Roy W. Wesley, Inspector General Bryan B. Beyer, Chief Deputy Inspector .

Return to Contents2020 Annual Report5Reports Published in 2020In 2020, we issued 22 public reports detailing our oversight ofthe California Department of Corrections and Rehabilitation:six reports on medical inspection results; two reports and foursentinel cases concerning monitoring the department’s internalinvestigations and employee disciplinary process; one report oncomplaint intake and field inquiries; one report on monitoringthe department’s use of force; one special review comprising thefirst two parts of our three-part series concerning the pandemicspread of the novel coronavirus disease (COVID-19) throughoutthe State’s prison system; three special reviews or reports; onereport on the status of the Blueprint; one report on the CaliforniaRehabilitation Oversight Board; and our 2019 annual report. Visitour website, www.oig.ca.gov, to view our public reports.Internal Investigations and EmployeeDiscipline MonitoringA cadre of OIG attorneys are responsible for the contemporaneousoversight of the department’s internal investigations andemployee disciplinary process. We account for our monitoringof these activities twice annually when we publish our disciplinemonitoring reports. These reports document our assessment of thequality of the department’s internal investigations and its handlingof the employee disciplinary process, as well as our evaluation ofthe department’s adherence to its own rules and procedures whenperforming these activities. Our attorneys monitor and assess thework of the Office of Internal Affairs’ special agents who conductthe department’s internal investigations, the performance of thehiring authorities who make decisions concerning employeedisciplinary actions, and the performance of department attorneysthroughout the disciplinary, litigation, and appeals processes.As part of our monitoring process, we monitored the Office ofInternal Affairs’ weekly central intake meetings pursuant towhich the Office of Internal Affairs made decisions concerningemployee misconduct referrals it received from the hiringauthorities. In 2020, the Office of Internal Affairs addressed andmade decisions concerning 2,061 referrals for investigation orfor authorization to take direct disciplinary action. Of these, theOffice of Internal Affairs approved 2,002 referrals, and the OIGidentified 283 of these as cases to monitor. We identified forOffice of the Inspector General, State of California

Return to Contents6 2020 Annual Reportmonitoring the most serious and sensitive internal investigations,including those involving allegations of dishonesty, sexualmisconduct, use of deadly force, code of silence, abuse ofauthority, and criminal conduct.In addition, we monitored and closed 292 cases in 2020. Ofthose cases, 252 involved administrative allegations, and40 cases involved alleged criminal activity by departmental staffmembers. Furthermore, of the 292 cases we monitored and closed,12 administrative investigations and seven criminal investigationsinvolved the use of deadly force.Applying the methodology we used last year, we categorizedour assessments into six separate phases, or indicators. TheOIG assessed how well the hiring authorities discovered allegedemployee misconduct and referred the allegations to the Office ofInternal Affairs; how well the Office of Internal Affairs processedand analyzed the referrals; the performance of the Office ofInternal Affairs in investigating the allegations; the performanceof the hiring authorities in making findings concerning theinvestigations, and the alleged misconduct and processing of themisconduct cases; the performance of the department attorneysin providing legal advice to the Office of Internal Affairs; andhow well the department advocates (either department attorneysFigure 2. The Six Indicators We Used to Assess the Department’s Internal Investigations andEmployee Disciplinary Process in Determining Our Overall Ratings of Departmental PerformanceHiring Authorities’Performance inDiscovering and ReferringEmployee MisconductCases to the Office ofInternal AffairsThe Office ofInternal Affairs’Performancein ConductingInvestigationsIndicator 2Department Attorneys’Performance inProviding Legal AdviceIndicator 4Indicator 3Indicator 1The Office of InternalAffairs’ Performance inProcessing the HiringAuthorities’ ReferralsSource: The Office of the Inspector General.Office of the Inspector General, State of CaliforniaIndicator 6Indicator 5Hiring Authorities’Performance in MakingFindings on theAllegations, Identifyingthe Appropriate Penalty,and Service of theDisciplinary ActionDepartment Attorneys’Performance inRepresenting theDepartment DuringLitigation

Return to Contents2020 Annual Report7or employee relations officers) represented the department inemployee misconduct litigation.When assessing a case, the OIG attorney answered a series ofcompliance- and performance-related questions and, dependingon the answers, assigned a rating of superior, satisfactory, or poorto each of the six indicators, in addition to providing an overallrating for each case. To monitor and track this data, we assigneda numerical point value to each of the individual indicator ratingsand to the overall rating for each case. The OIG assigned fourpoints for a superior rating, three points for a satisfactory rating,and two points for a poor rating. We then added the assignedpoints for each indicator and divided the total by the numberof points possible to arrive at a weighted average score. Weassigned a rating of superior to weighted averages that fell between100 percent and 80 percent, satisfactory to weighted averagesthat fell between 79 percent and 70 percent, and poor to weightedaverages that fell between 69 percent and 50 percent.Using the above methodology, we found that, from Januarythrough December 2020, overall, the department’s performancewas satisfactory in conducting internal investigations and handlingthe employee disciplinary process. However, hiring authorities’overall performance was poor in processing the employeediscipline cases, and the department attorneys’ performance waspoor in providing legal representation during litigation.The OIG also identified and made recommendations regardingspecific issues concerning the department’s internal investigationsand employee disciplinary process. We recommended thedepartment develop and implement a policy for the Office ofInternal Affairs to concurrently open an administrative casein those instances in which a corresponding criminal investigationis also pending and that it not wait until the conclusion of thecriminal investigation to actively conduct the administrativeinvestigation. The OIG also recommended the policy specifythat although the Office of Internal Affairs will consult with aprosecuting agency (such as a district attorney’s office) concerningwhether to conduct investigative work on an administrative casein those instances in which there is also a corresponding criminalinvestigation, the Office of Internal Affairs not relegate itsdecision to the prosecuting agency.Furthermore, the OIG recommended the department formulate apolicy concerning how it will manage employees who are subjectto domestic violence restraining orders, including whether and inwhich instances such employees will be nonpunitively dismissed,Office of the Inspector General, State of California

Return to Contents8 2020 Annual Reportredirected to another post, or placed on administrative time offfrom work, and the time frames in which hiring authorities shouldmake such decisions.Finally, the OIG recommended the department modify itsexecutive review policy to restrict a department attorney’s abilityto elevate or invoke executive review of a hiring authority’sdecision in employee discipline cases to cases in which one of thefollowing criteria is met: A hiring authority clearly ignored critical evidence andwas not able to logically explain the finding he or shemade; or No reasonable person could have made the investigativeor disciplinary finding the hiring authority made; or The department attorney has a reasonable belief that thehiring authority is acting contrary to departmental policyor the law.We further recommended the department attorney be requiredto declare which of the above factor(s) forms the basis for theexecutive review; to inform the hiring authority, the OIG, andthe hiring authority’s supervisor of that basis; and to provide awritten analysis supporting the invocation of executive review. Toaddress the situation in which some department attorneys holda position vehemently opposed to a hiring authority’s decision tomove forward with discipline—and have posited during executivereviews that they do not believe in a case; that there is no chanceor minimal chance the department will prevail before the StatePersonnel Board; and that, after the case is lost, the departmentwill be responsible for back pay—we recommended thedepartment immediately reassign the case to another departmentattorney, one who will advocate for the hiring authority’s positionto the State Personnel Board.In addition to publishing semiannual discipline monitoringreports, the OIG may issue a separate public report regardingsome cases, called Sentinel Cases. The OIG issues Sentinel Caseswhen it has determined the department’s handling of a case wasparticularly poor. In 2020, the OIG issued four Sentinel Cases,including one case that involved departmental executives refusingto take disciplinary action against an officer who punched hisgirlfriend and then slammed a truck door on her hand, completelysevering a portion of her thumb at the first joint.Office of the Inspector General, State of California

Return to Contents2020 Annual Report9Use-of-Force MonitoringAnother means by which we fulfilled our oversight mandatewas by monitoring the department’s process for reviewing useof-force incidents at institutional executive review committeemeetings and division force review committee meetings. Weused a monitoring methodology to assess whether departmentalstaff complied with the department’s use-of-force policies andprocedures prior to, during, and following each incident wemonitored. Our methodology consisted of 11 units of measure wecall performance indicators. We developed a series of compliancerelated questions for each indicator, and based on the collectiveanswers, we assigned a rating of superior, satisfactory, or poorto each indicator as well as to the overall incident. This toolaggregates information that allows for an in-depth analysis ofincidents and the identification of problematic trends. We metregularly with departmental executives to share informationrelated to trends we observed.In July 2020, we published Monitoring the Use-of-Force ReviewProcess of the California Department of Corrections and Rehabilitation.This report covered use-of-force incidents we monitored thatoccurred during the period from January 1, 2019, throughDecember 31, 2019.Use-of-Force Statistics, January 1, 2019, ThroughDecember 31, 2019The list below offers details concerning the department’s usesof force; Figure 3 on the next page shows the distribution ofthe incidents. The OIG monitored 2,296 of the 9,692 use-of-forceincidents that occurred (24 percent). The OIG attended 973 of the 1,861 review committeemeetings (52 percent). More than 92 percent of the use-of-force incidents wemonitored (2,125 of 2,296) occurred at the adult prisonsand contract facilities housing adult incarcerated persons,with the remainder involving use-of-force incidents atjuvenile facilities (136), or involving parole staff (19) orOffice of Correctional Safety staff (16). Approximately 35 percent of the incidents we reviewedoccurred at only five prisons: Salinas Valley State Prison (215);Office of the Inspector General, State of California

Return to Contents10 2020 Annual ReportCalifornia State Prison, Sacramento (206); Kern ValleyState Prison (190); High Desert State Prison (104); andCalifornia State Prison, Corcoran (89). The 2,296 incidents we monitored involved7,717 applications of force. An incident may have involvedmore than one application of force. For example, twobaton strikes count as two applications of force during asingle incident. Chemical agents accounted for 3,511 ofthe total applications (45 percent), while physical strengthand holds accounted for 2,713 (35 percent). The remaining20 percent of force applications consisted of force optionsavailable to departmental staff such as less-lethalprojectiles, baton strikes, tasers, and firearms.Figure 3. Distribution of the 2,296 Use-of-Force Incidents the Office of theInspector General Monitored by Division and Other EntitiesOffice of CorrectionalSafety – 16 (1%)Division of Adult ParoleOperations – 19 (1%)Departmentof Juvenile Justice136(6%)N 2,296Incidents2,125Division of AdultInstitutions(92%)Source: The Office of the Inspector General Tracking and Reporting System.Highlights of Our Use-of-Force MonitoringWe monitored 2,296 of the 9,692 use-of-force incidentsthat occurred in 2019, and concluded that the department’sperformance was overall satisfactory. We assessed thedepartment’s performance as superior in 24 incidents, satisfactoryin 2,063 incidents, and poor in 209 incidents. In the 24 incidentsin which we assessed the department’s performance as superior,the staff performed exceptionally well in multiple areas, such asin attempting to de-escalate the situation prior to using force,decontaminating involved incarcerated persons and the exposedarea following the use of chemical agents, and describing in therequired reports the force used and observed. In the 209 incidentsin which we assessed the department’s overall performanceas poor, we identified multiple failures, such as not followingOffice of the Inspector General, State of California

Return to Contents2020 Annual Report11decontamination protocols after using chemical agents, medicalstaff not evaluating incarcerated persons as soon as practicalfollowing an incident, and the levels of review failing to identifyand address policy deviations. The incidents in which we assessedthe department’s performance as poor also included incidentsin which we identified a single violation that was particularlyegregious, such as officers using unnecessary force or staff failingto recognize and address an incarcerated person’s allegation ofunreasonable force.The department performed satisfactorily prior to the use offorce. However, we identified two areas of concern regarding theofficer’s actions prior to force being used. Departmental policyrequires officers to use verbal persuasion to mitigate the needfor force whenever possible. We identified 23 instances in whichofficers had the opportunity, but did not attempt to de-escalate apotentially dangerous situation prior to using force; we rated thoseincidents as poor. In addition, we identified 74 instances in whichan officer’s actions (or failure to act) unnecessarily contributed tothe need to use force; we also rated those instances as poor.We found that, overall, the department performed satisfactorilyduring the actual force. We identified one key area of concernregarding the force used. In some instances, officers failed todescribe an imminent threat to justify the force used, leading usto conclude that the force was unnecessary. The department’spolicy for the use of immediate force requires officers to providejustification for using force by articulating their reasoning inreports. Despite this requirement, we concluded that officersdid not adequately articulate an imminent threat in 51 of the2,296 incidents, and we rated those 51 incidents as poor. Figure 4on the next page is reproduced from the report, and it outlines theratings and indicators in detail.We assessed the department’s performance in several areasfollowing the use of force. While the department performedsatisfactorily in most areas, one area of concern we identifiedwas the quality of the reviews conducted by supervisors andmanagers at the prisons. Following a use-of-force incident, thereview process involved a minimum of five levels of review, duringwhich each reviewer was required to review and evaluate staffs’actions and identify policy deviations. Of the 2,296 incidents wemonitored, we identified 799 incidents in which one or morereviewer did not identify a deficiency, leading us to questionwhether the supervisors and managers required additionaltraining or whether they merely neglected their duty to make agood faith effort to review each incident thoroughly.Office of the Inspector General, State of California

Return to Contents12 2020 Annual ReportFigure 4. The Office of the Inspector General’s Overall Rating of the Department’s Handling ofIts Use-of-Force erage77%62,296CasesMonitoredby the OIG75%770%70%108PoorPerformance Ratings by 2.3.4.5.Prior to the Use of ForceDuring the Use of ForceDecontaminationMedical EvaluationsSupervision Following6. Documentation of Incident (staff who used force)7. Documentation of Incident (staff who did not use force)8. Allegation: Video-Recorded Interviews9. Serious Bodily Injury/Great Bodily Inquiry10. Institutional Quality of Review11. Departmental Quality of ReviewSource: The Office of the Inspector General Tracking and Reporting System.Cycle 6 Medical Inspection eOverallRatingInadequateNew styling for the ratingseals used in MIU reportsas introduced for Cycle 6Office of the Inspector General, State of CaliforniaIn 2020, the OIG continued its sixth cycle of medicalinspections and published a report for each of thefollowing prisons: California State Prison, Los AngelesCounty; Wasco State Prison; Valley State Prison;California State Prison, Solano; California CorrectionalCenter; and California Rehabilitation Center. The ratingsfor these six prisons were adequate, as set forth in Table 1on the following page. The table lists the prisons forwhich we completed our Cycle 6 inspections and issuedfinal reports, the month each report was published, andthe rating we assigned to each prison. Through thosereports, the OIG made several recommendations to thedepartment to further improve the delivery of medicalcare to its patients.

Return to Contents2020 Annual Report13In 2020, the OIG also completed inspections of the followingseven prisons: Corcoran State Prison, California MedicalFacility, North Kern State Prison, Salinas Valley State Prison,Richard J. Donovan Correctional Facility, California SubstanceAbuse Treatment Facility, and Folsom State Prison. We anticipatepublishing inspection reports for the above prisons in 2021.Table 1. The Office of the Inspector General Cycle 6 Medical Inspections:Final Reports Published in 2020Institution InspectedPublication MonthOverall RatingJulyAdequateWasco State PrisonAugustAdequateValley State PrisonAugustAdequateCalifornia State Prison, SolanoSeptemberAdequateCalifornia Correctional CenterSeptemberAdequateCalifornia Rehabilitation CenterDecemberAdequateCalifornia State Prison, Los Angeles CountySource: The Office of the Inspector General medical inspection results.Whistleblower Retaliation ClaimsIn addition to receiving complaints as described in thepreceding paragraphs, our statutory authority directs us toreceive and review complaints of whistleblower retaliation thatdepartmental employees levy against

4. The Office of the Inspector General's Overall Rating of the Department's Handling of Its Use-of-Force Incidents 12 5. Total Complaints the Office of the Inspector General Received Over the Past Five Years, From 2016 Through 2020 15 6. Total Number of Mail Complaints the Office of the Inspector General Received Each Month During 2020 16 7.