Roy W. Wesley , Inspector General

Bryan B. Beyer, Chief Deputy Inspector General

OIG

OFFICE of the
INSPECTOR GENERAL

Independent Prison Oversight

February 2021

SPECIAL REVIEW
The California Department
of Corrections and Rehabilitation
Its Recent Steps Meant to Improve the Handling of
Incarcerated Persons’ Allegations of Staff Misconduct Failed
to Achieve Two Fundamental Objectives: Independence and Fairness;
Despite Revising Its Regulatory Framework and
Being Awarded Approximately $10 Million of Annual Funding,
Its Process Remains Broken

Electronic copies of reports published by the Office of the Inspector General
are available free in portable document format (PDF) on our website.
We also offer an online subscription service.
For information on how to subscribe,
visit www.oig.ca.gov.
For questions concerning the contents of this report,
please contact Shaun Spillane, Public Information Officer,
at 916-255-1131.

STATE of CALIFORNIA

of the
OIG OFFICE
INSPECTOR GENERAL

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

Independent Prison Oversight

Regional Offices
Sacramento
Bakersfield

February 16, 2021

Rancho Cucamonga

The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
State Capitol
Sacramento, California
Dear Governor and Legislative Leaders:
Enclosed is the Office of the Inspector General’s report titled The California Department of Corrections and
Rehabilitation: Its Recent Steps Meant to Improve the Handling of Incarcerated Persons’ Allegations of Staff Misconduct
Failed to Achieve Two Fundamental Objectives: Independence and Fairness; Despite Revising Its Regulatory Framework
and Being Awarded Approximately $10 Million of Annual Funding, Its Process Remains Broken. On January 24, 2019,
we published a report criticizing Salinas Valley State Prison’s handling of incarcerated persons’ allegations
of staff misconduct; we found that the inquiries it performed into allegations of staff misconduct were mostly
inadequate and suffered from a number of weaknesses, including a lack of independence. To address the lack
of independence, we recommended the department consider redesigning its process statewide by reassigning
responsibility for conducting staff complaint inquiries (referred to in this present report as staff misconduct
inquiries) to employees who work outside the prison’s command structure. In response, the department
submitted a budget proposal to the legislature, requesting $9.8 million in ongoing additional funding to perform
inquiries into incarcerated persons’ allegations of staff misconduct through a new unit, called the Allegation
Inquiry Management Section (AIMS). In June 2019, the Governor and the legislature approved the department’s
proposal as part of the State’s 2019–20 Budget Act. In turn, the department developed new regulations and
procedures for handling grievances involving staff misconduct; it also established AIMS and hired staff. The new
process went into full effect on April 1, 2020.
In this present report, we conclude that the lack of independence we highlighted two years ago still persists, even
in this new process. Unfortunately, our review, which covers a five-month period in 2020 after the department
established AIMS, found that wardens largely avoided referring staff misconduct grievances to the new unit.
According to the department’s data, incarcerated persons filed 50,412 grievances during the five-month period
from April 1, 2020, through August 31, 2020. Wardens decided that 2,339 of these grievances (4.6 percent)
actually alleged staff misconduct; however, they chose to refer only 541 of the 2,339 (23 percent) to AIMS. In
effect, wardens elected not to refer to AIMS the remaining 1,798 grievances. Ultimately, the lack of referrals
undermined AIMS’s reason for existence—increasing the independence of the process­—and diminished the new
unit’s effectiveness in making that process more independent. While the department had pledged that AIMS
would perform 474 inquiries per month (for a total of nearly 5,700 per year), AIMS opened just 86 inquiries per
month (18 percent of the projected volume). Nevertheless, prisons collectively received 468 staff misconduct
grievances per month, nearly equal to the volume of inquiries the department had initially projected AIMS was
capable of performing. Perhaps contributing to the low rate of referrals is the complexity and subjectivity of the

Gavin Newsom, Governor
10111 Old Placerville Road, Suite 110
Sacramento, California 95827
Telephone: (916) 255-1102
www.oig.ca.gov

Respectfully submitted,

Finally, we found that weaknesses in the department’s collection and tracking of staff misconduct data limit its
ability to effectively analyze trends or perform meaningful assessments of its process. Despite having numerous
information systems that contain data related to the staff misconduct process, the department lacks the ability to
produce reports that are capable of identifying the names of all staff accused of misconduct or the names of all
staff who were found to have violated policy as well as several other types of critical information. We also suspect
the department has severely undercounted—potentially by the thousands—the number of allegations of staff
misconduct. Without having these types of reports available or having an accurate count of the universe of staff
misconduct allegations, the department has no way of knowing how effective its regulatory changes have been
and has no way of measuring its success.

Moreover, we are deeply concerned about the low rate at which wardens determined their staff violated policy
(regardless of the entity that prepared the inquiry), which raises serious issues about the overall fairness of the
process. Most notably, of the 1,293 allegations that wardens resolved between June 1, 2020, and August 31, 2020,
wardens found that their staff violated policy in only 22 (1.7 percent). Our experience monitoring the
department’s formal disciplinary process over the last 15 years leads us to conclude that an exoneration rate of
more than 98 out of every 100 instances demonstrates a lack of fairness in the process.

referral decision-making process. The department’s process provides numerous methods of diverting allegations
of staff misconduct away from AIMS, giving wardens ample reasons for retaining such allegations at the
local prisons.

The California Department of Corrections and Rehabilitation: Its Recent Steps Meant to Improve the Handling of Incarcerated Persons’
Allegations of Staff Misconduct Failed to Achieve Two Fundamental Objectives: Independence and Fairness; Despite Revising Its Regulatory
Framework and Being Awarded Approximately $10 Million of Annual Funding, Its Process Remains Broken
Page 2

The Governor and Legislative Leaders
February 16, 2021

J

J

cJ
Roy W. Wesley
Inspector General

~

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The Department’s Staff Misconduct Inquiry Process Remains Broken | iii

Contents
Illustrations

iv

Terms Used in This Report

viii

Summary

1

Introduction

5

Background

5

Scope and Methodology

12

Review Results

13

Perpetuating Our Concerns About Independence, the
Department’s Newly Created Allegation Inquiry Management
Section Handled Relatively Few Staff Misconduct Grievances;
It Should Have Handled Many More

13

The Department’s Process for Determining How to Handle Staff
Misconduct Grievances Is Overly Complex and Subjective;
These Factors May Explain Why Prisons Dealt With Them
Internally Rather Than Refer Them to the Allegation Inquiry
Management Section

23

Without Reasonable Justification, the Allegation Inquiry
Management Section Refuses to Investigate Several Serious
Types of Staff Misconduct and Allegations That Do Not Meet
Several Poorly Conceived Procedural Requirements

31

Rather Than Perform a Complete Inquiry Into a Staff Misconduct
Grievance, Allegation Inquiry Management Section Investigators
Abruptly Stop Their Work as Soon as They Form a Reasonable
Belief That Staff Misconduct Occurred

42

The Low Rate at Which Wardens Determined Their Staff
Violated Policy Raises Serious Concerns Regarding the
Fairness of the Process

47

Weaknesses in the Department’s Data Collection and Tracking
Process Limit the Department’s Ability to Effectively Analyze
Trends and Assess Its Process for Handling Staff
Misconduct Grievances

53

The Department Should Require Incarcerated Persons to Submit
Staff Misconduct Grievances Directly to the Allegation Inquiry
Management Section to Increase Independence and Fairness

63

Recommendations

67

Response to the OIG’s Report

69

Comments Concerning the Response Received From
the Department of Corrections and Rehabilitation

71

Office of the Inspector General, State of California

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iv | The Department’s Staff Misconduct Inquiry Process Remains Broken

Illustrations
Figures
1. Excerpt From the California Department of Corrections and
Rehabilitation’s Training Materials for Employees Concerning the
Grievance Process for Incarcerated Persons

8

2. Wardens Referred Few Staff Misconduct Grievances to AIMS
for Inquiry During the Five-Month Period From April 1, 2020,
Through August 31, 2020

15

3. Both the Number of Staff Misconduct Grievances Wardens Referred
to AIMS and Those Handled by AIMS Were Relatively Low in Each
of the Five Months From April 1, 2020, Through August 31, 2020

17

4. Most Wardens Referred a Relatively Small Percentage of Staff
Misconduct Grievances to AIMS During the Five-Month Period
From April 1, 2020, Through August 31, 2020

18

5. Types of Allegations Among the Staff Misconduct Grievances AIMS
Did Not Accept and Returned to Prisons During the Five-Month
Period From April 1, 2020, Through August 31, 2020

20

6. Filled Staffing Levels for AIMS to Conduct Inquiries Were Near or
Above Capacity During the Five-Month Period From April 1, 2020,
Through August 31, 2020

21

7. The Department’s Budget Proposal Demonstrated AIMS Had Ample
Capacity to Handle Staff Misconduct Grievances Filed During the
Five-Month Period, From April 1, 2020, Through August 31, 2020

22

8. The Department’s Staff Misconduct Grievance Process Flowchart

24

9. The Office of the Inspector General’s Analysis of the Department’s
Existing Staff Misconduct Grievance Process During the Five-Month
Period From April 1, 2020, Through August 31, 2020

27

10. Very Few of the Department’s Resolved Claims of Staff Misconduct
Resulted in Policy Violations During the Three-Month Period From
June 1, 2020, Through August 31, 2020

48

11. Wardens Frequently Overruled Grievance Coordinators When
Determining Whether a Grievance Alleged Staff Misconduct, Leading
Us to Believe the Actual Number of Staff Misconduct Grievances Was
Much Higher Than Reported During the Three-Month Period From
June 1, 2020, Through August 31, 2020

60

12. The Department’s Identification and Routing of Grievances That
Potentially Alleged Staff Misconduct During the Three-Month Period
From June 1, 2020, Through August 31, 2020

61

13. Recommended Process for Handling Incarcerated Persons’ Grievances
Alleging Staff Misconduct

63

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | v

Tables
1. The Office of the Inspector General’s Analysis of Grievances Potentially
Containing Allegations of Staff Misconduct

62

Graphics
California Department of Corrections and Rehabilitation: Institutions
and Parole Regions

vi

The OIG’s Mandate

vii

Excerpt From an Incarcerated Person’s Staff Misconduct Grievance Form

38

Office of the Inspector General, State of California

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vi | The Department’s Staff Misconduct Inquiry Process Remains Broken

California Department of Corrections and Rehabilitation

Institutions and Parole Regions
8

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Office of the Inspector General, State of California

LOCATION

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The Department’s Staff Misconduct Inquiry Process Remains Broken | vii

W

hen requested by the Governor, the Senate
Committee on Rules, or the Speaker of the
Assembly, the Inspector General shall initiate
an audit or review of policies, practices, and procedures
of the department. . . . Following a completed audit or
review, the Inspector General may perform a followup
audit or review to determine what measures the
department implemented to address the Inspector
General’s findings and to assess the effectiveness of
those measures.
Upon completion of an audit or review . . . , the Inspector
General shall prepare a complete written report,
which may be . . . disclosed in confidence . . . to the
Department of Corrections and Rehabilitation and to the
requesting entity.
The Inspector General shall also prepare a public
report. . . . Copies of public reports shall be posted on the
Office of the Inspector General’s internet website.
The Inspector General shall . . . during the course of
an audit or review, identify areas of full and partial
compliance, or noncompliance, with departmental
policies and procedures, specify deficiencies in the
completion and documentation of processes, and
recommend corrective actions . . . including, but not
limited to, additional training, additional policies,
or changes in policy . . . as well as any other findings
or recommendations that the Inspector General
deems appropriate.
The Inspector General shall provide contemporaneous
oversight of grievances that fall within the department’s
process for reviewing and investigating inmate
allegations of staff misconduct and other specialty
grievances, examining compliance with regulations,
department policy, and best practices. . . . The Inspector
General shall issue reports annually, beginning in 2021.
— State of California
Excerpted from
Penal Code section 6126 (b), (c), (d), and (i)

Office of the Inspector General, State of California

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viii | The Department’s Staff Misconduct Inquiry Process Remains Broken

Terms Used in This Report

AIMS

Acronym for the California Department of Corrections and Rehabilitation’s
Allegation Inquiry Management Section when referring to the new
unit dedicated to conducting inquiries into claims of staff misconduct;
the Allegation Inquiry Management System when referring to the data
information system related to staff misconduct grievance inquiries (The
California Code of Regulations (CCR), Title 15, Section 3484(a)).

Appeal

A claimant’s written request to the Office of Appeals for review of a decision
issued by the institutional or regional Office of Grievances (CCR, Title 15,
Section 3480(b)(3)).

Claim (or Allegation)

A claim is a single complaint within a grievance arising from a unique set of
facts or circumstances. The term allegation is used synonymously with the
term claim. Both claim and allegation are assertions without proof or before
proving (CCR, Title 15, Section 3480(b)(5)).

Claimant

An incarcerated person or a parolee under the custody or control of the
department who files a grievance or appeal with the department (CCR, Title
15, Section 3480(b)(6)).

Grievance

An incarcerated person’s written request to the institutional or regional Office
of Grievances for review of one or more claims or allegations (CCR, Title 15,
Section 3480(b)(10)).

Allegation Inquiry

The process of gathering preliminary information concerning a claim or
allegation of staff misconduct (CCR, Title 15, Section 3480(b)(2)).

Investigation

The collection of evidence that supports or refutes an allegation of staff
misconduct, including criminal investigations, administrative investigations,
retaliation investigations, or allegation inquiries (Department Operations
Manual, Section 31140.3).

Staff Misconduct
Grievance

A grievance brought forward by an incarcerated person alleging facts that
would constitute one or more allegations or claims of staff misconduct (CCR,
Title 15, Section 3480(b)(10), (14).

Staff Misconduct

An allegation or claim that departmental staff violated a law, regulation,
policy, or procedure, or acted contrary to an ethical or professional standard,
which, if true, would more likely than not subject a staff member to adverse
disciplinary action (CCR, Title 15, Section 3480(b)(14)).

Terminology compiled from The California Code of Regulations and the department’s operations manual.

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 1

Summary
The Office of the Inspector General is required to provide
contemporaneous oversight of the California Department of Corrections
and Rehabilitation’s (the department) process for reviewing and
investigating incarcerated persons’ allegations of staff misconduct.
This report provides a review of the department’s new unit, called
the Allegation Inquiry Management Section (AIMS), dedicated to
performing inquiries (or investigations) into such allegations, called staff
misconduct grievances, and serves as a progress report on the department’s
implementation of its new process for handling such allegations. We
have established a monitoring team to provide some oversight of the
department’s new staff misconduct grievance process.
On January 24, 2019, we issued a report titled Special Review of Salinas
Valley State Prison’s Processing of Inmate Allegations of Staff Misconduct,
in which we concluded that Salinas Valley State Prison’s handling of
incarcerated persons’ allegations of staff misconduct was inadequate:
more than half the inquiries into the allegations we reviewed were
performed inadequately because the prison staff who investigated the
allegations did not follow sound practices in interviewing, collecting
evidence, and writing reports. We also concluded that the reviewers’
lack of independence—their bias in favor of coworkers—contributed
significantly to the inadequacy of their investigative efforts.
We recommended the department consider a complete overhaul of its
process statewide. Specifically, we urged the department to reassign
responsibility for conducting staff complaint inquiries (referred to in
this present report as staff misconduct inquiries) to employees who work
outside the prison’s command structure. We also urged the department
to adopt a regionalized staffing model so that staff members performing
inquiries at the prisons are not located at and do not work in facilities
with the staff whose actions they investigate.
In response, the department submitted a budget proposal to the
legislature, requesting $9.8 million in ongoing additional funding
to perform inquiries into incarcerated persons’ allegations of staff
misconduct through a new unit, now called AIMS. In June 2019, the
Governor and the legislature approved the department’s proposal as
part of the State’s 2019–20 Budget Act. The department later developed
new regulations and procedures for handling grievances involving
staff misconduct.

Office of the Inspector General, State of California

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2 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Highlights of our review include the following:
We remain concerned about the independence of the department’s process,
since the vast majority of staff misconduct grievances were handled
internally, at the prisons; the department’s newly created Allegation Inquiry
Management Section handled relatively few staff misconduct grievances even
though it should have handled many more. The department formed AIMS
to create an independent entity, outside the prisons’ chain of command,
to investigate possible misconduct committed by staff at the prisons.
However, prisons largely avoided using AIMS, instead investigating the
vast majority of such complaints internally. Because we also established
a new unit to monitor the handling of staff complaints by predominantly
monitoring AIMS, the prisons’ lack of referrals to AIMS has, essentially,
circumvented our oversight process.
•

Between April 1, 2020, and August 31, 2020, incarcerated persons
filed 50,412 grievances; wardens determined that 2,339 alleged
staff misconduct (4.6 percent); wardens referred 541 of the
2,339 to AIMS (23 percent).

•

By not referring to AIMS the remaining 1,798 staff misconduct
grievances (77 percent), wardens undermined the purpose of the
new unit.

•

The department’s budget proposal, which requested $9.8 million
in additional funding, provided AIMS with 47 new positions,
36 of which were investigators (lieutenants) who were expected
to perform about 13 inquiries per month; collectively, the
department projected that AIMS would perform 474 inquiries
per month and 5,690 inquiries per year.

•

In the first five months that AIMS was fully operational, AIMS
accepted for inquiry only 86 inquiries per month (18 percent
of the projected volume); however, prisons received 468 staff
misconduct grievances per month, nearly equal to the volume the
department projected AIMS could perform.

•

AIMS unnecessarily returned to the prisons many of the staff
misconduct grievances wardens referred. Of the 541 staff
misconduct grievances wardens referred to AIMS, the new unit
returned 113 (21 percent) without an inquiry.

The department’s process for determining where to route staff misconduct
grievances is overly complex and subjective, diverts staff misconduct
grievances from the Allegation Inquiry Management Section, and lacks
oversight. The department requires staff to make a complex series of
subjective decisions to screen grievances before the grievances reach
AIMS to be investigated; at each screening juncture, more grievances are
diverted away from AIMS’s independent investigative process. All these
decisions occur without oversight.

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 3

The department defines the term staff misconduct as an allegation that
staff violated a law, regulation, policy, or procedure, or acted contrary
to an ethical or a professional standard that would more likely than not
lead to adverse disciplinary action if it were found to be true. Prison staff
must apply their subjective interpretations of the term staff misconduct
to decide where to route incarcerated persons’ grievances; to further
determine where to route each grievance, wardens must subjectively
determine, before any investigation, whether or not an allegation is likely
to be true.
AIMS returned various types of staff misconduct grievances without
conducting investigations. Despite regulations requiring AIMS to conduct
an allegation inquiry into every staff misconduct grievance it receives,
AIMS returned without investigation many grievances that fit certain
categories it used to screen referrals. The following list presents the
types of staff misconduct that AIMS returned uninvestigated, despite
having no reasonable justification for doing so:
•

Allegations of excessive use of force that staff self-reported,
but did not result in serious bodily injury; sexual misconduct
or harassment; due process violations during the disciplinary
process; disagreement with staff decisions during the
disciplinary process; false rules violation reports; and staff
misconduct related to the Americans With Disabilities Act’s
(ADA) reasonable accommodation process

•

Allegations filed more than 30 days after the misconduct
allegedly occurred

•

Allegations about which AIMS overruled the warden’s decision
that the accused staff would likely incur adverse disciplinary
action if the allegations were proven true

Rather than perform a complete inquiry into a staff misconduct grievance,
investigators abruptly stop their work as soon as they form a reasonable
belief that staff misconduct occurred. AIMS investigators conduct
interviews and gather evidence to help wardens determine whether
an allegation is likely true; however, when an investigator forms a
reasonable belief that any misconduct occurred, the department requires
the investigation be terminated—even though it is incomplete—and a
report be sent immediately to the warden for review. Yet terminating
an inquiry before gathering all evidence and interviewing all witnesses
risks leaving undiscovered relevant evidence and may cause allegations
to pass uninvestigated.
Fewer than 2 percent of staff misconduct allegations were found to have
merit, resulting in a policy violation; the low rate at which wardens
determined their staff violated policy and the department’s use of ambiguous
language to track the results of its reviews raise serious concerns about
the fairness and transparency of the process. The department could not

Office of the Inspector General, State of California

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4 | The Department’s Staff Misconduct Inquiry Process Remains Broken

produce a report showing the number of inquiries that resulted in policy
violations. We reviewed, as an alternative, a departmental report that
showed the number of staff misconduct allegations that wardens had
resolved, including those labeled as approved (as those would be the only
ones capable of including a violation of policy). Of the 1,293 allegations
the department resolved between June 1, 2020, and August 31, 2020,
only 70 (5.4 percent) were labeled approved. Our closer inspection of those
70 approved allegations, however, revealed that only 22 were found to
actually contain policy violations, or 1.7 percent of the total 1,293.
Weaknesses in the department’s data collection and tracking process limit the
department’s ability to effectively analyze trends and self-assess its process
for handling staff misconduct grievances. The department maintains
numerous information systems that capture data regarding the staff
misconduct grievance process, but none of these systems can produce
some basic management reports that enable managers to perform
meaningful trend analyses or assessments of the process. The department
cannot produce basic reports necessary to successfully manage the
process from a statewide perspective, including any of the following:
•

The number or names of staff who have been accused of
misconduct by incarcerated persons

•

The names of staff found to have violated a policy in connection
with a staff misconduct grievance allegation

•

Any actions taken against staff to rectify any related
policy violations

Because of the department’s subjective internal grievance review process,
wardens may have misclassified as routine thousands of grievances
potentially alleging staff misconduct in just a three-month period, bypassing
the allegation inquiry process and raising concerns about underreporting
and data collection. Wardens overruled grievance coordinators more
than two-thirds of the time to reclassify nearly 2,600 staff misconduct
grievance allegations in three months as merely routine. At this rate,
the annualized number of staff misconduct grievances may be as high as
10,000 more than reported by the department.
The department should require incarcerated persons to submit staff
misconduct grievances directly to AIMS to increase the independence and,
ultimately, the fairness of the process. To provide greater independence
and consistency, and increase the legitimacy of the staff misconduct
grievance process, we recommend, among other things, that the
department restructure its grievance routing process so that incarcerated
persons submit allegations of staff misconduct directly to AIMS,
bypassing prison staff’s subjective determinations. The department
should also establish a new central intake function specifically for AIMS
so that it can consistently process all allegations of staff misconduct
arising from this process.

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 5

Introduction
Background
California Penal Code Section 6126 requires the Office of the Inspector
General to provide contemporaneous oversight of grievances that fall
within the California Department of Corrections and Rehabilitation’s
(the department) process for reviewing and investigating incarcerated
persons’ allegations of staff misconduct. Generally speaking, this
oversight includes our examination of compliance with regulations,
departmental policy, and best practices. The law requires that we issue
reports annually, beginning in 2021. This report is intended to serve
as a progress report covering the department’s implementation of its
new grievance process along with its creation of a new unit, called the
Allegation Inquiry Management Section (AIMS). This new unit, which
is part of the department’s Office of Internal Affairs, is dedicated to
performing inquiries (or investigations) into grievances that contain
allegations of staff misconduct.

The Department Received About $10 Million in Annual Funding,
Including 47 Positions, to Improve the Independence and Quality
of Its Staff Misconduct Grievance Inquiries, Based in Part on
Recommendations From Our 2019 Review of Salinas Valley
State Prison
On January 24, 2019, we issued a report titled Special Review of Salinas
Valley State Prison’s Processing of Inmate Allegations of Staff Misconduct.
That report concluded, among other things, that Salinas Valley State
Prison’s handling of allegations of staff misconduct was inadequate and
may have resulted in decisions the department could not defend. We
noted in that report that more than half of the staff misconduct inquiries
we reviewed were performed inadequately because the staff misconduct
reviewers—supervisors the prison assigned to investigate allegations
of staff misconduct—did not follow sound practices in interviewing,
collecting evidence, and writing reports.
Moreover, we concluded that the reviewers’ lack of independence
contributed significantly to the inadequacy of the prison’s investigative
efforts. For example, we found that reviewers were frequently peers
or coworkers of the accused staff and worked in the same location.
The reviewers also displayed signs of bias in favor of fellow staff
when conducting staff misconduct inquiries and sometimes ignored
corroborating evidence offered by incarcerated witnesses. We also found
that reviewers often compromised the confidentiality of the process,
which could have exposed the incarcerated persons to retaliation for
raising their concerns about staff behavior.

Office of the Inspector General, State of California

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6 | The Department’s Staff Misconduct Inquiry Process Remains Broken

To address these concerns, we recommended the department consider
a complete overhaul of the staff misconduct inquiry process statewide.
Specifically, we urged the department to reassign the responsibility for
conducting staff misconduct inquiries to employees who work outside
the prison’s command structure. We also recommended the department
adopt a regionalized staffing model so that the staff members performing
the inquiries were not embedded with the staff whose actions they were
tasked with investigating.
In response to our findings and recommendations, the department
submitted a budget proposal to the legislature, requesting approximately
$9.8 million in funding and 47 positions in fiscal year 2019–20 and
ongoing. Among the 47 positions were 36 lieutenants to perform the
inquiries, and six captains, three office technicians, one analyst, and
one chief deputy administrator to provide supervision, management,
and administrative work.1 These staff would work in a new unit, later
dubbed AIMS, within the department’s Office of Internal Affairs, with
the goal of increasing the objectivity and quality of the department’s staff
misconduct inquiries. Using the comparative number of staff misconduct
grievances the department processed in the 2018 calendar year, the
department projected that AIMS would handle approximately 5,690 staff
misconduct grievance inquiries per year (or 474 per month). At this rate,
each investigator would have to complete approximately 13 inquiries
per month. In June 2019, the Governor and the legislature approved the
department’s proposal as part of the State’s 2019–20 budget.

The Department Revised Its Process for Reviewing Incarcerated
Persons’ Allegations of Staff Misconduct: An Explanation of the
Revised Process
In March 2020, the department proposed a new regulatory framework for
processing allegations of staff misconduct. Generally, the new framework
was supposed to move the responsibility for performing inquiries into
these allegations away from staff working at the prisons and delegate
that responsibility to staff working in AIMS.
In this new process, incarcerated persons file grievances by dropping
them in collection boxes located in their housing units and at other
locations throughout the prison.2 Each day, a prison staff member
collects the grievances from all the prison’s lockboxes and provides them
to an analyst in the prison’s Office of Grievances. The analyst reviews
and logs each grievance, then passes the grievances to the prison’s
grievance coordinator. The grievance coordinator reviews each grievance
and separates out the grievances he or she believes contain allegations
of staff misconduct from the routine grievances that do not contain
1. Throughout this report, we refer to the lieutenants who conduct staff misconduct
inquiries for AIMS as investigators.
2. Prior to June 2020, incarcerated persons filed appeals. That term has been replaced
with grievances.

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 7

allegations of misconduct. The grievance coordinator provides the set
of grievances he or she believes allege staff misconduct to the prison’s
reviewing authority (either the warden or chief deputy warden3), who
then determines whether the grievances officially contain allegations of
staff misconduct. The department’s regulations provide the following
two-part definition to guide grievance coordinators, wardens, and other
departmental staff in determining whether to classify a grievance as a
staff misconduct grievance:4

Staff misconduct means an allegation that
1. departmental staff violated a law, regulation,
policy, or procedure, or acted contrary to an
ethical or professional standard,
2. which, if true, would more likely than not subject
a staff member to adverse disciplinary action.
When an allegation meets both of these parameters, departmental
regulations require the warden to refer the grievance to the Office of
Internal Affairs. The particular unit within the Office of Internal Affairs
that should receive the grievance depends on whether the grievance
provides sufficient information to establish a reasonable belief that the
alleged misconduct occurred. If so, the warden must refer the grievance
to the Office of Internal Affairs’ Central Intake Unit, requesting either
a formal investigation or permission to take adverse action without
additional investigation. If not, the warden must refer the grievance
to the Office of Internal Affairs’ AIMS, requesting an inquiry. The
department’s regulations mandate that wardens refer all staff misconduct
grievances to one of these two units in the Office of Internal Affairs; the
unit must investigate the allegations:5

1. [If] the claim warrants a request for an allegation
inquiry [it] shall be referred to the Office of Internal
Affairs, Allegation Inquiry Management Section. An
allegation inquiry shall be conducted whenever the
claim meets the definition of staff misconduct but the
[warden] does not have a reasonable belief that the
misconduct occurred. [emphasis added]
2. [If] the claim warrants a request for a formal
investigation [it] shall be referred to the Office
of Internal Affairs, Central Intake Unit. A formal
investigation shall be conducted whenever the claim
3. Throughout this report, we use the term warden to refer to the reviewing authority.
4. The California Code of Regulations (CCR), Title 15, section 3480(b)(14), “Implementation
Date and Definitions.”
5. CCR, Title 15, section 3484(a), “Allegations of Staff Misconduct.”

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8 | The Department’s Staff Misconduct Inquiry Process Remains Broken

meets the definition of staff misconduct and the
[warden] has a reasonable belief that the misconduct
occurred. [emphasis added]
When a grievance does not contain an allegation that qualifies as staff
misconduct, wardens assign that grievance to supervisory staff at the
prison for a review. The department provides a handout to staff to
explain these different processes (see Figure 1).

Figure 1. Excerpt From the California Department of Corrections and
Rehabilitation’s Training Materials for Employees Concerning the Grievance
Process for Incarcerated Persons

ALLl!GATI N AGAINST STAlrlr
WHERE
602) PROCESS
WHERE DO
DO CLAIMS
:LAIMS WITHIN
THIN THE
HE GRIEVANCE
GRIEVANCE (CDCR
,CD R61
Pl O .ESS GO?
GO'

OIA – Formal Investigation

Allegation with staff misconduct with reasonable belief

AIMS – Allegation Inquiry

Allegation with staff misconduct without reasonable
belief

Local - Supervisorial Review
Allegation against staff that, if true, is
likely to lead to corrective action
(Not likely to lead to staff misconduct)

FORMAL INVESTIGATION
A criminal or administrative investigation
concerning a claim that involves an
allegation of staff misconduct with
reasonable belief staff misconduct
occurred.

ALLEGATION INQUIRY
The process of gathering preliminary
information concerning a claim that
involves an allegation of staff misconduct
without reasonable belief staff misconduct
occurred.

SUPERVISORIAL REVIEW
The process of gathering preliminary
information concerning a claim, which if
true, is likely to lead to corrective action.

Staff misconduct is defined in CCR 3480 as “allegation against staff which, if true, would more likely than not subject a staff member to adverse
disciplinary action.” Reasonable belief is established when facts and circumstances are known that make a reasonable person of average
caution believe that staff misconduct occurred. Claims alleging staff misconduct coupled with a reasonable belief the claim is true are referred
to the Office of Internal Affairs Central Intake Unit (CIU).
The newly-created Allegation Inquiry Management Section (AIMS) will process staff misconduct allegations when a “reasonable belief” has not
been established. Exceptions are grievances that include staff sexual misconduct and staff sexual harassment (PREA) allegations, and Use of
Force (UOF) allegations. For these exceptions, see the Flowchart: “Processing Allegations Against Staff”
An allegation against staff includes all claims in a grievance that staff violated a law, regulation, policy, or procedure, or acted contrary to an
ethical or professional standard. Some allegations, which if true, will only require corrective action (training, remedial training, verbal
counseling, employee counseling record, letter of instruction). Local supervisors and/or managers will conduct these reviews.

Source: The California Department of Corrections and Rehabilitation.

05-20-2020

The department chose to exempt several types of claims from being
referred to AIMS, instructing prison staff to retain the following staff
misconduct allegations at the prison:
•

Unnecessary or excessive use of force that was reported by staff
but did not result in serious bodily injury

•

Sexual misconduct or sexual harassment against an
incarcerated person

•

Staff involvement in due process violations during the
disciplinary process

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 9

•

Disagreement with staff decisions during the
disciplinary process

•

Issuance of false rules violation reports

•

Staff misconduct in connection with the Americans With
Disabilities Act’s (ADA) reasonable accommodation process

When AIMS receives a staff misconduct grievance referral from a prison,
AIMS staff first review the grievance to determine whether it possesses
any of the following characteristics:
•

The claim falls within any of the six categories of misconduct
that prison staff are instructed to retain for handling at
the prison

•

The claimant filed the grievance more than 30 days after the
alleged misconduct occurred

•

The staff at AIMS disagrees with the warden’s determination
that the allegation meets the definition of staff misconduct

•

The claim is not specific enough to be investigated

•

The claim of staff misconduct did not have a material adverse
effect on the claimant

•

The claimant is refusing to cooperate with the department’s
attempts to obtain additional information

•

The claim concerns harm to a person other than the person who
signed the grievance

•

The claim of staff misconduct was committed by staff not
employed or under the control of the department

•

The claim duplicates a claim that has already been filed

If a grievance meets any of these criteria, AIMS does not accept the
grievance, returning it to the prison without performing an inquiry or
investigation. The warden must then decide how prison staff will address
the incarcerated person’s allegations.
When AIMS accepts a staff misconduct grievance, it assigns the
grievance to an investigator, who performs an allegation inquiry into
the allegations contained in the grievance. During the inquiry, the
investigator performs interviews and gathers records and physical
evidence that may prove or disprove the allegations. In essence, the
investigator performs an investigation. At the conclusion of this activity,
the AIMS investigator prepares a report summarizing the evidence
gathered during the inquiry. The report does not offer a judgment
concerning the guilt or innocence of the accused staff; it merely recounts
the evidence gathered.

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10 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Although the regulations are silent regarding what AIMS should do with
the completed inquiry report, we have observed that the inquiry report
is then returned to the warden of the corresponding prison, who decides
whether or not the staff member likely committed the alleged acts. If the
warden believes the evidence establishes a reasonable belief that the staff
member engaged in misconduct, the warden returns the inquiry report
to the Office of Internal Affairs, this time to the Central Intake Unit. The
Office of Internal Affairs’ Central Intake Unit then reviews the referral and
takes one of three actions: (1) if the Central Intake Unit concludes there
is sufficient evidence to sustain the allegations by a preponderance of the
evidence, it will authorize the warden to take adverse action against the
subject employee without further investigation; (2) if the Central Intake
Unit concludes there is a reasonable belief that misconduct occurred,
it will approve and open a formal investigation into the allegation (or a
subject-only interview); or (3) if the Central Intake Unit concludes there is
no reasonable belief that misconduct occurred, it will reject the request to
open an investigation and return the report to the warden.

We Established a Monitoring Team to Provide Some Oversight of
the Department’s New Staff Misconduct Grievance Process
Soon after the legislature approved the department’s nearly $10 million
budget request, it also augmented our authority, requiring that we begin
providing contemporaneous oversight of the department’s process for
reviewing and investigating staff misconduct grievances. In response to
this broadened statutory authority, we established a Staff Complaints
Monitoring Team composed of five positions. To date, our staff have
monitored the department’s implementation of AIMS and observed
several of AIMS’s inquiries. We began our formal monitoring of AIMS’s
investigative activities on January 1, 2021. We are mandated to issue
public reports summarizing our monitoring activities in this area just
as we publish reports summarizing our monitoring activities of the
department’s disciplinary and use-of-force review processes. We are also
developing a data dashboard, which we plan to publish and regularly
update on our public-facing website to provide the public a better
understanding of AIMS’s progress and the quality of its inquiries.

Differences Between an Inquiry and an Investigation
From our experience working with various professional oversight entities
from around the country, investigative entities often interchangeably use
the words inquiry and investigation to mean an examination or the attempt
to determine the facts of an event or situation. In fact, the definition of
investigation or to investigate includes the word inquiry as a synonym for
investigation, such as in the following example:

Investigation: The activity of trying to find out the
truth about something, such as a crime, accident, or

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 11

historical issue; especially, either an authoritative inquiry
into certain facts, as by a legislative committee, or a
systematic examination of some intellectual problem or
empirical question, as by mathematical treatment or use
of the scientific method.6
Indeed, a standard thesaurus we reviewed identified the word inquiry as a
synonym for investigation.7
Despite these generally accepted meanings, the department does not
use the words interchangeably, instead distinguishing between inquiries
and investigations. The California Code of Regulations, Title 15,
section 3480(b)(2), offers the following definition of an allegation inquiry:

Allegation inquiry: the process of gathering preliminary
information concerning a claim or allegation of staff
misconduct.
While this passage describes an allegation inquiry as “preliminary” in
nature, the department’s definition of an investigation, in its Department
Operations Manual (31140.3), offers the term “allegation inquiries” as a
type of investigation:

Investigation: The collection of evidence that supports
or refutes an allegation of misconduct, including criminal
investigations, administrative investigations, retaliation
investigations, or allegation inquiries. [emphasis added]
Simply put, the department defines an allegation inquiry as a type of
investigation, yet the department also attempts to distinguish between
an inquiry and an investigation. In reality, however, whether the activity
is called an inquiry or an investigation, staff who conduct either activity
generally perform the same actions: they interview relevant parties,
gather and examine relevant documentary evidence, and draft a report.
They do this to accomplish the same objective: to discover factual
evidence to support or refute allegations of staff misconduct. As a
result, we do not believe there is a material distinction between these
activities; for the department to hold otherwise is to engage in sophistry.
Throughout this report, we generally refer to the inquiry work performed
by departmental staff as an investigation.

6. Black’s Law Dictionary, ed. B. Garner, 10th ed. (Thomson Reuters, 2014). Entry:
“investigation.”
7. Merriam-Webster’s Thesaurus, online: https://www.merriam-webster.com/thesaurus/
inquiry.

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12 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Scope and Methodology
For the purposes of this report, we reviewed a number of key documents,
including the department’s revised regulations and the related training
materials used to instruct both staff who conduct inquiries and those who
interact with the process at the prisons. We also reviewed the workload
analysis prepared by the department as part of its fiscal year 2019–20
budget proposal. In addition, our staff attended various live training
sessions held by departmental instructors on the new inquiry process.
We observed, in real time, 24 inquiries conducted by AIMS’s
investigators. We also reviewed AIMS’s intake procedures, including its
decision-making process, to determine whether to accept new inquiries
or return them to the prison wardens without an inquiry. For the purpose
of this review, however, we did not provide an assessment of the quality
of those particular inquiries that AIMS conducted. Rather, this report
considered how the department’s process functioned and whether it had
achieved one of its desired objectives: independence.
We obtained and analyzed data from a number of the department’s
electronic tracking systems, including the offender grievance tracking
system, inmate appeals tracking system (now retired), allegation
inquiry management system, internal affairs tracking logs (referred
to as CDCR Form 2140 spreadsheets), and various COMPSTAT8
reports. To better understand the meaning of key data fields, we held
numerous discussions with departmental staff regarding the design and
implementation of these systems and to gain a better understanding of
how the department defines key terms.
We reviewed supporting documentation for all 70 claims involving
allegations of staff misconduct that wardens approved from June 1, 2020,
to August 31, 2020. The purpose of this review was to fully understand
the specific allegations, or claims, the department had approved.
We describe the results of this testing on page 49. In addition, we
interviewed four wardens to understand their working definition of the
term approved. We describe these interviews on page 50.
To validate a portion of the department’s data tracking for claims that
wardens disapproved, we selected a random sample of 40 grievances
involving allegations of staff misconduct that the data-tracking system
identified as disapproved. We matched this conclusion with source
records to ensure the data reflected the same conclusion. Without
exception, we matched the conclusion to supporting documentation.
Finally, we selected a random sample of 15 claims in which wardens
disagreed with their staff’s initial determinations that the claims related
to staff misconduct. We discuss the results of this testing on page 60.
8. COMPSTAT (COMParative STATistics) is a department-wide collaborative database
designed for collecting, analyzing, and reporting strategic and operational performance
data. Department Operations Manual, Section 101090.5, “Responsibility.”

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 13

Review Results
Perpetuating Our Concerns About
Independence, the Department’s Newly Created
Allegation Inquiry Management Section Handled
Relatively Few Staff Misconduct Grievances; It
Should Have Handled Many More
In 2020, the department formed the Allegation Inquiry Management
Section (AIMS), a designated entity that functions as an independent unit
responsible for reviewing and investigating staff misconduct grievance
allegations raised by persons under the department’s jurisdiction. The
section is unattached to the prisons’ chain of command, yet prisons
did not use AIMS, instead continuing to investigate the vast majority
of such complaints internally and without independent oversight.
During the five months ending August 31, 2020, incarcerated persons
filed 50,412 grievances, of which the department’s wardens determined
that 2,339 alleged staff misconduct (4.6 percent).9 Of those 2,339 staff
misconduct grievances, the wardens referred only 541 (23 percent) to
AIMS. In turn, AIMS accepted 428 of the referrals for inquiry and
returned the remaining 113 referrals to the wardens without having
conducted an inquiry. However, by not referring to AIMS the balance
of 1,798 grievances involving staff misconduct (77 percent), wardens
effectively avoided using the newly established unit. In tandem with the
department’s creation of this new section, the OIG also established a new
unit, which is mandated to predominantly monitor AIMS in its handling
of these staff misconduct grievances. Thus, the prisons’ lack of referrals
to AIMS has also circumvented our oversight.
Moreover, according to the analysis the department presented in its
budget proposal, the department projected that AIMS would conduct
6,259 staff misconduct grievance inquiries each year, requiring about
54 additional staff positions, 39.6 of which included investigator
positions. At this staffing level, the department believed that AIMS
would be able to conduct about 158 inquiries per investigator per year.
Instead of asking for the total projected amount, however, the
department adjusted its request to 47 total positions (36 of which would
be for investigators). Therefore, at the rate of 158 inquiries per
investigator per year and the newly requested staffing level of
36 investigators, its adjusted capacity would equate to 5,690 inquiries per
year. This in turn would yield a capacity of approximately 474 inquiries
per month, or about 13 inquiries per investigator per month.
Nevertheless, in the first five months during which AIMS was fully
9. The figure 2,339 refers to the number of grievances the department determined included
at least one claim (or allegation) of staff misconduct. Grievances often contained more than
one claim of staff misconduct. On June 1, 2020, the department began including the number
of claims in its database known as the strategic offender management system.

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14 | The Department’s Staff Misconduct Inquiry Process Remains Broken

operational, the new section opened inquiries into only 86 staff
misconduct grievances per month, on average, or about 18 percent of the
monthly volume it had pledged to produce. Yet AIMS had the capacity—
according to its own analysis—to handle all the grievances statewide that
the department designated as staff misconduct grievances during this
five-month period.10 On average, prisons received 468 staff misconduct
grievances per month, which is just within the monthly volume of 474 the
department had told the legislature that AIMS could perform with a
nearly $10 million annual budget augmentation.

Wardens must decide if a claim (or allegation) meets the definition of staff misconduct:
An allegation that departmental staff violated a law, regulation, policy, or procedure, or acted
contrary to an ethical or a professional standard, which, if true, would more likely than not subject a
staff member to adverse disciplinary action.
After determining that an allegation satisfies this definition, wardens have three options to consider:
1. Refer the allegation to the Office of Internal Affairs’ Central Intake Unit if he or she
determined the allegation(s) met the definition of staff misconduct and has a reasonable
belief that the allegation(s) is/are true.
2. Refer the allegation to the Office of Internal Affairs’ AIMS if he or she determined the
allegation(s) met the definition of staff misconduct, but does not have a reasonable belief
that the allegation(s) is/are true.
3. Retain the grievance at the prison if he or she determined the allegation(s) did not meet the
definition of staff misconduct or determined the allegation(s) fell into one of six categories
excluded from referral to AIMS. Typically, a warden refers the grievance to a locally
designated investigator or a supervisor to handle internally.
Source: The Office of the Inspector General’s analysis of the department’s regulations.

Prisons Handled the Vast Majority of Staff Misconduct Grievances
Internally, Choosing to Refer Only a Small Percentage of Them to
the Department’s Allegation Inquiry Management Section
On January 27, 2020, the department formally activated a portion
of AIMS. As part of this initial activation, the department directed
prisons and parole offices in northern California as well as at the
Richard J. Donovan Correctional Facility in San Diego to refer
allegations of staff misconduct, also referred to as claims, to the new
unit. Approximately two months later, on April 1, 2020, the department
fully activated AIMS by including the remaining prisons and parole
offices in central and southern California. For the five-month period of
April 1, 2020, through August 31, 2020, incarcerated persons statewide
filed a total of 50,412 grievances. Wardens designated 2,339 of those
grievances as staff misconduct grievances in the various information
systems the department used to track incarcerated persons’ grievances.
10. As we discuss further on in this report (beginning on page 53), we have significant
concerns that the department may have undercounted and underreported the actual
number of grievances that include one or more claims of staff misconduct.

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 15

Figure 2. Wardens Referred Few Staff Misconduct Grievances to AIMS for Inquiry
During the Five-Month Period From April 1, 2020, Through August 31, 2020

113 Referred Staff
Misconduct Grievances
Not Accepted by AIMS
(21%)

1,798
(77%)

N = 2,339

Total
Staff Misconduct
Grievances

541

(23%)

Total
Staff Misconduct
Grievances
Referred to AIMS

428 Referred Staff
Misconduct Grievances
Accepted by AIMS
(79%)

█ Staff Misconduct Grievances Wardens Retained at the Prisons
█ Staff Misconduct Grievances Wardens Referred to AIMS for Inquiry
Source: The Office of the Inspector General’s analysis of the California Department of Corrections and
Rehabilitation’s grievance data associated with its 35 prisons.

However, as we show in Figure 2 (above), wardens referred only 541 of
those 2,339 staff misconduct grievances to AIMS (23 percent). According
to the department’s regulatory framework, a warden is supposed to refer
a grievance to AIMS when he or she concludes that one or more claims
within that grievance has met the definition of staff misconduct, but
the warden also does not have a reasonable belief that the misconduct
occurred. The text box on the previous page presents the regulatory
framework that wardens must follow.
Furthermore, we found no evidence of wardens immediately referring
for a formal investigation any of the 2,339 grievances to the Office of
Internal Affairs’ Central Intake Unit, leading us to conclude that, without
having first ordered an inquiry, wardens had no reasonable belief that
misconduct had occurred in any of these grievances.
This means that wardens retained the remaining 1,798 (77 percent)
staff misconduct grievances for their own local inquiry or supervisorial
review. We find troubling the sheer number of grievances wardens
chose not to refer to either AIMS or the Central Intake Unit. These
data suggest—at a minimum—that wardens were reluctant to refer staff
misconduct grievances to an entity outside the prison. As we explain
later in this report, beginning on page 23, the department’s process by
which wardens decide whether to refer a staff misconduct grievance
to AIMS for an inquiry or to perform the inquiry themselves is overly

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16 | The Department’s Staff Misconduct Inquiry Process Remains Broken

complex and subjective, offering wardens wide discretion in choosing to
retain such grievances. However, since the process was intended to divert
the handling of such grievances to an outside entity, we believe that the
vast majority of these grievances should have been referred to AIMS or to
the Central Intake Unit, as the following examples make clear.
In one of these 1,798 staff misconduct grievances that a warden did not
refer to AIMS, an incarcerated person made several serious allegations
involving unreasonable uses of force, neglect of duty, and retaliation
by staff. The individual alleged that staff used unnecessary force on
him that required subsequent medical treatment and that staff denied
his request for medical attention; that he was pepper sprayed, but staff
did not allow him to decontaminate as required by policy; that he was
pushed to his knees while staff cut off his personal clothing; and that
staff moved him to a different cell nine times in retaliation for filing
multiple grievances. All of these allegations, if true, constituted serious
violations of law or policy that would more likely than not result in
adverse action (potentially as high as dismissal) in the judgment of any
reasonable person. The warden decided, however, to avoid referring the
matter to AIMS and instead ordered a supervisorial review at the prison.
Departmental regulations define a supervisorial review as the gathering
of preliminary information concerning a claim that does not involve an
allegation of staff misconduct.11 Since these were potentially allegations
of serious misconduct that, if true, would warrant significant discipline,
the warden’s decision not to forward the matter to the Office of Internal
Affairs not only defies the regulatory framework, it defies all logic. Staff
at the prison performed a supervisorial review into the allegations in this
particular staff misconduct grievance. The warden reviewed the resulting
report and found no policy violations.
In another staff misconduct grievance selected from among the
1,798 staff misconduct grievances handled by prison staff—and not by
AIMS—an incarcerated person made several serious allegations of staff
misconduct involving excessive use of force, neglect of duty, and making
threats. He alleged that staff beat him with specialized batons and
pepper-sprayed him; that he was locked in what he called a “miniature
cage” for 6.5 hours while being deprived of water, ventilation, and
medical treatment; and that staff had threatened him, although he did
not explain the nature of the threats. Again, given the seriousness of
these allegations and the requirements of the regulatory framework, the
warden should have referred this staff misconduct grievance to AIMS.
The minimum penalty for significant unreasonable use of force likely to
cause injury is a salary reduction or suspension. Despite the incarcerated
person’s grievance clearly describing misconduct that would, if
true, result in adverse action, the warden chose not to refer the staff
misconduct grievance to AIMS and instead ordered a local inquiry.

11. CCR, Title 15, section 3480(b)(15), “Implementation Date and Definitions.”

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 17

Figure 3. Both the Number of Staff Misconduct Grievances Wardens
Referred to AIMS and Those Handled by AIMS Were Relatively
Low in Each of the Five Months From April 1, 2020,
Through August, 31, 2020

N = 2,339
500

421
400

372

378
338

289

300

200

100

14
83

0

April

17
58
May

38
91
June

20
24

130

66
July

August

█ Staff Misconduct Grievances Wardens Retained at the Prisons
█ Staff Misconduct Grievances Wardens Referred to AIMS for Inquiry
That AIMS Did Not Accept
█ Staff Misconduct Grievances Wardens Referred to AIMS for Inquiry
That AIMS Accepted
Source: The Office of the Inspector General’s analysis of the California Department of
Corrections and Rehabilitation’s grievance data associated with its 35 prisons.

Staff at the prison conducted the inquiry, and the warden found no
policy violations.
After first considering the total number of staff misconduct grievances
that wardens referred to AIMS during the unit’s first five months
in operation, we then considered the department’s staff misconduct
grievance data on a monthly basis, as shown in Figure 3 (see above).
We found the number of staff misconduct grievances that wardens
collectively referred to AIMS each month appeared relatively consistent,
albeit low when compared with the total number of grievances
designated as staff misconduct grievances in the department’s grievance
tracking systems. In April, for example, wardens collectively referred
only 97 staff misconduct grievances (19 percent) to AIMS, which was
approximately 2.8 per prison. Although this was only the first full month

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18 | The Department’s Staff Misconduct Inquiry Process Remains Broken

of AIMS’s activation, we found it surprising to learn that wardens
retained the vast majority of the staff misconduct grievances internally.
The volume of referrals during this five-month period peaked in August,
when wardens referred 150 staff misconduct grievances (34 percent) to
AIMS, at a rate of 4.3 per prison, which was still lower than the rate we
expected to see, given the 2018 staff misconduct grievance totals and the
department’s corresponding workload projections.
Across the department’s 35 prisons statewide (Figure 4, below), the
volume and rate of referrals to AIMS was inconsistent during the
five-month period from April 1, 2020, through August 31, 2020; on a
percentage basis, referrals ranged from zero to 100 percent. Only six
prisons referred more than half of their staff misconduct grievances
to AIMS, while 13 prisons referred 10 percent or less of their staff
misconduct grievances to AIMS. Of greatest concern to us, California
Correctional Institution—a high-security prison—referred none of the
21 staff misconduct grievances it received to AIMS, and Salinas Valley
State Prison—another high-security prison and the prison we previously
criticized in 2019 for its inadequate handling of staff misconduct

Figure 4. Most Wardens Referred a Relatively Small Percentage of Staff Misconduct Grievances to AIMS
During the Five-Month Period From April 1, 2020, Through August 31, 2020

100%

6

90%

11
58

80%

N = 2,339

70%
60%

27

50%

7

40%

41
23

30%
20%
10%
0%

21
CCI

56 129
6 14

9

116
18

ASP

SVSP

6
1

17
3

CVSP

CIM

16
3

55
12

57
22 122
14
5
28

32
9

182
20 62
6

.. 111111111111111111111
39
1

53
2

SQ

CIW

50
3

127 43
46 112 67 153
11 4
12
5
8
3

SOL

ISP

CMC HDSP CCWF CMF PBSP

■

CAL

VSP

1

Staff Misconduct Grievances
Wardens Retained at Prisons

SCC

CHCF PVSP

■

LAC

SATF

DVI

CEN

SAC

12
7

14
9

29

62
74

4
5

62
90

6

8
3

CAC MCSP

FSP

CCC

WSP KVSP

COR

CRC

RJD

Staff Misconduct Grievances
Wardens Referred to AIMS for Inquiry

Source: The Office of the Inspector General’s analysis of the California Department of Corrections and Rehabilitation’s grievance data
associated with its 35 prisons.

Office of the Inspector General, State of California

CTF

NKSP

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 19

grievances—referred only 18 of its 134 staff misconduct grievances to
AIMS (13 percent). Given the nature of the findings we published in 2019
concerning the handling of these types of inquiries at Salinas Valley
State Prison, we think it is likely that the wardens’ retention of so many
grievances at their prisons continued to undermine the independence of
the process.

The Department’s Allegation Inquiry Management Section
Unnecessarily Rejected Many of the Staff Misconduct Grievances
That Wardens Did Refer
The department’s regulations make it clear that “the reviewing authority
shall refer claims alleging staff misconduct to the Office of Internal Affairs
for completion of an allegation inquiry or formal investigation pursuant
to section 3484.”12 Despite the relatively low volume of staff misconduct
grievances that wardens referred to AIMS, we were surprised to find that
AIMS did not accept for inquiry some of those grievances it did receive,
instead returning them to the prisons to handle locally. Although wardens
referred 541 staff misconduct grievances to AIMS—requesting AIMS to
conduct an inquiry—AIMS returned 113 (a rate of 21 percent) without
having done so. AIMS cited a primary reason for each return, with the two
most commonly listed reasons for returning a referred staff misconduct
grievance being supervisorial and exceeds time constraints.
We learned that supervisorial returns occurred when AIMS disagreed with
the warden’s determination that the matter would more likely than not
result in adverse action. We also learned that the category exceeds time
constraints applied to grievances AIMS returned because the grievance
was not filed within 30 days of the allegation described in the grievance.
We find these two reasons for returning grievances particularly
troubling. Neither of these causes for return, which accounted for just
over half (51 percent) of the grievances AIMS did not accept for inquiry,
provide a legitimate justification to refuse a warden’s request that AIMS
investigate allegations of staff misconduct.
Of similar concern were the types of allegations contained in the
grievances AIMS returned, which included allegations of staff dishonesty,
discourteous treatment, and unreasonable use of force, to name a few
(refer to Figure 5 on the following page). These types of allegations were
very serious and, depending on the behavior of the individuals, could
have resulted in severe forms of discipline, including dismissal from
State service.
While it is reasonable for AIMS not to accept claims for which it lacks
jurisdiction and claims that duplicate another active or previously
investigated claim, we believe that AIMS should have accepted for
inquiry the vast majority of these 113 staff misconduct grievances.
12. CCR, Title 15, section 3484(d), “Allegations of Staff Misconduct.”

Office of the Inspector General, State of California

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20 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Figure 5. Types of Allegations Among the Staff Misconduct Grievances AIMS Did Not
Accept and Returned to Prisons During the Five-Month Period From April 1, 2020,
Through August 31, 2020

Use of
Force

32

Discrimination/
Harassment

13

Discourteous
Treatment

12

Threat/
Intimidation

11

Neglect of Duty

10

Dishonesty

10

Retaliation
Misuse
of Authority
Sexual
Misconduct
Other
Criminal Act
Overfamiliarity
Assault
Confidential
Information
Weapons

--

N = 113

Staff Misconduct Grievances
AIMS Did Not Accept

7
5
5

3

■
2

I
I
I
1
1

1

0

5

10

15

20

25

30

35

Source: The Office of the Inspector General’s analysis of the California Department of Corrections and Rehabilitation’s
grievance data associated with its 35 prisons.

According to the Department’s Own Analysis and the Number of
Positions Funded by the Legislature, the Department’s Allegation
Inquiry Management Section Had Ample Capacity to Handle
Significantly More Staff Misconduct Grievances Than It Did
When the department sought additional, ongoing funding from the
legislature to create AIMS, it informed the legislature that AIMS could
handle 5,690 staff misconduct inquiries per year, or about 474 per month.
At this rate, each investigator would need to handle about 13 inquiries per
month. However, during the first five months of full operation, with nearly

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 21

all positions filled, AIMS opened a total of only 428 inquiries, far short of
the 2,370 inquiries it predicted it would handle in the same time frame.
Further, between April 2020 and August 2020, AIMS’s investigators
generally handled between one and four inquiries per month, well
short of the estimated 13 inquiries per month. Yet, as shown in
Figure 6 (below), the number of investigators and captains AIMS
employed during this period was either near or above its authorized
capacity. In this time frame, AIMS accepted, on average, only 86 staff
misconduct grievances per month, which again, is far short of the
projected monthly average of 474 grievances the department promised
the legislature.

Figure 6. Filled Staffing Levels for AIMS to Conduct Inquiries Were
Near or Above Capacity During the Five-Month Period
From April 1, 2020, Through August 31, 2020

Full staffing capacity of 42 positions,
including 36 investigator-lieutenants
and six captains.*

50

4.5
40

5.0

5.9

4.5

5.5

30

41.6

20

34.4

34.0

42.0

35.3

10

0

April

May

June

July

August

█ Retired Annuitant, Intermittent   █ Permanent, Full Time
* This analysis excludes the four support positions and the one managerial position that
were also established within AIMS. For comparison purposes, we adjusted the number
of retired annuitants to reflect their full-time equivalent value. Some retired annuitant
positions did not perform investigations: for example, one retired annuitant maintained
an information system.
Source: The Office of the Inspector General’s analysis of the California Department of
Corrections and Rehabilitation’s fiscal year 2019–20 budget proposal and Allegation
Inquiry Management Section staffing and workload data.

Office of the Inspector General, State of California

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22 | The Department’s Staff Misconduct Inquiry Process Remains Broken

As illustrated in Figure 7, below, if AIMS had met its workload estimates,
it could have handled all the staff misconduct grievances that incarcerated
persons had filed, compared with only a fraction of them (18 percent).

Figure 7. The Department’s Budget Proposal Demonstrated AIMS
Had Ample Capacity to Handle Staff Misconduct Grievances Filed
During the Five-Month Period From April 1, 2020,
Through August 31, 2020

N = 2,339

AIMS’s Funded Capacity
(474 per month)

500

___________t_______________________________________ _
421

400

372

378

338

289

300

200

100

14
83

0

April

17
58
May

38
91
June

20
24

130

66
July

August

█ Staff Misconduct Grievances Wardens Retained at the Prisons
█ Staff Misconduct Grievances Wardens Referred to AIMS for Inquiry
That AIMS Did Not Accept
█ Staff Misconduct Grievances Wardens Referred to AIMS for Inquiry
That AIMS Accepted
Note: The dotted line represents AIMS’s average monthly handling capacity of
474 staff misconduct grievances. We calculated this value by dividing 5,690 (the
number of staff misconduct grievances the department estimated in its fiscal year
2019–20 budget proposal that it would handle) by 12 (the number of months in a year).
Source: The Office of the Inspector General’s analysis of the California Department
of Corrections and Rehabilitation’s grievance data associated with its 35 prisons.

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 23

The Department’s Process for Determining How
to Handle Staff Misconduct Grievances Is Overly
Complex and Subjective; These Factors May
Explain Why Prisons Dealt With Them Internally
Rather Than Refer Them to the Allegation Inquiry
Management Section
When the department redesigned its grievance and appeals process by
transferring the responsibility for conducting staff misconduct inquiries
from the prisons to the Office of Internal Affairs, it sought to accomplish
two objectives: to increase the independence and improve the quality
of these inquiries. Our present monitoring and review of this process
shows that the department’s new process has abandoned the first
objective; we will address in a subsequent report the second objective.
Instead of creating a straightforward process that can be applied
consistently from prison to prison, the department designed a convoluted
process replete with exceptions and subjective decisions that result in
prison staff handling staff misconduct grievances rather than AIMS’s
investigators, thereby undermining the independence of the process. As
we explained in our 2019 Special Report on Salinas Valley State Prison’s
staff misconduct process, prison staff cannot be relied upon to perform
independent, objective, or thorough staff misconduct inquiries.
The department’s new process for handling incarcerated persons’
allegations of staff misconduct requires that staff make a complex
series of decisions to screen grievances before they reach AIMS to be
investigated; at each decision point, grievances were—and continue
to be—diverted from AIMS’s independent investigative process. To
help train wardens, investigators, and other stakeholders in how to
route grievances under the new staff misconduct grievance process,
the department created a decision flowchart (see Figure 8 on the
following page).

Office of the Inspector General, State of California

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24 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Figure 8. The Department’s Staff Misconduct Grievance Process Flowchart

AIMS ROLE – Allegations Against Staff

Revised
05-20-2020

Is there a grievance with an
allegation against staff?

Revised
05-20-2020

NO

l

YES

-UOF
(unnecessary or excessive)
o Not reported (no 837 or 1662)
AIMS or OIA.
o Reported – With SBI
~
AIMS or OIA.
o Reported – No SBI
3013/3014 process at
institution with uninvolved
custody supervisor.

-

-PREA

o Assigned to Locally Designated
Investigator (LDI) at institution
to complete an allegation
~
inquiry. The LDI will address
all associated staff misconduct
claims raised within the PREA
allegation.

YES

No AIMS
involvement.

Is it a claim or allegation regarding
UOF, PREA, offender discipline, or a
reasonable accommodation?

YES
Adverse

NO
Allegation
Inquiry

Is there a reasonable
belief the misconduct
occurred?

NO

If proven true,
would the misconduct
more likely than not
result in adverse
disciplinary action?

NO
Corrective

Supervisorial
review

YES
Formal
Investigation

Refer to OIA
Central Intake
(989)

No AIMS
involvement

Offender Discipline
o Claim of due process violation
Supervisorial review.
o Disagreement with decision
Supervisorial review.
o Claim disciplinary report as
written is untrue
Case-by-case review, based on
the facts alleged and not the
opinion of the complainant.

~

Reasonable Accommodation
o Requests
RAP Panel.

Within 5 calendar days of discovery of the allegation
The Hiring Authority shall:
·
Prepare a memorandum to AIMS with the following information:
o Grievance log/claim number (when applicable).
o A clear summary of the allegation(s), including documented recent related acts of
misconduct.
·
Attach a copy of the CDCR 602 and all documents that were submitted with the
grievance.
·
Attach a copy of any additional supporting documents that will assist AIMS.
·
Email the package to the AIMS within five (5) calendar days of discovery of the
allegation. Electronically attach a copy of any video recordings; otherwise, send via an
overnight courier service (i.,e., GSO).

~

o Dispute RAP decision
Supervisorial review.

AIMS accepts
referral?

NO

AIMS Captain
presents case to Chief
Deputy Administrator
(CDA) for review

YES

,.,

AIMS completes
allegation inquiry
report and returns to
Hiring Authority within
30 calendar days

NO

CDA agrees with
AIMS Captain?

YES➔

Return to Reviewing
Authority within five
(5) business days.

Note: If at any time reasonable belief is established that staff misconduct occurred, the allegation inquiry shall be stopped, the AIMS report will be
completed and the matter will be forwarded to the Hiring Authority for consideration of referral to the Office of Internal Affairs for a formal investigation.

Notes: OIA is the abbreviation for the department’s Office of Internal Affairs. GSO is the abbreviation for Golden State
Overnight, a commercial overnight courier service located in California.
Source: The California Department of Corrections and Rehabilitation. The flowchart is reproduced verbatim.

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 25

The flowchart demonstrates the sheer complexity of what should be a
fairly straightforward process. It also demonstrates how many criteria
a single grievance must fulfill to be referred to AIMS, even though the
process as outlined in the department’s budget proposal was supposed
to transfer the authority for handling staff complaint grievances to
AIMS. By highlighting all the exceptions to the process that was
designed to route all staff misconduct grievances to the Office of Internal
Affairs, the department’s flowchart demonstrates how the process, in
reality, operates to divert grievances away from AIMS and into local
prison processes.
Equally problematic is the complete lack of oversight of the decisions
staff make while applying criteria from this flowchart, resulting in their
routing or not routing staff misconduct grievances to AIMS. These early
decisions whittle away the number of staff misconduct grievances that
make their way to AIMS for an independent investigation. An added
concern is that mistakes made at this early step in the process remain
unchecked, creating the risk that allegations that would otherwise meet
the definition of staff misconduct continue being handled by prison staff
instead of by Office of Internal Affairs’ investigators.

The Department’s New Process Requires Wardens and Other
Prison Staff to Apply Their Personal, Subjective Interpretations of
the Term Staff Misconduct in Deciding Which Entity Within the
Department Will Handle Staff Misconduct Grievances
To follow the department’s decision flowchart, staff are required to
make a series of judgments, using criteria that are neither objective nor
consistent. Immediately upon receipt of a grievance, prison staff are
tasked with making a determination that could irretrievably prevent
an allegation of staff misconduct from being referred to AIMS for an
independent assessment. At this first step in the department’s grievance
routing process, an analyst, a grievance coordinator, and the prison’s
warden are each independently tasked with evaluating incarcerated
persons’ allegations. Each individual must apply his or her personal
understanding of both the law and departmental policy to his or her
personal interpretations of the incarcerated persons’ allegations. If
these staff members determine a grievance does not warrant a referral
to AIMS, then the grievance is to be handled locally by prison staff as a
routine or supervisorial grievance.
The classification of a grievance as one involving staff misconduct
involves a two-part determination. First, the reviewer must determine
whether the grievance presents an allegation that departmental staff
violated a law, regulation, policy, or procedure, or acted contrary to an
ethical or professional standard. Although this part of the definition
seems straightforward, it may not always be clear whether a specific law,
regulation, policy, procedure, or standard is in place that governs the
alleged acts. Some individuals who review the grievances may bring to

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26 | The Department’s Staff Misconduct Inquiry Process Remains Broken

bear more familiarity with the decision-making process or command a
better understanding of the applicable laws and regulations than others.
Accordingly, one reviewer may recognize that the complained-of acts
qualify as a violation of law, regulation, policy, procedure, or other ethical
or professional standard, whereas another reviewer may not recognize
the violation; this situation can lead reviewers to arrive at opposite
conclusions regarding the same behavior.
After filtering out grievances that do not meet the first part of the
definition, staff reviewing the remaining grievances must then make the
second part of the determination: the reviewer must determine whether
the alleged acts, if later found to have occurred, would more likely than
not subject a staff member to adverse disciplinary action. This, too,
requires subjective analysis by reviewing staff, who must apply their
own independent judgment to determine whether the complained-of
act would warrant adverse disciplinary action or a penalty less severe,
such as corrective or informal action. These determinations are highly
subjective and can vary according to individuals’ experiences and beliefs.
Misconduct that one warden or grievance coordinator would elect to
address by adverse disciplinary action may not warrant such action in the
mind of another warden or grievance coordinator.
The State’s progressive discipline system makes it particularly difficult
to predict the appropriate penalty level in isolation from any context,
especially without considering other critical factors as the department’s
process requires. The California Department of Human Resources
provides the following description of the progressive discipline process,
by which State agencies impose discipline on State employees:13

Progressive discipline is the overarching process
that starts with corrective action and includes formal
discipline. Progressive discipline requires that when you
first address an employee’s performance deficiencies,
you start with a modest correction, like verbal
counseling, or an informal email or memorandum
documenting your conversation with the employee and
the employee’s agreement to improve. If there is no
improvement, the actions you take are progressively
more formal and serious, from counseling memos to a
formal adverse action.
A formal adverse action is the final phase of progressive
discipline in which the actions taken will have a negative,
often financial, impact on the employee’s job status.

13. California Department of Human Resources, “CalHR’s Supervisors Guide to Addressing
Poor Performance,” https://www.calhr.ca.gov/Training/Pages/supervisors-guidebook.aspx
(last visited January 28, 2021).

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 27

Figure 9. The Office of the Inspector General’s Analysis of the Department’s
Existing Staff Misconduct Grievance Process During the Five-Month Period
From April 1, 2020, Through August 31, 2020

Incarcerated person submitted
grievance to the local prison’s Office of
Grievances where staff and the warden
made the following determinations:

N = 50,412

f
Step
1

Did the grievance contain allegations
that staff violated a law, regulation,
policy, or procedure?

YES
Step
2

If the allegation(s) was/were true, would
the behavior more likely than not result
in adverse disciplinary action?

YES

-

i

1

NO

Retained the grievance at the prison
and categorized the grievance as a
ROUTINE GRIEVANCE

N = 48,073 *

* We suspect that as many as
4,200 of these were potentially
mischaracterized as a routine
grievance when they should have
been characterized as a staff
misconduct grievance, as discussed
on page 62

NO

The grievance was officially
categorized as a
STAFF MISCONDUCT GRIEVANCE

N = 2,339

i
Step
3

Step
4

Did the hiring authority have a
reasonable belief that the alleged
misconduct occurred?

YES

-

i

Referred to the Office of Internal Affairs’
Central Intake Unit
for consideration of a formal investigation
or for permission to take adverse action
without an investigation

N=0

NO

Did any of the allegations indicate that
staff engaged in one of the six types
of misconduct that the department
precludes AIMS from investigating?*

YES

Retained the grievance at the prison for
a local inquiry or a supervisory review

N = 1,798 (77%)

I

Referred to the Office of Internal
Affairs’ AIMS for inquiry

NO

N = 541 (23%)

* The department precludes AIMS from investigating the following six types of misconduct:
1) unnecessary or excessive use of force that staff self-reported, but did not result in serious bodily
injury, 2) sexual misconduct or harassment by staff against an incarcerated person, 3) due process
violations during the disciplinary process, 4) disagreement with staff decisions during the disciplinary
process, 5) issuance of false rules violation reports, and 6) staff misconduct related to the reasonable
accommodation process under the Americans With Disabilities Act.
Source: The Office of the Inspector General’s analysis of the California Department of Corrections and
Rehabilitation’s staff misconduct grievance process. The data included in this flowchart are for the
five-month period ending August 31, 2020.

Office of the Inspector General, State of California

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28 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Staff members’ decisions about the appropriate level of discipline
to impose, therefore, will depend not only on the severity of the
alleged misconduct but also on the accused staff member’s history of
training, prior corrective action, and prior disciplinary action. These
critical details are not among the information provided to a grievance
coordinator or warden reviewing the grievance to determine whether the
alleged misconduct would lead to disciplinary action.
Departmental policy also dictates that the warden must consider several
aggravating and mitigating factors before determining an appropriate
penalty for any sustained allegation of misconduct. Many of these
factors cannot be known to the warden until the accused employee
is interviewed about the incident: examples of such factors include
whether the misconduct was intentional or premeditated; whether the
employee had a primary role in the misconduct or played a more minor
role; whether the employee reasonably should have understood the
consequences of the actions; and whether the employee was forthcoming
or remorseful, or accepted responsibility for the actions.
Hypothetically, an officer’s failure to wear a face covering to protect
against transmission of the novel coronavirus may be initially remedied
by informal corrective action. The first violation may result in verbal
counseling, during which the officer’s supervisor tells the officer that
he or she has violated policy and must wear a mask while at work.
The second violation may result in a written counseling memo that
includes the same instruction, but which may be placed in the officer’s
supervisory file. It may not be until the third or fourth violation that the
warden decides to impose formal adverse action, such as a formal letter
of reprimand. On the other hand, adverse action may be appropriate
after the first or second violation if the officer was particularly
lacking in remorse or expressed blatant disregard for the maskwearing requirement.
By asking prison staff to predict a penalty without having access to all
the details outlined above, the department inappropriately treats every
allegation in isolation, ignoring the alleged wrongdoer’s past actions
and discounting the possibility that aggravating factors may exist. In
reality, those specific past actions and aggravating factors might elevate
the appropriate level of discipline from one of corrective action—which
would not trigger a referral to AIMS—to adverse action that would
trigger a referral to AIMS.
The decision to route a staff misconduct grievance to either AIMS or the
Central Intake Unit also requires staff to prejudge the allegations. The
warden must determine the likelihood that the alleged misconduct has
actually occurred, but the warden must make that determination before
any evidence has been collected, using only the incarcerated person’s
grievance and the Office of Grievance staff’s summary of that grievance.
If the warden has a reasonable belief the allegation is true, the staff

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 29

misconduct grievance is supposed to be routed to the Office of Internal
Affairs’ Central Intake Unit; if not, then the grievance is supposed to be
routed to AIMS for an inquiry. In the absence of information from an
investigation, a warden could have no way of knowing whether or not an
allegation was likely to be true; thus, we would expect wardens to route
all or nearly all staff misconduct grievances to AIMS.
Yet as we noted earlier on page 15, we found no evidence that wardens
referred any of the 2,339 staff misconduct grievances during the fivemonth period of our review directly to the Central Intake Unit. We
also found that wardens referred to AIMS only 541 of the 2,339 staff
misconduct grievances (23 percent). Given the highly subjective nature of
this process, we examined the products of those referral decisions—the
disposition of staff misconduct grievances—and questioned staff who
made those types of decisions, so we could better understand how so few
allegations of staff misconduct were referred to AIMS.
We spoke with staff in the Office of Grievances at several of the prisons
to understand how they made their determinations. (Our discussion
with four wardens, regarding their understanding of the term approved,
is presented on page 50.) When we spoke to grievance coordinators, we
were surprised—and concerned—to hear some of their perspectives
regarding the new AIMS referral process. One individual expressed some
displeasure with AIMS and stated she purposefully held back some staff
misconduct grievances because she believed AIMS would just return
them without performing an inquiry, so she saw no reason to recommend
their referral. We find this philosophy troubling because it potentially
violates the regulations that govern the grievance process, highlights
the subjective nature of the referral process, and demonstrates the ease
with which AIMS can be circumvented. Office of Grievances staff may
easily choose not to identify a grievance as a staff misconduct grievance,
which in turn would bypass the wardens’ review without allowing for any
oversight. Similarly, a warden may just as easily choose not to refer a staff
misconduct grievance to AIMS, regardless of the merits of the grievance.
The highly subjective nature of the department’s definition of staff
misconduct creates a risk that any one of the reviewers at any level
may improperly filter out a grievance that would qualify for referral
to AIMS. Specifically, the subjectivity involves a risk that staff will
apply the term staff misconduct inconsistently, both within each prison
(different staff at a single prison could have different definitions) and
statewide (definitions could vary from prison to prison). The inconsistent
application of these essential standards early in the department’s
screening process is particularly concerning because the screening
process itself is not subject to any scrutiny or oversight. The grievance
coordinator and warden have complete discretion to determine whether
an allegation meets the definition of staff misconduct and to prevent a
staff misconduct grievance from being referred to AIMS.

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30 | The Department’s Staff Misconduct Inquiry Process Remains Broken

The end result of the department’s routing decisions is illustrated in
Figure 9 (page 27). Ultimately, the department’s new process frustrates
the objective of making inquiries independent of bias shown at the
prison level. By injecting subjectivity into the grievance referral process,
the department has empowered the prisons to continue using the
process we criticized in 2019 and circumvent the new independent entity
the department created to investigate misconduct grievances brought
forward by incarcerated persons.

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 31

Without Reasonable Justification, the
Allegation Inquiry Management Section
Refuses to Investigate Several Serious Types
of Staff Misconduct and Allegations That
Do Not Meet Several Poorly Conceived
Procedural Requirements
Several provisions in the new regulations governing the department’s
revised staff misconduct grievance process instruct grievance
coordinators to refer certain types of grievances to other administrative
processes at the prison. At the same time, the revised regulations
also require wardens to refer to AIMS all allegations incarcerated
persons raise in a grievance that meet the department’s definition of
staff misconduct. Once a warden determines an allegation qualifies as
staff misconduct (that it alleges a policy violation which would likely
result in adverse disciplinary action if found to be true) and refers
the allegation to AIMS, the regulation dictates that “an allegation
inquiry shall be conducted[.]”14 Nothing in the department’s new
regulations permits AIMS to refuse to perform an inquiry into an
allegation of staff misconduct once a warden has referred it to AIMS.
Nor do the new regulations expressly authorize AIMS to overrule a
warden’s determination that a grievance contains an allegation of staff
misconduct. Nevertheless, AIMS screens every complaint it receives and
rejects wardens’ requests to investigate grievances it believes should have
been handled by another process or grievances that failed to comply with
the new grievance regulations.
Specifically, the department precludes AIMS from performing inquiries
into the following six serious types of staff misconduct allegations:
•

Unnecessary or excessive use of force that was reported by staff
but did not result in serious bodily injury15

•

Sexual misconduct or sexual harassment against an incarcerated
person under the Prison Rape Elimination Act16

•

Staff involvement in due process violations during the
disciplinary process

14. CCR, Title 15, section 3484(a)(1), “Allegations of Staff Misconduct.”
15. Although the new regulations do not instruct reviewing authorities to refer to AIMS
claims involving unnecessary or excessive use of force that were reported by staff but did
not result in serious bodily injury, the regulations do not authorize AIMS to reject cases on
this basis. CCR, Title 15, section 3484(d), “Allegations of Staff Misconduct.”
16. For claims involving allegations of sexual misconduct, the new regulations require a
local prison official to “immediately commence an appropriate response as required by
all applicable laws and regulations.” CCR, Title 15, section 3483(a), “Grievance Review.”
Although the Department Operations Manual places the responsibility for conducting an
inquiry with local prison staff, we identified nothing in law or regulation that prohibits
AIMS from investigating an allegation, especially if an inquiry or investigation has not
already been performed. Department Operations Manual, Section 54040.12, “Investigation.”

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32 | The Department’s Staff Misconduct Inquiry Process Remains Broken

•

Disagreement with staff decisions during the
disciplinary process

•

Staff’s issuance of false rules violation reports

•

Staff misconduct in connection with the ADA’s reasonable
accommodation process17

Furthermore, AIMS refuses to perform an investigation for the following
procedural reasons:
•

The incarcerated person filed the grievance more than 30 days
after the alleged misconduct occurred

•

The staff at AIMS disagrees with the warden’s determination
that the allegation meets the definition of staff misconduct

•

The grievance is not specific enough to be investigated

•

The misconduct alleged in the grievance did not have a material
adverse effect on the claimant

•

The claimant is refusing to cooperate with the department’s
attempts to obtain additional information

•

The claim concerns harm to a person other than the person who
signed the grievance or appeal

•

The claim falls outside of AIMS’s jurisdiction

•

The claim duplicates another active or previously
investigated claim

Apart from the last two reasons listed above, we do not believe a
logical reason exists to exempt any of these types of claims from AIMS.
These screening criteria reduce the already low number of grievances
AIMS investigates, frustrating the intent of the amended grievance
and appeals process. Moreover, because AIMS instructs wardens
and grievance coordinators not to refer grievances it would reject for
these reasons, this screening process also reduces the number of staff
misconduct grievances wardens refer to AIMS in the first place. While
we know AIMS rejected 113 of the 541 grievances wardens referred to
it, as displayed in Figure 2 on page 15, we do not know how many staff
misconduct grievances wardens chose not to refer to AIMS because
those allegations fell into the categories of claims AIMS refuses to
review or because the wardens believed AIMS would ultimately reject the
grievances for any other reason.

17. The new regulations state that claims which make a request for a reasonable
accommodation shall be redirected to the institutional or regional ADA coordinator,
but these regulations do not exempt claims of staff misconduct related to the reasonable
accommodation process from AIMS’s purview. CCR, Title 15, section 3483(b)(2),
“Grievance Review.”

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 33

The Department Excludes Six Serious Types of Staff
Misconduct Grievances from the Allegation Inquiry Management
Section’s Jurisdiction
In accordance with training AIMS provides to prison staff related to
the grievance referral process, prison staff typically retain the following
types of allegations for handling at the prison instead of referring them
to AIMS:
•

Unnecessary or excessive use of force that was reported by staff,
but did not result in serious bodily injury

•

Sexual misconduct or sexual harassment against an incarcerated
person under the Prison Rape Elimination Act

•

Staff involvement in due process violations during the
disciplinary process

•

Disagreement with staff decisions during the
disciplinary process

•

Staff’s issuance of false rules violation reports

•

Staff misconduct in connection with the ADA’s reasonable
accommodation process

However, when wardens refer these types of allegations to AIMS, AIMS
returns the grievances to the wardens, refusing to perform an inquiry
into the allegations. Although each prison has in place a local process to
address these types of allegations, the existence of these local processes
does not justify an automatic exemption from AIMS. These six categories
of behavior are among the most serious types of staff misconduct
that could occur, including criminal acts, physical and sexual assault,
dishonesty, and various other acts having the potential to inflict serious
and irreversible harm. These instances of staff misconduct require the
independent investigations AIMS was specifically intended to provide.
Yet AIMS rejected 14 grievances wardens referred for an inquiry between
April and August 2020 because those grievances contained allegations
that fell within one of these six categories of misconduct; those grievances
comprised 12 percent of the claims AIMS rejected during that time.
Of these six serious categories of staff misconduct that the department
excludes from AIMS, the exclusion of claims in which the staff member
reported the use of force, but the force used did not cause serious bodily
injury, is of particular concern. Whenever staff use unnecessary or
excessive force, the potential for serious injury always exists. The fact
that a particular use of unnecessary or excessive force did not happen
to cause serious bodily injury does not justify the department’s decision
to treat staff’s actions any differently than it treats incidents in which
the use of unnecessary or excessive force results in serious injury.
Staff who used unnecessary or excessive force should be investigated
by an independent entity and face discipline—when appropriate—for

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34 | The Department’s Staff Misconduct Inquiry Process Remains Broken

confirmed uses of unnecessary or excessive force, regardless of the injury
inflicted. The department should not wait until serious injury occurs
before taking seriously a complaint of unnecessary or excessive force by
referring it for an independent investigation.
Similarly, staff sexual misconduct is among the most heinous actions
and abuses of power a staff member can take against an incarcerated
person. The seriousness of this matter was among the reasons that
the legislature recently passed California Senate Bill No. 1421, which
increased public access to records of incidents in which allegations
of staff sexual misconduct have been sustained against peace officers.
Although the federal Prison Rape Elimination Act and the California
Sexual Abuse in Detention Elimination Act both require prison staff to
take immediate action to protect the incarcerated victim, the department
can satisfy this obligation and simultaneously refer the allegation to
AIMS for a prompt, independent inquiry. In other words, this local
process, although necessary to carry out an important legal obligation,
could work in concert with AIMS: prison staff could ensure the safety of
the victim while AIMS performs an independent investigation into the
allegations of staff misconduct. Similarly, due process violations and false
rules violation reports can result in a denial of an incarcerated person’s
constitutionally protected rights, while misconduct occurring during
the ADA’s reasonable accommodation process can cause substantial and
prolonged harm to an incarcerated person with a disability. By exempting
these serious allegations from AIMS’s purview and electing to have these
allegations handled by local prison staff in a process the department has
acknowledged lacks independence, objectivity, and compliance with
standard investigative practices, the department intentionally subjects
these serious allegations to an investigative process which it knows to be
seriously flawed.
Moreover, staff’s decisions are not subject to any oversight, either
internally or externally, when they choose not to refer to AIMS the
allegations of staff misconduct that fall within one of these six categories.
Such staff misconduct grievances, excluded from AIMS’s purview, are
handled by local prison staff; those grievances will not be referred to the
Office of Internal Affairs unless the local inquiry causes the warden to
form a reasonable belief that staff misconduct did in fact occur.

The Allegation Inquiry Management Section Rejects Staff
Misconduct Grievances If They Are Filed More Than 30 Days After
the Misconduct Allegedly Occurred, Further Limiting the Volume
of Staff Misconduct Grievances It Handles
Although not apparent from the flowchart (Figure 8, page 24), another
factor that prevents allegations of staff misconduct from being
investigated by AIMS is the department’s imposition of a 30-day time
limit for incarcerated persons to raise allegations of staff misconduct
through the grievance process. AIMS rejected 28 grievances wardens

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 35

referred for an inquiry between April 1, 2020, and August 31, 2020,
because claimants had exceeded the arbitrary 30-day time limit. This was
the second most frequently listed justification for AIMS’s decisions to
reject staff misconduct grievances during that five-month period, making
up 25 percent of the rejections.
California law generally provides employers a full calendar year to
investigate allegations of peace officer misconduct; however, the
department has authorized AIMS to refuse wardens’ requests to
investigate incarcerated persons’ allegations of staff misconduct if
those allegations are not raised within 30 days of the date the alleged
misconduct occurred. While departmental regulations impose a general
30-day time limit during which an incarcerated person must file a
grievance, no statute or regulation limits AIMS’s ability to investigate
allegations of staff misconduct once it becomes aware of them.18 Nor
should there be such a restriction. The department has a legal obligation
to review and appropriately respond to all allegations of staff misconduct,
regardless of their source.19 When anyone other than an incarcerated
person presents a warden with allegations of staff misconduct,
department policy generally provides the warden 45 days to request that
the Office of Internal Affairs open an investigation. However, the Office
of Internal Affairs does not refuse to perform an investigation when
wardens fail to meet this deadline. By providing a 30-day deadline for
incarcerated persons to file a grievance alleging staff misconduct, and not
providing the same deadline for others, the department treats allegations
raised by incarcerated persons as less worthy of investigation. There is
no logical reason to treat incarcerated persons’ allegations any differently
than all other allegations.
Nevertheless, even though AIMS refuses to investigate allegations filed
after the 30-day deadline, AIMS recognizes that department regulations
do not forbid investigation of allegations of staff misconduct that are
not filed within the 30-day deadline. In the various letters AIMS sent
to wardens explaining its decision to reject their requests to investigate
a particular grievance, AIMS typically included one of the two
following statements:

AIMS is returning this case back to [the prison] for review
and disposition with the recommendation that the
grievance be logged into the CDCR Form 2140, Internal

18. Staff misconduct grievances are unlike typical, or routine, grievances: while both may
request some form of personal remedy, the primary purpose behind designating a grievance
as a staff misconduct grievance is to put the department on notice that a staff member
may have violated policy so the staff member can be held accountable for any alleged
wrongdoing. Therefore, while the regulations permit the department to reject a grievance
for various reasons, once the department has notice of an allegation of staff misconduct, it
is obligated to examine those allegations even if the traditional grievance process and the
associated remedies are unavailable for other reasons.
19. California Penal Code section 832.5.

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36 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Affairs Allegation Log and an inquiry conducted outside
the grievance process.
The return of this grievance does not excuse [the prison]
from logging the complaint onto the CDCR Form 2140,
Internal Affairs Allegation Log and conducting an inquiry
outside the appeals process.
By suggesting that prisons should conduct their own investigation into
the allegations, AIMS acknowledges that departmental regulations do
not preclude investigations into allegations that are more than 30 days
old. We do not know how many grievances wardens did not refer to
AIMS because they were not filed within 30 days of the alleged incident.
However, during the course of our monitoring, we reviewed several
grievances that wardens referred to AIMS, but that AIMS returned to
the wardens because they did not comply with the 30-day filing rule,
including the following:
•

An incarcerated person submitted a grievance form on
June 2, 2020, alleging that on May 3, 2020, two officers, whom
he identified by name, had a conversation in the day room that
was loud enough for everyone in the building to hear. During
this conversation, one of the officers stated that the incarcerated
person was “a piece of shit, [who] raped his wife and kids” and
specifically identified the cell number in which the incarcerated
person lived. The prison’s appeals office did not receive the
grievance until the next day, which was 31 days after the incident
allegedly occurred. Although the grievance coordinator and
the chief deputy warden determined the grievance contained
allegations that met the definition of staff misconduct, AIMS
refused to investigate the allegations because the grievance was
filed 31 days after the alleged incident occurred.

•

An incarcerated person submitted a grievance on May 29, 2020,
alleging that on March 13, 2020, two officers “beat him very
terribly,” called him a “bitch” because he urinated in his holding
cell, and did not provide him his meal. The chief deputy warden
referred the case to AIMS, recommending it perform an inquiry
into the allegations. AIMS refused to perform an inquiry and
returned the grievance to the prison because the grievance was
not filed until 77 days after the incident allegedly occurred.

•

An incarcerated person submitted an undated grievance that the
prison received on June 4, 2020, alleging that an officer grabbed
him by one of his arms, which was broken, and pulled him down
to the ground. At that point, another officer started beating the
person’s leg and knee with his baton. Although the person did
not state the date on which the event allegedly occurred, prison
staff, after performing some research, identified April 29, 2020,

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 37

as the likely date of the incident and referred the grievance to
AIMS, requesting it perform an inquiry into the allegations.
AIMS refused to perform an inquiry and returned the grievance
to the prison because the grievance was not received until
36 days after the incident allegedly occurred.
•

An incarcerated person submitted a grievance on June 6, 2020,
alleging an officer filed a false rules violation report against him;
harassed and bullied him; placed falsified information in his
central file; and threatened to plant a weapon on him, instruct
other officers to file false rules violation reports against him,
take away his assigned job, throw his grievances in the trash,
and falsely convict him of a serious rules violation. Although
the person did not identify the dates of these incidents in
his grievance, AIMS staff reviewed the person’s records and
identified a recent rules violation report that appeared to be
related to the incident described in the grievance. AIMS used
the information in that rules violation report to conclude the
incidents occurred between May 10, 2020, and May 18, 2020,
meaning the incarcerated person filed the grievance within
19 to 27 days of the incidents. This information suggests that
the grievance was filed within the required time frame. AIMS,
however, rejected the grievance for several reasons, including
that the grievance did not contain the date of the alleged
incident, which, according to AIMS, meant that staff at the unit
could not conclusively determine that the grievance complied
with the requirement it be filed within 30 days of the incident.
In his grievance, the person explained he did not attach the
rules violation report that would have provided the incident
dates because he was afraid it would be destroyed; he promised
to bring a copy of the document with him when the department
interviewed him about his grievance.

The juxtaposition of these last two staff misconduct grievances is
particularly revealing. In both cases, because the grievances omitted the
dates of the alleged incidents, departmental staff performed independent
research to determine whether any departmental records might help
them determine the dates on which the alleged incidents occurred. In
one case, this additional research provided sufficient information to
lead prison staff to believe that the incident occurred more than 30 days
before the grievance was filed. AIMS staff used this information to
conclude that the grievance was untimely and rejected the grievance
accordingly. However, in the second case, AIMS staff’s independent
research demonstrated that the grievance was filed within 30 days of
the incident. In this instance, AIMS staff did not use the information to
judge whether the grievance was filed within the required time frame.
Instead, they turned to the grievance’s undated description of alleged
staff misconduct to dismiss the grievance on the grounds that AIMS staff
could not conclusively determine that it met the 30-day requirement.
AIMS rejected both cases as untimely, leading us to believe that AIMS is

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38 | The Department’s Staff Misconduct Inquiry Process Remains Broken

willing to rely on information that enables it to reject a staff misconduct
grievance, but it is not willing to rely on similar information that would
allow it to investigate a staff misconduct grievance.
While the department should certainly encourage incarcerated persons
to raise allegations of staff misconduct as soon as possible so that the
department can preserve evidence and gather witness accounts while
they are still fresh, the department should not automatically reject
allegations of staff misconduct because they were not filed within
30 days. When incarcerated persons choose to formally accuse staff
of misconduct, they place themselves at risk of retaliation. This is not
an easy decision for anyone to make; it may take some time before an
incarcerated person feels comfortable or decides that the benefit of filing
the complaint will outweigh the risk of retaliation. Changes to staff
assignments that occur weeks or months after the incident, such as an
officer’s transfer to another prison or to another housing unit within the
same prison, may also make a person more willing to file a complaint. As
one incarcerated person explained in a grievance AIMS rejected because
it was not filed within 30 days of the incident, it can be traumatic to file
a staff misconduct grievance against an officer, especially against an

Excerpt From an Incarcerated Person’s Staff Misconduct Grievance Form, June 6, 2020.
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Source: The California Department of Corrections and Rehabilitation.

Office of the Inspector General, State of California

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 39

officer who has already subjected the incarcerated person to threats and
retaliation before he filed the grievance:
Although the passage of time may increase the difficulty of investigating
and substantiating allegations, the department should treat incarcerated
persons’ allegations the same way it treats those presented by any other
person. AIMS should not refuse to examine an allegation simply because
more than 30 days have elapsed since the incident occurred.

The Allegation Inquiry Management Section Rejected Grievances
by Overruling Wardens’ Determinations That Allegations of Staff
Misconduct Would Result in Adverse Disciplinary Action If Found
to Be True
AIMS rejected 30 grievances wardens referred for an inquiry between
April 1, 2020, and August 31, 2020, because AIMS believed the
allegations would not likely have resulted in adverse disciplinary action
even if an inquiry or investigation determined the allegations were true.
This was the most frequently cited justification for AIMS’s decisions
to reject staff misconduct grievances during that five-month period,
making up 27 percent of its rejections. We find this practice, whereby
AIMS second-guesses and overrules wardens’ disciplinary decisions,
particularly puzzling.
The department’s regulations authorize only wardens to determine
whether an allegation of staff misconduct, if found true, would more likely
than not result in adverse disciplinary action.20 Once a warden reviews
the allegation and determines it warrants a referral to AIMS because it
meets the definition of staff misconduct but the warden does not have
a reasonable belief that the misconduct occurred, the regulations state
that “an allegation inquiry shall be conducted.”21 This responsibility
properly resides with wardens, because as hiring authorities, they are
the departmental officials authorized to make disciplinary decisions
regarding the majority of the staff working at their prisons.22 Since the
official in charge of making disciplinary decisions has already decided
that he or she would more likely than not institute adverse action if the
allegations were true, AIMS staff have no need to consider whether the
grievance meets this requirement. AIMS’s investigative personnel, who
occupy a rank well below that of warden, are not reviewing authorities
and have no experience making such difficult, complex disciplinary
decisions. As AIMS is not authorized to overrule the disciplinary
determinations a warden makes after an investigation has been performed,
it makes no sense that AIMS would assume the authority to overrule a
warden’s disciplinary determinations before an inquiry is conducted.

20. CCR, Title 15, section 3484(a), “Allegations of Staff Misconduct.”
21. CCR, Title 15, section 3484(a)(1), “Allegations of Staff Misconduct.”
22. The prison’s chief executive officer is the hiring (or reviewing) authority for health care
staff working at the prison.

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40 | The Department’s Staff Misconduct Inquiry Process Remains Broken

The Allegation Inquiry Management Section Rejects Staff
Misconduct Grievances It Determines Do Not Comply with Various
Procedural Claim-Filing Requirements
The department’s revised grievance and appeal regulations contain
various procedural filing requirements. Some of these requirements are
reasonable, such as the requirement that an incarcerated person may
not file a claim regarding the behavior of employees who work outside
the department, such as county jail staff or outside hospital employees.
Similarly, it is reasonable to disallow duplicate claims. If the department
is already performing an inquiry into the allegation, an additional claim
serves no purpose. However, the department maintains several other
claim-filing requirements that are less sound, causing AIMS to refuse
wardens’ requests to investigate allegations of staff misconduct. AIMS
refuses to open the following claims that violate the department’s
procedural claim-filing requirements:
•

Staff misconduct that did not have a material adverse effect on
the claimant

•

Claims in which the claimant is refusing to cooperate with the
department’s attempts to obtain additional information

•

Claims concerning harm to a person other than the person who
signed the grievance or appeal

•

Claims that are not specific enough to be investigated

AIMS refused to investigate nine grievances wardens referred for an
inquiry between April and August 2020 because those grievances failed
to comply with one of these claim-filing requirements; those grievances
comprised 8 percent of the claims AIMS refused to accept for inquiry
during that period.
Although a claimant’s refusal to cooperate with an investigation will
increase the difficulty of investigating a claim, as the claimant is
typically the most important witness, the department should not refuse
to investigate an allegation of staff misconduct on this basis without
first taking other investigative steps to determine whether any other
information exists to corroborate the claim, such as a video recording or
an incident report. As discussed on page 38, it takes considerable courage
for an incarcerated person to file a claim against a staff member. It takes
even more courage to proceed with the investigative process. When
people are incarcerated, they face potential consequences if they choose
to speak with law enforcement, such as retaliation by staff and ostracism
by other incarcerated persons. One should not interpret a claimant’s
decision not to cooperate with an investigation as meaning the allegation
is untrue or cannot be substantiated, nor should the claimant’s lack of
cooperation prevent an investigation into the allegation.

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 41

We find equally unjustified the department’s refusal to investigate an
allegation of staff misconduct because it was filed by a witness to the
alleged misconduct instead of by the person harmed by the misconduct.
The department is obligated to investigate all allegations of staff
misconduct, even if the person harmed by the misconduct is unwilling
to report the misconduct. The person who filed the claim should be
interviewed to determine whether he or she is a percipient witness or if
he or she filed the claim based on rumors or other indirect information.

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42 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Rather Than Perform a Complete Inquiry Into a
Staff Misconduct Grievance, Allegation Inquiry
Management Section Investigators Abruptly Stop
Their Work as Soon as They Form a Reasonable
Belief That Staff Misconduct Occurred
Wardens refer staff misconduct grievances to AIMS because they
do not yet have a reasonable belief that the alleged staff misconduct
occurred. When assigned to investigate a grievance, AIMS investigators
interview witnesses and subjects as well as gather evidence to help
wardens determine whether such reasonable belief exists. However, the
department has illogically decided that once AIMS’s staff have gathered
enough evidence to form a reasonable belief that any misconduct has
occurred, AIMS’s staff must not investigate any further. At this point, the
investigator ceases all investigative activity, summarizes the information
gathered so far into a report, and provides the report concerning the
unfinished investigation to the warden. The warden then reviews the
report of the evidence gathered before the investigation was stopped and
independently determines whether the investigator’s report provides
sufficient information to establish a reasonable belief that misconduct
occurred. If the report meets this standard, the warden is supposed to refer
the matter to the Office of Internal Affairs’ Central Intake Unit, requesting
either a formal investigation or permission to take adverse action without
additional investigation. The Office of Internal Affairs’ Central Intake
Unit then independently reviews the report and either authorizes the
warden to take adverse action against the subject employee, approves its
own formal investigation into the allegation, or rejects the request to open
an investigation and returns the report to the warden.
This practice of stopping an investigation before completion is
problematic because it is unclear whether a warden would request that
AIMS reopen an inquiry that has been prematurely closed if the warden
disagrees with the AIMS investigator and believes the inquiry did not
uncover sufficient information to warrant a referral to the Office of
Internal Affairs’ Central Intake Unit. By terminating the inquiry before
gathering all evidence and interviewing all witnesses and subjects, the
department risks leaving undiscovered, potentially relevant evidence that
could be factored into the decisions wardens and the Office of Internal
Affairs’ Central Intake Unit staff make after reviewing the inquiry report.
If the warden disagrees with the AIMS investigator’s determination that
a reasonable belief of misconduct exists, the warden would not send the
inquiry report to the Office of Internal Affairs’ Central Intake Unit for
further action. In our observations, wardens do not refer inquiry reports
back to AIMS to reopen the inquiry and collect the remaining evidence.
The inquiry is over despite its being incomplete.
One inquiry we observed demonstrates how AIMS’s practice of
terminating inquiries prematurely causes allegations to fall out of

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 43

the investigative process. In this case, AIMS opened an inquiry into
allegations that an officer used excessive force when he struck a
disabled incarcerated person in the chest and shoved him into a counter,
causing him to fall to the floor and aggravate his preexisting back
injury. The AIMS investigator interviewed the claimant, the accused
officer’s partner, and an incarcerated person who allegedly witnessed
the incident. The accused officer’s partner stated that she was in the
restroom when the incident occurred and did not see anything, but she
had heard some yelling while in the restroom. She stated that after she
left the restroom, another staff member told her that an incarcerated
person had fallen. She also stated that she spoke with her partner, who
explained that the incarcerated person had fallen on his own after
leaning against a table or cabinet that was mounted on wheels, which had
slipped out from behind him. When probed about the identities of the
people she spoke with about the incident, she provided the investigator
with somewhat evasive and conflicting answers: she could not recall
with whom she spoke, whether that person was her partner or a nurse, or
whether she spoke with a man or a woman. Given this information, the
AIMS investigator felt that the partner’s behavior during the interview
established a reasonable belief that misconduct had occurred. The AIMS
investigator decided to conclude the inquiry at that moment. He finalized
his report and returned it to the warden. After reviewing the inquiry
report, the warden sent the claimant a response stating the following:

[Incarcerated person’s name]’s appeal is granted in part
that this matter was thoroughly investigated. In regards
to the Allegation of Unnecessary or Excessive Force:
Staff did not violate CDCR policy with respect to the
issues raised.
The warden’s assertion that an investigation had been performed into
the allegation of unnecessary or excessive force was inaccurate. The
investigation into this allegation had never been completed. AIMS
terminated the inquiry into the allegation after its staff had formed the
belief that a different staff member engaged in an unrelated form of
misconduct: dishonesty during an administrative investigation. AIMS
had been planning to interview the officer who allegedly pushed the
incarcerated person, but because the AIMS investigator concluded the
inquiry after interviewing the accused officer’s partner, this critical
interview never occurred.
In addition, the investigation was not thorough. The department’s
investigation into the actual allegation presented—the use of
unnecessary force—consisted of an interview of the claimant, an
interview with one other incarcerated person who was in the area of the
incident, and an interview with one staff member who did not actually
witness the incident. During his interview, the claimant reiterated his
allegations and insisted the officer hit and pushed him. The incarcerated

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44 | The Department’s Staff Misconduct Inquiry Process Remains Broken

witness confirmed seeing the claimant fall down but did not have a
clear view of the incident and did not see what caused the claimant to
fall. The only staff member interviewed—the officer’s partner—stated
she had not witnessed the incident but was told that the incarcerated
person fell down on his own. Although the investigation uncovered
sufficient information to substantiate that the incarcerated person fell
down, the investigation included no information from which anyone
could determine whether the officer pushed the person or whether the
person fell accidentally. A thorough investigation would have included
interviews of the subject and other witnesses who were in the same area
on the date the incident occurred to determine whether anyone could
shed light on this critical detail.
When the AIMS investigator terminated the inquiry, he risked the
possibility that the warden would disagree with his assessment that a
reasonable belief of misconduct existed. In this case, that risk became
reality: the warden decided the inquiry did not sufficiently establish that
the officer was dishonest in her interview and, therefore, did not refer the
AIMS inquiry report to the Office of Internal Affairs’ Central Intake Unit
for further action. Significantly, the inquiry report included no indication
the inquiry had been cut short; such an indication might have caused the
warden to request further investigation into the use-of-force allegation.
As a direct result of AIMS’s practice of terminating an inquiry once an
investigator has formed a reasonable belief that any form of misconduct
occurred, even if that misconduct was not what was alleged in the staff
misconduct grievance, the incarcerated person’s specific allegation of
staff misconduct was not fully investigated.
Similarly, if a grievance contains multiple allegations of staff misconduct
and the AIMS investigator determines that one of the allegations meets
the standard of reasonable belief, the entire inquiry is stopped, and the
incomplete report is sent to the warden. If the warden agrees with the
AIMS investigator’s determination that the evidence gathered provides
a reasonable belief of misconduct regarding this one allegation, the
warden will send the entire inquiry report to the Office of Internal
Affairs’ Central Intake Unit for further action. However, because the
AIMS investigator did not complete the investigation into all the
claimant’s allegations, the Office of Internal Affairs’ Central Intake
Unit may not have enough information to assess the allegations that
were not fully investigated. Without sufficient information to establish
a reasonable belief that any alleged misconduct occurred, the Office of
Internal Affairs’ Central Intake Unit will not open an investigation into
the allegation. Once the Office of Internal Affairs’ Central Intake Unit
opens an investigation into the allegation for which a reasonable belief
exists, the assigned Office of Internal Affairs’ agent may add the related
allegation on his or her own, but the Office of Internal Affairs’ agent is
not required to do so. Therefore, when AIMS stops its investigative work
into a staff misconduct grievance before completing its inquiry into all of

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 45

a claimant’s allegations, it creates a risk that any remaining allegations
raised in the grievance will go uninvestigated.
Another AIMS inquiry we monitored most unfortunately demonstrates
this effect. In this instance, an incarcerated person filed a grievance
alleging he told a nurse during pill call that he was feeling suicidal and
that he later started a fire in his cell and began cutting himself to get
staff’s attention. He also alleged that he placed a sign in his cell window
stating that he was suicidal, and that even though several custody and
medical staff saw the sign, they refused to provide him medical treatment
or alert mental health staff. AIMS opened an inquiry into the allegations,
interviewed the claimant, reviewed video footage of the incident, and
gathered various records. The video footage corroborated some of the
claimant’s allegations, specifically that he had started a fire in his cell
for a brief period of time and that several staff saw signs he had placed
in the windows of his cell. The footage also provided sufficient evidence
for AIMS’s investigators to determine there was a reasonable belief that
several staff members shown on the video recording failed to correctly
perform their mandated 30-minute welfare checks on the incarcerated
person and that other staff shown on the video failed to maintain
constant observation of him after learning he was feeling suicidal.
However, AIMS had not yet completed the inquiry into the other
allegations the incarcerated person raised in his grievance, specifically
that he informed the pill call nurse he was feeling suicidal, but she had
not provided him with assistance; that he had cut himself; or that the
staff who came to his cell failed to summon the appropriate medical
and mental health personnel. At this point, the AIMS investigator’s
supervisor, a captain, after consulting with the warden, determined
the video footage provided a reasonable belief that some misconduct
occurred, and AIMS closed the inquiry.
The AIMS investigator then drafted an inquiry report summarizing
the incomplete inquiry’s results and sent it to the warden, along with
the evidence gathered during the partial investigation. Ultimately, the
warden sent the report to the Office of Internal Affairs’ Central Intake
Unit, requesting permission to take disciplinary action against the
involved staff. The Office of Internal Affairs’ Central Intake Unit opened
an investigation to obtain further information to determine whether the
incarcerated person ever told anyone he was suicidal, since the video
did not provide an audio recording of the incident. However, the other
allegations the incarcerated person included in the grievance were not
included within the initial scope of the internal affairs’ investigation
because the report of the interrupted inquiry did not provide the Office
of Internal Affairs’ Central Intake Unit with sufficient evidence to
suggest a reasonable belief that these alleged acts had occurred. The
assigned Office of Internal Affairs’ agent could add these allegations to
the scope of the investigation at a later date, but as of the date of this
publication, that agent had not done so.

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46 | The Department’s Staff Misconduct Inquiry Process Remains Broken

AIMS’s practice of stopping an inquiry as soon as the investigator
discovers evidence that may establish a reasonable belief that staff
misconduct had occurred undermines the unit’s purpose, which is to
provide investigations into incarcerated persons’ allegations of staff
misconduct. By not completing their inquiries, AIMS investigators leave
staff misconduct grievances uninvestigated, truncate the unit’s work, and
diminish AIMS’s usefulness to the department.

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 47

The Low Rate at Which Wardens Determined
Their Staff Violated Policy Raises Serious
Concerns Regarding the Fairness of the Process
Our analysis of the department’s documentation concerning the
outcomes of inquiries into staff misconduct grievances revealed a
troubling reality: very few allegations (or claims) of staff misconduct—
fewer than 2 percent—were found to be true or resulted in findings
of policy violations against staff. For instance, according to the
department’s offender grievance tracking system, during the threemonth period ending August 31, 2020, the department completed an
investigation or some type of review into 1,293 allegations, or claims,23
of staff misconduct serious enough to lead to adverse action if true, yet
wardens found policy violations in only 22 (or 1.7 percent). In essence,
the department fully cleared staff in 98.3 percent of incarcerated
persons’ allegations it investigated or otherwise resolved. We found
very little difference in results between the inquiries performed by
AIMS and those performed by local prison staff; both generally resulted
in the exoneration of staff. Surprisingly, this rate of exoneration was
even higher than our prior findings at Salinas Valley State Prison,
where we concluded, in part, that the prison fully cleared staff in
183 of the 188 inquiries we reviewed, an exoneration rate of 97 percent.
Consequently, given the very low rate of policy violations resulting from
its inquiry efforts, the department has not increased our confidence in
the fairness of its process.
Because the department could not provide us with a report showing how
many inquiries resulted in policy violations directly, we considered an
alternative departmental report that showed the number of allegations
of staff misconduct that wardens had approved (the category that
presumably contained policy violations). According to this report, the
rate of policy violations at first appeared to be 5.4 percent (70 out of 1,293)
when we considered the number of approved claims, but a closer analysis
revealed that the actual number of policy violations was only 1.7 percent
(22 out of 1,293). We are concerned about the low rate of findings of
policy violations and the department’s use of the term approved, which
obscured accurate reporting. The department’s use of ambiguous
language in reporting its responses to staff misconduct grievances makes
its reporting less transparent; in the next section, beginning on page 53,
we address how the department’s insufficient information management
systems continue to diminish the transparency of its reporting as well
as inhibit the department’s ability to analyze, manage, and improve its
staff misconduct grievance monitoring process. Moreover, the lack of
transparency in the department’s information systems and practices also
causes us to question the overall fairness of the department’s process.

23. A single staff misconduct grievance may contain several allegations, or claims,
of misconduct.

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48 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Fewer Than 2 Percent of Staff Misconduct Grievance Allegations
Were Found to Have Merit, Resulting in a Policy Violation
We also question the fairness of a process for handling incarcerated
persons’ allegations of staff misconduct that finds almost no policy
violations against staff. In the three months ending August 31, 2020,
the department processed 1,293 allegations of staff misconduct serious
enough to lead to adverse action if they were found to be true. Wardens
found policy violations stemming from just 22 allegations (or 1.7 percent).
This information was not readily available from the department; in fact,
the department’s documentation of staff misconduct grievance outcomes
obscures this information. To retrieve these data from the department,
we asked the department for a report that showed us the number of staff
misconduct grievances in which accused staff had violated policy.

Figure 10. Very Few of the Department’s Resolved Claims of Staff
Misconduct Resulted in Policy Violations During the Three-Month Period
From June 1, 2020, Through August 31, 2020
All Resolved Claims
of Staff Misconduct
Determined as Approved

All Resolved Claims of Staff Misconduct

22
Policy
Violations
4 Pending
1,070

Disapproved
No
Policy
Violations
(83%)

N = 1,293

Total Resolved
Claims of Staff
Misconduct

70

Approved
(5%)

153

Other
Resolved
Claims
(12%)

Total Approved
Staff Complaint
Claims

10 Unknown

34
No
Policy
Violations

█ Disapproved The reviewing authority found by a preponderance of the evidence available
that all applicable policies were followed and that all relevant decisions, actions, conditions,
or omissions by the department or departmental staff were proper.
█ Approved The reviewing authority did not find by a preponderance of the evidence
available that all applicable policies were followed or that all relevant decisions, actions,
conditions, or omissions by the department or departmental staff were proper.
█ Other Resolved Claims We are using the term resolved to include grievance decisions
of approved, disapproved, rejected, and time expired. We exclude unresolved claims
categorized as no jurisdiction, reassigned, redirected, and under investigation.
CCR, Title 15, Section 3483(i), “Grievance Review.”
Source: The Office of the Inspector General’s analysis of the California Department of
Corrections and Rehabilitation’s grievance data associated with its 35 prisons.

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The department, however, could not provide us with that information
because the department does not track it. Rather than record whether
an incarcerated person’s staff misconduct grievance resulted in a finding
that staff did or did not violate policy, the department recorded whether
or not the warden approved or disapproved an incarcerated person’s
allegation of staff misconduct.24
In its regulations, the department defines approved claims as those
that “the reviewing authority did not find by a preponderance of the
evidence available that all applicable policies were followed or that all
relevant decisions, actions, conditions, or omissions by the department
or departmental staff were proper” (emphasis added).25 In plain language,
this definition means that when a warden approves a claim, the warden
has determined that staff may have violated some type of policy. In
contrast, the department defines disapproved claims as those in which
“the reviewing authority found by a preponderance of the evidence
available that all applicable policies were followed and that all relevant
decisions, actions, conditions, or omissions by the department or
departmental staff were proper” (emphasis added).26 In plain language,
again, this definition means that when a warden disapproves a claim, the
warden has found that staff did not violate policy in connection with the
allegation of staff misconduct or with any other surrounding matter.
As shown in Figure 10 on the previous page, during the three-month
period ending with August 2020, the department’s offender grievance
tracking system indicated that wardens approved only 70 of the
1,293 allegations of staff misconduct that wardens resolved during this
time frame (5.4 percent).27 According to the department’s definitions,
only those staff misconduct grievance claims in which wardens found
staff to have violated policy or possibly violated policy could be categorized
as approved. Therefore, to better understand which allegations wardens
approved among these claims, we reviewed documentation for all 70 claims.
To our surprise, and as we show in Figure 10, we discovered that wardens
found staff had violated policy in only 22 of the 70 approved claims and
had not violated policy in 34 of the 70 approved claims. Of the remaining
14 approved claims, we determined that 10 did not specifically identify
whether staff had likely violated policy or not and that the final results
for the remaining four were still pending. This means that the overall
rate at which staff were found to have violated policy was only 1.7 percent
(22 of 1,293). Stated another way, the department concluded that more
than 98 out of every 100 claims were unsubstantiated, or lacked merit.
24. The warden could also choose to enter a final determination of a claim of no
jurisdiction, redirected, reassigned, under inquiry or investigation, pending legal matter,
rejected, time expired, and disallowed. CCR, Title 15, Section 3483(i), “Grievance Review.”
25. CCR, Title 15, Section 3483(i)(2), “Grievance Review.”
26. CCR, Title 15, Section 3483(i)(1), “Grievance Review.”
27. We are using the term resolved to include grievance decisions of approved,
disapproved, rejected, and time expired. We exclude unresolved claims categorized as no
jurisdiction, reassigned, redirected, and under investigation. CCR, Title 15, Section 3483(i),
“Grievance Review.”

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In our opinion, among other factors contributing to wardens’ low rate of
finding policy violations against their staff is the requirement that wardens
predetermine the outcome of the inquiry before it has even begun. By
design, for a staff misconduct grievance to result in a referral to AIMS in
the first place, the warden must have already made two determinations:
1) that the alleged acts met the definition of staff misconduct and 2) that
the alleged acts were not reasonably believed to have occurred. However,
without having investigated the claims, how can a warden know in
advance the likelihood of whether the alleged acts occurred? To refer the
staff misconduct grievance to AIMS, the warden must decide, without any
evidence outside of the original complaint, that the staff member had not
likely committed the misconduct. Given this decision-making calculus at
the start, the wardens’ final determinations give the impression that the
end result was simply a self-fulfilling prediction.

We Found Inconsistencies in Staff’s Application of the Term
Approved, and We Question Its Usefulness for Analyzing Data
The exact rate at which the department found policy violations was
obscured by the department’s ambiguous use of the term approved. Since
the term was applied to claims that wardens determined to be in policy,
out of policy, or still pending, the inconsistent usage of the word made
it difficult to understand which meaning staff meant to convey; the
department’s collection of such disparate outcomes under the umbrella
of one term makes it difficult to discover how many claims of staff
misconduct led to a finding that staff committed misconduct.
Given the range of meanings attributed to claims marked as approved,
we spoke with four wardens along with their key staff, to obtain their
working perspective of the term approved as applied to staff misconduct
claims. All the wardens stated that, generally, an approved claim is one
in which they had identified a policy violation. One warden even read
back to us the definition from the regulation verbatim; however, when we
presented him with an example of a claim he had approved, his answer
became less clear. In this instance of a claim the warden approved, in
which the incarcerated person alleged that he told staff that canteen
workers were extorting him, but staff did nothing (and told him they did
not care), the prison staff’s written response to the incarcerated person
was the following:

Inmate canteen workers are not allowed to select or
decide which inmates shop for canteen items. After
further inquiry, it was discovered the inmate IDs are
collected by Facility A Yard Officers and/or by the
canteen staff. Therefore, not making it possible for
inmates to dictate or give priority to inmates paying
for expedited service. The Warehouse manager was
informed of your allegation. [Staff Name] stated the
inmate ID’s are collected by Facility A Yard Officers

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and/or by the canteen staff; therefore, not making it
possible for inmates to dictate or give priority to inmates
paying for expedited service.
Prison staff who responded to the incarcerated person identified no
policy violation; instead, they essentially cleared staff of wrongdoing, yet
did so without stating so directly. After we presented this information
to the warden, his response was “I see what you are saying.” The warden
then stated that the process is still new, and his staff are unsure of how
the term approved should be defined and applied.
We brought another example to a different warden (and his staff)
regarding an incarcerated person’s claim of having been sexually
harassed and propositioned by a staff member. Although the warden
had approved this grievance, the response to the claimant indicated
that the matter was still being reviewed. During our discussion with
the warden and the grievance coordinator, the coordinator said that,
in the beginning, the prison was trying to respond to the claimant
right away and that, since the prison was conducting a review of the
claim, they decided to approve it. The coordinator said that they have
since received additional instruction from the department’s Office of
Appeals indicating that they should wait, up to the time afforded by the
regulatory process, to respond to the claimant.
In another example at a different prison, an incarcerated person
alleged staff used unreasonable force when a staff member grabbed the
incarcerated person’s arm. The warden approved the claim, but the prison
staff’s written response to the incarcerated person stated the following:

[Incarcerated Person’s name] appeal is Approved in
that the matter was thoroughly investigated. In regards
to the Allegation of Unnecessary or Excessive Force:
Staff DID NOT violate CDCR policy with respect to the
issues raised.
In this example, the prison staff’s response is emphatic, even using
all capital letters to state that staff did not violate policy. Notably, this
response posits another possible interpretation: that the term approved
means to investigate. We found other approved claims that used a similar
justification in concluding there were no policy violations. We also found
examples of claims in which the outcome was not specifically identified.
In one such approved claim, an incarcerated person alleged staff were not
following face-covering guidelines. In the prison staff’s response to the
incarcerated person, staff wrote:

It is the personal responsibility of each staff member
and inmate to ensure compliance with face covering

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mandates. It is the expectation set forth by the California
Department of Corrections and Rehabilitation to hinder
the spread of COVID-19.
Prison staff further informed the incarcerated person that staff would
be reminded to ensure they wear masks; however, the written response
to the incarcerated person gave no indication whether staff had violated
policy. When we followed up with the warden of the prison, he responded
by saying:

I can not [sic] confirm whether policy was violated or not
as the inmate alleged. There was no submission of a 989
and no OIA investigation. But the appeal was approved
and supervisory personnel were tasked to ensure
future compliance.
The warden’s apathetic response was surprising—and concerning—
because the warden, who directs the custody and administrative
operations of the prison, could not find out what happened, and because
he presented the matter as if it were out of his hands as there had been no
investigation. Ironically, it is the warden who dictates which claims are
referred to the Office of Internal Affairs for an investigation; therefore, it
was his decision not to refer the matter. Nevertheless, because he did not
know whether or not there had been a policy violation concerning a staff
misconduct grievance he approved, the warden left himself, his prison
staff, and the department exposed to criticism for—at minimum—not
thoroughly documenting staff’s efforts to address the allegation.
These examples, along with the 32 others that resulted in no policy
violations, illustrate the inconsistency in staff’s application of the term
approved. Wardens and departmental staff use the term (which is defined
in regulation to indicate that misconduct may have occurred) even
when the warden has not found a policy violation. Thus, the term itself
obscures the fact that the department’s rate of finding policy violations is
even lower than its data suggest.

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Weaknesses in the Department’s Data
Collection and Tracking Process Limit the
Department’s Ability to Effectively Analyze
Trends and Assess Its Process for Handling Staff
Misconduct Grievances
The department maintains numerous information systems that capture
data regarding the staff misconduct grievance process, but none of
these systems is capable of generating some basic management reports
that would allow managers to perform meaningful trend analyses or
assessments of the process statewide. For example, the department
cannot produce a report identifying the number or names of staff who
have been accused of misconduct by incarcerated persons. Likewise,
the department cannot produce a report identifying the names of staff
found to have violated a policy in connection with an allegation of
staff misconduct. Further, the department cannot produce a report
identifying the actions it took, if any, against staff to rectify any related
policy violations. Without these basic and essential types of management
reports, the department limits its ability to properly manage—and
assess—the staff misconduct grievance process and even prison
operations in general.
Moreover, we are concerned that due to the department’s subjective
internal grievance review process, it may be significantly underreporting,
by thousands, the number of staff misconduct grievances incarcerated
persons have filed. In the three-month period for which data were
available, we found that wardens disagreed more than two-thirds of the
time with their staffs’ recommendations to treat allegations as claims
of staff misconduct. Wardens reclassified nearly 2,600 possible staff
misconduct grievance allegations as merely routine. Without accurately
counting all the claims of staff misconduct, the department limits its
ability to conduct effective analyses concerning the staff misconduct
grievance process; and without accurately tracking all claims of staff
misconduct, the department cannot be certain that it handled them
all properly.

The Department Has Created Numerous Information Systems,
But None of Them—Individually or Collectively—Contain
Reliable Data Concerning Certain Types of Outcomes of Staff
Misconduct Grievances
None of the information systems that the department uses to track
incarcerated persons’ staff misconduct contain the outcomes of
investigations or the names of the staff involved, among other crucial
data points necessary to effectively manage the process. The department
uses several information systems in connection with its process for
handling incarcerated persons’ allegations of staff misconduct; however,
various entities within the department have created separate and

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54 | The Department’s Staff Misconduct Inquiry Process Remains Broken

incomplete methods of tracking various components of the process.
For example, the Office of Internal Affairs uses the allegation inquiry
management system for allegations referred to it for inquiry. It uses a
separate system, called the case management system, for allegations
referred to the Office of Internal Affairs’ Central Intake Unit for formal
investigation. Beginning June 1, 2020, the department also implemented
a new module for its strategic offender management system, called the
offender grievance tracking system, to track statewide grievance-related
data. Finally, each prison also independently uses a spreadsheet, called
an Internal Affairs’ allegation log (CDCR Form 2140), to track—among
other things—incarcerated persons’ allegations of staff misconduct.
We found, however, that none of these systems can be used to examine
key elements of the grievance process, such as the names of staff
accused of misconduct and the final outcome (or disposition) of a staff
misconduct grievance, identifying whether or not the claim was found to
be true. Instead, each system tracks information within narrowly defined
parameters for specific purposes. For example, the Office of Internal
Affairs’ allegation inquiry management system tracks data points
related to the progress of an inquiry only while the inquiry remains
within AIMS’s jurisdiction; this information system focuses mainly
on workloads and timeliness. Although this system tracks some useful
information, it cannot be used as an overall management tool because
it is limited to only those claims referred to AIMS; even more strictly,
it does not include any information before or after the involvement of
AIMS, including the end result or the inquiry outcome. In other words,
AIMS does not track what happens after it returns a completed or
rejected inquiry to prisons, including whether any of the claims resulted
in a policy violation or disciplinary action.
Similarly, each prison tracks staff misconduct grievances they receive
on a spreadsheet (again, called the Internal Affairs allegation log, or
CDCR Form 2140), but they do so independently of one another, and
inconsistently, with each prison tracking its own data points. One
major shortcoming we observed concerning these types of spreadsheets
was that prisons included little to no information regarding the final
outcomes of the claims or the grievances, such as whether or not the
warden found policy violations in connection with the allegations in
the staff misconduct grievance or whether the allegations resulted
in any disciplinary action against staff. For example, although the
department’s Internal Affairs allegation log has a field for recording
resulting data and action, we found that staff at California State Prison,
Corcoran, only recorded the dates on the log, not the actions. None of
the log’s entries in that field included whether or not the allegation was
substantiated. Although the log at California State Prison, Corcoran,
included additional fields not available in the department’s official log,
entries in those fields still did not consistently document outcomes
for staff misconduct grievances listed on the log. Because the prison
did not track outcomes, it cannot sort the spreadsheet data to identify

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trends or determine whether staff members have had multiple sustained
allegations, which is information key to determining the appropriate
level of progressive discipline.
The log for Richard J. Donovan State Prison was also missing pertinent
information for most of its entries. Although staff at that prison did
document resulting actions and dates for most of the log’s entries, staff
frequently omitted information necessary to identify the subjects of the
allegations. Specifically, staff frequently left blank or incomplete two of
the log’s fields: subject first name and subject badge number. There were
no entries at all in the badge number field of the log. And although many
of the log’s entries did include the subjects’ first initials, few entries
included the subjects’ full first names. Because the prison employs
hundreds of employees, it is likely that some of them may share the
same last names, even among employees in the same job classifications.
Because staff so frequently omitted important identifying information,
it would be difficult—if not impossible—for Richard J. Donovan State
Prison management to use the data to conduct important analysis,
including determining whether particular staff members had multiple
sustained allegations.
Although the spreadsheet used at California State Prison, Sacramento,
did document outcomes, the spreadsheet was separated into multiple
worksheets, which made it difficult for prison management to identify
trends or easily determine whether staff members had multiple sustained
allegations. This prison’s spreadsheet contained six different worksheets,
one each for different categories of allegations, such as concerns with
equal employment opportunity or staff misconduct grievances. Each
of the worksheets included the required fields, and staff at the prison
consistently provided information in those fields. However, because
Microsoft Excel only lets users search and analyze data on one worksheet
at a time, such a segregated log of separate sheets would not allow prison
management to easily search or sort across worksheets to identify trends
or staff members who have repeatedly violated departmental policy;
this shortcoming potentially limits management’s ability to determine
appropriate levels of progressive discipline.
In addition to the use of this segregated log at California State Prison,
Sacramento, which made it difficult for management to effectively
aggregate and parse the available data, our review of the log itself
revealed the prison further limited management by circumventing the
department’s grievance and appeals policies and regulatory requirements
for numerous staff misconduct allegations it had received from
incarcerated persons. As mentioned in the previous paragraph, this
log contained multiple worksheets that segregated the allegations by
type; it also contained a separate worksheet tab titled “WARDEN2020.”
This worksheet contained numerous allegations, which according to
the log’s data entries, were based on letters received from incarcerated
persons, their family members, or representatives. Many of these entries

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were complaints that alleged staff misconduct. However, even though
the letters alleged staff misconduct, entries in the log clearly indicated
that the prison did not process the allegations consistent with the
department’s staff misconduct grievance policies and regulations. For
example, the log included one incarcerated person’s allegation that he
had been assaulted by various officers and that officers took several of
the incarcerated person’s personal belongings and gave them to other
incarcerated persons. These allegations, if true, were certainly serious
enough to result in adverse action. If the prison had adhered to the
grievance and appeal requirements, management should have referred
the allegations to AIMS for an inquiry or to the Office of Internal Affairs’
Central Intake Unit for a formal investigation. Instead of referring the
allegation to either of these units, however, the log’s resulting action
field indicated that a prison sergeant interviewed the incarcerated
person and encouraged him to use the grievance process to resolve any
future issues. By not following the grievance and appeal regulatory
requirements and instead handling the allegations at the local level,
the prison circumvented the AIMS process as well as outside oversight.
Additionally, by processing and tracking the staff misconduct grievances
separately, the prison prevented the staff misconduct grievances from
being tracked in the department’s tracking system, thus undercounting
the prison’s staff misconduct grievances and preventing anyone who did
not have access to the spreadsheet from viewing any of the grievance’s
details or even knowing that the grievance existed at all.
In addition to circumventing the grievance and appeal policies and
regulations, the practice at California State Prison, Sacramento,
of processing staff misconduct allegations not received on the
department’s official grievance form outside the department’s grievance
and appeals process resulted in prison staff instituting an unnecessary
administrative hurdle for incarcerated persons to surmount before
they could submit grievances and have them properly adjudicated.
For the several staff misconduct allegations on the spreadsheet’s
“WARDEN2020” worksheet, the resulting action field indicated that
prison staff performed a limited review of the allegations, or none at
all, and then told the incarcerated person to document and submit the
allegations on the department’s official grievance form. That instruction
placed an unnecessary administrative requirement on the incarcerated
person when the prison had already received the incarcerated person’s
written staff misconduct grievance. In addition, such action could
potentially set the stage for administrative denial of the grievance since
presumably the 30-day deadline would not be tolled until the grievance
form was filed.
In one such example, the log documented an incarcerated person’s
letter requesting an investigation due to being harassed by an officer
because he had filed a grievance against other officers. The spreadsheet’s
resulting action field for this staff misconduct allegation documented
only that the incarcerated person was advised and encouraged to use the

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 57

staff misconduct grievance process. Even though
the prison possessed a documented staff misconduct
allegation from an incarcerated person, it required
the incarcerated person to resubmit the information
on the department’s form. The unreasonableness
of the prison’s practice was supported by a later
email message from the department’s associate
director of its Office of Appeals to the department’s
grievance coordinators. The associate director’s
message stated that, while the department preferred
that grievances be filed on the department’s official
form, if a grievance was received by a prison’s office
of grievances “on any kind of paper (including a
paper towel) they are to process the grievance in
OGT [offender grievance tracking system].” The
prison’s practice of unnecessarily requiring an
incarcerated person to use the department’s official
grievance form could result in an inadequate
investigation by prison staff into the allegations
and could discourage incarcerated persons from
submitting legitimate staff misconduct grievances,
preventing the department from identifying
staff misconduct.
Beginning on June 1, 2020, the department replaced
its inmate appeals tracking system with the offender
grievance tracking system. This system serves as the
department’s primary data system for the grievance
process. Among other changes, it tracks some new
data points, such as the total number of grievances,
the number of individual claims noted in each
grievance, the number of claims that were approved
or disapproved, and the number of staff misconduct
grievances that a grievance coordinator forwarded
to the warden. However, this system fails to track
other basic information about the grievance process,
such as the specific outcomes of the inquiry (apart
from the vague terms approved or disapproved), the
names of staff involved, and details regarding any
disciplinary actions resulting from the inquiry.

Questions we asked of the department
concerning its grievance reporting
capabilities. Due to limitations in the
department’s data-tracking processes,
it could not produce any of the
requested documents.
1. Can the department run a
summary report, showing the
decisions, dispositions, or
outcomes of completed inquiries,
statewide or by prison? In other
words, can the department
quantify how many inquiries
resulted in no policy violations or
policy violations; or in corrective
or adverse actions?
2. Is there a data field in any of
the departments IT systems
that identifies decisions,
dispositions, or outcomes of a
completed inquiry?
3. Can the department run a
complaint-level report, showing
the decision, disposition,
or outcome of an inquiry in
detail? Or can someone in the
department pull up an inquiry and
see what ultimately happened?
4. Can the department run a
report identifying the names of
employees who were accused
of misconduct as a result of an
inquiry or inquiries?
5. Can the department run a
report identifying the names of
employees who were found to
have violated policy or to have
committed misconduct as a result
of an inquiry or inquiries?
Source: Email sent on August 20, 2020, to
the Director of Correctional Policy Research
and Internal Oversight.

Consequently, despite some limited tracking ability,
the department does not have a single, effective tool to track the staff
misconduct grievance process from start to finish, nor can it effectively
produce management reports that include such basic information as
the number and names of staff who were accused of misconduct or
were found to have violated policy, nor any of the resulting disciplinary
actions (corrective or adverse) taken as a result of the process. More
important, however, these flaws also limit the department’s—and the

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58 | The Department’s Staff Misconduct Inquiry Process Remains Broken

wardens’—ability to perform meaningful trend analyses that may pertain
to actions of the staff accused of misconduct throughout the State and
any subsequent actions taken to address future misconduct.
We asked the department about its data tracking and management
reporting capabilities. Our questions, shown in the text box, were
fundamental in nature and represented what we believed were the
minimum components necessary for an effective data tracking and
reporting tool. The department, however, could not produce any of
the requested reports or provide any of the information from its data
systems. The department’s response to these questions, from its director
of Correctional Policy Research and Internal Oversight, included
the following:

We have completed a thorough review of all of our
tracking systems used in the Office of Appeals and the
Office of Internal Affairs. None of our systems currently
have the ability to do everything you have asked [in your
email]. The Offender Grievance Tracking (OGT) system
in SOMS tracks all grievances, including complaints
against staff, that meet the criteria to be responded to
via the Administrative Remedies (Grievance and Appeals)
process, and this system documents whether the claim
was approved or disapproved, however, this system does
not record information regarding any corrective action
or discipline that was imposed as a result of a claim
finding. The Allegation Inquiry Management System
(AIMS) tracking is designed to track the inquiry process
from referral to the point that the completed inquiry
report is provided to the Reviewing Authority, however,
this system does not record information specific to
whether the claim (that led to the inquiry) was approved
or disapproved and the system does not record
information regarding any corrective action or discipline
that was imposed as a result of a claim finding. Finally,
the Case Management System (CMS) does track
investigation requests from when the request is made
by the hiring authority to the final decision by the hiring
authority regarding misconduct and any corrective action
or disciplinary action that is taken as a result. However,
CMS does not track all staff complaints or allegation
inquiries; CMS only tracks cases that have been referred
to OIA for investigation or direct action.28

28. Email from the Director of Correctional Policy Research and Oversight sent on
September 2, 2020.

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 59

The director’s response highlighted our fundamental concern: The
department cannot produce basic types of reports to successfully manage
the process from either a statewide perspective or at the level of the
individual prison. Moreover, we observed that the department does not
appear to have assigned one person in the department full responsibility,
or ownership, of the staff misconduct grievance process. By design, the
process spans multiple offices and divisions within the department, but
that should not prevent a single point of leadership or ownership of the
program. Instead, from what we have seen, each departmental entity
tracks its own data in a silo: prisons have a piece that they track, the
Office of Internal Affairs has two pieces that it tracks separately (formal
investigations in the Central Intake Unit and inquiries in AIMS), and
the Office of Appeals, which is responsible for responding to appeals
of grievances, has a piece that it tracks. However, none of these systems
are useful from an overall data management perspective. As a result, the
department’s managers and executives, who work in different offices
and divisions, are left without key information to make better decisions,
analyze trends, and assess and correct deficiencies in the process.

Thousands of Grievances Possibly Alleging Staff Misconduct
Could Have Been Misclassified as Routine Grievances in Just a
Three-Month Period, Bypassing the Allegation Inquiry Process and
Raising Concerns About Underreporting and Data Collection
One of the new data points collected in the department’s offender
grievance tracking system is an entry for the number of grievances that
staff in the prisons’ Office of Grievances identify as a “possible” staff
misconduct grievance. Once an incarcerated person files a grievance,
it is reviewed by staff in the prison’s Office of Grievances to determine
how the prison will handle it. If staff believe the allegations contained
in the grievance constitute possible staff misconduct, they forward
the grievance (or certain allegations or claims within it) to the warden
for review. If the warden agrees, the grievance is identified in the
department’s offender grievance tracking system as a staff misconduct
grievance. If the warden disagrees with his or her staffs’ initial
determination, the warden designates the grievance as routine.
However, when we reviewed the department’s grievance data for the
three-month period in which it tracked these particular data, we
grew alarmed at the volume and rate at which wardens disagreed with
their staffs’ initial determinations. According to the department’s
data, wardens agreed with their staffs’ initial determinations
only 35 percent of the time, disagreeing with them for the remaining
65 percent. This resulted in 2,563 grievances in just a three-month
period that were ultimately classified as routine, despite containing
indications of alleged staff misconduct (refer to Figures 11 and 12 on
pages 60 and 61, respectively).

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60 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Figure 11. Wardens Frequently Overruled Grievance Coordinators When Determining
Whether a Grievance Alleged Staff Misconduct, Leading Us to Believe the Actual Number
of Staff Misconduct Grievances Was Much Higher Than Reported During the Three-Month
Period From June 1, 2020, Through August 31, 2020

1,400
1,200

1,374
(35%)

N = 3,937
Grievances
Potentially
Alleging
Staff Misconduct

2,563

1,000

(65%)

800

860

863

840

854 Additional
Grievances
Potentially
Alleging
Staff Misconduct
Each Month,
on Average

600
400

█

Grievances That Potentially Contained
Allegations of Staff Misconduct, According
to Prison Grievance Coordinators

█

Grievances That Reviewing Authorities
Determined Were Staff Misconduct Grievances

200
0

467

468

June

July

439

August

458 Grievances
Identified as
Staff Misconduct
Grievances by
Wardens
Each Month,
on Average

Note: Prior to June 2020, the department did not track the number of grievances categorized as staff misconduct by
grievance coordinators.
Source: The Office of the Inspector General’s analysis of the California Department of Corrections and Rehabilitation’s
Offender Grievance Tracking System data for June 1, 2020, through August 31, 2020.

To better understand the types of allegations included in these
2,563 routine grievances, we selected a random sample of 15 to review.
In every grievance, we believed there were allegations made against
staff that met the department’s definition of staff misconduct and
should have been classified as a staff misconduct grievance. Although
the 15 grievances we reviewed were not intended to represent all
2,563 routine grievances that fell into this category, we are concerned
that, given those we did review, the department has misclassified many
grievances as routine, thereby potentially undercounting the actual
number of staff misconduct grievances.
For example, of among the 2,563 routine grievances, an incarcerated person
alleged that a captain forged the incarcerated person’s signature while the
captain conducted an administrative review into the incarcerated person’s
placement in the administrative segregation unit. This is an allegation of
peace officer dishonesty carrying the highest possible penalty—dismissal

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 61

from State service. Staff at the prison’s Office of Grievances identified that
the incarcerated person’s grievance alleged staff misconduct; but again,
the warden determined that the grievance did not contain any allegations
of staff misconduct and ordered the grievance to be processed as routine.
This grievance was not counted among the number of staff misconduct
grievances filed by incarcerated persons in the time frame we reviewed,
even though the claim clearly met the definition of staff misconduct.
The reviewing staff who processed this routine grievance at the prison did
at least conduct an interview of the accused captain. That conversation,
along with copies of the underlying documentation, revealed a reasonable
explanation of what had transpired: the captain indicated that the
incarcerated person refused to sign the administrative order; as a result,
the captain marked “RTS,” a common initialism for “refused to sign.”
Further, the captain placed his own signature in the signature block
where the incarcerated person was supposed to sign. The documentation
we reviewed supported the conclusion of disapproved, essentially clearing
the captain of the suspected forgery. However, since this grievance was
not designated a staff misconduct grievance, the prison’s records will
never show that the incarcerated person made these allegations nor will
they show that the captain was essentially exonerated.
Figure 12. The Department’s Identification and Routing of Grievances
That Potentially Alleged Staff Misconduct During the Three-Month
Period From June 1, 2020, Through August 31, 2020

Grievances That Potentially
Contained Allegations of Staff
Misconduct, According to Prison
Grievance Coordinators

Grievances Wardens
Determined Were Staff
Misconduct Grievances
Staff Misconduct Grievances
Referred to AIMS

N = 3,937
(100%)

1,374
(35%)

369
(9%)

Note: Prior to June 2020, the department did not track the number of grievances categorized
as staff misconduct by grievance coordinators.
Source: The Office of the Inspector General’s analysis of the California Department of
Corrections and Rehabilitation’s grievance data associated with its 35 prisons.

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62 | The Department’s Staff Misconduct Inquiry Process Remains Broken

The effect of misclassifying the types of grievances could potentially be
quite significant: if our sample of routine grievances is consistent with
the other grievances designated as routine, the actual number of staff
misconduct grievances across the department could be drastically
underreported by, possibly, thousands of claims. For instance, in just the
three-month period we reviewed, wardens rejected 2,563 claims that the
prisons’ Office of Grievances determined contained allegations of staff
misconduct. At this rate, the number of misclassified (or uncounted) staff
misconduct grievances could be as high as 10,000 in a year, which would
more than double the total number of staff misconduct grievances
currently reported (refer to Table 1, below). These uncounted staff
misconduct grievances themselves alter the department’s understanding
of what it is accomplishing. Having the ability to connect them to the
rest of the collected data and analyze them would enable the department
to more effectively manage its program and be more transparent. This
problem, however, is far more significant than mere underreporting of
data: it also means that claims alleging staff misconduct were likely
processed without an inquiry and without any oversight.

Table 1. The Office of the Inspector General’s Analysis of Grievances Potentially
Containing Allegations of Staff Misconduct

A

Grievances That Potentially Contained
Allegations of Staff Misconduct, According to
Prison Grievance Coordinators

B

Grievances That Reviewing Authorities
Determined Met the Criteria for a Staff
Misconduct Grievance

C

Staff Misconduct Grievances Referred to AIMS

Grievances We Believe Were Potentially
Mischaracterized as Routine Grievances
(the difference between A and B)

3-Month Period, 5-Month Period,
Ending
Ending
August 31, 2020 August 31, 2020 *

Annualized *

3,937

6,562

15,748

1,374

2,339

5,614

369

541

1,298

2,563

4,223

10,134

* Prior to June 1, 2020, the department did not capture the number of grievances that prison grievance
coordinators identified as potentially containing allegations of staff misconduct. Due to this limitation,
we adjusted the values in bold for the five-month period based on the monthly average for the threemonth period. We then annualized the values on all three rows based on the monthly average for the fivemonth period.
Source: The Office of the Inspector General's analysis of the department's grievance data associated with
its 35 prisons.

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 63

The Department Should Require Incarcerated
Persons to Submit Staff Misconduct Grievances
Directly to the Allegation Inquiry Management
Section to Increase Independence and Fairness
To provide a greater degree of independence, consistency, and legitimacy
to the staff misconduct grievance process, the department should,
among other things, completely restructure its grievance routing process
(refer to Figure 13, below). The first and most important change we
recommend is to require incarcerated persons to submit their allegations
of staff misconduct directly to AIMS. The department could easily
create separate lockboxes for staff misconduct grievances and instruct
staff who collect those grievances to send them to AIMS electronically.
This would enable every allegation of staff misconduct to bypass the
subjective determinations wardens and other prison staff make while
reviewing grievances to decide whether they meet the definition of staff
misconduct. With this system of direct referral, there would be no need
for the analyst, grievance coordinator, and warden at each of the State’s
35 adult prisons to individually review each grievance and apply this set
of subjective determinations that is preventing AIMS from reviewing
allegations of staff misconduct.
Figure 13. Recommended Process for Handling Incarcerated
Persons’ Grievances Alleging Staff Misconduct
Incarcerated Person
Deposits Into
Lockbox Grievance
Form Alleging Staff
Misconduct

+
Prison Staff Scans
Forms to AIMS Central
Intake

!
AIMS Central Intake
Decides to
Refer, Open, or Return
Complaint

Refer

Return

-

Grievances Not Alleging
Staff Misconduct
Returned to Warden to
Handle Internally

-

Completed Inquiry
Returned to Warden for
Disposition If There Is
No Reasonable Belief
of Staff Misconduct

-

Completed
Investigative Report
Returned to Warden
for Disposition of
Staff Misconduct

t
Request a Formal
Investigation If There Is
Reasonable Belief of
Staff Misconduct

Open Formal
Investigation or
Approve Direct Action

Central Intake

Open AIMS Inquiry

I

j
AIMS

Warden

Source: The Office of the Inspector General.

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64 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Upon receipt of the staff misconduct grievances, AIMS staff would
review each grievance and assess the allegations contained in the
grievance to identify any issues that prison staff would need to address
immediately, such as safety concerns or sexual assault allegations. The
AIMS intake staff would then notify the appropriate prison personnel
of these concerns so they could be addressed. From that point, we
recommend AIMS create a process similar to that used by the Office of
Internal Affairs’ Central Intake Unit so that a designated group of AIMS
staff review each grievance and assess whether the allegations in each
grievance meet the department’s definition of staff misconduct. When a
relatively small number of AIMS staff are charged with reviewing every
grievance, those staff members will develop expertise that can be applied
consistently statewide. This change also eliminates the time spent by the
approximately three individuals who currently review the grievances at
each prison—a total of approximately 105 different prison staff.
Grievances that AIMS staff determine do not contain allegations of staff
misconduct could be returned to their respective prisons and handled by
prison staff. For grievances that contain allegations of staff misconduct,
we recommend AIMS open an inquiry into each allegation. We issue
a separate recommendation that the department revise its definition
of staff misconduct to include all allegations that a staff member
violated a law, regulation, policy, or procedure, or acted contrary to an
ethical or professional standard, not just those that are likely to lead to
adverse disciplinary action if found to be true. However, in the event
the department is unwilling to revise its definition of staff misconduct,
we recommend AIMS include within the scope of each inquiry any
other related allegations that meet the first part of the definition of staff
misconduct—conduct that violates any law, regulation, policy, or procedure,
or is contrary to an ethical or a professional standard—regardless of
whether those individual actions may lead to formal adverse action or
informal corrective action. This guarantees only one set of investigators
interviews the complainant, witnesses, and staff about any single incident.
We further recommend AIMS investigators complete their investigations
into every allegation before terminating the inquiry and drafting a report.
This will ensure every allegation receives a complete and thorough inquiry
and that no allegation is assessed based on limited evidence.
At the end of the inquiry, rather than refer the inquiry report back to
the warden of the corresponding prison, we recommend AIMS send the
inquiry report directly to the Office of Internal Affairs’ Central Intake
Unit if AIMS’s staff have formed a reasonable belief of misconduct;
otherwise, AIMS should send the report to the respective prison’s
warden. By referring the inquiry report directly to the Office of Internal
Affairs’ Central Intake Unit, the department ensures that an experienced
group of decision makers will consistently apply the standard of
reasonable belief in their assessment throughout the State as part of their
daily job duties.

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 65

This new process would also be far more efficient. All requests for formal
investigations and the imposition of formal discipline must be approved
by the Office of Internal Affairs’ Central Intake Unit, so the department
would save the time it now takes to return the inquiry report to the
prison, where the warden must then review the inquiry report and send it
to the Office of Internal Affairs’ Central Intake Unit. This direct referral
from AIMS to the Office of Internal Affairs’ Central Intake Unit would
reduce the risk that wardens will make improper determinations that
would terminate the investigative process. In addition, direct referral
would ensure that all decisions resulting from an inquiry are subject to
independent oversight and scrutiny.
Finally, by sending all staff misconduct grievances directly to AIMS, this
new process would address our concern regarding the underreporting of
allegations. It would also enable the department to use a single tracking
system and place responsibility of that system within one unit.

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 67

Recommendations
To address our greatest concern—that the department’s revised process
for handling allegations of staff misconduct is still not independent—
the department should completely overhaul the process by requiring
incarcerated persons to file allegations of staff misconduct directly to
AIMS, bypassing staff and the warden of the prison. As part of this
recommendation, the department should take the following actions:
•

Detach allegations of staff misconduct from the grievance
process, entirely. The department should create a separate
form that is specific to allegations of staff misconduct, such
that the form could be used by anyone who has a complaint,
including incarcerated persons, department staff, and members
of the public.

•

Eliminate the 30-day time limit placed on incarcerated persons
to file allegations of staff misconduct and instead encourage
them to file their allegations as soon as possible.

•

Process and consider allegations from any source, even if it
is a person who is not directly or personally affected by the
alleged misconduct, such as a witness or other third party with
knowledge of a perceived improper act.

•

Create a separate central intake function at AIMS to process all
allegations of staff misconduct brought forward utilizing the new
form we recommend creating above, returning to the prisons
only those allegations that do not relate to staff misconduct.

•

Require AIMS to address all allegations of staff misconduct by
either completing an inquiry or referring allegations directly to
the existing Central Intake Unit for formal investigation.

•

Eliminate the requirement that AIMS investigators stop their
inquiry work when they form a reasonable belief of misconduct;
they should instead continue to gather and analyze all relevant
evidence and complete their inquiry.

•

Require AIMS to refer completed inquiries directly to the
existing Central Intake Unit for formal investigation when there
is a reasonable belief that the alleged misconduct occurred.
AIMS should return to the wardens for a final review and
determination fully completed inquiries in which there is not a
reasonable belief that the alleged misconduct occurred.

To ensure AIMS has sufficient staffing levels, the department should
prepare a workload analysis, factoring the length of time it takes to
conduct an inquiry and the number of staff it would need to handle the
total volume of allegations of staff misconduct.

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68 | The Department’s Staff Misconduct Inquiry Process Remains Broken

To address our concern that the department’s definition of staff
misconduct is overly subjective, the department should redefine the
meaning of staff misconduct as “an allegation or claim that departmental
staff violated a law, regulation, policy, or procedure, or acted contrary
to an ethical or professional standard.” We believe that the current
definition includes too much subjectivity by having decision-makers
determine, prior to the completion of an inquiry or investigation,
whether there is a likelihood that the alleged conduct, if true, would
result in adverse action.
To address another of our significant concerns that the department’s
revised process for handling allegations of staff misconduct is not fair,
the department should develop a statewide review process to ensure
wardens make consistent and fair disciplinary determinations following
the completion of an inquiry or formal investigation. The department
should pay close attention to key performance indicators, such as the
number of allegations found to be true. In addition, this review process
should ensure that any resulting disciplinary penalties from the inquiry
process were reasonable and effectuated.
To address our concern that the department cannot effectively
analyze trends and assess the effectiveness of its staff misconduct
process, the department should consider developing a new centralized
information tracking system or modifying an existing system so that it
comprehensively tracks key information and data involving the entire
staff misconduct process. Toward that end, the department should
account for all allegations of staff misconduct and identify by location, at
a minimum, the following:
•

The number of reported allegations of staff misconduct

•

The logistical details of an allegation of staff misconduct, such
as any relevant dates or time frames, relevant locations, and the
categorical nature of the allegation

•

The names and other related information of those who filed
allegations of staff misconduct

•

The names, badge numbers (or other unique identifiers), and
titles of the accused staff

•

The outcome or disposition of each allegation of staff
misconduct, such as whether or not the allegation was sustained
(or found to be true)

•

The disciplinary determinations made for each sustained
allegation, such as whether the subject(s) received corrective or
adverse action

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The Department’s Staff Misconduct Inquiry Process Remains Broken | 69

Response to the OIG’s Report
STATE OF CALIFORNIA- DEPARTMENT OF CORRECTIONS AND REHABILITATION

OFFICE OF THE SECRETARY
P.O. Box 942883
Sacramento, CA 94283-0001

February 8, 2021

GAVIN NEWSOM, GOVERNOR

0

Mr. Roy Wesley
Office of the Inspector General
10111 Old Placerville Road, Suite 110
Sacramento, CA 95827
Dear Mr. Wesley:
The California Department of Corrections and Rehabilitation (CDCR) has reviewed the draft
entitled The California Department of Corrections and Rehabilitation: Its Recent Steps Meant to

Improve the Handling of Incarcerated Persons' Allegations of Staff Misconduct Failed to Achieve
Two Fundamental Objectives: Independence and Fairness; Despite Revising Its Regulatory
Framework and Being Awarded Approximately $10 Million of Annual Funding, Its Process
Remains Broken.
CDCR takes every allegation of employee misconduct very seriously, and we are committed to
ensuring all allegations are properly and fairly reviewed, whether at the Department or at the
local level. The Department appreciates this review by the Office of Inspector General (OIG), and
recognizes the report provides valuable feedback which we will consider as we continue to
improve how allegations against staff are reviewed. However, some of the conclusions in the
report may be premature, given the Allegation Inquiries Management Section (AIMS) structure
was activated less than a year ago.

1

■

As is expected with the activation of such a significant new unit and processes, CDCR has
encountered challenges, especially in the beginning. Wardens and grievance coordinators
struggled with the new screening process.
However, CDCR has not found evidence
demonstrating wardens are intentionally circumventing the new process. Rather, typical learning
curve challenges have transpired . CDCR has worked diligently to address this and have taken
steps to provide additional training to wardens and grievance coordinators including relevant job
aid as well as established increased performance monitoring to ensure allegations of misconduct
are handled appropriately.
We recognize the OIG's position that an investigation and an inquiry is one in the same. CDCR's
historical policy and application recognize inquiries and investigations as different in operational
practice. Nomenclature for inquiry versus investigative process was determined as part of the
Madrid Remedial Plan, and the OIG participated in developing this Plan. As a result of the Madrid
Remedial Plan, only the civil service classifications in the special agent series can complete an
investigation. As such, AIMS Lieutenants are able to perform inquiries but cannot complete the

■
2

formal investigation process.

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70 | The Department’s Staff Misconduct Inquiry Process Remains Broken

Roy Wesley, Office of the Inspector General
Page 2

We thank you for the opportunity to review and comment on the draft report. CDCR wholly
appreciates the importance of maintaining independence and fa irness when reviewing
allegations of staff misconduct. We are committed to persistently working to improve our
processes in this regard, and we value the observations of the OIG as they continue to monitor
this process.
If you have further questions, please contact me at (916) 323-6001.
Sincerely,

/~~
~

THLEEN ALLISON

Secretary

Office of the Inspector General, State of California

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Comments Concerning the Response
Received From the Department of
Corrections and Rehabilitation
To provide clarity and perspective, we comment on the California
Department of Corrections and Rehabilitation’s (the department)
response to our report. The numbers below correspond with the numbers
we have placed in the margin of the department’s response.
1.

In its response, the department asserts our conclusions may be
“premature” given that the department activated AIMS less than
a year ago. Yet the problems we discuss are structural and are
not dependent on when it activated AIMS. The primary reason
we published this progress report was to highlight structural
problems in the department’s regulations and to point out
that those problems will remain until the department changes
the regulations (and its process), again. The faulty regulatory
structure has introduced unnecessary complexity and subjectivity
within several stages of the decision-making process and our
recommendations are aimed at addressing these, and other,
weaknesses in it.

2.

We raised this point to ensure that when department staff
complete an inquiry, that they do so with the same level of due
diligence and professionalism as they would with any other
investigation. The department, in its response, did not articulate
any material difference between inquiries and investigations.
As we explained in the Introduction of this report, the activities
of these two terms are identical: they both involve interviewing
claimants, witnesses, and subjects; collecting evidence; and
writing reports. We found no legal criteria barring a lieutenant
from performing any of these activities, and by extension,
from performing an investigation. Likewise, we found no legal
criteria that specifies that only special agents can perform an
investigation; that is simply an operational choice made by the
department. We mention this because we believe that an inquiry
in this context is on equal footing with an investigation. To us,
they are one and the same.

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Special Review
The California Department of
Corrections and Rehabilitation
Its Recent Steps Meant to Improve
the Handling of Incarcerated Persons’
Allegations of Staff Misconduct
Failed to Achieve Two Fundamental
Objectives: Independence and Fairness;
Despite Revising Its Regulatory
Framework and Being Awarded
Approximately $10 Million of Annual
Funding, Its Process Remains Broken

OFFICE of the
INSPECTOR GENERAL
Roy W. Wesley
Inspector General
Bryan B. Beyer
Chief Deputy Inspector General

STATE of CALIFORNIA
February 2021

OIG