Office of the Inspector General
Matthew L. Cate, Inspector General

The California Institution for Women
Quadrennial and Warden Audit

December 2007

State of California

Contents
Executive Summary .................................................................................................1
Institution Overview ................................................................................................4
Chapter 1: One-Year Evaluation of Warden Dawn S. Davison ..........................6
Objectives, Scope, and Methodology..........................................................6
Background of Warden ...............................................................................6
Discussion of Warden’s Strengths..............................................................7
Discussion of Criticisms...............................................................................9
Warden’s Response to Criticisms...............................................................11
Summary Discussion....................................................................................12
Chapter 2: Quadrennial Audit Findings and Recommendations .......................13
Objectives, Scope, and Methodology..........................................................13
Finding 1 .......................................................................................................15
The aging and overcrowded institution has fallen into disrepair, and many
buildings have become inadequate, yet the institution still waits for overdue
repair funds from department headquarters.

Finding 2 .......................................................................................................19
The attendance rate is poor in education classes because of frequent
cancellations and other factors.

Finding 3 .......................................................................................................23
The California Institution for Women does not always assign inmates with low
reading abilities to adult basic education classes.

Finding 4 .......................................................................................................27
Inmates sent to off-site medical specialists do not always receive prompt followup medical care.

Finding 5 .......................................................................................................29
The California Institution for Women does not complete its use-of-force incident
packages within the required timelines.

Finding 6 .......................................................................................................31
The visiting center staff does not consistently adhere to visiting policies and
regulations, increasing the risk of visitors bringing banned materials into the
institution.

Finding 7 .......................................................................................................35
The California Institution for Women fails to ensure that staff members assigned
to armed posts always meet their quarterly weapons qualifications requirements.

California Department of Corrections and Rehabilitation’s Response ..............38

Executive Summary
This report presents the results of an audit by the Office of the Inspector General
(OIG) concerning the operations of the California Institution for Women (CIW)
and the performance of its warden. The audit was performed under California
Penal Code section 6126 (a)(2), which requires the Inspector General to audit
each warden one year after his or her appointment, and to audit each correctional
institution at least once every four years.
Our team of inspectors examined CIW’s operations and programs to identify
problem areas and recommend workable solutions. The institution, which houses
23 percent of California’s adult female inmates, gave our inspectors full access to
its records, logs, and reports. In addition, site visits allowed us to observe CIW’s
day-to-day operations. We also conducted interviews of various staff members
and inmates, and we surveyed three distinct focus groups: institution management
and staff, California Department of Corrections and Rehabilitation management,
and key government and union stakeholders. In all, our inspectors made seven
audit findings and 23 recommendations, which are detailed in Chapter 2 of this
report.
Overall, Warden Davison performs her duties well. As detailed in Chapter 1 of
this report, we used surveys, personal interviews, and our audit findings to
evaluate Warden Dawn S. Davison’s performance. Although Davison has
numerous challenges ahead, her supporters describe her as a compassionate
warden who is devoted to CIW’s mission, and she has made great strides in
steering the institution in a positive direction. Since her appointment as CIW’s
warden, Davison has implemented several innovative programs, and she brings a
positive energy to the staff and inmates. We found that Davison is hard working
and generally performs her duties well. However, she could improve by requiring
a greater degree of compliance with department policy by her staff. Nonetheless,
Davison is steadily improving the prison, and she should continue serving as
warden at CIW.
Challenges persist due to an aging, overcrowded facility. The warden is
challenged by an aging, overcrowded facility that results in ongoing building
maintenance problems. The institution was built over 50 years ago and suffers
from a lack of preventive maintenance, caused in part by inadequate funding to
repair or upgrade the aging facility. For example, the institution received only
partial funding to renovate the support care unit after it found lead-based paint on
the walls—even though the department approved the project, which has been on
an “unfunded” list for the last seven years.

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The California Institution for Women’s education department needs to
improve its operations. While our evaluation of the warden’s performance was
mostly positive, our audit of the institution’s programs in Chapter 2 uncovered a
number of concerns in the education department. Most notably, attendance data
showed that students in the education department’s academic and vocational
programs attended class for only 42 percent of the total available classroom hours.
Although absences caused by students and custody-related matters contributed to
lost classroom time, we found other factors, such as no provision for substitute
teachers and classrooms without air conditioning, caused the school to cancel 28
percent of available classroom time. Further, we found that students often miss
class time without an approved excuse, and teachers sometimes fail to initiate
disciplinary action against students for their missed time.
We also found that CIW did not always identify and assign inmates who read
below the ninth grade level to the academic program or, at the least, place them
on a waiting list, a necessary step to comply with state law. Instead, the institution
assigned many inmates with low reading abilities to its pre-forestry training
program, fire camp program, or other institutional jobs. The inmate assignment
errors occurred, in part, because CIW’s inmate assignment practices conflict with
state law.
The California Institution for Women needs to improve its adherence to
established policies. During our review of CIW and its warden, we found several
areas in which staff members deviated from accepted standards, regulations, and
policies. In the area of medical care, the Division of Health Care Services requires
that an inmate receiving a routine specialty service must receive follow-up
medical care from her primary care physician within 14 days. We found,
however, that CIW’s medical staff missed the 14-day standard in nearly half the
files reviewed and that the delay averaged 12 days beyond the 14-day standard—
potentially endangering the inmates’ health and jeopardizing the department’s
compliance with the court-ordered quality-of-care standard.
Similarly, over half the use-of-force incident packages (incident report and
supplemental documents) prepared by CIW staff members are not submitted to
headquarters within the 30-day time requirement. For 21 percent of those late
packages, the use-of-force committee recommended further on-the-job training to
address staff deficiencies; consequently, a delay in corrective training increases
the possibility that the staff’s inappropriate use of force could reoccur.
During our unannounced site visit, we found that the visiting center staff was
unfamiliar with visiting procedures because they lacked training, and the staff was
not consistently screening visitors to prevent them from bringing weapons or
unapproved materials into the visiting center. In addition, despite a department
requirement that only peace officers who have completed firearms training and
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are currently qualified be assigned to armed posts, we found seven peace officers
assigned to armed posts who did not participate in the last quarterly range
qualification. Thus, more than three months elapsed between each of their
qualifications. When peace officers do not maintain their proficiency with their
firearms, they expose themselves and others to risk of unintentional injury.

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Institution Overview
CIW is one of 33 adult prisons operated by the California Department of
Corrections and Rehabilitation. As of September 30, 2007, the department
reported that it housed 10,993 female inmates, primarily in three facilities. With a
design capacity of 1,325 inmates, CIW is home to 2,511 (23 percent) of
California’s female inmates.
Established in 1952, CIW’s primary mission is to provide a safe and secure
environment while providing quality health care and institution programs geared
to meet the special needs of female offenders. CIW also houses inmates with
special needs, including maternity care, psychiatric care, methadone treatment,
and medical problems such as HIV infection. Located in Corona in Riverside
County, the institution accommodates all custody levels of female inmates and
functions as a reception center for incoming female inmates.
For fiscal year 2007-08, the institution’s operating budget is $101.6 million with
985.8 budgeted positions, of which 479.1 (48.6 percent) are custody staff. The
table below compares CIW’s budgeted and filled positions as of November 15,
2007. Notably, CIW has filled more than 96 percent of its custody positions and
almost 92 percent of its education positions. Overall, the institution filled 94.1
percent of its total budgeted positions.
Staffing Levels at the California Institution for Women
Position

Filled Positions

Budgeted Positions

Percent Filled

Custody
Support
Medical
Education

462.9
203.7
226.8
34.0

479.1
216.0
253.7
37.0

96.6%
94.3%
89.4%
91.9%

Total

927.4

985.8

94.1%

Many programming opportunities exist for inmates at the California
Institution for Women. CIW offers a variety of education and vocational
programs designed to elevate inmates’ social awareness and personal
responsibility. For example, the institution provides substance abuse
programming, firefighting training, and a number of self-help groups and
community improvement projects. In partnership with the Center for Children of
Incarcerated Parents, one of the institution’s notable programs is the Family
Reunification Program, which helps incarcerated mothers maintain or regain
contact with their children.
The California Institution for Women provides comprehensive care for
inmates requiring mental health treatment. CIW provides inmates with mental
health disorders different levels of treatment. The institution offers general
population inmates outpatient mental health care through its Correctional Clinical
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Case Management System. In addition, CIW has an Enhanced Outpatient
Program for inmates needing more intensive mental health care, and the
institution houses those inmates in its support care unit. CIW also recently opened
a ten-cell psychiatric services unit, which it uses to house violent inmates who
require an enhanced outpatient level of care. The institution continues to offer
inmates brief inpatient care through its Correctional Treatment Center, where the
mental health crisis beds are located. CIW transfers inmates who need long-term
inpatient care (more than ten days) to Patton State Hospital for treatment and
evaluation.
The Prison Industry Authority introduced the nation’s first prison preapprenticeship carpentry program for women at the California Institution
for Women. In August 2007, 11 female inmates graduated from the newly
established pre-apprenticeship carpentry program that trains inmates in
construction skills. As part of their training, the inmates renovated the California
Department of Forestry and Fire Protection training facility located at the
institution. Once inmates complete their training, they are eligible for placement
in construction industry jobs. The Prison Industry Authority gives the inmates
who complete the program the carpentry tools they need and provides
employment assistance after release.
The Prison Industry Authority also employs about 125 inmates in the
institution’s textile factory. CIW’s textile factory produces numerous items for
other California prisons. These items include men’s boxer shorts, sports shirts,
food service shirts, potholders, and aprons. CIW reports that the factory’s annual
revenue has been over $3 million in recent years. The institution indicated that
most of the factory’s revenue comes from the sale of orange poplin work shirts
and other apparel to the California Department of Transportation and fireretardant jackets and trousers to the California Department of Forestry and Fire
Protection. According to CIW, the inmates assigned to work in the factory earn
between $.30 and $.95 per hour and may receive certain privileges, such as paid
state holidays, telephone calls, and reductions in their sentences as allowed by
law.

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Chapter 1:
One-Year Evaluation
of Warden Dawn S. Davison
California Penal Code section 6126(a)(2) requires the OIG to audit each warden
of an institution one year after his or her appointment, and to audit each
correctional institution at least once every fours years. The OIG must fully
comply with these requirements by July 2009. To satisfy this requirement for
CIW, our inspectors audited the warden’s performance and the institution’s
operations simultaneously.

Objectives, Scope, and Methodology
To understand how the staff and other stakeholders view the warden’s
performance, we surveyed three distinct focus groups. Specifically, we sent
surveys to 18 department officials and CIW managers. Of those surveys, we
received 11 responses. We also delivered surveys to 176 CIW employees and
received 35 responses. Finally, we sent surveys to 16 key stakeholders, including
certain members of the Legislature, representatives of unions and associations,
and a local district attorney. However, we received only one response.
We toured CIW to gain insight into the environment where the warden must
perform and we inspected various operational areas. These operational areas
included, but were not limited to, the following areas: business services, inmate
appeals, investigative services, litigation, labor relations, inmate records, plant
operations, transportation services, education programs, inmate visiting, receiving
and release, personnel assignment, and employee relations. During our site visits,
we interviewed 52 individuals within the institution, including custody staff,
executive management team members, labor union representatives, education and
health care professionals, and representatives from the Women’s Advisory
Committee, the Inmate Family Council, and the Citizens’ Advisory Committee.
We also reviewed pertinent logs, reports, and other documents related to the
warden’s performance over the past year, including the results of our institutional
audit contained in Chapter 2.
Background of Warden
The Governor appointed Dawn S. Davison as the warden of CIW in November
2004. Davison began her career with the State of California in January 1980 as a
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graduate student assistant at Lanterman Developmental Center. In 1986, Davison
transferred to the department as a personnel supervisor at CIW. Over the next
eight years, she advanced through various administrative classifications, which
provided her with extensive personnel experience. In January 1994, Davison was
promoted to business manager at Calipatria State Prison. In October 1997,
Davison received a promotion to correctional administrator at California State
Prison, Los Angeles County. In May 2000, she transferred to the California
Rehabilitation Center in Norco, where she planned and directed the overall
housing operations for approximately 4,000 level II inmates. Davison then served
as the chief deputy warden at CIW from 2002 until she became warden in 2004.
We evaluated Davison in October 2005 following the enactment of Penal Code
section 6126(a)(2).1

Discussion of Warden’s Strengths
Davison is one of the department’s more innovative wardens, specifically in
dealing with female inmates. Davison is known to be a statewide expert in
gender-specific correctional issues and has implemented gender-responsive
strategies within the institution. At CIW, the warden focuses on the differences
between male and female offenders in terms of the crimes they commit and the
pathways to incarceration that bring them into the system, their risks and needs,
and their roles in the community from which they have come and to which they
will return. Several staff members noted gender responsiveness as one of
Davison’s accomplishments.
Davison also initiated California’s first in-prison nursery, the Bonding Mothers
with Babies Program. This new program will allow inmates to deliver their babies
while in prison and then care for the child for up to 15 months. This program falls
under the institution’s Family Reunification Program. The warden believes that
female offenders who maintain strong family ties during incarceration—
specifically between a mother and child—have a greater chance of positive
rehabilitation and have a lower risk of recidivism. According to the department,
gender-specific rehabilitation programs such as this are one of many statewide
efforts to reduce recidivism rates.
In addition, Davison thinks “outside the box” by supporting inmate programs like
the Chaffey College Program, the Prison Pup Program, and the Alpha Faith-Based
Reentry Program. The Chaffey College Program is a state-funded educational
program that offers academic support services to students who have experienced
limited success in high school or college. The ultimate goal of the program is for
1

Warden Davison’s appointment in 2004 required Senate confirmation. Before she could be confirmed,
that requirement was replaced by the warden evaluation process conducted by the Office of the Inspector
General under Penal Code section 6126(a)(2).
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the students to obtain associate degrees. The Prison Pup Program allows inmates
to raise and train service dogs for mobility-impaired members of the community.
The Alpha Faith-Based Reentry Program focuses on a curriculum of five core
areas of instruction based on biblical principles: anger management,
spiritual/values clarification, substance abuse relapse prevention, parenting/family
relationships, and daily living skills development. Many staff members and
inmates praise the warden for providing these opportunities to help inmates
succeed once they leave the institution.
Overall, Davison’s ability to initiate and operate these programs effectively,
despite the overcrowding and infrastructure problems discussed in Chapter 2, is
further indication of her strength as a warden.
Those interviewed describe Davison as being honest, knowledgeable,
compassionate, and committed to rehabilitation. Many said the warden is a
person of integrity who is concerned about doing the right thing. An administrator
told us that he often heard Davison say, “I don’t want you to allow me to lead us
down the wrong road.” Staff members told us that Davison has an open-door
policy and is very approachable; she often seeks opinions from her managers. She
is viewed as a hard worker, and she genuinely cares about the institution’s
success. Many staff members told us that the warden’s biggest accomplishments
have been the implementation of the gender-responsive strategies, activation of
the correctional treatment center, and planned activation of the Bonding Mothers
with Babies Program.
Inmates also praise Davison, stating that the warden is genuinely concerned about
their future beyond prison. This concern is demonstrated by the large number of
programs offered to the inmates. Several inmates told us that Davison and her
management team members are receptive and supportive of their concerns. The
executive body of the Women’s Advisory Committee, which is a committee that
represents the inmates, meets with the warden and the associate wardens monthly
to discuss any issues they may have. The inmates feel that they have direct access
to the warden. Also, committee members describe the warden as an excellent
crisis manager, as evidenced by her handling of the gastroenteritis virus outbreak,
the transfer of inmates from the California Rehabilitation Center, and addressing
the needs of an aging inmate population.
Davison has made a positive impression on both the Inmate Family Council and
the Citizens’ Advisory Committee, which are external organizations that support
the inmates’ families and the community, respectively. Council and committee
members told us that the warden is open to new ideas and is responsive to issues
brought to her attention; they feel informed as to what is going on in the prison.
Both organizations meet with Davison or her representatives every other month.

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In summary, 46 of the 52 individuals interviewed provided an overall rating for
Davison. Seventy-two percent of the individuals who provided an overall rating of
the warden rated her either “very good” or “outstanding.”
Institutional Staff’s Replies to the Question: “Rate the Warden’s Overall Performance”
Rating

Responses

Percent

Outstanding
Very Good
Satisfactory
Improvement Needed
Unacceptable

14
19
12
1
0

30%
42%
26%
2%
0%

Total

46

100%

Overall, the survey results were favorable. In addition to conducting face-toface interviews with staff members, we sent surveys to 34 individuals from the
department’s headquarters, the institution’s management team, and external
stakeholders. Twelve individuals responded to the survey, a 35 percent response
rate. We asked respondents to rate the warden’s various management skills and
qualities—from “outstanding” to “unacceptable.” In general, after we converted
the ratings to a numerical score between 1 and 5, with 1 being “outstanding” and
5 being “unacceptable,” the results indicated a high opinion of the warden in all
categories. Specifically, nearly 90 percent of all ratings were either “very good”
or “outstanding.” Moreover, several respondents provided written comments that
were quite positive. For example, one respondent stated that the warden “acts as a
role model and mentor to other less senior wardens.” Another respondent stated
that the warden is a “highly effective communicator.”
We administered another survey to 176 institutional staff members. Thirty-five
staff members responded to the survey, a 20 percent response rate. Respondents
included custody staff and employees working in health care, plant operations,
food service, administration, and education programs. One notable condition
identified by the survey was that nearly 89 percent of the respondents indicated
that they usually or always feel safe while in the institution. Additionally, over 94
percent of responding institution staff members indicated that they feel adequately
trained to perform their job duties. Nearly 83 percent of the same staff members
said the warden and her executive management team are ethical and emphasize an
institution culture that calls for staff members to be highly ethical, professional,
and honest. Finally, 77 percent of the respondents have no desire to transfer to
another institution or resign within the next 12 months.

Discussion of Criticisms
Several staff members told our inspectors that communication between the
management team and the custody staff needs improvement. Custody staff
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members do not feel they are completely informed about institution changes or
new programs being implemented. For example, some staff members expressed
concerns about the Bonding Mothers with Babies Program, but after further
discussions with them, most concerns resulted from the absence of information
related to program details. In speaking with the administrators, they mentioned
that the warden is trying new ways to improve communication among staff
members. Davison recently held a town hall meeting where all staff members
were invited. During this meeting, the warden and her management team
members were available to answer staff members’ questions or concerns.
Administrators told us that staff members appear to be receptive to the warden’s
approach; therefore, the warden plans to regularly conduct town hall meetings in
the future.
Institution staff members say that Davison should spend more time walking
around the institution and visiting the housing units. Some staff members told
us they only see the warden when she is on her way to committee meetings. They
said the warden appears to be more accessible to the inmates; therefore, they
perceive her to be more supportive toward the inmates’ needs instead of staff
members’ needs. The warden’s increased presence around the institution would
provide staff members the opportunity to get to know her and to build better
relationships with her. Such increased presence would also allow the warden to
observe whether the staff is following her directives.
Accountability may need to be addressed. Some of Davison’s critics do not
view her to be enough of a disciplinarian. Several praised the working
relationship between the prior chief deputy warden and Davison, saying their
management styles complimented each other. The chief deputy warden focused
on making sure the warden’s directives were carried out. However, since the chief
deputy warden’s retirement, some staff members expressed concerns about
whether the management team members will be held accountable. They said the
warden needs to be more firm, and some fear that staff members may take
advantage of her good nature.
Some of the audit findings discussed in Chapter 2 support staff comments
concerning whether the warden holds management team members accountable.
For example, our audit found lapses in adherence to visiting policies, use-of-force
incident requirements, and quarterly weapons qualification policies. In addition,
the audit found weaknesses in the way teachers are utilized in the bridging
program and in the methods used to identify and assign inmates to academic
literacy programs. For each of these examples, an opportunity exists for the
warden to hold institution managers more accountable.
Our inspectors also noted a few areas of concern in the survey results. Thirtyfour percent of institutional staff respondents indicated that management seldom
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or never listens to staff concerns or gives their concerns due consideration.
Further, 46 percent of respondents said the warden seldom or never walks through
the institution. Although we noted these minor concerns, the survey results were
generally very positive and did not disclose any issues that were of significant
concern to the OIG.
Warden’s Response to Criticisms
In her November 29, 2007, interview with the Inspector General, Davison noted
that the focus of her job is to determine what measures or programs to implement
that will address the inmates’ rehabilitative needs. Davison stated that she is
genuinely concerned with providing the inmates with the tools and skills
necessary for their success when they parole and to decrease California’s inmate
recidivism rate. With that goal in mind, she researches, implements, and supports
programs to allow as many inmates as possible to be successful in their transition
to society, whether it be education, substance abuse treatment, vocational, or any
of the other programs available at the institution. Communicating her vision to the
staff and ensuring their support can be challenging, but she sees signs of progress
each day.
Davison conceded that her efforts to walk throughout the institution to talk with
staff members informally have been insufficient. She noted that her temporary
assignment at headquarters as an acting associate director took her away from the
institution. However, she understands the importance of being more visible to all
her staff, and she plans to make a concerted effort to walk the institution grounds
more often.
Davison also told us that her town hall meetings are very effective and are
attended by many staff members. She has also placed a television monitor at the
front entrance to inform the staff of current events at the institution, and she
believes it has alleviated some of the prior communication complaints. Plus, she is
working with her management team to help them become better communicators.
She expects each member of her management team to communicate her message
and direction to their respective staff members.
Davison stated that this report characterized her accurately. She has worked hard
to earn her reputation as an honest, hard-working leader with a passion to carry
out her vision. She does not consider herself a disciplinarian, but she does believe
in holding her managers accountable, and her style obtains her desired results.
Davison cites that an increase in the number of staff disciplinary actions has
occurred over the past few years—evidence that staff members are held
accountable. Also, in selecting her new chief deputy warden, she looked for
someone who would compliment her management style.
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Davison accepted the criticism offered in her interview with the Inspector General
and readily admitted her shortcomings. She showed great concern, as well as
sincere appreciation for the criticism. She also expressed a commitment to
continue implementing positive changes and improvements at CIW.
Summary Discussion
Davison has over 21 years of work experience at the California Department of
Corrections and Rehabilitation. Despite the challenges every warden currently
faces, our review found Davison is honest and hard working, and she brings a
positive energy to the staff and inmates at the institution. She is devoted to the
institution’s mission, and she believes that inmates need social, vocational,
educational, and personal skills to become successful once they leave the
institution. By most accounts, Davison passionately cares about CIW and
demonstrates a personal commitment to carrying out its mission.
The findings in this report, however, indicate a need for Davison to hold her
management team accountable for enforcing critical policies and procedures. In
addition, Davison can improve communication with staff by increasing her
visibility to staff members and continuing her town hall meetings.
In summary, Warden Dawn S. Davison appears to be performing her duties well
and should continue serving as warden at the California Institution for Women
while addressing the recommendations identified in this report.

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Chapter 2:
Quadrennial Audit Findings
and Recommendations
Objectives, Scope, and Methodology
Our inspectors gained an understanding of the institution’s mission, safety and
security procedures, and management practices by reviewing various laws,
policies and procedures, and other criteria related to key facility systems,
functions, and processes. As detailed in Chapter 1, we also inspected the
institution, observed its general operations, and interviewed various staff
members and inmates concurrently with the warden evaluation process. In
addition, we surveyed key groups and reviewed statistical data reports that pertain
to the institution’s population and programs.
After assessing the institution’s operations and the survey results, we focused our
audit on the following areas:
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ

Identifying infrastructure challenges
Providing education programming to inmates
Ensuring that inmates receive prompt follow-up medical care
Submitting incident packages promptly
Providing a safe and secure visiting environment
Ensuring custody staff meets weapons proficiency requirements

In conducting our work, we performed the following procedures:
ƒ

To identify the facility’s infrastructure challenges, we observed several
infrastructure concerns during our site visits and interviewed staff
members to obtain feedback regarding additional preventive
maintenance issues. We then discussed the infrastructure concerns with
facility management to determine what steps they have taken to address
the concerns.

ƒ

To review the effectiveness of the institution’s education program at the
El Prado Adult School, we studied state law and education policies and
procedures, interviewed several education and management staff
members, and consulted with the department’s Office of Correctional
Education. We also reviewed student attendance reports and monthly
summaries, which included the hours each student attended classes.

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ƒ

To determine whether inmates receive prompt follow-up medical care
after they are sent to specialists, we interviewed staff members to gain an
understanding of the medical care process, reviewed documents related
to off-site medical transports, reviewed inmates’ medical records, and
used information obtained from the Inmate Medical Services Scheduling
and Tracking System. We did not review any other aspect of the prison’s
medical program.

ƒ

To determine whether the institution promptly processes incident
packages, including those involving use of force, we interviewed staff
members responsible for monitoring and tracking incident packages,
reviewed the incident log, and assessed whether CIW met the
timeframes.

ƒ

To determine whether the institution provides a safe visiting
environment, we reviewed policies and procedures for the inmate
visiting center and conducted an unannounced site visit in June 2007, to
observe the staff processing visitors during visiting hours. We also
interviewed key staff members to understand their roles and
responsibilities.

ƒ

To determine whether custody staff members in armed posts meet
weapons proficiency requirements, we reviewed relevant policies and
procedures, interviewed the institution’s training manager and
individuals at the personnel assignment office, examined officer firearms
qualifications and related training records, and obtained copies of
employee rosters.

Finally, we summarized the results of the above work and formulated our findings
and recommendations.

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Finding 1
The aging and overcrowded institution has fallen into disrepair, and many
buildings have become inadequate, yet the institution still waits for overdue
repair funds from department headquarters.

Built over 50 years ago, CIW suffers from an overall lack of preventive
maintenance, due in part to inadequate funding to repair or upgrade the aging
facility. For example, many buildings need their roofs replaced, the perimeter
security fence is rusty and deteriorating in some locations, and many windows in
the inmate housing units are drafty because they do not properly open or close. In
addition, the concrete and asphalt walkways and roads between institution
buildings are cracked, uneven, and in such poor condition that they create a safety
hazard for staff members and inmates. The deterioration, coupled with
overcrowding, creates inhospitable living conditions for some inmates and
jeopardizes the health and safety of staff and inmates. In many instances, CIW has
received approval for special repair projects from the department’s headquarters,
but the institution has only received limited funding to pay for the repairs because
of department budget constraints.
The institution submitted special repair project requests to headquarters, but
years later, the projects have yet to be funded. Budget constraints have
hindered CIW’s ability to address its many structural issues. For example, CIW
submitted a capital outlay budget change proposal on December 19, 2000, to
renovate and reroof the north and west wings of its support care unit. The
department’s capital outlay unit approved this request, called a special repair
project, on January 18, 2001, but seven years later, the department has still not
funded the project.
According to the associate warden for business services, CIW has received
funding from the department for several projects, including replacing roofs on
four inmate housing units and the medical clinic, and upgrading alarm and
electrical equipment. However, the associate warden also noted that CIW has
numerous approved but unfunded special repair projects that include:
ƒ
ƒ
ƒ
ƒ

Renovating the support care unit.
Repairing the inner perimeter fence.
Repairing the roofs for the education buildings, administration building,
and two of the six inmate housing units.
Repairing asphalt roadways.

The institution used its own funds to renovate the support care unit after it
found lead-based paint on the walls. Although CIW requested funding nearly
seven years ago to renovate its support care unit, the department approved the
project but placed it on an “unfunded” list, where it still sits today.
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Example of living unit cell prior
to support care unit renovation.

In early 2007, CIW discovered lead-based paint in
the support care unit and subsequently moved the
inmates from that unit, recognizing the critical
need to address the problem due to the inmates’
poor living conditions. According to the associate
warden, between May and June 2007, the
institution abated the lead paint and received
funding for the costs at year-end. In October 2007,
CIW completed its renovation of the support care
unit, using its own funding, and has submitted a
request to headquarters for reimbursement.

The two photographs illustrate the living conditions in the support care unit before
and after the renovation.
Overcrowded inmate living units cause
36 women to share one toilet and sink.
Although the department does not have
standards limiting the number of inmates
who can share a toilet and sink,
California does impose limitations on
local jails. In dormitory settings,
California regulations require local jails
to provide one toilet and sink for every
ten inmates.

Living unit cell after renovation.

To accommodate its increasing inmate population, CIW management converted
the 700 square foot dayrooms and 500 square foot storage rooms in three of the
six inmate housing units into dormitory housing. In each of these three housing
units, up to 36 inmates occupy the converted spaces in double-bunk beds. Because
these spaces were not designed to house
inmates, there is only one toilet and sink for
the inmates’ use. When possible, housing
unit staff members make two additional
toilets and sinks available by leaving two
inmate cells unoccupied; however, both the
inmates and officers told us that this is not a
consistent practice among the three housing
units. Institution management further told us
that population pressures could partially
Double bunks in storage area.
explain why extra toilets and sinks are not
always available. Nonetheless, because of the

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lack of space and toilet facilities within these
three housing units, tensions and frustration
are increased among the inmates. Requiring
36 inmates to share one toilet and sink is
unreasonable and should be unacceptable to
the department.
Several rooms in the education building
lack adequate cooling. During summer
Housing unit roof that needs repair.
months, education classroom temperatures
often exceed 89 degrees Fahrenheit. Once the
temperatures exceed 89 degrees, potential health dangers for students taking
certain medications cause the school administrators
to dismiss all students in the affected education
classrooms, resulting in lost education time. Most
rooms in the education building have no air
conditioning, or they have small portable air
conditioning units that cannot provide sufficient
cooling to keep the temperature below 90 degrees. In
July 2007, the institution submitted an architectural
and engineering request to the department for the
installation of new air conditioning equipment in the
education buildings. As discussed in detail in
Example of cracked, rutted, and
uneven roadway.
Finding 2 of this report, students’ progress toward
their education goals is delayed when classes are
canceled because of heat.
Other areas of the institution are also
deteriorating. During visits to CIW, we noted
numerous examples of deteriorating
infrastructure at the institution. For example,
many walkways and roadways between
buildings are severely cracked or rutted, which
can cause staff members or inmates to trip and
fall and creates hazards as pedestrians and
vehicles attempt to avoid ruts and potholes. In
addition, the window opening and closing
Water damage in education room
caused by leaking roof.
mechanisms are broken in many inmate living
units, preventing windows from closing or
opening properly and creating drafts or entry points for water. Similarly, many
roofs have leaks that have caused water damage to the interior spaces of the
buildings. Lastly, the perimeter fence has rusted in certain sections, posing a risk
that an inmate could slip under the fence. Replacement of the fence was approved
in December 2004, but similar to the institution’s request for funding to renovate
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the support care unit, CIW is still waiting for
department funding to replace the fence.
During our interviews with staff members
and inmates, we repeatedly heard complaints
about the deteriorating condition of the
buildings and surrounding grounds. The staff
cited the lack of preventive maintenance,
timely repairs, and sufficient maintenance
staff necessary to maintain the aging
structures as reasons for the continued
deterioration.

Rusted wire on perimeter fence.

Recommendations
To prevent further deterioration of the state’s prison facilities and to ensure
that inmates are housed in decent living units, the Office of the Inspector
General recommends that the California Department of Corrections and
Rehabilitation take the following actions:
ƒ

Assemble an experienced team and conduct a thorough physical
plant inspection of the California Institution for Women.

ƒ

Using the results of the inspection, identify all maintenance and
safety problems and generate a corrective action plan.

ƒ

Using the corrective action plan, identify staffing requirements and
resources necessary to complete repairs and maintain the
institution’s infrastructure.

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Finding 2
The attendance rate is poor in education classes because of frequent
cancellations and other factors.

Students in the CIW education department’s academic and vocational programs
attended class for only 42 percent of the total available classroom hours. Although
the education department emphasizes the many opportunities available to
students, some factors, such as teacher absences and classrooms that are too hot,
caused the school to cancel 28 percent of the available classroom time. Other
contributing factors to low student attendance included class time lost because of
custody-related matters and absences caused by the students themselves; these
combined factors reduced attendance by another 30 percent. Consequently,
students take longer to complete their remaining course objectives and may never
complete their educational goals before they parole, thereby diminishing their
chances for employment and increasing their chances for reoffending and
returning to prison.
Education programs reduce inmate recidivism rates. A January 2006 study by
the Washington State Institute for Public Policy of ten basic adult and vocational
education programs found that such programs reduce inmate recidivism. The
study found that basic adult education programs reduced recidivism by an average
of 5.1 percent and that vocational education programs reduced recidivism by an
average of 12.6 percent.2
Students miss class more often than they attend class. CIW’s education
department (known as the El Prado Adult School) operates a main education
program that consists of academic and vocational programs, in addition to other
educational programs, such as bridging, pre-forestry training, and an inmate
library. According to the school’s Educational Staff Handbook, its mission “is to
provide inmates with the educational, occupational, and social skills to help them
better function in the institution; and upon their return, to society.”
However, we found students were out of class more often than they attended.
Based on our review of four months’ worth of academic and vocational
attendance data for fiscal year 2006-07, students did not attend class 58 percent of
the time, meaning they attended class only 42 percent of the time. The following
chart summarizes our findings. As shown on the chart, we found that 24 percent
of class time was lost because when teachers are absent, the school does not use
other available teachers as substitutes. Another 4 percent of available class time
was lost because classrooms lack adequate air conditioning. Custody-related
reasons such as training, modified programming, and a lack of sufficient custody
2

Washington State Institute for Public Policy, “Evidence-Based Adult Corrections Programs: What Works
and What Does Not,” January 2006.
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officer coverage caused an additional 20 percent of lost classroom time. Finally,
student absences for such reasons as illness, or voluntary unwillingness to attend
class accounted for the remaining 10 percent of lost classroom time.
Student Attendance and Class Closures
for Sampled Months in Fiscal Year 2006-07
Custody-related Class
Cancellations
20%

Source: CIW’s student academic and vocational
program attendance reports for August 2006,
December 2006, January 2007, and April 2007.

Attendance
42%

Student Absences
10%
Excessive Heat Class
Cancellations
4%
Teacher Absences
Class Cancellations
24%

Although the education department employs qualified teachers in its
bridging program, it does not redirect any of them to the main education
program when teachers there take time off. CIW’s main education program
had an average of 15 academic and vocational teachers in fiscal year 2006-07
(through April 30, 2007); however, the program had no teachers assigned to act as
substitutes. As a result, the school canceled classes when teachers became sick,
took vacation, attended training, or participated in teacher work days. During the
four months we reviewed, teacher absences forced class cancellations for 24
percent of the available class time and totaled over 41,000 student hours of lost
classroom time out of a possible 173,000 student hours available. These closures
equate to over 6,300 days of lost student time.
We identified a potential source of substitute teachers within the school’s bridging
program, which provides educational programming for inmates who cannot
participate in regular academic and vocational programming—typically because
the inmates reside in the prison’s reception center and are awaiting transfer to a
permanent prison location. According to the acting vice principal, most of these
teachers have the required credentials to act as substitute teachers for the main
education program, and we found that the teachers are currently underutilized by
the bridging program. Between July 2006 and April 2007, the school had seven
bridging classes taught primarily by teachers holding teaching credentials similar
to those of the teachers in the main academic education program. During that
same period, the average student enrollment in the bridging program fell from 45
students to 26 students per class, indicating that bridging program teachers are
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being increasingly underutilized. We estimated that from July 2006 through April
2007, approximately $163,400 in teacher salaries and benefits could have been
more effectively used if the bridging teachers had been redirected as substitutes to
avoid canceling academic and vocational classes.
The department’s Office of Correctional Education told us that redirecting
underutilized teachers to act as relief staff was well within the school
management’s authority. We met with the institution’s warden, associate warden,
labor relations officer, and acting vice principal to discuss consolidating the
school’s half-filled bridging classes and redirecting teachers to substitute for the
regular academic and vocational program classes when those teachers are absent.
The prison’s officials could not think of any significant reasons why this solution
could not be feasible. In fact, after bringing the issue to management’s attention,
the acting principal told us that in August 2007 the education department began
reassigning some of the bridging teachers to act as substitute teachers in the
academic program. However, because these initial actions took place near the end
of our field work, we did not verify the extent of their effectiveness.
The school cancels many of its classes because some classrooms lack
adequate air conditioning. The main education programming takes place
primarily in two older buildings that have inadequate air conditioning. As a result,
the school’s management releases all students in a class any time the inside
temperature exceeds 89 degrees. We reviewed attendance records from August
2006 and found that excessive heat caused the institution to cancel class for 17
percent (over 7,700 hours) of the total available class time during that month. In
addition, the school provided us documentation that identified 3,100 and 13,100
additional classroom hours lost because of excessive heat for the months of June
and July 2006, respectively.
Students’ absences also play a part in causing low attendance and lost
classroom time. Our review found that students also contribute to lost classroom
time. Ten percent of all available academic and vocational classroom time lost is
attributable to students who do not attend class for either approved or unapproved
reasons. Specifically, 7 percent of all classroom time is lost because students have
approved absences for such reasons as illness or attorney visits. For the remaining
3 percent of the time, students are absent from class without proper authorization,
and sometimes teachers do not initiate disciplinary action when students are
habitually late or absent. For example, we selected six students whose unexcused
absences generated high amounts of lost classroom hours, and we found that
teachers had initiated discipline for only about 20 percent of the lost hours. It
appears that the school’s management does not enforce the procedures contained
in the Education Staff Handbook regarding situations in which a teacher must
issue a minor rules violation or even a more serious rules violation disciplinary
report when circumstances warrant. Although 3 percent is a small portion of the
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overall classroom time, inconsistent student discipline sends a mixed message to
students about the importance of their attendance and can interrupt their learning
process.
The institution cancels some of the classroom time because of custody-related
matters. During the four months sampled from fiscal year 2006-07, we found that
20 percent of all available academic and vocational classroom time lost was
directly attributable to custody-related reasons. The custody-related reasons are
beyond the education program’s or the students’ control and can include custody
staff training, modified programming, and custody staff shortages.
In summary, when students miss classes for any of the reasons cited above, they
take longer to complete their remaining course objectives. In some instances, they
may never complete their educational goals before they parole. When this
happens, students diminish their chances for employment and increase the
likelihood they will reoffend and return to prison.
Recommendations
To minimize the number of lost classroom hours and increase student
attendance, the Office of the Inspector General recommends that the
California Institution for Women and the school’s management:
ƒ

Ensure that they effectively utilize all available teaching staff and
redirect teachers as necessary.

ƒ

Ensure that the classrooms have adequate air conditioning by
obtaining sufficient capital outlay funding to purchase and install
appropriate air conditioning units.

ƒ

As part of the performance appraisal process, periodically review
teacher files to ensure that teachers initiate disciplinary actions in
accordance with the policies established in the Education Staff
Handbook.

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Finding 3
The California Institution for Women does not always assign inmates with low
reading abilities to adult basic education classes.

State law requires institutions to have literacy programs designed to ensure
inmates read at the ninth grade level. However, we found that CIW did not always
identify and assign inmates who read below the ninth grade level to an academic
literacy program or, at the least, place them on a waiting list. Instead, the
institution assigned many inmates with low reading abilities to other institutional
jobs or its firefighting programs. The lack of policy adherence occurred, in part,
because the institution’s inmate assignment practices conflicted with policies
published by the department and with state law designed to ensure that inmates
read at a ninth grade level upon parole. As a result of CIW placing inmates with
low reading scores in programs other than education, the inmates miss an
opportunity to increase their reading skills and their overall educational
proficiency, thus diminishing their potential for success on the outside.
The Legislature and the department consider education to be an important
part of successful reentry into society. According to California Penal Code
section 2053, the Legislature has found and declared “that there is a correlation
between prisoners who are functionally literate and those who successfully
reintegrate into society upon release.” Penal Code section 2053.1 requires that
every state prison have a literacy program to ensure that, upon parole, inmates
have a ninth grade reading ability. The department’s Operations Manual section
101010.1 similarly states that the goal of offering programs such as academic and
vocational classes “is to provide inmates with educational, occupational and
social skills to help them function better in the facility and upon return to
society.”
Contrary to its requirements, the
July 12, 2007 - Job Assignments for
institution assigned many inmates
Students with Reading Scores Lower Than
the Ninth Grade Level
with low reading abilities to
Number of
programs other than its adult basic
Job Assignment
Inmates
education program.
Cooks, porters, other
74
We found that inmates with reading
Fire camp or training
137
scores below ninth grade level were
Total
211
assigned as cooks, porters, utility
workers, sewing machine operators, firefighters, and fire camp trainees, rather
than assigned to adult basic education literacy classes or placed on a waiting list.
Specifically, based on information provided by CIW, we reviewed the reading
scores for inmates assigned to various non-literacy programs as of July 12, 2007,
and found 211 inmates with reading scores below the ninth grade level. These
inmates included 74 inmates assigned to other institution jobs and 137 inmates
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assigned to the firefighting program, which includes the fire camp or its
prerequisite training programs.
The institution’s assignment lieutenant could not give a reason why inmates with
low reading abilities would have been assigned to non-firefighting program jobs
such as cooks and porters instead of assigned to the education program or placed
on a waiting list. But the assignment lieutenant speculated that because the inmate
assignment process is sometimes chaotic, the education requirement was
overlooked in these instances.
With respect to firefighting, the assignment lieutenant and the chairman of the
Unit Classification Committee stated that low reading levels do not disqualify
inmates from being endorsed to firefighting programs. When the assignment
lieutenant assigns firefighting-endorsed inmates to their initial firefighting
training jobs, reading levels are not evaluated first to determine if the inmates
should be recommended for reendorsement to CIW’s general population so that
the inmates can be assigned to literacy classes. Both the Unit Classification
Committee’s chairman and the Inmate Assignment Office’s lieutenant told us that
they allowed the practice of assigning inmates with low reading skills to
firefighting programs because they thought firefighting program endorsements
had priority over education literacy requirements. However, we could find no
approved policies and procedures to support this practice. When we interviewed
CIW’s warden, the associate warden of custody operations, and the department’s
classification services representative assigned to CIW, they all acknowledged that
an inmate’s need to meet literacy reading requirements should have priority over
firefighting program assignments.
The OIG acknowledges that inmate firefighters provide valuable services to
protect California’s citizens during wildfires and other state emergencies. Striking
a proper balance between providing these important services and also providing
literacy programs for inmates creates a potential conflict for the department. In
resolving this conflict, the department should work with the Legislature so that
the need to fulfill both important objectives does not conflict with state law.
The institution excludes some inmates from educational literacy
requirements if the inmate has a high school diploma or equivalent. Not only
does the institution fail to assign inmates with low reading scores to literacy
programs, but it also excludes from consideration inmates with low reading scores
who have prior academic certifications, such as a high school diploma or a pass
on the test of general education development (GED). According to the inmate
assignment lieutenant, if an inmate possesses a high school diploma or a GED
certificate, the inmate assignment office assumes the inmate reads at or above the
ninth grade level, and as a result, the inmate is not assigned to academic education
classes.
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Our review of assignment office and education department records identified
more than 100 inmates, in addition to the 74 discussed earlier, who were assigned
to non-literacy programs yet still had reading scores below the ninth grade level
even though the inmates reportedly had GED certificates or high school diplomas.
This practice is inconsistent with California Penal Code section 2053.1, which
requires that the institution have a program that ensures all inmates read at a ninth
grade level. The Penal Code has no provisions to exclude inmates who have a
high school diploma or its equivalent. Further, as illustrated during our review,
having a high school diploma or equivalent does not assure that an inmate can
read at the ninth grade level.
The Penal Code and the department Operations Manual set different
minimum standards. According to California Penal Code section 2053.1, every
state prison must have a literacy program to ensure that, upon parole, inmates
have at least a ninth grade reading ability. In contrast, the department’s
Operations Manual section 101010.1 establishes a lower reading level standard
than the Penal Code, requiring that inmates below a sixth grade reading level be
assigned to adult basic education or English as a second language programs.
Although both requirements are designed to improve the literacy of inmates, the
department’s policy does not fully comply with the Penal Code. Until the
department aligns its standard with the Penal Code, the institutions cannot
develop their own inmate education procedures that are consistent with both the
Penal Code and the department’s Operations Manual.
Recommendations
To ensure that the department’s policies to improve inmate literacy are
consistent with the requirements in the California Penal Code, the Office of
the Inspector General recommends that the department:
ƒ

Compare the inmate literacy requirements contained in its
Operations Manual section 101010.1 with those of Penal Code
section 2053.1 and change the department Operations Manual as
necessary.

ƒ

For the inmate firefighting program, assess whether legislative
exemptions are needed from current state laws related to inmate
literacy, especially during dry years.

To ensure that the prison assigns inmates with low reading abilities to
appropriate education programming, the Office of the Inspector General
recommends that the California Institution for Women:
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ƒ

Assign all inmates with reading scores below the ninth grade level to
formal education programs regardless of their educational
attainment.

ƒ

Develop written procedures that align with the department’s current
education policies.

ƒ

Provide training to members of the Unit Classification Committee
and the Inmate Assignment Office staff on the proper way to assess
test scores before assigning inmates to education, forestry, and other
programs at the institution. If exceptions to the written policies and
procedures are necessary, written approval from an associate
warden or higher should be placed in the inmate’s case file.

ƒ

Monitor the work of the Unit Classification Committee and the
Inmate Assignment Office until the staff demonstrate that they
consistently comply with the written policies and procedures.

Bureau of Audits and Investigations
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Finding 4
Inmates sent to off-site medical specialists do not always receive prompt
follow-up medical care.

The Division of Health Care Services requires that an inmate receiving a routine
specialty service (typically an off-site appointment) must receive follow-up
medical care from her primary care physician within 14 days. However, we found
that CIW medical staff members missed the 14-day standard in nearly half the
files reviewed and that the delay averaged 12 days beyond the 14-day standard.
Excessive delays in follow-up care by the primary care physician can endanger
inmates’ health and jeopardize compliance with the court-ordered quality-of-care
standard.
Prison medical care is overseen by a federal court-appointed receiver and
has been the subject of lawsuits. In 2001, the Prison Law Office, on behalf of
various inmates, brought a class action lawsuit, Plata v. Schwarzenegger, against
the State of California over the quality of medical care in the state’s prison
system. In June 2005, the United States District Court appointed a receiver to
oversee medical care in the prison system.
Although inmates eventually received follow-up care, the care was delayed in
nearly half the cases the OIG reviewed. According to the policies of the
department’s Division of Correctional Health Care Services, the division is
required to provide medically necessary specialty services to inmates. In order to
do so, the division is to establish a diagnosis, make recommendations for a
diagnostic work-up, provide therapy, and establish a treatment plan that includes
follow-up visits with the specialist or the primary care physician. The division’s
procedures require the patient to be seen by the primary care physician within 14
calendar days of a routine specialty service. Of the 20 inmate files we sampled,
the follow-up care was delayed beyond the required 14 days for nine inmates. The
average delay in providing follow-up visits for these nine inmates was 12 days
beyond the 14-day requirement, and in one instance, the delay was 22 days.
We selected seven of the nine instances in which follow-up care was delayed and
reviewed the inmate medical files to identify the reason for the delay. No
explanation for the delay was evident in five of the seven files, and the two
remaining files were unavailable during our review. We asked the medical
appeals coordinator at the institution if there were any reasons for these delays.
She told us that she was unable to identify reasons for these specific cases, but
that scheduling difficulties caused by too many inmates and too few doctors are a
typical reason. During our exit interview at CIW, the health care manager stated
that part of the problem was the failure by the health care administrative staff to
schedule the appointments timely.
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The requirement for a prompt follow-up visit ensures that the primary care
physician or the specialist develop a treatment plan for each inmate without
unreasonable delay. Delays in follow-up care can potentially have a negative
effect on inmates’ health. Further, failure to follow the prescribed timeline for
follow-up visits jeopardizes compliance with the federal court-ordered quality-ofcare standard.
Recommendation
The Office of the Inspector General recommends that the department’s
Division of Health Care Services and the California Health Care
Receivership assess the possible causes for the delays in providing inmates
with prompt follow-up care, including the timely scheduling of appointments
and whether there are too few doctors available to meet the 14-day
requirement, and take appropriate corrective action.

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Office of the Inspector General

Page 28

Finding 5
The California Institution for Women does not complete its use-of-force
incident packages within the required timelines.

Over half the use-of-force incident packages prepared by CIW staff members are
not submitted to headquarters within the 30-day time requirement. For 21 percent
of those late packages, the use-of-force committee recommended further on-thejob training to address staff deficiencies. When use-of-force packages are not
submitted on time, delays occur in corrective training, thereby increasing the
possibility that the staff’s deficiencies in following use-of-force rules could
reoccur.
A use-of-force incident package consists of the incident report and other
supplemental documents, such as the manager’s review, the incident
commander’s review, the staff’s synopsis of the incident, and any reports of injury
to staff members and inmates.
Over half the use-of-force incident packages are submitted late. The
California Institution for Women Department Operations Manual Supplement
section 51030.1 states that packages on “all incidents involving UOF [use of
force] need to be in the Associate Director Reception Centers Section3, Division
of Adult Institutions office within 30 days.” To meet this requirement, the
supplement sets the following time schedule:
Week One
Week Two
Week Three
Week Four

Sergeant and Lieutenant review, 72 hours; Facility Captain review, three business
days
Associate Warden review, two business days; Use-of-Force Coordinator, four
business days
Use-of-Force Committee review, third Monday
Associate Director Reception Centers Section, fourth Monday

Of the 33 incidents at CIW that resulted in use of force from January 1, 2007,
through May 13, 2007, the use-of-force coordinator did not receive 19 packages
(58 percent) within 30 days of the occurrence date—a delay that rendered the
packages overdue for submittal to headquarters even before CIW’s use-of-force
committee review. The use-of-force coordinator received seven of the packages
more than two months after the occurrence date, two of which were forwarded 3½
months after the incident date. Of the 19 late packages, the use-of-force
committee concluded that four incidents required on-the-job staff training to
address deficiencies in staff actions. The specific training areas included
searching administrative segregation inmates before moving them, responding to
alarms and emergencies, ensuring staff safety, and properly assessing threats.
3

Since the establishment of the CIW supplement, the responsibility has transitioned to the Associate
Director, Female Offender Programs and Services.
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Facility staff told our inspectors that the use-of-force packages are late mainly
because the use-of-force coordinator is not tracking the packages, following up
with report preparers to ensure on-time submittals, or alerting her supervisor of
overdue reports. In addition, her supervisor, who works in the investigative
services unit, does not have access to the automated use-of-force log, hindering
his ability to obtain updated information when the use-of-force coordinator is not
in the office.
The use-of-force coordinator already keeps and updates a log via electronic
spreadsheet that identifies the dates of incidents and other relevant information.
The use-of-force coordinator could use the information contained in the log to
provide staff reminders of due dates as deadlines approach and also quickly
identify and follow up on late packages.
The effects of late submissions are significant. When use-of-force incident
packages are submitted late to the use-of-force committee, there are two potential
effects. First, if the use-of-force committee recommends job training to prevent
reoccurrence of a staff member’s improper use of force, then any delay increases
the possibility of that staff member’s repeated improper use of force, which could
lead to safety concerns as well as potential litigation. Second, unduly delayed
packages erode the one-year time limit the department has to review the use-offorce committee findings, investigate possible excessive use of force, and initiate
adverse action against sworn staff. Any delay in the investigation of an incident
can lead to the degradation of evidence and the inability of staff members to recall
the details of the incident.
Recommendations
The Office of the Inspector General recommends that the California
Institution for Women:
ƒ

Use the current electronic use-of-force log as a tracking system to
ensure the prompt follow-up on use-of-force incident packages
submitted late.

ƒ

Immediately enforce its policy that all staff members are to
forward their use-of-force incident packages to the use-of-force
coordinator within stated timeframes. The institution should use
performance appraisals and progressive discipline to hold staff
members and the use-of-force coordinator accountable for their
adherence to the policy.

Bureau of Audits and Investigations
Office of the Inspector General

Page 30

Finding 6
The visiting center staff does not consistently adhere to visiting policies and
regulations, increasing the risk of visitors bringing banned materials into the
institution.

The custody officers who staff the visiting center were unfamiliar with visiting
procedures because they lacked training, and the staff was not properly screening
visitors to prevent them from bringing weapons or unapproved materials into the
visiting center. Also, none of the visiting center staff members monitored the
visitors and inmates during their visits by actively roaming the visiting area to
ensure they were adhering to the visiting rules and regulations. When staff
members fail to properly screen or monitor inmates and their visitors, there is
increased risk that banned substances, dangerous weapons, or prohibited clothing
are allowed into the visiting center, potentially jeopardizing the safety and
security of the visitors, inmates, and staff.
Although the department considers inmate visits crucial for improving inmate
morale and maintaining inmate and family connections, the visiting center is also
a vulnerable entry point for contraband items, such as drugs and weapons. As
such, existing visiting policies and regulations protect the safety of inmates,
visitors, staff members, and the public. Not enforcing or adhering to the
regulations places everyone at risk and diminishes the overall security of the
institution.
California Institution for Women Procedure #307 – Inmate Visiting (June 2006)
requires that each visitor pass a metal detector test. Visitors who cannot clear the
metal detector are subject to additional searches before they enter the visitor
waiting room. Moreover, the California Visiting Rules and Regulations (May
2006), California Institution for Women Procedure #307 – Inmate Visiting (June
2006), and the California Code of Regulations, Title 15, section 3174, describe
the rules and regulations visitors and inmates are to adhere to during visiting,
including the clothing that visitors are prohibited from wearing. Some of the
disallowed items are underwire bras, form-fitting clothing, and green or blue
clothing.
The staff does not consistently screen visitors for weapons, other contraband,
or unapproved clothing. During our unannounced site visit in June 2007, we
observed the visiting center staff allowing visitors to enter the facility who had
not cleared the metal detector and who were wearing prohibited clothing. Rather
than strictly enforcing existing policy, the visiting center staff relied on the
visitors’ explanations of why they did not clear the metal detector. For example,
one woman said it was probably her underwire bra that was setting off the metal
detector, and another mentioned it was probably the tassels on her shorts. Despite
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not clearing the metal detector, visiting center staff still allowed the visitors to
enter the facility without using a handheld metal detector or performing other
additional searches. Also, the metal detector’s sound option was turned off
because the detector’s sensitivity causes it to sound off on every visitor. An
indicator light on top of the detector also showed whether a visitor has cleared the
metal detector, but only the tallest officer was able to see the light.
In addition to not properly using the metal detector to screen visitors, some staff
members allowed visitors into the visiting center with banned clothing. One
visitor was told he could not visit wearing blue jeans, but when he returned, he
was allowed to enter the visiting center wearing olive-green corduroy pants—a
disallowed color and a shade of green that is similar to that used by the uniformed
custody staff. The intent of specifying disallowed clothing is to ensure that
visitors do not resemble inmates or custody staff.
Poor screening of visitors increases the risk that weapons, drugs, or other
contraband may be introduced into the institution. Even though staff members
perform unclothed searches of the inmates before returning them to their housing
units, contraband brought into the visiting area is still a threat to other visitors,
inmates, and staff. This is because inmates and visitors can hide the contraband in
the visiting area and arrange for the item to be retrieved by other inmates, or they
can throw or place items over the fence for later retrieval.
The staff does not monitor the inmates and visitors during their visits. During
the four hours we observed the visiting area, none of the visiting center staff
roamed the visiting area to monitor visitor and inmate activities to mitigate the
exchange of contraband and to ensure that inmates and visitors adhered to the
visiting rules and regulations. Instead, the visiting center staff stayed at the front
counter. During standing count when all visitors are required to stay in the inside
visiting room, staff members did not walk among the visitors, thereby increasing
the potential for visitors to hide contraband for later retrieval by inmates. Because
there are no video cameras installed in the visiting rooms, the staff’s ability to
identify contraband exchanges is even further limited.
Many visitors and inmates mentioned that the visiting center staff was not
monitoring visits closely enough and that contraband can easily be brought into
the institution. Having visitors notice and comment on the lack of monitoring is
yet another sign of the institution’s vulnerability. We also observed that one
inmate with a male visitor had moved two chairs to the perimeter fence, the
furthest point from the visiting room and a violation of security procedures that
state that visitors and inmates are to stay away from the fence. Allowing inmates
and visitors to move furniture near the perimeter fence could enable inmates to
climb the fence and escape.

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Little or no training and high turnover contribute to lax enforcement of
visiting policies and procedures. The visiting center staff members mentioned to
us that they had not received any training related to inmate visiting, and only two
of the six correctional officers knew how to operate the terminals used to verify
visitor approval. The most senior staff member had only four months experience
in visiting, and three others had four or fewer days experience. For one officer,
the day of our visit was her first day as part of the visiting center staff, and she
was reading the CIW visiting rules and regulations to familiarize herself with the
visiting policy because no one provided her with any guidance on her
responsibilities. In addition, the visiting center sergeant had been assigned to
visiting for only three months. He acknowledged he had not provided any training
to his staff, noting he also had not received any training on his duties and
responsibilities. Not only had none of the visiting center staff members received
formal or on-the-job training, but also none of the officers had signed the post
orders.4
The Visiting Sergeant Post Orders, signed by the visiting center sergeant on April
7, 2007, require that the sergeant ensure he complies with all the visiting room
procedures and regulations and that he provide his subordinates with the
necessary on-the-job training. Improperly trained staff members jeopardize the
safety and security of the facility by potentially endangering themselves, as well
as other staff members, visitors, and inmates.
Another factor contributing to the lax enforcement of visiting rules is the high
turnover of visiting center staff. When we discussed our concerns with the visiting
center sergeant, he noted that the different visiting hours on Saturday (8:30 a.m. to
3:00 p.m.) and Sunday (1:30 p.m. to 8:00 p.m.) do not appeal to officers when
they select posts. This lack of appeal contributes to a high turnover rate for the
visiting center officers.
One more factor contributing to the lax enforcement of visiting rules may be an
inadequate staffing level for CIW’s visiting center. Of the three adult female
correctional institutions, CIW processes the most visitors yet has the fewest
visiting center staff members. CIW’s visiting center staff consists of one
correctional sergeant and six correctional officers, while the visiting center staff at
the Central California Women’s Facility and the Valley State Prison for Women
each consists of one correctional lieutenant, one correctional sergeant, and 12
correctional officers. The Central California Women’s Facility and the Valley

4

The department’s Operations Manual, sections 51040.1 to 51040.6.1, requires that each posted position in
an institution have a post order that details the general functions and specific duty directives for that post.
Employees under post orders are required to sign and date the post order, signifying they understand the
duties and responsibilities of the post “when the employee is assigned to the post, when the post order has
been revised, or upon returning from an extended absence.”
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State Prison for Women have twice the number of visiting center staff members
yet typically process fewer visitors per day than CIW.
In addition to its comparatively low staffing levels, CIW’s visitor processing
structure is located outdoors and is small—factors which may cause officers to
rush security procedures during inclement weather and restrict officers’ ability to
conduct private searches. According to the warden, CIW received $500,000 for a
new modular building to replace the prison’s current outdoor visitor processing
structure.
Recommendations
The Office of the Inspector General recommends that the California
Institution for Women:
ƒ

Immediately provide training to all visiting center staff members
regarding their responsibilities for enforcing the visiting rules and
regulations.

ƒ

Provide adequate oversight of the visiting function to ensure the
visiting center staff is enforcing all inmate visiting policies and
regulations, terminating visiting for non-compliance with visiting
regulations, and roaming the visiting areas.

ƒ

Use the sound option on the metal detector to prevent
misinterpretation of the metal detector’s readings.

ƒ

Consider installing security cameras to provide an additional
deterrent to the introduction of contraband.

ƒ

Implement measures to address the high turnover of custody staff
assigned to the visiting area.

The Office of the Inspector General also recommends that the California
Department of Corrections and Rehabilitation perform an analysis of the
visiting center staffing levels at the three adult women’s correctional facilities
to determine whether appropriate staffing exists at each facility based on the
average number of visitors each institution processes daily and the physical
layout of each visiting facility.

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Finding 7
The California Institution for Women fails to ensure that staff members
assigned to armed posts always meet their quarterly weapons qualifications
requirements.

Despite a department requirement that only peace officers who have completed
firearms training and are currently qualified be assigned to armed posts, we found
seven peace officers assigned to armed posts who did not participate in the last
quarterly range qualification session in April 2007. Therefore, more than three
months elapsed between each of their qualifications. As a result, seven of the 58
employees tested who required quarterly weapons qualifications were not current
with their quarterly requirements. A contributing factor is that training staff was
not tracking compliance with the quarterly requirement.
The department Operations Manual section 32010.19.7 requires that all
department peace officers issued a department weapon as part of their regular or
special assignment, such as armed posts, must complete a proficiency course on a
quarterly basis before assuming the post. Title 15 of the California Code of
Regulations section 3276(a), further stipulates that only peace officers who have
satisfactorily completed firearms training and who are currently qualified to fire
department firearms will be assigned to armed posts.
Some staff members are not meeting quarterly weapons qualification
requirements. Of the 58 employees tested who required quarterly weapons
qualifications, seven peace officers (12 percent) were not current with their
quarterly requirements. Two peace officers had actually qualified before they
assumed their posts; however, because they did not qualify during the April 2007
range sessions, they allowed between four and six months to elapse between their
qualifications. The remaining five peace officers did not qualify before they
assumed their posts, and because they did not qualify in April 2007, they
continued to be out of compliance. Although four of these five staff members
qualified within the next quarter, the length of time between their qualifications
ranged between seven and nine months. One of the five peace officers had not
requalified as of June 30, 2007, and went on extended medical leave beginning
July 1, 2007. As a result, the peace officer did not requalify during the July 2007
range sessions.
An ineffective process is in place to track the quarterly requirement. The
institution’s in-service training staff was not aware of the seven peace officers
who had not qualified, but they agreed that the staff had not met the quarterly
qualification requirements. The training staff incorrectly believed that a peace
officer’s last annual qualification would be sufficient for the post assignment until
the next quarterly qualification, even if that qualification occurred more than a
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quarter ago. In such cases, the peace officers would simply attend the next
quarter’s range qualification session to stay on track with the quarterly
requirements instead of having them immediately attend a special session.
On June 11, 2007, we identified the exceptions by comparing the peace officers’
names from two different lists: one that included the post assignments for all staff
members and another that indicated who had successfully completed the range
sessions held in April 2007. The training manager agreed that comparing the two
lists periodically would help identify staff members who have yet to qualify
during a particular period, including those staff members who did not qualify
before assuming their posts. Furthermore, shortly after we discussed these
exceptions with the training staff, the acting in-service training manager issued a
memorandum on June 19, 2007, to all custody staff members emphasizing which
posts required quarterly qualifications and reminding the custody staff that they
needed to meet the quarterly requirements before assuming their posts.
Danger exists when staff members are not adequately qualified. Regularly
qualifying with a firearm helps to keep the staff’s weapons skills fresh in case
they are ever needed. The importance of adequate weapons training is evidenced
in the OIG’s Special Review into the Shooting of Inmate Daniel Provencio on
January 16, 2005 at Wasco State Prison issued in June 2005. Inmate Provencio
died after being struck in the head by a 40 mm launcher fired by an officer
attempting to quell a fight between inmates. We reported that one of the
contributing factors for the control booth officer’s inaccurate placement of the 40
mm projectile may have been inadequate training on the weapon with live rounds.
Although the control booth officer participated in weapons training one month
before the incident, we could not determine from the records whether the officer
had actually fired a 40 mm round during this training or had simply handled the
weapon.
Without having demonstrated recent proficiency, staff members potentially place
themselves and others at risk of injury and expose the state to litigation if they
make a mistake with their firearms, such as shooting an unintended target. Thus, it
is imperative that staff members demonstrate their proficiency at the required
intervals.
Recommendations
The Office of the Inspector General recommends that the California
Institution for Women:
ƒ

Ensure all staff members who are issued a department firearm as part
of their regular or special assignment, such as armed posts, complete

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a quarterly proficiency course before and after assuming the
assignment.
ƒ

Set up a process to track adherence to the quarterly weapons
requirement for peace officers who are issued a department firearm
as part of their regular or special assignment.

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California Department of Corrections
and Rehabilitation’s Response

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