Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_90-cv-00520/USCOURTS-caed-2_90-cv-00520-1252/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 42:1983 Prisoner Civil Rights

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8 UNITED STATES DISTRICT COURT 

9 FOR THE EASTERN DISTRICT OF CALIFORNIA 

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17 On February 7, 2023, as part of his comprehensive twenty-ninth monitoring round, the 

18 Special Master filed two reports. The first, “Report Part C,” is on findings from monitoring tours 

19 at fifteen institutions in the California Department of Corrections and Rehabilitation (CDCR) 

with Enhanced Outpatient Program (EOP) units.1 20 ECF No. 7715. The second, “Report Part D,” 

21 is on findings from monitoring tours at thirteen institutions with Correctional Clinical Case 

Management Services (3CMS) programs.2 22 ECF No. 7716. Both reports are based on monitoring 

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 California Health Care Facility (CHCF); California Institution for Women (CIW); 

California Medical Facility (CMF); California Men’s Colony (CMC); California State Prison, 

Corcoran (CSP/Corcoran); California State Prison, Los Angeles County (CSP/LAC); California 

State Prison, Sacramento (CSP/Sac); California Substance Abuse Treatment Facility (CSATF); 

Central California Women’s Facility (CCWF); Kern Valley State Prison (KVSP); Mule Creek 

State Prison (MCSP); Richard J. Donovan Correctional Facility (RJD); Salinas Valley State 

Prison (SVSP); San Quentin State Prison (SQ); and Valley State Prison (VSP). 

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 Avenal State Prison (ASP); California Correctional Institution (CCI); California 

Institution for Men (CIM); California Rehabilitation Center (CRC); California State 

RALPH COLEMAN, et al., 

Plaintiffs, 

v. 

GAVIN NEWSOM, et al., 

Defendants. 

No. 2:90-cv-0520 KJM DB

ORDER 

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tours between May 2021 and May 2022, ECF No. 7715 at 13-15,3and a review of CDCR 

documents. See, e.g., ECF No. 7715 at 32 n.10, 68-70, 72 n.22, 97-110; ECF No. 7716 at 38-39, 

40, 46, 48. Several sections of Report Part C are incorporated by reference into Report Part D. 

ECF No. 7716 at 29-30. The Special Master makes no formal recommendations in either report; 

nor does he request any additional court orders. ECF No. 7715 at 173; ECF No. 7716 at 99-100. 

The Special Master circulated a draft of Report Part C to the parties on December 8, 2022 

and a draft of Report Part D on December 16, 2022. ECF No. 7715 at 15. On December 16, 

2023, the Special Master granted defendants’ request to extend the time for responses to January 

25, 2023. Id. Both parties sent responses to the Special Master on that date, and he revised and 

clarified the Reports, which he then filed with the court on February 7, 2023. Id. at 15-30. 

On February 17, 2023, defendants objected to both Reports. ECF No. 7733. With leave 

of court, ECF No. 7745, on March 1, 2023, plaintiffs responded to defendants’ objections, ECF 

No. 7749. Defendants’ objections focus primarily on Report Part C; therefore, unless otherwise 

noted, Report as used in this order refers to Report Part C. Where appropriate, Report Part C and 

Report Part D are referred to collectively as Reports. The court adopts the Special Master’s 

16 Reports in full and overrules defendants’ objections, as explained below. 

17 I. LEGAL STANDARD

18 Paragraph C of the Order of Reference specifies the legal standard this court applies in

19 response to Defendants’ objections: 

20 [A]ny compliance report of the special master filed in accordance with paragraph

21 A(5) above shall be adopted as the findings of fact and conclusions of law of the

22 court unless, within ten days after being served with the filing of the report, either

23 side moves to object or modify the report. . . . The objecting party shall note each

24 particular finding or recommendation to which objection is made, shall provide

25 proposed alternative findings or recommendations, and may request a hearing before

Prison/Solano (CSP/Solano); Correctional Training Facility (CTF); Folsom State Prison 

(Folsom)/Folsom Women’s Facility (FWF); High Desert State Prison (HDSP); North Kern State 

Prison (NKSP); Pelican Bay State Prison (PBSP); Pleasant Valley State Prison (PVSP); Sierra 

Conservation Center (SCC); and Wasco State Prison (WSP). 

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 Citations to page numbers in documents filed in the Court’s Electronic Case Filing 

(ECF) system are to the page number assigned by the ECF system and located in the upper right 

hand corner of the page. 

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1 the court. Pursuant to Fed. R. Civ. P. 53(e)(2), the court shall accept the special 

2 master’s findings of fact unless they are clearly erroneous. 

3 ECF No. 640, at 8. As required, the court adopts the Special Master’s findings of fact unless 

4 those findings are “clearly erroneous.” Id. “A finding is ‘clearly erroneous’ when although there 

5 is evidence to support it, the reviewing court on the entire evidence is left with the definite and 

6 firm conviction that a mistake has been committed.” United States v. U.S. Gypsum Co., 333 U.S. 

7 364, 395 (1948) (quoted in Anderson v. City of Bessemer City, N.C., 470 U.S. 564, 573 (1985)). 

8 II. ANALYSIS

9 The court addresses defendants’ objections in turn.

10 A. Staffing Shortages

11 Report Part C includes a section with findings about “the vacancy rate explosion among 

12 primary clinicians (psychologists and social workers)” and defendants’ ability “to provide 

13 anything close to Program Guide-compliant mental health care” at some CDCR institutions. ECF 

14 No. 7715 at 30. In their response to the draft Reports, defendants requested a general 

15 acknowledgment “that CDCR is not an outlier [in mental health staffing shortages]—there is a 

16 nationwide and state-level shortage of mental health professionals, and the shortage acutely 

17 affects prison systems like CDCR because of additional challenges professionals face in treating 

18 patients in remote areas or under dangerous or difficult conditions.” ECF No. 7715-1 at 34 

19 (internal citation omitted). The Special Master granted that request and quoted defendants’ 

20 statement in a footnote in both Reports. See ECF No. 7715 at 22, 30 n.9; ECF No. 7716 at 30 n.8. 

21 Defendants object here that the footnote did not go far enough. They protest that the Report “fails 

22 to acknowledge, much less address, this important and widespread concern head-on, failing to 

23 reference the labor economists’ reports in Defendants’ response (ECF No. 7715-1 at 33-34) or 

24 offering the Court context on how this crisis is impacting Defendants’ ability to comply with 

25 Coleman staffing mandates.” ECF No. 7733 at 3. 

26 First, as the court previously has observed, “tight labor markets do not relieve defendants 

27 of their constitutional obligations.” February 28, 2023 Order, ECF No. 7742 at 4 (internal 

28 citation omitted). Second, as the Special Master reiterates, defendants have fallen short of their 

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obligations for many years, not only in current labor markets, and even though they have had 

several options to reduce mental health staffing shortages. ECF No. 7715 at 169 (citing 

October 10, 2017 Order, ECF No. 5711, at 27). Finally, as the Special Master correctly observes, 

defendants may now need to consider “‘transformational’ solutions” to persistent mental health 

staffing shortages to meet their Eighth Amendment obligations. Id. at 170. Defendants have a 

constitutional duty to “employ mental health staff in ‘sufficient numbers to identify and treat in an

individualized manner those treatable inmates suffering from serious mental disorders.’” 

Coleman v. Wilson, 912 F. Supp. 1282, 1306 (E.D. Cal. 1995). Nationwide labor shortages still 

do not relieve defendants of this duty, but rather indicate defendants must act without further 

delay to fill the chronic, longstanding gap between the number of available staff and the number 

of staff necessary to treat mentally ill inmates in California’s prisons. As the Ninth Circuit has 

determined, “[l]ack of resources” does not relieve defendants of their duty “because prison 

13 officials may be compelled to expand the pool of existing resources in order to remedy continuing 

14 Eighth Amendment violations.” Peralta v. Dillard, 744 F.3d 1076, 1083 (9th Cir. 2014) (internal 

15 citations omitted); see also Spain v. Procunier, 600 F.2d 189, 200 (9th Cir. 1979) (“cost or 

16 inconvenience . . . is not a defense to” meeting Eighth Amendment requirements). The court, the 

17 Special Master, and defendants themselves all have delineated a wide range of options available 

18 to defendants to meet this constitutional obligation. See ECF No. 5711 at, e.g., 7-8, 27. 

19 Defendants have not exhausted the options available to them, including clustering of mentally ill 

20 inmates and voluntary reduction of the mentally ill prison population. See February 28, 2023 

21 Order, ECF No. 7742, at 4; see also, generally, ECF No. 5711. 

22 Defendants also object to the Special Master’s statement that “[t]ime spent training and 

23 supervising unlicensed clinicians further strained licensed staff members’ ability to focus on 

24 delivery of care to patients.’” ECF No. 7733 at 3 (quoting ECF No. 7715 at 32). Defendants 

25 contend this training is necessary “to create a pipeline for future licensed staff.” Id. This 

26 objection does not show the Special Master’s finding is clearly erroneous. It is an explanation for 

27 defendants’ staffing decisions. The objection is overruled. 

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1 B. Data Remediation

2 1. Requests from Defendants to the Special Master

3 In Section IB1 of Report Part C, incorporated by reference into Report Part D, the Special 

4 Master provides an update on ongoing data remediation efforts. ECF No. 7715 at 34-47; see ECF 

5 No. 7716 at 29. Defendants first object to the Special Master’s denial of “Defendants’ oft 

6 repeated requests for the Special Master’s guidebook, business rules, sample size methodology 

7 and other necessary documents to properly replicate the monitoring process so that it aligns with 

8 Defendants’ data indicators.” ECF No. 7733. 

9 This objection identifies no error; it is effectively a discovery request. Defendants may 

10 not use objections to seek discovery from the Special Master as though he were an opposing 

11 party. The Special Master is not an opposing party, but rather an arm of the court tasked with 

12 supervising and guiding both the data remediation process and the development and 

implementation of a final continuous quality improvement tool (CQIT).4 13 The information 

14 necessary “to properly replicate the monitoring process,” both for data remediation and for CQIT, 

15 is identified in the Special Master’s twenty-eight monitoring reports and many other reports that 

16 preceded this one as well as this court’s previous orders. The unresolved issues related to the 

17 scope and substance of data remediation are for another day. See ECF No. 7733 at 4-6; see also

18 ECF No. 7721 at 6-12. This objection is overruled. 

19 Defendants object similarly that the Reports “obfuscate” the Special Master’s alleged 

20 refusal to “define ‘data remediation’ and ‘certification,’” and they contend they cannot 

21 successfully complete data remediation without “clarity as to the requirements to achieve data 

22 remediation.” ECF No. 7733 at 6. This objection is based on defendants’ demonstrably false 

23 assertion that the Special Master has refused to define data remediation and certification. See, 

24 e.g., ECF No. 7715 at 26; ECF No. 7715-1 at 42-45. The record rather demonstrates defendants’

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 CQIT is a “comprehensive tool that, once finalized, defendants will . . . use as part of a process 

to ‘self-monitor’ the key components of the remedy in this action.” September 3, 2020 Order, 

ECF No. 6846, at 10.

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refusal to accept those definitions. See, e.g., ECF No. 7715-1 at 47-53. The Special Master has 

exercised discretion at this juncture not to “attempt to force the Special Master’s preferred 

definitions on defendants through a formal recommendation” to the court. Id. at 26. Any dispute 

over the scope and substance of data remediation is not now before the court at this time. This

objection is overruled. 

2. Characterization of Post-Certification Process

Defendants object that footnote 12 of Report Part C contains an outdated description of 

the post-certification process for key indicators, and they contend the Special Master ignored their 

request to remove the outdated post-certification process or clarify that defendants no longer 

intend to follow that process. ECF No. 7733 at 8. In context, the footnote accurately describes 

what CDCR had included in its Preliminary Activation Schedule for Completion of CourtOrdered Data Remediation. ECF No. 7715 at 39 & n.12. The Special Master also responded to 

the objection as raised to the draft Report Part C, by revising the final report to specify that his 

expert, Dr. Potter, and defendants’ principal, Dr. Cartwright, are addressing development of an 

adequate post-certification review process in their regular discussions. Id. at 26, 47. The 

objection is overruled. 

C. Connectivity Issues with Telepsychiatry and Telehealth

Defendants object that internet connectivity issues identified by the Special Master “appear

anecdotal in nature and lack specificity.” ECF No. 7733 at 8. This objection identifies no clear 

error. As defendants acknowledge, the Report contains specific information about institution and 

mental health programs in which connectivity issues hampered the delivery of mental health care, 

id. at 8-9 (internal citations omitted), and the Special Master directs the reader’s attention to specific 

institutional summaries that provide additional specificity about these issues and their impacts. 

ECF No. 7715 at 22. This information allows defendants to investigate further “the number of 

complaints and technical issues compared to the total number of telehealth encounters observed.” 

ECF No. 7733 at at 9. Defendants can track connectivity issues through a quality improvement 

27 process; it is not the Special Master’s job to do that for them. This objection is overruled. 

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1 D. Psychiatrist Vacancy Data

2 Defendants object to the Special Master’s finding of a “‘shocking’ vacancy rate of 51 

3 percent for psychiatrists at the 15 EOP institutions visited . . . during the Twenty-Ninth Round,” 

4 contending “this calculation is grossly and demonstrably inaccurate.” ECF No. 7733 at 9 (quoting 

5 ECF No. 7715 at 77-78). The objection misstates the relevant finding, which reads as follows: 

6 The institutions continued to report extremely high staff vacancy rates for virtually 

7 all disciplines. Except for telepsychiatry, all such vacancy rates exceeded ten 

8 percent. These vacancy rates included a shocking 55 percent vacancy rate for senior 

9 psychiatrists, and a 51 percent staff psychiatry vacancy rate, which registry staff 

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ECF No. 7715 at 77-78. In addition, defendants contend falsely that the Special Master has failed

to identify the source he relied on for the challenged vacancy rate and that they are “left to 

surmise as to the source of the miscalculation.” Id. at 10. The Special Master cited the sources 

for this data and comprehensively responded to defendants’ objection. See ECF No. 7715 at 21-

22, 72 n.22. That response is adopted in full. 

Defendants’ failure to acknowledge the Special Master’s response and their registering of 

this objection are grounds for the court’s summarily overruling it. See Fed. R. Civ. P. 11; 

April 24, 2020 Order, ECF No. 6639, at 8 n.8; February 20, 2019 Order, ECF No. 6096, at 7; see 

also August 29, 2022 Order, ECF No. 7608, at 6 & n.3. Failures to certify future filings as 

required may lead to the striking of noncompliant objections. 

The court also observes that the Special Master’s finding is based on data from August 

2022. See ECF No. 7715 at 21-22, 72 n.22. Defendants’ objection, by contrast, is based in 

substantial part on data from December 2022. ECF No. 7733 at 9-10. For this reason as well, the 

objection demonstrates no errors in the Special Master’s findings about staffing vacancy rates as 

of August 2022. 

E. Inpatient Referral Process

Defendants contend the Report “fails to correctly describe [the] inpatient referral process.” 

ECF No. 7733 at 10 (citing ECF No. 7715 at 129). Specifically, defendants state that prison

29 institutions are responsible for referring inmates to inpatient care, and that once the referrals are 

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1 made, the Inpatient Referral Unit (IRU) and the Health Care Placement Oversight Program 

2 (HCPOP) “identify an appropriate bed and authorize movement.” Id. Defendants ask the court to 

3 direct the Special Master to amend the Report “to reflect that transfers to inpatient care are not an 

4 institutional-level issue after a referral is made.” Id. In response, plaintiffs observe “the cited 

5 portion of the Report does not make any factual findings describing the inpatient referral process. 

6 It simply reports compliance with transfer timelines by institution.” ECF No. 7749 at 10 

7 (emphasis in original). 

8 Defendants’ objection identifies no clear error. This section of the Report focuses on 

9 whether inmates who are referred to inpatient care are timely transferred to that care. The Special 

10 Master reported on the timeliness of those transfers by sending institution. His decision to 

11 present this part of the Report in this way is not clearly erroneous. Moreover, the section of the 

12 Report that immediately precedes the sections cited by defendants includes findings on the 

13 timeliness of “submission of both acute and intermediate care referrals to IRU.” ECF No. 7715 at 

14 128-29. The Report includes findings that thirteen specified institutions timely completed IRU 

15 referrals for both acute and intermediate inpatient care, one institution timely completed IRU 

16 referrals for intermediate but not acute inpatient care, and one institution did not timely complete 

17 IRU referrals for either level of inpatient care. Id. The Report also includes findings of the 

18 timeliness of referrals to inpatient care from those institutions, including findings of compliance 

19 and non-compliance with Program Guide timelines for transfer following referral as well as 

20 findings of compliance and non-compliance with the Program Guide requirement that inpatient 

21 transfers be accomplished within seventy-two hours of acceptance for admission. Id. at 129-30. 

22 The Report thus provides information to determine whether delays in timely transfers to inpatient 

23 care are caused by delays in institutional referrals or, instead, delays in bed identification and/or 

24 movement authorization, i.e., at IRU or HCPOP. 

25 This objection is overruled. 

26 F. Length of Stay in Mental Health Crisis Beds (MHCBs) 

27 Defendants object that the Special Master’s reporting on lengths of stay in MHCBs is 

28 incomplete. ECF No. 7733 at 11. Specifically, defendants cite the Special Master’s alleged 

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1 failure to clarify that MHCB stays can exceed the ten-day period prescribed by the Program 

2 Guide if the chief psychiatrist or a designee authorizes an extended stay. Id. 

3 In Report Part D, the Special Master correctly observes that defendants’ objections to his 

4 draft report cite findings concerning transfers to acute inpatient care, and not to lengths of stay in 

5 MHCBs. See ECF No. 7716 at 26-27. Both Reports set out the statement defendants contend is 

6 incomplete: that the Program Guide provides for a clinical length of stay of up to ten days in 

7 MHCBs. ECF No. 7715 at 130; ECF No. 7716 at 75. These statements are followed by factual 

8 findings concerning the average length of MHCB stays at the various prison institutions. ECF 

9 No. 7715 at 130; ECF No. 7716 at 75-76. Neither section characterizes any institution as 

“noncompliant.”5 10 Defendants’ objection here, as with some of their objections reviewed above, is 

11 aimed at providing additional context and fails to demonstrate clear error. 

12 The objection is overruled. 

13 G. Class Members’ Access to Jobs 

14 Defendants object to the Special Master’s findings (1) that inmates who are not part of 

15 CDCR’s Mental Health Services Delivery System (MHSDS) held more job assignments than 

16 inmates who were part of MHSDS and (2) that within the MHSDS, 3CMS patients hold more job 

17 assignments than EOP patients. ECF No. 7733 at 11. Defendants contend these findings “fail to 

18 acknowledge that EOP patients are less likely to accept jobs due to mental illness and may instead 

19 choose EOP group treatment.” Id. Defendants cite no evidence to support their assertion and in 

20 any event do not demonstrate clear error. 

21 This objection is overruled. 

22 H. Terms Used to Report on Quality of Treatment 

23 Defendants objected to the use of three categories—“adequate quality,” “marginally 

24 adequate quality,” and “inadequate quality”—in the Draft Report Part D to summarize the overall 

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 The Special Master does use the word “compliance” in connection with average lengths 

of stay in MHCBs at page 125 of Report Part C. There, the findings report improved lengths of 

stay in MHCBs. ECF No. 7715 at 125. In Report Part C, the Special Master summarizes the 

relevant findings, reporting that in MHCBs, “clinical lengths of stay rarely exceeded ten days.” 

ECF No. 7716 at 78. 

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1 quality of care provided. See ECF No. 7733 (citing ECF No. 7715-1 at 39). The Special Master 

2 “declined to recategorize these cases in response to defendants’ assertion that they were ‘vague” 

3 as the categorizations speak for themselves.” ECF No. 7716 at 29. Defendants contend this 

4 sentence is “conclusory and unsupported” and should not be adopted by the court. ECF No. 7733 

5 at 12. 

6 This objection is without merit. The words “adequate” and “inadequate” are clear on their 

7 face, and Report Part D clearly states that “marginally adequate” care means “there were concerns 

8 about the care of the patient that bordered on inadequacy (e.g., failure to provide required 

9 contacts, untimely IDTTs, poor documentation, and untimely responses to consult requests).” 

10 ECF No. 7716 at 48. Moreover, the Special Master has previously used the term “marginally 

11 adequate” in findings related to quality of care, see ECF No. 7074 at, e.g., 863, without objection 

12 from defendants. See generally ECF No. 7082. It was not clear error to rely on any of these 

13 definitions. 

14 The objection is overruled. 

15 III. CONCLUSION 

16 In accordance with the above, IT IS HEREBY ORDERED that: 

17 1. The Special Master’s Twenty-Ninth Monitoring Report—Part C, ECF No. 7715, is 

18 ADOPTED IN FULL; and 

19 2. The Special Master’s Twenty-Ninth Monitoring Report—Part D, ECF No. 7716, is 

20 ADOPTED IN FULL. 

21 DATED: April 12, 2023. 

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