting "separate actions by or against individual
13 class members would create a risk of . . . adjudications
14 with respect to individual class members that, as a
15 practical matter, would be dispositive of the interests
16 of the other members not parties to the individual
17 adjudications or would substantially impair or impede
18 their ability to protect their interests." Fed. R. Civ.
19 P. 23(b)(1)(B). The classic application of the rule is
20 in "limited fund" cases, where the putative class
21 members' only source of recovery comes from a limited
22 fund. See Ortiz v. Fibreboard Corp., 527 U.S. 815,
23 834–838 (1999). Nevertheless, the rule may be applied
24 outside the "limited fund" context, and in particular has
25 been applied in actions by prisoners challenging the
26 conditions of their confinement. See Hilton v. Wright,
27 235 F.R.D. 40, 53 (N.D.N.Y. 2006) (certification of
28 inmate class challenging prison's Hepatitis C treatment
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policy under 23(b)(1)(B)); Ingles v. City of New York, 1
2003 WL 402565, at *8 (S.D.N.Y. Feb. 20, 2003) 2
(certification under 23(b)(1)(B) of class of inmates 3
challenging prison's use of force policy and seeking 4
injunctive relief); Coleman v. Wilson, 912 F. Supp. 1282, 5
1293 (E.D. Cal. 1995) (certification of inmate class 6
challenging prison's mental health care policies under 7
23(b)(1)(B)). 8
9 The Classes and Subclasses proposed seek injunctive
10 relief, that, if granted, would affect the rights of
11 similarly situated potential plaintiffs who are affected
12 by the Defendant's policies. If the Plaintiffs do not
13 succeed on the their claims, the ability of future
14 plaintiffs to challenge the same practice will be
15 inhibited under stare decisis. See Riley v. Nevada
16 Supreme Court, 763 F. Supp. 446, 453 (D. Nev. 1991)
17 (certification of class of inmates sentenced to death
18 challenging state court policies under 23(b)(1)(B)
19 because "collateral estoppel would not bind a subsequent
20 plaintiff to a finding of constitutionality. However, if
21 the subsequent plaintiff ended up in this particular
22 court, our previous finding of constitutionality would
23 bind the subsequent plaintiff as a practical matter
24 because of stare decisis.").
25
26 Defendant opposes certification under both sections
27 of 23(b)(1) on the basis that Plaintiffs have not
28 proposed an enforceable injunction. (Opp'n. at 39.) The
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Court has addressed Defendant's challenge to the proposed 1
injunction above, and accordingly, finds the Classes and 2
Subclasses appropriate for certification under Rule 3
23(b)(1)(A) and 23(b)(1)(B). 4
5 E. Appointment of Class Counsel
6 After certifying a Class and Subclasses, the Court
7 must appoint class counsel. Fed. R. Civ. P. 23(g).
8 Under Rule 23(g), the Court considers the work counsel
9 has done in identifying or investigating potential claims
10 in the action; counsel's experience in handling class
11 actions, other complex litigation, and the types of
12 claims asserted in the action; counsel's knowledge of the
13 applicable law, and the resources that counsel will
14 commit to representing the class. Id.
15
16 Plaintiffs' counsel submitted the declarations of
17 Shawn Hanson (Doc. No. 35) and Sara Norman (Doc. No. 30),
18 which attest to the experience, qualifications, and
19 resources of Akin Gump Strauss Hauer & Feld LLP ("Akin
20 Gump") and the Prison Law Office. These declarations
21 clearly establish that Plaintiffs’ counsel has extensive
22 experience in complex prisoner civil rights litigation
23 and class actions. Ms. Norman has worked at the Prison
24 Law Office for 18 years, and has represented prisoner
25 plaintiff classes in several complex and significant
26 actions in California. (Norman Decl. ¶ 5.) Similarly,
27 Mr. Hanson has represented plaintiffs in several civil
28 rights class actions, including multiple prisoner
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plaintiff civil rights actions. (Hanson Decl. ¶ 4.) In 1
addition, Akin Gump, and the Prison Law Office have a 2
long history of advocating on behalf of prisoners through 3
class action law suits. Indeed, the Prison Law Office is 4
a leading advocacy organization in this area of law. 5
6 Counsel has already invested thousands of hours
7 investigating potential claims, interviewing Plaintiffs
8 and class members, drafting declarations and pleadings,
9 and conducting discovery. (Norman Decl. ¶¶ 2-3; Hanson
10 Decl. ¶ 8.) Consequently, the Court finds that
11 Plaintiffs’ proposed counsel are more than qualified and
12 appoints the Prison Law Office and Akin Gump as class
13 counsel.
14
15 F. Stay
16 On June 5, 2014, the Ninth Circuit's opinion in
17 Parsons II affirmed certification of a class action
18 brought by prisoners challenging the provision of
19 healthcare and the conditions of confinement in prisons
20 under the control of the Arizona Department of
21 Corrections. The issues addressed in Parsons II are
22 largely similar to the questions presented in this case,
23 and the Court has looked to the reasoning of Parsons II
24 in ruling on class certification. On July 3, 2014, the
25 defendants in Parsons II requested a rehearing en banc.
26 On July 8, 2014, the plaintiffs in Parsons II were
27 ordered to file a response to defendants' request for
28 rehearing en banc, and on July 29, 2014, the Parsons II
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plaintiffs filed a Response to Petition for Rehearing En 1
Banc. The Ninth Circuit has not yet issued a decision as 2
to whether it will rehear Parsons II en banc. 3
4 The County argues that these events indicate that
5 Parsons is likely to be reversed en banc. At the
6 hearing, the Court raised the issue of a stay pending the
7 Ninth Circuit’s decision as to whether it will grant en
8 banc review of Parsons II. Although Defendant suggested
9 a stay would be appropriate at the hearing, the County
10 did not request a stay in a formal motion.
11
12 A district court has the discretionary power to stay
13 cases to control its docket and promote efficient use of
14 judicial resources. Dependable Highway Express v.
15 Navigators Ins. Co., 498 F.3d 1059, 1066 (9th Cir. 2007);
16 Lockyer v. Mirant Corp., 398 F.3d 1098, 1110–09 (9th Cir.
17 2005) (citing Landis v. North American Co., 299 U.S. 248
18 (1936)). "In determining whether a stay is appropriate
19 pending the resolution of another case, a district court
20 must consider various competing interests, including: (1)
21 the possible damage which may result from the granting of
22 a stay; (2) the hardship to the parties if the suit is
23 allowed to go forward; and (3) the orderly course of
24 justice measured in terms of the simplifying or
25 complicating of issues, proof, and questions of law which
26 could be expected to result from a stay." Nelson v.
27 Sisto, 2009 WL 2579194, at *1 (E.D. Cal. Aug. 20, 2009)
28 (citing Lockyer, 398 F.3d at 1110-09). The Court must
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balance the likely length of the stay against the 1
strength of the justification given for it; the longer 2
the stay, the greater the showing must be to justify it. 3
Yong v. I.N.S., 208 F.3d 1116, 1119 (9th Cir. 2000). 4
5 At this time it is uncertain whether the Ninth
6 Circuit will rehear Parsons II en banc. The Court notes
7 that Parsons is currently set for trial beginning on
8 October 21, 2014 and a stay has not been entered in that
9 proceeding. In this case, a stay would result in
10 hardship to the Plaintiffs, especially since the case
11 involves the alleged existence of conditions in the
12 Riverside Jails that result in inadequate medical and
13 mental health care for inmates. It is unknown how long
14 the Ninth Circuit will take to decide whether to consider
15 Parsons en banc. The uncertainty of the length of the
16 stay outweighs the interest in staying class
17 certification because there is a possibility Parsons will
18 be reheard en banc. Accordingly, a stay of this Order is
19 not warranted at this time. If Parsons is reheard en
20 banc, the Court will consider a motion to stay the
21 proceedings at that time.
22
23 VII. CONCLUSION
24 For the foregoing reasons, the Court GRANTS
25 Plaintiffs' Motion for Class Certification and DENIES
26 Defendant’s Motion to Dismiss. The following Class and
27 Subclasses are certified under Rule 23(b)(2), (b)(1)(A),
28 and (b)(1)(B) and defined as:
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(A) Class — all prisoners who are now, or will be in 1
the future, subjected to the medical and mental health 2
policies and practices of Riverside County. Named 3
Plaintiffs Gray, Patterson, Kujawsky, Wohlfeil Rosson, 4
McClellan, and Miller are appointed Class 5
Representatives. The class is certified as to the 6
alleged practices detailed in the Medical and Mental 7
Health Subclasses. 8
9 (B) Medical Subclass — All prisoners who are now, or
10 will in the future be, subjected to the medical care
11 policies and practices of the Riverside Jails. Named
12 Plaintiffs Gray, Patterson, Kujawsky, and Wohlfeil are
13 appointed class representatives. The Subclass is
14 certified as to the following alleged practices:
15 1. Inadequate medical staffing and reliance on
16 temporary staff;
17 2. Ineffective intake screening performed by
18 untrained custody staff who fail to identify
19 health concerns and accurately record medical
20 issues on booking forms;
21 3. Inadequate medical records system and note
22 taking practice that deviates from written
23 policies;
24 4. Failure to provide timely medical care;
25 5. Reliance on court orders to spur provision of
26 medical care;
27 6. Lack of adequate policies and procedures to
28 provide specialty medical consultations and
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procedures; 1
7. Deficient procedures in the distribution and 2
refill of medications, including delivery of 3
evening pills in the early afternoon; 4
8. Medical request and grievance policy that 5
inappropriately involves custody staff. 6
7 (B) Mental Health Subclass — All prisoners who are
8 now, or will in the future be, subjected to the mental
9 health care policies and practices of the Riverside
10 Jails. Named Plaintiffs Gray, Rosson, McClellan, and
11 Miller are appointed class representatives. The subclass
12 is certified as to the following alleged practices:
13 1. Inadequate mental health staffing and chronic
14 staffing shortages;
15 2. Inadequate intake polices and procedures,
16 including use of intake officers with no
17 specialized training to conduct mental health
18 screenings during intake procedures;
19 3. Inadequate mental health record system;
20 4. Failure to provide timely access to mental
21 health care;
22 5. Failure to manage mental health medication
23 administration, including prescribing
24 medication; monitoring side effects and tracking
25 dangerous drug interactions; relying on inmates
26 to initiate refills of medication, including
27 psychotropic medication; and failing to
28 distribute medication at proper times and in
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proper doses; 1
6. Inadequate suicide prevention policies, 2
including delegating decisions regarding removal 3
from safety cells to unqualified mental health 4
staff and conducting evaluations of inmates in 5
safety cells through the pill slot; 6
7. Failure to care for inmates in safety cells and 7
restraint chairs, including failure to monitor 8
restrained inmates, perform regular motion 9
checks, administer mental health treatment, or 10
provide food and water. In addition, there is a 11
pattern of inmates being removed from safety 12
cells before the internal 48 hour time limit and 13
then being returned to the cell shortly after; 14
8. Failure to provide mental health treatment in a 15
confidential setting and grievance policy which 16
inappropriately involves custody staff and 17
mental health practices. 18

19 (C) Akin and Gump and the Prison Law Office are
20 appointed counsel to the Class and Subclasses.
21

22

23

24 Dated:
25
26
27

September 2, 2014

VIRGINIA A. PHILLIPS United States District Judge

28

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 Case 5:13-cv-00444-VAP-OP Document 150 Filed 11/24/15 Page 1 of 63 Page ID #:16615

PRISON LAW OFFICE 1 DONALD SPECTER (SBN 83925)
SARA NORMAN (SBN 189536) 2 1917 Fifth Street
Berkeley, California 94710 3 Telephone: (510) 280-2621
Fax: (510) 280-2704 4 Email: dspecter@prisonlaw.com
snorman@prisonlaw.com
5

6 AKIN GUMP STRAUSS HAUER & FELD LLP

7

SHAWN HANSON (SBN 109321) DANIELLE GINTY (SBN 261809)

8

NICHOLAS GREGORY (SBN 275582) 580 California Street, Suite 1500

9

San Francisco, CA 94104-1036 Telephone: (415) 765-9500

10

Fax: (415) 765-9501 Email: shanson@akingump.com, dginty@akingump.com

11

ngregory@akingump.com

12 Attorneys for Plaintiffs

13

UNITED STATES DISTRICT COURT

14

FOR THE CENTRAL DISTRICT OF CALIFORNIA

15

EASTERN DIVISION – RIVERSIDE

16

17

18 QUINTON GRAY, et al., on behalf of themselves and all others similarly
19 situated,

20

Plaintiffs,

21 v.

22 COUNTY OF RIVERSIDE,

23 Defendant.

Case No. EDCV13-0444 VAP (OP)
CLASS ACTION
THIRD AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

24

25

26

27

28

THIRD AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 150 Filed 11/24/15 Page 2 of 63 Page ID #:16616

1

NATURE OF THE ACTION

2

1. Riverside County has one of the largest jail systems in California, with

3 nearly 4,000 men and women held in five detention facilities (“Riverside jails”).

4 This population consists of both pretrial detainees and people serving sentences in

5 local custody (collectively referred to herein as “prisoners”).

6

2. The thousands of men and women locked up in Riverside’s jails face

7 cruel and inhumane deficits in medical and mental health care. Defendant has

8 known for years that its inadequate health care delivery system places prisoners

9 entering the jails at a serious risk of harm but has failed to take the necessary steps

10 to mitigate the risk. As a result, prisoners in the Riverside jails are subjected to

11 policies and practices that systematically deprive them of their constitutional right to

12 basic life-saving care. Further, prisoners with disabilities face discrimination in

13 housing and in denial of reasonable accommodations as set forth below, in violation

14 of the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation

15 Act.

16

JURISDICTION

17

3. The jurisdiction of this Court is invoked pursuant to 28 U.S.C. §§ 1331,

18 1343, and 1367. Plaintiffs seek declaratory and injunctive relief under 28 U.S.C. §§

19 1343, 2201, and 2202; 42 U.S.C. § 1983; 42 U.S.C § 12101 et seq.; and 29 U.S.C. §

20 794.

21

VENUE

22

4. Venue is proper in the Central District of California under 28 U.S.C. §

23 1391(b) because Plaintiffs’ claims for relief arose in this district and Defendant is

24 located in the district.

25

PARTIES

26 Plaintiffs

27

28
1
THIRD AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 150 Filed 11/24/15 Page 3 of 63 Page ID #:16617

1

5. At the time of the filing of the Complaint and the First Amended

2 Complaint in the Case, Plaintiff Quinton Gray was a prisoner in the Riverside jails

3 in custody of Defendant Riverside County. He has multiple chronic medical and

4 mental health conditions, including seizures, high blood pressure, severe arthritis,

5 and visual and auditory hallucinations and depression. He has experienced repeated

6 treatment failures, including delays in adjusting medication regimens, lack of

7 appropriate laboratory monitoring and frequent missed doses. His initial intake

8 form, similar to other Riverside files, documented “no” to all questions (including

9 history of seizures and high blood pressure)—demonstrating inadequate intake

10 procedures. Even when Mr. Gray has been seen, he has not received adequate basic

11 primary care: for example, he was not screened for high cholesterol or diabetes,

12 despite his chronic high blood pressure.

13

6. Further, Mr. Gray was placed on potent psychotropic medications

14 which were either suddenly discontinued or multiple doses missed, placing him at

15 serious risk of serious side effects and psychiatric decompensation. He in fact

16 experienced significant, injurious side effects from his medication mismanagement

17 and treatment failures. Mr. Gray has exhausted his administrative remedies.

18

7. At the time of the filing of the original Complaint in this case, Plaintiff

19 Angela Patterson was a prisoner in the Riverside jails in custody of Defendant

20 Riverside County. After sustaining severe injuries in a car accident in June 2009,

21 Ms. Patterson had a temporary filter placed in her inferior vena cava (IVC), the

22 blood vessel supplying the heart, to prevent blood clots. She was booked into the

23 Riverside jails shortly thereafter, where she was subjected to multiple delays,

24 cancellations, appointment mix-ups, and failures to provide appropriate follow-up

25 regarding safe removal of the temporary filter. Nearly a year later, when she was

26 finally taken for surgery, it was found that the filter could not be removed due to the

27 build-up of scar tissue. As a result, Ms. Patterson is now condemned to a lifetime of

28

2

THIRD AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

Case 5:13-cv-00444-VAP-OP Document 150 Filed 11/24/15 Page 4 of 63 Page ID #:16618

1 daily anticoagulation medications and frequent laboratory monitoring, with

2 significant risk of fatal bleeds and other complications. She is 27 years old. If

3 physicians had appropriately obtained and reviewed her records, and made efforts to

4 refer her for IVC filter removal in a timely fashion, it is likely that the filter could

5 have been removed and Ms. Patterson would need no further treatment.

6

8. In addition, she has experienced multiple delays in follow-up with the

7 orthopedic and vascular surgery clinics. As of late 2012, she still had not had a

8 follow-up CT scan of her head to determine whether a growth on her scalp was a

9 slow-growing tumor, more than a year after it was ordered to be performed. Since

10 being placed on anti-coagulant therapy and for the duration of her stay in the

11 Riverside jails, she has also not had timely and effective medication monitoring and

12 administration, resulting in frequent stretches of time throughout her time in the jails

13 where her anticoagulation levels are too low or too high, placing her at risk for

14 further complications. Ms. Patterson has exhausted her administrative remedies.

15

9. At the time of the filing of the original Complaint in this case, Plaintiff

16 Stanley Kujawsky1 was a prisoner in the Riverside jails in custody of Defendant

17 Riverside County. He has been subjected to substandard care while in Defendant’s

18 custody, with inadequate medication administration and treatment of his high blood

19 pressure and multiple delays in the work-up and diagnosis of his chronic neck pain.

20 As a result, he has suffered and continues to suffer unnecessary pain and

21 Defendant’s treatment has endangered his cardiovascular health. Mr. Kujawsky has

22 exhausted his administrative remedies.

23

10. Plaintiff John Rosson III is a prisoner in the Riverside jails in custody

24 of Defendant Riverside County. Mr. Rosson suffers from bipolar affective disorder

25

26 1 Due to a clerical error, Mr. Kujawsky is referred to as Stanley Kwawsky or 27 Kujansky in the Riverside jail records.

28

3

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1 and has received and continues to receive substandard mental health care while in

2 the jails that has endangered his health and safety. While in the Riverside jails, he

3 has been prescribed major psychotropic medications which have repeatedly been

4 renewed without any regular assessment of his progress, side effects, and co-

5 existing medical issues, a clear violation of the standard of care and particularly

6 dangerous given his history of diabetes and hyperlipidemia, which can be worsened

7 by the psychotropic medications he takes. Acute psychiatric symptoms, such as

8 hearing voices, have been ignored by Riverside jail mental health treatment staff.

9 He suffers frequent lapses in medication delivery: after one such episode in early

10 2013, when he was denied his necessary psychotropic medications for more than

11 two weeks, he became actively self-harming and cut himself. As a result, he was

12 placed in a filthy “safety cell” with blood and feces on the wall and subsequently in

13 the county hospital for several days. He continues to experience medical delivery

14 interruptions to this day. Mr. Rosson has exhausted his administrative remedies.

15

11. At the time of the filing of the Second Amended Complaint in this case,

16 Plaintiff Brandy McClellan was a prisoner in the Riverside jails in the custody of

17 Defendant Riverside County. She experienced a dangerous and entirely predictable

18 and avoidable side effect of the psychotropic medications she was prescribed,

19 resulting in her hospitalization after she nearly collapsed and had serious cardiac

20 complications. Nonetheless, in order to get any attention from mental health staff

21 after returning from the hospital she had to file a health care request form (“blue

22 slip”) and wait several weeks to be seen by a psychiatrist. During this time, the

23 medications she had been misprescribed and which caused her hospitalization

24 continued to be presented to her at pill call. If she had not had the presence of mind

25 to refuse them, she could have been in serious danger. The treating psychiatrist was

26 not made aware of her hospitalization until she told him. Ms. McClellan has

27 exhausted her administrative remedies.

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1

12. At the time of the filing of the Second Amended Complaint in this case,

2 Plaintiff Julie Miller was a prisoner in the Riverside jails in the custody of

3 Defendant Riverside County. She is a chronic care patient with major depression

4 and suspected bipolar disorder. She is given Norvir for her medical condition in the

5 jails. In February 2013, Ms. Miller was prescribed Paxil and Trazodone. Norvir

6 inhibits the metabolism of both of these drugs and as a result, can increase blood

7 levels of the drugs to dangerous levels. Increased blood levels of Trazodone and

8 Paxil can be associated with more side effects, including dry mouth, sedation,

9 dizziness, and weight gain, which she has experienced. Also, both drugs increase

10 serotonin blood levels, placing Ms. Miller at higher risk of serotonin syndrome -- a

11 potentially life-threatening condition consisting of altered mental status, muscle

12 contractions, fever and autonomic instability. There is no notation in her medical

13 file to indicate that she was regularly assessed for possible side effects from these

14 medications, nor is there documentation that those medications were given at lower

15 doses while she was on Norvir. She has never been told about possible side effects

16 of new medications or monitored to determine their effects. Ms. Miller has

17 exhausted her administrative remedies.

18

13. At the time of the filing of the Second Amended Complaint in this case,

19 Plaintiff Michael Wohlfeil was a prisoner in the Riverside jails in the custody of

20 Defendant Riverside County. Since early 2011 Mr. Wohlfeil has suffered from

21 chronic daily diarrhea and has lost more than 30 pounds. Given this history, he

22 should have been promptly evaluated for possible colon cancer. But after an initial

23 referral in 2011, it took more than two years for Mr. Wohlfeil to be seen by a

24 gastroenterology clinic and finally receive a recommendation for an upper

25 endoscopy and a colonoscopy.

26

14. Early in his confinement in Defendant’s custody, Mr. Wohlfeil

27 complained of lumps on his skin; these tumors subsequently grew in number to

28

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1 cover much of his body. Despite the knowledge of the tumors by Jail medical staff,

2 however, no biopsies were done until October 2013. Had they been malignant, Mr.

3 Wohlfeil might not have survived Defendant's substandard medical care and

4 attention. Mr. Wohlfeil also reported lower extremity weakness and severe back

5 pain to Defendant’s staff in 2011. Although an MRI was ordered for him multiple

6 times, he did not receive one for two and a half years. Mr. Wohlfeil also reported a

7 history of Hepatitis C on his intake form in 2011, and was recommended for testing

8 for this disease in May 2011. Even though failure to conduct this testing put Mr.

9 Wohlfeil at risk for liver scarring and possible liver failure, he has never been tested

10 for Hepatitis C while in Defendant's custody. To get assistance from medical staff,

11 he has had to file grievances and obtain a court order. Mr. Wohlfeil has exhausted

12 his administrative remedies.

13

15. Plaintiff David Madrid is a prisoner in the Riverside jails in the custody

14 of Defendant Riverside County. He was born with a club foot: his right foot turns

15 inward significantly and his toes are curled in tightly, making him unable to walk

16 normally without footwear to correct for the condition. He has been refused

17 appropriate footwear in the Riverside jails. Since his arrival in August 2015, he has

18 been allowed only plastic slip-on shoes that fall off his foot and make it impossible

19 to walk normally, or to walk at all without serious pain. As a result, he has

20 significantly limited his walking and has lost his ability to exercise to maintain his

21 cardiovascular health. He has been refused the reasonable accommodation of shoes

22 that support his foot and allow him to walk without any valid justification for the

23 refusal.

24

16. Plaintiff Nikko Quarles is a prisoner in the Riverside jails in the

25 custody of Defendant Riverside County. On or about September 5, 2015, he was

26 seriously injured in an attack by other prisoners at Southwest Detention Center.

27 Among other injuries, his leg was broken. He was taken for emergency care to the

28

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1 Riverside County Regional Medical Center, where a cast was placed on his leg and

2 he was told that he cannot walk or place any weight on the leg. He was also given

3 crutches. He was returned to Southwest Detention Center the following day and

4 placed in a cell in the booking area of the jail. His crutches were taken from him,

5 over his protest, and placed outside his cell, out of reach. As a result, for the

6 approximately four days he spent in that cell, he had to crawl or drag himself from

7 his bunk to the toilet as well as to pick up his food from staff at his cell door. In

8 addition, when he left his cell for daily dressing changes for another wound, he was

9 refused his crutches and had to drag himself along the floor as a result. At times Mr.

10 Quarles found it impossible to avoid placing his weight on his injured leg, which

11 was contrary to medical orders and caused him severe pain.

12

17. Mr. Quarles was subsequently transferred to Presley Detention Center,

13 where he was again deprived the use of his crutches. He was placed in a cell with

14 the crutches once more outside his cell door. His complaints to the nurses he saw

15 daily were unsuccessful. Mr. Quarles was not provided his crutches until he was

16 seen by a doctor, approximately three to five days after his arrival at Presley. He

17 has subsequently been informed by medical staff that he would require another hard

18 cast on the leg because the premature walking he was forced to do might have

19 reinjured it. Although he currently has the use of crutches, he has no confidence

20 that staff will not once again confiscate them for no reason.

21

18. Mr. Quarles has never been charged with assault or any violent actions

22 in the Riverside jails

23

19. Mr. Quarles is currently housed on the seventh floor of the Presley jail,

24 which is considered sheltered housing for medical patients, solely because of his

25 inability to walk and his use of crutches. As a result, he has fewer privileges and

26 programming opportunities than he would if he were housed in general population.

27 He has no dayroom access and no religious programming in his current restricted

28

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1 medical housing, and for his GED class, he is merely provided with materials by a

2 teacher who comes to his door. At Southwest Detention Center before his injury, he

3 had daily dayroom access with other prisoners in his housing unit, church services

4 two to three times each week with community volunteers, and group classes for

5 GED students every other week.

6 Defendant

7

20. Defendant County of Riverside operates five jails -- the Robert Presley

8 Detention Facility, the Smith Correctional Facility, the Indio Jail, the Southwest

9 Detention Center, and the Blythe Jail – that incarcerate nearly 4,000 prisoners. The

10 County is responsible for providing a constitutional level of health care for those in

11 its custody, including the funding, oversight, and corrective action to ensure

12 adequate conditions. As a public entity, the County is also required to ensure that it

13 does not discrimination against prisoners with disabilities.

14
FACTUAL ALLEGATIONS
15

16 I. Riverside County exhibits systemic failures in the provision of basic

health care to prisoners in its jails.

17

21. Defendant, by policy and practice, maintains and runs a health care

18

system that lacks basic elements necessary to provide constitutional care: it

19

systematically fails to identify and diagnose serious conditions, to provide timely

20

care, to administer appropriate medications, to employ adequate staff to meet

21

prisoners’ basic needs, to maintain records that allow informed treatment decisions,

22

to establish legally required confidentiality, and to identify and correct its own

23

failings.

24

22. Prisoners’ access to health care is so inadequate at all the Riverside

25

jails as to constitute deliberate indifference to their serious medical and mental

26

health needs. Further, Defendant is deliberately indifferent to the fact that these

27

systemic failures result in significant injury and a substantial risk of serious harm.

28

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1

A. Delays in and denial of access to care

2

23. Defendant has a policy and practice of failing to provide timely access

3 to necessary health care and is deliberately indifferent to the risk of harm and injury

4 to prisoners that results from this systemic failure. Care is often delayed or denied

5 entirely, causing unnecessary pain and suffering as well as physical injury to the

6 patients. The two basic mechanisms to alert health care staff to prisoners’ needs --

7 intake screening and sick call – are inadequate in both policy and practice.

8
1. Intake screening and treatment planning

9
24. Riverside’s jail screening and intake process fails to adequately identify
10
and treat the medical and mental health care problems of newly arriving prisoners.

11
25. Insufficient numbers of nursing staff are available to identify and

12
evaluate medical conditions on intake, resulting in dangerous delays in treatment.
13
Prisoners are rarely assessed for communicable diseases when they arrive at the

14
jails, and medically high-risk prisoners do not have histories taken, physical

15
assessments, or treatment plans.
16
26. Plaintiff Quinton Gray arrived at the Riverside jails with a chronic

17
seizure disorder and high blood pressure. His initial intake form nonetheless has

18
“no” marked for every question about health care needs, including those that should
19
clearly be marked “yes.” Numerous other prisoners with longstanding chronic

20
conditions have intake forms with the same deficiencies, demonstrating an

21
inadequate intake screening process.
22
27. As a result, prisoners are placed at serious risk of harm. For example,

23
one woman who regularly takes medication for her chronic severe high blood

24
pressure entered the Riverside jails on September 9, 2011. She received no
25
medication or, indeed, any recorded medical screening or attention until she suffered

26
chest pain and hypertensive emergency nearly three weeks later. At that time, she

27

was sent to the emergency room at Riverside County Regional Medical Center

28

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1 (RCRMC) and found to have blood pressure of 230/140 -- high enough to cause a

2 stroke, vision loss, or a heart attack.

3

28. Another woman with multiple serious medical conditions, including

4 hypothyroidism, diabetes, and a recent history of gastric bypass surgery, had no

5 record of any of these crucial health factors on her booking form, in which every

6 question regarding the presence of health care needs was marked “no.” Treatment

7 for her serious chronic conditions was delayed, resulting in significant health risks.

8

29. Another patient who arrived in the Riverside jails with multiple

9 longstanding chronic conditions -- a seizure disorder, asthma, psoriasis, and

10 Hepatitis C -- had “no” marked for every question on his booking form regarding

11 medical history. As a result, he did not receive all of his necessary medications for

12 several weeks.

13

30. Another prisoner with a clear prior history of diabetes, glaucoma,

14 and arthritis has a booking form from August 2012 noting no chronic conditions and

15 no medications. It is unlikely, from subsequent records, that he failed to report his

16 conditions: his records show that he informed nurses at pill call five days later of the

17 conditions and he subsequently filed grievances and obtained court orders for care.

18

31. Plaintiff Julie Miller had to get court order to get her chronic care

19 medications started five months after her arrival in the Riverside jails.

20

32. Initial mental health screening at the jails is faulty because it is

21 performed by untrained custody staff, a practice that Riverside Sheriff Stanley Sniff

22 knows is inadequate and dangerous because, as he states, “correctional officers may

23 not recognize hidden medical and/or mental health problems that could be best

24 observed by a medical/mental health expert. This could result in delaying needed

25 treatment.” Appropriate screening is particularly important since, according to the

26 Sheriff, “the time period immediately following admission to a jail is the most

27 dangerous time for an inmate, and over half of in-custody deaths occurred within

28

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1 one month of admissions, with 24% of deaths occurring within two days of

2 admission.”

3

33. One man admitted to the Smith Jail had no recorded intake or screening

4 at all. He was eventually placed in a suicide watch “safety cell” and given

5 psychotropic medications (Zoloft and Trazodone). His medical records contain no

6 diagnosis, medical administration records, review of symptoms, psychiatric history,

7 social history, review of current medications, allergies, mental status examinations,

8 vital signs, risk assessments or treatment goals.

9

34. Plaintiff John Rosson was started on psychotropic medications

10 including Risperdal, Trileptal, Trazodone and Prozac with no recorded evaluation

11 for his underlying medical conditions, despite the fact that he had a noted history of

12 diabetes and hyperlipidemia and Risperdal can worsen these conditions.

13

35. Plaintiffs Quentin Gray, Julie Miller, and Brandy McClellan were

14 similarly prescribed powerful psychotropic medications with inadequate assessment

15 and treatment planning regarding medication interactions, safety, and efficacy.

16

36. Another patient was prescribed Trazodone, Risperdal and Zoloft

17 although he had a pre-existing seizure disorder and type-II diabetes. Risperdal

18 lowers the seizure threshold and can worsen type-II diabetes. On the day he was

19 prescribed Risperdal, Trazodone and Zoloft, he submitted a health needs request

20 stating he had a seizure in his cell. Risperdal should be attempted to be lowered or

21 discontinued if patients are having uncontrolled seizures prior to starting or on the

22 medication. There is no documentation of screening for active seizures prior to

23 initiating Risperdal and no documentation addressing co-management of his seizure

24 disorder and use of Risperdal with a neurology specialist.

25

2. Sick call and access to care

26

37. Even if their serious medical concerns are flagged at intake, patients are

27 often unable to obtain care because the sick call system is inadequate. Outside

28

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1 monitors have repeatedly found the Riverside jails incapable of providing the daily

2 sick call that state law requires. These conditions harm prisoners, who experience

3 extreme difficulty in obtaining necessary medical and mental health appointments.

4 In the absence of a functioning sick call system they must either obtain a court order

5 from the criminal court or file repeated blue slips (health care request forms) and

6 grievances. Plaintiff Quinton Gray has never seen a Riverside jail doctor without

7 an order from the Superior Court for care. He has received three orders: in late

8 2011, in June 2012, and in September 2012. Plaintiffs Stanley Kujawsky and

9 Michael Wohlfeil similarly have had to obtain court orders to see a doctor in the

10 Riverside jails.

11

38. Court orders, blue slips, and grievances regarding health care are

12 routinely ignored. The County maintains an extensive computerized list of court-

13 ordered appointments that notes how long the prisoners have been waiting; delays of

14 one, two, or three months are common. One prisoner obtained a court order on

15 November 21, 2011, that orders her “to see medical doctor within 48 hours to be

16 evaluated for severe pain due to hernia on back. Court recommends medication

17 treatment to control pain.” After waiting several weeks, the prisoner filed a

18 grievance asking that the order be honored. The response, dated December 23,

19 2011, acknowledged the court order and the month-long delay and stated that

20 “nurses confirmed they are waiting for the doctor to show up to see the court

21 orders.” Plaintiff Stanley Kujawsky was prescribed pain medication without ever

22 seeing a doctor in the jails; he received a court order on November 22, 2011, to see a

23 doctor for his pain, but was not actually seen until January 25, 2012.

24

39. Some prisoners who request medical attention are told that doctors are

25 only seeing patients with court orders for care.

26

40. Prisoners also file repeated blue slips without any result except a $3

27 charge exacted for each request. As a result, they are placed at serious risk of harm.

28

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1 For example, one patient filed numerous blue slips complaining of serious stomach

2 pain but was never seen by a doctor. After three months of such complaints, he

3 submitted a blue slip stating that he was vomiting blood, a symptom that can

4 indicate an emergency leading to death and which is at minimum is concerning for

5 gastric disease such as peptic ulcers or cancer. The patient should have seen a

6 physician immediately, had his vital signs and blood counts checked, and possibly

7 even have been referred to an emergency room or gastroenterologist for further

8 evaluation. None of this was done. He was not even referred to see a doctor for

9 another month.

10

41. Compounding the problem, prisoners often have extreme difficulty

11 grieving inadequate access to care since they must request grievance forms from

12 sheriffs’ deputies, who often refuse to provide them. Plaintiff Quinton Gray filed a

13 grievance in September 2012 noting serious ongoing problems with access to

14 medical and mental health care, and stating that he had to get a grievance form from

15 “an outside agency” because of custody staff’s refusal to provide him with a form

16 and their interference with access to adequate health care.

17

42. As a result of these policies and procedures, prisoners experience

18 dangerous delays in access to both primary and specialty care.

19

43. One woman entered the Presley jail with Stage Four colon cancer in

20 late July 2011. In early August, she was seen for abdominal pain, nausea and

21 vomiting, similar to the colon cancer symptoms she had experienced on first

22 diagnosis. Her outside medical records, obtained at that time by the County,

23 documented chemotherapy in 2009 for colon and ovarian cancer and a recent CT

24 scan showing possible recurrence. With these strong indicators that her cancer had

25 returned, she should have received a colonoscopy and referral to an oncologist

26 within a very few weeks. Although both referrals were made on August 3, neither

27 was completed by the time she was released from custody in December 2011. For

28

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1 more than four months, County medical providers demonstrated gross incompetence

2 and negligence, with unexplained delays, apparently lost referrals, and a botched

3 attempt at a colonoscopy, for which she was not given a basic bowel preparatory

4 procedure – an elementary mistake. Throughout this time, the patient repeatedly

5 complained of abdominal pain and rectal and vaginal pressure. The lack of care for

6 her malignancy possibly allowed it to progress to a point where she was no longer a

7 candidate for further treatment, shortening her life expectancy. The inadequate

8 treatment for her symptoms forced her to endure unnecessary pain and suffering.

9

44. Another woman with a breast tumor suffered significant delays in care:

10 she was denied timely appointments with a physician; multiple specialty

11 appointments were not scheduled or were skipped, despite physician referrals; and

12 she was frequently not notified of important test results such as biopsies, when

13 standard practice is to notify patients of results within one to two weeks. Nearly

14 every time her complaints were addressed by medical staff was in response to a

15 court order. Her tumor was found to be benign; had it been malignant, these

16 cumulative delays could have been life-threatening. Although she received some

17 medications to treat her ovarian cyst-related pain, she continued to have pain and

18 physicians failed to order a repeat vaginal ultrasound or refer her to gynecology for

19 further evaluation and management, as the standard of care requires.

20

45. Plaintiff Angela Patterson arrived at the Riverside jails following

21 surgery to place a temporary filter in a major blood vessel supplying her heart. She

22 was discharged directly from the RCRMC hospital to the jail. Despite the fact that

23 such filters should be removed within three months, there was no acknowledgment

24 of the existence of the filter in her jail medical records for over a month. Ms.

25 Patterson then endured many months of delays, cancellations, and scheduling mix-

26 ups in specialty care, as well as repeated medication administration failures that

27 have continued throughout her time in the Riverside jails. For nearly six months,

28

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1 medical staff documented confusion over whether the IVC filter was temporary or

2 permanent; they did not resolve the matter until March 2010, nine months after the

3 filter was placed in her body. She was not seen in surgery until June 25, 2010, at

4 which point it was discovered that the filter could not be safely removed because of

5 the accumulation of scar tissue.

6

46. Following the surgery, a Riverside jail doctor discontinued Ms.

7 Patterson’s anticoagulation medication because of “filter removal,” despite the fact

8 that it was still in her body and there was a note in her medical records from two

9 days earlier reporting that the filter had not been removed. In August 2010, she was

10 placed on life-long anticoagulation therapy. Anticoagulation therapy has significant

11 risks, including the risk of fatal bleeds, and requires daily medication and frequent

12 laboratory monitoring -- a weighty burden, particularly for Ms. Patterson, who is 26

13 years old. If physicians had appropriately obtained and reviewed her records and

14 made efforts to refer her for IVC filter removal in a timely fashion (within a few

15 months of placement), it is likely that the filter could have been removed and Ms.

16 Patterson would need no further anticoagulant therapy, with all the risks that entails.

17 The risks are significantly enhanced by the repeated medication administration

18 failures she continued to suffer throughout her time in the Riverside jails: the

19 frequent missed dosages, switched dosage times, and inadequate monitoring have

20 resulted in blood anti-coagulation levels so low as to put her at risk for blood clots.

21

47. A patient with chronic high blood pressure was inadequately screened

22 on intake, as described above, which resulted in an emergency room visit and

23 dangerously high blood pressure. Subsequent months in custody saw no

24 improvement in her care, as Riverside County medical staff failed utterly to monitor

25 her chronic condition. Her care was repeatedly delayed, prescribed medications

26 repeatedly not offered, and the sub-par care led to multiple episodes of uncontrolled

27 hypertension and preventable emergency room visits.

28

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1

48. A patient experiencing uncontrolled seizures and multiple emergency

2 room visits was not given a neurology referral for more than three months after his

3 arrival in the Riverside jails. After the referral was made, he waited for two more

4 months to actually see a neurologist, although he was having seizures two to three

5 times per week, often sustaining head trauma and other injuries, and although

6 managing his condition was clearly beyond the scope of a general medicine

7 practitioner. The neurologist recommended an EEG, which was never performed.

8 The patient continued to have uncontrolled seizures and emergency room visits; he

9 had another neurologist appointment two months later, at which point the EEG was

10 re-ordered. The patient was never referred to an epilepsy specialist, despite the clear

11 indication that his medication regime was ineffective and such a consultation was

12 needed. Continued, untreated generalized seizures place patients at high risk for

13 immediate injury (such as he repeatedly sustained) as well as worsening long-term

14 cognitive impairment, decreased function, and diminished quality of life.

15

49. Another patient arrived in jail with a lap-band that had been surgically

16 inserted into his stomach for weight loss. He soon began to demonstrate symptoms

17 of a esophageal obstruction (a known complication of such surgery), including

18 significant weight loss, nausea, vomiting, and extreme hunger. Despite numerous

19 requests for help, he experienced unnecessary delays in diagnosis and treatment and

20 failure to respond to his multiple health complaints. For example, after two

21 episodes of loss of consciousness, a documented 17-pound weight loss in 30 days,

22 complaints of inability to tolerate any food or liquid intake, and a blood pressure of

23 90/60, he was merely referred for a medical appointment more than a week in the

24 future. The delays in diagnosis of his obstruction put him at risk for serious health

25 complications due to rapid weight loss and deprivation of essential nutrients.

26

50. A prisoner who filed blue slips complaining of a head injury in

27 October 2012, after an assault, was given only Tylenol and not assessed for serious

28

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1 injuries for several days, despite repeated complaints of pain in his head and right

2 side, which are indicators of potential brain injury. When he was finally sent to the

3 emergency room, he was given a CT scan that showed a brain bleed. Fortunately,

4 the brain bleed was small; if he had suffered a more serious injury, the delay could

5 have been fatal.

6

51. Plaintiff Michael Wohlfeil experienced delays of more than two years

7 in getting even basic diagnostic tests to determine appropriate treatment for his

8 numerous tumors and his chronic diarrhea and weight loss.

9

52. Access to mental health care is no better. Defendant’s deficient system

10 forces mentally ill prisoners to wait weeks or months for mental health assessment

11 and evaluation by clinical staff, during which time they are denied essential

12 psychotropic medications and other treatment. The Sheriff admitted this problem in

13 July 2011, acknowledging that “such delays may impact an inmate’s mental

14 stability.” As with medical care, many mental health patients must file repeated

15 blue slips or grievances to get seen; others are only seen by clinicians after the

16 judges in their criminal cases have ordered care. Patients experience a range of

17 symptoms, from auditory hallucinations to severe depression, while enduring these

18 lengthy delays.

19

53. Plaintiffs Quinton Gray, John Rosson, Brandy McClellan, and Julie

20 Miller have all experienced significant delays in access to care. Instead of receiving

21 the appropriate oversight that standard of care demands for patients with their

22 significant mental health conditions, they have been forced to file blue slips and

23 grievances, get court orders, and seek help from outside advocates in order to

24 receive basic care and attention from mental health staff in the jails.

25

54. Patients with serious dental care needs suffer from the same pattern and

26 practice of injurious delays. Patients in severe pain wait for months to see a dentist

27 and face significant pain and suffering as a result. For example, one patient with

28

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1 only two functioning teeth lost more than 20 pounds in the six months he has been

2 incarcerated because he is unable to eat much of the food he is served and he cannot

3 afford to buy his own. He has submitted blue slips to see a dentist to get dentures

4 without success.

5

55. Another patient experienced serious delays in care: her complaints of

6 tooth pain were first documented in her health records in December 2011. On

7 March 17, 2012, a progress note in her file simply reads “Back upper Rt tooth broke

8 and gum swollen.” This one-line progress note, with no medical history, duration of

9 symptoms, or full exam, is inconsistent with accepted medical standards of care. In

10 addition, the patient was prescribed penicillin and motrin for her symptoms without

11 any mention of a dental referral or evaluation.

12

56. Another patient filed a request complaining of a broken tooth and

13 requesting a dental referral on September 21, 2011. He submitted a repeat request a

14 month later also requesting a dental referral. He was not seen for these complaints

15 until November 1, 2011, at which time medical staff noted that he had decayed teeth

16 and referred him to dental staff without any mention of his ability to eat or whether

17 the tooth looked infected. In the many months he has been waiting, he has

18 experienced intermittent severe pain in his teeth that makes him unable to eat

19 several times a week.

20

57. Plaintiff Michael Wohlfeil has suffered from chronic tooth pain caused

21 by cavities. He has had twelve teeth pulled in the last three years. In all but one

22 case, the dentist could not or would not provide Mr. Wohlfeil with a filling and told

23 him that he was only able to pull the teeth.

24

3. Specialty referrals and diagnostic tests

25

58. The Riverside jails lack adequate policies and procedures to provide

26 patients with needed referrals for specialty medical consultations and procedures.

27 For example, a patient with colon cancer was referred for a colonoscopy and to an

28

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1 oncologist on August 3, 2011, but neither was completed by the time she was

2 released from custody in December 2011. Given that her cancer was Stage IV, she

3 should have been seen in a very few weeks.

4

59. As discussed above, Plaintiff Angela Patterson experienced numerous

5 delays and cancellations in specialty referrals, which likely led to build-up of scar

6 tissue on a temporary filter in a blood vessel near her heart. As a result, she will live

7 the rest of her life with this filter in her chest and suffer a lifetime of serious

8 anticoagulation medication with related health risks and the burden of frequent

9 monitoring. In addition, a CT scan was ordered in January 2011 to be performed in

10 six months to rule out a possible slow-growing tumor on her scalp. As of January

11 2013, it had not yet been performed – well over a year late.

12

60. As discussed above, Plaintiff Michael Wohlfeil spent more than two

13 years waiting for specialty care and tests to diagnose and develop a treatment plan

14 for his chronic, debilitating diarrhea and the dozens of tumors that cover his body.

15 He still has not been tested for Hepatitis C, despite reporting a history of the disease.

16 These unacceptable delays exposed him to serious risk of harm.

17

61. Another man with uncontrolled seizures and multiple emergency room

18 visits was not given a neurology referral for more than three months after his arrival

19 in the Riverside jails. After the referral was made, he waited for two more months

20 to actually see a neurologist, although he was having seizures two to three times per

21 week.

22

62. A man who had experienced severe recent head injuries was ordered an

23 ENT consultation by a Riverside jail doctor but it did not take place and had to be

24 re-ordered one month later. When the ENT consultation finally took place, he was

25 not sent with his crucial records and the appointment was of limited use. He was

26 referred for surgery on September 30, 2011, but did not receive it, and despite

27

28

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1 repeated complaints of pain and two more court orders for care, he was not seen

2 again until November 8, 2011, when the surgery was re-ordered “ASAP.”

3

63. A patient with multiple chronic conditions -- a seizure disorder, asthma,

4 psoriasis, and Hepatitis C -- experienced multiple delays in obtaining timely

5 referrals, even after ordered by physicians, as well as follow-up, resulting in sub-

6 standard care.

7

64. One prisoner who complained of a tumor on his neck in September

8 2012 was referred for an ultrasound but it was not done for nearly six weeks, and the

9 results – which were atypical -- were not communicated to the prison for two weeks.

10 After the results were finally reviewed, he was ordered a CT scan and a surgery

11 referral “ASAP.” Despite this order and his complaints of worsening pain, he was

12 not seen in surgery for more than four weeks, at which time the CT scan was re-

13 ordered. The CT scan results showed some abnormalities, and a follow-up CT scan

14 and surgery consultation were ordered in December 2012, but the CT scan was not

15 done and the patient was not seen in surgery until March 2013, more than three

16 months after the referral.

17

65. The March 2013 appointment was of limited value because the

18 patient’s medical records from a previous surgery (ordered three months earlier) had

19 never been obtained. As it was, he was scheduled for surgery on April 3, but the jail

20 did not bring him to the surgery and it had to be rescheduled for several weeks later.

21 If this patient’s abnormal mass had proven to be cancerous, these delays could have

22 been deadly.

23

66. A diabetic prisoner was given substandard care for his chronic

24 condition. Hemoglobin A1c tests are standard monitoring mechanisms given to

25 diabetics every three months. Despite repeated orders, there are no hemoglobin A1c

26 test results in his records from his arrival in August 2012 through February 2013, a

27 failure that places him at serious risk for inadequate care. In the same time period,

28

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1 he was never given a foot exam, a standard annual precaution for diabetics to assess

2 for neuropathy, despite the fact that he was being medicated for peripheral

3 neuropathy.

4

4. Denials of care

5

67. Some prisoners face outright denials of basic and necessary medical

6 care. Plaintiff Quinton Gray was prescribed Dilantin on his arrival at the jail, but

7 even after two emergency room readings taken over the next few days showed that

8 the Dilantin level in his blood was far below the therapeutic level, jail medical staff

9 did nothing for well over a year. Plaintiff Michael Wohlfeil reported a history of

10 Hepatitis C on his arrival at the jail in 2011, and was recommended for testing, but

11 has not received it, placing him at risk for liver damage or failure.

12

68. A prisoner with thyroid disease was denied medication for nearly three

13 months. Although her initial screening form missed the condition, it was noted

14 repeatedly on her charts for several months by medical staff before she was finally

15 prescribed medication. Missed doses of thyroid medication for a prolonged period

16 put patients at risk for severe fatigue, slow heart rates, weight gain, constipation,

17 hair loss, edema, and eventually coma. The same patient also has a history of

18 gastric bypass surgery; the jail doctor refused her any dietary supplements to ensure

19 proper nutrition throughout her jail stay, despite repeated requests. Patients are at

20 risk for malnutrition following bypass surgery and require life-long vitamin

21 supplementation. In addition, no tests were ordered to assess any nutritional

22 deficiencies, another violation of the standard of care.

23

69. Another prisoner fell and hurt his back at Presley in November 2010

24 and again in March 2011. He was provided inadequate neurologic exams after his

25 falls, several-month delays for scheduling of x-rays and consultations (even when

26 ordered “as soon as possible”), and inadequate trial of physical therapy; his back

27 pain went essentially untreated. Two clinic appointments were cancelled due to

28

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1 “too many ad-segs” and one was cancelled because a wheelchair van was not

2 available.

3

70. A patient with high blood pressure and a history of coronary artery

4 disease complained to staff of an irregular heartbeat and chest pain in July 2012. He

5 was told simply to tell staff if it happened again, which is dangerously inappropriate

6 due to the serious risk of heart attack this patient presents. Five weeks later, he was

7 found unresponsive, pale, and sweaty, with high blood pressure and a heart flutter.

8 There is no indication in his medical records that any tests were done or vital signs

9 taken at the jail; he was subsequently hospitalized for several days. A month later,

10 in September 2012, the jail doctor ordered a regime of blood pressure checks (daily

11 for five days, weekly for two weeks, and then monthly) as well as a follow-up

12 appointment; the blood pressure checks were not done and the appointment never

13 took place. In November 2012, his blood pressure was found to be high, but he was

14 not seen by a doctor.

15

71. The same patient has records from July 2012 noting that he has

16 Hepatitis C, but there is no further follow-up regarding this condition in his medical

17 record, a clear violation of the standard of care, which requires a determination of

18 whether he has cirrhosis or is a candidate for treatment.

19

B. Substandard medication management and administration

20

72. Reliable and systematic medication delivery is an essential element to a

21 constitutional health care system. Defendant has a policy and practice of failing to

22 prescribe, provide, and properly manage medication, and of providing incorrect,

23 interrupted, or incomplete dosages. As a result, prisoners with serious health care

24 conditions are placed at substantial risk of harm and are in fact harmed.

25

73. Many patients are provided substandard care because there is

26 inadequate staff to distribute medications. (Staffing deficiencies are described in

27 more detail in the following section.) Medication deliveries are often skipped

28

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1 entirely, leaving patients without essential treatment. Plaintiffs Quinton Gray,

2 Angela Patterson, Stanley Kujawsky, and John Rosson have experienced numerous

3 skipped medication dosages at various Riverside jail facilities, placing Mr. Gray at

4 serious risk for heart attack, stroke, and seizures; exposing Ms. Patterson to an

5 increased risk of recurrent thrombosis; endangering Mr. Kujawsky’s cardiovascular

6 health, and seriously endangering Mr. Rosson’s mental health and risk of self-harm.

7

74. Other prisoners face the same problems. One patient who is prescribed

8 medications for his chronic high blood pressure has experienced a dangerous

9 number of missed doses: for example, in April 2011 he was not given nine doses of

10 both of his medications, and in September 2011 staff did not administer 14 doses of

11 one and eight doses of the other medication. Another patient who has been

12 prescribed medications for his diabetes has experienced numerous missed

13 medication doses – 21 missed doses in one month alone.

14

75. One patient with a fractured foot was prescribed pain medications but

15 repeatedly denied scheduled doses of his medications throughout the second half of

16 2012, despite his frequent requests.

17

76. In practice, medication distribution in the jails takes place only once or

18 at most twice daily, leaving patients who require multiple daily dosages, or bedtime

19 delivery, unserved. Since the Smith facility is so large, nurses start evening pill call

20 at approximately 2 p.m. to allow them to deliver medications throughout the

21 institution. This includes sleep medications: some patients receive their pills in the

22 middle of the afternoon and fall asleep within a few hours. Pill call is erratic for

23 many prisoners, and evening pills might arrive any time from 3 to 11 p.m., if at all,

24 which is particularly dangerous for diabetics, many of whom must receive

25 medications at regular intervals, coordinated with meal times. Plaintiffs Julie

26 Miller, Brandy McClellan, and John Rosson have experienced and continue to

27 experience these fluctuating medication delivery times to their detriment.

28

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1 Throughout 2012 and 2013, Plaintiff Angela Patterson has had her medications

2 delivered at inconsistent times, including being switched by jail staff from morning

3 to evening, despite the fact that the medication should be taken at the same time

4 daily, likely affecting her treatment stability.

5

77. Defendant’s policy and practice is to require patients to alert staff when

6 their medications run out. As a result, some prisoners’ prescriptions are not

7 renewed until they file multiple health care requests or grievances, resulting in

8 significant treatment interruptions with resulting, predictable harm to the patients.

9 Plaintiffs John Rosson and Julie Miller are two of the many prisoners who suffer

10 from this policy and practice. In another example, a patient at Southwest Detention

11 Center has experienced several one-month gaps between refills of his psychiatric

12 medications, including Paxil. Paxil has a well-documented discontinuation

13 syndrome: the lengthy lapses in medication delivery place him at serious risk for

14 severe discontinuation symptoms including flu-like symptoms, nausea, vomiting,

15 and headaches. A Presley patient prescribed pain medications for his severe back

16 pain is frequently deprived of the medications when the prescriptions run out and

17 refills are not provided; doctors also renew his medications without assessing their

18 efficacy.

19

78. Plaintiff Stanley Kujawsky has been denied medications on the days he

20 goes to court for hearings in his criminal case as well as on the days he goes to see

21 outside specialists for medical care. These deprivations are pursuant to policy and

22 practice: numerous other prisoners are denied medications altogether when they

23 attend court hearings or are transported to outside appointments. Some prisoners

24 regularly miss medications in the morning because they are asleep and staff

25 routinely fail to announce medication delivery effectively.

26

79. Riverside also has a policy and practice of failing to monitor the effects

27 of medication to determine whether dosages are correct or medications should be

28

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1 changed. Plaintiffs Quinton Gray, Angela Patterson, Stanley Kujawsky, Brandy

2 McClellan, Julie Miller, and John Rosson have suffered from inadequately

3 monitored medication regimens which have seriously endangered their health and

4 forced them to endure unnecessary pain and suffering. Their problems are typical of

5 those experienced by medical and mental health patients in the Riverside jails.

6

80. For example, one man with high blood pressure has been given two

7 medications to treat his condition, but on occasion, without explanation, he has been

8 abruptly discontinued from one of the medications. No monitoring of his condition

9 is documented in his medical records, suggesting that either such documentation is

10 missing or it was never charted -- either way, lack of proper documentation can be

11 dangerous for patient care and signifies a concerning level of disorganization within

12 the medical department.

13

81. The same patient’s file lacks any progress notes documenting any

14 blood pressure, history, physical exam or lab tests during the duration of treatment.

15 In general, when starting or changing blood pressure regimens, patients’ blood

16 pressures should be checked to ensure that they are not over-medicated or given low

17 blood pressure, which can be dangerous. In addition, without monitoring blood

18 pressure, there is no way to know if the patient was actually adequately controlled --

19 high blood pressure could put him at risk for strokes, brain bleeds and heart attacks.

20 Further, because one of his medications can be associated with electrolyte

21 abnormalities, the standard of care requires physicians to check basic blood tests for

22 sodium, potassium and kidney function levels either prior to or shortly after starting

23 such agents. None of this was done.

24

82. A diabetic man who entered the Riverside jails with an elevated blood

25 sugar count was prescribed medications and ordered glucose checks twice daily for

26 two weeks and then weekly thereafter, as well as various blood work. These orders

27 were apparently ignored, however, along with two subsequent orders for weekly

28

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1 blood sugar checks: his health records show only two glucose checks over the next

2 several months and no evidence that he ever had the blood work performed. This

3 failure to monitor his condition placed him at serious risk of harm, particularly since

4 one of the medications he was prescribed, Glipizide, can make patients

5 hypoglycemic.

6

83. In one of the most disturbing events of medication mismanagement, a

7 patient who was clearly documented as allergic to Dilantin was repeatedly

8 prescribed the medication, placing him at serious risk of medical complications. He

9 had to repeatedly refuse doses of the medication in June 2012.

10

84. Psychotropic medications also are not monitored to determine whether

11 they are effective or whether they cause severe side effects. Quinton Gray, Julie

12 Miller, and Brandy McClellan all experienced distressing and painful side effects

13 (including involuntary muscle contractions and incontinence for Mr. Gray,

14 significant weight gain for Ms. Miller, and severe cardiac complications for Ms.

15 McClellan) that could have been avoided or ameliorated with oversight, monitoring,

16 and treatment adjustment that met the community standard of care.

17

85. Patients face serious consequences from the denial of appropriate

18 medications. For example, one man experienced uncontrolled seizures resulting in

19 serious injuries. His medication regimen was clearly ineffective, but he was merely

20 prescribed increases in his existing medication, contrary to the standard of care. He

21 continued to suffer from frequent seizures and resulting physical injuries.

22

86. Another patient fell in his cell and hurt his hand (he uses a cane due to

23 leg injuries, but is only allowed it to ambulate longer distances). He was sent to the

24 emergency room one day later with increasing pain in his hand. He was found to

25 have suffered a fracture and prescribed Vicodin and Ibuprofen for the pain. He was

26 never given these medications on his return to the jail, and suffered unnecessary

27 pain as a result.

28

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1

87. Medication lapses can be particularly devastating in the mental health

2 realm. According to Sheriff Sniff, “continuity in delivery of mental health

3 medications may affect the stability of an inmate’s mental health and is critical to

4 inmate care.” More specifically, delays in administering psychotropic medications

5 to mental health patients can result in serious harm. Such harm is occurring in the

6 Riverside jails: prisoners experience frequent gaps in medication delivery, as the

7 Sheriff has admitted. Sometimes psychotropic medications are not distributed at all

8 in entire housing units, since nurses are simply overwhelmed. At other times,

9 patients’ medications are abruptly changed with no examination and no explanation.

10

88. These interruptions harm prisoners. Plaintiff John Rosson experienced

11 a lapse of more than two weeks in medication delivery, despite filing a blue slip and

12 speaking to a doctor about his need for the medications. As a result, he became

13 despondent and self-harming, cutting his arm and leg. He was placed in a filthy

14 safety cell and the county hospital, where his medications were final stabilized. The

15 medication failures have been of long standing: Mr. Rosson has filed repeated

16 grievances over the last several years regarding medication failures, but these

17 attempts to obtain appropriate care have been unsuccessful.

18

89. Similarly, over many months in the Indio, Presley, and Smith jails,

19 Plaintiff Quinton Gray had his powerful psychotropic medications either suddenly

20 discontinued or multiple doses missed. Another man held in the Presley facility

21 experienced significant lapses, without explanation, in receiving medication for his

22 bipolar disorder: his Zoloft was not renewed for nearly one month, and his Topomax

23 was not renewed for nearly three months. Further, neither medication was

24 appropriately titrated on being restarted. Sudden discontinuation of these

25 medications can cause manic episodes and seizures as well as physical symptoms

26 such as nausea, vomiting, and headaches; sudden resumption after a significant gap

27

28

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1 in time can also cause damaging side effects. The patient in fact experienced

2 depression and severe mood swings due to the medication mismanagement.

3

90. Similarly, a patient at Smith had his psychotropic medications and

4 dosages changed repeatedly over two years, including the abrupt and unexplained

5 cessation of his antipsychotic medications. A Presley patient also had psychotropic

6 medications abruptly started, stopped, and renewed over several years with little or

7 no evaluation or assessment. This pattern and practice of medication

8 mismanagement places these patients at serious risk for decompensation, untreated

9 mental illness, and severe side effects.

10

91. Another patient arrived at the jails with a diagnosis of bipolar disorder,

11 on psychiatric medications, and with a reported history of prior suicide attempts.

12 Bipolar disorder has one of the highest rates of suicide for any psychiatric condition,

13 20 to 30% higher than the suicide rate of the general population. He was prescribed

14 Lithium and Depakote, medications typically used for bipolar disorder. He had

15 multiple documented suicide attempts while in jail, and multiple visits to safety

16 cells. Despite severe and life-threatening suicide attempts there is no documentation

17 of any psychiatric intervention, including psychiatric hospitalization, assessment or

18 change in medications. Even after repeated attempts at self-hanging he continued to

19 have access to implements by which he could attempt to hang himself again. When

20 he did receive medications, they were not given as directed and were given

21 inconsistently.

22

92. Another prisoner has a history of high blood pressure treated with the

23 medication Norvasc. He was started on the drug Olanazapine. A patient with this

24 history should have had baseline labs done prior to initiation of Olanazapine,

25 including a lipid panel and HbA1C levels, because Olanazapine can cause weight

26 gain, hyperlipidemia and metabolic syndrome, which would place him at higher risk

27 of cardiac and metabolic complications. No such baseline assessment was done.

28

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1 This patient's medical administration records indicate that on multiple occasions he

2 was not given Risperdal. Missing doses of Risperdal can cause discontinuation

3 symptoms of nausea, sweating, dizziness and dyskinesias.

4

93. Another prisoner was prescribed Thorazine and Prozac. This patient's

5 medications were renewed late, doses were not delivered, and his medications were

6 abruptly discontinued, with no indication that he was assessed prior to

7 discontinuation and no rationale given for discontinuation. This left the prisoner at

8 risk for rebound tardive dyskinesias, extrapyramidal symptoms, and worsening

9 psychiatric symptoms.

10

94. Another prisoner with a history of schizophrenia was prescribed a high

11 dose of Thorazine, which was suddenly discontinued in October 2012. Sudden

12 discontinuation of Thorazine can lead to rapid decompensation of psychotic

13 symptoms (e.g., voices, paranoia). His antipsychotic was restarted two months later

14 but at a much lower dose. The two-month period without an anti-psychotic

15 medication left him at risk for worsening psychiatric symptoms. Two weeks later he

16 attempted suicide by cutting his neck and wrists and was hospitalized.

17

C. Severe staffing deficits

18

95. Many of the deficits described herein stem from the inadequate health

19 care staffing levels maintained by Defendant in the jails. There are simply not

20 enough doctors, nurses, mental health providers, pharmacists, or medical records

21 staff to meet the needs of the population.

22

96. Defendant’s policy and practice of severely understaffing health care

23 positions in the jails is long standing and has been repeatedly censured by the county

24 Grand Jury. In 2010, the Grand Jury found that “[m]ental health staff is not

25 available in any county jail facility in sufficient numbers to identify and treat in an

26 individualized manner those treatable inmates suffering from serious mental

27

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1 disorders.” The Grand Jury Report released on June 14, 2012, states the problem in

2 clear terms:

3

In July, 2011, DMH was advised. . . .that the medical/mental health

4

staffing levels in county jails needed to be restored to 2007 levels, in

5

order to be in compliance with [state law]. As of this writing, the

6

Grand Jury learned through sworn testimony that during the eight

7

months following the 2010-2011 Grand Jury report, DMH staffing

8

levels were allowed to decrease even further.

9

97. Medical care is no better: according to the independent Inmate Medical

10 Quality evaluators, invited by Sheriff Sniff to identify deficiencies in jail health

11 care, “[t]he request for medical care exceeds the capability of the staff to meet the

12 demands.” The Detention Health Services administrator agreed, admitting that “the

13 demand exceeds the resources available to provide the requested services.”

14

98. Long-term medical vacancies are endemic, particularly given the

15 competition with the higher salaries offered by the state prison system. For

16 example, at the beginning of 2011, there were only three physicians for well over

17 3,000 prisoners in the five jails. Two doctors subsequently resigned and for at least

18 several months, there was not a single physician, physician assistant, or nurse

19 practitioner working in the Riverside jails – only a “Chief of Medical Specialty”

20 who rarely saw patients. Only two of the five full-time physician positions in the

21 jails were filled as of May 31, 2012.

22

99. Other medical staffing is also deficient. As of May 2012, the County

23 had multiple vacancies for nurses and nurse supervisors, and only 65 of 101 total

24 Detention Health Services positions were filled. Further, according to the state’s

25 Corrections Standards Authority (CSA), a body with statutory duty to regularly

26 inspect county facilities, “there is no budget for overtime and no staff available to

27 provide services in the event of illness, injury, or vacation.”

28

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1

100. Staffing has not improved meaningfully since that time. As of

2 September 2013, the County had only a 63% fill rate for medical staff in the jails,

3 including three of five physician slots vacant; all three nurse practitioner slots

4 vacant; and 22 of 57 institutional nurse slots vacant. County records from October

5 7, 2013, show similar severe deficiencies: three of five physician slots are still

6 empty and the sole physician’s assistant position is also empty. The October 2013

7 records further show 28 out of 73 institutional nurse positions vacant (including

8 senior and supervisor positions, and excluding positions at the juvenile halls) and 16

9 out of 42 licensed vocational nurse positions vacant (excluding positions at the

10 juvenile halls).

11

101. Defendant lacks the staff necessary to provide minimally adequate

12 dental care. By the County’s own assessment, two full-time dentists and two full-

13 time dental assistants are required to offer basic dental care to the nearly 4,000

14 prisoners. As of May 2011, only one dentist and one dental assistant were working

15 in the jails. As of October 2013, there were still just one chief of dentistry and one

16 dental assistant working in the jails.

17

102. A patient at the Smith Jail with chronic high blood pressure filed a

18 grievance complaining that although the doctor had ordered blood pressure checks

19 every three days, he had only received them twice in the preceding 23 days. The

20 grievance response from Senior Corporal Diaz confirms that the patient “is still not

21 having his blood pressure checked. When he asked the nursing staff they stated they

22 do not have the time.”

23

D. Violations of patients’ confidentiality rights

24

103. According to the Grand Jury, Riverside “has no confidential self-

25 referral system by which inmates can request mental health care without revealing

26 the nature of their request to correctional officers,” as required by federal and state

27 law. See 45 C.F.R. §§ 164.500 et seq.; Cal. Civil Code §§ 56.10 et seq. Requests

28

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1 for medical care have historically not been confidential, since they too have been

2 delivered to medical staff by custody staff. Prisoners were until recently directed to

3 give blue slips requesting health care directly to custody staff; many believe that

4 they must provide as much detail as possible about their health care needs in order

5 to increase their chances to be seen. It remains to be seen whether the policies,

6 changed on paper, result in improved privacy. Further, many prisoners, including

7 Plaintiffs Gray and Kujawsky, also must file grievances in order to be seen by

8 clinicians. To get grievance forms, they must persuade custody staff that their

9 concerns are significant. The grievances are then heard by custody staff, who make

10 the determination whether to involve health care staff.

11

104. Examination space at Southwest Detention Center is not confidential:

12 patients can overhear other patients’ examinations through an open door, as they

13 wait in the hallway for their own treatment.

14

105. In addition, mental health care encounters are often held in the

15 presence of custody staff and even other prisoners. Such violations of privacy do

16 not allow for effective treatment, since they reduce the likelihood that patients will

17 provide a thorough account of their concerns and needs. Plaintiffs Miller, Rosson,

18 and Gray have all experienced such substandard mental health encounters.

19

E. Poor records administration

20

106. Adequate health care cannot be provided in the absence of adequate

21 health records: clinicians must know their patients’ medical histories, past diagnoses

22 and treatment, and for psychiatric patients, a history of suicidal thinking or attempts.

23

107. Riverside’s medical records system is profoundly disorganized and

24 incomplete. Some psychiatric patients have no diagnosis recorded, despite the

25 prescription of psychotropic medications. Some patients are prescribed medications

26 but lack any record of medication administration in their file, or any record that the

27

28

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1 effects of the medication were tracked and reviewed. All three Plaintiffs’ health

2 care records demonstrate Riverside’s failures in this area.

3

108. It is not surprising that record-keeping is inadequate: as of December 6,

4 2011, the entire medical records staff for five jails and well over three thousand

5 prisoners was three medical records technicians and no medical clerks.

6

109. The record-keeping gaps impact patient care because clinicians and

7 nurses will be unable to track physician’s orders, medication administration records,

8 and general patient care.

9

F. Inadequate quality assurance

10

110. Not surprisingly, given the paucity or records and severe staffing

11 shortages, Riverside officials lack the ability to identify and correct the problems

12 described herein. Health care staff do not systematically correct identified

13 deficiencies, and there is inadequate staff for oversight and review of care.

14 II. Even If Prisoners See Health Care Providers, They Do Not Receive Constitutionally Adequate Medical or Mental Health Care
15
111. As detailed in the previous section, Riverside’s lack of the basic
16
elements of a health care delivery system -- policies and procedures to ensure timely
17
access to appropriate care, medication management, adequate staffing, patient
18
confidentiality, medical records, and quality assurance – harms Plaintiffs and
19
members of the plaintiff class. Even when they are able to see health care providers,
20
prisoners are by policy and practice denied adequate medical and mental health care
21
in the Riverside jails: they experience gross treatment failures, inadequate
22
examinations, and the failure to provide necessary specialty appointments and
23
diagnostic tests.
24
A. Substandard medical care
25
112. Plaintiffs Gray, Patterson, Kujawsky, and Wohlfeil, on behalf of
26
themselves, the plaintiff class, and the medical subclass, assert the following.
27

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1

113. Prisoners – even those with serious medical conditions -- rarely see

2 physicians, and health care records demonstrate a paucity of appropriate follow-up,

3 monitoring, and specialty referrals, as well as improper care.

4

114. Plaintiff Quinton Gray has chronic high blood pressure that has been

5 inadequately monitored and controlled by Riverside jail medical staff. He has

6 experienced multiple elevated blood pressure measurements without any assessment

7 of the efficacy of his medications and dosages. He has twice gone without blood

8 pressure check for more than four months, despite his history of elevated readings

9 and despite the fact that regular readings had been ordered by physicians. In

10 addition, he is frequently not provided his medications at all, thus increasing his risk

11 of poorly controlled blood pressure. Uncontrolled blood pressure can cause heart

12 attacks, heart failure and strokes.

13

115. Mr. Gray’s seizure disorder has also been inadequately treated. He was

14 prescribed Dilantin on his arrival at the jail, but two emergency room readings taken

15 over the next few days showed that the Dilantin level in his blood was far below the

16 therapeutic level. Jail medical staff did nothing for well over a year, at which point

17 a Dilantin level check was ordered, then re-ordered after it was not performed.

18 Moreover, Mr. Gray is frequently not provided his Dilantin at all, placing him at

19 serious risk for seizures, which he has experienced in the jails.

20

116. Plaintiff Angela Patterson has experienced significant and damaging

21 sub-standard health care, as described above, which has likely caused her permanent

22 injury.

23

117. Plaintiff Stanley Kujawsky has chronic high blood pressure. Sub-

24 standard care in the Riverside jails has endangered his cardiovascular health. First,

25 multiple dosages of his blood pressure medication have not been administered as

26 prescribed at several different jails. He has been denied his long-prescribed

27 medications on his transfer to different jails in the Riverside system and has been

28

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1 denied medications when jail staff allow the prescriptions to run out without

2 refilling them. He is also denied medications on the days he appears in court as well

3 as the days he has specialty care appointments in the Riverside county hospital, in

4 part because there are no medical staff on duty at the Presley jail who could deliver

5 the medications on his return, after 6 p.m. As a result of these missed dosages of

6 blood pressure medication, Mr. Kujawsky has suffered from abrupt and repeated

7 fluctuations in his blood pressure.

8

118. Mr. Kujawsky has filed repeated grievances on this denial of

9 medications, notably on June 15, 2012; July 15, 2012; August 15, 2012; and January

10 30, 2013. These grievances have either been granted or ignored, but the problem

11 has not been solved.

12

119. Further, the blood pressure medication Mr. Kujawsky has been

13 prescribed in the jails -- Clonidine -- is usually a last-resort drug to control blood

14 pressure since it can cause severe dizziness and low blood pressure and in particular

15 can cause rebound tachycardia (an elevated heart rate) if doses are missed. It should

16 not be prescribed unless a patient can take it consistently and reliably, which is

17 clearly not the case in the Riverside jails, as medical staff should well know and as

18 is amply demonstrated by the medication administration record showing repeated

19 missed doses of his medications. Moreover, the frequent use of Ibuprofen, as

20 prescribed to Mr. Kujawsky, can also elevate blood pressure, which has likely

21 contributed to some of his high readings.

22

120. Plaintiff Michael Wohlfeil has experienced significant and damaging

23 sub-standard health care, as described above, which has placed him at serious risk of

24 harm.

25

121. Other patients experience similarly inadequate and at times life-

26 threatening medical care. For example, one patient arrived in the Riverside jails

27 after having been assaulted with a crowbar just three weeks earlier. He had spent

28

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1 two of those weeks in the hospital and had undergone surgery to repair his jaw and

2 implant hardware. Despite obvious facial injuries and blood noted in his ear on his

3 arrival at the jail, he was not seen by a doctor for three weeks, and not until he

4 received a court order for treatment. At that time, his severe recent head trauma was

5 noted and the doctor ordered an ENT consultation. However, it did not take place,

6 and the consultation had to be re-ordered one month later. Following a second

7 court-ordered doctor’s appointment, the patient’s implanted hardware was found to

8 be coming out of his jaw. He was diagnosed in the emergency room with a

9 fractured dental plate. He was again referred for an ENT consultation, which finally

10 took place a week later. Because he was not sent with his crucial records, however,

11 the appointment was of limited use. He was referred for surgery on September 30,

12 2011, but did not receive it; despite repeated complaints of pain and two more court

13 orders for care, he was not seen again until November 8, when the surgery was re-

14 ordered “ASAP.” Throughout, the patient was never seen except in response to a

15 court order. Repeated warning signs – complaints of incontinence, evidence of

16 memory loss and confusion – were ignored, and there are no documented attempts

17 to determine whether he was experiencing brain trauma symptoms or displaying

18 underlying dementia, psychiatric disease, or cognitive deficits. Had the patient

19 been evaluated when he was first noted to have his injuries at the time of booking,

20 with records requested sooner and a more timely evaluation and appointment in both

21 the ENT clinic and the oral and maxillofacial surgery clinic, his serious

22 complications could have been minimized and they certainly would have been

23 treated earlier, likely reducing the unnecessary pain and suffering that he endured.

24

122. A patient at the Smith jail was seen by a nurse for ear pain on August 2,

25 2011. The doctor did not examine him, but prescribed medication over the

26 telephone. Five days later he was seen again by a nurse for worsening pain and

27 redness of the ear; the doctor, again over the telephone, referred him to the

28

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1 emergency room at RCRMC. Following that visit, the same doctor prescribed

2 antibiotics over the telephone, which he never received. Two weeks later, he had

3 another emergency room visit and was again prescribed the same antiobiotic by the

4 same doctor by telephone. Three weeks after that, on September 15, the patient

5 underwent tympanoplasty and mastoidectomy at RCRMC. On his return to the jail

6 after the surgery, he was prescribed Vicodin and antibiotics over the telephone but

7 never received them. On September 22, he reported blood coming from the ear but

8 was only seen by the nurse and not a doctor; the doctor ordered medications over the

9 telephone. He again reported bleeding on October 1 to the nurse but was not seen

10 by a doctor. He was finally seen on October 5, 2011, by a specialist at RCRMC and

11 was noted to have pus in his ear. Throughout the entire ordeal, he never once saw a

12 doctor at the jail.

13

123. Another patient with a long history of seizures endured many months

14 during which he was denied all seizure medications. Jail medical staff were aware

15 of his seizure disorder on November 8, 2011, but despite multiple blue slips

16 requesting care, he was not prescribed seizure medications until April 9, 2012. He

17 suffered several seizures in custody which would likely have been prevented if he

18 had been evaluated by a physician sooner and continued on his stable, home anti-

19 seizure medication regimen.

20

124. Another patient was seen, pursuant to court order, for ovarian cyst-

21 related pain. She was given some medication but continued to have pain. Jail

22 physicians failed to order a repeat vaginal ultrasound or refer her to gynecology for

23 further evaluation and management, as the standard of care requires.

24

125. Even when prisoners get to see the doctor, the examinations are often

25 ludicrously inadequate. Patients at Presley are “examined” in the non-contact

26 attorney visiting booth. However, instead of sitting on the well-lighted attorney side

27 of the booth facing the patient behind glass, the doctor places himself outside of the

28

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1 booth, where the deputies ordinarily sit, visible only through a slot for passing

2 documents. No meaningful physical examination is possible under such conditions.

3 Without meaningful physical examinations, the standard of care cannot be met.

4

B. Substandard mental health care

5

126. Plaintiffs Gray, Rosson, McClellan, and Miller, on behalf of

6 themselves, the plaintiff class, and the mental health subclass, assert the following.

7

127. Riverside County lacks an adequate system to provide a basic level of

8 constitutional mental health care. In the absence of such a system, the County fails

9 utterly to provide appropriate, informed diagnoses and treatment plans, ensure

10 continuity of psychotropic medication, monitor prisoners prescribed such

11 medication, make available medications that are effective in treating serious mental

12 disorders, or provide necessary therapeutic treatment.

13

128. Many prisoners do not get the right medications, the right dosages, or

14 appropriate ongoing care: the Grand Jury found that “[i]nmates with assessed

15 moderate mental health problems such as neuroses, phobias, panic disorders, etc.,

16 are not always offered appropriate mediation and counseling by qualified staff to get

17 and maintain them in a stable condition.” As a result, they suffer severe side effects

18 and decompensation.

19

129. Mentally ill prisoners are regularly started on powerful psychotropic

20 medications with no record of any evaluation or treatment plan that takes into

21 account medication interactions and underlying medical conditions. This practice is

22 dangerous because it does not allow subsequent monitoring or review, and places

23 patients at serious risk of harm through lack of treatment or inappropriate treatment

24 for their mental illness.

25

130. Even prisoners prescribed appropriate medications face frequent

26 disruptions in medication delivery, including abrupt cessation and missed pill

27

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1 deliveries, which cause serious suffering for these mentally ill patients, as described

2 in more detail in the prior section on medication administration.

3

131. No tracking is done of patients’ symptoms and any reaction they might

4 have to the medication, except for a cursory, non-confidential questioning at their

5 cell doors. The monitoring of vital signs such as weight, cholesterol, and glucose

6 levels, which is essential to ensure the patients are not suffering adverse effects from

7 psychotropic drugs, is absent. Dosages are changed abruptly, with no explanation.

8

132. On arrival in the Riverside jails, Plaintiff Quinton Gray was prescribed

9 several powerful psychotropic medications with no evaluation or assessment by a

10 mental health professional regarding his underlying physical condition and medical

11 treatment needs, and no baseline laboratory test to monitor known risky side effects

12 of the medications.

13

133. One of his medications, Geodon, must be taken with food or much of it

14 is not absorbed. Mr. Gray was not ordered to be given his Geodon with food, which

15 placed him at risk for varying blood levels and varying side effects and efficacy. He

16 was also started on the maximum dose, which increases the risk of severe side

17 effects such as acute muscle stiffness and tremors. Several months later, Mr. Gray’s

18 medications were discontinued suddenly without appropriate tapering off of the

19 maximum dose of Geodon, which placed him at risk for rebound tardive dyskinesia,

20 seizures, discontinuation syndrome (flu-like illness) and decompensation of

21 psychiatric symptoms (paranoia, hallucinations, and thought disorganization).

22

134. Months later, Mr. Gray was started on a second antipsychotic while

23 also on Geodon, despite the lack of clinical evidence that treating schizophrenic

24 patients with two antipsychotics provides better efficacy or treatment outcomes, and

25 despite the increased risk of side effects and drug-drug interactions. When

26 prescribed together, Mr. Gray’s two medications increase the risk of tardive

27 dyskinesia (such as tongue-biting), acute muscle stiffness and tremors, and cardiac

28

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1 events (arrhythmias). Both medications also lower the seizure threshold and when

2 given together in a patient with a history of seizure disorder, could cause increased

3 seizure events.

4

135. In July 2012, Mr. Gray was started on Benadryl and Cogentin at the

5 same time, with no documented explanation in his health care records. There is

6 never a need to treat a patient with both of these medications at the same time, and

7 they have multiple side effects including constipation and delirium.

8

136. Multiple doses of Mr. Gray’s medications have not been administered

9 to him during his stay in the jails. Missed doses can alter blood levels in a way that

10 increases side effects (including worsening of tardive dyskinesia), variably changes

11 seizure thresholds and can cause decompensation of psychiatric symptoms.

12

137. As a result of Defendant’s failed mental health delivery system, Mr.

13 Gray has in fact experienced twitching, tongue-biting, increased seizures and tongue

14 swelling, all predictable side effects from taking near maximum dose of these two

15 antipsychotic medications. He lives with racing thoughts, disorientation,

16 depression, and chronic sleep loss. He has not been appropriately monitored or

17 treated for these damaging side effects and signs of the inefficacy of his medication

18 regimen.

19

138. Plaintiff John Rosson, as described above, has experienced repeated

20 failures to adequately treat and monitor his serious mental illness, culminating in an

21 extended deprivation of his long-term psychotropic medications. As a result, he

22 decompensated and exhibited symptoms of self-harm serious enough to warrant

23 hospitalization.

24

139. Plaintiff Brandy McClellan experienced medication mismanagement

25 that severely endangered her health when she was started on Thorazine, an outdated

26 antipsychotic medication far from the standard of care in a modern mental health

27 delivery system, along with Vistaril, a medication with overly sedating effects that

28

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1 may impair a patient’s ability to realize there is a problem. Thorazine presents an

2 unacceptable risk of sudden death due to cardiac arrhythmia and in fact, Ms.

3 McClellan experienced a cardiac event serious enough to land her in the hospital.

4 Riverside mental health staff not only failed to monitor her when she was placed on

5 this dangerous combination of medications, but they were unaware of the dangerous

6 effect she experienced, and the medications continued to be offered to Ms.

7 McClellan daily at pill call for weeks after her hospitalization. They were not

8 changed until she herself notified mental health staff. This event demonstrates

9 dangerous indifference to patient care.

10

140. Plaintiff Julie Miller has also been placed at serious risk by substandard

11 care in the Riverside jails. She has been prescribed multiple psychotropic

12 medications that have the potential to interact dangerously with each other and with

13 one of her physical medications, with no adjustments or monitoring of her condition

14 to assure her safety and the efficacy of her mental health care.

15

141. These failures are typical of the policies and practices that produce

16 substandard mental health care generally for patients in the Riverside jails. For

17 example, one Southwest Detention Center patient was maintained on Paxil, an

18 antidepressant with an extremely short-half life that can lead to a severe

19 discontinuation syndrome if the dose is missed even for 24 hours. He has

20 experienced multiple incidences of missing days of medications as well as not

21 having his medications renewed for one month periods, placing him at risk for

22 severe discontinuation symptoms as well as decompensation. There are no

23 medication monitoring standards set in place, particularly to monitor for weight gain

24 on Paxil. His medications were repeatedly renewed without evidence of evaluation.

25

142. Another patient housed in Presley was started on multiple

26 antipsychotic, anti-depressant, and bipolar disorder medications. Multiple times her

27 medications were renewed, stopped, started or changed without any documentation

28

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1 or assessment: in particular, her medications were renewed repeatedly for more than

2 two years without any indication of ever being evaluated by a medical doctor;

3 during this period two new medications were started without a medical evaluation or

4 documentation of informed consent; and once her medications were not renewed for

5 an entire month. Sudden discontinuation of medications puts patients at risk for

6 severe side effects and decompensation of psychiatric illnesses. She was also

7 started on multiple medications at high doses without appropriate titration, resulting

8 in severe side effects, and subjected to the abrupt discontinuation of medications

9 that might have been helpful for her symptoms. Further, she was placed on safety-

10 cell observation but was never evaluated by a medical doctor despite this being a

11 psychiatric emergency.

12

143. Another Presley patient was prescribed multiple psychotropic

13 medications, two of which are relatively contraindicated and should have had clear

14 documented psychiatric necessity for concomitant use including special monitoring

15 for side effects. There was none in her records.

16

144. Further, the patient was started and stopped on multiple medications

17 and had doses changed without any documentation of evaluation for efficacy, side

18 effects or informed consent. Such reviews were essential for this patient, since she

19 was placed on Thioridazine, a drug used to treat psychosis, anxiety and insomnia,

20 that with long-term use can cause tardive dyskinesia, a highly distressing and

21 uncomfortable phenomenon consisting of involuntary movements. There is no

22 documentation she was ever evaluated for such side effects.

23

145. In addition, she had significant periods of not receiving her medications

24 as well as frequent missed delivery of individual doses, placing her at risk for

25 discontinuation syndrome including intense anxiety, flu-like symptoms, headache,

26 nausea/vomiting, and parasthesias as well as rapid decompensation of mental illness.

27 Moreover, despite missing significant periods of medications, the medications were

28

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1 suddenly restarted or given again at their regular doses rather than appropriately re-

2 titrated. One of her medications, Lamotrigine, can result in a life-threatening rash if

3 it is suddenly started after stopping it for several days, as happened in her case.

4 Sudden starting of Paroxetine, another of her medications, can lead to severe gastro-

5 intestinal upset, sedation and anxiety.

6

146. A patient at Smith was started on numerous psychotropic medications

7 without any documentation he was monitored for efficacy or side effects. He

8 experienced significant lapses in medication administration, placing him at risk for

9 discontinuation syndrome associated with his medications, including severe

10 headache, nausea, vomiting, flu-like symptoms, agitation and anxiety.

11

147. One reason for this inadequate care might be the abysmally poor

12 communication with clinical staff that some prisoners experience. For example, one

13 Smith prisoner described his interview as taking place in a non-contact attorney

14 visiting booth, with glass separating doctor from patient. He answered some

15 questions from the psychiatrist, who then held up a piece of paper on which he

16 wrote words such as “mood swings” and “voices.” The patient nodded in response.

17 No history was taken – he is a disabled veteran with severe anxiety and PTSD – and

18 there was no discussion of medication side effects. The entire session lasted 15-20

19 minutes. The psychiatrist then briefly held up a piece of paper with information

20 about medications, but the patient did not have a chance to read it. The psychiatrist

21 handed the paper to a deputy, who gave it to the patient and rushed him to sign it.

22 When the patient asked, “can I read it?” the deputy responded: “just sign it.” The

23 patient did not find out the names of the medications he was prescribed for three

24 days after he started taking them. For the first two days, when he asked the nurses

25 the names of the pills, they would respond but he could not understand. When he

26 requested clarification, they would say “next person” and rush him through.

27

28

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1

148. Another prisoner arrived at the Smith jail with a list of her prescribed

2 psychotropic medications, which was placed in her property. She waited two weeks

3 to see a psychiatrist, but could not recall for him which medications she had taken

4 and did not have the list to consult. He told her he would prescribe medications and

5 when she asked for her diagnosis, and he responded “That is not important right

6 now, just go ahead and take your medications.” A week later, the pills arrived and

7 she took them without knowing what they were. Within three days, she experienced

8 a severe reduction in her ability to function and could not walk unassisted. She

9 stopped taking the pills. A week later, her mother spoke to a sergeant and told him

10 that the medication list should be retrieved from her property. He assured her it

11 would be done and the proper pills would be dispensed. The following day, new

12 pills arrived, which again made her feel “woozy” and “dizzy.” She again stopped

13 taking them.

14

149. A crucial element of an adequate mental health care delivery system is

15 an appropriate means to assess and monitor patients who exhibit or contemplate

16 self-harming behavior. Here, too, Riverside’s practices fall far short of acceptable

17 mental health care procedures. Prisoners believed to be suicidal or self-harming are

18 placed in a barren cell with only a rough smock to wear and a hole in the ground to

19 relieve themselves. The so-called “safety cells” are often filthy and stink of the

20 urine and feces that is visible on the walls and floor. Patients are left in the cells for

21 many days, with inadequate monitoring or supervision and no meaningful treatment,

22 under lights that are never turned off. Plaintiff Quinton Gray was forced to endure

23 these conditions for 48 hours simply because he told custody staff on entering the

24 jail that he needed psychiatric medications. John Rosson has also experienced the

25 damaging conditions and treatment deprivations in safety cells and, like many other

26 Riverside patients, has been moved in and out of the regional medical center for

27 suicidality to little effect. Another man was placed in a safety cell and removed

28

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1 more than a day later with no risk assessment, explanation, or criteria for removal –

2 a gross departure from the standard of care.

3

150. Riverside’s current practices concerning use of safety cells and safety

4 “restraint chairs” are ineffective and potentially dangerous. Deputies routinely log

5 that prisoners are placed in safety cells for “destroying jail property” or for being

6 “combative with jail staff.” Using the safety cell as a punitive measure exceeds the

7 proper use of such placements, which is to protect and treat patients who exhibit or

8 contemplate imminent self-harming behavior. It also makes it less likely that

9 patients will report serious emotional distress or suicidal ideation. People placed in

10 Riverside’s safety cells sometimes go more than 10 or 20 hours without offers of

11 food, and 10 hours or more without offers of water.

12

151. In some cases, when placing a prisoner in the safety cell, deputies also

13 strap his or her arms and legs to a restraint chair, completely immobilizing that

14 person for hours or even days at a time. These placements are often disciplinary as

15 well, such as for “destruction of jail property.” These chairs are dangerous: as

16 reported in the national press, they have caused the death of people subjected to

17 their use in other jurisdictions, some who suffered from seizures and choked to

18 death on their own vomit and others who developed blood clots from the

19 immobilization and died as they were released from the chair. Even without causing

20 death, the improper use of these chairs can exacerbate patients’ injuries while

21 preventing them from demonstrating the need for immediate medical care.

22 Riverside’s logs of restraint chair use are limited to documenting the time that the

23 chair is used and do not indicate why the chair was used or why the duration of its

24 use was appropriate; the logs also demonstrate frequent failures in provided

25 necessary checks on the restrained person’s welfare. These practices remove

26 accountability and depart from the standard of care required for mental health

27 treatment.

28

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1 III.

Defendant has known for years of the significant risk of harm from its inadequate jail health care system and has failed to take reasonable steps

2

to mitigate the risk to prisoners

3

152. Defendant Riverside County has for many years woefully underfunded

4 detention health care. The lack of infrastructure and staff to deliver life-saving care

5 has resulted, as Sheriff Stanley Sniff has told the Board of Supervisors, in a “crisis

6 in the jail system.”

7

153. The County’s own Grand Jury as well as several independent auditors

8 have come to the same conclusion: dangerous deficits in health care services at the

9 jails threaten the lives and health of the thousands of men and women they hold.

10

154. The severe deficiencies in health care services in Riverside’s jails are

11 thus well established by admissions from Sheriff Sniff and reports from state and

12 county watchdogs and independent auditors. Defendant has long been aware of the

13 harm its deficient system causes to patients with serious health care needs through

14 these reports as well as numerous grievances and health needs requests from

15 prisoners. Defendant’s failure to take action to ameliorate the conditions constitutes

16 deliberate indifference to Plaintiffs’ serious health care needs.

17

155. Several 2011 reports documented extensive health care violations in the

18 jails. The 2010-11 Grand Jury Report: Riverside County Detention Health Care

19 Administration found systemic failures in treatment, medication management,

20 record-keeping, and administration of forced medications, among other areas. On

21 July 5, 2011, the Sheriff responded that he “generally concurs with the findings of

22 the Grand Jury and has been outspoken on the need to remedy these issues over the

23 last two years.”

24

156. The Grand Jury’s report on mental health care deficiencies, 2010-11

25 Grand Jury Report: Mental Health Detention Services, noted serious health care

26 staffing deficiencies. Again, the Sheriff agreed with this assessment. The Grand

27

28

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1 Jury released an updated report in June 2012, noting that mental health staffing has

2 in fact decreased since its prior year’s report.

3

157. The Sheriff invited the state’s Corrections Standards Authority (CSA),

4 a body with statutory duty to regularly inspect county facilities, to perform an

5 additional inspection in January 2011. The CSA found numerous violations of state

6 law, including a widespread failure to provide daily sick call and insufficient

7 oversight of prisoners on suicide watch. They also found serious deficits in

8 medication administration: missed pill calls, night-time medications administered

9 between 4 and 6 p.m., and prisoners going to court denied medications entirely.

10

158. At the CSA’s recommendation, Sheriff Sniff contracted with the

11 independent Inmate Medical Quality (IMQ) to identify deficits and make

12 recommendations. IMQ performed their evaluation May 2-5, 2011, and reported

13 significant and potentially harmful systemic deficiencies in staffing, screening, sick

14 call, quality assurance, medical records, management of communicable diseases,

15 medication management, and use of restraints and safety cells for suicidal or self-

16 harming prisoners. As with both of the Grand Jury reports, the Sheriff accepted

17 these findings as requiring immediate and drastic attention.

18

159. The health care deficiencies in the Riverside jails, and Defendant’s

19 awareness of them, predate the 2011 reports and stem in part from years of drastic

20 cost-cutting measures. As Sheriff Sniff has explained, the County made “deep cuts

21 to medical personnel staffing levels” in fiscal year 2008-09, which “unacceptably

22 impacted the delivery of medical services. . . and other jail operations.” Instead of

23 correcting the problem, the County made another 20% reduction in medical and

24 mental health care staff as of July 1, 2010.

25

160. On January 12, 2012, Plaintiffs’ counsel sent Defendant officials a

26 sixteen-page letter detailing the systemic problems set forth in this Complaint.

27

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1 Defendant did not make any substantive response to the specific concerns described

2 in the letter.

3

161. The County’s systemic failures, as outlined in this Complaint, in

4 Plaintiffs’ January 2012 letter, and in the numerous reports of independent auditors,

5 result in significant injury and the unnecessary and wanton infliction of pain in

6 violation of the Eighth and Fourteenth Amendments. The injuries, as described

7 above, include drastically inadequate cancer treatment that may have significantly

8 decreased one patient’s life expectancy; severe and unnecessary pain;

9 unconstitutional conditions on suicide watch; exacerbated mental illness from

10 failure to provide appropriate screening and medications; and severe reactions from

11 inadequate and frequently interrupted medication delivery.

12 IV. Disability discrimination

13

162. The County, by policy and practice, discriminates against certain

14 prisoners with disabilities in the following ways.

15

163. Prisoners with mobility impairments who are housed in special units

16 because they have mobility impairments or use assistive devices are provided fewer

17 privileges and programming as a result. This denial of privileges and programming

18 constitutes disability discrimination. For example, Plaintiff Nikko Quarles is housed

19 in the medical floor at the Presley jail solely because of his mobility impairment and

20 use of crutches. As a result, he is denied the dayroom access and religious

21 programming he had before he became disabled, and his educational programming

22 opportunities are more limited.

23

164. Prisoners who need reasonable accommodations for their mobility

24 impairments have been denied or have faced significant delay or difficulty obtaining

25 them due to unduly restrictive security concerns. For example, Plaintiff David

26 Madrid, who has a club foot, has been repeatedly denied footwear that would allow

27

28

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1 him to walk normally and without serious pain, despite the fact that such footwear is

2 available and provided to other prisoners.

3

165. Prisoners who use assistive devices such as canes, crutches, and

4 walkers, have them confiscated or disallowed due to unduly restrictive security

5 concerns and have been provided no substitute or n inadequate or poorly functioning

6 substitute. For example, Plaintiff Nikko Quarles, who has no record of violence in

7 the Riverside jails, has been denied the use of his crutches both inside and outside of

8 his cell, despite the fact that he is under doctor’s orders not to place weight on his

9 injured leg. As a result, he has had to crawl and drag himself to obtain basic

10 services such as nursing care and use of the toilet, causing him pain and possibly

11 further injuring his leg.

12

CLASS ACTION ALLEGATIONS

13 Plaintiff class

14

166. Plaintiffs bring this action on their own behalf and, pursuant to Rule

15 23(a), b(1), and (b)(2) of the Federal Rules of Civil Procedure, on behalf of all adult

16 men and women who are now, or will be in the future, in the custody of Riverside

17 County and who are now, or will be in the future, subject to an unreasonable risk of

18 harm due to Defendant’s policies and practices of denying prisoners minimally

19 adequate medical care and minimally adequate mental health care, and are subject to

20 disability discrimination based on failure to provide equivalent programming in

21 restricted housing and failure to provide reasonable accommodations for mobility

22 impairments.

23

167. The class is so numerous that joinder of all members is impracticable.

24 There are currently nearly 4,000 people incarcerated in the five Riverside jails, all of

25 whom are entirely dependent on Defendant for medical and mental health care. All

26 prisoners are at risk of developing serious medical and mental health conditions

27 while in the Riverside jails. Due to Defendant’s policies and practices, all Riverside

28

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1 jail prisoners receive or are at risk of receiving inadequate health care while in the

2 Riverside jails.

3

168. There are questions of law and fact common to the class including

4 whether the failure to provide minimally adequate medical and mental health care

5 violates the Due Process Clause of the Fourteenth Amendment and the Cruel and

6 Unusual Punishment Clause of the Eighth Amendment to the United States

7 Constitution and whether Defendant has been deliberately indifferent to the serious

8 health care needs of class members. Defendant is expected to raise common

9 defenses to these claims.

10

169. Since there are several thousand class members, separate actions by

11 individuals would in all likelihood result in inconsistent and varying decisions,

12 which in turn would result in conflicting and incompatible standards of conduct for

13 Defendant.

14

170. Defendant has acted and failed to act on grounds that apply generally to

15 the class, so that final injunctive or corresponding declaratory relief is appropriate

16 respecting the class as a whole.

17

171. The claims of the named Plaintiffs are typical of the claims of the class

18 and subclasses, since their claims arise from the same policies, practices, and

19 courses of conduct and their claims are based on the same theory of law as the

20 class’s claims.

21

172. The named Plaintiffs, through counsel, will fairly and adequately

22 protect the interests of the class. Plaintiffs do not have any interests antagonistic to

23 the plaintiff class. Plaintiffs, as well as the Plaintiff class members, seek to enjoin

24 the unlawful acts and omissions of Defendant. Further, Plaintiffs are represented by

25 counsel experienced in civil rights litigation, prisoners’ rights litigation, and

26 complex class action litigation.

27 Medical Subclass

28

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1

173. Plaintiffs Gray, Patterson, Kujawsky, and Wohlfeil bring this action on

2 their own behalf and, pursuant to Rule 23(a), b(1), and (b)(2) of the Federal Rules of

3 Civil Procedure, on behalf of a subclass of prisoners (hereinafter “Medical

4 Subclass”) who are now, or will in the future be, subjected to the medical care

5 policies and practices of the Riverside jails.

6

174. The Medical Subclass is so numerous that joinder of all members is

7 impracticable. There are currently nearly 4,000 people incarcerated in the five

8 Riverside jails. All prisoners are at risk of developing serious medical conditions

9 while in the Riverside jails. Due to Defendant’s policies and practices, all Riverside

10 jail prisoners receive or are at risk of receiving inadequate medical care while in the

11 Riverside jails.

12

175. There are questions of law and fact common to the Medical Subclass

13 including whether the failure to provide minimally adequate medical care violates

14 the Due Process Clause of the Fourteenth Amendment and the Cruel and Unusual

15 Punishment Clause of the Eighth Amendment to the United States Constitution and

16 whether Defendant has been deliberately indifferent to the serious health care needs

17 of Medical Subclass members. Defendant is expected to raise common defenses to

18 these claims.

19

176. Since there are several thousand Medical Subclass members, separate

20 actions by individuals would in all likelihood result in inconsistent and varying

21 decisions, which in turn would result in conflicting and incompatible standards of

22 conduct for the Defendant.

23

177. Defendant has acted and failed to act on grounds that apply generally to

24 the Medical Subclass, so that final injunctive or corresponding declaratory relief is

25 appropriate respecting the Medical Subclass as a whole.

26

178. The claims of the named Plaintiffs are typical of the claims of the

27 Medical Subclass, since their claims arise from the same policies, practices, and

28

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1 courses of conduct and their claims are based on the same theory of law as the

2 Medical Subclass’s claims.

3

179. The named Plaintiffs, through counsel, will fairly and adequately

4 protect the interests of the Medical Subclass. Plaintiffs do not have any interests

5 antagonistic to the Medical Subclass. Plaintiffs, as well as the Plaintiff class

6 members, seek to enjoin the unlawful acts and omissions of Defendant. Further,

7 Plaintiffs are represented by counsel experienced in civil rights litigation, prisoners’

8 rights litigation, and complex class action litigation.

9 Mental Health Subclass

10

180. Plaintiffs Gray, Rosson, McClellan, and Miller bring this action on

11 their own behalf and, pursuant to Rule 23(a), b(1), and (b)(2) of the Federal Rules of

12 Civil Procedure, on behalf of a subclass of prisoners (hereinafter “Mental Health

13 Subclass”) who are now, or will in the future be, subjected to the mental health care

14 policies and practices of the Riverside jails.

15

181. The Mental Health Subclass is so numerous that joinder of all members

16 is impracticable. There are currently nearly 4,000 people incarcerated in the five

17 Riverside jails. All prisoners are at risk of developing serious mental health

18 conditions while in the Riverside jails. Due to Defendant’s policies and practices,

19 all Riverside jail prisoners receive or are at risk of receiving inadequate mental

20 health care while in the Riverside jails.

21

182. There are questions of law and fact common to the Mental Health

22 Subclass including whether the failure to provide minimally adequate mental health

23 care violates the Due Process Clause of the Fourteenth Amendment and the Cruel

24 and Unusual Punishment Clause of the Eighth Amendment to the United States

25 Constitution and whether Defendant has been deliberately indifferent to the serious

26 health care needs of Mental Health Subclass members. Defendant is expected to

27 raise common defenses to these claims.

28

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1

183. Since there are several thousand Mental Health Subclass members,

2 separate actions by individuals would in all likelihood result in inconsistent and

3 varying decisions, which in turn would result in conflicting and incompatible

4 standards of conduct for the Defendant.

5

184. Defendant has acted and failed to act on grounds that apply generally to

6 the Mental Health Subclass, so that final injunctive or corresponding declaratory

7 relief is appropriate respecting the Mental Health Subclass as a whole.

8

185. The claims of the named plaintiffs are typical of the claims of the

9 Mental Health Subclass, since their claims arise from the same policies, practices,

10 and courses of conduct and their claims are based on the same theory of law as the

11 Mental Health Subclass’s claims.

12

186. The named plaintiffs, through counsel, will fairly and adequately

13 protect the interests of the Mental Health Subclass. Plaintiffs do not have any

14 interests antagonistic to the Mental Health Subclass. Plaintiffs, as well as the

15 Mental Health Subclass members, seek to enjoin the unlawful acts and omissions of

16 Defendant. Further, Plaintiffs are represented by counsel experienced in civil rights

17 litigation, prisoners’ rights litigation, and complex class action litigation.

18 Disabilities Subclass

19

187. Plaintiffs Madrid and Quarles bring this action on their own behalf and,

20 pursuant to Rule 23(a), b(1), and (b)(2) of the Federal Rules of Civil Procedure, on

21 behalf of a subclass of prisoners (hereinafter “Disabilities Subclass”) who are now,

22 or will in the future be, subjected to policies and practices of the Riverside jails

23 regarding specialized or sheltered housing for prisoners due to their mobility

24 impairments and need for assistive devices, and the provision and confiscation of

25 accommodations for prisoners with mobility impairments.

26

188. The Disabilities Subclass is so numerous that joinder of all members is

27 impracticable. There are currently nearly 4,000 people incarcerated in the five

28

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1 Riverside jails. Although the exact number of prisoners with mobility impairments

2 is unknown, plaintiffs believe there are dozens of prisoners with these disabilities,

3 all of whom are at risk of being placed in sheltered housing due to a mobility

4 impairment or unable to receive reasonable accommodations for mobility

5 impairments.

6

189. There are questions of law and fact common to the Disabilities

7 Subclass including whether the failure to provide reasonable accommodations for

8 mobility impairments violates the ADA and Section 504 of Rehabilitation Act and

9 whether placement of prisoners in more restrictive housing environments due to

10 their disabilities violates the ADA and Section 504 of the Rehabilitation Act.

11 Defendant is expected to raise common defenses to these claims.

12

190. Since in Plaintiffs’ belief there are dozens of Disabilities Subclass

13 members, separate actions by individuals would in all likelihood result in

14 inconsistent and varying decisions, which in turn would result in conflicting and

15 incompatible standards of conduct for the Defendant.

16

191. Defendant has acted and failed to act on grounds that apply generally

17 to the Disabilities Subclass, so that final injunctive or corresponding declaratory

18 relief is appropriate respecting the Disabilities Subclass as a whole.

19

192. The claims of the named plaintiffs are typical of the claims of the

20 Disabilities Subclass, since their claims arise from the same policies, practices, and

21 courses of conduct and their claims are based on the same theory of law as the

22 Disabilities Subclass’s claims

23

193. The named plaintiffs, through counsel, will fairly and adequately

24 protect the interests of the Disabilities Subclass. Plaintiffs do not have any interests

25 antagonistic to the Disabilities Subclass. Plaintiffs, as well as the Disabilities

26 Subclass members, seek to enjoin the unlawful acts and omissions of Defendant.

27

28

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1 Further, Plaintiffs are represented by counsel experienced in civil rights litigation,

2 prisoners’ rights litigation, and complex class action litigation.

3

CLAIMS FOR RELIEF

4

5

First Cause of Action

6

(Plaintiffs Gray, Patterson, Kujawsky, Rosson, McClellan, Miller, and Wohlfeil and the plaintiff class

7

v. Defendant County of Riverside)

8

(Eighth Amendment; 42 U.S.C. § 1983)

9

194. By its policies and practices described in paragraphs 1 through 165,

10 Defendant subjects Plaintiffs and the Plaintiff class to an unreasonable risk of harm

11 and injury from inadequate health care. These policies and practices have been and

12 continue to be implemented by Defendant and its agents or employees in their

13 official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff class’s

14 ongoing deprivation of rights secured by the United States Constitution under the

15 Eighth Amendment.

16

195. Defendant has been and is aware of all of the deprivations complained

17 of herein, and has condoned or been deliberately indifferent to such conduct.

18

19

Second Cause of Action

20 (Plaintiffs Gray, Patterson, Kujawsky, Rosson, McClellan, Miller, and Wohlfeil

and the plaintiff class
21
v. Defendant County of Riverside)
22
(Fourteenth Amendment; 42 U.S. C. § 1983)

23

24

196. By its policies and practices described in paragraphs 1 through 165,

25 Defendant subjects Plaintiffs and the Plaintiff class to an unreasonable risk of harm

26 and injury from inadequate health care. These policies and practices have been and

27 continue to be implemented by Defendant and its agents or employees in their

28

official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff class’s
55

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1 ongoing deprivation of rights secured by the United States Constitution under the

2 Fourteenth Amendment.

3

197. Defendant has been and is aware of all of the deprivations complained

4 of herein, and has condoned or been deliberately indifferent to such conduct.

5

Third Cause of Action

6 (Plaintiffs Gray, Patterson, Kujawsky, and Wohlfeil and the Medical Subclass v. Defendant County of Riverside)
7
(Eighth Amendment; 42 U.S.C. § 1983)
8

9

198. By its policies and practices described in paragraphs 1 through 165,

10 Defendant subjects Plaintiffs and the Medical Subclass to an unreasonable risk of

11 harm and injury from inadequate medical care. These policies and practices have

12 been and continue to be implemented by Defendant and its agents or employees in

13 their official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff

14 class’s ongoing deprivation of rights secured by the United States Constitution

15 under the Eighth Amendment.

16

199. Defendant has been and is aware of all of the deprivations complained

17 of herein, and has condoned or been deliberately indifferent to such conduct.

18

Fourth Cause of Action

19 (Plaintiffs Gray, Patterson, Kujawsky, and Wohlfeil and the Medical Subclass

20

v. Defendant County of Riverside)

21

(Fourteenth Amendment; 42 U.S. C. § 1983)

22

200. By its policies and practices described in paragraphs 1 through 165,

23 Defendant subjects Plaintiffs and the Medical Subclass to an unreasonable risk of

24 harm and injury from inadequate medical care. These policies and practices have

25 been and continue to be implemented by Defendant and its agents or employees in

26 their official capacities, and are the proximate cause of Plaintiffs’ and the Plaintiff

27

28

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1 class’s ongoing deprivation of rights secured by the United States Constitution

2 under the Fourteenth Amendment.

3

201. Defendant has been and is aware of all of the deprivations complained

4 of herein, and has condoned or been deliberately indifferent to such conduct.

5

6

Fifth Cause of Action

(Plaintiffs Gray, Rosson, McClellan, Miller, and the Mental Health Subclass v.

7

Defendant County of Riverside)

8

(Eighth Amendment; 42 U.S.C. § 1983)

9

202. By its policies and practices described in paragraphs 1 through 165,

10 Defendant subjects Plaintiffs and the Mental Health Subclass to an unreasonable

11 risk of harm and injury from inadequate mental health care. These policies and

12 practices have been and continue to be implemented by Defendant and its agents or

13 employees in their official capacities, and are the proximate cause of Plaintiff’s and

14 the Plaintiff class’s ongoing deprivation of rights secured by the United States

15 Constitution under the Eighth Amendment.

16

203. Defendant has been and is aware of all of the deprivations complained

17 of herein, and has condoned or been deliberately indifferent to such conduct.

18

19

Sixth Cause of Action

20 (Plaintiffs Gray, Rosson, McClellan, Miller, and the Mental Health Subclass v.

Defendant County of Riverside)
21
(Fourteenth Amendment; 42 U.S. C. § 1983)
22

23

204. By its policies and practices described in paragraphs 1 through 165,

24 Defendant subjects Plaintiffs and the Mental Health Subclass to an unreasonable

25 risk of harm and injury from inadequate mental health care. These policies and

26 practices have been and continue to be implemented by Defendant and its agents or

27 employees in their official capacities, and are the proximate cause of Plaintiff’s and

28

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1 the Plaintiff class’s ongoing deprivation of rights secured by the United States

2 Constitution under the Fourteenth Amendment.

3

205. Defendant has been and is aware of all of the deprivations complained

4 of herein, and has condoned or been deliberately indifferent to such conduct.

5

6

Seventh Cause of Action

(Plaintiffs Madrid and Quarles and the Disabilities Subclass v. Defendant

7

County of Riverside)

8

(Americans with Disabilities Act)

9

206. By its policies and practices of discriminating against prisoners with

10 disabilities as described in paragraphs one through 165, Defendant violates the

11 Americans with Disabilities Act, 42 U.S.C. § 12132 and 28 C.F. R. § 35.152(b)(1).

12

207. Plaintiffs Madrid and Quarles and the subclass of prisoners with

13 disabilities they represent are qualified individuals with disabilities as defined by the

14 ADA.

15

208. Defendant has violated the ADA by failing or refusing to provide

16 plaintiffs with reasonable accommodations and other services related to their

17 disabilities. See generally 28 C.F.R. Section 35.130. Defendants have violated the

18 ADA by failing to make “reasonable modifications in policies, practices, or

19 procedures when the modifications are necessary to avoid discrimination on the

20 basis of disability . . . .” 28 C.F.R. Section 35.130(b)(7).

21

209. Defendant has violated the ADA by failing to “furnish appropriate

22 auxiliary aids and services where necessary to afford individuals with disabilities . . .

23 an equal opportunity to participate in . . . a service, program, or activity of a public

24 entity.” 28 C.F.R. Section 35.160(b)(1).

25

210. Defendant has violated the ADA by failing to “ensure that inmates or

26 detainees with disabilities are housed in the most integrated setting appropriate to

27 the needs of the individuals.” 28 C.F.R. Section 35.152(b)(2).

28

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1

211. As a result of Defendant’s policy and practice of failing to provide

2 reasonable accommodations, Plaintiffs Madrid and Quarles, and the subclass of

3 prisoners with disabilities they represent, do not have equal access to jail activities,

4 programs, and services for which they are otherwise qualified.

5

6

Eighth Cause of Action

7

(Plaintiffs Madrid and Quarles and the Disabilities Subclass v. Defendant County of Riverside)

8

(Section 504 of the Rehabilitation Act)

9
212. By its policies and practices of discriminating against prisoners with

10
disabilities as described in paragraphs one through 165, Defendant violates Section

11
504 of the Rehabilitation Act, 29 U.S.C. § 794.

12
213. Plaintiffs Madrid and Quarles and the subclass of prisoners with

13
disabilities they represent are qualified individuals with disabilities as defined by

14
Section 504 of the Rehabilitation Act.

15
214. At all times relevant to this action, Defendant was the recipient of

16
federal funding within the meaning of the Rehabilitation Act. As a recipient of

17
federal funds, Defendant is required to reasonably accommodate inmates with

18
disabilities in their facilities, program activities, and services.

19
215. As a result of Defendants’ policy and practice of failing to provide

20
reasonable accommodations, Plaintiffs Madrid and Quarles, and the subclass of

21
prisoners with disabilities they represent, do not have equal access to jail activities,

22
programs, and services for which they are otherwise qualified.

23
PRAYER FOR RELIEF

24

216. Plaintiffs and the class they represent have no adequate remedy at law

25 to redress the wrongs suffered as set forth in this complaint. Plaintiffs have suffered

26 and will continue to suffer irreparable injury as a result of the unlawful acts,

27 omissions, policies, and practices of the Defendant as alleged herein, unless

28

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1 Plaintiffs are granted the relief they request. The need for relief is critical because

2 the rights at issue are paramount under the Constitution and laws of the United

3 States.

4

217. WHEREFORE, Plaintiffs, on behalf of themselves and the class they

5 represent, request that this Court grant them the following relief:

6

A. Declare the suit is maintainable as a class action pursuant to Federal Rule

7 of Civil procedure 23(a) and 23(b)(1) and (2);

8

B. Adjudge and declare that the conditions, acts, omissions, policies, and

9 practices of Defendant and its agents, officials, and employees are in violation of the

10 rights of Plaintiffs and the class they represent under the Eighth and Fourteenth

11 Amendments to the U.S. Constitution, the ADA, and Section 504 of the

12 Rehabilitation Act;

13

C. Order Defendant, its agents, officials, employees, and all persons acting

14 in concert with them under color of state law or otherwise, to develop and
15 implement, as soon as practical, a plan to eliminate the substantial risk of serious
16 harm that Plaintiffs and members of the Plaintiff class suffer due to Defendant’s
17 inadequate medical and mental health care and disability discrimination.
18 Defendant’s plan shall include at a minimum the following:
19
1. Staffing: Staffing shall be sufficient to provide Plaintiffs and the Plaintiff
20
class with timely access to qualified and competent clinicians who can provide
21
routine, urgent, emergent, and specialty health care;
22

23

2. Access: Policies and practices that provide timely access to health care;

24

3. Screening: Policies and practices that reliably screen for medical and

25 mental health conditions that need treatment;

26

4. Emergency response: Timely and competent responses to health care

27 emergencies;

28

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1

5. Medication and supplies: Timely prescription and distribution of

2 medications and supplies necessary for medically adequate care;

3

6. Chronic care: Timely access to competent care for chronic illnesses;

4

7. Mental health treatment: Timely access to necessary treatment for serious

5 mental illness, including medication, therapy, inpatient treatment, suicide

6 prevention, and suicide watch;

7
8. Quality assurance: A regular assessment of health care staff, services,
8
procedures, and activities designed to improve outcomes, and to identify and correct
9
errors or systemic deficiencies; and
10

11

9. Disability discrimination: Policies and practices to ensure prisoners placed

12 in specialized housing due to disabilities are provided equivalent programming to

13 what they would otherwise receive and to ensure that prisoners with mobility

14 impairments are provided reasonable accommodations for their disabilities.

15

D. Enjoin Defendant, its agents, officials, employees, and all persons acting

16 in concert with them under color of state law or otherwise, from continuing the

17 unlawful acts, conditions, and practices described in this Complaint and from failing

18 to provide minimally adequate health care and from discrimination based on

19 disability;

20

E. Award Plaintiffs, pursuant to 42 U.S.C. §§ 1988, 12205 and 12133, and 29

21 U.S.C. § 794(a), the costs of this suit and reasonable attorneys’ fees and litigation

22 expenses;

23

F. Retain jurisdiction of this case until Defendant has fully complied with the
24

orders of this Court, and there is a reasonable assurance that Defendant will continue
25

26 to comply in the future absent continuing jurisdiction; and

27

G. Award such other and further relief as the Court deems just and proper.

28

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1 Dated: November 24, 2015 PRISON LAW OFFICE

2

3

By:

/s/ Sara Norman

4

DONALD SPECTOR

SARA NORMAN

5

6

AKIN GUMP STRAUSS HAUER & FELD LLP

7

8

By:

/s/ Danielle Ginty

9

SHAWN HANSON

DANIELLE GINTY

10

NICHOLAS GREGORY

11
Attorneys for PLAINTIFFS
12

13

14

All signatories listed, and on whose behalf this filing is submitted, concur in

15 the filing’s content and have authorized the filing.

16

17

18

By:

/s/ Danielle Ginty

DANIELLE GINTY

19

20

21

22

23

24

25

26

27

28
62
THIRD AMENDED CLASS ACTION COMPLAINT FOR INJUNCTIVE AND DECLARATORY RELIEF

 
 1

2

3

4

5

JS-6

6

7

8

UNITED STATES DISTRICT COURT

CENTRAL DISTRICT OF CALIFORNIA

9

EASTERN DIVISION - RIVERSIDE

10

11 12 QUINTON GRAY, et al.

13

Plaintiffs,

14

v.

15 COUNTY OF RIVERSIDE, 16
Defendants. 17

Case No. EDCV 13-0444 VAP (OPx) CONSENT DECREE

18

19

20

21

22

23

24

25

26

27

28

CASE NO. EDCV12-0444 VAP (OP)

1 Introduction 2
1. The parties enter into this Consent Decree to ensure the provision of 3 4 constitutional health care and to ensure non-discrimination for inmates with disabilities

5 in the Riverside County Jails.1 The parties to this Consent Decree are Plaintiffs Quinton 6
Gray, Angela Patterson, Stanley Kujawsky, John Rosson III, Brandy McClellan, Julie 7 8 Miller, Michael Wolhfeil, David Madrid, and Nikko Quarles and the class and

9 subclasses of inmates they represent, and the Defendant County of Riverside. 10
2. This action was filed by Plaintiffs on March 8, 2013. A Second Amended 11
12 Complaint was filed on August 20, 2014, and a Third Amended Complaint on

13 November 24, 2015. The action alleges that the County of Riverside fails to provide 14
minimally adequate medical and mental health care to the people incarcerated in its 15
16 jails, in violation of the Eighth and Fourteenth Amendments to the United Constitution,

17 as well as discrimination against certain inmates with disabilities in violation of the 18
Americans with Disabilities Act and Section 504 of the Rehabilitation Act. On 19
20 September 2, 2014, the Court denied Defendant’s motion to dismiss and granted

21 Plaintiffs’ motion for class certification.

22

23

3. The Plaintiff class consists of “all prisoners who are now, or will be in the

24

25

1 For the purposes of this Consent Decree, references to the Riverside Jails

26

include the five jails (Presley Detention Center, Smith Correctional Facility, Southwest Detention Center, Indio Jail, and Blythe Jail) as well as the Riverside University

27

Medical Center, to the extent it houses inmates under the jurisdiction of the Riverside County Sheriff, and any new structures designated to house prisoners under the

28

jurisdiction of the Riverside County Sheriff subsequent to the date of this Consent Decree.

1
Case No. EDCV12-0444 VAP (OP)

1 future, subjected to the medical and mental health policies and practices of Riverside 2
County.” The medical subclass comprises “[a]ll prisoners who are now, or will in the 3 4 future be, subjected to the medical care policies and practices of the Riverside Jails” and

5 the mental health subclass comprises “[a]ll prisoners who are now, or will in the future 6
be, subjected to the mental health care policies and practices of the Riverside Jails.” In 7 8 addition, the parties hereby stipulate to an additional subclass of all prisoners who are

9 now, or will be in the future, subjected to policies and practices of the Riverside jails 10
regarding specialized or sheltered housing for prisoners due to their mobility 11
12 impairments and need for assistive devices, and the provision and confiscation of

13 accommodations for prisoners with mobility impairments, and agree that this class
14 meets the requirements of Rule 23(a) and (b) of the federal Rules of Civil Procedure.
15

16

4. In January 2015, the parties suspended regular and expert discovery for the

17 purpose of settlement negotiations. To aid in settlement negotiations, the parties agreed
18 on February 20, 2015, to hire neutral experts “to determine whether the health care
19

20 currently provided poses a significant risk of serious harm to prisoners confined in the

21 Jails and, if so, to make recommendations for improvements that will provide the
22 23 minimum care guaranteed by the U.S. Constitution.” Should the experts determine that

24 health care does fail to meet the constitutional minimum, the parties agreed to negotiate

25 a Remedial Plan to address the identified deficiencies, including a commitment to 26 27 secure funding necessary for implementation of the Remedial Plan and a timeframe for

28 implementation. The parties further agreed that the Court would retain jurisdiction to

2
Case No. EDCV12-0444 VAP (OP)

1 enforce the terms of its judgment and Plaintiffs would be prevailing party. 2
5. The parties jointly selected Dr. Scott Allen, Professor of Medicine at the 3 4 University of California-Riverside, as the expert on medical care and Dr. Bruce Gage,

5 Chief Psychiatrist of the Washington State Department of Corrections, as the expert on

6 mental health care. The parties directed them to begin their work on March 3, 2015.
7

8

6. Both experts conducted extensive tours and reviews of the jail facilities,

9 policies and procedures as well as interviews with staff and inmates. They drafted 10
preliminary reports setting forth their findings and recommendations, and both parties 11
12 were given the opportunity to review the reports and make comments. The experts

13 submitted their final reports to the parties on July 15, 2015.
14 7. Each party to this Consent Decree was represented by counsel during its
15

16 negotiation and execution. Plaintiffs and the Plaintiff classes and subclasses are

17 represented by Donald Specter and Sara Norman, Prison Law Office, and Shawn
18 Hanson and Danielle Ginty, Akin Gump. Defendant is represented by Arthur
19

20 Cunningham, Lewis Brisbois Bisgaard & Smith, and James Brown, Assistant County

21 Counsel for the County of Riverside.

22

23

8. Through this Consent Decree, Defendant agrees to implement the measures

24 set forth in the Remedial Plan attached as Appendix A, subject to monitoring by the

25 Court experts and Plaintiffs’ counsel, negotiation between the parties, and if necessary, 26 27 enforcement by the Court.

28

3
Case No. EDCV12-0444 VAP (OP)

1 Remedial Plan 2
9. Defendant shall fully implement all of the remedial measures, according to 3 4 the specified timeframes, set forth in the Remedial Plan attached as Appendix A.

5 Defendant shall secure the funding necessary to implement the Remedial Plan. The 6
Remedial Plan is designed to meet the minimum level of health care necessary to fulfill 7 8 Defendant’s obligations under the Eighth and Fourteenth Amendments, as well as to

9 ensure non-discrimination against inmates with disabilities in the areas addressed by the

10 Plan, as required by the ADA and Section 504 of the Rehabilitation Act.
11

12

10. Defendant shall, in consultation and collaboration with Plaintiffs’ counsel,

13 develop and implement appropriate and adequate plans, policies, and practices to ensure
14 compliance with the Remedial Plan. At least 30 days prior to finalizing or
15

16 implementing any new plans or policies developed to meet the terms of the Remedial

17 Plan, Defendant will submit such plans or policies to Plaintiffs’ counsel for their review
18 and comments. Disagreements about the adequacy of such plans or policies shall be
19

20 resolved pursuant to the dispute resolution procedure set forth below.

21

11. Defendant may seek to modify the Remedial Plan if they believe in good

22

23 faith that there is a significant change in the facts or the law such that the terms of the

24 Remedial Plan will not effectively accomplish the goals set forth in Paragraph 1.

25 Defendant’s violations. Plaintiffs may seek to modify the Remedial Plan if the plan 26 27 does not effectively accomplish those goals, or a modification is necessary to ensure

28 Plaintiff class members receive adequate healthcare under the Eighth and Fourteenth

4
Case No. EDCV12-0444 VAP (OP)

1 Amendment to the United States Constitution or to ensure that inmates are not subjected 2
to disability discrimination under the ADA and/or Section 504 of the Rehabilitation Act 3 4 in the areas covered by the Plan. Any party wishing to modify the plan must submit a

5 proposed modification to the opposing party. The opposing party may request further 6
information, request that the modification(s) be reviewed by the Court’s experts, and/or 7 8 request that the proposed modification(s) be subjected to the dispute resolution process

9 described below. If the parties fail to reach agreement on the proposed modification(s),

10 the party proposing the modification(s) may seek relief from the Court.
11

12

12. Within 180 calendar days of the date this Consent Decree is approved by

13 the Court, Defendant shall provide to Plaintiffs’ counsel a status report stating whether
14 it is complying with the terms of this Consent Decree. This report shall include a
15

16 description of the steps that Defendant has taken to implement the Remedial Plan. At

17 the end of each subsequent 180-day period during the pendency of this Consent Decree,
18 Defendant shall provide to Plaintiffs’ counsel a status report addressing each item of the
19

20 Remedial Plan and shall specify each and every item with which it is not in compliance.

21 Court Experts

22

23

13. The parties jointly request the appointment of Drs. Gage and Allen as

24 Court experts pursuant to Rule 706 of the Federal Rules of Evidence to advise the Court

25 on the County’s compliance or non-compliance with the Remedial Plan, dispute resolution 26
matters addressed in paragraph (4), and testimony, if required, as addressed in paragraph (6), 27
28 below. . During the first year of this Consent Decree, the Court experts shall complete

5
Case No. EDCV12-0444 VAP (OP)

1 two comprehensive reviews and reports, at least four months apart, to advise the parties 2
and the Court on Defendant’s progress in implementing the Remedial Plan. For the 3 4 remaining duration of this Consent Decree, the Court experts shall complete

5 comprehensive reviews and reports as they determine to be necessary, or as requested 6
by the parties, but not more than twice in one year, to advise the parties and the Court 7 8 on Defendant’s compliance or non-compliance with the Remedial Plan. These

9 comprehensive reviews and reports shall be considered separate and apart from any 10
evaluations and reports prepared as part of the dispute resolution process described 11
12 below.

13

14. The experts’ duties specified in Appendix B shall be provided to the

14 experts pursuant to Rule 706(b). The Court experts shall be entitled to reasonable
15

16 compensation in an amount approved by the Court, which shall be paid by Defendant.

17

15. The Court experts shall have reasonable access to all parts of any Riverside

18 Jail, with appropriate notice, and access to the facilities will not be unreasonably
19

20 restricted. The experts shall have access to correctional and health care staff and

21 inmates, including confidential and voluntary interviews as they deem appropriate. The
22 23 experts shall also have access to documents, including budgetary, custody, and health

24 care documents, and institutional meetings, proceedings, and programs to the extent the

25 experts determine such access is needed to fulfill their obligations. The experts’ tours 26 27 shall be undertaken in a manner that does not unreasonably interfere with jail operations

28 as determined by jail administrators.

6
Case No. EDCV12-0444 VAP (OP)

1

16. The parties agree that they are each entitled to engage in ex parte

2 communications with the Court experts. However, all of the experts’ findings and
3

4 recommendations shall be set forth in writing in their reports.

5

17. If for any reason either one is not appointed or can no longer serve, the

6 parties shall attempt to agree on who shall be appointed in their place. If the parties do
7

8 not agree, Defendant and Plaintiffs shall each nominate and submit two potential experts

9 to be chosen and appointed by the Court.

10 Notice to Class Members
11

12

18. Defendant shall post notices of this action in a manner agreed upon by the

13 parties. Such notices shall include a brief description of Plaintiffs’ claims, the definition
14 of the classes and subclasses, that the parties have entered into a Consent Decree to
15

16 ensure constitutional medical and mental health care for the Plaintiff class, as well as to

17 ensure non-discrimination as to inmates with disabilities in certain areas, and the contact
18 information for the Prison Law Office to allow inmates to contact Plaintiffs’ counsel.
19

20 Plaintiffs’ Monitoring and Access to Information

21

19. Plaintiffs shall monitor Defendant’s compliance with the Remedial Plan.

22

23 Plaintiffs shall inform Defendant of alleged noncompliance with any aspect of the

24 Remedial Plan. Defendant shall investigate alleged failures and provide Plaintiffs with

25 a response in writing within 30 calendar days. If Plaintiffs are not satisfied with 26 27 Defendant’s response, the parties shall engage in the dispute resolution process

28 described below.

7
Case No. EDCV12-0444 VAP (OP)

1

20. Defendant shall provide Plaintiffs with access to information, including all

2 Riverside Jail facilities, documents, records, and staff, that Plaintiffs believe in good
3

4 faith is necessary to monitor Defendant’s compliance with the Remedial Plan. From the

5 date this Consent Decree is entered by the Court, Defendant shall provide Plaintiffs with 6
access to such information within 15 calendar days of their request. If Defendant 7 8 believes that the information requested by Plaintiffs is not necessary to monitor

9 compliance with the Remedial Plan, the parties shall engage in the dispute resolution

10 process described below.
11

12

21. Defendant shall grant Plaintiffs and their consultants the opportunity to

13 conduct at least two tours of the Riverside Jails per calendar year for the purpose of
14 monitoring compliance with the Remedial Plan. Tours by Plaintiffs and/or their
15

16 consultants shall include reasonable access to all of the jail facilities, including all

17 housing units, facilities where health care services are provided, facilities where inmates
18 with disabilities are or may be housed and provided programming, and any other
19

20 facilities where services are provided pursuant to the Remedial Plan. During the tours,

21 Defendant shall make available for interview any supervisory, clinical, custodial, and
22 23 program staff that have direct or supervisory responsibility for health care and disability

24 accommodations. Defendant shall provide a Sheriff’s Department contact person to

25 ensure cooperation of institution staff with Plaintiffs in obtaining information they 26 27 request during the tours. During the tours, Defendant shall permit and facilitate

28 Plaintiffs having confidential and voluntary discussions with any inmate identified by

8
Case No. EDCV12-0444 VAP (OP)

1 Plaintiffs. Upon request by Plaintiffs and pursuant to the protective order entered in this 2
case, Defendant shall make available for inspection and/or copying the health care 3 4 and/or custody files of specified inmates.

5

22. In the event that Defendant fails to make the employee or an agent

6 requested by Plaintiffs available for an interview, the parties shall seek a determination
7

8 from Judge Raul Ramirez by telephone as to whether Plaintiffs may depose the

9 employee or agent who has not been made available. The parties agree that should such 10
a deposition be required, the employee or agent shall be compelled to attend by 11
12 subpoena, and the deposition may be taken in Riverside County without further leave of

13 the Court.
14 23. Plaintiffs’ counsel retain the ability to interview their clients pursuant to
15

16 regular attorney-client visiting procedures established by the Sheriff’s Department. The

17 parties will attempt to establish an efficient means to allow Plaintiffs’ counsel
18 confidential telephonic interviews with individual inmates, with reasonable notice, in a
19

20 manner that does not disrupt jail operations.

21

24. Plaintiffs’ counsel shall be allowed to send postage pre-paid envelopes to

22

23 their clients in the Riverside Jails.

24 Individual Advocacy

25

25. Plaintiffs may bring individual inmates’ health care or disability

26

27 accommodation concerns to the attention of Defendant’s counsel, or their designee, who

28 shall respond in writing within seven calendar days. This process is not meant to

9
Case No. EDCV12-0444 VAP (OP)

1 replace or circumvent the existing processes for requesting medical or mental health 2
services, or the existing grievance processes. Inmates will be encouraged to make use 3 4 of those processes except where exigent circumstances or failures of those processes

5 have occurred.

6 Dispute Resolution
7

8

26. At the request of any party, the parties shall conduct good faith

9 negotiations to resolve informally any matter in dispute, including but not limited to any 10
contention that Defendant is not substantially complying as required by this Consent 11
12 Decree or the Remedial Plan(s), or any contention that Defendant has demonstrated

13 sufficient compliance with the Consent Decree and/or Remedial Plan(s) that the Consent
14 Decree and monitoring thereunder should be modified or terminated. Any party may
15

16 begin this dispute resolution process by telephonic notice to the opposing party. The

17 parties shall speak on the telephone or in person to attempt to resolve the dispute.
18 27. If the parties are unable to resolve the dispute within 30 days of the original
19

20 notice, either party may inform the relevant Court experts of the area of disagreement

21 and request that the experts evaluate the issue and prepare a report. The experts must
22 23 provide their report regarding the area of disagreement within 30 days of the request.

24 Defendant will pay the experts’ reasonable fees for any reports prepared by a Court

25 expert at the request of a party about a disputed issue, as contemplated by this 26 27 paragraph. Any report prepared by a Court expert at the request of a party about a

28 disputed issue, as contemplated by this paragraph, shall be admissible as evidence at the

10
Case No. EDCV12-0444 VAP (OP)

1 request of any party in any judicial proceeding in this case, subject to appropriate

2 objections pursuant to the Federal Rules of Evidence.
3

4

28. If within 30 calendar days of receipt of the Court experts’ report, the parties

5 are unable to reach a mutually satisfactory resolution of the dispute, either party may 6
request mediation with Judge Raul Ramirez. The form of the mediation (whether in 7 8 person or by telephone, timeframes, and any briefing to be provided) shall be

9 established by Judge Ramirez after consultation with the parties. 10
29. If mediation with Judge Ramirez does not resolve the dispute to the mutual 11
12 satisfaction of the parties, either party may file a motion for relief to the Court of

13 continuing jurisdiction.
14 Enforcement
15

16

30. The Court shall retain jurisdiction to enforce the terms of this Consent

17 Decree, and shall have the power to enforce the agreement through specific performance
18 and all other remedies permitted by law until Defendant fulfills its obligations under this
19

20 Consent Decree.

21 Duration and Termination

22

23

31. The duration of this Consent Decree is four years from the date this

24 Consent Decree is entered by the Court, except that this time period may be extended as

25 to any provision of this Consent Decree with which the Defendant is not in substantial 26 27 compliance for so long as substantial non-compliance persists. Any such extension not

28 mutually agreed upon by the parties shall be subject to the dispute resolution process set

11
Case No. EDCV12-0444 VAP (OP)

1 forth above. 2
32. Defendant shall not file a termination motion pursuant to 18 U.S.C. § 3 4 3626(b)(1)(A)(i) for three years from the date this Consent Decree is entered by the

5 Court. Any termination motion shall be based on a record of no less than one year of 6
substantial compliance with all the requirements of this Consent Decree and the 7 8 Remedial Plan.

9

33. Defendant may request a finding that Defendant is in substantial

10 compliance with the Remedial Plan or a material component (defined as one of the (20)
11

12 subparts of the Remedial Plan) thereof and has maintained substantial compliance for a

13 period of twelve months. Such a finding will result in a reduction or suspension of
14 monitoring of that material component. If Plaintiffs present evidence that Defendant is
15

16 no longer in substantial compliance with material component(s) previously found in

17 substantial compliance, the Court may order additional relief including but not limited
18 to reinstating full monitoring.
19

20 Costs and Fees

21

34. Costs and Fees For Monitoring and Enforcement: Plaintiffs shall be

22

23 compensated for their reasonable time and reasonable expenses relating to monitoring

24 and enforcing this Consent Decree and Remedial Plan. For monitoring fees and

25 expenses, Plaintiffs shall submit a detailed invoice for their fees and expenses (including 26 27 the date, amount of time spent, and a general description of each task) at the end of

28 every quarter and Defendant shall pay the amount requested by Plaintiffs within 60

12
Case No. EDCV12-0444 VAP (OP)

1 calendar days of receipt of each invoice, provided that Defendant need not pay any fees

2 and expenses that exceed $150,000 per calendar year.
3

4

35. In addition, and notwithstanding the monetary limit set forth above,

5 Defendant agrees to pay Plaintiffs’ counsel for reasonable time and expenses in 6
connection with efforts to resolve informally or through mediation or litigation any 7 8 dispute related to this Consent Decree and Remedial Plan, subject to Defendant’s right

9 to dispute any such request for compensation, as provided in the dispute resolution

10 mechanism set forth above.
11

12

36. For any tasks related to monitoring and enforcing this Consent Decree and

13 Remedial Plan that relate to health care, Defendant shall pay Plaintiffs at hourly rates set
14 forth under the PLRA, 42 U.S.C. Section 1997e. For any tasks related to monitoring
15

16 and enforcing this Consent Decree and Remedial Plan that relate to ensuring non-

17 discrimination based on disability, Defendant shall pay Plaintiffs pursuant to the ADA
18 and Section 504 of the Rehabilitation Act.
19

20

37. Costs and Fees Prior to Entry of the Consent Decree: The parties agree

21 that, by entry of this Consent Decree, Plaintiffs are the prevailing party in this litigation.
22 23 As a result, Defendant agrees to pay Plaintiffs their reasonable fees and costs, subject to

24 the provisions of the PLRA, 42 U.S.C. Section 1997e, including its limitations as to

25 hourly rates as applicable. Defendant agrees to pay Plaintiffs $1,250,000 for reasonable 26 27 fees and expenses incurred through Final Approval of the Consent Decree, including

28 approval of all Remediation Plan(s). The parties acknowledge that Court approval of the

13
Case No. EDCV12-0444 VAP (OP)

1 fees and expenses is required.

2 Liability and Necessity for Relief
3

4

38. Defendant admits for the purpose of this lawsuit only that there exists

5 probable cause to believe that violations of the federal rights of plaintiffs have occurred 6
sufficient to warrant the relief contained herein. The parties agree that the relief 7 8 contained herein is narrowly drawn, extends no further than necessary to ensure the

9 protection of the federal constitutional and statutory rights of Plaintiffs, and is the least
10 intrusive means necessary to accomplish those objectives.
11

12

IT IS SO AGREED AND STIPULATED.

13

14 DATED: November 24, 2015
15

LEWIS BRISBOIS BISGAARD & SMITH LLP

16

17

By:

/s/ Arthur K. Cunningham

18

Arthur K. Cunningham

Attorneys for Defendant,

19

COUNTY OF RIVERSIDE

20

21

IT IS SO AGREED AND STIPULATED.

22

23 DATED: November 24, 2015

PRISON LAW OFFICE

24

25

By:

/s/ Sara Norman

26

Sara Norman

27

Attorneys for Plaintiffs

28

14
Case No. EDCV12-0444 VAP (OP)

1

ORDER

2

3

Pursuant to the stipulation of the parties and following careful review of the

4 expert reports filed under separate cover and the Third Amended Complaint, the Court
5
6 hereby certifies a subclass of all prisoners who are now, or will be in the future,

7 subjected to policies and practices of the Riverside jails regarding specialized or
8 sheltered housing for prisoners due to their mobility impairments and need for assistive
9 10 devices, and the provision and confiscation of accommodations for prisoners with

11 mobility impairments. 12
Pursuant to the stipulation of the parties and following careful review of the 13 14 expert reports filed under separate cover, and as mandated by 18 U.S.C. Section 3626,

15 the Court hereby finds that the remedy set forth herein is narrowly drawn, extends no 16
further than necessary to correct the violation of the federal rights, and is the least 17 18 intrusive means necessary to correct the violation of the federal rights.

19

Therefore and good cause appearing, the Court approves this Consent Decree,

20 orders the parties to comply with all its terms, and orders Defendant to implement the
21

22 attached Remedial Plan pursuant to the schedule set forth therein.

23

24

IT IS SO ORDERED.

25 Dated: June 07, 2016
26
27
28

______________________________ The Honorable Virginia A. Phillips U.S. District Court Judge

15
Case No. EDCV12-0444 VAP (OP)

 
 Case 5:13-cv-00444-VAP-OP Document 177 Filed 04/06/20 Page 1 of 28 Page ID #:17110

PRISON LAW OFFICE 1 DONALD SPECTER (SBN 83925)
dspecter@prisonlaw.com 2 SARA NORMAN (SBN 189536)
snorman@prisonlaw.com 3 1917 Fifth Street
Berkeley, California 94710 4 Telephone: (510) 280-2621
Fax: (510) 280-2704
5
6 Attorneys for Plaintiffs

7

8

UNITED STATES DISTRICT COURT

9

FOR THE CENTRAL DISTRICT OF CALIFORNIA

10

EASTERN DIVISION – RIVERSIDE

11

12 QUINTON GRAY, et al., on behalf of 13 themselves and all others similarly 14 situated,
Plaintiffs,
15
16 v.
17
18 COUNTY OF RIVERSIDE, 19 Defendant.

Case No. EDCV13-0444 VAP (OP) CLASS ACTION EMERGENCY MOTION TO ENFORCE OR, IN THE ALTERNATIVE, MODIFY CONSENT DECREE Judge: Hon. Virginia A. Phillips Date: To be determined Time: To be determined Courtroom: Telephonic

20

21

22

23

24

25

26

27

28

PLTFS’ EMERGENCY MOTION TO ENFORCE CONSENT DECREE

Case 5:13-cv-00444-VAP-OP Document 177 Filed 04/06/20 Page 2 of 28 Page ID #:17111

1

TABLE OF CONTENTS

2 TABLE OF AUTHORITIES.............................................................................................iii

3 NOTICE OF MOTION AND MOTION ............................................................................ 1

4 MEMORANDUM OF POINTS AND AUTHORITIES ..................................................... 2

5

INTRODUCTION................................................................................................... 2

6

ARGUMENT .......................................................................................................... 4

7

I. Procedural History .............................................................................4

8

II. People Housed in the Riverside County Jails Are at Profound

Risk of Serious Illness and Death from the COVID-19

9

Pandemic ........................................................................................... 7

10

A. COVID-19 is particularly dangerous in correctional

settings .................................................................................... 7

11

B. The Riverside jails present extremely high risk for rapid,

12

uncontained spread of the disease............................................9

13

C. Despite repeated pleas, the County has provided

minimal information regarding preparation for the

14

pandemic and there is no indication that essential

population density reduction measures have been

15

instituted ............................................................................... 11

16

D. Time is of the essence to prevent COVID-19 from

exacting a deadly toll in the Riverside jails as well as the

17

Riverside community ............................................................ 11

18

III. The County Has Acted with Deliberate Indifference to the

Imminent Risk that People in Its Custody are Likely to Fall

19

Severely Ill or Die Because of COVID-19 ....................................... 12

20

A. People in the jails are at substantial risk of severe illness

or death due to COVID-19 .................................................... 13

21

B. The County’s failure to take adequate steps to protect

22

against the spread of COVID-19 constitutes deliberate

indifference ........................................................................... 14

23

C. The Court should enforce the Consent Decree....................... 16

24

IV. In the Alternative, the Court Should Modify the Remedial Plan

25

to Include Basic Measures to Protect Class Members against

the Threat of COVID-19 .................................................................. 20

26

A. The Global Pandemic Constitutes a Changed

27

Circumstance ........................................................................ 20

28

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B. The Relief Requested Would Directly Address the

1

Needs of the Medically Vulnerable Population and

Those Living in Congregate Settings and Would

2

Therefore Be Tailored to the Changed Circumstances ........... 21

3

CONCLUSION ..................................................................................................... 21

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

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1

TABLE OF AUTHORITIES

2

Cases

3 Armstrong v. Brown, 768 F.3d 975 (9th Cir. 2014) .......................................................... 20

4 Bell v. Wolfish, 441 U.S. 520 (1979) ................................................................................ 13

5 Bellevue Manor Assocs. v. United States, 165 F.3d 1249 (9th Cir. 1999) ......................... 20

6 Brown v. Plata, 563 U.S. 493 (2011).......................................................................... 15, 20

7 Doty v. Cty. of Lassen, 37 F.3d 540 (9th Cir. 1994).......................................................... 13

8 Estelle v. Gamble, 429 U.S. 97 (1976) ............................................................................. 13

9 Farmer v. Brennan, 511 U.S. 825 (1994) ................................................................... 12, 15

10 Gates v. Collier, 501 F.2d 1291 (5th Cir. 1974) ............................................................... 15

11 Gordon v. Cty. of Orange, 888 F.3d 1118 (9th Cir. 2018) ................................................ 13

12 Grenning v. Miller-Stout, 739 F.3d 1235 (9th Cir. 2014).................................................. 15

13 Helling v. McKinney, 509 U.S. 25 (1993)................................................................... 12, 15

14 Hutto v. Finney, 437 U.S. 678 (1978)......................................................................... 13, 15

15 Jones v. Blanas, 393 F.3d 918 (9th Cir. 2004) .................................................................. 13

16 Kelly v. Wengler, 822 F.3d 1085 (9th Cir. 2016) .............................................................. 20

17 McGuckin v. Smith, 974 F.2d 1050 (9th Cir. 1992) .......................................................... 14

18 Parsons v. Ryan, 754 F.3d 657 (9th Cir. 2014)................................................................. 12

19 Peralta v. Dillard, 744 F.3d 1076 (9th Cir. 2014) (en banc) ............................................. 13

20 Pierce v. Cty. of Orange, 526 F.3d 1190 (9th Cir. 2008) .................................................. 13

21 Plata v. Brown, No. 01-cv-1351-TEH, 2013 WL 3200587 (N.D. Cal. Jun. 24, 2013)....... 17

22 Revere v. Mass. Gen. Hosp., 463 U.S. 239 (1983) ............................................................ 13

23 Rufo v. Inmates of Suffolk County Jail, 502 U.S. 367 (1992) ............................................ 21

24 Salazar v. Buono, 559 U.S. 700 (2010) ............................................................................ 20

25 Valdivia v. Schwarzenegger, 599 F.3d 984 (9th Cir. 2010)............................................... 20

26

Statutes

27 Cal. Gov't Code § 8658 .................................................................................................... 17

28

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Cal. Health & Safety Code § 101029 ............................................................................... 17 1
Cal. Health & Safety Code § 120155 ............................................................................... 17 2
Cal. Penal Code § 4012 .................................................................................................... 17 3
Rule 4
Federal Rule of Civil Procedure 60(b)(5) ......................................................................... 19 5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

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PRISON LAW OFFICE 1 DONALD SPECTER (SBN 83925)
dspecter@prisonlaw.com 2 SARA NORMAN (SBN 189536)
snorman@prisonlaw.com 3 1917 Fifth Street
Berkeley, California 94710 4 Telephone: (510) 280-2621
Fax: (510) 280-2704
5
6 Attorneys for Plaintiffs

7

8

UNITED STATES DISTRICT COURT

9

FOR THE CENTRAL DISTRICT OF CALIFORNIA

10

EASTERN DIVISION – RIVERSIDE

11

12 QUINTON GRAY, et al., on behalf of 13 themselves and all others similarly 14 situated,
Plaintiffs,
15
16 v.
17
18 COUNTY OF RIVERSIDE, 19 Defendant.

Case No. EDCV13-0444 VAP (OP) CLASS ACTION EMERGENCY MOTION TO ENFORCE OR, IN THE ALTERNATIVE, MODIFY CONSENT DECREE Judge: Hon. Virginia A. Phillips Date: To be determined Time: To be determined Courtroom: Telephonic

20

21

NOTICE OF MOTION AND MOTION

22 TO THE PARTIES AND ALL COUNSEL OF RECORD:

23

PLEASE TAKE NOTICE THAT as soon as the matter may be heard before

24 the Honorable Virginia A. Phillips, Plaintiffs move the Court to enforce the Consent

25 Decree to compel Defendants to meet their constitutional obligation to preserve life

26 and health in the Riverside County Jails during the coronavirus pandemic.

27

Given the urgency, Plaintiffs request that the Court set an expedited briefing

28

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Case 5:13-cv-00444-VAP-OP Document 177 Filed 04/06/20 Page 7 of 28 Page ID #:17116

1 schedule and review this motion as soon as practicable.

2

The motion is based on this Notice of Motion and Motion, the accompanying

3 Memorandum of Points and Authorities, and the supporting declarations and

4 associated documents, filed herewith.

5

MEMORANDUM OF POINTS AND AUTHORITIES

6

INTRODUCTION

7

Riverside County, like the rest of California and much of the country, is under

8 a state of emergency due to the spread of the novel coronavirus and COVID-19, the

9 deadly disease it causes. The County is bracing for the potentially catastrophic

10 ravages of this pandemic.

11

California’s Governor has taken significant steps to flatten the curve of new

12 cases before hospitals are overwhelmed and the death toll skyrockets, as it has in

13 other states. Declaration of Sara Norman in Support of Plaintiffs’ Emergency

14 Motion (Norman Decl.), filed herewith, Exh. A (Newsom March 19, 2020 Executive

15 Order N-33-20). The primary components of the Governor’s actions have been to

16 require physical distancing to keep Californians at least six feet apart at all times and

17 to prepare hospitals and health care workers for the coming surge in cases.

18

Neither of these requirements can be implemented in the Riverside County

19 jails, however. Living conditions in the jails, with large dormitories so crowded that

20 people sleep on the floor, make it impossible to practice physical distancing and set

21 the stage for a disastrous spread of the virus. In addition, the jails lack medical

22 settings necessary to treat COVID-19 patients with serious complications, so all

23 such patients must be sent to outside hospitals, which already face a potentially

24 overwhelming influx of patients.

25

According to the former head of California’s prison system, correctional

26 facilities are “a tinderbox of potential infection as you go forward, especially if you

27 are just watching what’s going on around the world.” Norman Decl., Exh. B at 2.

28

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1 Another former corrections chief from Colorado sounded a similar warning: “I don’t

2 think people understand the gravity of what’s going to happen if this runs in a

3 prison.… You’re going to see devastation that’s unbelievable.” Norman Decl.,

4 Exh. C at 2.

5

Tragically, the pandemic has already taken a brutal toll at the jails. Two

6 Riverside Sheriff’s deputies have died of COVID-19, and at least 11 incarcerated

7 people have been hospitalized due to the virus. Norman Decl., Exh. D. But the

8 County faces far more severe illness and death if it fails to act now. The continued

9 spread of the virus, unchecked by physical distancing -- considered essential by the

10 Governor, the Court experts in this case, and public safety experts everywhere --

11 poses a dire threat to the nearly 4,000 people incarcerated there, as well as to the

12 deputies, health care staff, and other staff who move in and out of the jails every day

13 as they perform their essential jobs. Moreover, people housed at the jails are

14 released daily, returning to their homes and families, and anyone in the jails who has

15 to be hospitalized will be sent to a community hospital. This unavoidable

16 movement means that any COVID-19 outbreak in the jails will inevitably spread to

17 the community outside, further overwhelming health care resources and endangering

18 the larger community.

19

The Remedial Plan in this case is designed “to meet the minimum level of

20 health care necessary to fulfill Defendant’s obligations under the Eighth and

21 Fourteenth Amendments. . .” Consent Decree, June 7, 2016, ECF No. 173 (Consent

22 Decree), ¶ 9. Defendants’ failure to implement basic protocols to contain the spread

23 of COVID-19 in the jails clearly falls short of that obligation, as described by the

24 Court’s own experts. Accordingly, Plaintiffs seek to enforce the Consent Decree by

25 requiring the County to submit a plan to the Court to implement the Governor’s

26 order for physical distancing for all Californians housed in the jails and to provide

27 sanitation and other essential services generally accepted as necessary in

28

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1 correctional facilities to provide for the basic health needs of incarcerated people.

2

The County has ample means to meet its constitutional obligation to contain

3 the spread of this deadly infectious disease. The sanitation and educational

4 components require some staff time and expenditure of funds but are not

5 unmanageable. For physical distancing, the Sheriff has numerous options. There is

6 a new jail in Indio that has not yet been activated; the Sheriff can use that space to

7 transfer many of the people currently crowded into the other jails. He could further

8 use his statutory authority pursuant to Government Code Section 8658 to relocate

9 particularly vulnerable people to alternative secure settings in order to avert

10 potentially deadly consequences and reduce the dire burden on County health care

11 operations if vulnerable people remain inside to become infected. Other means are

12 not necessary given these alternatives but are also available to reduce population

13 density: the Sheriff can employ the population reduction measures he already has at

14 his disposal to reduce the population density significantly in order to allow six feet

15 of space between all people living in the jails. He can also do as other sheriffs have

16 done, and exercise his emergency statutory authority pursuant to Government Code

17 Section 8658 to release people to allow for physical distancing.

18

The Court should allow Defendant to develop a plan but should set the end

19 goal: swift implementation of meaningful public health measures as recommended

20 by the Court’s own experts in this case. It is a matter of utmost urgency that the

21 County implement such measures as will accomplish the goal of constitutional care,

22 and the Court should order Defendant to produce a plan to that end.

23

ARGUMENT

24 I. Procedural History

25

This case was filed on March 8, 2013. Plaintiffs alleged that the County of

26 Riverside failed to provide minimally adequate medical and mental health care to

27 the people incarcerated in its jails, in violation of the Eighth and Fourteenth

28

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1 Amendments to the United States Constitution. (A Third Amended Complaint, filed

2 on November 24, 2015, added a claim of discrimination against certain people with

3 disabilities in violation of the Americans with Disabilities Act and Section 504 of

4 the Rehabilitation Act.) On September 2, 2014, the Court denied Defendant’s

5 motion to dismiss and granted Plaintiffs’ motion for class certification.

6

The Plaintiff class consists of “all prisoners . . . who are now, or will be in the

7 future, subjected to the medical and mental health policies and practices of

8 Riverside County.” Consent Decree, ¶ 3. The medical subclass comprises “[a]ll

9 prisoners . . . who are now, or will in the future be, subjected to the medical care

10 policies and practices of the Riverside Jails”; the mental health subclass comprises

11 “[a]ll prisoners . . . who are now, or will in the future be, subjected to the mental

12 health care policies and practices of the Riverside Jails”; and the disabilities subclass

13 consists of “all prisoners who are now, or will in the future be, subjected to policies

14 and practices of the Riverside jails regarding specialized or sheltered housing for

15 prisoners due to their mobility impairments and need for assistive devices, and the

16 provision and confiscation of accommodations for prisoners with mobility

17 impairments.” Third Amended Complaint, November 24, 2015, ECF No. 150.

18

In January 2015, the parties suspended regular and expert discovery for the

19 purpose of settlement negotiations and hired neutral experts “to determine whether

20 the health care currently provided poses a significant risk of serious harm to

21 prisoners confined in the Jails and, if so, to make recommendations for

22 improvements that will provide the minimum care guaranteed by the U.S.

23 Constitution.” Consent Decree, ¶ 4. The parties jointly selected Dr. Scott Allen,

24 Professor of Medicine at the University of California-Riverside, as the expert on

25 medical care and Dr. Bruce Gage, Chief Psychiatrist of the Washington State

26 Department of Corrections, as the expert on mental health care. They submitted

27 their final reports to the parties on July 15, 2015.

28

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1

The parties subsequently negotiated a Remedial Plan to address the identified

2 deficiencies and asked the Court to enter a Consent Decree to resolve Plaintiffs’

3 claims. The parties further agreed that the Court would retain jurisdiction to enforce

4 the terms of its judgment. Consent Decree, ¶ 30. The Consent Decree also

5 guarantees access to information for Plaintiffs and the experts and requires

6 Defendant, “in consultation and collaboration with Plaintiffs’ counsel, [to] develop

7 and implement appropriate and adequate plans, policies, and practices to ensure

8 compliance with the Remedial Plan.” Id., ¶¶ 10, 15, 20.

9

Since that time, the experts have made numerous trips to the jails and issued

10 reports regarding their findings. Plaintiffs have done the same, engaging in fruitful

11 negotiations with County officials from the Sheriff’s Department as well as medical

12 and behavioral health leadership in the County, as the County has worked to

13 implement the Remedial Plan.

14

On March 16, 2020, Plaintiffs’ counsel spoke to Defendants’ counsel

15 regarding the County’s response to the COVID-19 threat in the jails, and followed

16 the conversation with a letter on the same day. Norman Decl., ¶ 6 and Exh. E.

17 Plaintiffs urged the County to adopt various measures in response to the virus,

18 including early release to lessen population density to prevent rapid transmission,

19 education of incarcerated people and staff, provision of hygiene supplies, and

20 precautions for particularly vulnerable populations. Id. Plaintiffs requested a

21 meeting with County officials and copies of any plans that cover any of the

22 measures Plaintiffs discussed in the letter. Id., p. 4. Defendant responded in writing

23 on March 22, providing partial responses but no plan and no date for a meeting.

24 Norman Decl., Exh. F. Plaintiffs provided follow-up questions the same day,

25 Norman Decl., Exh. G, but to date have received no substantive response or

26 documents and have had no conversations with County officials. Norman Decl., ¶ 8.

27

On March 28, 2020, Plaintiffs proposed that the Remedial Plan be modified

28

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1 on an emergency basis “to require (a) the release of enough people living in the jail

2 to allow for social distancing in all living spaces, and (b) the release of elderly and

3 high-risk patients to protect them from the dangers of the pandemic behind bars.”

4 Norman Decl., Exh. H. On March 30, 2020, Plaintiffs proposed an additional

5 modification: “to require the County to provide, in cases of public health

6 emergencies, ample free soap for personal use, cleaning supplies to sanitize cells

7 and common living areas, and public health education regarding handwashing,

8 sanitizing, and social distancing.” Id., Exh. I. The modification proposal was made

9 pursuant to the Consent Decree, ¶ 11 (“Plaintiffs may seek to modify the Remedial

10 Plan if the plan does not effectively [ensure provision of constitutional care], or a

11 modification is necessary to ensure Plaintiff class members receive adequate

12 healthcare under the Eighth and Fourteenth Amendment to the United States

13 Constitution”).

14

Plaintiffs further requested on March 28 that if Defendant disagreed, the

15 parties would stipulate to waive the dispute resolution mechanism set forth in the

16 Consent Decree and agree to an expedited briefing schedule before the Court. Id.,

17 Exh. H. Defendant has not to date responded. Norman Decl., ¶ 10.

18

Also on March 28, Plaintiffs asked the Court experts to review the proposal

19 and provide a response as soon as possible. Norman Decl., Exh. H. Dr. Allen, the

20 medical expert, provided a Supplemental Report on March 30. Norman Decl.,

21 Exh. J (Supplemental Report of Scott Allen) (Allen Expert Report). Dr. Gage, the

22 mental health expert, provided a Supplemental Report on March 31. Norman Decl.,

23 Exh. K (Supplemental Report of Bruce Gage) (Gage Expert Report). See Consent

24 Decree, ¶ 27 (expert reports admissible at the request of either party).

25 II.
26 27 28

People Housed in the Riverside County Jails Are at Profound Risk of Serious Illness and Death from the COVID-19 Pandemic A. COVID-19 is particularly dangerous in correctional settings
COVID-19, the disease caused by the coronavirus, is spreading rapidly
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1 around the United States. As confirmed cases worldwide approach one million,

2 U.S. cases have exceeded 300,000, with more than 7,500 deaths. Norman Decl., ¶

3 13. The disease is dangerous because it is a novel virus: the pre-existing immunity

4 that checks the spread of the common flu does not exist. Allen Expert Report, ¶ 3.

5 It further causes serious and sometimes deadly respiratory complications in some

6 patients, particularly those over 60 or with chronic medical problems. Id., ¶ 4.

7 There is no vaccine for COVID-19, nor is there a treatment, other than supportive

8 care. Based on early data, it appears that about 20% of those infected will require

9 hospitalization, and 5% will require treatment in an Intensive Care Unit. Id., ¶ 4.

10 Those requiring intensive treatment in a hospital setting will often require the use of

11 ventilators, which are now in short supply around the world. The overall case-

12 fatality rate “for those infected is estimated to be between 0.2% and 3%.” Id.

13

COVID-19 spreads primarily through person-to-person droplets. Thus people

14 in close proximity to each other are at highest risk for spreading the disease. The

15 rate of spread for COVID-19 appears to be as high or higher than that for influenza

16 or chicken pox. Id., ¶ 9. Thus, experts recognize that to mitigate the risk of

17 infection and the impact of the virus, “physical distancing” is essential. Id., ¶ 14.

18 That is why the Governor has ordered, and County officials have implemented,

19 physical distancing measures to keep Californians at least six feet from each other.

20 As a result, schools and businesses have closed, and parks and pools and

21 playgrounds and other places that people congregate in groups have shut down

22 because of the unacceptable risk of transmission of the virus.

23

This risk is particularly dangerous because “[t]raditional methods employed

24 by jails and prisons to slow or prevent the spread of infectious diseases,” including

25 immediate testing and quarantining, do not work for COVID-19. Id., ¶ 10.

26 Currently, those methods are simply not available “because there is no rapid test

27 [readily available] and current testing is in limited supply and most individuals who

28

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1 are infectious are without symptoms early on in the process (for up to two weeks).”

2 Id. Moreover, as explained further below, jails like Riverside’s that are at or over

3 capacity “will lack the flexibility required to successfully cohort or isolate

4 individuals or groups.” Id.

5

B. The Riverside jails present extremely high risk for rapid,

uncontained spread of the disease

6

Congregate living facilities, including nursing homes, universities and cruise

7

ships, all are at serious risk from the coronavirus, but “jails carry an even higher risk

8

because jail settings have even closer living quarters.” Id., ¶ 15. This is true of

9

Riverside County jails, where detainees share bunk areas, dining facilities and

10

bathroom facilities in extremely close quarters.

11

Currently, Riverside jails hold hundreds of people in dormitory settings. Two

12

of the five jails – Indio Jail and Blythe Jail – consist almost entirely of congregate

13

dorm housing. Norman Decl., Exh. L (Gage expert report, September 2019) at 25

14

(“Almost all inmates at both these facilities are in dormitory style units”). There are

15

multiple dorms at the other jails: Robert Presley Detention Center (Presley), Cois

16

Byrd Detention Center (Byrd), and Larry D. Smith Correctional Facility (Smith).

17

See Norman Decl., Exh. M (Gage expert report, December 2017) at 29 (noting a 40-

18

bed dorm); Norman Decl., Exh. N (Gage expert report, June 2018) at 17 (noting that

19

housing units 12A and 14G are dorm settings); Norman Decl., Exh. O (Board of

20

State and Community Corrections, 2018-2020 Biennial Inspection of Riverside

21

County Sheriff’s Office Jail and Court Holding Facilities).

22

In addition, the jails house too many people: Indio’s dorms were at 150% of

23

capacity in December 2019, according to the Board of State and Community

24

Corrections inspection, and people were sleeping on the floor at Presley, Byrd, and

25

Smith. Norman Decl., Exh. O at 2-3.

26

The dorms at Indio Jail, in particular, are crowded and unsanitary. As

27

Plaintiffs wrote in the February 2017 report,

28

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1

We are concerned about prisoners spending long periods of time in the

extremely crowded and close quarters of Housing Unit 15 and other

2

similar units at Indio (Units 13 and 14). These housing units consist of

a small dayroom with a shower on the other side of a small divider. The

3

cells are just behind the dayroom. The dayroom is off a dark hallway

which is behind a locked door separating it from the mail jail corridors;

4

there is no fresh air. We saw more than 20 people crowded into the

dayroom, which is their entire living space while they are awake….The

5

ventilation is minimal and the shower frequently in use. One prisoner

described how difficult and dangerous it is to experience withdrawal

6

from opiate addiction in those extremely close quarters, with frequent

vomiting and uncontrolled bowel movements. Other prisoners

7

described the experience of being in a small, unventilated space where

often two or more people are going through withdrawal. People

8

universally described it as extremely unhygienic, unsafe, and stressful,

with the lack of movement or programming compounded by the

9

inescapable sights, sounds, and smells of people in extreme distress.

10 Norman Decl., Exh. P (Pltfs’ February 2017 report), at 2-3. As of December 2019,

11 these conditions had not materially changed. Norman Decl., ¶ 18. As Dr. Gage

12 explains, the dirty conditions in the jail provide a vector for disease: “[t]he jails are

13 operationally challenged to conduct cleaning and sanitization at the frequency and

14 level needed to prevent the spread of the virus through contact with surfaces having

15 live virus.” Gage Expert Report, ¶ 7.

16

In addition to their dismal housing conditions, many people are routinely held

17 in crowded holding tanks with 10-20 other people, sometimes for several days. By

18 their accounts, people held in the Riverside jails often spend time in large holding

19 cells in close proximity to other people when they are first processed into the jails,

20 when transferring between jails for court dates or alternate housing, or when leaving

21 for or returning from outside medical appointments. On every tour of the jails,

22 Plaintiffs hear reports of stays of several days in these holding cells, often under

23 extremely crowded, unsanitary, and dangerous conditions. Plaintiffs have

24 repeatedly reported these incidents to the County. For example, the most recent

25 reports included the following accounts:

26

-- One patient “reported he was held in a holding cell for four days at

RPDC when he was booked on September 13 [2019]; he said he slept

27

on the floor and on benches. He said there were no sheets, blankets,

grooming supplies, or showers, and the number of people in the tank

28

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varied between seven and 15.” Norman Decl., Exh. Q (Pltfs’ December

1

2019 report) at 4.

2

-- another patient “reported that he spent more than three days in a

holding cell in intake at RPDC ...[in September 2019]… while waiting

3

for housing assignment. He said he was going through heroin

withdrawal and there were 16-20 people in the holding cell, with one

4

toilet and one sink. He thought several others in the cell were also

going through withdrawal. He reports he spent another four days in

5

intake one month later after he was rehoused at RPDC, and this time

there were about 15 people in the cell. He said that three weeks later he

6

spent three days in a holding cell again after he was again rehoused. At

that point, he estimates there were about 12 people in the holding cell

7

with him.” Id.

8

-- another patient “reported he spent three days in a holding cell in Cois

Byrd following surgery on his foot for a staph infection at the Riverside

9

University Medical Center. He said he had an open wound but no

dressing change, medications, or facilities to clean the wound for that

10

entire time. He said there were usually 10-11 other people in the cell

with him….” Id.
11

-- another patient “said that at Smith, the week prior to the tour [in

12

January 2019], he spent two to three days in a holding cell at intake

with seven or eight other people, sleeping on the floor…. He was

13

shortly thereafter found to have staph or MRSA in his finger and sent to

the emergency room. The long-term stay in extremely close quarters is

14

clearly a public health concern, given his condition; although staff

could not have known of it at the time, this situation illustrates why

15

such practices present a risk of harm to people’s health.” Norman

Decl., Exh. R (Pltfs’ January 2019 report) at 3.
16

In addition to living space problems, health care space in the jails is also

17

inadequate even under ordinary conditions. The most serious deficiency is the lack

18
of an infirmary that can provide any complex care. According to the Court’s

19

medical expert, this means that the only access incarcerated people have to a higher

20

level of care is through community emergency rooms or the County hospital.

21

Expert Report of Scott Allen, M.D., November 25, 2015, ECF No. 152-1, at 22.

22

C. Despite repeated pleas, the County has provided minimal

23

information regarding preparation for the pandemic and there is

no indication that essential population density reduction measures

24

have been instituted

25

As noted in the Section I, supra, Plaintiffs have made repeated requests for

26 information, plans, and meetings regarding Defendant’s response to the looming

27 COVID-19 threat in the jails. Plaintiffs requested plans on March 16 and have to

28

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1 date received none. Norman Decl., ¶ 8 and Exhs. E, G, H, and I. Plaintiffs asked to

2 speak with County officials on March 16, 22, 25, 28, and 31, and April 1 and 3, but

3 have never had a telephone call. Id., ¶ 8 and Exhs. E, G, H, T, U, and V.

4

The one substantive communication provided to Plaintiffs, on March 22,

5 contained broad generalizations and no concrete data or information. Id., Exh. F.

6 Plaintiffs’ follow-up questions of the same date have gone unanswered. Id.,¶ 8.

7

D. Time is of the essence to prevent COVID-19 from exacting a deadly

toll in the Riverside jails as well as the Riverside Community

8

9

The conditions in the Riverside jails create a tinderbox for rapid spread of the

10 virus, imperiling the people who live there, the staff who work there, and the

11 community at large. Allen Expert Report, ¶ 13. The harm is not speculative –

12 people are already dying of COVID-19 in the Riverside jails. Norman Decl., Exh.

13 D. The stakes could not be higher.

14

Rapid response is critical because under the existing conditions, a large

15 number of incarcerated people are likely to become sick within a short period.

16 When that happens, a substantial number will require medical intervention at local

17 hospitals, “thus increasing the risk of infection to the public at large and

18 overwhelming treatment facilities.” Allen Expert Report, ¶ 12. Dr. Allen explains,

19

As local hospital systems become overwhelmed by the patient flow from jail

outbreaks, precious health resources will be less available for people in the

20

community. To be more explicit, a detention center with a rapid outbreak

could result in multiple detainees—five, ten or more—being sent to the local

21

community hospital where there may only be six or eight ventilators over a

very short period. As they fill up and overwhelm the ventilator resources,

22

those ventilators are unavailable when the infection inevitably is carried by

staff to the community and are also unavailable for all the usual critical

23

illnesses (heart attacks, trauma, etc.).

24 Id., ¶ 13.

25

The County must be ordered to meet its constitutional obligation to prevent

26 the spread of infectious illness, including through implementation of physical

27 distancing and stringent hygiene measures. The County can achieve this by moving

28

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1 detainees out of congregate living facilities. By so doing, “the tinderbox scenario of

2 a large cohort of people getting sick all at once is less likely to occur, and the peak

3 volume of patients hitting the community hospital would level out.” Id. By

4 flattening the curve of the new infections, Riverside can avoid the crisis of

5 overloaded community resources. “In the first scenario, many people from the jail

6 and the community die unnecessarily for want of a ventilator. In the latter, survival

7 is maximized as the local mass outbreak scenario is averted.” Id. (emphasis in

8 original).

9 III.
10 11

The County Has Acted with Deliberate Indifference to the Imminent Risk that People in its Custody are Likely to Fall Severely Ill or Die Because of COVID-19. Under the terms of the Consent Decree, the County must provide

12 constitutionally adequate medical care to the people living in its jails: “The

13 Remedial Plan is designed to meet the minimum level of health care necessary to

14 fulfill Defendant’s obligations under the Eighth and Fourteenth Amendments. . . .”

15 Consent Decree, ECF No. 173, ¶ 9. In the face of the current public health crisis,

16 the County has failed to live up to that commitment.

17

It is well established that “[a] prison official’s ‘deliberate indifference’ to a

18 substantial risk of serious harm to an inmate violates the Eighth Amendment.”

19 Farmer v. Brennan, 511 U.S. 825, 828 (1994); see Parsons v. Ryan, 754 F.3d 657,

20 677 (9th Cir. 2014) (same). Specifically, the Supreme Court has recognized that

21 officials may not be “deliberately indifferent to the exposure of inmates to a serious,

22 communicable disease.” Helling v. McKinney, 509 U.S. 25, 33 (1993). This is true

23 even when “the complaining inmate shows no serious current symptoms.” Id; see

24 also Hutto v. Finney, 437 U.S. 678, 682 (1978) (finding Eighth Amendment

25 violation and noting incarcerated people were placed in conditions where infectious

26 diseases could spread easily). By failing to act meaningfully and decisively to

27 prevent the rapid spread of COVID-19 in its jails, the County has violated the

28

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1 Consent Decree and failed to fulfill its obligations under the U.S. Constitution.1

2

A. People in the jails are at substantial risk of severe illness or death

due to COVID-19.

3

“To establish unconstitutional treatment of a medical condition . . . a prisoner

4

must show deliberate indifference to a ‘serious’ medical need.” Doty v. Cty. of

5

Lassen, 37 F.3d 540, 546 (9th Cir. 1994); see also Estelle v. Gamble, 429 U.S. 97,

6

104-05 (1976). “A medical need is serious if failure to treat a prisoner’s condition

7

could result in further significant injury or the unnecessary and wanton infliction of

8

pain.” Peralta v. Dillard, 744 F.3d 1076, 1081 (9th Cir. 2014) (en banc) (citation

9

omitted). Indicators of a serious medical need include: whether “a reasonable

10

doctor or patient would find important and worthy of comment or treatment; the

11

presence of a medical condition that significantly affects an individual’s daily

12

activities; or the existence of chronic and substantial pain.” McGuckin v. Smith, 974

13

F.2d 1050, 1059-60 (9th Cir. 1992) (overruled on other grounds).

14

COVID-19 is an undeniably serious threat for people living in the Riverside

15

jails for several reasons. First, many people in the jails are elderly and have

16

underlying medical conditions that make them particularly vulnerable to severe

17

complications or death from the virus. Allen Expert Report, ¶ 19. Second,

18

everyone who lives in the jails is at an unnecessary and disproportionate risk of

19

20 1 Many members of the Plaintiff class are pre-trial and are thus protected by the

21

Fourteenth Amendment’s Due Process Clause. See Bell v. Wolfish, 441 U.S. 520, 533-37 (1979); Pierce v. Cty. of Orange, 526 F.3d 1190, 1205 (9th Cir. 2008).

22

Under the Fourteenth Amendment, pretrial detainee are not required to prove that an official knew of and disregarded an excessive risk to their health or safety; instead,

23

they need only prove that the official “did not take reasonable available measures to abate that risk, even though a reasonable official in the circumstances would have

24

appreciated the high degree of risk involved.” Gordon v. Cty. of Orange, 888 F.3d 1118, 1125 & n.4 (9th Cir. 2018). Accordingly, deprivations of health care that

25

violate the rights of the convicted population a fortiori violate the rights of those who are pretrial. See City of Revere v. Mass. Gen. Hosp., 463 U.S. 239, 244 (1983)

26

(holding that the protections of the Due Process clause “are at least as great as the Eighth Amendment protections available to a convicted prisoner”); Jones v. Blanas,

27

393 F.3d 918, 931 (9th Cir. 2004) (noting that the Fourteenth Amendment is “more protective”). Because the County’s actions plainly violate the Eighth Amendment,

28

Plaintiffs rely primarily on cases interpreting the Eighth Amendment in this motion.
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1 contracting COVID-19 because it is transmitted primarily person-to-person and the

2 fundamental prevention technique -- physical distancing -- is impossible in many of

3 the crowded dormitories in the County’s jails. See supra, Section II.B. Finally,

4 access to cleaning supplies has been a chronic problem in many areas of the jails,

5 with general cleanliness a problem in several jail facilities. See supra, Section II.B;

6 Gage Expert Report, ¶ 7. Failure to clean and sanitize frequently also places people

7 at enhanced risk of infection. Id.

8

The Court’s own experts have made it abundantly clear that crowded

9 congregate living quarters, inadequate cleaning, and the disproportionate presence

10 of vulnerable populations makes the jails ripe for the rapid spread of COVID-19 and

11 thus potentially very dangerous to the people locked inside them during the

12 pandemic as well as the staff and surrounding communities. Allen Expert Report,

13 ¶¶ 9-10, 14-16 Gage Expert Report, ¶¶ 5-10. There is clear consensus among public

14 health experts, including the Centers for Disease Control and Prevention, on these

15 points. See Allen Expert Report, ¶¶ 10, 16. Tragically, two Riverside sheriff’s

16 deputies have already died of the virus and numerous people living in the jail have

17 tested positive. Norman Decl., Exh. D. It is only a matter of time before the death

18 toll increases.

19

B. The County’s Failure to Take Adequate Steps to Protect Against

20

the Spread of COVID-19 Constitutes Deliberate Indifference.

21

“A showing of deliberate indifference . . . requires a showing that the

22 defendant knew of an excessive risk to inmate health or safety that the defendant

23 deliberately ignored.” Grenning v. Miller-Stout, 739 F.3d 1235, 1239 (9th Cir.

24 2014); see also Farmer, 511 U.S. at 839-40 (adopting subjective recklessness as the

25 test for deliberate indifference under the Eighth Amendment). Failure to prevent the

26 spread of a contagious illness constitutes deliberate indifference to a serious medical

27 need. See Hutto, 437 U.S. at 682; Gates v. Collier, 501 F.2d 1291, 1300, 1303 (5th

28

Cir. 1974) (holding plaintiffs entitled to relief under Eighth Amendment due to,
15

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1 among other conditions, allowing “inmates with serious contagious diseases . . . to

2 mingle with the general prison population”). It is well established that the

3 Government may not “ignore a condition of confinement that is sure or very likely

4 to cause serious illness.” Helling, 509 U.S. at 33. See Brown v. Plata, 563 U.S. 493,

5 508-09, 519-20 (2011) (affirming population reduction order and citing findings that

6 “[o]vercrowding had increased the incidence of infectious disease” in California

7 prisons, and that crowded living quarters “where large numbers of prisoners may

8 share just a few toilets and showers [were] ‘breeding grounds for disease’”).

9

The County is well aware of the risk posed by COVID-19. See Allen Expert

10 Report, ¶ 17; Norman Decl., Exhs. E, G, H, I, T, U, and V. The County’s response

11 to these warnings has been opaque, with a consistent failure or refusal to provide

12 meaningful information about any steps taken. Norman Decl., Exhs. F, T, U, and V.

13 As a result, Plaintiffs can have no confidence that any meaningful steps have been

14 taken to mitigate the deadly potential of the disease. Specifically, significant

15 improvements in access to soap, disinfectant, and other hygiene measures are

16 necessary, but there is no clear plan aside from a general assurance that the County

17 “follow[s] public health guidelines to maintain hygiene for the inmates,” which

18 includes “soap and access to water” and “access to cleaning supplies.” Norman

19 Decl., Exh F. Plaintiffs’ follow-up questions have gone unanswered, so Plaintiffs

20 can have no confidence that soap is available free of charge, for example, and that

21 the cleaning supplies include disinfecting agents demonstrated to be effective

22 against the coronavirus. See Norman Decl., ¶ 8.

23

Moreover, population density in the dorms presents a serious risk of harm but

24 Defendant has provided no plan to address it in a concrete way, including whether

25 people with high risk of morbidity and mortality have been included in any density

26 reduction measures. Norman Decl., Exh. F. This gap occurs despite ample

27 authority regarding the urgency to take action, including clear direction from the

28

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1 Court’s experts, appointed to advise Defendant and the Court regarding essential

2 steps to reach constitutional levels of care. In particular, the County has apparently

3 not elected to spread out the population in the jails, which is the most effective

4 means to prevent the rapid spread of the virus and to protect the medically

5 vulnerable. Allen Expert Report, ¶ 10; Gage Expert Report, ¶ 8.

6

C. The Court Should Enforce the Consent Decree

7

The Consent Decree grants the Court “the power to enforce the agreement

8 through specific performance and all other remedies permitted by law.” Consent

9 Decree, ¶ 30. Plaintiffs seek enforcement of the following provisions of the Consent

10 Decree: first, the requirement that Defendant, “in consultation and collaboration

11 with Plaintiffs’ counsel,” must “develop and implement appropriate and adequate

12 plans, policies, and practices to ensure compliance with the Remedial Plan,” and

13 second, the requirement that “Defendant shall provide Plaintiffs with access to

14 information, including all Riverside Jail facilities, documents, records, and staff, that

15 Plaintiffs believe in good faith is necessary to monitor Defendant’s compliance with

16 the Remedial Plan,” and that such information shall be provided “within 15 calendar

17 days of their request.” Id., ¶¶ 10, 20. Plaintiffs’ requests for plans and further

18 information from Defendant of March 16 and 22 have gone unanswered.2 Norman

19 Decl., ¶ 8.

20

Plaintiffs request that the Court exercise its authority under the Consent

21
22 2 Plaintiffs recognize that the Consent Decree sets forth a dispute resolution process: the parties shall negotiate any dispute in good faith, may request reports from the
23 Court experts in an attempt to resolve the disagreement, and shall then attempt to 24 resolve the matter through mediation with Judge Raul Ramirez prior to filing a
motion for relief to the Court. Consent Decree, ¶¶ 27-19. The first two 25 requirements have been met. Norman Decl, ¶ 6, Exhs. E-I, T-V. Given the urgent 26 nature of the proceedings, Plaintiffs request the Court modify the Consent Decree to
allow for urgent appeal for enforcement directly to the Court.
27

28

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1 Decree to order Defendants to submit a plan for compliance with the Court Expert’s

2 recommendations by April 10, 2020. In particular, the plan must address the need

3 for ready access to hygiene materials and physical distancing in the jails and detail

4 the steps the County will take to achieve it. Dr. Allen has already provided

5 Defendant with an example of a plan. Allen Expert Report, ¶ 17.

6

Such steps need not involve release of prisoners or reduction of the jail

7 population. The empty jail at Indio provides the readiest means by which

8 population density may be reduced and lives saved. See, e.g., Gage Expert Report,

9 ¶¶ 8-9; Allen Expert Report, ¶ 10. It is within the Court’s power to direct transfers

10 of people from one correctional facility to another in order to maintain minimum

11 constitutional health standards. Plata v. Brown, No. 01-cv-1351-TEH, 2013 WL

12 3200587, at *1 (N.D. Cal. June 24, 2013). Further, Section 8658 of the California

13 Government Code grants Defendant the power when faced with emergencies like

14 COVID-19 to relocate vulnerable populations:

15

In any case in which an emergency endangering the lives of inmates of

a state, county, or city penal or correctional institution has occurred or

16

is imminent, the person in charge of the institution may remove the

inmates from the institution. He shall, if possible, remove them to a

17

safe and convenient place and there confine them as long as may be

necessary to avoid the danger, or, if that is not possible, may release

18

them.

19 See also Cal. Penal Code § 4012 (“When a pestilence or contagious disease breaks

20 out in or near a jail, and the physician thereof certifies that it is liable to endanger

21 the health of the prisoners, the county judge may, by a written appointment,

22 designate a safe and convenient place in the county, or the jail in a contiguous

23 county, as the place of their confinement.”); Cal. Health & Safety Code §§ 101029

24 & 120155 (granting the Sheriff authority to enforce public health orders “issued for

25 the purpose of preventing the spread of any contagious, infectious, or communicable

26 disease”).

27

Counties across California have invoked these statutes to prevent the spread

28

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1 of COVID-19 in their jails.3 The California Department of Corrections and

2 Rehabilitation has taken the significant step of releasing early approximately 3500

3 people who are within 60 days of release. Norman Decl., Exh. S. Other states and

4 counties around the country have similarly worked to reduce population density to

5 give people inside prisons and jails a fighting chance against the virus.4 Defendant

6

7

3 See, e.g., Request for Judicial Notice, filed herewith, Exhs. 1-5: Order Authorizing Sacramento County Sheriff’s Department to Grant Release (Cal. Super. Ct.

8

Sacramento Cty. Mar. 25, 2020) (granting the Sheriff authority to release 421 people from county jail “because the parties agree that it is in the best interest of public

9

health to reduce the population of the Sacramento County Jail System”); General Order Releasing Named Persons from Santa Rita Cty. Jail Due to COVID-19

10

Pandemic, In re: List of 247 Persons in Santa Rita County Jail (Cal. Super. Ct., Alameda Cty. Mar. 19, 2020) (ordering the release of 247 sentenced people from the

11

Alameda County jails “in light of the COVID-19 pandemic”); Local Rule 4.115, Emergency Rule Adopting Temporary Emergency Bail Schedule, (Cal. Super. Ct.,

12

Alameda Cty.) (suspending the Uniform Bail Schedule and adopting an emergency bail schedule “[d]uring the COVID-19 crisis) (effective April 3, 2020); Standing

13

Order of the Court Deferring Sentence Surrender Dates and Permitting Sheriff to Authorize Credit for Participation in the Sheriff Work Program (Cal Super. Ct.,

14

Santa Clara Cty. Mar. 18, 2020) (recognizing that people who live or work in the jail “are at a particular risk to COVID-19 due to the confined nature of the jail

15

environment” and that “[r]educing the jail population is a critical preventative measure for inmates and staff,” and so continuing all surrender dates for 60 days and

16

authorizing extended credit for sheriff’s work program, pursuant to agreement between the People and the defense); Ruling re: Authorizing Release of Sentenced

17

Inmates Pursuant to Gov. Code Section 8658, In re the Application of Orange County Sheriff’s Dep’t, (Cal. Super. Ct., Orange Cty. Mar. 27, 2020) (finding that

18

“inmates in the Orange County Jail live, work, eat and recreate within a close environment in which it is not feasible to maintain six (6) feet of distance between

19

each inmate,” which “heightens the potential for COVID-19 to spread,” and so clarifying the Sheriff’s authority to release people “in this time of crisis” under

20 Government Code Section 8658).

21

4Request for Judicial Notice, filed herewith, Exhs. 6-9: Consent Order, In re Request to Commute or Suspend County Jail Sentences, Docket No. 084230 (N.J. Mar. 22,

22

2020) (ordering the release of a large class of people incarcerated in county jail “in light of the Public Health Emergency” caused by COVID-19); Committee for Public

23

Counsel Servs. v. Chief Justice of the Trial Ct., Case No. SJC-12926 (Mass. April 3, 2020) (Slip. Op.) (recognizing “that the situation is urgent and unprecedented, and

24

that a reduction in the number of people who are held in custody is necessary,” and so ordering courts to hold expedited bail hearings with a rebuttable presumption of

25

release for many pretrial detainees, and ordering the prisons and jails to provide daily reports regarding COVID-19 to defense attorneys); Amended Order, In re

26

Statewide Response by Washington State Courts to the COVID-19 Public Health Emergency, No. 25700-B-607 (Wash. Mar. 20, 2020) (ordering courts to “hear

27

motions for pretrial release on an expedited basis” and “find[ing] that for those identified as part of a vulnerable or at-risk population by the Centers for Disease

28

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1 also has the ability to “continually look[] at early releases and conduct them most

2 days,” with “criteria for early release” that are “fluid and changes upon our daily

3 needs,” and is thus able to “consider all sentences with less than 18 months

4 remaining.” Norman Decl., Exh. F at 2. Despite these options, Defendant has

5 deliberately failed to provide a plan in accordance with the direction from the

6 Court’s experts.

7 IV. In the Alternative, the Court Should Modify the Remedial Plan to

8

Include Basic Measures to Protect Class Members against the Threat of COVID-19

9

If this Court finds this motion warrants a remedy outside the scope of the

10 Consent Decree, Plaintiffs request the Court modify the Remedial Plan to direct

11 such action. See Consent Decree, ¶ 11 (“Plaintiffs may seek to modify the Remedial

12 Plan if the plan does not effectively [ensure provision of constitutional care], or a

13 modification is necessary to ensure Plaintiff class members receive adequate

14 healthcare under the Eighth and Fourteenth Amendment to the United States

15 Constitution”). In particular, the Remedial Plan should include basic measures to

16 protect class members against the threat of COVID-19, to allow for meaningful

17 physical distancing in the dorms and essential sanitation measures.

18

This Court “retains the authority, and the responsibility, to make further

19 amendments to [an] existing order or any modified decree it may enter as warranted

20 by the exercise of its sound discretion.” Plata, 563 U.S. at 542; see also Kelly v.

21 Wengler, 822 F.3d 1085, 1098 (9th Cir. 2016) (“Courts have long had inherent

22 power to modify court orders in changed circumstances.”); cf. Parsons v. Ryan, 949

23 F.3d 443, 454 (9th Cir. 2020) (affirming district court’s power to issue injunctions

24

25 Control, COVID-19 is presumed to be a material change in circumstances”); General Order Bond for Certain Offenses (Tex. Crim. Dist. Ct. Trial Div. Mar. 21,
26 2020) (ordering “the immediate release of people arrested and charged with certain non-violent state jail felony offenses).
27

28

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1 and enforcement orders to enforce prison conditions settlement agreement).

2 Specifically, under Federal Rule of Civil Procedure 60(b)(5), this Court may modify

3 “a final judgment, order, or proceeding” if “applying it prospectively is no longer

4 equitable.” As prospective relief “is drafted in light of what the court believes will

5 be the future course of events, . . . a court must never ignore significant changes in

6 the law or circumstances underlying an injunction lest the decree be turned into an

7 instrument of wrong.” Salazar v. Buono, 559 U.S. 700, 714-15 (2010) (citations

8 omitted).5

9

A party seeking modification must show that “a significant change in

10 circumstances warrants revision of the decree. If the moving party meets this

11 standard, the court should consider whether the proposed modification is suitably

12 tailored to the changed circumstance.” Rufo v. Inmates of Suffolk County Jail, 502

13 U.S. 367, 383 (1992). The court should apply a “flexible approach,” id. at 381, in

14 recognition that the parties could not “anticipate every exigency that could

15 conceivably arise during the life of a consent decree,” id. at 385. A “flexible

16 approach” is particularly important in institutional reform cases like this one

17 because these cases “reach beyond the parties involved directly in the suit and

18 impact on the public’s right to the sound and efficient operation of its institutions.”

19 Id. at 381 (citations omitted). In such cases, the “ability of a district court to modify

20

21
5 Rule 60(b)(5) applies to all orders and judgments with prospective application. 22 See Armstrong v. Brown, 768 F.3d 975, 986 (9th Cir. 2014) (upholding the

23 modification of a stipulated injunction, and holding that “[t]he ongoing, intractable nature of this litigation affords the district court considerable discretion in
24 fashioning relief”); Bellevue Manor Assocs. v. United States, 165 F.3d 1249, 1255

25 (9th Cir. 1999) (holding that “Rufo sets forth a general, flexible standard for all petitions brought under the equity provision of Rule 60(b)(5)” and applying Rufo to
26 court-ordered injunction in a private commercial case); Valdivia v. Schwarzenegger,

27 599 F.3d 984, 986, 994 (9th Cir. 2010) (discussing Rufo’s application to motion to

modify injunction arising out of parties’ stipulation).

28

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1 a decree in response to changed circumstances [is] all the more important . . .

2 [b]ecause such decrees often remain in place for extended periods of time, [and] the

3 likelihood of significant changes occurring during the life of the decree is

4 increased.” Id. at 380-81.

5

A. The Global Pandemic Constitutes a Changed Circumstance

6

The degree to which the coronavirus global pandemic has impacted every

7 aspect of life in the United States and around the world cannot be overstated. At the

8 time of this writing, over a hundred million Americans, and all Californians, have

9 been ordered to shelter in their homes except for essential needs. There have been

10 hundreds of thousands of cases and at least 7,500 deaths reported in the United

11 States. Norman Decl., ¶ 13. Health care facilities around the world have

12 experienced or are bracing for an extraordinary influx of patients, as the virus

13 sweeps through populations and strikes the most vulnerable as well as many others.

14 See Section II.A, supra.

15

B. The Relief Requested Would Directly Address the Needs of the

16

Medically Vulnerable Population and Those Living in Congregate Settings and Would Therefore Be Tailored to the Changed

17

Circumstances

18

Plaintiffs request relief closely tailored to the recommendations of the Court’s

19 own experts, who agree that the County must modify the Remedial Plan to allow for

20 physical distancing and to provide for basic sanitation needs for people incarcerated

21 in the jails.

22

The enforcement sought is directly tailored to the risk of harm to the Plaintiff

23 classes in the current coronavirus pandemic.

24

CONCLUSION

25

For the foregoing reasons, Plaintiffs respectfully ask the Court to enforce the

26 Consent Decree by ordering Defendant to submit a plan for compliance with the

27 Court Experts’ recommendations and respond to Plaintiffs’ information requests by

28

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1 April 10, 2020. In the alternative, Plaintiffs seek an order modifying the Remedial

2 Plan to require the County to fully implement the Governor’s order for physical

3 distancing for all Californians housed in the jails and to provide sanitation and other

4 essential services generally accepted as necessary in correctional facilities to protect

5 basic health of incarcerated people.

6

7 Dated: April 6, 2020

PRISON LAW OFFICE

8

9

By: __/s/ Sara Norman______

SARA NORMAN

10

Attorneys for Plaintiffs

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

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 Case 5:13-cv-00444-VAP-OP Document 178 Filed 04/06/20 Page 1 of 5 Page ID #:17138

PRISON LAW OFFICE 1 DONALD SPECTER (SBN 83925)
dspecter@prisonlaw.com 2 SARA NORMAN (SBN 189536)
snorman@prisonlaw.com 3 1917 Fifth Street
Berkeley, California 94710 4 Telephone: (510) 280-2621
Fax: (510) 280-2704
5
6 Attorneys for Plaintiffs

7

8

UNITED STATES DISTRICT COURT

9

FOR THE CENTRAL DISTRICT OF CALIFORNIA

10

EASTERN DIVISION – RIVERSIDE

11
12 QUINTON GRAY, et al., on behalf of 13 themselves and all others similarly 14 situated,
Plaintiffs,
15
16 v.
17
18 COUNTY OF RIVERSIDE, 19 Defendant.

Case No. EDCV13-0444 VAP (OP) CLASS ACTION DECLARATION OF SARA NORMAN IN SUPPORT OF PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE OR MODIFY THE CONSENT DECREE Judge: Hon. Virginia A. Phillips Date: To be determined Time: To be determined Courtroom: Telephonic

20
DECLARATION OF SARA NORMAN
21

22

I, Sara Norman, declare:

23

1. I am an attorney duly admitted to practice before this Court. I am the

24 managing attorney at the Prison Law Office, counsel of record for Plaintiffs in Gray

25 v. Riverside. I have personal knowledge of the facts set forth herein, and if called as

26 a witness, I could competently so testify. I make this declaration in support of

27 Plaintiffs’ Emergency Motion.

28

DECL. OF SARA NORMAN IN SUPPORT OF PLTFS’ EMERGENCY MTN

Case 5:13-cv-00444-VAP-OP Document 178 Filed 04/06/20 Page 2 of 5 Page ID #:17139

1

2. Attached hereto as Exhibit A is a true and correct copy of Executive

2 Order N-33-20, issued by Governor Gavin Newsom on March 19, 2020, available at

3 https://covid19.ca.gov/img/Executive-Order-N-33-20.pdf.

4

3. Attached hereto as Exhibit B is a true and correct copy of a news article

5 dated March 23, 2020 from KQED entitled “California Prisons Are a ‘Tinderbox of

6 Potential Infection,’ Former CDCR Secretary Warns,” available at

7 https://www.kqed.org/news/11808282/california-prisons-are-a-tinderbox-of-

8 potential-infection-former-cdcr-secretary-warns.

9

4. Attached hereto as Exhibit C is a true and correct copy of a news article

10 dated March 25, 2020 from Pew Trusts entitled “‘Prisons Are Bacteria Factories’;

11 Elderly Most at Risk,” available at https://www.pewtrusts.org/en/research-and-

12 analysis/blogs/stateline/2020/03/25/prisons-are-bacteria-factories-elderly-most-at-

13 risk.

14

5. Attached hereto as Exhibit D is a true and correct copy of a newspaper

15 article from the Los Angeles Times, entitled “Riverside Sheriff’s Department Loses

16 Two Deputies in 24 Hours,” found at https://www.latimes.com/

17 california/story/2020-04-03/riverside-sheriffs-department-loses-two-deputies-in-24-

18 hours (last viewed April 5, 2020).

19

6. On March 16, 2020, I called Deputy County Counsel Jeb Brown,

20 counsel for Defendant, to relay my concerns about the potential for a significant

21 outbreak of COVID-19 in the Riverside jails. We agreed that I would memorialize

22 my concerns in a letter. Attached hereto as Exhibit E is a true and correct copy of

23 the letter I sent to Mr. Brown on March 16, 2020, following our phone call.

24

7. Attached hereto as Exhibit F is a true and correct copy of the written

25 response I received from Mr. Brown on March 22, 2020: the copy of my letter, with

26 responses interspersed.

27

28

2

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Case 5:13-cv-00444-VAP-OP Document 178 Filed 04/06/20 Page 3 of 5 Page ID #:17140

1

8. Attached hereto as Exhibit G is a true and correct copy of the email I

2 sent to Mr. Brown on March 22 with follow-up questions to his letter. I have not

3 received any substantive written responses to these questions, nor have I had any

4 discussions with County officials regarding COVID-19 in the jails or received any

5 plans or any other documents in writing, despite repeated requests.

6

9. Attached hereto as Exhibit H is a true and correct copy of an email I

7 sent to Mr. Brown and to Court experts Dr. Allen and Dr. Gage on March 28, 2020.

8

10. Attached hereto as Exhibit I is a true and correct copy of an email I sent

9 to Mr. Brown and to Court experts Dr. Allen and Dr. Gage on March 30, 2020. I

10 have not had a substantive response from the County to either email (of March 28 or

11 March 30) to date.

12

11. Attached hereto as Exhibit J is a true and correct copy of the

13 Supplemental Report of Scott Allen, medical expert to the Court, emailed to both

14 parties on March 30, 2020, including a plan he referred to in his report and attached

15 to his email.

16

12. Attached hereto as Exhibit K is a true and correct copy of the

17 Supplemental Report of Dr. Bruce Gage, mental health expert to the Court, emailed

18 to both parties on March 31, 2020.

19

13. On April 6, 2020, I viewed the website of the Centers for Disease

20 Control and Prevention, update on cases in the United States (available at

21 https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html). I saw

22 that the website reported 304,826 total cases of COVID-19 in the United States and

23 7,616 deaths.

24

14. Attached hereto as Exhibit L is a true and correct copy of the expert

25 report of Dr. Gage, dated September 2019, provided to the parties in the course of

26 his monitoring duties under the Consent Decree.

27

28

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1

15. Attached hereto as Exhibit M is a true and correct copy of the expert

2 report of Dr. Gage, dated December 2017, provided to the parties in the course of

3 his monitoring duties under the Consent Decree.

4

16. Attached hereto as Exhibit N is a true and correct copy of the expert

5 report of Dr. Gage, dated June 2018, provided to the parties in the course of his

6 monitoring duties under the Consent Decree.

7

17. Attached hereto as Exhibit O is a true and correct copy of Board of

8 State and Community Corrections, 2018-2020 Biennial Inspection of Riverside

9 County Sheriff’s Office Jail and Court Holding Facilities, available through the

10 BSCC website (http://www.bscc.ca.gov/

11 s_fsolocaldetentionfacilityinspectionreports/), specifically at

12 https://drive.google.com/file/d/1vYeb29RP8a7tkKHG7ikJoVyxI6sBQiH2/view.

13

18. Attached hereto as Exhibit P is a true and correct copy of the

14 monitoring report I provided to Defendant for my jail trip in February 2017,

15 pursuant to my monitoring powers under the Consent Decree. (Redactions are made

16 as appropriate to protect the privacy of people who are named in the report.) The

17 conditions I describe in that report were consistent with the descriptions I heard

18 from numerous detainees interviewed by the Prison Law Office in December 2019.

19

19. Attached hereto as Exhibit Q is a true and correct copy of the

20 monitoring report I provided to Defendant for my jail trip in December 2019,

21 pursuant to my monitoring powers under the Consent Decree. (Redactions are made

22 as appropriate to protect the privacy of people who are named in the report.)

23

20. Attached hereto as Exhibit R is a true and correct copy of the

24 monitoring report I provided to Defendant for my jail trip in January 2019, pursuant

25 to my monitoring powers under the Consent Decree. (Redactions are made as

26 appropriate to protect the privacy of people who are named in the report.)

27

28

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Case 5:13-cv-00444-VAP-OP Document 178 Filed 04/06/20 Page 5 of 5 Page ID #:17142

1

21. Attached hereto as Exhibit S is a true and correct copy of a news

2 release from the California Department of Corrections and Rehabilitation, dated

3 March 31, 2020, found at https://www.cdcr.ca.gov/ news/2020/03/31/cdcr-

4 announces-plan-to-further-protect-staff-and-inmates-from-the-spread-of-covid-19-

5 in-state-prisons/ (last viewed April 6, 2020).

6

22. Attached hereto as Exhibit T is a true and correct copy of an email I

7 sent to Mr. Brown on March 31, 2020.

8

23. Attached hereto as Exhibit U is a true and correct copy of an email I

9 sent to Mr. Brown on April 1, 2020.

10

24. Attached hereto as Exhibit V is a true and correct copy of an email I

11 sent to Mr. Brown on April 3, 2020.

12

13

I declare under penalty of perjury under the laws of the United States of

14 America that the foregoing is true and correct, and that this declaration is executed

15 at San Francisco, California, this 6th day of April, 2020.

16

/s/ Sara Norman

17

Sara Norman

18

19

20

21

22

23

24

25

26

27

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EXHIBIT A

Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 2 of 88 Page ID #:17144
EXECUTIVE DEPA RTMENT STATE OF CALIFORNIA
EXECUTIVE ORDER N-33-20
WHEREAS on March 4, 2020, I proclaimed a State of Emergency to exist in California as a result of the threat of COVID-19; and
WHEREAS in a short period of time, COVID-19 has rapidly spread throughout California, necessitating updated and more stringent guidance from federal, state, and local public health officials; and
WHEREAS for the preservation of public health and safety throughout the entire State of California, I find it necessary for all Californians to heed the State public health directives from the Department of Public Health.
NOW, THEREFORE, I, GAVIN NEWSOM, Governor of the State of California, in accordance with the authority vested in me by the State Constitution and statutes of the State of California, and in particular, Government Code sections 8567, 8627, and 8665 do hereby issue the following Order to become effective immediately:
IT IS HEREBY ORDERED THAT:
1) To preserve the public health and safety, and to ensure the healthcare delivery system is capable of serving all, and prioritizing those at the highest risk and vulnerability, all residents are directed to immediately heed the current State public health directives, which I ordered the Department of Public Health to develop for the current statewide status of COVID-19. Those directives are consistent with the March 19, 2020, Memorandum on Identification of Essential Critical Infrastructure Workers During COVID-19 Response, found at: https://covid19.ca.gov/. Those directives follow:
ORDER OF THE STATE PUBLIC HEALTH OFFICER March 19, 2020
To protect public health, I as State Public Health Officer and Director of the California Department of Public Health order all individuals living in the State of California to stay home or at their place of residence except as needed to maintain continuity of operations of the federal critical infrastructure sectors, as outlined at https://www.cisa.gov/identifying-critical-infrastructure-during-covid-19. In addition, and in consultation with the Director of the Governor's Office of Emergency Services, I may designate additional sectors as critical in order to protect the health and well-being of all Californians.
Pursuant to the authority under the Health and Safety Code 120125, 120140, 131080, 120130(c), 120135, 120145, 120175 and 120150, this order is to go into effect immediately and shall stay in effect until further notice.
The federal government has identified 16 critical infrastructure sectors whose assets, systems, and networks, whether physical or virtual, are considered so vital to the United States that their incapacitation or

Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 3 of 88 Page ID #:17145
destruction would have a debilitating effect on security, economic security, public health or safety, or any combination thereof. I order that Californians working in these 16 critical infrastructure sectors may continue their work because of the importance of these sectors to Californians' health and well-being.
This Order is being issued to protect the public health of Californians. The California Department of Public Health looks to establish consistency across the state in order to ensure that we mitigate the impact of COVID-19. Our goal is simple, we want to bend the curve, and disrupt the spread of the virus.
The supply chain must continue, and Californians must have access to such necessities as food, prescriptions, and health care. When people need to leave their homes or places of residence, whether to obtain or perform the functions above, or to otherwise facilitate authorized necessary activities, they should at all times practice social distancing.
2) The healthcare delivery system shall prioritize services to serving those who are the sickest and shall prioritize resources, including personal protective equipment, for the providers providing direct care to them.
3) The Office of Emergency Services is directed to take necessary steps to ensure compliance with this Order.
4) This Order shall be enforceable pursuant to California law, including, but not limited to, Government Code section 8665.
IT IS FURTHER ORDERED that as soon as hereafter possible, this Order be filed in the Office of the Secretary of State and that widespread publicity and notice be given of this Order.
This Order is not intended to, and does not, create any rights or benefits, substantive or procedural, enforceable at law or in equity, against the State of California, its agencies, departments, entities, officers, employees, or any other person.
IN WITNESS WHEREOF I have hereunto set my hand and caused the Gre t Seal of the tote of
d his 19th day
ATTEST:
ALEX PADILLA Secretary of State

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EXHIBIT B

Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 5 of 88 Page ID #:17147
KQED California Prisons Are a 'Tinderbox of Potential Infection,' Former CDCR Secretary Warns
By Sukey Lewis Marisa Lagos Julie Small Mar 23, 2020
An inmate of a state prison in Los Angeles County tested positive for COVID-19, prison officials announced Sunday, and staff at three other prisons have also been diagnosed with the disease. (Michal Czerwonka/Getty Images)

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A man held at the California State Prison in Los Angeles County is the first inmate in the state to test positive for COVID-19, according to the California Department of Corrections and Rehabilitation. He was put in isolation on March 19 after telling staff he felt sick.
As of Monday, five correctional officers in three different prisons — California Institution for Men in Chino, Folsom State Prison and California State Prison, Sacramento — have also been diagnosed with the disease caused by the novel coronavirus. An employee at San Quentin State Prison reported on Friday to have tested positive for COVID-19 does not in fact have the disease, prison officials said Saturday.
Scott Kernan, a former secretary of CDCR, is among officials and inmate rights groups expressing concern over a potentially widespread outbreak in the state’s prisons and jails.
“You think cruise ships are a petri dish?” Kernan said in an interview Monday. “Prisons are even more so the mass of humanity. So I'm very concerned about my colleagues and the inmates and their families in jails and prisons across the country.”
Kernan said state leaders need to look at all options to reduce the prison population to mitigate the worst impacts of an outbreak. The state’s prisons are overcrowded, operating at about 130% of capacity, with more than 123,000 people incarcerated across California. An additional 65,000 people work for the state prison system.
However, all Board of Parole Hearings, which generally assess prisoners who are eligible for release, have been suspended for at least a week. In-person visits and nearly all rehabilitative and educational programs have been canceled in an attempt to slow the spread of the virus.
Kernan said the lack of activities and connection is also likely to take a toll on people being held in prison.
“It's a tinderbox of potential infection as you go forward, especially if you are just watching what's going on around the world,” he said. “I know Italy and Brazil had serious violence and even escapes and murders in the jails as a result of COVID-19.”
CDCR posted a list of precautions the department is implementing, which includes social distancing, a two-week quarantine for all new inmates and immediate isolation for anyone who has a fever, to prevent the spread of the disease.
But the Prison Law Office and a number of other advocacy groups are also pushing for the state to do more to protect the elderly and those with compromised immune systems in prison.
“We've been imploring the state through various channels to do what county jails are doing all over the state, which is reduce the density of the population by releasing people who are low risk,” said Don Specter, executive director of the Prison Law Office.

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Last week, the Santa Clara County and Alameda County sheriffs both moved to release hundreds of people early from jail. San Francisco courts have ordered dozens of inmates released early. Contra Costa County is also looking at steps to cut down the number of people held in jail.
On Monday, a group of 28 advocacy organizations wrote a letter to California Attorney General Xavier Becerra requesting the state’s top cop expand these localized efforts by directing all sheriffs to release people who have six months or less left on their sentences and asking local law enforcement to reduce arrests and bookings.
“Without action, thousands will likely die with the suffering falling disproportionately on lowincome families, particularly Black and Latinx families,” the letter says.
Gov. Gavin Newsom addressed the calls from advocates in his Monday afternoon briefing.
“I have no interest — and I want to make this crystal clear — in releasing violent criminals from our system. I won’t use a crisis as an excuse to create another crisis,” he said.
Newsom said he has a task force looking at how to release people incarcerated for non-violent crimes in a “deliberative” way. He warned that the large-scale release of tens of thousands of prisoners called for by advocacy groups could cause a whole new set of problems for emergency medical providers.
“If we start to release prisoners that are not prepared with their parole plans, they may end up out on the streets and sidewalks, in a homeless shelter,” Newsom said.
So far, the prison system has not announced any concrete steps to release people. A spokesperson for CDCR declined to answer questions, but said the department has been posting all COVID-19 updates directly on its website.
“We are continuously evaluating and implementing proactive measures to help prevent the spread of COVID-19 and keep our CDCR population and the community-at-large safe,” the CDCR website says. “Additional measures will continue to be developed based on the rapidlyevolving situation.”

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EXHIBIT C

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PEW ‘Prisons Are Bacteria Factories’; Elderly Most at Risk
Stateline Article March 25, 2020 By: David Montgomery Topics: Health & Justice Read time: 5 min ‘Prisons Are Bacteria Factories’; Elderly Most at Risk
A prisoner in his 70s takes stock of his day in a small cubicle that serves at his home in the geriatric dormitory at the Estelle prison unit at Huntsville, Texas. The sparse furnishings consist of his bunk and a small utility table cluttered with items such as a clock radio, a bottle of hot sauce and a Max Brand Western checked out from the prison library. Courtesy of the Texas Department of Criminal Justice

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Editor’s note: This story was updated March 25 to include information about a Texas inmate who tested positive for COVID-19.
HUNTSVILLE, Texas — Here in the Estelle prison unit, most of the male inmates in the geriatric dormitory first ran afoul of the law years or even decades ago, convicted of crimes ranging from murder and sex offenses to forgery and repeat DWIs.
Today, any outward hint of menace has evaporated. White-haired, frail and often tethered to canes or wheelchairs, they live in small rectangular cubicles and while away the days in unwavering sameness.
As the coronavirus pandemic sweeps the globe, prisoner advocates are warning of the potential for a disastrous outbreak among inmates. The elderly are most vulnerable, and the U.S. inmate population is aging. Jails and prisons, crowded places where social distancing is nearly impossible, are breeding grounds for contagious disease.
“These prisons are bacteria factories,” said Rick Raemisch, a consultant and former executive director at the Colorado Department of Corrections. “I don’t think people understand the gravity of what’s going to happen if this runs in a prison, and I believe it’s inevitable.
“You’re going to see devastation that’s unbelievable.”
New York inmates tested positive at Rikers Island and at a regional detention center in Brooklyn. The Texas Department of Criminal Justice reported its first two positive cases of COVID-19 this week: an inmate and an employee. A 37-year-old inmate has been medically isolated, and other inmates and staff who may have had contact with him are now being medically restricted. The contract employee was ordered to self-quarantine. The employee had contact with other prison workers and inmates, but so far none of them has developed symptoms.
While state prisons have resisted calls to release inmates, several large county and municipal jurisdictions have freed hundreds of jail inmates deemed low-risk, including seniors and those in poor health.
New Jersey plans to release as many as a thousand people from its county jails, including inmates jailed for probation violations and those sentenced for low-level offenses. Democratic Mayor Bill de Blasio said Monday that New York City may release more than 200 inmates, according to news reports. Los Angeles County and Ohio’s Cuyahoga County also have released prisoners.
Prisoner advocacy groups in more than a half-dozen states, including Texas, New York, Illinois, Pennsylvania, Indiana and Michigan, have called on governors to release state prisoners, especially elderly inmates, through compassionate release or medical furlough.

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EXHIBIT D

Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 12 of 88 Page ID #:17154
Los Angeles Times
‘We are reeling’: Coronavirus kills two Riverside sheriff’s deputies in 24 hours
David Werksman, a longtime bomb technician and deputy for the Riverside County Sheriff’s Department, died Thursday of complications from COVID-19, hours after fellow Deputy Terrell Young had died. (Riverside County) By Matthew Ormseth, Kailyn Brown, Nicole Santa Cruz April 3, 2020 6:28 PM
In the end, it was not the bombs he disarmed, the suspicious packages he retrieved or the meth labs he raided that killed David Werksman, a 22-year deputy with the Riverside County Sheriff’s Department.
It was the coronavirus.
Werksman, 51, died Thursday night, the second Riverside sheriff’s deputy killed by the virus in a day. Terrell Young, 52, a deputy who worked in the county jails, died Thursday morning.
“We are reeling from the reality that this virus has taken the lives of two of our family members within the past 24 hours,” Sheriff Chad Bianco said Friday.
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Law enforcement officers serve on the front lines of the pandemic, and most have little or no ability to do their jobs in isolation or without coming into contact with the public or their colleagues. As of Friday afternoon, 35 sworn officers and eight civilian employees with the Los Angeles Police Department have tested positive for COVID-19, the disease caused by the coronavirus. Within the New York Police Department, 1 in 6 officers are out sick, and about 1,400 have tested positive for COVID-19.
Bianco, the Riverside County sheriff, appeared frustrated with the public for flouting stay-athome orders intended to slow the virus’ spread. “Take it from me, losing two family members right here,” he said. “You don’t want to be the next.”
Bill Young, president of the union that represents Riverside County sheriff’s deputies, said he knew both Werksman and Young and called them “the nicest guys that you could meet.”
“It’s too much of a coincidence for me, personally,” he said.

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Young and Werksman did not work together and did not encounter each other while infected with the coronavirus, Bianco said. No Sheriff’s Department employees who worked with Werksman have shown symptoms of the virus as of Friday. Twenty-six Sheriff’s Department employees and 13 inmates in the county’s jails have tested positive. Two employees and no inmates have been hospitalized.
Young, a deputy of 15 years, was working March 22 at the Cois M. Byrd Detention Center near Murrieta when he fell ill and went home early, Bianco said. A week earlier, Young had escorted an inmate from the detention center to the Riverside University Health System Medical Center. The inmate has tested positive for COVID-19.
Young was a family man, a caring husband to his wife of nearly 31 years, Marie, and an attentive father to their four children, said Tania Gergel, a longtime friend of Young and his family. Since launching a fundraiser for his family, Gergel has heard that Young was a smiling face to strangers at his local church in Murrieta, where he worked security and ushered cars into the parking lot every Sunday.
Werksman joined the Riverside County Sheriff’s Department in 1998, working in the jails, on patrol and then on the bomb squad, an assignment he held for 11 years, Bianco said. His first day on the bomb squad, Werksman was sent to a vineyard in Temecula, where a man digging with a backhoe had unearthed an unexploded World War II-era artillery shell, Werksman’s older brother, Harry, said in an interview.
“David said, ‘What are we going to do?’ And the guys said, ‘Pick it up.’ He said, ‘What if it goes off?’ And they said, ‘We won’t know. We’ll be pink mist.’”
Despite its stress and the toll it took on his body, Werksman loved the work. One day, he called his brother and told him to turn on the news. A TV crew showed a day care, its basement converted into a meth lab, and a solitary figure approaching. “There he was in his bomb suit,” Harry Werksman recalled, “trudging toward it.”
“He really felt like he was saving not just one person, but as many people that might be affected by a meth lab blowing up or by a suspicious package in a courthouse,” he said. “For him, it was about helping as many people as possible. And when he told me those stories, I’d look at him and think, ‘I am the most selfish person in the world.’”
After 11 years, though, David Werksman’s shoulders, knees and back were aching. He moved into the Sheriff’s Department’s administration unit, handling public records requests, Bianco said Friday. He was in the process of being declared medically retired, his brother said, and was looking forward to purchasing a catamaran, moving with his wife to the Caribbean and opening a charter boat company.
On March 17, Werksman’s mother, Mary, died at her home in Rancho Mirage. She was 88 and suffering from leukemia, Harry Werksman said. Though Bianco said Friday that Werksman may have contracted the coronavirus at the funeral or while making arrangements for his mother’s

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burial, Harry Werksman said there was no funeral service out of concerns about spreading the virus.
“I was told don’t come — sorry,” Harry Werskman said. His brothers told him they stood several feet from one another and the cemetery workers, in line with social distancing requirements, as a mechanical lift hoisted their mother’s coffin into a vault beside her husband. “They said it didn’t take longer than five minutes.”
After the funeral, David Werksman told his brother he felt run down, but they both figured it stemmed from the stress of losing a loved one. When he spoke to his brother last Saturday, the deputy was coughing and his voice was all but gone. He checked into a hospital the next day and went on a ventilator.
The last thing he said before he was hooked up to the machine, hospital workers later told Harry Werksman, was “take care of my kids.” He leaves behind a wife, son and two daughters.
“At the end,” his brother said, “they were his concern.”

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EXHIBIT E

Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 16 of 88 Page ID

#:17158

PRISON LAW OFFICE

Director: Donald Specter

General Delivery, San Quentin, CA 94964

Telephone (510) 280-2621  Fax (510) 280-2704
www.prisonlaw.com

Managing Attorney: Sara Norman

Jeb Brown Deputy County Counsel VIA EMAIL ONLY

March 16, 2020

Staff Attorneys: Rana Anabtawi Patrick Booth Steven Fama Alison Hardy Sophie Hart Corene Kendrick Rita Lomio
Margot Mendelson

RE: Jail Plans for COVID-19 Management

Dear Jeb:

I am grateful to you for agreeing to take up these matters with the Sheriff’s Department and medical and mental health leadership at the jails, and to set up a call to discuss them. As I told you on the phone, these measures are of profound import to my clients and it is essential to me to engage with the County to represent their interests. At the same time, I am mindful of the extraordinary pressures on those in charge of the jails right now and I want to provide minimal distraction from essential work.

As you and the County leadership know, people in jail are highly vulnerable to outbreaks of contagious illnesses. They are housed in close quarters and are often in poor health. People detained in these conditions unnecessarily will be at substantially higher risk of exposure and serious health consequences, including death, than if they were in the community. The risk extends to staff as well. Furthermore, COVID-19 outbreaks in jails threaten the larger public, as large numbers of individuals move through jails on a daily basis and correctional, medical, and other staff interact with the incarcerated population and circulate back into communities. Reducing the jail population and taking proactive health measures in the jail are critical for protecting those who are detained as well as the broader community.

We ask that you immediately and publicly announce your plans to address the virus in the jail system as an urgent matter. Having an appropriate, evidence-based plan in place can help prevent an outbreak and minimize its impact if one does occur; and not having one may cost lives.

The following are the crucial elements to any plan and I look forward to discussing them with County officials:

• Early release: We encourage you to assess sentenced individuals who are particularly vulnerable to COVID-19 for immediate release, unless there is clear evidence that release would present an unreasonable risk to the physical safety of the community. The
Board of Directors Penelope Cooper, President  Michele WalkinHawk, Vice President • Marshall Krause, Treasurer
Harlan Grossman • Christiane Hipps  Margaret Johns • Cesar Lagleva  Jean Lu Laura Magnani  Michael Marcum  Ruth Morgan  Seth Morris  Vishal Shah

Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 17 of 88 Page ID #:17159
Jeb Brown Gray v. Riverside Response to COVID-19
March 16, 2020 Page 2
CDC has classified as vulnerable those who are elderly and those with asthma, cancer, heart disease, lung disease, and diabetes. To further reduce the population, we also urge you to accelerate the release of all individuals who have 30 days or fewer of their sentence remaining pursuant to Penal Code Section 4024.1. We understand that several counties in California, as well as Ohio and other states, are currently implementing population reduction measures along these lines.
• Education of the people in your custody: People housed in the jails need to be informed about the virus and the measures they can take to minimize their risk of contracting or spreading the virus. They must be educated on the importance of proper handwashing, coughing into their elbows, and social distancing to the extent they can. Information about the spread of the virus, the risks associated with it, and prevention and treatment measures must be based on the best available science. Education should be reiterated upon release to best inform individuals on how to prepare for a healthy return to the public. I have examples of CDCR’s educational materials that I am sending for the County’s review.
• Education of the staff: Correctional, administrative, and health care staff all must be educated about the virus to adequately protect themselves and their families, as well as the people in their custody.
• Staffing plans: Regardless of how many staff stay home because they are sick, the jails will have to continue maintain a staffing level to ensure adequate and humane functioning. There must be a plan for how necessary functions and services will continue if large numbers of staff are out related to the virus.
• Staffing plans for services provided by people living in the jail: Many tasks in jails, such as food preparation and basic sanitation, are performed by people living in the jail. The plans for an outbreak must also address how necessary tasks performed by them will continue if large numbers become ill.
• Provision of hygiene supplies: The most basic aspect of infection control is hygiene. There must be ready access to warm water and adequate hygiene supplies provided to inmates and to staff, both for handwashing and for cleaning, at no cost. I ask that you consider relaxing any rules banning alcohol-based hand sanitizer.
• Screening and testing of the people in your custody: The plan must include guidance, based on the best science available and advice from the County public health officials, on how and when to screen and test people in your facilities for the virus. The

Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 18 of 88 Page ID #:17160 Jeb Brown Gray v. Riverside Response to COVID-19 March 16, 2020 Page 3
County must advocate strongly for an adequate supply of test kits for people living and working in the jails.
• Housing of persons exposed to the virus: The plan must describe how and where people in the jail system will be housed if they are exposed to the virus, are at high risk of serious illness if they become infected, or become sick with it. This should not result in prolonged, widespread lockdowns. Any lockdowns or interruptions in regular activities, such as exercise or visits and phone calls with families or attorneys, should be based solely on the best science available and should be as limited as possible in scope and duration. I am particularly concerned with the Indio dorms. I would like to hear about whether the new Indio jail is available to move large numbers of people into a more spacious environment that will allow the social distancing that is essential to control the spread of the virus.
• Treatment: Courses of treatment must be evidence-based, available immediately, and in compliance with scientifically based public health protocols.
• Vulnerable Populations: The plan must provide for additional precautions for those who are at high risk of serious illness if they are infected, such as pregnant women and people with chronic illnesses, compromised immune systems, or disabilities, and people whose housing placements restrict their access to medical care and limit the staff’s ability to observe them.
• Data collection: The collection of data regarding COVID-19 will be part of the public health response. As with any contagious disease, data collection is critical to understanding and fighting the virus. The jail system must be part of this process. The same information that is tracked in the community must be tracked in the jails.
• Family and community engagement: If Riverside is cutting off all visiting, as many systems have, we ask that you increase phone call access and offer free or reduced rates, to allow people to communicate with their families and loved ones in these very difficult times.
Additional measures
It is also essential to limit the jail populations as much as is consistent with public safety. We ask that the County take the following measures:
• Release of pre-trial detainees: The California Constitution allows courts to release individuals on their own recognizance “in the court’s discretion.” Article 1, Section 12.

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Jeb Brown Gray v. Riverside Response to COVID-19
March 16, 2020 Page 4
Section 1275 of the California Penal Code states the considerations in setting bail, and makes clear that “[i]n setting, reducing, or denying bail, a judge or magistrate shall take into consideration the protection of the public” and that “public safety shall be the primary consideration.” (Emphasis added). In this case, public safety requires that as few individuals as possible circulate through the jail system. We therefore encourage presumptive release on recognizance for as many people as possible, particularly for vulnerable populations, including people over the age of 60 and people with special health vulnerabilities.
• Minimizing the use of detention: To reduce crowding, courts should default to noncustodial sentences wherever possible, including resolutions that avoid immigration detention where outbreak potential is highest.
• Reducing court appearances and other in-person meetings: Courts should reduce the risk to their staff and to the general public by declining to issue “failure to appear” warrants or “bench warrants.” If requested by defense counsel, courts should agree to waive clients’ appearance for status court dates (for people both in and out of custody). Courts should also cancel all probation, parole, and pretrial meetings; court-ordered classes; in-person drug testing; collection of court debt; and modify all reporting conditions to phone-reporting.
I am eager to discuss all of these measures with County officials, to hear what has already been done and what is being planned. I ask that you send me copies of any plans that cover any of these points that have been drafted. As we discussed, I very much hope we can talk this week.

Cc: Scott Allen Bruce Gage

Sincerely,
Sara Norman Sara Norman

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EXHIBIT F

Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 21 of 88 Page ID #:17163

PRISON LAW OFFICE
General Delivery, San Quentin, CA 94964
Telephone (510) 280-2621  Fax (510) 280-2704
www.prisonlaw.com

Director:Donald Specter
Managing Attorney: Sara Norman

Jeb Brown Deputy County Counsel

March 16, 2020

Rana Anabtawi Patrick Booth Steven Fama Alison Hardy Sophie Hart Corene Kendrick Rita Lomio Margot Mendelson
Staff Attorneys:

VIA EMAIL ONLY
RE: Jail Plans for COVID-19 Management
Dear Jeb:
I am grateful to you for agreeing to take up these matters with the Sheriff’s Department and medical and mental health leadership at the jails, and to set up a call to discuss them. As I told you on the phone, these measures are of profound import to my clients and it is essential to me to engage with the County to represent their interests. At the same time, I am mindful of the extraordinary pressures on those in charge of the jails right now and I want to provide minimal distraction from essential work.
As you and the County leadership know, people in jail are highly vulnerable to outbreaks of contagious illnesses. They are housed in close quarters and are often in poor health. People detained in these conditions unnecessarily will be at substantially higher risk of exposure and serious health consequences, including death, than if they were in the community. The risk extends to staff as well. Furthermore, COVID-19 outbreaks in jails threaten the larger public, as large numbers of individuals move through jails on a daily basis and correctional, medical, and other staff interact with the incarcerated population and circulate back into communities. Reducing the jail population and taking proactive health measures in the jail are critical for protecting those who are detained as well as the broader community.
We ask that you immediately and publicly announce your plans to address the virus in the jail system as an urgent matter. Having an appropriate, evidence-based plan in place can help prevent an outbreak and minimize its impact if one does occur; and not having one may cost lives.

Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 22 of 88 Page ID #:17164 Jeb Brown Gray v. Riverside Response to COVID-19 March 16, 2020 Page 2
The following are the crucial elements to any plan and I look forward to discussing them with County officials:
• Early release: We encourage you to assess sentenced individuals who are particularly vulnerable to COVID-19 for immediate release, unless there is clear evidence that release would present an unreasonable risk to the physical safety of the community. The
Board of Directors Penelope Cooper, President  Michele WalkinHawk, Vice President • Marshall Krause, Treasurer
Harlan Grossman • Christiane Hipps  Margaret Johns • Cesar Lagleva  Jean Lu Laura Magnani  Michael Marcum  Ruth Morgan  Seth Morris  Vishal Shah
CDC has classified as vulnerable those who are elderly and those with asthma, cancer, heart disease, lung disease, and diabetes. To further reduce the population, we also urge you to accelerate the release of all individuals who have 30 days or fewer of their sentence remaining pursuant to Penal Code Section 4024.1. We understand that several counties in California, as well as Ohio and other states, are currently implementing population reduction measures along these lines. Riverside County is unique in this area. Due to the federal court order for overcrowding, we are continually looking at early releases and conduct them most days. Our criteria for early release is fluid and changes upon our daily needs, however, when we look at early releases we consider all sentences with less than 18 months remaining.
• Education of the people in your custody: People housed in the jails need to be informed about the virus and the measures they can take to minimize their risk of contracting or spreading the virus. They must be educated on the importance of proper handwashing, coughing into their elbows, and social distancing to the extent they can. Information about the spread of the virus, the risks associated with it, and prevention and treatment measures must be based on the best available science. Education should be reiterated upon release to best inform individuals on how to prepare for a healthy return to the public. I have examples of CDCR’s educational materials that I am sending for the County’s review. CHS put a slide show together educating the inmates about personal hygiene, hand washing, and not touching your face. This has been added to the inmates dedicated channel and is playing in all dayrooms. During the medical screening process at intake and at each of the medical offices in the jail, nursing staff continually educate the inmates on the importance of personal hygiene and hand washing.
• Education of the staff: Correctional, administrative, and health care staff all must be educated about the virus to adequately protect themselves and their families, as well as the people in their custody. Education of staff has been conducted via doc reads, power points, and training bulletins put together by CHS and county health. The training material consists of personal protection, and protection of others (family, friends, inmates).

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• Staffing plans: Regardless of how many staff stay home because they are sick, the jails will have to continue maintain a staffing level to ensure adequate and humane functioning. There must be a plan for how necessary functions and services will continue if large numbers of staff are out related to the virus. We are in the process of moving some staff from specialty assignments back to the jail to assist with the movement and housing of inmates who are at risk of infection. We also have a plan in place to move additional staff from other assignments if needed.
• Staffing plans for services provided by people living in the jail: Many tasks in jails, such as food preparation and basic sanitation, are performed by people living in the jail. The plans for an outbreak must also address how necessary tasks performed by them will continue if large numbers become ill. If our inmate workers become ill and can no longer work inside the jail, we will use non inmate workers to complete those jobs.
• Provision of hygiene supplies: The most basic aspect of infection control is hygiene. There must be ready access to warm water and adequate hygiene supplies provided to inmates and to staff, both for handwashing and for cleaning, at no cost. I ask that you consider relaxing any rules banning alcohol-based hand sanitizer. We follow public health guidelines to maintain hygiene for the inmates. This includes supplies of soap and access to water to ensure they have every opportunity to wash their hands. In addition, we provide access to cleaning supplies regularly to keep the housing units clean.
• Screening and testing of the people in your custody: The plan must include guidance, based on the best science available and advice from the County public health officials, on how and when to screen and test people in your facilities for the virus. The County must advocate strongly for an adequate supply of test kits for people living and working in the jails. We are working well with county health officials to begin testing inmates in our custody that show symptoms of the virus. Any inmate that we determine to be at moderate risk of infection is tested and placed in quarantine.
• Housing of persons exposed to the virus: The plan must describe how and where people in the jail system will be housed if they are exposed to the virus, are at high risk of serious illness if they become infected, or become sick with it. This should not result in prolonged, widespread lockdowns. Any lockdowns or interruptions in regular activities, such as exercise or visits and phone calls with families or attorneys, should be based solely on the best science available and should be as limited as possible in scope and duration. I am particularly concerned with the Indio dorms. I would like to hear about whether the new Indio jail is available to move large numbers of people into a more spacious environment that will allow the social distancing that is essential to control the spread of the virus.

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We have developed and implemented a fluid housing plan that addresses housing of inmates that have been exposed or are at a moderate risk of contracting the virus. Inmates who are isolated from the general population due to potential exposure will have the same access to regular activities and privileges as those who have not.
• Treatment: Courses of treatment must be evidence-based, available immediately, and in compliance with scientifically based public health protocols. Correctional Health meets with County Public Health on an ongoing basis to identify and utilize best practices and industry standards.
• Vulnerable Populations: The plan must provide for additional precautions for those who are at high risk of serious illness if they are infected, such as pregnant women and people with chronic illnesses, compromised immune systems, or disabilities, and people whose housing placements restrict their access to medical care and limit the staff’s ability to observe them. We regularly review and evaluate the ability to release high risk inmates while weighing the need to release and the obligation to public safety.
• Data collection: The collection of data regarding COVID-19 will be part of the public health response. As with any contagious disease, data collection is critical to understanding and fighting the virus. The jail system must be part of this process. The same information that is tracked in the community must be tracked in the jails. Correctional Health in conjunction with County Public Health meet daily and collect this information.
• Family and community engagement: If Riverside is cutting off all visiting, as many systems have, we ask that you increase phone call access and offer free or reduced rates, to allow people to communicate with their families and loved ones in these very difficult times. We are increasing phone access for all inmates and offering limited free phone calls at this time.
Additional measures
It is also essential to limit the jail populations as much as is consistent with public safety. We ask that the County take the following measures:
• Release of pre-trial detainees: The California Constitution allows courts to release individuals on their own recognizance “in the court’s discretion.” Article 1, Section 12.
Section 1275 of the California Penal Code states the considerations in setting bail, and makes clear that “[i]n setting, reducing, or denying bail, a judge or magistrate shall take into consideration the protection of the public” and that “public safety shall be the primary consideration.” (Emphasis added). In this case, public safety requires that as few individuals as possible circulate through the jail system. We therefore encourage presumptive release on

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recognizance for as many people as possible, particularly for vulnerable populations, including people over the age of 60 and people with special health vulnerabilities. The process of releasing inmate pre-trial on their own recognizance is done by the probation department. We do not determine which inmate qualifies for these types of releases.
• Minimizing the use of detention: To reduce crowding, courts should default to noncustodial sentences wherever possible, including resolutions that avoid immigration detention where outbreak potential is highest. The courts are responsible for sentencing and deciding on noncustodial sentences. We do not hold inmates based on their immigration status.
• Reducing court appearances and other in-person meetings: Courts should reduce the risk to their staff and to the general public by declining to issue “failure to appear” warrants or “bench warrants.” If requested by defense counsel, courts should agree to waive clients’ appearance for status court dates (for people both in and out of custody). Courts should also cancel all probation, parole, and pretrial meetings; court-ordered classes; in-person drug testing; collection of court debt; and modify all reporting conditions to phone-reporting. The Riverside County Courts are responsible for determining what cases will be seen. The courts recently advised they will only be seeing felony and misdemeanor arraignments, gun violation restraining orders, and bail motions. The courts are currently closed to the public outside of any essential business.
I am eager to discuss all of these measures with County officials, to hear what has already been done and what is being planned. I ask that you send me copies of any plans that cover any of these points that have been drafted. As we discussed, I very much hope we can talk this week.

Cc: Scott Allen Bruce Gage

Sincerely,
Sara Norman Sara Norman

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EXHIBIT G

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EXHIBIT H

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EXHIBIT I

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EXHIBIT J

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SUPPLEMENTAL REPORT OF SCOTT A. ALLEN, MD REGARDING COVID-19 RISKS IN RIVERSIDE COUNTY JAIL
March 30, 2020
This supplemental report is prepared in response to a request by Plaintiff’s counsel citing imminent threats to individuals incarcerated in the Riverside County Jail posed by the COVID-19 pandemic.
1. I am a physician, board certified in internal medicine, with extensive experience in correctional and detention health care. I am a Professor Emeritus of Medicine, a former Associate Dean of Academic Affairs and former Chair of the Department of Internal Medicine at the University of California Riverside School of Medicine. From 1997 to 2004, I was a full-time correctional physician for the Rhode Island Department of Corrections; for the final three years, I served as the State Medical Program Director. I have published over 25 peer-reviewed papers in academic journals related to prison health care and am a former Associate Editor of the International Journal of Prisoner Health Care. I have consulted on detention health issues both domestically and internationally for the Open Society Institute and the International Committee of the Red Cross, among others. I have worked with the Institute of Medicine on several workshops related to detainee healthcare and serve as a medical advisor to Physicians for Human Rights. I am the co-founder and co-director of the Center for Prisoner Health and Human Rights at Brown University (www.prisonerhealth.org), and a former CoInvestigator of the University of California Criminal Justice and Health Consortium. I am also the founder and medical director of the Access Clinic, a primary care medical home to adults with developmental disabilities based at the Riverside County Hospital (RUHSMC).
2. I am the court appointed monitor for the consent decree in litigation involving medical care at Riverside County Jails (Grey v. Riverside). In that capacity I have conducted multiple inspections of all five jail facilities in Riverside County since 2015 with my most recent inspections having been completed in January 2020.
3. We are currently in the middle of an unprecedented global pandemic involving a novel corona virus known as COVID-19. There is no vaccine for COVID-19. There is no proven treatment other than supportive care for COVID-19. COVID-19 is easily transmitted from person to person by droplet or aerosol spread. As the virus is novel, the vast majority of humanity has no immunity to this virus.
4. Based on early data from testing, 80% of people infected with COVID-19 will have mild or no disease, 20% will be sick enough to require hospitalization and 5% of the total will require ICU level care. We also know that those rates will be much higher for elderly and those with chronic illness such as respiratory disease, heart disease, and hypertension. The overall case-fatality rate for those infected is estimated to be between 0.2% - 3%

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making is up to three times more deadly that influenza virus. The death rate is highest for those over age 60, those with chronic diseases and men. https://wwwnc.cdc.gov/eid/article/26/6/20-0320_article
5. Worldwide there are 710,000 confirmed cases resulting in 33,000 deaths. According to the Centers for Disease Control (CDC at cdc.gov) there are over 122,000 confirmed COVID-19 cases in the Unites States in the U.S. resulting in over 2000 deaths to date. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-inus.html#reporting-cases. Those numbers are increasing.
6. Riverside County has reported 195 COVID-19 cases resulting in 8 deaths to date. https://www.latimes.com/projects/california-coronavirus-cases-tracking-outbreak/
7. Riverside County Jail has now reported its first inmate infection and two deputy infections with COVID-19. https://www.pe.com/2020/03/28/first-inmate-at-riversidecounty-jail-and-two-more-deputies-test-positive-for-coronavirus/
8. COVID-19 is affecting other jails and prisons as well including an outbreak reported at Rikers Island with 21 inmates and 17 employees testing positive for the virus. https://www.nbcnewyork.com/news/coronavirus/21-inmates-17-employees-testpositive-for-covid-19-on-rikers-island-officials/2338242/. Dozens of inmates have been infected in Louisiana resulting in one inmate death and the hospitalization of a correctional officer so far. https://www.washingtonpost.com/national/an-explosion-ofcoronavirus-cases-cripples-a-federal-prison-in-louisiana/2020/03/29/75a465c0-71d511ea-85cb-8670579b863d_story.html The California Department of Corrections and Rehabilitation (CDCR) reports that so far five employees and one incarcerated person have tested positive for COVID-19. https://www.cdcr.ca.gov/covid19/ The actual number of infections is likely to be higher due to the testing shortage.
9. One of the risks of incarcerating individuals in congregant settings such as jails is the high risk of rapid spread of infectious diseases. Although much is still unknown, the case-fatality rate (number of infected patients who will die from the disease) and rate of spread for COVID-19 appears to be as high or higher than that for influenza or varicella (chicken pox).
10. Traditional methods employed by jails and prisons to slow or prevent the spread of infectious diseases will not work for COVID-19 because there is no rapid test and current testing is in limited supply and most individuals who are infectious are without symptoms early on in the process (for up to two weeks). Options for medical isolation of COVID-19 cases are limited and vary depending on the type and size of facility, as well as the current level of available capacity, which is partly based on medical isolation needs for other conditions. https://www.cdc.gov/coronavirus/2019ncov/community/correction-detention/guidance-correctional-detention.html Facilities that are at or near full capacity will lack the flexibility required to successfully cohort or

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isolate individuals or groups as such procedures require spare capacity to allow for flexible housing.

11. A real threat to all healthcare systems, including Riverside County, is the threat of a large number of people getting sick at the same time or within a short period. Rapid spread through a jail would create that very scenario.
12. Because COVID-19 can spread so quickly, those who contract COVID-19 with symptoms that require medical intervention will need to be treated at local hospitals, thus increasing the risk of infection to the public at large and overwhelming treatment facilities. As local hospital systems, including but not limited to RUHSMC, become overwhelmed by the patient flow from jail outbreaks, precious health resources will be less available for people in the community, including community members affected by coronavirus, or simply those presenting with the usual illnesses (heart attacks, accidents, etc.).
13. As local hospital systems become overwhelmed by the patient flow from jail outbreaks, precious health resources will be less available for people in the community. To be more explicit, a detention center with a rapid outbreak could result in multiple detainees—five, ten or more—being sent to the local community hospital where there may only be six or eight ventilators over a very short period. As they fill up and overwhelm the ventilator resources, those ventilators are unavailable when the infection inevitably is carried by staff to the community and are also unavailable for all the usual critical illnesses (heart attacks, trauma, etc.). In the alternate scenario where detainees are released from high risk congregate settings, the tinderbox scenario of a large cohort of people getting sick all at once is less likely to occur, and the peak volume of patients hitting the community hospital would level out. In the first scenario, many people from the jail and the community die unnecessarily for want of a ventilator. In the latter, survival is maximized as the local mass outbreak scenario is averted.
14. “Social distancing” is essential to slow the spread of the coronavirus to minimize the risk of infection and to try to reduce the number of those needing medical treatment from the already-overwhelmed and inadequately prepared health care providers and facilities. However, social distancing is an oxymoron in congregate settings, which because of the concentration of people in a close area with limited options for creating distance between detainees, are at very high risk for an outbreak of infectious disease.
15. While all congregate settings (cruise ships, nursing homes, college dorms) carry high risk of rapid spread of infection, jails carry an even higher risk because jail settings have even closer living quarters. In particular, Riverside County Jails have housing units where multiple detainees share bunk areas, dining facilities and bathroom facilities.

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16. While the CDC has provided interim guidance for correctional facilities in reducing the risks posed by COVID-19 https://www.cdc.gov/coronavirus/2019ncov/community/correction-detention/guidance-correctional-detention.html experts in the correctional field have increasingly called for release of individuals who do not pose a significant and immediate risk to public safety, especially those at highest risk of complications of infection such as age over 60 and chronic diseases including heart disease, hypertension and pulmonary disease. https://www.washingtonpost.com/opinions/2020/03/17/we-must-release-prisonerslessen-spread-coronavirus/
17. A COVID-19 plan co-developed by Dr. Newton Kendig, former Medical Director of the Federal Bureau of Prisons has been shared with the Riverside County Jail Medical Leadership and the Medical Health County COVID-19 Operations teams by way of emails to Dr. Michael Mesisca on March 19, 2020 with updates of the plan shared as they became available. A copy of the plan is attached. As I am sensitive to the fact that developing a plan to address the threat of COVID-19 from scratch would be a challenge during this crisis, I have provided this well thought out plan so that it may serve as a model for Riverside County. It could potentially be adopted with minimal to no modification.
18. In the preparation phase, that plan calls for Phase I Preparations:
Emphasis is placed on coordinating with local law enforcement & court officials to reduce crowding:
a. alternatives to in-person court appearances b. maximize use of existing policies for alternatives to incarceration c. expedite implementation of compassionate release policies d. explore strategies to reduce new intakes to the correctional facility e. explore strategies for releasing inmates at low risk for violent crime –particularly
those with risk factors for severe COVID-19
19. High priority for consideration for release should be given to patients with chronic diseases. As of March 30, 2020, the chronic illness roster for Riverside County Jails had 991 individuals, including 432 with hypertension, 48 with heart diseases, 256 with lung disease, 32 with cancer, 26 with HIV and 15 with kidney disease. All of these individuals are at higher risk of serious illness should they become infection. The number of inmates over age 60 – another high-risk group – is not immediately available but could be easily pulled from the inmate master list.
20. The attached mitigation plan involves multiple strategies to slow the spread of COVID19 in facilities, and all measures should be employed. However, reduction of the population, particularly reducing those at greatest risk for serious illness, is likely to be the most effective strategy.

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21. Incarceration is justified by protecting public safety. Public safety risk now must consider considerable risk to the public safety created by the possibility of a jail COVID19 outbreak that might overwhelm local hospitals over a short period of time.
22. Therefore, I agree with Plaintiff request that the Remedial Plan be modified to require (a) the release of enough people living in the jail to allow for social distancing in all living spaces, and (b) the release of elderly and medically high-risk patients at low risk for violent crime to protect them from the dangers of the pandemic behind bars. These extraordinary measures are justified by real threats posed to public health and safety created by maintaining the current population in settings that have become unsafe for the inmates, staff and surrounding communities during this extraordinary pandemic.
23. I also support the Plaintiff request that The Remedial Plan must further be modified to require the County to provide, in cases of public health emergencies, ample free soap for personal use, cleaning supplies to sanitize cells and common living areas, and public health education regarding handwashing, sanitizing, and social distancing. These recommendations are consistent with both CDC recommendation and detailed recommendations I have previously shared with the County (and attached to this report).

Scott A. Allen, MD Riverside, CA

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COVID-19 Pandemic Response Plan
March 26, 2020
What’s New since the March 19, 2020 Version?
On March 23, 2020, the Centers for Disease Control and Prevention (CDC) published “Interim Guidance On Management of COVID-19 in Correctional and Detention Facilities”. The guidance is very detailed and provides an excellent roadmap for correctional facilities responding to COVID-19. This version of the COVID-19 Pandemic Response Plan integrates most of the CDC guidance, as well as other infection prevention and control best practices.
Below are substantive updates primarily based on the new CDC guidance. All changes in this version are highlighted in YELLOW to facilitate recognition of What’s New. For readability, these highlights can all be removed In MSWORD® by going to the far-right ribbon of “Home” and “Select All”. Then go to the “Font” section and select ab (highlighter) and select “No Color”
Element 1. Administration/Coordination:
The purpose of this section is to provide step-by-step guidance for Chief Executive Officers and the leadership team of a correctional facility. It is now divided into two phases: Phase I. Preparation Steps for COVID-19 (for preparing for the possibility of COVID-19 in a facility); and Phase II. Response Steps for Managing COVID-19 (for steps to take once COVID-19 is identified in a staff person or incarcerated person).
Phase I. Preparation Steps for COVID-19 § Emphasis is placed on coordinating with local law enforcement & court officials to reduce crowding:
o alternatives to in-person court appearances o maximize use of existing policies for alternatives to incarceration o expedite implementation of compassionate release policies o explore strategies to reduce new intakes to the correctional facility o explore strategies for releasing inmates at low risk for violent crime –particularly those with risk
factors for severe COVID-19 § A new section on personnel policies and practices was added. § The rest of this section tracks closely with the recommendations in Elements #2 - #13.
Phase II. Response Steps for Managing COVID-19 § The text in this section closely parallels the CDC guidance. § Reference this section once a case of suspected or confirmed COVID-19 is identified in a staff person or
incarcerated person.
Element 2 Communication: § Additional recommendations are added regarding signage throughout the facility. § Additional key communication messages for employees were added. § Communication message for incarcerated persons were added– that sharing drugs and drug preparation
equipment can spread COVID-19.
Element 3. General Prevention Measures: § Environmental Cleaning: More detail is provided regarding cleaning/disinfecting hard surfaces, soft (porous
surfaces), and electronics. Emphasis is placed on the need to clean dirty surfaces prior to disinfecting them. CDC is recommending use of household bleach solutions, alcohol solutions, EPA registered household disinfectants (so hospital-grade disinfectants are not required).
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COVID-19 Pandemic Response Plan
March 26, 2020
What’s New since the March 19, 2020 Version? (continued)
§ Social distancing measures: Additional examples of social distancing measures are included. § Infection prevention & control guidance for staff screening visitors, staff, and new intakes was added.
Element 4. Visitors / Volunteers / Contractors / Lawyers: § If visits are continuing, post signage to instruct visitors to postpone visits if respiratory illness. Screen visitors
for symptoms and a temperature prior to entry. § Attachment 1a. Visitor Screening form was added .
Element 5. Employee Screening: § Attachment 1b. Employee Screening form was revised.
Element 6. New Intake Screening: § Attachment 2. New Intake Screening form was revised.
Element 8. Personal Protective Equipment: § N95 respirators are generally preferred over face masks, if available. § Table 3. COVID-19 Personal Protective Equipment Recommendations provides an at-a-glance chart to
identify the type of PPE to be used in various situations. Consider posting this throughout your facility.
Element 10. Isolation (Symptomatic Persons): § Ideally isolation will occur in a private room with a bathroom attached. CDC provides guidance on the order of
preference for rooms for isolating inmates. Cohorting is a last resort option. § If possible, designated custody staff should be assigned to monitor isolated individuals to minimize exposures. § Specific guidance regarding handling isolation room laundry is provided. § Specific guidance regarding handling food service items is provided. § Information is provided regarding cleaning spaces where COVID-19 cases spent time.
Element 11. Care for the Sick: § Identify if ill persons have risk factors for COVID-19 complications. Those with increased risk should be
monitored more closely. § Implement telemedicine or provider-to-provider consultations for management of COVID-19
patients. Element 12. Quarantine: § Close contact to COVID-10 is defined and discussed § CDC recommends that close contacts be quarantined individually if feasible. Cohorting multiple quarantined
close contacts could result in transmission of COVID-19 to persons who are uninfected so should only be practiced if there are no other available options. § CDC provides guidance on the order of preference for rooms for quarantining inmates § CDC recommends that PPE for quarantine include: face mask, eye protection, gloves. A gown should be worn if close contact with a quarantined person is anticipated. § Attachment 4. Quarantine Room Sign was revised.
Element 13. Data Collection, Analysis and Reporting was added.
Element 14. Summary, Evaluation and Continuous Quality Improvement was added.
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COVID-19 Pandemic Response Plan
March 26, 2020
Plan Overview (March 16, 2020)
COVID-19 presents unique challenges for containment in the confined correctional environment. Knowledge about COVID-19 and public health guidance for responding to this Pandemic is evolving quickly. Adaptable and updatable practical tools are needed to develop infection prevention and control plans for COVID-19 across a diverse array of U.S. jails and prisons.
This COVID-19 Correctional Pandemic Response Plan provides an outline of infection prevention and control information that should be considered for correctional facilities related to a COVID-19 response. The plan outline is paired with a fillable MS WORD® Implementation Worksheet that can be easily customized to address local issues of concern for the facility and affected community.
The 1918-19 influenza pandemic provides important lessons for responding to COVID-19. During the 1918–19 influenza (“flu”) pandemic, certain cities fared better than others. Those U.S. cities that both acted promptly to control the flu and implemented multiple layers of protective measures had fewer flu cases and lower overall mortality. This VitalCore COVID-19 Correctional Response Plan includes multiple layers of protective measures to minimize the impact of the virus in the correctional environment.
The Response Plan is divided into 14 response elements. Each element is outlined in the plan with a corresponding section of the Implementation Worksheet. When completing the Worksheet, it is recommended to reference the corresponding text in the Response Plan. This worksheet can be readily adapted to meet the unique challenges of a specific facility.
This COVID-19 Correctional Response Plan is based upon current guidance from the CDC that is adapted for the correctional setting. It is anticipated that the CDC guidance will continue to change so the plan will require updating accordingly.
Effective response to the extraordinary challenge of COVID-19 is going to require that all disciplines in a correctional facility come together to develop, modify and implement plans as information and conditions change. Swift, decisive, yet evidenced-based planning is paramount. I hope you find this document useful in advancing our collective efforts to better ensure the health and safety of our correctional workers and our incarcerated patient populations.
Viola Riggin, CEO VitalCore Health Strategies Approved by: Lannette Linthicum, MD, VitalCore Medical Consultant Developed by: Sarah Bur, MPH, RN, VitalCore Consultant Newton E. Kendig, MD, VitalCore Consultant
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COVID-19 Pandemic Response Plan
March 26, 2020
Table of Contents
COVID-19 Overview.................................................................................................. 5 COVID-19 Pandemic Response Plan Elements........................................................... 6
1. Administration/Coordination ............................................................................. 6 2. Communication ................................................................................................ 10 3. General Prevention Measures.......................................................................... 11 4. Visitors / Volunteers / Contractors / Lawyers .................................................. 15 5. Employee Screening ......................................................................................... 15 6. New Intake Screening....................................................................................... 15 7. Initial Management and Testing of Cases of Respiratory Illness ..................... 16 8. Personal Protective Equipment (PPE) and Other Supplies ............................... 17 9. Transport .......................................................................................................... 20 10. Isolation (Symptomatic Persons) ................................................................... 20 11. Care for the Sick ............................................................................................ 22 12. Quarantine (Asymptomatic Exposed Persons)............................................... 23 13. Data Collection, Analysis & Reporting ........................................................... 24 14. Summary, Evaluation and Continuous Quality Improvement (CQI) .............. 25 COVID-19 Pandemic Response Plan Implementation Worksheet.............................26
Attachment 1a. COVID-19 Visitor Screening Form ..................................................37 Attachment 1b. COVID-19 Employee Screening Form .............................................38 Attachment 2. COVID-19 New Intake Screening Form ............................................39 Attachment 3. Respiratory Infection Isolation Room Sign ........................................40 Attachment 4. Quarantine Room Sign ....................................................................42 TABLE 3. COVID-19 Personal Protective Equipment Recommendations………………..19
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COVID-19 Pandemic Response Plan
March 26, 2020
COVID-19 Overview
This guidance provides general information regarding the COVID-19 pandemic and will be updated regularly.
What is Coronavirus Disease 2019 (COVID-19)? Coronavirus Disease 2019 (COVID-19) is a respiratory illness that can spread from person-to-person. The virus that causes COVID-19 is a Novel Coronavirus that was first identified during an investigation into an outbreak in Wuhan, China and is now causing an International Pandemic.
How is the virus causing COVID-19 transmitted? The virus is thought to spread mainly between people who are in close contact with one another (within approximately 6 feet) through respiratory droplets produced when an infected person coughs or sneezes. It also may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes.
What are the symptoms of COVID-19? Patients with COVID-19 have had mild to severe respiratory illness with symptoms of: § Fever § Cough § Shortness of breath Complications of COVID-19 can include pneumonia, multi-organ failure, and in some cases death.
How can I help protect myself? People can help protect themselves from respiratory illness with everyday preventive actions. § Avoid close contact with people who are sick. § Avoid touching your eyes, nose, and mouth with unwashed hands. § Wash your hands often with soap and water for at least 20 seconds. § Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not
available.
How long does it take for symptoms to develop? The estimated incubation period (the time between being exposed and becoming ill) averages 5 days after exposure with a range of 1-14 days.
Is there a vaccine? There is currently no vaccine to protect against COVID-19. The best way to prevent infection is to take everyday preventive actions, like avoiding close contact with people who are sick and washing your hands often.
Is there a treatment? There is no specific antiviral treatment for COVID-19. People with COVID-19 can seek medical care to help relieve symptoms.
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COVID-19 Pandemic Response Plan
March 26, 2020
COVID-19 Pandemic Response Plan Elements
1. Administration/Coordination
This section on Administration/Coordination is designed for use by Chief Executive Officers to provide a broad overview of the plan. The subsequent elements provide detailed information about how to implement the plan. This section is divided into two phases:
PHASE I. PREPARATION STEPS for COVID- 19 summarizes activities that all correctional facilities should be engaged in while preparing for the possibility of COVID-19 in the facility. These steps can be used as an outline for daily meetings about COVID-19 to quickly review the status of plan implementation.
PHASE II. RESPONSE STEPS for MANAGING COVID-19 summarizes activities that should be implemented after case(s) of suspected or confirmed COVID-19 have been identified in the facility in either a staff person or incarcerated person.
PHASE I. PREPARATION STEPS for COVID-19
a) Coordination of Facility Response § It is critically important that correctional and health care leadership meet regularly to review the current status of COVID-19, review updated guidance from the Centers for Disease Control and Prevention (CDC) and flexibly respond to changes in current conditions. § Regular meetings should be held, roles and responsibilities for various aspects of the local response determined, and evidence-based plans developed and rapidly implemented. § Consideration should be given to activating the Incident Command System within the facility to coordinate response to the crisis. § Responsibility should be assigned for tracking National and Local COVID-19 updates.
b) Coordination with local law enforcement and court officials to minimize crowding. § Explore alternatives to in-person court appearances. § Maximize use of existing policies for alternatives to incarceration. § Expedite implementation of compassionate release policies. § Explore strategies to reduce new intakes to the correctional facility. § Explore strategies for releasing inmates at low risk for violent crime –particularly those with risk factors for severe COVID-19.
c) Review Personnel Policies and Practices § Review the sick leave policies of each employer in the facility to determine which officials will have authority to send symptomatic staff home. § Review/revise/devise telework policies. § Review contingency plans for reduced staffing.
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§ Consider offering alternative duties to staff at higher risk of severe illness with COVID-19. § Remind staff to stay at home if they are sick § Institute employee screening of all employees (see Element #5) § Send staff home if they are identified with identified symptoms (fever, cough or shortness of
breath) and advise to follow CDC recommended steps for persons with COVID-19 symptoms § Utilize following criteria for symptomatic staff to return to work:
o no fever for at least 72 hours (i.e., 3 full days of no fever without use of medicine that reduces fever); AND o other symptoms improved (e.g., cough or shortness of breath have improved); AND o at least 7 days have passed since symptoms first appeared
§ Identify staff with COVID-19 Exposures (see definition of close contact in Element #12) o If a staff member has a confirmed COVID-19 infection, inform other staff about possible exposure to COVID-19 (maintaining confidentiality per American with Disabilities Act. o Decide if exposed staff will self-quarantine for 14-days or work wearing face mask.
§ NOTE: CDC recommends that employees, who are COVID-19 close contacts, self-monitor for symptoms and, if feasible—given staffing constraints—be under self-quarantine for 14 days. If due to staffing constraints, self-quarantine is determined not to be feasible, then asymptomatic exposed staff should come to work and wear a face mask (cloth or disposable) while working, with frequent hand hygiene.
d) Communication (Element #2):
§ Initiate and maintain ongoing communication with local public health authorities
§ Communicate with community hospital about procedures for transferring severely ill inmates.
§ Develop and implement ongoing communication plans for staff, incarcerated persons, and families.
e) Implement General Prevention Measures (Element #3)
§ Promote good health habits among employees (Table 1)
o Review current policy regarding alcohol-based hand sanitizer and consider relaxing restrictions to allow more staff to carry individual-sized bottles for hand hygiene.
§ Conduct frequent environmental cleaning of high touch surfaces. Increase number of inmate workers assigned to this duty.
§ Institute social distancing measures to prevent spread of germs. Review list of possible measures listed in Element #3 and develop plans for your facility.
o Make decisions about movement § Minimize movement both within the facility and between facilities
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§ Consider restricting transfers of incarcerated persons to and from other jurisdictions unless necessary for medical evaluation, isolation/quarantine, clinical care, extenuating security concerns or to prevent overcrowding.
o Postpone non-urgent outside medical visits § Employees stay at home if sick. Review communications with employees about this. § If influenza vaccination is still in stock offer to unvaccinated staff (higher priority) and
incarcerated persons. § Implement infection prevention control guidance for staff doing screening (of visitors,
employee, new intakes) (Element #3) f) Make decisions about access for visitors, volunteers, contractors and lawyers (Element #4)
§ Communicate with potential visitors § Institute screening of visitors for symptoms and temperature (Attachment #1a) g) Institute Employee Screening (Element #5) (Attachment #1b) h) Institute New Intake Screening (Element #6) (Attachment #2) i) Appropriately manage and test symptomatic incarcerated persons (Element #7) § Suspend co-pays for incarcerated persons seeking medical evaluation for respiratory symptoms. j) Attempt to acquire needed personal protective equipment (PPE) and other supplies (Element #8) § Ensure that sufficient stocks of hygiene supplies, cleaning supplies, personal protective
equipment (PPE) , and medical supplies are available and there is a plan in place for re-stocking. § Review Table 3. COVID-19 Personal Protective Equipment Recommendations and post as
needed in facility. § Implement staff training on donning and doffing PPE. k) Assure that transport officers have received training on safe transport utilizing PPE (Element #9). § Identify staff who will provide transport l) Identify rooms to be used for isolation (Element #10) and quarantine (Element #12).
§ NOTE: CDC strongly recommends single rooms for persons isolated and quarantined. Cohorting of groups of persons should be done as a last resort.
§ Print out color isolation and quarantine signs for future use (Attachment #3 & Attachment #4). § Discuss how custody staff will be assigned to work in isolation/quarantine rooms.
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§ Appropriately train staff and incarcerated workers who work in laundry and food service. § Train staff and incarcerated workers on how to clean spaces where COVID-19 workers spent
time. m) Health services should review procedures for caring for the sick (Element #11)
§ Maintain communication with public health authorities to determine how COVID-19 testing will be performed and recommended criteria for testing
§ Explore options for expanding telehealth capabilities.
PHASE II. RESPONSE STEPS for MANAGING COVID-19
n) Implement alternative work arrangements, as deemed feasible.
o) Suspend all transfers of incarcerated persons to and from other jurisdiction and facilities unless necessary for medical evaluation, medical isolation/quarantine, extenuating security concerns, or to prevent over-crowding.
p) When possible, arrange for lawful alternatives to in-person court appearances.
q) Consider quarantining all new intakes for 14 days before they enter the facility’s general population, if feasible.
r) Incorporate screening for COVID-19 symptoms and a temperature check into release planning. Provide inmates who are under isolation or quarantine who are releasing with education about recommended follow-up.
s) Coordinate with local public health authority regarding persons being isolated/quarantined with COVID-19.
t) Communicate with community hospital regarding potential need to transfer severely ill inmates.
u) Hygiene: § Continue to ensure that hand hygiene supplies are well-stocked in all areas of the facility. § Continue to emphasize practicing good hand hygiene and cough etiquette
v) Environmental Cleaning: § Continue emphasis on cleaning and disinfection especially on frequently touched surfaces § Reference specific cleaning and disinfection procedures for areas where a COVID-19 case spent time (Element #10)
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x) Implement medical isolation of confirmed or suspected COVID-19 cases (see Element #10). Implement telehealth modalities as much as possible.
y) Implement quarantine of close contacts of COVID-19 cases (see Element #12).
z) Implement system for tracking information about incarcerated persons and staff with suspected/confirmed COVID-19 and quarantined persons (Element #13).
2. Communication § The importance of regular communication with staff, the incarcerated population, and their families
cannot be over-emphasized. You cannot communicate too much. § Specific methods of communication for all groups should be established. Staff should be assigned to
be responsible for crafting and disseminating regular updates. § Post signage throughout the facility communicating the following:
o For all: symptoms of COVID-19 and hand hygiene instructions o For incarcerated/detained persons: report symptoms to staff o For staff: stay at home when sick; if symptoms develop while on duty, leave the facility as
soon as possible and follow CDC-recommended steps for persons who are ill with COVID-19 symptoms.
o Ensure that signage is understandable for non-English speaking persons and those with low literacy
§ During COVID-19, group educational sessions should be avoided and instead, communicate with electronic and paper methods of communication.
§ Key communication messages for employees include: o Symptoms of COVID-19 and its health risks o Reminders about good health habits to protect themselves, emphasizing hand hygiene. o The importance of staying home if signs and symptoms of fever, cough, or shortness of breath or if known close contact with a person with COVID-19. o Review of sick leave policy o If staff develop fever, cough, or shortness of breath at work: immediately put on a face mask, inform supervisor, and leave facility, and follow CDC recommended steps for persons who are ill with COVID-19 symptoms. o Elements of the facility COVID-19 Response Plan to keep employees safe, including social distancing.
§ Key communication messages to incarcerated persons: o The importance of reporting fever and/or cough or shortness of breath (and reporting if another incarcerated person is coughing in order to protect themselves). Indicate how these reports should be made. o Reminders about good health habits to protect themselves, emphasizing hand hygiene. o Communicate that sharing drugs and drug preparation equipment can spread COVID-19. o Plans to support communication with family members (if visits are curtailed). o Plans to keep incarcerated persons safe, including social distancing.
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§ Key communication messages for families: o Information about visiting. If visiting is curtailed information about alternatives to in-person visits. o What the facility is doing to keep incarcerated persons safe.
§ Local public health authorities: Contact should be made and maintained with local public health authorities to get local guidance, especially with regard to managing and COVID-19 testing of persons with respiratory illness.
§ Local hospital: Communication should also be established with your local community hospital to discuss referral mechanisms for seriously ill incarcerated persons.
3. General Prevention Measures Throughout the duration of the COVID-19 pandemic the following general prevention measures should be implemented to interrupt viral infection transmission. These are listed in Table 1 below.
Table 1. General Prevention Measures
a. Promote good health habits among employees and incarcerated individuals: 1) Avoid close contact with persons who are sick. 2) Avoid touching your eyes, nose, or mouth. 3) Wash your hands often with soap and water for at least 20 seconds. 4) Cover your sneeze or cough with a tissue (or into a sleeve). Then throw the tissue in the trash. 5) Avoid non-essential physical contact. Avoid handshakes, “high-fives”
b. Conduct frequent environmental cleaning of “high touch” surfaces. c. Institute social distancing measures to prevent spread of germs, e.g., minimize self-
serve foods, minimize group activities. d. Employees stay at home if they are sick. e. Influenza (flu) vaccine is recommended for persons not previously vaccinated. f. Infection prevention and control guidance for persons doing screening (visitors, employees, new intakes)
a. Good Health Habits § Good health habits should be promoted in various ways, i.e., educational programs, posters,
campaigns, assessing adherence with hand hygiene, etc. § This CDC website has helpful educational posters: § Each facility should assure that adequate supplies and facilities are available for hand
washing for both incarcerated individuals and employees, including: soap, running water, hand drying machines or disposable paper towels. § Provide tissues and no-touch trash receptacles for disposal. § With approval of the Chief Executive Officer (CEO), health care workers should have access
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to alcohol-based hand rub.
§ Provisions should be made for employees and visitors and new intakes to wash their hands when they enter the facility.
b. Environmental Cleaning
§ The frequency of routine cleaning of surfaces that are frequently touched should be increased. These can include doorknobs, keys, handrails, telephones, computer keyboards, elevator buttons, cell bars, etc.
§ One strategy is to increase the number of incarcerated individuals who are assigned to this duty.
§ Hard Surfaces: o If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection. o For disinfection, diluted household bleach solutions, alcohol solutions with at least 70% alcohol, and most common EPA-registered household disinfectants should be effective. § Diluted, unexpired household bleach can be used if appropriate for the surface. Never mix household bleach with ammonia or any other cleanser. § Prepare bleach solution by mixing: 5 tablespoons (1/3 cup) bleach per gallon of water or 4 teaspoons of bleach per quart of water
§ Soft (porous) surfaces, i.e., carpeted floor, rugs, drapes o Remove visible contamination and clean with appropriate cleaners for these surfaces o If washable, launder in hottest water setting for the item and dry completely o Otherwise, use products with EPA-approved viral pathogens claims
§ Electronics cleaning and disinfection o For electronics such as tablets, touch screens, keyboards, and remote controls, remove visible contamination if present. o Follow the manufacturer’s instructions for all cleaning and disinfection products. o Consider use of wipeable covers for electronics. o If no manufacturer guidance is available, consider the use of alcohol-based wipes or spray containing at least 70% alcohol to disinfect touch screens and other surfaces. Dry surfaces thoroughly to avoid pooling of liquids.
c. Social Distancing Measures
Strategies for social distancing are myriad and markedly dependent on local factors. Various administrative measures should be implemented to reduce contact between people and reduce chance of spreading viruses. It is recommended that an interdepartmental brainstorming meeting be held to discuss what would work in your facility.
Examples of such measures include:
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§ Common areas o Enforce increased space between individuals in holding cells, as well as in lines and waiting areas such as intake (e.g., remove every other chair in a waiting area).
§ Recreation o Choose recreation spaces where individuals can spread out o Stagger time in recreation spaces o Restrict recreation space usage to a single housing unit (where feasible), performing. o Disinfection between individual use of equipment and between groups o Eliminate close-contact sports, i.e., basketball, soccer o Emphasize individual activities, i.e., running, walking, jumping jacks o Stop the use of equipment that multiple people will touch
§ Meals o Stagger meals o Rearrange seating in dining hall to increase space between individuals, e.g., remove every other chair and use only one side of a table o Minimizing self-serve foods, e.g., eliminate salad bars o Provide meals inside housing units or cells
§ Group activities o Limit size of group activities o Increase space between individuals during group activities o Consider alternatives to existing group activities, in outdoor areas or other areas where individuals can spread out o Suspend group programs* *Note: With discontinuation of group activities, it is vitally important to creatively identify and provide alternative forms of activity to support the mental health of incarcerated individuals during the pandemic.
§ Education o Convert curriculum to self-study o Provide education through use of video modalities
§ Housing o Arrange bunks so that individuals sleep head to foot o Rearrange scheduled movements to minimize mixing of individuals from different housing units o Ensure thorough cleaning/disinfection of living space when inmates leave o If space allows, reassign bunks to provide more space between individuals (ideally 6 feet or more in all directions
§ Medical o Leverage telehealth modalities, e.g., tele-video and provider to provider consultation o If possible, designate a room near each housing unit to evaluate individuals with COVID-19 symptoms o Designate a room near intake area to evaluate new intakes with identified COVID-19 symptoms or exposure risk before they move to other parts of facility o Discontinue pill-lines and administering medication on units
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o Assure that inmates who come to sick call with respiratory symptoms are immediately placed in separate room with mask on and perform hand hygiene.
§ Minimize inmate movement o Minimize transferring of inmates between units o Stopping movement in and/or out o Suspending work release programs
§ Providing virtual visits
d. Sick/exposed employees remain home
§ COVID-19 could gain entrance to a facility via infected employees. Staff should be educated to stay home if they have fever and respiratory symptoms.
§ If employees become sick at work, they should be advised to promptly report this to their supervisor and go home.
§ Employees should be advised to consult their health care provider by telephone.
§ Employees who are sick should be advised to follow CDC guidance on What to do if you are sick?
§ Determine employee policy regarding quarantine, i.e., exposed employees self-quarantine for 14 days or come to work wearing a facemask and frequent hand hygiene. Exposed staff should promptly report symptoms if they occur.
e. Influenza vaccination § While influenza season is still ongoing flu vaccination remains an important measure to
prevent an illness that presents similarly to COVID-19. § If there is influenza vaccine still in stock, unvaccinated staff (highest priority) and
incarcerated persons should be offered the flu vaccine.
f. Infection prevention & control guidance for staff screening visitors, staff, and new intakes. The following is a protocol to safely check an individual’s temperature: o Perform hand hygiene o Put on a face mask, eye protection (goggles or disposable face shield that fully covers the front and sides of the face) and a single pair of disposable gloves* o Check individual’s temperature § Non-contact or disposable thermometers are preferred over reusable oral thermometers. § If disposable or non-contact thermometers are used and the screener did not have physical contact with an individual, gloves do not need to be changed before the next check. If non-contact thermometers are used, they should be cleaned routinely as recommended by CDC for infection control. § If performing oral temperature check on multiple individuals, ensure that a clean pair of gloves is used for each individual and that the thermometer has been thoroughly disinfected in between each check. o Remove and discard PPE o Perform hand hygiene
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* Note: CDC recommends wearing a gown for this process. Given the current shortage of gowns in many facilities this is not routinely recommended in this plan.
4. Visitors / Volunteers / Contractors / Lawyers § Consideration should be given to begin limiting access to the facility by visitors and volunteers and
non-essential contractors. o Arrangements should be made to increase options for incarcerated persons to communicate with their families via telephone or tele-video.
§ If possible, legal visits should occur remotely. § Communicate with potential visitors instructing them to postpone visits if they have respiratory
illness. Post signage regarding visitor screening. § All visitors should be screened for symptoms and a temperature taken prior to entry utilizing the
form in Attachment 1a.
5. Employee Screening § In locations where it is identified that there is sustained COVID-19 community transmission,
employees should be screened upon arrival with a temperature, and asked questions about respiratory symptoms and if they have had contact with a known COVID-19 patient (Attachment 1b). § This form can be laminated for employees to review the questions for individuals to verbally respond to them. § A temperature should also be taken ideally with a no-touch infra-red thermometer. § Employee screenings do not require documentation unless the person responds “YES” to any question or has a temperature. § Screening can be performed by any staff person with training. § Employees who screen positive for symptoms should be sent home and advised to consult their healthcare provider. § Employees who have had close contact with a COVID-19 case should self-monitor for symptoms (i.e., fever, cough, or shortness of breath) and, if feasible given staffing constraints, be under selfquarantine for 14 days. If due to staffing constraints, self-quarantine is not feasible, asymptomatic exposed staff should come to work and wear a face mask (cloth or disposable) while working, with frequent hand hygiene.
6. New Intake Screening § New intakes should be screened per usual protocols. Consider conducting this screening outdoors or
in a covered area (weather and logistics permitting). § Temperature should be taken, ideally with an infra-red no-touch thermometer with staff wearing
PPE as described in Element #3f.
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§ Additional questions should be asked regarding symptoms and exposure to COVID-19 (Attachment 2).
§ New arrivals should be segregated from other incarcerated individuals until the screening process has been completed.
§ If new intakes are identified with symptoms then immediately place a face mask on the person, have the person perform hand hygiene, and place them in a separate room with a toilet while determining next steps. Staff entering the room shall wear personal protective equipment (PPE) in accordance with guidance in Element #8.
§ Identify incarcerated persons who were transferred with the symptomatic new intake for need for quarantine (see Element #12).
§ If new intakes report history of exposure to COVID-19 then they should be placed in quarantine (see Element #12).
7. Initial Management and Testing of Cases of Respiratory Illness § Source control (placing a mask on a potentially infectious person) is critically important. If
individuals are identified with symptoms, then immediately place a face mask on the patient and have them perform hand hygiene. § Place them in a separate room with a toilet and sink while determining next steps. If the facility has an airborne infection isolation room this could be used for this purpose. Staff in the same room shall wear personal protective equipment (PPE) as outlined in Element #8. § Decisions about how to manage and test incarcerated persons with mild respiratory illness should be made in collaboration with public health authorities. The vast majority of persons with respiratory illness will not have COVID-19, especially during seasonal flu season. It is unlikely that hospitals will have the capacity to evaluate incarcerated persons with mild respiratory illness. § The CDC current priorities for testing are listed at this link. § CDC recommendations for clinical specimens for COVID-19 include collecting and testing upper respiratory tract specimens (nasopharyngeal swab). New (3/24/20) CDC recommendation indicate that if nasopharyngeal swabs are not feasible that nasal swabs are an acceptable alternative. CDC also recommends testing lower respiratory tract specimens, if available. For patients who develop a productive cough, sputum should be collected and tested for COVID-19. Note: rapid blood tests for COVID-19 have become commercially available that test for IgG and IgM. These indicate that the results should not be the sole basis to diagnose or exclude infection. Therefore, at this time it is recommended that these tests not be used. § If feasible, during flu season it is recommended that rapid flu tests with nasopharyngeal swab be performed. It is important that nasopharyngeal swabs be performed correctly. § Nasopharyngeal swabbing should only be performed by staff with demonstrated competency. See instructional video at: https://www.youtube.com/watch?v=DVJNWefmHjE
§ Suspend co-pays for incarcerated persons seeking medical evaluation for respiratory symptoms.
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8. Personal Protective Equipment (PPE) and Other Supplies
PERSONAL PROTECTIVE EQUIPMENT § The CDC recommends the following PPE when a person comes into contact with a person with suspected or confirmed COVID-19. o N95 respirator or face mask
§ N95 respirators are preferred. When N95 respirators are in short supply they should be reserved first for use when a patient is undergoing an aerosol-generating procedure including testing for COVID-19 and second for confirmed COVID-19 patients.
§ N95 respirators should not be worn with facial hair that interferes with the respirator seal.
§ If N95 respirators are to be used, they must be used in the context of a fit-testing program. Fit
testing is specific to the brand/size of respirator to be used.
Table 2. Definitions of “Face Masks” and “Respirators”
Face Masks: Disposable FDA-approved masks, which come in various shapes and types (e.g., flat with nose bridge and ties, duck billed, flat and pleated, pre-molded with elastic bands).
Respirators: N-95 or higher filtering, face-piece respirators that are certified by CDC/NIOSH.
o Gown
§ If gowns are in short supply they can be reserved for times when direct, close contact with a patient is being implemented.
o Gloves o Eye Protection (goggles or disposable face shield that fully covers the front and sides of the face).
§ This does not include personal eyeglasses. § If reusable eye protection is used, it should be cleaned and disinfected in accordance with
manufacturer’s instructions.
§ It is strongly emphasized that hand hygiene be performed before and after donning and doffing PPE.
§ Staff who are wearing PPE should be trained on its use. CDC instructions on donning and doffing PPE are available at: https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf.
§ Inventory current supplies of PPE. § CDC (3/17/20) has published new recommendations on strategies to use in the absence of
available PPE. § Criteria for using various types of PPE based upon the situation is outlined in Table 3 (next page). § Make contingency plans for the probable event of PPE shortages during the COVID-19 pandemic
(see CDC guidance on optimizing PPE supplies). CDC now recommends that in the case of shortage of disposable face masks that re-usable cloth masks can be considered.
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OTHER SUPPLIES § Other supplies that should be obtained and inventory tracked include:
o Standard medical supplies and pharmaceuticals for daily clinic needs o Tissues o Liquid soap o Bar soap o Hand drying supplies o Alcohol-based hand sanitizer containing at least 60% alcohol (where permissible based on
security restrictions) o Cleaning supplies, including EPA-registered disinfectants effective against the virus that causes
COVID-19 o Sterile viral transport media and sterile swabs to collect nasopharyngeal specimens if COVID-19
testing is indicated
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Table 3. COVID-19 Personal Protective Equipment Recommendations

Situation

N95 Face respirator mask

Eye protection

Gloves

Gown/ coveralls

STAFF

Staff performing temperature checks on: staff, visitors, or incarcerated/detained persons

X

X

X

1

Isolation: Staff providing medical care for suspected/confirmed COVID-19 cases

X 2

X

X

X

Isolation: Correctional staff entering isolation room

X 2

X

X

X

Staff present during aerosolizing procedure on suspected or confirmed COVID-19 case (including testing)

X

X

X

X

Staff handling laundry (from a COVID-19 case or case contact)

X

X

Staff handling used food service items (from a COVID-19 case or case contact)

X

X

Staff cleaning an area (where a COVID-19 case has spent time)

Additional PPE may be needed based on the disinfectant label.

X

X

Transport of suspected/confirmed COVID-19

X 2

During transport

Prior to & following transport (if close contact)

X 2

X

X

X

Quarantine: No direct contact with asymptomatic persons who are close contacts to COVID-19

X

X

X

Quarantine: Direct contact with asymptomatic persons (including medical care/temperature checks)

X

X

X

X

INCARCERATED/DETAINED PERSONS

Confirmed or suspected COVID-19 cases, or showing symptoms of COVID-19

X

Laundry worker (handling items from COVID-19 case or case contact)

X

X

Food service worker (handling items from COVID-19 case or case contact)

X

X

Worker performing cleaning (areas where COVID-19 case has spent time)

Additional PPE may be needed based on the disinfectant label.

X

X

Quarantine: Asymptomatic COVID-19 close contacts 3

Apply face masks for source control, as feasible, based on local supply, especially if cohorted

1 Note: CDC recommends wearing a gown for this process. Given the current shortage of gowns in many facilities this is not
routinely recommended in this plan.
2 A NIOSH-approved N95 is preferred. However, based on local and regional situational analysis of PPE supplies, face masks
(including cloth face masks) are an acceptable alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to staff.
3 If a facility chooses to quarantine new intakes (without symptoms or known exposure to a COVID-19 case) before integrating
into the facility’s general population, face masks are not necessary.
Adapted from: CDC. Interim Guidance On Management of COVID-19 in Correctional and Detention Facilities (Table 1); 3/24/19. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidance-correctionaldetention.html#Min_Mod_Trans

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9. Transport
If a decision is made to transport a patient with signs and symptoms of severe respiratory illness, to a health care facility the following guidance should be followed regarding transport. § Notify the receiving health care facility of the pending transport of a potentially infectious patient. § Patient wears a face mask and performs hand hygiene. § Correctional officer wears face mask (or N-95 respirator). Wear gloves, gown, and eye protection if
in close contact with inmate prior to transport. § Prior to transporting, all PPE (except for face mask / N-95 respirator) is removed and hand hygiene is
performed. This is to prevent contaminating the driving compartment. § Ventilation system should bring in as much outdoor air as possible. Set fan to high. § DO NOT place air on recirculation mode. § Weather permitting, drive with the windows down. § Following the transport, if close contact with the patient is anticipated, put on new set of PPE.
Perform hand hygiene after PPE is removed. § After transporting a patient, air out the vehicle for one hour before using it without a face mask or
respirator. § When cleaning the vehicle wear a disposable gown and gloves. A face shield or face mask and
goggles should be worn if splashes or sprays during cleaning are anticipated. § Clean and disinfect the vehicle after the transport utilizing instructions in Element #3b.
Table 4. Definitions of “Isolation” and “Quarantine” Isolation: Confining individuals who are sick either to single rooms or by cohorting them with other viral infection patients. Quarantine: Confining asymptomatic persons who are contacts to COVID-19 while they are in the incubation period (up to 14 days for COVID-19).
10. Isolation (Symptomatic Persons) § Isolation Defined: A critical infection control measure for COVID-19 is to promptly separate
incarcerated individuals who are sick with fever or respiratory symptoms away from other incarcerated individuals in the general population. Ideally isolation will occur in a private room with a bathroom attached. If not, incarcerated individuals will have to wear a face mask to go to the bathroom outside the room. § Cohorting: As a last resort option, persons with diagnosed COVID-19 can be cohorted together. Inmates with laboratory confirmed COVID-19 should be housed separately from those with undiagnosed respiratory illness. § The CDC guidelines describe the order of preference of rooms for isolating inmates. § Rooms where incarcerated individuals with respiratory illness are either housed alone or cohorted should be identified and designated “Respiratory Infection Isolation Room”. No
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special air handling is needed. The door to the isolation room should remain closed.
o Note: The PPE requirements for COVID-19 do not fall into any one of the usual categories for the CDC transmission-based precautions, i.e., droplet, airborne, or contact. For the purposes of this document we have labeled the precaution sign “Respiratory Infection Isolation Room” since the rooms may house persons with undiagnosed respiratory infection as well as diagnosed COVID-19.
§ Signage: A sign should be placed on the door of the room indicating that it is a Respiratory Infection Isolation Room that lists recommended personal protective equipment (PPE) (see Attachment 3) described in Element #8.
§ Face Masks: If available—to minimize the likelihood of disease transmission—persons who are isolated or cohorted should wear a face mask while isolated. Face masks should be replaced as needed. It is particularly important for those cohorted with undiagnosed respiratory illness to wear a mask so that persons with respiratory illnesses other than COVID-19 are protected.
§ Bunk beds: Depending on how ill the incarcerated individuals are, bunk beds may or may not be suitable.
§ Assignment of custody staff: If feasible, designated custody staff should be assigned to monitor isolated individuals in order to minimize exposures.
§ Provide individuals in isolation with tissues, and if permissible and available, a lined notouch trash receptacle.
§ Dedicated medical equipment, i.e., blood pressure cuffs should be left in room (ideally) or decontaminated in accordance with manufacturer’s instructions.
§ Masks outside of room: If individuals with respiratory illness must be taken out of the isolation room, they should wear a face mask and perform hand hygiene before leaving the room.
§ Aerosol generating procedures: If a patient who is in isolation must undergo a procedure that is likely to generate aerosols (e.g., suctioning, administering nebulized medications, testing for COVID-19) they should be placed in a separate room. An N-95 respirator (not a face mask), gloves, gown, and face protection should be used by staff.
§ Laundry: o Laundry from a COVID-19 cases can be washed with other individuals’ laundry. o Individuals handling laundry from COVID-19 cases should wear disposable gloves, discard after each use, and perform hand hygiene. o Do not shake dirty laundry. This will minimize the possibility of dispersing virus through the air. o Launder items using the hottest appropriate water setting and dry items completely.
§ Food service items. Cases under medical isolation should throw disposable food service items in regular trash in their medical isolation room. Non-disposable food service items should be handled with gloves and washed with hot water or in a dishwasher. Individuals handling used food service items should clean their hands after removing gloves.
§ Criteria for discontinuing isolation § For individuals who will NOT be tested to determine if they are still contagious: o The individual has been free from fever for at least 72 hours without the use of fever-reducing medications; AND o The individual’s other symptoms have improved (e.g., cough, shortness of breath); AND o At least 7 days have passed since the first symptoms appeared
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§ For individuals who had a confirmed positive COVID-19 test but never showed symptoms: o At least 7 days have passed since the date of the individual’s first positive COVID-19 test; AND o The individual has had no subsequent illness
§ Cleaning spaces where COVID-19 cases spent time o Close off areas used by infected individual. If possible, open outside doors and windows to increase air circulation in the area. o Wait as long as practical, up to 24 hours under the poorest air exchange conditions before beginning to clean and disinfect. o Ensure that persons performing cleaning wear recommended PPE for isolation (See Table 3). o Thoroughly clean and disinfect utilizing instructions in Element #3b with an emphasis on frequently touched surfaces.
11. Care for the Sick § There are no specific treatments for COVID-19 illness. Care is supportive. § Identify if ill persons have risk factors for COVID-19 complications. Those with increased risk
should be monitored more closely. § Treatment consists of assuring hydration and comfort measures. The recipe for oral
rehydration solution is in Table 4 below. § Acetaminophen is the preferred antipyretic for treating fever in most patients with COVID-19
considering its efficacy and safety profile. Ibuprophen is as an alternative, antipyretic choice; however, it can cause kidney damage and other adverse effects in some patients. Recent reports suggest that ibuprophen may worsen the course of COVID-19; however, this theoretical risk is still under investigation. § Patients should be assessed at least twice daily for signs and symptoms of shortness of breath or decompensation. § A low threshold should be used for making the decision to transport an inmate to the hospital if they develop shortness of breath. § Implement telemedicine or provider-to-provider consultations for management of COVID-19 patients.
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Table 5. Oral Rehydration Solution Recipe
1-gallon clean water 10-tablespoons of sugar 4-teaspons salt Directions: Stir up. Do not boil. Can add sugar -free drink mix to flavor. Use within 24 hours.
12. Quarantine (Asymptomatic Exposed Persons) § The purpose of quarantine is to assure that incarcerated individuals who are known to have
been exposed to the virus are kept separate from other incarcerated individuals to assess whether they develop viral infection symptoms. If cases of COVID-19 are identified, it may be appropriate to identify close contacts and quarantine them in a separate room or unit. § Close contact defined: In the context of COVID-19, an individual is considered a close contact if they have:
o Been within 6 feet of a COVID-19 case for a prolonged period of time OR o Had direct contact with infectious secretions of a COVID-19 case Considerations when assessing close contact include the duration of exposure and the clinical symptoms of the person with COVID-19 (i.e., coughing likely increases exposure risk as does exposure to a severely ill patient). § Identification of Quarantine Rooms: Facilities should make every effort to quarantine close contacts of COVID-19 cases individually. Cohorting multiple quarantined close contacts could result in transmission of COVID-19 to person who are uninfected. Cohorting should only be practiced if there are no other available options. o If an entire housing unit is under quarantine due to contact with a case from the same
housing unit, the entire housing unit may need to be treated as a cohort and quarantine in place. o Ideally do not cohort individuals who are at higher risk of severe illness from COVID-19. o CDC guidelines describe the order of preference for housing of inmates in quarantine. § Signage: The door to the Quarantine Room should remain closed. A sign should be placed on the door of the room indicating that it is a Quarantine Room which lists recommended personal protective equipment (PPE) (see Attachment 4). PPE includes face mask, eye protection, gloves, and a gown if close contact with a quarantined person is anticipated. § Face masks: (If there is a sufficient supply of face masks) To minimize the likelihood of disease transmission to persons cohorted in quarantine, quarantined persons should be required to wear a face mask. Face masks should be replaced as needed. § As feasible, the beds/cots of quarantined incarcerated individuals should be placed at least 6 feet apart.
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§ No Movement: Quarantined incarcerated individuals should be restricted from being transferred, having visits, or mixing with the general population.
§ PPE: A face mask, eye protection and gloves are recommended for staff who are in direct, close contact (within 6 feet) of asymptomatic quarantined incarcerated individuals.
§ Monitoring: CDC recommends that inmates in quarantine should be screened twice daily for symptoms including subjective fever, and a temperature. Symptomatic patients need to be isolated.
§ Laundry: o Laundry from quarantined persons can be washed with other individuals’ laundry. o Individuals handling laundry from quarantined persons should wear disposable gloves, discard after each use, and clean their hands after. o Do not shake dirty laundry. This will minimize the possibility of dispersing virus through the air. o Launder items using the hottest appropriate water setting and dry items completely. o Clean and disinfect clothes hampers according to guidance above for surfaces. If permissible, consider using a bag liner that is either disposable or can be laundered.
§ Meals should be provided to quarantined individuals in their quarantine spaces. Disposable food service items can be disposed of in regular trash. Individuals handling used food service items should wear gloves and dishes washed in hot water. Wash hands after removing gloves.
§ The duration of quarantine for COVID-19 is the 14-day incubation period. If a new case is identified in the quarantine unit then the 14-day quarantine period starts again.
13. Data Collection, Analysis & Reporting
Implement systems for tracking information about incarcerated persons and staff with suspected/confirmed COVID-19
§ Ill/Exposed Staff Persons: The following basic information should be tracked on a line list o Symptomatic Y/N o Date of symptom onset o Exposed? Y/N o Date of exposure o Current status (will change over time) § Exposed – Working § Exposed – Self-Quarantine § Person Under Investigation (PUI)- testing pending § PUI, test result pending § PUI, tested negative § Laboratory confirmed case
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o Date left work
o Date returned to work
§ Incarcerated Persons - Symptomatic: The following basic information should be tracked on a line-list: o Date of symptom onset o Reported symptoms (fever, cough, shortness of breath) o Date isolated o Influenza tested? Y/N o Influenza result o Date COVID-19 tested o Date COVID-19 test result o Result o Current status (will change over time) § Person Under Investigation (PUI)- testing pending § PUI, test result pending § PUI, tested negative § Laboratory confirmed case o Current housing: Isolation o Date isolation discontinued o Hospitalized Y/N o Hospitalization Date o Deceased Y/N
NOTE: Incarcerated persons who are identified with suspected/confirmed COVID-19 must be reported to public health authorities. You will be asking questions about cases found on this CDC COVID-19 reporting form.
§ Incarcerated Persons – Exposed o Date of exposure o Current Housing § Quarantined – alone § Quarantined – cohort o Date quarantine discontinued o Developed signs and symptoms of COVID-19? Y/N o Date Isolated
14. Summary, Evaluation and Continuous Quality Improvement (CQI)
Periodically and at the conclusion of the outbreak review the implementation of the COVID-19 Pandemic Response Plan and identify what has worked well and what has not worked well, total numbers of cases and contacts treated/evaluated. Engage the CQI committee in evaluating the facility pandemic response. Identify areas for improvement and report these recommendations to the leadership team.
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COVID-19 Pandemic Response Plan Implementation Worksheet

This MS Word® template worksheet is designed for facilities to operationalize the guidance in this COVID-19 Response Plan. It should be adapted to the unique needs of your facility.

Date Updated:

Completed by:

1. Administration/Coordination
Coordination of Response Identify members of the facility leadership team responsible for COVID-19 response planning and implementation: Will the facility utilize the Incident Command System? YES NO If not, how will COVID-19 response plans be developed and implemented?

Schedule regular meetings to review implementation of all elements listed in the Administration/Coordination section of the document.
Who is responsible for monitoring COVID-19 updates from CDC and State Health Department?
CDC Website: https://www.cdc.gov/coronavirus/2019-ncov/index.html State of _________ Website:_________________________________________________________
Coordinate response with local law enforcement and court officials.
§ Explore alternatives to in-person court appearances:
§ Maximize use of existing policies for alternatives to incarceration:
§ Expedite implementation of compassionate release policies:

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§ Explore strategies to reduce new intakes to the correctional facility: § Explore strategies for releasing inmates at low risk for violent crime –particularly those with
risk factors for severe COVID-19:
Personnel Policies and Practices. § Review the sick leave policies of each employer that operates in the facility. o Do policies actively encourage staff to stay home when sick? YES NO. If no, how will staff be encouraged to stay home if sick? o What officials will have the authority to send symptomatic staff home? § Identify staff whose duties would allow them to work from home and review/revise telework policies. § What/where are contingency plans for reduced staffing? § Will your facility offer revised duties to staff who are at higher risk of severe illness with COVID-19? YES NO § What mechanisms are in place to remind staff to stay at home if they are sick? § When will you institute employee screening of all employees (see Element #5) (even if you are not in a community with sustained community transmission)?
§ Review and incorporate into your plans the criteria for staff to return to work with COVID19 symptoms:
§ Review guidelines regarding COVID-19 Exposures/Quarantine. What is the policy in your facility regarding staff related to self-quarantine vs continue working with face mask?
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§ The plan suggests consider relaxing restrictions on allowing alcohol-based hand sanitizer. In this facility the following categories of staff can carry alcohol-based hand sanitizer:
Movement
How will movement be minimized within the facility?
How will movement be minimized between facilities?
Will non-urgent medical visits be postponed? YES NO
Will copays for incarcerated persons seeking medical evaluation for respiratory symptoms be waived? YES NO
2. Communication The mechanisms for regular updates (paper/electronic/telephonic) will be as follows: -----Staff: -----Incarcerated persons: -----Families of incarcerated persons: The following staff person(s) are responsible for assuring regular communication with stakeholders:
Review recommendations regarding signage in the facility. What signage will be posted in the
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facility and where will it be posted?
c. Local Public Health Agency: Contact person(s) for COVID-19: Phone: Email:
d. Communicate with your local health department and discuss guidance on management and COVID-19 testing of persons with respiratory illness. Document date of communication and the plans discussed: __/__/__
e. Local community referral hospital: ______________________________________ Contact person(s) for COVID-19: Phone: Email:
3. General Prevention Measures a. Good Health Habits: How will good health habits be promoted with your staff (e.g., posters,
leadership emphasizing hand hygiene, email messages to staff)?
1) Are there facilities for employees and visitors to wash hands when entering and leaving the facility? YES NO If no, what are plans to address this issue?
2) Are there facilities for incarcerated individuals to wash hands at intake? YES NO If no, what are plans to address this issue?
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3) Are soap dispensers or hand soap available in all employee and incarcerated person restrooms? YES NO What is the plan to assure that soap dispensers are refilled regularly?
4) What is the plan to assure incarcerated individuals have an adequate supply of bar soap?
5) Is signage for hand hygiene and cough etiquette at entry, in public and visible areas around?
6) Are tissues available? YES NO If so, where? 7) Are no-touch trash receptacles available? YES NO If so, where?
b. Environmental Cleaning: Review updated CDC recommendations regarding environmental cleaning – noting that common EPA-registered household disinfectants are considered effective? What disinfectants will you use in your facility?
(If deemed necessary) purchase EPA hospital-grade disinfectants from Schedule N: https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2. (Recommended products are both a surface cleaner and disinfectant with a 3-minute wet time or less.)
Identify “high-touch” surfaces in this facility (i.e., doorknobs, keys, telephones): The following plan will be implemented to increase frequency and the extent of cleaning and disinfection of high-touch surfaces in this facility:
c. Social Distancing Measures: What administrative measures is your facility going to institute to increase social distancing within your facility (Review across all departments in the facility)?
REVIEW additional suggested measures in the plan. It is recommended that an interdepartmental group review the list and brainstorm what would work In your facility. Then add those agreed upon to the list below. 1) Measure…
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The following new activities will be implemented for incarcerated persons while they are confined to a housing unit:
d. Employees Stay Home When Sick: Does communication with employees include message that they should stay home when sick or under quarantine? YES NO
Sick employees should be advised to follow CDC guidance on What to do if you are sick?
e. Flu Vaccine: Is there flu vaccine in stock? YES NO If yes, number of doses? If yes, what plans are there to continue offering vaccination to employees who have not been vaccinated? If yes, what plans are there to continue offering vaccination to incarcerated persons who have not been vaccinated?
f. Review and implement infection prevention and control guidance for staff screening visitors, staff, and new intakes. How will these be implemented?
4. Visitors / Volunteers / Contractors / Lawyers What changes in procedures / polices are being instituted in response to COVID-19 for: a. Visitors: b. Volunteers: c. Non-Essential Contractors: d. Lawyers:
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What signage/communication is being used to communicate with visitors? Is screening for visitors for symptoms and temperature being implemented? YES NO If yes, who will be conducting this screening?
5. Employee Screening Is sustained community-transmission occurring in your community? YES NO If yes, screening of employees upon arrival to work is recommended. Do you have an infrared no-touch thermometer for this purpose? YES NO If no, what are your plans for acquiring them? What are your plans for employee screening? The following system will be utilized for employees to report illness/exposures and to track this information:
6. New Intake Screening It is recommended that new arrivals be isolated from rest of population until screening is performed. New intakes should be screened with temperature and questionnaire. Where will screening occur?
Who will conduct screening?
What other screening logistics are being considered?
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7. Initial Management and Testing of Cases of Respiratory Illness It is recommended that individuals with symptoms be immediately issued a face mask and be placed in a separate room with a toilet and sink. What separate room will be used for this purpose?
Do you have capacity in this facility to perform rapid flu tests? YES NO If yes, what are plans to assure competency in nasopharyngeal swabbing?
What are current recommendations from your local health department regarding COVID-19 testing?
Review CDC recommendation for clinical specimens? Do you have needed supplies for testing? YES NO If no, what are your plans to obtain them?

8. Personal Protective Equipment and Other Supplies
Date: __ /__/__ What is the current inventory of the following PPE: Face Masks: N-95 respirators: Gowns (disposable): Gowns (washable): Eye Protection- Goggles: Eye Protection—Disposable face shields:
What is your plan for securing and maintaining an adequate supply of PPE?

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If respirators are available what activities will they be prioritized for?
What is your plan for fit-testing correctional officers?
What is your plan for fit-testing health care workers?
What are your plans for training regarding donning & doffing of PPE? Correctional Officers? Who? When? Health Care Workers? Review Table 3. COVID-19 Personal Protective Equipment Recommendations. What are your plans for posting this chart throughout the facility?
4. Review supply list in plan and determine current stock. What are your strategies for acquiring more supplies during this time of shortage?
o Standard medical supplies for daily clinic needs o Tissues o Liquid soap o Bar soap o Hand drying supplies o Alcohol-based hand sanitizer containing at least 60% alcohol (where permissible based on
security restrictions) o Cleaning supplies, including EPA-registered disinfectants effective against the virus that
causes COVID-19 o Sterile viral transport media and sterile swabs to collect nasopharyngeal specimens if
COVID-19 testing is indicated
9. Transport
What categories of staff will be responsible for transport of ill persons?
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What is your plan for training transport officers on procedures for transport?
10. Isolation / Cohorting (Symptomatic Persons)
Review CDC guidelines regarding the order of preference of rooms for isolating inmates. Are there any changes to your responses below based upon this? (On right-hand ribbon go to “Management” and scroll down to “Medical Isolation…”
What is your capacity for isolating ill inmates in single rooms with a toilet? Detail available rooms: What is your capacity for cohorting inmates together in a room with toilets/sinks? Detail available rooms or unit: What is your plan for designating and training officers assigned to isolation rooms on isolation room procedures? Is it feasible to designate specific custody staff to only monitor isolated individual to minimize exposures? YES NO If yes, how will staff be selected for this duty? Review recommendations for laundry and food service items? What are your plans for educating staff and incarcerated workers regarding these recommendations?
Review recommendations for cleaning spaces where COVID-19 cases spent time. What are your plans for training staff and incarcerated workers regarding these recommendations?
11. Care for the Sick
Do you have an adequate supply of Tylenol and other medications for supportive care of a respiratory illness? How will you identify if ill persons have risk factors for COVID-19 complications who are in need of closer monitoring? What plan will you have for monitoring ill inmates?
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12. Quarantine
Review CDC guidelines regarding the order of preference of rooms for isolating inmates. Are there any changes to your responses below based upon this? (On right-hand ribbon go to “Management” and look for “Quadrating Close Contacts…” What rooms could be used for individual quarantine? What rooms could be used for charted (group quarantine)? How do you plan to monitor persons under quarantine? What is your plan for supplying face masks needed for an entire housing unit of incarcerated persons for a period of 14 days? What is you plan/ability to provide single rooms for exposed persons who have risks for complications, e.g., over age 60 or with medical risk factors?
Note that the BLUE Quarantine sign has been changed. Destroy these signs if you have printed them and print the RED Quarantine sign (which includes wearing gowns if close contact with quarantined persons).
12. Data Collection, Analysis, and Reporting
What is your plan for ongoing collection of data on staff and incarcerated persons with suspected/confirmed for COVID-19 or history of exposure?
Who is responsible for data collection, and analysis? This person should be prepared to updated numbers at each of the regularly schedule planning meetings.
14. Summary, Evaluation and Continuous Quality Improvement (CQI)
Who is responsible for ongoing evaluation of the pandemic response?
How will these evaluations be incorporated into local planning meetings?
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Attachment 1a. COVID-19 Visitor Screening Form (revised 3/25/20)
§ It is suggested that this be form be laminated. Upon arrival to the facility that visitors are be asked to respond verbally to these questions and a temperature taken.
§ Screening can be conducted by any staff person. § If an answer to one of the questions is YES or a temperature exceeds 100.4 then hand the ask
the visitor to leave immediately. Advise them to communicate with their doctor by telephone.

YES NO

In the past 14 days, have you had contact with a person known to be infected with COVID-19 (corona virus)?

Today or in the past 24 hours, have you had any of the following symptoms?

YES NO YES NO YES NO

Fever, felt feverish, or had chills? Cough? Difficulty Breathing? Temperature

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Attachment 1b. COVID-19 Employee Screening Form (revised 3/25/20)
§ It is suggested that this be form be laminated. Upon arrival to the facility the employees are be asked to respond verbally to these questions and a temperature taken.
§ Screening can be conducted by any staff person. § If an answer to one of the questions is YES or a temperature exceeds 100.4 then hand the
employee a mask to wear and send them home and recommend that they call their supervisor and consult their doctor. § A written copy of this form is only required for employees that answer YES to any of the screening questions or have a temperature exceeding 100.4.

YES NO

In the past 14 days, have you had contact with a person known to be infected with COVID-19 (corona virus)?

Today or in the past 24 hours, have you had any of the following symptoms?

YES NO YES NO YES NO

Fever, felt feverish, or had chills? Cough? Difficulty Breathing? Temperature

Screening Date: ____/____/_____

Employee Name (Last/First): _____________________________

Phone Number: ____________________________

Screening Employee Name: __________________ Signature:________________

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Attachment 2. COVID-19 New Intake Screening Form (revised 3/25/20)

1. Assess the Risk Of Exposure Have you……
Yes In the past 14 days, have you had contact with a person known to be infected with No COVID-19 (corona virus) ?

2. Assess for Signs or Symptoms of Illness
• Persons with symptoms of illness or cough should be masked immediately and separated from others.
Do you have a……..
Yes Fever, felt feverish, or had chills? Record temperature: No
Yes Cough? No
Yes Difficulty Breathing? No

Date of Onset:

3. If YES SYMPTOM questions, place mask on person and have them perform hand hygiene and evaluate in accordance with instructions in Element 7.
4. If YES to ANY RISK questions, but NO, to all SIGNS or SYMPTOMS, place person in QUARANTINE.

Inmate Name: _________________________________ Number: _____________________ Employee Name: ____________________________________ Date: ___/___/___ Employee Signature: ____________________________________________

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Attachment 3. Respiratory Infection Isolation Room Sign
On the following page is a Respiratory Infection Isolation Room sign for posting on the doors of isolation units.
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Attachment 4. Quarantine Room Sign
On the following page is a Quarantine Room Sign for posting on the doors of housing units being used for quarantine. Note that this sign was modified in the March 25, 2020 version of this document to include use of gown when in close contact with a person in quarantine, i.e., medical personnel taking temperatures.
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EXHIBIT K

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Case 5:13-cv-00444-VAP-OP Document 178-1 Filed 04/06/20 Page 87 of 88 Page ID #:17229

 
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EXHIBIT L

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 2 of 343 Page ID #:17232
Bruce C. Gage, M.D. Puget Sound Mental Health General and Forensic Psychiatry
6108 Community Place S.W., Suite 3 Lakewood, WA 98499
September 13, 2019
INTRODUCTION
This Fifth Report sets forth the Mental Health Expert’s assessments of the implementation of the terms of the Consent Decree, signed June 7, 2016, and associated Remedial Plan stemming from Gray v. County of Riverside. It covers Riverside County's (the County) reported results from the time of the fourth report through June 2019 (the “Fifth Reporting Period”) and reflects the observations and analysis of the Mental Health Expert regarding the County's compliance during that period.
As used herein, “Substantial Compliance” means that the County has achieved compliance with the material components of the relevant provisions of the Remedial Plan in accordance with the agreed-upon Compliance Measures for assessing Substantial Compliance submitted by the Mental Health Expert. “Partial Compliance” means that the County has achieved compliance on some, but not all, of the material components of the relevant provision of the Remedial Plan or have not achieved the quantitative results specified in the Compliance Measures; and “NonCompliance” means that the County has not met most or all the material components of the relevant provisions of this Agreement.
This Fifth Report is based upon the Mental Health Expert's review of provided policies, procedures and directives proposed and/or implemented by the County, observations and assessments of the Mental Health Expert based on tours of the jails, and review of medical records and data collected by the County. Site visits were conducted 2/19/19-2/20/19 and 2/28/19-3/1/19. I visited Smith Correctional Facility (SCF) for a day, Indio Jail for a half day, Blythe Jail for a half day, Robert Presley Detention Center (RPDC) for three quarters of a day, Cois Byrd Detention Center (CBDC) for a half day, and the Detention Care Unit (DCU) for two hours. I was provided full access to patients and staff and was assisted by staff knowledgeable in relevant topic areas including mental health, nursing, custody, classification, quality assurance, and administration.
I observed five groups (three at SCF, and one each at CBDC and RPDC); met with psychiatrists, Clinical Therapists, nurses, Recreation Therapists, and Behavioral Health Specialists; observed pill lines at RPDC and multi-disciplinary team meetings at RPDC and SCF; conducted group interviews on general population units; rounded on patients in the DCU; reviewed medical records; interviewed 12 patients in private; and spoke with many more patients during visits to

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 3 of 343 Page ID

September 13, 2019

#:17233 Fifth Semi-Annual Mental Health Assessment

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the units. In addition, I met with mental health and medical leadership and quality management staff at a County office for four hours.
All staff were forthcoming, helpful, and professional. I was provided unfettered access to facilities, patients, and records.
I reviewed medical records of selected patients (see APPENDIX) to assess elements of compliance (detailed in the body of the report).
The County provided the following information for my review:
 Riverside County Correctional Health Services Policy J-127: Restraints Applied by Custody Staff Requiring Nursing Assessment (Chair, Carotid) o I received copies specific to Blythe and CBDC, which were the same and presumably are the same for all facilities
 RUHS-CHS Pharmacy Policy/Procedures – P-106: Emergency Pharmacy Hours  Riverside University Health System-Behavioral Health (RUHS-BH) Detention Services
Policies: o Process for making changes to the Detention electronic health record knows as TechCare o Restraint and Seclusion o Safety Cell Placement o Behavioral Health Care Requests and Services
 List of urgent stock medications from Blythe  Document entitled “RPDC Master Daily Assign Sch Rev. 1 2019.xlsx” – RPDC general
daily schedule of medical and mental health activities  Undated document showing RPDC schedule of groups for the 5th and 6th floors (mental
health housing)  Schedule of Clinical Therapist (CT) and Behavioral Health Specialist (BHS) coverage for
RPDC dated 3.13.19  Document entitled “Behavioral Health, Robert Presley Detention Center” detailing a
plan for timely completion of mental health assessments and care plans (treatment plans) – no author, no date  RUHS-BH document entitled “Behavioral Health Indicators” from 1/1/19 to 1/31/19  Document entitled “Month SC Cleaning Report.xlsm” that shows safety cell cleaning from 5/20/18 to 5/31/18 for an unknown facility with 8 safety cells, likely RPDC  Document entitled “Detention Chart Reviews first half 2019.xlsx” listing 21 patients with acuity ratings of Moderately Severe and higher  Document entitled “Detention Chart Reviews Updated 4-22-19.xlsx” listing 20 patients with acuity ratings of Moderately Severe and higher  Riverside County Correctional Health Services slide presentation entitled “Know Your HIPAA”

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 Riverside County Sheriff’s Department (RCSD) HIPAA training rosters from CBDC, RPDC, and SCF with dates of attendance from June 2018 to May 2019
 RCSD data on dayroom times: o CBDC from 1/6/19 to 1/19/19 o RPDC from 1/7/19 to 1/11/19 and 1/14/19 to 1/18/19 o SCF from 1/6/19 to 1/19/19
 RCSD data on recreation times from all five facilities for February 2019  RCSD document entitled “15+ Year Sentence Oct 18 to Mar 19.pdf” detailing convictions
for long sentences and whether the inmate was referred to RUHS-BH  RCSD documents entitled “Administrative Segregation Review Log – RPDC” from
October 2018 to March 2019  RCSD documents entitled “Inmate Movement List” from RPDC from October 2018 to
March 2019 and from SCF from October 2018 to January 2019 with transfers involving seriously mentally ill (SMI) inmate-patients highlighted  RCSD policy 5-8.06 “Inmate Medical Care”  A sample of RCSD Inmate Classification Assessments from RPDC and SCF involving inmate-patients with health issues  Spreadsheets related to my data requests from RUHS-BH entitled:
o AdMin Housing BH.xlsx o BH Housing PsyMeds Discharged.xlsx o LAIs STAT Q3.xlsx o Restraint Chair.xlsx o Safety Cell to DCU.xlsx o Safety Cell No DCU.xlsx o Bridge Meds Orders JAN-MAR 2019 o Random Bridge Meds JAN-JUNE 2019.xlsx  Safety cell logs o 15 inmate-patients from CBDC from February 2019 o 19 inmate-patients from Indio from February 2019 o 47 inmate-patients from RPDC from February 2019 o 69 inmate-patients from SCF from February 2019  Safety cell logs for seven inmate-patients placed in the restraint chair  Safety cell logs for nine inmate patients placed in safety cells and sent to the DCU corresponding to the spreadsheet “Safety Cell to DCU.xlsx”  Safety cell logs for 11 inmate patients placed in safety cells and not sent to the DCU corresponding to the spreadsheet “Safety Cell No DCU.xlsx”

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EXECUTIVE SUMMARY
In this Fifth Report, I have continued the more quantitative approach to compliance measurement adopted for the Fourth Report. I provide some qualitative comments as well. The County is not yet fully able to provide proof of practice for all elements of the Remedial Plan but has continued to expand its capacity to support this more quantitative approach. However, much of the quantitative review still had to be done by my review of medical records, a very inefficient methodology. Records were again pre-selected according to criteria and then a random subset was selected from these records according to criteria that are included in the Appendix; these were modified slightly from the Fourth Report. Some of the cases requested were not provided.
I asked to meet with representatives from custody, medical, and mental health to discuss possible changes; during my site visit I did meet with representatives from medical and mental health services, but no custody staff were present.
As was the case for the Fourth Report, high-level items in the remedial plan were broken into smaller elements and subtopics within some of those elements. As noted previously, some of the elements were moved to different sections than they occupy in the Remedial Plan for ease of review. For example, mental health treatment of those on administrative segregation is covered under Mental Health Care rather than Custodial Environment. The 28 items and elements (referred to together as components) that are provided ratings (in bold text) in this report include:
 Health Care Generally (five scored elements) o Intake Screening o Medication Administration and Monitoring o Confidentiality o Health Care Records o Timely Access to Care
 Staffing (four scored elements) o Staffing sufficient to execute the Remedial Plan o 90% filled positions o Clinicians meet community standard of care o Annual assessment of the adequacy of staffing
 Custodial Environment (seven scored elements) o Policies and procedures to maximize dayroom time o Dayroom time o Recreation (yard) usage o Programming and structured activities in mental health housing o Self-isolating inmate training o Custody referrals to mental health

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o Inmate classification o Administrative segregation  Review of in Custody Deaths (scored as a single item)  Continuous Quality Improvement (two scored elements) o Peer review of psychiatrists o Quality Improvement Committee (mental health components)  Mental Health Care (six scored elements) o Treatment according to a Program Guide (including treatment of those in
administrative segregation which was moved from Custodial Environment) o Psychiatric care timelines o Housing of the seriously mentally ill o Treatment space o Suicide prevention o Restraint  Policies and Procedures (scored as a single item)  Consent Decree Training (scored as a single item)
Overview
The County continues to make steady progress in almost all areas of the remedial plan. Riverside University Health System – Behavioral Health (RUHS-BH) continues to make steady progress in the development of data and reports. Mental health intakes are being done reliably and RUHS-BH clinicians are more consistently completing assessments and treatment plans; though the treatment plans are almost all quite generic, the assessments are generally sound.
One point that deserves mention is that inmates complained much more about medical care and medical responsiveness than mental health services. Many also complained of being charged co-pays even for clinician-requested follow-up, e.g., for assessment of wounds or efficacy of antibiotic therapy.
Service delivery remains similar to levels prior to June 2017. Access to care challenges persist and out of cell time in general remains relatively limited for the mentally ill, though County has been taking steps to address the limited out of cell time of the mentally ill on administrative segregation status. The County has largely overcome the limitations on access to mental health care stemming from enhanced security requirements for clinical contacts with the mentally ill and access to groups has improved as a result. As noted in previous reports, the County adopted security requirements for program rooms that had reduced access to care until electronic door locks were installed. Those door locks have continued to function well; there have been no significant safety problems or failures, so this system is not a barrier to access at this time. However, whether the requirement to have a deputy standing by for all groups will limit access as more groups are run remains a question. In that regard, mental health runners are more consistently available but are still sometimes unavailable to escort patients to

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services. Access to patients has generally improved, but there continue to be problems with access in some areas, including at residential mental health units (more so at RPDC, primarily owing to space limitations) and for the mentally ill on administrative segregation, though it is too early to assess the effect of recent changes in managing the mentally ill on administrative segregation (e.g., the development of a new unit at CBDC to manage this population).
Cell front contacts continue to be excessive. Individual contact at CBDC has improved substantially due to the opening of program rooms to individual mental health contacts and the scheduling of the program rooms for medical and mental health.
The expansion of clinical space at RPDC and SCF continues forward but is not yet completed. The new clinic at SCF has been completed and the additional interview room on housing unit 16 (the residential mental health unit) has been started. The office build-out on the seventh floor of RPDC had been delayed several months due to needing some redesign but was recently completed. There has been some improvement in the space challenges at CBDC with some expanded availability of unit program rooms; the modifications to the intake area have not yet been started but should improve privacy and communication once completed. A new clinic is in the design phase at Blythe.
Program tables are being used and a bulletin was published on their use. This bulletin specifies that patients will be cuffed to the table when meeting with mental health clinicians, even if they would otherwise not be restrained for other clinical activities such as groups or medical appointments. Restraints should be used only when necessary and patients should not be routinely restrained for any treatment but only when there is some immediate concern based on behavior, the patient’s classification requires restraint, or at the request of the clinician. Similarly, it is not clear why the Clinical Therapist at Blythe is not allowed to meet face-to-face with patients while, for instance, the chaplain is allowed to do so with the same inmate. These kinds of inconsistencies, especially when they interfere with access to care, must be resolved across the jails.
While group treatment has returned to previous levels, access and fragmentation remain a problem. There is both limited capacity (not enough groups to accommodate the numbers of patients) and custody practices that prevent patients from completing group curricula. The latter is related to limitations on mixing of patients, some of which are unnecessary, as well as frequent moves. It is far from clear how custody is deciding which patients may be in groups or in groups together; there is no formal process for making such designations and it seems to vary from facility to facility and even unit to unit. At Blythe, custody determines who may participate in groups (at the time I was visiting, only four patients were enrolled in an anger management group), but it is not clear how this determination was made. A formal process that clearly identifies inmate-patients who must be kept separate would help tremendously; some conflict in this population is inevitable but, in most instances, need not result in enduring separation. Careful attention to group enrollment that both addresses clinical need and potential interpersonal conflict is needed and requires collaboration between custody and

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mental health. It is important to recognize that interpersonal conflict is much more of a risk in unstructured activities (e.g., unstructured dayroom or yard time) than in structured activities such as groups; thus, keeping inmates separate (e.g., by tiers) for the unstructured activities but allowing some mixing for structured activities is reasonable and promotes access to care and efficiency while addressing the risk of patient conflict. This not only serves treatment needs but provides a measure of readiness to advance to a lower level of care/custody; those who can succeed in structured group activities may be allowed a trial of conjoint unstructured activities in a more broadly mixed population. In general, the expectation should be that patients are allowed out to groups absent an imminent risk, in accordance with the movement requirements of their custody classification. The mentally ill should be treated no differently than others regarding access to all forms of treatment and other privileges and activities. Clearly, limitations are reasonable when based on current behavior (even if behavioral problems are related to mental illness) and formal classification, but not because of being on a residential mental health unit or being mentally ill. When behavioral problems limiting access are related to mental illness, it is incumbent on mental health staff, with the assistance of custody in gaining safe access to care, to provide treatment to reduce behavioral problems to allow greater access and privileges, including involuntary treatment when necessary.
There remain substantial problems in delivering services to the seriously mentally ill on administrative segregation. The greater collaboration between mental health and custody in reviewing the need for continued administrative segregation continues; documentation of this review has reportedly begun but the standards for determining who is placed on administrative segregation are very non-specific and it is not clear how or on what basis these decisions are being made. The remedial plan requirement for daily mental health contacts for patients on administrative segregation has continued to be very difficult to achieve and diverts resources from productive treatment; I understand the parties are revisiting this provision. While regular welfare checks (by both custody and healthcare staff) are important, they are not treatment; treatment cannot be administered at cell front.
The County continues to make progress in quality of care. The intake process is sound and most seriously mentally ill are being promptly identified; though initial medications are not always being promptly ordered, this is improving as well. More consistent availability of runners has reduced cancellations and facilitated access for some clinical contacts, especially scheduled groups.
The County has also made progress in expanding the data systems needed for proof of practice and improving relevant reports. RCSD has continued to use hand generated reports (spreadsheets) to track out of cell time; Information Technology (IT) support continues to be a challenge for RCSD. There remains limited conjoint Continuous Quality Improvement (CQI) between RCSD and both RUHS-CHS and RUHS-BH. RCSD participates in some CQI but there has been limited integration around critical issues such as access to care and management of the behaviorally disturbed. There has been some improvement in the collaboration between

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RUHS-CHS and RUHS-BH. As noted previously, areas that are particularly important for robust collaboration include: CQI, referral, patient healthcare requests (kites), safety cell and restraint assessment, and medication administration. Assuring that relevant policies, procedures, charters, and the like address the relationship and responsibilities would help promote coordination and facilitate compliance with the Remedial Plan.
The County has begun to track the retrieval, triaging, and response to patient requests for mental health care, but the process continues to need refinement. Improved tracking of the process will be necessary to both troubleshoot and provide proof of practice. Automating reporting to the maximum extent possible will be important.
Safety cell management is generally sound except that required stepdown procedures, in terms of restoration of property and privileges during safety cell placement, are still not in place. Patient safety cell assessments are still occasionally being done at cell front (usually owing to patient refusal but documentation shows a substantial minority of such assessments being due to lack of available custody staff) and mental health contacts with those in safety cells are regular. Nursing monitoring is much more consistent; patients are being evaluated at least every 12 hours in almost all cases and on each shift in most cases. Safety cell logs are being completed consistently, though meals are occasionally not being noted as offered. Transitional mental health services for those leaving safety cells and returning from the DCU are administered consistently, though not reliably daily as intended. Nursing assessment of those in restraints needs to include neurovascular checks.
Patients are more often being better stabilized at the DCU prior to returning to the jail from the DCU, but record review revealed a substantial minority of patients that were returned to the jails still acutely psychotic. There is much better coordination of care since the posting of two Clinical Therapists at the DCU. However, the two Clinical Therapists are yet to be fully utilized. Though they are having more face-to-face contact with patients, this is generally just a single weekly meeting. Patients in the DCU remain largely isolated with very little activity or materials available to them, regardless of their custody status. The mentally ill are treated in a uniformly more restrictive fashion than the medically ill. Also, the psychiatric documentation that is returned with the patient is woefully inadequate. This is doubtless due, at least in part, to having different electronic health record (EHR) systems in the DCU and the jails. Regardless, this needs to be improved.
The County has not made any progress in providing emergency or involuntary medications in the jail, despite the recent statutory change permitting this. But the County has made substantial progress in administering long-acting injectable antipsychotics, which has helped stabilize several seriously ill patients and reduced their returns to the DCU.
Reentry services have also been improved. There is better documentation of both individual and group reentry services. But it is important to note that many EHR entries with titles related to reentry show no evidence of the delivery of any reentry services; thus, any demonstration of

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reentry services based on the type of progress note will not be an accurate reflection of such services. There are still seriously mentally ill patients who have received no reentry services and medications are not consistently being provided at the time of release. A plan to have peers assist in reentry remains on hold; this is a method used by many systems to both augment traditional services and, more importantly, engage distrustful patients.
It is important to note that the County has filled over 90% of its mental health positions. While there is some turnover, many staff remain and retain a positive outlook on their jobs, with several commenting on the steady improvement they have seen in the ability to render services and the collaboration with custody. I continue to be impressed by the commitment of staff and the quality and integrity of the leadership.
I will note that it is not clear how to provide proof of practice regarding referral of self-isolating inmates. I recommend that the regular meetings between custody, medical, and mental health include brief minutes of patients and topics discussed, to include self-isolation.
In terms of formal compliance, I report on the following measures, consistent with the above 28 rated items and elements. The County previously achieved substantial compliance on the following and they remain substantially compliant:
 Consent Decree Training  Health Care Generally
o Health Care Records  Mental Health Care
o Housing of the seriously mentally ill  Staffing (elements relevant to mental health services)
o 90% filled positions  Custodial Environment (elements relevant to mental health services)
o Self-isolating inmate training
The County is newly rated as substantially compliant on:
 Custodial Environment (elements relevant to mental health services) o Administrative segregation [Note: This only reflects substantial compliance in completing 30-day reviews; aspects of care related to administrative segregation are rated under mental health treatment.]
The County continues to achieve partial compliance on the following:
 Health Care Generally (elements relevant to mental health services) o Intake Screening o Medication Administration and Monitoring o Confidentiality o Timely Access to Care

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 Staffing (elements relevant to mental health services) o Clinicians meet community standard of care
 Custodial Environment (elements relevant to mental health services) o Dayroom time o Recreation (yard) usage o Custody referrals to mental health
 Continuous Quality Improvement (elements relevant to mental health services)  Mental Health Care
o Treatment according to a Program Guide (including treatment of those in administrative segregation which was moved from Custodial Environment)
o Psychiatric care timelines o Treatment space o Suicide prevention o Restraint o Continuity of care  Policies and Procedures
The County is non-compliant on:
 Staffing (elements relevant to mental health services) o Annual assessment of the adequacy of staffing
The following were not rated:
 Staffing (elements relevant to mental health services) o Staffing sufficient to execute the Remedial Plan
 Custodial Environment (elements relevant to mental health services) o Policies and procedures to maximize dayroom time o Programming and structured activities in mental health housing o Inmate classification
 Review of In Custody Deaths (elements relevant to mental health services)

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Table of Contents
HEALTH CARE GENERALLY (elements relevant to mental health services) ................................................ 13 Intake Screening...................................................................................................................................... 13 Observations and Interviews .............................................................................................................. 13 RUHS-BH Data ..................................................................................................................................... 14 Summary ............................................................................................................................................. 15 Medication Administration and Monitoring........................................................................................... 15 Observations and Interviews .............................................................................................................. 15 Policies and Procedures Regarding Medication Administration and Monitoring .............................. 17 RUHS-BH Data ..................................................................................................................................... 17 Summary ............................................................................................................................................. 17 Confidentiality......................................................................................................................................... 18 Summary ............................................................................................................................................. 19 Health Care Records................................................................................................................................ 19 Summary ............................................................................................................................................. 20 Timely Access to Care ............................................................................................................................. 20 Observations and Interview ................................................................................................................ 20 RUHS-BH Data ..................................................................................................................................... 21 Summary ............................................................................................................................................. 21
STAFFING..................................................................................................................................................... 22 Observations and Interviews .................................................................................................................. 22 RUHS-BH Data ......................................................................................................................................... 22 Summary ................................................................................................................................................. 23
CUSTODIAL ENVIRONMENT ........................................................................................................................ 24 General Observations and Interviews..................................................................................................... 24 Policies and Procedures to Maximize Dayroom Time ............................................................................ 26 Dayroom and Recreation ........................................................................................................................ 26 Patient Reports ................................................................................................................................... 26 RCSD Reports ...................................................................................................................................... 27 Programming and structured activities in mental health housing ......................................................... 35 Self-Isolating Inmate Training ................................................................................................................. 35 Custody Referrals .................................................................................................................................... 36 Inmate Classification ............................................................................................................................... 36

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Administrative Segregation..................................................................................................................... 36 Summary ................................................................................................................................................. 37 REVIEW OF IN CUSTODY DEATHS (elements relevant to mental health services) ..................................... 38 CONTINUOUS QUALITY IMPROVEMENT PROGRAM (elements relevant to mental health services) ........ 39 MENTAL HEALTH CARE ............................................................................................................................... 39 Treatment According to a Program Guide and Psychiatric Care Timelines ............................................ 39
Observations and Interview ................................................................................................................ 39 RUHS-BH Data ..................................................................................................................................... 42 Summary ............................................................................................................................................. 44 Housing of the Seriously Mentally Ill ...................................................................................................... 44 Treatment Space ..................................................................................................................................... 46 Suicide Prevention .................................................................................................................................. 47 Observations and Interviews .............................................................................................................. 47 RCSD Data ........................................................................................................................................... 49 RUHS-BH Data ..................................................................................................................................... 50 Summary ............................................................................................................................................. 50 Restraint.................................................................................................................................................. 50 Continuity of Care ................................................................................................................................... 51 Observations and Interviews .............................................................................................................. 51 RUHS-BH Data ..................................................................................................................................... 51 Summary ............................................................................................................................................. 52 POLICIES AND PROCEDURES ....................................................................................................................... 52 CONSENT DECREE TRAINING ...................................................................................................................... 52 CONCLUSION............................................................................................................................................... 53 APPENDIX .................................................................................................................................................... 54

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HEALTH CARE GENERALLY (elements relevant to mental health services)
Some of the elements of this are themselves broad and are broken into subtopics for ease of discussion as follows (the scored elements are in bold):
 Intake Screening o Timeliness of mental health intake screening (done prior to placement with special provisions for Blythe) o Confidentiality of intake o Content of mental health intake o Bridge medications
 Medication Administration and Monitoring o Pill call o Court and transport medications o Medication monitoring o Prescription filling from the pharmacy
 Confidentiality  Health Care Records  Timely Access to Care
o Inmate healthcare requests o Inmate declared emergencies o Clinician initiated follow-up
Intake Screening
The subtopics here are:
 Timeliness of mental health intake screening (done prior to placement with special provisions for Blythe)
 Confidentiality of intake  Content of mental health intake  Bridge medications
Observations and Interviews There have been no significant changes to the intake process. A QMHP does the mental health portion of the intake except when there is no QMHP on duty, nurses do the screening (off hours at Blythe and Indio) and then contact a QMHP for verification of level of care; a QMHP later conducts an in-person screening of those screened by nurses.
Though the intake process is working smoothly, the physical plant limitations remain, primarily the poor audio quality and limited privacy at CBDC and limited space at SCF. The RPDC screening setting also has limited privacy due to traffic passing behind QMHPs while conducting intakes; however, patients cannot easily overhear each other as they can at CBDC. These should be corrected once planned construction is completed. All settings have access to medical records through wi-fi connections to laptops. Wi-fi coverage is spotty in the jails, but generally good in intake areas.
Clinical Therapists report that mental health intakes are rarely conducted beyond 12 hours after booking and I saw only a few instances in medical records. Processes have been put in place to assure that

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inmates are not placed in housing until seen except in rare circumstances, e.g., a violent inmate, though many of these inmates are, appropriately, placed in safety cells prior to being housed. Unstable patients and those that need more immediate mental health assessment admitted to Blythe are transferred to Indio, usually within 12 hours. While awaiting transfer, they are placed in a cell directly across from the Deputy’s station in intake; a restraint chair is available for at risk patients pending transfer.
The pre-booking screen is still done with the arresting officer present. The more complete nursing intake is generally conducted in a nursing office or exam room with custody outside the door.
Mental health screenings are done in private except in unusual circumstances, such as a restrained patient. But mental health staff report that in such cases, custody will generally remain at a distance to provide some privacy. Records do not always indicate whether screenings were private, but generally confirm these reports.
I observed a mental health intake at CBDC. The intake booths at CBDC have yet to be modified to provide for confidential interaction and adequate sight and sound. During the intake, the inmate had to stand to both see and hear the Clinical Therapist. The Clinical Therapist went through the screening questions and inquired more deeply into several issues and came to reasonable conclusions and made an appropriate disposition. It was a sound intake that included a limited, but adequate, supportive/crisis response element.
I also observed a routine mental health intake at RPDC. It was also sound.
Discussions with staff regarding bridge medications revealed that, other than at Blythe, mental health staff do most of the psychotropic medication verification rather than nursing staff.
RUHS-BH Data The report “Behavioral Health Detention Indicators” from 1/1/19-1/31/19 shows that for inmates in custody for more than 24 hours, 2121/2176 = 97.9% are screened by a QMHP. All facilities were above 95% except Blythe, which was at 88/9%. These findings are similar to the previous reporting period.
Review of medical records showed that screenings were complete in almost all cases when patients were cooperative. The quality of the screening was consistently solid.
A new bridge medication verification report was included in this same report. Of 198 inmates that reported being on psychotropic medications at intake, all were verified without the necessity of inputting a sick call (done when initial verification not completed within 48 hours to assure subsequent verification or evaluation). Note that this is only a proxy measure of bridge medication verification and is dependent on staff inputting a sick call request. A more direct measure is being developed.
I also reviewed the records of 20 patients that reported being on psychotropic medications at the time of admission. Of these, 4 were not qualifying cases (three left almost immediately and one reported being on medications but then reported not taking medications for months). Of the remaining 16, 10/16 were bridged within the parameters of the remedial plan. Of those not bridged, most had never been seen by psychiatry (the shortest stay among these was five days but some were in for over a month).
I asked for, but did not receive, data verifying that patients are screened prior to placement.

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Summary Mental health intakes are likely reliably conducted prior to placement in housing but there is no proof of practice. Those done at Blythe are being done timely and Indio mental health staff continue to assist with assigning a level of care when nurses conduct intakes. The timeliness of intakes generally is within substantial compliance.
Intakes are being done in private settings in almost all instances. While confidentiality at CBDC continues to be limited, staff have adopted strategies to reduce problems while awaiting the changes to the physical plant. Once completed, this element will also likely be substantially compliant.
Mental health is generally doing a good job of detecting cases at intake and the screenings are providing reasonable acuity ratings and identifying inmates at risk of harm to self. The content of the mental health screening is adequate and within substantial compliance.
Bridge medications continue to represent a challenge, but the County is making progress on both getting this task done timely and reliably (both the bridge orders and prompt psychiatric follow-up) and in creating measures to accurately track this important function. Bridge medications are not at substantial compliance.
Thus, Intake Screening, with respect to the mental health component, remains in partial compliance.
Medication Administration and Monitoring
The subtopics here are:
 Pill call  Court and transport medications  Medication monitoring  Prescription filling from the pharmacy
Observations and Interviews I again observed morning medication administration at RPDC on a male residential mental health unit. It ran the same as during my last visit. Nurses go cell-to-cell for patients on administrative segregation. For top tier patients, the nurse carries envelopes of medications with patient names and cell numbers and then later inputs the information into the electronic medication administration record; I continue to have concerns about this process, but patient identification is more reliable than previously. On other units, deputies announce pill call and patients come to receive meds through a small port. The nurse properly identified patients. If patients are suspected of cheeking, custody reportedly usually does prompt cell searches. Nurses continue to be assigned to housing areas and continue to report that this has been beneficial in terms of familiarity with the clinical status of the patients; QMHPs also report that the teamwork benefits also persist.
The nurse I observed at RPDC did a very good job; she knew the patients, interacted with them professionally, and was attentive to their clinical status. The nurse did a much better job of mouth checks than previously. Deputies stood by during pill lines conducted through the dayroom port and assisted to a limited extent in assuring mouth checks were done. Though improved, not all patients did proper mouth checks. It remains difficult for the nurse to hear through the port and it was difficult to communicate with the patients. Those patients who do not push their call button are still not allowed

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out of their cells and are marked as no show for medications whereas those who refuse face-to-face are marked as refusals; though the eMAR shows refusal for both, notes on the refusal form, when done, specify if it was a refusal or no show. Note also that patients are not asked to sign refusal forms which are simply signed by the nurse and the deputy, making it entirely uncertain whether the patient actually refused. For no shows, mental health will usually follow-up with a visit to cell front or in a booth, but the nurse usually does not go to the cell front to encourage adherence. There were a few patients that did not come out and the mental health clinician intended to check with them after pill call. Medications for one patient were missing and the nurse planned to get the medications from the seventh floor after pill call; QMHPs report that nurses are more consistently retrieving medications when this occurs. One patient’s medications had expired, and the nurse electronically requested renewal from the doctor.
Staff and patients reported that expiration without renewal was uncommon across facilities. As was the case previously, nurses report that they enter patients into a queue for mental health review after missing three days of medications in a row. It remains unclear how reliably this is being done.
A nurse at RPDC explained that injections of long-acting injectable (LAI) antipsychotics are given in treatment rooms on the floors.
Patients report that medications are coming on time both in the morning and the evening at all facilities except RPDC, where evening pill call is still often late, though improved since the development of a master schedule. A variety of staff confirmed that pill call is generally running within an hour of the specified time (e.g., 0700-0900 and 1900-2100), though occasionally starts and ends late at SCF. Nursing staff at RPDC noted that they are required to submit an occurrence report if they do not complete pill call timely. Tallying these reports would assist in proof of practice.
Review of medical records shows MARs are being completed; it is not possible to determine their accuracy or timeliness from review of medical records.
Note that Pyxis machines (automated machines for dispensing medications) have been rolled out at RPDC and CBDC. This will make stocking of medications, including urgent stock, more reliable. I inspected urgent stock at all facilities and spot checks of psychotropics showed that almost all were in stock. However, I continue to have concerns that no benzodiazepines are included in floor stock; injectable lorazepam is an important emergency medication and should be included. At Blythe, there were no intramuscular antipsychotics in floor stock, though there were supposed to be; there were oral benzodiazepines with the controlled substances, though they are not listed as floor stock. Only haloperidol was available as an emergency intramuscular injectable antipsychotic which will be inadequate once emergency medications are provided at the jails. How stock medications are determined is not clear; the Remedial Plan requires that the Medical Director and pharmacy determine what is included in stock medications.
Psychiatrists had no concerns about the availability of laboratory examinations or specialty studies, though none reported accessing any (e.g., neuroimaging). I discussed medication monitoring and some psychiatrists reported that they would not get baseline laboratories if they had been done in the last year. Others reported that they routinely got them. I got inconsistent reports from psychiatrists on frequencies of monitoring after initiation of medications and on conducting AIMS.

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There remains no formal way to track court medication administration; processes exist, though nursing staff continue to report that they do not always get notified when a patient is going out to court but are being notified more consistently. Typically, they receive a list the previous evening through JIMS and the night nurse administers medications prior to the patient leaving the facility. There are no provisions for administering medications while patients are away from the facility. I was this time informed that a “c” was placed in the MAR when medications were administered prior to normal medication administration when going to court; I was previously told that the “c” indicated that the patient did not receive the medication due to being out to court; consistency is needed.
Policies and Procedures Regarding Medication Administration and Monitoring RUHS-CHS Policy P-106 provides for 24/7 access to stat medications within 6 hours at all facilities except Blythe, which is within 12 hours. I have not been provided policy and procedure regarding the provision of medications when out to court, in transit to outside appointments, or during transfer. Peer review documents adequately lay out expectations for monitoring of psychotropic medications.
RUHS-BH Data The report “Behavioral Health Detention Indicators” from 1/1/19-1/31/19 includes a report based on electronic medication administration records (E-MAR). It shows recorded missed doses of psychotropic medications in only 1.14% of 74,105 administrations. Only 30 medications were missed three or more times. It is important to recall that the accuracy of this data is dependent on nurses reliably recording whether patients took medications, including the quality of mouth checks to assure that medications were swallowed. Regardless, these numbers are quite low and even slightly better than previous data. Note that this is not a measure of lapses of prescriptions, that is, when prescribers fail to timely update medications.
Medical record review shows that of 19 patients on LAI antipsychotics requiring monitoring, only 3/19 = 16% were properly monitored. Psychiatrists almost never obtain baseline laboratories and rarely monitor for metabolic syndrome (with the exception of the DCU and Indio where monitoring is done more reliably). Checking of levels for medications such as valproic acid and lithium is uneven. Abnormal Involuntary Movement Scales (AIMS) are being done more reliably. Of these 19, 14/19 = 74% received the LAI antipsychotic timely across the order period.
Chart reviews of those in residential settings more than 30-days (see APPENDIX) demonstrate that laboratory medication monitoring is adequate in 5/18 cases and AIMS were timely in 11/15 cases.
Summary Twice daily pill lines are reportedly being provided at all housing units but there is no data or proof of practice. Psychiatrists reported no problems if special pill times are needed. While complaints of untimely medication administration are fewer, there are still numerous reports from staff and patients alike that medications are still coming more than an hour late, primarily at evening pill call at RPDC. MARs indicate that medications generally are being administered reliably. However, LAI are not being administered sufficiently reliably. The subtopic of pill call and alternative medication administration (e.g., LAI antipsychotics) is in partial compliance.
Policies, procedures, and published expectations (including peer review documents) are sufficient for medication monitoring. Psychiatrists are still challenged to see new patients and those just started on medications timely but are seeing established patients regularly and timely. Laboratory studies are still

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not being done consistently for medications needing monitoring and AIMS are occasionally not done timely. Medication lapses also remain a problem. I have not received policy or procedure regarding court medications, in transit medications, or transfer medications.
There is also no proof of practice for court (and other transport) medications though there are some processes that have been established to assure medications are available during transport and court. Their efficacy is unknown.
I saw no evidence of problems filling orders from the pharmacy or with floor stock. However, I received no proof or practice of this element. This element is likely in or near substantial compliance.
In general, psychiatric performance regarding follow-up, including after bridge medications and other initiation of medication, has improved but is still short of targets. Medication monitoring remains uneven; AIMS are being done more reliably, but laboratory monitoring by most psychiatrists is poor.
Medication Administration and Monitoring, with respect to the mental health component, remains in partial compliance, largely owing to lack of proof of practice for pharmacy deliveries, pill line times, and court and other transit medications, as well as needing improvement needed in psychiatric follow-up and medication monitoring.
Confidentiality
There have been no significant changes or developments here. Progress will depend mostly on completion of planned construction at CBDC and RPDC. This should allow reduction of cell front visits, one of the chief problems with confidentiality, and improve access to care as well.
In general, respect for confidentiality on the part of most custody staff was reasonable. Clinicians note that this continues to be going well in most instances, though there remain challenges with some individual Deputies, especially around refusal to bring out patients, forcing cell front contacts. While this is sometimes reasonable and occasional challenges are to be expected, it is a recurrent problem, especially on HU-16 at SCF with certain teams.
When QMHP encounters are not at cell front but in provided booths and office spaces, confidentiality is adequate. As noted above, intake screening by QMHPs is confidential except at those locations where the intake area has not yet been modified, primarily CBDC and, to a lesser extent, RPDC. While custody attends pill call, clinical staff do a good job of limiting discussion of protected health information. It is reasonable for custody to attend pill call both for exchange of information and to assist in the process. Psychiatric visits are subject to the same limitations as QMHP visits; when not at cell front (cell front visits are primarily a problem at RPDC for both psychiatrists and QMHPs and at SCF for QMHPs), they are sufficiently confidential. Groups are being run in program rooms that are visible to others but provide for privacy of conversation; this is reasonable in the correctional setting.
Those custody staff that review grievances, which may include healthcare grievances, are supposed to have received training related to confidentiality of medical information. Previously provided information on HIPAA training was primarily a recitation of the statute itself rather than instruction on how to implement HIPAA. Custody staff I interviewed seemed to have a generally sound understanding of the need to know standard as did mental health staff, with almost all properly emphasizing the prevention of harm as the main general reason for breaching confidentiality. Previously, about half the sergeants were trained in HIPAA:

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 Blythe – 4/9  CBDC – 22/22  Indio – 10/22  RPDC – 16/49  SCF – 36/40
A more recent training, entitled “Know Your HIPAA” from Riverside County Correctional Health Services provides a little more guidance regarding minimum necessary information and need to know. Rosters of custody participation in 2019 from CBDC, RPDC, and SCF (none were received from Indio or Blythe ) shows that overall, 474/800 = 59% of custody staff at these facilities were trained. Both CBDC and RPDC were about 70% while SCF was about 40%. There were no significant differences between different categories of custody staff; those with access to healthcare grievances (that is, the grievance sergeants) are required to have confidentiality training but it is unclear which those are in the rosters provided. If only those sergeants who were trained in HIPAA are reviewing grievances, then this is adequate in terms of the remedial plan. All the sergeants I interviewed stated that they had had HIPAA training. One sergeant at Indio reported that there had been a HIPAA refresher 6-8 months previously for those who had not previously received this training.
The RCSD policy 508.06 Inmate Medical Care includes adequate provisions for confidentiality, even requiring that both custody and healthcare staff get permission when healthcare staff wish to have custody be within hearing distance. However, I saw many instances where custody staff were within listening, many of which were clearly routine, including cell front contacts by mental health, safety cell assessments, and pill call. As I have noted previously, this is not a problem for pill call but the excessive number of cell front contacts by mental health and the limited confidentiality of these visits remains a problem. As noted above, cell front wellness checks (rounds) are a reasonable component of health surveillance but are not treatment. Cell front assessment is also reasonable in some cases where patients are extremely agitated, but such situations should almost always result in some mental health intervention; if a patient is so dangerous owing to mental illness, treatment is required, potentially including involuntary and/or emergent treatment.
Summary This element of Health Care Generally, with respect to the mental health component, remains in partial compliance but should be readily brought into substantial compliance once construction is completed, assuming there are adequate numbers of runners or other provisions for accessing confidential locations and cell front visits are substantially reduced. Confirmation that grievances are only collected and reviewed by sergeants who have received HIPAA training is also needed.
Health Care Records
There is now an EHR that both medical and mental health clinicians can fully access. The document “RUHS-BH Detention Services Policy – Process for making changes to the Detention electronic health record known as TechCare” provides for a committee that includes representatives from RUHS-BH and RUHS-CHS to work with RUHS-IT and the EHR vendor to make modifications to the EHR. And as noted in previous reports, changes have been made to the EHR in response to clinical and data needs.

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Summary The County provided policy that meets the terms of the Remedial Plan, this item is in substantial compliance.
Timely Access to Care
The subtopics of Timely Access to Care are:
 Inmate healthcare requests  Inmate declared emergencies  Clinician initiated follow-up
Note that access to care is also relevant to mental health treatment generally (without access, there is no care), rather than the limited areas officially designated under access to care in the Remedial Plan. Thus, this topic is also addressed in the section “Mental Health Care” below.
Observations and Interview Health Care Request Forms are only available on the units, not in libraries and program rooms. The parties should revisit this requirement to determine whether spaces outside of living areas require these forms to be stocked. Health Care Request Forms were available on the vast majority of units I visited. They were missing on three dayrooms at SCF, though reportedly had been stocked that morning, and two at CBDC. These represented a small minority of the dayrooms visited. Most were well stocked. All housing units had lock boxes except medical floors, where they are collected by nurses, and units with one-man cells where nurses told me inmates generally put them in the slot of the door and they are collected by nurses. I was also told by administrative leadership that those in administrative segregation place forms in a lock box on the unit and that these are collected on the same schedule as other units (see below); they may also be collected during nursing rounds Mondays, Wednesdays, and Fridays.
Virtually no health care staff reported helping illiterate inmates write Health Care Request Forms, as required by the Remedial Plan, instead noting that other inmates provided this assistance. Staff at RPDC noted that they generally inform Deputies of inmates who cannot write and ask that Deputies solicit verbal requests for healthcare and then call a clinician, usually a nurse. This is despite the fact that policy RUHS-BH Detention Services Policy: Behavioral Health Care Requests and Services expressly provides that “Inmates are informed that they may request assistance in completing a healthcare request form from any Correctional Health Serviced (CHS) or Behavioral Health Services (BHS) staff member.”
At Blythe, nurses collect Health Care Request Forms and triage them. If there is an immediate concern, they contact the Clinical Therapist or, after hours, a QMHP at Indio. Since they do not triage these at night, the lack of night QMHPs at Blythe or Indio does not present a problem for this method.
At Indio, night shift nursing staff collects and scans Health Care Request Forms. Those for mental health are sent to RPDC for review and the patient is placed in the mental health queue for local follow-up by a QMHP. For emergent cases, nurses either contact a local QMHP or, during the night, an RPDC QMHP.
Nurses collect Health Care Requests from lock boxes on night shift at CBDC and then triage them and forward them to RUHS-BH, also entering the case in the mental health queue in the EHR. A QMHP triages these in the morning.

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At RPDC, nurses collect Health Care Request forms from lock boxes at about 0300 and triage them, sending them to RUHS-BH if they include mental health concerns and enter the case in the mental health queue in the EHR. A QMHP reviews these in the morning. Nurses call if there is an emergent issue.
At SCF, nursing staff collect Health Care Request forms from lock boxes typically at 2300 and triage them about 0100. Nursing staff reported that they collect them directly from those on administrative segregation during pill call or during routine rounds on Monday, Wednesday, and Friday. They then give them to RUHS-BH who signs for them and scans them into the EHR.
RUHS-CHS nursing staff have continued tracking the retrieval of Health Care Request Forms in logs detailing the disposition of each form.
RUHS-BH Data The report “Behavioral Health Detention Indicators” from 1/1/19-1/31/19 shows the following with respect to response to inmate requests for mental health care:
 Of 135 patient generated Health Care Request Forms for behavioral health needs, the average days to completion was 1.4 days. o 68/83 (81.9%) of priority requests were seen within 48 hours (or 72 hours over weekends) o The computed time was from when the sick call request was entered in the EHR by a nurse; time from the actual Health Care Request was not included nor was the time the form was picked up by nursing staff. It was not clear from the data whether all 135 were responded to.
I requested, but did not receive, data on the timeliness of nurses picking up Health Care Request Forms and delivering them to mental health.
Developing a mechanism for tracking responses to psychiatric emergencies remains challenging. QMHP response to safety cell placements (see Suicide Prevention below) demonstrate prompt response. While this does not guarantee that a QMHP is responding promptly to all emergencies, it is likely a reasonable proxy.
In terms of follow-up, QMHPs regularly conduct follow-up visits without requiring a Health Care Request Form to be completed. These are sometimes regular and scheduled and other times contacts are simply made when convenient. Groups are being regularly scheduled and usually held on time. Psychiatrists are routinely scheduling patients for follow-up.
Summary There is some lack of consistency in how Health Care Request Forms are collected from those on administrative segregation but as long as the County can demonstrate that the forms are collected daily and meets the requirements of direct viewing by healthcare staff if picked up by Custody (which no facility reported doing), the method is up to the County.
Policy has provided for, and mental health clinicians make, appointments for follow-up so this subtopic is compliant. Presumably, the previous policy “Riverside County Department of Mental Health, Mental Health Detention Services, Section III. Policy/Procedure 302: Follow Up Assessments” that provided for

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clinicians to schedule appointments without an inmate request has a current counterpart in RUHS-BH; this should be verified.
It does not appear that health care staff are assisting inmates in completing Health Care Request Forms, as provided in policy and required by the remedial plan.
The County continues to make steady progress on responding to inmate Health Care Requests. There is still further work to do on proof of practice but logs demonstrating collection of forms is a good start, though I did not receive any of these or any aggregate data based on them. A conjoint quality management process will be necessary to fully comply with the requirement for tracking the timely collection, triaging, and response to such requests for mental health services.
There is still no mechanism for tracking inmate declared psychiatric emergencies.
Timely Access to Care remains in partial compliance.

STAFFING
Elements of staffing relevant to mental health care include:
 Staffing sufficient to execute the Remedial Plan  90% filled positions  Clinicians meet community standard of care  Annual assessment of the adequacy of staffing
Observations and Interviews
The only mental health staff at Blythe is a single Clinical Therapist; the other Clinical Therapist position was never able to be filled and was moved. Psychiatric services are exclusively by telepsychiatry from Indio, which continues to work well.
SCF was in the process of hiring two new BHSs at the time of my visit. There were about 2.5 FTE psychiatrists for HU-16 and another 2 FTE for the rest of the facility.
Runners continue to be available at all facilities except Blythe. At Indio, there are two runners during the day, one each for mental health and medical, and one during swing shift. This is a big help but does not meet all the escorting needs so other staff assist; when unavailable, some appointments are cancelled or meetings are held at cell front.
SCF has one runner for HU-16 and four runners for the new clinic.
RUHS-BH Data The document Riverside University Health System – Behavioral Health, Jail Staffing dated 1/7/19 shows the mental health staffing as of that date. The number of positions remains the same at 150 but the filled has increased from 128.48 to 136.64, putting the overall fill rate at 91%, over the 90% benchmark in the remedial plan. There were no significant changes in the general distribution of job classes. The biggest gains were in the Clinical Therapist job class, a welcome improvement.

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The lowest fill rate is 84% at RPDC, which is also the site with the most seriously mentally ill patients, though there are many at SCF as well. The main shortages at RPDC are Clinical Therapists and Psychiatrists, the core clinical providers. The only other notable shortages were Recreation Therapists.

Below is a table of system-wide positions.

Position Type Sr. Medical Records Technician Office Assistant II Office Assistant III Behavioral Health Service Supervisor Clinical Therapist II Behavioral Health Specialist III Behavioral Health Specialist II Senior Clinical Therapist Recreation Therapist Psychiatrist IV Medical Records Technician Total

Funded FTE 4 7 5 7 76 4 21 6 5 13 2 150

Number Filled 4 6 5 7
69.5 3 20 5 2
13.14 2
136.64

Percent Filled 100% 86% 100% 100% 91% 75% 95% 83% 40% 101% 100% 91%

Summary
There is still no annual assessment of staffing that addresses the requirements in the remedial plan; this element is non-compliant. Largely owing to the lack of such a report and the fact that data are not sufficiently developed to determine whether failure to meet the requirements of the remedial plan are due to inadequate staffing; this element is not rated.
Mental health has more than 90% of positions filled, so this element is in substantial compliance.
Meeting the community standard of care is little different from meeting the terms of the remedial plan. However, a different way to view this, and the view taken here, is to differentiate the care provided in individual cases from the ability of the system to care for the total population. Put differently, the former answers the question whether care, when provided, meets the standard of care. This contemplates all realms of clinical activity from intake to treatment to discharge planning. It is also a largely qualitative assessment. This content is addressed in the relevant sections and in my case reviews in the Appendix. In general terms, there remain some shortcomings in the intake process (primarily bridge medications) and medication monitoring as above. The care provided by non-psychiatrists is uneven. In most cases, individual contacts and groups are sound, but there is room for improvement, especially with individual contacts which tend to consist in assessment but often show little evidence of treatment rendered. Treatment plans are being done in most cases but are quite generic and nonspecific. In short, the quality of care usually does meet the standard of care when provided, just not yet consistently.
The other aspect, caring for the total population, can be equated with access to care at a population level. This primarily contemplates timeliness of care and ability to provide adequate treatment dosage. Timeliness data shows that most contacts are timely, but these data primarily track one-time events

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such as intake, assessment, and health care request responses. The greater problem is that individual contacts and groups are far too infrequent to meet the standard of care, especially for the most seriously mentally ill. It is not clear whether this is attributable to limited mental health staffing, inability of the available staff to access patients, or both. Review of medical records (Mental Health Care, Treatment section below and Appendix) demonstrates that in some cases, gaining access to patients is a problem. Access is clearly a problem for those on administrative segregation where cell front contacts (that do not qualify as treatment) are the rule.
As there were no clinical productivity data provided, it is difficult to know whether the mental health staff are operating at full efficiency, but informal reports suggest that staff productivity is above average. While such data are not explicitly required by the Remedial Plan, an analysis of the adequacy of staffing would clearly require this as well as setting general benchmarks for treatment dosage. Benchmarks exist for the frequency of visits by Clinical Therapists and psychiatrists that are reasonable in general terms, but individual cases may require more frequent contact than the minimum contacts required by the benchmarks. For example, it is reasonable for a psychiatrist to see a stable patient every 90 days, but it is not reasonable for an acutely ill patient. The same is true for the monthly individual Clinical Therapist contacts required for those at higher levels of care; sometimes more than monthly visits are needed. Chart review demonstrates that, in many cases, more frequent contacts are being done when necessary, but not always. Here again, one of the main challenges is providing higher treatment dosage for those on administrative segregation, who are often the most ill. This is evident in the reviews of medical records summarized in the APPENDIX.
There are no benchmarks for providing groups, which are reaching only a small portion of the population in need, also evident in the medical records reviews in the APPENDIX.
As the standard of care is more often met than not, when care is provided, this element is rated partially compliant.

CUSTODIAL ENVIRONMENT
Though this item is listed under Health Care Generally, most of the elements have nothing to do with healthcare, so it is treated as a separate item. The item consists of the following elements:
 Policies and procedures to maximize dayroom time  Dayroom time  Recreation (yard) usage  Programming and structured activities in mental health housing  Self-isolating inmate training  Custody referrals to mental health  Inmate classification  Administrative segregation
General Observations and Interviews
I note that the jails were somewhat less cleanly than on previous visits, especially RPDC and CBDC.

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Inmates at Blythe were clearly the most satisfied with custodial conditions, including the professionalism of custody staff and promptness of response to problems such as plugged toilets. Inmates at Indio and SCF were most dissatisfied with the professionalism of custody staff with several inmates at SCF reporting excessive use of force by Deputies on some shifts. One patient at SCF reported that he had pushed his call button recently because of abdominal pain and diarrhea but got no answer; he also stated that he had been previously told to limit his use of the call button. Clinical staff echoed concerns about the professionalism and cooperation of some deputy teams at HU-16 and even noted retaliation when systems issues were raised, including name calling and slow responses to bringing out patients for clinical services. I noted that many patients had long nails at SCF and were unshaven; they told me that they were not allowed to use nail clippers and complained of difficulty getting a haircut and shave. However, both patients and clinical staff reported that most deputy teams were helpful and professional.
Custody staff uniformly reported dayroom times as beginning at 0800 and ending at 2300 except at Blythe where it reportedly began at 0700. At SCF, all units come out as the full dayroom regardless of classification except HU-16, the residential mental health unit. At CBDC, larger dayrooms also come out by tiers. Those on administrative segregation come out one at a time throughout the system. All similarly reported that suspension of dayroom time was rare and usually followed a fight with the dayroom opening that same shift unless there was a group disturbance, which might lead to suspension for 24 hours. Custody staff at Indio noted that dayroom suspension required supervisor approval.
Custody staff similarly reported that all inmates were offered yard twice a week for a total of three hours, except at SCF where yard times were sometimes noted to be one hour but reportedly were offered more than twice week (note that the yard for HU-16 is connected to the dayroom and generally available to inmate-patients during dayroom time). Staff at Blythe noted that sometimes yard is cancelled due to being short-staffed but that they tried to make it up later in the day, sometimes up to 2300 at night. Custody staff reported some problems with tracking yard usage and noted that, at least at Indio, tracking was returned to classification rather than floor staff to improve the quality of data. At CBDC, recreation is tracked by two recreation deputies who reportedly track this by individual inmate. Staff reported rare yard suspensions (it was suspended at Indio the day I was there, reportedly because an inmate had broken lights with a handball).
Inmates reported that yard times were generally offered at Blythe, though often at hours they did not want to attend. Those at Indio noted that yard times were sometimes cancelled but usually were conducted, though often for less than an hour and a half. Almost all inmates at both these facilities are in dormitory style units, so dayroom time is not an issue. The few that are not generally reported that dayroom times were offered as scheduled.
Patients on HU-16 gave varying reports about yard availability, but several noted that it was available most of the time when they were in the dayroom. Most reported very limited dayroom time, all reporting between 1.5 to 3 hours per day.
Patients at RPDC reported dayroom being available 3-4 times per day for 45 minutes to as much as two hours. They gave varying reports about yard access, but most reported it was offered twice each week, with several noting that it was available “too early” and that it was cold at that time.

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Whether inmates are classified according to policy is unclear. No data on inmate classification were provided. Those with mental illness are subject to more restrictive conditions, e.g., on HU-16 where they are not allowed as much out of cell time as inmates of similar classification.
It is important to note that the mentally ill with higher acuity ratings on administrative segregation that were historically housed at RPDC are being transferred to a housing unit at CBDC. How this will be run and what impact it will have on out of cell time and access to care will be assessed at the next report.
I attended a five-minute morning meeting including custody, nursing, and mental health at 0900 at SCF. There was virtually no discussion. Only one case was discussed; an inmate who was upset about a new charge and potential long sentence. There was no discussion of inmates who were not coming out of their cells or not allowed to come out of their cells or the progress or lack of progress of any others. As I had noted previously, custody staff sat in the back of the room and clinical staff in the front. There was very little interaction. At 0905, there was a brief mental health and medical meeting that also discussed just one patient with chronic medical issues.
At RPDC, I attended two joint meetings between custody, medical, and mental health (male and female residential units). There was much more robust discussion of multiple patients, expected admissions, and discharges. They identified clogged plumbing, addressed three patients not wanting their cells cleaned and how to evaluate and address their cleanliness, and had good discussions about several patients. There was good interchange of relevant information between disciplines.
Policies and Procedures to Maximize Dayroom Time
I have not been provided a policy that expresses an intent to maximize dayroom time.
Dayroom and Recreation Patient Reports
At Blythe, where almost all are in dormitories, dayroom is not a substantial issue. Inmates report that yard is usually available in one-hour sessions for a total of three hours per week. Though the schedule stated that morning yard time was 0800, staff and patients noted that it was sometimes done at 0630 (after breakfast) to allow yard before it got too hot.
At CBDC, inmates reported no problems with yard or dayroom access. They reported being offered yard twice weekly for 1 and a half to two hours.
Inmates at Indio reported that they get three hours of yard time per week. Most are in dorms so that dayroom time is not generally a problem.
Patients at RPDC gave varying reports; many of these individuals were severely mentally ill. Most reported getting out of their cells once daily for 30-60 minutes. They reported getting access to the yard once or twice each week.
Patients at SCF, many also severely mentally ill, gave varying reports on dayroom time, from 30-60 minutes to three hours daily. All reported coming out one tier at a time (different from general population units, such as housing unit 15, where both tiers come out at the same time). There were many complaints regarding limited out of cell time. They reported being offered yard usually twice weekly for 45 minutes, though some noted that it was usually available whenever they were in the

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dayroom. The patients reported eating in their cells; the pilot of staff eating with patients seems to have been halted.
RCSD Reports RCSD has been hand collecting data on dayroom time and yard usage. I again commend the effort but note that it is an inefficient and error-prone approach.
For dayroom time, RCSD provided information for two weeks in January from all facilities except Blythe and Indio, which have mostly open dayrooms. Inspection of the raw data reveals that dayroom times rarely start before 0800 or end past 2300. There was no report on suspension of dayroom and inspection of the raw data did not show any information on suspensions. There were occasional notations of cancellation and yard times varied quite widely with some being quite short; it is unclear if some of these are due to suspensions. Thus, it is not possible to comment on the extent of suspensions; however, for the weeks reviewed it did not appear that there were substantial limitations on dayroom time due to cancellations or suspensions of dayroom access.
At CBDC, results were similar to results at the time of the Fourth Report, though showing slightly less time out. Data was from Housing Units C, D, E, F, and G for 1/6/19-1/19/19 (except dayroom 2 from C and D). The raw data again show that inmates are coming out by tiers (upper and lower) for some dayrooms and both tiers for others, each generally in 30-60-minute blocks of time. Inmates coming out by tiers receive an average of between 3.0 and 3.7 hours per day and those coming out by dayroom receive an average of between 6.2 and 7.1 hours per day. Times are fairly consistent from day to day. However, as was the case for the last report, there were no data on individual times out of cell for those on administrative segregation, so it is not clear how much time out of cell this population receives at CBDC. Though this population did not historically include inmates with serious mental illness, beds were recently repurposed to house some of the mentally ill at RPDC that were on administrative segregation. It will be essential to track this population separately, even if they are not formally on administrative segregation.
As noted above, there were no data from Indio, including Housing Unit 18, the only unit without an open dayroom. Last time, this unit received only about an hour of dayroom time daily, but this unit does not house any seriously mentally ill.
At RPDC, data was provided for Housing Units 3A (male PC, level 3-5, and “GP GOALS”), 3B (“GP Trusty,” levels 1-4, 4 and GP males, levels 4-5), 4A dayroom 1 (female GP, level 3-5), 4A dayroom 3 (female mental health and PC, level 1-5), 4B (female mental health, level 1-5), 5A (male mental health, mental health PC, and Liberty, level 1-5), and 5B dayroom 2 (male mental health PC, level 1-5). This is again not complete data for the residential mental health units but gives some idea of how dayroom time is being managed and provides data from other units not designated as residential mental health for comparison.
Inmates come out by tiers on units 4A (sometimes), 4B, and 5B but both tiers come out together on the remainder, which are not mental health units. Note that no data were provided for the mentally ill on administrative segregation (5B dayroom 1 for males and 6A dayroom 2 for females).

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Data were provided in aggregate, so it is unclear how long dayroom times lasted. Total daily out of cell time varied from either zero (or this was missing data – the report does not specify) or 1.5 hours to 12.57 hours.
RCSD reported the average hours out of cell daily for different populations. It is unclear whether this was based on 10 days or 14 days (which is moot if there is no dayroom time on weekends). They reported as follows:
 General Population (GP) = 6.72 hours/day (1/7-1/11) and 4.6 hours/day (1/14-1/18)  Protection Custody (PC) = 6.28 hours/day (1/7-1/11) and 3.9 hours/day (1/14-1/18)  GP SMI = 10.45 hours/day (1/7-1/11) and 6.33 hours/day (1/14-1/18)  PC SMI = 9.71 hours/day (1/7-1/11) and 6.63 (1/14-1/18)
It is not clear how RCSD calculated average dayroom times. Out of cell time should be reported as the average (offered) per individual. However, it appears that the data were collapsed across different units and dayrooms with different populations, in which case the average time is not the average offered per individual because these locations house different numbers of inmates, so the data should be normalized to the population on each of the units included in the average. RCSD needs to include its methodology when sending data so that such calculations can be checked.
Doing my own calculations based on the raw data RCSD provided, I found the following by unit (and sometimes tier) across the two weeks of data:
 Unit 3A (PC males, levels 3-5, and “GP GOALS”) = 10.0 hours/day  Unit 3B (“GP Trusty,” levels 1-4, 4 and GP males, levels 4-5) = 8.0 hours/day  Unit 4A, dayroom 1, top tier (female GP, level 3-5) = 5.1 hours/day  Unit 4A, dayroom 1, bottom tier (female GP, level 3-5) = 5.0 hours/day  Unit 4A, dayroom 3, top tier (female mental health and PC, level 1-5) = 3.4 hours/day  Unit 4A, dayroom 3, bottom tier (female mental health and PC, level 1-5) = 3.2 hours/day  Unit 4B dayroom 1, top tier (female mental health, level 1-5) = 3.3 hours/day  Unit 4B dayroom 1, bottom tier (female mental health, level 1-5) = 3.5 hours/day  Unit 4B dayroom 2, top tier (female mental health, level 1-5) = 3.1 hours/day  Unit 4B dayroom 2, bottom tier (female mental health, level 1-5) = 3.2 hours/day  Unit 5A (male mental health, mental health PC, and Liberty, level 1-5) = 6.6 hours/day  Unit 5B, top tier (male mental health PC, level 1-5) = 4.0 hours/day  Unit 5B, bottom tier (male mental health PC, level 1-5) = 3.8 hours/day
This demonstrates the importance of tallying the data properly. Contrary to the averaged data presented by RCSD, this analysis clearly shows that those housed on the residentially mental health units consistently get less dayroom time. Note also that this does not include all male residential mental health units.
At SCF, data was provided for Housing Units 15 (GP, level 3-5), 16 (mental health, level 1-5), and 17 (GP, level 4-5); the other units have open dayrooms. On HU-15 and HU-17, top and bottom tiers come out at the same time and on HU-16 they come out separately. The data show the following average dayroom times for the two-week period:

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 HU-15 = 5.7 hours/day  HU-17 = 6.0 hours/day  HU-16, top tier = 2.3 hours/day  HU-16, bottom tier = 2.3 hours/day
In addition to the substantial difference created by universally doing dayroom by tiers on the mental health residential unit, the total average dayroom times for HU-16 are 2.3 + 2.3 = 4.6, which is less than the other units. This was a consistent finding across days rather than a difference created by substantial reductions on particular days. In general, there was less variation from day-to-day in dayroom times at SCF. The number of sessions of dayroom was similar to the previous report. The total hours out of cell were slightly greater than previously; it is unclear whether this reflects a trend or random fluctuation.
Individual dayroom time for administrative segregation inmates was not provided so it is not clear how much out of cell time they are receiving and how administrative segregation differentially affects the mentally ill and non-mentally ill. Out of cell time for those on administrative segregation and in the new CBDC unit housing mentally ill patients formerly on administrative segregation at RPDC also needs to be tracked.
These data clearly demonstrate, consistent with the reports of the patients themselves, that the mentally ill are provided substantially less dayroom time than other inmates. It is clear from the data that this is due in part because they are coming out by tier whereas other comparable units come out as the whole dayroom. Classification level cannot account for this as, for instance at SCF, the classification levels of the GP units are higher than the mentally ill residential units.
RCSD provided a report on yard times for February 2019 from all facilities. At Blythe, the data show that all dayrooms were offered two yard sessions per week and indicates that each session was offered for 90 minutes. A small minority of inmates attended yard and yard times were occasionally curtailed, reportedly by inmate request. Access to the yard was between 0635 and 1500. However, if no inmates attended yard, no start time was listed. This is important as it appears from the data that earlier times may be associated with lower attendance, which is understandable in the winter. While it is reasonable to offer early morning yard times in the summer, it is not reasonable in the winter. However, the remedial plan does not specify when yard recreation may be offered as it does for dayroom times.
At Indio, where there are no residential mental health units, of the housing units reporting, 95% of weekly yard quotas were met, including inmates on administrative segregation. Like Blythe, yard times often started as early as 0600 but there were also evening times finishing as late as 2303 and a number after 2000 when it would be dark. Fewer inmates appeared to refuse recreation than at Blythe, but refusal rates were still substantial.
The refusal rate was not as high at CBDC, with an overall refusal rate of 56.4%. The data show that about 75 yard sessions were cancelled due to rain. These were appropriately included in the average calculations and largely accounted for the failure to achieve 90 minutes per session. Three sessions were cancelled due to a “disturbance.” The two weeks of data were aggregated by RCSD into dayrooms that served GP and PC inmates. The results were:
 GP: 173 sessions of recreation averaging 61.5 minutes  PC: 82 sessions of recreation averaging 64 minutes

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Even though these average yard hours were substantially below 90 minutes, all dayrooms were counted as compliant. It is reasonable to count yard sessions refused by all inmates as 90 minutes and yard times curtailed at inmate request as 90 minutes but if the reason for cancelling yard due to rain is failure to provide proper clothing or shelter, that is unreasonable; either proper clothing or shelter should be provided or the sessions made up.
RPDC made several housing moves related to construction. These results are tallied from the two weeks of raw RCSD data according to the RPDC housing profile at the time. The results were as follows:
 3A dayroom 1 (PC males, level 3-4) o Inmates were offered 10 yard times, more than two yard times weekly o All inmates reportedly refused 4/10 = 40% of yard times o Inmates refused 76.5% of total yard slots (by “slot” I mean a yard session available to an individual) o Yard times were at least 90 minutes unless inmates requested to return before that (one instance)
 3A dayroom 2 (PC males, level 4-5) o Inmates were offered 12 yard times, more than two yard times weekly o All inmates reportedly refused 3/12 = 25% of yard times o Inmates refused 79.3% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (two instances)
 3A dayroom 3 (male “GP GOALS”) o Inmates were offered 9 yard times, more than two yard times weekly o All inmates reportedly refused 0/9 = 0% of yard times o Inmates refused 33.5% of total yard slots o All but one yard times were at least 90 minutes unless inmates requested to return before that (one instance)
 3B dayroom 1 (male “GB Trusty,” level 1-4) o Inmates were offered 8 yard times, two yard times weekly o All inmates reportedly refused 2/8 = 25% of yard times o Inmates refused 88.3% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (six instances, all attended yard times)
 3B dayroom 2 (GP males, level 4-5) o Inmates were offered 8 yard times, two yard times weekly o All inmates reportedly refused 3/8 = 37.5% of yard times o Inmates refused 87.5% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (two instances)
 4A dayroom 1 (GP females, level 3-5) o Inmates were offered 8 yard times, two yard times weekly o All inmates reportedly refused 3/8 = 37.5% of yard times o Inmates refused 92% of total yard slots

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o Yard times were at least 90 minutes unless inmates requested to return before that (five instances, all attended yard times)
 4A dayroom 3, bottom tier (female mental health and PC, level 1-5) o Inmates were offered 7 yard times, less than two yard times weekly o All inmates reportedly refused 2/7 = 28.6% of yard times o Inmates refused 79.5% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (three instances)
 4A dayroom 3, top tier (female mental health and PC, level 1-5) o Inmates were offered 7 yard times, less than two yard times weekly o All inmates reportedly refused 5/7 = 71.4% of yard times o Inmates refused 90.9% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that two instances, all attended yard times)
 4B dayroom 1, bottom tier (female mental health, level 1-5) o Inmates were offered 8 yard times, two yard times weekly o All inmates reportedly refused 1/8 = 12.5% of yard times o Inmates refused 77.4% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (six instances)
 4B dayroom 1, top tier (female mental health, level 1-5) o Inmates were offered 8 yard times, two yard times weekly o All inmates reportedly refused 0/8 = 0% of yard times o Inmates refused 62.5% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (five instances)
 4B dayroom 2, bottom tier (female mental health, level 1-5) o Inmates were offered 8 yard times, two yard times weekly o All inmates reportedly refused 1/8 = 12.5% of yard times o Inmates refused 62.1% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (six instances)
 4B dayroom 2, top tier (female mental health, level 1-5) o Inmates were offered 8 yard times, two yard times weekly o All inmates reportedly refused 0/8 = 0% of yard times o Inmates refused 64.5% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (eight instances, all attended yard times)
 6A dayroom 1 (male mental health, level 1-5) o Inmates were offered 9 yard times, more than two yard times weekly o All inmates reportedly refused 1/8 = 25% of yard times o Inmates refused 86% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (three instances)

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 6A dayroom 3 (male mental health and Liberty, level 1-5) o Inmates were offered 9 yard times, more than two yard times weekly o All inmates reportedly refused 1/8 = 25% of yard times o Inmates refused 83.5% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (five instances)
 6B dayroom 1, bottom tier (male mental health PC, level 1-5) o Inmates were offered 8 yard times, two yard times weekly o All inmates reportedly refused 0/8 = 0% of yard times o Inmates refused 71.4% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (five instances)
 6B dayroom 1, top tier (male mental health PC, level 1-5) o Inmates were offered 8 yard times, two yard times weekly o All inmates reportedly refused 0/8 = 0% of yard times o Inmates refused 73.7% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (four instances)
 6B dayroom 2 (mental health administrative segregation) o Inmates were offered 10 yard times, more than two yard times weekly o All inmates reportedly refused 2/10 = 20% of yard times (but yard times were marked as 0 minutes for an additional 3 sessions) o Inmates refused 92.9% of total yard slots o Yard times were at least 90 minutes unless inmates requested to return before that (eight instances, all attended yard times)
It is hard to know what to make of the data from 6B dayroom 2 given that those on administrative segregation are only allowed out singly but the data show from 1 to 4 coming out at a time (1 or 2 for yard times greater than 0). The times for this unit also vary widely from 0 minutes to 155 minutes.
The data also report that sometimes those on mental health units allow both tiers out for yard time including 4A dayroom 3 (female mental health and PC, level 1-5), 4B dayroom 2 (female mental health, level 1-5), and 6B dayroom 1 (male mental health PC, level 1-5). Thus, it is unclear why they cannot come out together for dayroom time.
The yard times offered for the mentally ill at RPDC appear to meet requirements and are similar to the yard times available to non-mentally ill inmates.
At SCF, the data are not as confounded by changes in unit profiles. The summaries provided by RCSD are correct except for unit 12C, which was incorrectly categorized as mental health residential on the report; it was converted back to GP and thus not included in the mental health tallies below.
The summary reports that no GP dayrooms were out of compliance. However, the majority of dayrooms had less than two yard sessions per week: 05D0, 06D0, 07D0, 09DA, 09DB, 09DC, 09DD, 10DA, 10DB, 10DC, 10DD, 11DA, 11DB, 11DD, 12DD, 12DE, 12DG, 15DB, 15DD, and 15DF. This was not due to inmate refusal, as these instances were counted as compliant. Inmates received an average of

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35.3 minutes per session. The low numbers were almost all reportedly due to inmate requests to return, though there are several short yard times without specified reasons.
For PC dayrooms, the results were similar except that none of these dayrooms had two yard sessions per week. The average time per session was 36.7 minutes.
For non-PC mental health dayrooms, it is very difficult to make sense of the data. All are reported as compliant, yet the results are as follows:
 12DA o Inmates were offered 5 yard sessions o All inmates reportedly refused 1/5 o Inmates refused 80.4% of total dayroom slots o No yard times were for 90 minutes, all reportedly at inmate request
 12DB o Inmates were offered 4 yard sessions o All inmates reportedly refused2/4 o Inmates refused 88% of total dayroom slots o No yard times were for 90 minutes, all reportedly at inmate request
 16DA o Inmates on both tiers were reportedly offered 8 yard sessions, all of which were attended by 100% of the dayroom (exceedingly unlikely) – but HU-16 comes out only by tiers o Inmates on the bottom and top tiers were each offered one yard session on 2/1/19 which only one inmate from the bottom tier reportedly attended o The amount of yard time offered was impossibly lengthy (480 minutes for the 8 sessions of both tiers, 780 minutes for the bottom tier)
 16DC o Inmates on both tiers were reportedly offered 8 yard sessions, all of which were attended by 100% of the dayroom (exceedingly unlikely) – but HU-16 comes out only by tiers o Inmates on the bottom and top tiers were each offered one yard session on 2/1/19 which 12 inmates from the bottom tier and 11 inmates from the top tier reportedly attended, each for exactly 60 minutes o The amount of yard time offered was impossibly lengthy for most (480 minutes for the 8 sessions of both tiers)
 16DD o Inmates on both tiers were reportedly offered 5 yard sessions, 4 of which were attended by 100% of the dayroom (exceedingly unlikely) and one by none – but HU-16 comes out only by tiers o Inmates on the bottom and top tiers were not offered separate yard times o The amount of yard time offered was impossibly lengthy for most (480 minutes for the 4 sessions of both tiers)

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 16DF o Inmates on both tiers were reportedly offered 4 yard sessions, all of which were attended by 100% of the dayroom (exceedingly unlikely) – but HU-16 comes out only by tiers o Inmates on the bottom and top tiers were each offered one yard session on 2/16/19 which no inmates from the bottom tier and 2 inmates from the top tier reportedly attended for 10 minutes o The amount of yard time offered was impossibly lengthy for most (480 minutes for the 4 sessions of both tiers)
The situation is similar for the mental health PC dayrooms:
 14DC o Inmates were offered 5 yard sessions o All inmates reportedly refused 2/5 o Inmates refused 92% of total dayroom slots o No yard times were for 90 minutes (none were more than 25 minutes), all reportedly at inmate request
 14DD o Inmates were offered 6 yard sessions o All inmates reportedly refused 1/6 o Inmates refused 78.6% of total dayroom slots o No yard times were for 90 minutes, all reportedly at inmate request
 14DE o Inmates were offered 6 yard sessions o All inmates reportedly refused 1/6 o Inmates refused 84% of total dayroom slots o No yard times were for 90 minutes, all reportedly at inmate request
 16DE o Inmates on both tiers were reportedly offered 8 yard sessions, all of which were attended by 100% of the dayroom (exceedingly unlikely) – but HU-16 comes out only by tiers o Inmates on the bottom and top tiers were each offered one yard session on 2/1/19 which 2 inmates from the bottom tier and 1 inmates from the top tier reportedly attended, the former with no time noted and the latter for exactly 60 minutes o The amount of yard time offered was impossibly lengthy for most (480 minutes for the 8 sessions of both tiers)
These data for HU-16 are clearly erroneous. However, I was informed both while on site and subsequently that on HU-16, the door to the yard is generally open when patients are in the dayroom. Thus, access to the yard is the same as access to the dayroom. But this erroneous data seems to have been included in calculating the yard time per session and inmate refusal which were as follows:
 SMI o 268.1 minutes per yard session o 29.3% refusal rate

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 SMI/PC o 195.4 minutes per yard session o 44% refusal rate
These results are clearly erroneous. If yard time for HU-16 is the same as dayroom time, and using the dayroom times from above, HU-16 patients received 2.3 hours of yard access per day. It is important to note that this is not time in addition to dayroom but is at the same time. Thus, it appears that those in HU-16 are getting a total of 2.3 hours out per day whereas on HU-15 and HU-17 (comparable to HU-16) are getting over twice as much dayroom time and yard time in addition that HU-16 does not get.
These data need to be clarified and continue to demonstrate the error-proneness of this method of collecting data.
Programming and structured activities in mental health housing
As noted above, I was provided no data on this topic. Observations and reports reveal that there is very little programming such as education or other custody programs on these units. There are some unit jobs, but it is unclear how many.
Self-Isolating Inmate Training
RCSD reports that “at least 75% of staff on each shift at every jail … received training from jail medical staff regarding the effects of segregation and self-isolation” during the “RSO Staff Training” cited in an April 2017 report. This included three slides on the effects of isolation but does not address selfisolation. The Phase IV Training on the remedial plan contained two slides on the self-isolating inmate; more than 90% of custody staff received this training in 2017. This training is also marginally adequate. None of the training really addressed the problem of self-isolation, that is, the problem of severely mentally patients not coming out of their cells because of their mental illness. It focused almost exclusively on the impact of custody-imposed isolation, which is important but does not get at the need to proactively respond when patients are isolating. That said, the Phase IV slides do operationalize selfisolation as three consecutive days in cell and indicate the expectation of referral to mental health.
From my reviews of charts and observations, mental health staff are aware of patients who are not coming out of their cells or not being allowed out of their cells due to concerns about their behavior, but a proactive approach in such cases was often not evident. Most of these were addressed by ultimate placement in the DCU, though this was sometimes after weeks of isolation in a cell, usually under administrative segregation. As noted elsewhere, the County has not yet implemented involuntary treatment within the jails, part of the reason DCU placement is the primary avenue to address these cases. But this requires that the patient meet criteria for civil commitment. Oftentimes, patients are not seen as meeting civil commitment criteria because they are eating and drinking, even though they are so ill that they are refusing social interaction or are considered so dangerous that they are not being allowed out of their cell. If they are that dangerous or engaging in self-isolation (i.e., high rates of yard or dayroom refusal) that is known to be detrimental to their health, then they should be considered for civil commitment. It should be noted that some of these patients are refusing medical treatment, which is sometimes not being considered in the evaluation of grave disability.
Custody staff on the residential mental health units at RPDC seem much more attuned to the condition and degree of self-isolation inmates are engaging in than at SCF. It is likely that this is due, at least in

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part, to the more robust discussions at staff meetings between custody, mental health, and medical at RPDC.
Custody Referrals
There is currently no method to track referrals for self-isolating inmates. However, those on the residential mental health units are discussed in meetings between custody, medical, and mental health at RPDC. Whether this meets the requirement of the remedial plan is not clear.
Custody made referrals to RUHS-BH in 91.5% of cases of inmates receiving lengthy sentences from October 2018 through March 2019. Some without trackable referrals were nonetheless seen by a QMHP. However, the timeliness of the notification and QMHP follow-up are not tracked.
Inmate Classification
I was provided 21 raw classification assessments from RPDC and SCF. All but one had mental health issues noted on the form. Interestingly, all 10 at RPDC were either made PC or administrative segregation while only one of 11 at SCF was made PC. It appears that the classification tree was followed in all cases. However, I am unable to determine whether policy was followed as I do not have the raw data to review. I also do not know whether those placed on PC or administrative segregation were made so per policy. In the future, I request that RCSD conduct its own review of a random sample of 20 mentally ill and determine whether classification was done per policy (proof of practice) which I will then review.
Administrative Segregation
Clinical Therapists at CBDC report that there are some SMI patients in administrative segregation. However, they note that if their acuity requires, transfer to a residential setting is done promptly.
Those on administrative segregation at Indio are allowed 30 minutes out in the dayroom by themselves on a rotating basis through the day. The associated logbook showed this was generally adhered to. There was no other information on out of cell time for those on administrative segregation, including those on the residential mental health units. Thus, it must be presumed that the problems noted in my third report persist.
Regarding yard time, RCSD provided data as above, which was only for Indio (the RPDC data were not readily interpretable). What is not clear is whether those patients marked as refusing yard time were themselves refusing or were considered too unpredictable or violent to come out and were marked as refusing.
As noted in the section Medication Administration, I observed nurses giving medications cell-to-cell for the mentally health segregation unit at RPDC. I was not provided any data on delivery of medications by healthcare staff for all patients in administrative segregation.
I was provided data on the completion of 30-day reviews of those on administrative segregation, including a number on the mental health caseload. The results of these reviews were not included. A reviewed a sample of 20 patients on the mental health case load on administrative segregation for more than 30 days. They required a total of 106 30-day reviews and 102/106 = 96.2% of reviews were conducted. The provisions for placement on administrative segregation are so broad, it would be difficult to say that policy was not followed but nonetheless, the reviews are occurring. RUHS-BH staff

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inform me that mental health and classification are jointly reviewing the mentally ill on administrative segregation in the residential mental health units on a regular basis; a tracking system for this is being developed. This should include at least the grounds for the decision regarding continuation of administrative segregation.
Behavior management plans, used to assist custody and mental health in providing consistent and complimentary services, have still not been instituted yet. These are required by the Remedial Plan.
Mental health services for those on administrative segregation are reviewed in the Mental health Care Section.
Summary
The jails were somewhat less cleanly than during my previous visits. However, inmate satisfaction was, if anything, somewhat higher, though I did no systematic review.
I have not been provided policy that specifically reflects “the intent to provide inmates with as much dayroom time as is consistent with institutional safety and security” so this element is not rated. If no such policy is produced by the next report, this item will be rated non-compliant.
Access to dayroom and yard remains a problem for those in residential mental health units. They are being systematically offered less time than the non-mentally ill. Dayroom times rarely begin before 0800 and do not extend beyond 2300. Suspension of dayroom time was not addressed in any of the materials provided, but it is also unclear how to assess whether any suspensions are unreasonably long. Yard times vary a good deal but are short of 1.5 hours in a substantial minority of instances, though they are usually provided twice per week (occasionally three times). These two elements are clearly not in substantial compliance. Partial compliance is justified for both, primarily due to the County’s efforts to make changes to increase access to dayrooms especially and to track dayroom and yard time.
I have been provided no information on programming and structured activities in mental health housing. Observations demonstrate that there are limited programs, but there is not enough information to determine the degree of compliance, so this element is not rated. This item will also be rated non-compliant for the next reporting period if no data are produced demonstrating the availability of programming in mental health housing.
The training provided to custody staff regarding self-isolating inmates was marginal at best as it was more targeted at the effects of isolation than identifying and responding to self-isolating inmates, which appears to be the intent of the Remedial Plan. However, as it provides basic guidance to custody, including the expectation of referral and 90% of staff received this Phase IV training, I believe this element must be rated as in substantial compliance.
Custody referrals for those who have received lengthy sentences are being done remarkably reliably, given the opportunities for failure. Referrals for self-isolation are difficult to track and the need has been largely obviated by the regular mental health and custody meetings; awareness of self-isolation does not seem to be the problem; it is addressing the problem that is proving challenging. I request guidance regarding whether alternative means of detecting self-isolation (such as regular mental health, medical and custody meetings on residential mental health units) would be satisfactory. Note that referral of self-isolating inmates is not limited to those in residential mental health units so some alternative approach is needed in other settings, which will likely be ordinary custody referral. Referral

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of those with long sentences is nearly meeting the compliance standard of 95%; if the measure were being seen by a QMHP, which is clearly most important, it would likely be meeting the standard. This element is rated as in partial compliance owing to the problem of tracking referrals for self-isolating inmates.
If the parties agree that the regular morning meetings at SCF and RPDC that address self-isolating inmates in mental health housing, assuming these meetings actually address such issues, coupled with standard custody referrals for other settings are an adequate means of detecting and referring the selfisolating inmate, some standards will be necessary for monitoring. I recommend specifying a frequency for the mental health housing meetings as well as brief minutes to demonstrate self-isolation is being considered. It is not clear how to assess custody referrals from other settings. It would be a helpful for the County to recommend an approach to this.
I was not provided any data on inmate classification generally or that would demonstrate that inmates are not being placed in restrictive settings solely because of mental illness. As noted in my last report, the mentally ill are disproportionately represented in administrative segregation but that does not necessarily mean they are so classified because of their mental illness; it may be their behavior. But until data is produced to demonstrate this, it is not possible to assess this element. Even though I received examples of classification reports, it was not possible to determine if the classification was done per policy without the raw data, so this element is not rated.
Those on administrative segregation remain highly isolated, raising concerns about the balance between custody limitations due to actual or presumed risk and mental health determinations of the need for commitment. In terms of those that are not allowed out due to a custody determination that the patient is a danger to others, either that determination is incorrect, or the patient should be committed to the DCU as surely if they are too dangerous to be let out by custody staff, they are dangerous enough to meet civil commitment criteria. For those that are self-isolating, much stronger consideration needs to be given to involuntary treatment in the jail and/or commitment to the DCU as gravely disabled. How much self-isolation is “enough” to determine grave disability is certainly a question, but given the degree of purported yard refusals, the number who are refusing over extended periods is clearly substantial. It can be argued that this should not count as grave disability, but the definition is poorly applicable to corrections; for instance it could be argued that such patients are not providing food, clothing, or shelter but being forcibly sheltered and given food and clothing such that an analysis of their ability to secure these for themselves or with the help of willing others (jails are not “willing” but mandated to provide food, clothing, and shelter) should be undertaken. A different, more expansive approach to grave disability that takes into account the nature of the correctional environment has been adopted by CDCR here in California. Most elements of administrative segregation have to do with treatment requirements and are thus included in the section “Mental Health Treatment” below. I was provided data showing that those in administrative segregation are re-evaluated every 30 days over 95% of the time. While it is not clear what this re-evaluation consisted of, the Remedial Plan only requires that this be done so this narrow element is in substantial compliance.

REVIEW OF IN CUSTODY DEATHS (elements relevant to mental health services)
I was not provided any death reviews. Thus, this item is not rated.

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CONTINUOUS QUALITY IMPROVEMENT PROGRAM (elements relevant to mental health services)
The following are the elements of the Continuous Quality Improvement Program (CQIP) relevant to mental health are:
 Peer review of psychiatrists  Quality Improvement Committee (mental health components)
RUHS-BH continues to conduct its own CQIP but there has been increased collaboration between RUHSBH and RUHS-CHS. Custody still does not provide data for the healthcare CQIP and does not have any healthcare related measures. As mentioned before, custody participation is crucial, especially in the area of access to care and other areas where custody functions are relevant to mental health care such as safety cell monitoring, restraint, privacy and confidentiality, and access to out of cell activities (structured and unstructured). Achievement of substantial compliance will require greater collaboration.
I did not receive peer reviews or minutes (or other data) of CQIP meetings so cannot comment on their content or other aspects of the function of the committee. In fact, I received virtually no CQIP data for this reporting period.
Though I did not receive any meaningful CQIP data other than the document “Behavioral Health Detention Indicators” from 1/1/19-1/31/19, I continue to rate this as in partial compliance owing to the continued efforts of RUHS-BH to expand its reporting capacity.

MENTAL HEALTH CARE
The elements of mental healthcare include:
 Treatment according to a Program Guide (including treatment of those in administrative segregation, which was moved from Custodial Environment)
 Psychiatric care timelines  Housing of the SMI  Treatment space  Suicide prevention  Restraint  Continuity of care
Treatment According to a Program Guide and Psychiatric Care Timelines Observations and Interview
There is still no formal Program Guide.
Patients were generally very positive about their interactions with mental health staff, though expressed a wish for more frequent contacts, including individual contacts with QMHPs and psychiatrists and groups.

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Groups continue to be conducted by Recreation Therapists and Behavioral Health Specialists. Clinical Therapists focus on intake, assessment, rounds (usually during pill call), crisis response, and individual contacts. Psychiatrists provide medication support services. The mainstay of treatment remains, appropriately, groups and medication management. The County still struggles to engage the seriously mentally ill in consistent programming; at any one time, most patients in the residential mental health units are in no groups. They primarily receive brief check-ins, often at cell front. Access to correctional programming is minimal on these units as well. At SCF, those patients in the so-called “med beds” on HU-12 and HU-14 have access to correctional programming that is similar to other inmates. Those on HU-16 have some access to limited on unit jobs and educational services. Those on the residential units at RPDC (they have been moving around due to construction and maintenance) also have limited access to correctional programming. That said, many of these patients have limited capacity to participate in traditional correctional programming, making it all the more important that they have more regular access to mental health groups. Most groups for the seriously mentally ill are recreation-oriented. This is reasonable for the most acute, but there is a need for some more structured groups such as psychoeducational groups, including medication education. Nursing is reportedly considering developing a medication education module. There are also groups on substance abuse, reentry, anger management, and skill development for patients able to avail themselves of these groups.
Throughout the system, admissions to groups are mostly rolling in order to maximize group attendance. This limits the ability to provide a complete curriculum and undermines fidelity to some groups but is reasonable for other groups, e.g., recreation therapy. Being able to provide more structured group with formal curricula for those who are likely to remain for extended periods (three months or greater) would require a concerted effort to reduce transfers and to allow patients from different living units to attend groups together, as is done in many correctional facilities.
The groups being run at Blythe include Dialectical Behavior Therapy (DBT), anger management, and a reentry group. There were 23 patients currently enrolled in DBT groups at the time of my visit. This is an improvement from previous visits. However, the Clinical Therapist reported that, reportedly due to lack of interest, there were not enough patients interested to run other groups, resulting in a focus on more individual contacts. The Clinical Therapist reported that while custody still cleared patients for groups, enrollment is more consistent with clinical need, though as noted above, only four patients had been cleared to attend the anger management group. The Clinical Therapist reported seeing patients on her caseload about twice monthly and is working on developing an in-reach program where community mental health staff would meet with patients in the attorney booth.
At Indio, groups included discharge planning, WRAP, DBT, and New Directions. These are reasonable groups for this population, but only 10 hours of groups are run per week owing to limited space. There are reportedly 5-10 patients in each group, so roughly serving 50 to 100 patients (though some are in more than one group, so it is likely at the lower end). Individual meetings vary but reportedly primarily consist of initial orientation to the jail and crisis response and brief check-ins. There are occasional courses of brief supportive therapy.
At CBDC, groups are still limited by lack of space (see below). Groups include Recreation Therapy, COLORS, New Directions, DBT, Seeking Safety, and Anger Management. 5-10 patients are enrolled in each group. I attended a Recreational Therapy group at CBDC; the group was run by two co-therapists. It was a well-run Recreational Therapy group. While the patients did not exhibit any significant

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psychopathology, it is possible that their needs are more substantial than is apparent during a single group, though there was no evidence of active psychosis or mood disorder. However, the QMHPs were clear that they make every effort to assure that patients in groups have a moderate level of care (generally, the highest acuity at CBDC at the time).
Groups at SCF include Recreation Therapy, a hygiene group, New Direction, and Seeking Safety. On HU14 and HU-16, New Direction is the primary group. Staff note that group attendance has fallen off on these latter units, possibly due to gang penetration of these units that were intended to provide a safe haven away from gang politics so that patients could take medications and attend treatment without fear of gang interference.
Groups at RPDC include DBT, Recreational Development, New Direction, Activities of Daily Living, Seeking Safety, COLOR, Anger Management, and Reentry.
I attended two groups at SCF HU-16. I came in at the end of a Recreation Group attended by only three patients with serious mental illness from HU-16F. The subsequent group included just two patients from HU-16E, both with serious mental illness. The two BHSs used a structured poetry activity to help patients explore their strengths they could build on. The group was run well. The group leaders noted that groups have gotten smaller in part because patients are only allowed to come out by tier from one unit. They also noted that they are often not allowed to go on the unit to ask if patients are willing to participate. This is unreasonable. Patients on HU-16 complain of limited access to groups as well.
I also attended one group at HU-14. The was New Direction. While the group leader did too much of the talking, it was sound content and relevant for the five patients in attendance, two of which were new to the group that day. These were not seriously mentally ill patients, but several had clear evidence of psychiatric symptoms.
I attended a Recreation Therapy group at CBDC attended by 8 inmates with primarily substance-related disorders; none had overt psychopathology. It was very well run, teaching coping skills through activities and using a drawing activity to prompt self-exploration and relatedness to others.
Clinical Therapists at RPDC report that, due to both increased staffing and better organization, they have been able to decrease crisis calls and increase assessments and treatment plans, as well as deliver more structured services. Permanent assignments have also increased familiarity with patients on their caseloads and provided better continuity of care. They also note that increased runners have provided much better access to both group and individual treatment services. They particularly noted how helpful the liaison sergeant had been in facilitating the custody end of many of these improvements.
At the DCU, no groups are yet being conducted, but Clinical Therapists attempt to meet with patients individually two or three times each week. There is also a book cart and those patients not restricted from them for clinical safety reasons are being allowed to check out books. Despite these small gains, patients remain largely isolated in their rooms with no activities, still far more isolated than medical patients. The DCU is still being run like a restrictive housing unit for the mentally ill. In medical records reviews, I saw several cases where patients were returned to the jail still very unstable. Charting from the DCU and the release summary accompanying patients back to the jails is exceedingly minimal and does not sufficiently capture the treatment and clinical course at the DCU. Clinical Therapists at the DCU are doing a better job of promoting continuity of care, but the supporting documentation is inadequate.

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While I understand the DCU uses a different EHR, documentation for continuity of care purposes must be improved.
RUHS-BH Data The group schedule and roster for RPDC for March shows the following (while it says for the fifth floor, the patients are from different locations but are all male residential mental health patients):
 Monday o 0900-1030 – DBT (to start later in the month) o 1430-1530 -- Activities of Daily Living (7 patients)
 Tuesday o 0900-? – Recreational Development (7 patients) o 1000-1100 – Jail In-Reach (no patients listed) o 1400-? – Seeking Safety (8 patients)
 Wednesday o 0915-1000 – Recreational Development (7 patients) o 1200-1330 – Activities of Daily Living (8 patients) o 1345-1500 – Recreational Development (7 patients)
 Thursday o 0900-? – New Direction (12 patients)
 Friday o 1215-1300 – Recreational Development (5 patients)
This represented a total of 61 patient slots with 42 different patients enrolled from housing units 5A, 6A, and 6B. Thus, most patients in groups are getting one group per week. The majority of patients were in no groups.
The group schedule and roster for RPDC for March shows the following (while it says for the sixth floor, the patients are from different locations but are all female residential mental health patients):
 Monday o 0915-1045 – Recreational Development (9 patients) o 1300-1400 -- Activities of Daily Living (8 patients) o 1400-1500 – COLOR (5 patients)
 Tuesday o 1100-1200 – Jail In-Reach (no patients listed) o 1200-1300 – Recreational Development (9 patients) o 1300-1400 – Seeking Safety (no patients listed) o 1415-1515 – Activities of Daily Living (9 patients)
 Wednesday o 0900-1030 – Activities of Daily Living (8 patients) o 1500-1630 – DBT (9 patients)
 Thursday o 1200-1330 – New Direction (no patients listed) o 1300-1430 – COLOR (8 patients) o 1400-1530 – Recreational Development (10 patients)

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 Friday o 0900-1000 – Anger Management (5 patients)
This represented a total of 80 patient slots with 53 different patients enrolled from housing units 4A and 4B. Almost half of females with SMI in residential housing were in a group.
The report “Behavioral Health Detention Indicators” from 1/1/19-1/31/19 shows the following with respect to treatment provision:
 Behavioral Health Assessments: Of those inmates with a behavioral health flag (indicating the inmate is an identified mental health patient) in custody for more than 14 days with a level of care rating of moderately-severe or severe, 95.7% (112/117) had an assessment. The low of 95.7% was at CBDC; the highs of 100% were at Indo and SCF (no cases were reported for Blythe). o 105/112 (93.8%) were completed within 14 days. o Note that the denominator (total cases) is substantially decreased from June 2018 when it was 397. This is likely due to only reviewing patients with level of care ratings of moderately-severe and severe.
 Behavioral Health Care Plans: Of those inmates with a behavioral health flag in custody for more than 14 days with a level of care rating of moderately-severe or severe, 88.9% (104/117) had a care plan within the last year. The low was 86.6% at RPDC; the high was 100% at SCF. o Of the 104 assessments completed, 84.6% had a care plan within 14 days of booking. o Again, the number of total cases is about 30% of the number in June 2018. This is likely due to only reviewing patients with level of care ratings of moderately-severe and severe.
 1772/2456 – 72% of expected individual contacts for the 105 mentally ill ever in administrative segregation for the month were done. o 34/105 = 32.4% of patients had all expected visits o Most missed days were for one day periods. There were 17 patients who missed 5 or more days in a row.
Review of medical records of those from those patients listed on “Random Bridge Meds JAN-JUNE 2019.xlsx” and ordered bridge medications at admission, 7/9 = 78% were seen within 7 days. Of those later started on medications, 6/8 = 75% were seen for follow-up by psychiatry within 30 days. I saw only rare instances of patients on long-term psychotropics who were not seen every 90 days (e.g., 2017010403522649).
In my detailed medical record reviews of 22 seriously mentally patients spending at least 30 days on a residential treatment unit, I found that 11/19 = 58% of patients in residential mental health units not on administrative segregation received adequate treatment (note that I exclude medication monitoring but do evaluate the adequacy of the medication regimen and individual and group therapy). Three cases were indeterminate. I had interviewed two of these patients, both of whom received adequate treatment and were seriously mentally ill.
I reviewed 10 patients in residential mental health units on administrative segregation. 2/6 = 33% received adequate treatment. Four were indeterminate. Access to care for these seriously ill was a major obstacle.

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I noted that care rendered by the DCU was too often inadequate, again largely owing to poor access to care but also to failure to adequately stabilize a number of patients prior to returning them to the jail.
Summary Treatment continues to slowly improve. Development of infrastructure continues, including group content (and staff trained in delivery), encounter tracking, structuring of staff resources to maximize treatment delivery, and access to care (which requires sufficient program space, runners, out of cell access to patients, and clinical staff). The primary determinate of expanding treatment resources to patients in need is, at this point, access to care, especially for the most ill and those on administrative segregation. Once access to care is maximized, it will be possible to determine if there are enough clinical staff to meet the basic needs of the mentally ill. In my opinion, the mental health service has done almost all it can to prepare to expand services once access to care barriers are eliminated.
While there is no program guide, there is a good deal of material indicating the kinds of services that are to be delivered as would be expected in a formal program guide. There are requirements that patients be seen individually every 30 days, but this alone is not adequate treatment and primarily consists of assessment and case management. Occasional patients receive more regular individual contact that would qualify as therapy. That said, there are no benchmarks regarding dosage expectations of overall treatment (though there are at least minimum standards for individual contacts) with no group requirements at all. Treatment in accordance with a program guide is in partial compliance.
As the data above shows, psychiatric care timelines are also in partial compliance, largely owing to challenges seeing patients promptly upon admission following initiation of medications. Psychiatrists are generally doing well in terms of 90-day follow-ups. As noted above, medication monitoring is also in need of improvement.
Housing of the Seriously Mentally Ill
There has been an increased to 610 beds designated as residential mental health units throughout the system. So-called “med beds” (units where patients not requiring residential level care but need a safe place to continue their medications, free from the influence of non-mentally ill inmates) have been expanded to 110 beds on HU-12 and HU-14 (if the SCF Housing Profile is accurate). There are still 192 residential mental health beds in HU-16. The remainder are at RPDC as follows (per the 3/9/19 RPDC Housing Unit Profile):
 5A Dayroom 1 – 28 beds, GP, level 1-5 males  5A Dayroom 2 – 32 beds, GP/Liberty, level 1-5 males  5A Dayroom 3 – 28 beds, Liberty/PC ,level 1-5 males  5B Dayroom 1 – 40 beds, Ad Seg, level 1-5 males  5B Dayroom 2 – 40 beds, PC, level 1-5 males  6A Dayroom 2 – 32 beds, Ad Seg, level 1-6 females  6A Dayroom 3 – 28 beds, PC, level 1-5 females (includes some who are nonmentally ill PC)  6B Dayroom 1 – 40 beds, GP, level 1-5 females  6B Dayroom 2 – 40 beds, GP, level 1-5 females
While these all add up to 610 (with 308 at RPDC), some units, such as administrative segregation, include single-occupancy cells.

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RCSD provided tables of transfers of patients with acuity ratings of moderately severe to acute from RPDC and SCF to other facilities. The data from SCF is explicit that mental health approved and provided the name of the approving clinician. 161 of 165 from October 2018 through January 2019 were approved for transfer, there was no entry for four, and none were marked as not approved. From RPDC, the data is less clear. Most entries under the column “Mental Health Review” were one of the following: “NEW BOOKING” or “PER HOUSING PROFILE.” Upon inquiry, I was informed that:
“New Booking means they were a new arrestee, was never housed at RPDC and Mental Health cleared them for transfer.
Per Housing Profile means the inmate was removed from their unit at RPDC due to a conflict (unknown what conflict) and Mental Health cleared them to be housed at another facility per their housing profile (Mental Health acuity rating and classification rating).
…Classification … stated the approval was implied because they were transferred.”
However, there were other entries where a patient was disapproved by a mental health clinician but was still transferred. Thus, it is unclear how reliable this data is. RCSD plans to bring greater consistency to this process and I have encouraged the practice of specifying the approving or disapproving mental health clinician.
If the data on these transfers to other facilities are accurate, 613/620 = 98.9% were approved by mental health. No data were provided on what process occurred when mental health disapproved to demonstrate that there was time for consultation and resolution of differences between custody and mental health regarding the appropriateness of transfer.
No data were provided on transfers of the mentally ill within facilities or from the other three facilities (Blythe, Indio, or CBDC).
I confirmed that entrance and exit from residential mental health settings is driven by the acuity code; this is a reasonable means for mental health to provide input. However, proof of practice still needs to be provided but could simply consist of a cross-sectional report from a random sample of days reporting on the number of patients whose acuity codes matched their housing location.
In my opinion, transfers of those with acuity ratings below moderately-severe do not require approval for transfer by mental health. If the parties concur, I will conform future reports to that interpretation. I would also welcome input on the necessity and nature of the approval of transfers within the facility. In my view, if patient acuity codes drive placement, then transfers within facilities to settings matching those codes should not require additional mental health input. I would appreciate the parties’ views on this as well.
Mental health staff report there continues to be good collaboration on transfers, but proof or practice remains to be solidified.
With the understanding that some components of this element of Mental Health Care have been moved elsewhere (out of cell time and correctional programming is covered in Custodial Environment and provision of structured treatment activities under Treatment According to a Program Guide), housing of the seriously mentally ill remains in substantial compliance, though subject to the above clarifications from the parties and return to clearer confirmation of mental health consultation prior to transfer. I

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take the statement that SMI are to be “housed in units designated for such housing” to require adequate beds to meet the needs of the SMI population; in my opinion, the County has sufficient residential mental health beds at this time.
Treatment Space
Treatment space remains a problem but there is clear progress on this. A new clinic has opened at SCF and appears to be well-designed for workflow, confidentiality, and safety. Construction at RPDC is underway and will improve access to space, and thus access to care, substantially.
Clinical spaces are well lit and generally have access to medical records through wi-fi, though there are some problems with reception in certain locations such as some of the program rooms and the law library at CBDC and units 3A and 4 at RPDC. However, this has not been a substantial barrier as clinicians generally review records prior to patient contact and conduct charting after visits. Psychiatrists rarely have patient contacts in locations without medical records access except occasionally at RPDC.
The ability to fully utilize treatment space will be contingent on having enough custody staff (runners) to assure patient movement.
At Blythe, groups continue to be run in a single program room that is shared with others. This has limited group offerings, though the Clinical Therapist believes that more times could be scheduled; this will be necessary to review further as the other Clinical Therapist position at Blythe has been abolished, leaving only one to do all clinical work. As noted above, the Clinical Therapist is still not allowed to meet face-to-face with patients, though the Clinical Therapist is satisfied with the booth arrangement. However, I sat in the patient area of the booth and the sound system intermittently cut out and was not adequate for clinical work; the staff was unaware of this problem and it should be corrected. The setting for conducting telepsychiatry at Blythe remains sufficiently confidential. Interestingly, the QMHP is in the room with patients doing telepsychiatry, though not when meeting individually with patients.
At Indio, there are no program rooms. The only room available is the Briefing Room that is available to mental health two hours daily, the primary reason that relatively few groups are run at Indio for the population number. This should be remedied by the new jail. When the psychiatrist conducts telepsychiatry for Blythe, this is done from a private office space with full access to records. There are four booths available for mental health interactions, though two are attorney booths that are often unavailable. Psychiatric contacts are almost all done privately but many other mental health contacts are at cell front.
Program space has improved substantially at CBDC with the development of a schedule for use of the program rooms that divides time among different disciplines; the schedule is working well and provides adequate time for QMHPs to conduct their clinical work. Groups are being run in the Law Library and some recreation therapy is done in yards, both of which are shared with others. The program rooms are not being used for groups, though there is no reason they could not be used. There have not been any changes to the intake area yet, but this is work is reportedly still planned.
On the fifth floor at RPDC, which houses the most acutely mentally ill, there are only two interview booths that must be shared with attorneys and Liberty Health staff. There are also only one or two

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program rooms available. Clinical staff note that sometimes the only way they can meet with their patients is at cell front.
There have been no changes to the intake area at SCF which remains limited to two interview booths. These are also used for safety cell interviews. This can result in delays in both functions. There are three interview booths on HU-16 (the mental health residential pods) and only one program room. Space is limited on other living units as well. However, the new clinic will be able to help mitigate some of these problems as will the planned additions of an interview room at HU-16. It will depend on how these additional spaces are used, but the addition of a group room in the clinic should help substantially if fully utilized. The current plan is to give lists of patients to sergeants who arrange for patients to be brought to the clinic in groups. SCF is also considering the addition of telepsychiatry in the new clinic, but this has yet to be implemented.
While there has been substantial progress here, this element of Mental Health Care remains in partial compliance but is expected to become substantially compliant upon completion of construction.
Suicide Prevention
Observations and Interviews Stepdown procedures allowing restoration of property while in safety cells have not been implemented; there is no process for restoring property and privileges in a stepwise manner based on mental health assessment of risk. The RUHS-BH Detention Services Policy: Safety Cell Placement provides for restoration of property, but this is not being followed. All those in safety cells for danger to self are in suicide gowns with no property. While at SCF, there was a patient in a safety cell naked with nothing in the way of covering, blanket or mattress. This is unacceptable for any period of time.
I inspected safety cells at all four facilities having them. Those that were occupied had logs posted at the door that were generally complete. There are no safety cells at Blythe; a cell across from the Deputy’s station in intake with direct visibility into the cell is used to temporarily house patients pending transfer, usually to Indio. The two safety cells at Indio were both clean. The safety cells at CBDC were not well cleaned but were not grossly dirty, though one was malodorous. Safety cells at SCF were fairly clean except one had feces in the drain and was malodorous. Those at RPDC were clean except some vents were quite dirty. Cameras in safety cells were functional. I did not receive safety cell cleaning logs, so it is unclear how often they are cleaned and whether these logs are being reviewed (some facilities reported sergeants review logs, others, lieutenants). Staff at Indio reported they were inspected by a sergeant before each usage and during safety checks. Staff at CBDC reported that sergeants inspect safety cells. At SCF, the safety cells are reportedly cleaned after each usage. At RPDC, they are reportedly regularly inspected and cleaned if needed. RCSD is developing a proof of practice for safety cell cleaning.
Staff and patients report that most safety cell assessments are not being done at cell front, unless patients refuse to come out or are highly agitated. Mental health staff report that custody staff are generally very good at bringing patients out but are sometimes unavailable, leading to delays (this was evident in medical records reviews). However, most patients are being seen regularly and within time frames for QMHP assessment. QMHPs report that they frequently do crisis interventions with those in safety cells in addition to assessments; medical records demonstrated uneven crisis intervention for this population.

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Staff were uncertain and many seemed confused when questioned about the availability of one-to-one monitoring if needed, e.g., pending admission to the DCU for imminent suicidality. The RUHS-BH Detention Services Policy: Safety Cell Placement provides for one-to-one monitoring At Blythe, these patients are placed in the observation cell across from the Deputy’s station. At Indio, they are reportedly removed from the safety cell and chained for observation from the Deputy’s station in the intake area. At CBDC, none could recall an instance of needing a one-to-one, but the sergeant reported he could order that to be available. At SCF, staff were clear that a one-to-one could be ordered. There was no clear answer from staff at RPDC, who simply noted that patients were quickly transferred to the DCU. The general impression was that it was rarely being considered and it was unclear to staff whether it was available, the presumption being that use of the safety cell was sufficient. A few staff noted the restraint chair being used if a person was actively self-harming, but this is a different situation than imminent suicidality. The RUHS-BH Detention Services Policy: Safety Cell Placement provides for treatment to occur while patients are in safety cells and records reflect that patients are receiving some counseling with an emphasis on use of coping skills during the safety cell assessments occurring in noncontact booths but, as noted above, this is uneven. Virtually all patients transferred to the DCU are in safety cells pending transfer.
I observed a safety cell assessment at RPDC. The patient was seriously mentally ill with overt psychosis and had a history of assaults and suicidal ideation. The patient was planning to stop his medication and the Clinical Therapist planned to arrange a visit with the psychiatrist that day. The patient was, reasonably, not released from the safety cell.
I reviewed the records of 20 patients identified as being placed in safety cells, including 10 that were not sent to the DCU from the document “Safety Cell No DCU.xlsx” and 10 that were sent to the DCU from “Safety Cell to DCU.xlsx.” I determined that none were in the safety cell longer than 48 hours. All those in safety cells are in a smock with no more than a mattress and blanket so all the 17/20 that were in for more than 12 hours met the operationalized definition of being in seclusion and were in over the time limit defined by the remedial plan. Consistent with the lack of stepdown procedures, I saw no evidence that property was restored during safety cell placements; all patients appear to go from being on full restrictions and then being placed back in their cells with property. Different than what staff reported to me, I found that only 9/20 cases were consistently assessed out of cell (I excluded instances where the patient refused to come out or when the patient was not allowed out of the safety cell due to dangerousness, as long as there was documentation that was consistent with possible dangerousness). There were occasional instances where patients were not evaluated timely. One patient was in the safety cell over 24 hours before being seen at cell front and was not seen face-to-face until over 30 hours. Two patients did not have an initial assessment until in a safety cell for more than six hours. In another case , a patient was initially assessed but was not later seen for a period of over 24 hours. Another patient was in the safety cell for over 24 hours and was seen only once. When reviewing these, I also excluded instances when the Clinical Therapist reasonably elected to allow a patient to continue sleeping. However, the majority pf patients were seen regularly and timely by a Clinical Therapist, just often at cell front. There were no cases that clearly had no face-to-face assessment during their placement in the safety cell. Documentation of treatment was seen in a minority of cases; almost all notes were assessments. That said, many patients were promptly referred to and seen by psychiatry and medications changed or ordered when indicated. For those patients going to the DCU, I saw two cases where the Clinical Therapist tried to provide some support and de-escalation. I saw no cases

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where a Clinical Therapist ordered one-to-one or other special conditions or monitoring pending transfer to the DCU.
Seven of the eight patients in the sample that were on medications while in the safety cell received their medications. Nursing monitoring was done per policy in 14 of 20 cases. Most failures were because they were not timely, but many were incomplete assessments with many blanks and no explanation. Again, I excluded cases where patient refusal was documented, or the assessment was not allowed due to dangerousness. Only one case had no nursing assessment while in the safety cell. Note that timeliness was determined by chart entry here rather than safety cell log entry. It may be that nurses are not always documenting their safety cell checks in the medical record.
Clinical staff did not consistently assess for consumption of food or fluids. Many nursing assessments did not assess hydration status but wrote in the EHR field for fluid intake and hydration status “per custody.” While it is reasonable for custody to be responsible for tracking meals and access to fluids, it is up to clinical staff to assess hydration.
RCSD Data Review of safety cell logs demonstrates that patients are being regularly checked with few going more than 15 minutes. Check times are generally well staggered, though at SCF, many checks remained exactly 15 minutes, raising concern about the accuracy or the variation of these checks. Documentation of meals being offered was the most common shortcoming. However, the vast majority of these logs were well-done, thorough, and complete. I saw no evidence of patients staying in safety cells more than a few minutes past 48 hours.
At CBDC, safety cell logs are largely complete and document timely supervisor, QMHP, and medical assessments. Some show checks repeatedly at exactly 15 minutes, but most show variation. Many showed careful review by supervisors, noting the occasional problems with checks, though rarely commented on those lacking documentation of meals being offered. Documentation of being offered three meals per day remains inconsistent but is present on most logs. Offering of water is regularly documented.
At Indio, most logs were complete and without any problems except occasionally not documenting whether meals were offered. Supervisor, QMHP, and medical assessments were timely.
At RPDC, most logs were complete with only rare misses of meals being offered and rare untimely medical assessment. Supervisor, QMHP, and most medical assessments were timely.
At SCF, logs were less complete with inconsistent documentation of offering food and water. Supervisor, QMHP, and medical assessments were timely. There is provision for one-to-one observation when necessary at SCF.
Review of 10 patients in safety cells not sent to the DCU from the document “Safety Cell Restraint Chair DCU.xlsx” showed no evidence of step-down protocols. None of the 10 were in longer than 48 hours. 9/10 appeared to be in seclusion for more than 12 hours (operationalized as being in the safety cell with only a smock, mattress, and blanket).

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RUHS-BH Data The report “Behavioral Health Detention Indicators” from 1/1/19-1/31/19 includes a report entitled Safety Cell Transitional Follow-up that reports on how often a QMHP is meeting the RUHS-BH target of QMHP follow-up of those transitioning out of safety cells for five consecutive days. For the 168 safety cell placements that month, 62% had all five meetings or all required meetings up to a QMHP determination that further transitional follow-up was not needed. 21 (12.5%) had no follow-up, though some of these were determined not to need follow-up.
Summary There continues to be steady improvement and more assiduous attention to detail regarding this provision. Continued careful attention to safety cell logs, especially to meal provision, and safety cell cleanliness will be crucial to achieving substantial compliance. In my opinion, the policy provision for one-to-one monitoring and for treatment in safety cells meets the criteria for treatment provision pending DCU transfer. However, clear verification of the availability of one-to-one monitoring, such as its demonstrated use or RSD policy that aligns with the RUHS-BH Detention Services Policy: Safety Cell Placement are needed to provide confidence that this degree of monitoring is available.
Once stepdown procedures are implemented (which should address the problem with seclusion) and with slight improvement in the timeliness of assessments, this element of Mental Health Care will likely be at or near substantial compliance but remains in partial compliance at this time.
Restraint
Policy J-127 specifies that health (nursing) monitoring is to be at “medically appropriate intervals” and that the inmate must be seen “…at the time of placement into a restraint chair and at a minimum of very two hours thereafter….” The policy specifies:
“Assessment of the inmate shall include, but not be limited to the following:
1. Vital signs (temperature, pulse, respirations, blood pressure, oxygen saturation and capillary refill)
2. Neurological signs and symptoms, including loss of consciousness, seizures, mental status changes, amnesia, visual changes, cortical blindness, movement disorders, stroke like symptoms
3. Difficulty swallowing, difficulty or pain when speaking, shortness of breath, and/or respiratory distress
4. Extremity circulatory checks 5. Hydration status 6. Presence or absence of ligature marks, neck contusions, voice changes, and petechial
hemorrhage”
These are comprehensive expectations and sufficient for monitoring those in restraint, with the exception of failing to require assessment of peripheral nerves that can be compressed by restraints.
Use of the emergency restraint chair continues to be relatively rare. I saw no instances of restraint lasting more than 8 hours in the cases I reviewed.
Restraint chairs were clean and operational; the restraint chair at Indio was somewhat worn.

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QMHPs reported that face-to-face assessment of those in restraint was done except at SCF where it was done through the tray slot, often during limb rotations. In most instances the QMHP would stand at the safety cell door with the patient in the restraint chair in a safety cell except at Blythe where the chair is bolted to the floor in a hallway (it is rarely used) and on rare occasions in other facilities prior to placing the restraint chair in a safety cell. However, face-to-face assessment is sometimes denied “for safety reasons.” Face-to-face assessment is a requirement of the Remedial Plan unless there is a likelihood of inmate violence; given that patients are restrained, it is hard to imagine a safety reason for denying face-to-face assessment. In my experience, I have never been unable to conduct a face-to-face assessment of a properly restrained patient and am unaware of this ever being the case. In general, the more agitated the patient, the more necessary it is to do an evaluation to assure that they are not at risk of imminent harm or suffering from a medical condition requiring emergent assessment and treatment.
I reviewed 10 medical records of those placed in restraints. I could verify at least some face-to-face assessment during the time of restraint in four cases. In two cases there was no face-to-face assessment. For the remaining four cases, the documentation was unclear. In no case did the nursing assessment meet the above standards. Only one case was there a circulatory check. In two cases, there was no nursing assessment at all. There was only one nursing assessment that I reviewed that was consistent with the above policy but there were no further assessments even though the patient remained restrained for five hours.
There were no data provided about restraint use at the DCU.
Because of the problems with assessments by QMHPs (not face-to-face) and by nursing staff (some very poor, virtually all lacking circulation checks), this item meets partial compliance currently. It could be argued that non-compliance is warranted, but patients are being monitored by healthcare staff to some degree in virtually every case (though sometimes only by a QMHP), so this is not a question of neglect but of not getting proper access to the patient to provide a thorough clinical assessment. Instances of restraint are high risk and due attention is required.
Continuity of Care Observations and Interviews
Reentry initiatives continue. RUHS-BH continues to use both reentry groups and/or individual contacts addressing reentry planning. Reentry teams from the community are still coming to the jails (except Blythe) but peer reentry helpers are only being used in the community. Community reentry is being channeled through the AB109 clinics in the community.
Psychiatrists report that they order 30-45 days of release medications. If a release is unexpected, medications may be sent to a community address when available.
RUHS-BH Data The report “Behavioral Health Detention Indicators” from 1/1/19-1/31/19 shows:
 278/286 = 97.2% of releasing inmates with a behavioral health flag in custody more than 30 days received an individual encounter addressing discharge planning. o This included any note during the inmate’s stay coded as “Discharge Planning” but does not differentiate types of notes; it includes notes where there was no patient contact.

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Review of 10 cases from “BH Housing PsyMeds Discharged.xlsx” showed that only seven were actual cases of discharge, the others were transfers. Of these, 2/7 = 29% received release mediations and 4/7 = 57% received reentry planning services (one other patient received a packet of information, but this was considered inadequate for a seriously ill man with a rating of moderately severe).
Many patients have notes with titles indicating that reentry services were the subject of the encounter but include no documentation of any reentry services. Sometimes they are notes regarding possible enrollment in groups (non-specific groups) and sometimes are simply notes saying that reentry services will be rendered, but then that often never occurs. This is almost certainly the source of the discrepancy between RUHS-BH data and my own review.
Summary RUHS-BH is making substantial efforts in this area. One difficulty I previously noted is that the remedial plan calls for “connecting” to community services, which may not always be available. I will continue to interpret this as meaning that RUHS-BH has made necessary referrals and taken what steps it can to connect the SMI to treatment, social services, housing, and other appropriate services.
Continuity of care is in partial compliance.

POLICIES AND PROCEDURES
I was not provided with any new or updated policies or procedures since my previous report. The issues raised above regarding needed policy statements, e.g. to maximize out of cell time, remain to be addressed.
As I have been told that many are being modified, I will continue to rate this as in partial compliance at this time.

CONSENT DECREE TRAINING
The County was previously rated as in substantial compliance for this component.

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CONCLUSION
This concludes my Fifth Report, again utilizing a quantitative approach supplemented by qualitative reviews as necessary. As in the Fourth Report, I assessed 28 components. The methodology was refined for this report based on experience from the Fourth Report. The components themselves remain subject to modification, in accordance with the remedial plan, if needed.
The County continues to make progress towards meeting the requirements of the Remedial Plan. The County has achieved substantial compliance on 6/28, is in partial compliance on 16/28 (with a few of those nearing substantial compliance), is non-compliant with 1/28, and 5/28 were not rated, primarily because no information on these was provided.
Respectfully submitted,

Bruce C. Gage, M.D.

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APPENDIX
To follow

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EXHIBIT M

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Bruce C. Gage, M.D. Puget Sound Mental Health General and Forensic Psychiatry
6108 Community Place S.W., Suite 3 Lakewood, WA 98499

INTRODUCTION
This Second Report sets forth the Mental Health Expert’s assessments of the implementation of the terms of the Consent Decree, signed June 7, 2016, and associated Remedial Plan stemming from Gray v County of Riverside. It covers the Riverside County's (the County) reported results from the time of entering the Consent Decree from January 31, 2017 through July 31, 2017 (the “Second Reporting Period”), and reflects the observations and analysis of the Mental Health Expert regarding the County's compliance during that period.
As used herein, “Substantial Compliance” means that the County has achieved compliance with the material components of the relevant provisions of the Remedial Plan in accordance with the agreed-upon Compliance Measures for assessing Substantial Compliance submitted by the Mental Health Expert. “Partial Compliance” means that the County has achieved compliance on some, but not all, of the material components of the relevant provision of the Remedial Plan or have not achieved the quantitative results specified in the Compliance Measures; and “NonCompliance” means that the County has not met most or all the material components of the relevant provisions of this Agreement.
This Second Report is based upon the Mental Health Expert's review of provided policies, procedures and directives proposed and/or implemented by the County, observations and assessments of the Mental Health Expert based on tours of the jails, and review of medical records and data collected by the County. I visited Smith Correctional Facility (SCF) for one and a half days, Southwest Detention Center (SWDC) for a day, Robert Presley Detention Center (RPDC) for two days, the Detention Care Unit (DCU) for two hours, the Indio jail (Indio) for a half day, and the Blythe jail (Blythe) for a half day. I was provided full access to patients and staff and was assisted by staff knowledgeable in relevant topic areas including mental health, nursing, custody, classification, quality assurance, and administration.
I observed three groups (two at SWDC and one at RPDC; none were being held at the other facilities); met with psychiatrists, Clinical Therapists, nurses, Recreation Therapists, and Behavioral Health Specialists; observed pill lines and multi-disciplinary team meetings; conducted group interviews on general population units; rounded on patients in the DCU; and interviewed 26 patients in private. In addition, I met with mental health leadership at County offices for one hour.

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The County provided the following information for my review:
 Response to issues raised in my February 2017 report and to a request pursuant to this assessment: o Presence of lock boxes for medical request forms o Riverside County Sheriff’s Department (RCSD) Corrections Division Policy Manual, policy number 508.06 Inmate Medical Care dated 5/17/17 o Physical plant barriers and remedies to confidentiality o RCSD Corrections Division Policy Manual, policy number 504.42 Dayroom Management dated 9/9/15 o Training materials and reports of staff attendance regarding self-isolating inmates o RCSD Corrections Division Policy Manual, policy number 508.12 Mental Health Services o RCSD Corrections Division Policy Manual, policy number 503.07 Emergency Restraint Chair dated 6/6/16 o Report of percent of staff who received training regarding the consent decree
 Copies of important forms  Staffing data, including a 7/18/17 email from Assistant Sheriff Gutierrez to mental
health leadership: Deborah Johnson, William Wilson, and Brian Betz  Group therapy schedules  Resource (curriculum) materials for some groups  Results of a survey of Behavioral Health Detention staff dated 3/30/17  Communique from Riverside University Health System Behavioral Health (RUHS-BH) to
the Riverside Sheriff’s office regarding request for assistance in providing behavioral health services – hand-written date of 6/20/17  Ratings of mental health acuity at RPDC from 8/1/17  Samples of dayroom logs from RPDC, SCF, SWDC, and Indio  Email from Jerry Gutierrez to Deborah Johnson, William Wilson, and Brian Betz dated 7/18/17  RUHS-BH Detention Survey dated 3/30/17  RUHS-BH request to RCSD regarding support for mental health services (hand dated 6/20/17)  Electronic document entitled “Clinical Therapist Training Manual 10-5-17 (1).pdf”  Electronic document entitled “Data Request 10-5-17.pdf”  Electronic document entitled “2017 Safety Cell Stats – July.pdf”  Electronic document entitled “April and May SC Comparison.docx”  Electronic document entitled “MH RATINGS BY FLOOR FROM JIMS HEAD COUNT.xls”  Electronic document entitled “Referrals by urgency level.doc” (unclear which facilities are included or whether it is all facilities)

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 Detention Mental Health Sheriff MOU Monthly Reports from July 2017 and September 2017
 Behavioral Health PLO Indicators Step by Step Status report: Draft Version 1.3  Behavioral Health Detention Indicators (March through May 2017)  The following from Blythe Jail:
o Blythe Jail discharge data May 2017 o FBH Blythe Jail Sick Call Response Time May 2017 o Blythe Jail MH Screenings/FBH Ratings  The following from Indio Jail: o Indio Jail CQI Data – MH Ratings and Discharge Planning May 2017 o Indio Jail Safety Cell Step Down Stats (January through May 2017)  The following from SCF: o SCF Jail Safety Cell Step Down Stats (January through May 2017) o SCF – Inmates’ Response for Meals at Table Survey (and associated written
responses) o Smith Correctional (SCF) CQI Studies o Electronic document entitled “May Sick calls completed SCR.xlsx”  The following from RPDC: o Electronic document entitled “Number of days to triage.docx” o RPDC BH Screenings (for January through May 2017)  The following from SWDC: o Electronic document entitled “Southwest Detention Center BH Screening
Statistics APR17-JUN17.docx” o Electronic document entitled “SWDC Sick Call Response Time May 2017.xlsx” o Southwest Detention Center Behavioral Health Safety Cell Statistics  Email from Jeb Brown to Bruce Gage, MD on 10/26/17 regarding card readers in program rooms  Slides of CIT training by RUHS-BH and RCSD  RSD CIT training rosters from 7/12/16, 11/29/16, 1/18/17, 5/22/17, 7/17/17, and 9/18/17  Word documents from RUHS-BH entitled: o From the desk of AB109 new mgt. e-mail AB 109 new mgt..docx o Audit Smith HU 16.docx o Audit 2A July2017.docx o AdSeg Audit.docx o 7th floor1st audit 7-25-17.docx o 5B ad-seg 7-24-17.docx o 2AD3 Mental Health Audit_7.24.17.docx o RPDC Audit.docx

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EXECUTIVE SUMMARY
While Riverside County has continued to make evident progress towards meeting the requirements of the mental health components of the Remedial Plan in most regards, the adoption of more stringent security requirements for clinicians seeing patients in contact areas has substantially reduced clinical services since implemented in June. The County mandated that contact spaces outside the living units where clinicians see patients (generally, program rooms) be locked. Because clinicians are not provided keys, this meant that they would be locked in the room with the patients. Custody was not able to routinely stand-by and monitor these settings. Because of concerns of the risk to clinicians, RUHS-BH made the decision to cancel treatment activities in the absence of direct custody monitoring. This was made more poignant by a serious fight that occurred during a group at SCF during which the mental health staff was unable to leave the room and had no means of calling for help. Thankfully, staff were not the target of any violence.
This change has substantially curtailed therapeutic activities, especially groups, most predominantly at SCF where the majority of the mentally ill needing such services are housed. It has also resulted in a substantial return to use of the non-contact booths for individual meetings, which has had the additional effect of reducing access to care due to competition for those limited spaces. Many patients reported on this to me, expressing their disappointment and hope that treatment activities, especially groups, can be restored.
The County is to be commended for reporting this problem directly. The County is actively seeking a solution to provide safety and security while not limiting access to care. One important initiative is to provide electronic locks that clinicians would be able to activate from inside the rooms. The County has already started at SWDC and is slated to be completed at RPDC by December and at SCF by January. This should permit the County to return to at least the level of service it was providing prior to this change.
Access to care has also been impacted by recent reductions in the “runners” (custody staff assigned to facilitate patient contacts primarily by escorting) available to assist mental health staff. The County had augmented this function but has been challenged to maintain adequate numbers of staff to fill the need. They have made an effort to retain runners for psychiatry, which has been largely successful at SCF, SWDC, and Indio, but less so at RPDC.
Taken together, this has resulted in a reduction in individual and group treatment and a return to primarily non-contact visits. In general, clinician access to mental health patients remains a problem especially at RPDC and, now, SCF, primarily because these are the sites that have residential mental health housing units. There are also challenges at SWDC with clinicians sometimes only able to see patients in the intake area (rather than on the living units), assuming there is custody staff to escort patients to the intake area. This is reportedly due to limited staffing on the units to bring patients out and provide security for the patient contacts. In this regard, I continue to observe that mental health has more limited access and is under

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greater strictures with regard to direct patient contact than medical clinicians and other staff such as chaplain services.
In a July 18/2017 email, Assistant Sheriff Gutierrez laid out the plan for custody staff assigned to assist health care staff going into the future:
 Medical Sergeants at all facilities (except Blythe): 0730-1600 Monday through Friday  Medical, Dental, and X-Ray runners at all facilities: 0730 to 1600 Monday through Friday  Mental Health Sergeant at RPDC and SCF: 0830 to 1700 Monday through Friday  Mental Health runners at all facilities: 0830 to 1700 Monday through Friday  Two Mental Health nightshift runners at SCF: 1330 to 2200 Sunday through Thursday
and 1330 to 2200 Tuesday through Saturday  Liberty Health runner at RPDC: 0730 to 1600 Monday through Friday
Other than the nightshift runners at SCF, the numbers of runners were not specified.
Another challenge has been uncertainty about how to safely use the programming tables purchased by RUHS-BH. At present, these tables, which provide for restraint but allow face-toface interaction, are not supposed to be used except for piloting of individual sessions at RPDC. The County is considering how to utilize this resource.
Most other aspects of the County’s efforts to meet the requirements of the remedial plan continue to progress. It is important to again convey that the County has continued to focus on the development of systems and sustainable long-term solutions rather than endeavoring only to meet the requirements of the remedial plan in isolation.
As before, this focus on infrastructure limits the County’s current ability to generate the documentation necessary for proof of practice of many of the more detailed requirements of the Remedial Plan. However, the County is beginning to develop the capacity to report on important measures, including access to care and other clinical measures, primarily through the application of information technology (IT) resources to mining the new electronic medical record. The County has generated several reports relevant to the remedial plan as well as other important measures of system function using their quality improvement processes. This is an area of substantial improvement from my previous visit.
The County is also working to track time out of cell (dayroom and recreation) but this remains a challenge due to the limited electronic data systems available to RCSD for this purpose. In general, the County is challenged to provide data with sufficient detail to either provide proof of practice or conduct its own QA/QI. The main thing the County must do in this regard is to demonstrate provision of recreation twice each week for at least 1.5 hours for all inmates (absent safety and security concerns) and to show that dayroom time is not being suspended longer than needed to ensure safety and security. One aspect of this is demonstrating that similar populations are being treated the same, for example the mentally ill and non-mentally ill with the same custody and classification designations receive comparable dayroom time.

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While the new electronic medical record should provide the foundation for such functions in medical and mental health, the systems available to RCSD are very limited and not designed to facilitate the kind of individual or aggregate data needed for QA/QI or proof of practice of some components of the remedial plan.
The County has continued to customize the Electronic Health Record (EHR) to better serve its needs. While mental health must still retrieve information from three different record systems, all of the jail medical and mental health records are available to all clinicians. The integration of health services under the Riverside University Health System (RUHS) will also doubtless promote better processes and monitoring capacity as integrated systems develop.
In terms of mental health services, apart from the problems of access owing to the changes in security conditions for clinicians, the County has made some progress. This includes improvements in the intake process, better response to inmate requests for mental health services, improvements in the assessment process, and growth in treatment planning. There are also plans to begin to deliver services other than just medications at the DCU.
In general, I did not detect significant problems in the suicide-related provisions.
The collaboration between custody and mental health continues despite the understandable tension caused by the security changes. It is clear that there is growing recognition of the need for mental health must be embedded in the facilities in a different manner than medical services. To repeat a comment from my last report, the depth of this challenge and the necessity to sustain this collaboration cannot be overemphasized.
Two important examples of this collaboration are placement decisions and unit management. From my patient contacts, records reviews, and other reports, I did not see any significant problems with placement of the mentally ill in appropriate settings except for the still large number of mentally ill on administrative segregation. Regular meetings on the living units that include mental health and custody (classification and medical attend as well) address important management issues and discussions with staff demonstrate that mental health considerations are being taken seriously in placement and management decisions.
The substantial use of administrative segregation for behavioral problems related to mental illness continues to be a problem. Many needing protective custody due to their mental illness are also placed in the same settings as those on administrative segregation with the result that this population is also more restricted. It limits access to treatment, the very thing that is most likely to reduce the behavioral problems that resulted in these statuses. This amounts to restrictive placement for being ill. Clearly, there are times when clinical considerations require restriction. The County needs to develop greater clarity about restrictions necessary for clinical reasons versus those necessary for custodial or correctional reasons. The former should be determined by clinicians, the latter by custody and classification staff. A related issue is the need for the County to develop and implement step-down procedures for those placed in

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safety cells where mental health should be determining their degree of restriction, subject to reasonable limitations based on a structured classification process.

In terms of formal compliance, I report on the following measures, most of which remain global at this time. The County has achieved substantial compliance on the following measures:
 Consent Decree Training
The County has achieved partial compliance on the following measures:
 Intake Screening (elements relevant to mental health services) – likely nearing substantial compliance
 Timely Access to Care (elements relevant to mental health services)  Medication Administration and Monitoring (elements relevant to mental health
services)  Confidentiality (elements relevant to mental health services)  Health Care Records – likely nearing substantial compliance  Staffing (elements relevant to mental health services)  Custodial Environment (elements relevant to mental health services)  Treatment of the mentally ill  Housing the mentally ill – likely nearing substantial compliance  Treatment Space for mental health services  Suicide Prevention  Restraint  Continuity of Care for the releasing mentally ill  Policies and Procedures  Continuous Quality Improvement (elements relevant to mental health services)
The following measures were not rated:
 Review of In Custody Deaths (elements relevant to mental health services)

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Table of Contents
HEALTH CARE GENERALLY (elements relevant to mental health services) .................................................. 9 Intake Screening........................................................................................................................................ 9 Timely Access to Care ............................................................................................................................. 11 Medication Administration and Monitoring........................................................................................... 15 Confidentiality......................................................................................................................................... 16 Health Care Records................................................................................................................................ 17 Staffing .................................................................................................................................................... 18 Custodial Environment............................................................................................................................ 19
REVIEW OF IN CUSTODY DEATHS (elements relevant to mental health services) ..................................... 22 CONTINUOUS QUALITY IMPROVEMENT PROGRAM (elements relevant to mental health services) ........ 23 MENTAL HEALTH CARE ............................................................................................................................... 23
Treatment ............................................................................................................................................... 23 Housing ................................................................................................................................................... 27 Treatment Space ..................................................................................................................................... 30 Suicide Prevention .................................................................................................................................. 32 Restraint.................................................................................................................................................. 33 Continuity of Care ................................................................................................................................... 35 POLICIES AND PROCEDURES ....................................................................................................................... 36 CONSENT DECREE TRAINING ...................................................................................................................... 36 Appendix ..................................................................................................................................................... 37

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HEALTH CARE GENERALLY (elements relevant to mental health services)
Intake Screening
The County’s plan to have a Qualified Mental Health Professionals (QMHP) do the mental health intake screening, except at times when there is no mental health on site when an RN will continue to provide that function, is proceeding but not fully implemented.
The Mental Health Screening form is generally sound but has some weaknesses that should be addressed. It could be clearer in distinguishing current from past issues both in terms of treatment and symptoms. Signs (observed) and symptoms (reported) could also be more clearly distinguished and conceptualized in a complementary fashion (e.g., complaints of auditory hallucinations and observations of responding to internal stimuli; complaints of anxiety and observations of signs of anxiety). Some of the questions are too high level or broad, especially with regard to current observations. There also needs to be a clearer assessment of the potential for victimization (which should also be added to the PREA training in the Clinical Therapist Training Guide as well). The County may make some alternative suggestions regarding the specific content that is listed in the Remedial Plan. Assuming the suggestions are reasonable and capture the essential content areas, I would not object.
It is not clear how MH is to notify custody of risk of (sexual) victimization. Whether the form Detention Health Services – Notice of Medical Restrictions or Special Housing is an appropriate vehicle is questionable but some mechanism is needed.
The County provided data on intake screenings using different approaches. The results vary substantially. The Behavioral Health PLO Indicators Step by Step Status report: Draft Version 1.3 indicates (in hand-written notes) that “In the last month” (the month is not specified), there were 2881 health screens and 2771 mental health screens (this likely represents the whole system). It goes on to report that 88 were not screened by mental health since January 2017. It is clear that this data was obtained from TechCare. However, the electronic document “Data Request 10-5-17.pdf” shows that at RPDC, mental health screenings were only completed on about 70% of those admitted during weeks in July and August. In yet another document (electronic file “Data Request 10-5-17”), the County reported mental health screenings of all admissions at all facilities to be at 93.5% from July through September of 2017. In that document, RPDC was shown at 94-95%, much higher than in the other report that included data from this same period. These data need to be reconciled and the methodology made explicit in order to interpret these numbers.
Another electronic report from SWDC speaks to a number of inmates being transferred to SWDC from RPDC without having been screened. The County demonstrated that it reduced this number from 29 (for only part of April 2017) to 13 in May and 10 in June.
I saw the locations where intake screening is being conducted at all five facilities I visited. Confidentiality of the intake process for mental health has been improved though remains a challenge at some locations.
At RPDC, the pre-booking screening continues to be conducted in the vehicle sally port with arresting officers standing by; in the one instance I observed, the officer stood apart enough to afford some modicum of privacy. After the pre-booking screening, I observed the full nurse initial screening of this man. The nurse stated that she calls mental health if the patient has acute needs but otherwise the patient proceeds to mental health routinely for the mental health screening. The nurse also forwards

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medication verification to mental health if able to get it (the nurse reported that nurses do this primarily when patients bring their own pill bottles, which is uncommon).
The RPDC mental health intake area has five semi-private work stations with patients in private noncontact booths across from each work station. It was very difficult to hear patients in this setting. With the planned build-out noted in my first report, there will be six stations with improved privacy and improved audio connections. I observed QMHP screenings and interviewed the staff. Screenings were all adequate or better and QMHPs demonstrated diligence in reviewing records prior to screening as well as attempting to verify prescriptions. They also reported that when unable to verify prescriptions for patients on important psychotropics, the patient was prioritized for psychiatric assessment.
When patients screened at RPDC are psychiatrically unstable, the QMHP endeavors to expedite their placement but this is not always successful and patients may stay in the basement screening area for hours. Mental health attempts to manage them and if particularly unstable, they can contact the Medical Sergeant assigned to work with mental health or mental health leadership, who frontline staff report usually intervene promptly.
I observed an initial nurse screening and mental health intake at SCF. These were done in private settings with the nurse having a face-to-face contact while the mental health intake was in a noncontact booth. As noted in my previous report, the physical plant at SCF provides limited options for private screening other than the non-contact booths. Both of these were well-done.
At SWDC, the nurse screening process is unchanged. I observed a mental health intake in a non-contact booth; it was adequate but the clinician did not follow-up on several clinical issues raised by the prisoner. While the intake was conducted, deputies walked by clinicians repeatedly as the clinicians are in a series of open booths (with patients on the other side of the window) with traffic behind them. Patients complained about this lack of privacy. There is a plan to build non-contact intake booths at SWDC.
At Indio, mental health staff is on site from 0700 to 2400. I observed a mental health intake conducted in a non-contact booth. Despite there being an open mesh, the clinician had to use the telephone because the ventilation system was so loud.
At Blythe, pre-booking screenings are conducted in the outdoor sally port; there is a plan to install a modular building in this space for medical and mental health screening and additional office space. It is slated to be completed in about a year. Nurses conduct their initial screening in an office with custody standing by outside the room. Nurses also conduct mental health screenings after hours. The mental health clinician does an acuity rating based on the nurse screening and, if necessary, does additional assessment. On weekends, a Clinical Therapist at Indio is contacted to provide the acuity rating and to assist with bridge orders for medications when necessary. Medication verification is done both by the nurses and the Clinical Therapist. If a psychotropic medication is verified, they contact on-call psychiatrists for orders after hours, the Indio psychiatrist during regular working hours and Saturdays, and the SCF psychiatrist on Sundays. The Blythe Clinical Therapist does intakes in a non-contact booth; it is not clear why this is the case as nurses see intakes face-to-face.
Continuation of medications upon intake is variable but in most cases patients whose medications are verified are started promptly, either by obtaining a bridge order (generally a telephone order from a

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psychiatrist) or following a face-to-face meeting with a psychiatrist, sometimes in the intake area. However, numerous patients complained that it took several weeks to get medications initiated; it is not clear how many of them had verifiable community prescriptions. Follow-up with a psychiatrist following bridge orders is variable. One patient at RPDC (201742387) had not been seen for over a month following an initial bridge order. Medical record review showed to psychiatrist appointments that he reportedly refused. However, the psychiatrist did not speak with him personally; it was based on deputy report. The patient had been meeting regularly with other clinicians, so it would be unclear why he refused to meet with the psychiatrist as he ultimately did. There was no discussion in the record of his refusals so it is not clear exactly what happened.
The County is modifying TechCare to better support verification and ordering of bridge medications. These modifications should also make it easier for the County to prove its practice. A RUHS-BH report from August 2017 demonstrates that in most cases where bridge medications were attempted (presumably, in cases where the patient reported current medications), 88% had medications ordered and 97% of those orders were within 24 hours. Only 21% received a follow-up visit within a week. This is the first clear data on bridge orders for psychotropic medications. However, during medical record review I saw a little evidence of attempts to verify medication. It may be that verification efforts are not being consistently charted or are in a section of the chart that I could not access.
Compliance contemplates patients receiving initial medications within 48 hours, getting them immediately from stock, or being seen by a psychiatrist within 24 hours. While this report does not clearly demonstrate that patients are receiving medications within 48 hours, it represents a substantial step in terms of measuring proof of practice and demonstrates that the County is likely nearing substantial compliance on this element.
Review of medical records demonstrates problems detecting the seriously mentally ill during the intake process, though less marked than before. Nursing assessments seem prone to missing serious mental illness, but these cases are being captured by having mental health staff redo the intake the next working day. Changes to the process and the content of the screening are necessary.
The County has taken sufficient steps towards implementation of the mental health elements of intake screening to be in partial compliance with this element.
Timely Access to Care
The County has not yet modified its approach to managing Health Care Request Forms for mental health. As I noted in my previous report, the intention is for RUHS-BH to take a more direct role in initial triage of Health Care Request Forms for mental health; how this will be operationalized is yet to be determined. At the present time, nurses continue to pick up Health Care Request Forms (custody performs this function in some instances but does not view the forms). They then sort them and set aside those for mental health who then triage them the following morning. Nurses reportedly respond to any that are emergent in nature. There is still no mechanism for tracking the nature or timeliness of responses to Health Care Request Forms through the whole process. However, the County reports that it is nearly ready to start reporting on this important function.
The County does not have a means of tracking response time to inmate declared emergencies. This will likely require coordination between custody, medical, and mental health in order to ascertain how to track this and with which data system(s).

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An electronic report from RPDC entitled “Number of days to triage.docx” shows that of 241 cases from June 1-15, RUHS-BH received for triage, 229/241 (95%) were triaged the same day. Only 3 took four or more days. Thus, RUHS-BH is responding promptly to cases that it receives. Since urgent cases are to be seen within 24 hours, it is critical that the triage be done as soon as possible.
A CQI project at Blythe Jail in August 2017 demonstrated that while the average response time to urgent mental health referrals (once received by RUHS-BH) was less than a day, only 7/12 were actually seen within 24 hours with two waiting more than three days. Another CQI project looked at response times to routine and “priority” (urgent) mental health referrals at all facilities for August and September 2017. Response times to urgent referrals averaged 4 days. SCF and SWDC were at 5-6 days, which is unreasonably long. The report did not include a percentage of those that were within 24 hours so it is difficult to map this onto the compliance measure.
A similar CQI study at SCF for May 2017 showed 37 emergent (many of which were felt to be incorrectly categorized and no further analysis was provided), 73 urgent and 276 routine patient sick call requests. Response times averaged 8.83 days for urgent and 8.78 days for routine requests. The County reported 10% and 14% compliance respectively, however, it is not clear how that was computed. I reviewed what appears to be the underlying data for this in an Excel file entitled “May Sick calls completed SCF.xlsx” and found 204/276 (74%) to have been responded to within two weeks as required by the remedial plan.
A study from SWDC reported that responses to sick calls averaged 2.8 days for all calls and 1.9 days for urgent calls.
The average response time for all facilities was under 14 days for routine referrals, but the report does not include information on how many lay outside 14 days so it is not possible to determine whether this reflects substantial compliance but it is certainly consistent with at least partial compliance.
Here again, the County is to be commended for getting this data and beginning to use CQI processes to improve its practices.
At RPDC, Health Care Request Forms and lockboxes were generally available (except on the 7th floor that houses primarily those with medical problems so this is not a problem). However, patient reports as to picking up forms and responses were generally negative, though variable. It was difficult to interpret their reports but most expressed dissatisfaction with response times except there were mixed reports regarding Clinical Therapist response, which was generally better than for other disciplines. During my visit to RPDC, 21 Health Care Request Forms were delivered to mental health staff at the lunch hour. Of these, 10/21 were from that day but the rest were from 1-4 days earlier, demonstrating continued problems with timely delivery and response.
At SCF, patients were generally satisfied with responses and reported regular retrieval of forms. Their only complaint was that access to a psychiatric prescriber sometimes took several weeks, though all reported being seen, most at least monthly. Lockboxes were present except in areas with isolation cells where wall space is inadequate.
At SWDC, most units I visited were missing Health Care Request Forms as well as grievance forms. Lockboxes were present though RCSD reports there is not one in A-Pod (Sheltered Housing). Patients described being offered some groups but limited individual sessions.

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At Blythe, prisoners reported that Health Care Request Forms were picked up twice daily or at pill call, depending on the location. They were available on the units and lockboxes were present except in smaller units. Mental health triages Health Care Request Forms on weekdays at 0730.
At Indio, prisoners reported that Health Care Request Forms were picked up reliably (mostly twice per day) and generally responded to promptly. Health Care Request Forms and lockboxes were available on all units visited but grievance forms were sometimes missing. There are several units at Indio that do not have lockboxes, which should be resolved once the new jail opens. One Indio patient reported being seen within a week by a Clinical Therapist and within two weeks by psychiatry; record review demonstrated a Health Care Request Form from 7/24/17, Clinical Therapist Contact 7/28/17, and a psychiatric visit 8/2/17.
Note that several patients at SWDC and SCF reported that gang members sometimes take all the Health Care Request Forms and hide or destroy them to prevent other gang members from asking for health care services or to keep for themselves. It is critical for custody staff to be attentive to this problem.
Patients report that mental health is generally responsive to requests to be seen, whether to Health Care Request Forms or direct requests to health care staff but response times were days to weeks, though rarely more than one week for Clinical Therapists and two weeks for psychiatrists. Reports were mixed regarding requests made directly to deputies with those at SCF, Blythe, and Indio reporting good responses most of the time but those at RPDC and SWDC offering that responses depended on the particular deputy.
Psychiatrists reported that they were usually able to see routine patients within 30 days and conduct follow-ups every 30 to 90 days. They noted there is no priority scheme for scheduling patients and sometimes schedulers reschedule patients to later dates when they should not. Other than at RPDC, psychiatrists report generally having good access to patients and reliable assistance from custody. Psychiatrists are afforded sufficient time to see patients by RUHS-BH but the time may be curtailed owing to the challenges with access to patients. Other than delays with initiation of medications, most patients described good access to psychiatrists, even if they would prefer more. Almost all described visits with a psychiatrist at least monthly, sometimes more often.
Patients at Blythe currently must go to Indio to see a psychiatrist. They are not always transferred to a different facility but are if they need more intensive care.
Psychiatric encounters have increased to 2063 in July and 1601 in September. However, the data does not include timeliness figures so all that can be said is that, on average, open cases are being seen monthly by a psychiatrist.
One issue that patients complained of repeatedly was co-pays, especially for medication refills. While not an explicit part of the remedial plan, it is important to note that co-pays are likely to limit access to care. Most research has also demonstrated that co-pays do not save money because of reduced health care usage resulting in patients being more ill when they seek care and thus costing more.
I also note that many patients complained of problems with access to medical care both in terms of timeliness and responsiveness to complaints. They were much more critical of medical staff than mental health staff. While this is not a positive finding, it does suggest that positive reports about mental health staff are likely to reflect the true impressions of the inmates.

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In addition, the County provided information on open mental health cases, the number of new mental health cases opened monthly, the number of patients on psychotropic medications, the number of psychiatric encounters, and the number of mental health clinical encounters (other than psychiatry) from July and September of 2017. These numbers reflect open cases at about the same rate as previously (1595 and 1229 for these two months). Of these, 95% or more were on psychotropic medications.
Chart reviews demonstrated that in almost all instances, patients on psychotropic medications were being seen at least every 90 days, and almost always substantially more often. However, psychiatrists at RPDC report that accessing patients remains difficult and impairs productivity because of space limitations, challenges getting patients out to interview rooms, patients being out to court or other locations at the time of the appointment (there is little coordination between custody and health services in terms of scheduling), and because of the time it takes to move through the facility.
Despite the access challenges, other mental health encounters in general population settings have continued to increase to 6907 in July and 11,141 in September, doubtless reflecting the steady increase in staffing and improvements in information management and documentation. Here again, the timeliness of encounters is difficult to assess.
The average number of patients housed in residential mental health units has stabilized at around 400. The numbers of encounters on these units remains difficult to interpret but is about 1500 per month both at SCF and RPDC (though higher for both months at SCF), which house similar numbers of mentally ill.
These numbers demonstrate that the County has maintained increased mental health services compared to before the Consent Decree, predominantly with respect to non-pharmacologic treatment and expanding residential mental health units, despite the recent challenges to access. However, these numbers are likely to drop without the planned changes to security. It is also important to note that while the numbers of encounters are still high, the nature of those encounters has changed substantially in ways that reduce the efficacy of treatment, primarily owing to the growth in non-contact and cell front visits and the reduction in groups.
Patients in the residential units continued to report that mental health staff do rounds almost every day and ask how they are doing (often during pill call). They reported meeting with a Clinical Therapist individually at varied frequencies, mostly consisting of brief contacts on a monthly basis that were primarily focused on current symptoms or release planning. However, almost all felt the Clinical Therapists were helpful and had their best interests in mind; they simply wished for more contact and more opportunities for therapeutic sessions. Many lamented the loss of groups.
Review of medical records demonstrated consistency with the preceding: most patients are being seen sufficiently regularly by a psychiatrist, most patients are getting occasional case management contacts with a QMHP, and a few patients are getting active treatment either in group or, rarely, individual therapy.
In summary, the primary work for the County in the jails, in terms of access, is to address the security issues limiting access, complete the restructuring of the mental health intake and Health Care Request

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processes, and achieve and demonstrate timeliness of treatment services. The treatment element is addressed in greater detail in the “Treatment” section of “MENTAL HEALTH CARE” below.
Here again, the County is in partial compliance with respect to the mental health services elements relevant to Timely Access to Care.
Medication Administration and Monitoring
I again observed morning medication administration at RPDC on a residential mental health unit. Prior to going to the unit, the nurse reviews the unit roster to see if there are any new patients and if so, reviews the EHR for the patient to check on any health conditions and review current medications. A QMHP and deputy accompany the nurse from cell-to-cell as the nurse administers medications. There was no change in the procedure from my previous visit. However, when asked for a Health Care Request Form, a patient was directed to the supply in the dayroom, though it was inaccessible to the patient at that time. Several patients at different facilities (RPDC, SCF, and SWDC) reported that nurses would sometimes not give them Health Care Request Forms during pill call and told them to get them from the supply in the dayroom. Nurses should hand out Health Care Request Forms during pill call.
Neither the nurse nor the QMHP spoke with the patients about protected health information other than some communication regarding medications that occasionally included medication names.
The mouth checks to assure adherence remained marginally adequate. In most cases, the nurse watched the patient take the medications but did not uniformly do a mouth check. But, as noted last time as well, the nurse was aware of which patients were prone to “cheeking” medications (appearing to take the medication but sequestering it, typically in the cheek) and did more thorough checks with these patients.
The nurse did not uniformly check identification but knew most of the patients. In one instance, the nurse did not know the patient and the patient did not have his identification bracelet; the nurse verified the patient’s name with the accompanying deputy and Clinical Therapist.
When the nurse administered medications on a lower tier, the nurse had the medication cart and a computer with access to the medical record and medication administration record (MAR). When the nurse administered medications on an upper tier, the nurse did not have the medication cart or a computer with access to the medical record or to the MAR. The nurse had pre-packaged medications for each patient but this time they were in envelopes that had a post-it with patient names and cell numbers written on them. The nurse completed the administration on the upper tier and then entered the information in the MAR for the whole tier. While this remains a problematic practice, at least the envelopes had identifying information on them, though post-its could fall off. I continue to recommend that the County seek a remedy to this.
Review of a selection of MARs showed that they were almost always complete; it was not possible to verify their accuracy other than for the lower tier administrations I reviewed, which were accurate. In the residential mental health units, both nurses and QMHPs report adherence problems to the psychiatric prescribers. The general practice is to notify the prescriber after three days of refusal, either by using the sick call queue or email. Psychiatric prescribers reported that they were informed of adherence problems at RPDC and SCF but the psychiatrist at SWDC was uncertain how reliable the reporting was.

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Medication administration is scheduled for reasonable times. Patients in all facilities reported that morning medication administration was generally timely (within an hour of the designated time) and that while evening medications were sometimes late, they reported much more timely administration than previously, though still more problematic at RPDC than other facilities. The County does not yet have access to summary statistics on medication administration so it is not possible to know how common the problems with timeliness are. This needs to be tracked.
The County is not yet able to demonstrate its compliance with the provisions for medication administration when patients are out to court, in transit to outside appointments, or upon transfer. The nurse I observed administering medications reported that when they know a patient is going to court and will need medications during that time, the pill line nurse contacts the intake nurse who is then responsible for assuring medications accompany the patient to court.
A number of patients reported that they had medications expire and were without them, though most report this was rectified within 1-4 days. However, all were clear that this was uncommon. The County also produced a report entitled E-MAR Psychotropic Medication Lapses showing that 93.6% had not lapses in medication administration; for those that did lapse, it was an average of two days before patients received another dose (the vast majority missed only 2 doses). This demonstrates fair performance on this indicator but the percentage of lapses can be improved.
I was not provided policies or procedures regarding medication monitoring. Psychiatrists report that they have full access to laboratory studies with the exception of imaging, electrophysiological studies, and ECG, all of which must be authorized by medical. Unless all physicians are subject to similar limitations, this is unreasonable; psychiatrists are specialized physicians and are best suited to know what studies are indicated for psychiatric care. Regardless, it impedes access to care, especially with regard to ECG which must be obtained prior to initiation of psychotropics in many instances. Psychiatrist continue to report that it may take up to two weeks to get ECG results. While this is not a requirement of the Remedial Plan, the current practice places barriers that may interfere with proper medication monitoring by psychiatrists.
Medical record review demonstrated that laboratory monitoring and administration of Abnormal Involuntary Movements Scales (AIMS) of patients on psychotropic medications is inconsistent. In addition to lack of baseline laboratories in most cases (not necessary when continuing community therapy but when starting medications de novo), there were many instances where there was a lack of or untimely monitoring of medication levels and potential adverse reactions such as metabolic syndrome, blood dyscrasias, hepatic dysfunction, and other complications. However, there was clear improvement in the number of AIMS being done and one psychiatrist reliably monitoring patients on antipsychotics for metabolic syndrome.
Owing to inconsistent medication monitoring and concerns about upper tier medication administration, the elements of Medication Administration and Monitoring relevant to mental health services is in partial compliance. This should be easily remedied.
Confidentiality
The County has not made any substantial changes since my previous report with regard to confidentiality of intake except at SCF. As noted above, intakes at SCF are now being done in the non-

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contact booths. Though this causes other challenges, it is confidential. Once the planned construction noted in the section on intake is completed, this issue should be resolved.
Because access to care has been reduced by virtue of the security requirement for program rooms to be locked when clinicians are with patients, this has resulted in an increase in cell front interactions, which are inherently non-confidential. Clinicians endeavor to minimize discussion of personal health information at cell front. Patients at RPDC note this as a problem more than at other jail settings. It remains a major problem at the DCU where most patient contacts are at cell front.
There has been clear improvement in evaluations of those in safety cells who are now routinely being seen in a confidential setting.
As noted above, pill call is not confidential but clinicians reveal minimal protected health information during medication administration. In my opinion, the added communication that occurs during the conjoint rounds between nurses, QMHPs, and custody during medication administration is worth the loss of opportunity to discuss more personal medical or mental health problems as long as clinicians do, in fact, follow-up with requests for private interviews and sick call requests. Patients report that QMHPs generally do honor such requests.
Policy 508.05 Inmate Medical Care specifies that patients are afforded the same confidentiality as “…in the general community.” However, it goes on to say that “When inmates are receiving medical services from a jail health care provider, custody staff shall maintain visual supervision but may not be close enough to overhear communication….” This is not consistent with the previous statement regarding being afforded the same confidentiality as in the community. It notes that custody staff may be close enough to overhear communication “…based on an individual determination of risk…” requiring closer supervision. The healthcare staff is then directed to document “[t]he reason(s) for allowing custody staff to be within hearing distance….” It does not specify who makes the decision to allow this proximity. I also note that I have seen numerous instances where custody is within earshot but I have seen no evidence of documentation of the reasons in any medical records. This needs to be clarified and managed.
With regard to the elements of confidentiality relevant to mental health services, the County is in partial compliance with improvements in some areas and losses in others.
Health Care Records
There is now an EHR that both medical a mental health clinicians can fully access. Policy to support needed modifications, maintenance, and improvements was not provided to me.
As noted previously, the County is making key modifications to the EHR and has a number of initiatives related to mental health. These modifications will be necessary in order to establish adequate quality improvement and quality assurance as well as proof of practice of a number of measures within the Remedial Plan.
Once policy is provided that meets the terms of the Remedial Plan, this item will be in substantial compliance; at this point partial compliance is warranted.

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Staffing
The official staffing report I received from the County shows RUHS-BH having 150 full time equivalent positions (FTE) – unchanged from my previous report. As of 7/11/17, 85% were filled. Empty positions were relatively evenly distributed across disciplines. Notable empty positions included 3 of 6 Senior Clinical Therapists and only 3 of 5 Recreation Therapist positions. Other than only one of three positions being filled at Blythe, no other jail showed a notable difference from the others in terms of unfilled positions.

The County has not yet developed a report to assess the impact of staffing. Note that the fill rate is below the 90% target the County was expected to reach within 12 months of the Consent Decree.

The following is a table of funded FTE. Of note, there have been no changes since last time, likely demonstrating that the County has completed the basic restructuring of its mental health program.

July 2015

Psychiatrists

9.8

Clinical Therapists

43.3

Support Staff

9

Behavioral Health

3

Supervisors

Registered Nurses

1

(RN)

Behavioral Health

2

Specialists

Recreation Therapists 0

Total

68.1

May 2016
12.76 81 19 7
1
24
5 149.76

November 2016 13 80 18 7
1
25
5 149

February 2017 13 82 18 7
0?
25
5 150

July 2017
13 82 18 7
0?
25
5 127.48

The following shows actual staffing at the time of my first report and currently.

Psychiatrists Clinical Therapists Support Staff Behavioral Health Supervisors Registered Nurses (RN) Behavioral Health Specialists Recreation Therapists
Total

February 2017 11.32 66.5 17 7
0 23
2 126.82

July 2017 10.98 67.5 16 8
0 23
2 127.48

There are three Clinical Therapists and two Behavioral Health Specialists at Indio providing services 7 days per week from 0700 to 2400.

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There is currently one Clinical Therapist at Blythe; they are funded for two. Once hired, this will allow 12 hour coverage 7 days per week. RUHS-BH leadership noted that they are developing telepsychiatry capacity at Blythe to address the challenge of getting adequate psychiatric coverage there. The equipment is already on site.
SWDC reports that there are 8 Clinical Therapists on days (with four on duty at any one time) and four on evenings (two at a time); two positions are open. There are nine Behavioral Health Specialists working day shift with eight assigned to housing units and one floating. There is a psychiatrist on site seven days per week from 0830 to 1900 (2.5 FTE), though this may be reduced to five days per week due to custody runners only being available on weekdays.
The RCSD will likely need additional custody staff to meet the expanding needs represented by the growth in health care services in response to the Consent Decree. In this regard, it should be noted that I saw numerous entries in medical records regarding time spent waiting for patients and cancelled meetings because of custody limitations.
At this point, the County remains in partial compliance with the elements of Staffing relevant to mental health services.
Custodial Environment
I walked through the majority of residential mental health units and visited most cells on those units. While there were numerous patients whose cells were in some degree of disarray, I did not see any that were grossly unsanitary or malodorous and custody staff reported that they had to clean the cells of some patients repeatedly. Custody staff demonstrated familiarity with most of the population.
Custody staff were generally respectful and professional with staff and prisoners. Several patients in the residential units reported that a minority of custody staff were not respectful and even made fun of the mentally ill; with a few exceptions, most were reportedly not regularly assigned to these units.
The facilities themselves were generally clean though RPDC was notably less cleanly. Shower curtains at RPDC were in tatters and a shower was running continuously (maintenance had been called) but the showers themselves were clean.
Some patients complained that they were not given “fish kits” (basic supplies such as toiletries) at RPDC.
The RCSD policy Recreation specifies that inmates will receive three hours of recreation every seven days. The remedial plan specifies that each recreation period will be at least one and a half hours. The policy also specifies that for those on administrative segregation: “Only one cell at a time shall be allowed in the recreation area.”
The RCSD policy 504.42 Dayroom Management reflects that dayroom times extend from 0800 to 2300 as specified in the Remedial Plan. The policy does generally reflect an intention to maximize dayroom time. It does not specify how much time inmates are to be afforded in the dayroom or how dayroom time varies with custody or classification level. Thus it is difficult to determine what the expected amount of dayroom time is. This makes it impossible to determine if dayroom time is being offered according to policy. This leaves the only way to assess the dayroom time for the mentally ill is to compare it to dayroom time of other inmates. While this is not a formal measure, if there is a marked and consistent reduction of dayroom time for the mentally ill, this would suggest that dayroom time is

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not being maximized for the mentally ill. While some reduction compared to general population inmates would be expected in higher acuity settings owing to an expected increase in behavioral disorder in this population, that should not be true for those in lower acuity settings.
The County provided some hand-collected data on dayroom times. There are problems with this data. In some cases, the time in and time out are reversed. There are other errors as well. While this does not undermine the credibility of the data entirely, it makes it clear that there are inaccuracies, the scope of which is unknown. Despite that, the data provides useful information and gives some picture of how dayroom time is being managed. I offer the following salient observations.
At SWDC, those on administrative segregation status are tracked individually. They appear to get 30-60 minutes (most are nearer 30 and many are exactly 30 minutes, raising concerns about the accuracy of the data) dayroom time on days when they get dayroom time. It is unclear whether all inmates get out daily as the data does not include a count of the inmates in a particular pod. Dayroom times occasionally occur outside of 0800-2300, beginning as early as 0654 and ending as late as 0007. On other units (B through G pods that are not administrative segregation), dayroom time is not tracked by individual and does not include the actual time in the dayroom, only a starting time. Thus it is not possible to determine actual dayroom time. Further, there seems to be no standard approach to dayroom. While almost all pods bring inmates out by upper and lower tier, sometimes it is also divided up by dayrooms but in varying ways. There is no reason for this variation given. In general, it appears that some inmates are out in the dayroom 6-12 times per day for some period of time, perhaps up to an hour. But it is not possible to say anything more than that from the data. Whether all inmates are offered dayroom is not clear.
In my interviews with patients, I asked about dayroom and yard times. Patients in residential mental health units at RPDC reported highly variable access to dayrooms, almost all noting that it depended on the deputy with some making a concerted effort to maximize dayroom time and others not. Those not on administrative segregation reported getting out in the dayroom one to three times daily, usually for an hour or nearly an hour. They reported usually come out one tier at a time but sometimes in smaller groups. They gave variable reports on access to the recreation area, most saying it was once per week for 90 minutes and others saying it was one to two times per week for about an hour.
Those on administrative segregation at RPDC report that they get 30-60 minutes in the dayroom each day (in one or two sessions). They reported that they get access to the recreation yard one to three times per week for varying amounts of time.
At SCF unit 16 (residential mental health), patients report that they get dayroom 2-4 times daily, up to an hour each, though some reported the frequency had dropped recently. There were several who reported that dayroom access was less on F pod (where the most ill are housed). They gave varying reports regarding access to the recreation yard (which is quite small) from once each week for about an hour to daily during morning dayroom time.
It is important to note that the County has endeavored to reduce the different types of inmates mixed on the residential mental health units in order to make it easier to maximize out of cell time. Their total out of cell time is unknown but since there are no other populations on this unit, the impact on those not on administrative segregation has been reduced. See “Housing” for further discussion.

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At SWDC, patients reported limited access to the yard, usually once per week. They reported having access to the dayroom typically 2-3 times per day for 30-60 minutes, depending on their custody level.
Prisoners at Blythe were very satisfied with the services and conditions in the jail generally, though noted that programs were limited at Blythe except a few jobs. They are in dorm settings so dayroom is not an issue. They report access to the yard three times weekly.
Prisoners at Indio were mixed in their reports regarding access to the yard. Most reported weekly access to the yard for several hours. As most settings are dorms, dayroom access is not an issue. Conditions at the archaic Indio jail remain problematic but this will be remedied when the new jail opens.
Another problem with yard times is that they are sometimes very early in the morning. Because many psychotropic medications are sedating, it is unreasonable to ask those in the residential mental health units to utilize early morning yard times; it effectively limits their access. They should be scheduled for yard times no earlier than 0800, just as for dayroom times.
The DCU continues to be run like a restrictive housing unit and the comments from my previous report continue to apply. While there is now a Clinical Therapist there (and a second starting soon), they have limited access to patients even for individual meetings. Patient are still mostly locked in their rooms 24 hours per day. There is a plan to use one of the holding cells for patient meetings but this has not yet been implemented. As a result, Clinical Therapist work has primarily consisted of insuring continuity of care through communication with the jail mental health staff. Access to patients is also limited to some degree by requiring two deputy escorts for those on administrative segregation status (many seriously ill continue to be placed on this status owing to their mental illness resulting in problem behavior) and sometimes those not on administrative segregation are being required by custody to have two escorts for security reasons. In addition to the plans to increase treatment space and patient contact, the staff at the DCU is discussion expanded property options.
I attended two multi-disciplinary meetings at RPDC (for 5A/5B male residential mental health and 6A/6B for females, which is not exclusively for the mentally ill), each lasting about 15 minutes. These included mental health staff, nursing, unit custody staff, classification staff, and the Medical Sergeant working with mental health units. They discussed specific patients and those who were having problems. They discussed the possibility of removing two patients from administrative segregation; the discussion focused on behavior and classification but did not include changes in their mental health status. During the discussion, it emerged that there were 5-6 patients in the intake area for 1-2 days who were in need of beds. There was no other discussion of placement or transfer issues.
At SCF, staff use the multi-disciplinary meetings, which are held daily, to discuss transfers as well as review the status of the population. I also attended a core team meeting at SCF that was a facility-wide group of health care staff and custody staff. This meeting is used to address important health-related issues. It was notable that health care staff sat at the front of the room and custody staff stood separately at the back of the room.
In my first report, I noted that there are two trainings, one by custody (included in new Custodial Conflict Intervention Training (CCIT)) and by mental health in the suicide training module (IFT Suicide Prevention Training), that address the “self-isolating inmate.” The County reported that it would

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complete the IFT Suicide Prevention Training by 10/31/16 but I have not received verification of completion or the curriculum demonstrating that self-isolation was covered. The County has offered CCIT since 7/24/16 and reports that it has trained 149 (rosters show 174); it is unclear what percentage of custody staff this represents but it does not appear to be nearly complete. I reviewed the slides for the training and they are adequate in terms of content and do address the self-isolating inmate. The training could be improved by the addition of a practicum component but this is beyond the scope of the remedial plan. The RCSD provided its training on the remedial plan; it includes two slides related to the self-isolating inmate. I was also provided a training for custody staff conducted by Correctional Healthcare Services that also addressed the self-isolating inmate; attendance records were not provided. The County cannot yet demonstrate its ability to consistently detect such inmates, but it remains clear that in residential mental health units there is a great deal of communication about such behavior and related problems, including poor hygiene, poor oral intake, and the manifestation of behavior indicative of mental illness. I heard such discussions during rounds and at meetings between mental health and custody.
The use of administrative segregation of the mentally ill within residential mental health units remains a logistical challenge and raises questions about limiting privileges because of mental illness. Those on this status are offered only one hour out of cell time per day, solo yard access, and cannot attend groups; in short, they are under conditions quite similar to restrictive housing. Clinicians note that access to those on this status for one-to-one meetings can also be limited, interfering with their ability to provide needed services; Clinical Therapists are conducting daily rounds on them but this is a brief cell front check-in, not treatment. Clearly, safety and security must be provided for patients and staff alike. However, it is necessary to be able to consistently meet the clinical needs of the patients, necessitating better access. There is a plan to procure classroom seating that provides for restraint to allow the most dangerous to begin attending groups, an important first step in determining their readiness to have more unrestricted access to peers and staff alike. The County has purchased correctional tables to serve this purpose and to provide options for meeting with patients individually, though as noted previously, the County is yet to make full use of these. Assuring ready access for individual meetings with clinicians is also necessary. While there is regular review of the need for continued administrative segregation (at least every 30 days), there must be access to care regardless of whether they are on this status or not.
Those who custody staff are concerned are in crisis, constituting an emergency, are evaluated by a QMHP at any time of day. As noted above in this regard, proof of practice is hampered by difficulty identifying qualifying cases.
Behavior management plans, used to assist custody and mental health in providing consistent and complimentary services, have not been instituted as yet. These are required by the Remedial Plan.
The elements of the Custodial Environment related to mental health services remains in partial compliance.

REVIEW OF IN CUSTODY DEATHS (elements relevant to mental health services)
I asked for information on any in-custody deaths that were suicides or possible suicides. BHDS staff replied that RCSD has this data. No data was provided.

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As such, there is nothing to review at this time. This item is not rated with regard to the elements relevant to mental health services.

CONTINUOUS QUALITY IMPROVEMENT PROGRAM (elements relevant to mental health services)
The Continuous Quality Improvement Program (CQIP) remains in development but this is an area where the County has made substantial progress. The County has further expanded its data collection, developed TechCare reports, and engaged in facility-level CQI projects. Much of the needed data is still not readily available but progressively more, and better, information is being collected and analyzed.
Data collection and analysis is a much greater problem for custody whose data systems are antiquated and not designed to perform CQI functions. It is not clear where work towards developing a data warehouse stands. This will be a key element for both CQI and proof of practice, especially given the limitations of the custody databases. Robust coordination of CQI between mental health, custody, and medical remains to be developed.
The document Behavioral Health PLO Indicators Step by Step Status report: Draft Version 1.3 demonstrates the work RUHS-BH is doing to develop measures both related to the remedial plan and to the long term CQI needs of the system. The document Audit Smith HU 16.docx shows that RUHS-BH has done a good job of evaluating level of function and service needs on this unit. Additional CQI data was provided in the electronic document “Data Request 10-15-17.” This included an interesting study of fights and grievances in SCF housing unit 16 (mental health housing) which has seen a substantial increase in higher acuity patients. There is a high number of fights on the unit compared to others (which is consistent with the acuity of the population and also seemed to correspond to an influx of a large number of mentally ill from RPDC), but grievances dropped substantially with the influx of staff and programs.
Peer review processes remain in development for mental health.
However, I did not receive any minutes of the Quality Improvement Committee nor any Corrective Action Plans (CAPs) for mental health that were developed by the Quality Improvement Committee.
At this time, the County is partially compliant with this measure, owing primarily to the development of more reports and greater usage of the CQI process.

MENTAL HEALTH CARE
Treatment
It is important to note that the number of patients on the mental health caseload has changed very little since my initial report. This is reasonable as the number is consistent with data on the prevalence of mental illness in jails.
There is no formal Program Guide as yet but a draft is reportedly nearly complete. There is a comprehensive Clinical Therapist Training Guide which is more a compendium of important information than a guide but has many of the elements of a program guide. It provides good quality information on

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the jails, jail practices and procedures, and, most importantly, sound evidence-based approaches to clinical work in the jails including crisis response, assessment of management of suicide risk, intake, general mental health assessment, acuity ratings, treatment planning, and discharge planning. It also includes a section on danger to others that needs development and a better evidence-based foundation.
This manual also addresses dosing of treatment adequately, specifically mandating 10 hours of behavioral health programming weekly for those with moderately-severe and severe acuity ratings. For those with less acute problems, the requirement is for a monthly individual contact, psychiatric treatment (as indicated - with monthly follow-up), and at least one group. It is unclear whether the one group is to be on-going or a single group; this needs to be clarified.
The section on acuity ratings represents sound training on making rating and also lays out the general architecture of the various treatment settings and how they relate to the acuity ratings. Guidance regarding care plans is sound but needs to be updated to reflect the change to TechCare. While the requirements for discharge planning are aspirational at present, this manual and the policy on Discharge Planning represent reasonable expectations.
Intake data was reported above in the corresponding section. Following intake, further assessment is needed for those with mental health problems. The County provided data on these assessments from some settings. Of assessments conducted on 6B (female mental health housing) 53% were done timely, 28% were late (more than two weeks following intake), 8% already had an assessment from a previous admission, and 11% had no assessment. A similar CQI study at SCF found that only 48 out of 544 inmates with behavioral health flags had no assessment.; further analysis showed that in actuality, only 9 were missing for no reasonable cause. It is difficult to know how to interpret these in light of the fact that there is some uncertainty regarding the numbers screened by mental health according to data presented above in the section Intake Screening. Presumably, the SCF study represents the number who had assessments that were screened by MH. If that interpretation is correct, it demonstrates that RUHS-BH is good at assuring follow-up assessment for those they have identified as having MH issues. Though improvement is needed, this is important data and it demonstrates fairly good performance, though not at the level of substantial compliance. In another CQI study included in the electronic file “Data Request 10-5-17” the County found that 60.5% of all those on the mental health caseload had an assessment for July through September 2017 (up from 46.6% in March through May). The percentages varied from a low of about 33% at Blythe to a high of about 75% at SCF with the others in the 50-60% range. As with the mental health intake assessments, these data need to be reconciled and the methodology provided in order to better interpret the findings. However, it is clear that the County is making improvements here.
The County also examined the timeliness of intake assessments following booking. Here, the County was only looking at completed assessments. It found that 85% were completed within 14 days (up from 66.6% in March through May) and demonstrated a small but significant continued increase from July to September at all facilities. This shows that when cases are identified and an assessment done, they are generally done promptly.
The County has recently begun to emphasize the need for care plans (treatment plans). In yet another CQI study, the County demonstrated that 52% (up from 37.2% in March through May) of those on the mental health caseload had such plans. While not a high number, this is really quite good given how recently this initiative has been undertaken. Further, of those done, 81% were completed within 14 days (up from 62.9% in March through May). Taken with the intake and assessment data, it is clear that the County is making substantial progress and is developing the capacity to track its own performance.

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One challenge that the county faces in terms of developing adequate mental health treatment is continuity of providers. At this point the County remains oriented to crisis management. Patients are frequently seen by a variety of different Clinical Therapist and Behavioral Health Specialists. To provide structured mental health services, continuity of provider is very important in both group and individual therapy. The County has done well in assuring consistent group leadership and some of the structural changes being made in Clinical Therapist assignments should help provide the organizational foundation rendering structured treatment at an individual level.
The County is not yet able to report on the attendance, completion, or cancellation of groups, but they have developed group schedules (where they are still able to run groups) and were running up to three groups per day at SCF housing unit 16. The groups are evidence-based and address relevant topics. Attendance is determined by mental health, subject to custody limitations and availability. Patients report that, other than recent problems with cancellation and reduction of groups in general, the groups are run reliably, take the full time, and address the topic areas advertised. The groups I attended were sound. Other than at SWDC, those attending groups were clearly mentally ill and were generally appropriately placed in the groups, a clear improvement since my first report. This is almost certainly a function of implementation of the acuity scales, assuring that the needs of those on each unit are likely to be similar. There were also fewer complaints of being moved before finishing groups; even though lessened, it is not clear how often this is happening. Custody and mental health have been meeting to address this issue. The County is looking at how to capture this data.
The County reports that it has nearly completed a report that will detail the timeliness of psychiatric encounters. While many patients complained of inadequate psychiatric encounters, record review demonstrates that the vast majority of patients are being seen at regular intervals. While there remain challenges with bridge medications and prompt psychiatric assessment following intake, my reviews suggest that routine initial assessment and on-going psychiatric care are timely and clinically adequate.
The County provided data on the number of psychiatric visits and the number of patients receiving medications. Taken together, these show that patients are being seen more than monthly on average. The numbers of monthly psychiatric encounters has not changed significantly during that time so the main question is whether these encounters are better targeted to meet the needs of the patients and timelines required.
Those patients on administrative segregation continue to receive limited services. They are not eligible for groups and mental health staff report that it can be challenging to get access to these patients owing to custody challenges getting them out of their cells and limited space for meeting, especially at RPDC. Access to one-on-one meetings for treatment modules such as life skills has been reduced owing to the general impact on access to care discussed above. Patients on administrative segregation report that mental health visits them most days but not daily; this is almost always at cell front. The County produced a report entitled Administrative Segregation Follow-up showing that 71% of the mentally ill in administrative segregation received daily follow-up. However, almost 20% had no contacts for four or more days. This is clearly not substantial compliance but is well into partial compliance.
Psychiatrists note that collaboration with other mental health staff is very good but that there are challenges coordinating care with medical providers.
By using the new acuity codes and organizing units according to acuity and by mental health and custody paying greater attention to transfers, the problem of patients being transferred in the middle of groups has been reduced, though still occurs.

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I observed a discharge planning group at RPDC. It included six patients from 5B and 5A – they were allowed to be in the same group because they had the same custody classification. Group participants were selected by review of patient requests, individual meetings to determine need, and whether the patient was to be released in the near future. While I was in this group, the door was open (contrary to the edict from RCSD) with a custody staff standing by outside the room. A radio was brought to the group leader 30 minutes into the group. One of the group leaders closed the door 45 minutes into the group. At the end of the group, the custody staff radioed to have the door open but it was several minutes before it was actually opened. The group was conducted by two Behavioral Health Specialists. The group was generally well done and the patients participated actively.
I also observed a recreation therapy group at RPDC. There were four women in the group, most of whom were higher functioning than the group was targeted to. The group was a word game similar to The Wheel of Fortune that was designed to promote teamwork, handling failure, and using cognitive skills. The leaders did a very good job of using this format for therapeutic purposes. The door was open during the group and a sergeant was standing by outside the room.
There were no groups running when I was at SCF.
I observed a recreation therapy group at SWDC. Two Behavioral Health Specialists ran the group for five patients who exhibited limited evidence of mental illness. They met in a recreation yard and after some stretching and warm up, engaged in a game-like activity that included responding to questions such as “What was a stressful experience that you got through?” They used this to discuss coping skills for different situations. The group members participated actively and expressed a wish for more such opportunities. The co-leaders told me that they identified potential participants from the AB109 population (there is a statutory requirement, whether mentally ill or not) and mental health rolls. They also tailor group recommendations to patient needs, such as chemical dependency. Groups have relatively consistent membership and group members may come from different units. Groups include recreation therapy (9-10 and 3-4 five days per week), chemical dependency groups (COLORS, an eight week program run two days per week), and discharge planning. I also observed a Life Skills group at SWDC co-led by two Behavioral Health Specialists. The group was well run and appropriately focused. Here again, there were no overtly mentally ill among the 10 attendees, though clearly some had anxiety disorders.
At Indio, Behavioral Health Specialists run daily groups, mostly discharge planning but some treatment groups as well. They provide individual discharge planning as well. Clinical Therapists focus on assessment, crisis response, and provide some individual therapy.
There are no groups at Blythe. The Clinical Therapist does some individual treatment.
At SWDC, most Clinical Therapists were recently assigned to particular pods rather than having facilitywide functions. There are three assigned to pods during days with one on crisis response. There are two Clinical Therapists on in the evenings, both with facility-wide responsibilities. Individual sessions have been substantially reduced owing to problems with accessing patients and inability to use program spaces due to the new security requirements.
Individual treatment is still largely lacking, especially in terms of structured individual interventions targeted at specific problems. The County intends to restructure services away from crisis response

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towards a more balanced approach. This will also necessitate the implementation of more robust treatment planning which is, at present, largely absent or overly generic. There is no provision for treatment team meetings on residential mental health units. The County would do well to consider developing regular multi-disciplinary treatment planning conferences on these units; this approach helps assure consistency in treatment and coordination of care as well as providing a ready vehicle for communication. This would also be consistent with my earlier recommendation to develop a conjoint treatment plan.
Owing to the highly restrictive conditions at the DCU, there is essentially no treatment other than medications.
I also note that the RUHS-BH staff at SCF decided to engage in a practice of joining patients at meals. They then did a survey of the patients, most of whom approved of the practice. While not formal treatment, it is the sort of practice that helps bolster the treatment alliance and brings a more therapeutic atmosphere to the living units.
The County remains in partial compliance with the mental health treatment provisions of the Remedial Plan. There has been remarkable progress and the County is making very solid plans for the provision of sound treatment and for the management of the mentally ill population.
Housing
This is an area where there has been substantial progress and collaboration between mental health, custody, and classification. While mental health staff are not uniformly consulted regarding transfers, I continued to see little evidence of inmates without mental illness being housed in residential mental health units. I saw fewer less seriously ill patients being housed at RPDC, which is intended for the severely mentally ill, during this visit.
The seven-level acuity scheme maintained by mental health staff, and regularly reviewed by leadership, has continued to provide a sound basis for stratification of the population. However, there remains no policy detailing a formal transfer procedure for the mentally ill. Policy 508.12 Mental Health Services states that, absent an emergency, “inmates will not be transferred to or from a mental health housing unit unless mental health staff have been consulted beforehand to determine whether the transfer is beneficial or detrimental to the inmate’s mental health care.” It goes on to specify that “[c]onflicting recommendations may be resolved between mental health staff and the jail commander, or designee, for transfers between housing units in the same jail, or a mental health supervisor and the jail commander, or designee from the sending jail for transfers between jails.” There is no tracking of this nor is there any guidance about how to make the decision. This process is opaque and fraught with the potential for an inconsistent, or even capricious, approach to transfers. However, it is consistent with the provisions of the remedial plan. But in order to achieve substantial compliance, the County must demonstrate actual adherence to this policy. The County also provided a training slide specifying that “[c]lassficiation will enter the mental health recommendation and the name of the mental health clinician or supervisor in JIMS classification notes.” What the proof of practice will require is not clear; the County has not offered any verification that this policy is being followed.
More acutely ill are housed in RPDC (272 beds), less acutely ill at SCF (232 beds), and still less mentally ill in general population (with only the least ill permitted at Indio and Blythe). SCF continues to have units serving varying levels of acuity, providing both for a step-down process and a step-up process without

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having to resort to transfer to RPDC except for the most decompensated mentally ill. It should be noted that the acuity at SCF has increased somewhat, though by design.
As noted in the previous section, RUHS-BH and custody have been working together to minimize transfers to allow patients to complete groups; it is not clear how successful they have been but it is important that this practice has begun. While this is likely to be effective at SCF where most mental health transfers are within the facility and there is currently limited pressure on bed space, it is a challenge at RPDC where beds are often full owing to there being a premium on high acuity beds and some continued difficulties effecting prompt transfer to lower acuity settings.
While appropriate placement of the mentally ill is now the norm and mental health staff report that patients are rarely transferred into or out of residential mental health settings without their involvement, there is no way to determine the consistency of the process as there is no way to track it. That said, the acuity ratings are a reasonable proxy of whether the mentally ill are being appropriately placed. Mental health staff reported that there had been a concerted effort at both SCF and RPDC to limit transfers and to consider group completion when making transfers, as well as other clinical issues. Mental health staff also let classification staff know when patients need to be moved to higher or lower levels of care and report that their recommendations are generally followed unless there are classification or other legitimate custody reasons. Further, patients in residential mental health units made fewer comments about sudden moves and felt that custody and mental health generally collaborated on placement changes. However, owing to limited space at RPDC, patients are sometimes moved or not moved when clinically indicated. Owing to limited bed space, there has been some overflow of the mentally ill to the seventh and second floors primarily.
As noted in “Custodial Environment” above, the County has endeavored to reduce the numbers of different types of inmates on residential mental health units, making it easier to maximize out of cell time. At RPDC, 5B dayroom 1 is administrative segregation, 5B dayroom 2 is protective custody (PC), 5A dayroom 2 is half PC and half general population (GP) mental health, and 5A dayrooms 1 and 3 are GP. Those on administrative segregation must come out singly. Those in 5B dayroom 2 come out one tier at a time. I was told that in other PC settings, inmates come out from both tiers simultaneously but because there are limited PC settings for the mentally ill, the tiers are divided in order to provide separation for incompatible inmates. The effect is to reduce their out of cell time but since out of cell time is not able to be fully tracked, it is not clear whether the impact is such that out of cell time targets cannot be achieved. Those in 5A dayroom 2 also come out one tier at a time. Those in 5A dayrooms 1 and 2 come out simultaneously.
There remain a large number of mentally ill on administrative segregation. In fact, the population has overflowed from 5B dayroom 1 (dayroom 2 is for protective custody) in RPDC to 2A, the 4th floor, and even the 7th floor (designated a medical setting). I saw a mentally ill man on the 7th floor that I had met previously who was there for no obvious reason; he was moved to another floor during my visit. The documents 7th floor1st audit 7-25-17.docx and 7th floor audit 7-25-17.docx provide basic information on four patients on the 7th floor who were all on administrative segregation; most had psychotic disorders and were of moderate or higher acuity. This is a seriously mentally ill population.

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The document Audit 2A July2017.docx is a review of those on the mental health caseload on 2A. There were 11 in dayroom 1 and 11 in dayroom 2. They ranged in acuity from none (two were reduced to none at the time of this review) to severe, with most in between. These cases are reportedly reviewed every 30 days by custody, classification, and RUHS-BH; at these meetings, a decision is made whether to continue administrative segregation. This process is not formally tracked but RUHS-BH produced a document entitled AdSeg Audit.docx summarizing the clinical status of those on administrative segregation and tracks whether the patient was to remain on administrative segregation or be discontinued. Of the 20 included in the review, 14 were to be discontinued and 6 remain on administrative segregation. The document 2AD3 Mental Health Audit_7.24.17.docx provides the same information on 15 patients, though is not clear about whether the patient is to remain on administrative segregation. This group was more mixed with several showing no evidence of mental illness and others with serious mental illness.
The document 5B ad-seg 7-24-17.docx was another RUHS-BH review of 20 mentally ill on administrative segregation on 5B. Three were recommended to come off administrative segregation but it is unclear whether this was done. This report again documented the serious mental illness of this population.
These documents demonstrate that there is a thorough review of administrative segregation for the mentally ill but there is lack of clarity about decisions to continue patients on administrative segregation and who made these decisions. The decisions regarding placement and removal of the mentally ill on administrative segregation should be more formally tracked but this is a good beginning.
Mentally ill women are housed on 6A and 6B in RPDC, though they are mixed with non-mentally ill. This has caused some difficulty in that the mentally ill are sometimes ill-treated by the non-mentally ill, including some assaults (such an instance was reported during the multi-disciplinary team meeting I attended on those units). A significant number had had recent safety cell placements and DCU hospitalizations. Half of them had psychotic disorders and the remainder had primarily mood disorders. Most were on medications. In short, this is a population with substantial mental illness.
Issues related to restrictions on movement and programming are addressed under “Treatment Space” below.
With regard to limitations placed on those in residential housing, it is of note that when meeting individually face-to-face with mental health clinicians, patients at RPDC are required to be in cuffs even when custody is standing by. This is not true for medical contacts. It is not clear why this is being done for those not on administrative segregation status. It is an impediment to treatment.
At SCF, the 192 beds of unit 16 continue to be organized into six pods with a progressive stepdown in acuity. SCF recently developed a 40-bed dorm (unit 14) used to stepdown gang members who are trying to avoid gang pressures not to accept mental health treatment. This has proven very effective and the patients I spoke with there were quite grateful. However, they noted that after a fight on the unit, groups had been substantially curtailed.

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While there are no formal residential mental health units at SWDC, the mentally ill are reportedly preferentially placed on pods D and E.
Please see my comments in this section of my previous report regarding the problems with classification, transfer, and administrative segregation policies which all continue to apply. I would add that during my medical records review for this report, I saw numerous documents entitled “Transfer Screening” completed by nurses at the time of transfer. There are checkboxes for confirming four action items: record review, notification of transfer sent to mental health, no further action required, and further action required. Nurses almost never check the box that indicates that mental health was notified, even for patients in residential mental health settings.
Here again, the County remains in partial compliance with this measure. Progress is substantial but there remain some problems with the housing process but most all should be easily remedied from a policy perspective; practice may be a greater challenge.
Treatment Space
The plan to augment treatment space at RPDC is still in place. There have been no significant changes in treatment space generally. However, as noted several times earlier, RCSD recently decreed that when mental health staff meet with a patient in program rooms and other treatment spaces off the units, the door must be closed and locked. As mental health staff do not have any means of unlocking the doors, mental health leadership directed their staff not to meet under such conditions without custody standing by should they need assistance. Prior to this decision by mental health leadership, there was an instance at SCF where patients in a group were fighting and the mental health staff were unable to exit and not custody was standing by to assist; staff were not hurt but it demonstrated the risk posed by such a situation. This has led to a substantial reduction in access to treatment space and, accordingly, access to treatment. Groups have been suspended at SCF and substantially reduced at RPDC and SWDC (no groups were being held at Blythe or Indio). Individual meetings have also been reduced for the same reason. It has also forced a return to the use of non-contact booths in settings where those are available. Cell front visits have also increased.
It is also important to note that custody had made a concerted effort to provide “runners” (deputies that assist in moving patients to treatment) at Indio, SWDC, SCF, and RPDC. However, this has been curtailed to some degree recently, notably at RPDC. This has had a further impact on groups at RPDC, which had been running at almost 100% of scheduled times but is now at about 75%.
Psychiatrists at RPDC noted that because of limited spaces to see patients and difficulty getting assistance from custody to take patients out of their cells, they are also sometimes forced to see patients at cell front. Because they have no dedicated space at RPDC, they move through the facility, reducing their efficiency substantially. This is not generally a problem at other facilities where psychiatrists have a dedicated space and custody has been more able to assist in getting patients out at other facilities.
These problems have also made it almost impossible to schedule individual meetings at RPDC as clinicians are forced to see whatever patients are available and where there is an available space to meet. This interferes with timely follow-up and regular, structured individual therapy.

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When I met with patients at RPDC, I was asked to use the non-contact booths. The sound quality was poor and interfered with communication. The booths are also quite uncomfortable and have limited desk space and virtually no room for others, such as trainees. It would be difficult to have a series of individual patient meetings under these conditions. It is unreasonable to rely so heavily on such spaces for conducting routine clinical work.
At SCF the impact has been felt in other ways, in addition to holding no groups at present. Crisis response is now being done in non-contact booths as are all contacts on units 12, 14, and 16. Those from units 12 and 14 have to be moved to the intake area for these visits, which is sometimes not possible if no deputy is available. The lack of groups has necessitated increased individual contacts with Clinical Therapists seeing the most ill and Behavioral Health Specialists seeing the more stable patients. They endeavor to have weekly contacts but this has been challenging.
It should also be noted that there is a plan to add a contact interview room on unit 16 to augment the three non-contact booths. The new SCF medical building slated to be complete in a year will have 8 behavioral health rooms for treatment and 14 work stations for mental health staff.
At SWDC, the changes have reduced groups to a limited extent (they are running six groups five days per week) because groups are run in the library and clinical staff have electronic key cards so they can exit on their own, making it unnecessary for custody to stand by. However, owing to being unable to use the program rooms, groups have been reduced in frequency. Individual meetings have been reduced to almost none. Pod deputies are often unable to help mental health staff with bringing patients to treatment spaces and/or standing by owing to the locked door requirement. Most individual meetings are crisis responses in the non-contact booth. It has also force Clinical Therapists to conduct assessments in the booking area rather than on the units where the patients reside, necessitating special transport. Clinical Therapists try to meet with patients on the pods at least once per month.
The impact has been less at Indio and Blythe. At Blythe, the Clinical Therapist was only seeing patients in a non-contact booth so there has been no change there, though it is unclear why this is the case, especially given that patients at Blythe are low acuity and there is a program room available, which is also sufficiently large to run groups. Indio is also using a non-contact booth; they share this with investigators, limiting access to patients.
Patient reports were consistent with the above. Those at SCF especially lamented the loss of groups. Those at RPDC noted a decrease of out of cell contacts and increased cell front visits, including by psychiatrists. Virtually all those in the residential mental health units who had been there more than three months noted a reduction in clinical contact recently.
The County is about to start using telepsychiatry at Blythe. Once operational, I will assess the adequacy of the facilities and equipment.
The County is clearly taking reasonable steps to provide adequate treatment space but recent changes have set the County back with regard to its ability to use current spaces. The general provisions for treatment space meet partial compliance and will almost certainly be substantially compliant once the changes have been completed and the security provisions have been resolved.

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Suicide Prevention
Policy and procedure for step-down from safety cells is not yet implemented. Mental health is not yet involved in setting the conditions of confinement in safety cells but this is to be part of the impending plan; RUHS-BH and custody are working jointly on how to operationalize this process and policy is reportedly pending. The Remedial Plan species that policy and procedures for a step-down program were to be in place one month after issuance of the Consent Decree. The specific language is:
“Within one month of the date of the Consent Decree is issued by the Court, the County shall develop and implement policies and procedures to allow step-downs for inmates placed in safety cells because of potentially self-harming behavior. The step-down program shall gradually add property in privileges and programming consistent with clinical assessment of a [sic] inmate’s condition, with the intent to minimize the time spent in the safety cells under conditions of total deprivation of property and programming.”
The form "Safety Cell Visit Questions" provides reasonable basic guidance but may convey the sense that its completion is adequate in all cases, which it is not. Consider using more general topic headings allowing for narrative in a variety of domains that might be pertinent to placement in a safety cell or, alternatively, providing guidance through a protocol (this could be drawn from the materials in the Clinical Therapist Training Manual). It also does not indicate the need to consider gradual restoration of property and privileges as required for the step-down element of the remedial plan.
For the present, the provision for seclusion to last no more than 12 hours has been operationalized by defining seclusion as placement in a safety cell with no more than a smock, safety blanket, and mattress. The County cannot yet provide data on this in the jails or in DCU. Adherence will also be difficult to ascertain through auditing as the information will be difficult to obtain from records and inspection will not provide sufficient information.
One-to-one monitoring of those who are an imminent danger to self and are awaiting transfer to the DCU under 4011.6 commitment continues to be available if deemed necessary by a QMHP. RUHS-BH staff report no problems securing this when needed, which is, and should be, rare.
Safety cells were not as uniformly clean as during my last visit, vents were especially dirty. This was most problematic at RPDC. In one, the floor drain was plugged and the cell quite malodorous. Another had been recently vacated but not yet cleaned. There was also one accessible fixture without a cage that could have been broken or used as an anchor point (seventh floor of RPDC). The safety cells at SCF were fairly clean though one was less cleanly; staff pressure washed it while I was there. Those at Indio were clean and in good order. The County has taken measures to ensure oversight of their cleanliness, including more direct supervisory oversight. Supervisors had signed off on some of the uncleanly safety cells but not all.
Per the Remedial Plan, water is to be offered every two hours, meals offered three times per day, and medications offered as prescribed. I reviewed a number of safety cell logs at RPDC, SCF, and SWDC. I was also provided a sample of safety cell logs for those in restraints as noted in the section Restraint. Those reviewed demonstrated regular checks (almost always less than every 15 minutes and irregular), water offered every two hours, and custody supervisor reviews in almost all cases. Three meals per day were documented in a little more than half of cases and toileting was never documented, presumably because all safety cells had toileting provisions. Medication administration was not noted but health

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care visits were documented to be timely in most cases but a number of initial assessments were undated and/or untimed. Logs demonstrated regular and timely QMHP assessment. Nursing assessments of those in safety cells are not uniformly done every 8 hours but most are within timeframes. They often do not include vital signs and the required elements are sometimes blank. Nurses general write on “per deputy” (or similar verbiage) under the section “Fluid Intake/Hydration Status;” this is not adequate as the charge is to assess their hydration status, which deputies are not qualified to do.
Almost all QMHP safety cell assessments are now being done in a private space rather than at cell front. Both mental health and custody are to be commended for this important change.
Once released from safety cells, mental health conducts transitional services (follow-up visits) for 5 consecutive days (unless deemed unnecessary with supervisory review), only occasionally missing them or conducting them late. I note parenthetically that the County is also conducting a series of five transitional visits for those patients returning to the jail from DCU; while not a part of the remedial plan this is an important step to assure the safety and stability of this vulnerable population, most of whom were in safety cells prior to admission to the DCU and who, because of the restrictive conditions in the DCU, have effectively been in isolation. The County produced a report demonstrating that only 45% of patients releasing from safety cells received any transitional services. Of those receiving any transitional services, a minority received all five visits.
There is no safety cell at Blythe and the observation cell there is not suicide proof and has no camera. Those needing safety cell placement are transferred to Indio, which normally takes 2-4 hours. Pending transfer, they are placed in the observation cell with 15-minute checks; the observation cell is across from the intake deputy’s station which affords some view into the cell. If patients are acutely suicidal or harming themselves, they are place in a restraint chair; this occurs every few months. In July 2017, there were three patients that had to be transferred to Indio for a safety cell. Those pending commitment to the DCU are also placed in the observation cell or, if necessary, placed in the restraint chair.
The County is producing lists of those sentenced for longer than 15 years so that mental health can conduct an assessment and any needed intervention. The County produced data from December 2016 through August 2017, reporting that in 80-95% of cases, mental health was notified. Mental health saw the inmate at a similar percentage. It is clear that both custody and mental health are doing a good job on this and are nearing substantial compliance.
The County provided data on safety cell usage for January through August 2017. The number of inmates placed in safety cells is just over 200 per month. About 25% of those are for more than 24 hours. The percentage of those placed in safety cells that are civilly committed is also about 25%. These numbers and percentages have not changed significantly since my initial evaluation. While some reduction in safety cell usage is desirable, I do not see evidence that current usage levels are unreasonable.
Here again the County remains in partial compliance.
Restraint
While this is included in the section on suicide prevention, I have considered it separately since it applies to other situations as well.

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Use of the emergency restraint chair is reportedly rare. Logs demonstrate that it is not uncommon but I received no data on overall use and it is not clear how the logs were selected so it is not possible to assess the frequency of usage for the data I have.
I witnessed a prisoner being placed into a restraint chair at SCF. He was agitated and possibly intoxicated. The restraint went smoothly and there were no injuries.
Restraint chairs were uniformly clean and in good working order.
Asked to provide the policy addressing monitoring of those in restraint, the County again forwarded Policy 503.07 Emergency Restraint Chair; it mandates limb exercises every 30 minutes (absent safety concerns), medical staff evaluation initially and every two hours, visual checks every 30 minutes, and use of toilet and access to water every two hours. However, it does not provide sufficient specificity with regard to the medical monitoring of those in restraint which should include regular neurovascular evaluation (including an assessment for blood clots), brief mental status examination, skin checks, vital signs, and consideration of any contraindications to restraint. It also does not specify access to food. The remedial plan specifies “continuous health care monitoring of inmates in restraints consistent with NCCHC standards.” Since NCCHC does not mandate one-to-one or direct observation of those in restraint, I take this to mean on-going health care monitoring that meets NCCHC standards. NCCHC mandates apply only to “clinical restraints.” Since the remedial plan speaks to the use of the restraint chair rather than restraint at the DCU and addresses monitoring of those in safety cells and the restraint chairs, I presume that the NCCHC standards are to apply to those in restraint chairs. With regard to monitoring, NCCHC requires 15 minute checks by “health-trained personnel or health services staff,” checking circulatory and respiratory function, and providing nutrition, hydration, and toileting. They also speak to assuring that restraints are jeopardizing the health or mental health of the inmate. Standards in the field also require checking peripheral neurological function. These things need to be explicitly addressed in policy and tracked in logs. The addition of provisions in policy for nutrition, neurovascular monitoring, and skin checks as well as explicit provision for assessing whether restraint is jeopardizing the health or mental health of the inmate are all that is needed. The logs include all the components applicable to custody, including meals.
I was provided some logs of restraint chair and safety cell usage from Indio, RPDC, SWDC, and SCF. This was reportedly a complete set of logs for March 2017 – August 2017. The same logs are used for safety cells and restraint chair usage and it can be difficult to ascertain whether an inmate is in the restraint chair or just in a safety cell as there is no formal or consistent way to indicate restraint chair placement or removal; in some cases, these logs did not seem to indicate that the patient was in a restraint chair. The logs consistently demonstrate checks occurring at least every 15 minutes. While most show variable times, there remain some that are exactly every 15 minutes, casting doubt on their accuracy. They are variable in terms of demonstrating the provision of water, meals (the log is problematic as the code for meals and hygiene is the same so unless the deputy notes a meal, it is not possible to tell which it is), and toileting. Range of motion is also not consistently documented but is most often present and close to every 30 minutes. The logs corroborate reports that mental health is usually not conducting evaluations at cell front.
At the DCU, the standards are consistent with the Centers for Medicare and Medicaid Services standards. I did not receive any restraint logs from the DCU.

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The documentation in the logs has improved somewhat though are still often incomplete and it is still difficult to determine if or when restraints were removed. The checks are being done frequently, restraints are clean, activity is being consistently documented, and supervisors are performing checks. The County also must develop the step-down protocol. For now, partial compliance remains appropriate.
Continuity of Care
With the reorganization of health care services, there have been changes to the processes around reentry. RUHS now encompasses all healthcare at the jail and also provides community mental health services. While there was previously a common administration of mental health in the jail and the community, this collaboration has continued to develop. Community mental health providers are providing some in-reach services to the jail population. They are even documenting some of their work in TechCare (the jail electronic health record). Those being released continue to receive a two-week supply of release medications (though sometimes they are provided a 30-day supply) and generally have an appointment with community mental health, though it is not clear whether they are able to uniformly get access to community medications within that two weeks.
Mental health staff conduct discharge planning groups and patients also note that mental health staff discuss discharge planning with them. The County provided tables (logs) demonstrating discharge planning efforts by frontline staff. The table are difficult to interpret demonstrate the County's clear effort to enhance discharge planning through the use of both groups and individual release planning. The table covers all important areas except finances. The tables also demonstrate the limitations of its efforts thus far, appearing to show that about half of mental health inmates get some discharge planning. It does provide some sense of the amount and types of services but is not collected in a manner that allows a quantitative evaluation of it accomplishments. It should be noted that it appears that there has been some reduction in penetration lately, likely reflecting the recent challenges of running groups. It is notable that the tables show that the provision of release medications is inconsistent. This is a critical function that needs to be better tracked and deficiencies addressed through corrective action.
A CQI project at SWDC showed that of 50 mentally ill inmates release, 14 were referred for services but only three followed through. This demonstrates that RUHS-BH is having difficulty getting discharge services to the mentally ill at SWDC. However, inspection also shows that many patients are refusing; the County should not be counting patient refusals as failure to provide the service. However, it is important to track this to assure that refusals are minimized.
The County looked at how many of those who received discharge planning actually followed through at facilities other than SWDC. With regard to keeping appointments at community mental health centers, the County found that only a small minority showed up for their appointments. While this is not a formal compliance measure, it is encouraging that the County is pursuing this information as the success rate of those needing discharge planning is arguably more important than the success rate of providing discharge planning to those who need it.
This open demonstration of its efforts is, once again, to be commended. One point to make is that the remedial plan speaks to discharge planning for those with "serious mental illness." The County needs to focus these resources on that population (the tables show a good deal of resource going to those with minimal to moderate mental health acuity and some with higher acuity going unserved). If there are

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additional resources to provide discharge planning to the broader mentally ill population, I encourage that expansion.
I was not provided with new policy correcting the deficiencies noted previously.
Here again, the County remains in partial compliance and is taking appropriate steps to build out these services.

POLICIES AND PROCEDURES
I was provided two updated RCSD Corrections Division Policies: 508.06 Inmate Medical Care and 508.12 Mental Health Services. Both these policies continue to have problems. The former has problems in the confidentiality section as noted above and the latter does not adequately address the transfer process for the mentally ill. Most of the deficiencies noted in my previous report have not been addressed. These include: step-down procedures for safety cells, policy supporting direct observation of those pending DCU admission, refusal of mental health services (follow-up by mental health staff and competency to refuse), handling protected health information in the grievance process, policy to support needed changes to the EHR, policy on dayroom management does not address equity of dayroom time, inconsiste
ncy between the remedial plan and policy with regard to yard times, problems with the classification policy addressing mental health issues outside the reasonable scope of classification staff and elements related to housing the mentally ill, inadequate provisions for mental health staff participation in discipline and administrative segregation, policy addressing the full range of the provision regarding continuity of care, and insufficient language regarding mental illness in the ADA policy. These need to be corrected. Some are arguably not in the purview of the remedial plan; I am open to discussion with the parties to resolve any such issues. As I have been told that many are being modified, I will continue to rate this as in partial compliance at this time.

CONSENT DECREE TRAINING
The County provided additional data regarding training on the consent decree. Nearly 100% of staff received one phase of the Remedial Plan training and about 90% received all phases. In conjunction with the previously reported trainings, I believe the County is in substantial compliance for this component.
This concludes my second semi-annual self-assessment. In my opinion, despite the recent challenges with access to care, the County is taking appropriate steps to meet the terms of the Remedial Plan. The County has achieved partial compliance on almost all measures, substantial compliance on one, and is near substantial compliance on a number more.
Respectfully submitted,

Bruce C. Gage, M.D.

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Appendix
The following medical record reviews are not intended to be thorough but to follow-up on certain patients, claims by some patients, and to review the provision of care in light of the remedial plan. I did not conduct as complete a review of records for this visit as the County has been clear that it is still developing its treatment program. I expected and saw little change from the general findings of my previous report. As before, this is reasonable considering the County’s efforts to focus on infrastructure and the development of a sound system that will be sustainable beyond exit from this law suit.
I reviewed cases from each facility. In what follows, I provide some brief notes on some of the patient records and general observations of the records from each facility. I did not meet with the patients from Indio and Blythe but did meet with those from other facilities.
Note: I was unable to open scanned documents in the medical record. It is possible that these scanned documents contained evidence of treatment is not available to me.
Blythe Ceja, A. 201722662 This man was admitted in June 2017. He had a history of anxiety and unspecified mood disorder as well as chronic methamphetamine use. He was appropriately screened and acuity rated. He was seen periodically by mental health initially in response to kites and subsequently as part of a treatment plan included both medications (lithium and trazodone) and periodic meetings with a Clinical Therapist. However, there is no evidence that he was seen in regular sessions with the Clinical Therapist or enrolled in any groups. He was seen periodically by various Clinical Therapists, but this was always in response to another staff’s request to see the patient. He was seen regularly by psychiatry who ordered appropriate laboratory evaluations medications.
Estrada, V. 201729872 This man was admitted in August 2017. He was initially mental health screened by a nurse and subsequently screened by a Clinical Therapist. The latter made more findings, some of which were significant, including that the patient was drinking a 12 pack of beer a day and taking regular Xanax. In addition, the Clinical Therapist reported that the patient had a history of suicide attempts. The nurse had not detected these important issues but did make a referral to mental health. He was evaluated a Clinical Therapist and referred to a psychiatrist started him on an antidepressant and antipsychotic depression with psychotic features. A mental health care plan spoke only to the need for substance abuse treatment but referred to the need for an appointment with a psychiatrist and individual and/or group treatment. Subsequently, it was noted that he needed assistance with self-injurious behavior. The Clinical Therapist made repeated efforts to meet with the patient, but he refused almost all contacts. He did meet periodically with the psychiatrist and was continued on medications. Appropriate laboratory tests and AIMS (abnormal involuntary movement scale) were in the record.

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Garcia, G. 201725940 This man was admitted in July 2017. He was appropriately screened and acuity rated by the Clinical Therapist. He reported being on a number of medications including mood stabilizers, antipsychotics, and antidepressants. However, the Clinical Therapist was unable to verify medications. He was referred to psychiatry but not seen for over two weeks. The psychiatrist diagnosed an affective disorder and started him on hydroxyzine (an antihistamine), mirtazapine (an antidepressant), and olanzapine (an antipsychotic). He had subsequent medication adjustments and changes done based on side effects and treatment response. Appropriate labs and AIMS were done.
There was a care plan but it does not speak to any mood disturbance or psychosis, only to symptoms of anxiety. The plan is very generic reading “FBH clinical staff will continue to follow up with the client to provide interventions and case management services.” While the care plan was not updated as far as the records demonstrated, new goals for psychosis were added in progress notes. He was regularly seen by a psychiatrist and Clinical Therapist, though generally in response to his requests rather than planned follow-up. He was enrolled in a discharge planning group which he attended.
Gurney, O. 201711758 This man was admitted in March 2017. The admission mental health screening was uniformly negative (the note said repeatedly that he said “no” to questions) except for a comment that the patient reported he did not expect to be in jail for domestic violence charge. He was seen two weeks later after requesting to be seen with the complaint of auditory hallucinations. At that time, he was noted to have hallucinations, delusions, and depressed mood. He was referred to a psychiatrist started him on an antidepressant and antipsychotic. Appropriate labs and AIMS were done.
It is likely that these symptoms were present at intake. Whether they were missed because of an inadequate screening interview or the patient was essentially uncooperative and denying symptoms is unclear. However, the almost complete lack of information in the screening raises concerns. If the patient was uncooperative or appeared to be simply answering “no” to all questions, this should have been reported.
The Clinical Therapist met with him approximately monthly initially, though notes suggested there would be more frequent contact, but the patient later declined meetings. He continued to meet with the psychiatrist who reported a good response to medications.
Walker, T. 201720439 This young man was admitted in May 2017. His intake mental health screening was negative. He was found to have no mental health needs. Subsequently placed in a safety cell about a month after admission due to expressing thoughts of harming himself in the context of feeling ignored by deputies. He was appropriately assessed and moved from the safety cell. He was seen in follow-up and some limited skills development in crisis worked on with him. No further services were indicated.
Indio Castro, S 201705740 This man was admitted in February 2017. The mental health screening was negative except for a history of substance use, primarily methamphetamine. No mental health appointment was said to be needed.

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However, on that same date the Clinical Therapist wrote a note that indicated that he was to receive a mental health rating of moderate and was referred for a complete assessment; no reason was given. Upon assessment, the patient was noted to have symptoms consistent with mania don’t know psychotic features. He was not interested in seeing a psychiatrist though was prescribed carbamazepine and topiramate, ostensibly for a seizure disorder, and he recognize that these may help with mood stabilization. A care plan from the same day indicated an intention to refer the patient to WRAP group and utilize coping skills that he learns.
He was later started on fluoxetine and mood stabilizers were adjusted by the psychiatrist. Appropriate laboratories were in the record.
Subsequent notes reflect regular meetings with a psychiatrist, individual sessions with a Clinical Therapist addressing relevant issues and skills, and enrollment in the WRAP group.
Granich, S 201710273 This woman was admitted in March 2017. During the mental health intake screening, she endorsed a history of PTSD and taking venlafaxine. There is no evidence of symptoms of current mental illness. The patient was seen the following day by a psychiatrist who reported that the patient had been on venlafaxine since 2013 little benefit. The psychiatrist started her on citalopram, buspirone, and trazodone. The psychiatrist subsequently adjusted and added medications, ultimately including mood stabilizers and antipsychotics. Appropriate medication monitoring with lab tests and AIMS was done.
For understandable reasons, the patient was placed in protective custody. She was seen regularly by Clinical Therapists and Behavioral Health Specialists, the latter using group curricula with her on a 1 to 1 basis due to being in protective custody. There was a generic care plan that did not well correspond to the treatment rendered. However, progress notes indicate appropriate services were delivered.
Maciel, E 201708688 This man was in March 2017. A nurse conducted the mental health intake screening; it was incomplete. No mental health symptoms were identified. He was rescreened by mental health the following day and noted to have suicidal ideation just prior to his arrest but not currently. He had some mild anxiety and depressive symptoms and a referral was made to mental health. He was seen by a psychiatrist the following day who started him on an antidepressant. A psychiatrist saw him regularly thereafter and adjusted doses and added medications appropriately.
Owing to his crime and being assaulted, he was placed on administrative segregation. A Clinical Therapist saw him almost every day during his time on administrative segregation. The Clinical Therapist working most closely with him ultimately recommended to custody that he be given a cellmate as his status was more consistent with protective custody. He was rehoused with the cellmate which seemed to help promote mental health stability. While he was not rendered any structured mental health treatment, he was seen regularly by Clinical Therapists for supportive contact and some limited skills development.

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Jimenez, A 201732418 This woman was admitted in August 2017. The Clinical Therapist to screened her did not detect any evidence of significant mental illness but endorsed a history of hospitalization and mental health treatment, those not currently on any medications. She was referred to mental health owing primarily to her request for services. The patient had a history of substantial heroin use and subsequently evidenced signs of withdrawal. When seen for a full assessment by mental health, the patient endorsed psychotic symptomatology and was subsequently seen by the psychiatrist who described her as very psychotic with a paucity of speech. She was started on antipsychotics and an antidepressant as well as medications to reduce anxiety and treat side effects. She improved with medication. Medication monitoring included appropriate labs and AIMS testing.
Despite her symptomatology, she remained in general population at Indio. She often refused mental health contacts and had to be encouraged and rescheduled to see the psychiatrist. She expressed an interest in groups that did not begin until after her release. She had periodic contacts with a Clinical Therapist, but no structured treatment and she was likely not stable enough to receive such services. Had she stayed longer, residential mental health placement would have been indicated.
Vazquez, G 201724320 This man was admitted in June 2017. During intake mental health screening, the patient denied a mental health history and denied any mental health symptoms. He was not referred to mental health at that time. About two months later he submitted a kite for mental health care due to depression. He was promptly evaluated by the Clinical Therapist and referred to the psychiatrist started him on antidepressants and medication for anxiety. A month later he was seen again by a Clinical Therapist and Behavioral Health Specialist referred him to groups. There were no further notes.
SWDC Hernandez, Raul 201719121 I saw this man with the psychiatrist. He was depressed and tearful, worried about his ill wife. The psychiatrist encouraged groups and planned to refer him. He was taking bupropion and olanzapine.
He had been admitted in May 2017. His intake mental health screening was negative and there was no referral for additional mental health assessment or treatment. He subsequently became more depressed and distraught and two months later was reevaluated and refer to a psychiatrist who started him on antidepressants and an antipsychotic depression with psychotic features though a history of previous diagnosis of bipolar disorder was also noted. He was not started on a stable despite some evidence mixed disturbance. Appropriate laboratory monitoring for metabolic syndrome was not done nor was an AIMS.
Lloyd, Matthew 201742214 This man had been jailed for two months and complained that he couldn’t sleep. After submitting a kite, he reported being seen by a Clinical Therapist in week and a psychiatrist a week later with follow-up every 2-4 weeks. He had been offered individual and group treatment but declined because it interfered with his job. He was taking buspirone and mirtazapine, which he had taken in the past.
He had been admitted in March 2017. On mental health screening he denied any psychiatric problems though endorsed a long history of methamphetamine, marijuana, and alcohol use. He was not referred

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to mental health though the note seems to indicate that he refused mental health assessment; it is not clear why further assessment was indicated based on the intake screening. He subsequent we kited for assistance as noted above and was promptly seen evaluated by Clinical Therapist and referred to psychiatry he was started on antidepressants and followed up regularly by psychiatry. He was seen monthly by a Clinical Therapist for case management services. Treatment was appropriate except that necessary laboratories for monitoring psychotropics were not ordered.
Ortiz, Moses 201710150 This man had been in jail for 5 months with three years left. He reported no access to any programming owing to being custody level 5. He had started mental health treatment just before being jailed but had not been ordered medications. He had been on medications in jail for two months, which included mirtazapine and something he could not remember. He stated that he had been offered individual therapy but refused due to “politics.” However, he decided to participate in a recreation therapy group.
He reported that kites were often unavailable on the units and noted long delays before getting a response.
He reported that he received dayroom 2-3 times daily for 45 minutes each but was not sure about yard at it was often offered early in the morning.
He had been admitted in March 2017. He reported problems with anxiety, restlessness and insomnia and was referred for further mental health assessment. He refused the scheduled appointment a week later, but the Clinical Therapist checked on him to assure that he was functioning adequately, which he was. He was approached again a month later but again refused. The following month he expressed some interest in receiving treatment for depression and anxiety. He was evaluated by a psychiatrist and offered medications but refused initially though a month later agreed to start on antidepressants and antianxiety agents were added later. He was also enrolled in several groups and participated actively. His care was adequate and addressed his needs apart from medications not being properly monitored with laboratory studies.
Morrison, Ted 201714641 This middle-aged man had been in jail for five months with three years left. He reported being on medication in the community through a private psychiatrist. He stated that it took a month to get medications started after admission. He reported being ordered duloxetine (an antidepressant), asenapine (an antipsychotic), and something he could not recall. He reported now seeing the psychiatrist every few weeks. He was also in the COLORS group (for substance abuse) but getting no other treatment.
He had been admitted in April 2017. He endorsed a history of bipolar disorder but also substantial substance abuse including methamphetamine, heroin, and marijuana. He had been in past drug and mental health treatment. He was separately assessed and referred to Behavioral Health Specialist for group and the psychiatrist for medication. The psychiatrist found him to have a thought disorder and mood lability. The psychiatrist started an antidepressant and antipsychotic. The psychiatrist saw the patient numerous times thereafter and made many medication changes, primarily in response to numerous complaints of side effects. The patient also refused medications many times, also complaints of side effects, some of which were unlikely to be medication-induced side effects. The patient attended the COLOR group and completed the life skills group and was pending involvement in WRAP. He met approximately monthly with a Clinical Therapist for case management. In general, his treatment

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was appropriate except for inadequate medication monitoring for a patient on antipsychotics; there was no AIMS and no laboratory monitoring for metabolic syndrome.
Brimmer, Reginald 201637226 This middle-aged man on pretrial detention had been in jail for a year. He had not been in treatment before jail but saw a psychiatrist a few days after admission when he complained of depression and decreased sleep. He also had individual therapy with a Clinical Therapist for some time but reported this stopped after he declined a visit. He had been offered groups but refused saying “I don’t want my business out there” and went on to say that he wanted the individual sessions again. He complained of a lack of privacy in many treatment settings.
He stated he was taking mirtazapine and saw the psychiatrist monthly.
He noted that sometimes the mentally ill are missed at intake and come to the GP units where they “may get hurt.” While he had often reported this to the deputies, he said they usually did nothing.
He was admitted in September 2016. On the mental health intake screen, he complained of depression and a history of suicide attempts. He was referred for further mental health assessment and psychiatric evaluation. The psychiatrist saw him promptly and started him on an antidepressant. He was seen every one to two months by psychiatry in medications adjusted appropriately and he showed a good response to treatment. However, he did not receive appropriate medication laboratory monitoring for metabolic syndrome.
He was offered groups but refused. He was seen periodically by Clinical Therapist to monitor his progress and to provide case management.
SCF Morton 201724081 (number incorrect – unable to find patient in TechCare) This man was in a safety cell and had a history of cutting. He had been in jail for two weeks but had many prior incarcerations. His primary problem was substance abuse though he was prescribed hydroxyzine (an antihistamine used for side effects, sedation, and anxiety) and mirtazapine (an antidepressant). However, he had been on Unit 16 D or E, residential mental health.
He reported having met one time each with a psychiatrist and a Clinical Therapist.
He reported access to the dayroom twice in the morning and twice in the evening for about an hour and yard access once a week for about an hour.
Timmons 201727523 This woman was also in a safety cell. She complained of getting no water; inspection of the log indicated that she had refused water. She demonstrated no evidence of mental illness.
Admitted July just prior to my visit. At intake, she endorsed depression and suicidal ideation during the mental health screening. She was tearful and endorsed a history of suicide attempts and psychiatric hospitalization related to suicidal ideation. She was placed directly in a safety cell. A psychiatrist saw her that day and started her on sertraline.

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When evaluated the following day she was released to population with a mild mental health acuity rating. She had follow-up with psychiatry and Clinical Therapists over the next week and was then released. Of note she did receive discharge medications.
Marruffo, E. 201737174 This man on 16F had been admitted in February 2017 and had been at SCF since March. He demonstrated clear psychotic symptoms and was quite bizarre. He was malodorous with matted hair.
He reported seeing a psychiatrist “now and then” and meeting with a QMHP every 2-3 weeks. He noted that mental health responded promptly to kites but that medical was not prompt and often did not respond. He had been in groups but noted they had been discontinued.
He noted that dayroom time was “less and less,” now at three times daily for varying times. He was uncertain about yard times.
During the mental health intake screening, the patient reported previous psychiatric hospitalizations and having been on paroxetine (an antidepressant). He was noted to be mildly unkempt, but no psychosis was noted. However, he was rated as moderate/severe and acuity and referred for mental health housing at RPDC. He was not seen by a psychiatrist until three weeks later when he was started on paroxetine.
He was ultimately placed at SCF. While there he was diagnosed with schizoaffective disorder and agreed to start on an antipsychotic. Monitoring for metabolic syndrome was not done, however an AIMS was completed.
He was generally uncooperative with treatment outside of taking medications (no groups were being offered at the time, but he also refused individual contacts). Clinical Therapists and Behavioral Health Specialist followed up with him periodically and endeavored to encourage engagement and improved hygiene. It was repeatedly noted that he was ill kempt, but the assessment was that he did not meet grave disability standards. Staff were clearly attending to this issue.
Berglund 201721080 This man was also on 16F. He had been in jail a little more than a month and had a month left. He had just begun working with staff on a discharge plan.
He exhibited poor eye contact and talked about past delusions (e.g., his parents were not actually his parents). He was taking risperidone, which he had been on since he was 18 years old, and that he got medications promptly after admission (which was not the case – see below). He met with the psychiatrist once (which was accurate). He also noted that he had been in groups, but they were discontinued. He felt fortunate that he was one of the patients who had regular individual meetings with a Clinical Therapist.
He reported access to the dayroom “at least” once per day, most days for a total of about an hour. He recalled that the hard was open “about half the time” it was supposed to be. He noted that they normally got to the yard once per week during cell searches.
This man was admitted in June 2017. During the intake mental health screening he was noted to be mildly unkempt and to have a history of treatment and hospitalization for mental health problems. He

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had been taking a mood stabilizer and antipsychotic for 10 years though had been off it for the last three weeks. He was transferred from Blythe to SCF soon thereafter. He was not seen by a psychiatrist until four weeks after admission at which time he was started on the antipsychotic risperidone. An AIMS was done but no laboratory examinations for monitoring metabolic syndrome.
His acuity code was ultimately raised to severe. He was seen regularly by Clinical Therapist and Behavioral Health Specialists primarily focused on release planning given his impending discharge date. He received release medications at discharge.
Driskill 201739483 This middle-aged man had been admitted a few days before and now on 16F. He was clearly thought disordered, bizarre, and rambling. He reported being off medications for a year and half and was normally on sertraline, trazodone, and quetiapine. He had a history of extended psychiatric hospitalizations. He received medications his first night in jail, likely because he was “yelling in intake.” He had met with a psychiatrist.
Of note, he had a clear anatomical abnormality of his right shoulder and could not lift his arm. I informed the jail staff.
During his initial mental health intake screening, the intake nurse noted that he was quite disorganized. He was placed in safety cell. He was seen that day by a psychiatrist to started him on olanzapine and trazodone and later added sertraline and hydroxyzine. There was a recent negative AIMS in the record; no laboratories for monitoring metabolic syndrome were in the record.
Mental health saw him the following day found him grossly psychotic, rated his acuity is severe, moved him from the safety cell and sought residential mental health placement. The client was released less than a week later and was referred for civil commitment under 5150.
Briseno 201722824 This man was housed on 16F, the step-down for gang dropouts. He was labile and had clear psychotic symptoms. Despite wanting treatment, he was fearful of meeting with mental health, believing it might lengthen his jail time. He was taking medications but could not recall what.
He reported dayroom on 16F about twice daily for 15-30 minutes but that on 16D, he had gotten out three times daily. He thought they got access to the yard during morning dayroom times.
He had been admitted in June 2017. The intake mental health screening initially conducted by a nurse was all negative. The following day mental health did the intake screening again and found that he had a history of self injury, was currently thinking of harming himself, endorsed auditory hallucinations, and had a history of treatment for mental health and substance abuse. He was placed in a safety cell. He also exhibited overt signs of mental illness. He was seen by a psychiatrist that day and started on an antipsychotic and antidepressant the psychiatrist ordered appropriate laboratory is for monitoring metabolic syndrome and did AIMS testing.
During his three-month stay, he was seen regularly by a psychiatrist and by Clinical Therapists and Behavioral Health Specialists. Meetings primarily focused on medication management and adherence. There was some evidence of release planning prior to his discharge, however it was not clear that he received discharge medications though there was a common in the final Clinical Therapist note about

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receiving “post release medication instructions and encourage client to follow through on outpatient [behavioral health] services.”
RPDC Furr 201714779 This young man was on administrative segregation on unit 5B where I observed a Clinical Therapist conduct an assessment following return from the DCU owing to self-injury (head banging) and medication refusal. This was his third hospitalization during this stay.
After previous hospitalizations, chart review demonstrated that he did receive the five daily transitional visits upon his return to the jail. Otherwise, his treatment consisted of medications and daily brief visits (owing to his administrative segregation status) with no evidence of any plan to address his recurrent behavioral problems. It is likely that intellectual disability and or head trauma in the associated cognitive deficits contributed to his behavioral difficulties. There is no evidence of a behavioral plan are appropriate interventions to try to reduce his problem behavior. Likely lack of access to the patient because of administrative segregation at a good deal to do with this.
This man was admitted in April 2017. He had an extensive mental health history. While he denied most symptoms, he was clearly suffering from a psychotic disturbance and was responding to internal stimuli. His acuity rating at intake was severe and he was placed in a safety cell and referred for residential mental health treatment. He was seen the following day by a psychiatrist who also found clear evidence of psychosis. The psychiatrist started him on olanzapine, an antipsychotic. The psychiatrist did the AIMS and ordered laboratory screening to monitor metabolic syndrome.
He was on administrative segregation during his stay in placed on unit 5B in RPDC. He was back and forth to the DCU owing to recurrent self-harm and general instability.
Allen, Robert 201714719 (unable to find patient in TechCare) This middle-aged man was on administrative segregation on unit 5B; he had been admitted in April 2017. He had previously been in prison for 29 years. He was arrested for staying in an abandoned building. In addition to evidence of hypomania and likely somatic delusions, this man has a history of substance use.
He was paranoid and concerned that custody listens in to all his conversations and relatedly reported that he had overheard a deputy talking with another patient about their medications, which he was able to overhear. He stated that one time when he tried to hang himself, deputies assaulted him when they came to stop him. He spoke of nurses having “favorites” that they would give additional or special snacks to at pill call. He reported that mental health staff joined nurses on pill call rounds. Regarding dayroom time, he reported this was highly variable but usually 1-3 times daily for about 30 minutes. He reported that mental health responded well to requests to be seen. He also noted responses to grievance but that they had no impact.
He reported taking bupropion and oxcarbazepine. He received no other treatment except occasional visits with a therapist but primarily cell front check-ins.
Montiel 201649964 This man was admitted in December 2016 and reported he was soon to be transferred to a state hospital (presumably for competency restoration). He was also on administrative segregation on 5B.

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He stated he was on no medication. He reported being on medications and in groups in the community. His farther visited twice a week. He reported access to the dayroom only once a day, adding that he used to get out twice a day and that on occasion that would get a second session in the evening. Yard was offered “today and Friday.” He said that it was usually offered 2-3 times per week for about 3 hours.
He reported that he met with a Clinical Therapist weekly and that they do “writing and coloring” in the non-contact booth. However, he stated that he was not visited daily. He used to have a life skills session weekly but that was stopped; he did not know why.
He was clearly intellectually limited.
He had been admitted in December 2016. On admission the patient reported being “developmentally disabled… Autistic.” He was a client at the Regional Center. He was unable to remember the medications he was on but believed that his father knew what they were.
He was seen by a psychiatrist two weeks later, but he refused medications at that time. A psychiatrist saw him every one to two months thereafter; he continued to refuse medications in the psychiatrist ultimately opined that medications were not indicated.
Most of the meetings with clinical staff were at the cell front. The exception was weekly meetings with a Recreation Therapist that occurred in a noncontact booth, though occasionally these had to be at cell front as well due to unavailability of the booth or inability to escort the patient to the booth. Mental health staff endeavored to get permission to meet with him face-to-face to facilitate recreation therapy services were not permitted to do so.
He was not seen every day though on administrative segregation status. There are often several days between meetings in these were generally brief cell front check ins.
Frazier, Joaquin 201721185 This overtly psychotic man was on administrative segregation on 5B. He was hostile and refused to meet with me and refused medications during pill call.
He was admitted in June 2017. During the intake mental health screening, he refused to participate stating that he was falsely imprisoned. However, he was identified as mentally ill and referred for mental health housing. A psychiatrist saw him about a week later. He was continuing to refuse to participate both with Clinical Therapists and with the psychiatrist. The psychiatrist went to the cell front and tried to engage the patient with minimal success. No medications were ordered. Strangely, there was an AIMS done by the psychiatrist that day; it would not be possible to do an AIMS properly from cell front.
He was also said to have threatened deputies but did not require a safety cell. He was also refusing food and later throwing water. He was placed on administrative segregation, even though his behavior was highly likely due to his mental illness. There is no indication that DCU placement was considered a that time. He was not seen daily by mental health while on administrative segregation, but was seen every few days on average.

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Of note, he was also refusing his HIV medications. I saw no evidence of an evaluation of his competency to refuse. This went on for over a month. During this time, a Clinical Therapist documented that the patient he had the delusional belief that his medications were being poisoned, clearly indicative of incompetency. This refusal was not noted in the record, other than nurses charting his refusal, until after 6 weeks of refusal. A week later, a Clinical Therapist documented consultation regarding possible commitment to the DCU and the patient was placed in a safety cell. That same day, he refused psychiatric contact, but the psychiatrist made no note of concerns regarding dangerousness or grave disability. However, committed to the DCU.
Notes from the DCU clinical staff clearly demonstrate that he was severely psychotic and that his delusional beliefs were directly related to his not eating and not taking medications.
Notes from medical staff detailed his refusals to be seen and medication refusals but there was no discussion of whether he was competent to refuse. There was no evidence in the medical record that mental health and medical ever discussed his medication refusal and steps to be taken to address his competency.
This case was clearly mismanaged.
Williams 201711352 This was another overtly mentally ill man on administrative segregation on 5B. He was reportedly isolative and deputies had to periodically clean his cell. He was admitted in March 2017. He was placed on administrative segregation in June due to inappropriate masturbation, not responding to deputies, and poor relations with cellmates. He had reportedly improved little since admission. He refused treatment and often refused to come out of his cell. He had been on the waiting list for competency restoration at Patton State Hospital since June. He refused contact when the Clinical Therapist came to the cell front to ask if he would come out to talk.
The Clinical Therapist conducting the intake mental health screening observed that the patient was a poor historian and found clear evidence of a history of serious mental illness including recent hospitalization. In addition, the patient had a history of traumatic brain injury with resulting deficits. He was admitted to SWDC but was quickly transferred to SCF’s residential mental health unit. There, it became clear that he was grossly psychotic. It was at this point that he began engaging in the repetitive masturbatory behavior. Here again, this behavior was related to his mental illness that this did not seem to be considered in his placement on administrative segregation status.
Two weeks following his admission he was seen by a psychiatrist. He was started on olanzapine and hydroxyzine. In AIMS was completed, however there were no laboratories ordered to monitor for metabolic syndrome. He was poorly adherent to medications from the outset. Ultimately, he was in a fight with his cellmate following a period of disagreement with the cellmate. He was bizarre and repeatedly pressing the button and telling staff that he was supposed to be released from custody. Notes make it quite clear that he was very disorganized and did not well understand his situation.
He was ultimately placed in a safety cell and was transferred to RPDC. There, he continued his nonadherence and persisted in a decompensated state. He was next seen by a psychiatrist about a month after his first visit. The psychiatrist changed him to a rapidly absorbing form of olanzapine but there is no discussion of referral to the DCU. The psychiatrist did another AIMS, but did not order laboratory studies for monitoring metabolic syndrome.

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He continued to be ill kempt, malodorous, disorganized, nonadherent with treatment, and largely isolative until he was finally transferred to Patton State Hospital for competency restoration at the end of July 2017.
Hankins 201714644 This deaf man on numerous medications was also on administrative segregation unit 5B, though presumably on protective custody (PC) status. He almost fell upon standing. He was sleeping on the floor instead of his assigned top bunk.
During mental health intake screening, the patient denied any problems. However, the screening was done handwritten notes owing to the patient’s deafness. The Clinical Therapist noted a history of mental health treatment and psychiatric hospitalization. The patient was placed at SCF on unit 16, the residential mental health unit. He continued to communicate in writing for the next two months until an interpreter was finally secured.
Patient was not initially recommended for medications as it was not clear that he was suffering from a mental health problem. He was seen by a psychiatrist almost 2 months after admission at which point he was started on an antipsychotic and an antidepressant for depression with psychotic features. An AIMS was done but laboratories for monitoring metabolic syndrome were not ordered.
He had difficulty getting along with peers and frequently complained of being victimized some of which was verified. He was placed in a safety cell owing to expressions of suicidal ideation related to his difficulties managing in the jail setting. He was ultimately transferred to RPDC and housed on 5B, the administrative segregation mental health unit.
Clinical staff made some effort to bring in interpreters and had limited success with this but there were several sessions utilizing an interpreter.
There is no evidence that any release planning was done for this needy man.
Sanchez 201721893 This is another mentally ill man on administrative segregation on 5B. He was on numerous medications and was shifting from foot to foot, almost certainly a side effect of antipsychotic medications.
This man was admitted in June 2017. He was very unstable throughout his stay. During his intake mental health screening he endorsed constant suicidal ideation, history of suicide attempts, psychiatric hospitalizations, multiple losses, and a history of psychiatric outpatient treatment the was not currently taking medications. He was placed in a safety cell and shortly thereafter admitted to the DCU. Upon his return, he was placed in residential mental health on unit 5B on PC status.
A psychiatrist saw him shortly after his return. He was yelling, crying and demonstrated substantial mood lability. The psychiatrist ordered an antipsychotic and antidepressant, presumably continuing therapy started at the DCU. The psychiatrist did an AIMS or laboratory studies for monitoring metabolic syndrome were not done. Psychiatric follow-up was regular and appropriate medication adjustments were made except for failing to address his akathisia (restlessness caused by antipsychotics).

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Patient had regular meetings with mental health staff during his stay. They worked with him on skill development and crisis management.
Thomas 201725483 This man, also on 5B, was less overtly mentally ill at the time I saw him. When he asked the nurse for a “kite” the nurse declined and referred him to the box of kites on the wall of the dayroom, though he did not have access to the box at that time as he was locked in his cell.
He was admitted in July 2017. Note that in May 2017, he was overtly psychotic at the time of admission to Jail and upon release shortly thereafter was civilly committed on a 5150. He returned to jail in July 2017. He was again showing evidence of psychosis. He was placed in a safety cell at RPDC. He was seen the following day by a psychiatrist but refused to come out of the safety cell. The psychiatrist restarted olanzapine, an antipsychotic. There was no AIMS or laboratory testing for monitoring metabolic syndrome done.
Care plan was done but it was very generic, indicating only that he would receive individual therapy and case management. The goal was for him to be able to identify and explain to mental health symptoms per week. There is no evidence that this plan was followed through. However, various mental health staff saw him on a regular basis and provided some support and activities oriented interventions. He remained episodically hostile but showed some improvement in his symptomatology over time though continued to have auditory hallucinations and thought disorder.
Harris 201719883 (Unable to find medical record; name or number given were incorrect) This middle-aged woman was admitted in May 2017 and had been on 6B since admission. She reported auditory hallucinations and talked about delusional beliefs she formerly held. She was on psychotropic medical before jail, receiving monthly injections of the antipsychotic Invega Sustenna. She reported not receiving any medication until the beginning of July. She reported meeting with a Clinical Therapist once, also in July, for 20 minutes and believe she met with a psychiatrist the week prior to our visit for 15 minutes. She reported not being offered any groups or therapy, though wished for such assistance.
I was unable to verify her reports as either she gave me the wrong name or number.
She reported that time in the dayroom varied from 1-3 times a day for up to an hour, depending on the deputy, naming one female deputy who worked to get the inmates out. She reported getting yard access once each week for an hour and a half.
Limar 201722428 This woman had been admitted a month before our visit and was slated to leave within days. She reported being homeless after her baby’s father was deported; her children were taken from her. She demonstrated mood lability and odd beliefs likely of delusional proportions. She stated that she had been offered mental health services and placement in the community. However, she was told she would have to call the facilities herself but that the phone number was blocked by the jail.
She had been in a safety cell in late June due to suicidal ideation related to releasing homeless and with conditions for her release. She was in for a violation and reported that it was very difficult to meet her conditions when homeless.

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She stated she was on olanzapine and trazodone and that these helped prevent mania. She stated that she had not seen a psychiatrist during this incarceration but had during previous ones. However, she did say she met with a Clinical Therapist weekly and worked on skill development.
She reported betting dayroom access several times per day for varying times and access to the yard about twice per month.
During her intake mental health screening in June 2017, the patient endorsed vague suicidal ideation and complained of depression and anxiety. She was categorized as moderate severe and referred to mental health housing and to the psychiatrist. A note by a psychiatrist seems to indicate declining to order bridge medications the following day, but there were orders for an antipsychotic and antidepressant placed immediately thereafter. The patient was seen two weeks later and regularly thereafter. The psychiatrist did an AIMS there was no laboratory monitoring for metabolic syndrome.
She was seen on a regular basis by mental health throughout her stay. However, there was no evidence of any structured treatment, encounters consisted primarily of crisis response.
Burke 201725470 This woman was admitted shortly before my visit and was housed on 6B. She reported a history of ADHD and problems with methamphetamine use. She reported that two jail psychiatrists told her they did not want to see her and that she had not had a visit with a psychiatrist, though had been on no medications in the community. She had some paranoid and likely delusional ideas about her art having been plagiarized and other themes. She reported being victimized repeatedly, primarily in the community.
She reported that she was about to start in some groups. She met with the Clinical Therapist “but not often enough.” She said she was offered dayroom 2-3 times daily for about an hour each and yard access 1-2 times per week for about an hour.
During the mental health intake screening, she did not endorse psychotic symptoms but was observed to exhibit thought disorder and have likely delusional beliefs. She was rated as having severe acuity and was directed to mental health residential housing.
A psychiatrist first attempted to see here week after admission, but she was at court. She was finally seen a month and a half after admission. At that time, she was started on an antipsychotic. The psychiatrist did an AIMS, but no laboratories were ordered for monitoring metabolic syndrome.
In the ensuing weeks, she was seen regularly by Clinical Therapists and Behavioral Health Specialists. She received some structured treatment designed to address her anxiety and coping skills. She improved some but was still slated for treatment in a competency restoration program due to her continued symptomatology.
Olson 201720226 This seriously mentally ill woman with poor dentition and likely Tardive Dyskinesia (a movement disorder caused by antipsychotic medications) was housed on 6B. She had been in jail for three months, initially at SCF but moved to RPDC within three days. She had regular mental health services at the Blythe clinic and had a protective payee, was on injectable antipsychotics (Invega Sustenna), and had her room and board provided through the clinic.

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She made a variety of unlikely claims about having medical conditions as well as other clear evidence of a psychotic illness.
She stated she was ordered Invega Sustenna, divalproex sodium, and bupropion. The psychiatrist had met with her the day before our meeting. Groups included Dialectical Behavior Therapy (DBT) and another she could not recall.
She reported dayroom three times daily for about 45 minutes and yard once per week but could not recall for how long.
She was admitted in May 2017. She was overtly psychotic during the intake mental health screening and rated at moderate-severe acuity. As noted above, she was placed in residential mental health at RPDC within three days. She was ordered bridge medications two weeks after admission. She submitted a kite complaining of being allergic to one of the medications but when seen by the psychiatrist two days later, there was no discussion of this kite or the nature of her purported reaction; the medication was continued and she began to refuse it periodically. Clinical Therapists saw her multiple times but never commented on her medication refusal, despite notes speaking to monitoring her adherence to medications. A psychiatrist saw her about a month after starting the medication and made no comment on her adherence or any problems with medications reporting her adherence as “fair” (despite refusing several times that week and about 25% of the time generally) and no side effects. Later Clinical Therapist notes reported her as medication compliant despite continued periodic refusals. The psychiatrist did an AIMS but there was no laboratory monitoring for metabolic syndrome.
The patient was seen periodically by a Clinical Therapist for support and enrolled in two different groups. She also received some discharge planning, primarily housing assistance.
She was referred to the Liberty jail competency restoration program, though it took two months before she was enrolled. Records demonstrate that her medications were changed soon after entering their program.
Friedman, Christopher 201722052 This overtly manic man was on 5B on administrative segregation which he thought was because of having problems with another inmate. He had been there for one month. He reported past civil commitment and being prescribed an antipsychotic.
He reported he was currently prescribed olanzapine and diphenhydramine as well as a muscle relaxer and naproxen. He stated that he had not seen a psychiatrist but had visited two times with different Clinical Therapists while on 5A. He was in no groups because of being on administrative segregation but had been offered anger management and substance abuse treatment on 5A, though never started.
He stated that he got dayroom 1-2 times daily for 20-30 minutes and access to the yard about once weekly but irregularly.
Alvarez 201711012 This obviously mentally ill man with a history of spending 1.5 years at Patton State Hospital had been on 5B since March 2017 on administrative segregation. He reported that he had always been placed on administrative segregation since having a fight with a cellmate in 2014.

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He stated he was on olanzapine and benztropine, which were helpful, though he noted note receiving medications for a day the previous week. He recalled the psychiatrist coming to his cell weekly when he “walks the tier” but having no private meetings. He met with the Clinical Therapist every other week.
He stated that he got 30 minutes of dayroom time daily and an hour of yard weekly.
He was admitted in March 2017 as a return from Patton State Hospital; intake mental health screening noted his severe mental health condition. The psychiatrist wrote bridge orders to continue his medications and saw him a week later at which time the patient was still overtly psychotic. The psychiatrist conducted an AIMS but there were no laboratories for monitoring metabolic syndrome. The psychiatrist saw him approximately monthly subsequently.
A generic case plan was entered a week later. He had occasional sessions with a Clinical Therapist that were consistent with a case management approach. He declined groups.
Over time he stabilized and was transferred to the second floor where he had monthly meetings with a Clinical Therapist.
He remained on administrative segregation despite doing well clinically and behaviorally. He was not seen daily by mental health but approximately 2-3 times per week on average for cell front check-ins.
Cole 201719161 This man was on administrative segregation, housed on the 7th floor (special housing for medical patients). I had met him during a previous visit.
While he stated he was ordered quetiapine and oxcarbazepine, he reported never having met with a psychiatrist but also stated he refused. He complained of receiving ordered snacks inconsistently. He was clear that he was not being seen daily by mental health.
He was frustrated with his continued placement on a medical unit.
During mental health intake, the patient denied all problems but was identified as having mental health needs owing to his extensive mental health history in jail and the community. Bridge medications were ordered on day 3. Multiple refusals ensued and his medications expired without being seen. He decompensated and was transferred to the more acute setting of 5B. He was seen by a psychiatrist a month after admission and continued on his medications. He later refused all but a mood stabilizer, which was continued.
He again decompensated and agreed to restart an antipsychotic. An AIMS was done as was laboratory testing for metabolic syndrome.
This patient made repeated threats to harm himself and exhibited other behaviors consistent with a severe personality disorder (in addition to his serious mental illness). He had multiple safety cell placements. No behavioral management plan was put in place. Responses continued to be primarily to emergencies, likely reinforcing his acting out. Mental health staff did attempt to engage him in groups and tried to help him develop and utilize coping skills.

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He was not seen daily by mental health but about 3-4 times weekly for check-ins.
Ramirez 201727362 This grossly psychotic man was in a safety cell. He was clearly in need of hospitalization.
He was identified as seriously mentally ill and a danger to self upon admission and was placed in a safety cell and sent to the DCU shortly thereafter.
He remained quite unstable with frequent safety cell placements. He had repeated psychiatric and Clinical Therapist contacts. He was partially adherent to medications, including antipsychotics. The psychiatrist did an AIMS, but no laboratory studies were done for monitoring metabolic syndrome.
He eventually began to stabilize and became more cooperative with treatment, even engaging in some release planning.
While rehospitalization at the DCU might have been indicated, the team did a good job of stating in contact with the patient and trying to engage him in treatment, with some degree of success ultimately.

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EXHIBIT N

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June 3, 2018

Bruce C. Gage, M.D. Puget Sound Mental Health General and Forensic Psychiatry
6108 Community Place S.W., Suite 3 Lakewood, WA 98499

INTRODUCTION

This Third Report sets forth the Mental Health Expert’s assessments of the implementation of the terms of the Consent Decree, signed June 7, 2016, and associated Remedial Plan stemming from Gray v County of Riverside. It covers the Riverside County's (the County) reported results from the time of entering the Consent Decree from July 31, 2017 through February 28, 2018 (the “Third Reporting Period”) and reflects the observations and analysis of the Mental Health Expert regarding the County's compliance during that period.

As used herein, “Substantial Compliance” means that the County has achieved compliance with the material components of the relevant provisions of the Remedial Plan in accordance with the agreed-upon Compliance Measures for assessing Substantial Compliance submitted by the Mental Health Expert. “Partial Compliance” means that the County has achieved compliance on some, but not all, of the material components of the relevant provision of the Remedial Plan or have not achieved the quantitative results specified in the Compliance Measures; and “NonCompliance” means that the County has not met most or all the material components of the relevant provisions of this Agreement.

This Third Report is based upon the Mental Health Expert's review of provided policies, procedures and directives proposed and/or implemented by the County, observations and assessments of the Mental Health Expert based on tours of the jails, and review of medical records and data collected by the County. I visited Smith Correctional Facility (SCF) for one days Cois Byrd Detention Center (CBDC – formerly Southwest Detention Center) for a half day, Robert Presley Detention Center (RPDC) for one and a half days, the Detention Care Unit (DCU) for three hours. I was provided full access to patients and staff and was assisted by staff knowledgeable in relevant topic areas including mental health, nursing, custody, classification, quality assurance, and administration.

I observed three groups (one at CBDC, one at RPDC and one at SCF); met with psychiatrists, Clinical Therapists, nurses, Recreation Therapists, and Behavioral Health Specialists; observed pill lines and multi-disciplinary team meetings; conducted group interviews on general population units; rounded on patients in the DCU; reviewed medical records; interviewed 14 patients in private; and spoke with many more patients during visits to the units. In addition, I met with mental health leadership at County offices for one hour, met with a variety of staff to discuss the Continuous Quality Improvement Program, and conducted a one-hour exit

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interview. We also had a one-hour conference call with counsel from the Prison Law Offices and Riverside County and mental health leadership to discuss moving into the quantitative phase of review. Included in this report is a section outlining a plan for moving this forward.
I reviewed medical records of 13 patients that I also interviewed while on site. These are included as Appendix 1.
The County provided the following information for my review:
 Two DVD’s of data from the County including: o Recreation (yard) statistics from August through December 2017 for each jail (RPDC and SCF were each missing one month) o Tabulation of notifications to mental health regarding lengthy sentences for 2017 o Tabulation of mental health participation in transfers o Inmate Death Review policy 501.22 o Two inmate death reviews
 RUHS-BH detention services staffing for March 2018  Slides of RUHS-BH Detention Services trainings:
o Professional Behavior o Risk Assessment o Self-Care  RUHS-BH Detention Services 2017-2018 Detention Reports Catalog (draft)  RUHS-BH Detention Services quality improvement meeting agendas and reports o Time studies o Chart reviews o Indio, RPDC, CBDC presentation summaries on Service Codes, o Indio presentation summaries on Client Care Plan o Indio, SCF, CBDC presentation summary on Documentation Workshop o Listing of CQI studies from each facility (local CQI initiatives)  RUHS-CHS CQI minutes and supporting materials from January 2018 meeting  Reports on mental health population: o Acuity ratings for all evaluated inmates and evaluated inmates in administrative
segregation – countywide and by facility o February 2018 reports on:
 Behavioral health screenings  Behavioral health needs requests  E-MAR psychotropic medication lapses  Bridge medication verification  Administrative segregation follow-up  Safety cell transitional follow-up  Open behavioral health cases

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 Open cases with an assessment  Psychiatric encounters  Inmates on psychotropic medications o Behavioral Health Indicators from 3/1/18 to 3/31/18, including  Behavioral health screenings  Behavioral health assessments (including timeliness data)  Behavioral health care plans (including timeliness data)  Behavioral health needs requests (including timeliness data)  Psychotropic medication lapses  Bridge medication verification  Safety cell transitional follow-up  Administrative segregation follow-up  Discharge planning for inmates release during that time period  Acuity level for inmates booked during that time period  RUHS-BH Detention Services training rosters and training materials for comprehensive mental health services training from 10/2/17 at all sites  RUHS-BH Detention Services training rosters and training materials for new Card Reader System Training  RUHS-BH Detention Services Behavioral Health Specialist training manual for RPDC  RUHS-BH Detention Services Clinical Therapist training manual for RPDC  Group schedules for RPDC

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EXECUTIVE SUMMARY
I begin by congratulating the County on achieving NCCHC accreditation at all five facilities. NCCHC accreditation demonstrates that the County has put in place policies in key healthcare areas. While the NCCHC accreditation is not quality oriented (i.e., does not depend substantially on the actual care delivered) and the standards lack some degree of specificity, largely because they must apply to all jurisdictions and all types of facilities, they address general and essential systems issues. In short, this accreditation reflects the County’s efforts to develop the infrastructure needed to deliver care properly.
Riverside County has made a reasonable adaptation to the security requirements for clinicians seeing patients in contact areas that had substantially reduce patient contact at the time of my previous report. The County has installed electronic locks that clinicians are able to activate from inside the rooms; clinicians have radios as well. The County has also restored or added runners who are providing much needed access to care for the mentally ill, though access to patients on residential units, especially at RPDC (where neither mental health nor psychiatry are seeing patients in the clinic), remains a challenge owing in part to space limitations; the planned physical plant changes are not yet done. This has helped return services back to levels prior to June 2017.
Non-contact visits remain the rule at RPDC. The plans to expand RPDC and SCF clinical space continue forward. Space challenges have increased at CBDC owing to mental health staff now not being able to utilize some unit program rooms.
Program tables have begun to be used, but there remains some uncertainty about how they will be used. There is no consistent practice regarding their use, including when patientinmates must be restrained to the table, and I have not been provided a RCSD policy or procedure covering their use. The practice should be consistent, and restraint used only when necessary; for example, if a patient would not be restrained for a medical appointment, they should similarly not be restrained to the table for mental health treatment.
The County has also made progress in other areas, including further development of the data systems needed for proof of practice. The County’s ability to extract data from the Electronic Health Record (EHR) has continued to grow. Custody has also begun to develop some reports to track out of cell time more effectively, largely using spreadsheets they have created; Information Technology (IT) support would greatly speed and enhance this process, but RCSD is to be commended for moving this forward internally.
I note that coordination between medical and mental health could be stronger. While not an element of the remedial plan, solid coordination between mental health and medical is necessary to achieve substantial compliance. Areas that are particularly important in this regard are: CQI, referral, patient healthcare requests (kites), safety cell and restraint assessment, and medications generally. Assuring that relevant policies, procedures, charters, and the like address the relationship and responsibilities would help promote coordination.

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Regarding access to care and quality of care, the County is making progress. The intake process is improved and most seriously mentally ill are being promptly identified, though initial medications are not always being promptly ordered. The improvements to the intake area at CBDC are not done but should help facilitate communication.
The retrieval, triaging, and response to patient requests for mental health care continues to need refinement. Improved tracking of the process will be necessary to both troubleshoot and provide proof of practice.
Safety cell management is sound except that stepdown procedures, in terms of restoration of property and privileges during safety cell placement, are not in place. Patients are being seen less frequently at cell front and mental health contacts are regular. Nursing monitoring is mixed, but patients are being evaluated at least every 12 hours in almost all cases. Logs are being completed consistently. Transitional services of those leaving safety cells and returning from the DCU are administered consistently, though not reliably on a daily basis as intended.
There remain substantial problems in delivering services to the seriously mentally ill on administrative segregation. One notable positive development is the greater collaboration between mental health and custody in reviewing the need for continued administrative segregation; documentation of this review is also being developed. The remedial plan requirement for daily mental health contacts for patients on administrative segregation has both proven very difficult to achieve and diverted resource from productive treatment. In addition, access to these patients to provide services remains a significant problem; even if more mental health resources were available, it is unlikely that current limitations on access would provide adequate access to render needed services. I noted some evidence that patients are being returned to the jail from the DCU without being fully stabilized, likely due to insufficient use of involuntary medications and longer-term commitment. There are now two Clinical Therapists at the DCU, but they are yet to be fully utilized; plans for providing greater access to patients are being developed. The County is also moving to develop mechanisms for providing emergency and, ultimately, involuntary medications in the jail, the latter in accordance with recent statutory change permitting this. In addition, the County is developing a clinic to administer long-acting injectable antipsychotics. These developments should help address the needs of the seriously mentally ill, especially those on administrative segregation and in the DCU.
While group treatment has returned to previous levels, access and fragmentation remain a problem. There is both limited capacity (not enough groups to accommodate the numbers of patients) and custody provisions that prevent patients from completing group curricula. The latter is related to limitations on mixing of patients, some of which are unnecessary, as well as frequent moves. For instance, at SCF (at least), patients on upper and lower tiers of a single unit are not allowed to attend groups together. A formal process that clearly identifies inmatepatients who must be kept separate would help tremendously; some conflict in this population is inevitable but, in most instances, need not result in enduring separation. Careful attention to

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group enrollment that both addresses clinical need and potential interpersonal conflict is needed and requires collaboration between custody and mental health. Here, it must be recognized that interpersonal conflict is much more of a risk in unstructured activities (e.g., dayroom or yard with no formal, structured activity) than in structured activities such as groups; thus, keeping tiers separate for the unstructured activities but allowing some mixing for structured activities is reasonable and promotes access to care and efficiency while addressing the risk of patient conflict. This not only serves treatment needs but provides a measure of readiness to advance to a lower level of care/custody; those who can succeed in structured communal activities may be allowed a trial of communal unstructured activities in a more broadly mixed population.
Reentry services have also been improved. There is better documentation of both individual and group reentry services. However, there are still seriously mentally ill patients who have received no reentry services and medications are not consistently being provided at the time of release. A plan to have peers assist in reentry is currently on hold; this is a method used by many systems to both augment traditional services but, more importantly, serves as a
It is important to note that the County has not yet been able to fill 90% of its mental health positions. The County should consider what steps it can take to streamline the hiring process, make the positions more attractive, and widen the potential pool of candidates. Despite the staffing shortfall, the County has continued to make progress. I also note that while there is some turnover, a good many staff remain – a testimony to their commitment and to the quality of the leadership.

In terms of formal compliance, I report on the following measures, most of which remain global currently. The County previously achieved substantial compliance on the following measures:
 Consent Decree Training
In my opinion, the County is also now meeting substantial compliance on:
 Health Care Records (contingent on production policy on maintenance of the EHR)  Housing the mentally ill
The County has achieved partial compliance on the following measures:
 Intake Screening (elements relevant to mental health services) – very near substantial compliance
 Timely Access to Care (elements relevant to mental health services)  Medication Administration and Monitoring (elements relevant to mental health
services)  Confidentiality (elements relevant to mental health services)  Custodial Environment (elements relevant to mental health services)

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 Treatment of the mentally ill  Treatment Space for mental health services  Suicide Prevention  Continuity of Care for the releasing mentally ill  Policies and Procedures  Continuous Quality Improvement (elements relevant to mental health services)  Review of In Custody Deaths (elements relevant to mental health services)
The County is downgraded to non-compliant on:
 Staffing (elements relevant to mental health services)
The following is not rated owing to limited data:
 Restraint
In Appendix 2 of this report, I comment on plans to move towards a more quantitative approach to compliance monitoring; the County has made sufficient progress in infrastructure development to move in this direction. I welcome comments from the County and plaintiff regarding both the general plan and the County’s ability to take on certain elements of the data collection, almost of which will support CQI initiatives in the future.

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Table of Contents
HEALTH CARE GENERALLY (elements relevant to mental health services) .................................................. 9 Intake Screening........................................................................................................................................ 9 Timely Access to Care ............................................................................................................................. 10 Medication Administration and Monitoring........................................................................................... 13 Confidentiality......................................................................................................................................... 15 Health Care Records................................................................................................................................ 15 Staffing .................................................................................................................................................... 16 Custodial Environment............................................................................................................................ 16
REVIEW OF IN CUSTODY DEATHS (elements relevant to mental health services) ..................................... 21 CONTINUOUS QUALITY IMPROVEMENT PROGRAM (elements relevant to mental health services) ........ 21 MENTAL HEALTH CARE ............................................................................................................................... 23
Treatment ............................................................................................................................................... 23 Housing ................................................................................................................................................... 30 Treatment Space ..................................................................................................................................... 31 Suicide Prevention .................................................................................................................................. 32 Restraint.................................................................................................................................................. 34 Continuity of Care ................................................................................................................................... 34 POLICIES AND PROCEDURES ....................................................................................................................... 34 CONSENT DECREE TRAINING ...................................................................................................................... 35 APPENDIX 1 ................................................................................................................................................. 36 APPENDIX 2 ................................................................................................................................................. 54 Outline of Quantitative Mental Health Compliance Monitoring ............................................................ 54 Draft Information Request...................................................................................................................... 68

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HEALTH CARE GENERALLY (elements relevant to mental health services)
Intake Screening
The County’s plan to have a Qualified Mental Health Professionals (QMHP) do the mental health intake screening, except at times when there is no mental health on site when an RN will continue to provide that function, is largely implemented.
The screening form still needs some minor modifications as mentioned in my previous report. However, review of medical records demonstrates continued improvement in detecting the seriously mentally ill during the intake process.
The first set of data the County provided on intake screenings was included with reports under the general title: 2017-2018 Detention Reports Catalog (the copy provided was in draft form). RUHS-BH leadership informed me that there are some methodological problems with some of the reports in the catalog; comments below regarding concerns about methodology or data from this catalog are offered to help refine the reports. It showed results for March and April of 2017 only. In those two months, of 4219 bookings, 91% received a behavioral health screening. Note that those jailed less than 10 hours were, reasonably, excluded (the County intends to extend this to those admitted for more than 24 hours which will eliminate the cite and release population, which is reasonable). Owing to inaccurate release dates in TechCare, the eligible population included those “between an inmate’s time of booking and next booking.” This would seem to exclude those who had no subsequent bookings. However, there is no reason to believe that this would create any systematic error. The numbers examined were also large enough that the percentage is likely an accurate reflection of practice. Most facilities were similar in terms of percentages, though Blythe was notably lower, likely reflecting both staffing and transport issues. The general figures are in line with date provided for my previous report. That data was from later in 2017 and showed some inconsistency.
RU-BHS also provided data for February and March 2018 in the document Behavioral Health Screening, Assessments, & Care Plans. While the complete methodology was not provided, it appears that the County has standardized its approach. The overall rate of completion was 93.4% in February and 95.2% in March with all facilities above 90%. No longer trend data were provided but the numbers suggest slight improvement and it is likely that mental health screening is consistently being done in more than 90% of cases. However, no timeliness data were provided. Record review showed that in almost all cases mental health screening was done within 24 hours of booking and most were within 8 hours.
The intake locations and confidentiality issues are largely unchanged. Plans to make modifications remain in place but are yet to be completed.
The County included a May 2017 report on bridge medications. The methodology appears to be that the County examined those patients on psychotropic medication currently (it is not clear what date or date ranges current included) and then determined the number of those booked in May: 600. Of those 600, they then queried TechCare to determine how many of those 600 stated that they were on psychotropic medications at the time of intake: 100. Then the percentage of those that had a sick call request generated within 48 hours; the purpose of this is that the expectation is that if a patient did not have medications verified within 48 hours, a sick call request was to be generated. The County found that 100% had no sick call, indicating that all had, presumably, been verified within 48 hours.

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The Behavioral Health Indicators from March 2018 uses a better methodology in that it identifies patients that reported taking psychotropics at the time of booking, but it still uses the generation of sick calls to determine whether verification was done. Of 222 qualifying cases, only 1 had a sick call generated. It is highly unlikely that 221/222 (99.5%) had medications verified.
There were no data regarding psychiatric follow-up within 7 days for those patients receiving bridge medications nor on whether those verified but without and order for psychotropics were seen by psychiatry within 24 hours.
Psychiatrists report that medication verification is being done more reliably and that they are being notified quickly, usually within a day, of patient admission.
RU-BHS also provided data for February 2018 in the document Behavioral Health Screening, Assessments, & Care Plans showing that 87% had medications verified. This report also includes a pie chart indicating that 9% of patients reported being on psychotropics at intake, somewhat different than the 100/600 = 16.7% above); it is not clear if the methodology was changed.
The methodology is flawed. First, including only those on psychotropics would exclude those who reported being on psychotropics but never received any. Second, the report would mark as compliant any case where a sick call was not generated, whether or not the medications were verified. Third, there was no determination of whether positive verifications resulted in an actual order of medications within 48 hours. Lastly, it is virtually impossible that 100% of those patients reporting being on psychotropics at intake had this verified; the reduction to 87% suggests that staff are more assiduously placing non-verified patients on sick call, but it remains unclear how accurately these data reflect reality.
Chart review demonstrated that while most patients whose medications are verified are started promptly, but there were some cases where patients reported taking medications but there was no evidence of verification, ordering of psychotropics, or a visit with a psychiatrist within 48 hours. It was also not uncommon for the first psychiatric visit, and initial medication orders, to be at about two weeks after admission, even for patients rated at higher levels of acuity.
Compliance contemplates patients on psychotropics being seen by a psychiatrist within 24 hours, getting them immediately from stock, or receiving verified initial medications within 48 hours if ordered through the pharmacy.
The County continues to be in partial compliance with this element. The screening process is substantially improved. Medication verification, bridging orders, and initiation of appropriate medications are inconsistent. Once the County can better demonstrate prompt psychiatric
Timely Access to Care
The RU-BHS document Behavioral Health Screening, Assessments, & Care Plans showed 1,581 open cases as of 3/1/18: 20 at Blythe, 343 at CBDC, 117 at Indio, 477 at RPDC, and 624 at SCF; this is similar to previous data and in line with national statistics.
Health Care Request Forms are only available on the units, not in libraries and program rooms. Custody staff will examine the feasibility of expanding the availability of Health Care Request Forms, but there are legitimate logistical problems. The parties may want to revisit this requirement. There is also inconsistency in the process of accessing and collecting Health Care Request Forms in restrictive housing

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settings with nurses collecting them from patients in some and patients putting them in dayroom collection boxes in others. This should be standardized in a manner that best assures promptness and accessibility.
The County has not modified its approach to managing Health Care Request Forms for mental health. Nurses continue to triage these requests and forward them to mental health. This is a legitimate approach but must have an accompanying proof of practice that includes verifying that the forms are picked up daily, triaged promptly and accurately, forwarded to mental health according to the acuity of the problem, and responded to timely by mental health. This is an essential CQI function.
At CBDC, Health Care Request Forms were available on all units. Nurses reportedly pick them up after midnight, triage them, scan them, and send them to mental health. Mental health reports getting these timely. Night shift mental health staff then review them; any reporting symptoms are placed in the triage queue for follow-up within 48 hours; there are usually four to five of these every day. Others are slated for routine follow-up within two weeks.
At SCF, Health Care Request Forms were available on all units I visited. At RPDC, Health Care Request Forms were available on almost all the units I visited. At both facilities, I had varying reports regarding the process, but it was generally the same as at CBDC. While at RPDC, I asked to see that day’s Health Care Request Forms for mental health. Of the 10 that were delivered to mental health on the day of my visit, 9 were more than 24 hours old; of these, 4 were three days old and 1 was four days old. Clearly, this does not represent a timely process and does not comport with the CHS CQI report of 100% of health care requests collected, presuming that this is measuring timeliness as there would be no way to know if a health care request was not collected.
The RUHS-BH report 2017-2018 Detention Catalog Report (draft) showed that from 8/1/17 to 11/21/17 there were 4,512 Health Care Request Forms related to behavioral health, of which one third were priority requests. The percentage of priority requests (those reporting symptoms) completed within 48 hours (72 hours on weekends) was about 20% and the average time for all requests to be completed varied from 0.8 days to 8.8 days for different types of practitioners (these different queues are being eliminated with all going into either a behavioral health triage or psychiatry queue, which will simplify tracking and analysis).
These data are difficult to interpret as the numbers accounted for in the associated table are 2,913 and the associated bar graphs do not include the numbers for each type of practitioner. There were also problems and questions regarding the methodology; note that this is the catalog that RUHS-BH leadership is aware has some methodological problems. First, those pending sick call requests were excluded from the cases. If these include large numbers of cases that are greater than the timelines reported above, then this data may appear better than reality; at the least, the percent of pending reports and their average time pending should also be reported. Second, the time begins from the “creation date,” but it is not clear from the report whether this is the date the patient made the request (the critical date), the date the nurse input the request, or the date mental health input the request. Third, the number of requests is substantially more than in subsequent months and it is unclear which is a more accurate reflection of numbers of patients submitting Health Care Request Forms for mental health reasons.

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The CHS CQI minutes from 1/18/18 included response times for an unnamed facility for 11/8/1712/6/17. 154/177 for those for Clinical Therapists were routine and were seen an average of six days, 22/177 were urgent and were seen in an average of five days, and the one emergent request was seen at four days. The BHS responses were all routine and seen in an average of 4.5 days. 81/102 routine psychiatrist responses were seen in an average of five days and 21/102 urgent responses were seen in an average of 3.7 days.
RU-BHS also provided data for February 2018 in the document Behavioral Health Screening, Assessments, & Care Plans. These data appear to have been collected in the same manner and show reductions in time to completion to an average of from 0.7 to 5.5 days for both routine and priority cases. The percent of priority cases seen within 48 hours was also improved to 35.9%, though some average wait times for the larger queues were around a week. Routine requests were often seen sooner.
The Behavioral Health Indicators from March 2018 show only 63 patient Health Care Request Forms for mental health, 34 or which were priority and 29 were routine. 88.2% of priority requests were seen within 48 hours and the average time to completion for all requests was 0.8 days. Note that the data excluded any incomplete requests, which would be expected to skew the data towards shorter times as cases that were never seen and were pending (likely to be more than one day) were excluded; these cases should be included in the analysis to give a more accurate picture of timeliness of response.
Though there are questions about the accuracy and completeness of the data, it appears that response times to Health Care Request Forms for priority requests have improved. Whether the County is including too many cases in the priority (urgent/emergent) category is a question. Even if a patient reports symptoms, a rapid response may not be necessary, though that is a best practice. Some symptoms, for example isolated insomnia, may be responded to on a routine basis, i.e., within two weeks.
The County continues to have no means of tracking response time to inmate declared emergencies. This will likely require coordination between custody, medical, and mental health to ascertain how to track this and with which data system(s).
Patients report that mental health is generally responsive to requests to be seen, whether to Health Care Request Forms or direct requests to health care staff and deputies. Reported response times were usually 1-5 days except for psychiatrists, which was typically reported as weeks. This is better than previous patient reports. Patients almost universally stated that mental health response times were much better than medical response times.
Psychiatrists continued to report that they were usually able to see routine patients within 30 days of an initial visit and conduct follow-ups every 30 to 90 days. Record review demonstrated that psychiatrists see patients regularly, though as noted above, initial visits were sometimes delayed given the acuity. In almost all instances, patients on psychotropic medications were being seen at least every 90 days, and almost always substantially more often. Psychiatrists at RPDC continue to report that accessing patients remains difficult and impairs productivity because of space limitations, challenges getting patients out to interview rooms, patients being out to court or other locations at the time of the appointment (there is little coordination between custody and health services in terms of scheduling), and because of the time it takes to move through the facility.

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Patients in the residential units continued to report that mental health staff do rounds almost every day and ask how they are doing (almost always during pill call). They reported meeting with a Clinical Therapist individually at varied frequencies, mostly consisting of brief monthly contacts that were primarily focused on current symptoms or release planning. However, almost all felt the Clinical Therapists were helpful and had their best interests in mind; they simply wished for more contact and more opportunities for therapeutic sessions. Many lamented the loss of groups.
Consistent with my previous report, most patients are being seen sufficiently regularly by a psychiatrist. Most patients are getting occasional case management contacts with a QMHP, and a few patients are getting active treatment either in group or, rarely, individual therapy. The penetration and dosage of groups remains a challenge. There are too few groups to meet the needs of the population and many patients do not complete course of group therapy. It was not uncommon to see patients attending a single session of several different groups. Patient moves and custody limitations on which patients can be in groups together hamper the ability to provide appropriate services. For instance, patients at SCF on different tiers within the same pod are not allowed to attend groups together.
That said, with the increase in runners and the reasonable resolution of security requirements for program spaces, there are fewer groups being cancelled and they more often run on time and for the full session. Whether the County has sufficient staffing in both custody and mental health to provide access to all seriously mentally ill, given current policy and practice, remains a question.
The exception to the above are patients on administrative segregation whose access to care is limited. Many of these patients are severely mentally ill and doubtless are on administrative segregation due to behavioral problems related to their mental illness. In visiting unit 5B and attending the conjoint staff review of patients, it remained clear that many of these patients often refuse care, including medical care (I saw no assessments of patients’ competency to refuse care), and often refuse to come out for other activities. They are substantially isolated. The day I was on the unit, it was malodorous, several patients’ cells were filthy, including two smeared with feces, and several had days of food detritus. Medical records demonstrated significant problems with the care of one of the two patients reviewed, in part due to failures related to DCU services and not securing involuntary antipsychotic treatment. More aggressive treatment of this seriously ill population is needed.
Here again, the County remains in partial compliance with respect to the mental health services elements relevant to Timely Access to Care.
Medication Administration and Monitoring
I again observed morning medication administration at RPDC on a residential mental health unit. It ran the same as during my last visit except that the nurse handed out Health Care Request Forms, though some patients continued to complain at RPDC, SCF, and CBDC that nurses would sometimes not hand them out. Nurses go cell-to-cell for patients on administrative segregation (e.g., unit 5B at RPDC). For top tier patients, the nurse carried envelopes of medications with patient names and cell numbers and then later input the information into the electronic medication administration record; I continue to have concerns about this process, but it is being done better than before. On other units, deputies announce pill call and patients come to the unit door one by one. The nurse properly identified patients and did mouth checks most of the time. If patients are suspected of cheeking, custody reportedly usually does prompt cell searches.

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One important change is that nurses are no longer frequently changing the floors where they do sick call. They reported that this had helped clinically both easing patient identification and allowing them to better monitor patient status. The nurse I observed at RPDC did a very good job; she knew the patients, interacted with them professionally, and was attentive to their clinical status. A deputy and mental health clinician accompanied us cell-to-cell on 5B; the mental health clinician had brief contacts and asked some patients if they would come out.
Review of medical records demonstrated that almost all MARs are complete; it is not possible to determine their accuracy.
Nursing staff reported that they send refusal notices (using a sick call notice) after three days of a patient refusing a medication. Psychiatrists reported that non-adherence was being reported fairly reliably, but more often by Clinical Therapists than nurses. Records showed that most charting on nonadherence was by Clinical Therapists.
Emergency medication orders are shipped from the pharmacy to the facility the same day; routine orders are by the next day. There is a regular monthly report that is monitored weekly to assure that medications are given daily.
Patient reports regarding medication administration varied some. Patients reported that pill call was generally on time except one female patient reported pill call was sometimes three hours late (the other two women I spoke to were too ill to reliably report). Custody and mental health staff also reported that sometimes the pill line at the female mental health unit is sometimes quite late.
Few patients reported that ordered medications were unavailable. Several reported that their medications had expired but if so were usually restarted within days, rarely longer; this was consistent with the County’s report based on aggregate data reported below. One patient at RPDC reported waiting several days to get a newly ordered medication and being told by a staff member that the medication was available, but the nurse refused to go to the seventh floor to get it.
RU-BHS also provided data for February 2018 in the document Behavioral Health Screening, Assessments, & Care Plans showing that there were 1298 patients on psychotropics at the end of the month. The jail census at the time of my visit was 3905 so about 1298/3905 = 33% on psychotropics, which is slightly higher than would be expected, though it depends a good deal on the fraction of the population that is female as psychotropic use is about 50% in the female population (I did not receive data on the male/female distribution).
The report 2017-2018 Detention Reports Catalog includes a section on psychotropic medication lapses based on the electronic medication administration record. This appears to be a report showing when active prescriptions are unavailable to the nurse when the time of administration arrives. 71% had no lapses. Of the remaining number, almost all were single dose lapses. RU-BHS also provided data for February 2018 in the document Behavioral Health Screening, Assessments, & Care Plans which showed only 4.48% missing any doses (9/10 were just one dose). Similar data from March 2018 in the document Behavioral Health Indicators showed that 13.68% had lapses with an average of 1.6 doses missed; only 15 patients missed three or more doses. The report excludes many reasons for missing doses (e.g., not administered due to lockdown and not administered because the medication was not available), presumably because it is intended to capture only medication lapses, though lapses are not clearly

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defined. While the County should not have even that many lapses, the fact that almost none were for more than a single dose and that the percent was dramatically reduced indicates that it is not a significant problem, especially from a purely pharmacologic perspective, though missed doses will be stressful for many patients. However, failure to administer ordered medications for any reason should also be tracked and falls under the provision in the remedial plan which only provides for lapses related to those “required by non-routine facility security concerns.”
The County remains unable to demonstrate its compliance with the provisions for medication administration when patients are out to court, in transit to outside appointments, or upon transfer.
At the DCU, Clinical Therapists and nurses reported several problems with medication orders. After hours admission orders generally were often not timely because the psychiatrists who evaluate patients at the emergency room do not have admitting privileges so that orders must be written by a different psychiatrist; these admitting psychiatrists are often unwilling to order medications owing to not having evaluated the patient. This is a structural problem that needs to be addressed. The clinical staff also note difficulty getting long term involuntary medication orders; this likely needs to be addressed through supervision.
Psychiatrists report that laboratory results are returned timely but that they are sometimes not informed when patients refuse blood collection. For those patients on antipsychotics, most had completed AIMS. However, obtaining baseline laboratories and laboratory monitoring, especially for metabolic syndrome (a common problem for those taking antipsychotics) remains problematic.
Owing to inconsistent medication monitoring and concerns about upper tier medication administration, the elements of Medication Administration and Monitoring relevant to mental health services is in partial compliance. This should, still, be easily remedied.
Confidentiality
There have been no changes or developments here. Progress will depend mostly on completion of planned construction. This should allow reduction of cell front visits, one of the chief problems with confidentiality. Development of some intake areas will also help.
I did see a degree of greater respect for confidentiality on the part of some custody staff who purposefully maintained some distance to allow more private communication with clinicians, but it was not consistent.
This remains in partial compliance.
Health Care Records
There is now an EHR that both medical and mental health clinicians can fully access. Policy to support needed modifications, maintenance, and improvements was not provided to me.
As noted previously, the County is making key modifications to the EHR and has several initiatives related to mental health. These modifications will be necessary to establish adequate quality improvement and quality assurance as well as proof of practice of a number of measures within the Remedial Plan.

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Once policy is provided that meets the terms of the Remedial Plan, this item will be in substantial compliance; this rating is contingently offered.

Staffing
A RUHS-BH jail staffing report from 5/15/17 is the most recent overall staffing I received this reporting period, though I previously received a 7/17 report that shows identical numbers of funded positions and about the same fill rate. The overall positions and filled positions are in the following table.

Position Type Sr. Medical Records Technician Office Assistant II Office Assistant III Behavioral Health Service Supervisor Clinical Therapist II Behavioral Health Specialist III Behavioral Health Specialist II Senior Clinical Therapist Recreation Therapist Psychiatrist IV Medical Records Technician Total

Funded FTE 5 7 5 7 76 4 21 6 5 13 1 150

Number Filled 4 6 6 6
63.5 4 21 4 2
10.98 1
128.48

Percent Filled 80% 86% 120% 86% 84% 100% 100% 67% 40% 84% 100% 86%

The total number of positions
At present, eight Clinical Therapist positions are empty but there are four pending hires. Behavioral Health Specialist Positions are full (actually, one over at 25). There remains only one mental health clinician at Blythe.
CBDC is down only one Senior Clinical Therapist; there are 14 Clinical Therapists total. Clinical Therapists are divided between intake and unit coverage, which has been effective for both getting intakes done timely and providing more consistent and structured coverage for the units. There are about 2.5 FTE psychiatrists, providing coverage six days per week. There are six Behavioral Health Specialists and one Recreation Therapist who run groups.
Overall, RUH-BH has still been unable to fill 90% of its positions.
I have not been provided an annual assessment of staffing corresponding to the requirements of the remedial plan.
At this point, largely owing to the failure to fill 90% of positions, challenges achieving substantial compliance that may readily be due to inadequate staffing, and the lack of an annual assessment, this element must be downgraded to non-compliant.
Custodial Environment
The total census of the jails was 3905 at the beginning of my site visit.

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Custody staff were generally respectful and professional with staff and prisoners. Several patients in the residential units continued to report that a minority of custody staff were not respectful and made fun of the mentally ill.
In general, the facilities were clean, though RPDC less so than SCF and CBDC. As noted above, unit 5B at RPDC was malodorous and many cells were unreasonably filthy.
At CBDC, when patients are seen in the program rooms, they are uniformly cuffed to the program tables, even if not on administrative segregation. This interferes with treatment and is not consistent with practice in other clinical settings (e.g., medical clinics). The Recreation Therapist is also only able to provide treatment for those in administrative segregation at cell front; this clearly interferes with treatment and either forces breeching confidentiality or precludes discussion of any significant personal clinical issues.
Behavior management plans, used to assist custody and mental health in providing consistent and complimentary services, have not been instituted yet. These are required by the Remedial Plan. At SCF, they do what might be termed rudimentary behavior management plans through email, team meetings, and the use of the unit log books. RPDC does something similar for patients with self-injurious behavior but there are no formal plans.
Patients on 12A and 14G at SCF complain that they cannot work out on the units and cannot even stretch. They report having access to the yard 2-3 times weekly where they can exercise, though not on a set schedule and sometimes as early as 0600. These are dorm settings, so dayroom access is not an issue.
Unit 16 patients at SCF reports regarding access to the dayroom varied but most reported getting out for 30-60 minutes 2-3 times daily. Yard access was consistently reported to be 2-3 times weekly, usually for 30-45 minutes; some reported that it was available even more frequently.
Patients in the mental health units at RPDC reported access to the dayroom 2-3 times per day for 30-60 minutes.
SCF patients reported that custody staff were generally respectful and helpful, though one patient reported seeing custody beat another patient on evening shift but could not identify either the patient or the custody staff. RPDC patient reports regarding custody staff were more mixed.
Cell searches are conducted randomly about twice per month; the results are conveyed in team meetings with mental health staff. Clinical staff reports that if patients are suspected of hoarding, custody conducts cell searches promptly in most instances.
RCSD provided data on yard times from the last several months of 2017. The summary tables suggested that the those in mental health residential units, including those on administrative segregation, were almost always being offered or did receive 3 hours of yard time per week. The following table shows a summary of the data for the residential treatment units serving the seriously mentally ill (SMI) for those on administrative segregation in RPDC and those in GP residential mental health units for RPDC and SCF. The numbers in the table are the percent of the population receiving 3 hours of yard time that week.
August 2017 September 2017 October 2017 November 2017 December 2017 RPDC SMI Ad Seg

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Week 1

85

90

Week 2

80

90

Week 3

95

100

Week 4

55

95

Week 5

RPDC SMI GP

Week 1

100

100

Week 2

100

100

Week 3

100

100

Week 4

100

100

Week 5

SCF SMI GP

Missing

Week 1

Missing

100

Week 2

Missing

100

Week 3

Missing

99

Week 4

Missing

100

Week 5

100

100

Missing

100

95

Missing

100

100

Missing

100

100

Missing

100

100

100

Missing

100

100

Missing

100

100

Missing

100

100

Missing

100

100

100

99

100

100

100

99

Missing

100

49

Missing

100

100

Yard times varied; some were before 0700 and these were often unattended or had low attendance.
I reviewed the raw data for September and October for one tier on one unit at SCF in detail and inspected the whole raw data set: Unit 16E, bottom tier. I added up all the minutes of yard time, many of which were not reported because no patients went to the yard (the number going to the yard was reported for these units). For September, RCSD reported 12 yard periods for that particular tier. The shortest time was 10 minutes and the longest 65 minutes, but most were 40 to 60 minutes. For four of the 12, no patients went out. At most, 5 patients went out; most often it was one or two. The average documented yard time per week was 78 minutes (a total of 313 minutes were documented). Setting the times for the 4 sessions with no patients to 60 minutes, the average available time was 153 minutes per week. The results for October were similar, with 88 hours per week documented with five sessions showing zero patients attending yard. Substituting 60 minutes for those sessions, there were 165 minutes per week. Looking at each individual week, none of the weeks in September totaled more than 180 minutes, even using the 60 minutes when none went to yard, so it is clear that the 100% reported (see above table) cannot be correct. This is also the case for the second week in October; the first week reached 180 exactly if the -5 minutes reported for one session is changed to 60 minutes.
I also reviewed the administrative segregation data for RPDC unit 5B. RCSD examined 20 individual cells for this data. What stands out is that for most days, the majority of the in/out times are not indicated, which appears to indicate that they are not out of their cell. While for some data points, there is an indication that tiers or cells were “not cleared,” presumably meaning that deputies cancelled yard time. But for the administrative segregation cells there is no such indication. I inspected the yard times for two cells in November 2018: 5B48 and 5B49. There were 10 possible yard times but neither cell showed any in and out time, only “R@[time]” where the time was filled in, presumably indicating this was when they were offered yard. However, all the cells having no in and out time had the same time entered for “R@[time].” There is no indication whether the patient refused to come out or whether they were denied yard time. It is unlikely that all were offered yard at that same time, so it is not clear

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what this means or how it was counted. There was no day where more than half of the cells showed an in and out time and many days where none did.
RCSD also provided data for inmates not in residential housing units for comparison. While the questions regarding the accuracy of the data make it difficult to know how valid this comparison is, since the methodology used was the same, the relative times (if not the absolute differences) may reflect general practice. The data show that at RPDC, the GP/PC populations are offered similar yard opportunities, though the numbers reported coming out of the individual units are lower on the residential mental health units. Those on administrative segregation also appear to be treated similarly, though the percentage is notably lower in August 2017. At SCF, the GP/PC data show similar yard times, again with fewer utilizing the yard from the mental health units. Inspection of the data does not show any obvious differences, other than the lower numbers of mentally ill in the yard. For SCF units 9D and 10A, the weekly averages were 77 minutes and 90 minutes respectively. Thus, even on the GP units, inmates are not receiving three hours of yard time weekly.
The RCSD policy Recreation specifies that inmates will receive three hours of recreation every seven days. The remedial plan specifies that each recreation period will be at least one and a half hours. The above data shows that this is not yet being achieved.
In summary, it appears that the actual yard times were not used in the calculation of yard times offered to units (or tiers of units). And for those on administrative segregation, it is unknown whether yard times are being offered or not when there is no in and out time. Thus, it is highly unlikely that the percentage of the mentally ill are actually being offered 3 hours of yard time per week was as high as reported. That said, three points need to be made. First, RCSD is doing its best to collect this data without a proper system in place to do so. It is essentially a hand collection process and those doing this are to be commended for their substantial effort; with further refinement, it might be possible to make this methodology yield accurate data, but it is not sustainable and highly prone to error. There are clear errors in the raw data (e.g., in times before out times) and many missing data points. The second point is that RCSD does appear to be offering regular yard times, but it remains unclear for how long and how many patients are not being allowed out versus refusing time out, especially for those on administrative segregation. While the summary report included a column entitled “cells not cleared for recreation.” I could not ascertain how this number was computed and it did not always account for the difference between numbers of inmates reported as receiving (or offered?) yard time and the number of cells. Lastly, there is no apparent difference between the yard times for the mentally ill, though fewer use the yard, which is to be expected to some degree.
The RCSD policy 504.42 Dayroom Management reflects that dayroom times extend from 0800 to 2300 as specified in the Remedial Plan. The policy does generally reflect an intention to maximize dayroom time. It does not specify how much time inmates are to be afforded in the dayroom or how dayroom time varies with custody or classification level. Thus, it remains difficult to determine what the expected amount of dayroom time is, so it is still impossible to determine if dayroom time is being offered according to policy. This leaves the only way to assess the dayroom time for the mentally ill is to compare it to dayroom time of other inmates. While this is not a formal measure, if there is a marked and consistent reduction of dayroom time for the mentally ill, this would suggest that dayroom time is not being maximized for the mentally ill. While some reduction compared to general population

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inmates would be expected in higher acuity settings owing to an expected increase in behavioral disorder in this population, that should not be true for those in lower acuity settings.
I did not receive any data on dayroom times for this report.
In my interviews with patients, I asked about dayroom and yard times. As before, patients in residential mental health units at RPDC reported highly variable access to dayrooms, almost all noting that it depended on the deputy. Those not on administrative segregation continued to report getting out in the dayroom one to three times daily, usually for 30-60 minutes. They reported usually come out one tier at a time but sometimes in smaller groups. They gave variable reports on access to the recreation area (yard), most saying it was once per week for 90 minutes and others saying it was one to two times per week for about an hour.
Those on administrative segregation at RPDC continue to report that they get 30-60 minutes in the dayroom each day (in one or two sessions). They gave variable and likely unreliable reports regarding yard time.
At SCF unit 16 (residential mental health), patients continue to report that they get dayroom 2-4 times daily, up to an hour each. They gave more consistent reports regarding access to the recreation yard with most all reporting 30-60 minutes, 2-3 times weekly.
The DCU is slowly moving to be less like a restrictive housing unit. There is now a room with a program table where Clinical Therapists can meet with patients one-to-one. Additional opportunities are being developed.
I attended a multi-disciplinary meeting at RPDC (for 5A/5B male residential mental health); it lasted about 15 minutes. As before, mental health staff, nursing, unit custody staff, classification staff, and the Medical Sergeant working with mental health units were in attendance. They discussed specific patients and those who were having problems as well as admissions and discharges. It was clear that staff were aware of at least some of the most ill and were attending to both dangerousness and grave disability.
In my first report and reiterated in my second report, I noted that there are two trainings, one by custody (included in new Custodial Conflict Intervention Training (CCIT)) and by mental health in the suicide training module (IFT Suicide Prevention Training), that address the “self-isolating inmate.” The County reported that it would complete the IFT Suicide Prevention Training by 10/31/16 but I have not received verification of completion or the curriculum demonstrating that self-isolation was covered. The County has offered CCIT since 7/24/16 and reports that it has trained 149 (rosters show 174); it is unclear what percentage of custody staff this represents but it does not appear to be nearly complete.
The use of administrative segregation of the mentally ill within residential mental health units remains a logistical challenge and raises questions about limiting privileges because of mental illness. Those on this status are offered only one hour out of cell time per day, solo yard access, and cannot attend groups; in short, they are under conditions quite similar to restrictive housing. Clinicians note that access to those on this status for one-to-one meetings can also be limited, interfering with their ability to provide needed services; Clinical Therapists are conducting daily rounds on them, but this is a brief cell front check-in, not treatment. Clearly, safety and security must be provided for patients and staff alike. However, it is necessary to be able to consistently meet the clinical needs of the patients, necessitating better access. There is a plan to procure classroom seating that provides for restraint to

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allow the most dangerous to begin attending groups, an important first step in determining their readiness to have more unrestricted access to peers and staff alike. The County has purchased correctional tables to serve this purpose and to provide options for meeting with patients individually, though as noted previously, the County is yet to make full use of these.
The elements of the Custodial Environment related to mental health services remain in partial compliance.

REVIEW OF IN CUSTODY DEATHS (elements relevant to mental health services)
I was told that there have been two deaths since my last report, one a suicide by ligature and the other related to rhabdomyolysis related to agitation. Death reviews on these were not provided.
Two death reviews of patients on the mental health caseload were provided. EH died in August 2016; the autopsy found the cause of death to be pneumonia and lung cancer. The death review found no problems. However, I have several concerns. First, the responding nurse found the body cold and with signs of rigor mortis. Rigor mortis rarely sets in less than two hours before death, especially in a person quiescent at the time of death. It is unlikely that the report that EH was seen alive 75 minutes before is accurate. Second, the patient was showing evidence of debilitation that appeared not to have been well evaluated. The review does not sufficiently address the possible causes of his lethargy or psychomotor retardation, poor cell care (to the point of smelling rotting food), lack of cooperation with forensic mental health evaluation, and psychotropic medication non-adherence. As these signs could have been caused by pneumonia, cancer, and/or depression, this should be explored in the review. This is especially important given that the illnesses causing his death were not detected. Depression itself is well-known to be associated with medical illness and it would be important to know whether this was considered, especially in a 58-year-old man with no known medical or mental health history. Third, there were no laboratory or other studies noted in the review. While that may have been reasonable, the review provides insufficient detail to determine whether such should have been ordered, whether by mental health or medical. Fourth, the potential impact of awaiting housing on the Behavioral Health Housing Unit was not considered, especially regarding possible differences in monitoring and treatment. In my opinion, the review is insufficient to determine whether there were problems with monitoring or mental health treatment.
SS died in January 2017. The autopsy found the cause of death to be peritonitis. There was no reason to believe that the patient’s mental health condition was related to the cause of death. The mental health review was limited in scope but sufficient to make this determination.
The mental health component of the death reviews is in partial compliance owing to the shortcomings noted above.

CONTINUOUS QUALITY IMPROVEMENT PROGRAM (elements relevant to mental health services)
The Continuous Quality Improvement Program (CQIP) continues to develop soundly. I met with CQIP representatives from RUHS-CHS, RUHS-BH, and custody. Custody does not provide data for the healthcare CQIP and does not have any healthcare related measures. However, custody has started to

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participate in the healthcare CQIP, hopefully heralding a more robust coordination that can both facilitate proof of practice for the purposes of achieving compliance with the terms of the remedial plan and, more important, to pave the way for continued healthcare operations enhancements in the jails in the future, especially access to care, which is a function of all elements of the system. Right now, access to care problems are tracked by unusual occurrence reports involving healthcare reports to custody when there are custody limitations that impact access. This is an inefficient and largely ineffective approach as it does not examine access generally and focuses only on failures in the existing system rather than also exploring opportunities for system improvement (in CQI language, it is a quality assurance approach, rather than a combined quality assurance and quality improvement approach).
As mentioned above in Timely Access to Care, tracking Health Care Request Forms assiduously from beginning of the process to the end is also an essential CQI function in correctional settings that is not fully tracked at this time.
There are certain RUHS-BH global reports that are not included in the combined CQIP reports. This includes important reports such as self-harm and staff injuries. While it is reasonable for local and limited CQIP projects to be developed and reviewed within each discipline or at a facility, key global reports and dashboard items for all disciplines should be part of the combined CQIP.
Current RUHS-BH CQI initiatives include: tracking a new substance abuse treatment program in the jails called “New Directions,” evaluation of a 12-session reentry group developed at RPDC, and collecting baseline data prior to initiating use of emergency psychotropic medications and starting the long-acting injectable antipsychotic clinics at RPDC and SCF.
RUHS-BH Detention Services produced CQI studies on a wide range of topics and measures, including: open cases, acuity, intakes, assessments, treatment plans, administrative segregation follow-up, safety cell follow-up, psychotropic usage, clinical supervision (primarily record review), and local CQI studies. Most of the data are covered in the relevant sections but some of these studies deserve comment here. Most notable was a very thorough set of reviews of clinical documentation from November and December of 2017; this is an important element of peer review. Each facility also conducted CQI studies (some the same across facilities, others unique to the facility) including: discharge planning outcome data, mental health screenings and resulting mental health acuity levels, safety cell outcome data, response times to urgent and routine sick calls, successful linkage to outpatient behavioral health clinic upon release, medication compliance of inmates, mental health assessment completion times, kite response times, grievance response times and process for appeal, percentage booked that were screened by RUHS-BH, bridge medication ordering times, duration of safety cell placements, timely access to care, total screenings in 2017, patient contact prior to civil commitment, review of man-down related to suicide or mental health issues, tracking treatment refusals, snack orders for antipsychotics, medication expiration, inaccurate sick call triage, time to completion of sick calls, study of problems with transport at release, safety cell usage, assessment of eating meals with patients, decline of encounters, impact of treatment on fights and grievances, AB 109 mental health services, length of stay in residential mental health unit, transfers without screening, sick call response by staff member, and hospital visits for self-harm not reported to mental health. While some of these were noted in my previous report, this list gives a sense of the breadth of issues RUHS-BH Detention Services is evaluating through its CQIP.
For some of the RUHS-BH Detention Services CQI data in the topic sections elsewhere in this report, I note some problems with methodology. While there are problems, some are related to limitations in

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information currently available through the EHR. However, the most important point is that there is substantial progress on the CQIP. This will make it more possible to take a more quantitative approach to proof of practice. It would be impossible to hand count many of the remedial plan requirements from individual medical records, so development of associated reports is critical.
I also reviewed the Correctional Health Services (CHS) Operational Indicators from the third quarter of 2017; most do not apply to mental health. I note that the Receiving Screening indicator is 99%; given data above showing lower percentages on mental health intake screening, that data was presumably not included in this indicator. The indicator Health Care Request Collected is reported at 100%, which is not at all consistent with what I found (see Timely Access to Care above). When we discussed this during the meeting with the CQI teams, it emerged that this indicator is not based on actual checks on form collection but on self-report of collection; this is not sound CQI methodology or proof of practice. The report also included several of the facility-specific RUHS-BH Detention Services reports noted above.
Data collection and analysis remains a much greater problem for custody whose data systems are antiquated and not designed to perform CQI functions. The difficulty of tracking yard time noted above and out of cell time generally is a clear marker of this challenge. It is not clear where whether a data warehouse is being developed, but without such an approach, it is unlikely that the existing systems will be able to produce and analyze aggregate data needed for CQI and proof of practice.
The County remains partially compliant with this measure, but it is important to note the substantial and commendable progress in this area.

MENTAL HEALTH CARE
Treatment
There is still no formal Program Guide. There are comprehensive Standards for Clinical Therapist Training and Standards for Behavioral Health Specialist Training which are more a compendium of important information than a guide, but they contain many of the elements of a program guide (there was an earlier version for Clinical Therapists called the Clinical Therapist Training Manual reviewed in the previous report). However, they indicate that they are for RPDC only. They provide good quality information on the jails, jail practices and procedures, and, most importantly, sound approaches and information for conducting clinical work in the jails including crisis response, assessment and management of suicide risk, intake, bridge medications, hospital returns, civil commitment, general mental health assessment, acuity ratings, treatment planning, and discharge planning. There is also a range of groups, most of which have a strong evidence base and are appropriate for the setting.
The content for Clinical Therapists has been augmented since last time; it is a sound and comprehensive document. The information for Behavioral Health Specialists is more limited, in line with their role, but does include good overviews of groups, including Anger Management, Discharge Planning, Life Skills, Seeking Safety, Wellness Recovery Action Plan (W.R.A.P.), and a brief outline of New Direction (the new substance abuse group that is designed to work for those with and without mental illness). It also has a section on Recreation Therapy. In terms of types of groups, the main thing that is needed is enhancement of offerings for the seriously mentally ill. While Recreation Therapy is a valuable tool with this population, other psychosocial rehabilitative and psychoeducational groups are needed, for

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instance, medication education, and offerings designed to help patients manage in the correctional environment including relating to custody, getting needs met, self-care, and so on.
Both include a Prison Rape Elimination Act (PREA) training that adequately introduces the most important elements.
The section on acuity ratings represents sound training on generating ratings and succinctly lays out the general architecture of the various treatment settings and how they relate to the acuity ratings.
Guidance regarding care plans is sound but needs to be updated to reflect the change to TechCare. While some of the requirements for discharge planning are aspirational at present, this manual and the policy on Discharge Planning represent reasonable expectations.
The manual addresses overall dosing of treatment, specifically mandating 10 hours of behavioral health programming weekly for those with moderately-severe and severe acuity ratings. For those with less acute problems, the requirement is for a monthly individual contact, psychiatric treatment (as indicated - with monthly follow-up), and at least one group. It is unclear whether the one group is to be on-going or a single group session; this needs to be clarified as a single group session would not be sufficient. Attainment of this amount of programming, assuming it is properly structured treatment and targeted to patient needs, is an adequate amount of programming to address the needs of the mentally ill. Group manuals should clearly spell out numbers of sessions and distinguish groups with progressive curricula (which require regular attendance to be of any clinical value) from open-ended groups, such as some of the recreation therapy groups where each group session stands independently. There is a relationship between the type of group and patient acuity. More acutely ill patients often do not benefit from progressive groups. Correspondingly, and as noted above, group offerings should be targeted to acuity, which would also simplify group attendance as patients are aggregated by acuity in the residential mental health units. This is being done to some extent already but should be more formalized and specifically addressed in the Program Guide.
The manuals should more clearly distinguish different forms of individual contacts beyond screening and assessment. This is done to some degree, the section on crisis response being a good example. Many of the elements of individual contact are already laid out to some degree but organizing them more clearly would be helpful. One typical approach for the treatment component (as opposed to evaluation) is to distinguish case management (which is all most patients need), crisis management (sometimes broken into crisis response and crisis treatment), and psychotherapy (which will be limited and almost all short term). The interventions in the manual roughly correspond to these categories but could be spelled out more and each have general frequency and duration (dosage) expectations laid out. The transition follow-ups after safety cell placement could be viewed in this way as crisis treatment, which would help guide clinicians towards more focused treatment interventions (different types of which should be spelled out, e.g., solution focused therapy) to prevent viewing it simply as a check-in to assess risk, which is how many of the transition notes currently read. Specific treatments or interventions could also be attached to each type as well as to diagnosis or problem, making treatment planning easier and faster as well as providing more structured and clinically appropriate care. At present, most treatment plans are quite generic and refer to developing non-specific skills. A simple example would be a patient with the problem of medication non-adherence, a frequent issue in the jails. The long-term goal would be medication adherence. One appropriate intervention (that could be specified in the Program Manual) is Motivational Interviewing, which is often used to promote medication adherence. The shortterm goal would depend on the stage (e.g., precontemplation) which then guides the intervention and charting can be simplified. A progress note would then simply consist of any key functional and mental

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status information (e.g., “still non-adherent, psychotic symptoms unchanged, no dangerous behavior or intent to harm self or others”) and the intervention (e.g., “used MI techniques to help patient clarify goals – identified getting a job in the kitchen”). The purpose of the example is to show how a Program Guide can help focus treatment at the appropriate level and simplify treatment planning and charting by referencing a specific type of recognized (preferably evidence-based) and agency sanctioned intervention.
Psychiatric services are not addressed in these manuals; they should be included in a complete Program Guide. In addition to the above comments, to convert these documents into a complete Program Guide for the whole system, the following content should be added or expanded (or addressed by reference to other documents such as treatment manuals, guidelines, protocols, procedures, and policies, which may or may not be included in the Program Guide itself, depending on how the county wishes to use it):
 The functions of different settings in all the jails (as has been done for the units at RPDC and to a limited extent in the acuity ratings for other facilities)
 Transfer procedures (addressed to a limited extent in the manuals, primarily to the DCU)  Referral to other services (e.g., medical) and for specialized testing  Involuntary medications  Medication monitoring  Coordination with competency restoration services
Before discussing treatment, consideration of the general illness burden is instructive. The County provided data on the acuity (level of care) of the populations presented in various ways: at the system level, in administrative segregation, and by facility. As intended, CBDC, Blythe, and Indio have fewer mentally ill and none with acuity ratings higher than moderate. RPDC has the highest percentage of mentally ill and the highest percentage of moderate-severe and severe patients (34% of the total RPDC population). One point that is important to make, and to take note of, is that the population in administrative segregation is disproportionately mentally ill (70% with any mental illness) compared to the total jail population (59% with any mental illness) and has a much higher percentage of moderatesevere/severe (27%) than the total population (12%). This demonstrates clearly that the mentally ill are almost certainly being placed on administrative segregation due to behavioral problems related to their mental illness. As noted below, this population also gets the least treatment. There are 117 mentally ill on administrative segregation. If the reason for those with moderate-severe/severe mental illness being on administrative segregation is due to true dangerousness, this population would often meet criteria for civil commitment. Put differently, if they are too dangerous to be out with others and their dangerousness is due to mental illness, this is almost the definition of meeting criteria for civil commitment. There are 45 of these moderate-severe and severe administrative segregation patients in the system.
While some form of limitation (external control) is necessary for some patients, owing to their agitation or propensity for violence related to mental illness, this needs to be managed more fluidly. There has been some improvement here in that mental health and custody are conjointly and regularly reviewing these cases and are starting to keep a log of their decisions. This needs to be a formal process that is driven by their current status only, absent a legitimate classification issue related to the patient’s criminal history, violence history, and other ordinary classification considerations. Patients should also not be placed in segregation for their own protection; the County should not punish patients for being

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vulnerable. Other mechanisms need to be developed for those that are vulnerable due to mental illness or cognitive limitations.
The Behavioral Health Indicators from March 2018 included a report on the average number of days at each acuity level for those booked during the month. The average time on each acuity level were about 10 days for all but the acute category, which was 3 days. The distribution was as expected: the vast majority were “none” with progressively fewer as acuity increased.
RU-BHS provided data for February 2018 in the document Behavioral Health Screening, Assessments, & Care Plans showing that 43% on administrative segregation received the required daily follow-ups. One of the associated graphs is cut off but appears to demonstrate for about 40% of those cases missed, it was missed only for one day.
These visits are almost exclusively at cell front; this population continues to receive very limited services and many of them are very ill. These daily cell front visits achieve no clinical end other than ascertaining how debilitated the patient is, which could be done with less than daily check-ins. What is needed is more active treatment, even if in non-contact booths or restrained to program tables. The parties may want to reconsider this aspect of the remedial plan.
Turning to treatment provision generally, the County has continued its drive to use groups as a primary modality of non-pharmacologic treatment. This is an efficient and effective approach.
Groups at CBDC run in the morning and the afternoon. The Recreation Therapist I spoke with reported that clinicians select patients for groups. Groups are reportedly rarely cancelled, and attendance is consistent. The recreation therapy group I saw was well-run and relevant. The Recreation Therapist also provides individual treatment to patients on administrative segregation (which is all done at cell front) and in A pod (the medical unit).
CBDC will soon roll out the “New Directions” chemical dependency group. In addition, CBDC is focusing on doing a better job of meeting timeliness of some types of clinical encounters and on developing treatment plans.
Groups at SCF reportedly run reliably from 0930-1100 and 1300-1430 (confirmed by interviews with staff and patients). Mental health staff select patients for groups depending on need. There are openended and curriculum-based groups, but all have a therapeutic function, including some Dialectical Behavior Therapy groups (a modality very appropriate for the severely personality disordered commonly found in correctional settings – Clinical Therapists are receiving important quarterly training on this difficult modality). I attended one group on unit 16 (COLORS – a chemical dependency group), run by two Behavioral Health Specialists; it was well-run and clinically relevant for the patients in attendance but could have gone into more depth.
Group schedules at RPDC were organized by floor. The third floor had six slots available (when listed, they were for an hour and a half) but only three groups of 5-6 running (Criminal and Addictive Behaviors, Anger Management, and “Open Group”). The fourth floor had five group slots available each week but only one group with four patients running (Anger Management). The fifth floor (almost all seriously mentally ill) had nine group slots available each week with seven groups of 5-10 patients running (two sessions of Anger Management, Life Skills, WRAP, Seeking Safety, and three sessions of Rec Therapy). The sixth floor (mixed female population) had thirteen group slots available each week with

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nine groups of 5-10 patients running (Criminal and Addictive Thinking, “Open Group,” Anger Management, Life Skills, WRAP, two sessions of Seeking Safety, and three sessions of Rec Therapy).
I attended a WRAP (reentry group) at RPDC. Five patients attended; no restraints were used. Custody (a runner deputy) stood by in the hallway for most of the group. The group was on time and ran almost a full hour. The group was fairly well run and clinically relevant for the participants.
No data are yet available on the dosage of group treatment patients are receiving. Review of records shows that most patients are getting some group exposure, but most are not getting enough to provide significant benefit. Building sufficient capacity will require the planned additional program space and continued efforts to get patients out timely and consistently at group times.
Almost all patients reported meeting with a Clinical Therapist periodically. Though none reported receiving individual therapy (consistent with my medical record reviews), they did feel that the Clinical Therapists were respectful and concerned. Most reported being offered groups; most had very positive reports about the treatment they received in the groups and wished to have more access.
Regarding psychotropic medication management, patients reported regular meetings with psychiatrists and were generally satisfied with their medications as well as the care and attentiveness of the psychiatrists.
There are still no conjoint treatment team meetings where psychiatrists and other mental health providers discuss and formulate treatment plans. Treatment planning remains an area targeted for development; some training and has already begun.
Two Clinical Therapists are now assigned to the DCU. They have recently installed a program table in a designated treatment room and are about to start having individual sessions with patients. This is an important step that will both provide better treatment and make it easier to determine when a patient is capable of managing interpersonal engagement that is necessary to determine readiness for discharge and return to the jail.
Turning to data on treatment provided, the (draft) report Detention Reports Catalog 2017-2018 reports on assessments (these are more complete evaluations than an intake screening) completed by RUHS-BH in the jails. The data are from January and December of 2017, so are reasonably reflective of trend and current status. The methodology is difficult to determine from the report; note that this is the catalog of reports that RUHS-BH is aware has some methodological flaws. The related text speaks to “1,048 bookings between the months of December and January 2017 that were eligible” for assessment. Eligibility for assessment was determined the presence of a Behavioral Health Flag (a manual flag in TechCare indicating an open case; it is not automatically marked based on other information in TechCare) in those admitted for more than 10 hours.
However, a completed assessment is defined as the presence of any assessment within the last year or a new assessment at any time during the current incarceration. This definition does not rise to the level of “thorough assessment” required by the remedial plan. Much can change clinically in a year’s time. It would be reasonable to conduct an abbreviated assessment (update) of any patients having had an assessment within the last year that reports on any important psychosocial changes, community treatment, and current clinical status. It is also not reasonable to count as compliant cases for which there is an assessment at any time following admission or after identification of a potential case

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following admission, regardless how much later after identifying the need it was done. Assessments should be completed promptly (within two weeks) following intake or later identification. There is also no information regarding the completeness or quality of assessments; this could be done through a peer review process or a more formal audit process.
The County also reported on the timeliness of assessments for March and April of 2017, reporting that of 1,424 completed assessments, 73.2% were completed within 14 days, with a slight drop from March to April of uncertain significance. Eligible cases included those with new assessments or updates but not those with existing assessments. It is difficult to reconcile the number of assessments in these two months with those in January and December, especially since the latter included those who had assessments within the last year and the former did not; that is, the number from January and December should have had more eligible cases. However, here again the methodology is somewhat unclear as in one place the report indicates that the measure examines those “being assessed within 14 days of their booking date” and the methodology note indicates that the time “was calculated from the time the behavioral health flag was placed on an inmate during their current stay.” If the latter included patients who had behavioral health flags placed any time after booking, it is possible that this number would be larger.
The CHS CQI meeting minutes from 1/16/18 reported on timeliness of completed RUHS-BH assessments on RPDC unit 6B. 42/72 (58%) had a completed assessment within 14 days of booking (including 5 who had an assessment during the previous year). Only 5 (7%) did not have an assessment.
RU-BHS also provided data for February 2018 in the document Behavioral Health Screening, Assessments, & Care Plans. The methodology for the report is not completely shown, but it appears to be the number of open cases that had an assessment in the record. In February, there were 899 open cases with an assessment. As noted above, there were 1581 total open cases on 3/1/18 so about 899/1581 = 57% had assessments, with RPDC having less than 50%. It is not clear how recently an assessment had to be to be considered compliant for this report. This data appears to show a substantial drop in completion percentage from December 2017. Whether this reflects differences in methodology, a real drop in completion, or some combination is not clear. The March report indicates that there were 429 inmates booked in March with a behavioral health flag who remained in custody for more than 14 days. Of these, 318 (74.1%) “received an assessment.” The data varied from a low of 60.9% at SCF to a high of 85.4% at CBDC. The majority of cases came from RPDC where 73% had assessments. 237/318 (74.5%) were completed within 14 days of booking.
Given that there are about 60,000 bookings per year and about half stay for more than one day, about (30,000/12) = 2500, then that the expected prevalence of serious mental illness is about 20%, 2500 * .2 = 500 is the expected number of assessments for one month, so the data are in line with expected numbers. The methodology for March 2018 appears sound and likely reflects the County’s performance. While not outstanding, it is solid and likely reflects improvement, though it is difficult to be sure given changes in methodology.
The (draft) report Detention Reports Catalog 2017-2018 also included data on RUHS-BH care plans (treatment plans) for March and April 2017. The eligible cases for this were also 1, 424 (likely the same cases as reported for timeliness of assessments). This element indicates that the 1,424 eligible cases were reportedly identified as follows: “The overall number of bookings was calculated for inmates with a behavioral health flag, and who remained in custody for more than 10 hours.” This would seem to

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indicate that the first criterion applied was the presence of a behavioral health flag and then of these how many had been admitted for more than 10 hours. Of these, 56% had a current care plan. An active care plan was defined as having an active care plan within the previous year or a care completed at any time since admission.
As with assessments, this is not an adequate measure, but again RUHS-BH is aware of the limitations. As with assessments, care plans done within the past year need only be updated but must reflect the patient’s current clinical needs, which often are substantially different upon admission. Also, a care plan should be done proximate to an assessment when the assessment indicates the need for a care plan.
On the other hand, the definition of eligible cases is also over-inclusive. It is unreasonable to expect a care plan to be completed on patients in jail for less than two weeks (the time it takes to complete an assessment and have a first psychiatric visit upon which the care plan should be based) or who have likely stays less than a month; patients with shorter stays may be managed without a care plan through crisis stabilization, support services, medication management, and reentry planning. Further, care plans of those in residential treatment units should be far more extensive than those in general population who are receiving primarily medication and support services. The latter need only a brief care plan specifying the degree of medication support services or case management needed by the patient and, for those few needing group or individual therapy, a brief explanation of the type(s) of therapy and goal(s) of therapy.
The County reported on the timeliness of care plans for January and December of 2017 as well. In these months, of 637 care plans developed, 417 (65.5%) were within 14 days of booking with a slight improvement in December. RPDC was notably below the other facilities, which is of concern given the acuity and numbers of mentally ill there. Note that here also, the language was unclear about exactly when the cases were drawn from (“between the months of December and January”) but appear to be for those two months individually.
These figures likely represent a limited picture of the care planning process for 2017. The timeliness data is likely a more accurate reflection of reality than the completed care plan data. It is also difficult to get a picture of any trends due to the limited data points and stale data, but it appears the County is making some progress on timeliness of care plans.
The county also provided data on care plans from March 2018. These data report on the same 429 eligible cases for assessments from that month; 300/429 (69.9%) of those admitted that month who had a behavioral health flag had a care plan. 166 of those were at RPDC where 70% had care plans. The low was at SCF (53.1%) and the high at CBCD (82%). Of the 300 done, 214 (71.3%) were done within 14 days of booking. There was some variation between facilities, but all were above 60%. The methodology for this report is reasonable so the data are likely an accurate representation of practice.
RU-BHS also provided data for February 2018 on face-to-face psychiatric encounters (which included non-confidential contacts, presumably mostly at cell front) in the document Behavioral Health Screening, Assessments, & Care Plans. There were 842 contacts, or 842/1581 = .53 contacts/patientmonth. Thus, patients are being seen, on average, about once every two months. However, no data were provided on distribution of time between visits. Thus, it is unclear if there are many who are seen much less frequently, which is reasonable provided it is not less than every 90 days.

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In accordance with a recent statutory change, RUHS-BH plans to begin use of involuntary antipsychotics in the jails, beginning with use of emergency medications. As there is a new California statute providing for long-term involuntary treatment in the jails, this should be developed as well as it is both clinically indicated and promotes safety of both staff and patients. Further, failure to implement it places the county at risk should there be a bad outcome that could have been averted by use of involuntary medications. RUHS-BH is also started long-acting injectable antipsychotic clinics at RPDC and SCF. These are critical initiatives that should facilitate involuntary medications and the general use of these important medications as well as ensuring their safe administration. The County is to be commended for promptly moving forward on this.
The RUHS-BH report 2017-2018 Detention Reports Catalog includes a report on mental health follow-up of those on administrative segregation. The report shows that for 119 patients 57% of total expected daily visits (1534/2698) were completed, 29.4% received all the required visits. It is not clear for what time period this was conducted. No data on visits within 48 hours of placement on administrative segregation were provided. The Behavioral Health Indicators from March 2018 shoed that there were 122 patients in administrative segregation during that month for a total of 3,026 days (meaning most of the patients were on administrative segregation the whole month). There were 61% (1,857/3,026) of those encounters were completed. The vast majority of lapses were for one or two days, but there were 27 instances of lapses lasting 5 or more days. This was consistent with what I saw in medical record reviews and is likely an accurate representation of practice.
It important to note that the county has taken steps to promote continuity of providers, and thus continuity of care, by continuing to expand the practice of assigning a portion of mental health staff to specific units. Patients are still frequently seen by a variety of different Clinical Therapist and Behavioral Health Specialists, but there has been some reduction in fragmentation.
The County remains in partial compliance with the mental health treatment provisions of the Remedial Plan. There has been steady progress; expansion of offerings, continuity of care, and focus on targeting treatment based on patient need are the keys to achieving substantial compliance.
Housing
There have been no significant changes to beds designated as residential mental health units. Collaboration between mental health, custody, and classification on placement continues to be solid. While mental health staff are not uniformly consulted regarding transfers, I continued to see little evidence of inmates without mental illness being housed in residential mental health units. Mental health and custody have regular meetings at RPDC and SCF where housing is discussed; I attended one such meeting at RPDC where patient status and housing were addressed in a collaborative manner.
The most ill patients in the jails are housed at both RPDC and SCF. “Bouncing” of patients back from general population to residential settings has been decreased by mandating mental health supervisor review of level of care (acuity) codes. This has also reduced pressure on clinicians to increase acuity codes to force movement of inmates with behavioral problems but without significant mental health needs.
Transfer of the mentally ill in residential mental health units to other facilities is being tracked by RCSD. The data from December 2017 and January 2018 provided by RCSD showed transfers from RPDC and SCF. In all cases, mental health was consulted (the mental health clinician’s name is noted in the data

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set). There were only two transfers out of 208 that mental disapproved. One, a patient on administrative segregation, was overridden by RCSD and moved from RPDC to SCF. The other was a patient slated to release from SCF; the transfer to RPDC was halted.
The progressive step-down on unit 16 at SCF continues to function well in terms of effectively sorting patients by the seven-level acuity scheme (level of care); mental health staff review group participation, medication adherence, and tenure on the unit when deciding who to stepdown, which is ultimately decided by the Senior Clinical Therapist who then works with custody and classification to effect the transfer. Staff report that violence has not been a significant problem over recent months at SCF. Placement decisions are reviewed by senior clinicians every two months to insure fidelity of decisionmaking. The special settings on 12A (GP) and 14G (PC) for gang dropouts and stepdown from unit 16 continue to function; though patients complain that they have no access to mental health groups and limited access to other programs, they appreciate being in a setting where they can continue taking medication without fear of gang reprisal.
In my opinion, this element is now in substantial compliance.
Treatment Space
While runners for mental health have been augmented or restored, it is important to note that no new custody positions have been added. It will be important to assure the sustainability of these runners provide consistent access to the treatment spaces, whether programming spaces, the clinic, or required escorts to interview rooms. This is an essential custody function without which access to care is undermined or safety compromised. The need for runners is likely to increase as treatment spaces are developed and full access to care becomes possible.
There are now four medical and four mental health runners at SCF. Mental health staff report that they are consistently available and facilitate access to treatment spaces and movement to the clinic. Having the program rooms available again has also reduced competition for the non-contact booths in intake, facilitating both the intake process and treatment.
The plan to augment treatment space at RPDC is still in place and construction has begun on the seventh floor. At SCF, the plans for a new healthcare building are moving forward (construction has begun) as are the plans to convert space near the residential treatment unit (Unit 16) to augment interview space there. Plans continue to be in place to improve intake at CBDC, but construction has not begun. But there has been no significant increase in treatment space yet.
The new electronic locks for program spaces have reportedly been functioning well, including tests of the fobs that mental health staff use to open the doors themselves during emergencies (there have been no actual emergencies). To facilitate movement, mental health staff primarily use their radios to contact custody who reportedly responds promptly and has been able to facilitate almost all scheduled groups. With the new electronic door locks, most treatment spaces have been restored to use.
However, at CBDC, only three of the seven available program rooms have been allowed to be used for patient contacts for the last few weeks (units B, C, and D); the reason for this is not clear as the rooms are reportedly not otherwise being used. While they are not optimal rooms for programming, they could be used for at least individual meetings. The newly purchased program tables (tables facilitating activities and having the option to restrain to the table) have been placed in the three program rooms in

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use and have been functioning as expected. Patients are being uniformly restrained when in these program rooms, though it is not clear why. Patients on the other CBDC units must be seen in the upstairs non-contact attorney booths which mental health accesses by going outside security; custody has been sending a series of patients to reduce the need for mental health staff to have to move back and forth through security, but this is still impeding access to care and reducing productivity.
Groups are run only in the law library and recreation yards at CBDC. This limits the number of groups that can be run, though currently, mental health leadership is satisfied with the number of groups available for the population currently at CBDC. Given that the acuity at CBDC is kept low, this is probably reasonable.
Treatment space remains tight at RPDC. Psychiatrists continue to meet with patients in the non-contact booths. They report some improvement in having patients brought to the booths by the runners and that custody is almost never refusing to bring patients out. Seeing patients in booths also impairs clinical work for a variety of reasons, including inability to conduct a physical examination. Despite these efforts, psychiatrists still must visit patients at cell front about 25% of the time owing to lack of an available booth; this has especially been a problem on 5A. Having to move around the facility to see patients also reduces their productivity.
The lack of space for groups at RPDC continues to limit the number of group offerings, though scheduling of the group room has improved, allowing a few more groups and limiting conflicts with other services.
The County is clearly taking reasonable steps to expand treatment space, except for not using program rooms at CBDC, though programming requirements there are less than at SCF and RPDC. The general provisions for treatment space meet partial compliance and will almost certainly be substantially compliant once construction is done and the new spaces put into use.
Suicide Prevention
I inspected safety cells at all three facilities. Those that were occupied had logs posted at the door that were complete. Safety cells at CBDC and SCF were clean except the vents. Those at RPDC were not clean though were not grossly malodorous or feces smeared.
Staff and patients report that most safety cell assessments are not being done at cell front, an important improvement.
I observed a Clinical Therapist conducting a safety cell assessment of a patient just jailed. The assessment was conducted in a non-contact booth. The Clinical Therapist did an excellent job of quickly establishing rapport and then assessing the patient’s clinical condition and risk and protective factors, finally developing a sound plan with the patient’s participation.
In one instance, a male patient was left naked in a safety cell pending obtaining a safety gown (see Appendix 1). The initial safety cell assessment was not completed as the patient was naked; this was at least two hours after a note indicating placement in the safety cell. This is not reasonable.
Policy and procedure for step-down from safety cells is not yet implemented. Mental health is not yet involved in setting the conditions of confinement in safety cells, but this is reportedly still to be part of the impending plan; RUHS-BH and custody are working jointly on how to operationalize this process and

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policy is pending. The Remedial Plan species that policy and procedures for a step-down program were to be in place one month after issuance of the Consent Decree. The specific language is:
“Within one month of the date of the Consent Decree is issued by the Court, the County shall develop and implement policies and procedures to allow step-downs for inmates placed in safety cells because of potentially self-harming behavior. The step-down program shall gradually add property in privileges and programming consistent with clinical assessment of a [sic] inmate’s condition, with the intent to minimize the time spent in the safety cells under conditions of total deprivation of property and programming.”
For the present, the provision for seclusion to last no more than 12 hours has been operationalized by defining seclusion as placement in a safety cell with no more than a smock, safety blanket, and mattress. The County cannot yet provide data on this in the jails or in DCU. Adherence will also be difficult to ascertain through auditing as the information will be difficult to obtain from records and inspection will not provide sufficient information. At present, many of those placed in safety cells would qualify as being in seclusion under this definition; implementation of the step-down process must address this issue.
I saw no evidence of patients staying in safety cells for longer than 48 hours; most of those who approached that time were committed to the DCU. Nursing checks of those in safety cells were very inconsistent both in terms of timeliness and completeness.
The County endeavors to have patients released from safety cells followed-up for five consecutive days; this is not a requirement of the remedial plan. The RUHS-BH report 2017-2018 Detention Reports Catalog includes a report from March 2017 on the percentage receiving all five. Of 95 released from safety cells, one (1%) received all five (or had a note indicating no follow-up was necessary). By this report, none of the 95 received any services, which is highly unlikely. It is unclear what this report means; it may be that the type of TechCare notes counted do not capture safety cell follow-up.
RU-BHS also provided data for February 2018 in the document Behavioral Health Screening, Assessments, & Care Plans showing 51% of patient receiving all five transitional follow-ups, though about 25% received no follow-up. The Behavioral Health Indicators from March 2018 showed that of 227 safety cell discharges, 78 (34%) received five consecutive visits. 75% received some transitional services with over half receiving 4 or 5 visits. Of those whose records I reviewed, most received some follow-ups but rarely received them on five consecutive days. Though this is not a formal indicator in the remedial plan, this practice and the improvements in the data are clear indicators that the county is making substantial and sound efforts to respond to patients at risk of self-harm. Expanding structured treatment, especially for a subset of this population, would help reduce the number of crises and provide more appropriate overall treatment.
The County provided data from RCSD reporting on the number of notifications to mental health for inmates receiving sentences longer than 15 years. Only one month was below 90% and for the year, 95% of notifications were made. Mental health staff noted no issues with these notifications, so this is likely accurate.
Here again the County remains in partial compliance.

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Restraint
Use of the emergency restraint chair continues to be rare, though I did not receive any data on restraint usage. The restraint chairs were uniformly clean and operational.
I saw evidence of two patients being restrained in the medical record. One was only in restraints during transport, so no healthcare interventions would have been expected. The other was evaluated by mental health, but the note indicates that the patient was to remain in restraint “per custody.” There was no indication of collaborative decision-making. The patient was seen by nursing while in restraint but there was no documentation of appropriate physical assessment. Logs were not available in the record to verify continuous monitoring or other interventions.
There was no information on DCU restraint usage.
The data are too limited to make a rating.
Continuity of Care
Since the reorganization mentioned in my last report, the county has continued to develop reentry services. Reentry services were much more commonly documented in the medical records of more recently released patients. Reentry groups (mentioned above in the section Treatment) continue, but individual contacts were much more ubiquitous as well.
Reentry specialists (who are BHSs) & peers from community AB109 clinics were doing a 90-120 minute group every other week with jail MH staff for identified patients whose acuity rating is moderate or more severe (not just AB109) within 40 days of release. This has been put on hold owing to a demand that those entering have background checks. While the County is free to exclude peer counselors, it is important to note that other systems have effectively used peer counselors both to augment resources and to “legitimize” the activities of staff (or in this case, the value of community resources) in the eyes of the incarcerated. Jail mental health staff identified those who need such services beforehand using a 30-question screening in ELMR.
Another approach the County has taken is using AB109 clinics for all jail reentry, primarily to take advantage of existing infrastructure.
Psychiatrists report that they are being notified of impending releases more reliably and are ordering 30-day supplies of medication. However, some patient are still leaving jail without release medications.
The Behavioral Health Indicators from March 2018 showed that of 288 patients with a behavioral health flag that were released that month, 43.1% were offered discharge planning. The percentage varied from a low of 28.6% at RPDC (who had about half the discharges) to 63.9% at CBDC.
Here again, the County remains in partial compliance and is taking appropriate steps to build out these services.

POLICIES AND PROCEDURES
I was not provided with any new or updated policies since my previous report. The issues raised remain to be addressed.

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As I have been told that many are being modified, I will continue to rate this as in partial compliance at this time.

CONSENT DECREE TRAINING
The County was previously rated as in substantial compliance for this component.
This concludes my second semi-annual self-assessment. In my opinion, the County continues to make progress towards meeting the requirements of the Remedial Plan. The County has achieved substantial compliance in three areas (contingent on production of a modified policy for one), is in partial compliance on 12 (with a few of those nearing substantial compliance), and one being reduced to non-compliance. The latter is the Staffing component; the failure to achieve 90% of positions filled and the lack of the required report mandate reduction to non-compliance. However, both may be achievable prior to my next report.
Respectfully submitted,

Bruce C. Gage, M.D.

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APPENDIX 1

I was unable to access scanned documents embedded in the EHR. I sought assistance, but this was not resolved.
20180855
I interviewed this patient at SCF 2/21/18. It was clear that he suffered from a psychotic illness. He told me that he had been offered groups but has not availed himself of them. He reported having been in the safety cell at the time of admission because he was feeling suicidal and depressed. He reported regular contacts with psychiatry and periodic contacts with a counselor but wish to have more individual contact.
Medical Record Review
The patient was booked into RPDC on 1/7/18, three days after being leased from jail. The arresting officer report noted that he was under the influence of drugs or alcohol but was otherwise negative. The medical screening showed that he was taking olanzapine, reportedly taking the last dose four days before. It also indicated diagnosis of schizophrenia and that he denied suicidal or homicidal ideation.
Patient had a mental health screening approximately 13 hours later after he had been placed in a safety cell following expressions of suicidal ideation during the classification interview. The patient reported a high degree of depression and stated that he wanted “to hurt someone real bad.” He reported a suicide attempt by overdose prior to his arrest and a previous history of cutting was noted. He was noted to be disoriented and confused. Medical records show past psychiatric hospitalizations in 2015. Despite the screening noting that he had been taking olanzapine during the previous incarceration, the screener marked that he was not on current psychotropic medication. His level of care was designated as acute.
There is no evidence that the overdose was further characterized or evaluated. The medical screening indicated that he had ingested methamphetamine and heroin and “came to medical office diaphoretic, irritable, restless, dilated pupils.” His pulse was elevated at 122 but his blood pressure was within normal limits.
He was seen later that day by a psychiatrist in a face-to-face interview. He was noted to be depressed and angry with labile mood. He reported auditory hallucinations but now had no thoughts of harming himself and others. No delusions or thought disorder were found, though he exhibited obsessions/preoccupations. Though he had been on olanzapine previously, he was started on ziprasidone.
He was seen about every four hours while in the safety cell and received sound evaluations. Once he had sobered, the Clinical Therapist provided appropriate supportive therapy in suicide assessment. He was released from the safety cell about 24 hours after booking. He was changed to moderately severe level of care placed

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While in the safety cell, he was seen by a nurse at the time of placement, five hours later, and 11 hours after that. He was then released from the safety cell.
He refused two doses of medications over the following 24 hours. He was seen daily for transitional care following safety cell placement except the second day was missed; this was around the time of his transfer from RPDC to SCF. Notes reflected a good balance of assessment and supportive therapy. There was a cursory treatment plan that consisted in the goal of reducing auditory hallucinations from seven days a week to four days per week; this is a goal that makes no sense given the nature of hallucinatory symptoms which do not come and go that way.
He was seen by a psychiatrist on 1/20/18. He continued to have auditory hallucinations, insomnia and depression. The psychiatrist added mirtazapine and continued the low dose of ziprasidone 20 mg twice daily.
He was transferred again on 2/6/18 then seen by a Clinical Therapist on 2/12/18. This was a brief visit that reported continued auditory hallucinations and depression. Limited supportive interventions were offered. The plan was to enroll him in a dialectical behavior therapy (DBT) group.
He was transferred again on 2/15/18.
He was next seen by a psychiatrist on 3/10/18. The psychiatrist reported decreased depression but did not comment on psychotic symptoms. It also stated “no AIMS change,” though it is uncertain what this means, and “no labs indicated.” However, no labs had ever been done and were in fact indicated.
A Clinical Therapist saw him on 3/15/18 and did a brief assessment. There is no evidence that any therapeutic services were rendered.
On 3/17/18, he was step down from SCF unit 16 to a medication support bed on SCF unit 14 G and the security code was changed to moderate. His last mental health contact before release on 4/6/18 was a “wellness check” by a Behavioral Health Specialist on 3/27/18. There was no evidence of reentry planning.
The patient never received any group therapy and other than the initial supportive therapy, received no individual therapy. However, it appears that he improved with medications and was monitored reasonably regularly.

201505914
I interviewed this patient at SCF 2/21/18. He showed evidence of a cluster B personality disorder, likely response to complex trauma. I did not see evidence of major mental illness he had many complaints. He claimed that he had not been evaluated but did say that he had refused medications.

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Medical Record Review
The patient was booked into Indio on 2/13/18. During medical screening, the patient reported having bipolar disorder and depression and was on olanzapine and fluoxetine. He denied suicidal ideation but reported having been at Telecare two days previously; he would not answer questions about past suicide attempts. He reportedly denied any substance problems or use. He was screened by mental health four hours later, reportedly telling the Clinical Therapist that he had used methamphetamine. He was partially cooperative with the intake, still not wanting to speak about his history of suicide attempts. He flooded his cell and was banging on the cell door and exhibiting agitation and mood lability. He was responding to internal stimuli. He was found to have a level of care of severe and was placed in mental health housing after transfer to SCF2/14/18. He was seen the following day by the Clinical Therapist and continued to be largely uncooperative. He was referred urgently to a psychiatrist. The Clinical Therapist documented an extensive mental health history with various diagnoses including schizoaffective disorder, bipolar disorder, schizophrenia. He had been released from San Bernardino community Hospital on 1/26/18. The treatment goal was to “participate in behavioral health treatment and will be able to identify at three behavioral health symptoms over the next 12 months.” While the goal to participate in treatment was important, the real issue was to develop the treatment alliance with the patient. Identifying three symptoms over 12 months is a meaningless goal.
He was next seen by a Clinical Therapist on 2/22/18. At that time, he was seen in relation to a possible PREA incident. He was initially possible and was agitated. He continued to refuse mental health treatment (and asked for transfer to GP) but admitted that he was having hallucinations. The Clinical Therapist use de-escalation techniques the patient was able to calm down enough and did not require safety cell placement. He continued to be agitated and uncooperative and was transferred the following day to RPDC where he remained in mental health housing.
He was seen by a Clinical Therapist on 2/26/18. He reported hallucinations but did not show any other evidence of psychosis. The plan was to follow-up in a week, see a psychiatrist on 3/5/18, and refer to the Behavioral Health Specialist for services. He initially refused group services and later agreed to start the group seeking safety but left the first group after just a few minutes.
He was not seen by a psychiatrist, or started on psychotropic medications, until 3/2/18 and was at that time started on risperidone, mirtazapine, and olanzapine, all at reasonable starting doses. However, appropriate laboratory studies for monitoring metabolic syndrome were not done. When seen in regular follow-up by the psychiatrist, the psychiatrist noted that he was responding well to medications and initially reported he was 100% adherent to medications but in fact the patient regularly refused medications though took most. The psychiatrist later noted that he exhibited “good compliance for the most part.”
The patient continued to be resistant to treatment other than medications and clearly wanted medications for nighttime sedation primarily. He slowly became less hostile and belligerent and ultimately was transferred to a lower level of care and moved into a general population setting.

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This patient was largely uncooperative with treatment other than medications, which he was only partially adherent to. Mental health staff attempted to engage him but ultimately ended up primarily responding to his urgent requests and misbehavior. It is likely that a structured behavior management plan would’ve been the most appropriate intervention for this patient.

2017100713580821
I interviewed this patient at SCF on 2/21/18. He had a clear psychotic disorder with active delusions and thought disorder. He told me that he was now taking his medications and attending some groups. He made reference to harming cellmates while at RPDC. While he complained about not having one to one meetings except for occasional check ins, he also said that he did not like to speak to staff because “their time dilation is different.”
Medical Record Review
The patient was booked into RPDC on 10/7/17. He denied all problems on the medical intake screening. He was uncooperative with the mental health screening, but the Clinical Therapist rated him as moderately severe based on his history in ELMR and JIMS (electronic medical record and custody database). He had past diagnoses of schizoaffective disorder and schizophrenia. No medication information was included.
In the ensuing days he was screened for involvement in recreation therapy.
He was first seen by a psychiatrist on 10/21/17. The psychiatrist found that the patient had auditory hallucinations and depressed mood. He diagnosed schizoaffective disorder, depressed type started the patient on olanzapine 10 mg and sertraline 50 mg, medications the patient had taken previously. No delusions or thought disorder were identified. The psychiatrist also noted that the patient had cognitive limitations and was likely borderline intellectual functioning.
There were no laboratories for monitoring metabolic syndrome in the record but an AIMS was done which was zero.
Subsequent charting reveals that the patient was thought disordered and delusional. He had periodic placements in safety cells, primarily owing to agitation and disagreements with cellmates.
The patient was seen weekly for individual recreation therapy and nearly weekly by a Clinical Therapist until transferring to SCF on 12/18/17. The sessions addressed appropriate clinical issues, primarily development of coping skills such as relaxation techniques and anger management skills. They also addressed medication adherence.
The day prior to the transfer he had been placed in a safety cell owing to threats to his cellmate related to his cellmate’s poor hygiene and other complaints. However, he was not seen for an assessment for almost 12 hours with notes indicating that custody was not able to get the patient out of the safety cell for assessment.

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The first two days of transitional appointments were not completed, reportedly because the patient was “awaiting housing.” Following the final three transitional meetings, the patient was not seen again until 1/1/18 when he was again placed in a safety cell after refusing to go back to sell from yard, complaining that the error in his cell had been cut off and that he could not breathe. He had been nonadherent with medications in the interim period. He was agitated, thought disordered, and paranoid. He was seen the following day by a psychiatrist and agreed to take aripiprazole and bust around instead of olanzapine. The sertraline was continued. He remained in the safety cell for just short of 48 hours he had regular checks by mental health and nursing.
The patient continued to refuse most medications. On 1/5/18, a treatment plan targeted his repeated safety cell placements. The interventions were generic and lacked clear short-term treatment target. The basic plan was to attend individual sessions and groups, though some specific skills were named. However, there was nothing regarding his psychotic symptoms, his lack of insight, and his medication nonadherence. In short, the treatment plan did not address the immediate and important issues leading to safety cell placement.
Subsequent charting shows that the patient was seen regularly by Clinical Therapists, though primarily at cell front following medication refusal. He had occasional one to one meetings that reflected some limited attention to development of skills. He was enrolled in a group and had weekly groups through February and then single groups in March and April. The groups addressed relevant topic issues.
He continued to refuse aripiprazole on the Swiss later stopped. He was continued on sertraline and buspirone.
He stabilized to a substantial degree after an initial rocky. Following is transferred to SCF.
This patient received a reasonable degree of contact an individual and group sessions. A motivational interviewing strategy might have been more effective, but he was ultimately stabilized and the supportive and group therapy provided was reasonably sound. The medications he was prescribed were reasonable, however he did not get proper laboratory monitoring.

201804547
I met this patient on 2/21/18 at SCF. He was somewhat hyperactive and thought disordered and appeared to be responding to internal stimuli. He had some odd and likely delusional ideas about symptoms that he was having being related to an ear surgery that he had when he was 17 years old. He spoke about going into a safety cell after expressing suicidal ideation but related that the true reason was that he was afraid of his cellmate reportedly said he would hit the patient. He stated he had been in no groups and could not call seeing a therapist.
Medical Record Review
The patient was booked into RPDC on 2/3/18. The initial medical screening was completely negative. During the mental health screening an hour and a half later, the patient denied

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symptoms but was noted to be responding to internal stimuli and to be expressing delusional and paranoid ideation. He denied having treatment on the outside except for being hospitalized. He was categorized as severe and placed in a safety cell.
He was seen the following day by a psychiatrist who noted that he had been “yelling in the holding cell naked responding to [internal stimuli].” He was diagnosed as having an acute manic episode and started on olanzapine 20 mg, trazodone 100 mg, and valproic acid 500 mg starting dose.
He remained in the safety cell for almost 48 hours during which time he received involuntary medications to do his agitation. Mental health staff attempted to meet with the patient regularly, but he generally refused to refuse to come out of the safety cell. As he came up on the 48-hour mark, he finally came out and met with the Clinical Therapist. The Clinical Therapist discussed possible civil commitment with the supervisor and ultimately decided not to commit him. While the safety cell he had nursing checks almost every 12 hours but some were missed or late.
His treatment plan goals were to “reduce symptoms of anxiety from seven days per week to three days per week in a 12 month period” and “reduce symptoms of psychosis from seven days per week to three days per week and a 12 month period.” Again, these goals make no sense given the nature of the symptoms; they do not come and go during a week in the manner suggested.
He was seen essentially every day for the following week, though usually at cell front because of his refusal to come out. He continued to show evidence of psychosis. He was again placed in the safety cell on 2/16/18 released the following day.
It appears that on 2/17/18, he was transferred to SCF.
The patient refused laboratory testing; an AIMS from 2/17/18 was zero.
For the remainder of his stay until discharge on 3/7/18, he was largely uncooperative with treatment. Clinical Therapists made regular attempts to speak with him which he would refuse. They came to the cell front to do welfare checks an attempt to engage him with little success. He was also largely nonadherent with medications. He remains psychotic. There is no evidence of any release planning in the record. There is no evidence he was assessed for possible civil commitment at the time of his release though all indications suggest that he remained floridly psychotic.

201803768
I met this patient on 2/21/18 at SCF. He showed evidence of thought disorder, mood lability and was at times tearful. He stated he had a history of Bipolar II Disorder and was in the Full Service Program. He complained that deputies were not helping him get a new PIN to make phone calls and reported that he had seen deputies mistreating another patient but did not know the patient’s name. He also stated that he had been seen by psychiatry twice and buy a Clinical Therapist once.

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Medical Record Review
He was booked into jail on 1/29/18. During the receiving screening by the nurse, he reported being on long-acting injectable Abilify and being in the Full Service Program for mental health in the community. He also reported that he had stabbed himself in the arm two months earlier. He was seen about seven hours later by mental health. The Clinical Therapist noted that he had multiple suicide attempts and chronic suicidal ideation as well as a strong family history of suicide. His community treatment was confirmed as well as an extensive hospitalization history. He was delusional and reported auditory hallucinations, both of the persecutor nature. His level of care was rated as severe.
He was not started on medications until 2/5/18, at which time he was put on Abilify, hydroxyzine, and trazodone. Appropriate labs were ordered, however there was no AIMS done.
On that date he had both a psychiatric visit and an assessment by a Clinical Therapist. His primary symptoms were paranoid psychosis, auditory hallucinations, and mood lability. A treatment plan from 2/6/18 demonstrated the intention to provide both individual therapy to focus on skill development, with a focus on Dialectical Behavior Therapy tools. On 2/7/18, he was given some worksheets for coping skills. He was next seen on 2/15/18 by the Clinical Therapist for a brief check-in. He had an individual therapy session on 2/20/18 that addressed appropriate issues. He was seen the following day by a Behavioral Health Specialists and also attended his first Dialectical Behavior Therapy group.
On 2/24/18, the patient received a six-year sentence and was closely followed by mental health provided appropriate support. He refused some sessions but mental health made a point of seeking him out and making sure he was doing alright given his history of self harm. He was transferred to prison on 3/1/18. A release summary from that day does not cover mental health issues and was therefore inadequate.
Other than getting medications later than he should have, care for this patient was reasonable and targeted his needs adequately.

201803602
I interviewed this patient at SCF on 2/21/18. At that time, he had no overt psychotic symptoms but did express some unusual ideas about spiritual realms and premonitions. He complained of fragmented sleep but had no other mental health complaints. He stated he had been seen twice by a Clinical Therapist. He noted that he had been to the emergency treatment center several times and described problems with methamphetamine use. He had been a forklift driver.
Medical Record Review
The patient was booked on 1/28/18. There was no arresting officer information in the receiving screening, though he was said to have been escorted by the arresting officer to the screening. The patient reportedly denied all medical and mental health problems, reporting being on no medications. He had a mental health screening about eight hours later. He was largely

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uncooperative with the screening, though did report being depressed. He was noted to be irritable and angry and his history of hospitalization and emergency services as well as past safety cell placements were noted. He was categorized as level of care moderately severe and was placed in SCF HU16.
A Clinical Therapist did a mental health assessment on 2/2/18. There were good mental health and substance abuse histories, but the psychosocial history was very limited. He was noted to be irritable, logical, paranoid, and grandiose. He was referred to psychiatry. The treatment plan was done that same day and is very generic.
He was seen by a psychiatrist on 2/22/18 who noted that he had some ideas of reference and possible auditory hallucinations as well as some depressive symptoms. The psychiatrist started olanzapine and mirtazapine. There were no monitoring labs or AIMS in the record. The patient refused a psychiatric appointment on 3/20/18.
He was seen in individual sessions with a Clinical Therapist on 2/12/18, 2/26/18 (patient refused seen at cell front and given information), 3/19/18,
He attended a discharge planning group on 3/2/18.
The patient also had brief check-ins with a Clinical Therapist, typically during pill call 2/23/18, 3/18/18.
The patient refused an individual contact with Behavioral Health Specialist on 3/29/18.
There were several discharge planning notes in the following days, including arranging for release medications and mental health follow-up. He was released on 4/3/18.
This patient received adequate basic services. He was promptly identified as having mental health needs despite his denials and lack of cooperation. The psychiatrist placed him on reasonable medications, however did not do appropriate monitoring. He received good reentry supports and supportive contacts with mental health when he would agree to the meetings.

201800950
I interviewed this patient at SCF on 2/21/18. At that time, he showed no overt evidence of mental illness but reported flashbacks and reported having PTSD and problems with anger. He reported being seen twice by psychiatry but no individual therapy. He stated he had had groups when on HU16 D but not since moving to A, the lowest acuity pod.
Medical Record Review
The patient was booked on 1/8/18. The receiving screening noted only that he took Zyprexa for bipolar disorder. He had a mental health screening about six hours later and reported taking Zyprexa, trazodone, and Prozac and receiving treatment at a mental health clinic in Banning. The patient also reported having been civilly committed to times three weeks ago following self-harm attempts. He reported auditory hallucinations, but no other psychotic symptoms were noted. He

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was rated as moderately severe. There was a mental health assessment from the following day that noted he had not been picking up medications per the batting mental health clinic. There was a reasonable summary of his mental health history including diagnostic considerations. It also noted inconsistency in his reports of history. He was noted to have primarily mood symptoms but also reported continued auditory hallucinations. He was diagnosed as having bipolar disorder and psychosis due to a substance. He was referred to a psychiatrist. There was a generic treatment plan that same day.
He was seen the following day by a psychiatrist who noted that he had delusions of being watched by the United States government. The psychiatrist started olanzapine for psychosis. No mood symptoms or history was included. The note was quite brief. The psychiatrist reported spending 30 minutes with the patient and 20 minutes on documentation. An AIMS from that date was zero; there were no labs for monitoring metabolic syndrome the record. He had psychiatric follow-ups on 2/7/18 and 4/6/18 but refused the latter.
He had an individual session with a Clinical Therapist on 1/17/18. The plan was to enroll the patient in individual and group therapy. He received no individual therapy but had brief individual contacts with mental health.
He attended single sessions of the following groups: life skills on 2/8/18, seeking safety on 2/24/18, discharge planning on 3/2/18, social skills on 3/19/18, and coping skills on 3/19/18. There was no reason given why he was discharged from the life skills group on 2/27/18. He was reportedly discharged from the seeking safety group on 3/2/18 because he had been moved to the top tier and patients from the top and bottom tiers “are unable to be mixed at this time for services.” Why he was only in single sessions of the other groups is not indicated.
Prior to discharge on 4/10/18, the patient received several discharge planning contacts. These medications were ordered.
Given that this patient had relatively limited needs, the treatment provided was marginally adequate. However, it is important to note that it is of very limited value for patients to attend single groups for most of the types of groups that he was enrolled in.

201802808
I interviewed this patient at SCF on 2/21/18. At that time, he exhibited no obvious mental health symptoms but described a long history of methamphetamine use, including presently, though reported being clean for five years in the past. He was homeless and had been in and out of jail in prison. He reported having seen the psychiatrist 1 to 2 times in a Clinical Therapist twice. He was going to be starting groups in the next cycle. He reported that he was a trustee.
Medical Record Review
He was booked into jail on 1/22/18. The screening was negative for all medical and mental health problems except that the patient reported actively using methamphetamine. The mental health screening from about eight hours later was very limited and reported only that he was

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mildly unkempt and had paranoid/psychotic behavior. Most of the items were completed with “unable to respond.” He was rated as moderately severe and targeted to mental health housing. He refused mental health contact on 1/25/18 but had a mental health assessment on 1/31/18. He was more cooperative and reported that he had had some delusional beliefs around the time of his arrest that were felt likely due to methamphetamine use as they were no longer in evidence. Depression and anxiety were identified as the primary problem. The patient reported having been treated with benzodiazepines at the Avalon mental health clinic. A treatment plan from that same day indicated a plan to develop coping skills related to depression and anxiety.
A2/1/18 note indicated that the pharmacy was called for medication verification. The patient had not filled prescriptions for lorazepam, duloxetine, and ibuprofen since November 2017.
He was seen by a psychiatrist on 2/6/18. The psychiatrist noted that the delusional material from around the time of arrest was no longer in evidence and that the patient primarily presented with depressed mood. The psychiatrist started mirtazapine. An AIMS from that day was reported as zero, but it is unclear why it was done as the patient had not been on antipsychotics and was not being ordered antipsychotics. There were no laboratories for monitoring metabolic syndrome, which can occur with mirtazapine, but there is also a notation in the chart that he refused laboratories. He was seen in follow-up on 3/9/18 following submission of a healthcare quest. The psychiatrist added venlafaxine and buspirone to treat ADHD and PTSD symptoms.
He had an individual session with a Clinical Therapist on 2/16/18 where they discussed and practiced coping skills.
He had one session of the coping skills group on 3/22/18 and one session the jail in-reach group on 4/13/18 but was not selected to continue in this group, though the note does not say why.
He had a case management visits with a Behavioral Health Specialist on 3/19/18.
His acuity level was decreased to moderate and he was transferred out of the SCF residential treatment unit HU16 to the stepdown on 12A on 3/23/18. There were no subsequent individual mental health visits until May.
Here again, this patient had a limited mental health needs which were marginally but adequately met. He received appropriate medications, though it is not clear whether or not appropriate laboratory monitoring was ordered.

201748511
I interviewed this patient at SCF on 2/21/18. At that time, he showed no obvious mental health symptoms. He had been in a safety cell in RPDC after expressing a desire to commit suicide by cop. He had a history of heroin use and was homeless. He reported seeing a psychiatrist “occasionally.” He did indicate that he had regular follow-up after being released from the safety cell but otherwise had rare contacts with mental health.

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Medical Record Review
There are receiving screenings from both 12/19/17 and 12/20/17 at RPDC. Neither report any mental health history or symptoms. There was no mental health screening in the record until 12/26/17. However, he was placed in a safety cell on 12/20/18 after telling deputies “he wanted to hang himself once he got back from court. He stated he wanted to commit suicide by cop.” He had also been placed in restraint chair due to becoming combative when leaving court but released upon return to the jail; thus, there was no health care documentation of restraint assessment. The initial safety cell assessment was not completed as the patient was naked and had not yet been given a safety gown; this was two hours after a note indicating placement in the safety cell. Then about eight hours after safety cell placement, the patient refused to meet with mental health. He was finally seen in the noncontact booth the following morning but was largely uncooperative. He continued to express suicidal ideation remained in safety cell. He was largely uncooperative with subsequent attempts to assess him. On 12/22/17 he did cooperate and stated that he was cold and close. Clinical Therapist “reminded client that while in [safety cell] for [danger to self] there are no close, however once client is out of [safety cell] he will be clothed.” He continued to be uncooperative and was placed on a 4011.6 then transferred to the DCU.
While in the safety cell he was seen at varying intervals by nursing staff every 4 to 12 hours; the associated forms were completed to varying degrees.
He was returned to RPDC 12/26/17. He had his mental health intake screening done at that point and was rated as severe acuity level. The following day he was transferred to SCF and placed in the residential treatment unit HU16 on the acute, F pod. He was upset about this placement and subsequently brought to noncontact booth on 12/28/17 by deputies. He told Behavioral Health Specialist that he did not want to be on a mental health unit and explained that he was feeling better now that he had been off heroin for a week.
He was seen by a psychiatrist on 1/3/18. Mirtazapine had been started at the DCU and was continued by the psychiatrist. He had a lipid panel done in March 2018 that showed mild abnormalities. He had already been changed to venlafaxine and was subsequently changed to Wellbutrin.
He attended seeking safety regularly through February and March and was also involved in some other groups.
He was periodically disruptive and required crisis contacts, likely related to personality disorder. Mental health staff did a good job of preventing these from deteriorating into substantial use of force or safety cell placements.
In general, the mental health staff did a good job of managing this patient with very disruptive behaviors. They were able to minimize safety cell usage and other negative outcomes both by virtue of engaging the patient in more structured treatment, primarily group, and by appropriate crisis response.

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201805831
I interviewed this middle-aged female at RPDC on 2/23/18. At that time, she was floridly psychotic and demonstrated labile mood. It was difficult to get any clear history or reports from her. She did say that she had seen a Clinical Therapist that day and, though she had met with a psychiatrist, did not want to be on any medications. She also reported refusing medications for diabetes.
Medical Record Review
The patient was booked into jail on 2/12/18. The receiving screening done by nursing staff indicated that she reported a history of PTSD and that she had been on Abilify, most recently in 2015. She also reported a remote history of sexual abuse. The checklist notes that she has in recent history of substance use, including benzodiazepines. However, the narrative states that the patient had no drug or alcohol problem mental illness problem. She was noted to be “very talkative, stated that since she came from Canada she does not take her medication.” The mental health screening from about 8 hours later indicated that she was delusional, reporting that she was an Indian chief and was on sacred Indian ground. She also reported that she had been electrocuted at a hospital and made other bizarre statements. She denied psychiatric hospitalization, the records demonstrated she had a previous history of hospitalization three times during 2017 and as recently as November 2017 with diagnoses of schizophrenia and bipolar disorder. She exhibited thought disorder and was generally difficult to get a clear history from. She is recommended for mental health housing and was rated as moderately severe and acuity. She was placed on unit 6B in RPDC.
The patient had a mental health assessment on 2/18/18 (she was out at court when previously attempted on 2/15/18). She remained grossly psychotic and largely uncooperative. The Clinical Therapist noted that deputies reported she was eating her meals. She refused diabetic care and medications. The plan was to refer to a psychiatrist. The treatment plan from that date noted her treatment refusal in the intention to continue to offer services and encourage participation in treatment. The Clinical Therapist also made a prayer report to custody staff owing to the patient stating that she had been raped by a police officer in Oklahoma in 2017.
A psychiatrist saw her on 2/21/18. The psychiatrist noted continued florid psychosis and minimal cooperation. The patient continued to refuse medication the plan was for follow-up in 2 to 3 weeks.
The next mental health contact was an attempted visit on 2/27/18, but the patient refused. Clinical Therapist spoke to the nurse reported that her blood sugars, when the patient allowed them to be checked, within normal limits. Follow-ups with a psychiatrist and Clinical Therapist were planned.
The next mental health note is from 3/13/18. In the intervening time the patient was refusing medications. The patient again refused to meet but the Clinical Therapist came to cell front and noted that while her cell was clean, the patient reported that she was not coming out for showers and was refusing all medications, including hypertensive medication she had been taking. The

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patient was also refusing blood pressure and blood sugar checks. Her case had been discussed with custody owing to concerns about her well-being.
The patient came out to meet with the Clinical Therapist on 3/18/18. The meeting was in an Atty. booth owing to the absence of mental health runner that day. The patient continued to be floridly psychotic and to refuse treatment. The Clinical Therapist consulted with the supervisor and owing to the fact that the patient reportedly had no overt medical problems and sufficient selfcare, no civil commitment was indicated.
On 3/21/18, the patient psychiatrist continued to refuse treatment. On 3/27/18, the patient refused to meet with the Clinical Therapist and the Clinical Therapist was not allowed to go to the cell front due to no escort being available. The Clinical Therapist discussed the case with custody and medical, identifying no urgent problems; the patient had come out to meet with a court appointed mental health professional. The psychiatrist met with her briefly on 4/4/18; the patient again refused medication and, owing to three consecutive refusals, the plan was not to follow up unless needed. A Clinical Therapist again attempted to meet with her on 4/10/18 and was only able to talk briefly with the patient at cell front. The Clinical Therapist noted that the patient was being monitored for grave disability. The patient had continued to refuse any medical checks and all medications.
There were no clinical contacts of any kind until 5/4/18. On that date, the patient again refused to meet but the Behavioral Health Specialist did not go to cell front. A Behavioral Health Specialist had a five-minute telephone call on the pod telephone, asking if the patient was interested in residential substance abuse treatment. The patient stated she was in the plan was to refer her.
On the morning of 5/15/18, the patient was combative with deputies when they asked her to return to her cell in order to respond to them medical emergency elsewhere on the unit. She was placed in restraint chair and in a safety cell at 0425. Per an 0510 mental health note, she was uncooperative with deputy’s attempts to do range of motion while in restraint and was to remain in restraints “per custody.” Soon thereafter, she became cooperative and was released from restraints at 0549, though remained in the safety cell. There was a nursing assessment at 0518 that states only that the patient was alert and agitated; there is no evidence that vital were attempted (though were done two hours later) or that there was any neurovascular assessment. No logs were available in the EHR to determine whether the patient was on continuous monitoring while in restraints. The patient repeatedly refused to speak with Clinical Therapists who regularly came to the safety cell that day. The patient refused to meet with the psychiatrist that day as well. She also refused her lunch and dinner in only acceptable water on one occasion, despite multiple offers. She finally agreed to meet with a Clinical Therapist shortly before midnight. The Clinical Therapist asked nursing to evaluate the patient, but the patient refused vital signs though did not appear obviously dehydrated. She continued to be overtly psychotic and several hours later was placed on a 4011.6 hold. She was sent to the DCU on 5/16/18.
This seriously mentally ill woman was promptly detected by mental health staff at intake. She was uncooperative and refused treatment. Mental health staff were appropriately concerned about grave disability and generally monitored her reasonably well, though the. Between

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meetings was too long and failed to observe her in the cell when she refused to meet. Whether she should have been permitted to essentially isolate in her cell and refuse all medical attention for three months is questionable but a judgment call. There is no evidence that she was a danger to herself or others, perhaps because she was isolated in the cell, or at medical risk; thus, there is no clear evidence that this judgment was in error.
201721704
I interviewed this middle-aged female patient at RPDC on 2/23/18. At that time, she was grossly psychotic. It was difficult to get any clear reports from her, but she did say that she met with mental health staff approximately once per month.
Medical Record Review
The patient was booked into CBDC on 6/7/17. The nursing receiving screen noted only that she was taking vitamins and had problems with anxiety and urinary incontinence “when nervous.” She denied medical problems but stated she was menopausal. She had a mental health screening about five hours later during which the patient reported that the “neighbor’s house caught on fire and the roof fell down.” There were no findings on mental status than that the patient was dirty and disheveled. She was placed in general population within level of care rating of minimal.
The patient was seen the following day by a Clinical Therapist, though the reason was not indicated. She was noted to be on and to have some memory problems, but not to mental health services. However, the patient was placed in a safety cell by custody on 6/11/17 at around 11 PM a nursing note at that time reports “bizarre behavior.” She was seen about four hours later by a Clinical Therapist noted that the patient was not oriented and was demonstrating thought blocking. She was talking to herself and responding to internal stimuli. In that note it is reported that she was jailed for arson. A psychiatrist saw him following morning and noted that she was overtly psychotic and started her on risperidone 1 mg. It was a very brief note and concluded that she was “clear to house.” She was released from the safety cell on the evening of 6/12/17 and recommended for mental health housing. She was transferred to RPDC, housing unit 6B. she received her transitional services daily following release from the safety cell. While in the safety cell she was seen by nursing staff about every four hours.
She began to refuse medications and mental health services in general. She remained bizarre but was only seen about weekly, in response to deputy referrals related to her bizarre behavior, outbursts, and difficulty getting along with cellmates. She continued to deteriorate was again placed in a safety cell on 7/13/18. On 7/15/18, she was committed to the DCU. Two days later she was returned to RPDC on Zyprexa 10 mg and risperidone 2 mg. She remained disorganized, rambling, incoherent, and delusional.
There was a minimum treatment plan on 7/19/17 that indicated only that the patient would be provided individual therapy and case management. She was soon medication nonadherent and deteriorated further. She was again committed to the DCU on 8/1/17. She was returned on 8/6/17, now on risperidone 1 mg.

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Things continued much in this vein through April 2018. She refused medications and services, had episodic safety cell placements primarily due to agitation. She was seen anywhere from every day, following safety cell release, or every one to three weeks. She was entered into the Liberty competency restoration program in January and discharged in March. From the time of her 3/13/18 discharge from the competency restoration program until a release summary from 4/10/18, there are no clinical contacts whatsoever. The release summary does not indicate what the release plan is and includes virtually no information about her mental health condition.
It is likely that this seriously mentally ill should of been detected at receiving screening, but was identified shortly thereafter and appropriately placed in a residential mental health unit. She had to brief DCU hospitalizations with little evidence of improvement. Follow-up for the first several months was reasonable and included efforts to engage her (including offering different types of groups) but towards the end of her stay, the frequency of follow-up deteriorated, especially following her discharge from competency restoration treatment. The release summary is completely inadequate; there is no evidence of release planning and mental health issues were entirely left out, despite being her most serious problem. Note also that it is problematic that interventions and monitoring by Liberty are not included in the medical record, making the monitoring and evaluation of the adequacy of her treatment difficult to assess during the time they were involved.

2000052910455908
I interviewed this middle-aged male patient on administrative segregation at RPDC on 2/23/18. At that time, he was grossly psychotic and somewhat agitated. He stated he was being held there legally and reported that he was being poisoned. He stated that he had lost 25 pounds. He also stated that he was being forced to take Haldol but then stated he was not taking it and wanted to take Abilify or Geodon. He told me he was waiting to be admitted to Patton State Hospital.
Medical Record Review
The patient was booked into SCF on 6/3/17. The nurse receiving screening notes that he was largely uncooperative and would not reveal medical history but denied any mental health problems. He was placed in the sobering cell overnight, the denied using any drugs and there is no evidence of intoxication in the record. A nurse receiving screen done the following morning noted that he remained uncooperative and was wearing a spit mask. He was reportedly alert and oriented. The health assessment notes no problems and reported that he was appropriate and not in any distress. This assessment also noted that the initial mental health screening had been reviewed, but the patient had not yet been screened by mental health and had been refusing. The mental health screening form noted this refusal but indicated that he stated that he was being falsely held. He was noted to be mildly unkempt and hostile. He was referred to mental health housing, though it is not clear why. A progress note from several hours later has essentially no information in it, though states that records were reviewed.

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He was transferred to RPDC 6/6/17. He was seen at that time by a Clinical Therapist and was marginally cooperative. There were no overt findings, though he showed delayed responses. He was placed on the medical floor on 6/13/17. The next attempt to see him was on 6/17/17 at which time he refused contact. He had been refusing all medications and labs, including important infectious disease medications. An attempt to see him the following day was met with an irritable refusal. A psychiatrist came to see him on 6/19/17 and though he refused contact, the psychiatrist came to his medical cell. He continued to be hostile and labile and refuse nor health treatment. The psychiatrist did not comment on his medical treatment refusal. The next attempt to see him was 7/6/17 after a referral from a Hu 5B deputy following the patient threatening custody staff. He was marginally cooperative but felt not to represent a danger to self or others. However, he was noted to be delusional, reporting “they are poisoning my meds and playing with my food.”
The patient continued to refuse medications. He refused repeated attempts by mental health staff to interview him and conduct an assessment. He was placed on administrative segregation status on 7/13/17 “due to his threatening behavior towards cellmates.” A 7/19/17 note finally reported on his significant mental health history, including contacts with emergency treatment services and hospitalizations for psychotic disorder. At that time his refusal of medical medications was noted as well. However, his competency to refuse was not indicated.
He was released from the medical floor on 7/22/17. Note that during that time, there are no notes from a medical provider despite his medication refusal and serious illness. He was simply allowed to refuse treatment and then discharged from the medical floor.
On 7/24/17, HU 5B deputies referred him to mental health because he was throwing water at them. He was finally coaxed to engage in interview and a noncontact booth. He continued to express the delusion that his food was being tampered with and was hostile and labile. He was placed in a safety cell. He refused to speak to a psychiatrist. He was committed to the DCU later that day on a 4011.6 hold.
He was returned to jail on 8/9/17. He continued to present does psychotic and paranoid. He refused medications and refused most mental health contact. He agreed to see a psychiatrist on 8/18/17 and the psychiatrist changed him to Depakote and Abilify, medications that he had requested previously but had not been given at the DCU. He continued to express paranoid ideas and to refuse medical medications. He was marginally cooperative with attempts to engage him by mental health, those these were almost exclusively at cell front. He also began refusing his psychotropic medications though agreed to start them again seen by a psychiatrist on 8/30/17. Despite this, he continued to refuse medications on a regular basis.
An AIMS was done 10/23/17 and scored as zero.
Things continued in this vein with frequent refusals of contact, refusal of almost all medication, continued paranoid ideation, and ultimately beginning to throw food in the toilet and demanding sack lunches. He was seen every 2 to 5 days throughout the time he was on administrative segregation, though almost all contacts were at cell front.

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On 12/1/17, he was finally committed again to the DCU. In addition to refusing treatment and often not eating, wasn’t even coming out of his cell. Cell is a mess. He had been gassing deputies as well. A DCU Clinical Therapist note from 12/18/17 reads:
“Client’s 5250 hold has expired and remains [sic] extremely paranoid, believing that he is being poisoned. Client only recently became men compliant [for] three days but, has refused Geodon last three days. DCU [Clinical Therapist] apprised contact liaisons at RPDC regarding client’s [discharge] from DCU. DCU summary of care form completed with housing acuity rating; psychiatric [discharge] summary entered into TechCare. Client added to [transitional series] queue. Due to severity of continued paranoia, client should not be placed in holding cell with others. DCU [behavioral health] acuity rating: severe.”
Not surprisingly, he continued to refuse treatment and was frequently not eating his meals, complaining that they were poisoned. Contacts continued every 2 to 5 days at cell front. He was once again committed to the DCU on 2/2/18. Documentation demonstrates that he was even more decompensated than he had been previously. The patient was returned to the jail on 2/18/18 with little to no evidence of improvement.
On 2/27/18, a release summary was done. It does not indicate where the patient is going. There is virtually no mental health information. It does not indicate that he has been refusing medications for delusional reasons.
The treatment of this patient was grossly inadequate. Though the intake documentation was poor, he was clearly identified as a mentally ill individual and was promptly placed in a residential treatment unit. However, for the following eight months, this man was allowed to languish essentially in isolation, refusing all treatment, including treatment for an infectious disease that represented a threat to his life. There was no assessment of his competency to refuse. Hospitalizations in the DCU proved no help; this man clearly needed long-term involuntary medication and hospitalization. Though the documentation does not say so, it is likely that he was finally transferred to Patton State Hospital, as he reported to me was pending.

201745991
I interviewed this male patient on administrative segregation at RPDC on 2/23/18. At that time, he was delusional about being a rapper and exhibited thought blocking. He stated that he was waiting for admission to Patton State Hospital. He stated that he saw a psychiatrist about once a month and that mental health would only visit him at morning pill call.
Medical Record Review
This patient was booked into RPDC on 11/30/17. Of note, he had been released a week previously but had not gotten release medications as documented by an 11/29/17 note. The nurse receiving screening noted that he had a mental health history and that he was prescribed Topamax and olanzapine. He had a mental health screening the following morning, though less

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than 24 hours from admission. However, he refused to participate. Because of his well-known history including hospitalization at Patton State Hospital and assaultiveness, he was rated as severe. He was placed on administrative segregation. Bridge orders for psychotropic medications were obtained that day. He met briefly with the psychiatrist and agreed to restart his medications. He presented primarily with negative symptoms; no mood or psychotic symptoms were reported. The plan was to start him on Zyprexa, Zoloft, and Artane.
The patient reported suicidal ideation to deputies on 12/6/17 and after a Clinical Therapist assessment was placed in the safety cell. He expressed paranoid delusions as well as suicidal intent. He initially met with Clinical Therapists and gave mixed reports about whether he was having command hallucinations to harm himself. However, he continued to express suicidal ideation. Over the following hours, he refused to come out and was placed on a 4011.6 and committed to the DCU the following day. While in the safety cell, he was not evaluated by nursing staff until he had been in there for almost 24 hours and then was seen every 3 to 8 hours.
He was returned to the jail on 12/14/17.
He remained on administrative segregation through the end of the record in May 2018. There was no evidence of any significant behavioral problems, but he continued to exhibit psychotic symptoms including delusions and thought disorder, though the thought disorder appeared to diminish with time. He also continued to complain of hallucinations but did not seem to be is preoccupied and reported them reducing as well. While his medication adherence was not outstanding, it was sufficient to get a pharmacologic response. He was not seen daily while in administrative segregation but was most often seen daily or every other day with the longest. Being about five days between visits. Mental health staff made repeated efforts to engage him in groups, but he continued to refuse. Clinical Therapists occasionally brought him out for face-toface visits. He saw a psychiatrist about every month. An AIMS was done 4/23/18 and was scored as zero. Most laboratories were done, however there were no metabolic studies done to monitor for metabolic syndrome though he remained on second generation antipsychotics.
In general, treatment of this patient was sound. Mental health staff monitored him on a regular basis and attempted to engage him in appropriate group treatment. Medication management was appropriate, except for the failure to monitor for metabolic syndrome.

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APPENDIX 2
Outline of Quantitative Mental Health Compliance Monitoring
This outline is offered as a proposal. It needs to be reviewed in light of the terms of the remedial plan and modified in accordance to the availability of information. It is based on the mental health elements of an outline submitted in November 2016. Following the outline is a draft of an associated data request to the County. The goal would be to have this done prior to my next site visits in July and August of this year.
Bold text indicates the essential provision of the compliance measure Red text indicates suggested clarifications, definitions, or additions Violet text indicates suggested methods for compliance monitoring
Random record identification should be done in advance by the County in most cases because many of the measures will first require pulling a subset of records from which to select the random sample. Note, unless otherwise specified, the pool for data pulls will consist only in inmates admitted for at least one week.
I. Intake MH Screening – changed to reflect 100% screening by MH staff a. Prior to placement in jail housing (95%) – i. Random selection of medical records with booking admissions for previous 6 months and pulling corresponding jail placement time stamp (From JIMS?) 1. At Blythe, done within 14 h when RN not on duty at time of booking (90%) – Random selection of medical records with booking admissions for previous 6 months (if booking time stamp in EHR is accurate) b. Confidential setting for intake (custody visual supervision allowed) unless security risk (90% of intakes confidential) – direct observation c. MH intake content (95%) – Random selection of medical records with booking admissions for previous 6 months i. Mental health does screening for all patients now; elements to be consistent with initial report (in general terms below): 1. Mood/affect a. Patient report b. Observation 2. Psychosis (including delusions, thought disorder, hallucinations) a. Patient report b. Observation 3. Suicide and self-harm a. Current SI b. Hx self-harm behavior 4. Current psychotropics a. What b. Adherence

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5. Current MH services (including related services, such as for ID, SA)
6. Current MH complaints 7. Hx of MH services
a. Inpatient b. Outpatient 8. Substance abuse a. Current (may be in medical portion) b. Past 9. Sexual behavior a. History of aggressive sexual behavior b. History of sexual victimization c. Risk of sexual victimization ii. Other observations 1. Neurocognitive a. Slow speech/lack of comprehension indicative of DD b. Level of consciousness c. Orientation 2. Self-care a. Hygiene b. Clothing 3. Behavior a. Cooperativeness b. Communication c. Psychomotor d. Psychotropics at intake i. Staff take reasonable steps to verify current prescriptions by each of the following methods when applicable 1. Review of RUHS-BH data on Rx verification for previous 6 months a. Verify methodology b. Spot check random charts of those admitted in the last six
months for more than 72 hours 2. Content
a. County’s electronic mental health records (95%) b. Call pharmacy (95%) c. Call practitioner (95%) d. Paper prescriptions provided by inmates or families at
booking (95%) ii. Three options (One occurs 90%) – review of random medical records from
previous 6 months where a patient reported taking psychotropic medications prior to arrest during the intake assessment
1. Seen by a psychiatrist within 24 hours, 2. Community meds or meds considered medically necessary by
psychiatrist are ordered and offered immediately if in jail stock – unclear how this would be determined (suggestion?)

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3. If not in jail stock, community meds or meds considered medically necessary by psychiatrist are ordered and offered within 48 hours
II. Access to Care (note: timelines and completeness set at 90% to correspond to mandated staffing assessment captured under Staffing below) a. Inmate healthcare requests i. Health Care Request Forms available in: 1. All housing units (95%) – direct observation 2. All dayrooms (95%) – direct observation 3. All program rooms (85%) – direct observation 4. All libraries (85%) – direct observation ii. Locked boxes in all housing units (95%) – direct observation 1. Emptied by nursing staff every 24 h (90%) –review of random log entries or other tracking system from previous 6 months (proof of practice may have to be developed) iii. Sheltered housing 1. Health Care Request Forms picked up by healthcare staff directly from inmates every 24 h (90%) –review of random log entries or other tracking system for previous 6 months (proof of practice may have to be developed) a. Custody may collect if dayroom closed to healthcare if healthcare observes and receives directly from custody (90%) –review of random log entries or other tracking system for previous 6 months (proof of practice may have to be developed) iv. Health care staff provide writing assistance to inmates requiring accommodation to complete Health Care Request Forms upon request (90%) – staff and inmate interview v. Health Care Request Form triage by QMHP for MH requests (95% are triaged by QMHP) – review of RUHS-BH data and methodology; spot check random medical records involving Health Care Request Forms for mental health reasons from previous 6 months (current RUHS-BH data does not clearly specify time of receiving request from nursing or time of QMHP triage) a. Within 24 hours if collected from patients by healthcare staff (90%) b. Same day if collected from lockbox (90%) – recommend making this 24 hours as well vi. Timeliness of QMHP response following RN referral or QMHP triage of Health Care Request Form – review of RUHS-BH data and methodology; spot check random medical records involving Health Care Request Forms for mental health reasons from previous 6 months 1. Emergent – immediate unless to ER/hospital (90%) 2. Urgent – within 24 h (90%) 3. Clinical Symptom Described – within 72 hours (90%) 4. Routine – 2 weeks (90%)

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vii. County tracking of Health Care Request Form response – must be “regular” (quarterly) (y/n) – review of county tracking data and associated CQIP review from the previous 6 months 1. Collection of Health Care Request Forms (90% of reviews include) 2. Triage of Health Care Request Forms (90% of reviews include) 3. RN response times – by review of nursing sick calls (90% of reviews include) 4. Clinician response times – by review of clinician sick calls (90% of reviews include)
b. Inmate declared medical or psychiatric emergency (including “man down” call by other inmates) i. RN or higher sees inmate or interviews inmate by telephone ASAP (90%) – review of random medical records involving a patient declared mental health emergency or a “man down” scenario for self-harm behavior during the previous 6 months
c. Policy provides for clinicians to request follow-up without requiring inmate Health Care Request Form (y/n) – review of policy
III. Clinical settings (mental health) – direct observation, staff interview, random medical record review of patients on MH case load during previous 6 months a. In-person i. Proper lighting (99%) ii. Medical record access (95%) iii. Confidential setting unless documented threats, intimidation, or violence towards staff or individual determination including consideration of healthcare request (95% confidential where none of documented problems exist) b. Telemedicine i. Appropriate equipment (99%) ii. Adequate space (99%) iii. Computer records access (95%) iv. Confidential setting unless documented threats, intimidation, or violence towards staff or individual determination including consideration of healthcare request (95% confidential where none of documented problems exist)
IV. Medication administration and monitoring a. Pill call – direct observation, staff interview, review of logs i. BID pill lines provided in each housing unit (99%) – direct observation, staff interview, review of logs from the previous 6 months ii. Regular times (within 1 h of designated time 90%) – direct observation, staff interview, review of logs from the previous 6 months iii. Policies provide for therapeutically appropriate times as determined by the ordering physician (y/n) – review of policy 1. Alternate pill times ordered by physician honored (90%) – review of MAR for psychotropic medications ordered for administration at times other than routine pill times during the

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previous 6 months (possible sources include standing orders for QID medications, now/stat orders, LAI clinics) b. Court medications i. Policies and procedures to ensure inmates provided medications at therapeutically appropriate times – review of policy 1. When out to court (y/n) 2. In transit to outside appointments (y/n) 3. During transfer (y/n) ii. Medications administered “as close as possible to the regular administration time” (within 2 hours) –review of random records of inmates on medications that have gone out to court, been in transit to an outside appointment, or transferred to another institution during the previous 6 months (proof of practice and/or mechanism to identify cases may need to be developed) 1. Staff administered psychotropic medication (90%) c. Policies and procedures to ensure medication side effects and efficacy monitored and reviewed at appropriate intervals (y/n) – review of policies and procedures i. Medication monitoring is done per policy (85%) –review of random records of inmates on psychotropic medications during the previous 6 months d. Prescription filling from pharmacy i. Done by RUMC (y/n) – review of relevant documentation ii. Filled on all weekdays (90%) – review relevant pharmacy logs and/or random records of inmates on medications iii. Stock medications at jails 1. Every jail (y/n for each) – direct observation, review of logs 2. Determined by Medical Director and pharmacy (y/n) – review of relevant documentation 3. Consistent with State Board of Pharmacy regulations for newly arrived patients or missed deliveries (y/n) – review of relevant documentation iv. If ordinary delivery times would compromise care –review of random records of inmates on medications with “stat,” “next day,” or equivalent orders for psychotropic medications during the previous 6 months 1. Staff call RUMC pharmacy to obtain (90%) 2. Medications arrive the following day (90%) V. Confidentiality a. Policies and procedures ensure appropriate confidentiality for health care services – review of policies and procedures, direct observation, staff interview i. Clinical encounters by QMHP (y/n) 1. Confidentiality is provided (95%) ii. Health care intake screening by QMHP (y/n) 1. Confidentiality is provided (90%) iii. Pill call – on residential mental health units (y/n) 1. Confidentiality is provided (95%)

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iv. Provider sick call by psychiatrists (y/n) 1. Confidentiality is provided (95%)
v. Mental health treatment during groups (y/n) 1. Confidentiality is provided (95%)
b. Custody staff tracking the filing and disposition of grievances i. Are appropriately trained (85%) – review of training materials and training logs ii. Are subject to the same patient confidentiality as health care staff (y/n) – review of policy and confidentiality statements, staff interview
c. Identification of inmates with a mental health need is accessible to appropriate staff on a need to know basis (y/n) – direct observation, staff interview
VI. Health Care Records a. There is an Electronic Health Record System with medical and mental health information in a single record within 12 months of the date of the Consent Decree (y/n) – direct observation, staff interview i. There is policy and procedure to monitor the deployment of the CHS Electronic Health Records to ensure the system is modified, maintained, and improved as needed on an ongoing basis including IT support for network infrastructure and end users (y/n) – review of policies and procedures 1. This policy and procedure is implemented (y/n) – review of relevant documentation b. Prior to 12 months: i. Policies and procedures have been implemented allowing medical and mental health staff access to medical and mental health information need to perform their clinical duties (y/n) – review of policies and procedures 1. Medical and mental health staff are trained within one month of the Consent Decree (85%) – review of training materials and training logs
VII. Staffing a. Staffing is sufficient to execute the health care components of the Remedial Plan (y/n) – expert assessment b. Within 12 months of the Consent Decree, 90% of positions in the following categories are filled with staff attending work i. Exhibit A – or current agreed upon staff positions c. Healthcare staff provide community standard of care i. Mental health (95% of records, y/n for materials) – review of random medical records for the previous 6 months, review of mental health guidelines, review of manualized treatments, review of mental health group curricula d. There is an annual assessment of adequacy of staffing – review of annual assessment and associated recommendations and corrective action plans, review of positions filled and empty i. In all categories of medical and mental health (including clinical and support staff) to assure adequacy of services and includes:

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1. Provision of clinical supervision (y/n) 2. Review of compliance with:
a. Chronic care guidelines (y/n) b. Sick call triage timelines (y/n) c. Medication refusal polices (y/n) d. Delays in prescription renewals (y/n) e. Daily pill call policies (y/n) f. Wait times to see nurses and providers (y/n) 3. If any category is less than 90%, the assessment reviews hiring and retention and indicates steps to be taken to fill positions (y/n) 4. Custody staffing is adequate to assist with a. Medication administration (y/n) b. Movement of inmates to health care services (y/n) c. Custody staff performing these and any other health care
functions are included in the annual assessments (y/n) ii. The assessment is done (y/n) iii. The assessment recommendations are undertaken (y/n)
1. If any category is less than 80% for three consecutive months, county will take all steps required to fill vacancies within 12 months, including, if needed, adjustments to compensation (y/n) a. Pending hiring, the county will fill vacancies with temporary staff so that the category is higher than 80% within 3 months (y/n)
VIII. Custodial Environment a. Policies, procedures, and other provisions reflect the intent to provide inmates with as much dayroom time as is consistent with institutional safety and security (y/n) – review of policies and procedures b. Dayroom time i. Begins no later than 0800 and ends at 2300 (85%) – review of TITLE 15 or similar logs for the previous 6 months, interview of staff and inmates 1. Timelines exclude individual cell returns, group disturbances, or institutional emergency (unclear how to measure compliance) a. Suspension of dayroom access shall last only so long as needed to ensure safety and security (85%) (unclear how to verify compliance) c. Recreation area i. Inmates are offered recreation area – review of TITLE 15 or similar logs for the previous 6 months, interview of staff and inmates 1. Twice each week (85%) 2. Each session is at least 1.5 h (85%) a. Times exclude institutional emergencies requiring temporary suspension of rec time (unclear how to measure compliance)

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b. Suspension of recreation access shall last only so long as needed to ensure safety and security (85%) (unclear how to verify compliance)
d. Custody staff are trained in identifying inmates who self-isolate (85%) – review of training and training logs
e. Custody staff make referrals to mental health for: i. Self-isolating inmates (inmates not leaving their cell for 3 consecutive days) (95%) – identify inmates not leaving their cell for 3 consecutive days from TITLE 15 or similar logs for those in residential mental health settings; review associated medical records for evidence of referral. (not clear if this methodology is possible; if not, recommend alternative approaches) ii. Those who have recently (3 working days) received lengthy sentences (more than 15 years) or a death sentence (95%) – review of medical records of random selection of qualifying cases 1. Within one month of the Consent Decree, there is policy and procedure for this referral (y/n) – review of policies and procedures
f. Inmates are classified per the classification policy (y/n?) – review of classification reports i. Inmates are not placed in more restrictive custody solely because – direct observation, interviews of staff and inmates, review of records of random selection of cases with qualifying disability on administrative segregation, review of determinations of administrative segregation status 1. They have a mental illness (y/n)
g. Administrative segregation i. Inmates on mental health caseload are seen daily by mental health staff at Clinical Therapist or higher (85%) – review of medical records of random selection of those in ad seg during the last 6 months that were on the mental health caseload (consider revisiting daily requirement) ii. Inmates placed in administrative segregation who are not receiving mental health services are evaluated by a Clinical Therapist or higher within 48 hours of housing (95%) – review of medical records of random selection of those placed in ad seg during the last 6 months that were not on the mental health caseload
iii. Inmates on prescription Rx receive medications from medical staff at the cell (y/n) – direct observation, staff and inmate interview
iv. Inmates who report or demonstrate decompensation or distress are seen within 24 hours by an appropriate clinician (95%) – review of random medical records of custody referrals, Health Care Request Forms triaged as urgent/emergent by a QMHP, or inmate declared emergencies during the last 6 months for inmates on administrative segregation 1. The clinician shall confer with the medical liaison Lt or facility commander/designee when there is evidence of decompensation or distress to determine if alterations to placement and living conditions are appropriate (85%)

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2. This provision may be modified by an appropriate behavior management plan
v. Assignment to administrative segregation is be re-evaluated every 30 days (95%) – review of relevant records or reports
IX. Quality Management a. Continuous Quality Improvement Program (CQIP) i. The following are evaluated annually by peer review – review of peer review logs 1. Physicians (85%) 2. Physician’s Assistants (85%) 3. Nurse Practitioners (85%) ii. The Quality Improvement Committee – review of CQI minutes 1. Includes the Correctional Health Services Administrator, Correctional Health Services Medical Director, a mental health representative, a registered nurse, a pharmacy representative, a Sheriff’s Department representative (85%) 2. Meets quarterly (90%) 3. Provides systematic monitoring and analysis of health services for the purpose of improving processes (y/n) 4. Each of the following are reviewed at least annually a. Intake screenings i. Number performed (2 consecutive years) ii. Number not done prior to housing (2 consecutive years) b. Health needs requests i. Number submitted monthly (2 consecutive years) ii. Number triaged same day (2 consecutive years) iii. Number of emergent conditions (2 consecutive years) iv. Number of emergency conditions seen immediately (2 consecutive years) v. Number of urgent conditions (2 consecutive years) vi. Number of urgent conditions seen the same day (2 consecutive years) vii. Number who received visits with providers within 14 calendar days of receipt (2 consecutive years) viii. Number of “man down” responses (2 consecutive years) ix. Number of inmate requests indicating a clinical symptom not seen by an RN within 48/72 hours (2 consecutive years) c. Percent inmates not receiving first dose of essential medication within 24 hours of order (2 consecutive years) d. Percent inmates with medication lapses due to untimely renewal (2 consecutive years)

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e. Number of inmates verified on psychotropics at booking not receiving first dose within 48 hours of order or seen by psychiatrist within 24 hours (2 consecutive years)
f. Number inmates stating taking psychotropic medications at booking but staff did not take reasonable steps to verify prescription (2 consecutive years)
g. Length of time from specialty referral to completed appointment by service (2 consecutive years)
h. Number of inmates with chronic illnesses who did not receive medications within a day of order (2 consecutive years)
i. Number of inmates with chronic illnesses who did not receive H&P by RN, PA, NP, or physician within 2 weeks of booking (2 consecutive years)
j. Grievances over health care complaints and institutional responses (2 consecutive years)
k. Court orders for health care and institutional responses (2 consecutive years)
5. Corrective Action Plans (CAP) a. Appropriate CAP recommended for all deficiencies (95%) i. Deficiencies are based on reasonable targets (y/n) 1. Note: some are recommended under other items b. The Administrator ensures that CAP recommended by the committee are implemented and completed within 30 days of the recommendation unless extenuating circumstances (85%)
b. Reviews of in-custody deaths i. Preliminary review – review of Preliminary reviews of all in-custody deaths (focus on mental health elements) 1. Done within 30 days (95%) 2. Includes a written report a. Circumstances and events (95%) b. Reports whether there were any preventable causes of death or any potential systematic problems identified (95%) i. Remedy for any identifiable problems recommended (95%) ii. Mortality review includes – review of Mortality reviews for all in-custody deaths (focus on mental health elements) 1. Detailed assessment of events occurring prior to death (95%) 2. Analysis of any acts or omissions by any staff or inmates which might have contributed to the death (95%) 3. Psychological autopsies performed on any suspected suicide (95%) 4. Identifies any problems for which corrective action should be undertaken (95%) a. CAP created, implemented and completed (95%)

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X. Mental health care a. Mental Health Program Guide – review of Mental Health Program Guide i. Completed within 6 months of Consent Decree (y/n) ii. Conforms to community standards of care (y/n) iii. Specifies the following components 1. Assessment (y/n) 2. Structured treatment a. Face-to-face clinical contacts (y/n) b. Group therapy (y/n) c. Individual therapy as clinically indicated (y/n) d. For mental health housing units (y/n) e. For other settings (y/n) b. Psychiatric prescribers (see also Access to Care) – review of random medical records of inmates receiving psychotropic medications during the previous 6 months including a sample of those ordered at booking i. See patients started on psychotropics at booking within 7 days (85%) ii. See patients within 30 days of an initial visit when medications are ordered or as otherwise indicated (85%) iii. See patients at least every 90 days when on psychotropic medications (90%) c. Housing i. SMI are housed in units designated for such housing unless otherwise recommended by MH (95%) – review of random selection of medical records and housing assignments of those identified as level of care severe or moderate-severe ii. Mental health housing will provide movement consistent with classification level (95%) – review of TITLE 15 or equivalent logs for the previous 6 months, direct observation, interviews with staff and inmates 1. Maximum out of cell time is provided (85%) iii. Mental health housing provides programming and structured activities – review random selection of encounters and/or medical records of treatment activities of those in mental health housing for a minimum of 30 days during the previous 6 months, direct observation, review of manuals/curricula 1. Appropriate for acuity (y/n) 2. Consistent with community standard of care (y/n) iv. Transfers of mentally ill 1. Policies and procedures ensure clinical input prior to transfers of mentally ill inmates (y/n) – review of policies and procedures a. Policy provides adequate time for clinical staff to consult with facility commander/designee (for within facility transfers) or sending facility commander/designee and DMH supervisor prior to transfer (for between facility transfers), absent an emergency (y/n) – review of policies and procedures

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b. Absent emergency transfer, MH staff are consulted prior to transfer into or out of mental health housing and determine if transfer is therapeutically indicated (95%) – review of reports of transfers during the previous 6 months i. If conflicting recommendations, there is sufficient time to consult (95%)
d. Treatment space i. Adequate treatment space exists to provide individual and group treatment and has access to health care records at each facility (y/n) – direct observation, interviews with staff, review of group schedules 1. Space provides appropriate privacy (y/n)
e. Suicide prevention i. Within one month of the Consent Decree, there is policy and procedure providing for step-down from safety cells (y/n) 1. The policy and procedure provide for gradual restoration of property and privileges consistent with the clinical assessment (y/n) – review of policies and procedures 2. The policy and procedure demonstrate intent to minimize time in safety cells (y/n) – review of policies and procedures 3. Policy is implemented –review of medical records and conditions of confinement of random selection of inmates placed in safety cells during the previous 6 months a. Records reflect clinical assessment of restoration of property and privileges (95%) b. Records and observation reflect that restoration of property and privileges is consistent with the clinical assessment (95%) ii. Records and observations reflect that inmates in safety cells – direct observation, interviews with staff and inmates, review of safety cell logs and MAR for random selection of inmates placed in safety cells during the previous 6 months 1. Are offered meals three times per day (95%) 2. Are provided all prescribed medications (99%)
iii. Seclusion shall last no more than 12 hours (95%) – seclusion is defined as placement in a safety cell with no more than a smock, mattress, and blanket
iv. Within one month of the Consent Decree, there is policy and procedure providing for inmates awaiting transfer to RUMC due to serious risk of self-harm to receive treatment and attention consistent with MH determination (y/n) – review of policies and procedures 1. Provides for one-on-one observation (y/n) – review of policies and procedures 2. Determination of conditions and treatment determined by MH (y/n) – review of policies and procedures

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3. Policy is implemented – review of medical records and conditions of confinement of a random selection of those referred to RUMC for DTS during the previous 6 months, direct observation a. Records reflect determination of conditions and treatment pending transfer is done by MH clinician (95%) b. Records and observation reflect that conditions and treatment is consistent with the clinical determination (95%)
v. Records and observations reflect that safety cells are cleaned and sanitized on regular basis, including after each use and when conditions of an occupied cell are unsanitary (85%) – direct observation, review of safety cell cleaning logs
vi. Custody supervisors regularly inspect, at least each shift, safety cells and safety cell logs (85%)– review of safety cell logs of those placed in safety cells during the previous 6 months, direct observation 1. These inspections are reviewed at least weekly by a lieutenant (85%) – review of safety cell logs
vii. MH clinicians conduct face-to-face assessments and treatment of inmates in safety cells, unless there is a likelihood of inmate violence (95%) – review of safety cell logs and/or medical records of those placed in safety cells during the previous 6 months, direct observation, interviews with staff and inmates
f. Restraints i. There is policy and procedure that ensures continuous monitoring of inmates in restraints (y/n) – review of policies and procedures 1. Records and observations reflect continuous monitoring of inmates in restraints (95%) – review of restraint logs of those placed in safety cells during the previous 6 months, interview of staff and inmates ii. Records and observations reflect that restraint chairs are cleaned and sanitized on regular basis, including after each use and when conditions of an occupied chair are unsanitary (85%) – review of safety restraint chair cleaning logs from the previous 6 months, direct observation
iii. MH clinicians conduct face-to-face assessments and treatment of inmates in restraints, unless there is a likelihood of inmate violence (95%) – review of restraint logs and/or medical records of inmates placed in restraints during the previous 6 months, direct observation, interview of staff and inmates
g. Continuity of care i. Continuity of care is provided to all sentenced inmates and unsentenced inmates when there is enough time (length of stay more than 14 days) – review of random selection of medical records of those released during the last 6 months who had stays of at least 14 days 1. Referrals to community-based providers are done when determined by a jail provider to be needed (85%)

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2. Those with SMI receive discharge planning, when indicated, including connecting the inmate to: a. Community health care providers (85%) b. Community social services (85%) c. Community-based housing (85%) d. Other appropriate services (85%)
ii. Release psychiatric medications will be available to inmates ASAP following release (within 2 days) (85%) – review of pharmacy data for a random sample of released inmates, review protocol for release medications, interview staff and inmates
XI. Policies and procedures a. Policies and procedures support all the provisions of the remedial plan – expert review i. Policies and procedures are revised as necessary within 6 months of the Consent Decree (y/n) – review of policies and procedures b. The county follows policies and procedures i. The county follows current policies and procedures (y/n) – expert review ii. Revised policies and procedures are implemented within 9 months of the Consent Decree (y/n) – review of policies and procedures 1. Staff received training in revised policies and procedures within 9 months of the consent decree (85%) – review of training materials and training logs
XII. Consent Decree training a. Staff are trained in the provisions of the Consent Decree within 9 months of its issuance (85%) – review of training materials and training logs b. The correctional health services budget is sufficient to finance adequate health care and custody staff to comply with the Remedial Plan (y/n) – expert review

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Draft Information Request The following is a listing of information needed prior to the upcoming semi-annual mental health assessment regarding Gray v County of Riverside. Some require production of data while others require identification of a pool of random subjects for subsequent review (e.g., medical record numbers for different categories of patients). Unless otherwise specified, the pool for data pulls will consist only in inmates admitted for at least one week and inmates should be drawn from all facilities whenever possible.
The information is combined whenever possible to promote efficiency. For this reason, the order of the information request is not the same as the ordering of items in the remedial plan or other related documents. However, the topic area will be indicated to facilitate locating responsive information.

Intake
 Provide 40 random medical record numbers of inmates booked into the jail during the last 6 months. o For each of those 20, also include the time of initial cell placement (housing)
 Provide 20 random medical record numbers of inmates booked into the jail during the last 6 months who reported being on psychotropic medications in the community at the time of booking
Inmate Healthcare Requests
 Provide (quarterly) CQIP reports or other review of the County’s tracking of Inmate Healthcare Request From responses
 Provide summary data and methodology or log books for one of the previous six months (including dates and times) for each of the following o Pick up of Inmate Healthcare Requests from lock boxes  By custody  By nursing o Pick up of Inmate Healthcare Requests of inmates in sheltered housing  By custody  By nursing Note: If summary data and methodology are provided, include a random sample of medical record numbers of 20 patients who submitted Inmate Healthcare Requests for mental health.
 Provide summary data and methodology or log books for one of the previous six months including dates and times of for each of the following o Delivery of Inmate Healthcare Requests to mental health o Triage of Inmate Healthcare Requests by a QMHP o 40 random medical record numbers of inmates submitting Inmate Healthcare Requests for mental health during the last 6 months

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 10 with emergent needs  10 with urgent needs  10 with a clinical symptom described  10 with routine needs
Note: If summary data and methodology are provided, include a random sample of medical record numbers of 20 patients who submitted Inmate Healthcare Requests for mental health.
Medication Administration
 Provide 20 random medical record numbers of inmates ordered psychotropics in any of the following ways o Stat or now o QID o Long-acting injectable antipsychotics
 Provide 20 random medical record numbers of inmates provided medications when outside a jail for any of the following reasons o Court o Outside appointment o Transfer
 Provide 20 random medical record numbers of inmates ordered any of the following medications (alone, sequentially, or concurrently) by a psychiatric prescriber for a period of 30 days or longer: antipsychotics, lithium, valproic acid/sodium valproate, carbamazepine, mirtazapine, tricyclic antidepressants
 Pharmacy o Provide a summary report of medication deliveries to each jail for two random weeks during the last 6 months o Provide a list of stock medications to be maintained at each jail and any documentation related to maintaining each jail’s supply during the previous 6 months o Provide a summary report of medication order dates and fill dates (or equivalent) for two random weeks during the last 6 months o Provide a list of 20 inmates on psychotropic medications at the time of release  Include date of release  Include medications provided at the time of release or within two days of release
Mental Health Treatment
 Provide the Mental Health Program Guide or equivalent  Provide 20 random medical record numbers for inmates spending at least 30 days on a
residential mental health unit during the previous 6 months o At least 10 from RPDC o At least 5 females

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 Administrative segregation o Provide 10 random medical record numbers of inmates not on the mental health caseload that were placed on administrative segregation during the previous 6 months o Provide 10 random medical record numbers of inmates on administrative segregation who were seen (urgently or emergently) by a QMHP following custody referral, that submitted a Health Care Request Form that were triaged by a QMHP as urgent or emergent, or who declared a mental health emergency during the previous 6 months o Provide 10 random medical record numbers of inmates on administrative segregation longer than 30 days with level of care moderate-severe or severe during the previous 6 months
 Provide 20 random medical record numbers of inmates placed in safety cells during the previous 6 months o For these, provide the safety cell logs o Include at least 10 who were committed to the DCU before the expiration of their time in the safety cell
 Provide 10 random medical record numbers of inmates placed in restraints in the jails during the previous 6 months o For these, provide the safety cell logs
 Continuity of care o Provide 20 random medical record numbers of inmates released within the previous 6 months who had level of care ratings of moderate-severe, severe, or acute
Man Down
 Provide 10 random medical record numbers of “man down” calls involving self-injurious behavior or inmate-declared mental health emergencies
Custody and Classification
 Confidentiality of healthcare grievances o Provide documentation of confidentiality training for staff with access to healthcare grievances o Provide a log or copies of confidentiality agreements for staff with access to healthcare grievances
 Dayroom and yard time (information may be provided in a form convenient to RCSD as long as the data are clearly labeled and organized) o Provide summary reports of dayroom time or logs of two random weeks of dayroom time for four units at each facility (at least two of which are residential mental health units at RPDC and SCF) o Provide summary reports of yard time or logs of two random weeks of dayroom time for four units at each facility (at least two of which are residential mental health units at RPDC and SCF)

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 Identify 20 random inmates not leaving their cell for 3 consecutive days during the previous 6 months and their medical record numbers
 Provide a report of notification of mental health regarding inmates who received sentences longer than 15 years or a death sentence during the last 6 months; the report should include the date of notification and their medical record numbers
 Administrative Segregation o Provide random medical record numbers of 10 patients on administrative segregation during the previous 6 months who were on the mental health caseload o Provide 30-day reviews of inmates on administrative segregation who were on the mental health caseload
 Provide dates of transfers of inmates into or out of residential mental health settings and o Their medical record numbers or o Verification that a QMHP was consulted prior to transfer and the outcome of that consultation
 Safety cell inspection o Provide one random month of logs of safety cell inspections by custody supervisors from the previous 6 months o Provide one random month of logs of weekly safety cell inspections by Lts. from the previous 6 months
 Provide one random month of restraint chair cleaning logs from the previous 6 months
Staffing
 Provide the most recent annual assessment of the adequacy of staffing  Provide a current list of all funded mental health positions, the number of positions filled,
and any pending hires. 
Quality Management
 Provide minutes of CQIP meetings for the previous 6 months  Provide peer review logs or peer reviews for mental health staff for the previous 6
months  Provide reviews of in-custody deaths

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EXHIBIT O

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December 6, 2019

Chad Bianco, Sheriff Riverside County Sheriff’s Department P.O. Box 512 Riverside, CA 92051

2018-2020 BIENNIAL INSPECTION OF RIVERSIDE COUNTY SHERIFF’S OFFICE JAIL AND COURT HOLDING FACILITIES, PENAL CODE 6031

Dear Sheriff Bianco,

On September 16-26, 2019, staff of the Board of State and Community Corrections (BSCC) conducted the 2018-2020 biennial inspection of the Riverside County Jails and Court Holding Facilities. To prepare staff for the inspection, a pre-inspection briefing was held for both Corrections and Court Services divisions on March 13, 2019. The following facilities were inspected:

Detention Facility Robert Presley Detention Center Smith Correctional Facility Southwest Detention Center Blythe Jail Indio Jail

BSCC # 3910 3920 3930 3940 3960

Courthouse Facility Hall of Justice Southwest Justice Court 3934 Southwest Juv Court Family Law Court Larson Justice Center Banning Court Blythe Court

BSCC # 3916 3935 3937 3950 3970 3974 3975

Pursuant to Penal Code Section 6031, this inspection was performed to determine compliance with the Minimum Standards for Local Detention Facilities as outlined in Titles 15 and 24, California Code of Regulations (CCR). In addition, BSCC staff conducted compliance monitoring pursuant to Welfare and Institutions Code Section 209(f) for the federal Juvenile Justice and Delinquency Prevention Act (JJDPA).

The complete BSCC inspection report is enclosed and consists of: this transmittal letter; the Title 15 Procedures Checklist outlining applicable minimum standards; a Physical Plant Evaluation outlining Title 24 requirements for design; and, a Living Area Space Evaluation summarizing the physical plant configuration and showing the capacity of the facility. Refer to the Title 15 Checklist for indication of compliance status and evidence used to determine compliance.

LOCAL INSPECTIONS

In addition to the biennial inspection by the BSCC, inspections are also required annually by the County Health Officer and biennially by the State Fire Marshal or an authorized representative (Health and Safety Code Sections 101045 and 13146.1). Please consider our report in conjunction with the reports from the County Health Officer and the respective fire authorities for a comprehensive perspective of your facilities. Each of the local inspections were current.

3910 + Riverside Co 18-20 12/06/2019

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Chad Bianco, Sheriff

#:17414

Page |2

BSCC INPECTION
Title 15, CCR Inspection
Our evaluation consisted of reviewing only those policies and procedures related specifically to the applicable regulations included in Title 15, CCR. We found the following items of noncompliance:
• Title 15, Section 1027.5 Safety Checks: Safety checks shall be conducted at least hourly through direct visual observation of all inmates. There shall be no more than a 60-minute lapse between safety checks. The below facilities exceeded the 60-minute safety checks requirements.
Robert Presley Detention Center Cois Byrd Correctional Center Larry D. Smith Correctional Facility
• Title 15, Section 1058 Restraints Devices: In part the facility watch commander and responsible health care staff conduct a retention review a minimum of every hour. The below facilities exceeded the one-hour retention review:
Robert Presley Detention Center Cois Byrd Correctional Center Larry D. Smith Correctional Facility
Please refer to the Procedures Checklist for detailed information.
Title 24, CCR Physical Plant
The population of inmates continues to decrease in each jail. However, due to Blythe jail closing a housing unit for maintenance several inmates were transferred throughout the county’s jail system. “Stack-a-bunk” (with a mattress) is used for those inmates that are not assigned a bed that meets regulation. With the new 1536 rated capacity facility, John J. Benoit Detention Center, scheduled to open in early 2020 will allow the department to gain control of the crowding situation.
We identified the following items of non-compliance with Title 24:
Robert Presley Detention Center: Although the facility was not over the RC, there were four stack-a-bunk floor sleepers 3B1 and 3B2. As a result, the following areas of non-compliance:
• 1231.2.9 Dayrooms – Contained more inmates than tables and seating to accommodate the number of inmates;
• 1231.3.5 Beds must be elevated off the floor, have a solid bottom, and a sleeping surface of at least 30 inches wide and 76 inches. Stack-a-bunks do not meet this requirement.

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Chad Bianco, Sheriff

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Page |3

Cois Byrd Detention Center: Although the facility was not over the RC, there were Ten stacka-bunk floor sleepers in housing unit C4. As a result, the following areas of non-compliance:
• 1231.3.5 Beds must be elevated off the floor, have a solid bottom, and a sleeping surface of at least 30 inches wide and 76 inches. Stack-a-bunks do not meet this requirement.
Larry D. Smith Correctional Facility: Although the facility was not over the RC, there were four stack-a-bunk floor sleepers in housing Dormitories 14G and Building 9B & 9C. As a result, the following areas of non-compliance:
• 1231.2.8 Dormitories – Failed to provide 70 square feet of floor area per inmate • 1231.2.9 Dayrooms – Failed to provide 35 square feet of floor area per inmate • 1231.3.5 Beds must be elevated off the floor, have a solid bottom, and a sleeping
surface of at least 30 inches wide and 76 inches. Stack-a-bunks do not meet this requirement
Indio Jail: The facility continues to be over the rated capacity. The RC for the Indio Jail is 240. On the day of the inspection the population was 359. As a result, the following areas of noncompliance:
• 1231.2.8 Dormitories – Failed to provide 70 square feet of floor area per inmate • 1231.2.9 Dayrooms – Failed to provide enough tables and seating to
accommodate the maximum number of Inmates out in the dayroom. • 1231.3.4 Showers-Showers • Blythe Jail: Housing Dormitory A was closed for maintenance. This kept the facility under the rated capacity. However, the facility had one extra inmates in housing C1, C2, C3, D1 & D2. As a result, the following areas of non-compliance:
• 1231.2.6 Single-occupancy cells • Multiple Occupancy Cells (8227)
Please refer to the Physical Plant Checklist for detailed information.
Court Services Bureau
No areas of non-compliance were found in the Riverside County Court holding facilities. Five (5) out of seven (7) court facilities do not use its court holding cells like a traditional court holding facility. Inmates are held in the court holding cells for a very limited amount of time (less than 60 minutes), not long enough to log an hourly check. Therefore, many of the areas in Title 15 do not apply to these facilities except for the Banning courthouse and the newly opened Southwest Juvenile Court which is a stand-alone court facility. Juveniles are held at the Southwest Juvenile facility, but probation staff are responsible for their supervision. The court system is an efficient operation and all the facilities looked clean and orderly.

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Page |4

CORRECTIVE ACTION PLAN
Should efforts be made to remedy these issues please submit a Corrective Action plan by February 3, 2020.
This concludes our inspection report for the 2018 – 2020 inspection cycle. We would like to thank everyone involved in the inspection process for the hospitality and courtesy they extended during the inspection. If I can be of further assistance to you or your agency, please do not hesitate to call me at (916) 324-9861 or email me at michael.bush@bscc.ca.gov.
Sincerely,

Michael J. Bush Field Representative Facilities Standards and Operations Division
Enclosures
cc: Chairperson, Board of Supervisors, County of Riverside* Chief Administrative Officer, County of Riverside* Presiding Judge, Superior Court, County of Riverside* Grand Jury Foreman, Superior Court, County of Riverside* Raul Vergara, Assistant Sheriff, Riverside County Sheriff’s Department Edward Delgado, Chief Deputy, Riverside County Sheriff’s Department Donald Sharp, Chief Deputy, Riverside County Sheriff’s Department
*Copies of report can be access via BSCC website.

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TYPE II AND III FACILITIES
Board of State and Community Corrections
PROCEDURES1

Page 187 of 343

Page ID

FACILITY NAME: Robert Presley Detention Center Type II BSCC # 3910 DATE: 09/18/2019

FACILITY NAME: Larry Smith Correctional Facility Type II BSCC # 3920 DATE: 09/20/2019

FACILITY NAME: Cois Byrd Detention Center

Type II BSCC # 3930 DATE: 09/19/2019

FACILITY NAME: Blythe Jail

Type II BSCC # 3940 DATE: 09/24/2019

FACILITY NAME: Indio Jail

Type II BSCC # 3960 DATE: 09/23/2019

FIELD REPRESENTATIVE: Michael J. Bush

TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

1020 CORRECTIONS OFFICER CORE COURSE 2
(a) In addition to the provisions of California Penal Code Section 831.5, all custodial personnel of a Yes Type I, II, III, or IV facility shall successfully complete the “Corrections Officer Core Course” as described in Section 179 of Title 15, CCR, within one year from the date of assignment.

503.06 (1.0 – 3.0)
The STC Division found the department in compliance with Title Yes Yes Yes Yes 15 Sections 1020-1025.
503.06, Section 1.0 Personnel Training

(b) Custodial Personnel who have successfully completed the course of instruction required by Penal Code Section 832.3 shall also successfully complete the “Corrections Officer Basic Academy Yes Supplemental Core Course” as described in Section 180 of Title 15, CCR, within one year from the date of assignment.

Yes Yes Yes Yes

1021 JAIL SUPERVISORY TRAINING

503.06 (4.0)

Prior to assuming supervisory duties, jail Yes supervisors shall complete the core training requirements pursuant to Section 1020, Corrections Officer Core Course.

Yes Yes Yes Yes

1 This document is intended for use as a tool during the inspection process; this worksheet may not contain each Title 15 regulation that is required. Additionally, many regulations on this worksheet are SUMMARIES of the regulation; the text on this worksheet may not contain the entire text of the actual regulation. Please refer to the complete California Code of Regulations, Title 15, Minimum Standards for Local Facilities, Division 1, Chapter 1, Subchapter 4 for the complete list and text of regulations. 2 For STC participating agencies, consistency with training sections 1020, 1023 & 1025 is annually assessed by the STC Division. Unless otherwise indicated, the regulatory intent is for training to occur within one year from the date of assignment.

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TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

In addition, supervisory personnel of any Type I, II,

III or IV jail shall also be required to complete

either the STC Supervisory Course (as described in Section 181, Title 15, CCR) or the POST

Yes

supervisory course within one year from date of

assignment.

Yes Yes Yes Yes

1023 JAIL MANAGEMENT TRAINING

503.06 (5.0)

Managerial personnel of any Type I, II, III or IV jail shall be required to complete either the STC Yes management course (as described in Section 182, Title 15, CCR) or the POST management course within one year from date of assignment.

1025 CONTINUING TRAINING

PROFESSIONAL

Yes Yes Yes Yes 503.06 (3.0)

With the exception of any year that a core training module is successfully completed, all Yes facility/system administrators, managers, supervisors, and custody personnel of a Type I, II, III, or IV facility shall successfully complete the “annual required training” specified in Section 184 of Title 15, CCR.
1027 NUMBER OF PERSONNEL

A sufficient number of personnel shall be Yes employed in each local detention facility to ensure the implementation and operation of the programs and activities required by these regulations.
Whenever there is an inmate in custody, there shall be at least one employee on duty at all times in a local detention facility or in the building which houses a local detention facility who shall be Yes immediately available and accessible to inmates in the event of an emergency.

Such an employee shall not have any other duties which would conflict with the supervision and care Yes of inmates in the event of an emergency.

Whenever one or more female inmates are in custody, there shall be at least one female employee who shall be immediately available and accessible Yes to such females.

Note: Reference PC§ 4021.

To determine if there is a sufficient number of

personnel for a specific facility, the facility

administrator shall prepare and retain a staffing

plan indicating the personnel assigned in the

facility and their duties. Such a staffing plan shall be reviewed by the Board staff at the time of their

Yes

biennial inspection. The results of such a review

and recommendations shall be reported to the local

jurisdiction having fiscal responsibility for the

facility.

Yes Yes Yes Yes
BSCC reviewed a variety of timeoriented documents to include safety check logs, grievances, incident Yes Yes Yes Yes reports, classification histories, screening documents and floor logs.
502.10 (1.0 & 3.0) Security Logs/Checks Yes Yes Yes Yes All shifts have non-posted staff available to respond to an emergency
Yes Yes Yes Yes
Yes Yes Yes Yes
501.08
BSCC reviewed staffing assignments, the duty roster and the Yes Yes Yes Yes Correctional Sergeant’s Log to verify staffing patterns. All information appeared appropriate.

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TITLE 15 SECTION 1027.5 SAFETY CHECKS

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P/P REFERENCE –

COMMENTS

502.10

Safety checks shall be conducted at least hourly through direct visual observation of all inmates. Yes There shall be no more than a 60-minute lapse between safety checks.

Security Logs/Checks – Custody Yes Yes Yes Yes staff shall conduct a walk-through
security check of their respective areas at least once every hour.

There is a written plan that includes the

documentation of routine safety checks.

No

1028 FIRE AND LIFE SAFETY STAFF

Pursuant to Penal Code Section 6030(c), whenever there is an inmate in custody, there shall be at least Yes one person on duty at all times who meets the training standards established by the BSCC for general fire and life safety.

The facility manager shall ensure that there is at

least one person on duty who trained in fire and life safety procedures that relate specifically to the

Yes

facility.

1029 POLICY AND PROCEDURES MANUAL 3

Facility administrator(s) shall develop and publish

a manual of policy and procedures for the facility.

The policy and procedures manual shall address all

applicable Title 15 and Title 24 regulations and

shall be comprehensively reviewed and updated at

least every two years. Such a manual shall be made

available to all employees.

Yes

The policies and procedures required in subsections (a)(6) and (a)(7) may be placed in a separate manual to ensure confidentiality. Subsections c and d do not apply and have been deleted.

RPDC, LSC and CBD faculties

No

No

Yes

Yes

observation logs revealed housing safety checks were over the required

hour limit.

505.06 (4) Fire Suppression Preplanning

Yes Yes Yes Yes Staff has completed Core training, which includes fire and life safety training adequate to satisfy this regulation. At least one Core trained person is always available on-site.
505.05 Section 4
Yes Yes Yes Yes

The Riverside County Sheriff's Department Corrections Division continues to update the correctional detention policy manual, which is approved by the Div Chief.
Each correctional facility will have additional post orders specifically for their facility.
Yes Yes Yes Yes

(a) The manual for Temporary Holding, Type I, II, and III facilities shall provide for, but not be limited to, the following:

(1) Table of organization, including channels of communications.

Yes

(2) Inspections and operations reviews by the facility administrator/manager.

Yes

(3) Policy on the use of force.

Yes

(4) Policy on the use of restraint equipment, including the restraint of pregnant inmates as Yes referenced in Penal Code Section 3407.

Yes Yes Yes Yes 502.04 Facility Inspections
Yes Yes Yes Yes
Yes Yes Yes Yes 503.09 Use of Force 503.08 Restraint Devices
Yes Yes Yes Yes

3 Procedures related to security and emergency response may be in a separate manual to ensure confidentiality by limiting general access.

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TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

(5) Procedure and criteria for screening newly received inmates for release per Penal Code sections 849(b)(2) and 853.6, and any other such Yes processes as the facility administrator is empowered to use.

504.16 Misdemeanor Citation and Releases Yes Yes Yes Yes

(6) Security and control including:

Yes Yes Yes Yes Yes 504.07 Headcounts

(A) physical counts of inmates,

Yes Yes Yes Yes Yes 2.06 Housing Searches

(B) searches of the facility and inmates,

Yes Yes Yes Yes Yes 502.11 Inmate Searches

(C) contraband control, and,

Yes Yes Yes Yes Yes 502.02 Contraband

(D) key control.

Yes Yes Yes Yes Yes 502.08 Key control

Each facility administrator shall, at least annually,

review, evaluate, and make a record of security

measures. The review and evaluation shall include internal and external security measures of the facility

Yes

including security measures specific to prevention of

sexual abuse and sexual harassment.

502.04 Facility Inspections Yes Yes Yes Yes

(7) Emergency procedures include: (A) fire suppression preplan as required by Yes section 1032 of these regulations;

502.03 Escapes Yes Yes Yes Yes

(B) escape, disturbances, and the taking of hostages;

Yes

Yes Yes Yes Yes 505.07 Riot/Facility Disturbances

(C) mass arrests;

Yes Yes Yes Yes Yes 502.05

(D) natural disasters;

Yes Yes Yes Yes Yes 505.01 Critical Incidents

(E) periodic testing of emergency equipment; and,

Yes

Yes Yes Yes Yes 505.06 Fire Suppression Pre-Plan

(F) storage, issue, and use of weapons, ammunition, chemical agents, and related Yes security devices.

503.03 Less Lethal Weapons and Yes Yes Yes Yes Munitions

(8) Suicide Prevention.

Yes Yes Yes Yes Yes 508.15 Suicide Prevention Program

(9) Segregation of Inmates.

Yes Yes Yes Yes Yes 504.02 Administrative Segregation

(10) Zero tolerance in the prevention of sexual abuse and sexual harassment.
Yes

501.24 Sexual Assault
507.11 Orientation Yes Yes Yes Yes 508.10 Medical Screening/Medical
Release

(11) Policy and procedure to detect, prevent, and respond to retaliation against any staff or inmate after reporting any abuse.
(e) The manual for Temporary Holding, Court Holding, Type I, II, III, and IV facilities shall provide for, but not be limited to, the following:
(1) multiple internal ways for inmates to privately report sexual abuse and sexual harassment, retaliation by other inmates or staff for reporting sexual abuse and sexual harassment, and staff neglect or violation of responsibilities that may have contributed to such incidents,
(2) a method for uninvolved inmates, family, community members, and other interested third-parties to report sexual abuse or sexual harassment. The method for reporting shall be publicly posted at the facility.

Yes Yes Yes

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Yes Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes

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TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

1030 SUICIDE PREVENTION PROGRAM

508.15 Suicide Prevention Program

The facility shall have a comprehensive written suicide prevention program developed by the facility administrator, in conjunction with the Yes health authority and mental health director, to identify, monitor, and provide treatment to those inmates who present a suicide risk. The program shall include the following:

(a) Suicide prevention training for all staff that have direct contact with inmates.

Yes

(b) Intake screening for suicide risk immediately upon intake and prior to housing assignment.

Yes

(c) Provisions facilitating communication among

arresting/transporting officers, facility staff, medical and mental health personnel in relation to

Yes

suicide risk.

(d) Housing recommendations for inmates at risk of suicide.

Yes

(e) Supervision depending on level of suicide risk. Yes

(f) Suicide attempt and suicide intervention policies and procedures.

Yes

(g) Provisions for reporting suicides and suicides attempts.

Yes

(h) Multi-disciplinary administrative review of suicides and attempted suicides as defined by Yes the facility administrator.

1032 FIRE SUPPRESSION PREPLANNING

Pursuant to Penal Code Section 6031.1(b), the facility administrator shall consult with the local fire Yes department having jurisdiction over the facility, with the State Fire Marshal, or both, in developing a plan for fire suppression which shall include, but not be limited to:

(a) a fire suppression pre-plan developed with the

local fire department to be included as part of the policy and procedures manual (Title 15, California

Yes

Code of Regulations Section 1029);

(b) regular fire prevention inspections by facility staff on a monthly basis with two-year retention of Yes the inspection record;

(c) fire prevention inspections as required by Health and Safety Code Section 13146.1(a) and (b) which requires inspections at least once every two years; Yes

Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes 505.06 Fire Suppression and PrePlanning
Yes Yes Yes Yes

Each jail also has a Fire and Life

Yes

Yes

Yes

Yes

Safety manual specific to the facility.

BSCC reviewed records; all Yes Yes Yes Yes information was appropriate.

RPDC – 11/30/2018 LSC – 02/20/2019 Yes Yes Yes Yes CBC – 02/27/2018 BJ – 04/02/2015 IJ – 07/06/2019

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TITLE 15 SECTION (d) an evacuation plan; and,

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RPDC LSC CBD BJ IJ

P/P REFERENCE –

COMMENTS

505.04

Each facility has a Fire and Life Safety Manual specific to the facility.

Yes

(e) a plan for the emergency housing of inmates in the case of fire.

Yes

1040 POPULATION ACCOUNTING

Yes Yes Yes Yes Each shift will provide in-service training in fire drill procedures, including practical exercises. Each shift will conduct at least one drill per month.

Yes

Yes

Yes

Yes

504.07 Headcount 505.04 Evacuation Plan

504.07 Headcounts

Each facility administrator shall maintain an inmate demographics accounting system which reflects the Yes monthly average daily population of sentenced and non-sentenced inmates by categories of male, female and juvenile.
Facility administrators shall provide the BSCC with applicable inmate demographic information as Yes described in the Jail Profile Survey.
1041 INMATE RECORDS

(a) Each facility administrator of a Type I, II, III or IV facility shall develop written policies and procedures for the maintenance of individual inmate records which shall include, but not be Yes limited to, intake information, personal property receipts, commitment papers, court orders, reports of disciplinary actions taken, medical orders issued by the responsible physician and staff response, and non-medical information regarding disabilities and other limitations.

(b) Each facility administrator shall collect

accurate, uniform data for every allegation of

sexual abuse at facilities under its direct control and

from other facilities with which it contracts for the confinement of its inmates. The data collected shall

Yes

include, at a minimum, the data necessary to satisfy

the reporting requirements of 34 U.S.C. section

30303(a)(1) (federal survey on sexual violence).

1044 INCIDENT REPORTS

Each facility administrator shall develop written policies and procedures for the maintenance of Yes written records and reporting of all incidents which result in physical harm, or serious threat of physical harm, to an employee or inmate of a detention facility or other person.
Such records shall include the names of the persons involved, a description of the incident, the actions Yes taken, and the date and time of the occurrence.

Yes Yes Yes Yes
Yes Yes Yes Yes 506.04 Booking File organization 506.14 Purging of Records
Yes Yes Yes Yes
Yes Yes Yes Yes
501.01 Administrative Log 501.07 Crime Reports 501.14 Incidents/Pass on Log Yes Yes Yes Yes
Yes Yes Yes Yes

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TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

Such a written record shall be prepared by the staff

assigned to investigate the incident and submitted

to the facility manager or his/her designee.

Yes

Incident reports must be submitted within 24 hours. BSCC reviewed Yes Yes Yes Yes several incidents reports, all information was available and appropriate.

1045 PUBLIC INFORMATION PLAN

501.18 Release of Information / Media Interviews

Each facility administrator of a Type I, II, III or IV facility shall develop written policies and Yes procedures for the dissemination of information to the public, to other government agencies, and to the news media. The public and inmates shall have available for review the following material:

Yes Yes Yes Yes

(a) The Board of State and Community Corrections

Minimum Standards for Local Detention Facilities as found in Title 15 of the California Code of

Yes

Regulations.

507.07 Law Library Yes Yes Yes Yes 507.11 Orientation

(b) Facility rules and procedures affecting inmates as specified in sections:

Yes

Yes Yes Yes Yes Orientation handbook.

(1) 1045, Public Information Plan

Yes Yes Yes Yes Yes

(2) 1061, Inmate Education Plan

Yes Yes Yes Yes Yes

(3) 1062, Visiting

Yes Yes Yes Yes Yes

(4) 1063, Correspondence

Yes Yes Yes Yes Yes

(5) 1064, Library Service

Yes Yes Yes Yes Yes

(6) 1065, Exercise and Recreation

Yes Yes Yes Yes Yes

(7) 1066, Books, Newspapers, Periodicals and Writings

Yes

Yes Yes Yes Yes

(8) 1067, Access to Telephone

Yes Yes Yes Yes Yes

(9) 1068, Access to Courts and Counsel

Yes Yes Yes Yes Yes

(10) 1069, Inmate Orientation

Yes Yes Yes Yes Yes

(11) 1070, Individual/Family Service Programs

Yes

Yes Yes Yes Yes

(12) 1071, Voting

Yes Yes Yes Yes Yes

(13) 1072, Religious Observance

Yes Yes Yes Yes Yes

(14) 1073, Inmate Grievance Procedure

Yes Yes Yes Yes Yes

(15) 1080, Rules and Disciplinary Penalties

Yes Yes Yes Yes Yes

(16) 1081, Plan for Inmate Discipline

Yes Yes Yes Yes Yes

(17) 1082, Forms of Discipline

Yes Yes Yes Yes Yes

(18) 1083, Limitations on Discipline

Yes Yes Yes Yes Yes

(19) 1200, Responsibility for Health Care Services

Yes

Yes Yes Yes Yes

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TITLE 15 SECTION 1046 DEATH IN CUSTODY

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RPDC LSC CBD BJ IJ

P/P REFERENCE –

COMMENTS

501.22 (1.1) Inmate Deaths

(a) Death in Custody Reviews for Adults and Minors.

The facility administrator, in cooperation with the health administrator, shall develop written policy and procedures to ensure that there is an initial Yes review of every in-custody death within 30 days. The review team shall include the facility administrator and/or the facility manager, the health administrator, the responsible physician and other health care and supervision staff who are relevant to the incident.

Deaths shall be reviewed to determine the

appropriateness of clinical care; whether changes to policies, procedures, or practices are warranted; and

Yes

to identify issues that require further study.

(b) Death of a Minor In any case in which a minor dies while detained in Yes a jail, lockup, or court holding facility:

(1) The administrator of the facility shall provide to the Board a copy of the report submitted to the Attorney General under Government Code Section 12525. A copy of the Yes report shall be submitted within 10 calendar days after the death.

(2) Upon receipt of a report of death of a minor from the administrator, the Board may within 30 calendar days inspect and evaluate the jail, lockup, or court holding facility pursuant to the Yes provisions of this subchapter. Any inquiry made by the Board shall be limited to the standards and requirements set forth in these regulations.
1050 CLASSIFICATION PLAN

Yes Yes Yes Yes
501.22 Inmate Death Review Yes Yes Yes Yes Meeting
510.10.8 Juvenile in Adult Court Yes Yes Yes Yes Holding
504.02 Classification Yes Yes Yes Yes All facilities complete the Jail
Information management system (JIMS) Medical History/Suicide Assessment Form.
Yes Yes Yes Yes
504.02 Classification

(a) Each administrator of a temporary holding, Type

I, II, or III facility shall develop and implement a

written classification plan designed to properly

assign inmates to housing units and activities

according to the categories of sex, age, criminal

sophistication, seriousness of crime charged,

physical or mental health needs, assaultive/non-

assaultive behavior, risk of being sexually abused, or sexually harassed and other criteria which will

Yes

provide for the safety of the inmates and staff. Such

housing unit assignment shall be accomplished to

the extent possible within the limits of the available

number of distinct housing units or cells in a facility.

The written classification plan shall be based on

objective criteria and include receiving screening

performed at the time of intake by trained personnel,

and a record of each inmate's classification level,

housing restrictions, and housing assignments.

A preliminary screen is performed during booking. Inmates are separated based on charges, sex, and any known medical or gang-related issues until they are interviewed, classified and assigned housing by the Classification Officer.
Yes Yes Yes Yes

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TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

Each administrator of a Type II or III facility shall

establish and implement a classification system

which will include the use of classification officers

or a classification committee in order to properly

assign inmates to housing, work, rehabilitation

programs, and leisure activities. Such a plan shall

include the use of as much information as is available about the inmate and from the inmate and

Yes

shall provide for a channel of appeal by the inmate

to the facility administrator or designee. An inmate

who has been sentenced to more than 60 days may

request a review of his classification plan no more

often than 30 days from his last review.

Yes Yes Yes Yes

Subsection b does not apply and has been deleted.

(c) In deciding whether to assign an inmate to a

housing area for male or female inmates, and in

making other housing and programming

assignments, the agency shall consider on a case-

by-case basis whether a placement would ensure the inmate's health and safety, and whether the

Yes

placement would present management or security

problems. An inmate's own views with respect to

his or her own safety shall be given serious

consideration.

504.02 (2.0) Classification Yes Yes Yes Yes

1051 COMMUNICABLE DISEASES

508.02 Communicable Disease

The facility administrator, in cooperation with the responsible physician, shall develop written policies and procedures specifying those symptoms Yes that require segregation of an inmate until a medical evaluation is completed.

At the time of intake into the facility, an inquiry shall be made of the person being booked as to whether or not he/she has or has had any communicable diseases, such as tuberculosis or has observable symptoms of tuberculosis or any other Yes

communicable diseases, or other special medical

problem identified by the health authority. The

response shall be noted on the booking form and/or

screening device.

1052 MENTALLY

DISORDERED

INMATES

The facility administrator, in cooperation with the responsible physician, shall develop written Yes policies and procedures to identify and evaluate all mentally disordered inmates, and may include telehealth.

The Intake/Release Correctional Deputy completes a Medical PreYes Yes Yes Yes Screening Form for every arrestee. The form is forwarded to Medical Staff. If there are emergencies, Medical or Mental Health Staff will be notified immediately. 508.10 Medical Screening/Medical Release
Yes Yes Yes Yes
508.12 Mental Health Services
Any staff member may recommend mental health counseling by filling Yes Yes Yes Yes out a Request for Psychiatric Attention or by notifying Mental Health Staff. Mobile Crisis Service is available if Mental Health Staff is unavailable.

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TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

If an evaluation from medical or mental health staff

is not readily available, an inmate shall be

considered mentally disordered for the purpose of

this section if he or she appears to be a danger to

himself/herself or others or if he/she appears

gravely disabled.

Yes

508.14 Routine Medical Treatment 504.24 Safety Cells
Yes Yes Yes Yes

An evaluation from medical or mental health staff shall be secured within 24 hours of identification or at the next daily sick call, whichever is earliest.

Segregation may be used if necessary to protect the

safety of the inmate or others.

Yes

1053 ADMINISTRATIVE SEGREGATION

504.02 (2.0) Classification Yes Yes Yes Yes 508.10 Medical Screening/Medical
Release
504.01 Administrative Segregation

Except in Type IV facilities, each facility administrator shall develop written policies and procedures which provide for the administrative segregation of inmates who are determined to be prone to: promote activity or behavior that is criminal in nature or disruptive to facility operations; demonstrate influence over other inmates, including influence to promote or direct Yes action or behavior that is criminal in nature or disruptive to the safety and security of other inmates or facility staff, as well as to the safe operation of the facility; escape; assault, attempted assault, or participation in a conspiracy to assault or harm other inmates or facility staff; or likely to need protection from other inmates, if such administrative segregation is determined to be necessary in order to obtain the objective of protecting the welfare of inmates and staff.

Administrative segregation shall consist of separate

and secure housing but shall not involve any other deprivation of privileges than is necessary to obtain

Yes

the objective of protecting the inmates and staff.

1055 USE OF SAFETY CELL

The safety cell described in Title 24, Part 2, Section

1231.2.5, shall be used to hold only those inmates

who display behavior which results in the

destruction of property or reveals an intent to cause

physical harm to self or others.

Yes

Inmates who are psychologically or mentally impaired, may pose an escape or serious violent threat, who have known gang affiliations or are a known management problem, are a suicide risk, have medical problems, are examples of those Yes Yes Yes Yes who may be placed in administrative segregation

504.11 Isolation Cells Yes Yes Yes Yes 504.02 (4.2) Classification

504.24 Safety Cells 508.12

Safety cells at the jail are used for

inmates displaying behavior that

reveals intent to cause physical

Yes

Yes

Yes

Yes

harm to self or others or which results in the destruction or

property.

The facility administrator, in cooperation with the responsible physician, shall develop written policies and procedures governing safety cell use Yes and may delegate authority to place an inmate in a safety cell to a physician.
3910+ Riverside Co Sheriff’s TII; 09/18/2019

“Blythe” Inmates needing placement into a safety cell, shall be transferred to “Indio” Correction facility.
Yes Yes Yes Yes

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In no case shall the safety cell be used for punishment or as a substitute for treatment.

Yes

Yes Yes Yes Yes

An inmate shall be placed in a safety cell only with

the approval of the facility manager or designee, or responsible health care staff; continued retention

Yes

shall be reviewed a minimum of every four hours.

504.24 (2.1) Safety Cells Yes Yes Yes Yes

A medical assessment shall be completed within a

maximum of 12 hours of placement in the safety

cell or at the next daily sick call, whichever is

earliest.

Yes

CDPM 504.24
Yes Yes Yes Yes Medical assessments shall be completed every 8 hours and medical clearance for continued retention occurs every 24 hours.

The inmate shall be medically cleared for continued retention every 24 hours thereafter.

504.24. (2.1)

The facility commander or designee Yes Yes Yes Yes Yes must approve continued retention in
the safety cell every 8 hours, the documentation appeared thorough and complete.

The facility manager, designee or responsible health care staff shall obtain a mental health opinion/consultation with responsible health care Yes staff on placement and retention, which shall be secured within 12 hours of placement.

504.24 (1.1) Safety Cells 504.24 Safety Cells Yes Yes Yes Yes 508.12 Mental Health Services

Direct visual observation shall be conducted at

least twice every thirty minutes. Such observation

shall be documented.

Yes

504.24. (2.4.1)
Yes Yes Yes Yes BSCC reviewed a sample of observation logs. All were within the required time frame.

Procedures shall be established to assure administration of necessary nutrition and fluids.

Yes

Yes Yes Yes Yes

Inmates shall be allowed to retain sufficient

clothing, or be provided with a suitably designed

“safety garment,” to provide for their personal privacy unless specific identifiable risks to the

Yes

inmate's safety or to the security of the facility are

documented.

504.24.2.1 (2.5 – 2.6) Yes Yes Yes Yes

1056 USE OF SOBERING CELL

504.05 Sobering Cells

The sobering cell described in Title 24, Part 2, Section 1231.2.4, shall be used for the holding of Yes inmates who are a threat to their own safety or the safety of others due to their state of intoxication and pursuant to written policies and procedures developed by the facility administrator.

Such inmates shall be removed from the sobering

cell as they are able to continue in the processing.

Yes

Yes Yes Yes Yes Yes Yes Yes Yes

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In no case shall an inmate remain in a sobering cell over six hours without an evaluation by a medical staff person or an evaluation by custody staff, pursuant to written medical procedures in Yes accordance with section 1213 of these regulations, to determine whether the prisoner has an urgent medical problem.

In no case will an inmate remain in a sobering cell more than six hour without a recorded evaluation by a Yes Yes Yes Yes medical staff member.

At 12 hours from the time of placement, all inmates will receive an evaluation by responsible health Yes care staff.

Yes Yes Yes Yes

Intermittent direct visual observation of inmates held in the sobering cell shall be conducted no less than every half hour. Such observation shall be documented.
Yes

Direct visual supervision is conducted once every thirty minutes and noted on the sobering cell log.
BSCC reviewed a sample of observation logs. All was within the Yes Yes Yes Yes required time frame.

Supervisor will review the sobering cell log at least once every four hours and document time on the sobering cell log.

1057 DEVELOPMENTALLY DISABLED INMATES

508.04 Developmentally Disabled Inmates

The facility administrator, in cooperation with the responsible physician, shall develop written Yes policies and procedures for the identification and evaluation, appropriate classification and housing, protection, and nondiscrimination of all developmentally disabled inmates.

The health authority or designee shall contact the

regional center on any inmate suspected or

confirmed to be developmentally disabled for the purposes of diagnosis and/or treatment within 24

Yes

hours of such determination, excluding holidays

and weekends.

1058 USE OF RESTRAINT DEVICES

The facility administrator, in cooperation with the responsible physician, shall develop written policies and procedures for the use of restraint devices and may delegate authority to place an Yes inmate in restraints to a responsible health care staff.

Yes Yes Yes Yes
Yes Yes Yes Yes
503.08 503.07 Fluids and sanitation offered every two hours. Range of motion is Yes Yes Yes Yes conducted every thirty minutes. Incidents are documented on the Corrections Division Use of Force Report.

In addition to the areas specifically outlined in this

regulation, at a minimum, the policy shall address the following areas:

Yes

acceptable restraint devices;

Restraint Chair Yes Yes Yes Yes

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signs or symptoms which should result in immediate medical/mental health referral;

Yes

Yes Yes Yes Yes 503.07 (6.2.1)

availability of cardiopulmonary resuscitation equipment;

Yes

Yes Yes Yes Yes

protective housing of restrained persons;

Yes Yes Yes Yes Yes

provision for hydration and sanitation needs; and

Yes Yes Yes Yes Yes 503.08 (6.6)

exercising of extremities.

Yes Yes Yes Yes Yes 503.7 (5.1)

In no case shall restraints be used for punishment or as a substitute for treatment.

Yes

Yes Yes Yes Yes

Restraint devices shall only be used on inmates who display behavior which results in the destruction of property or reveal an intent to cause physical harm to self or others. Restraint devices include any devices which immobilize an inmate's extremities and/or prevent the inmate from being Yes ambulatory.

503.07 (1.3) Yes Yes Yes Yes

Physical restraints should be utilized only when it appears less restrictive alternatives would be ineffective in controlling the disordered behavior. Inmates shall be placed in restraints only with the approval of the facility manager, the facility watch commander, responsible health care staff; continued retention shall be reviewed a minimum No of every hour.
A medical opinion on placement and retention shall be secured within one hour from the time of placement.
No
A medical assessment shall be completed within four hours of placement.
Yes
If the facility manager, or designee, in consultation with responsible health care staff determines that an inmate cannot be safely removed from restraints Yes after eight hours, the inmate shall be taken to a medical facility for further evaluation.

503.07 (6.7) Emergency Restraint Chair
No No Yes Yes Observation logs reveals retention review were past the required hour review. 503.08 (6.2) Restraint Devices
No No Yes Yes RPDC, LSC and CDB facilities observation logs reveals retention review were past the required hour review. 503.07 (6.2) Emergency Restraint Chair
Yes Yes Yes Yes Health Services staff shall evaluate the inmate upon initial placement in the emergency restraint chair, and every hour thereafter. 503.07 (6.7.3 Emergency Restraint Chair
Yes Yes Yes Yes

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Direct visual observation shall be conducted at least twice every thirty minutes to ensure that the restraints are properly employed, and to ensure the safety and well-being of the inmate. Such observation shall be documented.

503.07 (.1) Emergency Restraint Chair
A Safety Cell Log (504.24 Attachment #1), or Special Housing log (RSD Form 563) recording the direct observation by facility staff shall be kept for every person restrained in the chair.

Yes Yes Yes Yes Yes

503.07 (6.2) Emergency Restraint Chair

Corrections staff shall visually check the inmate at least twice every thirty minutes to ensure the safety and well-being of the inmate

While in restraint devices all inmates shall be

housed alone or in a specified housing area for restrained inmates which makes provisions to

Yes

protect the inmate from abuse.

The provisions of this section do not apply to the use of handcuffs, shackles or other restraint devices Yes when used to restrain inmates for security reasons.

1058.5 RESTRAINTS AND PREGNANT INMATES

The documentation is thorough and complete. 5.08 Restraint Devices Yes Yes Yes Yes 503.07 Emergency Restraint Chair 503.08 Restraint Devices
503.08 (6.0) Yes Yes Yes Yes
508.19

The facility administrator, in cooperation with the responsible physician, shall develop written Yes policies and procedures for the use of restraint devices on pregnant inmates. In accordance with Penal Code 3407 the policy shall include reference to the following:

(1) An inmate known to be pregnant or in recovery

after delivery shall not be restrained by the use of leg irons, waist chains, or handcuffs behind the

Yes

body.

(2) A pregnant inmate in labor, during delivery, or in recovery after delivery, shall not be restrained by the wrists, ankles, or both, unless deemed necessary Yes for the safety and security of the inmate, the staff, or the public.

(3) Restraints shall be removed when a professional

who is currently responsible for the medical care of

a pregnant inmate during a medical emergency, labor, delivery, or recovery after delivery

Yes

determines that the removal of restraints is

medically necessary.

(4) Upon confirmation of an inmate's pregnancy, she shall be advised, orally or in writing, of the Yes standards and policies governing pregnant inmates.

Yes Yes Yes Yes
508.19 (2.1) Yes Yes Yes Yes
Yes Yes Yes Yes 50.19 (2.1)
Yes Yes Yes Yes 50.19 (2.1)
Yes Yes Yes Yes

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1059

USE OF REASONABLE FORCE TO COLLECT DNA SPECIMENS, SAMPLES, IMPRESSIONS

504.06 DNA Samples

(a) Pursuant to Penal Code Section 298.1, authorized law enforcement, custodial, or corrections personnel including peace officers, Yes may employ reasonable force to collect blood specimens, saliva samples, or thumb or palm print impressions from individuals who are required to provide such samples, specimens or impressions pursuant to Penal Code Section 296 and who refuse following written or oral request.
(1) For the purpose of this regulation, the “use of reasonable force” shall be defined as the force that an objective, trained and competent correctional employee, faced with similar facts Yes and circumstances, would consider necessary and reasonable to gain compliance with this regulation.
(2) The use of reasonable force shall be preceded by efforts to secure voluntary compliance. Efforts to secure voluntary compliance shall be documented and include Yes an advisement of the legal obligation to provide the requisite specimen, sample or impression and the consequences of refusal.
(b) The force shall not be used without the prior written authorization of the facility watch commander on duty. The authorization shall include information that reflects the fact that the offender was asked to provide the requisite Yes specimen, sample, or impression and refused.

Yes Yes Yes Yes

504.06.9.0 DNA Samples
If after the inmate’s case of 298.1 Yes Yes Yes Yes (a) PC is adjudicated and the court
remands the inmate into the sheriff’s custody for collection, the DNA sample will be taken. 504.06.9.1.2 DNA Samples A sergeant will be notified to respond to the area. Yes Yes Yes Yes

Corrections Division Policy § 504.06.9.1.3 DNA Samples

Yes

Yes

Yes

Yes

Any time force is used to obtain a DNA sample, it shall be videotaped

and archived for current year plus

one.

(c) If the use of reasonable force includes a cell

extraction, the extraction shall be videotaped,

including audio. Video shall be directed at the cell

extraction event. The videotape shall be retained by the agency for the length of time required by

Yes

statute. Notwithstanding the use of the video as

evidence in a criminal proceeding, the tape shall be

retained administratively.

1061 INMATE EDUCATION PROGRAM

The facility administrator of any Type II or III Yes facility shall plan and shall request of appropriate public officials an inmate education program.

When such services are not made available by the

appropriate public officials, then the facility administrator shall develop and implement an

Yes

education program with available resources.

Such a plan shall provide for the voluntary

academic and/or vocational education of housed inmates.

Yes

3910+ Riverside Co Sheriff’s TII; 09/18/2019

Yes Yes Yes Yes

507.04 Inmate Education Programs

Yes Yes Yes Yes Chaplain Religious Volunteer Services NA/AA Volunteer Services Library Book Cart
Yes Yes Yes Yes Residential Substance Abuse Treatment (RSAT) Program Education Adult Basic Education
Yes Yes Yes Yes Vocational Education GED testing

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Reasonable criteria for program eligibility shall be

established and an inmate may be excluded or removed based on sound security practices or

Yes

failure to abide by facility rules and regulations.

Yes Yes Yes Yes

1062 VISITING

Corrections Division Policy § 507.17 Visiting

(a) The facility administrator shall develop written

policies and procedures for inmate visiting which shall provide for as many visits and visitors as

Yes

facility schedules, space, and number of personnel

will allow.

Yes

Yes

Yes

Yes

Visits are by appointment only. Visitors must call the day before the

requested visiting day to set an

appointment

(TYPE II ONLY)

All inmates in Type II facilities are allowed at least two visits totaling at least one hour

Yes

per inmate each week.

(TYPE III ONLY)

Inmates in Type III facilities are allowed one or more visits, totaling at least one hour per

Yes

week.

(c) The visiting policies developed pursuant to this section shall include provision for visitation by Yes minor children of the inmate.

(d) Video visitation may be used to supplement

existing visitation programs, but shall not be used to fulfill the requirements of this section if in-

Yes

person visitation is requested by an inmate.

(e) Facilities shall not charge for visitation when visitors are onsite and participating in either inperson or video visitation. For purposes of this Yes subsection, “onsite” is defined as the location where the inmate is housed.

(f) Subdivision (d) shall not apply to facilities which (1) exclusively used video visitation prior to January 1, 2017 or (2) had been designed without Yes in-person visitation space and conditionally awarded by the Board prior to June 27, 2017.

(g) If a local detention facility offered video

visitation only as of January 1, 2017, the first hour of remote video visitation per week shall be offered

Yes

free of charge.

Types and availability of visitation, including: Note: Reference PC § 6031.1 (June 2017)

Yes

Mode of visitation;

Yes

Visitation hours;

Yes

Time inmates are allowed for visitation; and, Yes

Any restrictions on inmate visitation.

Yes

Each inmate is allowed two visits Yes Yes Yes Yes per day (50 minutes per visit).
Yes Yes Yes Yes 507.17 (2.1) Personal Visits
Yes Yes Yes Yes RPDC and LSC facilities only.
Yes N/A N/A N/A
Yes N/A N/A N/A

Yes N/A N/A N/A

Yes N/A N/A N/A

Yes Yes Yes Yes

Yes

Yes

Yes

Yes

Each facilities has non-contact visits.

Yes

Yes

Yes

Yes

Visiting appointments are scheduled daily from 9:00 am to 5:00 pm

Inmates are allowed a maximum of Yes Yes Yes Yes two visits per week and each visit is
approximately 45 minutes.

Yes Yes Yes Yes

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1063 CORRESPONDENCE

The facility administrator shall develop written

Yes

policies and procedures for inmate

correspondence which provide that:

(a) there is no limitation on the volume of mail that an inmate may send or receive;

Yes

507.09 Mail 504.02 Classification Yes Yes Yes Yes
Yes Yes Yes Yes 507.09 (1.2) Mail

(b) inmate correspondence may be read when there is a valid security reason and the facility manager or his/her designee approves;

507.09 (1.4) Mail Yes Yes Yes Yes Yes

(c) jail staff shall not review inmate

correspondence to or from state and federal courts,

any member of the State Bar or holder of public

office, and the State Board of State and Community Corrections; however, jail authorities

Yes

may open and inspect such mail only to search for

contraband, cash, checks, or money orders and in

the presence of the inmate;

507.09 (1.3) Mail Yes Yes Yes Yes

(d) inmates may correspond, confidentially, with the facility manager or the facility administrator; and,

Yes Yes Yes Yes Yes

(e) those inmates who are without funds shall be permitted at least two postage paid envelopes and two sheets of paper each week to permit correspondence with family members and friends Yes Yes Yes Yes Yes but without limitation on the number of postage paid envelopes and sheets of paper to his or her attorney and to the courts.

1064 LIBRARY SERVICES

507.07 Law Library

The facility administrator shall develop written

policies and procedures for library service in all

Type II, III, and IV facilities. The scope of such

service shall be determined by the facility

administrator. The library service shall include

Yes

access to legal reference materials, current

information on community services and resources,

and religious, educational, and recreational

reading material. In Type IV facilities such a

program can be either in-house or provided

through access to the community.

1065 EXERCISE AND RECREATION

Yes Yes Yes Yes 507.13 Recreation

(a) The facility administrator of a Type II or III facility shall develop written policies and procedures for an exercise and recreation program, in an area designed for recreation, which will allow Yes a minimum of three hours of exercise distributed over a period of seven days. Such regulations as are reasonable and necessary to protect the facility's security and the inmates' welfare shall be included in such a program.

Yes Yes Yes Yes

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1066 BOOKS, NEWSPAPERS, PERIODICALS, AND WRITINGS

507.13 (2.0) Recreation

The facility administrator of a Type II or III facility shall develop written policies and procedures Yes which will permit inmates to purchase, receive and read any book, newspaper, periodical, or writing accepted for distribution by the United States Postal Service. Nothing herein shall be construed as limiting the right of a facility administrator to:

(1) exclude any publications or writings based on any legitimate penological interest;

Yes

(2) exclude obscene publications or writings, and mail containing information concerning where, how, or from whom such matter may be obtained; and any matter of a character tending to incite murder, arson, riot, violent racism, or any other form of violence; any Yes matter of a character tending to incite crimes against children; any matter concerning unlawful gambling or an unlawful lottery; the manufacture or use of weapons, narcotics, or explosives; or any other unlawful activity;

(3) open and inspect any publications or packages received by an inmate; and

Yes

(4) restrict the number of books, newspapers,

periodicals, or writings the inmate may have in his/her cell or elsewhere in the facility at one

Yes

time.

1067 ACCESS TO TELEPHONE

Yes Yes Yes Yes
Yes Yes Yes Yes
Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes
507.15 Telephones

The facility administrator shall develop written policies and procedures which allow reasonable Yes access to a telephone beyond those telephone calls which are required by Section 851.5 of the Penal Code.
1068 ACCESS TO COURTS AND COUNSEL

The facility administrator shall develop written Yes policies and procedures to ensure inmates have access to the court and to legal counsel. Such access shall consist of:

(a) unlimited mail as provided in Section 1063 of these regulations, and,

Yes

(b) confidential consultation with attorneys.

Yes

1069 INMATE ORIENTATION

Yes Yes Yes Yes
507.20 Official Visits Yes Yes Yes Yes
Yes Yes Yes Yes 507.09 (1.3) Mail Yes Yes Yes Yes 507.20 Official Visits
507.11 Orientation

In Type II, III, and IV facilities, the facility administrator shall develop written policies and Yes procedures for the implementation of a program reasonably understandable to inmates designed to orient a newly received inmate at the time of placement in a living area.

Yes Yes Yes Yes

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Such a program shall be published and include, but not be limited to, the following:

Yes

Yes

Yes

Yes

Yes

Each inmate receives an inmate orientation booklet.

(1) correspondence, visiting, and telephone usage rules;

Yes

Yes Yes Yes Yes

(2) rules and disciplinary procedures;

Yes Yes Yes Yes Yes 507.11 (2.2) Orientation

(3) inmate grievance procedures;

Yes Yes Yes Yes Yes 507.11 (2.3) Orientation

(4) programs and activities available and method of application;

Yes

Yes Yes Yes Yes 507.11 (2.4) Orientation

(5) medical services;

Yes Yes Yes Yes Yes 507.11 (2.5) Orientation

(6) classification/housing assignments;

Yes Yes Yes Yes Yes 507.11 (2.6) Orientation

(7) court appearance where scheduled, if known;

Yes

Yes Yes Yes Yes 507.11 (2.7) Orientation

(8) voting, including registration; and,

Yes Yes Yes Yes Yes 507.19

(9) zero tolerance policy against sexual abuse and sexual harassment.

Yes

Yes Yes Yes Yes

1070 INDIVIDUAL/FAMILY SERVICE PROGRAMS

507.18 Volunteers

The facility administrator of a Type II, III, or IV facility shall develop written policies and procedures which facilitate cooperation with Yes appropriate public or private agencies for individual and/or family social service programs for inmates. Such a program shall utilize the services and resources available in the community and may be in the form of a resource guide and/or actual service delivery.

The Sheriff’s Inmate Training and Education Bureau (SITE-B) provides educational, counseling Yes Yes Yes Yes Chaplains, detention volunteers, transitional programs, occupational technologies and inmate support services to inmates within the Riverside Sheriff’s system.

The range and source of such services shall be at the discretion of the facility administrator and may include:

(a) risk and needs assessments;

(b) best practices in:

(1) individual, group and/or family counseling;

(2) drug and alcohol abuse counseling;

(3) cognitive behavioral interventions; (4) vocational testing and counseling;

Yes Yes Yes Yes Yes

(5) employment counseling;

(c) referral to community resources and programs;

(d) reentry planning and service development;

(e) legal assistance;

(f) regional center services for the developmentally disabled; and,

(g) community volunteers.

1071 VOTING

507.19 Voting

The facility administrator of a Type I (holding sentenced inmate workers) II, III or IV facility shall Yes develop written policies and procedures whereby the county registrar of voters allows qualified voters to vote in local, state, and federal elections, pursuant to election codes.

Yes Yes Yes Yes

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507.14 Religious Services

The facility administrator of a Type I, II, III or IV facility shall develop written policies and Yes procedures to provide opportunities for inmates to participate in religious services, practices and counseling on a voluntary basis.
1073 INMATE GRIEVANCE PROCEDURE

Yes Yes Yes Yes 507.02 Grievance/ Writ Petition

(a) Each administrator of a Type II, III, or IV facility and Type I facilities which hold inmate workers shall develop written policies and procedures whereby any inmate may appeal and have resolved grievances relating to any conditions Yes of confinement, including but not limited to: medical care; classification actions; disciplinary actions; program participation; telephone, mail, and visiting procedures; and food, clothing, and bedding.

Such policies and procedures shall include:

(1) a grievance form or instructions for registering a grievance;

Yes

(2) resolution of the grievance at the lowest

appropriate staff level;

Yes

Yes Yes Yes Yes

Yes

Yes

Yes

Yes

507.02 (2.1) Grievance/ Writ Petition

507.02 (1.0) Grievance/ Writ Yes Yes Yes Yes Petition

(3) appeal to the next level of review; Yes

(4) written reasons for denial of grievance at each level of review which acts on the Yes grievance;

(5) provision for response within a reasonable time limit; and,

Yes

(6) provision for resolving questions of jurisdiction within the facility.

Yes

(b) Grievance System Abuse:

The facility may establish written policy and procedure to control the submission of an excessive

Yes

number of grievances.

1080 RULES AND DISCIPLINARY PENALTIES

Yes Wherever discipline is administered, each facility administrator shall establish written rules and disciplinary penalties to guide inmate conduct.

507.02(2.9.4) Grievance/ Writ Petition Inmates may submit a hand-written appeal at the supervisor level within seven days. Yes Yes Yes Yes 507 02 (2.9.4) Grievance/ Writ Petition Grievances not resolved at the lieutenant level may be appealed to the facility commander within seven days.
Yes Yes Yes Yes
Yes Yes Yes Yes
Yes Yes Yes Yes
Yes Yes Yes Yes
504.09 Inmate Discipline Reviewed several discipline files Yes Yes Yes Yes from each facility.

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Such rules and disciplinary penalties shall be stated

simply and affirmatively, and posted conspicuously in housing units and the booking

Yes

area or issued to each inmate upon booking.

Yes Yes Yes Yes

For those inmates who are illiterate or unable to

read English, and for persons with disabilities,

provision shall be made for the jail staff to instruct them verbally or provide them with material in an

Yes

understandable form regarding jail rules and

disciplinary procedures and penalties.

Yes Yes Yes Yes

1081 PLAN FOR INMATE DISCIPLINE

Corrections Division Policy § 504.09 Inmate Discipline

Each facility administrator shall develop written Yes policies and procedures for inmate discipline. The plan shall include, but not be limited to, the following elements:

Yes Yes Yes Yes

(a) Temporary Loss of Privileges: For minor acts of non-conformance or minor violations of facility rules, staff may impose a temporary loss of privileges, such as access to television, telephones, Yes commissary, or lockdown for less than 24 hours, provided there is written documentation and supervisory approval.

Senior CD II or Corporal will serve the inmate with the proposed discipline. Yes Yes Yes Yes

(b) Punitive Actions: Major violations of facility rules or repetitive minor acts of non-conformance or repetitive minor violations of facility rules shall be reported in writing by the staff member Yes observing the act and submitted to the disciplinary officer. The consequences of such violations may include, but are not limited to:

Yes Yes Yes Yes

1. Loss of good time/work time.

Yes

Yes

Yes

Yes

Yes

Sergeants will approve all disciplinary actions.

2. Placement in disciplinary separation.

Yes Yes Yes Yes Yes

3. Disciplinary separation diet.

Yes Yes Yes Yes Yes

4. Loss of privileges mandated by regulations. Yes Yes Yes Yes Yes

A staff member with investigative and punitive authority shall be designated as a disciplinary Yes officer to impose such consequences.

Yes Yes Yes Yes

Staff shall not participate in disciplinary review if they are involved in the charges.

Yes

Yes Yes Yes Yes

Such charges pending against an inmate shall be acted on with the following provisions and within Yes specified timeframes:

Yes Yes Yes Yes

1. A copy of the report, and/or a separate written notice of the violation(s), shall be Yes provided to the inmate.

Yes Yes Yes Yes

2. Unless declined by the inmate, a hearing

shall be provided no sooner than 24 hours after

the report has been submitted to the

disciplinary officer and the inmate has been informed of the charges in writing. The hearing

Yes

may be postponed or continued for a

reasonable time through a written waiver by

the inmate, or for good cause.

504.09 (5.2) Inmate Discipline 504.09 (5.2.2) Inmate Discipline
Yes Yes Yes Yes

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TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

3. The inmate shall be permitted to appear on

his/her own behalf at the time of hearing and

present witnesses and documentary evidence. The inmate shall have access to staff or inmate

Yes

assistance when the inmate is illiterate or the

issues are complex.

Yes Yes Yes Yes

4. A charge(s) shall be acted on no later than 72 hours after an inmate has been informed of Yes the charge(s) in writing.

504.09 (5.2.2) Inmate Discipline Yes Yes Yes Yes

5. Subsequent to final disposition of disciplinary charges by the disciplinary officer, the charges and the action taken shall Yes be reviewed by the facility manager or designee.

Yes Yes Yes Yes

6. The inmate shall be advised in a written statement by the fact-finders about the evidence relied on and the reasons for the Yes disciplinary action. A copy of the record shall be kept pursuant to Penal Code Section 4019.5.

504.09 (5.1) Inmate Discipline Yes Yes Yes Yes

7. There shall be a policy of review and appeal to a supervisor on all disciplinary action.

Yes

Yes Yes Yes Yes

(c) Nothing in this section precludes a facility administrator from administratively segregating any inmate from the general population or program for reasons of personal, mental, or physical health, or under any circumstance in which the safety of Yes the inmates, staff, program, or community is endangered, pending disciplinary action or a review as required by Section 1053 of these regulations.

Yes Yes Yes Yes

(d) Nothing in this section precludes the imposition

of conditions or restrictions that reasonably relate to a legitimate, non-punitive administrative

Yes

purpose.

Yes Yes Yes Yes

1082 FORMS OF DISCIPLINE

504.09 (8.7) Inmate Discipline

The degree of punitive actions taken by the disciplinary officer shall be directly related to the

severity of the rule infraction. Acceptable forms of

discipline shall consist of, but not be limited to, the

following:

(a) Loss of privileges.

(b) Extra work detail.

Yes

(c) Short term lockdown for less than 24 hours.

(d) Removal from work details.

(e) Forfeiture of “good time” credits earned under Penal Code Section 4019.

(f) Forfeiture of “work time” credits earned under

Penal Code Section 4019.

(g) Disciplinary separation.

(h) Disciplinary separation diet.

Yes Yes Yes Yes

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TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

1083 LIMITATIONS ON DISCIPLINARY ACTIONS

The Penal Code and the State Constitution expressly prohibit all cruel and unusual punishment. Additionally, there shall be the following limitations: (a) If an inmate is on disciplinary separation status Yes for 30 consecutive days there shall be a review by the facility manager before the disciplinary separation status is continued. This review shall include a consultation with health care staff. Such reviews shall continue at least every fifteen days thereafter until the disciplinary status has ended. This review shall be documented.

(b) The disciplinary separation cells or cell shall

have the minimum furnishings and space specified

in Title 24, Part 2, 1231.2.6 and 2.7. Occupants

shall be issued clothing and bedding as specified in

Articles 13 and 14 of these regulations and shall not

be deprived of them through any portion of the day except that those inmates who engage in the

Yes

destruction of bedding or clothing may be deprived

of such articles. The decision to deprive inmates of

such articles of clothing and bedding shall be

reviewed by the facility manager or designee

during each 24-hour period.

(c) The delegation of authority to any inmate or

group of inmates to exercise the right of punishment over any other inmate or group of

Yes

inmates (Penal Code section 4019.5)

(d) In no case shall a safety cell, as specified in Title 24, Part 2, 1231.2.5, or any restraint device be used Yes for disciplinary purposes.

(e) No inmate may be deprived of the implements

necessary to maintain an acceptable level of personal hygiene as specified in Section 1265 of

Yes

these regulations

(f) Food shall not be withheld as a disciplinary measure.

Yes

(g) The disciplinary separation diet described in section 1247 of these regulations shall only be Yes utilized for major violations of institutional rules.

(1) In addition to the provisions of Section 1247, the facility manager shall approve the initial placement on the disciplinary Yes separation diet and ensure that medical staff is notified.

(2) In consultation with medical care staff,

the facility manager shall approve any continuation on that diet every 72 hours

Yes

after the initial placement.

Yes Yes Yes Yes
Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

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TITLE 15 SECTION

RPDC LSC CBD BJ IJ

P/P REFERENCE – COMMENTS

(h) Correspondence privileges shall not be

withheld except in cases where the inmate has

violated correspondence regulations, in which case correspondence may be suspended for no longer

Yes

than 72 hours, without the review and approval of

the facility manager.

Yes Yes Yes Yes

(i) In no case shall access to courts and legal counsel be suspended as a disciplinary measure.

Yes

Yes Yes Yes Yes

1084 DISCIPLINARY RECORDS

504.09 Inmate Discipline

Penal Code Section 4019.5 requires that a record is kept of all disciplinary infractions and punishment Yes administered therefore. This requirement may be satisfied by retaining copies of rule violation reports and report of the disposition of each.
DETENTION OF MINORS
Are minors held in this facility? If yes, the following sections including those summarizing the regulations identified in Title 15, Article 8 of these regulations apply (Minors in Jails). Note: Reference PC § 207.1(b), 207.6, 707.1

§ 506.14 Purging of Records Yes Yes Yes Yes
Minors are not held in any facilities.

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ADULT TYPE I, II, III AND IV FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community Corrections

Page ID

Applicable Title 24 Regulations: 3/80; 8/86; 5/88; 1/91/94

BSCC Code: 3910

FACILITY NAME: Robert Presley Detention Center

FACILITY TYPE: II

APPLICABLE REGULATIONS (Check All That Apply): FIELD REPRESENTATIVE: Michael J. Bush

3/80: X

8/86: X

5/88: X 1/91: X
DATE: 09/18/2019

OTHER: 94

TITLE 24 SECTION Temporary Holding Cells (2.2)
Contain 10 square feet of floor per inmate Limited to no more than 16 inmates No smaller than 40 square feet Contain sufficient seating to accommodate all inmates Toilet accessible Water fountain accessible Wash basin accessible Provides clear visual supervision Telephone accessible
Weapons Locker (3.12)
External to the security area and equipped with individual compartments, locks and keys

YES NO N/A

COMMENTS

X

X

X

X

Includes court holding cells (1986 Standards)

X

X

X

X

X

X

Temporary Staging Cell or Room (2.3)

1-91: Added provision for temporary staging cells-rooms

X

Holds inmates classified and segregated per Title 15 § 1050

and § 1053

Limited to holding inmates up to 4 hours

X

Maximum capacity of no more than 80 inmates

X

Contains 10 square feet of floor space per inmate and has a ceiling height of at least 8 feet

X

No smaller than 160 square feet

X

Contains seating to accommodate all inmates

X

Contains water closet, wash basin and drinking fountain

X

Provides unobstructed visual supervision of inmates by staff

X

Detoxification/Sobering Cells (2.4)

01: Name change to “sobering cell”

X

Contain 20 square feet of floor per inmate

Limited to no more than 8 inmates

X

No smaller than 60 square feet

X

Contain toilet

X

Contain washbasin

X

Contain drinking fountain

X

Partitions or handrails located next to toilet fixture to

provide support

X

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TITLE 24 SECTION Provide easy, unobstructed visual observation Padding on the floor

Document 178-2 Filed 04/06/20 #:17442
YES NO N/A X
X

Page 212 of 343 Page ID
COMMENTS

Shower-Delousing Room (3.4)

Available in reception/booking

X

Secure Vault or Storage Space (2.1)

Available for inmate valuables

X

Telephone (2.1)

Available for inmate use per Penal Code § 851.5

X

Safety Cells (2.5)

Contain 48 square feet with one floor dimension at least 6

X

feet and ceiling height of at least 8 feet

Limited to no more than one inmate

X

Contain flush ring toilet with controls located outside the cell X

Padded floor, door and walls

X

Equipped with variable intensity, security light, inaccessible to occupant

X

Vertical view panel not more than 4 inches wide and at least 24 inches long, in or adjacent to the door

X

Provide a food pass with lockable shutter no more than 4

inches high and located at least 30 inches above the floor

X

Single Occupancy Cells (2.6)

X

Maximum capacity of one inmate

Contain a minimum of 60 square feet of floor area in Type I facilities and 70 square feet in Type II and III facilities

X

Have a minimum ceiling height of 8 feet

X

Contain toilet, washbasin and drinking fountain

X

Contain a bunk, desk and seat (Desk and seat not required

in Type I in later, less restrictive 1986 standards)

X

1994 Standards

Multiple Occupancy Cells (8227)

8-86: Deleted provision for multiple occupancy cells

X

Contain 35 square feet per person

Limited to no more than 8 inmates

X

No smaller than 100 square feet

X

Minimum ceiling height of 8 feet

X

Water closet separate from washbasin and drinking fountain X

Sufficient bunks to accommodate each occupant

X

Provide storage space for each occupant's personal items

X

Multiple Occupancy Rooms (8229)

8-86: Deleted provision for multiple occupancy rooms

X

Limited to housing persons in Type III and IV facilities and

workers in Type I and II facilities

Contain 50 square feet of floor area per person and a minimum of 8 feet ceiling height

X

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TITLE 24 SECTION

YES NO N/A

Limited to no more than 16 persons

X

Access to toilets separate from washbasins (ratio 1:8) and drinking fountains

X

Provide storage space for each occupant's personal items

X

Page 213 of 343 Page ID
COMMENTS

Double Occupancy Cells (2.7)

5-88: Added provision for double occupancy cells

X

Maximum capacity of two inmates

Contain a minimum of 60 square feet of floor space in Type I facilities and 70 square feet in Type II and III facilities

X

Have a minimum ceiling height of 8 feet and one floor dimension at least 6 feet

X

Contain toilet, washbasin and drinking fountain

X

Contain 2 bunks, 1 desk and seat (Desk and seat not required

in Type I facilities)

X

3 inmates in 3B1 & 3B2 over the rated capacity. Inmates were sleeping in the dayroom on a stacka-bunk.

Dormitories (2.8)

X

8-86: Provision for dormitories added

Contain 50 square feet of floor area per inmate and a

minimum of 8 feet ceiling height

Be designed for no fewer than 8 and no more than 64

X

inmates

Facilities having a total rated capacity of 80 inmates or less,

X

may design dormitories for no fewer than 4 inmates

Access to toilets separate from washbasins (ratio 1:8) and

X

drinking fountains

01: Ratio changed to 1:10

Provide storage space for each inmate’s personal items

X

Dayrooms (2.9)

X

8-86: Added requirement for 3-foot-wide corridors in front

of cells-rooms

99: Corridor requirement deleted

35 square feet of floor area per inmate

X

Contain tables and seating to accommodate the maximum number of inmates served

X

Access to toilets, washbasins and drinking fountains

X

Available to all inmates in Type II and III facilities

(excluding special use cells) and to workers in Type I facilities

X

Housing unit 2A, 2C and 3B had more inmates out in the dayroom than the table and chairs allowed.

Shower (3.4)

Available on a ratio of 1:16

X

01: Ratio changed to 1:20

Lighting (3.6)

Sufficient to permit easy reading. Night lighting is sufficient

to allow good supervision.

X

8-86: Specifies at least 20 foot-candles at desk level and in

grooming areas, with night lighting not to exceed 5

foot-candles

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TITLE 24 SECTION Beds-Bunks (3.5)
30 inches wide and 76 inches long

Document 178-2 Filed 04/06/20 Page 214 of 343 Page ID

#:17444

YES NO N/A

COMMENTS

4-stack-a-bunk in housing units 3B1 & 3B2 during

X

the 2018-2020 inspection cycle.

Comfortable Living Environment [102(c)6]

A comfortable living environment is maintained through an

X

adequate heating and cooling system.

Exercise Area -Type II, III and WA IV (2.10)

At least one exercise area must contain a minimum of 900

X

square feet

8-86: Outdoor exercise area provided

X

8-86: Clear height of 15 feet with required surface area

meeting a formula of: 80% of maximum rated inmate population and number of one-hour exercise periods

X

per day = required surface area

Program Space - Type II and III (2.11)

Sufficient area and furnishings to meet the needs of the

X

facility programs

Dining Facilities (2.17)

X

15 square feet per inmate being fed

Toilets, washbasins and showers are not in the same room or

not in view of inmate dining

X

Visiting (2.18)

X

Sufficient visiting area

Contact visits whenever possible for minimum security

X

inmates

Attorney Interviews (2.26)

Provide for confidential attorney consultation

X

Safety Equipment Storage (2.19)

Adequate space is provided for storage of equipment such as X fire extinguishers, SCBA, emergency lights, etc.

Janitor Closet (2.20)

Located in security areas lockable, containing a mop sink

X

and storage space

Storage Rooms (2.21)

Sufficient space to accommodate inmate property, bedding

X

and supplies

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TITLE 24 SECTION

YES NO N/A

COMMENTS

Audio or Video Monitoring System -NA Type IV (2.22)

Audio monitoring system capable of alerting staff in a

X

central control point

Video monitoring in corridors, main entries and/or exits and

programs or activity areas

X

Fire Detection and Alarm System [102(c)6]

Automatic fire alarm system capable of alerting staff in a

X

central control point

Emergency Power (2.24)

Available to provide minimal lighting, maintain

X

communications, alarm, fire, life and security systems

Provide Space for:

Barber/beauty shop(2.15)

X

8-86: Limit requirement to Type II and III facilities

99: Requirement deleted

Canteen (2.16) 8-86: Added for II, III & IV facilities

X

Confidential Interview Rooms (2.25)

8-86: Added for Type II facilities

X

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 216 of 343 Page ID BOARD OF STATE AND COMMUNI#T:Y17C4O4R6RECTIONS-BIENNIAL INSPECTION
ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION
BSCC Code: 3910

FACILITY: Robert Presley Detention Center

TYPE: II

RC: 760

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/18/2019

ROOMS

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UW F S

Male Intake Release (Basement) - Safety Cell does not have an anchor for the pro-straint chair.

1-4

Safety

1980

4

1

(4)

6.2 X 7.3 X 9.2 1

1-2

Detox

1980

2

8

(16)

14.3 X 12.0 X 9.2 1

1 1

B106 – 110 Holding

1980

5

8

(40)

7.3 X 12.0 X 9.2 1

1 1

Pre-Housing (across from the ICE and Classification office)

B112

Holding

1980

1

8

(8)

7.0 X 12.0 X 9.2 1

1 1

Notes: Bench is 16’

B113

Holding

1980

1

9

(9)

8.0 X 12.0 X 9.2 1

1 1

Notes: Bench is 16’

Release

B206 (2) Holding

1980

1

10

(10)

8.8 X 12.0 X 8.0 1

1 1

Notes: Bench is 16’

B205 (1) Holding

1980

1

9

(9)

8.5 X 14.9 X 8.0 1

1 1

Notes: Bench is 14’

B202 (3) Holding

1980

1

12

(12)

9.3 X 13.0 X 10.4 1

1 1

Notes: Bench is 18’

B201 (4) Holding

1980

1

14

(14) 16.0 X 13.0 X 10.0 1

1 1

Notes: Bench is 21’

Female Intake Release (Basement) Change room/Dress out area.

B209

Holding

1980

1

3

(3)

13.5 X 8.5 X 8.0

1

Notes: Shower cell with 5’ bench

Pre-Release Holding

1980

1

10

(10)

8.5 X 12.0 X 8.0 1

1 1

Notes: Release cell with 16’ bench

B153

Detox

1980

1

3

(3)

7.7 X 10.7 X 8.0 1

1 1

B152

Detox

1980

1

3

(3)

7.9 X 10.7 X 8.0 1

1 1

5

Safety

1980

1

1

(1)

6.2 X 10.5 X 8.0 1

6

Safety

1980

1

1

(1)

6.2 X 10.5 X 8.0 1

1 & 2

Holding

1980

2

8

(16)

7.9 X 10.7 X 8.0 1

1 1

Transportation-

Briefing Room

old cell area 1-5

1980

8.9 X 20.0 X 9.4 1

1 1

Notes: 33’ Bench

0-3

Holding

1980

4

(16)

(64)

8.9 X 20.0 X 9.4 1

1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ROOMS

#:17447

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UWF S

Restraints/5 Holding

1980

2

9

(18)

7.5 X 12.0 X 9.4 1

1 1

4 & 5

Holding

1980

2

9

(18)

7.9 X 10.7 X 9.4 1

1 1

Notes: 18’ Bench

6, 7, 8

Holding

1980

3

16

(48)

14.0 X 11.9 X 9.4 1

1 1

Notes: 24’ Bench

9

Holding

1980

1

9

(9)

7.9 X 11.9 X 9.4 1

1 1

Notes: 24’ Bench

10

Holding

1980

1

8

(8)

7.9 X 10.7 X 9.4 1

1 1

Notes: 20’ Bench

11, 12

Holding

1980

2

12

(24)

9.5 X 13.1 X 9.4 1

1 1

Notes: 23’ Bench

Seventh Floor Infirmary – Medical Housing It is the department’s intent to double bunk all singles in this area; review next inspection cycle, MW 2007.

1-2

Multiple

1980

2

6

6

(12)

33.5 X 33.6

1

1 1 1

Notes: 495.8 square feet, irregular cell

7 & 8 (s) Safety

1980

2

1

(2)

6.2 X 8.0

1

3 & 7

Multiple

1980

2

4

4

(8)

1

1 1 1

Notes: 297 square feet, irregular cell

727

1980

Male showers

Notes:

728-732, Doubles

1980

7

2

2

(14)

734 & 735

11.9 X 9.3

1

1 1

733

Single

1980

1

1

1

(1)

11.9 X 9.3

1

1 1

Notes: Male Cell

750,751, Doubles

1980

3

2

3

(6)

753

8.6 X 11.3

1

1 1

752

Double

1980

1

2

2

(2)

8.6 X 11.3

1

1 1

743, 744, Doubles

1980

3

2

2

(6)

746

10.5 X 11.0

745

Double

1980

1

2

2

(2)

10.5 X 11.0

Notes: Ad-Seg cells

757

Multiple

1980

1

4

4

(4)

14.5 X 21.3

1

1 1 1

Notes: cell with shower

1-3

Holding

1980

3

1

1

(3)

7.0 X 6.0 X 8.7 1

1 1

Notes: 6’ Bench

Psych2 768

1980

10.5 X 10.8

Notes: Office Space

Psych2 769

1980

8.3 X 10.8

Notes: Office Space

770

1980

11.0 X 16.2

General Housing – Level 2 (Administrative Segregation)

2A1

Double

1994

12

2

2

24

6.0 X 12.5

1

1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ROOMS

#:17448

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UWF S

2A1

Double

1994

2

2

2

4

9.5 X 12.5

1

1 1

2A2

Double

1994

16

2

2

32

6.0 X 12.5

1

1 1

2A3

Double

1994

12

2

2

24

6.0 X 12.5

1

1 1

2A3

Double

1994

2

2

2

4

9.5 X 12.5

1

1 1

NOTE: “3 bunks” in cell 2A1, 2, 43, & 44. 3rd bunks are never used and are not part of the RC.

Level 3

3A1

Double

1994

12

2

2

24

6.0 X 12.5

1

3A1

Double

1994

2

2

2

4

9.5 X 12.5

1

3A2

Double

1994

8

2

2

16

6.0 X 12.0

1

3A2

Double

1994

8

2

2

16

6.0 X 12.0

1

3A3

Double

1994

12

2

2

24

6.0 X 12.0

1

3A3

Double

1994

2

2

2

4

9.5 X 12.0

1

3B1

Double

1994

18

2

2

36

6.0 X 12.0

1

3B1

Double

1994

2

2

2

4

9.5 X 12.0

1

3B2

Double

1994

18

2

2

36

6.0 X 12.0

1

3B2

Double

1994

2

2

2

4

9.5 X 12.0

1

Level 4

4A1

Double

1994

12

2

2

24

6.0 X 12.5

1

4A1

Double

1994

2

2

2

4

9.5 X 12.5

1

4A2

Double

1994

8

2

2

16

6.0 X 12.0

1

4A2

Double

1994

8

2

2

16

6.0 X 12.0

1

4A3

Double

1994

12

2

2

24

6.0 X 12.0

1

4A3

Double

1994

2

2

2

4

9.5 X 12.0

1

4B1

Double

1994

18

2

2

36

6.0 X 12.0

1

4B1

Double

1994

2

2

2

4

9.5 X 12.0

1

4B2

Double

1994

18

2

2

36

6.0 X 12.0

1

4B2

Double

1994

2

2

2

4

9.5 X 12.0

1

Level 5

5A1

Double

1994

12

2

2

24

6.0 X 12.5

1

5A1

Double

1994

2

2

2

4

9.5 X 12.5

1

5A2

Double

1994

8

2

2

16

6.0 X 12.0

1

5A2

Double

1994

8

2

2

16

6.0 X 12.0

1

5A3

Double

1994

12

2

2

24

6.0 X 12.0

1

5A3

Double

1994

2

2

2

4

9.5 X 12.0

1

5B1

Double

1994

18

2

2

36

6.0 X 12.0

1

5B1

Double

1994

2

2

2

4

9.5 X 12.0

1

5B2

Double

1994

18

2

2

36

6.0 X 12.0

1

5B2

Double

1994

2

2

2

4

9.5 X 12.0

1

Level 6

6A1

Double

1994

12

2

2

24

6.0 X 12.5

1

1 1 1 1 2 1 1 1 1 2 1 1 1 1 2 1 1 1 1 2 1 1 1 1 2
1 1 1 1 2 1 1 1 1 2 1 1 1 1 2 1 1 1 1 2 1 1 1 1 2
1 1 1 1 2 1 1 1 1 2 1 1 1 1 2 1 1 1 1 2 1 1 1 1 2
1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ROOMS

#:17449

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UWF S

6A1

Double

1994

2

2

2

4

9.5 X 12.5

1

1 1 2

6A2

Double

1994

8

2

2

16

6.0 X 12.0

1

1 1

6A2

Double

1994

8

2

2

16

6.0 X 12.0

1

1 1 2

6A3

Double

1994

12

2

2

24

6.0 X 12.0

1

1 1

6A3

Double

1994

2

2

2

4

9.5 X 12.0

1

1 1 2

6B1

Single

1994

18

2

2

36

6.0 X 12.0

1

1 1

6B1

Double

1994

2

2

2

4

9.5 X 12.0

1

1 1 2

6B2

Single

1994

18

2

2

36

6.0 X 12.0

1

1 1

6B2

Double

1994

2

2

2

4

9.5 X 12.0

1

1 1 2

Note: Number of double cells limited in each pod by lack of dayroom space. All other physical plant requirements in place. Level 4A State inmates; Level 4B inmate workers; Level 6 for female housing. BRC Total for Level 3 through 6: 142 X 4 (levels 3 – 6 ) = 568 BRC + 60 (level 2) = 628 BRC

Double buked singles cells in 6A2 – 02/07/2017 (MJB)

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ADULT TYPE I, II, III AND IV FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community Corrections

Page ID

APPLICABLE TITLE 24 REGULATIONS: 6/94; 2/99; 2001; 2005

BSCC Code: 3920

FACILITY NAME: Larry D. Smith Correctional Center

FACILITY TYPE: II

APPLICABLE REGULATIONS (Check All That Apply): 6/94: X FIELD REPRESENTATIVE: Michael J. Bush

2/99:

2001: X 2005: X
DATE: 09/20/2019

OTHER: 1963, 1980

TITLE 24 SECTION Reception and Booking (2.1)

YES NO N/A

COMMENTS

X Contains a weapons locker, designed as outlined in these regulations.

Contains a cell or room for confinement pending booking

X

Contains a detoxification cell, where applicable

01: Name change to “sobering cell.”

X

2-99: Two detoxification cells are provided if both male and

female inmates are held.

Contains safety cell(s) (WA) X

Shower room available

X

2-99: Access to shower must be within the secure area

Provides secure vault or storage for inmate valuables

X

Telephone(s) available for inmate use (PC § 851.5)

X

2-99: Unobstructed access to hot and cold running water

X

Four holding cells are located in the intake/release area.
Two sobering cells are located in the intake/release area. They were constructed under the 2001 standards. One sobering cell is located in Building 8. It was constructed under the 1994 standards.
Two safety cells are located in the intake/release area. They were constructed under the 2001 standards.
The inmate shower is located off of the property room.

Temporary Holding Cell or Room (2.2)

X

Contains 10 square feet of floor area per inmate

Holds no more than 16 inmates

X

Is not smaller than 40 square feet and has a clear ceiling height of 8 feet or more

X

Contains sufficient seating to accommodate all inmates

X

Contains water closet (toilet), wash basin, and drinking fountain

X

Provides for clear visual supervision by staff X

Large Holding rated for (4) Smallest Holding Cell is rated for (7)

Temporary Staging Cell or Room (2.3)
Holds inmates classified and segregated per Title 15 § 1050 and 1053 Detoxification/Sobering Cell (2.4)

No temporary staging cell or room, remainder of the regulation is deleted. X

X 01: Name change to “sobering cell.” Contains 20 square feet of floor area per inmate

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#:17451

TITLE 24 SECTION

YES NO N/A

COMMENTS

Is limited to no more than 8 inmates

X

The Rated Capacity for each sobering cell is (7)

Is no smaller than 60 square feet and has a clear ceiling height of 8 feet or more

X

145 Sq. Ft

Contains a water closet (toilet) wash basin and drinking fountain as specified by these regulations

X

Has padded partitions located next to toilet fixtures

X

Provides for clear visual supervision by staff

X

Padding on floor

X

01: A shower is accessible in the secure portion of the

facility

X

Located adjacent to the inmate property room.

Safety Cell (2.5) Contains 48 square feet with one floor dimension of a least 6 X feet and a clear ceiling height of 8 feet or more

Is limited to one inmate

X

Contains a flushing ring toilet, mounted flush with the floor, with controls located outside the cell

X

Padded floor, door and walls

X

Equipped with a variable intensity, security light, inaccessible to the occupant

X

Has one or more vertical view panels, not more than 4

inches wide nor less than 24 inches long, which provide a

X

view of the entire cell

Has a food pass with lockable shutter no more than 4 inches high and, with between 26 and 32 inches from the bottom of X the food pass to the floor

01: Wall or ceiling mounted devices are inaccessible to

inmate occupant.

X

Ceiling height is 8’6”. Room dimensions are 7’X7’
24”X5” wide; to be reduced to meet 4” requirement.

Single Occupancy Cells (2.6)

X

Maximum capacity of one inmate

Contain a minimum of 60 square feet of floor area in Type I facilities and 70 square feet in Type II and III facilities

X

Have a minimum clear ceiling height of 8 feet and a minimum width of 6 feet

X

Contain a water closet (toilet), wash basin and drinking fountain

X

Contain a bunk, desk and seat (Desk and seat not required in

Type I facilities.)

X

Disciplinary Isolation cells.
Approximately 77 Sq. Ft. 8’ 6” ceiling height.

Double Occupancy Cells (2.7) Maximum capacity of two inmates

Building 8 has three double occupancy cells; one cell has been converted to a sobering cell.
X

Contain a minimum of 60 square feet of floor area in Type I

facilities and 70 square feet in Type II and III facilities

X

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#:17452

TITLE 24 SECTION

YES NO N/A

Have a minimum clear ceiling height of 8 feet and a minimum width of 6 feet

X

Contain a water closet (toilet), wash basin and drinking fountain

X

Contain 2 bunks, 1 desk and 1 seat (Desk and seat not

required in Type I facilities.)

X

Page 222 of 343 Page ID
COMMENTS

Dormitories (2.8)
(Note: 2001 regulations reduced the double bunk requirement from 75 to 70 square feet and added provision for triple bunks. This is the “least restrictive standard.” 2005 revisions added clarifying language, but did not change the calculations.)

Dormitory C4 had 10 inmates sleeping in stack-abunks.

Contain at least 50 square feet of floor area per inmate for

single bed units; at least 70 square feet of floor space per

X

inmate for double bed units; and, at least 90 square feet for

triple bed units. Eight foot clear ceiling height required.

(To calculate double bunked BRC: 70 square feet divided by 2 inmates = 35 square feet + 35 square feet dayroom = 70 square feet per inmate. To calculate triple bunked BRC: 90 square feet divided by 3 inmates=30 square feet + 35 square feet dayroom=65 square feet per inmate.)

Designed for no fewer than 4 and no more than 64 inmates

X

Provide access to toilets separate from wash basins and

X

drinking fountains

Provide storage space for each inmate's personal items (NA

Type I)

X

Dayrooms (2.9) (Required for inmates in Type II and III facilities (excluding "special use" cells) and inmate workers in Type I facilities.)
Contain 35 square feet of floor area per inmate, exclusive of 3 foot wide corridors in front of cells/rooms 2-99: Deleted 3 foot corridor in front of cells/rooms Contain tables and seating to accommodate the maximum number of inmates allowed access at a given time. (Note 2001 revisions added reference to access at a given time and are the least restrictive standard.)

Housing unit 14 – Dormitory G over the rated capacity. X
Housing unit 14 – Dormitory G X

Exercise Area (2.10)

Provided in Type II and III facilities. Type IV facilities

X

must have a recreation area or provide community access to

one.

Clear height of 15 feet

X

Has required surface area: 80 % of maximum rated inmate

capacity, multiplied by 50 square feet, divided by number of one-hour exercise periods per day, equals the required

X

surface area.

Housing Unit 12 and 14 have designated outdoor recreation yards.
Rotating schedule.

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#:17453

TITLE 24 SECTION

YES NO N/A

2-99: Provides free access to a toilet, wash basin and drinking fountain

X

Provides adequate security

X

Page 223 of 343 Page ID
COMMENTS

Program/Multipurpose Space (2.11) (NA Type I)

Housing Area 12 and 14

There is sufficient area and furnishings to meet the needs of

X

the facility programs. (See regulation for discussion of

applicability to Type IV.)

Medical Examination Room (2.12)

There is one suitably equipped medical exam room in every Type II or III facility designed to house 25 or more inmates. X

2-99: Required in all facilities that provide on-site health care.

Located within the security area and provide for privacy of inmates

X

Not less than 100 square feet of floor space with no single dimension less than 7 feet

X

Provide hot and cold running water

2-99: Hot and cold running water in any room where

X

medical procedures are provided

2-99: Lockable storage for medical supplies

X

Pharmaceutical Storage Space (2.13)

There is lockable storage space for medical supplies and

X

pharmaceuticals (Title 15 § 1216).

10’ X 16’ with 8’6” ceiling height. 2010 Expansion- exam rooms-12’6 X 8’2 X 8’4
Located inside medical examination room. Lockable storage space in the medical examination room.

Medical Care Housing (2.14)
Applicable to Type II and III facilities where the facility program indicates special medical care housing is needed. Housing is located within the security area, accessible to both male and female inmates, but not in the living area of either. Provides lockable storage area for medical instruments 2-99: Negative pressure isolation rooms are designed to the
community standard.

Inmates with medical issues are housed at RPDC, SWDC, or Indio Jail. X
X X X

Hair Care Space (2.15)
Space and equipment are available. 2-99: Requirement deleted.

Not applicable for Housing Units 1 and 2 (constructed under the 2001 standards).
X

Commissary (2.16) (NA Type I) X
Inmates can purchase specified items.

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#:17454

TITLE 24 SECTION

YES NO N/A

There is secure storage for commissary stock.

01: Revisions limit requirement for secure storage to

circumstances when commissary supplies are kept

X

within the security perimeter.

Page 224 of 343 Page ID
COMMENTS

Dining Facilities (2.17) (NA Type I)

X There are 15 square feet and sufficient tables and seating for each inmate being fed.

Dining space does not include toilets, wash basins or

showers, without an appropriate visual barrier.

2-99: Visual barrier requirement deleted for wash basins

X

Visiting Space (2.18) There is sufficient visiting area.

Expanded time frame to accommodate more visiting. X

Safety Equipment Storage (2.19)

Adequate space is provided to store equipment such as fire

X

extinguishers, SCBA, emergency lights, etc.

Janitors' Closet (2.20)

A securely lockable janitor’s closet provides sufficient

X

storage for cleaning implements and supplies and is located

within the security area (Type II only).

A mop sink is available within the security area (Type II). It

may be outside the security area in CH, TH and Types I, III & IV.

X

Audio or Visual Monitoring (2.22)
(Prior to 2005 this was N/A for Type III and IV housing only minimum security inmates. In 2005 applicability was extended to all CH, TH, Type I, II, III and IV facilities regardless of security level.)

DVR

There is an audio monitoring system capable of alerting staff X in a central control. When visual electronic surveillance is used, it is located primarily in corridors, elevators, or at points on the security perimeter such as entrances and exits.
2-99: Video monitoring option and references to electronic surveillance located primarily in corridors, elevators or points in security perimeter were deleted.

Laundry Facilities (2.23)

Type IV facilities make provision for washing and drying

X

personal laundry.

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#:17455

TITLE 24 SECTION

YES NO N/A

COMMENTS

Emergency Power (2.24)

Diesel.

There is an emergency power source available and capable

of providing minimal lighting in all areas and maintaining fire and life safety, security, communication and alarm

X

systems.

Confidential Interview Rooms (2.25)

There is at least one suitably furnished confidential interview

room in every Type II facility designed for 25 or more

X

inmates.

2-99: Applicable to every facility which provides on-site health care

Located in the security area, accessible by both male and female inmates

X

Provides at least 70 square feet floor area with no single

dimension less than 6 feet

X

Three confidential interview rooms are located in intake and receiving.
10’ X 10’ (100 sf).

Attorney Interview Space (2.26) (NA Type IV) X
Available and provides for confidentiality

Attorney visiting is located at the main building

Water Closets (Toilets)/Urinals (3.1)

Provide for inmate privacy/modesty with staff being able to visually supervise; one is provided in every single and double occupancy cell and at the following ratio elsewhere:

1:10 in dormitories (changed from 1:8 in 2001);

1:8 in detoxification/sobering cells;

X

1:16 in holding cells;

1:20 in exercise areas; and,

Accessible to dayroom occupants no specified ratio.

2-99: Accessible at no specified ratio in exercise areas

See regulation for calculations of urinal substitutions.

Wash basins (3.2)

Provide hot and cold or tempered water; one is provided in every single and double occupancy cell and at the following ratio elsewhere:

1:10 in dormitories (changed from 1:8 in 2001);

1:8 in detoxification/sobering cells;

1:20 in exercise areas; and,

X

Accessible to dayrooms at no specified ratio.

2-99: Accessible in exercise areas at no specified ratio

See regulation for calculations of wash basin trough substitutions.

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#:17456

TITLE 24 SECTION

YES NO N/A

COMMENTS

Drinking Fountains (3.3)

One is provided in every single and double occupancy cell and in dormitories. Accessible to inmates in dayrooms 2-99: One is provided in every single and double occupancy X
cell, holding and staging cells and detoxification cells. It must be accessible to inmates in dayrooms and exercise areas.

The water outlet (bubbler) is mechanically actuated and at an angle that prevents wastewater from flowing over the outlet (bubbler). There is a mouth guard on the water outlet. X 2-99: Mouth guard requirement deleted

Showers (3.4)

Available at a ratio of 1:20; provide hot and cold or

tempered water; shower stalls/areas are designed and

constructed of materials that are impervious to water and soap so that they may be easily cleaned.

X

2-99: Ratio changed from 1:16; specified that shower areas

must provide modesty for inmates, with staff ability

to supervise.

Beds/Bunks (3.5)

2 inmates sleeping on stack-a-bunks.

At least 30 inches wide and 76 inches long with 21 inches

between pans; constructed of pan bottom type or concrete; securely fastened to the floor and/or wall in facilities higher

X

than minimum security.

01: Must be elevated off the floor.

Lighting (3.6)

Lighting in housing units, dayrooms and activity areas is

sufficient to permit easy reading by a person with normal

vision, and is not less than 20 foot-candles at desk level and

in the grooming area. Night lighting is sufficient for

purposes of supervision.

X

Lighting is centrally controlled and/or occupant controlled in housing cells or rooms. Light fixtures are of secure design in areas higher than minimum security.

Windows (3.7)

In housing areas higher than minimum security, windows that are accessible to inmates are no greater than 5 inches in

X

one dimension.

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#:17457

TITLE 24 SECTION

YES NO N/A

COMMENTS

Cell Padding (3.8)

The floors and partition are padded in detoxification cells.

In safety cells, floors, doors, walls and everything on them

X

are padded. All padded cells are equipped with a tamper

resistant fire sprinkler approved by the SFM.

All padding is: approved for use by the SFM; nonporous; at

least ½ inch thick; of a unitary or laminated construction; firmly bonded to all surfaces; and, without exposed seams.

X

Mirrors/Shelves/Clothes Hooks (3.9)

X A mirror of a material appropriate to the level of security is provided near each wash basin.

Consistent with security needs, shelves and clothes hooks

are provided wherever feasible.

X

2-99: Requirement for shelves and hooks deleted

Clothes hooks are of a collapsible hook type

2-99: Requirement for hooks deleted

X

Break away hooks.

Seating (3.10)

Seating is designed to the level of security. When bench

seating is used, eighteen inches of bench are provided per inmate.

X

2-99: In holding and staging cells, seating is securely

fastened to the wall and/or floor.

Table/Seat (3.11) (NA Type I)

A table and seat is provided in single and double occupancy X cells.

Weapons Locker (3.12) (NA type IV and Minimum Security Facilities)

A secure weapons locker is located outside the security

X

perimeter of the facility and no weapons are brought into the

security area. Lockers have individual compartments, locks

and keys.

Design Requirements (102(c)6)

Design requirements as specified in Title 24, Part 1, 102(c)6

are met. (See regulation for specific requirements. Note

X

areas of non-compliance that are applicable to the facility

type and construction date in the "comments" section.)

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 228 of 343 BOARD OF STATE AND COMMUNI#T:Y17C4O5R8RECTIONS - BIENNIAL INSPECTION
ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION

Page ID

BSCC Code: 3920

FACILITY: Larry D. Smith Correctional Facility

TYPE: II

RC: 1458

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/20/2019

ROOMS

Cell Applicable #

Location

Type Standards Cells

Intake – 1st New Addition

EACH CELL # Beds RC

Total RC

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

1

Sobering

2001

1

(7)

(7)

14’6 X 10’X 8’6 1

1 1

2

Sobering

2001

1

(7)

(7)

14’5 X 10’ X 8’6 1

1 1

1

Safety

2001

1

(1)

(1)

7 X 7 X 8’6

1

2

Safety

2001

1

(1)

(1)

7 X 7 X 8’6

1

3

Safety

2009

1

(1)

(1)

7’2 X 7’1” X 8’2 1

4

Safety

2009

1

(1)

(1)

7’7 X 7’9 X 8’2 1

1

Holding

2001

1

(7)

(7)

Approx 77 sf

1

1 1

Notes: 12’ bench space; Rated capacity is limited to 7 inmates based on 77 sf.

2

Holding

2001

1

(7)

(7)

Approx 102 sf

1

1 1

12’ bench space; Rated capacity is limited to 7 inmates based on 77 sf.

3

Holding

2001

1

(8)

(8)

Approx 85 sf

1

1 1

Notes: 13’8” bench space; Rated capacity is limited to 8 inmates based on 85 sf.

4

Holding

2001

1

(8)

(8)

Approx 85 sf

1

1 1

Notes: 13’9” bench space; Rated capacity is limited to 8 inmates based on 85 sf.

5

Holding

2001

1

(14)

(14)

Approx 142 sf

1

1 1

Notes: 22’ bench space; Rated capacity is limited to 14 inmates based on 142 sf.

6

Holding

2001

1

(14)

(14)

Converted to 2

1

safety cells, 2013

1 1

Notes: 22’ bench space; Rated capacity is limited to 14 inmates based on 142 sf. Holding cell number 6 is converted to 2 safety cells (the new safety cells have been added to the LASE this cycle, 2013)

Housing Unit 14- Male or Female housing in all units at this facility, designated housing units change with the need of the facility

A

Dorm

2001

1

10

10

10

Approx 753 sf

1

1 1 1

Notes. Dormitory A is ADA accessible; shower, washbasin, and stool.

B

Dorm

2001

1

10

10

10

Approx 753 sf

1

1 1 1

C

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

D

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

E

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

F

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

G

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

H

Iso

2001

1

1

1

(1)

Approx 77 sf

1

1 1

I

Iso

2001

1

1

1

(1)

Approx 77 sf

1

1 1

NOTE: Shower is accessible for inmates held in disciplinary isolation.

Housing Unit 12

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ROOMS

#:17459

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UW F S

A

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

B

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

C

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

D

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

E

Dorm

2001

1

22

20

20

Approx 1419 sf 2

2 2 2

F

Dorm

2001

1

10

10

10

Approx 753 sf

1

1 1 1

G

Dorm

2001

1

10

10

10

Approx 753 sf

1

1 1 1

NOTE: Dormitory G is ADA accessible; shower, washbasin, and seat.

Original Facility

Housing-Male or Female Units

1

Dorm

1980

2

32

32

64

8

8 1 4

2

Dorm

1980

2

32

32

64

8

8 1 4

3

Dorm

1980

2

32

32

64

8

8 1 4

4

Dorm

1980

2

32

32

64

8

8 1 4

NOTE: Sentenced inmates are housed in these dorms.

Housing-Male or Female Units

5

Dorm

1980

2

32

32

64

8

8 1 4

NOTE: Each of these dorms measure 31.0 ft. x 114 ft.

6

Dorm

1980

1

32

32

32

4

4 1 2

7

Dorm

1980

1

32

32

32

4

4 1 2

Doubles and Dorm Housing

8A

Double

1994

4

2

2

8

1

1 1

Converted- Former law library Detox

1998

1

1 1

B,C,D

Dorm

1994

3

16

12

36

2

2 1

NOTE: Sufficient square footage cells and dayroom. One cell and shower handicap accessible. One Shower

Bldg 9

A,B,C,D

Dorm

1994

4

16

12

48

2

2 1

NOTE: One shower. Four pods per building; each pod has 926 square feet. Applied 1994 Standards.

Bldg 10

A,B,C,D

Dorm

1994

4

16

12

48

2

2 1

NOTE: One shower - Each pod has 926 square feet. Applied 1994 Standards

Bldg 11

A,B,C,D

Dorm

1994

4

16

12

48

2

2 1

NOTE: Each pod has 936 square feet. One shower

NOTES: 5-foot urinal. These dorms are now used for program space and measure 2,062 sq. ft. x 10 ft. (Barracks #12 & #14 were rated for 42 each.

Current RSAT Housing Units

19

Dayroom 1963

23.0 x 50.0

4 3 5 1 3

NOTE: #15 is used as dayroom for #16.

19

Dorm

1963

1

32

32

32

23.0 x 50.0

4 3 5 1 3

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ROOMS

#:17460

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UW F S

Female

18

Dorm

1963

1

32

32

32

23.0 x 50.0

4 3 5 1 3

18

Dayroom 1963

1

23.0 x 50.0

4 3 5 1 3

NOTE: Sun porch prorated in dayroom for all dorms.

NOTE: Each pod has 936 square feet. One shower

(b) 08 A & B (over capacity) and (b) 09A – Dayroom Space

Location

Cell Type

ROOMS Applicable # Standards Cells

EACH CELL # Beds RC

Total RC

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

2nd New Addition 8/2010-Support Lower Floor, Transportation –under 2005 Title 24 Regulations

1 & 2

Holding

2005

2

(12)

(24)

15’4” X 8’4 X 8 1

1 1

3-5

Holding

2005

3

(14)

(42)

15’3” X 9’4 X 8 1

1 1

6-ADA Holding

2005

1

(16)

(16)

Irregular-approx 1

160 sft

1 1

7-11

Holding

2005

5

(14)

(70)

15’3 X 9’4X 8

1

12

Holding

2005

1

(12)

(12)

15’4 X 8’3 X 8

1

1 1

Note: 2- benches in each cell approx 22 ft in total except cell 6. Cell 6 has 22ft of bench space exceeding space for 16 inmates / ceiling height is 8’6 but clear ceiling height is 8 ft-Security ceiling double panel (welded metal).

13

Holding

2005

1

(11)

(11)

15’4 X 7’2 X 8

1

1 1

14

Holding

2005

1

(13)

(13)

15’4 X 8’5 X 8

1

1 1

15-17

Holding

2005

3

(12)

(36)

15’4 X 8’3 X 8

1

1 1

18-20

Holding

2005

3

(13)

(39)

15’4 X 8’5 X 8

1

1 1

Notes: 2-13 ft benches in all cells.

New 2010 Smith Expansion Housing Unit 15 Upper and Lower Floor

Location 15-A

Cell Type Double

Applicable Standards
2005

# Cells
16

15-B

Double

2005

16

15-C

Double

2005

16

15-D

Double

2005

16

15-E

Double

2005

16

15-F

Double

2005

16

Notes: Bottom shower is ADA accessible.

EACH CELL

# Beds RC

2

32

2

32

2

32

2

32

2

32

2

32

Total RC 32
32 32 32 32 32

DIMENSIONS (L x W x H)

FIXTURES* T UW F S

11’5 X 6’2 X 8’4 1

1 1

2

11’5 X 6’2 X 8’4 1

1 1

2

11’5 X 6’2 X 8’4 1

1 1

2

11’5 X 6’2 X 8’4 1

1 1

2

11’5 X 6’2 X 8’4 1

1 1

2

11’5 X 6’2 X 8’4 1

1 1

2

Ad-Seg,

Single

2005

2

2

2

2

11’5 X 9’ X 8’4 2

2 2 1

L-Floor

One (1) shower on each floor-2 showers total for each pod. One cell in each 16 cell pod (15, 16, 17) is an ADA cell that is 98 square feet

New 2010 Housing Unit 16 Upper and Lower

16-A

Double

2005

16

2

32

32

11’5 X 6’2 X 8’4

1

16-B

Double

2005

16

32

32

11’5 X 6’2 X 8’4

1

16-C

Double

2005

16

2

32

32

11’5 X 6’2 X 8’4

1

1 1 2 1 1 2 1 1 2

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ROOMS

#:17461

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UW F S

16-D

Double

2005

16

2

32

32

11’5 X 6’2 X 8’4

1

1 1 2

16-E

Double

2005

16

2

32

32

11’5 X 6’2 X 8’4

1

1 1 2

16-F

Double

2005

16

2

32

32

11’5 X 6’2 X 8’4

1

1 1 2

Ad-Seg,

2005

2

2

2

Single

L-Floor

2

11’5 X 9 X 8’4

1

1 1 1

Notes: One (1) shower on each floor-ADA shower bottom floor

New 2010 Housing Unit 17 Upper and Lower

Location 17-A

Cell Type Double

Applicable Standards
2005

# Cells
16

EACH CELL

# Beds RC

32

32

17-B

Double

2005

16

32

32

17-C

Double

2005

16

32

32

17-D

Double

2005

16

32

32

17-E

Double

2005

16

32

32

17-F

Double

2005

16

32

32

Ad-Seg,

2005

2

2

2

Single

L-Floor

Notes: One (1) shower on each floor- ADA shower bottom floor.

New Medical Clinic - 2019

1-4

H

2015

(4)

(4)

Total RC 32
32 32 32 32 32 2

DIMENSIONS (L x W x H)
11’5 X 6’2 X 8’4 11’5 X 6’2 X 8’4 11’5 X 6’2 X 8’4 11’5 X 6’2 X 8’4 11’5 X 6’2 X 8’4 11’5 X 6’2 X 8’4
11’5 X 9 X 8’4

FIXTURES*

T UW F S

1

1 1 2

1

1 1 2

1

1 1 2

1

1 1 2

1

1 1 2

1

1 1 2

1

1 1 1

(16)

9.4 x 11.5 x 10

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ADULT TYPE I, II, III AND IV FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community Corrections

Page ID

Applicable Title 24 Regulations: 3/80; 8/86; 5/88; 1/91

BSCC Code: 3930

FACILITY NAME: Cois Byrd Detention Center

FACILITY TYPE: II

APPLICABLE REGULATIONS (Check All That Apply): 3/80: FIELD REPRESENTATIVE: Michael J. Bush

8/86:

5/88: X 1/91:
DATE: 09/19/2019

OTHER: 1994

TITLE 24 SECTION Temporary Holding Cells (2.2)
Contain 10 square feet of floor per inmate Limited to no more than 16 inmates No smaller than 40 square feet Contain sufficient seating to accommodate all inmates Toilet accessible Water fountain accessible Wash basin accessible Provides clear visual supervision Telephone accessible

YES NO N/A X
X X X X X X X X

COMMENTS

Weapons Locker (3.12)

X

External to the security area and equipped with individual compartments, locks and keys

Temporary Staging Cell or Room (2.3)

X

1-91: Added provision for temporary staging cells-rooms

Holds inmates classified and segregated per Title 15 § 1050

and § 1053

Limited to holding inmates up to 4 hours

X

Maximum capacity of no more than 80 inmates

X

Contains 10 square feet of floor space per inmate and has a

X

ceiling height of at least 8 feet

No smaller than 160 square feet

X

Contains seating to accommodate all inmates

X

Contains water closet, wash basin and drinking fountain

X

Provides unobstructed visual supervision of inmates by staff X

1988 Standards (no smaller than 40 sq ft)

Detoxification/Sobering Cells (2.4)

X

01: Name change to “sobering cell”

Contain 20 square feet of floor per inmate

Limited to no more than 8 inmates

X

No smaller than 60 square feet

X

Contain toilet

X

Contain washbasin

X

Contain drinking fountain

X

Partitions or handrails located next to toilet fixture to

X

provide support

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Case 5:13-cv-00444-VAP-OP
TITLE 24 SECTION Provide easy, unobstructed visual observation Padding on the floor

Document 178-2 Filed 04/06/20 #:17463
YES NO N/A X
X

Page 233 of 343 Page ID
COMMENTS

Shower-Delousing Room (3.4)

Available in reception/booking

X

Secure Vault or Storage Space (2.1)

Available for inmate valuables

X

Telephone (2.1)

Available for inmate use per Penal Code § 851.5

X

Safety Cells (2.5)

Contain 48 square feet with one floor dimension at least 6

X

feet and ceiling height of at least 8 feet

Limited to no more than one inmate

X

Contain flush ring toilet with controls located outside the cell X

Padded floor, door and walls

X

Equipped with variable intensity, security light, inaccessible to occupant

X

Vertical view panel not more than 4 inches wide and at least 24 inches long, in or adjacent to the door

X

Provide a food pass with lockable shutter no more than 4

inches high and located at least 30 inches above the floor

X

Light fixture 7’ 6” Compliance Granted.

Single Occupancy Cells (2.6)

X

Maximum capacity of one inmate

Contain a minimum of 60 square feet of floor area in Type I facilities and 70 square feet in Type II and III facilities

X

Have a minimum ceiling height of 8 feet

X

Contain toilet, washbasin and drinking fountain

X

Contain a bunk, desk and seat (Desk and seat not required in

Type I in later, less restrictive 1986 standards)

X

Application of 1994 Standards.

Multiple Occupancy Cells (8227)

8-86: Deleted provision for multiple occupancy cells

X

Contain 35 square feet per person

Limited to no more than 8 inmates

X

No smaller than 100 square feet

X

Minimum ceiling height of 8 feet

X

Water closet separate from washbasin and drinking fountain

X

Sufficient bunks to accommodate each occupant

X

Provide storage space for each occupant's personal items

X

Multiple Occupancy Rooms (8229)

8-86: Deleted provision for multiple occupancy rooms

X

Limited to housing persons in Type III and IV facilities and

workers in Type I and II facilities

Contain 50 square feet of floor area per person and a minimum of 8 feet ceiling height

X

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#:17464

TITLE 24 SECTION

YES NO N/A

Limited to no more than 16 persons

X

Access to toilets separate from washbasins (ratio 1:8) and drinking fountains

X

Provide storage space for each occupant's personal items

X

Page 234 of 343 Page ID
COMMENTS

Double Occupancy Cells (2.7)

5-88: Added provision for double occupancy cells

X

Pod E, F, & G built under the 1994 Standards

Maximum capacity of two inmates

Contain a minimum of 60 square feet of floor space in Type I facilities and 70 square feet in Type II and III facilities

X

Have a minimum ceiling height of 8 feet and one floor dimension at least 6 feet

X

Contain toilet, washbasin and drinking fountain

X

Contain 2 bunks, 1 desk and seat (Desk and seat not required

in Type I facilities)

X

Dormitories (2.8)

8-86: Provision for dormitories added

X

Contain 50 square feet of floor area per inmate and a

minimum of 8 feet ceiling height

Be designed for no fewer than 8 and no more than 64 inmates

X

Facilities having a total rated capacity of 80 inmates or less, may design dormitories for no fewer than 4 inmates

X

Access to toilets separate from washbasins (ratio 1:8) and

drinking fountains

X

01: Ratio changed to 1:10

Provide storage space for each inmates' personal items

X

Dayrooms (2.9)

8-86: Added requirement for 3 foot wide corridors in front

of cells-rooms

99: Corridor requirement deleted

35 square feet of floor area per inmate

X

Contain tables and seating to accommodate the maximum number of inmates served

X

Access to toilets, washbasins and drinking fountains

X

Available to all inmates in Type II and III facilities

(excluding special use cells) and to workers in Type I facilities

X

X
Table space and seating has been increased from 60 to 64 in Pod D and C.(Determine Pod location)

Shower (3.4)

Available on a ratio of 1:16

X

01: Ratio changed to 1:20

Lighting (3.6)

Sufficient to permit easy reading. Night lighting is sufficient

to allow good supervision.

X

8-86: Specifies at least 20 foot-candles at desk level and in

grooming areas, with night lighting not to exceed 5

foot-candles

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#:17465

TITLE 24 SECTION

YES NO N/A

COMMENTS

Beds-Bunks (3.5)

30 inches wide and 76 inches long

X

Comfortable Living Environment [102(c)6]

A comfortable living environment is maintained through an

X

adequate heating and cooling system.

Exercise Area -Type II, III and WA IV (2.10)

At least one exercise area must contain a minimum of 900

X

square feet

8-86: Outdoor exercise area provided

X

8-86: Clear height of 15 feet with required surface area

meeting a formula of: 80% of maximum rated inmate population and number of one-hour exercise periods

X

per day = required surface area

Program Space - Type II and III (2.11)

Sufficient area and furnishings to meet the needs of the

X

facility programs

Dining Facilities (2.17)

X

15 square feet per inmate being fed

Toilets, washbasins and showers are not in the same room or

not in view of inmate dining

X

Visiting (2.18)

X

Sufficient visiting area

Contact visits whenever possible for minimum security

inmates

X

Attorney Interviews (2.26)

Provide for confidential attorney consultation

X

Safety Equipment Storage (2.19)

Adequate space is provided for storage of equipment such as X fire extinguishers, SCBA, emergency lights, etc.

Janitor Closet (2.20)

Located in security areas lockable, containing a mop sink

X

and storage space

Storage Rooms (2.21)

Sufficient space to accommodate inmate property, bedding

X

and supplies

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#:17466

TITLE 24 SECTION

YES NO N/A

COMMENTS

Audio or Video Monitoring System -NA Type IV (2.22)

Audio monitoring system capable of alerting staff in a

X

central control

Video monitoring in corridors, main entries and/or exits and

programs or activity areas

X

Fire Detection and Alarm System [102(c)6]

Automatic fire alarm system capable of alerting staff in a

X

central control point

Emergency Power (2.24)

Available to provide minimal lighting, maintain

X

communications, alarm, fire, life and security systems

Provide Space for:

Barber/beauty shop(2.15)

X

8-86: Limit requirement to Type II and III facilities

99: Requirement deleted

Canteen (2.16) 8-86: Added for II, III & IV facilities

X

Confidential Interview Rooms (2.25)

8-86: Added for Type II facilities

X

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 237 of 343 STATE CORRECTIONS STANDAR#D:1S7A4U6T7HORITY - BIENNIAL INSPECTION
ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION

Page ID

BSCC Code: 3930

FACILITY: Cois Byrd Detention Center

TYPE: II

BRC: 1142

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/19/2019

Cell

Location

Type

Receiving Area

ROOMS Applicable # Standards Cells

A-1008

Detox 1

1988

1

A-1010

Detox 2

1988

1

A-1064-#4 Detox

1988

1

A-1065-#3 Detox

1988

1

A-1004-#1 Safety

1988

1

A-1005-#2 Safety

1988

1

A-1062-#4 Safety

1988

1

A-1063-#3 Safety

1988

1

Intake medical Screen

A1018

Medical

1988

1

Offices

A-1066 (F)

S/A

1988

1

Notes: Hot and cold running water.

1013-Cell-1 Holding

1988

1

1014-Cell-2 Holding

1988

1

1015-Cell 3 Holding

1988

1

1016-Cell-4 Holding

1988

1

1017-Cell-5 Holding

1988

1

Notes: Handicap accessible.

1019-Cell-6 Holding

1988

1

1020-Cell-7 Holding

1988

1

1028-Cell-8 Holding

1988

1

1029-Cell-9 Holding

1988

1

R-

1988

1

1041-Cell-10 Holding

R-

1988

1

1042-Cell-9 Holding

R-

1988

1

1068-Cell-3 Holding

R-

1988

1

1069-Cell-2 Holding

R-

1988

1

1070-Cell-1 Holding

1072-Cell-12 R-Hold

1988

1

EACH CELL # Beds RC
(1) (8) (4) (4) (1) (1) (1) (1)
(6) (6) (6) (6) (8)
(6) (8) (8) (16) (4)
(4)
(6)
(6)
(9)
(3)

Total RC
(1) (8) (4) (4) (1) (1) (1) (1)

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

15.0 X 11.0 X 8.0 1 16.5 X 10.0 X 8.0 1 10.0 X 8.5 X 8.0 1 10.0 X 8.5 X 8.0 1
8.0 X 6.0 X 8.0 1 8.0 X 6.0 X 8.0 1 10.0 X 6.0 X 8.0 1 10.0 X 6.0 X 8.0 1

1 1 1 1 1 1 1 1

15.0 X 10.0 X 8.0 15.0 X 10.0 X 8.0

(6)

120.0 X 18.0 X 8.0 1

(6)

120.0 X 18.0 X 8.0 1

(6)

120.0 X 18.0 X 8.0 1

(6)

120.0 X 18.0 X 8.0 1

(8)

120.0 X 18.0 X 8.0 1

1 1 1 1 1 1 1 1 1 1

(6)

10.0 X 6.5 X 8.0 1

(8)

10.0 X 8.5 X 8.0 1

(8)

10.0 X 9.0 X 8.0 1

(16)

17.5 X 10.6 X 8.0 1

(4)

8.7 X 6.0 X 8.0 1

(4)

9.8 X 8.8 X 8.0 1

(6)

10.0 X 6.7 X 8.0 1

(6)

10.0 X 6.5 X 8.0 1

(9)

10.3 X 10.0 X 8.0 1

(3)

8.3 X 8.0 X 8.0 1

1 1 1 1 1 1 1 1 1 1
1 1
1 1
1 1
1 1
1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ROOMS

#:17468

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UW F S

R-

1988

1

1073-Cell-11 Holding

(3)

(3)

14.0 X 8.0 X 8.0 1

1 1

All Cell numbers reviewed during the 2008-2010 inspection cycle to clarify location, MW2009

Transportation Area

1090-Cell-7 Holding

1988

1

1091-Cell-6 Holding

1988

1

1092-Cell-5 Holding

1988

1

1093-Cell-4 Holding

1988

1

1094-Cell-3 Holding

1988

1

1095-Cell-2 Holding

1988

1

1096-Cell-1 Holding

1988

1

1102-Cell-8 Holding

1988

1

1103-Cell-9 Holding

1988

1

1104-Cell-10 Holding

1988

1

1105-Cell-11 Holding

1988

1

1106-Cell-12 Holding

1988

1

1107-Cell-13 Holding

1988

1

Pod B-Ad-Seg. Each Pod has its own yard.

Ground Level

Day 1

Double

1988

16

Mezzanine Level

Day 1

Double

1988

16

Ground Level

Day 2

Single

1988

8

Mezzanine Level

Day 2

Single

1988

8

Notes: Day 2 housing for Ad Seg.

Ground Level

Day 3

Single

1988

8

Mezzanine Level

Day 3

Single

1988

8

Notes: Day 3 housing for Ad Seg.

Ground Level

Day 4

Double

1988

16

Mezzanine Level

Day 4

Double

1988

16

Pod C

Ground Level

Day 1

Double

1988

16

(8)

(8)

11.0 X 8.0 X 8.0 1

(16)

(16)

16.5 X 10.0 X 8.0 1

(8)

(8)

10.5 X 8.5 8.0

1

(8)

(8)

10.5 X 8.5 8.0

1

(8)

(8)

10.5 X 8.5 8.0

1

(8)

(8)

10.5 X 8.5 8.0

1

(8)

(8)

10.5 X 8.5 8.0

1

(16)

(16)

20.3 X 8.3 X 8.0 1

(16)

(16)

20.3 X 8.3 X 8.0 1

(16)

(16)

20.3 X 8.3 X 8.0 1

(16)

(16)

20.3 X 8.3 X 8.0 1

(16)

(16)

20.3 X 8.3 X 8.0 1

(16)

(16)

20.3 X 8.3 X 8.0 1

2

2

2

2

2

2

2

2

32

12.5 X 6.0 X 8.0 1

32

12.5 X 6.0 X 8.0 1

16

12.5 X 6.0 X 8.0 1

16

12.5 X 6.0 X 8.0 1

2

2

2

2

16

12.5 X 6.0 X 8.0 1

16

12.5 X 6.0 X 8.0 1

2

2

2

2

32

12.5 X 6.0 X 8.0 1

32

12.5 X 6.0 X 8.0 1

2

2

32

12.5 X 6.0 X 8.0 1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1 2
1 1 2
1 1
1 1
1 1
1 1
1 1 2
1 1 2
1 1 2

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Mezzanine Level

#:17469

Day 1

Double

1988

16

2

2

32

12.5 X 6.0 X 8.0 1

1 1 2

Ground Level

Day 2

Single

1988

8

2

2

16

12.5 X 6.0 X 8.0 1

1 1 1

Mezzanine Level

Day 2

Single

1988

8

2

2

16

12.5 X 6.0 X 8.0 1

1 1 1

Notes: Day 2 housing for Ad Seg.

Ground Level

Day 3

Double

1988

8

2

2

16

12.5 X 6.0 X 8.0 1

1 1 1

Mezzanine Level

Day 3

Double

1988

8

2

2

16

12.5 X 6.0 X 8.0 1

1 1 1

Ground Level

Day 4

Dorm

1988

1

40

40

40

See Notes

4

4 4 2

Mezzanine Level

Day 4

Dorm

1988

1

24

24

24

See Notes

4

4 4 2

Notes: Dayroom and Dorms have a total square footage of 5,067.

Pod D – open dayrooms

Ground Level

Day 1

Double

1988

16

2

2

32

12.5 X 6.0 X 8.0 1

1 1 2

Mezzanine Level

Day 1

Double

1988

16

2

2

32

12.5 X 6.0 X 8.0 1

1 1 2

Ground Level

Day 2

Double

1988

8

2

2

16

12.5 X 6.0 X 8.0 1

1 1 1

Mezzanine Level

Day 2

Double

1988

8

2

2

16

12.5 X 6.0 X 8.0 1

1 1 1

Ground Level

Day 3

Double

1988

8

2

2

16

12.5 X 6.0 X 8.0 1

1 1 1

Mezzanine Level

Day 3

Double

1988

8

2

2

16

12.5 X 6.0 X 8.0 1

1 1 1

Ground Level

Day 4

Dorm

1988

1

40

40

40

See Notes

4

4 4 2

Mezzanine Level

Day 4

Dorm

1988

1

24

24

24

See Notes

4

4 4 2

Notes: Dayroom and Dorms have a total square footage of 5,067.

Pod E-

Disc. cells Double

1994

(2)

(1)

(1)

(2)

6’1 X 12.8 X 8

1

1 1

NOTE: Located in hallway of the Pod

Ground Level

Day 1

Double

1994

16

2

2

32

12.10 X 6.1 X 8.5 1

1 1 2

Mezzanine Level

Day 1

Double

1994

16

2

2

32

12.10 X 6.1 X 8.5 1

1 1 2

Notes: Day 2 has 8 tables with 64 seats.

Ground Level

Day 2

Double

1994

8

2

2

16

12.10 X 6.1 X 8.5 1

1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Mezzanine Level

#:17470

Day 2

Double

1994

8

2

2

16

12.10 X 6.1 X 8.5 1

1 1

Notes: Day 2 has 4 tables with 32 seats

Ground Level

Day 3

Double

1994

7

2

2

14

12.10 X 6.10 X 8.5 1

1 1

Mezzanine Level

Day 3

Double

1994

7

2

2

14

12.10 X 6.10 X 8.5 1

1 1

Notes: Day 3 has a handicapped shower and the 7 ground level rooms are designated as ADA cells. Day 3 has 3 tables with 8 seats and 1 table with 4 seats.

Ground Level

Day 4

Double

1994

15

2

2

30

12.10 X 6.1 X 8.5 1

1 1 2

Mezzanine Level

Day 4

Double

1994

16

2

2

32

12.10 X 6.1 X 8.5 1

1 1 2

Notes: The (16) VOIG cells are located in Day 4 and are # 63, 65, 67, 69, 71, 73, 75, 77, 79, 81, 83, 85, 87, 89, 91, and 93. Double bunking of single cells completed in November 2003.

POD F

Ground Level

Day 1

Double

1994

16

2

2

32

12.10 X 6.1 X 8.5 1

1 1 2

Mezzanine Level

Day 1

Double

1994

16

2

2

32

12.10 X 6.1 X 8.5 1

1 1 2

Notes: Day 1 has 8 tables and 64 seats.

Ground Level

Day 2

Double

1994

8

2

2

16

12.10 X 6.1 X 8.5 1

1 1

Mezzanine Level

Day 2

Double

1994

8

2

2

16

12.10 X 6.1 X 8.5 1

1 1

Notes: Day 2 has 4 tables and 32 seats.

Ground Level

Day 3

Double

1994

8

2

2

16

12.10 X 6.1 X 8.5 1

1 1

Mezzanine Level

Day 3

Double

1994

8

2

2

16

12.10 X 6.1 X 8.5 1

1 1

Notes: Day 3 has 4 tables and 32 seats.

Ground Level

Day 4

Double

1994

16

2

2

32

12.10 X 6.1 X 8.5 1

1 1 2

Mezzanine Level

Day 4

Double

1994

16

2

2

32

12.10 X 6.1 X 8.5 1

1 1 2

Notes: Day 4 has 8 tables and 64 seats.

POD G

Ground Level

Day 1

Double

1994

16

2

2

32

12.10 X 6.1 X 8.5 1

1 1 2

Mezzanine Level

Day 1

Double

1994

16

2

2

32

12.10 X 6.1 X 8.5 1

1 1 2

Notes: Day 1 has 8 tables and 64 seats.

Ground Level

Day 2

Double

1994

7

2

2

14

12.9 X 6.11 X 8.5 1

1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Mezzanine Level

#:17471

Day 2

Double

1994

7

2

2

14

12.9 X 6.11 X 8.5 1

1 1

Notes: Day 2 has a handicap shower and the 7 ground level rooms are designated as ADA cells. Day 2 has 3 tables with 8 seats and 1 table with 4 seats.

Ground Level

Day 3

Double

1994

8

2

2

16

12.10 X 6.1 X 8.5 1

1 1

Mezzanine Level

Day 3

Double

1994

8

2

2

16

12.10 X 6.1 X 8.5 1

1 1

Notes: Day 3 has 4 tables and 32 seats.

Ground Level

Day 4

Double

1994

16

2

2

32

12.11 X 6.2 X 8.5 1

1 1 2

Mezzanine Level

Day 4

Double

1994

16

2

2

32

12.11 X 6.2 X 8.5 1

1 1 2

Notes: Day 4 has 8 tables and 64 seats.

INFIRMARY

A-2054

Holding

1988

1

(6)

(6)

10.3 X 9.5 X 8.0 1

1 1

A-2055

Holding

1988

1

(5)

(5)

10.5 X 9.5 X 8.0 1

1 1

2079-Cell 10 Holding

1988

1

(5)

(5)

10.5 X 9.5 X 8.0 1

1 1

2080-Cell 9 Ward

1988

1

4

(4)

(4)

22.3 X 15.5 X 8.0 1

1 1 1

2081-Cell 8 Single

1988

1

1

(1)

(1)

15.5 X 8.5 X 8.0 1

1 1

2082-Cell 7 Single

1988

1

1

(1)

(1)

15.5 X 8.5 X 8.0 1

1 1 1

2083-Cell 6 Single

1988

1

1

(1)

(1)

15.5 X 9.0 X 8.0 1

1 1 1

2084-Cell 5 Mental

1988

1

1

(1)

(1)

15.5 X 8.7 X 8.0 1

1 1 1

2085-Cell 4 Mental

1988

1

1

(1)

(1)

15.5 X 8.5 X 8.0 1

1 1 1

2086-Cell 3 Mental

1988

1

1

(1)

(1)

15.5 X 9.0 X 8.0 1

1 1 1

2087-Cell 2 Mental

1988

1

1

(1)

(1)

15.5 X 11.6 X 8.0 1

1 1 1

2088-Cell 1 Mental

1988

1

1

(1)

(1)

15.5 X 11.6 X 8.0 1

1 1 1

A-2069

Exam

1988

1

2

(2)

(2)

9.8 X 12.0 X 8.0

Court Holding – Custody

Cell 1

Holding

1999

1

(2)

(2)

9’9” x 6’8” x 8’3” 1

1 1

Note: Seating Capacity 48”

Cell 2

Holding

1999

1

(1)

(1)

8’ x 10’ x 8’3”

1

1 1

Note: Seating Capacity 28”

Cell 3

Holding

1999

1

(2)

(2)

8’1” x 6’8” x 8’3” 1

1 1

Note: Seating Capacity 53”

Cell 4

Holding

1999

1

(1)

(1)

10’ x 6’8” x 8’3” 1

1 1

Note: Seating Capacity 28”

Cell 5

Holding

1999

1

(16)

(16)

15’5” x 15’1” x 8’3” 1

1 1

Note: Seating Capacity 351”

Cell 6

Holding

1999

1

(16)

(16)

21’9” x 13’6” x 8’3” 1

1 1

Note: Seating Capacity 336”

Cell 7

Holding

1999

1

(16)

(16)

19’6” x 11’4” x 8’3” 1

1 1

Note: Seating Capacity 317”

Cell 8

Holding

1999

1

(16)

(16)

19’1” x 11’4” x 8’3” 1

1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Note: Seating Capacity 321”

#:17472

Cell 9

Holding

1999

1

(7)

(7)

17’7” x 13’ x 8’3” 1

1 1

Note: Seating Capacity 135’

Cell 10

Holding

1999

1

(15)

(15)

13” x 12’6” x 8’3” 1

1 1

Note: Seating Capacity 286”

Cell 11

Holding

1999

1

(8)

(8)

16’3” x 6’8” x 8’3” 1

1 1

Note: Seating Capacity 148”

Cell 12

Holding

1999

1

(8)

(8)

15’11” x 8’ x 8’3” 1

1 1

Note: Seating Capacity 156”

Cell 13

Holding

1999

1

(9)

(9)

15’3” x 8’8” x 8’3” 1

1 1

Note: Seating Capacity 177”

Cell 14

Holding

1999

1

(3)

(3)

7’5” x 12’3” x 8’3” 1

1 1

Note: Seating Capacity 68”

Cell 15

Holding

1999

1

(2)

(2)

8’4” x 6’8” x 8’3” 1

1 1

Note: Seating Capacity 40”

Cell 16

Holding

1999

1

(2)

(2)

7’4” x 6’8” x 8’3” 1

1 1

Note: Seating Capacity 40”

Cell 17

Holding

1999

1

(3)

(3)

7’4” X 9’11” X 8’3” 1

1 1

Note: Seating Capacity 80”

Cell 18

Holding

1999

1

(9)

(9)

11’4” X 11’4” X 8’3” 1

1 1

Note: Seating Capacity 174”

Cell 19

Holding

1999

1

(1)

(1)

10’3” X 9’ X 8’3” 1

1 1

Note: Seating Capacity 18”

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 243 of 343 #:17473
ADULT TYPE I, II, III AND IV FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community Corrections

Page ID

FACILITY NAME: Blythe Jail

APPLICABLE TITLE 24 REGULATIONS: 6/94; 2/99; 2001

BSCC Code: 3940

FACILITY TYPE: II

APPLICABLE REGULATIONS (Check All That Apply): FIELD REPRESENTATIVE: Michael J. Bush

6/94: X

2/99:

TITLE 24 SECTION Reception and Booking (2.1)

YES NO N/A X

2001: X OTHER: 1963 DATE: 09/19/2019
COMMENTS

Contains a weapons locker, designed as outlined in these regulations.

Contains a cell or room for confinement pending booking

X

Contains a detoxification cell, where applicable

X

01: Name change to “sobering cell.”

2-99: Two detoxification cells are provided if both male and female inmates are held.

Contains safety cell(s) (WA)

X

Shower room available

X

2-99: Access to shower must be within the secure area

Provides secure vault or storage for inmate valuables

X

Telephone(s) available for inmate use (PC § 851.5)

X

2-99: Unobstructed access to hot and cold running water

X

Temporary Holding Cell or Room (2.2)

Contains 10 square feet of floor area per inmate Temporary Staging Cell or Room (2.3)

Holds inmates classified and segregated per Title 15 § 1050 and 1053

Detoxification/Sobering Cell (2.4)

X

01: Name change to “sobering cell.”

Contains 20 square feet of floor area per inmate

Is limited to no more than 8 inmates

X

Is no smaller than 60 square feet and has a clear ceiling

X

height of 8 feet or more

Contains a water closet (toilet) wash basin and drinking

X

fountain as specified by these regulations

Has padded partitions located next to toilet fixtures

X

Provides for clear visual supervision by staff

X

Padding on floor

X

Safety Cell (2.5)

X One pre-booking holding; not rated. Remainder of the regulation was removed
X No cell of this type, remainder of regulation was removed One cell under 1963 Standards and the other is under the 1994 Standards.
X No safety cell, remainder of regulation deleted

Contains 48 square feet with one floor dimension of a least 6 feet and a clear ceiling height of 8 feet or more

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Case 5:13-cv-00444-VAP-OP
TITLE 24 SECTION Single Occupancy Cells (2.6)

Document 178-2 Filed 04/06/20 Page 244 of 343 Page ID

#:17474
YES NO N/A

COMMENTS

X

Two inmates were occupying single cell D-1 – D-

3.

Maximum capacity of one inmate

3 single cells in old portion of jail (1963 Standards), the remainder of single cells are under the 1994 Standards.

Contain a minimum of 60 square feet of floor area in Type I X facilities and 70 square feet in Type II and III facilities

Have a minimum clear ceiling height of 8 feet and a

X

minimum width of 6 feet

Contain a water closet (toilet), washbasin and drinking

X

fountain

Contain a bunk, desk and seat (Desk and seat not required in X Type I facilities.)

Multiple Occupancy Cells (8227) 8-86: Deleted provision for multiple occupancy cells

X

Housing unit E exceeded the rated capacity.

Contain 35 square feet per person

Limited to no more than 8 inmates

X

No smaller than 100 square feet

X

Minimum ceiling height of 8 feet

X

Water closet separate from washbasin and drinking fountain X

Sufficient bunks to accommodate each occupant

X

Provide storage space for each occupant's personal items

X

Double Occupancy Cells (2.7)

X

New addition is under the 1994 Standards

Maximum capacity of two inmates

Contain a minimum of 60 square feet of floor area in Type I X facilities and 70 square feet in Type II and III facilities

Have a minimum clear ceiling height of 8 feet and a

X

minimum width of 6 feet

Contain a water closet (toilet), washbasin and drinking

X

fountain

Contain 2 bunks, 1 desk and 1 seat (Desk and seat not

X

required in Type I facilities.)

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TITLE 24 SECTION

#:17475
YES NO N/A

COMMENTS

Dormitories (2.8)

X

Dormitory “A” continues to exceed the rated

(Note: 2001 regulations reduced the double bunk

capacity.

requirement from 75 to 70 square feet and added provision

for triple bunks. This is the “least restrictive standard.”)

Contain at least 50 square feet of floor area per inmate for single bed units; at least 70 square feet of floor space per inmate for double bed units; and, at least 90 square feet for triple bed units. Eight foot clear ceiling height required.

(To calculate double bunked BRC: 70 square feet divided by 2 inmates = 35 square feet + 35 square feet dayroom = 70 square feet per inmate. To calculate triple bunked BRC: 90 square feet divided by 3 inmates=30 square feet + 35 square feet dayroom=65 square feet per inmate.)

Designed for no fewer than 4 and no more than 64 inmates

X

Provide access to toilets separate from washbasins and

X

drinking fountains

Provide storage space for each inmate's personal items (NA

X

Type I)

Dayrooms (2.9)

X

Required for inmates in Type II and III facilities - excluding "special use" cells - and inmate workers in Type I facilities) Contain 35 square feet of floor area per inmate, exclusive of 3 foot wide corridors in front of cells/rooms 2-99: Deleted 3 foot corridor in front of cells/rooms
Contain tables and seating to accommodate the maximum number of inmates allowed access at a given time. (Note 2001 revisions added reference to access at a given time and are the least restrictive standard.)

X

Although Dormitory “A” was remodeled and the

capacity was lowered to 44, the Rated Capacity is

24; does not meet this standard. It’s important to

note that the remodel definitely improved conditions in the housing area and the ability to supervise the inmates has increased tremendously.

X

Exercise Area (2.10)

X

Provided in Type II and III facilities. Type IV facilities must have a recreation area or provide community access to one.

Clear height of 15 feet

X

Has required surface area: 80% of maximum rated inmate

X

capacity, multiplied by 50 square feet, divided by number of

one-hour exercise periods per day, equals the required

surface area.

2-99: Provides free access to a toilet, washbasin and

X

drinking fountain

Provides adequate security

X

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Case 5:13-cv-00444-VAP-OP
TITLE 24 SECTION Program/Multipurpose Space (2.11) (NA Type I)

Document 178-2 Filed 04/06/20 #:17476
YES NO N/A
X

Page 246 of 343 Page ID
COMMENTS

There is sufficient area and furnishings to meet the needs of the facility programs. (See regulation for discussion of applicability to Type IV.)

Medical Examination Room (2.12)

X

There is one suitably equipped medical exam room in every Type II or III facility designed to house 25 or more inmates.

2-99: Required in all facilities that provide on-site health care.

Located within the security area and provide for privacy of

X

inmates

Not less than 100 square feet of floor space with no single

X

dimension less than 7 feet

Provide hot and cold running water

X

2-99: Hot and cold running water in any room where medical procedures are provided

2-99: Lockable storage for medical supplies

X

Pharmaceutical Storage Space (2.13)

X

There is lockable storage space for medical supplies and pharmaceuticals (Title 15 § 1216).

Medical Care Housing (2.14)
Applicable to Type II and III facilities where the facility program indicates special medical care housing is needed. Housing is located within the security area, accessible to both male and female inmates, but not in the living area of either. Provides lockable storage area for medical instruments 2-99: Negative pressure isolation rooms are designed to the
community standard.

X Inmates with medical housing needs are transferred to the Indio Jail or Robert Presley Detention Center.
X
X X

Hair Care Space (2.15)

X

Space and equipment are available. 2-99: Requirement deleted.

Commissary (2.16) (NA Type I)

X

Inmates can purchase specified items.

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#:17477

TITLE 24 SECTION

YES NO N/A

There is secure storage for commissary stock.

X

01: Revisions limit requirement for secure storage to

circumstances when commissary supplies are kept

within the security perimeter.

Page 247 of 343 Page ID
COMMENTS

Dining Facilities (2.17) (NA Type I)

X

There are 15 square feet and sufficient tables and seating for each inmate being fed.

Dining space does not include toilets, washbasins or

X

showers, without an appropriate visual barrier.

2-99: Visual barrier requirement deleted for washbasins

Visiting Space (2.18)

X

There is sufficient visiting area.

Safety Equipment Storage (2.19)

X

Adequate space is provided to store equipment such as fire extinguishers, SCBA, emergency lights, etc.

Janitors' Closet (2.20)

X

A securely lockable janitors’ closet provides sufficient storage for cleaning implements and supplies and is located within the security area (Type II only).
A mop sink is available within the security area (Type II). It X may be outside the security area in CH, TH and, Types I, III & IV.

Audio or Visual Monitoring (2.22)

X

(NA Type III and IV housing only minimum security

inmates)

There is an audio monitoring system capable of alerting staff in a central control. When visual electronic surveillance is used, it is located primarily in corridors, elevators, or at points on the security perimeter such as entrances and exits.
2-99: Video monitoring option deleted.

Laundry Facilities (2.23)

X

Type IV facilities make provision for washing and drying personal laundry.

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TITLE 24 SECTION

#:17478
YES NO N/A

COMMENTS

Emergency Power (2.24)

X

There is an emergency power source available and capable of providing minimal lighting in all areas and maintaining fire and life safety, security, communication and alarm systems.

Confidential Interview Rooms (2.25)

X

There is at least one suitably furnished confidential interview room in every Type II facility designed for 25 or more inmates.

2-99: Applicable to every facility which provides on-site health care

Located in the security area, accessible by both male and

X

female inmates

Provides at least 70 square feet floor area with no single

X

dimension less than 6 feet

Attorney Interview Space (2.26)

X

(NA Type IV)

Available and provides for confidentiality

Water Closets (Toilets)/Urinals (3.1)

X

Provide for inmate privacy/modesty with staff being able to visually supervise; one is provided in every single and double occupancy cell and at the following ratio elsewhere:
1:10 in dormitories (changed from 1:8 in 2001); 1:8 in detoxification/sobering cells; 1:16 in holding cells; 1:20 in exercise areas; and, Accessible to dayroom occupants no specified ratio. 2-99: Accessible at no specified ratio in exercise areas See regulation for calculations of urinal substitutions.

Washbasins (3.2)

X

Provide hot and cold or tempered water; one is provided in every single and double occupancy cell and at the following ratio elsewhere:
1:10 in dormitories (changed from 1:8 in 2001); 1:8 in detoxification/sobering cells; 1:20 in exercise areas; and, Accessible to dayrooms at no specified ratio. 2-99: Accessible in exercise areas at no specified ratio See regulation for calculations of washbasin trough substitutions.

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TITLE 24 SECTION

#:17479
YES NO N/A

COMMENTS

Drinking Fountains (3.3)

X

One is provided in every single and double occupancy cell and in dormitories. Accessible to inmates in dayrooms
2-99: One is provided in every single and double occupancy cell, holding and staging cells and detoxification cells. It must be accessible to inmates in dayrooms and exercise areas.

The water outlet (bubbler) is mechanically actuated and at

X

an angle that prevents wastewater from flowing over the

outlet (bubbler). There is a mouth guard on the water outlet.

2-99: Mouth guard requirement deleted

Showers (3.4)

X

Available at a ratio of 1:20; provide hot and cold or tempered water; shower stalls/areas are designed and constructed of materials that are impervious to water and soap so that they may be easily cleaned.
2-99: Ratio changed from 1:16; specified that shower areas must provide modesty for inmates, with staff ability to supervise.

Beds/Bunks (3.5)

X

At least 30 inches wide and 76 inches long with 21 inches between pans; constructed of pan bottom type or concrete; securely fastened to the floor and/or wall in facilities higher than minimum security.
01: Must be elevated off the floor.

Lighting (3.6)

X

Lighting in housing units, dayrooms and activity areas is sufficient to permit easy reading by a person with normal vision, and is not less than 20 foot-candles at desk level and in the grooming area. Night lighting is sufficient for purposes of supervision.

Lighting is centrally controlled and/or occupant controlled in housing cells or rooms. Light fixtures are of secure design in areas higher than minimum security.

Windows (3.7)

X

In housing areas higher than minimum security, windows that are accessible to inmates are no greater than 5 inches in one dimension.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 250 of 343 Page ID

TITLE 24 SECTION

#:17480
YES NO N/A

COMMENTS

Cell Padding (3.8)

X

The floors and partition are padded in detoxification cells. In safety cells, floors, doors, walls and everything on them are padded. All padded cells are equipped with a tamper resistant fire sprinkler approved by the SFM.

All padding is: approved for use by the SFM; nonporous; at X least ½ inch thick; of a unitary or laminated construction; firmly bonded to all surfaces; and, without exposed seams.

Mirrors/Shelves/Clothes Hooks (3.9)

X

A mirror of a material appropriate to the level of security is provided near each washbasin.

Consistent with security needs, shelves and clothes hooks

X

are provided wherever feasible.

2-99: Requirement for shelves and hooks deleted

Clothes hooks are of a collapsible hook type

X

2-99: Requirement for hooks deleted

Seating (3.10)

X

Seating is designed to the level of security. When bench seating is used, eighteen inches of bench are provided per inmate.
2-99: In holding and staging cells, seating is securely fastened to the wall and/or floor.

Table/Seat (3.11) (NA Type I)

X

A table and seat is provided in single and double occupancy cells.

Weapons Locker (3.12)

X

(NA type IV and Minimum Security Facilities)

A secure weapons locker is located outside the security perimeter of the facility and no weapons are brought into the security area. Lockers have individual compartments, locks and keys.

Design Requirements (102(c)6)

X

Design requirements as specified in Title 24, Part 1, 102(c)6 are met. (See regulation for specific requirements. Note areas of non-compliance that are applicable to the facility type and construction date in the "comments" section.)

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 251 of 343 BOARD OF STATE AND COMMUNI#T:1Y7C4O8R1RECTION - BIENNIAL INSPECTION
ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION

Page ID

BSCC Code: 3940

FACILITY: Blythe Jail

TYPE: II

RC: 79

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/19/2019

Location Station

Cell Type Holding

ROOMS

Applicable #

Standards Cells

1963

1

EACH CELL # Beds RC
(0)

Total RC (0)

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

5.0 x 4.0

Detox

1994

1

(3)

(3)

6.8 x 10

1

1 1

Detox

1963

1

(7)

(7)

8.0 x 13.5 x 10.0 1

1 1

NOTES: Holding cell is not rated. New detox cell in place. Both detox cells are padded.

“E” (Male) Multiple

1963

2

6

2

4

10.0 x 12.8 x 10.0 2

2 2 2

“B” (Inmate Dorm

1963

1

9

6

Workers)

6

12.0 x 10.0 x 10.0 1

1 1 1

NOTES: As the door is normally left open, the cell has adequate space. Tank E does not have enough square footage per bunk (70 square ft) to meet a dormitory requirement in order to increase rated capacity.

D 1-3

Single

1963

3

2

1

3

6.8 x 10.0 x 10.0 4

4 4

C 1-3

Multiple

1963

3

8

7

22

10.5 x 18.8 x 10.0 5 1 5 5 2

Dayroom

23.0 x 21.0 x 10.0

NOTE: Single cells in this area are reduced by one. One cell had the bunk removed and the floor padded to convert to a detox cell. Multiple cell rated for 22 inmates; Housing 24.

“A” Sentenced

Dorm

1963

1

44

24

24

38.5 x 33.5 x 10.0 4 2 3 3 3

NOTES: Recommend replacement of old wash basins. This dorm is over RC, 1/09; MW.

New Addition – VOIG – 1998

NEW ADDITION

“F” 1-6 Double

1994

6

2

2

12

7.2 x 10.8

1

1 1

“F” 7,8,9 Single

1994

3

2

2

6

7.2 x 10.8

1

1 1

“F” 10

Single

1994

1

2

1

1

12.5 x 9

1

1 1

NOTE: #10 cell is handicap accessible. 2 showers

Dayroom – Sufficient for 16 inmates. Tanks – seating not in place – Next on-site.

Review audio monitoring system, locks and furnished cells. 1,100 square feet.

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 252 of 343 #:17482
ADULT TYPE I, II, III AND IV FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community corrections

Page ID

FACILITY NAME: Indio Jail

Applicable Title 24 Regulations: 3/80; 8/86; 5/88; 1/91

BSCC Code: 3960

FACILITY TYPE: II

APPLICABLE REGULATIONS (Check All That Apply): FIELD REPRESENTATIVE: Michael J. Bush

3/80: X

8/86:

5/88:

1/91:
DATE: 09/23/2019

OTHER: 1963

TITLE 24 SECTION Temporary Holding Cells (2.2)
Contain 10 square feet of floor per inmate Limited to no more than 16 inmates No smaller than 40 square feet Contain sufficient seating to accommodate all inmates Toilet accessible Water fountain accessible Wash basin accessible Provides clear visual supervision Telephone accessible
Weapons Locker (3.12)
External to the security area and equipped with individual compartments, locks and keys

YES NO N/A
X
X X X X X X X X
X

COMMENTS

Temporary Staging Cell or Room (2.3)

1-91: Added provision for temporary staging cells-rooms

Holds inmates classified and segregated per Title 15 § 1050 and § 1053 Detoxification/Sobering Cells (2.4)

01: Name change to “sobering cell”

X

Contain 20 square feet of floor per inmate

Limited to no more than 8 inmates

X

No smaller than 60 square feet

X

Contain toilet

X

Contain washbasin

X

Contain drinking fountain

X

Partitions or handrails located next to toilet fixture to provide support

X

Provide easy, unobstructed visual observation

X

Padding on the floor

X

Shower-Delousing Room (3.4)

Available in reception/booking

X

No cell of this type, remainder of the regulation has been removed.
X

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#:17483

TITLE 24 SECTION

YES NO N/A

COMMENTS

Secure Vault or Storage Space (2.1)

Available for inmate valuables

X

Telephone (2.1)

Available for inmate use per Penal Code § 851.5

X

Safety Cells (2.5)

Contain 48 square feet with one floor dimension at least 6

X

feet and ceiling height of at least 8 feet

Limited to no more than one inmate

X

Contain flush ring toilet with controls located outside the cell X

Padded floor, door and walls

X

Equipped with variable intensity, security light, inaccessible to occupant

X

Vertical view panel not more than 4 inches wide and at least 24 inches long, in or adjacent to the door

X

Provide a food pass with lockable shutter no more than 4

inches high and located at least 30 inches above the floor

X

Single Occupancy Cells (2.6)

X

Maximum capacity of one inmate

Contain a minimum of 60 square feet of floor area in Type I facilities and 70 square feet in Type II and III facilities

X

Have a minimum ceiling height of 8 feet

X

Contain toilet, washbasin and drinking fountain

X

Contain a bunk, desk and seat (Desk and seat not required in

Type I in later, less restrictive 1986 standards)

X

Multiple Occupancy Cells (8227) 8-86: Deleted provision for multiple occupancy cells
Contain 35 square feet per person Multiple Occupancy Rooms (8229) 8-86: Deleted provision for multiple occupancy rooms
Limited to housing persons in Type III and IV facilities and workers in Type I and II facilities Contain 50 square feet of floor area per person and a minimum of 8 feet ceiling height Limited to no more than 16 persons Access to toilets separate from washbasins (ratio 1:8) and drinking fountains Provide storage space for each occupant's personal items
Double Occupancy Cells (2.7) 5-88: Added provision for double occupancy cells
Maximum capacity of two inmates Dormitories (2.8) 8-86: Provision for dormitories added
Contain 50 square feet of floor area per inmate and a minimum of 8 feet ceiling height
3960\Riverside Co\Indio Jail\18-20 PHY; 09/23/2019

X X X X X
X - 2 -

No cell of this type, remainder of the regulation X has been removed.
No cell of this type, remainder of the regulation X has been removed
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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20

#:17484

TITLE 24 SECTION

YES NO N/A

Be designed for no fewer than 8 and no more than 64 inmates

X

Facilities having a total rated capacity of 80 inmates or less, may design dormitories for no fewer than 4 inmates

X

Access to toilets separate from washbasins (ratio 1:8) and

drinking fountains

X

01: Ratio changed to 1:10

Provide storage space for each inmate’s personal items

X

Page 254 of 343 Page ID
COMMENTS

Dayrooms (2.9)

8-86: Added requirement for 3 foot wide corridors in front

X

of cells-rooms

99: Corridor requirement deleted

35 square feet of floor area per inmate

X

Contain tables and seating to accommodate the maximum number of inmates served

X

Access to toilets, washbasins and drinking fountains

X

Available to all inmates in Type II and III facilities

(excluding special use cells) and to workers in Type I facilities

X

Continue to exceed rated capacity Continue to exceed rated capacity
Continue to exceed rated capacity

Shower (3.4)

Continue to exceed rated capacity

Available on a ratio of 1:16

X

01: Ratio changed to 1:20

Lighting (3.6)

Sufficient to permit easy reading. Night lighting is sufficient

to allow good supervision.

X

8-86: Specifies at least 20 foot-candles at desk level and in

grooming areas, with night lighting not to exceed 5

foot-candles

Beds-Bunks (3.5)

30 inches wide and 76 inches long

X

Floor sleeper (portable beds) during the 20162018 inspection cycle.

Comfortable Living Environment [102(c)6]

A comfortable living environment is maintained through an

X

adequate heating and cooling system.

Exercise Area -Type II, III and WA IV (2.10)

At least one exercise area must contain a minimum of 900

X

square feet

8-86: Outdoor exercise area provided

X

8-86: Clear height of 15 feet with required surface area

meeting a formula of: 80% of maximum rated inmate population and number of one-hour exercise

X

periods per day = required surface area

Program Space - Type II and III (2.11)

Sufficient area and furnishings to meet the needs of the

X

facility programs

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#:17485

TITLE 24 SECTION

YES NO N/A

Dining Facilities (2.17)

X

15 square feet per inmate being fed

Toilets, washbasins and showers are not in the same room or

not in view of inmate dining

X

Page 255 of 343 Page ID
COMMENTS

Visiting (2.18)

X

Sufficient visiting area

Contact visits whenever possible for minimum security

inmates

X

Attorney Interviews (2.26)

Provide for confidential attorney consultation

X

Safety Equipment Storage (2.19)

Adequate space is provided for storage of equipment such as X fire extinguishers, SCBA, emergency lights, etc.

Janitor Closet (2.20)

Located in security areas lockable, containing a mop sink

X

and storage space

Storage Rooms (2.21)

Sufficient space to accommodate inmate property, bedding

X

and supplies

Audio or Video Monitoring System -NA Type IV (2.22)

Audio monitoring system capable of alerting staff in a

X

central control

Video monitoring in corridors, main entries and/or exits and

programs or activity areas

X

Fire Detection and Alarm System [102(c)6]

Automatic fire alarm system capable of alerting staff in a

X

central control point

Emergency Power (2.24)

Available to provide minimal lighting, maintain

X

communications, alarm, fire, life and security systems

Provide Space for:

Barber/beauty shop(2.15)

X

8-86: Limit requirement to Type II and III facilities

99: Requirement deleted

Canteen (2.16) 8-86: Added for II, III & IV facilities

X

Confidential Interview Rooms (2.25)

8-86: Added for Type II facilities

X

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 256 of 343 BOAD OF STATE AND COMMUNIT#Y:1C7O4R8R6ECTIONS - BIENNIAL INSPECTION
ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION

Page ID

BSCC Code: 3960

FACILITY: Indio Jail

TYPE: II

RC: 238

FIELD REPRESENTATIVE: Michael J. Bush

DATE:

ROOMS

Cell Applicable #

Location

Type Standards Cells

Old Court Holding Cells

EACH CELL # Beds RC

Total RC

09/23/2019

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

1

Holding

1963

1

(2)

(2)

9.5 X 4.0

1

1 1

2

Holding

1963

1

(5)

(5)

14.0 X 4.0

1

1 1

3

Holding

1963

1

(5)

(5)

13.0 X 4.0

1

1 1

4

Holding

1963

1

(3)

(3)

9.5 X 4.0

1

1 1

Addition to Intake:

1

Holding

1982

1

(6)

(6)

1

1 1

2

Holding

1982

1

(6)

(6)

1

1 1

3

Holding

1982

1

(8)

(8)

1

1 1

1

Safety

1982

1

(1)

(1)

6.0 X 8.0

2

Safety

1982

1

(1)

(1)

6.0 X 8.0

Male

Sobering

1982

1

(7)

(7)

1

1 1

Female Sobering

1982

1

(5)

(5)

1

1 1

Medical Observation:

1 - 4

Double

1982

4

4

(2)

(8)

15.0 X 7.5

1

1 1

5

Double

1982

1

2

(2)

(2)

11.3 X 10.4

1

1 1 1

Main Corridor:

Note: New shower added off of Main Corridor, male or female housing depending on need

Tank 1 Multiple

1963

3

8

8

24+ 15.5 X 60.0 X 11.2 5

5 5 2

Tank 2 Multiple

1963

3

8

8

24+ 15.5 X 60.0 X 11.2 5

5 5 2

Tank 4 Multiple

1963

3

8

8

24+ 15.5 X 60.0 X 11.2 5

5 5 2

Tank 5 Multiple

1963

3

8

8

24+ 15.5 X 60.0 X 11.2 5

5 5 2

Tank 3

Dorm

1963

1

21

16

16+ 20.0 X 30.0 X 11.2 2

2 2 1

6, 11, 12 Multiple

1963

3

21

10

30

28.0 X 23.4 X 11.2 3

3 3 1

7

Multiple

1963

1

21

10

10

28.0 X 23.4 X 11.2 3

3 3 1

10

Multiple

1963

1

16

10

10

28.0 X 23.4 X 11.2 2

3 3 1

8 (female Multiple

1982

1

3

2

overflow)

2

8.1 X 13.4 X 11.2 1

1 1 1

9

Multiple

1982

1

4

4

4

11.4 X 18.0 X 11.2 1

1 1 1

13

Dorm

1963

1

26

16

16+ 27.5 X 29.5 X 11.2 2

2 2 1

14

Dorm

1963

1

26

16

16

22.5 X 29.5 X 11.2 2

2 2 1

15 (females)

Dorm

1963

1

26

16

16

22.5 X 29.5 X 11.2 2

2 2 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 257 of 343 Page ID #:17487

Location 16

Cell Type Dorm

ROOMS

Applicable #

Standards Cells

1963

1

EACH CELL

# Beds RC

12

8

Total RC (8)

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

22.5 X 29.5 X 11.2 1

1 1 1

17

Multiple

1982

5

2

2

(10) 10.4 X 11.3 X 11.2 1

1 1 1

18 Ad Seg Single

1982

7

2

2

14

1

1 1

19 DI

Single

1992

4

1

(1)

(4)

1

1 1

Note: Overall dimension is 95 square feet; Unit 19 is designated as disciplinary isolation. Cells 1 and 2 are converted to negative pressure; however, the cells are still used for disciplinary isolation.

Ct. Holding in the Indio Jail

H1 -5

Holding

1992

5

(16)

(16)

See Note

2

2 2

Note: Overall dimension is 176 square feet.

H6

Holding

1992

1

(15)

(15)

See Note

2

2 2

Note: Overall dimension is 179 square feet.

H7

Holding

1992

1

(11)

(11)

See Note

2

2 2

Note: Overall dimension is 103 square feet.

H8

Holding

1992

1

(11)

(11)

See Note

2

2 2

Note: Overall dimension is 90 square feet.

H9

Holding

1992

1

(6)

(6)

See Note

2

2 2

Note: Overall dimension is 72 square feet.

H10

Holding

1992

1

(5)

(5)

See Note

2

2 2

H11 - 12 Holding

1992

2

(11)

(22)

See Note

2

2 2

Note: Overall dimension is 109 square feet.

Note: Overall dimension is 95 square feet. Rated capacity modified from 237 to 240 due to adding error of cells and beds, 2007MW. Number of cells and beds were reviewed this cycle, therefore the rated capacity has been adjusted, there are actually 10 medical beds in Tank 17 (we had listed 2 beds in 17), therefore overall we reduced the RC to 238 3/2013 MW.

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 #:17488
COURT HOLDING FACILITIES
Board of State and Community Corrections
PROCEDURES1

Page 258 of 343

Page ID

FACILITY NAME: Hall of Justice FACILITY NAME: Southwest Justice Center FACILITY NAME: Southwest Juvenile Center FACILITY NAME: Family Law Court FACILITY NAME: Larson justice Center FACILITY NAME: Banning Court FACILITY NAME: Blyth Court
FIELD REPRESENTATIVE: Michael J. Bush

Type: CH Type: CH Type: CH Type: CH Type: CH Type: CH Type: CH

BSCC #3916 BSCC #3935 BSCC #3937 BSCC #3950 BSCC #3970 BSCC #3974 BSCC #3975

DATE: 09/18/2019 DATE: 09/19/2019 DATE: 09/19/2019 DATE: 09/18/2019 DATE: 09/24/2019 DATE: 09/20/2019 DATE: 09/25/2019

1024

TITLE 15 SECTION
COURT HOLDING AND TEMPORARY HOLDING FACILITY TRAINING

YES NO N/A

P/P REFERENCE – COMMENTS

CSM 601.05

CDPM 503.06

Custodial personnel who supervise inmates in, and supervisors of, a Court Holding or Temporary Holding facility shall complete 8 hours of specialized training. Such training shall include, but not be limited to:

(a) applicable minimum jail standards;

(b) jail operations liability;

X

(c) inmate segregation;

(d) emergency procedures and planning, fire and life safety; and,

(e) suicide prevention.

Each agency shall determine if additional training is needed based upon, but not limited to, the complexity of the facility, the number of inmates, the employees' level of experience and training, and other relevant factors

Such training shall be completed as soon as practical, but in any event not more than six months after the date of assigned responsibility, or the effective date of this regulation. Successful completion of Core training or supplemental X Core training, pursuant to Section 1020, Corrections Officer Core Course, may be substituted for the initial eight hours of training.

Eight hours of refresher training shall be completed once

every two years. Successful completion of the requirements in Section 1025, Continuing Professional Training may be

X

substituted for the eight hour refresher.

Correctional deputies are responsible for inmates attending court proceedings. Deputies will deliver inmates via elevator to the receiving bailiff. Inmates will go directly into the courtroom. ☐ ☐ There are holding cells adjacent to the courtroom. They are only used for inmates to use the restroom or when there is a break during the proceedings. Inmates are only held for max 15-20 min.
☐ ☐
☐ ☐

1 This document is intended for use as a tool during the inspection process; this worksheet may not contain each Title 15 regulation that is required. Additionally, many regulations on this worksheet are SUMMARIES of the regulation; the text on this worksheet may not contain the entire text of the actual regulation. Please refer to the complete California Code of Regulations, Title 15, Minimum Standards for Local Facilities, Division 1, Chapter 1, Subchapter 4 for the complete list and text of regulations.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 259 of 343 Page ID

#:17489

TITLE 15 SECTION

YES NO N/A

P/P REFERENCE – COMMENTS

1027 NUMBER OF PERSONNEL

CDPM 501.20

A sufficient number of personnel shall be employed in each X local detention facility to ensure the implementation and operation of the programs and activities required by these regulations.

Whenever there is an inmate in custody, there shall be at least one employee on duty at all times in a local detention facility or in the building which houses a local detention X facility who shall be immediately available and accessible to inmates in the event of an emergency.

Such an employee shall not have any other duties which would conflict with the supervision and care of inmates in X the event of an emergency.

Whenever one or more female inmates are in custody, there

shall be at least one female employee who shall be immediately available and accessible to such females. Note:

X

Reference PC§ 4021.

To determine if there is a sufficient number of personnel for

a specific facility, the facility administrator shall prepare and

retain a staffing plan indicating the personnel assigned in the

facility and their duties. Such a staffing plan shall be reviewed by the Board staff at the time of their biennial

X

inspection. The results of such a review and

recommendations shall be reported to the local jurisdiction

having fiscal responsibility for the facility.

1027.5 SAFETY CHECKS

Safety checks shall be conducted at least hourly through X direct visual observation of all inmates. There shall be no more than a 60 minute lapse between safety checks.
There shall be a written plan that includes the documentation of routine safety checks.

X

1028 FIRE AND LIFE SAFETY STAFF
Whenever there is an inmate in custody, there shall be at X least one person on duty at all times who meets the training standards established by the BSCC for general fire and life safety. (Penal Code section 6030[e]) The facility manager shall ensure that there is at least one person on duty who trained in fire and life safety procedures X that relate specifically to the facility.

☐ ☐ CDPM 601.22 Section 2.0
☐ ☐
☐ ☐ ☐ ☐

☐ ☐

C601.22, requires visual checks of all occupied holding cells every hour.
☐ ☐

Except for Banning and Southwest Juvenile

court, Inmates are held in the court holding cells

for a very limited amount of time (less than 60

minutes), not long enough to log an hourly

☐

☐ check.

BSCC reviewed Banning and Southwest Juvenile court observation logs. each facility revealed compliance with regulation standard.

CDPM 505.05 Section 4.0

Each CH Facility has a Fire Life and Safety

☐

☐ Manual on site.

☐ ☐

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TITLE 15 SECTION

YES NO N/A

P/P REFERENCE – COMMENTS

1029 POLICY AND PROCEDURES MANUAL 2

Court Services Policy/Procedures Manual (CSM)

Facility administrator(s) shall develop and publish a manual

Riverside Sheriff’s Department Manual

of policy and procedures for the facility. The policy and

(RSDM)

procedures manual shall address all applicable Title 15 and

Corrections Division Policy Manual (CDPM)

Title 24 regulations and shall be comprehensively reviewed

and updated at least every two years. Such a manual shall be X

☐ ☐

made available to all employees.

The policies and procedures required in subsections (a)(6) and (a)(7) may be placed in a separate manual to ensure confidentiality. Subsections d does not apply and has been deleted.

(a) The manual shall provide for, but not be limited to, the

following: (1) Table of organization, including channels of

X

communications.

(2) Inspections and operations reviews by the facility administrator/manager.

X

(3) Policy on the use of force. X

(4) Policy on the use of restraint equipment, including the

restraint of pregnant inmates as referenced in Penal Code

Section 3407.

X

(6) Security and control including physical counts of

inmates, searches of the facility and inmates, contraband

control, and key control. Each facility administrator shall,

at least annually, review, evaluate, and make a record of security measures. The review and evaluation shall

X

include internal and external security measures of the

facility including security measures specific to prevention

of sexual abuse and sexual harassment.

(7) Emergency procedures include:

X

(A) fire suppression preplan as required by section 1032 of these regulations;

X

(B) escape, disturbances, and the taking of hostages;

X

RSDM ☐ ☐

☐

☐ CDPM 502.04

Facility Inspections

☐

☐ CSM 601.37

Non-Compliant Inmates

CSM

☐

☐ 601.28 Restraints

601.12 Custodial Situations and Prisoner

Transport

CSM 601.06

Duties 1.0

CSM 601.12

☐

☐ Custodial Situations

CSM 601.06

Duties

☐

☐ CSM 601.28 1.0

Escape

☐

☐ CDPM 502.04 Facility Inspections

CSM 601.28 1.0

Escape

CSM 601.07

☐

☐ General Procedures

CSM 601.17

Hostage Situations

(C) mass arrests;

X

☐

☐ CSM 601.07

General Procedures

(D) natural disasters;

X

☐

☐ CSM 601.15 Earthquake

(E) periodic testing of emergency equipment; and,

X

☐

☐ CSM 601.06 Duties 5.0

(F) storage, issue, and use of weapons, ammunition, chemical agents, and related security devices.

X

☐ ☐

2 Procedures related to security and emergency response may be in a separate manual to ensure confidentiality by limiting general access.

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TITLE 15 SECTION

YES NO N/A

P/P REFERENCE – COMMENTS

(8) Suicide Prevention.

X

☐

☐ CDPM 508.15

Suicide Prevention Program

(9) Segregation of Inmates.

X

☐

☐ CDPM 504.02

Admin. Segregation

(10) Zero tolerance in the prevention of sexual abuse and

501.24 Sexual Assault

sexual harassment.

X

☐

☐ 507.11 Orientation

508.10 Medical Screening/Medical Release

(11) Policy and procedure to detect, prevent, and respond

to retaliation against any staff or inmate after reporting X

☐ ☐

any abuse.

(b) The policies and procedures required in subsections (a)(6)

and (a)(7) may be placed in a separate manual to ensure X

☐ ☐

confidentiality.

(c) The manual for court holding facilities shall include all

of the procedures listed in subsection (a), except number (5) X

☐ ☐

(which has been deleted).

(e) The manual for Temporary Holding, Court Holding,

Type I, II, III, and IV facilities shall provide for, but not be X

☐ ☐

limited to, the following:

(1) multiple internal ways for inmates to privately report

sexual abuse and sexual harassment, retaliation by other

inmates or staff for reporting sexual abuse and sexual harassment, and staff neglect or violation of

X

☐ ☐

responsibilities that may have contributed to such

incidents,

(2) a method for uninvolved inmates, family,

community members, and other interested third-parties

to report sexual abuse or sexual harassment. The X

☐ ☐

method for reporting shall be publicly posted at the

facility.

1030 SUICIDE PREVENTION PROGRAM

CDPM 508.15

Suicide Prevention Program

The facility shall have a comprehensive written suicide

prevention program developed by the facility administrator, X

☐ ☐

in conjunction with the health authority and mental health

director, to identify, monitor, and provide treatment to those

inmates who present a suicide risk. The program shall

include the following:

(a) Suicide prevention training for all staff that have direct contact with inmates.

X

☐ ☐

(b) Intake screening for suicide risk immediately upon intake and prior to housing assignment.

X

☐ ☐

(c) Provisions facilitating communication among

arresting/transporting officers, facility staff, medical and X

☐ ☐

mental health personnel in relation to suicide risk.

(d) Housing recommendations for inmates at risk of suicide. X

☐ ☐

(e) Supervision depending on level of suicide risk.

X

☐ ☐

(f) Suicide attempt and suicide intervention policies and procedures.

X

☐ ☐

(g) Provisions for reporting suicides and suicides attempts.

X

☐ ☐

(h) Multi-disciplinary administrative review of suicides and attempted suicides as defined by the facility administrator.

X

☐

☐

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TITLE 15 SECTION

YES NO N/A

P/P REFERENCE – COMMENTS

1032 FIRE SUPPRESSION PREPLANNING

CSM 601.16 Fire

Pursuant to Penal Code Section 6031.1(b), the facility administrator shall consult with the local fire department X having jurisdiction over the facility, with the State Fire Marshal, or both, in developing a plan for fire suppression which shall include, but not be limited to:

(a) a fire suppression pre-plan developed with the local fire

department to be included as part of the policy and procedures manual (Title 15, California Code of Regulations Section

X

1029);

(b) regular fire prevention inspections by facility staff on a monthly basis with two year retention of the inspection X record;

(c) fire prevention inspections as required by Health and Safety Code Section 13146.1(a) and (b) which requires X inspections at least once every two years;

(d) an evacuation plan; and,

X

(e) a plan for the emergency housing of inmates in the case of fire.

X

1044 INCIDENT REPORTS

Each facility administrator shall develop written policies and procedures for the maintenance of written records and X reporting of all incidents which result in physical harm, or serious threat of physical harm, to an employee or inmate of a detention facility or other person.
Such records shall include the names of the persons involved, a description of the incident, the actions taken, and X the date and time of the occurrence.
Such a written record shall be prepared by the staff assigned to investigate the incident and submitted to the facility X manager or his/her designee.
1046 DEATH IN CUSTODY

(a) Death in Custody Reviews for Adults and Minors.

The facility administrator, in cooperation with the health administrator, shall develop written policy and procedures to X ensure that there is an initial review of every in-custody death within 30 days. The review team shall include the facility administrator and/or the facility manager, the health administrator, the responsible physician and other health care and supervision staff who are relevant to the incident.

Deaths shall be reviewed to determine the appropriateness of

clinical care; whether changes to policies, procedures, or practices are warranted; and to identify issues that require

X

further study.

(b) Death of a Minor

In any case in which a minor dies while detained in a jail, X lockup, or court holding facility:

(1) The administrator of the facility shall provide to the Board a copy of the report submitted to the Attorney General under Government Code Section 12525. A X copy of the report shall be submitted within 10 calendar days after the death.

☐ ☐

☐ ☐

Logs maintained with the Fire,

☐

☐ Life and Safety Manual.

All have been inspected with no issues except. ☐ ☐

☐ ☐

☐

☐ In FLS Manual

CSM 601.22 Documentation Section 3.2 601.22 Section 1.0 Activity Log ☐ ☐

☐ ☐ CSM 601.22 Section 3.2.2
☐ ☐ CSM 601.36 Death in Custody
☐ ☐

☐ ☐

CDPM 510.10

☐

☐ Death in Custody

☐ ☐

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TITLE 15 SECTION

YES NO N/A

P/P REFERENCE – COMMENTS

(2) Upon receipt of a report of death of a minor from the

administrator, the Board may within 30 calendar days

inspect and evaluate the jail, lockup, or court holding

facility pursuant to the provisions of this subchapter. X

☐ ☐

Any inquiry made by the Board shall be limited to the

standards and requirements set forth in these

regulations.

1050 CLASSIFICATION PLAN

CSM 601.12

Custody Situations

(b) Each administrator of a court holding facility shall

Questions included in booking paperwork.

establish and implement a written plan designed to provide

Remands are typically transported directly to the

for the safety of staff and inmates held at the facility. The X

☐

☐ jail facility where classification occurs.

plan shall include receiving and transmitting of information

regarding inmates who represent unusual risk or hazard

while confined at the facility, and the segregation of such

inmates to the extent possible within the limits of the court

holding facility.

(c) In deciding whether to assign an inmate to a housing area

for male or female inmates, and in making other housing and

programming assignments, the agency shall consider on a

case-by-case basis whether a placement would ensure the inmate's health and safety, and whether the placement would

X

☐ ☐

present management or security problems. An inmate's own

views with respect to his or her own safety shall be given

serious consideration.

1051 COMMUNICABLE DISEASES

CSD 601.12

Medical Releases for Booking Section 5.0

The facility administrator, in cooperation with the responsible physician, shall develop written policies and X

☐ ☐

procedures specifying those symptoms that require

segregation of an inmate until a medical evaluation is

completed

At the time of intake into the facility, an inquiry shall be

made of the person being booked as to whether or not he/she

has or has had any communicable diseases, such as

tuberculosis or has observable symptoms of tuberculosis or X

☐ ☐

any other communicable diseases, or other special medical

problem identified by the health authority. The response

shall be noted on the booking form and/or screening device.

1052 MENTALLY DISORDERED INMATES

CSD 601.12

Medical Releases for Booking Section 5.0

The facility administrator, in cooperation with the X

☐

☐ The practice is direct transport to the jail.

responsible physician, shall develop written policies and

Remands are typically direct transports to the jail

procedures to identify and evaluate all mentally disordered

facility where classification occurs.

inmates, and may include telehealth.

If an evaluation from medical or mental health staff is not

readily available, an inmate shall be considered mentally

disordered for the purpose of this section if he or she appears

to be a danger to himself/herself or others or if he/she

appears gravely disabled.

X

☐ ☐

An evaluation from medical or mental health staff shall be secured within 24 hours of identification or at the next daily sick call, whichever is earliest.

Segregation may be used if necessary to protect the safety of the inmate or others.

X

☐ ☐

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TITLE 15 SECTION

YES NO N/A

P/P REFERENCE – COMMENTS

1053 ADMINISTRATIVE SEGREGATION

CSM

601.08

Except in Type IV facilities, each facility administrator shall

Ad-Seg inmates are typically directly

develop written policies and procedures which provide for

transported to and from the jail facility.

the administrative segregation of inmates who are

determined to be prone to: promote activity or behavior that

is criminal in nature or disruptive to facility operations;

demonstrate influence over other inmates, including influence to promote or direct action or behavior that is X

☐ ☐

criminal in nature or disruptive to the safety and security of

other inmates or facility staff, as well as to the safe operation

of the facility; escape; assault, attempted assault, or

participation in a conspiracy to assault or harm other inmates

or facility staff; or likely to need protection from other

inmates, if such administrative segregation is determined to

be necessary in order to obtain the objective of protecting

the welfare of inmates and staff.

Administrative segregation shall consist of separate and

secure housing but shall not involve any other deprivation of privileges than is necessary to obtain the objective of

X

☐ ☐

protecting the inmates and staff.

1057 DEVELOPMENTALLY DISABLED INMATES

CSD 601.12 Medical Releases for Booking

The facility administrator, in cooperation with the X responsible physician, shall develop written policies and procedures for the identification and evaluation, appropriate classification and housing, protection, and nondiscrimination of all developmentally disabled inmates.
The health authority or designee shall contact the regional center on any inmate suspected or confirmed to be developmentally disabled for the purposes of diagnosis X and/or treatment within 24 hours of such determination, excluding holidays and weekends.
1058 USE OF RESTRAINT DEVICES
The facility administrator, in cooperation with the responsible physician, shall develop written policies and procedures for the use of restraint devices and may delegate authority to place an inmate in restraints to a responsible health care staff. In addition to the areas specifically outlined X in this regulation, at a minimum, the policy shall address the following areas: acceptable restraint devices; signs or symptoms which should result in immediate medical/mental health referral; availability of cardiopulmonary resuscitation equipment; protective housing of restrained persons; provision for hydration and sanitation needs; and exercising of extremities.
1058.5 RESTRAINTS AND PREGNANT INMATES

☐ ☐

☐ ☐

CSM 601.12

CSM 601.28

Long term restraints are not used in the Court

Holding Facility, the department practice is that

inmates who need behavioral restraints are direct

transports to and from court and the court

☐

☐ holding cells are not used for this type of inmate.

Remainder of regulation removed.

508.19

The facility administrator, in cooperation with the

responsible physician, shall develop written policies and X

☐ ☐

procedures for the use of restraint devices on pregnant

inmates. In accordance with Penal Code 3407 the policy

shall include reference to the following:

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TITLE 15 SECTION

YES NO N/A

P/P REFERENCE – COMMENTS

(1) An inmate known to be pregnant or in recovery after

508.19 (2.1)

delivery shall not be restrained by the use of leg irons, X

☐ ☐

waist chains, or handcuffs behind the body.

(2) A pregnant inmate in labor, during delivery, or in

recovery after delivery, shall not be restrained by the wrists, ankles, or both, unless deemed necessary for the

X

☐ ☐

safety and security of the inmate, the staff, or the public.

(3) Restraints shall be removed when a professional

50/.19 (2.1)

who is currently responsible for the medical care of a

pregnant inmate during a medical emergency, labor, X

☐ ☐

delivery, or recovery after delivery determines that the

removal of restraints is medically necessary.

(4) Upon confirmation of an inmate's pregnancy, she

50/.19 (2.1)

shall be advised, orally or in writing, of the standards X

☐ ☐

and policies governing pregnant inmates.

1068 ACCESS TO COURTS

CDPM 504.35

The facility administrator shall develop written policies and X

☐ ☐

procedures to ensure inmates have access to the court and to

legal counsel. Such access shall consist of:

(a) unlimited mail as provided in Section 1063 of these regulations, and,

X

☐ ☐

(b) confidential consultation with attorneys.

X

☐ ☐

DETENTION OF MINORS

Are minors held in this facility? If yes, the following

510.10

sections, including those summarized in Title 15, Article 10,

apply (Minors in Court Holding Facilities.)

☐

☐

X

Youth attending court proceedings at the new Southwest Juvenile Court are supervised by

probation staff.

1122.5 PREGNANT MINORS

(a) The health administrator, in cooperation with the facility ☐

☐

X

administrator, shall develop written policies and procedures

pertaining to pregnant minors that address the requirements

in Title 15, Section 1417.

(b) The facility administrator, in cooperation with the

responsible physician, shall develop written policies and

procedures for the use of restraint devices on pregnant ☐

☐

X

minors. The policy shall address requirements of Penal Code

3407. Policy shall include reference to the following:

(1) A minor known to be pregnant or in recovery after

delivery shall not be restrained by the use of leg irons, ☐

☐

X

waist chains, or handcuffs behind the body.

(2) A pregnant minor in labor, during delivery, or in

recovery after delivery, shall not be restrained by the wrists, ankles, or both, unless deemed necessary for the

☐

☐

X

safety and security of the minor, the staff, or the public.

(3) Restraints shall be removed when a professional who

is currently responsible for the medical care of a pregnant

minor during a medical emergency, labor, delivery, or ☐

☐

X

recovery after delivery determines that the removal of

restraints is medically necessary.

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TITLE 15 SECTION

YES NO N/A

(4) Upon confirmation of a minor's pregnancy, she shall

be advised, orally or in writing, of the standards and ☐

☐

X

policies governing pregnant minors.

1161 CONDITIONS OF DETENTION

Page 266 of 343 Page ID
P/P REFERENCE – COMMENTS

Court holding facilities shall be designed to provide the

X

following:

(a) Separation of minors from adults in accordance with Section 208 of the Welfare and Institutions Code.

☐

☐

X

(b) Segregation of minors in accordance with an established classification plan.

☐

☐

X

(c) Secure non-public access, movement within and egress.

If the same entrance/exit is used by both minors and adults, movements shall be scheduled in such a manner that there is

☐

☐

X

no opportunity for contact.

An existing court holding facility built in accordance with

construction standards at the time of construction shall be

considered as being in compliance with this article unless the

condition of the structure is determined by the appropriate

authority to be dangerous to life, health, or welfare of ☐

☐

X

minors. Upon notification of noncompliance with this

section, the facility administrator shall develop and submit a

plan for corrective action to the Corrections Standards

Authority within 90 days.

1162 SUPERVISION OF MINORS

A sufficient number of personnel shall be employed in each

facility to permit unscheduled safety checks of all minors at ☐ least twice every 30 minutes, and to ensure the

☐

X

implementation and operation of the activities required by

these regulations. There shall be a written plan that includes

the documentation of safety checks.

1163 CLASSIFICATION

The administrator of a court holding facility shall establish

and implement a written plan designed to provide for the

safety of staff and minors held at the facility. The plan shall

include receiving and transmitting of information regarding ☐ minors who represent a risk or hazard to self or others while

☐

X

confined at the facility, and the segregation of such minors

to the extent possible within the limits of the court holding

facility, and for the separation of minors from any adult

inmate(s) as required by Section 208 of the Welfare and

Institutions Code.

1047 SERIOUS ILLNESS OR INJURY OF A

MINOR IN AN ADULT DETENTION

FACILITY

The facility administrator shall develop policy and ☐

☐

X

procedures for notification of the court of jurisdiction and

the parent, guardian, or person standing in loco parentis, in

the event of a suicide attempt, serious illness, injury or death

of a minor in custody.

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ADULT COURT AND TEMPORARY HOLDING FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community corrections Applicable Title 24 Regulations: 6/94; 2/99; 2001
BSCC Code: 3916

FACILITY NAME: Hall of Justice– Court Holding

FACILITY TYPE: CH

APPLICABLE REGULATIONS (Check All That Apply): 6/94: x FIELD REPRESENTATIVE: Michael J. Bush

2/99:

TITLE 24 SECTION

YES NO N/A

Reception and Booking (2.1)

X

Contains a weapons locker, designed as outlined in these regulations.

Contains a cell or room for confinement pending booking

X

Contains a detoxification cell (WA in TH; NA in CH)

X

01: Name changed to “sobering cell.”

2-99: Two detoxification cells are provided if both male and female inmates are held.

Contains safety cell(s) (WA in TH; NA in CH)

X

Shower room available

X

2-99: Access to shower must be within the secure area

Provides secure vault or storage for inmate valuables

X

Telephone(s) available for inmate use (PC § 851.5)

X

2-99: Unobstructed access to hot and cold running water

X

2001:

OTHER:

DATE: 09/19/2019

COMMENTS

Temporary Holding Cell or Room (2.2)

X

Contains 10 square feet of floor area per inmate

Holds no more than 16 inmates

X

Is not smaller than 40 square feet and has a clear ceiling

X

height of 8 feet or more

Contains sufficient seating to accommodate all inmates

X

Contains water closet (toilet), washbasin, and drinking

X

fountain

Provides for clear visual supervision by staff

X

A bunk is provided if inmates are held 12 hours or more

X

Temporary Staging Cell or Room (2.3)

Holds inmates classified and segregated per Title 15 § 1050 and 1053

Detoxification/Sobering Cell (2.4)

01: Name change to “sobering cell”

Contains 20 square feet of floor area per inmate

Safety Cell (2.5)

Contains 48 square feet with one floor dimension of a least 6 feet and a clear ceiling height of 8 feet or more

Safety Equipment Storage (2.19)

X

Adequate space is provided to store equipment such as fire extinguishers, SCBA, emergency lights, etc.

X No cells of this type, remainder of the regulation is removed.
X No cell of this type, remainder of the regulation is deleted.
X No cell of this type, remainder of the regulation is deleted.
Located on the first floor.

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TITLE 24 SECTION

YES NO N/A

Janitors' Closet (2.20)

X

Lockable, containing a mop sink and storage space

01: Mop sink may be separate from janitors’ closet

Page 268 of 343 Page ID
COMMENTS

Audio or Visual Monitoring (2.22)

X

There is an audio monitoring system capable of alerting staff in a central control. When visual electronic surveillance is used, it is located primarily in corridors, elevators, or at points on the security perimeter such as entrances and exits.

2-99: Video monitoring option deleted.

Emergency Power (2.24)

X

There is an emergency power source available and capable

of providing minimal lighting in all areas and maintaining

fire and life safety, security, communication and alarm

systems.

Attorney Interview Space (2.26)

X

Available and provides for confidentiality

Water Closets (Toilets)/Urinals (3.1)

X

Provide for inmate privacy/modesty with staff being able to

visually supervise; provided at a ratio of 1:16 in holding and

staging cells. See regulation for calculations of urinal

substitutions.

Washbasins (3.2)

X

Provide hot and cold or tempered water; provided at a ratio

of 1:16 in holding and staging cells. See regulation for

calculations of washbasin trough substitutions.

Drinking Fountains (3.3)

X

2-99: Available in each temporary holding, staging and sobering cell.

Water outlet (bubbler) is mechanically actuated and at an

X

angle that prevents wastewater from flowing over the outlet

(bubbler); there is a mouth guard on the water outlet

(bubbler).

2-99: Mouth guard requirement deleted

Showers (3.4) (NA in CH)

X

Available in the security area; provide hot and cold or

tempered water; shower stalls/areas are designed and

constructed of materials that are impervious to water and

soap so that they may be easily cleaned.

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TITLE 24 SECTION

YES NO N/A

Beds/Bunks (3.5)

X

(NA in CH; applicable in TH if inmates are held longer than

12 hours)

Page 269 of 343 Page ID
COMMENTS

At least 30 inches wide and 76 inches long with 21 inches between pans; constructed of pan bottom type or concrete; securely fastened to the floor and/or wall in facilities higher than minimum security.

01: Must be elevated off the floor.

Lighting (3.6)

X

Lighting is sufficient to permit easy reading by a person with

normal vision, night lighting is sufficient for purposes of

supervision.

Lighting is centrally controlled and/or occupant controlled in housing cells or rooms. Light fixtures are of secure design.

Windows (3.7)

X

Windows that are accessible to inmates are no greater than 5

inches in one dimension.

Cell Padding (3.8)

X

The floors and partition are padded in detoxification cells.

In safety cells, floors, doors, walls and everything on them

are padded. All padded cells are equipped with a tamper

resistant fire sprinkler approved by the SFM.

All padding is: approved for use by the SFM; nonporous; at

X

least ½ inch thick; of a unitary or laminated construction;

firmly bonded to all surfaces; and, without exposed seams.

Seating (3.10)

X

Seating is designed to the level of security. When bench

seating is used, eighteen inches of bench are provided per

inmate.

2-99: In holding and staging cells, seating is securely

fastened to the wall and/or floor.

Weapons Locker (3.12)

X

(NA type IV and Minimum Security Facilities)

A secure weapons locker is located outside the security perimeter of the facility and no weapons are brought into the security area. Lockers have individual compartments, locks and keys.

Design Requirements (102(c)6)

X

Design requirements as specified in Title 24, Part 1, 102(c)6 are met. (See regulation for specific requirements. Note areas of non-compliance that are applicable to the facility type and construction date in the "comments" section.)

Outside of each courtroom.

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ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION

Page ID

BSCC Code: 3916

FACILITY: Hall of Justice Court Holding

TYPE: CH

RC: 0

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/19/2019

ROOMS

Cell Applicable #

Location

Type Standards Cells

Hall of Justice Court Room Holding Cells

EACH CELL # Beds RC

Total RC

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UWF S

Southside Holding

1988

10

2-6 floors

(7)

(70)

5.10 X 15.0 X 8.7 1

1 1

Notes: Holding cells for courtroom 2 - 5; Two cells per floor (2nd, 3rd, 4th and 5th).

Northside Holding

1988

8

3-6 floors

(5)

(40)

5.10 X 8.9.0 X 8.7 1

1 1

Notes: 2 cells on each floor, address 4100 main Street

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 271 of 343 #:17501
ADULT COURT AND TEMPORARY HOLDING FACILITIES PHYSICAL PLANT EVALUATION Corrections Standards Authority

Page ID

Applicable Title 24 Regulations: 6/94; 2/99; 2001

CSA Code: 3935

FACILITY NAME: Southwest Justice Center – Court Holding

FACILITY TYPE: CH

APPLICABLE REGULATIONS (Check All That Apply): 6/94: FIELD REPRESENTATIVE: Michel J. Bush

2/99: X

2001:

OTHER:

DATE: 09/19/2019

TITLE 24 SECTION

YES NO N/A

Reception and Booking (2.1)

Contains a weapons locker, designed as outlined in these

X

regulations.

Contains a cell or room for confinement pending booking

X

Contains a detoxification cell (WA in TH; NA in CH)

01: Name changed to “sobering cell.”

X

2-99: Two detoxification cells are provided if both male and

female inmates are held.

Contains safety cell(s) (WA in TH; NA in CH)

X

Shower room available 2-99: Access to shower must be within the secure area

X

Provides secure vault or storage for inmate valuables

X

Telephone(s) available for inmate use (PC § 851.5)

X

2-99: Unobstructed access to hot and cold running water

X

COMMENTS

Temporary Holding Cell or Room (2.2) Contains 10 square feet of floor area per inmate

X

Holds no more than 16 inmates

X

Is not smaller than 40 square feet and has a clear ceiling height of 8 feet or more

X

Contains sufficient seating to accommodate all inmates

X

Contains water closet (toilet), washbasin, and drinking fountain

X

Provides for clear visual supervision by staff

X

A bunk is provided if inmates are held 12 hours or more

X

Temporary Staging Cell or Room (2.3) Holds inmates classified and segregated per Title 15 § 1050 and 1053 Holds inmates for four hours or less Limited to holding no more than 80 inmates Contains 10 square feet of floor area per inmate and has a clear ceiling height of 8 feet or more. Is at least 160 square feet Contains sufficient seating to accommodate all inmates Contains water closets (toilets), wash basins and drinking fountains as specified by these regulations

Staging cells are located at the jail. X
X X X X X X

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Case 5:13-cv-00444-VAP-OP
TITLE 24 SECTION Provides for clear visual supervision by staff

Document 178-2 Filed 04/06/20 #:17502
YES NO N/A
X

Page 272 of 343 Page ID
COMMENTS

Detoxification/Sobering Cell (2.4)

01: Name change to “sobering cell”

Contains 20 square feet of floor area per inmate

Is limited to no more than 8 inmates

Is no smaller than 60 square feet and has a clear ceiling height of 8 feet or more

Contains a water closet (toilet) wash basin and drinking fountain as specified by these regulations

Has padded partitions located next to toilet fixtures

Provides for clear visual supervision by staff

Padding on floor

Safety Cell (2.5)

Contains 48 square feet with one floor dimension of a least 6 feet and a clear ceiling height of 8 feet or more

Is limited to one inmate

Contains a flushing ring toilet, mounted flush with the floor, with controls located outside the cell

Padded floor, door and walls

Equipped with a variable intensity, security light, inaccessible to the occupant

Has one or more vertical view panels, not more than 4 inches wide nor less than 24 inches long, which provide a view of the entire cell

Has a food pass with lockable shutter no more than 4 inches high and, with between 26 and 32 inches from the bottom of the food pass to the floor

Safety Equipment Storage (2.19)

Adequate space is provided to store equipment such as fire extinguishers, SCBA, emergency lights, etc.

X

X
X X X X X X X X X X X
X
X Located on the first floor.

Janitors' Closet (2.20)

Lockable, containing a mop sink and storage space 01: Mop sink may be separate from janitors’ closet

X

Located on the second floor.

Audio or Visual Monitoring (2.22)

There is an audio monitoring system capable of alerting staff

in a central control. When visual electronic surveillance is

used, it is located primarily in corridors, elevators, or at

X

points on the security perimeter such as entrances and exits.

2-99: Video monitoring option deleted.

Emergency Power (2.24)

There is an emergency power source available and capable

of providing minimal lighting in all areas and maintaining fire and life safety, security, communication and alarm

X

systems.

Lower level holding cells have call buttons in each cell. Holding cells on the upper levels are voice activated.

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Case 5:13-cv-00444-VAP-OP
TITLE 24 SECTION Attorney Interview Space (2.26) Available and provides for confidentiality

Document 178-2 Filed 04/06/20 #:17503
YES NO N/A
X

Page 273 of 343 Page ID
COMMENTS

Water Closets (Toilets)/Urinals (3.1)

Provide for inmate privacy/modesty with staff being able to

visually supervise; provided at a ratio of 1:16 in holding and staging cells. See regulation for calculations of urinal

X

substitutions.

Washbasins (3.2)

Provide hot and cold or tempered water; provided at a ratio

of 1:16 in holding and staging cells. See regulation for

X

calculations of washbasin trough substitutions.

Drinking Fountains (3.3)

2-99: Available in each temporary holding, staging and

X

sobering cell.

Water outlet (bubbler) is mechanically actuated and at an

angle that prevents wastewater from flowing over the outlet

(bubbler); there is a mouth guard on the water outlet

(bubbler).

X

2-99: Mouth guard requirement deleted

Showers (3.4) (NA in CH)

Available in the security area; provide hot and cold or

tempered water; shower stalls/areas are designed and constructed of materials that are impervious to water and



soap so that they may be easily cleaned.

Beds/Bunks (3.5)
(NA in CH; applicable in TH if inmates are held longer than 12 hours)

At least 30 inches wide and 76 inches long with 21 inches

between pans; constructed of pan bottom type or concrete;

X

securely fastened to the floor and/or wall in facilities higher

than minimum security.

01: Must be elevated off the floor.

Lighting (3.6) Lighting is sufficient to permit easy reading by a person with normal vision, night lighting is sufficient for purposes of supervision.
X
Lighting is centrally controlled and/or occupant controlled in housing cells or rooms. Light fixtures are of secure design.

Windows (3.7)

Windows that are accessible to inmates are no greater than 5 inches in one dimension.

X

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20

#:17504

TITLE 24 SECTION

YES NO N/A

Cell Padding (3.8)

The floors and partition are padded in detoxification cells.

In safety cells, floors, doors, walls and everything on them is padded. All padded cells are equipped with a tamper

X

resistant fire sprinkler approved by the SFM.

Page 274 of 343 Page ID
COMMENTS

All padding is: approved for use by the SFM; nonporous; at

least ½ inch thick; of a unitary or laminated construction; firmly bonded to all surfaces; and, without exposed seams.

X

Seating (3.10)

Seating is designed to the level of security. When bench

seating is used, eighteen inches of bench are provided per

inmate.

X

2-99: In holding and staging cells, seating is securely

fastened to the wall and/or floor.

Weapons Locker (3.12)

(NA type IV and Minimum Security Facilities)

A secure weapons locker is located outside the security

X

perimeter of the facility and no weapons are brought into the

security area. Lockers have individual compartments, locks

and keys.

Design Requirements (102(c)6)

Design requirements as specified in Title 24, Part 1, 102(c)6

are met. (See regulation for specific requirements. Note areas of non-compliance that are applicable to the facility

X

type and construction date in the "comments" section.)

Weapons locker is located near the jail entrances and in the sally port between holding cells and the courtroom.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 275 of 343 BOARD OF STATE AND COMMUNI#T:Y17C5O0R5RECTIONS– BIENNIAL INSPECTION
ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION

Page ID

BSCC Code: 3935

FACILITY: Southwest Justice Center Court Holding

TYPE: CH

RC: 0

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/19/2019

ROOMS

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UW F S

Court Holding First Floor – Courts – 2 courtrooms are on each floor that utilize the holding cells.

Cell 1A Holding

1999

1

(4)

(4)

6’4” x 13’8” x 8’3” 1

1 1

Note: Seating Capacity 77”

Cell 1B Holding

1999

1

(4)

(4)

6’4” x 13’8” x 8’3” 1

1 1

Note: Seating Capacity 77”

Cell 1C Holding

1999

1

(4)

(4)

6’4” x 12’ x 8’3” 1

1 1

Note: Seating Capacity 77”

Cell 1D Holding

1999

1

(5)

(5)

8’8” x 11’2” x 8’3” 1

1 1

Note: Seating Capacity 104”

Cell 1E Holding

1999

1

(2)

(2)

6’8” x 6’3” x 8’3” 1

1 1

Note: Seating Capacity 38”

Cell 1F Holding

1999

1

(2)

(2)

7’5” x 6’1” x 8’3” 1

1 1

Note: Seating Capacity 39”

Court Holding – Second Floor – Courts

Cell 2A Holding

1999

1

(4)

(4)

6’4” x 13’8” x 8’3” 1

1 1

Note: Seating Capacity 77”

Cell 2B Holding

1999

1

(4)

(4)

6’4” x 13’8” x 8’3” 1

1 1

Note: Seating Capacity 77”

Cell 2C Holding

1999

1

(4)

(4)

6’4” x 11’2” x 8’3” 1

1 1

Note: Seating Capacity 77”. Typically where juveniles are held (supervised by probation), this area is completely separate from the adult prisoners.

Cell 2D Holding

1999

1

(2)

(2)

9’2” x 6’4” x 8’3” 1

1 1

Note: Seating Capacity 38”

Cell 2E Holding

1999

1

(2)

(2)

6’8” x 6’4” x 8’3” 1

1 1

Note: Seating Capacity 38”

Cell 2F Holding

1999

1

(2)

(2)

7’5” x 6’1” x 8’3” 1

1 1

Note: Seating Capacity 38”

Court Holding Third Floor – Courts

Cell 3A Holding

1999

1

(4)

(4)

6’4” x 13’8” x 8’3” 1

1 1

Note: Seating Capacity 77”

Cell 3B Holding

1999

1

(4)

(4)

6’4” x 13’8” x8’3” 1

1 1

Note: Seating Capacity 77”

Note: It is recommended that the cells are reviewed (grills) to ensure the openings do not pose a safety threat.

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 276 of 343 Page ID

ROOMS

#:17506

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UW F S

Cell 3C Holding

1999

1

(4)

(4)

6’4” x 12’ x 8’3” 1

1 1

Note: Seating Capacity 78”

Cell 3D Holding

1999

1

(5)

(5)

8’8” x 11’2” x 8’3” 1

1 1

Note: Seating Capacity 104”

Cell 3E Holding

1999

1

(2)

(2)

6’8” x 6’3” x 8’3” 1

1 1

Note: Seating Capacity 38”

Cell 3F Holding

1999

1

(2)

(2)

7’4” x 6’2” x 8’3” 1

1 1

Note: Seating Capacity 42”

The court holding cells are rarely used. Typically inmates are held in the jury box. The Court Holding cells are clean and well maintained, 1/2009;MW.

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 277 of 343 #:17507
ADULT COURT AND TEMPORARY HOLDING FACILITIES PHYSICAL PLANT EVALUATION
BOARD OF STATE AND COMMUNITY CORRECTIONS

Page ID

Applicable Title 24 Regulations: 6/94; 2/99; 2001; 2005;2008;2010

BSCC Code: 3937

FACILITY NAME: Southwest Juvenile CH

FACILITY TYPE: CH

APPLICABLE REGULATIONS (Check All That Apply): FIELD REPRESENTATIVE: Michael J. Bush

6/94:

2/99:

2001:

2005:

2008:

DATE: 09/19/2019

2010: X

TITLE 24 SECTION

YES NO N/A

Reception and Booking (2.1)

Contains a weapons locker, designed as outlined in these

X

regulations.

Contains a cell or room for confinement pending booking

X

Contains a detoxification cell (WA in TH; NA in CH)

01: Name changed to “sobering cell.”

X

2-99: Two detoxification cells are provided if both male and

female inmates are held.

Contains safety cell(s) (WA in TH; NA in CH)

X

Shower room available 2-99: Access to shower must be within the secure area

X

Provides secure vault or storage for inmate valuables

X

Telephone(s) available for inmate use (PC § 851.5)

X

2-99: Unobstructed access to hot and cold running water

X

COMMENTS

Temporary Holding Cell or Room (2.2) Contains 10 square feet of floor area per inmate

X

Holds no more than 16 inmates

X

Is not smaller than 40 square feet and has a clear ceiling height of 8 feet or more

X

Contains sufficient seating to accommodate all inmates

X

Contains water closet (toilet), washbasin, and drinking fountain

X

Provides for clear visual supervision by staff

X

A bunk is provided if inmates are held 12 hours or more

2 – Adults 2 – Juveniles
X

Temporary Staging Cell or Room (2.3)

Holds inmates classified and segregated per Title 15 § 1050

X

and 1053

Safety Equipment Storage (2.19)

Adequate space is provided to store equipment such as fire extinguishers, SCBA, emergency lights, etc.

X

Janitors' Closet (2.20)

Lockable, containing a mop sink and storage space 01: Mop sink may be separate from janitors’ closet

X

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#:17508

TITLE 24 SECTION

YES NO N/A

Audio or Visual Monitoring (2.22)

There is an audio monitoring system capable of alerting staff

in a central control. When visual electronic surveillance is

use, it is located primarily in corridors, elevators, or at points

on the security perimeter such as entrances and exits.

2-99: Video monitoring option deleted.

X

10: Deleted language referring to central control point.

10: Terminate at a location where staff can respond

immediately.

Page 278 of 343 Page ID
COMMENTS

Emergency Power (2.24)

There is an emergency power source available and capable

of providing minimal lighting in all areas and maintaining fire and life safety, security, communication and alarm

X

systems.

Attorney Interview Space (2.26)

Available and provides for confidentiality

X

Water Closets (Toilets)/Urinals (3.1)

Provide for inmate privacy/modesty with staff being able to

visual supervise; provided at a ratio of 1:16 in holding and staging cells. See regulation for calculations of urinal

X

substitutions.

Washbasins (3.2)

Provide hot and cold or tempered water; provided at a ratio

of 1:16 in holding and staging cells. See regulation for

X

calculations of washbasin trough substitutions.

Drinking Fountains (3.3)

2-99: Available in each temporary holding, staging and

X

sobering cell.

Water outlet (bubbler) is mechanically actuated and at an

angle that prevents wastewater from flowing over the outlet

(bubbler); there is a mouth guard on the water outlet

(bubbler).

X

2-99: Mouth guard requirement deleted

Lighting (3.6) Lighting is sufficient to permit easy reading by a person with normal vision, night lighting is sufficient for purposes of supervision.
X
Lighting is centrally controlled and/or occupant controlled in housing cells or rooms. Light fixtures are of secure design.

Windows (3.7)

Windows that are accessible to inmates are no greater than 5 inches in on dimension.

X

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#:17509

TITLE 24 SECTION

YES NO N/A

Seating (3.10)

Seating is designed to the level of security. When bench

seating is used, eighteen inches of bench are provided per

inmate.

2-99: In holding and staging cells, seating is securely

fastened to the wall and/or floor.

Page 279 of 343 Page ID
COMMENTS

Weapons Locker (3.12)

A secure weapons locker is located outside the security

perimeter of the facility and no weapons are brought into the security area. Lockers have individual compartments, locks

X

and keys.

Design Requirements (102(c)6)

Design requirements as specified in Title 24, Part 1, 102(c)6

are met. (See regulation for specific requirements.

Noteareas of non-compliance that are applicable to the

x

facility type and construction date in the "comments"

section.)

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 ADULT DE#T:E1N7T5I1O0N FACILITY
LIVING AREA SPACE EVALUATION Board of State and Community Corrections

Page 280 of 343

Page ID

BSCC Code: 3937

FACILITY: Southwest Juvenile CH

TYPE: CHJ

RC:

FIELD REPRESENTATIVE: Michael J. Bush

DATE 09/19/2019

Location Adult

Cell Type

ROOMS Applicable # Standards Cells

EACH CELL # Beds RC

1 & 2

H

2010

2

(4)

Bench Space – 89”…… Irregular Cell (-4’.2” sq ft)

Juvenile

1 & 2

H

2010

(4)

Bench Space – 89” Irregular Cell (-4’.2” sq ft)

Total RC (8)
(8)

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

7.5 x 11.4 x 10

1

1 1

7.5 x 11.4 x 10

1

1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit. If "Total RC" appears in brackets ( ), it is not part of the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ADULT COURT AND TEMPORARY HOLDING FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community Corrections

Page ID

Applicable Title 24 Regulations: 6/94; 2/99; 2001

BSCC Code: 3950

FACILITY NAME: Family Law Courts

FACILITY TYPE: CH

APPLICABLE REGULATIONS (Check All That Apply): 6/94: X FIELD REPRESENTATIVE: Michael J. Bush

2/99:

2001:

OTHER:

DATE: 09/18/2019

TITLE 24 SECTION Reception and Booking (2.1)
Contains a weapons locker, designed as outlined in these regulations. Temporary Holding Cell or Room (2.2)
Contains 10 square feet of floor area per inmate Holds no more than 16 inmates Is not smaller than 40 square feet and has a clear ceiling height of 8 feet or more Contains sufficient seating to accommodate all inmates Contains water closet (toilet), washbasin, and drinking fountain Provides for clear visual supervision by staff A bunk is provided if inmates are held 12 hours or more

YES NO N/A

COMMENTS

No reception of booking, remainder of the

regulation has been deleted. X

X

X

X

X X

No drinking fountain

X

X

Temporary Staging Cell or Room (2.3)
Holds inmates classified and segregated per Title 15 § 1050 and 1053 Detoxification/Sobering Cell (2.4) 01: Name change to “sobering cell” Contains 20 square feet of floor area per inmate Safety Cell (2.5)
Contains 48 square feet with one floor dimension of a least 6 feet and a clear ceiling height of 8 feet or more Safety Equipment Storage (2.19)

No cell of this type, remainder of regulation has been removed. X
No cell of this type, remainder of the regulation X has been removed.
No cell of this type, remainder of the regulations has been removed. X

Adequate space is provided to store equipment such as fire

X

extinguishers, SCBA, emergency lights, etc.

Janitors' Closet (2.20)

Lockable, containing a mop sink and storage space

01: Mop sink may be separate from janitors’ closet

X

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#:17512

TITLE 24 SECTION

YES NO N/A

COMMENTS

Audio or Visual Monitoring (2.22)

There is an audio monitoring system capable of alerting staff

in a central control. When visual electronic surveillance is used, it is located primarily in corridors, elevators, or at

X

points on the security perimeter such as entrances and exits.

2-99: Video monitoring option deleted.

Emergency Power (2.24)

There is an emergency power source available and capable

of providing minimal lighting in all areas and maintaining

X

fire and life safety, security, communication and alarm

systems.

Attorney Interview Space (2.26)

Available and provides for confidentiality

X

Water Closets (Toilets)/Urinals (3.1)

Provide for inmate privacy/modesty with staff being able to visually supervise; provided at a ratio of 1:16 in holding and X staging cells. See regulation for calculations of urinal substitutions.

Washbasins (3.2)

Provide hot and cold or tempered water; provided at a ratio of 1:16 in holding and staging cells. See regulation for

X

calculations of washbasin trough substitutions.

Drinking Fountains (3.3)

X 2-99: Available in each temporary holding, staging and
sobering cell.

Water outlet (bubbler) is mechanically actuated and at an

angle that prevents wastewater from flowing over the outlet

(bubbler); there is a mouth guard on the water outlet

(bubbler).

X

2-99: Mouth guard requirement deleted

Showers (3.4) (NA in CH)

Available in the security area; provide hot and cold or

tempered water; shower stalls/areas are designed and

X

constructed of materials that are impervious to water and

soap so that they may be easily cleaned.

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#:17513

TITLE 24 SECTION

YES NO N/A

Beds/Bunks (3.5)

(NA in CH; applicable in TH if inmates are held longer than

12 hours)

Page 283 of 343 Page ID
COMMENTS

At least 30 inches wide and 76 inches long with 21 inches

between pans; constructed of pan bottom type or concrete;

X

securely fastened to the floor and/or wall in facilities higher

than minimum security.

01: Must be elevated off the floor.

Lighting (3.6)

Lighting is sufficient to permit easy reading by a person with

normal vision, night lighting is sufficient for purposes of

supervision.

X

Lighting is centrally controlled and/or occupant controlled in housing cells or rooms. Light fixtures are of secure design.

Windows (3.7)

Windows that are accessible to inmates are no greater than 5 X inches in one dimension.

Cell Padding (3.8)

The floors and partition are padded in detoxification cells.

In safety cells, floors, doors, walls and everything on them is

X

padded. All padded cells are equipped with a tamper

resistant fire sprinkler approved by the SFM.

All padding is: approved for use by the SFM; nonporous; at

least ½ inch thick; of a unitary or laminated construction; firmly bonded to all surfaces; and, without exposed seams.

X

Mirrors/Shelves/Clothes Hooks (3.9)

X A mirror of a material appropriate to the level of security is provided near each washbasin.

Consistent with security needs, shelves and clothes hooks

are provided wherever feasible.

X

2-99: Requirement for shelves and hooks deleted

Clothes hooks are of a collapsible hook type

2-99: Requirement for hooks deleted

X

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#:17514

TITLE 24 SECTION

YES NO N/A

COMMENTS

Seating (3.10)

Seating is designed to the level of security. When bench

seating is used, eighteen inches of bench are provided per inmate.

X

2-99: In holding and staging cells, seating is securely

fastened to the wall and/or floor.

Weapons Locker (3.12) (NA type IV and Minimum Security Facilities)

A secure weapons locker is located outside the security

X

perimeter of the facility and no weapons are brought into the

security area. Lockers have individual compartments, locks

and keys.

Design Requirements (102(c)6)

Design requirements as specified in Title 24, Part 1, 102(c)6

are met. (See regulation for specific requirements. Note

X

areas of non-compliance that are applicable to the facility

type and construction date in the "comments" section.)

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ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION

Page ID

BSCC Code: 3950

FACILITY: Family Law Courts

TYPE: CH

RC: 0

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/18/2019

Location

Cell Type Holding

ROOMS

Applicable #

Standards Cells

1994

1

EACH CELL # Beds RC
(4)

Total RC (4)

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

7' X 9'10" X 9'8" 1

1

Location

Cell Type Holding

Applicable Standards
1994

# Cells
1

EACH CELL # Beds BRC
(2)

Total BRC (2)

DIMENSIONS (L x W x H)
7' X 9'10" X 9'8"

FIXTURES*

T UW F S

1

1

Notes: Bench is 4' long in holding cell (2), RC is limited to (2). Bench in cell (1) is approximately 6’ long, RC is increased to 4.

Holding cells are not used daily…

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 286 of 343 #:17516
ADULT COURT AND TEMPORARY HOLDING FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community Corrections

Page ID

Applicable Title 24 Regulations: 6/94; 2/99; 2001

BSCC Code: 3970

FACILITY NAME: Larson Justice Center

FACILITY TYPE: CH

APPLICABLE REGULATIONS (Check All That Apply): 6/94: X FIELD REPRESENTATIVE: Michael J. Bush

2/99:

2001:

OTHER:

DATE: 09/23/2019

TITLE 24 SECTION Reception and Booking (2.1) Contains a weapons locker, designed as outlined in these regulations.
Temporary Holding Cell or Room (2.2) Contains 10 square feet of floor area per inmate Holds no more than 16 inmates Is not smaller than 40 square feet and has a clear ceiling height of 8 feet or more Contains sufficient seating to accommodate all inmates Contains water closet (toilet), washbasin, and drinking fountain Provides for clear visual supervision by staff A bunk is provided if inmates are held 12 hours or more

YES NO N/A

COMMENTS

X No reception or booking, remainder of the

regulations has been removed.

X

X X
X X
X X

Temporary Staging Cell or Room (2.3)

Holds inmates classified and segregated per Title 15 § 1050 and 1053

Detoxification/Sobering Cell (2.4)

01: Name changed to “sobering cell”

Contains 20 square feet of floor area per inmate

Safety Equipment Storage (2.19)

X

Adequate space is provided to store equipment such as fire extinguishers, SCBA, emergency lights, etc.

X No cell of this type, remainder of the regulation has been removed.
X No cell of this type, remainder of the regulation has been removed.

Janitors' Closet (2.20)

X

Lockable, containing a mop sink and storage space

01: Mop sink may be separate from janitors’ closet

Audio or Visual Monitoring (2.22)

X

There is an audio monitoring system capable of alerting staff

in a central control. When visual electronic surveillance is

used, it is located primarily in corridors, elevators, or at

points on the security perimeter such as entrances and exits.

2-99: Video monitoring option deleted.

Security camera; no audio monitoring.

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#:17517

TITLE 24 SECTION

YES NO N/A

Emergency Power (2.24)

X

There is an emergency power source available and capable

of providing minimal lighting in all areas and maintaining

fire and life safety, security, communication and alarm

systems.

Page 287 of 343 Page ID
COMMENTS

Attorney Interview Space (2.26)

X

Available and provides for confidentiality

Water Closets (Toilets)/Urinals (3.1)

X

Provide for inmate privacy/modesty with staff being able to

visually supervise; provided at a ratio of 1:16 in holding and

staging cells. See regulation for calculations of urinal

substitutions.

Washbasins (3.2)

X

Provide hot and cold or tempered water; provided at a ratio

of 1:16 in holding and staging cells. See regulation for

calculations of washbasin trough substitutions.

Drinking Fountains (3.3)

X

2-99: Available in each temporary holding, staging and sobering cell.

Water outlet (bubbler) is mechanically actuated and at an

X

angle that prevents wastewater from flowing over the outlet

(bubbler); there is a mouth guard on the water outlet

(bubbler).

2-99: Mouth guard requirement deleted

Showers (3.4) (NA in CH)

X

Available in the security area; provide hot and cold or

tempered water; shower stalls/areas are designed and

constructed of materials that are impervious to water and

soap so that they may be easily cleaned.

Beds/Bunks (3.5)

X

(NA in CH; applicable in TH if inmates are held longer than

12 hours)

At least 30 inches wide and 76 inches long with 21 inches between pans; constructed of pan bottom type or concrete; securely fastened to the floor and/or wall in facilities higher than minimum security.

01: Must be elevated off the floor.

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#:17518

TITLE 24 SECTION

YES NO N/A

Lighting (3.6)

X

Lighting is sufficient to permit easy reading by a person with

normal vision, night lighting is sufficient for purposes of

supervision.

Page 288 of 343 Page ID
COMMENTS

Lighting is centrally controlled and/or occupant controlled in housing cells or rooms. Light fixtures are of secure design.

Windows (3.7)

X

Windows that are accessible to inmates are no greater than 5

inches in one dimension.

Cell Padding (3.8)

X

The floors and partition are padded in detoxification cells.

In safety cells, floors, doors, walls and everything on them is

padded. All padded cells are equipped with a tamper

resistant fire sprinkler approved by the SFM.

All padding is: approved for use by the SFM; nonporous; at

X

least ½ inch thick; of a unitary or laminated construction;

firmly bonded to all surfaces; and, without exposed seams.

Seating (3.10)

X

Seating is designed to the level of security. When bench

seating is used, eighteen inches of bench are provided per

inmate.

2-99: In holding and staging cells, seating is securely

fastened to the wall and/or floor.

Weapons Locker (3.12)

X

(NA type IV and Minimum Security Facilities)

A secure weapons locker is located outside the security perimeter of the facility and no weapons are brought into the security area. Lockers have individual compartments, locks and keys.

Design Requirements (102(c)6)

X

Design requirements as specified in Title 24, Part 1, 102(c)6 are met. (See regulation for specific requirements. Note areas of non-compliance that are applicable to the facility type and construction date in the "comments" section.)

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 289 of 343 Page ID BOARD OF STATE AND COMMUNIT#Y:1C75O1R9RECTIONS – BIENNIAL INSPECTION
ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION

BSCC Code: 3970

FACILITY: Larson Justice Center

TYPE: CH

RC: 0

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/23/2019

Location 2E

Cell Type Holding

ROOMS

Applicable #

Standards Cells

1994

1

EACH CELL

# Beds RC

0

(8)

Total RC (8)

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

8’ x 10’6”

1

1 1

Note: Rated for 8. Typically used for Family Court Proceedings; MW 2007

2F

Holding

1994

1

0

(8)

(8)

8’ x 10’6”

1

1 1

Note: Rated for 8.

2G

Holding

1994

1

0

(8)

(8)

8’ x 10’6”

1

1 1

Note: Three benches rated for 8, now being used for Family law Ct. MW 1/2009

2H

Holding

1994

1

0

(8)

(8)

8’ x 10’6”

1

1 1

Note: Three benches rated for 8.

2J

Holding

1994

1

0

(9)

(9)

8’ x 14’

1

1 1

Note: 7’6” and 6’ benches.

2K

Holding

1994

1

0

(9)

(9)

8’ x 14’

1

1 1

Note: 7’6” and 6’ benches

3M

Holding

1994

1

0

(8)

(8)

8’ x 10’6”

1

1 1

Note: Rated for 8.

3N

Holding

1994

1

0

(8)

(8)

8’ x 10’6”

1

1 1

Note: Rated for 8.

3P

Holding

1994

1

0

(8)

(8)

8’ x 10’6”

1

1 1

Note: Rated for 8.

3R

Holding

1994

1

0

(8)

(8)

8’ x 10’6”

1

1 1

Note: Rated for 8.

3S

Holding

1994

1

0

(9)

(9)

8’ x 12’

1

1 1

Note: Rated for 9.

3T

Holding

1994

1

0

(9)

(9)

8’ x 12’

1

1 1

Note: Rated for 9.

The Court Holding cells are typically empty because the inmates are held in the jury box of the court room.

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ADULT COURT AND TEMPORARY HOLDING FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community Corrections

Page ID

Applicable Title 24 Regulations: 6/94; 2/99; 2001; 2005; 2008

BSCC Code: 3974

FACILITY NAME: Banning Court House

FACILITY TYPE: CHJ

APPLICABLE REGULATIONS (Check All That Apply): 6/94: FIELD REPRESENTATIVE: Michael J. Bush

TITLE 24 SECTION

YES

Reception and Booking (2.1)

Contains a weapons locker, designed as outlined in these

X

regulations.

Contains a cell or room for confinement pending booking

Contains a detoxification cell (WA in TH; NA in CH) 01: Name changed to “sobering cell.” 2-99: Two detoxification cells are provided if both male
and female inmates are held.

Contains safety cell(s) (WA in TH; NA in CH)

Shower room available

2-99: Access to shower must be within the secure area

Provides secure vault or storage for inmate valuables

X

Telephone(s) available for inmate use (PC § 851.5)

X

2-99: Unobstructed access to hot and cold running water

X

Temporary Holding Cell or Room (2.2) Contains 10 square feet of floor area per inmate

X

Holds no more than 16 inmates

X

Is not smaller than 40 square feet and has a clear ceiling height of 8 feet or more

X

Contains sufficient seating to accommodate all inmates

X

Contains water closet (toilet), washbasin, and drinking fountain

X

Provides for clear visual supervision by staff

X

A bunk is provided if inmates are held 12 hours or more

X

Temporary Staging Cell or Room (2.3)

Holds inmates classified and segregated per Title 15 § 1050 and 1053

Safety Equipment Storage (2.19)

Adequate space is provided to store equipment such as fire extinguishers, SCBA, emergency lights, etc.

X

2/99: 2001: NO N/A
X X X X
X

2005:
DATE: 09/20/2019

2008: X

COMMENTS

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TITLE 24 SECTION

#:17521
YES NO N/A

Janitors' Closet (2.20)

Lockable, containing a mop sink and storage space

01: Mop sink may be separate from janitors’ closet

Page 291 of 343 Page ID
COMMENTS

X

Audio or Visual Monitoring (2.22)

There is an audio monitoring system capable of alerting

staff in a central control. When visual electronic

surveillance is use, it is located primarily in corridors, elevators, or at points on the security perimeter such as

X

entrances and exits.

2-99: Video monitoring option deleted.

Emergency Power (2.24)
There is an emergency power source available and capable of providing minimal lighting in all areas and maintaining fire and life safety, security, communication and alarm systems.

Attorney Interview Space (2.26)

Available and provides for confidentiality

X

Water Closets (Toilets)/Urinals (3.1)

Provide for inmate privacy/modesty with staff being able to

visual supervise; provided at a ratio of 1:16 in holding and staging cells. See regulation for calculations of urinal

X

substitutions.

Washbasins (3.2)

Provide hot and cold or tempered water; provided at a ratio

of 1:16 in holding and staging cells. See regulation for

X

calculations of washbasin trough substitutions.

Drinking Fountains (3.3)

2-99: Available in each temporary holding, staging and

X

sobering cell.

Water outlet (bubbler) is mechanically actuated and at an

angle that prevents wastewater from flowing over the outlet

(bubbler); there is a mouth guard on the water outlet (bubbler).

X

2-99: Mouth guard requirement deleted

Lighting (3.6) Lighting is sufficient to permit easy reading by a person with normal vision, night lighting is sufficient for purposes of supervision.
X Lighting is centrally controlled and/or occupant controlled in housing cells or rooms. Light fixtures are of secure design.

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TITLE 24 SECTION

#:17522
YES NO N/A

Windows (3.7)

Windows that are accessible to inmates are no greater than 5 inches in on dimension.

X

Page 292 of 343 Page ID
COMMENTS

Seating (3.10)

Seating is designed to the level of security. When bench

seating is used, eighteen inches of bench are provided per

inmate.

X

2-99: In holding and staging cells, seating is securely

fastened to the wall and/or floor.

Weapons Locker (3.12)

A secure weapons locker is located outside the security

perimeter of the facility and no weapons are brought into the security area. Lockers have individual compartments,

X

locks and keys.

Design Requirements (102(c)6)

Design requirements as specified in Title 24, Part 1, 102(c)6

are met. (See regulation for specific requirements. Note areas of non-compliance that are applicable to the facility

X

type and construction date in the "comments" section.)

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 ADULT DE#T:E1N7T5I2O3N FACILITY
LIVING AREA SPACE EVALUATION Board of State and Community Corrections

Page 293 of 343

Page ID

BSCC Code: 3974

FACILITY: Banning Courthouse

TYPE: CHJ

RC: 0

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/20/2019

Location Basement

Cell Type

ROOMS Applicable # Standards Cells

EACH CELL # Beds RC

Total RC

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UWF S

1-4

Holding

2008

4

(4)

(16)

55 sq. ft

1

1 1

Bench Space – all 8 cells are a mirror image, cells 1-4 have 88 inches of bench space and 9ft. ceiling height. RC is limited due to bench space available.

5-8

Holding

2008

4

(6)

(24)

85 sq. ft.

1

1 1

Bench Space – cells 5-8 have 120 inches of bench space (two benches in each cell) and 9 ft/ ceiling height. RC is limited due to bench space available.

9-10

Holding

2008

2

(6)

(12)

7.5 x 14.6 x 9

1

1 1

Bench Space – cells 9 and 10 have 120 inches of bench space (two benches in each cell). RC is limited due to bench space available.

Juvenile

1-2

Holding

2008

2

(4)

(8)

7.9 x 6 x 9

1

Bench Space – 72 inches of bench space. RC is limited due to bench space available.

3-4

Holding

2008

2

(4)

(8)

7.5 x 9.5 x 9

1

Bench Space – 88 inches of bench space. RC is limited due to bench space available.

Notes: 2 attorney visiting rooms available.

First Floor

1 1 1 1

1

Holding

2008

1

Bench Space – 53 inches of bench space.

2

Holding

2008

1

Bench Space – 98 inches of bench space.

Second Floor

(2)

(2)

8.1 x 7.10 x 9

1

(5)

(5)

8.1 x 7.10 x 9

1

1 1 1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit. If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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ROOMS

#:17524

EACH ROOM

Cell Applicable #

EACH CELL

Total

DIMENSIONS

FIXTURES*

Location

Type Standards Cells # Beds RC

RC

(L x W x H)

T UWF S

Between Courtrooms 310 and 320

1

Holding

2008

1

(5)

(5)

8.2 x 7.10 x 9

1

1 1

Bench Space- cell 1 has 98 inches of bench space.

2

Holding

2008

1

(2)

(2)

8.1 x 7.9 x 9

1

1 1

Bench Space - 53 inches of bench space. RC is limited based on bench space available.

Between Courtrooms 330 and 340

3

Holding

2008

1

(5)

(5)

8.2 x 7.10 x 9

1

1 1

Bench Space- 98 inches of bench space.

4

Holding

2008

1

(2)

(2)

8.1 x 7.9 x 9

1

1 1

Bench Space - 53 inches of bench space. RC is limited based on bench space available.

Notes:

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit. If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 295 of 343 #:17525
ADULT COURT AND TEMPORARY HOLDING FACILITIES PHYSICAL PLANT EVALUATION
Board of State and Community Corrections

Page ID

FACILITY NAME: Blythe Court

Applicable Title 24 Regulations: 6/94; 2/99; 2001

BSCC Code: 3975

FACILITY TYPE: CH

APPLICABLE REGULATIONS (Check All That Apply): 6/94: X FIELD REPRESENTATIVE: Michael J. Bush

2/99:

2001:

OTHER:

DATE: 09/24/2019

TITLE 24 SECTION Reception and Booking (2.1)
Contains a weapons locker, designed as outlined in these regulations. Temporary Holding Cell or Room (2.2)
Contains 10 square feet of floor area per inmate Holds no more than 16 inmates Is not smaller than 40 square feet and has a clear ceiling height of 8 feet or more Contains sufficient seating to accommodate all inmates Contains water closet (toilet), washbasin, and drinking fountain Provides for clear visual supervision by staff A bunk is provided if inmates are held 12 hours or more

YES NO N/A

COMMENTS

No reception, remainder of regulation has been

removed. X

X
X X X X X X

Temporary Staging Cell or Room (2.3)

Remainder of this regulation is deleted.

Holds inmates classified and segregated per Title 15 § 1050 and 1053 Detoxification/Sobering Cell (2.4) 01: Name change to “sobering cell” Contains 20 square feet of floor area per inmate Safety Cell (2.5)

X
Remainder of this regulation is deleted. X
Remainder of this regulation is deleted.

X Contains 48 square feet with one floor dimension of a least 6 feet and a clear ceiling height of 8 feet or more
Safety Equipment Storage (2.19)

Adequate space is provided to store equipment such as fire

X

extinguishers, SCBA, emergency lights, etc.

Janitors' Closet (2.20)

Lockable, containing a mop sink and storage space

X

01: Mop sink may be separate from janitors’ closet

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TITLE 24 SECTION

#:17526
YES NO N/A

COMMENTS

Audio or Visual Monitoring (2.22)

Cells have cameras.

There is an audio monitoring system capable of alerting staff

in a central control. When visual electronic surveillance is used, it is located primarily in corridors, elevators, or at

X

points on the security perimeter such as entrances and exits.

2-99: Video monitoring option deleted.

Emergency Power (2.24)

Battery back up

There is an emergency power source available and capable

of providing minimal lighting in all areas and maintaining

X

fire and life safety, security, communication and alarm

systems.

Attorney Interview Space (2.26) Available and provides for confidentiality

Law library is used; adjacent to holding cell #2. X

Water Closets (Toilets)/Urinals (3.1)

Provide for inmate privacy/modesty with staff being able to visually supervise; provided at a ratio of 1:16 in holding and X staging cells. See regulation for calculations of urinal substitutions.

Washbasins (3.2)

Provide hot and cold or tempered water; provided at a ratio of 1:16 in holding and staging cells. See regulation for

X

calculations of washbasin trough substitutions.

Drinking Fountains (3.3)

2-99: Available in each temporary holding, staging and sobering cell.

X

Water outlet (bubbler) is mechanically actuated and at an

angle that prevents wastewater from flowing over the outlet

(bubbler); there is a mouth guard on the water outlet

(bubbler).

X

2-99: Mouth guard requirement deleted

Showers (3.4) (NA in CH)

Available in the security area; provide hot and cold or

tempered water; shower stalls/areas are designed and

X

constructed of materials that are impervious to water and

soap so that they may be easily cleaned.

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#:17527

TITLE 24 SECTION

YES NO N/A

Beds/Bunks (3.5)

(NA in CH; applicable in TH if inmates are held longer than

12 hours)

Page 297 of 343 Page ID
COMMENTS

At least 30 inches wide and 76 inches long with 21 inches

between pans; constructed of pan bottom type or concrete;

X

securely fastened to the floor and/or wall in facilities higher

than minimum security.

01: Must be elevated off the floor.

Lighting (3.6)

Lighting is sufficient to permit easy reading by a person with

normal vision, night lighting is sufficient for purposes of

supervision.

X

Lighting is centrally controlled and/or occupant controlled in housing cells or rooms. Light fixtures are of secure design.

Windows (3.7)

Windows that are accessible to inmates are no greater than 5

X

inches in one dimension.

Cell Padding (3.8)

The floors and partition are padded in detoxification cells.

In safety cells, floors, doors, walls and everything on them is

X

padded. All padded cells are equipped with a tamper

resistant fire sprinkler approved by the SFM.

All padding is: approved for use by the SFM; nonporous; at least ½ inch thick; of a unitary or laminated construction; firmly bonded to all surfaces; and, without exposed seams.

Mirrors/Shelves/Clothes Hooks (3.9)

X A mirror of a material appropriate to the level of security is provided near each washbasin.

Consistent with security needs, shelves and clothes hooks

are provided wherever feasible.

X

2-99: Requirement for shelves and hooks deleted

Clothes hooks are of a collapsible hook type

2-99: Requirement for hooks deleted

X

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#:17528

TITLE 24 SECTION

YES NO N/A

COMMENTS

Seating (3.10)

Seating is designed to the level of security. When bench

seating is used, eighteen inches of bench are provided per inmate.

X

2-99: In holding and staging cells, seating is securely

fastened to the wall and/or floor.

Weapons Locker (3.12) (NA type IV and Minimum Security Facilities)

A secure weapons locker is located outside the security

X

perimeter of the facility and no weapons are brought into the

security area. Lockers have individual compartments, locks

and keys.

Design Requirements (102(c)6)

Design requirements as specified in Title 24, Part 1, 102(c)6

are met. (See regulation for specific requirements. Note

X

areas of non-compliance that are applicable to the facility

type and construction date in the "comments" section.)

3975\Riverside Co\Blythe Court\18-20 PHY; 09/24/2019

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 299 of 343 BOARD OF STATE AND COMMUNI#T:Y17C5O2R9RECTIONS - BIENNIAL INSPECTION
ADULT DETENTION FACILITY LIVING AREA SPACE EVALUATION

Page ID

BSCC Code: 3975

FACILITY: Blythe Court

TYPE: CH

RC (6)

FIELD REPRESENTATIVE: Michael J. Bush

DATE: 09/24/2019

Location 1

Cell Type Holding

ROOMS

Applicable #

Standards Cells

1994

1

EACH CELL

# Beds RC

0

(4)

NOTE: 81” of Bench

2

Holding

1994

1

0

(2)

NOTE: 41” of Bench

Interview room is available in law library adjacent to cell #2.

Total RC (4)
(2)

EACH ROOM

DIMENSIONS

FIXTURES*

(L x W x H)

T UW F S

11.5 x 8.0

1

1 1

8.0 x 7.0

1

1 1

*T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit; If "Total RC" appears in brackets ( ), it is not part of

the facility's rated capacity. "+" indicates that capacity includes prorated air space from adjacent areas.

3975\Riverside Co\Blythe Court\18-20 LASE; 09/24/2019

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 300 of 343 Page ID #:17530
EXHIBIT P

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 301 of 343 Page ID #:17531
Grey v. Riverside Tour of Indio Jail, Southwest Detention Facility, and Robert Presley Detention Center, February 7-9, 2017
On February 7-9, attorney Sara Norman and litigation assistant Sarah Hopkins toured Indio, Southwest, and Presley jails. We spoke to several dozen prisoners in each jail, both individually in confidential interviews and in brief group interviews. We spoke to custody, medical and mental health staff and administrators at all the jails as well. We reviewed health care records for numerous patients. We are grateful for the courtesy and openness of the staff we met and the readiness with which our questions were answered and multiple jails processes explained. We would like to thank in particular Lt. Hal Reed, for his tireless help and thoughtful work as health care liaison, and Chief Deputy Sheriff Cheryl Evans, for her attention and engagement regarding the many issues discussed.
This report is not an overview or a comprehensive set of findings. Instead, it is a discussion and memorialization of several observations and concerns, with requests for follow-up from the County or the Court Experts as appropriate.
Indio Jail
Privacy at intake screening (Remedial Plan I.A.2, I.D.1): Patients coming into Indio Jail are screened by an RN in a sort of sally port located between the parking lot and the jail. The space looked clean and quiet, but we were told that the arresting officer is always present in that space along with the RN and patient during the screening. While we understand that space is a problem at the Indio facility, the presence of the arresting officer violates the Remedial Plan requirement that the “intake screening shall take place in a setting the ensures confidentiality of communications between nurses and individual inmates.” We had some conversations during the tour about whether a work-around might be possible, such as enhanced mental health screening shortly after the booking process, once inside the jail building.
Clinical space (Remedial Plan I.B.8, I.D.1, II.E.1): The clinic space in Indio Jail continues to be inadequate. Patients are seen for RN sick call face to face with the nurse and seated just inside a door to a busy hallway, with the deputy in the hallway outside. This might be compliant so long as the deputy remains out of earshot and the door is closed enough to provide privacy from passersby; we did not see an actual sick call to make that determination. However, on the other side of the RN is a work space with many other staff members seated at their desks, in full sight and earshot of the examination.
Similarly, the provider sick call and examination space is at the far end of the same room, around a corner. Although a curtain can be drawn, according to Nurse Practitioner Samson it is drawn for only about half of the appointments. Even if it is drawn, there is no sound separation from a roomful of people. Although those people are
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presumably health care staff, these are not confidential settings and it is not an appropriate work environment.

Medication administration (Remedial Plan I.C): We spoke to

who reported that a facility nurse mistakenly gave him

psychiatric medications at pill call instead of the Sudafed he had been

prescribed for his cold. He said he told the nurse that she had dispensed an unusual

amount of pills for him, and she responded, “You’re

, aren’t you?” He said he

swallowed the pills, went back to his bunk, and “knocked out” before the nurse realized

her mistake. His medical record shows that on 10/3/16 he was issued a potent dose of

schizophrenia medication instead of Sudafed. He was transferred to a medical tank for

observation. SOAP notes starting at 10/4/16 track his care in the medical tank. We were

relieved to hear from Mr.

that he emerged relatively unharmed from this incident

(though we do not know how this medication interruption affected

psychiatric condition, if at all). We recommend that the facility implement a system to

mitigate medication mix-ups and prevent any resultant harm to patients. If such a system

exists, we recommend that facility supervisors ensure that medical staff remain fully

aware of its implementation.

Transportation for specialty care (Remedial Plan II.B): Many prisoners related the process for traveling to the Riverside University Medical Center (RUMC) to receive specialty care. Their accounts were all the same: they leave Indio at 4 a.m. in a bus to Presley. From there, they wait in a holding cell for a van to RUMC. After the appointments are over, they are taken in a van back to Presley, then a bus to Smith Correctional Facility, then a bus to Indio Jail. They arrived back at the jail at 7 p.m. During this entire time -- 15 hours -- they are shackled. All described pain from such a long span of time in shackles. Several described severe anxiety over traveling on the buses and vans without seat belts and without the ability to brace themselves as the vehicles turned or braked. (With the shackles, they have “T Rex arms,” as one person put it.) The process they describe is an extremely arduous one, particularly for some of the sickest patients. It appears to pose an unnecessary barrier to care. We ask that the County explore direct transportation for the small Indio population who need specialty care in order to remove this barrier.

Medical and mental health consequences of Housing Units 13-15 (Remedial Plan I.G): We are concerned about prisoners spending long periods of time in the extremely crowded and close quarters of Housing Unit 15 and other similar units at Indio (Units 13 and 14). These housing units consist of a small dayroom with a shower on the other side of a small divider. The cells are just behind the dayroom. The dayroom is off a dark hallway which is behind a locked door separating it from the mail jail corridors; there is no fresh air. We saw more than 20 people crowded into the dayroom, which is their entire living space while they are awake. Some of them spend months or years in this environment, with no work or organized programming to occupy their time. The ventilation is minimal and the shower frequently in use.

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One prisoner described how difficult and dangerous it is to experience withdrawal from opiate addiction in those extremely close quarters, with frequent vomiting and uncontrolled bowel movements. Other prisoners described the experience of being in a small, unventilated space where often two or more people are going through withdrawal. People universally described it as extremely unhygienic, unsafe, and stressful, with the lack of movement or programming compounded by the inescapable sights, sounds, and smells of people in extreme distress.
We ask that the Court Experts review these conditions to determine whether they are consistent with basic medical and mental health needs of prisoners, particularly those with mental illness and those experiencing withdrawal.
Robert Presley Detention Center
Assistive devices in holding cells (Remedial Plan IV.2, IV.3, IV.5): The transportation sergeant told us that his understanding is that prisoners were not allowed to have canes and walkers with them in the holding cells in the transportation hub, and that those devices were automatically removed and kept outside the cells. He appeared to be extremely competent and knowledgeable, giving us the impression that he had not received training in the Remedial Plan requirement that “[a]n inmate who arrives at the jail with an assistive device shall be allowed to retain the device, or shall be provided with a jail-issued equivalent device, so long as it does not constitute an immediate risk of bodily harm or threaten the security of the facility based on an individualized assessment, unless a jail physician documents that the device is not medically necessary or reasonable to allow equal access to jail programs, services, or activities.” If a cane or walker is outside a holding cell, it is not “retained” by the prisoner.
We discussed this problem on the tour. One measure mentioned to address the problem was to have doctors more clearly indicate which prisoners needed assistive devices at all times as opposed to distance walking. As I noted on the tour, I urge you to avoid this distinction, which is unnecessarily confusing and sets up different rules for different people. It is also hard for providers to apply.
Accommodations for disabled prisoners in holding cells (Remedial Plan IV.2): We spoke to several disabled prisoners on the seventh floor who agreed that when they are waiting in the holding cells to go out to court or to specialty appointments, often for many hours, their hands are kept shackled. Even when they request for their hands to be freed to allow them to use the toilet or to eat, they said that they are often refused. One prisoner in a wheelchair described a deputy’s response to his request to have his hands freed: the deputy released only one hand and told him to make it work. He told us that he fell in attempting to maneuver himself onto the toilet. Prisoners with mobility impairments who use wheelchairs and walkers must have the use of their hands to safely transfer themselves to and from the toilet and perform other basic needs.
Medication administration (Remedial Plan I.C.1): We spoke to at Indio, who said that Presley medical providers had belatedly
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administered his post-operative medications. He said he was discharged from Moreno Valley Hospital on 1/3/17 after undergoing jaw surgery. He said he was transferred to Presley, where he suffered intense pain for a number of days without his prescribed painkillers, antibiotics, or liquid diet. His medical record bears this out. His postoperative orders from 1/3/17 state that his surgeon prescribed a six-week liquid diet, antibiotics (clindamycin and Keflex), and pain medication (hydrocodone). The record states the Keflex was administered seven days late (on 1/10/17); the clindamycin two days late (1/5/17); the hydrocodone four days late (1/7/17); and the liquid diet two days late (1/5/17). This is an obvious violation of the Remedial Plan’s requirement that the County “ensure that prescribed medications are provided at therapeutically appropriate times as determined by the ordering physician,” and raises a general concern about the facility’s ability to implement treatment plans as ordered by outside specialists.
Confidentiality of medical encounters on second floor (Remedial Plan I.B.8, I.D.1, II.E.1): We heard from one prisoner on the second floor (administrative segregation) who reported that it is common practice for nursing staff to take patients’ vital signs prior to provider appointments on the tier, in front of their cells. He said that it had happened to him and he heard that it had happened to others. If this is the case, it is obviously a concern as a violation of these patients’ confidentiality.
Mental health treatment space (Remedial Plan III.C): This is clearly inadequate at Presley. We heard about the plans to convert more rooms on the seventh floor for mental health treatment, which will be very welcome. In the interim, it seemed that more space might be available with better communication and direction between mental health and custody staff. For example, one of our escorts quickly enabled a confidential attorney interview with a seventh floor prisoner by bringing him down to the program room on another floor. Such measures, if made readily available to mental health staff, could enhance current capabilities.
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EXHIBIT Q

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 306 of 343 Page ID #:17536
Grey v. Riverside
Plaintiffs’ tour of Indio Jail, Smith Correctional Facility, Cois Byrd Correctional Facility, and Robert Presley Detention Center, December 2019
On December 2-5, 2019, attorneys Sara Norman and Shira Tevah toured the Indio Jail, Smith Correctional Facility, Cois Byrd Correctional Facility, and Robert Presley Detention Center. We spoke to a dozen or more people housed in each jail, both people we requested to see and people whose names we picked randomly from lists of patients with disabilities and medical and mental health diagnoses. We reviewed health care records for numerous patients. We also talked to custody, medical and behavioral health staff and administrators, and had a meeting with Chief Deputy Sheriff Edward Delgado; Deborah Johnson, RUHS Behavioral Health Assistant Director for Programs; Brian Betz, Behavioral Health Administrator for Detention Health Services; Mike Mesisca, Chief Medical Officer, Correctional Health; Correctional Health Care Administrator Bonnie Carl; and others on the executive team.
As I have said before, I continue to be grateful for the open discussions and collaborative approach from the Sheriff’s Department and behavioral health and medical leadership, as well as the courtesy and commitment we encountered from staff at the individual jails. Lieutenant Hyland’s organizational skills and the professionalism he brings to his job as health care liaison were impressive.
This report is intended to document general policy and systemic issues that we raised on the tour. It is not intended as an overview or a comprehensive set of findings – those reviews are left to the Court experts -- but to memorialize concerns for ongoing discussion and to suggest measures to move more effectively towards compliance.
1. ADA and disability access
(a) Accessible housing
The seventh floor of RPDC, which houses many of the people in the system with the most significant mobility impairments, is not wheelchair accessible. I have raised this point repeatedly over several years of reports. For example, after my July 2018 tour, I wrote:
Presley is not wheelchair accessible. The modifications for people with mobility impairments who use wheelchairs or other devices, on the seventh floor and in the holding cells for court or outside transportation, are clearly not up to the relevant standards, set forth in the Department of Justice ADA Accessibility Guidelines (ADAAG). People with disabilities on this tour, as on past tours, reported serious access problems, as described in more detail below. It is time for the County to do a thorough review of the facilities on the seventh floor and in the holding facilities,
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with expert help, to determine what physical plant changes and what policy solutions are needed.

I was extremely disappointed to see that nothing at all has been done to the seventh floor

in the years that I have been raising these concerns. People are being harmed by these

problems: for example,

, in Dorm 1, said he is paralyzed on the

left side and fell while attempting to use the shower in the dorm (which has a high lip and

is completely inaccessible). He said that deputies had to lift him off the floor. He said he

has not been offered the use of the accessible hallway shower and had not taken a shower

since.

said that when he has asked deputies to use the hallway

shower, they respond, “isn’t there one in the dayroom?” People generally said that either

the hallway shower was not available because of deputies’ reluctance to bring people out

to use it, or people had no idea that there was an alternative to the inaccessible dorm

showers. This situation is unacceptable – accessible facilities to shower, toilet, and

program generally must be readily accessible to and usable by people with disabilities.

Every time I go to the seventh floor, I hear of many clear ADA violations – the County

must take responsibility for fixing this chronic problem.

I have concerns about other housing for people with mobility impairments, such as A Pod at Cois Byrd. Any accessibility review should include that location as well.

We had a good discussion at the debrief about these concerns and the urgency with which the County must take remedial steps. There is undoubtedly expertise in other County departments on ADA accessibility requirements. Also, as I mentioned at the meeting, several other county sheriffs’ departments have used the ADA Coordinator Training Certification Program (https://www.adacoordinator.org/page/Training) to help their ADA staff learn some of the basics about compliance. I know little about the certification program and do not personally endorse it, but I know that people from Santa Clara (Sergeant Jared Marandino) and San Bernardino (Sergeant Brad Shaver) have attended the trainings and found them helpful. Sergeant Marandino in particular has developed an impressive range of expertise in architectural accessibility.

In addition to the architectural concerns, we heard of a few problems from

disabled people who are or were improperly housed.

in

Building 12 at Smith Correctional Facility, uses a walker. He said he was scheduled for

surgery for serious hip problems when he was arrested. He was booked on November 14

in Indio, and reported that he told staff about his hip problems but was nonetheless

housed in an upper tier at Smith for two days until he refused to climb the stairs. He said

he was put in the recreation yard for 12 hours and then the program room, where he spent

the night with no bed and only a blanket to sleep on, until he was rehoused accessibly the

next day. He also said it took two weeks to get a shower chair after it was prescribed for

him.

RPDC 3A, has crutches for a broken leg that occurred

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while he was on work release. Despite having crutches, he said he is housed on an upper tier (bottom bunk) and does not get any cuffing accommodations, although he is not able to use the crutches while cuffed with waist chains.

(b) Assistive devices

I was very glad to hear of the policy change to allow people to keep assistive devices during transfers and in holding cells. It is a welcome step forward. Unfortunately it is not fully implemented: we continue to get numerous reports from the people we interview from the Special Needs list that they are not always provided their assistive devices or allowed to keep them on transfers.



, in Cois Byrd E Pod, uses a cane. When he walked

up to meet me for the interview on this tour, the deputy with him matter-of-factly

took his cane from him. When I protested, the deputy said he would keep it ready

for Mr.

when he was done. Mr.

said that when he goes out to

court, it is sometimes removed from him and sometimes he is allowed to keep it;

they nearly always take it when he goes to RPDC.



Cois Byrd A Pod, uses a cane. He said it is

sometimes taken away from him in the holding cells at Cois Byrd and RPDC when

he goes out to court, but sometimes he is allowed to keep it. He needs it – he has

had a stroke and one leg drags; he said he has fallen without his cane.



also in A Pod, uses a wheelchair when he goes to

court. He reported that he is made to leave it outside the holding cell at Cois Byrd

when he goes out to court (the last time was in late November). He said he can’t

use the toilet in the holding cell because of the lack of grab bars and the removal

of his wheelchair, so he tries to stop eating and drinking early in the evening the

night before so he won’t have to. He said that another person once had an

accident on the bus and deputies ridiculed him.



Cois Byrd E Pod, said his cane is usually taken from him

in the holding cell, although he is sometimes allowed to keep it.



Cois Byrd F Pod, uses a walker and cane. He reported

that the holding cells while going to court are “first come first served” for sitting

down, have only one bench, and he has had to sit or lie down on the floor and

needed several men to help him stand up. He reported that he spent three days in a

holding cell while coming back from the hospital when he first entered the jail,

and his walker was removed from him. He reported that when he goes to court,

his cane is taken from him when he gets on the bus and he is without it all day. He

also reported that deputies have yelled at him for getting into the van too slowly

because of his mobility impairment.

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

Smith Building 1, reported that he has a wheelchair

prescribed for trips to court, the hospital, and the jail clinic but when he goes to

outside medical appointments, he is only allowed to use it to get to the bus—staff

do not bring it with him. As a result, he has to walk a great deal, which causes

him pain.



in RPDC 5A, reported that he was supposed to have a

cane for his multiple sclerosis, and the special needs list listed him as having one.

He said he went to the Riverside University Medical Center when he was arrested

and was given a cane there, but then he did not have it when he got to the jail. He

reported that he has asked for it multiple times to use when he goes to court but

has not seen it. He reported that his leg locks up every few days and puts him at

risk of falling.

2. Intake holding cells

We continue to hear accounts from people with disabilities or specialized health care needs who are required to spend multiple nights in harsh conditions in holding cells:



, Smith Building 14, reported he was held in a holding

cell for four days at RPDC when he was booked on September 13; he said he slept

on the floor and on benches. He said there were no sheets, blankets, grooming

supplies, or showers, and the number of people in the tank varied between seven

and 15. He told us he was taken from there to court and then to Smith, where his

cane was taken from him in the holding cell.



reported that he spent more than three days in a holding

cell in intake at RPDC starting around September 30, from Monday mid-day to

Thursday at 11 p.m., while waiting for housing assignment. He said he was going

through heroin withdrawal and there were 16-20 people in the holding cell, with

one toilet and one sink. He thought several others in the cell were also going

through withdrawal. He reports he spent another four days in intake one month

later after he was rehoused at RPDC, and this time there were about 15 people in

the cell. He said that three weeks later he spent three days in a holding cell again

after he was again rehoused. At that point, he estimates there were about 12

people in the holding cell with him.



reported he spent three days in a holding cell in

Cois Byrd following surgery on his foot for a staph infection at the Riverside

University Medical Center. He said he had an open wound but no dressing

change, medications, or facilities to clean the wound for that entire time. He said

there were usually 10-11 other people in the cell with him, and he was not

removed from the cell despite multiple complaints until an RN found him, got him

rehoused, and provided treatment.

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

RPDC 7th floor, said he has three separate times

spent three consecutive nights in holding cells at RPDC without blankets

following hospital stays. He said that this experience led him to refuse his last

hospital trip.



RPDC 7th floor, said that he spent three days in intake

at RPDC before being housed on the seventh floor, in a placement that had been

empty and available the entire time (according to his dorm-mates).

I do not understand why anyone would have to spend the night in an intake cell

after booking unless they arrived late in the evening and staff were not able to secure a

placement until the following morning. But more than one night is unacceptable,

particularly for the special needs patients described in the numerous examples in this and

past reports. In particular, Mr.

’s and Mr.

’s accounts should be

investigated, because as we have discussed several times on these tours, the hospital and

jail must communicate directly regarding immediate housing for patients who return

following medical procedures.

As a basic public health measure, the Sheriff’s Department should keep a supply of blankets and toiletry items to allow anyone experiencing an overnight stay in a holding cell to have some degree of comfort and sanitation, particularly where there are multiple people in close quarters. Medical staff should also screen those in the holding cells overnight to remove people who are suffering withdrawal or have significant medical conditions requiring treatment, and to ensure people have any assistive devices they are prescribed.

3. Confidentiality

We continue to see significant problems with confidentiality for health care

encounters. The County has installed cuff bars in medical exam rooms in many places,

but the use of restraints in medical appointments raises more concerns than it addresses.

For one thing, people widely reported that even when they are cuffed to the bar or to their

wheelchairs or waist chains, the exam room door remains open and deputies and other

patients outside can hear their private medical communications. This was the case for

nursing appointments on the housing units at Smith (reported by

12;

12; and

14;

among others). Similarly, at Cois Byrd, some people reported that they are cuffed to the

cuff bar, one person said the cuff bar is used sometimes, and another person said he is

sometimes cuffed to his wheelchair instead, but all said that the door is always open for

medical appointments. Some reported that deputies are situated in the open doorway and

others said they are sometimes across the hall.

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The main problem with restraints in health care appointments is that they interfere with the clinician-patient relationship and the kind of communication that is essential for adequate care. As a result, they should only be used during a health care encounter if there is an individualized safety concern about that particular patient. The problem with installing cuff bars in all exam rooms is that they become the default option, when in fact it should be the reverse – they should be used only in those cases where there is a demonstrated need. Judging from our patient interviews, the cuff bars are currently being used without regard to their purported purpose, which is to allow staff security from assaultive patients while also ensuring confidentiality.

Dr. Gage, in his September 2019 report, reported confidentiality problems with behavioral health encounters, particularly with excessive use of cell-front contacts, but also with custody presence for routine contacts (Report at pp. 18-19). He also described a policy that calls for cuffing patients to program tables for behavioral health clinical appointments even if they are not ordinarily cuffed for groups or medical appointments (p. 6), which seems similar to the blanket use of the cuff bar for medical appointments described above, and which he objected to as lacking in the kind of individualized safety assessment that is called for when determining whether a patient should be restrained.

Also on the behavioral health side, we heard from

,

RPDC 4A, said that a doctor reviewed his medications with him at the dayroom door

while dayroom was running and other people were within earshot in early September

2019. He said that he filed a grievance and the doctor subsequently saw him in an

attorney booth, but a deputy was next to him during the visit, so that was not confidential

either.

In positive developments, it is clear that Lieutenant Hyland and others have worked to train deputies to stand back from open doors, outside of hearing range of appointments inside. Based on patient interviews, however, this measure is not always followed. It was good to hear from patients that in the freestanding clinic at Smith, the exam room doors are closed and deputies are outside, which we also observed on the tour. (A few patients did say that in their experience, the exam room doors are sometimes left open.)

It is clear that there are problems with the physical plant of the exam facilities that render it difficult to provide confidential appointments in a secure setting: for example, the doors in some exam rooms open inwards, allowing an assaultive patient to blockade them; others lack adequate windows to allow visual supervision;1 and Dr. Gage described

1 The newly constructed pre-screening room in the RPDC booking area had a door that opened out and a window, making secure and confidential interviews possible. It was
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cell-front contacts due to lack of treatment space at RPDC (pp. 46-47). These problems can and are being addressed by the County. But the more elusive problem lies in the approach to addressing the issue, with blanket fear-based approaches that do not treat patient confidentiality as an important and essential aspect of health care. That attitude must be replaced by a patient-centered approach in order to achieve adequate care.
4. Behavioral health
We discussed on the tour Dr. Gage’s September 2019 report; I will not repeat his findings in detail here, except to say that I share his concerns. His most serious finding was that “individual contacts and groups are far too infrequent to meet the standard of care” (p. 24). This was consistent with what we heard in our interviews: most of the behavioral health patients we talked to described a paucity of individual or group therapy (although most were satisfied with their medications): few had anything more than rare group sessions, and many had none. They were, however, uniformly positive about those behavioral health staff they did encounter. Behavioral health leadership on the tour said they plan to gather data on group participation and availability from a patient level, which sounds like a very important metric to track.
It remains unclear if the paucity of treatment is a staffing or access problem; I look forward to hearing the results of the staffing assessment, which I was told would be done in early 2020, to help determine the way forward on this central issue.
Another area of significant concern in Dr. Gage’s report was the lack of safety cell stepdown procedures (p. 47) and the failure to implement one-on-one observations as an alternative (pp. 48-49). We discussed these on the tour, and I look forward to receiving the stepdown procedure policy when it is drafted.
Dr. Gage also found very spotty care in the safety cells (pp. 48-49), people kept in safety cells regularly for more than 12 hours (p. 48), and only 9 of 20 patients assessed outside the safety cell despite staff reports to the contrary (p. 48). He had similar concerns with the use of restraint chairs (pp. 50-51): while noting rare usage, which is welcome, he also found that face to face assessments were often denied for “safety reasons,” which is hard to imagine when the patient is secured in a restraint chair, and inadequate nursing assessments in 10 of 10 cases reviewed. Clearly, the area of safety cells and restraints, where patients are often at their most distressed and vulnerable, are an area that requires significant work to ensure consistent, compassionate treatment.
There were several points to follow up from Dr. Gage’s last report:
disappointing to see that the window was almost completely covered with non-official paperwork (saying “God Bless America”) that blocked any visual supervision.
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 He found substantial compliance with behavioral health 30-day reviews of people in administrative housing because they are done, and he does not review substance (p. 38). The parties agree that he should review the substance of the 30-day reviews.
 He asked us to weigh in on whether behavioral health approval is needed for transfers of people with acuity ratings below moderately-severe (p. 45); we agreed to accept his recommendation that they are not needed. He asked for guidance on intra-facility transfers; we also agree to accept his view that no additional behavioral health input is needed if patients are transferred within a facility to a placement designated for their acuity code.

Finally, I interviewed

a deeply troubled behavioral

health patient. She is currently at RPDC 6A, after moving back and forth between the

DCU, safety cells, and the seventh floor. She cuts herself often and her arms were deeply

distressing masses of scars. She is extremely well known to behavioral health staff and

clearly presents extraordinary difficulties in a custodial setting. We had multiple reports

from other women that Ms.

had cut herself and waited long periods of time,

bleeding, without staff response, which Ms.

confirmed. Ms.

herself

reported that at one point a sergeant in administrative segregation told her to “kill

yourself already” and the entire dayroom clapped. She said she filed a grievance about

this incident but had not received a response. We ask that you investigate these

allegations.

5. Administrative housing and out of cell time generally

On this tour, we were told that there were 36 men and four women in administrative housing. People in administrative housing also told us that they are now present for their regular status reviews, at which time they are given some indication of what they need to do to return to general population. These are significant accomplishments, and very welcome news.

We continue to have concerns over administrative housing conditions for men and women, other placements with severely restricted out of cell time, and out of cell time generally for behavioral health patients.

(a) Administrative housing conditions

The women in administrative housing at RPDC 6A reported receiving only one

hour a day out of their cells, which is sometimes closer to 45 minutes (depending on the

deputy). One woman said that every few days, they get a second rotation of 45 minutes

to an hour each. One woman,

, said she is pro per and must

use that time to speak to her investigator as well as her child and also to shower. It is not

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enough out of cell time, particularly since many of the men in administrative housing now receive more.

We were told that for the men in administrative housing on the second floor of RPDC, the planned 90 minutes per day of out-of-cell time rarely happens, because staff shorten dayroom time when behavioral health staff do walk-throughs or for various other administrative reasons. We were also told that people deeply regretted the loss of behavioral health classes and workbooks since the move to the second floor.

Several women in administrative housing spoke of spending extended periods in the isolation rooms on the seventh floor, sometimes for weeks at a time.
has been housed in one of the isolation cells for 10 months. He never leaves – there is a TV and shower in the cell – except for non-contact visits twice a week. Why are the seventh floor rooms used for administrative housing when they are so severely isolating?

While we are grateful for the ongoing efforts to limit administrative housing placements and the time spent in them, we continue to maintain that one two hours out of cell time a day for extended periods of time is inadequate and places people at risk of harm to their mental health and physical well-being. We look forward to ongoing conversations in this area, and to length-of-stay data, which is essential to an analysis of the adequacy of protective measures in restricted housing.

(b) Other placements with severely restricted out of cell time

I saw some examples of severely limited out of cell time for people in non-

administrative housing:

, in Tank 17 in Indio, said she is

in a four-person cell which she never leaves, except for two recreation sessions each

week. She said it is very small, and very stressful; some women “go crazy” and kick the

door repeatedly in frustration with their extremely limited movement. Similarly, people

in A Pod at Cois Byrd, which is sheltered medical housing, have showers and TVs in

their single-person cells and stay in them at all times except for recreation. The isolation

rooms on the seventh floor in RPDC appear to be the same.

I have reviewed Title 24 Section 1231.2.9, which allows dayroom space to be “part of a single occupancy cell used for administrative segregation or a dormitory, in which case the floor area of the cell or a dormitory must be increased by the square footage required for the dayroom.” Even if the rooms used for this purpose in Riverside meet this space requirement, I am concerned that confinement in a small room for 24 hours a day, nearly every day, runs afoul of constitutional requirement for humane living conditions. (I am not talking about large dormitories that have clearly defined and open dayroom and bed areas.) I would like to discuss this matter further on the next tour, with

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an understanding of how many people live in such housing and the dimensions of the cells.
(c) Out of cell time for behavioral health patients
There is a significant population of people in behavioral health housing on administrative housing status (there are even “ad seg” signs on some of the units). These people do not appear to be included in the totals for people in administrative housing (36 men and four women, as of the December tour). They appear to live in RPDC in one pod on the 5th floor and in Cois Byrd C Pod (population of 16). It appears that these patients generally get only 30-60 minutes a day out of cell unless they can come out in groups, in which case they get one hour. Very few reported attending groups regularly; those who had been to groups had no more than one or two a week (one patient at Cois Byrd reported a one-on-one “group” during which they played Uno).
Other behavioral health patients, not on ad seg status, spoke of getting out of their cells only one to three hours a day (for example, in Smith Building 16).
Dr. Gage’s report of September 2019 addressed out of cell time and dayroom fragmentation, noting that data is hand-gathered and error-prone (pp. 25-35). His report raises two significant problems in this area: (a) why is there no better data of this crucial metric? and (b) women and behavioral health patients consistently receive less out of cell time than men and non-behavioral health patients (p. 28).
Dr. Gage’s report pinpoints what we have generally observed, which is that dayrooms are uniformly open 8 a.m. to 11 p.m. around the system. The problem is one of fragmented opportunities for release rather than general dayroom availability. Sometimes these are unnecessary: for example, he wrote that some behavioral health units allow both tiers out to recreation yard together, so why not dayroom?
I am also concerned about Dr. Gage’s reports of the very large numbers of recreation yard refusals documented on the behavioral health units, including all people for some yard times (pp. 29-35). This bears further examination, to ensure that recreation is offered in a way that encourages patients to make use of it.
6. Custody functions
It was cold outside during our December site visits, and people we talked to in all the jails were cold. Very few had sweatshirts or extra blankets; nearly everyone wore short-sleeved white t-shirts with short-sleeved canvas tops and pants. Nobody had any kind of coat or jacket, even though many people in Smith walk outside regularly, including to the clinic, and all have recreation outdoors, sometimes as early as 6 a.m. People told us they wrap themselves in their blanket or even their sheets and towels while
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in their cells. One person said he wore socks on his hands to warm them until they were confiscated.

It was pouring outside during our visit to Smith, and nobody we spoke with had any kind of rain gear; we watched as people walked outside, including to the clinic, with no coat or umbrella and with only cotton socks and plastic slip-ons for their feet.

We were told varying rules at the different jails about extra blankets or sweatshirts, including that they are given out at some jails on a certain day in November (although it was December and nobody had them). There should be a clear, consistent, and humane policy that provides people with sweatshirts under normal circumstances and coats and appropriate footwear for inclement weather. The County must provide for the basic needs of the people in its custody

At Smith Correctional Facility, we got numerous reports of deputies being rude,

abusive, or unprofessional:

Building 12, said some are

respectful, especially the Wednesday-Saturday regulars, but others mock them (for

example, they make fun of last names, like call him “cerote,” or “piece of shit”) or yell at

them to “get away from the glass” when they are just looking at the commissary notices.

According to Mr.

, a few weeks ago, some people were being disruptive and

refusing to bunk up; they were taken to the rec yard and made to kneel on the ground for

approximately 30 minutes while a sergeant (tall, white, young, works mornings) yelled at

them: “They is our house!”

in Building 14, said that some

deputies are respectful but some curse at him.

, said deputies

in Building 16 were verbally abusive and bullying (his report was echoed by at least one

other person interviewed).

, formerly in Building 16,

reported the deputies there taunted him through the intercom, including calling him

“faggot.”

in Building 1, reported that he uses a wheelchair

and has collapsed spinal disks and a straightened cervical spine, as well as a torn shoulder

ligament, and is in a great deal of pain. He said that he had to go to mandatory rec on a

Friday or Saturday in late November or early December, and it was cold outside. His

sweatshirt was draped on his walker and he asked a deputy if he could put it on, but the

deputy said no and put his walker and sweatshirt away out of reach. He said he was

hunched over and trembling in pain and cold, and another deputy stepped in and allowed

to put on his sweatshirt.

Dr. Gage reported similar concerns at Smith, noting conflicts between behavioral health and custody staff in Building 16 (p. 25), including lack of professionalism and cooperation, retaliation, and name-calling. He also noted inadequate morning meetings with nonexistent custody involvement and only one patient discussed (in contrast with much more robust meetings at RPDC) (p. 26).

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7. Miscellaneous
Copays and hearing aids: Bonnie Carl confirmed that the County will implement the new state law banning copays for health care service and requiring counties to pay for durable medical equipment such as hearing aids and glasses. She said that the need for hearing aids would be evaluated on a case by case basis, and they are considering the use of amplifiers. We disagree with the use of amplifiers (sometimes called pocket talkers or Personal Sound Amplification Products) as an alternative to hearing aids. According to the United States Food and Drug Administration, consumers should not use pocket talkers as substitutes for hearing aids because they are “not intended to compensate for impaired hearing, but rather [are] intended for non-hearing-impaired consumers to amplify sounds in the environment for a number of reasons, such as for recreational activities.” The FDA defines a hearing aid as a sound-amplifying device intended to compensate for impaired hearing, and pocket talkers as devices that are not intended to make up for impaired hearing. (See FDA, Regulatory Requirements for Hearing Aid Devices and Personal Sound Amplification Products, February 25, 2009, at 1-2 (attached); FDA, Hearing Aids and Personal Sound Amplifiers: Know the Difference, October 20, 2009 (attached).)
We strongly believe that hearing aids should be treated as durable medical equipment, and patients with suspected hearing loss be routinely referred to audiologists for testing and, if appropriate, fitting of hearing aids.
Staffing: the Remedial Plan requires an annual assessment. I was told on the tour it would be done in the first quarter of 2020; I look forward to the results.
9. Next steps
To summarize, we ask that the following actions be taken:
 Have experts on ADA accessibility standards and the removal of architectural barriers to review all housing for people with mobility disabilities, particularly the seventh floor of RPDC and A Pod at Cois Byrd, to determine how to bring them into compliance with the ADA.
 Provide supplemental training and oversight for the policy on retention of assistive devices in holding cells (for example, have supervisors do regular unannounced spot checks to ask people in the cells if they have or need any assistive devices or accessible features (such as toilets with grab bars) that are not available to them).
 Provide clear policy direction on overnight stays in holding cells, including basic measures such as a supply of blankets and toiletry items for people experiencing an overnight stay in a holding cell and medical screenings for those in the holding cells overnight to remove people who are suffering withdrawal or have significant
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medical conditions requiring treatment, and to ensure people have any assistive

devices they are prescribed.

 Provide clear policy direction and supplemental training and oversight to all staff,

custody and health care, regarding privacy in health care appointments.

 Behavioral health: address the concerns in Dr. Gage’s report, particularly

regarding paucity of treatment, safety cell and restraint processes, and out of cell

time. Please also send me a copy of the Program Guide.

 Investigate Ms.

’s allegations.

 Administrative and other restricted housing: continue to work toward substantially

greater out of cell time for people in administrative housing and similarly

restricted settings, including through more group dayroom releases; generate data

on length of stay, both average and median, to inform efforts to decrease time

spent under these conditions; provide workbooks and other productive means for

people to pass the time.

 Revisit system-wide policies on clothing for cold and inclement weather,

particularly for people who must go outside in order to obtain health care at Smith.

 Review and address the allegations regarding behavior of some custody staff at

Smith.

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EXHIBIT R

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 320 of 343 Page ID #:17550
Grey v. Riverside
Plaintiffs’ tour of Smith Correctional Facility, Cois Byrd Correctional Facility, Robert Presley Detention Center, January 28-30, 2019
On January 28-30, 2019, attorneys Sara Norman and Shira Tevah toured the Smith Correctional Facility, Cois Byrd Correctional Facility, and Robert Presley Detention Center. We spoke to a dozen or more people housed in each jail, both people we requested to see and people whose names we picked randomly from lists of patients with disabilities and medical and mental health diagnoses. We reviewed health care records for numerous patients. We also talked to custody, medical and behavioral health staff and administrators, and had a meeting with Chief Deputy Sheriff Edward Delgado; Deborah Johnson, RUHS Behavioral Health Assistant Director for Programs; Brian Betz, Behavioral Health Administrator for Detention Health Services; CMO of the County Correctional Health Mike Mesisca; Correctional Health Care Administrator Bonnie Carl; and others on the executive team.
I am grateful, as always, for the courteous and open approach that characterizes the County’s response to these visits. In particular, I deeply appreciate the clear commitment to quality care from the new leaders in the Sheriff’s Department and Correctional Health, and have long valued the ongoing dedication of the Behavioral Health leaders. Line staff I encountered were uniformly helpful, and the custody health care liaisons, including Sergeant Nelson at Smith, Sergeant Conn at Byrd, and Sergeant Rivera at Presley, were all impressive. Although Lieutenant Hal Reed will be sorely missed as health care liaison, given his professionalism, thoughtfulness, and problemsolving approach, we are clearly in good hands with his replacement, Lieutenant Tom Hyland.
This report is intended to document general policy and systemic issues that we raised on the tour. It is not intended as an overview or a comprehensive set of findings – those reviews are left to the Court experts -- but to memorialize concerns for ongoing discussion and to suggest measures to move more effectively towards compliance.
1. Positive developments
There are significant signs of progress. I continue to be impressed with the integration of TechCare into the care systems for the jail, allowing health care staff far greater access to essential patient information.
There were differences in how some medical patients talked about their care. Every diabetic patient we talked to at Smith and Cois Byrd was satisfied with his or her care. This is an important sign that crucial treatment systems have been developed, given that diabetic care is difficult to manage in a correctional environment. Similarly, from
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the people we talked to and the TechCare files we reviewed, it appears that medication administration and start-up times after intake are significantly better. These are anecdotal findings; I will defer to the more comprehensive, data-driven findings from the Court Experts. But I did not get comparable responses from patients two years ago, and the difference is notable and praiseworthy.

2. Intake holding cells (for booking, hospital returns, and court dates)

People with disabilities continue to describe struggles with being improperly placed in inaccessible holding cells:



, who uses a wheelchair, said at his intake to Cois

Byrd three weeks ago, he spent one and a half days in a holding cell with no grab

bars on the toilet. He said he slept on a bench and was not given a blanket.



, Byrd A Pod, said that in October 2018 he spent more

than 19 hours in intake at Presley. He reported that his extra-wide wheelchair did

not fit in the cell doorway, so it was taken from him. He said he was given a

walker instead, and could barely use it (he had been bed-bound for seven months

in the hospital). He said it was then taken away from him while he was in the cell,

and when he asked for it back to use the toilet, he was refused; the deputy said

“figure it out.” He said he did not use the toilet the whole time.

In addition, we talked to several people who said they spent extreme lengths of time in holding cells in the intake area after being discharged from the hospital:



, currently housed in Byrd E Pod, described two

experiences at Presley in August and November 2017, in which he returned from

the hospital following heart attacks and spent approximately three days each time

in a holding cell filled with other people, with nowhere to lie down. He described

an experience at Byrd in November 2017, in which Deputy Hartman told him to

move faster. He said that he could not, given his weakened heart condition. He

said the deputy slammed him into the wall and told him to raise his arms, which he

couldn’t do because of his recent heart surgery. He said he subsequently spent

three days in his cell, unable to get up, and eventually had another heart attack and

was sent back to the hospital.



currently housed in Smith Building 15, said he spent

three days in an intake cell in Riverside, from September 24-27, 2018, on his

return from the hospital after falling from an upper bunk in Byrd (despite his lower

bunk chrono).

We were told of several other intake problems:

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

, said that at Smith, the week prior to the tour, he

spent two to three days in a holding cell at intake with seven or eight other people,

sleeping on the floor. He said they were given blankets after the first night. He

was shortly thereafter found to have staph or MRSA in his finger and sent to the

emergency room. The long-term stay in extremely close quarters is clearly a

public health concern, given his condition; although staff could not have known of

it at the time, this situation illustrates why such practices present a risk of harm to

people’s health.



said that last week he spent more than 12 hours in

intake at Southwest while detoxing from alcohol and meth, with no blankets or

food.

Lengthy stays in these holding cells, under crowded and often unsanitary conditions, are a risk for people with disabilities and medical and mental health conditions. We had a constructive discussion on the tour about ways to ensure hospital discharges go directly to a specific placement instead of spending lengthy periods in intake; we look forward to discussing potential solutions for the other concerns.

3. Confidentiality

I was pleased to see the response to my July 2018 tour report in this area: audits and training sounds like a productive approach to change staff behavior and improve confidentiality of health care information and encounters.

We continued to hear of concerns. People in Byrd complained that medical appointments in B, E, and G Pods were not confidential, with the doors open and the patients sitting near the door, which allows the deputy outside and passersby to overhear. We understand that the doors swing in so that shutting the door might still present a safety concern, since an attacker inside could block the deputy outside from intervening. We also understand there have been recent attacks on nurses, making security a particularly charged topic at present. But the compromised confidentiality and lack of individualized decision-making must be addressed. At the very least the doors should be changed for ones that swing out, so that they can be shut and the deputy outside can maintain visual supervision through the window.

In Smith,

told us about an incident in which,

first, a deputy announced to her in the dayroom in a loud voice that she needed to come

get a shot, and, second, the same deputy was inside the room with her when she had a

medical encounter and received a syphilis diagnosis. Another time, she said, a nurse

talking to her at the door to her dormitory—which houses 16 women—revealed her

syphilis diagnosis.

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We witnessed several questionable practices on this tour: In Byrd G Pod, we were waiting for the dayroom to be cleared so we could look at a particular cell. We were standing in a group outside the health care examination room, closer to the control area than to the deputy supervising the appointment. We could clearly hear the voice of the patient sitting in the chair just inside the exam room. People were coming and going in the hallway, including other people housed in the jail, and anyone passing by would be able to hear the content of the communication.

As Smith, we were walking outside and passed a deputy with a line of people who looked like workers returning from their job. She called out two of them by name, one for diabetic line and the other by asking, “you wanted to see the nurse, right?” It would be better for people not to be singled out as needing treatment, since it might discourage patients from seeking care.

4. ADA and disability access

Accessible holding cells: I was glad to see the County’s response to prior concerns about inaccessible transport and holding cells. Spot checking, regular audits, and frequent interviews with the patient population sound like important remedial steps. I look forward to discussing more specifically on the next tour the results of these efforts.

There were signs of progress on this tour. Several people we talked to said that

they were sometimes or usually allowed to keep their assistive devices in holding cells

and uncuffed for lunch. However, there were reports of ongoing problems: for example,

, at Cois Byrd in early January, and

at Presley in October 2018, detailed lengthy stays in inaccessible holding

cells (see Section 2, above).

who is now at Presley, said that

when he went to court in Banning two weeks ago, he spent four hours in a holding cell in

Smith, handcuffed the entire time. He said that the deputies refused his request to uncuff

his hands so he could use the toilet.

Accessible housing: People in Cois Byrd who use wheelchairs were housed

inaccessibly.

, in G Pod is a full-time wheelchair user who

can barely squeeze his wheelchair through his cell door (Dayroom 2, cell 34). His cell is

smaller than the others on his row and the stool in front of the desk is fixed in place

instead of swinging out the way. As a result, he does not have access to the desk. Lt.

Hyland agreed he should be moved and the cell should not be designated for wheelchair

users.

In A Pod, the medical unit, we saw only two cells with grab bars around the toilets: 8 and 10. They were poorly placed, however: not at right angles, and with the side bar too far from the toilet. These are not accessible placements.

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, was transferred from Byrd to Smith on December 3, 2018, because he was going to trial nearby. However, he is a full-time wheelchair user and cannot be housed accessibly at Smith. He said he had to argue with deputies about his placement and also to prevent the removal of his wheelchair. He was sent back to Byrd the next day, as the TechCare records confirm. He should never have been sent in the first place.

At Smith, we talked to

, who is prescribed a walker but

was housed on the upper tier in Building 15. This should not be allowed to happen. (He

also said he was also housed on an upper bunk at Byrd in September 2018 in violation of

a chrono, and rolled off, hurting his back and requiring a trip to the hospital.)

Assistive devices:

in Byrd A Pod, came to Byrd from

Presley around October, after being in the hospital for many months. He said he came

with an extra wide wheelchair, which he needs. After a short time at Byrd, he asked to

move to a walker to help him start to ambulate, and he was given one, with the

wheelchair kept in the hall for distance travel. But he said that the tag indicating it was

his fell off, and by mid-November it had disappeared. He said he asked for it repeatedly

but was told it was missing. He came to his interview with me in a shoddy wheelchair

with no footrests or sides, which is not acceptable for him – his feet were dragging and he

was spilling over the edges. He said he was provided with whatever wheelchair could be

found when he needed one. That is unacceptable – a wheelchair is a prescription device

and if his was missing, he should have been provided a replacement that met his needs.

This one was not in fact missing – Sergeant Conn found it in a matter of minutes in a

supply closet.

, housed at Smith Building 16, who uses a walker, said that he is not allowed to have it in his cell and has fallen as a result. For example, he said he was not given it for a recent court date and fell in the corridor. He said he did not ask for it because he said he had been told in the past he could not have it and deputies “made it known” he would not get it. He is seriously mentally ill; the default should be that he has his walker and is not allowed to leave without it, instead of requiring him to speak up in a situation in which he might be passive or fearful.

As a general matter, these serious incidents will keep happening unless people are allowed to keep their assistive devices at all times as the default, and custody and medical staff accept this as the rule. I do not understand why this rule has not been adopted in Riverside. The generalized safety concerns that I have been given do not stand up, given that CDCR allows people to keep their assistive devices with them at all times unless that individual has misused the device, and has operated even maximum security yards in this way for many years.

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The rule seems to extend to even apparently innocuous medical devices. , in Byrd E Pod, said he was not allowed to keep a compression
pillow in 2017 when he returned to Byrd after bypass surgery; it was removed for security reasons. He said that a staff member later secretly gave him a blanket wrapped up to resemble the pillow, which he said was useful and for which he was immensely grateful.

Housing accommodations: Several people with disabilities interviewed on the 7th

floor of Presley said that they sometimes have difficulty getting off their beds and coming

to the door to get their medications: for example,

said that his

left side is paralyzed from a stroke and he sometimes has difficulty getting up. Patients

said that most nurses will not take the medications to the patients in bed, but instead

require them to come to the door. They were very appreciative of the one nurse who will

accommodate them in this way. It seems like a small measure to accommodate certain

people whose disabilities make this effort difficult.

Why not allow people with mobility impairments on the 7th floor at Presley to have the TV remote control in their dorms? The current process requires them to flag down a passing deputy to turn the channel, which adds to the deputies’ workload and can be difficult for people with mobility impairments. Sheriffs’ department administrators brainstormed ways this can be accomplished at our meeting; I look forward to hearing about implementation on my next tour.

5. Staffing

The Remedial Plan requires an annual staffing review and analysis. I would like to receive documentation of this review.

I noted significant vacancies for medical staff: the assistant administrator, the UM nurse, two of four QA coordinators, two of seven MDs, two of nine NPs, three of nine senior nurses, three telemedicine nurses, and four of 13 medical records technicians. For behavioral health, the staffing looks fairly good, with only one psychiatrist at Riverside and several recreation therapist positions vacant.

6. Behavioral health

The patients we interviewed in the mental health unit at Smith (Building 16) were generally getting the medications they believed they needed, but reported a dearth of groups and very few one-on-one meetings with behavioral health staff. Many of them presented very obvious symptoms of mental illness. Those who did receive group or individualized treatment found it valuable. We were glad to hear that six clinical therapists were hired in December – that will hopefully make a big difference in providing treatment to this population.

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We heard from these patients that their dayroom time is separated for the upper and lower tiers. In other words, the 16 people on the upper tier and the 16 people on the lower tier are given dayroom at separate times, which halves the available out-of-cell time for all of them. There did not appear to be a security justification for limiting all the patients in this way. If some individuals are not appropriate to come out to dayroom with the entire group, due to past behavior or clinically determined limitations, surely others can. I suggested on the tour that staff explore the use of extra dayroom time as an incentive for people who can program with everyone?

We also passed on to staff the names of several patients who seemed in significant

distress and asked that they be seen: At Smith,

(whom we heard about

from another patient),

(who

subsequent to our interview had been placed in a safety cell), and

7. Miscellaneous

We heard some complaints from patients that they were charged copays for medical encounters to get lab results from an HIV blood test or diabetic compression socks, which seem like they could fall under chronic care exceptions. I ask that you send copies of your policies on copay charges and any other health care charges, including any exceptions for indigent patients.

On the next tour, I would like to discuss treatment for Hepatitis C, which we discussed briefly at our final meeting. We were given an “active HCV” list but we didn’t talk to anyone actually getting treatment yet.

8. Individual health care concerns

We raised the following individual concerns with staff at the facilities, but request a response as to any follow-up.

Cois Byrd Detention Center

, B Pod: Mr.

told me that he is 74 years old and

that he has dementia and was detoxing from methadone maintenance. He was not listed

on the detox list we were provided. He was shaking with cold when I saw him, although

I was told that he was quickly provided with a sweatshirt after I requested it. Given his

age and his self-reported dementia, detoxing, and heart condition, he is medically fragile

and should have been followed more closely.

F Pod: I am concerned that Mr.

serious

injury might have been missed by a nurse, and an appointment with a provider that might

have caught the problem never took place. On Saturday, January 12, 2019, Mr.

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injured his hand. I confirmed in TechCare that he saw a nurse, who indicated he would be seen on MD sick call the following Monday. He was never seen, and not examined until a different nurse saw him the following Saturday and immediately sent him to the hospital, where he was found to have a fracture and recommended for orthopedic evaluation as soon as possible. This case should be reviewed for possible violations of emergency protocols and follow-up care requirements.

told us that he had previously entered the jail and received bridging medications right away, but upon his most recent reentry he had not received his medications for over a week. He believed he would be leaving the jail on January 26 and wanted to make sure he had a 30-day supply upon release. He also told us that during his prior release around January 17, he had been dropped off at 2 a.m. in a place he did not recognize, in the rain and without shoes.

described having been interrogated by law enforcement at the Sheriff’s department for approximately 40 hours, while detoxing, and without food, before being brought to the jail.

Smith Correctional Facility

who was 12 weeks pregnant upon arrival at

Smith, informed us that she has lupus. She said the doctor she saw at 19 weeks pregnant

at Moreno Valley Hospital prescribed lupus medication (that her prior doctor had

discontinued before she was arrested), but that it took 12-13 weeks after her arrest for her

to receive the medication in custody. She told us that she experienced lupus flare-ups in

the interim. Ms.

was also concerned about getting to see a rheumatologist and

making sure there would not be a lapse in the lupus medication.

had just arrived at the facility the day before our tour. He informed us that he takes a sleeping aid, as well as medication for anxiety, depression, and schizophrenia. He told us that he had called the police in the midst of a mental health episode or breakdown because he felt he needed help, which resulted in his arrest. He said that although he spoke to mental health staff at the jail during intake, he had not spoken to any mental health staff since then although he asked to. He let us know he has a history of self-harming behavior and he wasn’t sure if he was OK.

Robert Presley Detention Center

The trays that hold health care request forms (blue slips) and grievances were empty on the second floor A side in all three dayrooms. They were also missing in one of the dayrooms on the B side of the sixth floor. We did not do a systematic review, but the fact that four of the five dayrooms we observed were missing the forms indicates a widespread problem. Staff in one unit said that people take the papers and use them for

8

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 328 of 343 Page ID #:17558

other purposes, but the management difficulties that entails do not excuse the failure to have them readily available for people who need them for their intended purpose.

was housed on the 7th floor. He said that he

receives dialysis at the jail but does not have any resources to continue this care or

connections to help him in the area when he is released, which he thinks will be in the

third or fourth week of February. Similarly,

also on the 7th

floor, said that he was at a nursing home when he was arrested, and uses a wheelchair due

to a below-the-knee amputation on his left side (with no prosthetic) and a recent partial

amputation of his right foot. He said that he cannot return to the nursing home and has

no resources to find a place to live on release, which he believes will be in February or

March. We were told on the tour that the case managers can help them with discharge

planning, which is good to hear.

a wheelchair user on the 7th floor, said that he is occasionally incontinent and it can be hard to get diapers and extra clothing from staff when he soils himself.

, told us that he had requested to be evaluated for his Hepatitis C seven months prior, and had never received any response to his request.

informed us that she has lupus but was not receiving

any treatment for it at the jail. She believed she previously received prednisone shots at

the hospital when she was detained at Smith. She also described a medical emergency

incident around January 27, 2019, in which she threw her back out and was unable to

move, and a nurse and deputy came into her cell. After the nurse examined her and called

the doctor, who prescribed muscle relaxers, Ms.

said the nurse came back to

administer the medication, and the deputy accompanied the nurse into the cell again

although both the nurse and the deputy knew at that point that Ms.

was

immobilized by back pain.

9. Next steps

To summarize, we ask for the following actions:

1. Intake holding cells: We ask that the County review its practices on keeping people in holding cells during booking, processing in and out of court, and particularly for medical transfers and hospital returns, and ensure that stays are shortened and that conditions are carefully monitored. People must have accessible placements and access to their assistive devices. On the tour, we discussed ways in which hospital returns could be planned so that people spend minimal time in intake, and are moved directly into a waiting, accessible cell. I

9

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 329 of 343 Page ID #:17559
am grateful for the creativity and problem-solving approach and look forward to hearing solutions for these patients as well as more generally.
2. Confidentiality: We applaud the efforts already undertaken, but more must be done with the physical plant, such as the doors in Byrd exam rooms, and to raise staff consciousness that health care appointments and communication about health-related matters should be conducted in as confidential a manner as possible.
3. Accessible holding cells and accessible housing: The County must determine which housing placements are accessible for which disabilities, and do a regular review to ensure people are accessibly placed (ground floor, lower bunk, wheelchair accessible cells, etc.) Lieutenant Reed already started working on a plan for this with Sergeant Nelson in Smith, to do weekly reviews. That is an excellent step. But there must also be a system to review transfers of people with disabilities before the fact, including hospital discharges, and to ensure they are being sent to open and accessible placements, and accommodated in in accessible holding cells along the way.
4. Assistive devices: People should be allowed to keep their assistive devices at all times as the default, and custody and medical staff should be trained accept this as the rule. Exceptions should be made only for patients who misuse their own devices.
5. Staffing: Please provide documentation of the annual staffing review and analysis required by the Remedial Plan.
6. Dayroom time for mental health programs (Smith Building 16): We ask that the County review dayroom time policies in the mental health buildings to try to give as much out-of-cell time to the population as possible, including using additional dayroom as an incentive for patients to learn to program in larger groups.
7. Policies: Please provide any policies on copay charges and any other health care charges, including any exceptions for indigent patients. Please also provide any Hepatitis C treatment policies or protocols.
8. Individual concerns: Please provide responses on the individual concerns that we raised on the tour and repeated in this report.
10

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EXHIBIT S

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 331 of 343 Page ID #:17561
CDCR Announces Plan to Further Protect Staff and Inmates from the Spread of COVID-19 in State Prisons
March 31, 2020
Plan will create increased capacity and space to help with inmate movement, physical distancing, isolation efforts
The department has taken several actions to mitigate the spread of COVID-19, including temporarily suspending the intake of new inmates, cancellation of in-person visiting, practicing physical distancing, and providing hand sanitizer across the system
SACRAMENTO – Today, the California Department of Corrections and Rehabilitation (CDCR) is amplifying actions to protect staff and inmates at the state’s institutions by implementing additional measures to help mitigate the spread of COVID-19. The measures will increase both capacity and physical space at the state’s prisons, which will allow the department to increase physical distancing, and assist it with isolation and quarantine efforts for suspected or positive COVID-19 cases.
CDCR’s plan includes expediting the transition to parole for eligible inmates who have 60 days or less to serve on their sentences and are not currently serving time for a violent crime as defined by law, a sex offense, or domestic violence. The plan also includes making more use of the state’s private and public Community Correctional Facilities, as well maximizing open spaces in the prisons, such as gymnasiums, to increase capacity and inmate movement options.
“We do not take these new measures lightly. Our first commitment at CDCR is ensuring safety – of our staff, of the incarcerated population, of others inside our institutions, and of the community at large,” said CDCR Secretary Ralph Diaz. “However, in the face of a global pandemic, we must consider the risk of COVID-19 infection as a grave threat to safety, too.”
These new measures build on many others already taken to reduce the risk of COVID-19 to all who work and live in the state prison system. Those measures include:
 Mandatory verbal and temperature screenings for staff before they enter any institutions and other CDCR work sites
 Suspension of intake from county jails, projected to reduce the population by 3,000 within 30 days
 Suspension of visitation; inmates will get additional free phone calls to their loved ones, made available through a partnership with inmate telephone network provider Global Tel Link (GTL)
 Suspension of access by volunteers and rehabilitative program providers  Suspension of inmate movement, other than for critical purposes

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 332 of 343 Page ID #:17562
 Measures to support increased physical distancing, including reducing the number of inmates who use common spaces at the same time
 Reinforced commitment to hygiene both institutional and personal, including greater availability of soap and hand sanitizer.
 Developed comprehensive health care guidelines based on CDC and CDPH recommendations for correctional settings, which includes procedures for infection control, assessment, testing, treatment, proper use of PPE and quarantine/isolation. Deployed educational materials for staff on the new guidelines, including posters, quick reference pocket guides, webinars and websites.
 Modified the delivery of non-emergent health care procedures such as routine dentals cleanings to redirect supplies of PPE. Created a network among all state-managed facilities to redirect PPE as needed.
 Created handouts, posters and continually updated video messaging for the population about COVID-19 and what CDCR and CCHCS is doing to respond to the virus.
As of March 30, 22 employees and four inmates have tested positive for COVID-19. For updated information, please view the department’s Patient Testing Tracker.
CDCR estimates that up to 3,500 incarcerated persons would be eligible for an expedited transition to parole. The department is preparing on-site multidisciplinary teams at each institution to expedite the pre-release coordination. Review of potential expedited transition will first focus on those with less than 30 days to serve, then those with less than 60 days to serve. Returning individuals will release to state parole or local probation supervision, or will discharge, depending on their individual sentence.
CDCR will also immediately expand space in community-based parolee programs, particularly for those at risk of homelessness or housing instability. Additionally, the department has been in communication with its county partners regarding these measures and will coordinate with them to promote a successful reentry. Finally, all victim notification requirements are being met.
For updates and information on CDCR’s efforts to protect staff and inmates from COVID-19, visit here. For Frequently Asked Questions on this plan, visit here.

Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 333 of 343 Page ID #:17563
EXHIBIT T

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EXHIBIT U

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 341 of 343 Page ID #:17571
EXHIBIT V

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Case 5:13-cv-00444-VAP-OP Document 178-2 Filed 04/06/20 Page 343 of 343 Page ID #:17573

 
 Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 1 of 20 Page ID #:17754

1 JAMES E. BROWN, Assistant County Counsel (SBN 162579)

KELLY A. MORAN, Deputy County Counsel (SBN 267147)

2 OFFICE OF COUNTY COUNSEL

3960 Orange Street, Suite 500

3 Riverside, CA 92501-3674

Telephone: (951) 955-6300

4 Facsimile: (951) 955-6363

Email: Jebbrown@rivco.org

5

kmoran@rivco.org

6 ARTHUR K. CUNNINGHAM, SBN 97506 LEWIS BRISBOIS BISGAARD & SMITH LLP
7 650 East Hospitality Lane, Suite 600 San Bernardino, California 92408
8 (909) 387-1130 - Phone (909) 387-1138 – Fax
9 Email: Arthur.Cunningham@lewisbrisbois.com

10
11 Attorneys for Defendant, COUNTY OF RIVERSIDE

12

13

UNITED STATES DISTRICT COURT

14

CENTRAL DISTRICT OF CALIFORNIA

15

QUINTON GRAY, et al., on behalf of themselves and all others similarly

16 situated,

17

Plaintiffs,

18 v.

19

COUNTY OF RIVERSIDE, Defendant.

20

21

22

23

24

25

26

) CASE NO. EDCV13-0444 VAP (OP) ) ) CLASS ACTION ) ) COUNTY OF RIVERSIDE’S ) OPPOSITION TO PLAINTIFFS’ ) EMERGENCY MOTION TO ) ENFORCE, OR IN THE ) ALTERNATIVE MODIFY, CONSENT ) DECREE (DOCKET NUMBER 177) ) ) (Filed concurrently with: ) Declaration of James E. Brown; ) Declaration of Bonnie Carl; ) Declaration of Dr. Matthew Chang; ) Declaration of Thomas Hyland; and ) Declaration of Misha Graves) ) ) JUDGE: Hon. Virginia Phillips ) DATE: TBD ) TIME: TBD ) COURTROOM: 8A ) LOCATION: 350 W. First Street, Los ) Angeles, CA 90012

27

28
1
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 2 of 20 Page ID #:17755

1

2
TABLE OF CONTENTS

3

4

Page

5 I. BACKGROUND AND FACTS ...............................................

4

6

II. LEGAL ARGUMENT................................................................

8

7

8

A. Plaintiffs have failed to Adhere to the Procedure Requirements

9

Outlined in the Consent Decree and thus their Emergency

10

Motion is Improper................................................................

8

11

12

B. Plaintiffs’ Request for Modification of the Remedial Plan

13

Is Improper ............................................................................

10

14
C. Plaintiffs’ Requested Relief is Barred by the Prison
15

16

Litigation Reform Act ...........................................................

12

17

D. The Court Must Give Deference to the County and the

18
County’s Record of Responsiveness to the COVID-19
19

20

Pandemic ...............................................................................

14

21

III. CONCLUSION...........................................................................

19

22

23

24

25

26

27

28
2
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 3 of 20 Page ID #:17756

1

TABLE OF AUTHORITIES

2
Cases
3

4 Cf. Parsons v. Ryan, 912 F.3d 486, 501 (9th Cir. 2018) ..................................................... 11

5 Coleman v. Brown, 922 F. Supp. 2d 1004, 1048 (E.D. Cal./N.D. Cal. 2013)..................... 11
6
Gates v. Rowland, 39 F.3d 1439, 1448 (9th Cir. 1994) ....................................................... 15
7

8 Griffin v. Gomez, 741 F.3d 10 (9th Cir. 2014)..................................................................... 15

9 Michenfelder v. Sumner, 860 F.2d 328 (9th Cir. 1988) ....................................................... 15
10
11 O’Lone v. Estate of Shabazz, 482 U.S. 342 (1987) ............................................................. 15

12 Procunier v. Martinez, 416 U.S. 396, 405 (1974) ............................................................... 15

13
Rufo v. Inmates of Suffolk Cty. Jail, 502 U.S. 367 (1992)................................................... 11
14
15 Sandin v. Conner, 515 U.S. 472, 482-83 (1995) ................................................................. 15

16 Thornburgh v. Abbott, 490 U.S. 401 (1989) ........................................................................ 15

17
Turner v. Safley, 482 U.S. 78, 84-85 (1987)........................................................................ 15
18

19 Statutes

20 18 U.S.C. § 3626(a)(1)(A) ............................................................................................. 12, 14
21

22 Other Authorities

23 Prison Litigation Reform Act.....................................................................................7, 12, 14
24
25 Rules

26 Rule 60(b)(5)........................................................................................................................ 11
27

28
3
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 4 of 20 Page ID #:17757

1 TO THE PLAINTIFFS AND THEIR COUNSEL OF RECORD:

2
DEFENDANTS, COUNTY OF RIVERSIDE (hereinafter the “County”) hereby offer
3
4 the following Opposition to Plaintiffs’ Emergency Motion to Enforce, or in the Alternative

5 Modify, the Consent Decree (Docket No. 177).

6
I.
7

8

BACKGROUND AND FACTS

9

These are unprecedented times. To date, the worldwide pandemic of COVID-19

10
disease, also known as “novel coronavirus,” has infected over 1.5 million individuals
11
12 worldwide in over 180 countries and is implicated in over 94,000 worldwide deaths,

13 including over 1,200 cases and 33 deaths in Riverside County. In response to this healthcare
14
crisis, the County, and the elected officials and employees therein, have been working
15
16 around the clock to determine how to best meet the needs of all residents. From the youngest

17 to the oldest, the inmate to the un-incarcerated, and the unsheltered to those residing in
18
mansions, the County is focused on protecting the health and safety of the more than 2.4
19
20 million people within its boundaries.

21

The County shares many of the concerns expressed in Plaintiffs’ Emergency Motion

22
to Enforce, or in the Alternative Modify, the Consent Decree (Motion) relating to the
23

24 potential impact that COVID-19 could have upon the County’s correctional system,

25 including inmates and staff. It is for this reason that the County has taken the following
26
extraordinary and unprecedented proactive measures (among many others described in
27
28 greater detail herein and in the declarations filed in support of the County’s Opposition)
4 COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 5 of 20 Page ID #:17758

1 designed to slow the spread of COVID-19 and to protect the health and well-being of those

2
who live and work within the County’s correctional facilities:
3

4

 All inmates are pre-screened prior to booking per the guidelines issued by the

5

Centers for Disease Control and Prevention (“CDC”). Inmates are

6
subsequently housed at the hospital, placed in quarantine, observation, or
7

8

housed according to their classification, per medical staff.

9

 The movement of inmates who test positive and those who are symptomatic are

10
tracked by staff to determine possible exposure and address accordingly.
11

12

 All inmate work crews receive temperature checks prior to working in the

13

facility and around food.

14
 Unlimited soap is provided to all inmates free of charge.
15

16

 A CDC recommended cleaning solution is provided to inmates throughout the

17

day and after every meal to sanitize inmate areas.

18

19

 Incoming and outgoing inmate mail rests in paper bags prior to handling and

20

processing.

21
 Most meals are served in disposable mediums.
22

23

 Inmate movement is restricted to only when absolutely necessary both within

24

a single facility and throughout the Corrections Division as a whole.

25
 All inmates and staff have been issued face coverings per the CDC guidelines,
26

27

which are to be worn at all times.

28
5
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 6 of 20 Page ID #:17759

1

 Inmate programs were modified to provide for educational and rehabilitative

2
services absent staff contact to promote social distancing.
3

4

 Dayroom time is implemented in ¼ tier dayroom increments to limit the

5

number of inmates in a common space and provide for social distancing.

6
 Inmates in dayrooms are regularly directed to adhere to social distancing
7

8

requirements.

9

 Dayrooms and common areas are sanitized with CDC approved cleansers

10
between use by inmates.
11

12

 Inmates receive education on personal hygiene, hand washing, social

13

distancing, and prevention of the spread of the coronavirus via the inmate

14

dedicated channel, which is broadcasted on televisions within each dayroom.
15

16

 No non-law enforcement individuals are permitted to come in contact with

17
inmates.
18

19

 Because personal visiting was cancelled as a result of the COVID-19 virus, two

20

free telephone calls per week have been provided by the Riverside County

21
Sheriff’s Department (“RSO”) to each inmate.
22

23

 By utilizing established system-wide partnerships, the County has been able to

24

offer technological-based alternatives to reduce transportation and to

25
encourage adherence to social distancing guidelines, such as an increase the
26

27

28
6
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 7 of 20 Page ID #:17760

1

number of video court appearances, telehealth appointments, and access to

2
professional visits via electronic means.

3

4

In short, the County has already taken immediate, bold, and appropriate steps in

5 response to this rapidly evolving crisis, and is constantly evaluating all processes to ensure

6
that the health and welfare of all inmates and staff is protected. The record demonstrates
7
8 that the County is working tirelessly to address the COVID-19 pandemic and its associated

9 risks to inmates, staff, and the community at large. This record in no way establishes a

10
pattern of deliberate indifference or a legal basis for the judicial intervention into and the
11
12 micromanagement of the County’s correctional system that has been requested by Plaintiffs.

13

Plaintiffs have not met the standards required for Court intervention. They have failed

14
to utilize the required mediation process dictated by the controlling Consent Decree in this
15
16 matter prior to coming before the Court. They have failed to adhere to the process required

17 by the Consent Decree for a modification of the Remedial Plan. They have failed to meet
18
the high standards for a prisoner release order as set forth in the Prison Litigation Reform
19
20 Act (“PLRA”), and this Court therefore cannot grant the requested relief. And finally, they

21 have failed to demonstrate that the County has been deliberately indifferent to the risk of
22
harm posed by COVID-19. Indeed, the evidence is overwhelmingly to the contrary. For
23
24 these reasons, Plaintiffs’ Motion must be denied.

25 / / /
26
/ / /
27
28 / / /
7 COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 8 of 20 Page ID #:17761

1

II.

2
LEGAL ARGUMENT
3
4 A. Plaintiffs Have Failed to Adhere to the Procedural Requirements Outlined in

5

the Consent Decree and thus their Emergency Motion is Improper.

6
On June 7, 2016, the Parties entered into a Consent Decree to “ensure the provision
7
8 of constitutional health care and to ensure non-discrimination for inmates with disabilities

9 in the Riverside County Jails” following the filing of a Class Action lawsuit by Plaintiffs on

10
March 8, 2013. See Document No. 173, Paragraph 1, at 2:2-4. To the extent Plaintiffs’
11
12 Emergency Motion falls within the scope of, and is based upon, alleged violations of the

13 Consent Decree and Remedial Plan, the County contends that the Court should order the
14
Parties to resolve these matters via the Dispute Resolution provisions laid out and agreed
15
16 upon in the Consent Decree. See Document No. 173, Paragraphs 26-29, at 11:6-12:15.

17 Namely:

18
1) “… the parties shall conduct good faith negotiations to resolve informally any matter
19

20

in dispute, including but not limited to any contention that Defendant is not

21

substantially complying as required by this Consent Decree or the Remedial Plan(s),

22
or any contention that Defendant has demonstrated sufficient compliance with the
23

24

Consent Decree and/or Remedial Plan(s) that the Consent Decree and monitoring

25

thereunder should be modified or terminated….” See Document No. 173, Paragraph

26
26, at 11:8-15.
27

28
8
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 9 of 20 Page ID #:17762

1 2) “If the parties are unable to resolve the dispute within 30 days of the original notice,

2
either party may inform the relevant Court experts of the area of disagreement and

3

4

request that the experts evaluate the issue and prepare a report. The experts must

5

provide their report regarding the area of disagreement within 30 days of the

6
request…” See Document No. 173, Paragraph 27, at 11:18-23.
7
8 3) “If within 30 calendar days of receipt of the Court experts’ report, the parties are

9

unable to reach a mutually satisfactory resolution of the dispute, either party may

10
request mediation with Judge Raul Ramirez...” See Document No. 173, Paragraph 28,
11

12

at 12:4-6.

13 4) “If mediation with Judge Ramirez does not resolve the dispute to the mutual

14
satisfaction of the parties, either party may file a motion for relief to the Court of
15

16

continuing jurisdiction.” See Document No. 173, Paragraph 29, at 12:11-13.

17

This process was made part of the Consent Decree because that process, with these

18
Parties and Mediator Ramirez, successfully resolved the entire dispute between the Parties
19

20 in the past. Despite Plaintiffs’ concession that the Consent Decree sets forth this dispute

21 resolution process (See Document No. 177 at 17:22-27), Plaintiffs have attempted to bypass
22
the same through the filing of their underlying motion prior to engaging in mediation efforts.
23
24 The County requests that the Court deny Plaintiffs’ motion until after the Parties have an

25 opportunity to engage in mediation with Judge Raul Ramirez as required by Paragraph 28
26
of the Consent Decree. Only after mediation with Judge Ramirez has occurred and if a
27
28 dispute between the parties remains, would Plaintiffs be permitted to move for relief from
9 COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 10 of 20 Page ID #:17763

1 this Court. As detailed in Section D below and through the Declarations filed in support of

2
this Opposition, the County remains confident, however, that those issues raised by Plaintiffs
3
4 are likely to be resolved in whole or in large part though good faith mediation. In

5 anticipation of proper adherence to the process outlined in the Consent Decree, the County

6
has contacted retired Judge Raul Ramirez, confirmed his availability, and has provided
7
8 available dates (April 17th, 22nd, and 23rd) to Plaintiffs’ counsel for consideration. Plaintiffs

9 have declined to proceed with mediation prior to appearing before the Court. See

10
Declaration of James E. Brown, Paragraphs 2-4 at 2:9-28, Exhibits “B” and “C”.
11

12

Plaintiffs have failed to adhere to the procedural requirements set forth in the Consent

13 Decree and thus their motion is premature. The County respectfully requests that the Court
14
deny Plaintiffs’ motion unless and until the Consent Decree’s agreed-upon mediation
15
16 process has been completed.

17 B. Plaintiffs’ Request for a Modification of the Remedial Plan is Improper.
18
Plaintiffs have, once again, failed to adhere to the requirements of the Consent Decree.
19
20 Plaintiffs are correct in their representation that “…Plaintiffs may seek to modify the

21 Remedial Plan if the plan does not effectively accomplish those goals, or a modification is
22
necessary to ensure Plaintiff class members receive adequate healthcare under the Eighth
23
24 and Fourteenth…” See Document No. 177 at 25:11-15. However, Plaintiffs’ request

25 neglects to fully reference the requirements of Paragraph 11 of the Consent Decree which
26
states, “Any party wishing to modify the plan must submit a proposed modification to the
27
28 opposing party. The opposing party may request further information, request that the
10 COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 11 of 20 Page ID #:17764

1 modification(s) be reviewed by the Court’s experts, and/or request that the proposed

2
modification(s) be subjected to the dispute resolution process described below. If the parties
3
4 fail to reach agreement on the proposed modification(s), the party proposing the

5 modification(s) may seek relief from the Court.” See Document No. 173, Paragraph 11 at

6
6:4-10.
7

8

The County has not been provided with a proposed modification of the Remedial Plan

9 to review, or with the opportunity to engage in dispute resolution concerning the same. This

10
failure to adhere to the procedural requirements set forth in the Consent Decree bars any
11
12 modification to the Remedial Plan at this time. However, Plaintiffs gloss over the critical

13 fact that a modification of the Remedial Plan is only permitted to the extent necessary to
14
ensure that the remedial structure remains tailored to cure the alleged constitutional
15
16 violations previously found by this Court. Coleman v. Brown, 922 F. Supp. 2d 1004, 1048

17 (E.D. Cal./N.D. Cal. 2013) (citing Rufo v. Inmates of Suffolk Cty. Jail, 502 U.S. 367 (1992).
18
Similarly, Rule 60(b)(5) does not provide the Court with free-standing authority to remedy
19
20 any alleged harm the County may inflict upon Plaintiffs, regardless of whether it is tethered

21 to the previous findings of structural constitutional shortcomings in the delivery of medical
22
and mental health care. Cf. Parsons v. Ryan, 912 F.3d 486, 501 (9th Cir. 2018) (explaining
23
24 that a modification of relief was appropriate because it was not issued “in response to new

25 violations of federal rights”).
26
The impetus for the relief Plaintiffs seek by way of their emergency motion is entirely
27
28 different from the allegations which served as the basis for their 2013 lawsuit. The specific
11 COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 12 of 20 Page ID #:17765

1 harm Plaintiffs allege is not caused by the alleged constitutional shortcomings in

2
Defendants’ ability to provide a system of “minimally adequate” medical and mental health
3
4 services or alleged discrimination against certain inmates with disabilities. Any claimed

5 constitutional violation in the County’s current response to the COVID-19 crisis is different,

6
in both nature and degree, from the alleged violations underlying the 2013 lawsuit. The
7
8 Consent Decree and Remedial Plan from the 2013 lawsuit were never intended to prepare

9 the County to confront an unprecedented pandemic. Nor could they have been, given that

10
the entire world was unprepared for the crisis that has ensued as a result of the COVID-19
11
12 virus.

13

As Plaintiffs’ Motion can only seek to address a different constitutional injury than

14
those asserted in the underlying litigation, relief cannot be granted through a modification
15
16 of the existing Remedial Plan. In the absence any argument that the County is out of

17 compliance with the Consent Decree or Remedial Plan and seeking relief on an entirely
18
novel basis, Plaintiffs’ Motion can only be seen as an improper attempt to raise a new
19
20 lawsuit, one filed without a Complaint, class certification, or adherence to any other proper

21 procedure.

22
C. Plaintiffs’ Requested Relief is Barred by the Prison Litigation Reform Act.
23

24

The Prison Litigation Reform Act (“PLRA”) mandates that prospective relief must be

25 narrowly drawn, extend no further than necessary, and be the least intrusive means of
26
addressing the violation of the Federal right. 18 U.S.C. § 3626(a)(1)(A). Plaintiffs’ vague
27
28 suggestions - that the County move “detainees out of congregate living facilities”, “direct
12 COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 13 of 20 Page ID #:17766

1 transfers of people from one correctional facility” to the not-yet-ready to be populated John

2 J. Benoit Detention Center1, “relocate vulnerable populations” to unidentified outside
3
4 locations, and “…look[] at early releases and conduct them most days”- extend further than

5 necessary and are not the least intrusive means of addressing the purported violation of

6
Plaintiffs’ rights.
7

8

Public health experts agree that the spread of COVID-19 is best addressed through

9 physical distancing and heightened cleanliness, including thorough and frequent hand

10
washing and regularly cleaning and disinfecting frequently touched surfaces. Plaintiffs’
11
12 suggestions and recommendations are not the least intrusive means of accomplishing such

13 goals. In fact, as detailed more fully below, the County has already put into place a
14
comprehensive plan and practice of: increasing healthcare screening for COVID-19
15
16 symptoms; increasing the use of technological platforms to reduce the need for

17 transportation outside of the facility; increasing access to cleaning supplies and personal
18
hygiene items; and increasing the awareness of and ability to adhere to social distancing
19
20 guidelines. Thus, less intrusive alternatives to achieve “ready access to hygiene materials

21 and physical distancing” exist, and are already being implemented by the County.
22

23

24

25
1 As further detailed in the Declaration of Chief Deputy Misha Graves, the John J. Benoit
26
Detention Center is not currently available to house inmates. See Declaration of Misha
27
Graves, Paragraph 3-6 at 2:15-3:3.
28
13
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 14 of 20 Page ID #:17767

1

Notably, to the extent that Plaintiffs’ request or suggest that the County engage in

2
release of inmates to increase social distancing, the PLRA mandates that “no court shall
3
4 enter a prisoner release order unless” orders for less intrusive relief have failed to remedy

5 “the deprivation of the Federal right sought to be remedied through the prisoner release

6
order,” and the defendant has been given sufficient time to comply with the previous orders.
7
8 18 U.S.C. § 3626(a)(3)(A) (emphasis added). Here, Plaintiffs seek to remedy the alleged

9 “unnecessary and disproportionate risk of contracting COVID-19” because “physical

10
distancing -- is impossible in many of the crowded dormitories in the County’s jails” See
11
12 Document No. 177 at 19:19 – 20:3. Yet, no prior order in the underlying case has required

13 the County to take affirmative steps to mitigate inmates’ risk of contracting COVID-19.
14
Because Plaintiffs fail to meet this important statutory requirement, any such claim for relief
15
16 must fail.

17 D. The Court Must Give Deference to the County and the County’s Record of

18
Responsiveness to the COVID-19 Pandemic.
19

20

The separation of powers is one of the core principles upon which our federal and

21 state governments are built. This constitutional construct mandates that the three branches
22
of government–executive, legislative, and judicial–remain separate and not otherwise
23
24 infringe upon the authority of one another. As it relates to the prison system, the Supreme

25 Court has aptly observed that “‘courts are ill equipped to deal with the increasingly urgent
26
problems of prison administration and reform,’” recognizing that “running a prison is an
27
28 inordinately difficult undertaking that requires expertise, planning, and the commitment of
14 COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 15 of 20 Page ID #:17768

1 resources, all of which are peculiarly within the province of the legislative and executive

2
branches of government.” Turner v. Safley, 482 U.S. 78, 84-85 (1987) (citing Procunier v.
3
4 Martinez, 416 U.S. 396, 405 (1974) [overruled on other grounds in Thornburgh v. Abbott,

5 490 U.S. 401 (1989)]) (emphasis added). Critically, the Supreme Court has held that

6
“[p]rison administration is, moreover, a task that has been committed to the responsibility
7
8 of those branches, and separation of powers concerns counsel a policy of judicial restraint.

9 Where a state penal system is involved, federal courts have, as we indicated in Martinez,

10
additional reason to accord deference to the appropriate prison authorities.” Turner, 482 U.S.
11
12 at 85.

13

The separation of powers and deference concepts have been relied upon in a wide

14
range of matters involving prison administration and reform. See, e.g., O’Lone v. Estate of
15
16 Shabazz, 482 U.S. 342 (1987) (examining extent of inmates’ free exercise of religion and

17 deference given to prison officials); Michenfelder v. Sumner, 860 F.2d 328 (9th Cir. 1988)
18
(upholding prison’s policies concerning strip searches and use of tasers); Gates v. Rowland,
19
20 39 F.3d 1439, 1448 (9th Cir. 1994) (prison policy preventing HIV-positive inmates from

21 holding food service jobs was properly within prison authorities’ discretion); Griffin v.
22
Gomez, 741 F.3d 10 (9th Cir. 2014) (holding district court improperly impeded state prison
23
24 management by ordering release of inmate from administrative segregation unit during

25 standard evaluation of his gang status); see also, Sandin v. Conner, 515 U.S. 472, 482-83
26
(1995) (observing that “federal courts ought to afford appropriate deference and flexibility
27
28 to state officials trying to manage a volatile environment [in a prison]”). Where, as in this
15 COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 16 of 20 Page ID #:17769

1 situation, the County has been actively responding to a global pandemic with no precedent,

2
these foundational principles must not be set aside.

3

4

As a whole, the County has issued some of the most aggressive and swift protective

5 measures in the State in an attempt to control the spread of COVID-19. On March 8, 2020

6
the County’s Public Health Officer, Dr. Cameron Kaiser, issued a Declaration of Local
7
8 Health Emergency based on an imminent and proximate threat to public health from the

9 introduction of novel COVID-19 in Riverside County. On March 10, 2020 the Board of

10
Supervisors of the County of Riverside issued a Resolution proclaiming the existence of a
11
12 Local Emergency in the County of Riverside regarding COVID-19 and a Resolution

13 ratifying and extending the Declaration of Local Health Emergency due to COVID-19. Also
14
on March 10, 2020, Dr. Kaiser issued an Order cancelling the Coachella Valley Music and
15
16 Arts Festival and Stagecoach Music Festival. On March 12, 2020, Dr. Kaiser issued an

17 Order cancelling all events with an anticipated attendance in excess of 250 persons. On
18
March 13, 2020, Dr. Kaiser issued an Order closing all schools (extended through June 19,
19
20 2020 by subsequent Orders of the Health Officer). On March 16, 2020 Dr. Kaiser issued an

21 Order prohibiting all gatherings with expected presence above ten (10) individuals. On
22
March 27, 2020, Dr. Kaiser issued an Order restricting short-term lodgings within the
23
24 County of Riverside. On April 2, 2020, the Health Officer and the County Executive Officer

25 as the Director of Emergency Services issued an Order closing all golf courses and ancillary
26
use areas. On April 4, 2020, the Health Officer and the County Executive Officer as the
27
28 Director of Emergency Services issued an Order prohibiting all public gatherings and
16 COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN
THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 17 of 20 Page ID #:17770

1 requiring the use of face coverings by all persons. See Declaration of James E. Brown,

2
Paragraph 4, at 4:1 – 5:23, Exhibits D through L.

3

4

The steps taken by the County as pertaining to the protection of the inmate population

5 have been no less aggressive. The Department of Behavioral Health, Correctional Health,

6
and the Riverside County Sheriff’s Department have worked in cooperation with one
7
8 another to put into place a system-wide COVID-19 Pandemic Response Plan (“Response

9 Plan”), a true and correct copy of which is attached as Exhibit “A” to the Declaration of

10
Bonnie Carl and included by reference in the Declarations of Dr. Matthew Chang and Lt.
11
12 Thomas Hyland. Some of the key alterations that have been made in order to combat the

13 COVID-19 virus while ensuring that the needs of all inmates are met include:

14
 Telework opportunities have been provided to all non-essential staff and staff
15

16

screening is being put into place.

17

 All inmates are pre-screened prior to booking per the guidelines issued by the

18
CDC. Inmates are subsequently housed at the hospital, placed in quarantine,
19

20

observation, or housed according to their classification, per medical staff.

21

 The movement of inmates who test positive and those who are symptomatic are

22
tracked by staff to determine possible exposure and address accordingly.
23

24

 All inmate work crews receive temperature checks prior to working in the

25

facility and around food.

26

27

 Unlimited soap is provided to all inmates free of charge.

28
17
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 18 of 20 Page ID #:17771

1

 A CDC recommended cleaning solution is provided to inmates throughout the

2
day and after every meal to sanitize inmate areas.
3

4

 Incoming and outgoing inmate mail rests in paper bags prior to handling and

5

processing.

6
 Most meals are served in disposable mediums.
7

8

 Inmate movement is restricted to only when absolutely necessary both within

9

a single facility and throughout the Corrections Division as a whole.

10
 All inmates and staff have been issued face coverings per the CDC guidelines,
11

12

which are to be worn at all times.

13
 Inmate programs were modified to provide for educational and rehabilitative

14

15

services absent staff contact to promote social distancing.

16

 Dayroom time is implemented in ¼ tier dayroom increments to limit the

17
number of inmates in a common space and provide for social distancing.
18

19

 Inmates in dayrooms are regularly directed to adhere to social distancing

20

requirements.

21
 Dayrooms and common areas are sanitized with CDC approved cleansers
22

23

between use by inmates.

24

 Inmates receive education on personal hygiene, hand washing, social

25
distancing, and prevention of the spread of the coronavirus via the inmate
26

27

dedicated channel, which is broadcasted on televisions within each dayroom.

28
18
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 19 of 20 Page ID #:17772

1

 No non-law enforcement individuals are permitted to come in contact with

2
inmates.
3

4

 Because personal visiting was cancelled as a result of the COVID-19 virus, two

5

free telephone calls per week have been provided by the RSO to each inmate.

6
 By utilizing established system-wide partnerships, the County has been able to
7

8

offer technological-based alternatives to reduce transportation and to

9

encourage adherence to social distancing guidelines, such as an increase the

10
number of video court appearances, telehealth appointments, and access to
11

12

professional visits via electronic means.

13

The County has already taken significant and meaningful steps to mitigate the deadly

14
potential of COVID-19 both within the jails and throughout the County as a whole. It is
15

16 evident that this crisis is being taken extremely seriously by the County’s elected officials

17 and employees. Thus, the County respectfully urges that it be given the opportunity to
18
continue to address these important issues without federal judicial intervention.
19

20

III.

21

CONCLUSION

22

The County shares Plaintiffs’ concerns relative to the COVID-19 pandemic and the
23

24 risk it poses to the inmates and staff who live and work within the County’s correctional

25 system. Because of this, the County, by and through well-established system-wide
26
partnerships, has taken and continues to take aggressive and unprecedented steps to confront
27

28
19
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

Case 5:13-cv-00444-VAP-OP Document 183 Filed 04/10/20 Page 20 of 20 Page ID #:17773

1 this crisis. The County has taken meaningful steps to increase ready access to hygiene

2
materials and to promote physical distancing. Through these measures—and others which
3
4 have already been implemented or may be implemented in the coming days as the need

5 arises and in response to the constantly evolving threat presented by COVID-19—the

6
County is “reasonably” acting to ensure the safety and security of all who live and work
7
8 within the correctional facilities.

9

Just as Plaintiffs have failed to adhere to the procedural requirements of the Consent

10
Decree; failed to adequately relate their emergency motion to the underlying lawsuit; and
11
12 failed to make a showing of deliberate indifference on the part of the County in the handling

13 of the COVID-19 crisis, so too must their request for relief before this Court fail.
14
Accordingly, the County respectfully submits that the Court must deny Plaintiffs’
15
16 Emergency Motion to Enforce, or in the Alternative to Modify, the Consent Decree in its

17 entirety.
18
19 Dated: April 10, 2020
20
21
22

/s/ James E. Brown
By: JAMES E. BROWN Assistant County Counsel Attorneys for Defendant, COUNTY OF RIVERSIDE

23

24

25

26

27

28
20
COUNTY OF RIVERSIDE’S OPPOSITION TO PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE, OR IN THE ALTERNATIVE MODIFY, CONSENT DECREE (DOCKET NUMBER 177)

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 Case 5:13-cv-00444-VAP-OP Document 185 Filed 04/13/20 Page 1 of 11 Page ID #:17879

1 PRISON LAW OFFICE DONALD SPECTER (SBN 83925)

2 SARA NORMAN (SBN 189536)

3 1917 Fifth Street Berkeley, California 94710

4 Telephone: (510) 280-2621

5 Fax: (510) 280-2704 Email: dspecter@prisonlaw.com

6

snorman@prisonlaw.com

7

8 Attorneys for Plaintiffs

9

UNITED STATES DISTRICT COURT

10

FOR THE CENTRAL DISTRICT OF CALIFORNIA

11

EASTERN DIVISION – RIVERSIDE

12

13 QUINTON GRAY, et al., on behalf of 14 themselves and all others similarly 15 situated,
Plaintiffs, 16
17 v.

Case No. EDCV13-0444 VAP (OP)
CLASS ACTION
PLAINTIFFS’ REPLY IN SUPPORT OF EMERGENCY MOTION TO ENFORCE CONSENT DECREE

18 19 COUNTY OF RIVERSIDE, 20 Defendant.
21

Judge: Hon. Virginia A. Phillips Date: To be determined Time: To be determined Courtroom: Telephonic

22

23

24

25

26

27

28

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1

INTRODUCTION

2

Plaintiffs filed a motion to enforce the Consent Decree by requiring the

3 County to submit a plan to implement essential COVID-19 preparation measures:

4 physical distancing and fundamental hygiene precautions. In response, Defendant

5 submits a plan that falls far short of the standard of care as described by the Court’s

6 experts and the Centers for Disease Control and Prevention (CDC). Defendant

7 concedes that “the spread of COVID-19 is best addressed through physical

8 distancing and heightened cleanliness,” Def’s Opp. to Pltfs’ Emergency Motion,

9 April 10, 2020, ECF No. 183 (Opp.), at 13, and does not dispute that a large number

10 of people in the Riverside jails live in crowded dorms with serious sanitation

11 problems. Nonetheless, Defendant’s COVID-19 plan lacks adequate measures to

12 address these essential points. The Court should therefore order Defendant to come

13 up with a revised plan that addresses these deficiencies.

14

Plaintiffs’ motion further seeks enforcement of the Consent Decree provision

15 guaranteeing Plaintiffs ready access to relevant information to monitor Defendant’s

16 implementation of constitutionally adequate healthcare. Even the Opposition fails

17 to provide crucial information Plaintiffs have been seeking for several weeks, such

18 as how many people live in dorms, how close are their beds, and how many

19 quarantine and isolation cells are available.

20

The paucity of information and inadequacy of the plan to address the experts’

21 and CDC’s most critical concerns underscores the need for Court action to enforce

22 the basic principles underlying the Consent Decree: constitutional care and the flow

23 of essential information to monitor Defendant’s performance. Defendant failed to

24 produce a plan despite repeated requests until Plaintiffs filed a motion. Court

25 intervention is necessary to prevent further stonewalling. Further delays could have

26 drastic consequences: in the week since Plaintiffs filed the present motion, the

27 number of people incarcerated in the jails who have COVID-19 has skyrocketed to

28

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1 80, with 55 staff sickened with the virus. Declaration of Sara Norman in Support of

2 Plaintiffs’ Reply (Norman Reply Decl.), filed herewith, Exh. A.

3

People living in the Riverside jails face serious illness and death because they

4 do not have the opportunity to practice physical distancing and appropriate hygiene.

5 Hundreds of millions keep to their homes, but the County refuses to extend basic

6 protections to people who are completely dependent on the County for their well-

7 being. This refusal is consistent with the public statements of the Sheriff

8 responsible for the jails: “If you don’t want to contract this virus while in custody,

9 don’t break the law.” Id. The Sheriff’s abdication of his duty to provide

10 constitutional health care demonstrates the necessity for Court intervention.

11

It is essential that the Court establish a process to review Defendant’s efforts

12 in real time and to ensure Plaintiffs access to information regarding the pandemic

13 response. Accordingly, Plaintiffs seek an order requiring Defendant to produce an

14 adequate plan and for the Court to hold regular case management conferences.

15 I. Defendant’s Plan Is Inadequate to Ensure Constitutionally Required Healthcare Because It Lacks Key Elements of a COVID-19 Response
16 Defendant has produced a COVID-19 response plan. 1 The Court’s inquiry
17 does not stop there, however. The Consent Decree requires that plans to effect
18 constitutional healthcare must be “appropriate and adequate.” Consent Decree, ¶ 30.
19 Defendant’s plan falls far short. See People of the State of New York ex rel.
20 Stoughton v. Brann, No. 451078/2020, 2020 WL 1679209, at *4 (N.Y. Sup. Ct. Apr.
21 6, 2020) (“[r]easonable care to mitigate must include an effort to employ an effective
22

23 1 Defendant’s Plan appears to take as a template the plan provided by Dr. Allen with
24 his Supplemental Report. See Exh. J to Norman Decl., ECF No. 178-1, at 42-84.

25 The template appears in the left column, marked “Pandemic Response Plan.” The right column has Defendant’s actions, marked “CHS [Correctional Health Services],
26 BH [Behavioral Health, and RSO [Riverside Sheriff] Action Plans.” See Exh. A to

27 Declaration of Bonnie Carl, ECF No. 183-2, at 5. Defendant thus appears to accept

that the plan provided by Dr. Allen represents the appropriate standard of care.

28

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Case 5:13-cv-00444-VAP-OP Document 185 Filed 04/13/20 Page 4 of 11 Page ID #:17882

1 ameliorative measure”) (emphasis in original).

2

In their Supplemental Reports, the experts describe essential elements of an

3 adequate response to the pandemic, grounded in consensus among corrections and

4 public health leaders. Decl. of Sara Norman in Support of Plfs’ Emergency Motion

5 (Norman Decl.), ECF No. 178-1, Exhs. J (Allen Expert Report), K (Gage Expert

6 Report). These elements include, most importantly, the implementation of physical

7 distancing and reduced population density (Allen Expert Report, ¶¶ 14, 20, 23; Gage

8 Expert Report, ¶¶ 2, 5, 9); 2 hygiene measures, including handwashing and sanitizing

9 supplies and education (Allen Expert Report, ¶ 23; Gage Expert Report, ¶¶ 7, 16);

10 measures to reduce risk for people “at highest risk of complications of infection

11 such as age over 60 and chronic diseases including heart disease, hypertension and

12 pulmonary disease” (Allen Expert Report, ¶¶ 16, 19, 22); and measures to ensure

13 access to adequate mental health care during quarantine and isolation. Gage Expert

14 Report, ¶¶ 10-14. These elements are also found in the CDC’s guidelines. Norman

15 Reply Decl., Exh. B, at 4 (social distancing), 9-10 (hygiene), 16, 20 (high risk

16 people), 12 (mental health). Defendant’s plan does not adequately address them.

17

A. Defendant’s plan does not include measures to reduce population

density in order to allow physical distancing

18

Defendant admits that “the spread of COVID-19 is best addressed through

19

physical distancing,” Opp. at 13, and does not dispute that the jail dormitory housing

20

is cramped and inconsistent with physical distancing principles. See Allen Expert

21

22
23 2 The experts both recommended achieving physical distancing through population reduction measures. Defendant argues that the PLRA deprives this Court of
24 jurisdiction to order releases in order to reduce the density of the population which 25 in turn is necessary to achieve physical distancing. Opp. at 14. The PLRA does not,
however, prohibit the Court from ordering Defendant to meet the physical 26 distancing requirement. It is up to Defendant to determine how to accomplish that 27 goal, and population reduction is one alternative that Defendant may consider.

28

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Case 5:13-cv-00444-VAP-OP Document 185 Filed 04/13/20 Page 5 of 11 Page ID #:17883

1 Report, ¶ 15; Gage Expert Report, ¶¶ 6-7; Plaintiffs’ Emergency Motion, April 6,

2 2020, ECF No. 177 (Motion), at 14-15. But Defendant provides no meaningful

3 measures to address population density in the dorms in order to provide minimally

4 adequate protection from the risk of harm posed by the pandemic.3

5

Under the requirement to “coordinat[e] with law enforcement to minimize

6 crowding,” the plan states that “[d]ue to our federal court order for overcrowding,”

7 the County already “continually conduct[s] releases of low level offenders,” which

8 “includes. . . inmates who are at a high risk factor for COVID-19.” Exh. A to

9 Declaration of Bonnie Carl in Support of Defendant’s Opposition, ECF No. 183-2

10 (Defendant’s Plan), at 5. The plan does nothing to increase such releases to

11 “minimize crowding,” however, or to target high-risk people; it merely describes the

12 practice in place before the pandemic. The plan also ignores the guideline that “[i]f

13 space allows, reassign bunks to provide more space between individuals (ideally 6

14 feet or more in all directions)”; it simply states that people will sleep head-to-foot,

15 but makes no mention of how far apart they will be. Id. at 11. Finally, the plan has

16 no provision for the requirement to “[e]nforce increased space between individuals

17 in holding cells” id., despite undisputed evidence that people are routinely held in

18 crowded holding cells with up to 20 people for days at a time. Motion at 15-16.

19

An example of an adequate plan is close at hand. In California’s prison

20 system, the Receiver responsible for medical care under the direction of a federal

21 court has issued clear guidance regarding physical distancing, based on “the

22 developing scientific and medical consensus regarding social distancing in

23 correctional settings.” Norman Decl., Exh C. The guidelines cite the Center for

24

25 3 The plan does contain measures such as cancelling visitation, minimizing transfers
26 and staff movement, and limiting recreation and large dayroom numbers that

27 advance the goal of physical distancing. These measures do not address the

population density that was central to the experts’ concerns, however.

28

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Case 5:13-cv-00444-VAP-OP Document 185 Filed 04/13/20 Page 6 of 11 Page ID #:17884

1 Disease Control’s Interim Guidance and state the following:

2

Necessary social distancing is already being achieved in both single-

and double-celled units. In double cells, cell mates constitute one

3

another’s “social distancing cohort” for correctional purposes and are

analogous to a family unit in the free world. With respect to housing

4

in dorm settings, the Receiver has determined that necessary social

distancing can be achieved by creating 8-person housing cohorts.

5

Each cohort is to be separated from the others by a distance of at least

six feet in all directions.

6

Id. at 1. Without such a provision, Defendant’s Plan fails to meet minimum

7

constitutional standards to protect the Plaintiff class from an unreasonable risk of

8

harm. See infra, Section II.B

9

B. Defendant’s plan does not address the most vulnerable populations 10
There is nothing in Defendant’s Plan to address the most vulnerable people: 11
those who are elderly or who have underlying health conditions such as cancer, lung 12
disease, or heart disease that make them particularly at risk for severe complications 13
or death with COVID-19. See Allen Expert Report, ¶¶ 16, 19. Dr. Allen expressed 14
serious concern that the County has too many such patients: should the virus spread 15
extensively in the jails, a large number of people with serious complications will 16
overwhelm the capacity of the County to care for them at local hospitals. Allen 17
Expert Report, ¶¶ 12-13, 21-22. Nothing is said in Defendant’s plan about 18
preparing for the needs of this population. Without measures to address the 19
heightened risk factors of these vulnerable people, the County subjects them to an 20
unacceptable risk of serious harm or death. 21

C. Defendant’s plan does not include adequate hygiene measures

22

Defendant does not dispute that there are serious ongoing problems with

23

hygiene in the jails, and admits that “the spread of COVID-19 is best addressed

24

through. . . heightened cleanliness, including . . . regularly cleaning and disinfecting

25

frequently touched surfaces.” Opp. at 13. However, although there are some

26

measures for hygiene and sanitation and patient education in Defendant’s plan, there

27

are significant gaps. For example, there is no provision to “[c]onduct frequent

28

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Case 5:13-cv-00444-VAP-OP Document 185 Filed 04/13/20 Page 7 of 11 Page ID #:17885

1 environmental cleaning of ‘high touch’ surfaces”; only daily cleaning is instituted.

2 Defendant’s Plan at 6, 10. The provision for masks is ambiguous: the plan appears

3 to say that masks are provided to all people in the jails, id. at 17 (“All inmates in our

4 jails have been issued surgical masks”), or only to those in quarantine or isolation.

5 Id. at 12 (“Inmates who develop COVID-19 symptoms are masked and placed in

6 isolation”), 14 (new arrestees who screen positive for symptoms “are given a mask

7 to wear”), 17 (people in medical isolation given masks). Either way, it is not stated

8 how often masks are provided – are they replaced as needed, as the guidelines

9 require? Or are people given only one mask to reuse, as the plan suggests? See id.

10 at 17 (“All inmates. . . have been given instruction on how to care for their mask.”).

11

Finally, although Defendant notes that signage and an educational video are

12 available to educate people in the jails about proper hygiene methods and the

13 reporting of symptoms, the required provisions to ensure that signs and other

14 communications are understandable for non-English speakers, people with limited

15 reading ability, and people with disabilities are absent. Id. at 9, 10. For example,

16 how can deaf people gain access to the video? How will blind people know what is

17 on the posters? Who can hear the video as it plays in the dayroom from their cells?

18

D. Behavioral health measures are nonexistent

19

Dr. Gage pointed out several measures essential to ensure adequate mental

20 health care for people in quarantine or isolation who might face exacerbation of

21 psychiatric symptoms or suicidal ideation, such as regular rounds by behavioral

22 health staff and the provision of cell activities. Gage Expert Report, ¶¶ 10-14.

23 Defendant’s Plan fails to address any of these critical needs of people who are

24 mentally ill in the face of the COVID-19 pandemic.

25 II. The Court Must Act to Enforce the Consent Decree to Secure Plaintiffs’

Rights to Constitutionally Adequate Healthcare

26

The Court has the power to enforce the Consent Decree to (a) order

27

Defendant to produce and implement an “appropriate and adequate” plan to provide

28

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Case 5:13-cv-00444-VAP-OP Document 185 Filed 04/13/20 Page 8 of 11 Page ID #:17886

1 constitutional health care and (b) require Defendant to respond to Plaintiffs’ request

2 for information. Defendant’s arguments to the contrary lack merit.

3

A. The Court can use its inherent powers to supersede the dispute

resolution process in an emergency 4

Defendant takes the position that the Court cannot act because Plaintiffs did

5 not first undertake mediation through the dispute resolution mechanism set forth in

6 the Consent Decree. Opp. at 8-12. At the same time, however, they acknowledge

7 that the pandemic is “unprecedented” and requires “extraordinary and

8 unprecedented” measures to address it. Id. at 4. It is for those precise reasons,

9 along with Defendant’s intransigence in ignoring numerous and repeated requests to

10

meet and to provide information, that Court intervention is necessary.

11

Defendant did not respond meaningfully to Plaintiffs until the present motion

12

was filed. It took Court action to make Defendant act. The opportunity for informal

13

dispute resolution is past; the dispute is squarely before the Court, and time is of the

14

essence. Under these circumstances, the Court has the inherent power to hear an

15

urgent appeal for enforcement. See Consent Decree, ¶ 30 (the Court has “the power

16

to enforce the agreement through . . . all other remedies permitted by law”).

17

B. Defendant’s inadequate plan violates the Eighth Amendment

18

It is undeniable that “the Eighth Amendment requires Defendants to take

19

adequate steps to curb the spread of disease within the prison system.” Coleman v.

20

Newsom/Plata v. Newsom, Nos. 90-cv-0520 KJM DB P, 01-cv-1351 JST, 2020 WL

21

1675775, at *5 (E.D. Cal./N.D. Cal., Apr. 4, 2020). More specifically,

22

Plaintiffs may go before a single [district court] judge to press their

23

claim that Defendants’ response to the COVID-19 pandemic is

constitutionally inadequate. For example, if they believe that the

24

response violates Plaintiffs’ right to adequate medical care, they may

seek relief before the individual . . . court [overseeing medical care

25

consent decree] . . . . If a single-judge court finds a constitutional

violation, it may order Defendants to take steps short of release

26

necessary to remedy that violation.

27 Id. at *7. That is precisely what Plaintiffs seek: a remedy for Defendant’s

28

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Case 5:13-cv-00444-VAP-OP Document 185 Filed 04/13/20 Page 9 of 11 Page ID #:17887

1 constitutionally inadequate response to the pandemic, which places the Plaintiff

2 class at unreasonable risk of harm. See id. at *6 (“to the extent Plaintiffs can

3 establish a constitutional violation based on the threat posed by COVID-19, it must

4 be based on shortcomings in Defendants’ response to the virus”).

5

Defendant’s argument that the motion presents a new issue, and that the

6 Consent Decree and Remedial Plan were “never intended to prepare the County to

7 confront an unprecedented pandemic,” Opp. at 12, is a red herring. The Consent

8 Decree and Remedial Plan are designed to bring the jails’ health care delivery

9 system into constitutional compliance. Consent Decree, ¶ 9. Constitutional care

10 requires measures to prevent the spread of a dangerous, contagious illness. See

11 Helling v. McKinney, 509 U.S. 25, 33 (1993) (8th Amendment requires a remedy for

12 conditions that allow the spread of “infectious maladies such as hepatitis and

13 venereal disease”) (citation omitted). There is no exception for times of emergency.

14

Defendant argues that the remedy Plaintiffs seek is vague, intrusive, and

15 extends further than necessary. Opp. at 12-13. Not so: Plaintiffs merely seek to

16 ensure that Defendant’s pandemic response plan conforms to the standards as

17 described by the experts and the CDC. See supra, Section I.

18

Contrary to Defendant’s assertion, Opp. at 14, Plaintiffs do not seek a

19 prisoner release order. Plaintiffs seek merely an order that Defendant implement

20 physical distancing and other required COVID-19 prevention measures in the jails.

21 Defendant may determine how to accomplish that goal; population reduction is one

22 alternative for Defendant to consider. See Decl. of Misha Graves, ECF No. 183-4

23 (new jail construction is complete and Sheriff’s Department has control of building).

24

Defendant argues the Court must defer to the County to manage the health

25 care for people in its jails. Opp. at 14-16. But while courts must give some

26 deference to prison administrators, the Supreme Court has counseled that where a

27 “government fails to fulfill [its] obligation [to provide adequate health care], the

28

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Case 5:13-cv-00444-VAP-OP Document 185 Filed 04/13/20 Page 10 of 11 Page ID #:17888

1 courts have a responsibility to remedy the resulting Eighth Amendment violation.”

2 Brown v. Plata, 563 U.S. 493, 511 (2011). Thus, while courts should be sensitive to

3 principles of federalism, “[c]ourts nevertheless must not shrink from their obligation

4 to enforce the constitutional rights of all persons, including prisoners,” and “may not

5 allow constitutional violations to continue simply because a remedy would involve

6 intrusion into the realm of prison administration.” Id. (quotations, citations omitted).

7

Moreover, Defendant’s argument that the County is entitled to deference

8 because it has acted to ward off the pandemic in the jails rings hollow given the

9 position of the Riverside Sheriff: “If you don’t want to contract this virus while in

10 custody, don’t break the law.” Norman Reply Decl., Exh. A. In so saying, the

11 Sheriff demonstrates not just deliberate indifference to constitutional norms but a

12 callous disregard to the human lives in his custody. The County’s stonewalling and

13 the inadequacy of its COVID-19 response plan must be viewed in this context.

14

C. Defendant’s actions demonstrate recalcitrance and a refusal to

provide essential information

15

Defendant has demonstrated recalcitrance in refusing to respond substantively

16

to Plaintiffs’ request for a COVID-19 response plan until ordered to do so by the

17

Court. That “system-wide COVID-19 Pandemic Response Plan” appears to have

18

been generated only recently, since it is based on a plan provided by Dr. Allen on

19

March 19, 2020. See Allen Expert Report, ¶ 17. Defendant has never answered

20

crucial questions sent on March 22, 2020, including basic information such as the

21

jails’ capacity to isolate or quarantine a large number of potential cases, the current

22

population of the jails, and whether there is a target population for safe jail

23

conditions based on maximizing social distancing and accounting for the capacity of

24

medical operations to care for people with COVID-19 complications. Norman

25

Decl., Exh. G. There is no reason to believe it will do so absent Court action.

26

Essential information is still lacking to determine the adequacy of

27

Defendant’s response to the pandemic: How many people live in dorms, and how

28

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Case 5:13-cv-00444-VAP-OP Document 185 Filed 04/13/20 Page 11 of 11 Page ID #:17889

1 close are their beds? How many quarantine and isolation cells are available? How

2 often are high-touch surfaces disinfected? How many masks are provided to people

3 in the jails? How many tests have been done, and how many tested positive? Are

4 clusters of positive cases tracked to determine the causes and to prevent such

5 clusters from occurring in the future?

6

Defendant must answer to the apparent inadequacies in the current plan, and

7 Plaintiffs need access to information in order to continue to monitor the

8 constitutional sufficiency of Defendant’s actions. In the Coleman v. Newsom class

9 action regarding mental health care in the California prison system, the court holds

10 regular case management conferences and has recently ordered the State to produce

11 a COVID-19 plan. See Request for Judicial Notice, filed herewith, Exhs. A, B. In

12 the Plata v. Newsom case, the court similarly holds case management conferences to

13 ensure the parties and the court are fully appraised of the State’s pandemic response.

14 Id., Exhs. C, D. Accordingly, Plaintiffs request that the Court hold regular case

15 management conferences to ensure that the County provides essential information to

16 Plaintiffs and the Court, with the involvement of the Court experts as appropriate to

17 advise the Court on the constitutional sufficiency of Defendant’s responses.

18

CONCLUSION

19

For the foregoing reasons, Plaintiffs respectfully request the Court to enforce

20 the Consent Decree by ordering Defendant (a) to submit a plan to correct the

21 deficiencies identified herein and (b) to respond to Plaintiffs’ information requests

22 by April 15, 2020. Plaintiffs further request that the Court set weekly cases

23 management conferences as described above.

24 Dated: April 13, 2020
25
26
27

PRISON LAW OFFICE
By: /s/ Sara Norman SARA NORMAN Attorneys for Plaintiffs

28

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PRISON LAW OFFICE 1 DONALD SPECTER (SBN 83925)
dspecter@prisonlaw.com 2 SARA NORMAN (SBN 189536)
snorman@prisonlaw.com 3 1917 Fifth Street
Berkeley, California 94710 4 Telephone: (510) 280-2621
Fax: (510) 280-2704 5 6 Attorneys for Plaintiffs

7

8

UNITED STATES DISTRICT COURT

9

FOR THE CENTRAL DISTRICT OF CALIFORNIA

10

EASTERN DIVISION – RIVERSIDE

11
12 QUINTON GRAY, et al., on behalf of 13 themselves and all others similarly 14 situated,
Plaintiffs, 15
16 v.
17 18 COUNTY OF RIVERSIDE, 19 Defendant.

Case No. EDCV13-0444 VAP (OP) CLASS ACTION DECLARATION OF SARA NORMAN IN SUPPORT OF PLAINTIFFS’ REPLY TO EMERGENCY MOTION TO ENFORCE THE CONSENT DECREE Judge: Hon. Virginia A. Phillips Date: To be determined Time: To be determined Courtroom: Telephonic

20

21

DECLARATION OF SARA NORMAN

22

I, Sara Norman, declare:

23

1. I am an attorney duly admitted to practice before this Court. I am the

24 managing attorney at the Prison Law Office, counsel of record for Plaintiffs in Gray

25 v. Riverside. I have personal knowledge of the facts set forth herein, and if called as

26 a witness, I could competently so testify. I make this declaration in support of

27 Plaintiffs’ Reply to the Emergency Motion to Enforce the Consent Decree.

28

REPLY DECL. OF SARA NORMAN IN SUPPORT OF PLTFS’ EMERGENCY MTN

Case 5:13-cv-00444-VAP-OP Document 186 Filed 04/13/20 Page 2 of 2 Page ID #:17891

1

2. Attached hereto as Exhibit A is a true and correct copy of a news article

2 dated April 11, 2020, from The Press-Enterprise entitled “80 inmates, 55 sheriff’s

3 workers in Riverside County have coronavirus,” available at https://www.pe.com/

4 2020/04/11/80-inmates-55-sheriffs-workers-in-riverside-county-have-coronavirus/.

5

3. Attached hereto as Exhibit B is a true and correct copy of the US

6 Centers for Disease Control and Prevention, “Interim Guidance on Management of

7 Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities,” March

8 23, 2020. I obtained this document from the website https://www.cdc.gov/

9 coronavirus/2019-ncov/community/ correction-detention/guidance-correctional-

10 detention.html. It is also cited in the Supplemental Report of Scott Allen, Exh. J to the

11 Declaration of Sara Norman in Support of Plaintiffs’ Emergency Motion, ECF No. 178-1,

12 ¶¶ 10, 16.

13

4. Attached hereto as Exhibit C is a true and correct copy of a Memorandum

14 of April 10, 2020, from J. Clark Kelso to Ralph Diaz. I received this memorandum

15 by email on April 10, 2020, from the office of the Receiver in the ordinary course of

16 my duties at the Prison Law Office, where we are counsel for the plaintiff class in

17 the Plata v. Newsom lawsuit regarding medical care in the California Department of

18 Corrections and Rehabilitation.

19

20

I declare under penalty of perjury under the laws of the United States of

21 America that the foregoing is true and correct, and that this declaration is executed 22 at San Francisco, California, this 13th day of April, 2020.

23

/s/ Sara Norman

24

Sara Norman

25

26

27

28

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REPLY DECL. OF SARA NORMAN IN SUPPORT OF PLTFS’ EMERGENCY MTN

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EXHIBIT A

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The Press-Enterprise 80 inmates, 55 sheriff’s workers in Riverside County have coronavirus
Riverside County Sheriff Chad Bianco, shown in a file photo, said April 11, 2020, that 80 inmates and 55 employees have tested positive for the coronavirus. (Photo by Terry Pierson, The Press-Enterprise/SCNG) By Brian Rokos | brokos@scng.com | The Press-Enterprise PUBLISHED: April 11, 2020 at 6:31 p.m. | UPDATED: April 11, 2020 at 6:52 p.m. At least 80 inmates and 55 Sheriff’s Department employees have tested positive for the novel coronavirus, Riverside County Sheriff Chad Bianco said on Saturday, April 11, a stunning jump in figures provided a little more than a week ago. On April 3, Bianco said 13 inmates and 26 employees had tested positive. Two employees, deputies David Werksman, 51, and Terrell Young, 52, died April 2. Of the 80 inmates, 16 have recovered and are no longer quarantined, the Sheriff’s Department said in a Tweet on Saturday. Of the 55 employees, three have returned to work, and “several” are expected to do so as they recover in coming weeks.

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Some inmates have complained that they are forced to live closer than the recommended 6 feet apart for social distancing and that their medical needs are not being met.
But Bianco said inmates are being well taken care of when he was interviewed on the “Exploited – Crime & Technology” radio show that aired Saturday on AM 590.
“They are being isolated and given medical care,” he said.
The sheriff has said he does not plan to release inmates early to create more space. He said there is no such thing as a low-level offender at his jails now that so few serve time for minor offenses.
“We are getting a lot of demands and requests for inmates to be released because they are contracting this. If you don’t want to contract this virus while in custody, don’t break the law. You can’t get any more plain than that,” Bianco said at an April 2 news conference after Young’s death.
Around Southern California, there are profound differences between the descriptions of the care and conditions in jails made by inmates and law enforcement officials. Inmates say sick people aren’t being treated, jails are dirty and supplies to clean the jails and themselves are minimal. Sheriff’s departments, which operate the jails, say the health of inmates is a high priority as evidenced by the quality and frequency of the medical care they receive and a focus on cleanliness.
Some jails have banned visitors and stepped up screening to prevent the spread of the virus.
One reason so many employees have been infected is that a large number were exposed to people who had the virus but showed no symptoms, Bianco said in the radio interview. In some cases, the virus spread from an asymptomatic deputy to a spouse who is also a deputy, and both would continue working.
“It shows us that this virus is definitely not discriminatory,” Bianco said. “Any of us can get it. I wish there was a medical study, if you will, of what happened to our agency and how fast it spread. … It showed us this is not what we prepared for.”
Bianco also addressed the public’s concerns about county health orders that prohibit most public gatherings and require face coverings to be worn outdoors.
“The purpose of these orders is not to take away someone’s freedoms or rights,” Bianco said. “The order is to limit exposure to each other and stop or slow down the spread of the virus. People are in an uproar; some of them want their neighbors arrested and others want their freedoms. We are getting calls from both.”
He added that contrary to rumors on social media, his deputies have not cited anyone for not wearing a face covering.

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An interview with Riverside County District Attorney Mike Hestrin also aired on the show Saturday. Hestrin sought to clarify the conditions under which his office would prosecute violators of the county orders.
“The orders carry the force of law and they are going to be enforced with common sense,” Hestrin said, noting his conversations with heads of other county law enforcement agencies. “If someone is out there and forgot their face mask, you are not going to get arrested and booked into jail. You might get a reminder. If you have extreme situations where someone thought that it’s a good time to have a concert … my office would be willing to file criminal charges if warranted.”
https://www.pe.com/2020/04/11/80-inmates-55-sheriffs-workers-in-riverside-countyhave-coronavirus/

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EXHIBIT B

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MEMORANDUM

Date:

April 10, 2020

To:

Secretary Ralph DIaz

From: Subject:

J. Clark Kelso, Receiver CCHCS Guidelines for Achieving and Maintaining Social Distancing in California Prisons

In the face of the ongoing COVID-19 pandemic, California Correctional Health Care Services (CCHCS) will continue to be guided by the developing scientific and medical consensus regarding social distancing in correctional settings, as well as by the Receiver’s authority under the Order Appointing Receiver and the applicable regulatory provisions of Title 15 of the California Code of Regulations. Accordingly, the Receiver has determined that CCHCS and California Department of Corrections and Rehabilitation (CDCR) should implement the following steps in their ongoing efforts to mitigate the risks associated with transmission of the COVID-19 coronavirus.

1. CDCR should not authorize or undertake any further movements of inmates between institutions to achieve necessary social distancing without the approval of Health Care Placement Oversight Program (HCPOP) in consultation with the CCHCS public health team. Inter-institution moves risk carrying the virus from one institution to another.

2. The Center for Disease Control’s “Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities,” dated March 23, 2020 (https://www.cdc.gov/coronavirus/2019-ncov/community/correctiondetention/guidance-correctional-detention.html), recommends maintaining social distance of 6 feet between inmates while acknowledging that “Strategies will need to be tailored to the individual space in the facility and the needs of the population and staff. Not all strategies will be feasible in all facilities.” Necessary social distancing is already being achieved in both single- and double-celled units. In double cells, cell mates constitute one another’s “social distancing cohort” for correctional purposes and are analogous to a family unit in the free world. With respect to housing in dorm settings, the Receiver has determined that necessary social distancing can be achieved by creating 8-person housing cohorts. Each cohort is to be separated from the others by a distance of at least six feet in all directions.

3. Any movement of inmates out of the dorms to achieve necessary cohort social distancing must be coordinated with, and may not occur without the concurrence of,

P.O. Box 588500 Elk Grove, CA 95758

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#:17898

MEMORANDUM

Page 2 of 2

HCPOP to ensure to the extent feasible that such movement does not cause, contribute to or exacerbate the potential spread of the disease.

4. CCHCS will continue to monitor developments closely and will modify these guidelines as necessary and appropriate.

P.O. Box 588500 Elk Grove, CA 95758

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EXHIBIT C

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Interim Guidance on Mana#:g17e90m0 ent of Coronavirus Disease 2019 (COVID-19) in Correctional and Detention Facilities

This interim guidance is based on what is currently known about the transmission and severity of coronavirus disease 2019 (COVID-19) as of March 23, 2020.
The US Centers for Disease Control and Prevention (CDC) will update this guidance as needed and as additional information becomes available. Please check the following CDC website periodically for updated interim guidance: https://www.cdc.gov/coronavirus/2019-ncov/index.html.
This document provides interim guidance specific for correctional facilities and detention centers during the outbreak of COVID-19, to ensure continuation of essential public services and protection of the health and safety of incarcerated and detained persons, staff, and visitors. Recommendations may need to be revised as more information becomes available.

In this guidance
• Who is the intended audience for this guidance?
• Why is this guidance being issued?
• What topics does this guidance include?
• Definitions of Commonly Used Terms
• Facilities with Limited Onsite Healthcare Services
• COVID-19 Guidance for Correctional Facilities
• Operational Preparedness
• Prevention
• Management
• Infection Control
• Clinical Care of COVID-19 Cases
• Recommended PPE and PPE Training for Staff and Incarcerated/Detained Persons
• Verbal Screening and Temperature Check Protocols for Incarcerated/ Detained Persons, Staff, and Visitors

Who is the intended audience for this guidance?
This document is intended to provide guiding principles for healthcare and non-healthcare administrators of correctional and detention facilities (including but not limited to federal and state prisons, local jails, and detention centers), law enforcement agencies that have custodial authority for detained populations (i.e., US Immigration and Customs Enforcement and US Marshals Service), and their respective health departments, to assist in preparing for potential introduction, spread, and mitigation of COVID-19 in their facilities. In general, the document uses terminology referring to correctional environments but can also be applied to civil and pre-trial detention settings.
This guidance will not necessarily address every possible custodial setting and may not use legal terminology specific to individual agencies’ authorities or processes. The guidance may need to be adapted based on individual facilities’ physical space, staffing, population, operations, and other resources and conditions. Facilities should contact CDC or their state, local, territorial, and/or tribal public health department if they need assistance in applying these principles or addressing topics that are not specifically covered in this guidance.

CS 316182-A  03/27/2020

cdc.gov/coronavirus

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Why is this guidance being issued?
Correctional and detention facilities can include custody, housing, education, recreation, healthcare, food service, and workplace components in a single physical setting. The integration of these components presents unique challenges for control of COVID-19 transmission among incarcerated/detained persons, staff, and visitors. Consistent application of specific preparation, prevention, and management measures can help reduce the risk of transmission and severe disease from COVID-19.
• Incarcerated/detained persons live, work, eat, study, and recreate within congregate environments, heightening the potential for COVID-19 to spread once introduced.
• In most cases, incarcerated/detained persons are not permitted to leave the facility.
• There are many opportunities for COVID-19 to be introduced into a correctional or detention facility, including daily staff ingress and egress; transfer of incarcerated/detained persons between facilities and systems, to court appearances, and to outside medical visits; and visits from family, legal representatives, and other community members. Some settings, particularly jails and detention centers, have high turnover, admitting new entrants daily who may have been exposed to COVID-19 in the surrounding community or other regions.
• Persons incarcerated/detained in a particular facility often come from a variety of locations, increasing the potential to introduce COVID-19 from different geographic areas.
• Options for medical isolation of COVID-19 cases are limited and vary depending on the type and size of facility, as well as the current level of available capacity, which is partly based on medical isolation needs for other conditions.
• Adequate levels of custody and healthcare staffing must be maintained to ensure safe operation of the facility, and options to practice social distancing through work alternatives such as working from home or reduced/alternate schedules are limited for many staff roles.
• Correctional and detention facilities can be complex, multi-employer settings that include government and private employers. Each is organizationally distinct and responsible for its own operational, personnel, and occupational health protocols and may be prohibited from issuing guidance or providing services to other employers or their staff within the same setting. Similarly, correctional and detention facilities may house individuals from multiple law enforcement agencies or jurisdictions subject to different policies and procedures.
• Incarcerated/detained persons and staff may have medical conditions that increase their risk of severe disease from COVID-19.
• Because limited outside information is available to many incarcerated/detained persons, unease and misinformation regarding the potential for COVID-19 spread may be high, potentially creating security and morale challenges.
• The ability of incarcerated/detained persons to exercise disease prevention measures (e.g., frequent handwashing) may be limited and is determined by the supplies provided in the facility and by security considerations. Many facilities restrict access to soap and paper towels and prohibit alcohol-based hand sanitizer and many disinfectants.
• Incarcerated persons may hesitate to report symptoms of COVID-19 or seek medical care due to co-pay requirements and fear of isolation.
CDC has issued separate COVID-19 guidance addressing healthcare infection control and clinical care of COVID-19 cases as well as close contacts of cases in community-based settings. Where relevant, community-focused guidance documents are referenced in this document and should be monitored regularly for updates, but they may require adaptation for correctional and detention settings.
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This guidance document provides additional recommended best practices specifically for correctional and detention facilities. At this time, different facility types (e.g., prison vs. jail) and sizes are not differentiated. Administrators and agencies should adapt these guiding principles to the specific needs of their facility.
What topics does this guidance include?
The guidance below includes detailed recommendations on the following topics related to COVID-19 in correctional and detention settings:
√ Operational and communications preparations for COVID-19
√ Enhanced cleaning/disinfecting and hygiene practices
√ Social distancing strategies to increase space between individuals in the facility
√ How to limit transmission from visitors
√ Infection control, including recommended personal protective equipment (PPE) and potential alternatives during PPE shortages
√ Verbal screening and temperature check protocols for incoming incarcerated/detained individuals, staff, and visitors
√ Medical isolation of confirmed and suspected cases and quarantine of contacts, including considerations for cohorting when individual spaces are limited
√ Healthcare evaluation for suspected cases, including testing for COVID-19
√ Clinical care for confirmed and suspected cases
√ Considerations for persons at higher risk of severe disease from COVID-19
Definitions of Commonly Used Terms
Close contact of a COVID-19 case—In the context of COVID-19, an individual is considered a close contact if they a) have been within approximately 6 feet of a COVID-19 case for a prolonged period of time or b) have had direct contact with infectious secretions from a COVID-19 case (e.g., have been coughed on). Close contact can occur while caring for, living with, visiting, or sharing a common space with a COVID-19 case. Data to inform the definition of close contact are limited. Considerations when assessing close contact include the duration of exposure (e.g., longer exposure time likely increases exposure risk) and the clinical symptoms of the person with COVID-19 (e.g., coughing likely increases exposure risk, as does exposure to a severely ill patient).
Cohorting—Cohorting refers to the practice of isolating multiple laboratory-confirmed COVID-19 cases together as a group, or quarantining close contacts of a particular case together as a group. Ideally, cases should be isolated individually, and close contacts should be quarantined individually. However, some correctional facilities and detention centers do not have enough individual cells to do so and must consider cohorting as an alternative. See Quarantine and Medical Isolation sections below for specific details about ways to implement cohorting to minimize the risk of disease spread and adverse health outcomes.
Community transmission of COVID-19—Community transmission of COVID-19 occurs when individuals acquire the disease through contact with someone in their local community, rather than through travel to an affected location. Once community transmission is identified in a particular area, correctional facilities and detention centers are more likely to start seeing cases inside their walls. Facilities should consult with local public health departments if assistance is needed in determining how to define “local community” in the context of COVID-19 spread. However, because all states have reported cases, all facilities should be vigilant for introduction into their populations.
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Confirmed vs. Suspected COVID-19 case—A confirmed case has received a positive result from a COVID-19 laboratory test, with or without symptoms. A suspected case shows symptoms of COVID-19 but either has not been tested or is awaiting test results. If test results are positive, a suspected case becomes a confirmed case.
Incarcerated/detained persons—For the purpose of this document, “incarcerated/detained persons” refers to persons held in a prison, jail, detention center, or other custodial setting where these guidelines are generally applicable. The term includes those who have been sentenced (i.e., in prisons) as well as those held for pre-trial (i.e., jails) or civil purposes (i.e, detention centers). Although this guidance does not specifically reference individuals in every type of custodial setting (e.g., juvenile facilities, community confinement facilities), facility administrators can adapt this guidance to apply to their specific circumstances as needed.
Medical Isolation—Medical isolation refers to confining a confirmed or suspected COVID-19 case (ideally to a single cell with solid walls and a solid door that closes), to prevent contact with others and to reduce the risk of transmission. Medical isolation ends when the individual meets pre-established clinical and/or testing criteria for release from isolation, in consultation with clinical providers and public health officials (detailed in guidance below). In this context, isolation does NOT refer to punitive isolation for behavioral infractions within the custodial setting. Staff are encouraged to use the term “medical isolation” to avoid confusion.
Quarantine—Quarantine refers to the practice of confining individuals who have had close contact with a COVID-19 case to determine whether they develop symptoms of the disease. Quarantine for COVID-19 should last for a period of 14 days. Ideally, each quarantined individual would be quarantined in a single cell with solid walls and a solid door that closes. If symptoms develop during the 14-day period, the individual should be placed under medical isolation and evaluated for COVID-19. If symptoms do not develop, movement restrictions can be lifted, and the individual can return to their previous residency status within the facility.
Social Distancing—Social distancing is the practice of increasing the space between individuals and decreasing the frequency of contact to reduce the risk of spreading a disease (ideally to maintain at least 6 feet between all individuals, even those who are asymptomatic). Social distancing strategies can be applied on an individual level (e.g., avoiding physical contact), a group level (e.g., canceling group activities where individuals will be in close contact), and an operational level (e.g., rearranging chairs in the dining hall to increase distance between them). Although social distancing is challenging to practice in correctional and detention environments, it is a cornerstone of reducing transmission of respiratory diseases such as COVID-19. Additional information about social distancing, including information on its use to reduce the spread of other viral illnesses, is available in this CDC publication.
Staff—In this document, “staff” refers to all public sector employees as well as those working for a private contractor within a correctional facility (e.g., private healthcare or food service). Except where noted, “staff” does not distinguish between healthcare, custody, and other types of staff including private facility operators.
Symptoms—Symptoms of COVID-19 include fever, cough, and shortness of breath. Like other respiratory infections, COVID-19 can vary in severity from mild to severe. When severe, pneumonia, respiratory failure, and death are possible. COVID-19 is a novel disease, therefore the full range of signs and symptoms, the clinical course of the disease, and the individuals and populations most at risk for disease and complications are not yet fully understood. Monitor the CDC website for updates on these topics.
Facilities with Limited Onsite Healthcare Services
Although many large facilities such as prisons and some jails usually employ onsite healthcare staff and have the capacity to evaluate incarcerated/detained persons for potential illness within a dedicated healthcare space, many smaller facilities do not. Some of these facilities have access to on-call healthcare staff or providers who visit the facility every few days. Others have neither onsite healthcare capacity nor onsite medical isolation/quarantine space and must transfer ill patients to other correctional or detention facilities or local hospitals for evaluation and care.
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The majority of the guidance below is designed to be applied to any correctional or detention facility, either as written or with modifications based on a facility’s individual structure and resources. However, topics related to healthcare evaluation and clinical care of confirmed and suspected COVID-19 cases and their close contacts may not apply directly to facilities with limited or no onsite healthcare services. It will be especially important for these types of facilities to coordinate closely with their state, local, tribal, and/or territorial health department when they encounter confirmed or suspected cases among incarcerated/detained persons or staff, in order to ensure effective medical isolation and quarantine, necessary medical evaluation and care, and medical transfer if needed. The guidance makes note of strategies tailored to facilities without onsite healthcare where possible.
Note that all staff in any sized facility, regardless of the presence of onsite healthcare services, should observe guidance on recommended PPE in order to ensure their own safety when interacting with confirmed and suspected COVID-19 cases. Facilities should make contingency plans for the likely event of PPE shortages during the COVID-19 pandemic.
COVID-19 Guidance for Correctional Facilities
Guidance for correctional and detention facilities is organized into 3 sections: Operational Preparedness, Prevention, and Management of COVID-19. Recommendations across these sections can be applied simultaneously based on the progress of the outbreak in a particular facility and the surrounding community.
• Operational Preparedness. This guidance is intended to help facilities prepare for potential COVID-19 transmission in the facility. Strategies focus on operational and communications planning and personnel practices.
• Prevention. This guidance is intended to help facilities prevent spread of COVID-19 from outside the facility to inside. Strategies focus on reinforcing hygiene practices, intensifying cleaning and disinfection of the facility, screening (new intakes, visitors, and staff), continued communication with incarcerated/ detained persons and staff, and social distancing measures (increasing distance between individuals).
• Management. This guidance is intended to help facilities clinically manage confirmed and suspected COVID-19 cases inside the facility and prevent further transmission. Strategies include medical isolation and care of incarcerated/detained persons with symptoms (including considerations for cohorting), quarantine of cases’ close contacts, restricting movement in and out of the facility, infection control practices for individuals interacting with cases and quarantined contacts or contaminated items, intensified social distancing, and cleaning and disinfecting areas visited by cases.
Operational Preparedness
Administrators can plan and prepare for COVID-19 by ensuring that all persons in the facility know the symptoms of COVID-19 and how to respond if they develop symptoms. Other essential actions include developing contingency plans for reduced workforces due to absences, coordinating with public health and correctional partners, and communicating clearly with staff and incarcerated/detained persons about these preparations and how they may temporarily alter daily life.
Communication & Coordination
√ Develop information-sharing systems with partners.
ο Identify points of contact in relevant state, local, tribal, and/or territorial public health departments before cases develop. Actively engage with the health department to understand in advance which entity has jurisdiction to implement public health control measures for COVID-19 in a particular correctional or detention facility.
ο Create and test communications plans to disseminate critical information to incarcerated/detained persons, staff, contractors, vendors, and visitors as the pandemic progresses.
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ο

#:17905 Communicate with other correctional facilities in the same geographic area to share information

including disease surveillance and absenteeism patterns among staff.

ο Where possible, put plans in place with other jurisdictions to prevent confirmed and suspected COVID-19 cases and their close contacts from being transferred between jurisdictions and facilities unless necessary for medical evaluation, medical isolation/quarantine, clinical care, extenuating security concerns, or to prevent overcrowding.

ο Stay informed about updates to CDC guidance via the CDC COVID-19 website as more information becomes known.

√ Review existing pandemic flu, all-hazards, and disaster plans, and revise for COVID-19.
ο Ensure that physical locations (dedicated housing areas and bathrooms) have been identified to isolate confirmed COVID-19 cases and individuals displaying COVID-19 symptoms, and to quarantine known close contacts of cases. (Medical isolation and quarantine locations should be separate). The plan should include contingencies for multiple locations if numerous cases and/ or contacts are identified and require medical isolation or quarantine simultaneously. See Medical Isolation and Quarantine sections below for details regarding individual medical isolation and quarantine locations (preferred) vs. cohorting.
ο Facilities without onsite healthcare capacity should make a plan for how they will ensure that suspected COVID-19 cases will be isolated, evaluated, tested (if indicated), and provided necessary medical care.
ο Make a list of possible social distancing strategies that could be implemented as needed at different stages of transmission intensity.
ο Designate officials who will be authorized to make decisions about escalating or de-escalating response efforts as the epidemiologic context changes.

√ Coordinate with local law enforcement and court officials.
ο Identify lawful alternatives to in-person court appearances, such as virtual court, as a social distancing measure to reduce the risk of COVID-19 transmission.
ο Explore strategies to prevent over-crowding of correctional and detention facilities during a community outbreak.

√ Post signage throughout the facility communicating the following:
ο For all: symptoms of COVID-19 and hand hygiene instructions
ο For incarcerated/detained persons: report symptoms to staff
ο For staff: stay at home when sick; if symptoms develop while on duty, leave the facility as soon as possible and follow CDC-recommended steps for persons who are ill with COVID-19 symptoms including self-isolating at home, contacting their healthcare provider as soon as possible to determine whether they need to be evaluated and tested, and contacting their supervisor.
ο Ensure that signage is understandable for non-English speaking persons and those with low literacy, and make necessary accommodations for those with cognitive or intellectual disabilities and those who are deaf, blind, or low-vision.

Personnel Practices
√ Review the sick leave policies of each employer that operates in the facility. ο Review policies to ensure that they actively encourage staff to stay home when sick. ο If these policies do not encourage staff to stay home when sick, discuss with the contract company. ο Determine which officials will have the authority to send symptomatic staff home.

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√ Identify staff whose duties would allow them to work from home. Where possible, allowing staff to work from home can be an effective social distancing strategy to reduce the risk of COVID-19 transmission. ο Discuss work from home options with these staff and determine whether they have the supplies and technological equipment required to do so.
ο Put systems in place to implement work from home programs (e.g., time tracking, etc.).
√ Plan for staff absences. Staff should stay home when they are sick, or they may need to stay home to care for a sick household member or care for children in the event of school and childcare dismissals.
ο Allow staff to work from home when possible, within the scope of their duties.
ο Identify critical job functions and plan for alternative coverage by cross-training staff where possible.
ο Determine minimum levels of staff in all categories required for the facility to function safely. If possible, develop a plan to secure additional staff if absenteeism due to COVID-19 threatens to bring staffing to minimum levels.
ο Consider increasing keep on person (KOP) medication orders to cover 30 days in case of healthcare staff shortages.
√ Consider offering revised duties to staff who are at higher risk of severe illness with COVID-19. Persons at higher risk may include older adults and persons of any age with serious underlying medical conditions including lung disease, heart disease, and diabetes. See CDC’s website for a complete list, and check regularly for updates as more data become available to inform this issue.
ο Facility administrators should consult with their occupational health providers to determine whether it would be allowable to reassign duties for specific staff members to reduce their likelihood of exposure to COVID-19.
√ Offer the seasonal influenza vaccine to all incarcerated/detained persons (existing population and new intakes) and staff throughout the influenza season. Symptoms of COVID-19 are similar to those of influenza. Preventing influenza cases in a facility can speed the detection of COVID-19 cases and reduce pressure on healthcare resources.
√ Reference the Occupational Safety and Health Administration website for recommendations regarding worker health.
√ Review CDC’s guidance for businesses and employers to identify any additional strategies the facility can use within its role as an employer.
Operations & Supplies
√ Ensure that sufficient stocks of hygiene supplies, cleaning supplies, PPE, and medical supplies (consistent with the healthcare capabilities of the facility) are on hand and available, and have a plan in place to restock as needed if COVID-19 transmission occurs within the facility. ο Standard medical supplies for daily clinic needs
ο Tissues
ο Liquid soap when possible. If bar soap must be used, ensure that it does not irritate the skin and thereby discourage frequent hand washing.
ο Hand drying supplies
ο Alcohol-based hand sanitizer containing at least 60% alcohol (where permissible based on security restrictions)
ο Cleaning supplies, including EPA-registered disinfectants effective against the virus that causes COVID-19
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ο

#:17907 Recommended PPE (facemasks, N95 respirators, eye protection, disposable medical gloves, and

disposable gowns/one-piece coveralls). See PPE section and Table 1 for more detailed information,

including recommendations for extending the life of all PPE categories in the event of shortages, and

when face masks are acceptable alternatives to N95s.

ο Sterile viral transport media and sterile swabs to collect nasopharyngeal specimens if COVID-19 testing is indicated

√ Make contingency plans for the probable event of PPE shortages during the COVID-19 pandemic, particularly for non-healthcare workers.
ο See CDC guidance optimizing PPE supplies.

√ Consider relaxing restrictions on allowing alcohol-based hand sanitizer in the secure setting where security concerns allow. If soap and water are not available, CDC recommends cleaning hands with an alcohol-based hand sanitizer that contains at least 60% alcohol. Consider allowing staff to carry individual-sized bottles for their personal hand hygiene while on duty.

√ Provide a no-cost supply of soap to incarcerated/detained persons, sufficient to allow frequent hand washing. (See Hygiene section below for additional detail regarding recommended frequency and protocol for hand washing.)
ο Provide liquid soap where possible. If bar soap must be used, ensure that it does not irritate the skin and thereby discourage frequent hand washing.

√ If not already in place, employers operating within the facility should establish a respiratory protection program as appropriate, to ensure that staff and incarcerated/detained persons are fit tested for any respiratory protection they will need within the scope of their responsibilities.

√ Ensure that staff and incarcerated/detained persons are trained to correctly don, doff, and dispose of PPE that they will need to use within the scope of their responsibilities. See Table 1 for recommended PPE for incarcerated/detained persons and staff with varying levels of contact with COVID-19 cases or their close contacts.

Prevention
Cases of COVID-19 have been documented in all 50 US states. Correctional and detention facilities can prevent introduction of COVID-19 from the community and reduce transmission if it is already inside by reinforcing good hygiene practices among incarcerated/detained persons, staff, and visitors (including increasing access to soap and paper towels), intensifying cleaning/disinfection practices, and implementing social distancing strategies.

Because many individuals infected with COVID-19 do not display symptoms, the virus could be present in facilities before cases are identified. Both good hygiene practices and social distancing are critical in preventing further transmission.

Operations
√ Stay in communication with partners about your facility’s current situation. ο State, local, territorial, and/or tribal health departments ο Other correctional facilities
√ Communicate with the public about any changes to facility operations, including visitation programs.

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√ Restrict transfers of incarcerated/detained persons to and from other jurisdictions and facilities unless necessary for medical evaluation, medical isolation/quarantine, clinical care, extenuating security concerns, or to prevent overcrowding. ο Strongly consider postponing non-urgent outside medical visits. ο If a transfer is absolutely necessary, perform verbal screening and a temperature check as outlined in the Screening section below, before the individual leaves the facility. If an individual does not clear the screening process, delay the transfer and follow the protocol for a suspected COVID-19 case— including putting a face mask on the individual, immediately placing them under medical isolation, and evaluating them for possible COVID-19 testing. If the transfer must still occur, ensure that the receiving facility has capacity to properly isolate the individual upon arrival. Ensure that staff transporting the individual wear recommended PPE (see Table 1) and that the transport vehicle is cleaned thoroughly after transport.
√ Implement lawful alternatives to in-person court appearances where permissible.
√ Where relevant, consider suspending co-pays for incarcerated/detained persons seeking medical evaluation for respiratory symptoms.
√ Limit the number of operational entrances and exits to the facility.
Cleaning and Disinfecting Practices
√ Even if COVID-19 cases have not yet been identified inside the facility or in the surrounding community, begin implementing intensified cleaning and disinfecting procedures according to the recommendations below. These measures may prevent spread of COVID-19 if introduced.
√ Adhere to CDC recommendations for cleaning and disinfection during the COVID-19 response. Monitor these recommendations for updates. ο Several times per day, clean and disinfect surfaces and objects that are frequently touched, especially in common areas. Such surfaces may include objects/surfaces not ordinarily cleaned daily (e.g., doorknobs, light switches, sink handles, countertops, toilets, toilet handles, recreation equipment, kiosks, and telephones). ο Staff should clean shared equipment several times per day and on a conclusion of use basis (e.g., radios, service weapons, keys, handcuffs). ο Use household cleaners and EPA-registered disinfectants effective against the virus that causes COVID-19 as appropriate for the surface, following label instructions. This may require lifting restrictions on undiluted disinfectants. ο Labels contain instructions for safe and effective use of the cleaning product, including precautions that should be taken when applying the product, such as wearing gloves and making sure there is good ventilation during use.
√ Consider increasing the number of staff and/or incarcerated/detained persons trained and responsible for cleaning common areas to ensure continual cleaning of these areas throughout the day.
√ Ensure adequate supplies to support intensified cleaning and disinfection practices, and have a plan in place to restock rapidly if needed.
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Hygiene

#:17909

√ Reinforce healthy hygiene practices, and provide and continually restock hygiene supplies throughout the facility, including in bathrooms, food preparation and dining areas, intake areas, visitor entries and exits, visitation rooms and waiting rooms, common areas, medical, and staff-restricted areas (e.g., break rooms).

√ Encourage all persons in the facility to take the following actions to protect themselves and others from COVID-19. Post signage throughout the facility, and communicate this information verbally on a regular basis. Sample signage and other communications materials are available on the CDC website. Ensure that materials can be understood by non-English speakers and those with low literacy, and make necessary accommodations for those with cognitive or intellectual disabilities and those who are deaf, blind, or low-vision.
ο Practice good cough etiquette: Cover your mouth and nose with your elbow (or ideally with a tissue) rather than with your hand when you cough or sneeze, and throw all tissues in the trash immediately after use.
ο Practice good hand hygiene: Regularly wash your hands with soap and water for at least 20 seconds, especially after coughing, sneezing, or blowing your nose; after using the bathroom; before eating or preparing food; before taking medication; and after touching garbage.
ο Avoid touching your eyes, nose, or mouth without cleaning your hands first.
ο Avoid sharing eating utensils, dishes, and cups.
ο Avoid non-essential physical contact.

√ Provide incarcerated/detained persons and staff no-cost access to: ο Soap—Provide liquid soap where possible. If bar soap must be used, ensure that it does not irritate the skin, as this would discourage frequent hand washing. ο Running water, and hand drying machines or disposable paper towels for hand washing ο Tissues and no-touch trash receptacles for disposal

√ Provide alcohol-based hand sanitizer with at least 60% alcohol where permissible based on security restrictions. Consider allowing staff to carry individual-sized bottles to maintain hand hygiene.

√ Communicate that sharing drugs and drug preparation equipment can spread COVID-19 due to potential contamination of shared items and close contact between individuals.

Prevention Practices for Incarcerated/Detained Persons
√ Perform pre-intake screening and temperature checks for all new entrants. Screening should take place in the sallyport, before beginning the intake process, in order to identify and immediately place individuals with symptoms under medical isolation. See Screening section below for the wording of screening questions and a recommended procedure to safely perform a temperature check. Staff performing temperature checks should wear recommended PPE (see PPE section below).
ο If an individual has symptoms of COVID-19 (fever, cough, shortness of breath):
 Require the individual to wear a face mask.
 Ensure that staff who have direct contact with the symptomatic individual wear recommended PPE.
 Place the individual under medical isolation (ideally in a room near the screening location, rather than transporting the ill individual through the facility), and refer to healthcare staff for further evaluation. (See Infection Control and Clinical Care sections below.)
 Facilities without onsite healthcare staff should contact their state, local, tribal, and/or territorial health department to coordinate effective medical isolation and necessary medical care.

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ο

#:17910 If an individual is a close contact of a known COVID-19 case (but has no COVID-19

symptoms):

 Quarantine the individual and monitor for symptoms two times per day for 14 days. (See Quarantine section below.)

 Facilities without onsite healthcare staff should contact their state, local, tribal, and/or territorial health department to coordinate effective quarantine and necessary medical care.

√ Implement social distancing strategies to increase the physical space between incarcerated/ detained persons (ideally 6 feet between all individuals, regardless of the presence of symptoms). Strategies will need to be tailored to the individual space in the facility and the needs of the population and staff. Not all strategies will be feasible in all facilities. Example strategies with varying levels of intensity include:
ο Common areas:  Enforce increased space between individuals in holding cells, as well as in lines and waiting areas such as intake (e.g., remove every other chair in a waiting area)
ο Recreation:  Choose recreation spaces where individuals can spread out
 Stagger time in recreation spaces
 Restrict recreation space usage to a single housing unit per space (where feasible)
ο Meals:  Stagger meals
 Rearrange seating in the dining hall so that there is more space between individuals (e.g., remove every other chair and use only one side of the table)
 Provide meals inside housing units or cells
ο Group activities:  Limit the size of group activities
 Increase space between individuals during group activities
 Suspend group programs where participants are likely to be in closer contact than they are in their housing environment
 Consider alternatives to existing group activities, in outdoor areas or other areas where individuals can spread out
ο Housing:  If space allows, reassign bunks to provide more space between individuals, ideally 6 feet or more in all directions. (Ensure that bunks are cleaned thoroughly if assigned to a new occupant.)
 Arrange bunks so that individuals sleep head to foot to increase the distance between them
 Rearrange scheduled movements to minimize mixing of individuals from different housing areas
ο Medical:  If possible, designate a room near each housing unit to evaluate individuals with COVID-19 symptoms, rather than having them walk through the facility to be evaluated in the medical unit. If this is not feasible, consider staggering sick call.
 Designate a room near the intake area to evaluate new entrants who are flagged by the intake screening process for COVID-19 symptoms or case contact, before they move to other parts of the facility.

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√ Communicate clearly and frequently with incarcerated/detained persons about changes to their daily routine and how they can contribute to risk reduction.
√ Note that if group activities are discontinued, it will be important to identify alternative forms of activity to support the mental health of incarcerated/detained persons.
√ Consider suspending work release programs and other programs that involve movement of incarcerated/detained individuals in and out of the facility.
√ Provide up-to-date information about COVID-19 to incarcerated/detained persons on a regular basis, including: ο Symptoms of COVID-19 and its health risks ο Reminders to report COVID-19 symptoms to staff at the first sign of illness
√ Consider having healthcare staff perform rounds on a regular basis to answer questions about COVID-19.
Prevention Practices for Staff
√ Remind staff to stay at home if they are sick. Ensure that staff are aware that they will not be able to enter the facility if they have symptoms of COVID-19, and that they will be expected to leave the facility as soon as possible if they develop symptoms while on duty.
√ Perform verbal screening (for COVID-19 symptoms and close contact with cases) and temperature checks for all staff daily on entry. See Screening section below for wording of screening questions and a recommended procedure to safely perform temperature checks. ο In very small facilities with only a few staff, consider self-monitoring or virtual monitoring (e.g., reporting to a central authority via phone). ο Send staff home who do not clear the screening process, and advise them to follow CDCrecommended steps for persons who are ill with COVID-19 symptoms.
√ Provide staff with up-to-date information about COVID-19 and about facility policies on a regular basis, including: ο Symptoms of COVID-19 and its health risks ο Employers’ sick leave policy ο If staff develop a fever, cough, or shortness of breath while at work: immediately put on a face mask, inform supervisor, leave the facility, and follow CDC-recommended steps for persons who are ill with COVID-19 symptoms. ο If staff test positive for COVID-19: inform workplace and personal contacts immediately, and do not return to work until a decision to discontinue home medical isolation precautions is made. Monitor CDC guidance on discontinuing home isolation regularly as circumstances evolve rapidly. ο If a staff member is identified as a close contact of a COVID-19 case (either within the facility or in the community): self-quarantine at home for 14 days and return to work if symptoms do not develop. If symptoms do develop, follow CDC-recommended steps for persons who are ill with COVID-19 symptoms.
√ If a staff member has a confirmed COVID-19 infection, the relevant employers should inform other staff about their possible exposure to COVID-19 in the workplace, but should maintain confidentiality as required by the Americans with Disabilities Act. ο Employees who are close contacts of the case should then self-monitor for symptoms (i.e., fever, cough, or shortness of breath).
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√ When feasible and consistent with security priorities, encourage staff to maintain a distance of 6 feet or more from an individual with respiratory symptoms while interviewing, escorting, or interacting in other ways.
√ Ask staff to keep interactions with individuals with respiratory symptoms as brief as possible.
Prevention Practices for Visitors
√ If possible, communicate with potential visitors to discourage contact visits in the interest of their own health and the health of their family members and friends inside the facility.
√ Perform verbal screening (for COVID-19 symptoms and close contact with cases) and temperature checks for all visitors and volunteers on entry. See Screening section below for wording of screening questions and a recommended procedure to safely perform temperature checks. ο Staff performing temperature checks should wear recommended PPE. ο Exclude visitors and volunteers who do not clear the screening process or who decline screening.
√ Provide alcohol-based hand sanitizer with at least 60% alcohol in visitor entrances, exits, and waiting areas.
√ Provide visitors and volunteers with information to prepare them for screening. ο Instruct visitors to postpone their visit if they have symptoms of respiratory illness. ο If possible, inform potential visitors and volunteers before they travel to the facility that they should expect to be screened for COVID-19 (including a temperature check), and will be unable to enter the facility if they do not clear the screening process or if they decline screening. ο Display signage outside visiting areas explaining the COVID-19 screening and temperature check process. Ensure that materials are understandable for non-English speakers and those with low literacy.
√ Promote non-contact visits: ο Encourage incarcerated/detained persons to limit contact visits in the interest of their own health and the health of their visitors. ο Consider reducing or temporarily eliminating the cost of phone calls for incarcerated/detained persons. ο Consider increasing incarcerated/detained persons’ telephone privileges to promote mental health and reduce exposure from direct contact with community visitors.
√ Consider suspending or modifying visitation programs, if legally permissible. For example, provide access to virtual visitation options where available. ο If moving to virtual visitation, clean electronic surfaces regularly. (See Cleaning guidance below for instructions on cleaning electronic surfaces.) ο Inform potential visitors of changes to, or suspension of, visitation programs. ο Clearly communicate any visitation program changes to incarcerated/detained persons, along with the reasons for them (including protecting their health and their family and community members’ health). ο If suspending contact visits, provide alternate means (e.g., phone or video visitation) for incarcerated/detained individuals to engage with legal representatives, clergy, and other individuals with whom they have legal right to consult.
NOTE: Suspending visitation would be done in the interest of incarcerated/detained persons’ physical health and the health of the general public. However, visitation is important to maintain mental health.
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If visitation is suspended, facilities should explore alternative ways for incarcerated/detained persons to communicate with their families, friends, and other visitors in a way that is not financially burdensome for them. See above suggestions for promoting non-contact visits.
√ Restrict non-essential vendors, volunteers, and tours from entering the facility.
Management
If there has been a suspected COVID-19 case inside the facility (among incarcerated/detained persons, staff, or visitors who have recently been inside), begin implementing Management strategies while test results are pending. Essential Management strategies include placing cases and individuals with symptoms under medical isolation, quarantining their close contacts, and facilitating necessary medical care, while observing relevant infection control and environmental disinfection protocols and wearing recommended PPE.
Operations
√ Implement alternate work arrangements deemed feasible in the Operational Preparedness section.
√ Suspend all transfers of incarcerated/detained persons to and from other jurisdictions and facilities (including work release where relevant), unless necessary for medical evaluation, medical isolation/quarantine, care, extenuating security concerns, or to prevent overcrowding. ο If a transfer is absolutely necessary, perform verbal screening and a temperature check as outlined in the Screening section below, before the individual leaves the facility. If an individual does not clear the screening process, delay the transfer and follow the protocol for a suspected COVID-19 case— including putting a face mask on the individual, immediately placing them under medical isolation, and evaluating them for possible COVID-19 testing. If the transfer must still occur, ensure that the receiving facility has capacity to appropriately isolate the individual upon arrival. Ensure that staff transporting the individual wear recommended PPE (see Table 1) and that the transport vehicle is cleaned thoroughly after transport.
√ If possible, consider quarantining all new intakes for 14 days before they enter the facility’s general population (SEPARATELY from other individuals who are quarantined due to contact with a COVID-19 case). Subsequently in this document, this practice is referred to as routine intake quarantine.
√ When possible, arrange lawful alternatives to in-person court appearances.
√ Incorporate screening for COVID-19 symptoms and a temperature check into release planning. ο Screen all releasing individuals for COVID-19 symptoms and perform a temperature check. (See Screening section below.)  If an individual does not clear the screening process, follow the protocol for a suspected COVID-19 case—including putting a face mask on the individual, immediately placing them under medical isolation, and evaluating them for possible COVID-19 testing.  If the individual is released before the recommended medical isolation period is complete, discuss release of the individual with state, local, tribal, and/or territorial health departments to ensure safe medical transport and continued shelter and medical care, as part of release planning. Make direct linkages to community resources to ensure proper medical isolation and access to medical care.  Before releasing an incarcerated/detained individual with COVID-19 symptoms to a communitybased facility, such as a homeless shelter, contact the facility’s staff to ensure adequate time for them to prepare to continue medical isolation, or contact local public health to explore alternate housing options.
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√ Coordinate with state, local, tribal, and/or territorial health departments. ο When a COVID-19 case is suspected, work with public health to determine action. See Medical Isolation section below. ο When a COVID-19 case is suspected or confirmed, work with public health to identify close contacts who should be placed under quarantine. See Quarantine section below. ο Facilities with limited onsite medical isolation, quarantine, and/or healthcare services should coordinate closely with state, local, tribal, and/or territorial health departments when they encounter a confirmed or suspected case, in order to ensure effective medical isolation or quarantine, necessary medical evaluation and care, and medical transfer if needed. See Facilities with Limited Onsite Healthcare Services section.
Hygiene
√ Continue to ensure that hand hygiene supplies are well-stocked in all areas of the facility. (See above.)
√ Continue to emphasize practicing good hand hygiene and cough etiquette. (See above.)
Cleaning and Disinfecting Practices
√ Continue adhering to recommended cleaning and disinfection procedures for the facility at large. (See above.)
√ Reference specific cleaning and disinfection procedures for areas where a COVID-19 case has spent time (below).
Medical Isolation of Confirmed or Suspected COVID-19 Cases
NOTE: Some recommendations below apply primarily to facilities with onsite healthcare capacity. Facilities with Limited Onsite Healthcare Services, or without sufficient space to implement effective medical isolation, should coordinate with local public health officials to ensure that COVID-19 cases will be appropriately isolated, evaluated, tested (if indicated), and given care.
√ As soon as an individual develops symptoms of COVID-19, they should wear a face mask (if it does not restrict breathing) and should be immediately placed under medical isolation in a separate environment from other individuals.
√ Keep the individual’s movement outside the medical isolation space to an absolute minimum. ο Provide medical care to cases inside the medical isolation space. See Infection Control and Clinical Care sections for additional details. ο Serve meals to cases inside the medical isolation space. ο Exclude the individual from all group activities. ο Assign the isolated individual a dedicated bathroom when possible.
√ Ensure that the individual is wearing a face mask at all times when outside of the medical isolation space, and whenever another individual enters. Provide clean masks as needed. Masks should be changed at least daily, and when visibly soiled or wet.
√ Facilities should make every possible effort to place suspected and confirmed COVID-19 cases under medical isolation individually. Each isolated individual should be assigned their own housing space and bathroom where possible. Cohorting should only be practiced if there are no other available options.
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ο If cohorting is necessary:

#:17915

 Only individuals who are laboratory confirmed COVID-19 cases should be placed under medical isolation as a cohort. Do not cohort confirmed cases with suspected cases or case contacts.

 Unless no other options exist, do not house COVID-19 cases with individuals who have an undiagnosed respiratory infection.

 Ensure that cohorted cases wear face masks at all times.

√ In order of preference, individuals under medical isolation should be housed:
ο Separately, in single cells with solid walls (i.e., not bars) and solid doors that close fully
ο Separately, in single cells with solid walls but without solid doors
ο As a cohort, in a large, well-ventilated cell with solid walls and a solid door that closes fully. Employ social distancing strategies related to housing in the Prevention section above.
ο As a cohort, in a large, well-ventilated cell with solid walls but without a solid door. Employ social distancing strategies related to housing in the Prevention section above.
ο As a cohort, in single cells without solid walls or solid doors (i.e., cells enclosed entirely with bars), preferably with an empty cell between occupied cells. (Although individuals are in single cells in this scenario, the airflow between cells essentially makes it a cohort arrangement in the context of COVID-19.)
ο As a cohort, in multi-person cells without solid walls or solid doors (i.e., cells enclosed entirely with bars), preferably with an empty cell between occupied cells. Employ social distancing strategies related to housing in the Prevention section above.
ο Safely transfer individual(s) to another facility with available medical isolation capacity in one of the above arrangements (NOTE—Transfer should be avoided due to the potential to introduce infection to another facility; proceed only if no other options are available.)

If the ideal choice does not exist in a facility, use the next best alternative.

√ If the number of confirmed cases exceeds the number of individual medical isolation spaces available in the facility, be especially mindful of cases who are at higher risk of severe illness from COVID-19. Ideally, they should not be cohorted with other infected individuals. If cohorting is unavoidable, make all possible accommodations to prevent transmission of other infectious diseases to the higher-risk individual. (For example, allocate more space for a higher-risk individual within a shared medical isolation space.)
ο Persons at higher risk may include older adults and persons of any age with serious underlying medical conditions such as lung disease, heart disease, and diabetes. See CDC’s website for a complete list, and check regularly for updates as more data become available to inform this issue.
ο Note that incarcerated/detained populations have higher prevalence of infectious and chronic diseases and are in poorer health than the general population, even at younger ages.
√ Custody staff should be designated to monitor these individuals exclusively where possible. These staff should wear recommended PPE as appropriate for their level of contact with the individual under medical isolation (see PPE section below) and should limit their own movement between different parts of the facility to the extent possible.
√ Minimize transfer of COVID-19 cases between spaces within the healthcare unit.

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√ Provide individuals under medical isolation with tissues and, if permissible, a lined no-touch trash receptacle. Instruct them to: ο Cover their mouth and nose with a tissue when they cough or sneeze ο Dispose of used tissues immediately in the lined trash receptacle ο Wash hands immediately with soap and water for at least 20 seconds. If soap and water are not available, clean hands with an alcohol-based hand sanitizer that contains at least 60% alcohol (where security concerns permit). Ensure that hand washing supplies are continually restocked.
√ Maintain medical isolation until all the following criteria have been met. Monitor the CDC website for updates to these criteria.
For individuals who will be tested to determine if they are still contagious:  The individual has been free from fever for at least 72 hours without the use of fever-reducing medications AND  The individual’s other symptoms have improved (e.g., cough, shortness of breath) AND  The individual has tested negative in at least two consecutive respiratory specimens collected at least 24 hours apart
For individuals who will NOT be tested to determine if they are still contagious:  The individual has been free from fever for at least 72 hours without the use of fever-reducing medications AND  The individual’s other symptoms have improved (e.g., cough, shortness of breath) AND  At least 7 days have passed since the first symptoms appeared
For individuals who had a confirmed positive COVID-19 test but never showed symptoms: ο At least 7 days have passed since the date of the individual’s first positive COVID-19 test AND ο The individual has had no subsequent illness
√ Restrict cases from leaving the facility while under medical isolation precautions, unless released from custody or if a transfer is necessary for medical care, infection control, lack of medical isolation space, or extenuating security concerns. ο If an incarcerated/detained individual who is a COVID-19 case is released from custody during their medical isolation period, contact public health to arrange for safe transport and continuation of necessary medical care and medical isolation as part of release planning.
Cleaning Spaces where COVID-19 Cases Spent Time
Thoroughly clean and disinfect all areas where the confirmed or suspected COVID-19 case spent time. Note—these protocols apply to suspected cases as well as confirmed cases, to ensure adequate disinfection in the event that the suspected case does, in fact, have COVID-19. Refer to the Definitions section for the distinction between confirmed and suspected cases.
ο Close off areas used by the infected individual. If possible, open outside doors and windows to increase air circulation in the area. Wait as long as practical, up to 24 hours under the poorest air exchange conditions (consult CDC Guidelines for Environmental Infection Control in Health-Care Facilities for wait time based on different ventilation conditions), before beginning to clean and disinfect, to minimize potential for exposure to respiratory droplets.
ο Clean and disinfect all areas (e.g., cells, bathrooms, and common areas) used by the infected individual, focusing especially on frequently touched surfaces (see list above in Prevention section).
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√ Hard (non-porous) surface cleaning and disinfection ο If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection.
ο For disinfection, most common EPA-registered household disinfectants should be effective. Choose cleaning products based on security requirements within the facility.  Consult a list of products that are EPA-approved for use against the virus that causes COVID-19. Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time, etc.).  Diluted household bleach solutions can be used if appropriate for the surface. Follow the manufacturer’s instructions for application and proper ventilation, and check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted. Prepare a bleach solution by mixing:
- 5 tablespoons (1/3rd cup) bleach per gallon of water or
- 4 teaspoons bleach per quart of water
√ Soft (porous) surface cleaning and disinfection ο For soft (porous) surfaces such as carpeted floors and rugs, remove visible contamination if present and clean with appropriate cleaners indicated for use on these surfaces. After cleaning:  If the items can be laundered, launder items in accordance with the manufacturer’s instructions using the warmest appropriate water setting for the items and then dry items completely.  Otherwise, use products that are EPA-approved for use against the virus that causes COVID-19 and are suitable for porous surfaces.
√ Electronics cleaning and disinfection ο For electronics such as tablets, touch screens, keyboards, and remote controls, remove visible contamination if present.  Follow the manufacturer’s instructions for all cleaning and disinfection products.  Consider use of wipeable covers for electronics.  If no manufacturer guidance is available, consider the use of alcohol-based wipes or spray containing at least 70% alcohol to disinfect touch screens. Dry surfaces thoroughly to avoid pooling of liquids.
Additional information on cleaning and disinfection of communal facilities such can be found on CDC’s website.
√ Ensure that staff and incarcerated/detained persons performing cleaning wear recommended PPE. (See PPE section below.)
√ Food service items. Cases under medical isolation should throw disposable food service items in the trash in their medical isolation room. Non-disposable food service items should be handled with gloves and washed with hot water or in a dishwasher. Individuals handling used food service items should clean their hands after removing gloves.
√ Laundry from a COVID-19 cases can be washed with other individuals’ laundry. ο Individuals handling laundry from COVID-19 cases should wear disposable gloves, discard after each use, and clean their hands after.
ο Do not shake dirty laundry. This will minimize the possibility of dispersing virus through the air.
ο Launder items as appropriate in accordance with the manufacturer’s instructions. If possible, launder items using the warmest appropriate water setting for the items and dry items completely.
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ο

#:17918 Clean and disinfect clothes hampers according to guidance above for surfaces. If permissible,

consider using a bag liner that is either disposable or can be laundered.

√ Consult cleaning recommendations above to ensure that transport vehicles are thoroughly cleaned after carrying a confirmed or suspected COVID-19 case.

Quarantining Close Contacts of COVID-19 Cases

NOTE: Some recommendations below apply primarily to facilities with onsite healthcare capacity. Facilities without onsite healthcare capacity, or without sufficient space to implement effective quarantine, should coordinate with local public health officials to ensure that close contacts of COVID-19 cases will be effectively quarantined and medically monitored.

√ Incarcerated/detained persons who are close contacts of a confirmed or suspected COVID-19 case (whether the case is another incarcerated/detained person, staff member, or visitor) should be placed under quarantine for 14 days (see CDC guidelines).
ο If an individual is quarantined due to contact with a suspected case who is subsequently tested for COVID-19 and receives a negative result, the quarantined individual should be released from quarantine restrictions.

√ In the context of COVID-19, an individual (incarcerated/detained person or staff) is considered a close contact if they:
ο Have been within approximately 6 feet of a COVID-19 case for a prolonged period of time OR
ο Have had direct contact with infectious secretions of a COVID-19 case (e.g., have been coughed on)

Close contact can occur while caring for, living with, visiting, or sharing a common space with a COVID-19 case. Data to inform the definition of close contact are limited. Considerations when assessing close contact include the duration of exposure (e.g., longer exposure time likely increases exposure risk) and the clinical symptoms of the person with COVID-19 (e.g., coughing likely increases exposure risk, as does exposure to a severely ill patient).

√ Keep a quarantined individual’s movement outside the quarantine space to an absolute minimum. ο Provide medical evaluation and care inside or near the quarantine space when possible. ο Serve meals inside the quarantine space. ο Exclude the quarantined individual from all group activities. ο Assign the quarantined individual a dedicated bathroom when possible.

√ Facilities should make every possible effort to quarantine close contacts of COVID-19 cases individually. Cohorting multiple quarantined close contacts of a COVID-19 case could transmit COVID-19 from those who are infected to those who are uninfected. Cohorting should only be practiced if there are no other available options.
ο If cohorting of close contacts under quarantine is absolutely necessary, symptoms of all individuals should be monitored closely, and individuals with symptoms of COVID-19 should be placed under medical isolation immediately.
ο If an entire housing unit is under quarantine due to contact with a case from the same housing unit, the entire housing unit may need to be treated as a cohort and quarantine in place.
ο Some facilities may choose to quarantine all new intakes for 14 days before moving them to the facility’s general population as a general rule (not because they were exposed to a COVID-19 case). Under this scenario, avoid mixing individuals quarantined due to exposure to a COVID-19 case with individuals undergoing routine intake quarantine.

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ο

#:17919 If at all possible, do not add more individuals to an existing quarantine cohort after the 14-day

quarantine clock has started.

√ If the number of quarantined individuals exceeds the number of individual quarantine spaces available in the facility, be especially mindful of those who are at higher risk of severe illness from COVID-19. Ideally, they should not be cohorted with other quarantined individuals. If cohorting is unavoidable, make all possible accommodations to reduce exposure risk for the higher-risk individuals. (For example, intensify social distancing strategies for higher-risk individuals.)

√ In order of preference, multiple quarantined individuals should be housed:
ο Separately, in single cells with solid walls (i.e., not bars) and solid doors that close fully
ο Separately, in single cells with solid walls but without solid doors
ο As a cohort, in a large, well-ventilated cell with solid walls, a solid door that closes fully, and at least 6 feet of personal space assigned to each individual in all directions
ο As a cohort, in a large, well-ventilated cell with solid walls and at least 6 feet of personal space assigned to each individual in all directions, but without a solid door
ο As a cohort, in single cells without solid walls or solid doors (i.e., cells enclosed entirely with bars), preferably with an empty cell between occupied cells creating at least 6 feet of space between individuals. (Although individuals are in single cells in this scenario, the airflow between cells essentially makes it a cohort arrangement in the context of COVID-19.)
ο As a cohort, in multi-person cells without solid walls or solid doors (i.e., cells enclosed entirely with bars), preferably with an empty cell between occupied cells. Employ social distancing strategies related to housing in the Prevention section to maintain at least 6 feet of space between individuals housed in the same cell.
ο As a cohort, in individuals’ regularly assigned housing unit but with no movement outside the unit (if an entire housing unit has been exposed). Employ social distancing strategies related to housing in the Prevention section above to maintain at least 6 feet of space between individuals.
ο Safely transfer to another facility with capacity to quarantine in one of the above arrangements

(NOTE—Transfer should be avoided due to the potential to introduce infection to another facility; proceed only if no other options are available.)

√ Quarantined individuals should wear face masks if feasible based on local supply, as source control, under the following circumstances (see PPE section and Table 1):
ο If cohorted, quarantined individuals should wear face masks at all times (to prevent transmission from infected to uninfected individuals).
ο If quarantined separately, individuals should wear face masks whenever a non-quarantined individual enters the quarantine space.
ο All quarantined individuals should wear a face mask if they must leave the quarantine space for any reason.
ο Asymptomatic individuals under routine intake quarantine (with no known exposure to a COVID-19 case) do not need to wear face masks.

√ Staff who have close contact with quarantined individuals should wear recommended PPE if feasible based on local supply, feasibility, and safety within the scope of their duties (see PPE section and Table 1).
ο Staff supervising asymptomatic incarcerated/detained persons under routine intake quarantine (with no known exposure to a COVID-19 case) do not need to wear PPE.

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√ Quarantined individuals should be monitored for COVID-19 symptoms twice per day, including temperature checks. ο If an individual develops symptoms, they should be moved to medical isolation immediately and further evaluated. (See Medical Isolation section above.)
ο See Screening section for a procedure to perform temperature checks safely on asymptomatic close contacts of COVID-19 cases.
√ If an individual who is part of a quarantined cohort becomes symptomatic: ο If the individual is tested for COVID-19 and tests positive: the 14-day quarantine clock for the remainder of the cohort must be reset to 0.
ο If the individual is tested for COVID-19 and tests negative: the 14-day quarantine clock for this individual and the remainder of the cohort does not need to be reset. This individual can return from medical isolation to the quarantined cohort for the remainder of the quarantine period.
ο If the individual is not tested for COVID-19: the 14-day quarantine clock for the remainder of the cohort must be reset to 0.
√ Restrict quarantined individuals from leaving the facility (including transfers to other facilities) during the 14-day quarantine period, unless released from custody or a transfer is necessary for medical care, infection control, lack of quarantine space, or extenuating security concerns.
√ Quarantined individuals can be released from quarantine restrictions if they have not developed symptoms during the 14-day quarantine period.
√ Meals should be provided to quarantined individuals in their quarantine spaces. Individuals under quarantine should throw disposable food service items in the trash. Non-disposable food service items should be handled with gloves and washed with hot water or in a dishwasher. Individuals handling used food service items should clean their hands after removing gloves.
√ Laundry from quarantined individuals can be washed with other individuals’ laundry. ο Individuals handling laundry from quarantined persons should wear disposable gloves, discard after each use, and clean their hands after.
ο Do not shake dirty laundry. This will minimize the possibility of dispersing virus through the air.
ο Launder items as appropriate in accordance with the manufacturer’s instructions. If possible, launder items using the warmest appropriate water setting for the items and dry items completely.
ο Clean and disinfect clothes hampers according to guidance above for surfaces. If permissible, consider using a bag liner that is either disposable or can be laundered.
Management of Incarcerated/Detained Persons with COVID-19 Symptoms
NOTE: Some recommendations below apply primarily to facilities with onsite healthcare capacity. Facilities without onsite healthcare capacity or without sufficient space for medical isolation should coordinate with local public health officials to ensure that suspected COVID-19 cases will be effectively isolated, evaluated, tested (if indicated), and given care.
√ If possible, designate a room near each housing unit for healthcare staff to evaluate individuals with COVID-19 symptoms, rather than having them walk through the facility to be evaluated in the medical unit.
√ Incarcerated/detained individuals with COVID-19 symptoms should wear a face mask and should be placed under medical isolation immediately. Discontinue the use of a face mask if it inhibits breathing. See Medical Isolation section above.
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√ Medical staff should evaluate symptomatic individuals to determine whether COVID-19 testing is indicated. Refer to CDC guidelines for information on evaluation and testing. See Infection Control and Clinical Care sections below as well.
√ If testing is indicated (or if medical staff need clarification on when testing is indicated), contact the state, local, tribal, and/or territorial health department. Work with public health or private labs as available to access testing supplies or services. ο If the COVID-19 test is positive, continue medical isolation. (See Medical Isolation section above.) ο If the COVID-19 test is negative, return the individual to their prior housing assignment unless they require further medical assessment or care.
Management Strategies for Incarcerated/Detained Persons without COVID-19 Symptoms
√ Provide clear information to incarcerated/detained persons about the presence of COVID-19 cases within the facility, and the need to increase social distancing and maintain hygiene precautions. ο Consider having healthcare staff perform regular rounds to answer questions about COVID-19. ο Ensure that information is provided in a manner that can be understood by non-English speaking individuals and those with low literacy, and make necessary accommodations for those with cognitive or intellectual disabilities and those who are deaf, blind, or low-vision.
√ Implement daily temperature checks in housing units where COVID-19 cases have been identified, especially if there is concern that incarcerated/detained individuals are not notifying staff of symptoms. See Screening section for a procedure to safely perform a temperature check.
√ Consider additional options to intensify social distancing within the facility.
Management Strategies for Staff
√ Provide clear information to staff about the presence of COVID-19 cases within the facility, and the need to enforce social distancing and encourage hygiene precautions. ο Consider having healthcare staff perform regular rounds to answer questions about COVID-19 from staff.
√ Staff identified as close contacts of a COVID-19 case should self-quarantine at home for 14 days and may return to work if symptoms do not develop. ο See above for definition of a close contact. ο Refer to CDC guidelines for further recommendations regarding home quarantine for staff.
Infection Control
Infection control guidance below is applicable to all types of correctional facilities. Individual facilities should assess their unique needs based on the types of exposure staff and incarcerated/ detained persons may have with confirmed or suspected COVID-19 cases.
√ All individuals who have the potential for direct or indirect exposure to COVID-19 cases or infectious materials (including body substances; contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air) should follow infection control practices outlined in the CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Monitor these guidelines regularly for updates.
22

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ο

#:17922 Implement the above guidance as fully as possible within the correctional/detention context. Some

of the specific language may not apply directly to healthcare settings within correctional facilities

and detention centers, or to facilities without onsite healthcare capacity, and may need to be adapted

to reflect facility operations and custody needs.

ο Note that these recommendations apply to staff as well as to incarcerated/detained individuals who may come in contact with contaminated materials during the course of their work placement in the facility (e.g., cleaning).

√ Staff should exercise caution when in contact with individuals showing symptoms of a respiratory infection. Contact should be minimized to the extent possible until the infected individual is wearing a face mask. If COVID-19 is suspected, staff should wear recommended PPE (see PPE section).

√ Refer to PPE section to determine recommended PPE for individuals persons in contact with confirmed COVID-19 cases, contacts, and potentially contaminated items.

Clinical Care of COVID-19 Cases
√ Facilities should ensure that incarcerated/detained individuals receive medical evaluation and treatment at the first signs of COVID-19 symptoms.
ο If a facility is not able to provide such evaluation and treatment, a plan should be in place to safely transfer the individual to another facility or local hospital.
ο The initial medical evaluation should determine whether a symptomatic individual is at higher risk for severe illness from COVID-19. Persons at higher risk may include older adults and persons of any age with serious underlying medical conditions such as lung disease, heart disease, and diabetes. See CDC’s website for a complete list, and check regularly for updates as more data become available to inform this issue.

√ Staff evaluating and providing care for confirmed or suspected COVID-19 cases should follow the CDC Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) and monitor the guidance website regularly for updates to these recommendations.

√ Healthcare staff should evaluate persons with respiratory symptoms or contact with a COVID-19 case in a separate room, with the door closed if possible, while wearing recommended PPE and ensuring that the suspected case is wearing a face mask.
ο If possible, designate a room near each housing unit to evaluate individuals with COVID-19 symptoms, rather than having them walk through the facility to be evaluated in the medical unit.

√ Clinicians are strongly encouraged to test for other causes of respiratory illness (e.g., influenza).

√ The facility should have a plan in place to safely transfer persons with severe illness from COVID-19 to a local hospital if they require care beyond what the facility is able to provide.

√ When evaluating and treating persons with symptoms of COVID-19 who do not speak English, using a language line or provide a trained interpreter when possible.

Recommended PPE and PPE Training for Staff and Incarcerated/Detained Persons
√ Ensure that all staff (healthcare and non-healthcare) and incarcerated/detained persons who will have contact with infectious materials in their work placements have been trained to correctly don, doff, and dispose of PPE relevant to the level of contact they will have with confirmed and suspected COVID-19 cases.

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ο

#:17923 Ensure that staff and incarcerated/detained persons who require respiratory protection (e.g., N95s)

for their work responsibilities have been medically cleared, trained, and fit-tested in the context of

an employer’s respiratory protection program.

ο For PPE training materials and posters, please visit the CDC website on Protecting Healthcare Personnel.

√ Ensure that all staff are trained to perform hand hygiene after removing PPE.
√ If administrators anticipate that incarcerated/detained persons will request unnecessary PPE, consider providing training on the different types of PPE that are needed for differing degrees of contact with COVID-19 cases and contacts, and the reasons for those differences (see Table 1). Monitor linked CDC guidelines in Table 1 for updates to recommended PPE.

√ Keep recommended PPE near the spaces in the facility where it could be needed, to facilitate quick access in an emergency.

√ Recommended PPE for incarcerated/detained individuals and staff in a correctional facility will vary based on the type of contact they have with COVID-19 cases and their contacts (see Table 1). Each type of recommended PPE is defined below. As above, note that PPE shortages are anticipated in every category during the COVID-19 response.
ο N95 respirator

See below for guidance on when face masks are acceptable alternatives for N95s. N95 respirators should be prioritized when staff anticipate contact with infectious aerosols from a COVID-19 case. ο Face mask ο Eye protection—goggles or disposable face shield that fully covers the front and sides of the face ο A single pair of disposable patient examination gloves

Gloves should be changed if they become torn or heavily contaminated.
ο Disposable medical isolation gown or single-use/disposable coveralls, when feasible
 If custody staff are unable to wear a disposable gown or coveralls because it limits access to their duty belt and gear, ensure that duty belt and gear are disinfected after close contact with the individual. Clean and disinfect duty belt and gear prior to reuse using a household cleaning spray or wipe, according to the product label.
 If there are shortages of gowns, they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of staff.

√ Note that shortages of all PPE categories are anticipated during the COVID-19 response, particularly for non-healthcare workers. Guidance for optimizing the supply of each category can be found on CDC’s website:
ο Guidance in the event of a shortage of N95 respirators
 Based on local and regional situational analysis of PPE supplies, face masks are an acceptable alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for staff engaging in activities that would expose them to respiratory aerosols, which pose the highest exposure risk.
ο Guidance in the event of a shortage of face masks
ο Guidance in the event of a shortage of eye protection
ο Guidance in the event of a shortage of gowns/coveralls

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Table 1. Recommended Personal Protective Equipment (PPE) for Incarcerated/Detained Persons and Staff in a Correctional Facility during
the COVID-19 Response

Classification of Individual Wearing PPE

N95 respirator

Face mask

Eye Protection

Gloves

Gown/ Coveralls

Incarcerated/Detained Persons

Asymptomatic incarcerated/detained persons (under Apply face masks for source control as feasible based on local supply, quarantine as close contacts of a COVID-19 case*) especially if housed as a cohort

Incarcerated/detained persons who are confirmed or

suspected COVID-19 cases, or showing symptoms of

–



–

–

–

COVID-19

Incarcerated/detained persons in a work placement

handling laundry or used food service items from a

–

–

–





COVID-19 case or case contact

Incarcerated/detained persons in a work placement Additional PPE may be needed based on

cleaning areas where a COVID-19 case has spent time the product label. See CDC guidelines for





more details.

Staff

Staff having direct contact with asymptomatic incarcerated/detained persons under quarantine as close contacts of a COVID-19 case* (but not performing temperature checks or providing medical care)

–

Face mask, eye protection, and gloves as local supply and scope of duties allow.

–

Staff performing temperature checks on any group

of people (staff, visitors, or incarcerated/detained persons), or providing medical care to asymptomatic

–

quarantined persons









Staff having direct contact with (including transport)

or offering medical care to confirmed or suspected

**

COVID-19 cases (see CDC infection control guidelines)







Staff present during a procedure on a confirmed

or suspected COVID-19 case that may generate respiratory aerosols (see CDC infection control



–







guidelines)

Staff handling laundry or used food service items from a COVID-19 case or case contact

–

–

–





Staff cleaning an area where a COVID-19 case has

Additional PPE may be needed based on

spent time

the product label. See CDC guidelines for





more details.

* If a facility chooses to routinely quarantine all new intakes (without symptoms or known exposure to a COVID-19 case) before integrating into the facility’s general population, face masks are not necessary.
** A NIOSH-approved N95 is preferred. However, based on local and regional situational analysis of PPE supplies, face masks are an acceptable alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to staff.

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Verbal Screening and Temperature Check Protocols for Incarcerated/Detained Persons, Staff, and Visitors
The guidance above recommends verbal screening and temperature checks for incarcerated/detained persons, staff, volunteers, and visitors who enter correctional and detention facilities, as well as incarcerated/detained persons who are transferred to another facility or released from custody. Below, verbal screening questions for COVID-19 symptoms and contact with known cases, and a safe temperature check procedure are detailed. √ Verbal screening for symptoms of COVID-19 and contact with COVID-19 cases should include
the following questions: ο Today or in the past 24 hours, have you had any of the following symptoms?  Fever, felt feverish, or had chills?  Cough?  Difficulty breathing? ο In the past 14 days, have you had contact with a person known to be infected with the novel coronavirus (COVID-19)?
√ The following is a protocol to safely check an individual’s temperature: ο Perform hand hygiene ο Put on a face mask, eye protection (goggles or disposable face shield that fully covers the front and sides of the face), gown/coveralls, and a single pair of disposable gloves ο Check individual’s temperature ο If performing a temperature check on multiple individuals, ensure that a clean pair of gloves is used for each individual and that the thermometer has been thoroughly cleaned in between each check. If disposable or non-contact thermometers are used and the screener did not have physical contact with an individual, gloves do not need to be changed before the next check. If non-contact thermometers are used, they should be cleaned routinely as recommended by CDC for infection control. ο Remove and discard PPE ο Perform hand hygiene
26

 
 Case 5:13-cv-00444-VAP-OP Document 193 Filed 04/16/20 Page 1 of 4 Page ID #:17961

1 PRISON LAW OFFICE DONALD SPECTER (SBN 83925)

2 SARA NORMAN (SBN 189536)

3 1917 Fifth Street Berkeley, California 94710

4 Telephone: (510) 280-2621

5 Fax: (510) 280-2704 Email: dspecter@prisonlaw.com

6

snorman@prisonlaw.com

7

8 Attorneys for Plaintiffs

9

UNITED STATES DISTRICT COURT

10

FOR THE CENTRAL DISTRICT OF CALIFORNIA

11

EASTERN DIVISION – RIVERSIDE

12

13 QUINTON GRAY, et al., on behalf of
14 themselves and all others similarly 15 situated,
Plaintiffs, 16 v. 17 COUNTY OF RIVERSIDE,
18 Defendant.
19

Case No. EDCV13-0444 VAP (OP) CLASS ACTION
ORDER GRANTING PLAINTIFFS’ EMERGENCY MOTION TO ENFORCE CONSENT DECREE

20

Before this Court is Plaintiffs’ Emergency Motion to Enforce the Consent

21 Decree. This Court, having considered the briefing, relevant legal authority, and the

22 record in this case, GRANTS Plaintiffs’ motion as follows:

23

IT IS HEREBY ORDERED that:

24

A. Defendant shall develop and implement a plan to minimize the spread

25 of COVID-19 in the Riverside County jails, consistent with the guidance of the

26 Centers for Disease Control and Prevention (CDC) and the Court experts. The plan

27 shall include:

28

ORDER, GRAY V. RIVERSIDE, NO. CV13-0444 VAP

Case 5:13-cv-00444-VAP-OP Document 193 Filed 04/16/20 Page 2 of 4 Page ID #:17962

1

1. An evaluation of current jail capacity to house people safely

2

consistent with physical distancing to reduce transmission of COVID-19,

3

including:

4

(a) a description of the size of all cells and dormitories noting

5

how many people can be housed safely in each;

6

(b) the distance between beds (including the distance between

7

upper and lower bunks);

8

(c) the size and location of shared toilet and shower facilities and

9

the number of people who use each at one time;

10

(d) the size of each dayroom and the number of people who are

11

permitted to use each one at the same time consistent with physical

12

distancing; and

13

(e) the number and location of all people who are sleeping in

14

plastic “boats” instead of beds, if any, as of April 14, 2020.

15

2. A plan to safely house and care for people incarcerated in the

16

jails who are at high risk for severe complications from COVID-19 based on

17

guidance from the CDC and the Court experts. Defendant shall identify each

18

such person and shall indicate:

19

(a) COVID-19 risk factor(s) as determined by the CDC;

20

(b) age;

21

(c) charges if pre-trial or current criminal conviction and

22

sentence if already sentenced;

23

(d) length of stay in the Riverside jails as of April 14, 2020; and

24

(e) expected release date, if known.

25

3. Adequate hygiene and cleaning measures, including education of

26

the people incarcerated in the jails, consistent with the CDC’s guidelines.

27

4. Measures to address the mental health needs of people held in

28

2

ORDER, GRAY V. RIVERSIDE, NO. CV-13-0444 VAP

Case 5:13-cv-00444-VAP-OP Document 193 Filed 04/16/20 Page 3 of 4 Page ID #:17963

1

quarantine or isolation, as noted by the Court mental health expert.

2

B. The parties shall participate in mediation with Judge Raul Ramirez on

3 Friday, April 17, to resolve any disputes over the adequacy of the plan and the

4 production of underlying data. Defendants shall provide Plaintiffs with a draft of a

5 proposed plan on Thursday April 16.

6

C. The Court shall hold further proceedings on this matter during the week

7 of April 20 or as determined by further order of this Court.

8

9

The Court finds that this relief meets the requirements of 18 U.S.C. § 3626.

10 In so doing, the Court finds that the relief is narrowly drawn, extends no further than

11 necessary to ensure the protection of the federal constitutional and statutory rights of

12 Plaintiffs, and is the least intrusive means necessary to accomplish those objectives.

13

14 15 Dated: April 16, 2020 16 17

_______________________________ Hon. Virginia A. Phillips Chief United States District Court

18

19

20

21 22 Approved as to form:
Dated: April 14, 2020 23
24

__/s/_____________________ James E. Brown Assistant County Counsel

25

26

27

28

3

ORDER, GRAY V. RIVERSIDE, NO. CV-13-0444 VAP

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
1
[DOC TITLE]

 
 Case 5:13-cv-00444-VAP-OP Document 191 Filed 04/14/20 Page 1 of 6 Page ID #:17954

UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA
CIVIL MINUTES – GENERAL

Case No. 5:13-cv-0444-VAP-OPx Title Quinton Gray v. County of Riverside

Date April 14, 2020

Present: The Honorable VIRGINIA A. PHILLIPS, CHIEF UNITED STATES DISTRICT JUDGE

CHRISTINE CHUNG Deputy Clerk

Not Reported Court Reporter

Attorney(s) Present for Plaintiff(s): None Present

Attorney(s) Present for Defendant(s): None Present

Proceedings: (IN CHAMBERS) MINUTE ORDER GRANTING “EMERGENCY MOTION TO ENFORCE CONSENT DECREE” [DKT. 177]

On April 6, 2020, Plaintiff Quinton Gray (“Plaintiff”) filed a document captioned “Emergency Motion1 to Enforce Consent Decree.” (“Motion,” Dkt. 177). Pursuant to this Court’s April 8, 2020 Minute Order, (Dkt. 182), Defendant County of Riverside (“Defendant”) opposed the Motion on April 10, 2020 (“Opp.,” Dkt. 183). After considering all papers submitted in support of, and in opposition to, the Motion, as well as the arguments advanced during the telephonic hearing on April 13, 2020, the Court GRANTS the Motion.
In 2016, the Parties entered into a Consent Decree “to ensure the provision of constitutional health care and to ensure non-discrimination for inmates with disabilities in the Riverside County Jails.” (Dkt. 173 ¶ 1). The plaintiff class includes three distinct subclasses: the medical subclass, which comprises “[a]ll prisoners who are now, or will in the future be, subjected to the medical care policies and practices of the Riverside

1 The Court notes that an “Emergency Motion” is procedurally improper. Plaintiff should have filed an ex parte application to shorten time for hearing on a motion, in conformance with Local Rule 7-19. In the interests of justice, the Court will treat Plaintiff’s Motion as though it had been filed properly.

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Jails”; the mental health subclass, which comprises “[a]ll prisoners who are now, or will in the future be, subjected to the mental health care policies and practices of the Riverside Jails”; and the disability subclass, which comprises “all prisoners who are now, or will be in the future, subjected to policies and practices of the Riverside jails regarding specialized or sheltered housing for prisoners due to their mobility impairments and need for assistive devices, and the provision and confiscation of accommodations for prisoners with mobility impairments[.]” (Dkt. 173 ¶ 3).
The Parties to the Consent Decree negotiated a Remedial Plan, which “is designed to meet the minimum level of health care necessary to fulfill Defendant’s obligations under the Eighth and Fourteenth Amendments, as well as to ensure nondiscrimination against inmates with disabilities in the areas addressed by the Plan, as required by the ADA and Section 504 of the Rehabilitation Act.” (Dkt. 173 ¶ 9). In light of the coronavirus (“COVID-19”) pandemic2, “Plaintiffs seek to enforce the Consent Decree by requiring the County to submit a plan to the Court to implement the Governor’s order for physical distancing for all Californians housed in the jails and to provide sanitation and other essential services generally accepted as necessary in correctional facilities to provide for the basic health needs of incarcerated people.” (Motion at 3-4).
As Defendant argues, the Consent Decree specifies a dispute resolution process which provides that the Parties first conduct negotiations to resolve informally matters in dispute, then, if they are unable to resolve the dispute, to request that the Relevant Court experts evaluate the issue and prepare a report. Following preparation of this report, if the parties still are unable to resolve the issue, they may request mediation with Judge Raul Ramirez. Only after having mediated are the parties to file a motion for relief with this Court. (Dkt. 173 ¶¶ 26–29). Here, the parties have conducted the first two steps, but have not yet mediated. Nevertheless, “[g]iven the urgent nature of the proceedings, Plaintiffs request the Court modify the Consent Decree to allow for urgent appeal for enforcement directly to the Court.” (Motion at 17 n.2).

2 The pandemic has caused unprecedented disruption to daily life. On March 13, 2020, the President of the United States declared a National Emergency in response to the Coronavirus Disease- 2019 (“COVID-19”) pandemic pursuant to the National Emergencies Act (50 U.S.C. § 1601, et seq.). California Governor Gavin Newson has declared a state of emergency in response to the COVID-19 outbreak and, in his March 19, 2020 Executive Order N-33-20, “require[d] physical distancing to keep Californians at least six feet apart at all times and to prepare hospitals and health care workers for the coming surge in cases.” (Motion at 2).

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The Court finds good cause to modify the Consent Decree to permit appeal to this Court. “[A] party seeking modification of a consent decree bears the burden of establishing that a significant change in circumstances warrants revision of the decree. . . . A party seeking modification of a consent decree may meet its initial burden by showing either a significant change either in factual conditions or in law.”” Rufo v. Inmates of Suffolk Cty. Jail, 502 U.S. 367, 383–84 (1992). The party seeking modification need not prove the change in circumstance was “unforeseen and unforeseeable” at the time of entering into the consent decree, but “[o]rdinarily, . . . modification should not be granted where a party relies upon events that actually were anticipated at the time it entered into a decree.” Id. at 385 (emphasis added). Here, clearly, the emergency resulting from the pandemic constitutes a “significant change in circumstances” that was not actually foreseen at the time the parties entered into the Consent Decree. Id. at 383.
The parties therefore meet the standard to modify the Consent Decree to permit appeal to this Court. In light of the urgency of the matter, the Court orders a two-track dispute resolution mechanism. The Parties are to proceed with mediation before Judge Ramirez on April 17, 2020, or an earlier date, if possible. (See Opp. at 10). The Court simultaneously assumes jurisdiction to enforce the Consent Decree to the extent specified in this Order.
The Court next turns to Defendant’s obligations under the Consent Decree. Plaintiff seeks to enforce the Consent Decree’s mandate to “meet the minimum level of health care necessary to fulfill Defendant’s obligations under the Eighth and Fourteenth Amendments,” (Dkt. 173 ¶ 9), by ensuring that Defendants implement the physical distancing recommendations made by the Court’s experts, (see Dkt. 178, Ex. J, Allen Expert Report, ¶¶ 9-10, 14-16; Dkt. 178, Ex. K, Gage Expert Report, ¶¶ 5-10.). Plaintiff argues that the County has several options available to limit the spread of the disease within the jails, including transferring prisoners to new, currently empty, John J. Benoit Detention Center (“JJBDC”) in Indio, California; relocating particularly vulnerable prisoners; and even release people to allow for physical distancing. (Motion at 4). At the hearing, Defendant did not have information regarding conditions in the existing county jail facilities, insisted that moving prisoners to a newly completed, empty jail in Indio was not feasible, and admitted that it had not researched alternative housing options such as recreation centers, halfway houses, and hotels. Rather than having created a plan to safeguard those most vulnerable to the COVID-19 virus, Defendant conceded that it has not conducted an analysis of its own records to identify particularly vulnerable prisoners. It also has not conducted an analysis of its jail population to determine whether there are any low-level offenders who might be eligible for early release.

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Despite Defendant’s insistence that conditions in the Riverside County jails are compliant with public health recommendations regarding social distancing, its counsel lacked information to respond to the Court’s questions regarding the ability to maintain 6 feet distance between all prisoners in the jail, at all times, its plan for doing so, the size of cells and dormitories, and the number of prisoners per room.
Defendant failed to provide satisfactory information about the feasibility of transfer of prisoners to other jail or non-jail facilities, including transfers of prisoners currently confined in crowded jails to the new, empty, John J. Benoit Detention Center (“JJBDC”) in Indio, California. The County states that it is “not-yet-ready to be populated” but provides no details as to why. (Opp. at 13). The County stated at the hearing that the facility was completed in February 2020, but maintained that it is not yet ready for prisoners. In their papers and at the hearing, Defendant argued that “[t]he Sheriff’s Department is currently in the midst of a ninety day ‘transition period’ of the facility to determine whether any issues arise that will need to be resolved before JJBDC can be populated with inmates.” (Dkt. 183-4, “Graves Decl.” ¶ 4). The County states that the technology used in the JJBDC facility differs from that of other County facilities, but did not explain, in its papers or at the hearing, why this would prevent the transfer of inmates in an emergency situation. (Graves Decl. ¶ 5).
Should the County be unable to implement adequate social distancing within its existing jail facilities and take other necessary steps to decrease risk of infection, this Court has the authority to order the transfer of prisoners to different facilities. Under California law, the Sheriff has the authority to relocate prisoners to respond to emergency situations:
In any case in which an emergency endangering the lives of inmates of a state, county, or city penal or correctional institution has occurred or is imminent, the person in charge of the institution may remove the inmates from the institution. He shall, if possible, remove them to a safe and convenient place and there confine them as long as may be necessary to avoid the danger, or, if that is not possible, may release them.
Other courts, including the Superior Court for the County of Sacramento County, already have ordered the Sheriff to use its authority under Cal. Gov't Code § 8658 to respond to the coronavirus emergency. See Order Authorizing Sacramento County Sheriff’s Department to Grant Release (Cal. Super. Ct., Sac. Cty., Mar. 25, 2020).
Defendant argues that the Prison Litigation Reform Act (“PLRA”) precludes this Court from ordering the release of prisoners. Even assuming this is true, nothing in the

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PLRA prohibits a district judge from ordering the transfer of prisoners in response to violations of their constitutional rights, as the district court did in Brown v. Plata, 2013 WL 3200587, No. C01-1351 TEH (N.D. Cal. June 24, 2013), nor would it prohibit the Court from ordering the Sheriff to use his authority under § 8658 to transfer prisoners.
“[A]n order to transfer any single inmate out of a prison to correct the violation of a constitutional right” where a “transfer was necessary for the inmate to obtain appropriate medical care” is not a “prisoner release order,” but rather a transfer. Plata v. Brown, 2013 WL 3200587 at *8. The same is true of “a policy that would result in transfer of a large group of inmates.” Id. Indeed, several potential courses of action qualify as “transfer” for the purposes of the PLRA. Relocation to halfway houses, for example, is a “transfer” rather than “release.” The PLRA defines a “residential reentry center” as a form of “prerelease custody.” See 18 U.S.C. § 3624(g)(2)(B) (“A prisoner placed in prerelease custody pursuant to this subsection who is placed at a residential reentry center shall be subject to such conditions as the Director of the Bureau of Prisons [(BOP)] determines appropriate.”). Ninth Circuit case law assumes that a person in a “residential reentry center” is a “prisoner” and subject to BOP control. See, e.g., Bottinelli v. Salazar, 929 F.3d 1196, 1200 (9th Cir. 2019) (citing 18 U.S.C. § 3624(c)(1) as “requiring that the BOP, ‘to the extent practicable, ensure that a prisoner serving a term of imprisonment spends a portion of the final months of that term’ in prerelease custody”).
In Plata v. Brown, the court declined to decide which standard governs the court’s review of such requests for transfer, finding that the Plata plaintiffs could satisfy the most burdensome standard. That standard “would require [them] to demonstrate that the [transfer] policy must be enforced because failure to do so would result in deliberate indifference under the Eighth Amendment.” Id. at *10. The Court makes no determination here as to whether Plaintiff has met this standard, but notes that the County’s recitation of “aggressive and swift” measures it has taken in response to COVID-19, none of which concern jails, suggests that the County’s failure to act to protect inmates does indeed constitute deliberate indifference. (Opp. at 16). The County’s assurances that it has provided unlimited free soap to prisoners and advised prisoners to remain physically distant—without establishing that it is physically possible to do so—is unlikely to be sufficient to defeat a claim of deliberate indifference (or sufficient to defeat the request to transfer prisoners for health reasons).
In sum, Defendant has failed to demonstrate that it is currently taking adequate precautions to protect the health of the prisoners in the county jails. Plaintiff’s request that Defendant be required “to submit a plan to the Court to implement the Governor’s order for physical distancing for all Californians housed in the jails” (Motion at 3-4), is therefore GRANTED.

Page 5 of 6

CIVIL MINUTES – GENERAL

Initials of Deputy Clerk cc

Case 5:13-cv-00444-VAP-OP Document 191 Filed 04/14/20 Page 6 of 6 Page ID #:17959
Plaintiffs are instructed to submit a proposed order detailing the findings and outstanding questions from the April 13, 2020 hearing no later than 4:00 p.m. on April 15, 2020. Prior to submission to the Court, Plaintiff shall share the proposed order with Defendant, who may approve the it as to form and content or submit objections to Court thereafter.
IT IS SO ORDERED.

Page 6 of 6

CIVIL MINUTES – GENERAL

Initials of Deputy Clerk cc

 
 Case 5:13-cv-00444-VAP-OP Document 196 Filed 04/24/20 Page 1 of 7 Page ID #:17967

ARTHUR K. CUNNINGHAM, SBN 97506 1 LEWIS BRISBOIS BISGAARD & SMITH LLP
650 East Hospitality Lane, Suite 600 2 San Bernardino, California 92408
(909) 387-1130 - Phone 3 (909) 387-1138 – Fax
Email: Arthur.Cunningham@lewisbrisbois.com
4

5 JAMES E. BROWN, Assistant County Counsel (SBN 162579)

KELLY A. MORAN, Deputy County Counsel (SBN 267147)

6 OFFICE OF COUNTY COUNSEL

3960 Orange Street, Suite 500

7 Riverside, CA 92501-3674

Telephone: (951) 955-6300

8 Facsimile: (951) 955-6363

Email: Jebbrown@rivco.org

9

kmoran@rivco.org

10

11 Attorneys for Defendant COUNTY OF RIVERSIDE
12

13

UNITED STATES DISTRICT COURT

14

CENTRAL DISTRICT OF CALIFORNIA

15 QUINTON GRAY, et al., on behalf of

16

themselves and all others similarly situated,

17

Plaintiffs,

18 v.

19 COUNTY OF RIVERSIDE, 20 Defendant.

21

22

23

) CASE NO. EDCV13-0444 VAP (OP) ) ) CLASS ACTION ) ) JOINT STATUS REPORT RE ) MEDIATION EFFORTS AND ) ONGOING DISCUSSIONS BETWEEN ) COUNSEL ) ) ) JUDGE: Hon. Virginia Phillips ) DATE: TBD ) TIME: TBD ) COURTROOM: 8A ) LOCATION: 350 W. First Street, Los ) Angeles, CA 90012 )

24

25 TO THE HONORABLE COURT:

26

Counsel for PLAINTIFFS, QUINTON GRAY, et al., on behalf of themselves and all

27

28 others similarly situated, and counsel for DEFENDANT, COUNTY OF RIVERSIDE

1 JOINT STATUS REPORT RE MEDIATION EFFORTS AND ONGOING DISCUSSIONS BETWEEN COUNSEL

Case 5:13-cv-00444-VAP-OP Document 196 Filed 04/24/20 Page 2 of 7 Page ID #:17968

1 hereby offer the following Joint Status Report concerning mediation effort and ongoing

2 discussions between counsel:

3
1. On April 6, 2020, Plaintiff Quinton Gray (“Plaintiff”) filed a document
4
5 captioned “Emergency Motion to Enforce Consent Decree.” (“Motion,” Dkt. 177).

6 Defendant County of Riverside (“Defendant”) opposed the Motion on April 10, 2020

7
(“Opp.,” Dkt. 183).
8

9

2. On April 13, 2020, counsel for the Parties appeared before this Court at a

10 hearing on the Emergency Motion.
11
3. Following the hearing, the Court ordered that the Parties proceed with
12
13 mediation before Judge Ramirez on April 17, 2020.

14

4. The Court further granted Plaintiffs’ request that Defendant be required “to

15
develop and implement a plan to minimize the spread of COVID-19 in the Riverside County
16

17 jails, consistent with the guidance of the Centers for Disease Control and Prevention (CDC)

18 and the Court experts”.
19
5. On April 17, 2020, the Parties engaged in a telephonic mediation with Judge
20
21 Ramirez. Throughout the mediation, Defendants provided information which satisfied a

22 significant number of the issues posed by Plaintiffs. Additionally, Defendant is in process
23
of preparing a written plan to provide to Plaintiffs, pursuant to the April 14, 2020 Order of
24
25 this Court.

26

6. Defendant agreed to provide certain information to counsel for Plaintiffs,

27
including:
28

2 JOINT STATUS REPORT RE MEDIATION EFFORTS AND ONGOING DISCUSSIONS BETWEEN COUNSEL

Case 5:13-cv-00444-VAP-OP Document 196 Filed 04/24/20 Page 3 of 7 Page ID #:17969

1

a. A written plan detailing the steps that Behavioral Health has taken and will take

2

to provide stimulation for inmates, both those in quarantine/isolation and those

3
not. This document was provided to counsel for Plaintiffs on Tuesday, April

4

5

21, 2020;

6

b. Further details concerning the inmate population, including identification by

7
Correctional Health Services of the number of those inmates who may be at a
8

9

higher risk of severe illness from COVID-19 due to factors such as age and

10

underlying health condition. This document was provided to counsel for

11
Plaintiffs on Wednesday, April 22, 2020;
12

13

c. A written plan detailing the Sheriff’s Department’s efforts and commitments to

14

combat the spread of COVID-19 in the jails, including changes in housing,

15
sanitation practices, and personal hygiene. This document was provided to
16

17

counsel for Plaintiffs on Tuesday, April 21, 2020.

18

7. Additional documents requested by counsel for Plaintiffs are being prepared

19
and will be provided to counsel on Friday, April 24, 2020.
20

21

8. Furthermore, the parties have established a process for providing updated

22 information to Plaintiffs’ counsel concerning the testing for and occurrences of COVID-19
23
in the jails. For the length of time that the State of Emergency declared by Governor
24
25 Newsom on March 4, 2020 exists in California, Plaintiffs’ counsel will be provided with the

26 following information every Monday, Wednesday, and Friday:
27
a. the number of COVID-19 tests performed on the incarcerated population;
28
3 JOINT STATUS REPORT RE MEDIATION EFFORTS AND ONGOING DISCUSSIONS BETWEEN COUNSEL

Case 5:13-cv-00444-VAP-OP Document 196 Filed 04/24/20 Page 4 of 7 Page ID #:17970

1

b. the number of confirmed cases among people living in the jails (including

2

names, booking numbers, and locations) and the number of confirmed cases

3
among jail staff to the extent that information is known and available;

4

5

c. the number of people living in the jails who are on quarantine or medical

6

isolation and their location;

7
d. the number of people living in the jails who have been sent to the hospital with
8

9

COVID-19 complications; and

10

e. the number of deaths among people living in the jails, and among staff to the

11
extent that information is known and available.
12

13

9. All information referenced in Paragraph 6(b), 7, and 8 and provided to

14 Plaintiffs’ counsel will be subject to the Stipulated Protective Order in this matter, signed

15
by the Court on October 21, 2013 (Docket No. 19).
16

17

10. It is anticipated by counsel that the parties will be able to reach agreement on

18 any outstanding issues. If additional issues remain, counsel agree to return to Judge Ramirez

19
on an expedited basis for further mediation assistance.
20

21 Dated: April 24, 2020 22
23

/s/ Sara Norman
By: SARA NORMAN THE PRISON LAW OFFICE Attorneys for Plaintiffs, QUINTON GRAY et al.

24

25 26 Dated: April 24, 2020 27 28

/s/ Art Cunningham By:
ARTHUR K. CUNNINGHAM LEWIS BRISBOIS BISGAARD & SMITH LLP Attorneys for Defendant, COUNTY OF RIVERSIDE

4 JOINT STATUS REPORT RE MEDIATION EFFORTS AND ONGOING DISCUSSIONS BETWEEN COUNSEL

Case 5:13-cv-00444-VAP-OP Document 196 Filed 04/24/20 Page 5 of 7 Page ID #:17971
Pursuant to Local Rule 5-4.3.4(a)(2)(i), I, ARTHUR K. CUNNINGHAM, attest that
1
all signatories listed, and on whose behalf the filing is submitted, concur in the filing’s
2
content and have authorized the filing.
3
/s/ Art Cunningham
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
5 JOINT STATUS REPORT RE MEDIATION EFFORTS AND ONGOING DISCUSSIONS BETWEEN COUNSEL

Case 5:13-cv-00444-VAP-OP Document 196 Filed 04/24/20 Page 6 of 7 Page ID #:17972

PROOF OF SERVICE
1
United States District Court Case No. 5:13-cv-00444-VAP-OP
2
I, the undersigned, say that I am a citizen of the United States and am employed in 3 the county of Riverside, over the age of 18 years and not a party to the within action or
proceeding; that my business address is: 3960 Orange Street, Suite 500, Riverside, CA 4 92501-3611.

5

On April 24, 2020 , a true and correct copy of the foregoing document entitled:

6 JOINT STATUS REPORT RE MEDIATION EFFORTS AND ONGOING DISCUSSIONS BETWEEN COUNSEL
7
was served on all parties pursuant to FRCivP 5(b) as follows:
8

9 Donald Specter Prison Law Office
10 1917 Fifth Street Berkeley, CA 94710
11 510-280-2621 Fax: 510-280-2704
12 Email: dspecter@prisonlaw.com

Arthur Kenneth Cunningham Lewis Brisbois Bisgaard and Smith LLP Tri-City Corp Center 650 East Hospitality Lane Suite 600 San Bernardino, CA 92408-3508 909-387-1130

13

Fax: 909-387-1138

Email: akcatty@lbbslaw.com

14

Sara Linda Norman 15 Prison Law Office

16

1917 Fifth Street Berkeley, CA 94710

17

510-280-2621 Fax: 510-280-2704

18 Email: snorman@prisonlaw.com

Christopher D Lockwood Arias and Lockwood 1881 South Business Center Drive Suite 9A San Bernardino, CA 92408 909-890-0125 Fax: 909-890-0185 Email:

19 20

Shawn Everett Hanson Akin Gump Strauss Hauer and Feld
LLP

christopher.Lockwood@ariaslockwood.com Stephanie Joy M Tanada Lewis Brisbois Bisgaard and Smith LLP

21

580 California Street 15th Floor San Francisco, CA 94104-1036

22

415-765-9500 Fax: 415-765-9501

Tri-City Corp Center 650 Hospitality Lane Suite 600 San Bernardino, CA 92408-3508

23 Email: shanson@akingump.com

909-387-1130 Fax: 909-387-1138

Email: tanada@lbbslaw.com

24 Danielle C Ginty

Akin Gump Strauss Hauer & Feld

25

LLP

580 California Street Suite 1500

26 San Francisco, CA 94104

415-765-9500

27 Fax: 415-765-9501

Email: dginty@akingump.com

28

6 JOINT STATUS REPORT RE MEDIATION EFFORTS AND ONGOING DISCUSSIONS BETWEEN COUNSEL

Case 5:13-cv-00444-VAP-OP Document 196 Filed 04/24/20 Page 7 of 7 Page ID #:17973

1

TO BE SERVED BY THE COURT VIA THE NOTICE OF ELECTRONIC FILING

(NEF). Pursuant to L.R. 5-3.2.3, the foregoing document will be served by the

2

court via NEF and hyperlink to the document. I checked the CM/ECF docket for this

case or adversary proceeding and determined that the following persons are on the

3

Electronic Mail Notice List to receive NEF transmission at the addresses stated.

4
I declare under penalty of perjury under the laws of the United States of America, 5 State of California that the foregoing is true and correct.

6

Executed on April 24, 2020 , at Riverside, California.

7
/s/ Michelle Quiroz
8
Michelle Quiroz
9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28
7 JOINT STATUS REPORT RE MEDIATION EFFORTS AND ONGOING DISCUSSIONS BETWEEN COUNSEL

 
 Case 5:13-cv-00444-VAP-OP Document 204 Filed 10/14/20 Page 1 of 3 Page ID #:18055

1

2

3

4

5

6

7

UNITED STATES DISTRICT COURT

8

FOR THE CENTRAL DISTRICT OF CALIFORNIA

9

10

11 QUINTON GRAY, et al., on behalf of 12 themselves and all others similarly
situated, 13
Plaintiffs, 14 v.
15 COUNTY OF RIVERSIDE,
16 Defendant.

Case No. EDCV13-0444 VAP (OP) CLASS ACTION
ORDER TO REVISE COVID-19 PLAN

17

18

On April 4, 2020, this Court granted Plaintiffs’ Emergency Motion to Enforce

19 the Consent Decree and ordered Defendant to develop and implement a plan to

20 minimize the spread of COVID-19 in the Riverside County jails, consistent with the

21 guidance of the Centers for Disease Control and Prevention and the Court experts.

22 ECF No. 193. On July 23, 2020, the Court ordered Defendant to implement the plan

23 that the parties had negotiated. ECF No. 202.

24

The parties have reported that since that time, Defendant has worked to

25 implement the Court-ordered plan. According to the parties, in recognition of the

26 importance of out-of-cell time for the physical and mental health of people in the

27 jails, Defendant sought to modify the plan to expand the size of cohorts throughout

28

ORDER REVISING COVID-19 PLAN

Case 5:13-cv-00444-VAP-OP Document 204 Filed 10/14/20 Page 2 of 3 Page ID #:18056

1 the jails to allow more dayroom time for people in celled housing while also

2 managing risk of exposure to the coronavirus. The parties negotiated in good faith

3 and agreed that the following modification to Defendant’s COVID-19 plan would

4 serve those interests:

5

1. In celled housing, the four-person cohorts will be expanded to ten-person

6 cohorts, allowing 10 people out of their cells in the dayroom at a time. All other

7 measures remain the same, and people in the dayroom will be required to wear

8 masks and keep six feet of physical distance where possible. This step is taken for

9 the purpose of providing people housed in cells more time out of their cells.

10

2. In dorm housing, people will no longer be required to remain on their beds

11 when other cohorts have dayroom time. People will be allowed to move around the

12 dorm without limitations by cohort. All other measures remain the same, and

13 people off their beds will be required to wear masks and keep six feet of physical

14 distance where possible.

15

3. The County will provide plaintiffs’ counsel with weekly data reports of (a)

16 out-of-cell time for each cohort in each celled housing unit for each day and (b) test

17 results as required in the current plan but including two additional pieces of

18 information for confirmed cases: the purpose of the testing (booking, symptoms, by

19 request, contact tracing, etc.) and the housing location at the time of testing. The out

20 of cell data will be a week “behind” due to the time required to compile the

21 information.

22

4. The parties will engage in future discussions regarding increasing dorm

23 capacity and adjusting cohort size based on testing results, data, and developing

24 science on COVID-19 transmission.

25

The Court agrees. Based on the record in this case, the Court finds that this

26 relief meets the requirements of 18 U.S.C. § 3626: the relief is narrowly drawn,

27 extends no further than necessary to ensure the protection of the federal

28 constitutional and statutory rights of Plaintiffs, and is the least intrusive means
2
ORDER REVISING COVID-19 PLAN

Case 5:13-cv-00444-VAP-OP Document 204 Filed 10/14/20 Page 3 of 3 Page ID #:18057

1 necessary to accomplish those objectives.

2

IT IS HEREBY ORDERED that Defendant’s COVID-19 Plan is amended as

3 stated herein.

4

5

Dated: October 14, 2020

6

7

_______________________________ Hon. Virginia A. Phillips, Judge United States District Court

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28
3
ORDER REVISING COVID-19 PLAN

 
 March

PRISON LAW OFFICE
General Delivery, San Quentin, CA 94964
Telephone (510) 280-2621  Fax (510) 280-2704
www.prisonlaw.com
18, 2013

FOR IMMEDIATE RELEASE

Riverside Prisoners Sue over Dangerous Jail Conditions Prisoners Suffer Daily from Serious Untreated Medical and Mental Health and Unnecessary Harm and Injuries

Contacts:

Donald Specter, Prison Law Office, (510) 280-2621 Shawn Hanson and Amit Kurlekar, Akin Gump Strauss Hauer & Feld LLP (415) 765-9500

Director: Donald Specter
Managing Attorney: Sara Norman
Staff Attorneys: Rana Anabtawi Rebekah Evenson Steven Fama Warren George Penny Godbold Megan Hagler Alison Hardy Corene Kendrick Kelly Knapp Millard Murphy Lynn Wu

RIVERSIDE, California (March 18, 2013) - Three prisoners in the Riverside Jails served a federal class action lawsuit today on Riverside County, claiming that the County is subjecting them to cruel and unusual punishment by depriving them of basic medical and mental health care. The prisoners seek an order from the court requiring County officials to provide basic health care for the people in their care and custody. A copy of the complaint is available at: www.prisonlaw.com.

Riverside County officials have known for years that the inadequate health care delivery system in the jails places prisoners at serious risk of harm, but instead of fixing the problems, the County has repeatedly slashed the health care budget. As a result, the jails’ health care system does not have that capacity to identify and diagnose serious conditions, provide timely care, to employ adequate staff to meet prisoners’ basic needs, or administer appropriate medications at the appropriate times.

Prisoners suffer as a result. For example,

 Angela Patterson, a plaintiff in the case, suffered nearly a year of delays, cancellations, and inadequate medical care for severe injuries she sustained in a car accident prior to entering the jail. As a result, a temporary filter implanted near her heart cannot be removed, and she will suffer a lifetime of anticoagulation medications and frequent laboratory monitoring, with significant risk of fatal bleeds and other complications.

---more---

Board of Directors Penelope Cooper, President  Michele WalkinHawk, Vice President  Marshall Krause, Treasurer
Honorable John Burton  Felecia Gaston  Christiane Hipps  Margaret Johns Cesar Lagleva  Laura Magnani  Michael Marcum  Ruth Morgan  Dennis Roberts

 Quinton Gray, another plaintiff, was given potent psychotropic medication without appropriate evaluation or follow-up, placing him at risk for life-threatening consequences. As a result of the medication mismanagement and treatment failures, he lives with agonizing side effects: twitching, tongue-biting, increased seizures and tongue swelling, racing thoughts, disorientation, depression, and chronic sleep loss.
“These people are entirely dependent on the jail for their health care – they have no other options,” said Donald Specter, Executive Director of the Prison Law Office. “The County does not provide the minimal care that the Constitution demands. To leave them in pain, at risk of lifethreatening injury and permanent disability is inhumane.” “Riverside County must comply with its constitutional obligations to provide adequate health care for prisoners,” said Shawn Hanson, a partner in the San Francisco office of Akin Gump Strauss Hauer & Feld LLP. The prisoners are represented by two law firms: (1) the Prison Law Office, a non-profit law firm, which has successfully challenged many unlawful conditions on behalf of California prisoners; and (2) Akin Gump Strauss Hauer & Feld LLP, an international, full-service law firm that routinely represents pro bono clients in trial and appellate litigation.
---End---

 
 (OPx),CLOSED,DISCOVERY,MANADR
UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA (Eastern Division - Riverside)
CIVIL DOCKET FOR CASE #: 5:13-cv-00444-VAP-OP

Quinton Gray et al v. County of Riverside Assigned to: Judge Virginia A. Phillips Referred to: Magistrate Judge Oswald Parada Related Cases: 5:15-cv-01859-VAP-DFM
5:16-cv-00355-VAP-DTB Cause: 28:1343 Violation of Civil Rights

Date Filed: 03/08/2013 Date Terminated: 04/28/2016 Jury Demand: None Nature of Suit: 550 Prisoner: Civil Rights Jurisdiction: Federal Question

Plaintiff
Quinton Gray on behalf of themselves and all others similarly situated

represented by Donald Specter Prison Law Office 1917 Fifth Street Berkeley, CA 94710 510-280-2621 Fax: 510-280-2704 Email: dspecter@prisonlaw.com LEAD ATTORNEY ATTORNEY TO BE NOTICED

Sara Linda Norman Prison Law Office 1917 Fifth Street Berkeley, CA 94710 510-280-2621 Fax: 510-280-2704 Email: snorman@prisonlaw.com LEAD ATTORNEY ATTORNEY TO BE NOTICED

Shawn Everett Hanson Akin Gump Strauss Hauer and Feld LLP 580 California Street 15th Floor San Francisco, CA 94104-1036 415-765-9500 Fax: 415-765-9501 Email: shanson@akingump.com LEAD ATTORNEY ATTORNEY TO BE NOTICED

Plaintiff
Angela Patterson on behalf of themselves and all others similarly situated

Amit Kurlekar Akin Gump Strauss Hauer and Feld LLP 580 California Street Suite 1500 San Francisco, CA 94104-1036 415-765-9500 Fax: 415-765-9501 Email: akurlekar@kaufholdgaskin.com TERMINATED: 04/10/2014
Anya J Freedman Meyers Nave Riback Silver & Wilson 633 West Fifth Street Suite 1700 Los Angeles, CA 90071 213-626-2906 Fax: 213-626-0215 Email: afreedman@meyersnave.com TERMINATED: 04/10/2014
Danielle C Ginty Akin Gump Strauss Hauer & Feld LLP 580 California Street Suite 1500 San Francisco, CA 94104 415-765-9500 Fax: 415-765-9501 Email: dginty@akingump.com ATTORNEY TO BE NOTICED
Kelsey Stapler Morris Email: kstaplermorris@gmail.com TERMINATED: 11/25/2015
Saurish Appleby-Bhattacharjee AUSA - Office of US Attorney Northern District of Illinois 219 South Dearborn Street 5th Floor Chicago, IL 60604 312-469-6045 Fax: 312-353-4322 Email: saurish.bhattacharjee@usdoj.gov TERMINATED: 07/22/2014
represented by Donald Specter (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Plaintiff
Stanley Kujansky on behalf of themselves and all others similarly situated

Sara Linda Norman (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Shawn Everett Hanson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Amit Kurlekar (See above for address) TERMINATED: 04/10/2014
Anya J Freedman (See above for address) TERMINATED: 04/10/2014
Danielle C Ginty (See above for address) ATTORNEY TO BE NOTICED
Kelsey Stapler Morris (See above for address) TERMINATED: 11/25/2015
Saurish Appleby-Bhattacharjee (See above for address) TERMINATED: 07/22/2014
represented by Donald Specter (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sara Linda Norman (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Shawn Everett Hanson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Plaintiff
John Rosson, III on behalf of themselves and all other similary situated

Amit Kurlekar (See above for address) TERMINATED: 04/10/2014
Anya J Freedman (See above for address) TERMINATED: 04/10/2014
Danielle C Ginty (See above for address) ATTORNEY TO BE NOTICED
Kelsey Stapler Morris (See above for address) TERMINATED: 11/25/2015
Saurish Appleby-Bhattacharjee (See above for address) TERMINATED: 07/22/2014
represented by Donald Specter (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Sara Linda Norman (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Shawn Everett Hanson (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Amit Kurlekar (See above for address) TERMINATED: 04/10/2014
Anya J Freedman (See above for address) TERMINATED: 04/10/2014
Danielle C Ginty

V. Defendant County of Riverside

(See above for address) ATTORNEY TO BE NOTICED
Kelsey Stapler Morris (See above for address) TERMINATED: 11/25/2015
Saurish Appleby-Bhattacharjee (See above for address) TERMINATED: 07/22/2014
represented by Arthur K. Cunningham Lewis Brisbois Bisgaard and Smith LLP Tri-City Corp Center 650 East Hospitality Lane Suite 600 San Bernardino, CA 92408-3508 909-387-1130 Fax: 909-387-1138 Email: Arthur.Cunningham@jacksonlewis.com ATTORNEY TO BE NOTICED
Christopher D Lockwood Arias and Lockwood 1881 South Business Center Drive Suite 9A San Bernardino, CA 92408 909-890-0125 Fax: 909-890-0185 Email: Christopher.Lockwood@ariaslockwood.com ATTORNEY TO BE NOTICED
James E Brown Office of County Counsel County of Riverside 3960 Orange Street Suite 500 Riverside, CA 92501 951-955-6300 Fax: 951-955-6322 Email: jebbrown@rivco.org ATTORNEY TO BE NOTICED
Kelly Anne Moran

Riverside County Counsel 3960 Orange Street Suite 500 Riverside, CA 92501 951-955-6300 Fax: 951-955-6363 Email: Kmoran@rivco.org ATTORNEY TO BE NOTICED
Stephanie Joy M Tanada Jackson Lewis 200 Spectrum Center Drive Suite 500 Irvine, CA 92618 949-885-1360 Fax: 949-885-1380 Email: Stephanie.Tanada@Jacksonlewis.com ATTORNEY TO BE NOTICED

Date Filed 03/08/2013
03/08/2013 03/08/2013 03/08/2013 03/12/2013 03/13/2013 03/20/2013

# Docket Text
1 COMPLAINT against Defendant County of Riverside. Case assigned to Judge Virginia A. Phillips for all further proceedings. Discovery referred to Magistrate Judge Oswald Parada. (Filing fee $ 350.00 paid), filed by plaintiffs Quinton Gray, Angela Patterson, Stanley Kujansky.(adu) (Additional attachment(s) added on 3/19/2013: # 1 Summons) (ad). (Entered: 03/11/2013)
2 CERTIFICATION AND NOTICE of Interested Parties filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson. (adu) (Entered: 03/11/2013)
3 NOTICE of Related Case(s) filed by plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson. Related Case(s): None. (adu) (Entered: 03/11/2013)
4 NOTICE TO PARTIES OF COURT-DIRECTED ADR PROGRAM filed.(adu) (Entered: 03/11/2013)
5 STANDING ORDER by Judge Virginia A. Phillips. (ad) (Entered: 03/13/2013)
21 DAY Summons Issued re Complaint 1 as to defendant County of Riverside. (ad) (Entered: 03/19/2013)
6 PROOF OF SERVICE Executed by Plaintiff Quinton Gray, Angela Patterson, Stanley Kujansky, upon Defendant County of Riverside served on 3/19/2013, answer due 4/9/2013. Service of the Summons and Complaint were executed upon Lorraine Canova, Assistant Clerk of the Board, County of Riverside in compliance with Federal Rules of Civil

03/20/2013 04/30/2013 05/23/2013 05/23/2013 05/23/2013 05/23/2013 05/28/2013 08/05/2013 08/05/2013 08/12/2013
08/12/2013

Procedure by personal service. Original Summons returned. (Freedman, Anya) (Entered: 03/20/2013)
7 PROOF OF SERVICE OF SERVICE filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, re Service of Summons and Complaint Returned Executed (21 days), 6 served on 03/20/2013. (Freedman, Anya) (Entered: 03/20/2013)
8 FIRST AMENDED COMPLAINT against defendant County of Riverside amending Complaint - (Discovery), 1 ,filed by plaintiffs Quinton Gray, Angela Patterson, Stanley Kujansky, John Rosson, III (am) (cys). (Entered: 05/08/2013)
9 ANSWER to Amended Complaint, 8 filed by defendant County of Riverside.(Lockwood, Christopher) (Entered: 05/23/2013)
10 ANSWER to Amended Complaint, 8 (corrected to include /s/ signature) filed by defendant County of Riverside.(Lockwood, Christopher) (Entered: 05/23/2013)
11 NOTICE of Interested Parties filed by defendant County of Riverside, identifying only the named parties. (Lockwood, Christopher) (Entered: 05/23/2013)
12 Association of Counsel filed by Defendant County of Riverside re: Answer to Complaint 10 (Tanada, Stephanie) (Entered: 05/23/2013)
13 ORDER SETTING SCHEDULING CONFERENCE by Judge Virginia A. Phillips. Scheduling Conference set for 8/12/2013 01:30 PM before Judge Virginia A. Phillips. (cys) (Entered: 05/28/2013)
14 STATEMENT Joint Rule 26(f) Statement filed by Plaintiff Quinton Gray (Specter, Donald) (Entered: 08/05/2013)
15 REQUEST for ADR Procedure No. 1 filed. Parties request to Appear Before Oswald Parada for settlement proceedings. Filed by Plaintiff Quinton Gray.(Specter, Donald) (Entered: 08/05/2013)
16 MINUTES OF SCHEDULING CONFERENCE held before Judge Virginia A. Phillips: The Court indicates that it will consult with the Retired Magistrate Judge, in the Eastern District, to determine if voluntary mediation services with the parties can be made. The Court recommends that the parties enter into a stipulation regarding the waiving of some of the Local Rule 16 requirements. Court Reporter: Phyllis Preston. Tape #: N/A. (ad) (Entered: 08/14/2013)
17 CIVIL TRIAL SCHEDULING ORDER by Judge Virginia A. Phillips: Plaintiffs Motion for Class Certification, to be filed not later than: April 14, 2014; Defendants Opposition, to be filed not later than: June 16, 2014; Plaintiffs Reply, to be filed not later than: June 30, 2014; Hearing on Plaintiffs Motion for Class Certification, to be held on: July 21, 2014, at 2:00pm. (ad) (Entered: 08/14/2013)

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18 Joint STIPULATION for Protective Order filed by Plaintiff Quinton Gray. (Attachments: # 1 Proposed Order)(Norman, Sara) (Entered: 10/11/2013)
19 PROTECTIVE ORDER by Magistrate Judge Oswald Parada, re Stipulation for Protective Order 18 (dc) (Main Document 19 replaced on 10/22/2013) (dc). (Entered: 10/22/2013)
20 STIPULATION for Leave to To take the deposition of incarcerated plaintiffs filed by defendant County of Riverside. (Attachments: # 1 Proposed Order)(Cunningham, Arthur) (Entered: 03/26/2014)
21 Notice of Electronic Filing re Stipulation for Leave 20 e-mailed to Attorney Amit Arun Kurlekar bounced due to invalid email. Primary email address corrected. Notice of Electronic Filing resent addressed to akurlekar@kaufholdgaskin.com. Pursuant to Local Rules it is the attorneys obligation to maintain all personal contact information including e-mail address in the CM/ECF system. THERE IS NO PDF DOCUMENT ASSOCIATED WITH THIS ENTRY. (ir) TEXT ONLY ENTRY (Entered: 03/26/2014)
22 ORDER by Judge Virginia A. Phillips Re Stipulation 20 : Pursuant to the stipulation of the parties, the Court grants permission for Defendant to take the depositions of incarcerated Plaintiffs Quinton Gray, Angela Patterson, and John Rosson III. (ad) (Entered: 03/27/2014)
23 Notice of Appearance or Withdrawal of Counsel: for attorney Saurish Bhattacharjee counsel for Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Adding Saurish Bhattacharjee as attorney as counsel of record for Plaintiffs for the reason indicated in the G-123 Notice. Filed by counsel for plaintiffs. (Attorney Saurish Bhattacharjee added to party Quinton Gray(pty:pla), Attorney Saurish Bhattacharjee added to party Stanley Kujansky(pty:pla), Attorney Saurish Bhattacharjee added to party Angela Patterson(pty:pla), Attorney Saurish Bhattacharjee added to party John Rosson, III(pty:pla))(Bhattacharjee, Saurish) (Entered: 04/10/2014)
24 Notice of Appearance or Withdrawal of Counsel: for attorney Saurish Bhattacharjee counsel for Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Amit A. Kurlekar is no longer attorney of record for the aforementioned party in this case for the reason indicated in the G-123 Notice. Filed by counsel for plaintiffs. (Bhattacharjee, Saurish) (Entered: 04/10/2014)
25 Notice of Appearance or Withdrawal of Counsel: for attorney Saurish Bhattacharjee counsel for Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Anya J. Freedman is no longer attorney of record for the aforementioned party in this case for the reason indicated in the G-123 Notice. Filed by counsel for plaintiffs. (Bhattacharjee, Saurish) (Entered: 04/10/2014)

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26 Notice of Appearance or Withdrawal of Counsel: for attorney Saurish Bhattacharjee counsel for Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Adding Danielle C. Crockett as attorney as counsel of record for plaintiffs for the reason indicated in the G-123 Notice. Filed by counsel for plaintiffs. (Bhattacharjee, Saurish) (Entered: 04/10/2014)
27 NOTICE of Manual Filing filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III of (1) Plaintiffs' Application to File Documents Under Seal in Connection with Plaintiffs' Motion for Class Certification; (2) [Proposed] Order Granting Plaintiffs' Application to File Documents Under Seal; (3) Unredacted Declaration of Danielle Crockett Filed in Support of Plaintiffs' Motion for Class Certification; (4) Exhibits 44-50, 53-57, 59-120, 126-127, 134-136, 139-146 to the Declaration of Danielle Crockett; (5) Unredacted Declaration of Dr. Pablo Stewart Filed in Support of Plaintiffs' Motion for Class Certification; (6) Unredacted Declaration of Dr. Todd Wilcox Filed in Support of Plaintiffs' Motion for Class Certification. (Crockett, Danielle) (Entered: 04/14/2014)
28 NOTICE OF MOTION AND MOTION to Certify Class filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Motion set for hearing on 7/21/2014 at 02:00 PM before Judge Virginia A. Phillips. (Attorney Danielle Christine Crockett added to party Quinton Gray(pty:pla), Attorney Danielle Christine Crockett added to party Stanley Kujansky(pty:pla), Attorney Danielle Christine Crockett added to party Angela Patterson(pty:pla), Attorney Danielle Christine Crockett added to party John Rosson, III(pty:pla))(Crockett, Danielle) (Entered: 04/14/2014)
29 DECLARATION of Pablo Stewart, M.D. in support of MOTION to Certify Class 28 filed by Plaintiff Quinton Gray. (Norman, Sara) (Entered: 04/14/2014)
30 DECLARATION of Sara Norman in support of MOTION to Certify Class 28 filed by Plaintiff Quinton Gray. (Norman, Sara) (Entered: 04/14/2014)
31 NOTICE OF MOTION AND MOTION to Certify Class filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Motion set for hearing on 7/21/2014 at 02:00 PM before Judge Virginia A. Phillips. (Attachments: # 1 Declaration, # 2 Declaration, # 3 Exhibit A, # 4 Proposed Order)(Crockett, Danielle) (Entered: 04/14/2014)
32 DECLARATION of Danielle Crockett re MOTION to Certify Class 28 filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. (Attachments: # 1 Exhibit 1-11, # 2 Exhibit 12, # 3 Exhibit 13-15, # 4 Exhibit 16-18, # 5 Exhibit 19-27, # 6 Exhibit 28-32, # 7 Exhibit 33-38, # 8 Exhibit 39-51, # 9 Exhibit 52-127, # 10 Exhibit 128-129, # 11 Exhibit 130A, # 12 Exhibit 130B, # 13 Exhibit

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131-149, # 14 Exhibit 150-153, # 15 Exhibit 155-156)(Crockett, Danielle) Modified on 4/15/2014 (adu). (Entered: 04/14/2014)
33 Plaintiff's APPLICATION to File Documents Under Seal in Connection with Plaintiff's Motion for Class Certification 31 filed by plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. (adu) (Entered: 04/15/2014)
34 NOTICE OF ERRATA filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. correcting MOTION to Certify Class 31 (Crockett, Danielle) (Entered: 04/15/2014)
35 DECLARATION re MOTION to Certify Class 28 filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. (Attachments: # 1 Declaration, # 2 Exhibit A, # 3 Proposed Order)(Crockett, Danielle) (Entered: 04/15/2014)
36 DECLARATION of TODD R. WILCOX re MOTION to Certify Class 28 filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. (Attachments: # 1 Exhibit A)(Crockett, Danielle) (Entered: 04/15/2014)
37 [PROPOSED] ORDER GRANTING PLAINTIFFS' MOTION FOR CLASS CERTIFICATION filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III re: MOTION to Certify Class 28 (Crockett, Danielle) (Entered: 04/15/2014)
38 PROOF OF SERVICE filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III, re APPLICATION to Seal 33 [Proposed] Order; Unredacted Declaration of Danielle Crockett; Exhibits 44-50,35-57, 59-120, 126-127, 134-136, 139-146; Unredacted Declaration of Dr. Pablo Stewart; Unredacted Declaration of Dr. Todd Wilcox; and Proof of Service served on April 14, 2014. (Crockett, Danielle) (Entered: 04/16/2014)
39 NOTICE TO FILER OF DEFICIENCIES in Electronically Filed Documents RE: Miscellaneous Document 37 . The following error(s) was found: Incorrect event selected. A proposed order needs to be submitted either as an attachment to a motion, application, or request or submitted as an attachment to a Notice of Lodging. Proposed Document was not submitted as a separate attachment. In response to this notice the court may order (1) an amended or correct document to be filed (2) the document stricken or (3) take other action as the court deems appropriate. You need not take any action in response to this notice unless and until the court directs you to do so. (mrgo) (Entered: 04/16/2014)
40 RESPONSE BY THE COURT TO NOTICE TO FILER OF DEFICIENCIES IN ELECTRONICALLY FILED DOCUMENTS RE: Miscellaneous Document 37 . Counsel is directed to re-file the document on or before Friday, May 2, 2014, in compliance with Local Rule 5-4.4.1. (adu) (Entered: 04/30/2014)

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41 ORDER by Judge Virginia A. Phillips: granting plaintiff's 33 Application to to File Documents Under Seal in Connection with plaintiff's Motion for Class Certification. (mrgo) (Entered: 04/30/2014)
42 SEALED DOCUMENT-EXHIBIT 44-50, 53-57, 59-120, 126-127, 134136, and 139-146 to the declaration of Danielle Crockett in support of plaintiffs' MOTION to Certify Class 28 filed . (VOLUME 1 OF 3)(Attachments: # 1 Exhibit Vol 1.1a)(mrgo) Modified on 5/1/2014 (mrgo). (Additional attachment(s) added on 5/1/2014: # 3 Exhibit Vol 1.2) (mrgo). (Additional attachment(s) added on 5/1/2014: # 1 Exhibit 44) (mrgo). (Additional attachment(s) added on 5/1/2014: # 2 Exhibit 45 part 1, # 3 Exhibit 45 part 2) (mrgo). (Additional attachment(s) added on 5/1/2014: # 4 Exhibit 46) (mrgo). (Additional attachment(s) added on 5/1/2014: # 5 Exhibit 47, # 6 Exhibit 48, # 7 Exhibit 49) (mrgo). (Additional attachment(s) added on 5/1/2014: # 8 Exhibit 50, # 9 Exhibit 53, # 10 Exhibit 54, # 11 Exhibit 55 part 1, # 12 Exhibit 55 part 2) (mrgo). (Additional attachment(s) added on 5/1/2014: # 13 Exhibit 56, # 14 Exhibit 57, # 15 Exhibit 58, # 16 Exhibit 59, # 17 Exhibit 60, # 18 Exhibit 61) (mrgo). (Additional attachment(s) added on 5/1/2014: # 19 Exhibit 62, # 20 Exhibit 63, # 21 Exhibit 64) (mrgo). (Additional attachment(s) added on 5/1/2014: # 22 Exhibit 65) (mrgo). (Additional attachment(s) added on 5/1/2014: # 23 Exhibit 66 part 1, # 24 Exhibit 66 part 2) (mrgo). (Additional attachment(s) added on 5/1/2014: # 25 Exhibit 67) (mrgo). (Additional attachment(s) added on 5/1/2014: # 26 Exhibit 68, # 27 Exhibit 69, # 28 Exhibit 70) (mrgo). Modified on 5/1/2014 (mrgo). Modified on 5/1/2014 (mrgo). (Entered: 05/01/2014)
43 SEALED DOCUMENT-UNREDACTED DECLARATION of Dr Pablo Stewart in support of plaintiffs' MOTION to Certify Class 28 filed. (mrgo) Modified on 5/1/2014 (mrgo). (Entered: 05/01/2014)
44 SEALED DOCUMENT-UNREDACTED DECLARATION of Dr Todd Wilcox in support of plaintiffs' MOTION to Certify Class 28 filed. (mrgo) (Entered: 05/01/2014)
45 SEALED DOCUMENT-UNREDACTED DECLARATION of Danielle Crockett in support of plaintiffs' MOTION to Certify Class 28 filed. (mrgo) (Entered: 05/01/2014)
46 SEALED DOCUMENT-EXHIBIT 44-50, 53-57, 59-120, 126-127, 134136, and 139-146 to the declaration of Danielle Crockett in support of plaintiffs' to MOTION to Certify Class 28 filed . (VOLUME 2 OF 3) (Attachments: # 1 Exhibit 71 part 2)(mrgo) (Additional attachment(s) added on 5/1/2014: # 2 Exhibit 71 part 2a, # 3 Exhibit 71 part 2b) (mrgo). (Additional attachment(s) added on 5/1/2014: # 4 Exhibit 71 part 3a, # 5 Exhibit 71 part 3b) (mrgo). (Additional attachment(s) added on 5/1/2014: # 6 Exhibit 71 part 4a, # 7 Exhibit 71 part 4b) (mrgo). (Additional attachment(s) added on 5/1/2014: # 8 Exhibit 71 part 5a, # 9 Exhibit 71 part 5b) (mrgo). (Additional attachment(s) added on

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5/1/2014: # 10 Exhibit 71 part 6a, # 11 Exhibit 71 part 6b) (mrgo). (Additional attachment(s) added on 5/1/2014: # 12 Exhibit 71 part 7a, # 13 Exhibit 71 part 7b) (mrgo). (Additional attachment(s) added on 5/1/2014: # 14 Exhibit 71 part 8a, # 15 Exhibit 71 part 8b) (mrgo). (Additional attachment(s) added on 5/1/2014: # 16 Exhibit 71 part 9a, # 17 Exhibit 71 part 9b) (mrgo). Modified on 5/1/2014 (mrgo). (Entered: 05/01/2014)
47 SEALED DOCUMENT-EXHIBIT 44-50, 53-57, 59-120, 126-127, 134136, and 139-146 to the declaration of Danielle Crockett in support of plaintiffs' MOTION to Certify Class 28 filed. (VOLUME 3 OF 3) (Attachments: # 1 Exhibit 73, # 2 Exhibit 74, # 3 Exhibit 75, # 4 Exhibit 76, # 5 Exhibit 77, # 6 Exhibit 78, # 7 Exhibit 79, # 8 Exhibit 80)(mrgo) (Additional attachment(s) added on 5/1/2014: # 9 Exhibit 82, # 10 Exhibit 83, # 11 Exhibit 84, # 12 Exhibit 85, # 13 Exhibit 86, # 14 Exhibit 87, # 15 Exhibit 88, # 16 Exhibit 89, # 17 Exhibit 90) (mrgo). (Additional attachment(s) added on 5/1/2014: # 18 Exhibit 91, # 19 Exhibit 92, # 20 Exhibit 93, # 21 Exhibit 94, # 22 Exhibit 95, # 23 Exhibit 96, # 24 Exhibit 97, # 25 Exhibit 98, # 26 Exhibit 99, # 27 Exhibit 100) (mrgo). (Additional attachment(s) added on 5/1/2014: # 28 Exhibit 101, # 29 Exhibit 102, # 30 Exhibit 103, # 31 Exhibit 104, # 32 Exhibit 105, # 33 Exhibit 106, # 34 Exhibit 107, # 35 Exhibit 108, # 36 Exhibit 109, # 37 Exhibit 110) (mrgo). (Additional attachment(s) added on 5/1/2014: # 38 Exhibit 111, # 39 Exhibit 112, # 40 Exhibit 113, # 41 Exhibit 114, # 42 Exhibit 115, # 43 Exhibit 116, # 44 Exhibit 117, # 45 Exhibit 118, # 46 Exhibit 119, # 47 Exhibit 120, # 48 Exhibit 121, # 49 Exhibit 126, # 50 Exhibit 127, # 51 Exhibit 128) (mrgo). (Additional attachment(s) added on 5/1/2014: # 52 Exhibit 134, # 53 Exhibit 135, # 54 Exhibit 136, # 55 Exhibit 139, # 56 Exhibit 140, # 57 Exhibit 141, # 58 Exhibit 142, # 59 Exhibit 143, # 60 Exhibit 144, # 61 Exhibit 145, # 62 Exhibit 146) (mrgo). (Entered: 05/01/2014)
48 NOTICE OF LODGING filed re Response By Court to Notice of Deficiencies (G-112B), 40 (Attachments: # 1 [Proposed] Order Granting Plaintiffs' Motion for Class Certification)(Crockett, Danielle) (Entered: 05/01/2014)
49 NOTICE OF MOTION AND MOTION to Amend the Complaint filed by Plaintiff Quinton Gray. Motion set for hearing on 7/7/2014 at 02:00 PM before Judge Virginia A. Phillips. (Attachments: # 1 Proposed Order)(Norman, Sara) (Entered: 06/09/2014)
50 DECLARATION of Sara Norman in support of MOTION to Amend the Complaint 49 filed by Plaintiff Quinton Gray. (Attachments: # 1 Exhibit)(Norman, Sara) (Entered: 06/09/2014)
51 OPPOSITION re: MOTION to Amend the Complaint 49 filed by Defendant County of Riverside. (Lockwood, Christopher) (Entered: 06/16/2014)

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52 OPPOSITION (supporting declarations and exhibits filed separately) re: MOTION to Certify Class 28 , MOTION to Certify Class 31 filed by Defendant County of Riverside. (Lockwood, Christopher) (Entered: 06/16/2014)
53 APPLICATION to Exceed Page Limitation opposition to motion for class certification filed by defendant County of Riverside. (Attachments: # 1 Proposed Order)(Lockwood, Christopher) (Entered: 06/16/2014)
54 DECLARATION of Stephanie J. Tanada opposition MOTION to Amend the Complaint 49 filed by Defendant County of Riverside. (Attachments: # 1 Exhibit 1, # 2 Exhibit 2, # 3 Exhibit 3, # 4 Exhibit 4, # 5 Exhibit 5, # 6 Exhibit 6, # 7 Exhibit 7, # 8 Exhibit 8, # 9 Exhibit 9, # 10 Exhibit 10, # 11 Exhibit 11, # 12 Exhibit 12, # 13 Exhibit 13)(Cunningham, Arthur) (Entered: 06/16/2014)
55 NOTICE of Manual Filing filed by Defendant County of Riverside of unredacted declaration of SJT in support of opposition to plaintiffs' motion to file second amended complaint. (Cunningham, Arthur) (Entered: 06/16/2014)
56 DECLARATION of Bradley Gilbert, M.D. opposition MOTION to Certify Class 28 , MOTION to Certify Class 31 filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 06/16/2014)
57 DECLARATION of defendant's opposition MOTION to Certify Class 31 filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 06/16/2014)
58 DECLARATION of County Personnel opposition MOTION to Certify Class 28 filed by Defendant County of Riverside. (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D, # 5 Exhibit E, # 6 Exhibit F, # 7 Exhibit G, # 8 Exhibit H, # 9 Exhibit I, # 10 Exhibit J, # 11 Exhibit K, # 12 Exhibit L, # 13 Exhibit M, # 14 Exhibit N)(Cunningham, Arthur) (Entered: 06/16/2014)
59 objection opposition re: MOTION to Certify Class 28 filed by Defendant County of Riverside. (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D, # 5 Exhibit E)(Cunningham, Arthur) (Entered: 06/16/2014)
60 objection opposition re: MOTION to Certify Class 28 filed by Defendant County of Riverside. (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D, # 5 Exhibit E, # 6 Exhibit F)(Cunningham, Arthur) (Entered: 06/16/2014)
61 NOTICE of Manual Filing filed by Defendant County of Riverside of Application to file declarations under seal. (Cunningham, Arthur) (Entered: 06/16/2014)
63 Defendant's APPLICATION to File Exhibits to Opposition to Motion to File a Second Amended Complaint Under Seal filed by defendant County

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of Riverside. (Attorney Stephanie Joy M Tanada added to party County of Riverside(pty:dft))(adu) (Entered: 06/18/2014)
62 NOTICE of Manual Filing filed by Defendant County of Riverside of Amended Notice of Manual Filing. (Cunningham, Arthur) (Entered: 06/17/2014)
64 Defendant's APPLICATION to File Exhibits to Opposition to Motion for Class Certification Under Seal filed by defendant County of Riverside. (adu) (Entered: 06/18/2014)
65 County of Riverside's EXHIBITS in Support of Opposition to Motion for Class Certification - Volume 3 filed by Defendant County of Riverside. (adu) (Main Document 65 Modified on 10/23/2014 (lmu). (Entered: 06/18/2014)
66 ORDER GRANTING APPLICATION FOR LEAVE TO FILE BRIEF OVER 25 PAGES by Judge Virginia A. Phillips. Good cause appearing it is ordered that the opposition brief submitted by defendant County of Riverside is ordered filed. (adu) (Entered: 06/20/2014)
80 SEALED DOCUMENT-UNREDACTED DECLARATION of Stephanie J Tanada in support of opposition to plaintiffs' MOTION to Amend the Complaint 49 filed. (Attachments: # 1 Declaration part 2)(mrgo) (Entered: 07/01/2014)
83 ORDER by Judge Virginia A. Phillips: granting 63 Application to File Declarations and Exhibits supporting opposition to plaintiffs' motion to file a second amended complaint under seal. (mrgo) (Entered: 07/01/2014)
67 NOTICE of Manual Filing filed by Defendant County of Riverside of Unredacted Notice of Errata. (Cunningham, Arthur) (Entered: 06/23/2014)
68 NOTICE filed by defendant County of Riverside. (Cunningham, Arthur) (Entered: 06/23/2014)
69 REPLY MOTION to Amend the Complaint 49 filed by Plaintiff Quinton Gray. (Attachments: # 1 Proposed Order)(Norman, Sara) (Entered: 06/23/2014)
70 DECLARATION of Sara Norman in support of MOTION to Amend the Complaint 49 (Reply) filed by Plaintiff Quinton Gray. (Attachments: # 1 Exhibit)(Norman, Sara) (Entered: 06/23/2014)
71 APPLICATION to File Notice of Errata Under Seal filed by defendant County of Riverside. (adu) (Entered: 06/26/2014)
73 SEALED DOCUMENT-EXHIBITS IN SUPPORT OF OPPOSITION to MOTION to Certify Class 28 filed . (Volume 1) (mrgo) (Additional attachment(s) added on 6/30/2014: # 1 Exhibit 501-part 1 of 2, # 2 Exhibit 501-part 2 of 2) (mrgo). (Additional attachment(s) added on 6/30/2014: # 3 Exhibit 502) (mrgo). (Additional attachment(s) added on 6/30/2014: # 4 Exhibit 503) (mrgo). (Additional attachment(s) added on 6/30/2014:

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# 5 Exhibit 505) (mrgo). (Additional attachment(s) added on 6/30/2014: # 6 Exhibit 506, # 7 Exhibit 507, # 8 Exhibit 509) (mrgo). (Additional attachment(s) added on 6/30/2014: # 9 Exhibit 510, # 10 Exhibit 511, # 11 Exhibit 512, # 12 Exhibit 513) (mrgo). (Additional attachment(s) added on 6/30/2014: # 13 Exhibit 514, # 14 Exhibit 515) (mrgo). (Additional attachment(s) added on 6/30/2014: # 15 Exhibit 516 part 1 of 2, # 16 Exhibit 516 part 2 of 2) (mrgo). (Additional attachment(s) added on 6/30/2014: # 17 Exhibit 519, # 18 Exhibit 520, # 19 Exhibit 521) (mrgo). (Additional attachment(s) added on 6/30/2014: # 20 Exhibit 522, # 21 Exhibit 523, # 22 Exhibit 524, # 23 Exhibit 527, # 24 Exhibit 528) (mrgo). (Additional attachment(s) added on 6/30/2014: # 25 Exhibit 522, # 26 Exhibit 523, # 27 Exhibit 524, # 28 Exhibit 527, # 29 Exhibit 528) (mrgo). (Additional attachment(s) added on 6/30/2014: # 30 Exhibit 529, # 31 Exhibit 530, # 32 Exhibit 531, # 33 Exhibit 533, # 34 Exhibit 534, # 35 Exhibit 535) (mrgo). (Additional attachment(s) added on 6/30/2014: # 36 Exhibit 536, # 37 Exhibit 537, # 38 Exhibit 538) (mrgo). (Additional attachment(s) added on 6/30/2014 (mrgo). Modified on 6/30/2014 (mrgo). (Entered: 06/30/2014)
78 SEALED DOCUMENT-EXHIBITS IN SUPPORT OF OPPOSITION (Volume 2) to MOTION to Certify Class 28 filed. (Attachments: # 1 Exhibit 541, # 2 Exhibit 542, # 3 Exhibit 543)(mrgo) (Additional attachment(s) added on 6/30/2014: # 4 Exhibit 545, # 5 Exhibit 546, # 6 Exhibit 547, # 7 Exhibit 548) (mrgo). (Additional attachment(s) added on 6/30/2014: # 8 Exhibit 549 part 1 of 2, # 9 Exhibit 549 part 2 of 2) (mrgo). (Additional attachment(s) added on 6/30/2014: # 10 Exhibit 551, # 11 Exhibit 552, # 12 Exhibit 553, # 13 Exhibit 555, # 14 Exhibit 556, # 15 Exhibit 557, # 16 Exhibit 558) (mrgo). (Additional attachment(s) added on 6/30/2014: # 18 Exhibit 560 part 1 of 2) (mrgo). (Additional attachment(s) added on 6/30/2014: # 19 Exhibit 560 part 2 of 2) (mrgo). (Additional attachment(s) added on 6/30/2014: # 20 Exhibit 561) (mrgo). (Additional attachment(s) added on 6/30/2014: # 21 Exhibit 562 part 1 of 2) (mrgo). (Additional attachment(s) added on 6/30/2014: # 22 Exhibit 562 part 2 of 2) (mrgo). (Additional attachment(s) added on 6/30/2014: # 23 Exhibit 563, # 24 Exhibit 564, # 25 Exhibit 565, # 26 Exhibit 570, # 27 Exhibit 571) (mrgo). (Entered: 06/30/2014)
79 SEALED DOCUMENT-OBJECTIONS to declaration of Pablo Stewart re: MOTION to Certify Class 28 filed. (Attachments: # 1 Obj part 2)(mrgo) (Entered: 07/01/2014)
81 SEALED DOCUMENT-OBJECTIONS to Pablo Stewart's Declaration for plaintiffs Gray, Rosson, and Inamtes Allen, McClellan, Miller re: MOTION to Amend the Complaint 49 filed. (Attachments: # 1 Obj part 2)(mrgo) (Entered: 07/01/2014)
82 SEALED DOCUMENT-OBJECTIONS AND RESPONSES TO DECLARATIONS OF TODD WILCOX M.D. re: MOTION to Certify

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Class 28 filed. (Attachments: # 1 Obj part 2, # 2 Obj part 3)(mrgo) (Entered: 07/01/2014)
84 ORDER by Judge Virginia A. Phillips: granting 64 Application to File Exhibits in support of opposition to motion for class certification under seal. (mrgo) (Entered: 07/01/2014)
85 SEALED DOCUMENT-UNREDACTED DEFENDANTS' OBJECTIONS to Inmate Declarations submitted by plaintiffs in support of their motion for class certification re: MOTION to Certify Class 28 filed. (Attachments: # 1 Obj part 2)(mrgo) Modified on 7/1/2014 (mrgo). (Entered: 07/01/2014)
86 SEALED DOCUMENT-UNREDACTED DECLARATIONS OF COUNTY PERSONNEL in support of opposition to MOTION to Certify Class 28 filed. (Attachments: # 1 Declaration)(mrgo) (Entered: 07/01/2014)
87 SEALED DOCUMENT-UNREDACTED DECLARATIONS AUTHENTICATING EVIDENCE in support of opposition to MOTION to Certify Class 28 filed. (mrgo) (Entered: 07/01/2014)
88 SEALED DOCUMENT-DECLARATIONS of Expert Physicians in support of opposition to MOTION to Certify Class 28 filed. (Attachments: # 1 Declaration part 2)(mrgo) (Entered: 07/01/2014)
105 SEALED DOCUMENT-UNREDACTED NOTICE OF ERRATA filed by Defendant County of Riverside correcting Declaration (Motion related), 58 . (mrgo) (Entered: 07/03/2014)
72 STIPULATION to Continue hearing on plaintiffs' motion for leave to file second amended complaint from 7/7/14 at 2:00 p.m. to 7/21/14 at 2:00 p.m. Re: MOTION to Amend the Complaint 49 filed by defendant County of Riverside. (Attachments: # 1 Proposed Order)(Lockwood, Christopher) (Entered: 06/26/2014)
74 First APPLICATION to Exceed Page Limitation Response to Defendant's Opposition to Plaintiff's Motion for Class Certification filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Application set for hearing on 7/21/2014 at 02:00 PM before Judge Virginia A. Phillips. (Attachments: # 1 Declaration, # 2 Proposed Order)(Crockett, Danielle) (Entered: 06/30/2014)
75 REPLY Support Motion for Class Certification filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. (Attachments: # 1 Proposed Order, # 2 Declaration, # 3 Exhibit Exhibit 1 to Crocket Decl, # 4 Exhibit Exhibit 2 to Crocket Decl, # 5 Declaration, # 6 Declaration, # 7 Exhibit Exhibit A to Lynch Decl, # 8 Exhibit Exhibit B to Lynch Decl, # 9 Exhibit Exhibit C to Lynch Decl, # 10 Exhibit Exhibit D to Lynch Decl, # 11 Exhibit Exhibit E to Lynch Decl)(Crockett, Danielle) (Entered: 06/30/2014)

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76 DECLARATION of Pablo Stewart, M.D. in support of MOTION to Certify Class 28 Reply declaration filed by Plaintiff Quinton Gray. (Norman, Sara) (Entered: 06/30/2014)
77 First APPLICATION for Relief from Publicity filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Application set for hearing on 7/21/2014 at 02:00 PM before Judge Virginia A. Phillips. (Attachments: # 1 Proposed Order)(Crockett, Danielle) (Entered: 06/30/2014)
89 ORDER by Judge Virginia A. Phillips Re Stipulation 72 : it is ordered that the hearing on plaintiffs motion for leave to file a second amended complaint 49 , currently set for July 7, 2014 at 2:00, is continued to July 21, 2014 at 2:00pm. (ad) (Entered: 07/02/2014)
91 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO SUMMARY OF EVIDENCE REFUTING DR. STEWART'S DECLARATION RE: JOHN ROSSEN filed. (mrgo) (Entered: 07/03/2014)
92 SEALED DOCUMENT-UNREDACTED DECLARATION of Megan Lynch in support of plaintiffs' reply in support of MOTION to Certify Class 28 filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D, # 5 Exhibit E).(mrgo) (Entered: 07/03/2014)
93 SEALED DOCUMENT-EX PARTE APPLICATION TO FILE DOCUMENTS UNDER SEAL IN CONNECTION WITH PLAINTIFFS' REPLY IN SUPPORT OF MOTION FOR CLASS CERTIFICATION filed. Lodged order.(mrgo) (Entered: 07/03/2014)
94 SEALED DOCUMENT-ORDER by Judge Virginia A. Phillips: granting 93 Ex Parte Application to Seal Document. (mrgo) (Entered: 07/03/2014)
95 SEALED DOCUMENT-PLAINTIFF'S RESPONSES TO DEFENDANT'S OBJECTIONS TO DECLARATION OF JOHN ROSSON filed. (mrgo) (Entered: 07/03/2014)
96 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO DEFENDANT'S OBJECTIONS TO DECLARATION OF PABLO STEWART MD filed.(mrgo) (Entered: 07/03/2014)
97 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO DEFENDANT'S OBJECTIONS TO DECLARATION OF TODD WILCOX filed. (mrgo) (Entered: 07/03/2014)
98 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO DEFENDANT'S OBJECTIONS TO DECLARATION OF MICHAEL WOLFHEIL filed.(mrgo) (Entered: 07/03/2014)
99 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO SUMMARY OF EVIDENCE REFUTING DR STEWART'S DECLARATION RE: QUINTON GRAY filed.(mrgo) (Entered: 07/03/2014)

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100 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO SUMMARY OF EVIDENCE REFUTING DR STEWART'S DECLARATION RE: ROBIN ALLEN filed. (mrgo) (Entered: 07/03/2014)
101 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO SUMMARY OF EVIDENCE REFUTING DR STEWART'S DECLARATION RE: BRANDY MCCELLAN filed. (mrgo) (Entered: 07/03/2014)
102 SEALED DOCUMENT-UNREDACTED DECLARATION of Danielle Crockett in support of plaintiffs' reply in support of MOTION to Certify Class 28 filed. (mrgo) (Entered: 07/03/2014)
103 SEALED DOCUMENT-UNREDACTED DECLARATION of Dr Pablo in support of plaintiffs' reply in support of MOTION to Certify Class 28 filed. (mrgo) (Entered: 07/03/2014)
104 SEALED DOCUMENT-UNREDACTED DECLARATION of Dr Todd Wilcox in support of plaintiffs' reply in support of MOTION to Certify Class 28 filed. (mrgo) (Entered: 07/03/2014)
106 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO DEFENDANT'S OBJECTIONS TO DECLARATION OF JULIE MILLER filed. (mrgo) (Entered: 07/03/2014)
107 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO DEFENDANT'S OBJECTIONS TO DECLARATION OF ANGELA PATTERSON filed.(mrgo) (Entered: 07/03/2014)
108 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO DEFENDANT'S OBJECTIONS TO DECLARATION OF BRANDY MCLELLAN filed. (mrgo) (Entered: 07/03/2014)
109 SEALED DOCUMENT-PLAINTIFFS' RESPONSES TO SUMMARY OF EVIDENCE REFUTING DR. STEWART'S DECLARATION RE: JULIE MILLER filed. (mrgo) (Entered: 07/03/2014)
90 PROOF OF SERVICE filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III, re Documents Filed Under Seal served on July 2, 2014. (Crockett, Danielle) (Entered: 07/03/2014)
110 ORDER by Judge Virginia A. Phillips: GRANTING 74 Application for Leave to File Brief Over 12 Pages. IT IS SO ORDERED. (ad) (Entered: 07/08/2014)
111 ORDER by Judge Virginia A. Phillips: granting 71 Application for Leave to File Notice of Errata and its exhibits Under Seal 71 . IT IS SO ORDERED. (ad) (Entered: 07/08/2014)
112 NOTICE of Manual Filing filed by Defendant County of Riverside of application to file objections to plaintiffs' evidence in support of reply. (Cunningham, Arthur) (Entered: 07/11/2014)
113 objection opposition re: MOTION to Certify Class 31 filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 07/11/2014)

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114 objection opposition re: MOTION to Certify Class 28 filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 07/11/2014)
115 objection opposition re: MOTION to Certify Class 28 filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 07/11/2014)
116 objection opposition re: MOTION to Certify Class 28 filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 07/11/2014)
117 APPLICATION TO FILE OBJECTIONS TO PLAINTIFF'S EVIDENCE IN SUPPORT OF REPLY UNDER SEAL filed. Lodged order. (mrgo) (Entered: 07/14/2014)
118 MINUTES (IN CHAMBERS) ORDER GRANTING MOTION TO FILE A SECOND AMENDED COMPLAINT by Judge Virginia A. Phillips re: 49 Motion to Amend/Correct. (See document for specifics) (mrgo) (Entered: 07/18/2014)
120 ORDER by Judge Virginia A. Phillips: granting 117 Application to file defendant's Objections to plaintiffs' evidence in support of reply under seal (mrgo) (Entered: 07/22/2014)
121 SEALED DOCUMENT-UNREDACTED DEFENDANT'S OBJECTIONS to the Declaration of Pablo Stewart in support of plaintiff's reply to the opposition to MOTION to Certify Class 28 filed . (mrgo) Modified on 7/22/2014 (mrgo). (Entered: 07/22/2014)
122 SEALED DOCUMENT-DEFENDANT'S UNREDACTED OBJECTIONS to Dr Wilcox's Declaration Submitted in Support of Plaintiff's Reply re: MOTION to Certify Class 28 filed. (mrgo) (Entered: 07/22/2014)
123 SEALED DOCUMENT-DEFENDANT'S UNREDACTED OBJECTIONS to Plaintiffs' Reply to the Opposition to Plaintiffs' MOTION to Certify Class 28 filed. (mrgo) (Entered: 07/22/2014)
119 STATEMENT of notice of pending petition for rehearing in banc in Parsons v. Ryan and order requiring a response thereto MOTION to Certify Class 28 filed by Defendant County of Riverside. (Attachments: # 1 Petition for rehearing en banc in Parsons v. Ryan, # 2 Order requiring a response to the petition)(Lockwood, Christopher) (Entered: 07/19/2014)
124 MINUTES OF Motion Hearing held before Judge Virginia A. Phillips re: Plaintiff's 28 Motion to Certify Class Action. Court issues a tentative ruling, hears oral argument and takes the matter under submission. Court instructs counsel to meet and confer, then afterwards submit a joint statement with proposed dates. Included within the issuing decision will be a telephonic conference call date and a trial date. Court Reporter: Deborah Parker. (mrgo) (Entered: 07/22/2014)
125 Notice of Appearance or Withdrawal of Counsel: for attorney Kelsey Stapler Morris counsel for Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Saurish Bhattacharjee is no longer

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attorney of record for the aforementioned party in this case for the reason indicated in the G-123 Notice. Filed by Plaintiffs Quinton Gray, et al.. (Attorney Kelsey Stapler Morris added to party Quinton Gray(pty:pla), Attorney Kelsey Stapler Morris added to party Stanley Kujansky(pty:pla), Attorney Kelsey Stapler Morris added to party Angela Patterson(pty:pla), Attorney Kelsey Stapler Morris added to party John Rosson, III(pty:pla))(Morris, Kelsey) (Entered: 07/22/2014)
126 NOTICE OF MOTION AND MOTION to Dismiss portions of second amended complaint filed by defendant County of Riverside. Motion set for hearing on 9/8/2014 at 02:00 PM before Judge Virginia A. Phillips. (Lockwood, Christopher) (Entered: 08/04/2014)
127 JOINT REPORT WITH PROPOSED DATES REPORT filed by Defendant County of Riverside. (Lockwood, Christopher) (Entered: 08/11/2014)
128 MEMORANDUM in Opposition to MOTION to Dismiss portions of second amended complaint 126 filed by Plaintiff Quinton Gray. (Attachments: # 1 Proposed Order)(Norman, Sara) (Entered: 08/18/2014)
129 Second AMENDED COMPLAINT against Defendant Quinton Gray amending Amended Complaint, 8 , filed by Plaintiff Quinton Gray (Norman, Sara) (Entered: 08/20/2014)
130 REPLY in support of MOTION to Dismiss portions of second amended complaint 126 filed by Defendant County of Riverside. (Lockwood, Christopher) (Entered: 08/22/2014)
131 ORDER by Judge Virginia A. Phillips GRANTING Plaintiffs' 28 Motion for Class Certification; DENYING Defendant's 126 Motion to Dismiss: (see document image for further details). (ad) (Entered: 09/02/2014)
132 ANSWER to Amended Complaint 129 (second amended) filed by defendant County of Riverside.(Lockwood, Christopher) (Entered: 09/15/2014)
133 MINUTE ORDER SETTING APPLICABLE DATES (IN CHAMBERS) by Judge Virginia A. Phillips Re Joint Report 127 : The Court sets the following dates: Last date to amend pleadings or add parties: 11-16-14; Last date to conduct settlement conference: 10-1-15; Initial expert disclosures: 5-4-15; Rebuttal expert designations: 6-8-14; Discovery cutoff (including motions): 8-10-15; Last date for hearing non-discovery motions: 8-31-15; Pre-trial conference (hearing on motions in limine): 112-15 at 2:30pm. Court Trial: 11-17-15 at 9am. Defendants may file two motions for summary judgment one on the medical subclass, and another on the mental health subclass. The Parties may submit joint applications to depose inmates without filing noticed motions or hearings. IT IS SO ORDERED. (ad) (Entered: 10/15/2014)
134 AMENDED MINUTE ORDER SETTING APPLICABLE DATES (IN CHAMBERS) by Judge Virginia A. Phillips: The Court has reviewed the

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Joint Report the Parties submitted on August 11, 2014. The Court sets the following dates: Last date to amend pleadings or add parties: 11-16-14; Last date to conduct settlement conference: 10-1-15; Initial expert disclosures: 5-4-15; Rebuttal expert designations: 6-8-15; Discovery cutoff (including motions): 8-10-15; Last date for hearing non-discovery motions: 8-31-15; Pre-trial conference (hearing on motions in limine): 112-15 at 2:30pm. Court trial: 11-17-15 at 9am. Defendants may file two motions for summary judgment one on the medical subclass, and another on the mental health subclass. The Parties may submit joint applications to depose inmates without filing noticed motions or hearings. This Order supersedes the Court's October 14, 2014 Order Setting Applicable Dates 133 . IT IS SO ORDERED. (ad) (Entered: 10/21/2014)
135 NOTICE OF MOTION AND MOTION to Correct Minutes of In Chambers Order/Directive - no proceeding held,,, 134 Plaintiffs' Motion for Correction of Scheduling Order Pursuant to Federal Rule of Civil Procedure 60(a) filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. (Crockett, Danielle) (Entered: 11/12/2014)
136 OPPOSITION to MOTION to Correct Minutes of In Chambers Order/Directive - no proceeding held,,, 134 Plaintiffs' Motion for Correction of Scheduling Order Pursuant to Federal Rule of Civil Procedure 60(a) 135 in reality an unnoticed motion to modify the scheduling order filed by Defendant County of Riverside. (Lockwood, Christopher) (Entered: 11/13/2014)
137 MINUTES (IN CHAMBERS) ORDER by Judge Virginia A. Phillips GRANTING IN PART Plaintiffs' 135 Motion for Correction of Scheduling Order: Good cause having been shown, the Court sets May 18, 2015, as the final day to amend the pleadings or add parties. All other dates in the scheduling order remain the same. IT IS SO ORDERED. (ad) (Entered: 11/14/2014)
138 ORDER from 9th CCA filed, CCA # 14-80122. The court, in its discretion, denies the petition for permission to appeal the district courts September 2, 2014 order granting class action certification. Order received in this district on 12/2/14. (mat) (Entered: 12/05/2014)
139 Notice of Appearance or Withdrawal of Counsel: for attorney James E Brown counsel for Defendant County of Riverside. Adding James E. Brown as attorney as counsel of record for County of Riverside for the reason indicated in the G-123 Notice. Filed by Defendant County of Riverside. (Attorney James E Brown added to party County of Riverside(pty:dft))(Brown, James) (Entered: 03/16/2015)
140 STIPULATION to Vacate Dates for Expert Reports filed by Plaintiff Quinton Gray. (Attachments: # 1 Exhibit A, # 2 Proposed Order)(Norman, Sara) (Entered: 04/21/2015)

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141 ORDER REGARDING DATES by Judge Virginia A. Phillips re: Stipulation to Vacate 140 . Therefore, the Court agrees to vacate the dates set in the Amended Minute Order of October 21, 2014 (Dkt 134) for initial expert disclosures (May 4, 2015) and rebuttal expert designations (June 8, 2015). IT IS SO ORDERED. (iva) (Entered: 04/30/2015)
142 MINUTE ORDER IN CHAMBERS SETTING STATUS CONFERENCE by Judge Virginia A. Phillips. (Status Conference set for 8/24/2015 at 01:30 PM before Judge Virginia A. Phillips.) (mrgo) (Entered: 08/06/2015)
143 STATUS REPORT filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 08/07/2015)
144 MINUTE ORDER IN CHAMBERS VACATING STATUS CONFERENCE by Judge Virginia A. Phillips. (see document for specifics.) (iva) (Entered: 08/07/2015)
145 JOINT REPORT AND REQUEST TO VACATE PRETRIAL CONFERENCE AND TRIAL DATES REPORT filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 09/30/2015)
146 REPORT of Report of Board Approval of Proposed Settlement and Request to Vacate Pre-trial Conference and Trial Dates filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 10/30/2015)
147 Third AMENDED COMPLAINT against Defendant All Defendants amending Amended Complaint 129 , filed by Plaintiff Quinton Gray(Norman, Sara) (Entered: 11/12/2015)
148 NOTICE TO FILER OF DEFICIENCIES in Electronically Filed Documents RE: Amended Complaint/Petition 147 . The following error(s) was found: Incorrect event selected.Other error(s) with document(s) are specified below: The correct event to be used is: Amend/Correct located under Civil Events; Other Filings; Stipulations. In response to this notice the court may order (1) an amended or correct document to be filed (2) the document stricken or (3) take other action as the court deems appropriate. You need not take any action in response to this notice unless and until the court directs you to do so. (iva) (Entered: 11/13/2015)
149 ORDER by Judge Virginia A. Phillips, re Report of Board Approval of Proposed Settlement and Request to Vacate Pretrial and Trial Dates 145 . IT IS ORDERED 1. The pending trial date of November 17, 2015 is vacated. 2. Plaintiffs are directed to file their further amended complaint within (7) days of the date of this Order. 3. Defendants are directed to file their Answer to the further amended complaint within (7) days of the filing of that Complaint. 4. Plaintiffs shall provide the Court, within (7) days of the date of this Order, with a proposed timetable for the further proceedings leading to the issuance of a Consent Decree and Remedial Plan. 5. Counsel are directed to appear for a Status Conference on

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December 7, 2015 at 1:30 p.m. to report on the progress of these steps. (mrgo) (Entered: 11/18/2015)
150 Third AMENDED COMPLAINT against Plaintiffs All Plaintiffs amending Amended Complaint 129 , filed by Plaintiffs Quinton Gray, Angela Patterson, Stanley Kujansky, John Rosson, III(Ginty, Danielle) (Entered: 11/24/2015)
151 Notice of Appearance or Withdrawal of Counsel: for attorney Danielle C. Ginty counsel for Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Kelsey S. Morris is no longer counsel of record for the aforementioned party in this case for the reason indicated in the G-123 Notice. Filed by Plaintiffs Plaintiffs. (Ginty, Danielle) (Entered: 11/25/2015)
152 Joint REPORT of Expert filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. (Attachments: # 1 Exhibit A, # 2 Exhibit B)(Ginty, Danielle) (Entered: 11/25/2015)
153 Joint NOTICE OF MOTION AND MOTION for Order for Preliminary Approval of Consent Decree and Notice to the Class filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Motion set for hearing on 12/21/2015 at 02:00 PM before Judge Virginia A. Phillips. (Attachments: # 1 Declaration Sara Norman, # 2 Exhibit 1, # 3 Exhibit 2, # 4 Proposed Order) (Ginty, Danielle) (Entered: 11/25/2015)
154 NOTICE OF MOTION AND MOTION for Attorney Fees and Expenses filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. (Attachments: # 1 Declaration Sara Norman, # 2 Proposed Order) (Ginty, Danielle) (Entered: 11/25/2015)
155 NOTICE TO FILER OF DEFICIENCIES in Electronically Filed Documents RE: NOTICE OF MOTION AND MOTION for Attorney Fees and Expenses 154 . The following error(s) was found: Hearing information is missing, incorrect, or not timely. In response to this notice the court may order (1) an amended or correct document to be filed (2) the document stricken or (3) take other action as the court deems appropriate. You need not take any action in response to this notice unless and until the court directs you to do so. (iva) (Entered: 11/30/2015)
156 ANSWER to Amended Complaint/Petition 150 (third amended complaint) filed by defendant County of Riverside.(Lockwood, Christopher) (Entered: 12/01/2015)
157 NOTICE TO FILER OF DEFICIENCIES in Electronically Filed Documents RE: Joint NOTICE OF MOTION AND MOTION for Order for Preliminary Approval of Consent Decree and Notice to the Class 153 . The following error(s) was found: Hearing information is missing, incorrect, or not timely. In response to this notice the court may order (1) an amended or correct document to be filed (2) the document stricken or

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(3) take other action as the court deems appropriate. You need not take any action in response to this notice unless and until the court directs you to do so. (mrgo) (Entered: 12/02/2015)
158 SCHEDULING NOTICE: Status Conference scheduled for December 7, 2015, at 1:30 p.m., is hereby taken off calendar, by Judge Virginia A. Phillips. THERE IS NO PDF DOCUMENT ASSOCIATED WITH THIS ENTRY. (wro) TEXT ONLY ENTRY (Entered: 12/02/2015)
159 MINUTES OF PLAINTIFFS MOTION FOR ORDER FOR PRELIMINARY APPROVAL OF CONSENT DECREE AND NOTICE TO THE CLASS 153 held before Judge Virginia A. Phillips. Court issues a tentative ruling, hears oral argument and takes the matter under submission. Court Reporter: Phyllis Preston. (iva) (Entered: 12/22/2015)
160 MINUTE ORDER GRANTING MOTION FOR PRELIMINARY APPROVAL OF CONSENT DECREE AND NOTICE TO THE CLASS (IN CHAMBERS) by Judge Virginia A. Phillips re: MOTION for Order for Preliminary Approval of Consent Decree 153 and MOTION for Attorney Fees 154 . (See document for specifics.) (iva) (Entered: 12/22/2015)
161 [DOCUMENT ORDERED STRICKEN PER DOCUMENT #162]DECLARATION of Sara Norman Attaching Comments by Class Members Regarding Proposed Settlement filed by Plaintiff Quinton Gray. (Norman, Sara) (Main Document 161 replaced on 2/16/2016) (mrgo). Modified on 2/16/2016 (mrgo). (Main Document 161 replaced on 2/17/2016) (mrgo). (Entered: 02/16/2016)
162 ORDER TO STRIKE ELECTRONICALLY FILED DOCUMENT(S) by Judge Virginia A. Phillips: the following document(s) be STRICKEN for failure to comply with the Local Rules, General Order and/or the Courts Case Management Order: Declaration 161 , for the following reasons: failure to comply with the Court's Local Rule, General Order, and/or Case Management Order. Document to be stricken and removed from the docket. Counsel to refile the document with the social security number redacted. (mrgo) (Entered: 02/16/2016)
163 DECLARATION of Sara Norman Attaching Comments by Class Members Regarding Proposed Settlement filed by Plaintiff Quinton Gray. (Norman, Sara) (Entered: 02/22/2016)
164 NOTICE of Related Case(s) filed by plaintiffs in related case George Topete, Zachery Shovey. Related Case(s): 16-355 (Knapp, Kelly) (Entered: 02/29/2016)
165 TEXT ONLY ENTRY: NOTICE TO PARTIES by District Judge Virginia A. Phillips. Effective March 28, 2016, Judge Virginia A. Phillips will be located in the Roybal Federal Building and United States Courthouse, COURTROOM 780, on the 7th floor, located at 255 East Temple Street, Los Angeles, California 90012. All Court appearances

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shall be made in Courtroom 780 of the Roybal Federal Building and United States Courthouse, and all mandatory chambers copies shall be hand delivered and placed in the drop box located outside of Room 181 Roybal Clerk's Office. Judge Phillips's new Courtroom Deputy Clerk, Wendy Rogers, may be reached at (213) 894-3480. THERE IS NO PDF DOCUMENT ASSOCIATED WITH THIS ENTRY. (rrp) TEXT ONLY ENTRY (Entered: 03/03/2016)
166 DECLARATION of Sara Norman Second Declaration Attaching Class Member Comments filed by Plaintiff Quinton Gray. (Attachments: # 1 Exhibit B)(Norman, Sara) (Entered: 03/18/2016)
167 Joint NOTICE OF MOTION AND MOTION for Settlement Approval of Class Action Joint Motion for Final Approval of Class Action Settlement filed by Plaintiffs Quinton Gray, Stanley Kujansky, Angela Patterson, John Rosson, III. Motion set for hearing on 4/11/2016 at 02:00 PM before Judge Virginia A. Phillips. (Ginty, Danielle) (Entered: 03/28/2016)
168 NOTICE TO FILER OF DEFICIENCIES in Electronically Filed Documents RE: Joint NOTICE OF MOTION AND MOTION for Settlement Approval of Class Action Joint Motion for Final Approval of Class Action Settlement 167 . The following error(s) was found: Hearing information is missing, incorrect, or not timely. In response to this notice the court may order (1) an amended or correct document to be filed (2) the document stricken or (3) take other action as the court deems appropriate. You need not take any action in response to this notice unless and until the court directs you to do so. (mrgo) (Entered: 03/28/2016)
169 RESPONSE BY THE COURT TO NOTICE TO FILER OF DEFICIENCIES IN ELECTRONICALLY FILED DOCUMENTS RE: Notice of Deficiency in Electronically Filed Documents (G-112A),, 168 , Joint NOTICE OF MOTION AND MOTION for Settlement Approval of Class Action Joint Motion for Final Approval of Class Action Settlement 167 by Clerk of Court. The document is accepted as filed., The hearings re Motion or Report and Recommendation deadlines originally scheduled have been rescheduled. (Motion reset for hearing on 4/25/2016 at 02:00 PM before Judge Virginia A. Phillips.) (mrgo) (Entered: 03/28/2016)
170 MINUTES OF JOINT MOTION FOR FINAL APPROVAL OF CLASS ACTION SETTLEMENT 167 held before Judge Virginia A. Phillips. Court issues a tentative ruling, hears oral argument and takes the matter under submission. Court Reporter: Phyllis Preston. (iva) (Entered: 04/25/2016)
171 ORDER GRANTING Final Approval of Class Action Settlement by Judge Virginia A. Phillips re: MOTION for Settlement 167 . (See document for specifics.) (iva) (Entered: 04/28/2016)

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172 STIPULATION for Order Approving Consent Decree filed by Plaintiff Quinton Gray. (Attachments: # 1 Proposed Order)(Norman, Sara) (Entered: 05/18/2016)
173 CONSENT DECREE by Judge Virginia A. Phillips Related to: STIPULATION for Order Approving Consent Decree 172 . Therefore and good cause appearing, the Court approves this Consent Decree, orders the parties to comply with all its terms, and orders Defendant to implement the attached Remedial Plan pursuant to the schedule set forth therein. (See document for specifics.) (iva) (Entered: 06/08/2016)
174 NOTICE OF DISCREPANCY AND ORDER: by Judge Virginia A. Phillips, ORDERING Comment to Honorable Virginia A. Phillips, United States District Judge submitted by Brian Swain received on 6/17/16 is not to be filed but instead rejected. Denial based on: Local Rule 83-2.5: No letters to the judge. Other: Case is closed. (bm) (Entered: 07/18/2016)
175 NOTICE OF DISCREPANCY AND ORDER: by Judge Virginia A. Phillips, ORDERING Letter submitted by Marilyn Mitchell received on 8/9/16 is not to be filed but instead rejected. Denial based on: Local Rule 11-3.1: Document not legible. Local Rule 11-3.8: Lacking name, address, phone, facsimile numbers, and e-mail address. Local Rule 83.2.5: No letters to the judge. Other: Case is closed. Relief sought is unclear. Author of letter is not a party in this action. (bm) (Entered: 08/15/2016)
176 Mail Returned addressed to John B Swain, Return to Sender, Not in Custody, re Notice of Document Discrepancies and Order Rejecting, 174 (bm) (Entered: 08/19/2016)
177 Emergency NOTICE OF MOTION AND MOTION to Enforce Consent Decree filed by Plaintiffs Quinton Gray. (Norman, Sara) (Entered: 04/06/2020)
178 DECLARATION of Sara Norman in support of Emergency NOTICE OF MOTION AND MOTION to Enforce Consent Decree 177 filed by Plaintiff Quinton Gray. (Attachments: # 1 Exhibit Exhibits A-K, # 2 Exhibit Exhibits L-V)(Norman, Sara) (Entered: 04/06/2020)
179 REQUEST FOR JUDICIAL NOTICE re Emergency NOTICE OF MOTION AND MOTION to Enforce Consent Decree 177 filed by Plaintiff Quinton Gray. (Attachments: # 1 Exhibit Exhibits 1-9)(Norman, Sara) (Entered: 04/06/2020)
180 NOTICE TO FILER OF DEFICIENCIES in Electronically Filed Documents RE: Motion and supporting documents 177 , 178 , 179 . The following error(s) was/were found: Hearing information is missing, incorrect, or not timely. Proposed Document was not submitted as separate attachment. Other error(s) with document(s): [Proposed] Order was not submitted as a separate, additional attachment. In response to this notice, the Court may: (1) order an amended or correct document to be filed; (2) order the document stricken; or (3) take other action as the Court

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deems appropriate. You need not take any action in response to this notice unless and until the Court directs you to do so. (bm) (Entered: 04/07/2020)
181 SCHEDULING NOTICE AND ORDER by Judge Virginia A. Phillips. The Court has received Plaintiffs' Emergency Motion to Enforce Consent Decree 177 filed on April 6, 2020. Any response or opposition to Plaintiff's Motion is due no later than 12:00 PM of Friday, April 10, 2020. THERE IS NO PDF DOCUMENT ASSOCIATED WITH THIS ENTRY. (cch) (Entered: 04/08/2020)
182 Notice of Appearance or Withdrawal of Counsel: for attorney Kelly Anne Moran counsel for Defendant County of Riverside. Adding Kelly A. Moran as counsel of record for County of Riverside for the reason indicated in the G-123 Notice. Filed by Defendant County of Riverside. (Attorney Kelly Anne Moran added to party County of Riverside(pty:dft))(Moran, Kelly) (Entered: 04/08/2020)
183 OPPOSITION IN OPPOSITION re: Emergency NOTICE OF MOTION AND MOTION to Enforce Consent Decree 177 filed by Defendant County of Riverside. (Attachments: # 1 Declaration of James E. Brown, # 2 Declaration of Bonnie Carl, # 3 Declaration of Matthew Chang, # 4 Declaration of Misha Graves, # 5 Declaration of Thomas Hyland, # 6 Declaration of Service)(Moran, Kelly) (Entered: 04/10/2020)
184 SCHEDULING NOTICE AND ORDER by Judge Virginia A. Phillips. COUNSEL OF RECORD ARE NOTIFIED that the Court hereby sets a hearing on Plaintiffs' Emergency Motion to Enforce Consent Decree 177 on April 13, 2020 at 2:00 PM. THERE IS NO PDF DOCUMENT ASSOCIATED WITH THIS ENTRY. (cch) TEXT ONLY ENTRY (Entered: 04/13/2020)
185 REPLY Support Emergency NOTICE OF MOTION AND MOTION to Enforce Consent Decree 177 filed by Plaintiff Quinton Gray. (Norman, Sara) (Entered: 04/13/2020)
186 DECLARATION of Sara Norman in support of Emergency NOTICE OF MOTION AND MOTION to Enforce Consent Decree 177 filed by Plaintiff Quinton Gray. (Attachments: # 1 Exhibit Exhibits A-C)(Norman, Sara) (Entered: 04/13/2020)
187 REQUEST FOR JUDICIAL NOTICE re Emergency NOTICE OF MOTION AND MOTION to Enforce Consent Decree 177 Reply filed by Plaintiff Quinton Gray. (Attachments: # 1 Exhibit Exhibits A-D)(Norman, Sara) (Entered: 04/13/2020)
188 MINUTE ORDER (IN CHAMBERS) Order Re: Telephonic Hearing on Plaintiffs' Emergency Motion to Enforce Consent Decree (ECF No. 177) by Judge Virginia A. Phillips: This hearing will take place telephonically. No participant or any other person may record or broadcast this hearing pursuant to Local Rule 83-6. Violation of this prohibition may constitute contempt of court. Access to this hearing for members of the public,

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including the press, is available in the George E. Brown Courthouse, Central District of California, Eastern Division, 3470 12th St., Riverside, California, Courtroom 2. (bm) (Entered: 04/13/2020)
192 MINUTES OF Telephonic Hearing on Plaintiffs' Emergency Motion to Enforce Consent Decree (ECF No. 177) held before Judge Virginia A. Phillips: Case called, and counsel make their appearance. Court and counsel confer as stated on the record. Counsel for Plaintiff shall submit a proposed order in accordance with the Court's ruling. A separate Order will issue. Court Reporter: Myra Ponce. (bm) (Entered: 04/14/2020)
189 NOTICE OF LODGING OF PROPOSED ORDER re Emergency NOTICE OF MOTION AND MOTION to Enforce Consent Decree 177 filed by Plaintiff Quinton Gray. (Attachments: # 1 Exhibit A)(Norman, Sara) (Entered: 04/14/2020)
190 TRANSCRIPT ORDER as to Plaintiffs Quinton Gray for Court Reporter. Court will contact Sara Norman at snorman@prisonlaw.com with further instructions regarding this order. Transcript preparation will not begin until payment has been satisfied with the court reporter. (Norman, Sara) (Entered: 04/14/2020)
191 MINUTES (IN CHAMBERS) MINUTE ORDER GRANTING "EMERGENCY MOTION TO ENFORCE CONSENT DECREE" [DKT. 177] by Judge Virginia A. Phillips: In sum, Defendant has failed to demonstrate that it is currently taking adequate precautions to protect the health of the prisoners in the county jails. Plaintiff's request that Defendant be required "to submit a plan to the Court to implement the Governor's order for physical distancing for all Californians housed in the jails" (Motion at 3-4), is therefore GRANTED. Plaintiffs are instructed to submit a proposed order detailing the findings and outstanding questions from the April 13, 2020 hearing no later than 4:00 p.m. on April 15, 2020. Prior to submission to the Court, Plaintiff shall share the proposed order with Defendant, who may approve the it as to form and content or submit objections to Court thereafter. (see document for further details) (bm) (Entered: 04/14/2020)
193 ORDER GRANTING PLAINTIFFS' EMERGENCY MOTION TO ENFORCE CONSENT DECREE by Judge Virginia A. Phillips, re Emergency NOTICE OF MOTION AND MOTION to Enforce Consent Decree 177 : The Court finds that this relief meets the requirements of 18 U.S.C. Section 3626. In so doing, the Court finds that the relief is narrowly drawn, extends no further than necessary to ensure the protection of the federal constitutional and statutory rights of Plaintiffs, and is the least intrusive means necessary to accomplish those objectives. (see document for further details) (bm) (Entered: 04/16/2020)
194 TRANSCRIPT ORDER as to Non-party Requester for Court Reporter. Court will contact Dylan Verner-Crist at dvernercrist@aclunc.org with further instructions regarding this order. Transcript preparation will not

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begin until payment has been satisfied with the court reporter. (ls) (Entered: 04/20/2020)
195 MINUTE ORDER RE: STATUS REPORT RE: MEDIATION (IN CHAMBERS) by Judge Virginia A. Phillips: On April 6, 2020, Plaintiff Quinton Gray filed an Emergency Motion to Enforce Consent Decree, (Dkt. 177), which this Court granted on April 16, 2020 (Dkt. 191). The Court ordered the Parties to proceed to mediation, as detailed in the Consent Decree. (Dkt. 191, 193). The Parties represented to the Court that they would conduct this mediation before Judge Raul Ramirez on April 17, 2020. The Court hereby ORDERS the Parties to file, no later than 4:00 p.m. on April 24, 2020, a status report detailing the outcome of the mediation. (bm) (Entered: 04/21/2020)
196 STATUS REPORT (Joint) filed by Defendant County of Riverside. (Moran, Kelly) (Entered: 04/24/2020)
197 TRANSCRIPT for proceedings held on 04/13/2020 at 2:07 p.m. Court Reporter/Electronic Court Recorder: Myra L. Ponce, CSR, RDR, CRR, email address myraponce@sbcglobal.net. Transcript may be viewed at the court public terminal or purchased through the Court Reporter/Electronic Court Recorder before the deadline for Release of Transcript Restriction. After that date it may be obtained through PACER. Notice of Intent to Redact due within 7 days of this date. Redaction Request due 5/27/2020. Redacted Transcript Deadline set for 6/8/2020. Release of Transcript Restriction set for 8/4/2020. (Ponce, Myra) (Entered: 05/06/2020)
198 NOTICE OF FILING TRANSCRIPT filed for proceedings 04/13/2020 at 2:07 p.m. re Transcript 197 THERE IS NO PDF DOCUMENT ASSOCIATED WITH THIS ENTRY. (Ponce, Myra) TEXT ONLY ENTRY (Entered: 05/06/2020)
199 STATUS REPORT filed by Defendant County of Riverside. (Moran, Kelly) (Entered: 05/08/2020)
200 STATUS REPORT Joint filed by Defendant County of Riverside. (Moran, Kelly) (Entered: 05/15/2020)
201 STIPULATION for Order on COVID-19 plan filed by Plaintiffs Quinton Gray. (Attachments: # 1 Proposed Order)(Norman, Sara) (Entered: 07/20/2020)
202 ORDER ON DEFENDANTS COVID-19 PLAN by Judge Virginia A. Phillips. The Court finds that this relief meets the requirements of 18 U.S.C. § 3626. In so doing, the Court finds that the relief is narrowly drawn, extends no further than necessary to ensure the protection of the federal constitutional and statutory rights of Plaintiffs, and is the least intrusive means necessary to accomplish those objectives. IT IS HEREBY ORDERED that Defendant shall implement the plan attached as Exhibit A. (See Order for further details) (yl) (Entered: 07/23/2020)

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203 STIPULATION for Order Revise COVID-19 Plan filed by Plaintiffs Quinton Gray. (Attachments: # 1 Proposed Order)(Norman, Sara) (Entered: 10/14/2020)
204 ORDER TO REVISE COVID-19 PLAN by Judge Virginia A. Phillips, re Stipulation for Order 203 . The Court agrees. Based on the record in this case, the Court finds that this relief meets the requirements of 18 U.S.C. 3626: the relief is narrowly drawn,extends no further than necessary to ensure the protection of the federal constitutional and statutory rights of Plaintiffs, and is the least intrusive means necessary to accomplish those objectives. IT IS HEREBY ORDERED that Defendant's COVID-19 Plan is amended asstated herein. (See Order for further details) (et) (Entered: 10/15/2020)
205 NOTICE of Change of firm name and address by Arthur K. Cunningham attorney for Defendant County of Riverside. Changing firm name to Jackson Lewis P.C. and address to 200 Spectrum Center Drive, Suite 500, Irvine, CA 92618. Filed by Defendant County of Riverside. (Cunningham, Arthur) (Entered: 11/16/2020)
206 NOTICE of Change of Attorney Business or Contact Information: for attorney Stephanie Joy M Tanada counsel for Defendant County of Riverside. Changing Firm and address to Jackson Lewis P.C., 200 Spectrum Center Drive, Suite 500, Irvine, CA 92618. Filed by Defendant County of Riverside. (Tanada, Stephanie) (Entered: 11/23/2020)

PACER Service Center Transaction Receipt

02/12/2021 13:03:54

PACER Login:

CRClearinghouse

Client Code:

Gillan

Description: Docket Report

Search Criteria:

5:13-cv-00444-VAP-OP End date: 2/12/2021

Billable Pages:

22

Cost:

2.20

Exempt flag: Not Exempt

Exempt reason:

Not Exempt