OFFICE OF THE INSPECTOR GENERAL
MATTHEW L. CATE, INSPECTOR GENERAL

BUREAU OF INDEPENDENT REVIEW
DAVID R. SHAW
CHIEF ASSISTANT INSPECTOR GENERAL
ROBERT A. BARTON
STEPHEN MILLER
HOWARD E. MOSELEY
TIM L. RIEGER
SENIOR ASSISTANT INSPECTORS GENERAL

SEMI-ANNUAL REPORT
JULY–DECEMBER 2006

MAY 2007
STATE OF CALIFORNIA

CONTENTS
FOREWORD ----------------------------------------------------------------------------------------------------1
INTRODUCTION ---------------------------------------------------------------------------------------------- 2
ASSESSMENT OF THE MADRID REMEDIAL PLAN ------------------------------------------------------- 3
DEPARTMENT EXECUTIVE MANAGEMENT ------------------------------------------- 3
OFFICE OF INTERNAL AFFAIRS, HEADQUARTERS ------------------------------------ 3
OFFICE OF INTERNAL AFFAIRS, NORTHERN REGION ------------------------------ 4
OFFICE OF INTERNAL AFFAIRS, CENTRAL REGION --------------------------------- 4
OFFICE OF INTERNAL AFFAIRS, SOUTHERN REGION ------------------------------- 5
EMPLOYMENT ADVOCACY AND PROSECUTION TEAM ------------------------------- 6
HIRING AUTHORITIES ------------------------------------------------------------------- 7
EXPLANATION OF REVISED FORMAT -------------------------------------------------------------------- 9
SUMMARY OF MONITORING ACTIVITIES ---------------------------------------------------------------- 12
TABLE OF DISTINGUISHED CASES ----------------------------------------------------- 15
TABLE OF DEFICIENT CASES ----------------------------------------------------------- 16
TABLE OF SATISFACTORY CASES ------------------------------------------------------- 21
TABLE OF CRITICAL INCIDENTS ------------------------------------------------------- 67

FOREWORD

M

y mission as the Inspector General is to ensure the integrity of California’s correctional
system. Through the Bureau of Independent Review, we can now provide real-time
monitoring and oversight of serious investigations and employee discipline processes. The
bureau works closely with the California Department of Corrections and Rehabilitation to make
certain that internal affairs investigations are fair—and that discipline is appropriate—while at the
same time safeguarding the rights of employees and inmates.
We have come a long way since establishing the Bureau of Independent Review just two years ago,
and I am pleased with the progress of both the bureau and the department. I believe that a sound
disciplinary process is key to addressing the reforms set out by the federal court; the following semiannual report is a testament to the department’s efforts to improve this process.
I am confident that the Department of Corrections and Rehabilitation is committed to achieving
reforms through a constitutionally valid internal affairs process. The department continues to
demonstrate this commitment by collaborating with the bureau to improve policies and procedures
affecting the department’s internal affairs and employee disciplinary systems. The public can now
depend on the department and the bureau to work together to accomplish these reforms, which are
essential to developing a model correctional system in California.
I would like to extend my support and heartfelt thanks to the department and to all the stakeholders
who assisted with the bureau’s first two years of operation. I would also like to thank the attorneys,
investigators, and support staff of the Bureau of Independent Review. Their dedication to correctional
reform and fair, independent oversight is vital to the mission of the Office of the Inspector General—
integrity in the correctional system, and professionalism and respect behind California’s prison walls.
— MATTHEW L. CATE, INSPECTOR GENERAL

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INTRODUCTION

I

am pleased to present the fourth semi-annual report of the Bureau of Independent Review. This
report details the bureau’s oversight and monitoring activities from July 1, 2006, to December 31,
2006, and comes at the close of the bureau’s second year of operations. During this two-year
period, the bureau has actively assisted the California Department of Corrections and Rehabilitation
in meeting its objectives pursuant to the Madrid Remedial Plan.1
The reforms envisioned by the Madrid Remedial Plan gained further momentum during this reporting
period, resulting in timelier and more thorough investigations, greater consistency and fairness in
disciplinary outcomes, and greater transparency in the process.
During the period covered in this report, the department underwent major structural changes as well
as changes in executive leadership that created challenges for the employee disciplinary process and
for the bureau. In addition, the department experienced significant turnover in hiring authorities,
especially among its wardens. The department and the bureau also experienced significant change
associated with the ongoing reforms of the correctional health care system.
The bureau experienced some of its own turnover with the loss of three special assistant inspectors
general, all of whom decided to return to their former careers as prosecutors. Meanwhile, the bureau
hired two new special assistant inspectors general with backgrounds in criminal and civil rights law.
In closing, I would like to thank the Inspector General and his administrative staff, whose unqualified
support of the bureau has made our continued success possible. I would also like to thank my
counterparts at the Department of Corrections and Rehabilitation, in particular at the Office of
Internal Affairs and the Employment Advocacy and Prosecution Team, whose daily cooperation and
support greatly assist the bureau in its oversight and monitoring responsibilities. I would especially like
to thank the dedicated staff of the Bureau of Independent Review, whose hard work and pursuit of
excellence have helped make significant progress in the Madrid Remedial Plan possible.
On behalf of the Office of the Inspector General, I invite you to review this fourth semi-annual
report at www.oig.ca.gov and provide us with your feedback.
— DAVID R. SHAW, CHIEF ASSISTANT INSPECTOR GENERAL,
BUREAU OF INDEPENDENT REVIEW

For a detailed explanation of the Madrid Remedial Plan, refer to the bureau’s semi-annual report for the period January–
June, 2005, Appendix A, “The Madrid Litigation.”

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ASSESSMENT OF THE MADRID REMEDIAL PLAN
At the close of the first two years of the Bureau of Independent Review’s operations, the reforms
envisioned by the Madrid 2 Remedial Plan continue to have a significant and positive impact on the
timeliness, quality, and objectivity of the California Department of Corrections and Rehabilitation’s
investigatory and employee discipline process. The following summary provides a general assessment
of the department’s key entities involved in investigating and prosecuting allegations of employee
misconduct. A more detailed assessment of individual cases monitored by the bureau during this
reporting period is presented in the tables later in this report.

Department Executive Management
There were significant changes to the department’s executive team during this reporting period. These
personnel and organizational changes inevitably had some impact on the effectiveness and pace of the
Madrid reforms. Almost all of the senior-level personnel at department headquarters who were
familiar with the Madrid Remedial Plan left their positions, creating a void of knowledge that resulted
in the delay of some personnel actions. These changes also caused the department’s responsibilities
pursuant to the Madrid Remedial Plan to be openly questioned. Although the department’s new
executive management has become generally supportive of the bureau and its monitoring activities,
the bureau continued to expend considerable time and resources familiarizing them with the
requirements of the Madrid Remedial Plan and related department policies and procedures.

Office of Internal Affairs, Headquarters
This reporting period began with a newly appointed assistant secretary for the Office of Internal
Affairs, the third person appointed to this position since the inception of the bureau’s operations in
2004. The department also created two new supervisory positions within the Office of Internal Affairs
in recognition of the complexity and significant workload involved in the office’s operations. The two
positions are the chief of field operations and the chief of administrative operations, to which the
department appointed well-qualified personnel. Together, the three new appointments brought
considerable experience and stability to the Office of Internal Affairs and improved the overall quality
of its leadership. Throughout these changes, the working relationship between the bureau and the
Office of Internal Affairs’ headquarters remained positive and productive.
Changes in department staffing policies have also had an impact on the department’s investigative and
disciplinary process during this reporting period. For example, liaison sergeant positions that
previously reported to investigative services units at the adult institutions were redirected to the Office
of Internal Affairs. These positions had historically been resources at the institutions upon which the
Office of Internal Affairs and the bureau had relied to assist in internal affairs operations.

Refer to the bureau’s first semi-annual report (January–June 2005) at www.oig.ca.gov for a full discussion of the Madrid
Remedial Plan (previously referred to as the Madrid v. Woodford litigation), including a synopsis of the court’s ruling.

2

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Another major change was the reclassification of the employee relations officer positions from
correctional lieutenants to non-peace officer positions. The loss of the peace officers serving as
employee relations officers has been somewhat problematic. Having peace officers serve as employee
relations officers had allowed the department to train its officers in employment actions, which served
them well when they moved into more senior positions. The training was especially valuable if they
later became hiring authorities.
In addition, as employee relations officers, the lieutenants were often in a better position to advise
hiring authorities as to appropriate levels of discipline and standards of acceptable employee conduct.
The impact of the loss of experienced peace officers as employee relations officers is increased
because civilian employee relations officers with less relevant experience are now responsible for
providing guidance to hiring authorities and representing the department in disciplinary actions. To
help alleviate these problems, the department scheduled extensive in-service training for the new
employee relations officers during the first quarter of 2007.

Office of Internal Affairs, Northern Region
The Office of Internal Affairs, northern region, experienced significant leadership changes during this
reporting period. A new special agent in-charge was appointed, as were two new senior special agents,
one of whom now heads the criminal investigation team. These changes, along with an increased
caseload, did not interfere with the generally positive relationship between the bureau and the Office
of Internal Affairs, northern region. The region’s management and agents notified the bureau of most
critical incidents and important events in a timely manner. Also, with few notable exceptions, the
special agents completed their cases within the applicable statute of limitations and routinely
consulted with the bureau concerning monitored investigations.
The Office of Internal Affairs, northern region, continued to refine its procedures and training for
conducting operations and investigations. This is especially true for operations and investigations
conducted in conjunction with outside law enforcement agencies such as police, sheriffs, and local
district attorney’s offices. As a result, investigations into illegal activities involving department staff
members during this reporting period were better coordinated with outside law enforcement agencies.
In addition, the northern region staff began working on improving training and communication with
law enforcement. They also worked on legislative issues by participating in law enforcement
associations, including the California District Attorney Association programs and the Prison Crimes
Council (formerly the Prison Crimes Working Group).

Office of Internal Affairs, Central Region
The Office of Internal Affairs, central region, also experienced significant personnel turnover, due
primarily to the retirement of three experienced special agents and the departure of a supervisor.
However, these changes, along with a growing caseload, did not significantly interfere with the
generally positive relationship between the bureau and the Office of Internal Affairs, central region.
Overall, cooperation and communication between the bureau and the Office of Internal Affairs,
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central region, remained positive during the reporting period. The special agents routinely consulted
with the bureau concerning the key aspects of monitored investigations.
Nevertheless, the changes noted above did pose some challenges. The bureau observed that the time
frames for completing investigations became longer during the reporting period, although cases were
typically completed within statutory deadlines. Some delays were attributable to cases that had to be
reassigned to other agents, resulting in a lag as newly assigned agents became familiar with the case
midstream. The bureau attempted to mitigate the delays on bureau-monitored cases by providing
detailed case briefings to newly assigned agents. The Office of Internal Affairs, central region,
attempted to fill its vacancies as soon as possible during the reporting period, and the agents who
were hired adapted quickly and were receptive to the bureau’s involvement.
The bureau in the central region encountered its own staffing challenges during the reporting
period. Two attorneys, one who had been with the bureau from its inception and one who was
recently hired, both returned to the practice of criminal law as prosecutors. This had a considerable
impact on the caseloads of the remaining three attorneys in the central region. Office of Internal
Affairs’ agents in the central region were understanding and patient when dealing with newly assigned
attorneys on their cases. Despite the staffing challenges faced in the central region by the bureau and
Office of Internal Affairs, the department continued to handle an extremely large volume of cases
with generally satisfactory outcomes.

Office of Internal Affairs, Southern Region
There was significant improvement in the southern region during this reporting period. The Office of
Internal Affairs, southern region, cooperated more with the bureau, completed investigations on time,
and improved the quality of its investigative reports under the leadership of the special agent incharge.
The vast majority of southern region agents contacted and met with bureau attorneys in a timely and
meaningful manner on initial case assignment. In most cases, agents continued to consult
appropriately with the bureau throughout the investigation as significant events occurred. Only a few
agents still failed to use the consultation process as an opportunity to discuss case strategy and other
issues in a meaningful way.
While the Office of Internal Affairs, southern region, improved the overall timeliness of its
investigations, some investigations were not completed quickly enough to provide hiring authorities
with sufficient time to take thoughtful disciplinary action in appropriate cases. The bureau recognizes
that many factors not directly within the control of the Office of Internal Affairs, southern region,
contributed to the delayed completion of some investigations; there were delays in the reporting of
alleged misconduct, late requests for investigations, and delayed processing of investigation requests
by Office of Internal Affairs headquarters.
To address timeliness issues in general, the Office of Internal Affairs, southern region, implemented a
new requirement that status meetings be held with all critical department entities and the bureau 60
and 30 days before the statutory deadline expires if an investigation has not already been completed.
As a result, the Office of Internal Affairs recognized the need in several cases to assign additional
agents or take other steps to complete an investigation on time. The status meetings, however, did not
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prevent all cases from being delayed. In one case, the Office of Internal Affairs did not follow
through on the recommendations made at the 60-day status meeting, resulting in a deficient
investigation and an inability to pursue an employee’s dismissal. In addition, a limited number of
agents did not hold the status meetings as required and, therefore, continued to have challenges in
completing their investigations in a timely manner.
The southern region also created an innovative plan to further improve the timeliness of their
investigations and the quality of investigative reports by submitting digital recordings of interviews for
transcription. The intent is to reduce costs and the time agents spend typing interview summaries.
Having full transcripts should also be of substantial benefit to hiring authorities and the department’s
attorneys.

Employment Advocacy and Prosecution Team, Office of Legal Affairs
During this reporting period, the department’s employment advocacy and prosecution team improved
and became a more robust and relevant component to the Madrid Remedial Plan. Article 22 of the
department’s operating procedures mandates that the team’s staff attorneys play a key role in the
investigation and prosecution of allegations of employee misconduct. During this reporting period,
the employment advocacy and prosecution team assigned staff attorneys to most of the cases the
bureau accepted for monitoring, in addition to other cases that met their criteria for legal
representation.
The bureau previously reported that the assistant general counsel could not provide effective
leadership to the team because the position directly supervised too many staff attorneys. The
department has since begun to remedy this problem by creating a more appropriate management
structure. The new structure elevates the assistant general counsel position and creates four new
assistant chief counsel positions to supervise four regions. There will be an office in each of the four
regions that will provide legal services to the institutions located in the region. In addition, at least one
vertical advocate will be assigned to each adult institution.
The new regional structure will mirror the Office of Internal Affairs’ and the bureau’s organizational
structures. This management and regional alignment should provide much needed consistency and
facilitate better communication and cooperation among all relevant department entities and the
bureau.
The bureau also previously reported a significant shortfall in the number of staff attorneys in the
employment advocacy and prosecution team, which resulted in a lack of consistent legal counsel for
the Office of Internal Affairs during the investigative process and for hiring authorities during
disciplinary proceedings. This problem persisted during this reporting period despite the department’s
efforts in good faith to assign a staff attorney to every case the bureau accepted for monitoring.
Often during the reporting period, when staff attorneys were assigned to a case, they were not fully
prepared to effectively represent the department during the formal disciplinary process because of the
size of their caseload, among other factors. Moreover, the department took disciplinary action in
many cases based on investigations that were conducted without the benefit of counsel from the
employment advocacy and prosecution team. In the absence of staff attorneys, the department’s
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hiring authorities relied on employment relations officers to handle issues raised by employees during
the Skelly hearing process and to represent the department in administrative hearings before the State
Personnel Board. This occurred even in cases where experienced union attorneys represented the
employee in contested hearings.
Although the department fully appreciates the need to increase the number of staff attorneys, it has
not been able to significantly increase the size of the employment advocacy and prosecution team
during this reporting period. The department has been hampered in this effort by a number of factors,
including the rigidity of the state civil service process, lack of competitive salaries in some areas, and
lack of promotional opportunities in the department. With the assistance of the federal court, the
department was able to obtain a $900 per month salary incentive for staff attorneys assigned to the
team to improve recruitment and retention.
Cooperation between the employment advocacy and prosecution team and the bureau generally
improved during this reporting period. While most staff attorneys promptly and efficiently cooperated
with the bureau as required, others did not. In some instances, certain staff attorneys refused to
consult with the bureau or did so in a way that was not productive or meaningful. The department’s
various attempts to address these violations of the department’s policies were not particularly effective
during this reporting period. The department anticipates that once the new regional offices are fully
staffed the addition of new supervisory staff combined with reduced caseloads will effectively prevent
or address such misconduct in the future.
Another issue the bureau previously reported was that many newly hired staff attorneys lacked the
type of litigation experience necessary to successfully represent the department through the
disciplinary process. The bureau continued to observe this as a significant issue during this reporting
period, and the department is actively recruiting new staff attorneys with litigation experience and is
implementing a new training program to provide inexperienced litigators with basic skills.
The department is also making a good faith effort to have supervisors assist newly hired staff
attorneys when they first represent the department in administrative hearings before the State
Personnel Board. By hiring experienced litigators and implementing the training programs for new
staff attorneys as discussed above, the employment advocacy and prosecution team is moving closer
to providing effective legal representation to the department in employee misconduct cases.
Finally, the bureau has previously reported that some employment advocacy and prosecution team
attorneys routinely encouraged hiring authorities to settle provable disciplinary cases in order to avoid
litigating the case before the State Personnel Board. During this reporting period, this conduct
appeared to occur less frequently and when identified, the department usually addressed it
appropriately.

Hiring Authorities
Although there was significant turnover among the department’s hiring authorities during the
reported period, the interaction between the department’s hiring authorities and the bureau continued
to proceed in a positive direction. Hiring authorities typically contacted the bureau when critical
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incidents occurred and when significant events arose during the employee disciplinary process. While
some hiring authorities again engaged or tried to engage in significant departures from the Madrid
Remedial Plan, fewer problems were noted during this reporting period.
The most significant departures continued to occur when hiring authorities attempted to avoid using
the established disciplinary matrix to determine the appropriate penalty in a case. While in some cases
this may have been done with good intentions, such departures from the matrix often led to a
substantially different result than the department intended for the type of misconduct alleged. In most
of these situations, the hiring authority attempted to lessen or avoid any penalty because of a
perception that the employee in question deserved a break for a variety of spoken or unspoken
reasons. Occasionally, a hiring authority sought to greatly exceed the range of punishment for certain
conduct because the employee had allegedly been involved in misconduct that had not been
investigated or proven.
Such practices, as previously reported, can undermine the department’s efforts to bring consistency
and overall fairness to the employee disciplinary process statewide. The bureau recommends
continued training for all hiring authorities regarding the procedures, the requirements, and the
purpose behind the employee disciplinary process, especially the disciplinary matrix. In addition, when
hiring authorities intentionally diverge from the disciplinary process, the bureau recommends
investigating the action.
In conclusion, the bureau is encouraged by the continued progress the Office of Internal Affairs, the
employment advocacy and prosecution team, and the hiring authorities have made during this
reporting period and during the bureau’s first two years of operation.

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EXPLANATION OF REVISED FORMAT
The bureau has implemented a new approach to assessing the department’s disciplinary process,
including internal affairs investigations and employee disciplinary actions. The most significant
improvement is that the bureau’s assessment of individual cases now focuses more on the ultimate
outcome, or disposition, of the case.
For example, investigations monitored by the bureau will now be categorized according to the
appropriateness of the case disposition. Cases with reasonable dispositions will be reported as either
“distinguished” or “satisfactory,” depending on how well the department complied with critical
Department Operations Manual (DOM) provisions in handling the case. Cases with unreasonable
dispositions (prior to executive review, if any) or cases in which the applicable statute of limitations
expired will be reported as “deficient.”
Another significant improvement is the method the bureau now uses to assess the cases it
monitors—the bureau developed standardized criteria to assess each case. The new criteria were
derived from a combination of the bureau’s statutory reporting requirements found in Penal Code
section 6133 and DOM articles 14 and 22. The assessment criteria have been incorporated into a
series of checklists that will be filled out electronically in the bureau’s case management system.
The bureau’s new approach for assessing cases will enable the bureau to present its findings in a
more concise and user-friendly format. This new assessment method will also allow for more indepth statistical analysis of the bureau’s findings, which will enable to bureau to better track trends
over time.

Assessing the Disposition of Cases
Beginning this reporting period, the disposition in each case (which includes the charges, findings, and
penalty imposed, if any) has been given one of the following ratings:
Symbol

Rating Explanation
Given the totality of circumstances, the disposition of the case was reasonable and substantially
consistent with the bureau’s recommendations.
Given the totality of circumstances, the disposition of the case was unreasonable and inconsistent
with the bureau’s recommendations.
Given the totality of circumstances, the initial disposition of the case was unreasonable and
inconsistent with the bureau’s recommendations but later rectified as a result of executive review;
or
The case eventually resulted in a finding that there was insufficient evidence of misconduct.
However, had actionable misconduct been found, no action could have been taken because the
time for a prosecutor to file charges (in a criminal case) or for the department to take disciplinary
action (in an administrative case) expired before the case was resolved.
The case monitored was a criminal case so there were no administrative charges, findings, or
penalties imposed by the department for the bureau to assess.

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Each case the bureau monitors will be presented in a table published in the bureau’s semi-annual
report, and the rating for each case disposition will appear in the DISPO column, as demonstrated
below.

Assessing the Department’s Compliance
The semi-annual report also provides an assessment of the department’s compliance with its own
policies and procedures governing internal investigations and employee discipline. Three critical
components make up the department’s investigatory and disciplinary processes. The first is the
investigatory component (INV), which encompasses the work conducted by the department’s special
agents and other investigatory personnel. The second is the advocacy component (ADV), which
comprises the work of the department’s staff attorneys who provide legal counsel to the investigators
and hiring authorities on employment matters, as well as employment relations officers or employee
disciplinary officers who are responsible for coordinating many of the department’s disciplinary
actions. The third critical component is performed by hiring authorities (HA) and other high-level
managers, such as wardens, superintendents, and regional parole administrators. They are responsible
for making all of the key disciplinary decisions, from requesting investigations of employee
misconduct to determining findings and imposing appropriate discipline, if any.
Beginning this reporting period, each critical component has been given one of the following ratings:
Symbol

Rating Explanation
The department complied with 100 percent of critical policies and procedures.
The department substantially complied with critical policies and procedures.
The department partially complied with critical policies and procedures.
The department failed to comply with critical policies and procedures.
There was insufficient data to provide an assessment or, due to the nature of the case, the
individual component was not involved.

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The rating for each critical component in a case can be found in the INV, ADV, and HA columns, as
demonstrated below.

As mentioned above, each case the bureau monitored will be presented in one of the following three
tables:
Distinguished Cases – cases that resulted in reasonable outcomes and that were well handled by
the department during each of the critical components in the process;
Deficient Cases – cases that initially resulted in unreasonable outcomes or cases in which the
applicable statute of limitations expired before the case was resolved; and
Satisfactory Cases – cases that resulted in reasonable outcomes but that were not well handled by
the department during one or more of the critical components in the process.
Finally, this report also includes the bureau’s assessment of “critical incidents” (high-risk incidents the
bureau monitors immediately upon notification). The manner in which the bureau reports on these
cases remains unchanged from prior semi-annual reports, and they appear in a separate table later in
the report.

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SUMMARY OF MONITORING ACTIVITIES
Case Monitoring Activities
Caseload trends. The bureau most often becomes aware of a case when the Office of Internal
Affairs considers a request for investigation. The bureau determines whether to monitor the case
based on the misconduct alleged, the bureau’s monitoring criteria, and other available information.
Once the case is selected for monitoring, bureau attorneys consult with investigators and observe
witness and subject interviews. If the case is administrative in nature, bureau attorneys also provide
feedback on case development to the department’s staff attorneys and confer with the hiring
authorities regarding investigatory findings and disciplinary penalties, if any. Once the disciplinary
process has concluded, the bureau’s monitoring activities also conclude and the case is reported here,
in the bureau’s semi-annual report.
During the six-month reporting period ending
December 31, 2006, the bureau concluded
monitoring 206 cases. This is significantly
higher than the 73 cases the bureau concluded
monitoring during the same period last year, as
demonstrated in the accompanying chart. The
increased monitoring is due to the addition of
the bureau’s newest attorneys, whose training
was completed during the reporting period, as
well as increased caseloads for all bureau
attorneys. It is evident, however, that the
bureau will not be able to sustain the current
rate of increase in bureau attorney caseloads without further increases in staffing levels or a reduction
in the percentage of cases accepted for bureau monitoring.

Monitored case types. Consistent with past practice, the
majority of internal affairs’ investigations monitored by the bureau
involved allegations of administrative misconduct (136 cases),
while a smaller portion involved allegations of criminal
misconduct (47 cases). In addition, the bureau monitored 23
administrative cases in which the department took corrective
action but for which an investigation was not necessary. As the
chart to the right demonstrates, the bureau expends about 70
percent of its monitoring resources on administrative misconduct
and only 30 percent on criminal misconduct. The bureau’s
emphasis on administrative misconduct is not accidental. As set
forth in the Madrid Remedial Plan, the bureau’s primary
responsibility is to ensure the department adequately investigates
and disciplines those found culpable of a broad range of
administrative misconduct.

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Allegation distribution. Cases
under investigation usually
include multiple allegations of
misconduct. Among the top five
categories of administrative
allegations selected by the bureau
for monitoring were the
following: (1) improper use of
force, (2) dishonesty in official
reports or during investigative
interviews, (3) failure to report
misconduct committed by
another or oneself, and (4) sexual
misconduct and (5) over-familiarity between staff members and those in their custody and care. The
first three allegations are of particular concern to the bureau because, if proven true, they raise the
possibility that serious civil rights violations have occurred. The remaining two allegations are also of
concern because acts of sexual misconduct and over-familiarity between staff members and those in
their custody and care (even when consensual) often compromise the overall safety and security of
correctional institutions. In light of their gravity, the bureau focused 60 percent of its monitoring
activities on these five allegations, as reflected in the chart above.

Case conclusions. One of the most important steps in the disciplinary process is when the hiring
authority determines the findings at the conclusion of the investigation. In an administrative case, this
step involves the hiring authority reviewing the investigative
report and determining if the allegations have been proven true by
a preponderance of the evidence. Unfortunately, among the 159
administrative investigations monitored by the bureau during this
reporting period, data concerning these investigative findings are
only available in 59 cases—meaning the department failed to
include this information in its case management system in more
than half of its cases. This gap in data has been brought to the
department’s attention and will be narrowed in the future. In the
meantime, what can be discerned from the remaining 59 cases is
that hiring authorities found ample evidence to sustain allegations
made against staff members in 61 percent of the cases
investigated, as reflected in the chart to the right.
Case assessments. Thanks to the bureau’s new approach to assessing the department’s investigatory
and disciplinary processes (described in the previous section of this report), it is now possible to
provide some context for the department’s overall progress in fulfilling the goals of the Madrid
Remedial Plan. For instance, during this reporting period the bureau identified five “distinguished”
cases, meaning the cases resulted in a reasonable outcome and the department followed procedure in
handling the case. In addition, the bureau identified 192 “satisfactory” cases, meaning the cases also
resulted in a reasonable outcome but there were procedural problems with the department’s handling
of the case. In contrast, the bureau identified nine “deficient” cases, meaning the cases resulted in an
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unreasonable outcome. The bureau
provides a detailed explanation in the
table of cases for each case identified as
deficient.

CASE ASSESSMENTS

5

9

In sum, perhaps the most noteworthy
DISTINGUISHED CASES
DEFICIENT CASES
statistic for this reporting period is the
SATISFACTORY CASES
overwhelming number of cases in which
the department reached a reasonable
192
outcome. Specifically, in 96 percent of all
reported cases the outcome was
reasonable. In light of the significant
number of reforms that the department
adopted in the past two years pursuant to the Madrid Remedial Plan, it is statistically significant and
commendable that the department has arrived at a fair disposition in the vast majority of cases
monitored by the bureau.

Critical Incident Activities
Caseload trends. As in each of the bureau’s previous reports, a table is included summarizing the
bureau’s monitoring activities related to certain critical incidents that occurred during the reporting
period. The most common type of critical incident that the bureau selects to monitor involves a
significant use of force that results in the death or serious injury of an inmate or staff member. First,
the bureau assists the department in any way it can with the task of responding to the crises. Second,
the bureau seeks to ensure that, if warranted, the Office of Internal Affairs initiates an investigation
into the circumstances surrounding the incident.
During this six-month period, the bureau concluded its monitoring activities for 61 critical incidents.
The table that follows provides detailed information concerning the facts of each incident, the
department’s resolution of each incident, and the bureau’s assessment of the department’s handling of
each incident.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

PAGE 14
STATE OF CALIFORNIA

DISTINGUISHE D CASE S
Case No. 06-0234

(North Region)

Administrative Case

FACTS OF CASE

On June 29, 2006, it was alleged that two officers assaulted and made racially derogatory comments to a disabled
inmate.

DISPOSITION OF CASE

Allegations of discrimination, harassment, and discourteous treatment were sustained against both officers. One
officer received a 60-day suspension from work. The other officer was dishonest during the internal affairs
investigation and, upon notice of dismissal, retired. The notice was placed in the officer's personnel file.

Case No. 06-0235

(North Region)

Administrative Case

FACTS OF CASE

In November 2005, a custodian supervisor allegedly developed a personal relationship with an inmate. The inmate
paroled into the community, and the custodian supervisor continued the relationship. It was alleged that the custodian
supervisor called in sick to work to spend time with the parolee.

DISPOSITION OF CASE

As a result of the disciplinary action, the custodian supervisor was dismissed. The dismissal was upheld on appeal.

Case No. 06-0236

(North Region)

Administrative Case

FACTS OF CASE

On October 24, 2005, it was alleged that a parole agent had an inappropriate relationship with a parolee the agent
supervised. It was also alleged that the agent failed to disclose the relationship to supervisors, had the parolee released
from parole, and married the parolee approximately 10 months later.

DISPOSITION OF CASE

Although the investigation revealed that the agent married the former parolee, there was insufficient evidence to
support the allegations of misconduct during the time that the agent supervised the parolee.

Case No. 06-0237

(South Region)

Administrative Case

FACTS OF CASE

On September 14, 2005, special agents searched the home of a parolee. The search revealed that the parolee was
married to an officer and that the officer was corresponding with inmates who had prison gang affiliations. It was also
alleged that the officer failed to notify the department of the marriage to a parolee and made false statements to the
agents.

DISPOSITION OF CASE

The hiring authority concluded there was sufficient evidence to sustain allegations of over-familiarity and making false
statements. The hiring authority initially dismissed the officer, however, the officer resigned while the disciplinary
action was pending.

Case No. 06-0238

(Headquarters)

Administrative Case

FACTS OF CASE

On September 13, 2005, an officer allegedly tried to intimidate another officer by driving fast through a staff parking
lot and narrowly missing the other officer, who was walking in the crosswalk.

DISPOSITION OF CASE

The hiring authority sustained the allegation, and the officer was served with a disciplinary action imposing a 5 percent
salary reduction for 36 months. The officer has appealed the action to the State Personnel Board.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

DE FICIE NT CASE S
Case No. 06-0239

(Central Region)

Administrative Case

FACTS OF CASE

It was alleged that on October 30, 2005, two officers assaulted an inmate and then falsified documents to conceal their
misconduct. It was also alleged that the inmate's injuries were inconsistent with one officer's description of the force
used.

DISPOSITION OF CASE

The hiring authority determined that the evidence was insufficient to support the allegations against the officers. As a
result, no disciplinary action was taken.

BUREAU ASSESSMENT

The investigative work on this case did not begin until 10 months after the allegations of misconduct were discovered.
As a result, the investigation was rushed to conclusion because the statutory deadline for taking disciplinary action was
expiring. The investigation was inadequate as important witnesses were not interviewed and important issues were not
addressed. The hiring authority did not identify all appropriate disciplinary charges against the officers based on the
evidence revealed during the limited investigation. The hiring authority's determination that the investigation did not
prove misconduct was inconsistent with the evidence or the bureau's recommendations. In addition, the hiring
authority's consultation with the bureau was not timely, as the statutory deadline for taking disciplinary action made
further investigation impossible and failed to provide sufficient time for the bureau to seek executive review of the
case.

Case No. 06-0240

(Central Region)

Direct Action Case

FACTS OF CASE

It was alleged that on September 5, 2005, excessive force was used against two inmates after one of the inmates
allegedly punched an officer. The two inmates and two officers sustained serious injuries as a result of the incident.
Multiple staff members responded to the incident and used force against the inmates. Staff reports of the force used
and witnessed were allegedly inconsistent with facial injuries the inmates sustained. It was also alleged that a lieutenant
helped to cover up the incident by accepting the staff's inadequate reports of the incident, and a sergeant was accused
of dereliction of duty for responding to the incident without wearing prescription glasses, which allegedly made the
sergeant unable to identify staff members involved in the incident.

DISPOSITION OF CASE

The lieutenant was issued a letter of reprimand. The sergeant was given a 5 percent reduction in salary for 12 months,
which was later reduced to a letter of reprimand.

BUREAU ASSESSMENT

After the hiring authority disciplined the lieutenant, the hiring authority represented that it would consult with the
bureau regarding discipline of the sergeant but did not do so. This case resulted in letters of reprimand being issued to
the employees as the result of an inappropriate settlement, about which the bureau was not consulted. The poor
quality of advocacy may have contributed to the inappropriate penalty because the hiring authority consulted its staff
attorney and then acted on a false premise regarding the statutory deadline for taking disciplinary action. As the
bureau was not consulted, the bureau did not have an opportunity to invoke the executive review process in this case.

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OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

DE FICIE NT CASE S
Case No. 06-0241

(Central Region)

Administrative Case

FACTS OF CASE

On August 23, 2005, a parole agent allegedly met with a parolee's employer and revealed confidential information
about the parolee, including the parolee's gang affiliation, use of psychotropic medications, and commitment offenses.

DISPOSITION OF CASE

The hiring authority did not sustain the allegation.

BUREAU ASSESSMENT

The bureau concurred with the hiring authority that the investigation did not reveal sufficient evidence to sustain the
allegation. However, even if the allegation had been sustained, the hiring authority would have been precluded from
taking appropriate disciplinary action in this case because the employee relations officer failed to bring the case to the
hiring authority's attention before the legal deadline for taking disciplinary action expired.

Case No. 06-0242

(South Region)

Administrative Case

FACTS OF CASE

On May 18, 2005, it was alleged that security squad officers were routinely instructed to falsify their time sheets to
reflect that they had worked on days when they did not in exchange for time spent serving search warrants on
weekends. This practice was allegedly a means of avoiding compensating the officers for overtime. It was also alleged
that the officers tried to cover up the misconduct, as did the warden.

DISPOSITION OF CASE

The investigation was terminated prior to completion because the time to take disciplinary action against the officers
expired.

BUREAU ASSESSMENT

Once assigned for investigation, the special agent waited approximately eight months before interviewing the
complainant. During the investigation, it was determined that the statutory deadline for taking disciplinary action
against the officers was earlier than originally thought. At the time of this discovery, the statutory deadline had already
passed. The expiration of the applicable statutory deadline would have been prevented had the investigator not waited
eight months before interviewing the complainant.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

DE FICIE NT CASE S
Case No. 06-0243

(Central Region)

Administrative Case

FACTS OF CASE

In March of 2005 it was reported that an officer provided an inmate with cigarettes, chewing tobacco, marijuana, and
food, as well as instructed the inmate to make a weapon and place it in another inmate's cell. The officer was also
allegedly dishonest during the investigation. Similar allegations were made against three additional officers during the
investigation, and two other officers allegedly observed the misconduct and failed to report it. Allegations were also
made against a registered nurse for engaging in an overly familiar relationship with inmates during the same period.

DISPOSITION OF CASE

The allegations that officers provided an inmate with contraband, instructed an inmate to make a weapon and place it
in another inmate's cell, and failed to report misconduct were not sustained. The allegations of dishonesty during the
investigation and neglect of duty were sustained against one officer, who was served with a notice of dismissal. This
penalty was subsequently reduced to a 60-day suspension without pay. The allegations of being overly familiar with
inmates against the registered nurse were sustained. The registered nurse was served with a notice of dismissal from
state service but retired before the dismissal took effect. The registered nurse's retirement under adverse
circumstances was documented in the nurse's personnel file.

BUREAU ASSESSMENT

This case was deficient because the investigation into the allegations of misconduct by the five additional officers was
not completed within the applicable statutory period. Had sufficient evidence of misconduct been revealed, it would
have been impossible to seek disciplinary action against the officers.

Case No. 06-0244

(South Region)

Administrative Case

FACTS OF CASE

On January 3, 2005, it was alleged that in June or July of 2003 a parole agent picked up a parolee at home to go to the
parole office. The parolee alleged that the agent took the parolee to a motel and raped the parolee. The parolee
allegedly did not report the agent for fear of going back to prison.

DISPOSITION OF CASE

The hiring authority ultimately concluded that, based on the administrative investigation, there was insufficient
evidence to sustain any of the allegations against the employee.

BUREAU ASSESSMENT

The hiring authority initially sustained the allegations and recommended that the parole agent be dismissed from state
service without consulting with the bureau. The penalty selected by the hiring authority was unreasonable as the
investigative report contained no evidence corroborating the sexual assault claims. The bureau met with the hiring
authority who agreed that the investigation did not contain sufficient evidence to sustain the allegations. The hiring
authority was frustrated, however, that the agent would remain in a peace officer position. The bureau urged the hiring
authority to consult with the staff attorney about the dismissal decision and requested executive review of the
decision. An executive review was held with the bureau, the parole director, the hiring authority, and an assistant chief
counsel. The parole director concluded that the disciplinary action should be withdrawn and the allegations not
sustained. The bureau concurred with the modification.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

DE FICIE NT CASE S
Case No. 06-0245

(North Region)

Administrative Case

FACTS OF CASE

On September 10, 2004, it was alleged that from November 2003 to May 2004 a parole agent had an overly familiar
relationship with the spouse of a parolee who was under the agent's supervision. The relationship allegedly included
sexual encounters in the parole agent's state vehicle and at the spouse's residence.

DISPOSITION OF CASE

The hiring authority sustained the allegations. No action could be taken against the parole agent, however, because the
investigation was not completed until after the statutory deadline for taking action had passed, due in part to the
department not appropriately documenting the complaint of alleged misconduct when it was initially received. The
bureau recommended training on the proper handling of citizen complaints, as well as the need for supervisory staff
to document their actions upon receiving reports of alleged staff misconduct.

BUREAU ASSESSMENT

The parole agent's supervisor did not properly document the alleged misconduct when it was initially reported in April
2004. The overall investigation was then severely compromised because the Office of Internal Affairs did not pursue a
timely investigation. Had the investigation commenced in October 2004 when it was first assigned to an investigator,
there would have been five months to uncover and correct the date of discovery, and the investigation could have
been completed in time. Instead, the Office of Internal Affairs did not pursue the investigation until April 2005, after
the statutory deadline for taking disciplinary action had passed. The combined inaction by the Office of Internal
Affairs and the parole agent's supervisor ultimately led to the department's inability to pursue action against the agent.

Case No. 06-0246

(South Region)

Administrative Case

FACTS OF CASE

A ward alleged that sometime in the summer of 2003 a correctional counselor made sexually explicit comments and
gestures toward the ward. The ward also alleged that in January of 2005 the correctional counselor treated the ward
discourteously and unprofessionally.

DISPOSITION OF CASE

The hiring authority did not sustain the allegations because of insufficient evidence but did give several staff members
work improvement discussion memoranda for failing to report the alleged misconduct.

BUREAU ASSESSMENT

The identity of the correctional counselor was not disclosed when the alleged misconduct was first reported, and the
department erroneously believed that the time to take disciplinary action did not begin until the correctional
counselor's identity was known. Had the investigation revealed sufficient evidence to support the underlying
allegations, disciplinary action could not have been taken because the statutory time to take disciplinary action expired
before the investigation was completed.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

DE FICIE NT CASE S
Case No. 06-0247

(Central Region)

Administrative Case

FACTS OF CASE

On June 4, 2003, five physicians were accused of "churning," a practice of scheduling inmate medical appointments at
lengthy intervals during time the physicians were on call, resulting in unnecessary and inefficient call-backs to the
institution, which increased the amount of money paid to the physicians. It was also alleged the physicians falsified
entries on time sheets.

DISPOSITION OF CASE

The hiring authority sustained the allegations against three of the physicians and sought to dismiss them from state
service. The hiring authority later offered to settle the cases by reducing the penalties to letters of instruction. Two of
the three physicians accepted the settlement offer and received letters of instruction. The third physician rejected the
settlement offer and appealed the dismissal to the State Personnel Board. The remaining two physicians voluntarily
resigned before the investigation could be completed. The case against those two physicians is reported in the table of
satisfactory cases.

BUREAU ASSESSMENT

When the investigation was eventually completed, approximately three years after the misconduct was discovered, it
revealed sufficient evidence of the physicians' misconduct. The hiring authority appropriately placed the physicians on
administrative time off. The hiring authority provided several reasons for offering to reduce the penalties. First, the
hiring authority questioned the accuracy of the facts written in the disciplinary action. Second, the hiring authority
stated that the practice of "churning" was widespread and had never been addressed through department policy.
Finally, the hiring authority stated that the receiver appointed by the federal court to oversee the department's medical
care system did not believe the State Personnel Board would uphold the discipline imposed. The discipline offered by
the department to all three physicians and ultimately imposed against two of them was unreasonably low for the
identified misconduct. The bureau was not adequately consulted by the department regarding the settlement
agreements and the department did not promptly respond to bureau inquiries regarding the matter.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0248

(South Region)

Direct Action Case

FACTS OF CASE

On September 13, 2006, an outside law enforcement agency reported that a lieutenant was convicted of felony witness
tampering in federal court. The lieutenant failed to notify the institution of the indictment and federal conviction.

DISPOSITION OF CASE

The institution immediately dismissed the lieutenant. The lieutenant resigned while the disciplinary action was
pending. The lieutenant's official personnel file reflects a resignation under unfavorable circumstances.

Case No. 06-0249

(Central Region)

Administrative Case

FACTS OF CASE

On August 16, 2006, an officer was arrested and charged with fraudulently obtaining a controlled substance.

DISPOSITION OF CASE

The allegations were sustained and combined with other investigations. The officer was dismissed. An appeal before
the State Personnel Board is pending.

Case No. 06-0250

(North Region)

Criminal Case

FACTS OF CASE

On August 13, 2006, a psychiatric technician allegedly engaged in a physical relationship with an inmate.

DISPOSITION OF CASE

The investigation revealed insufficient evidence of criminal activity. As a result, the case was not referred to the
district attorney's office. The subject resigned while the investigation was pending.

Case No. 06-0251

(North Region)

Criminal Case

It was alleged on August 10, 2006, that a registered nurse was involved in a sexual relationship with an inmate.

DISPOSITION OF CASE

The investigation revealed insufficient evidence of criminal conduct so no referral was made to the district attorney's
office.
(Central Region)

Administrative Case

FACTS OF CASE

It was alleged that, on July 28, 2006, an officer was under the influence of a controlled substance while on duty. A
search of the officer's pockets disclosed a cell phone and cigarettes.

DISPOSITION OF CASE

The allegations were sustained, the case was combined with others, and the officer was dismissed. An appeal before
the State Personnel Board is pending.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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Case No. 06-0252

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0253

(North Region)

Administrative Case

FACTS OF CASE

On July 28, 2006, it was alleged that an officer was trafficking tobacco and alcohol into the institution for sale to
inmates and for personal use. It was further alleged that the officer was dishonest during an investigative interview.
During the investigation, it was discovered that the officer allegedly failed to report to the hiring authority an arrest on
December 20, 2003, for driving under the influence of alcohol.

DISPOSITION OF CASE

The hiring authority sustained all of the allegations against the officer except the failure to report his arrest. The
officer was served with a notice of dismissal from his employment but resigned before its effective date.

Case No. 06-0254

(Central Region)

Criminal Case

FACTS OF CASE

On July 26, 2006, an inmate was stabbed in the lower back with an inmate-manufactured knife. When the discharge of
non-lethal rounds and chemical agents failed to stop the attack, an officer discharged a rifle at the assailant inmate.
The round penetrated the assailant's hand and struck the victim in the hand.

DISPOSITION OF CASE

A deadly force investigation did not identify probable cause to believe that a crime was committed by staff. Therefore,
the criminal investigation was closed without referral to the district attorney's office.

Case No. 06-0255

(Central Region)

Administrative Case

FACTS OF CASE

On July 19, 2006, an incident occurred involving an officer and an inmate. The incident led to the termination of the
officer due to unnecessary force issues and dishonesty. Another officer witnessed this incident, reported it, and
testified at an administrative hearing. The reporting officer was allegedly subjected to ridicule, harassment, threats, and
unprofessional treatment by other staff members.

DISPOSITION OF CASE

Three officers were identified as having made statements about the reporting officer that may have been construed as
harassing. Based upon the investigation, the hiring authority did not believe there was enough evidence to sustain the
allegations, and no discipline was imposed.

Case No. 06-0256

(Headquarters)

Criminal Case

FACTS OF CASE

On July 18, 2006, as a result of a search of institutional phone records related to another investigation, it was alleged
that a registered nurse was involved in an ongoing sexual relationship with an inmate who had been transferred to
another institution. The registered nurse was already under investigation for similar conduct with three other inmates.

DISPOSITION OF CASE

The case was referred to the district attorney's office, which declined to prosecute based on a lack of sufficient
evidence.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0257

(Central Region)

Administrative Case

FACTS OF CASE

On July 18, 2006, it was alleged that a non-sworn employee may have engaged in an overly familiar relationship with
an inmate and that the inmate may have contacted the employee at home via telephone and written correspondence.

DISPOSITION OF CASE

The hiring authority sustained the allegations of misconduct brought against the employee. The employee was served
with an adverse action for dismissal but retired before dismissal was imposed. The department will place a letter in the
personnel file indicating that the employee retired under adverse circumstances.

Case No. 06-0258

(Central Region)

Direct Action Case

FACTS OF CASE

On July 16, 2006, it was alleged that an off-duty officer brandished a firearm at another motorist while driving. The
California Highway Patrol stopped and arrested the officer. The officer was found in possession of a handgun, and his
off-duty weapons card had expired.

DISPOSITION OF CASE

The hiring authority sustained the allegations based upon the Highway Patrol's investigation. Because of prior
disciplinary actions as well as this incident, the officer's probationary employment status was terminated. The
termination was upheld on appeal.

Case No. 06-0259

(North Region)

Criminal Case

FACTS OF CASE

On July 7, 2006, it was alleged that a supervising cook was engaged in a sexual relationship with two inmates and
provided contraband to the inmates.

DISPOSITION OF CASE

The investigation revealed insufficient evidence of criminal wrongdoing so no referral was made to the district
attorney's office.

Case No. 06-0260

(North Region)

Administrative Case

FACTS OF CASE

On July 7, 2006, it was alleged that a supervising cook was engaged in a sexual relationship with two inmates and
provided contraband to the inmates. It was also alleged that the cook was dishonest during the investigative interview,
which was part of the administrative investigation.

DISPOSITION OF CASE

The hiring authority sustained the allegations concerning the sexual relationship and dishonesty. The supervising cook
was served with a notice of dismissal from employment, but the employee resigned before the effective date of the
notice.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0261

(Central Region)

Direct Action Case

FACTS OF CASE

On June 27, 2006, it was alleged that a registered nurse continued to report to work late and refused to follow
direction regarding working overtime. It was also alleged that the employee continued to prescribe medication to
inmates without an authorized physician's approval. It is further alleged that the employee was dishonest when
questioned about the misconduct.

DISPOSITION OF CASE

The employee was still on probation in her position and was rejected from remaining in the position as an alternative
to taking disciplinary action. The employee has appealed.

Case No. 06-0262

(North Region)

Criminal Case

FACTS OF CASE

On June 23, 2006, the institution received information that a material and stores supervisor was having a sexual
relationship with an inmate.

DISPOSITION OF CASE

The investigation revealed that there was insufficient evidence to prove that the subject engaged in a sexual act with
the inmate. The case was not referred to the district attorney's office.

Case No. 06-0263

(North Region)

Direct Action Case

FACTS OF CASE

On June 21, 2006, a lieutenant received information from an inmate alleging that another inmate was having a sexual
relationship with a registered nurse. It was further alleged that the nurse was providing contraband to the inmate,
including money, drugs, and a cell phone.

DISPOSITION OF CASE

The case was sent back to the institution without investigation for disciplinary action based on the employee's
admissions. The employee resigned prior to the imposition of discipline.

Case No. 06-0264

(North Region)

Administrative Case

FACTS OF CASE

On June 20, 2006, an inmate alleged that a supervising cook was trafficking narcotics, tobacco, and cell phones into
the institution.

DISPOSITION OF CASE

The supervising cook admitted to bringing tobacco into the institution. The hiring authority sustained allegations of
over-familiarity, bringing contraband into the institution, and neglect of duty, but the employee resigned before the
imposition of discipline.

Case No. 06-0265

(Central Region)

Direct Action Case

FACTS OF CASE

On June 13, 2006, a police officer arrested an off-duty correctional counselor for public drunkenness. The
correctional counselor failed to report the arrest to supervisors.

DISPOSITION OF CASE

The hiring authority sustained the allegations against the correctional counselor, but the subject retired from
employment while the disciplinary action was pending.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0266

(Headquarters)

Administrative Case

FACTS OF CASE

On June 12, 2006, a youth correctional officer was observed kissing a ward and initially suggested the incident was
accidental when interviewed.

DISPOSITION OF CASE

The hiring authority sustained the allegations and dismissed the youth correctional officer. The officer has appealed
his dismissal to the State Personnel Board.

Case No. 06-0267

(Headquarters)

Administrative Case

FACTS OF CASE

On June 6, 2006, it was alleged that an investigative services unit captain was dishonest when he misrepresented
investigative findings in May 2004. It was further alleged that the misrepresentations were made to cover up excessive
use of force against an inmate.

DISPOSITION OF CASE

The investigation revealed there was no evidence to support the allegations of misconduct. The hiring authority did
not sustain the allegations and no disciplinary action was taken.

Case No. 06-0268

(North Region)

Direct Action Case

FACTS OF CASE

On June 6, 2006, an officer allegedly used unnecessary force by discharging pepper spray on an inmate because the
inmate refused to get dressed.

DISPOSITION OF CASE

The allegation that the officer used unnecessary force was sustained and the officer received an official letter of
reprimand.

Case No. 06-0269

(North Region)

Criminal Case

FACTS OF CASE

On May 23, 2006, an inmate told a sergeant that a maintenance worker was bringing large quantities of tobacco and
narcotics into the institution. During unrelated cell searches, officers located a partial home address of the
maintenance worker, a cell phone, and billing records that indicated the cell phone was used to call the suspected
employee from the cells.

DISPOSITION OF CASE

The maintenance worker transferred to a different institution before the start of the investigation, thus making the
criminal investigation moot to the narcotics investigation. However, the Office of Internal Affairs opened an
administrative investigation that the bureau is monitoring.

Case No. 06-0270

(Central Region)

Administrative Case

FACTS OF CASE

On May 22, 2006, an officer was arrested for alleged lewd and lascivious acts with a child under 14 years of age.

DISPOSITION OF CASE

The hiring authority found insufficient evidence to sustain the allegation of sexual misconduct against the officer.
However, the hiring authority found the officer's statements to the minor's parents constituted discourteous treatment
and issued the officer a letter of reprimand.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0271

(Headquarters)

Direct Action Case

FACTS OF CASE

On May 6, 2006, during a pre-parole audit of an inmate's file, it was discovered that the inmate had been held in
custody 640 days beyond the inmate's actual parole date due to a record-keeping error. It was alleged that a
correctional case records analyst failed to conduct a required audit of the inmate's file, which would have revealed the
error.

DISPOSITION OF CASE

The hiring authority sustained the allegation, and the correctional case records analyst initially received a 5 percent
salary reduction for six months. The analyst subsequently produced reliable documentation minimizing the analyst's
role in the incident, and the discipline was reduced to a letter of reprimand.

Case No. 06-0272

(South Region)

Administrative Case

FACTS OF CASE

In May 2006, the department learned that a parole agent, who was also an attorney, had in his attorney capacity
counseled a witness in an internal affairs investigation not to speak with department investigators. The department
also learned that the agent, also in his attorney capacity, filed a civil lawsuit against the department on behalf of
another parole agent.

DISPOSITION OF CASE

The department initiated an investigation to determine whether the parole agent's conduct was a conflict of interest.
The department decided to terminate the investigation upon learning of the parole agent's voluntary retirement.

Case No. 06-0273

(Central Region)

FACTS OF CASE

It was alleged that on May 1, 2006, an officer falsely accused an inmate of assaulting the officer.

DISPOSITION OF CASE

The hiring authority did not sustain the allegations.

Case No. 06-0274

(North Region)

Administrative Case

Administrative Case

On April 29, 2006, a lieutenant, while assigned to visitor processing, obtained a criminal history report for an inmate's
visitor and subsequently gave the printout to the visitor. Unauthorized use of these reports is a misdemeanor pursuant
to the California Penal Code.

DISPOSITION OF CASE

The case was settled following the Skelly hearing for a one-day suspension without pay.
(Central Region)

Administrative Case

FACTS OF CASE

On April 28, 2006, while reviewing surveillance video as part of an investigation into alleged drug trafficking by
another employee, a sergeant observed a Prison Industry Authority supervisor trafficking tobacco with inmates in a
sewing machine repair area.

DISPOSITION OF CASE

The supervisor resigned while disciplinary action was pending.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

FACTS OF CASE

Case No. 06-0275

BUREAU ASSESSMENT

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

PAGE 26
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0276

(North Region)

Criminal Case

FACTS OF CASE

On April 27, 2006, an officer allegedly vacated an armed post without authorization to confront an inmate. It was
further alleged that the officer used excessive force against the inmate and assaulted, battered, and verbally abused
another officer during that confrontation.

DISPOSITION OF CASE

The investigation revealed probable cause to believe the officer committed several criminal offenses. However, the
district attorney's office declined to file charges in the case.

Case No. 06-0277

(Headquarters)

Administrative Case

FACTS OF CASE

On April 23, 2006, a sergeant allegedly used pepper spray on an inmate who refused to be placed in handcuffs instead
of allowing the inmate a "cooling-off" period.

DISPOSITION OF CASE

The sergeant was issued a letter of instruction.

Case No. 06-0278

(South Region)

Administrative Case

FACTS OF CASE

On April 17, 2006, employees discovered an inmate and a teacher in a compromising position in a classroom. A
search of the inmate's cell resulted in the discovery of a cell phone. The inmate and the teacher admitted to a sexual
relationship dating back to November 2005. The teacher denied furnishing the cell phone to the inmate but admitted
calling the inmate on the phone.

DISPOSITION OF CASE

The hiring authority concluded there was sufficient information to support the allegations of sexual misconduct and
over-familiarity. The teacher resigned pending dismissal.

Case No. 06-0279

(Central Region)

Administrative Case

FACTS OF CASE

On April 10, 2006, outside law enforcement officers served a correctional officer with an arrest warrant that charged
him with 14 counts of possession of a controlled substance for sale. On July 29, 2006, the officer pled guilty to two
felony counts of violation of Health and Safety Code section 11377(A) and was granted drug diversion pursuant to
Penal Code section 1000.2.

DISPOSITION OF CASE

Upon conviction of the officer, the department initiated an administrative investigation. However, the officer resigned
before being interviewed by the Office of Internal Affairs.

Case No. 06-0280

(North Region)

Criminal Case

FACTS OF CASE

On March 28, 2006, a sergeant received information that an officer was bringing a pipe and methamphetamine into
the institution and smoking it with inmates. The informant also advised that the officer was bringing marijuana into
the institution and selling it to inmates. The officer was stopped on the way into work but was not found with any
contraband. In addition, the officer voluntarily submitted to a drug test with negative results.

DISPOSITION OF CASE

The investigation revealed that there was inadequate evidence to refer the case to the district attorney's office.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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PAGE 27
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0281

(Central Region)

Criminal Case

FACTS OF CASE

On March 25, 2006, an inmate reported to a sergeant that an officer was smuggling tobacco and methamphetamine
into the institution. On April 12, 2006, members of the investigative services unit conducted a search of the officer
when he reported to work. The search revealed a large amount of loose tobacco, $118 in cash, cigarettes, rolling
papers, and a cell phone.

DISPOSITION OF CASE

The Office of Internal Affairs closed its investigation into allegations of criminal conduct by the officer without
referring the case to the district attorney's office. An administrative investigation was then conducted by the Office of
Internal Affairs and monitored by the bureau. The officer was dismissed from the department.

Case No. 06-0282

(Central Region)

Administrative Case

FACTS OF CASE

On March 25, 2006, an inmate reported to a sergeant that an officer was smuggling tobacco and methamphetamine
into the institution. On April 12, 2006, members of the investigative services unit conducted a search of the officer
when he reported to work. The search revealed a large amount of loose tobacco, $118 in cash, cigarettes, rolling
papers, and a cell phone.

DISPOSITION OF CASE

The hiring authority sustained the allegations against the officer, and the officer was dismissed from the department.

Case No. 06-0283

(North Region)

Criminal Case

FACTS OF CASE

On March 21, 2006, the department received a written complaint alleging that a physician used force to enter a home
and rape a registered nurse.

DISPOSITION OF CASE

The case was referred to the district attorney's office, which advised the Office of Internal Affairs that it would not
prosecute the case due to a lack of evidence and a lack of cooperation by the alleged victim. The department also
conducted an administrative investigation, which the bureau monitored.

Case No. 06-0284

(North Region)

Administrative Case

FACTS OF CASE

On March 21, 2006, the department received a written complaint alleging that a physician used force to enter a home
and rape a registered nurse.

DISPOSITION OF CASE

The physician resigned following the conclusion of the administrative investigation, which sustained the allegations.

Case No. 06-0285

(Central Region)

Administrative Case

FACTS OF CASE

On March 18, 2006, a search of an employee's home resulted in the seizure of heroin, cocaine, marijuana, and
evidence that the employee conspired with inmates to smuggle contraband into the institution.

DISPOSITION OF CASE

The allegations were sustained, and the employee was dismissed.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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PAGE 28
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0286

(Central Region)

Administrative Case

FACTS OF CASE

On March 17, 2006, letters were discovered during a cell search which indicated that an overly familiar relationship
existed between an inmate and an officer. The letters were routed through the inmate's mother, who disclosed that a
romantic relationship was ongoing between the inmate and the officer.

DISPOSITION OF CASE

The officer resigned after receiving a notice from the Office of Internal Affairs for an interview.

Case No. 06-0287

(Central Region)

Criminal Case

FACTS OF CASE

On March 13, 2006, an officer reported that the previous day another officer grabbed an inmate by the neck with both
hands, choked him, slammed the inmate against a wall, and verbally abused him. The reporting officer stated this
incident occurred in the presence of two other officers. It was further alleged that on March 17, 2006, the subject
officer approached the reporting officer and attempted to induce the officer to give false testimony about the incident.

DISPOSITION OF CASE

It was determined that the subject of this investigation could not be found criminally liable. The criminal case was
closed without a referral to the district attorney's office. An administrative investigation was initiated, which the
bureau is monitoring.

Case No. 06-0288

(Central Region)

Administrative Case

FACTS OF CASE

On March 8, 2006, after an inmate refused to return to a bunk, an officer grabbed the inmate's shirt sleeve and
ordered the inmate to turn around. As the officer escorted the inmate toward the door, the inmate attempted to spin
toward the officer and kick him. The officer forced the inmate to the ground. A second officer observed the entire
incident but did not immediately render assistance and instead proceeded to the door to unlock it for responding staff.
The first officer successfully placed the inmate in handcuffs. The inmate claimed the first officer drove his head into
the cement floor, causing a bump to his head. An allegation of unnecessary force was made against the first officer,
and failure to assist was alleged against the second officer.

DISPOSITION OF CASE

The use-of-force committee found the initial officer's use of force in compliance with department standards. The
committee found the second officer was not at fault under the circumstances. The hiring authority ordered on-the-job
training for both officers. Allegations of misconduct were not sustained; therefore, no discipline was imposed.

Case No. 06-0289

(North Region)

Criminal Case

FACTS OF CASE

On or before February 28, 2006, a recreational therapist allegedly provided methamphetamine to an inmate.

DISPOSITION OF CASE

The investigation revealed insufficient evidence to warrant a referral to the district attorney's office.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

PAGE 29
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0290

(Central Region)

Criminal Case

FACTS OF CASE

On February 16, 2006, two officers entered a cell occupied by one inmate in a mental health unit. One of the officers
allegedly struck the inmate in the head, while the other officer applied handcuffs. The officer who witnessed the
battery allegedly falsified documents regarding the incident by indicating that the inmate was placed in handcuffs
without the use of force. It is also alleged that one of the officers harassed a nurse who witnessed the incident.

DISPOSITION OF CASE

A criminal investigation was opened as to the officer who allegedly struck the inmate in the head. The case was
referred to the district attorney's office, which declined prosecution due to a lack of evidence. The criminal
investigation was closed and an administrative investigation was opened, which the bureau is monitoring.

Case No. 06-0291

(Central Region)

Administrative Case

FACTS OF CASE

On February 16, 2006, after custody staff members found a suicide note, a staff physician gave a verbal order to
remove an inmate from his cell for placement in a mental health crisis bed. The captain failed to follow the physician's
orders and instead ordered staff members to monitor the inmate by conducting 15-minute checks. Between checks,
the inmate overdosed, was rendered unconscious, and was found unresponsive. The inmate ultimately recovered.

DISPOSITION OF CASE

The captain retired from the department before completion of the investigation. Therefore, the institution did not
make a finding on the allegation but instead sent the captain a letter indicating that his retirement was under adverse
circumstances.

Case No. 06-0292

(North Region)

Administrative Case

FACTS OF CASE

On February 15, 2006, an officer allegedly failed to observe an inmate fall during a suicide watch. The officer was
making notations in a suicide record at the time and did not see the inmate. It was also alleged that on March 11, 2006,
the officer failed to observe an inmate who was on suicide watch attempt to hang himself.

DISPOSITION OF CASE

The officer received a letter of instruction for failing to properly observe inmates on suicide watch.

Case No. 06-0293

(Headquarters)

Administrative Case

FACTS OF CASE

On February 9, 2006, a review of records from a ward's seized cell phone revealed several calls between August and
November 2004 to a youth correctional counselor. In addition, an envelope with the youth correctional counselor's
name on it containing a pornographic magazine, a phone number belonging to the counselor, and letters of a personal
nature between the ward and counselor were obtained.

DISPOSITION OF CASE

The youth correctional counselor resigned during the investigation, and the department placed a letter in the
employee's file indicating that the resignation was under adverse circumstances.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

PAGE 30
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0294

(North Region)

Administrative Case

FACTS OF CASE

On February 8, 2006, an officer allegedly ordered an inmate to get up from the toilet in order for the cell to be
searched. The inmate stated that he was not finished using the toilet and asked the officer to have the sergeant come
to the cell. The officer again ordered the inmate to get up and exit the cell, and when the inmate failed to immediately
comply, the officer discharged pepper spray into the face of the inmate. The officer was allegedly dishonest in his
report and his internal affairs interview.

DISPOSITION OF CASE

The allegations of unnecessary use of force and dishonesty were sustained, and the officer was dismissed from state
service.

Case No. 06-0295

(Central Region)

Administrative Case

FACTS OF CASE

On February 6, 2006, it was learned that a witness in a pending internal affairs case had allegedly been harassed by an
officer and intimidated regarding his cooperation in the case against another officer.

DISPOSITION OF CASE

There was insufficient evidence to sustain the allegations.

Case No. 06-0296

(Central Region)

Direct Action Case

FACTS OF CASE

On numerous occasions since February 5, 2006, an employee allegedly submitted fraudulent time sheets. It is further
alleged that the employee displayed vehicle registration tags that had been stolen from his neighbor, was arrested for
failure to appear, and failed to report his police contacts to the institution.

DISPOSITION OF CASE

The hiring authority sustained the allegations and suspended the employee for 60 days.

Case No. 06-0297

(North Region)

Administrative Case

FACTS OF CASE

In February 2006, an officer allegedly delivered contraband to inmates in exchange for craft projects and art.

DISPOSITION OF CASE

The allegation was sustained and the officer was dismissed.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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PAGE 31
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0298

(South Region)

Administrative Case

FACTS OF CASE

On January 28, 2006, an administrative segregation unit inmate refused a reassignment from one housing unit to
another. The sergeant ordered the control booth officer to open the cell door, and the sergeant entered the cell with
four correctional officers. The inmate was handcuffed and escorted out of his cell without incident. The officers
reported that the inmate became resistive and attempted to slam officers against the wall. During the incident, the
inmate's head and face hit the wall, causing injury. Staff members at the new housing unit observed the inmate's
injuries, obtained medical treatment, and interviewed the inmate in accordance with policy. The inmate alleged that
five or six officers and the sergeant entered the inmate's cell and assaulted the inmate for no reason.

DISPOSITION OF CASE

The hiring authority concluded there was sufficient evidence to sustain an allegation of neglect of duty against the
sergeant for ordering staff to enter the inmate's cell after the inmate refused to be handcuffed and for failing to
implement a calculated cell extraction. The hiring authority imposed on the sergeant a 5 percent salary reduction for
12 months. The hiring authority also concluded there was sufficient evidence to sustain allegations that the four
escorting officers failed to report a use of force and failed to provide medical treatment for the inmate, but it
concluded that there was insufficient evidence to sustain an allegation that the officers' use of force was excessive. The
hiring authority imposed against these officers a 5 percent salary reduction for six months. Allegations against two
other officers were not sustained.

Case No. 06-0299

(North Region)

Criminal Case

FACTS OF CASE

On January 25, 2006, a former parolee alleged that while on parole and continuing for six months after discharge from
parole, the assigned parole agent engaged in an inappropriate sexual relationship with the parolee.

DISPOSITION OF CASE

The investigation revealed that there was insufficient evidence to establish that the sexual misconduct occurred while
the former parolee was being supervised by the parole agent. Consequently, after consultation with the district
attorney's office, no referral was made seeking prosecution. However, the Office of Internal Affairs opened an
administrative investigation that the bureau is monitoring.

Case No. 06-0300

(Central Region)

Administrative Case

FACTS OF CASE

On January 24, 2006, it was alleged that an officer had earlier given $180 to an inmate. It was also alleged that the
officer had a sexual relationship with a second inmate.

DISPOSITION OF CASE

The hiring authority sustained the allegations. The officer resigned under adverse circumstances immediately before
the dismissal became effective.

Case No. 06-0301

(North Region)

Criminal Case

FACTS OF CASE

On January 23, 2006, it was alleged that an officer was distributing tobacco to inmates.

DISPOSITION OF CASE

The Office of Internal Affairs determined that there was evidence exonerating the officer so no referral was made to
the district attorney's office.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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PAGE 32
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0302

(Central Region)

Administrative Case

FACTS OF CASE

On January 18, 2006, an inmate alleged that an officer used excessive force while handcuffing the inmate and pushed
him against a vent on a wall, causing pain. It was also alleged the use of force was not reported per department
procedures. In addition, another officer may have witnessed the use of force and failed to report it.

DISPOSITION OF CASE

The hiring authority determined there was insufficient evidence to sustain any of the allegations against either officer
so no discipline was imposed.

Case No. 06-0303

(Central Region)

Criminal Case

FACTS OF CASE

On January 13, 2006, a search was conducted of an officer's personal vehicle as part of another investigation. That
search disclosed 22 live 12 gauge shotgun shells and one live rifle round.

DISPOSITION OF CASE

The matter was submitted to the district attorney's office, which declined to prosecute. The department has opened an
administrative investigation, which the bureau is monitoring.

Case No. 06-0304

(Central Region)

Administrative Case

FACTS OF CASE

On January 12, 2006, two officers escorting an inmate to a cell allegedly used, and failed to report, excessive force. It
is also alleged that a sergeant observed the use of excessive force without stopping or reporting it.

DISPOSITION OF CASE

The hiring authority determined there was insufficient evidence to sustain the allegations.

Case No. 06-0305

(North Region)

Administrative Case

FACTS OF CASE

On January 6, 2006, an inmate alleged that three days earlier the inmate informed two officers that the inmate refused
to have a cellmate. Shortly after officers placed the cellmate in the cell, the inmate assaulted the cellmate. The two
officers subsequently arrived at the cell, handcuffed the inmate, and allegedly assaulted the inmate.

DISPOSITION OF CASE

The inmate was unable to reliably identify the two officers who allegedly committed the assault, and the cellmate was
not present when the alleged assault occurred. Therefore, there was insufficient evidence to sustain the allegations of
misconduct.

Case No. 06-0306

(Central Region)

Administrative Case

FACTS OF CASE

On January 6, 2006, an inmate alleged that officers used excessive force after the inmate threatened to throw bodily
fluids on staff members. The inmate was allegedly told to come out of the cell without handcuffs, thrown to the
ground, handcuffed, dragged across the floor, and shoved. The inmate had injuries consistent with being involved in a
physical struggle; however, the injuries may have existed before the alleged incident.

DISPOSITION OF CASE

Allegations of unnecessary force and neglect of duty were not sustained against any officer so no discipline was
imposed.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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PAGE 33
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0307

(North Region)

Administrative Case

FACTS OF CASE

In January 2006, a sergeant allegedly stated in a loud voice, "[inmate], you are nothing but a piece of shit child
molester and I fucked your mother on the streets," among other comments made loud enough for employees and
inmates to hear. It was also alleged that, on another occasion, an inmate broke free from an escort and assaulted the
sergeant in question, and the sergeant used unnecessary force by striking the inmate with a baton after the inmate had
already complied with staff orders.

DISPOSITION OF CASE

The allegations were sustained, and the sergeant received a 36-day suspension without pay.

Case No. 06-0308

(Central Region)

Criminal Case

FACTS OF CASE

A registered nurse reported that on December 22, 2005, a clinical laboratory technician poked his finger with a needle,
causing it to bleed, but did not discard the needle. The needle was subsequently used on an inmate.

DISPOSITION OF CASE

A criminal investigation was conducted and forwarded to the district attorney's office. The district attorney's office
rejected the case due to insufficient evidence. The technician resigned.

Case No. 06-0309

(Central Region)

Administrative Case

FACTS OF CASE

On December 20, 2005, an inmate attacked an officer. Physical force was used to gain control of the inmate, with no
injuries noted by the responding medical staff. Another officer subsequently escorted the inmate to a holding cell.
Shortly afterward, a lieutenant saw blood on the inmate's face. The inmate indicated that the escorting officer had
forced the inmate into the holding cell so hard that the inmate's head hit the wall, causing an injury. The inmate
received 19 sutures to close the wound.

DISPOSITION OF CASE

The hiring authority determined that there was insufficient evidence to sustain an allegation of excessive force;
however, an allegation of inexcusable neglect of duty for failure to follow procedures regarding monitoring and
placing inmates in a holding cell was sustained. A 10 percent salary reduction for six months was imposed and was
upheld following a State Personnel Board appeal.

Case No. 06-0310

(South Region)

Administrative Case

FACTS OF CASE

On December 20, 2005, an inmate refused a control booth officer's order to return to the inmate's assigned cell.
Another officer began talking with the inmate to resolve the issue. The control booth officer discharged a non-lethal
round at the inmate, missing the inmate and striking a second uninvolved inmate in the chest. A floor officer ran up
the stairs toward the inmates. Before the floor officer reached the top of the stairs, the control booth officer
discharged a second non-lethal round at the inmate, striking the inmate in the head and upper body.

DISPOSITION OF CASE

The hiring authority concluded there was sufficient evidence to support the allegation that the control booth officer
used excessive force and served the officer with a notice of dismissal. The officer appealed, and the department is
waiting for the State Personnel Board's decision.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

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HA

PAGE 34
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0311

(North Region)

Criminal Case

FACTS OF CASE

On December 19, 2005, an inmate alleged a sexual relationship with a parole agent. The inmate claimed that while
previously on parole, the agent made sexual comments and thereafter engaged in sexual liaisons with the inmate
spanning a period of several months.

DISPOSITION OF CASE

The case was not referred to the district attorney's office because the investigation revealed that there was insufficient
evidence to support the allegations.

Case No. 06-0312

(Central Region)

Criminal Case

FACTS OF CASE

On December 19, 2005, it was alleged that an officer was having a sexual relationship with an inmate and had made
deposits of cash into the inmate's account. After an initial investigation, it was further alleged the officer had sexual
relations with several other inmates and that at least two inmates were blackmailing the officer, demanding cash and
tobacco in exchange for their silence about his sexual relations with inmates.

DISPOSITION OF CASE

The investigation was submitted to the district attorney's office, but prosecution was declined. An administrative
investigation was initiated, which the bureau is monitoring.

Case No. 06-0313

(North Region)

Administrative Case

FACTS OF CASE

On December 16, 2005, it was alleged that an officer used excessive force to subdue an inmate by placing the inmate
in an unauthorized choke hold. In addition, it was alleged that the officer and a medical technical assistant falsified
their reports of the incident. It was further alleged that the reviewing sergeant instructed the medical technical
assistant to falsify the report.

DISPOSITION OF CASE

The investigation found insufficient evidence to support any of the allegations in this case. Therefore, no disciplinary
action was initiated.

Case No. 06-0314

(Central Region)

Administrative Case

FACTS OF CASE

A ward alleged that on December 13, 2005, an officer removed him from a security vehicle using unreasonable force
and causing injury.

DISPOSITION OF CASE

The allegations were sustained after the officer retired.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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PAGE 35
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0315

(South Region)

Criminal Case

FACTS OF CASE

On December 5, 2005, a citizen called a parole agent alleging that another parole agent was addicted to prescription
medication, had stolen prescription medications from parolees for personal use, resided with active parolees in the
past and present, was overly familiar with parolees, had received money from a parolee-at-large in exchange for not
reporting the parolee's status, and had accessed confidential computerized criminal information for personal reasons.

DISPOSITION OF CASE

The Office of Internal Affairs referred the matter to the district attorney's office. In October 2006, the district
attorney's office declined to prosecute the parole agent based on insufficient evidence. The bureau is monitoring an
administrative investigation stemming from this incident.

Case No. 06-0316

(South Region)

Administrative Case

FACTS OF CASE

On December 5, 2005, a citizen called a parole agent alleging that another parole agent was addicted to prescription
medication, had stolen prescription medications from parolees for personal use, had resided with active parolees in the
past and present, was overly familiar with parolees, had received money from a parolee-at-large in exchange for not
reporting the parolee's status, and had accessed confidential computerized criminal information for personal reasons.

DISPOSITION OF CASE

The hiring authority concluded there was insufficient evidence to sustain the allegations except that the parole agent
accessed confidential computerized information for personal reasons. The hiring authority imposed a 5 percent salary
reduction for 12 months against the parole agent.

Case No. 06-0317

(North Region)

Administrative Case

FACTS OF CASE

On December 3, 2005, an officer allegedly crashed his vehicle while driving under the influence of alcohol. The
officer fled the scene and falsely reported the vehicle as stolen.

DISPOSITION OF CASE

The department sustained the allegations and imposed a 10 percent reduction in salary for six months. Pursuant to a
settlement agreement, the officer received a 5 percent reduction in salary for six months.

Case No. 06-0318

(North Region)

Administrative Case

FACTS OF CASE

In December 2005, two officers allegedly derided two inmates about baby pictures found in their cell. Reports
indicated both inmates became agitated and hostile toward the officers. The officers then opened the cell door, and
one of the inmates came out, picked up a trash can, and threw it at the officers, who in turn used physical force to
subdue and control the combative inmate.

DISPOSITION OF CASE

The allegations of misconduct were not sustained, and no action was taken against the officers.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

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BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0319

(Headquarters)

Administrative Case

FACTS OF CASE

On December 1, 2005, a review of a ward's composition book revealed that a youth correctional counselor allegedly
touched the ward's buttocks, looked at the ward in a sexual manner, made sexual comments, and opened the door to
the ward's room while the ward was undressing.

DISPOSITION OF CASE

Following an investigation, the hiring authority did not sustain any of the allegations against the youth correctional
counselor so no disciplinary action was taken by the department.

Case No. 06-0320

(South Region)

Administrative Case

FACTS OF CASE

On November 28, 2005, an inmate threw urine on an officer. As a result, the inmate was moved, but the inmate
alleged that shortly thereafter two unidentified officers assaulted him. The inmate also alleged that he was assaulted by
an escorting officer the next day.

DISPOSITION OF CASE

Following an investigation, the hiring authority found insufficient evidence of misconduct to sustain the allegations.
Thus, no disciplinary action was imposed.

Case No. 06-0321

(Central Region)

Administrative Case

FACTS OF CASE

On November 27, 2005, an inmate committed suicide by self-induced asphyxiation inside a safety cell at the
institution. The cell was equipped with a video camera monitored by the officers'/nurses' station attached to a
recording device. The recording device was not functioning properly; therefore, there was no video of the incident.
Procedure requires testing of the video equipment before every shift. The inmate had attempted suicide in the past,
but medical staff members elected to place the inmate on "suicide precaution" status rather than on a heightened
"suicide watch" status.

DISPOSITION OF CASE

The hiring authority found staff members did not comply with policy to ensure that the video monitoring equipment
was functioning properly at the beginning of each shift but that non-punitive action was sufficient to address the
failure to comply with policy. The inmate's death was reviewed by the suicide review board, which found no fault with
medical staff members' placement of this inmate on "suicide precaution" as opposed to "suicide watch" status.

Case No. 06-0322

(Central Region)

Criminal Case

FACTS OF CASE

On November 24, 2005, two officers were injured after being assaulted by inmates. Officers accused the subject
officer of being overly familiar with the involved inmates, which placed the officers' safety in jeopardy. It was also
alleged that the subject officer failed to take appropriate action when witnessing the assault. It was further alleged that
the subject officer left staff members locked inside a dayroom with about six unsupervised inmates without gun
coverage.

DISPOSITION OF CASE

A criminal investigation was conducted and closed without referral to the district attorney's office because of
insufficient probable cause to believe that a crime had been committed. An administrative investigation into the
alleged policy violations was opened, which the bureau is monitoring.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0323

(North Region)

Administrative Case

FACTS OF CASE

On November 23, 2005, a ward alleged that a senior youth correctional counselor and two youth correctional officers
applied unnecessary and excessive force in restraining him.

DISPOSITION OF CASE

There was insufficient evidence to sustain the allegations of excessive force against the officers. The use of force was
prompted by the ward's declared intent to self-inflict wounds and the ward's resistance to staff's attempts to apply
restraints.

Case No. 06-0324

(North Region)

Administrative Case

FACTS OF CASE

On November 18, 2005, it was alleged that an officer exchanged handwritten letters with an inmate and provided that
inmate with a cell hone. It was also alleged that the officer was dishonest during an internal affairs investigation.

DISPOSITION OF CASE

The hiring authority sustained the allegations and served the officer with a notice of dismissal. The officer resigned
before the effective date of the dismissal.

Case No. 06-0325

(North Region)

Criminal Case

FACTS OF CASE

On November 16, 2005, a lieutenant allegedly directed an officer to rewrite his report regarding a use-of-force
incident to omit information concerning another staff member's use of a baton. The officer then rewrote his report
omitting information concerning his observation of the staff member's use of a baton.

DISPOSITION OF CASE

It was determined there was insufficient evidence to proceed with the criminal case. An administrative case was
subsequently opened and is being monitored by the bureau.

Case No. 06-0326

(Central Region)

Administrative Case

FACTS OF CASE

On November 13, 2005, an inmate reported that during a riot an officer used unnecessary and excessive force by
striking the inmate in the face while the inmate was restrained by two other officers. It was also alleged that the officer
knocked the inmate to the ground and choked the inmate.

DISPOSITION OF CASE

Following an investigation, the hiring authority did not sustain the allegation so no discipline was imposed.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0327

(South Region)

Administrative Case

FACTS OF CASE

On November 8, 2005, an officer used force on an inmate, which the officer and another officer reported. The
sergeant who responded to the incident failed to initiate an incident package after being told that force was used.
Instead, the sergeant told the lieutenant that no force had been used and completed a notice of unusual occurrence
stating that no force had been used.

DISPOSITION OF CASE

Based on the administrative investigation, the hiring authority concluded that sufficient evidence existed to sustain the
allegation that the sergeant failed to properly report a use of force. The hiring authority initially concluded that the
appropriate discipline was a 10 percent salary reduction for 12 months. Following the Skelly hearing, the hiring
authority reduced the penalty to a 5 percent salary reduction for 12 months.

Case No. 06-0328

(Central Region)

Administrative Case

FACTS OF CASE

On November 7, 2005, an officer assigned to an armed post allegedly threatened other officers with serious bodily
injury or death.

DISPOSITION OF CASE

The hiring authority sustained the allegation and dismissed the officer. The officer appealed to the State Personnel
Board but subsequently withdrew the appeal.

Case No. 06-0329

(South Region)

Administrative Case

FACTS OF CASE

On November 6, 2005, while escorting an inmate, an officer allegedly taunted the inmate, causing a second officer to
intervene as a third officer watched. As the escort continued, the first officer allegedly continued to taunt the inmate
and intentionally bumped the inmate's chest in an apparent attempt to provoke a confrontation. The control booth
officer saw the exchange and believed that the inmate and officer were involved in a confrontation and activated an
alarm. The escort officers and responding staff members did not report the use of force.

DISPOSITION OF CASE

The institution's employee relations officer received the completed administrative investigation from the Office of
Internal Affairs. The hiring authority concluded that based on the administrative investigation there was insufficient
evidence to sustain any of the allegations against the subject officers.

Case No. 06-0330

(Headquarters)

Criminal Case

FACTS OF CASE

On November 3, 2005, an inmate alleged that a nurse engaged in sexual conduct with inmates. The nurse was accused
of giving inmates cigarettes in return for the inmates allowing the nurse to touch the inmates' genitals and engage in
oral sex with the inmates.

DISPOSITION OF CASE

The district attorney's office declined to prosecute based on insufficient evidence.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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HA

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0331

(Central Region)

Administrative Case

FACTS OF CASE

On November 3, 2005, allegations were received that a non-sworn employee had engaged in overly familiar and
unwanted sexual acts with inmates.

DISPOSITION OF CASE

The hiring authority determined that the investigation was sufficient but that the allegations were not proven by a
preponderance of the evidence. Therefore, no adverse action was imposed.

Case No. 06-0332

(South Region)

Administrative Case

FACTS OF CASE

An officer assigned to a mental health housing unit was familiar with an inmate's prior history of suicide attempts and
suicidal ideations. On November 1, 2005, the inmate reported to the officer that a second inmate wanted the first
inmate to "take out" the officer at the time the first inmate killed himself. The officer took the first inmate to the
second inmate's cell and confronted the second inmate. The second inmate became angry and attempted to grab the
first inmate through the partially opened cell door. The officer secured the cell and allowed the first inmate to walk
away. The officer went to the first inmate's cell minutes later and found the inmate hanging by a sheet wrapped
around his neck. The inmate was cut down, treated by medical staff, and transported by ambulance to a local hospital,
where he was pronounced dead.

DISPOSITION OF CASE

The hiring authority found that the officer inappropriately allowed the first inmate to be present when she confronted
the second inmate. According to the employee relations officer, the hiring authority did not sustain an allegation of
misconduct for failing to prevent the suicide because of inadequacies in the investigation. The officer was issued a
letter of instruction.

Case No. 06-0333

(South Region)

Administrative Case

FACTS OF CASE

On October 28, 2005, it was alleged that a parolee boasted that his parole agent "was on the take" and had accepted
gifts and gratuities from the parolee. The agent also allegedly allowed the parolee to remain out of custody while the
parolee was challenging a recent felony arrest.

DISPOSITION OF CASE

The investigation found that there was no evidence the alleged misconduct occurred. The hiring authority did not
sustain any of the allegations against the agent.

Case No. 06-0334

(South Region)

Criminal Case

FACTS OF CASE

On October 24, 2005, an inmate alleged that on October 13, 2005, another inmate was taken into custody after
attacking a sergeant. It was then reported that the sergeant kicked and struck the handcuffed inmate with a baton.

DISPOSITION OF CASE

The Office of Internal Affairs concluded that the criminal investigation failed to corroborate the allegations and did
not submit the case to the district attorney's office for prosecution. The bureau is monitoring the administrative
investigation stemming from this incident.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0335

(North Region)

Criminal Case

FACTS OF CASE

On October 24, 2005, a parole agent allegedly married a former parolee that the agent supervised. The agent
reportedly dated the parolee while they were in high school and college. The agent allegedly recommended the
termination of parole, married the former parolee six months later, and failed to disclose the relationship to
supervisors.

DISPOSITION OF CASE

The case was not referred to the district attorney's office because there was insufficient evidence of criminal
misconduct. An administrative investigation was initiated by the Office of Internal Affairs. The bureau is monitoring
that investigation.

Case No. 06-0336

(Central Region)

Administrative Case

FACTS OF CASE

On October 23, 2005, an officer accompanied his girlfriend to exchange children with a former spouse. During an
argument, the officer brandished a knife and inappropriately used pepper spray. A second officer appeared at the
residence and allegedly pushed the father of the former spouse, grabbed his flashlight, and threw it 50 yards away.
Both officers were detained at gunpoint by responding outside law enforcement.

DISPOSITION OF CASE

The officer who brandished the knife pled guilty to misdemeanor trespass in criminal court. Criminal charges were
dismissed against the second officer. The hiring authority sustained the allegations on both officers for failure of good
behavior. The officer who initiated the incident was suspended for 50 days. The second officer was suspended for 30
days.

Case No. 06-0337

(Central Region)

Administrative Case

FACTS OF CASE

On October 19, 2005, an inmate reported that after a physical confrontation with an officer, the inmate was sprayed
with pepper spray. Two other officers took the inmate to a decontamination station and allegedly pushed his face into
the fountain, injuring his lip. The officers also allegedly hit the inmate on the leg with a baton.

DISPOSITION OF CASE

The allegations against the two officers were not sustained by the hiring authority. One officer received remedial
training on report writing, and another officer received a letter of instruction on proper inmate restraint before
opening a holding cell.

Case No. 06-0338

(Central Region)

Administrative Case

FACTS OF CASE

On October 18, 2005, an officer allegedly used unnecessary force, as well as witnessed another officer's use of
unnecessary force, on an inmate and then failed to accurately report the incident.

DISPOSITION OF CASE

Following an investigation, the hiring authority determined that there was insufficient evidence to sustain either of the
allegations against the officers.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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PAGE 41
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0339

(South Region)

Administrative Case

FACTS OF CASE

On October 18, 2005, officers used force against an inmate after removing the inmate from a cell. The officers filed
incident reports alleging that the inmate became combative, requiring their use of force, but the officers failed to
mention the presence of a sergeant in their incident reports. On October 20, 2005, the inmate alleged that the sergeant
and two officers had assaulted the inmate with their hands, feet, and batons.

DISPOSITION OF CASE

The hiring authority concluded that based on the administrative investigation there was insufficient evidence to
sustain any of the allegations against the employees.

Case No. 06-0340

(South Region)

Administrative Case

FACTS OF CASE

On October 12, 2005, it was alleged that an officer had physically abused a civilian at a convenience store while
assigned to transportation duties. It was also alleged that the officer had used excessive force against inmates while
conducting cell extractions.

DISPOSITION OF CASE

The investigation did not sustain any findings. The investigation was hampered because the complainant did not make
a prompt and specific complaint. Some of the allegations of wrongdoing were more than two years old.

Case No. 06-0341

(South Region)

Administrative Case

FACTS OF CASE

On the morning of October 11, 2005, personal car keys were accidentally dropped in the parking lot. At 1240 hours, a
work crew officer reported that an inmate was missing. The work crew officer reported that work crew inmates had
been counted three times between 1100 and 1240 hours, during which the inmate was accounted for. The work crew
officer completed an incident report claiming the missing inmate had been accounted for until 1240 hours. At 1345
hours, another officer reported that the officer’s personal car keys and personal car were missing. Within days, the
department located and arrested the inmate. The inmate stated that after finding the car keys in the parking lot, the
inmate stole the car at about 0845 hours after the work crew officer had just completed the count.

DISPOSITION OF CASE

The hiring authority determined that the investigation contained sufficient evidence to sustain allegations that the
work crew officer made false and misleading statements, both verbally and in writing, after the incident. The hiring
authority imposed a penalty of a 10 percent salary reduction for 24 months because of the mitigating circumstances
that the subject was acting as a relief officer, was later truthful, and expressed remorse. In addition, the hiring
authority determined that the investigation contained sufficient evidence to sustain an allegation that the second
officer's loss of keys and personal vehicle was negligent and resulted in serious consequences, for which a penalty of a
5 percent salary reduction for 12 months was imposed.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0342

(North Region)

Criminal Case

FACTS OF CASE

On October 11, 2005, it was alleged that a supervising cook had been selling heroin, methamphetamine, marijuana,
tobacco, and cell phones to inmates.

DISPOSITION OF CASE

The case was referred to the district attorney's office for criminal prosecution. However, the district attorney declined
to prosecute. In the related administrative case, which was not monitored by the bureau, the subject was dismissed.
The subject chose to resign before the effective date of that action.

Case No. 06-0343

(North Region)

Administrative Case

FACTS OF CASE

An inmate reported being thrown to the ground and repeatedly punched by two officers on October 9, 2005, while
being escorted in restraints. After the alleged assault, the two officers threatened the inmate in the presence of another
officer. The inmate claimed a sergeant witnessed the assault but failed to intervene and that the medical technical
assistant failed to properly document the injuries.

DISPOSITION OF CASE

The hiring authority determined that there was insufficient evidence of misconduct by the officers. There was
inconclusive evidence that the sergeant witnessed the assault as alleged by the inmate. The medical technical assistant's
conduct appeared to be unintentional and stemmed from a lack of experience and training that has since been
addressed.

Case No. 06-0344

(South Region)

Criminal Case

FACTS OF CASE

On October 7, 2005, the investigative services unit received information that a teacher and an inmate were having a
sexual relationship in a specific classroom storage room. Video surveillance revealed the inmate and the teacher in the
classroom storage room engaging in sexual activity. Two investigators interviewed the teacher after a Miranda
advisement. The teacher admitted to being in a romantic relationship with the inmate since June 2005 and claimed
that they were married. The teacher gave the investigators consent to search the teacher's residence to obtain the
marriage certificate, which was taken into evidence.

DISPOSITION OF CASE

The district attorney's office filed criminal charges against the teacher, resulting in a guilty plea to a charge of sexual
activity with an inmate. An administrative investigation was opened, which the bureau is monitoring.

Case No. 06-0345

(Central Region)

Criminal Case

FACTS OF CASE

In October 2005, a stationary engineer was accused of smuggling narcotics into the institution.

DISPOSITION OF CASE

The employee pled no contest to one felony count of possession of a controlled substance for sale and was sentenced
to state prison. The employee resigned from the department before sentencing.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0346

(North Region)

Administrative Case

FACTS OF CASE

On September 29, 2005, a lieutenant and a sergeant allegedly failed to follow departmental policies and procedures
related to the housing needs of inmates when they authorized the double-celling of two inmates with documented
histories as mutual enemies. Within minutes of an officer placing the two inmates in the cell, they began fighting.

DISPOSITION OF CASE

The allegations against the lieutenant and the officer were unsubstantiated. The sergeant who conducted the review
that led to the double-celling received an official letter of reprimand. The institution initiated new procedures that
require multiple reviews of inmate records when addressing housing needs.

Case No. 06-0347

(South Region)

Administrative Case

FACTS OF CASE

On September 29, 2005, it was alleged that a lieutenant prepared a memorandum describing events related to a
separate investigation as if it had been prepared by another officer. The officer in whose name the memorandum had
been prepared testified that the lieutenant was not authorized to prepare it and misrepresented the officer's perception
of what had occurred in the original incident.

DISPOSITION OF CASE

The hiring authority concluded that sufficient evidence existed to sustain an allegation that the lieutenant was
dishonest by submitting a memorandum in the officer's name without the officer's knowledge or consent. The hiring
authority imposed on the lieutenant a 10 percent salary reduction for 13 months.

Case No. 06-0348

(South Region)

Administrative Case

FACTS OF CASE

On September 28, 2005, an inmate reported being involved in a sexual relationship with an officer for approximately
seven years, starting in 1999. The inmate provided confidential personal information about the officer, including a
description of the officer's residence. The officer denied the sexual relationship but stated the inmate had offered to
have a sexual relationship in the past. The officer admitted to not documenting the inmate's conduct to a supervisor.

DISPOSITION OF CASE

The department concluded that the officer had engaged in an overly familiar relationship with an inmate and failed to
report the conduct. The officer was suspended without pay for 48 days. The matter is pending before the State
Personnel Board.

Case No. 06-0349

(South Region)

Administrative Case

FACTS OF CASE

On September 26, 2005, information was received alleging that a parole agent had been discourteous when an outside
law enforcement agency attempted to obtain address information for a parolee wanted on a fugitive warrant and that
the parole agent had warned the parolee that law enforcement was enroute.

DISPOSITION OF CASE

The hiring authority concluded that based on the administrative investigation there was insufficient evidence to
sustain the allegations.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0350

(South Region)

Administrative Case

FACTS OF CASE

On September 23, 2005, an inmate alleged that a sergeant and officers assaulted the inmate and another inmate
without cause. The inmate also alleged that staff members threatened violence if the assaults were reported. The
inmate made allegations against 12 staff members for unlawful force, threats, and failing to report.

DISPOSITION OF CASE

The hiring authority concluded that there was insufficient evidence to sustain the allegations against the staff members.

Case No. 06-0351

(North Region)

Administrative Case

FACTS OF CASE

On September 23, 2005, an officer allegedly used excessive force on an inmate. The officer's report stated the inmate
was unhappy about a bed move and made several comments, including an indirect threat to the officer. The officer
later attempted to place the inmate in mechanical restraints. The inmate resisted and pulled away from the officer, and
the officer allegedly grabbed the inmate around the neck and forced him to the ground. It was alleged the inmate
stated, "You're hurting my neck," and the officer replied, "That's right, I'll break your fucking neck."

DISPOSITION OF CASE

The allegation of excessive force was not sustained, but an allegation of discourteous treatment was sustained and the
officer received a letter of instruction.

Case No. 06-0352

(Central Region)

Criminal Case

FACTS OF CASE

On September 15, 2005, it was alleged that an officer had engaged in sexual misconduct with inmates.

DISPOSITION OF CASE

The matter was not referred to the district attorney's office for prosecution because of insufficient evidence. An
administrative investigation was opened. The bureau is monitoring the administrative investigation.

Case No. 06-0353

(Central Region)

Administrative Case

On September 16, 2005, it was alleged that an officer had engaged in illicit sexual activities with inmates and aided a
second officer in concealing that officer's overly familiar relationship with an inmate. It was further alleged that the
officer, who is a union steward, attempted to obtain a more favorable result in an employee discipline case by
blackmailing an administrator.

DISPOSITION OF CASE

The hiring authority sustained allegations relating to the blackmailing of an administrator and making false statements
during the investigation. The allegations relating to sexual misconduct and concealing over-familiarity were not
sustained. The officer was dismissed. An appeal to the State Personnel Board is pending.

OFFICE OF THE INSPECTOR GENERAL

DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

FACTS OF CASE

BUREAU OF INDEPENDENT REVIEW

BUREAU ASSESSMENT

INV

ADV

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0354

(North Region)

Administrative Case

FACTS OF CASE

On September 15, 2005, an officer reported finding a laundry cart with the words "GREEN WALL" scrawled across
it. The cart was located in the sally port area of the facility where the officer was scheduled to work that day. The
officer had previously testified in a whistle blower retaliation case filed by a former officer. It was alleged that the
officer's testimony hurt the former officer's case against the state and that someone sympathetic toward the former
officer was attempting to intimidate the officer.

DISPOSITION OF CASE

The administrative investigation revealed inconclusive evidence regarding the origin of the writing, when it was
written on the cart, and the connection between the officer's testimony and the writing. Consequently, the allegations
were not sustained.

Case No. 06-0355

(South Region)

Criminal Case

FACTS OF CASE

On September 15, 2005, an inmate told the investigative services unit that an officer was smuggling drugs into the
institution and delivering them to an inmate.

DISPOSITION OF CASE

Because its investigation failed to uncover evidence corroborating the complainant's allegations, the Office of Internal
Affairs decided not to refer the case to the district attorney's office. The bureau did not monitor the resulting
administrative investigation of minor vehicle code violations discovered during the criminal case.

Case No. 06-0356

(North Region)

Administrative Case

FACTS OF CASE

On September 10, 2005, a sheriff's deputy encountered an off-duty officer shooting a firearm with several
companions in a rural area at night. The officer repeatedly disobeyed the deputy's orders to set down his weapon and
lie on the ground. The officer also made demeaning and disrespectful comments to the deputy.

DISPOSITION OF CASE

The hiring authority sustained the allegations and imposed a 30-day suspension without pay. At the officer's Skelly
hearing, a settlement was reached that imposed a 10 percent reduction in salary for three months in exchange for a
waiver of the officer's appeal rights.

Case No. 06-0357

(South Region)

Administrative Case

FACTS OF CASE

On September 9, 2005, an inmate alleged that staff members became upset when the inmate refused to take
prescribed medication and threw a cup of water on an officer. The inmate alleged that officers entered the cell, pushed
the inmate to the floor, punched the inmate in the eye, and struck the inmate in the head with a baton. The institution
could not locate any institutional record regarding this alleged incident.

DISPOSITION OF CASE

The hiring authority concluded that there was insufficient evidence to sustain the allegations against the officers.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0358

(Central Region)

Administrative Case

FACTS OF CASE

On September 7, 2005, two officers allegedly used unnecessary force on another inmate and failed to report the
incident. The reporting inmate also accused the officers of using unnecessary force on him. During the investigation, it
was discovered that one of the officers used profanity when addressing the complaining inmate and had previously
used profanity on duty.

DISPOSITION OF CASE

The allegations of unnecessary force were not sustained, but an allegation of discourteous treatment by staff toward
the inmate was sustained. The officer received a letter of instruction on the use of profanity while on duty.

Case No. 06-0359

(Central Region)

Administrative Case

FACTS OF CASE

An inmate accused an officer on September 6, 2005, of ordering the inmate out of the housing unit. The officer then
allegedly kicked, punched, and threatened to beat the inmate. The inmate also alleged that a sergeant was present and
failed to intervene.

DISPOSITION OF CASE

The hiring authority determined that there was insufficient evidence to sustain any allegations.

Case No. 06-0360

(Central Region)

Administrative Case

FACTS OF CASE

It was alleged that on September 4, 2005, a sergeant improperly entered an inmate's cell and assaulted the inmate,
causing injuries.

DISPOSITION OF CASE

A 30-day suspension was imposed. The sergeant filed an appeal with the State Personnel Board.

Case No. 06-0361

(Central Region)

Administrative Case

FACTS OF CASE

An inmate accused a medical technical assistant of failing to provide adequate medical attention after the inmate was
assaulted by another inmate on September 3, 2005. The inmate also alleged that a sergeant failed to address medical
complaints after the inmate was housed elsewhere. The inmate made additional allegations against unidentified
medical staff members for improper medical attention to his injuries. The inmate further alleged that an officer told
nursing staff that the inmate was "a faker."

DISPOSITION OF CASE

The hiring authority concluded that the investigation did not reveal sufficient evidence to sustain the allegations
against the sergeant and the officer. However, a request for investigation as to possible neglect of duty by attending
medical staff members was recently accepted by the Office of Internal Affairs.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0362

(South Region)

Administrative Case

FACTS OF CASE

On September 3, 2005, an inmate alleged that an officer was involved in smuggling and distributing contraband in the
institution and that the officer wanted to harm the inmate because of the inmate’s competing tobacco distribution
operation. During the investigation, the inmate indicated that another officer was also involved in tobacco smuggling.
The officers denied providing tobacco or other contraband to inmates. However, the second officer admitted that
inmates solicited the officer to smuggle contraband or to pick up packages for them, which the officer failed to report
or document, as required.

DISPOSITION OF CASE

The hiring authority concluded that based on the administrative investigation there was insufficient evidence to
sustain allegations that either officer was involved in the smuggling and distribution of contraband to inmates.
However, the hiring authority concluded there was sufficient evidence to sustain the allegation that the second officer
was overly familiar with inmates and neglectful in official duties by failing to report being solicited by inmates to
engage in contraband smuggling. The hiring authority imposed a 5 percent salary reduction for 16 months on the
officer.

Case No. 06-0363

(North Region)

Criminal Case

FACTS OF CASE

It was alleged that on September 2, 2005, an officer fraudulently filed an unemployment insurance claim while serving
a four-month suspension from the department for a prior adverse action. It is also alleged that the officer falsified
time records.

DISPOSITION OF CASE

There was insufficient evidence to refer the case to the district attorney's office.

Case No. 06-0364

(Central Region)

Administrative Case

FACTS OF CASE

On September 2, 2005, an officer allegedly attempted to persuade another officer to change testimony in a State
Personnel Board hearing involving a fellow officer. It was further alleged that the subject officer attempted to have
other employees ridicule and demean the testifying officer for being a witness.

DISPOSITION OF CASE

The hiring authority concluded that there was not enough evidence to sustain the allegations. The subject officer
admitted having general conversation about the underlying case with other officers but denied enlisting them to harass
the testifying officer and denied trying to persuade any change in testimony. No discipline was imposed.

Case No. 06-0365

(North Region)

Criminal Case

FACTS OF CASE

On September 2, 2005, it was alleged that an officer attempted to extort money and vehicles from an inmate. The
inmate reportedly offered to transfer title of a vehicle to the officer. It was also alleged that the officer was involved in
the distribution of narcotics in the institution.

DISPOSITION OF CASE

The case was not referred to the district attorney's office because there was insufficient evidence to substantiate the
criminal allegations. However, an administrative investigation was opened and monitored by the bureau.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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PAGE 48
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0366

(North Region)

Administrative Case

FACTS OF CASE

As a result of the in-custody death of an inmate by hanging in September 2005, it was alleged that the medical
technical assistant who responded to the incident may not have performed life-support measures in a timely manner.

DISPOSITION OF CASE

The allegations were not sustained, and the investigation was closed. The investigation did reveal a need for additional
training relating to the responsibility to thoroughly and accurately document any care given during a medical
emergency.

Case No. 06-0367

(Central Region)

Administrative Case

FACTS OF CASE

It is alleged that from approximately September 1 to October 12, 2005, an officer was overly familiar with an inmate
and on September 15, 2005, may have retaliated against another officer for reporting misconduct to a sergeant. In
addition, the officer was accused of dishonesty in a criminal investigation involving another officer.

DISPOSITION OF CASE

The hiring authority did not sustain the first allegation of over-familiarity with an inmate. However, the officer
received corrective action in the form of a letter of instruction on appropriate contacts with inmates. The second and
third allegations of retaliation and dishonesty in the investigative interview were not sustained. Therefore, no
disciplinary action was imposed.

Case No. 06-0368

(North Region)

Administrative Case

FACTS OF CASE

In September 2005, an officer allegedly failed to account for all of the kitchen utensils under the officer's direct
supervision and signed the daily inventory log sheet indicating all of the kitchen utensils were accounted for. When
another officer reported for duty, a cutter was discovered missing. A search was conducted, and the cutter was
eventually located.

DISPOSITION OF CASE

Pursuant to settlement at a State Personnel Board hearing, the officer received a 5 percent reduction in salary for three
months.

Case No. 06-0369

(North Region)

Criminal Case

FACTS OF CASE

It was alleged in September 2005 that an officer had been selling tobacco and methamphetamine to inmates. On
March 20, 2006, the officer was tape-recorded selling methamphetamine and marijuana to an inmate in exchange for
$500. The officer was arrested at the institution on that same date in possession of the money and a nine-inch folding
knife.

DISPOSITION OF CASE

The investigation was referred to the district attorney's office for prosecution. The officer was criminally prosecuted
and sentenced to three years in prison.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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PAGE 49
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0370

(South Region)

Criminal Case

FACTS OF CASE

On August 31, 2005, an inmate's spouse alleged that three days earlier, officers beat the inmate without reason. The
inmate made similar allegations and also alleged that officers beat him in the transportation van for 20 minutes before
taking him for treatment. The inmate claimed that one area where he was beaten was monitored by a video camera,
which would corroborate his allegations. The officers stated they used force in self-defense when the inmate became
upset. The investigation determined that the video camera had malfunctioned and did not record the incident.

DISPOSITION OF CASE

The criminal investigation was not referred to the district attorney's office because there was insufficient evidence to
support the allegation of excessive force. An administrative investigation was subsequently opened, which the bureau
is monitoring.

Case No. 06-0371

(South Region)

Administrative Case

FACTS OF CASE

On August 31, 2005, an inmate's spouse alleged that three days earlier, officers beat the inmate without reason. The
inmate made similar allegations and also alleged that officers beat him in the transportation van for 20 minutes before
taking him for treatment. The inmate claimed that one area where he was beaten was monitored by a video camera,
which would corroborate his allegations. The officers stated they used force in self-defense when the inmate became
upset. The investigation determined that the video camera had malfunctioned and did not record the incident.

DISPOSITION OF CASE

The hiring authority concluded that based on the administrative investigation there was insufficient evidence to
sustain allegations of excessive force against the officers. The institution has corrected the problem with the video
camera.

Case No. 06-0372

(Central Region)

Criminal Case

FACTS OF CASE

A special agent interviewed a witness in a pending investigation. The witness alleged that on August 29, 2005, while
passing through central control at the institution, the witness heard a sergeant state, "There’s that rat bastard right
now." The witness later spoke to the sergeant who claimed he was referring to someone else. The witness also alleged
being called a "rat" by other persons and noticing security doors taking an inordinate amount of time to be opened by
staff.

DISPOSITION OF CASE

The case was closed without a referral to the district attorney due to lack of evidence to sustain a criminal case and the
complainant's desire not to go forward. An administrative case was opened, which the bureau is monitoring.

Case No. 06-0373

(South Region)

Administrative Case

FACTS OF CASE

On August 24, 2005, an inmate reported that a medical technical assistant was supplying medications to inmates
without a prescription. Although the reporting inmate was not prescribed Wellbutrin, a blood sample confirmed the
existence of that particular medication in the inmate's blood.

DISPOSITION OF CASE

The medical technical assistant retired while an earlier criminal investigation into similar conduct was being conducted
so no administrative charges were brought as a result of this investigation.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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PAGE 50
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0374

(Central Region)

Criminal Case

FACTS OF CASE

On August 23, 2005, the Office of Internal Affairs received a memorandum dated the same day authored by a
sergeant accusing an officer of using methamphetamine. A work history audit showed the officer in question was
absent from work an inordinate number of days. The next day, the officer was arrested for driving under the influence
and refused to allow law enforcement to draw blood for testing.

DISPOSITION OF CASE

The criminal investigation was closed as there was no evidence to substantiate the allegations, and no administrative
investigation was opened on similar grounds.

Case No. 06-0375

(North Region)

Administrative Case

FACTS OF CASE

On August 22, 2005, it was alleged that a psychologist was spending an inappropriate amount of time with an inmate
and sharing confidential information regarding another inmate with the inmate.

DISPOSITION OF CASE

The department sustained the allegation and took corrective action.

Case No. 06-0376

(South Region)

Administrative Case

FACTS OF CASE

On August 18, 2005, inmates attacked correctional staff members in multiple locations. In one location, inmates began
manufacturing weapons, at which time the control booth officer fired two non-lethal rounds with no effect. The
control booth officer then allowed responding staff to enter the area without advising them that the inmates were
lying in wait. When staff entered, the inmates attacked them with their weapons. During the subsequent melee, the
control booth officer observed an inmate striking a downed officer with a wooden handle and fired one round from a
rifle, striking the inmate in the lower mid-section. Despite medical assistance rendered by staff, the inmate died.
Immediately after the rifle round was discharged, the inmates stopped fighting and surrendered to staff. More than 25
staff members were injured during the incident.

DISPOSITION OF CASE

On August 15, 2006, the hiring authority concluded that based on the administrative investigation there was
insufficient evidence to sustain allegations of misconduct against the shooting officer. On October 2, 2006, the deadly
force review board concluded that the officer fully complied with department policy when discharging the weapon.

Case No. 06-0377

(South Region)

Administrative Case

FACTS OF CASE

On August 18, 2005, numerous inmates and employees were seriously injured during a major riot. Later, one of the
injured inmates alleged that the inmate was assaulted on two separate occasions, once by a sergeant and once by an
officer, in retaliation for the inmate's participation in the riot.

DISPOSITION OF CASE

The hiring authority concluded that there was insufficient evidence to sustain the allegations against the employees.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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ADV

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PAGE 51
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0378

(South Region)

Criminal Case

FACTS OF CASE

On August 18, 2005, a major riot involving hundreds of inmates and over one hundred staff members resulted in
numerous injuries to staff and inmates. Several inmates alleged that an inmate was handcuffed in a prone position and
was possibly unconscious from a head injury when two officers struck the inmate with a baton, kicked the inmate, and
pulled the inmate's T-shirt over the inmate's head. The officers reported using force on the inmate during the riot and
handcuffing the inmate.

DISPOSITION OF CASE

The district attorney's office declined to file charges because of insufficient evidence. The bureau monitored the
administrative investigation of alleged misconduct stemming from this incident.

Case No. 06-0379

(South Region)

Criminal Case

FACTS OF CASE

On August 18, 2005, inmates attacked correctional staff members in multiple locations. In one location, inmates began
manufacturing weapons, at which time the control booth officer fired two non-lethal rounds with no effect. The
control booth officer then allowed responding staff to enter the area without advising them that the inmates were
lying in wait. When staff entered, the inmates attacked them with their weapons. During the subsequent melee, the
control booth officer observed an inmate striking a downed officer with a wooden handle and fired one round from a
rifle, striking the inmate in the lower mid-section. Despite medical assistance rendered by staff, the inmate died.
Immediately after the rifle round was discharged, the inmates stopped fighting and surrendered to staff. More than 25
staff members were injured during the incident.

DISPOSITION OF CASE

On April 13, 2006, the final criminal investigative report was submitted to the district attorney's office. On June 1,
2006, the district attorney's office declined to prosecute the officer in the interest of justice. The bureau is monitoring
the administrative investigation stemming from this incident.

Case No. 06-0380

(South Region)

Criminal Case

FACTS OF CASE

On August 18, 2005, numerous inmates and employees were seriously injured during a major riot. Later, one of the
injured inmates alleged that the inmate was assaulted on two separate occasions, once by a sergeant and once by an
officer, in retaliation for the inmate's participation in the riot.

DISPOSITION OF CASE

The Office of Internal Affairs decided not to present the criminal investigation to the district attorney's office. The
bureau monitored the administrative investigation stemming from the same incident.

Case No. 06-0381

(Central Region)

Administrative Case

FACTS OF CASE

It is alleged that on August 12, 2005, two officers used excessive force on an inmate.

DISPOSITION OF CASE

The hiring authority determined that the evidence was insufficient to sustain the allegations. Thus, no disciplinary
action was imposed.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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PAGE 52
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0382

(North Region)

Administrative Case

FACTS OF CASE

On August 10, 2005, two officers allegedly observed another officer aggressively grabbing an inmate and pulling the
inmate toward a cell. Upon arriving at the cell, the officer pushed the inmate from behind with both hands and then,
without provocation, sprayed the inmate with pepper spray. As the cell door closed, the inmate kicked the officer in
the lower back. The officer then applied pepper spray a second time, and the inmate was secured in the cell.

DISPOSITION OF CASE

The hiring authority sustained the allegation that the officer used unnecessary force upon the inmate and that the
officer was dishonest during the investigative interview. The officer resigned after being served with a notice of
disciplinary action and rejection on probation.

Case No. 06-0383

(North Region)

Criminal Case

FACTS OF CASE

On August 9, 2005, it was alleged that an officer was involved in a relationship with a parolee. It was also alleged that
the officer met the parolee while working at a transitional residence. The parolee moved into the officer's residence
for 30 days before establishing a separate residence.

DISPOSITION OF CASE

The case was not referred to the district attorney's office.

Case No. 06-0384

(North Region)

Administrative Case

FACTS OF CASE

On August 9, 2005, it was alleged that an officer battered an inmate while being observed by two other officers and
filed a false report concerning the use of force. It was also alleged that the witness officers failed to report the use of
force. It was further alleged that all three officers were dishonest during investigative interviews and provided false
testimony at a State Personnel Board hearing on the incident.

DISPOSITION OF CASE

The hiring authority sustained the allegations against the first officer and served him with a notice of dismissal. The
hiring authority also sustained the allegations against the second officer and imposed a five-month suspension without
pay. The third officer resigned before any disciplinary action was taken.

Case No. 06-0385

(Central Region)

Administrative Case

FACTS OF CASE

Outside law enforcement arrested an officer on August 7, 2005, for spousal abuse and criminal threats. A search of
the officer's house yielded an inmate identification card for a parolee who was living out of the region where the
residence was located.

DISPOSITION OF CASE

The administrative allegation regarding the arrest was sustained. Allegations of dishonesty during the investigative
interview and improper possession of an inmate identification card were sustained. The hiring authority settled this
case with the officer for a 5 percent reduction in salary for 12 months.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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PAGE 53
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0386

(Central Region)

Administrative Case

FACTS OF CASE

On August 4, 2005, an officer allegedly failed to follow proper procedures after being struck by an inmate. The next
day, the officer called in sick but reported no injuries. That same day, the officer's roommate called the institution and
reported that the day before, the officer was assaulted by an inmate and received a fractured jaw.

DISPOSITION OF CASE

The hiring authority sustained the allegation of neglect of duty against the officer for failing to report the incident and
issued a letter of reprimand.

Case No. 06-0387

(Central Region)

Administrative Case

FACTS OF CASE

On August 2, 2005, an inmate alleged that an officer falsely accused the inmate of being in a fight, slammed the
inmate against a wall, and pushed the inmate onto the floor while handcuffed, causing a chipped tooth and injuries to
the mouth and chin requiring stitches. The officer claimed the inmate was in a fight with another inmate and became
combative during the escort. The officer's statement was inconsistent with witnesses' statements.

DISPOSITION OF CASE

Allegations were sustained against the officer for incompetence, neglect of duty, and failure of good behavior. The
officer was suspended without pay for 90 work days.

Case No. 06-0388

(North Region)

Administrative Case

FACTS OF CASE

In August 2005, an officer allegedly threw an inmate down a stairwell, causing injury to the inmate's head. It was also
alleged that the officer intimidated the inmate to withdraw an appeal and dissuaded the inmate from being truthful
during an interview on the use of force.

DISPOSITION OF CASE

The allegations against the officer were not sustained, and no disciplinary action was taken.

Case No. 06-0389

(Central Region)

Administrative Case

FACTS OF CASE

On July 31, 2005, an officer was arrested by outside law enforcement for an off-duty battery that occurred at a
restaurant.

DISPOSITION OF CASE

The hiring authority determined that the allegation could not be sustained because the officer's, victim's, and
witnesses' statements were inconsistent and contradictory as to who initiated the confrontation and whether the
officer was acting in self-defense. Therefore, no disciplinary action was imposed.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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PAGE 54
STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0390

(Central Region)

Administrative Case

FACTS OF CASE

On July 29, 2005, a sensitive needs inmate was attacked and injured by other inmates. An acting lieutenant was
accused of providing a false report of staff actions after the attack and of inappropriately housing the attacked inmate.
A sergeant was accused of providing a false report as to staff actions concerning the attack and of improperly
assessing and supervising the circumstances regarding the attack on the inmate. An officer was accused of failing to
respond properly to the attack and of submitting a false report regarding staff actions after the attack. Two additional
officers were accused of providing a false report as to staff actions after the attack on the inmate.

DISPOSITION OF CASE

The allegations initially sustained against two of the officers included inefficiency, inexcusable neglect of duty, willful
disobedience, and other failure of good behavior. These officers subsequently admitted to misconduct and settlements
were reached whereby they accepted a suspension for 60 work days. The allegations sustained against the third officer
included inefficiency and other failure of good behavior, for which the officer was dismissed from state service. The
allegations sustained against the lieutenant and sergeant included inefficiency, disobedience, and other failure of good
behavior, for which they were dismissed from state service. Appeals are pending before the State Personnel Board for
the officer, lieutenant, and sergeant who were dismissed from state service.

Case No. 06-0391

(North Region)

Administrative Case

FACTS OF CASE

On July 22, 2005, a parole agent was arrested at approximately 0100 hours after the victim and several witnesses
reported seeing the parole agent brandishing a firearm at them. The police responded to the scene, and while arresting
the parole agent, they located the parole agent's state-issued firearm on the floorboard of the parole agent's personal
vehicle.

DISPOSITION OF CASE

The hiring authority sustained the allegations of exhibiting a firearm and carrying an unauthorized weapon off duty.
The parole agent was subsequently dismissed from state service.

Case No. 06-0392

(Central Region)

Administrative Case

FACTS OF CASE

On July 21, 2005, an officer was observed challenging an inmate to a fight. The officer allegedly shoved the inmate,
and the inmate used his fist to strike the officer's jaw.

DISPOSITION OF CASE

Evidence developed during the investigation supported an allegation of dishonesty. The hiring authority sustained the
allegations and decided to seek dismissal, but the subject officer resigned before the penalty was imposed.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0393

(Central Region)

Administrative Case

FACTS OF CASE

On July 21, 2005, an inmate on suicide watch soiled his garment and the walls of the observation cell in which he was
housed. An officer gave the inmate a pair of boxer shorts to wear while the cell was cleaned. After the cell was
cleaned, the officer returned the inmate to the cell but failed to recover the boxer shorts. The inmate then fashioned
the boxer shorts into a ligature and used it to attempt suicide. The officer was previously counseled for similar
neglectful conduct.

DISPOSITION OF CASE

The officer received a penalty of 10 percent salary reduction for four months. No State Personnel Board appeal was
filed by the officer.

Case No. 06-0394

(Central Region)

Administrative Case

FACTS OF CASE

An inmate accused several officers of using unnecessary force and filing false reports regarding the use of force that
arose during an incident on July 15, 2005.

DISPOSITION OF CASE

This incident was reviewed twice by the use of force committee, which concluded that the officers' actions and
documentation of the incident were appropriate. The officers did receive corrective action in the form of on-the-job
training regarding holding cell log book procedures and the de-escalation of inmate conflict situations.

Case No. 06-0395

(South Region)

Administrative Case

FACTS OF CASE

On July 14, 2005, as a sergeant was escorting a handcuffed inmate, the inmate attempted to break away, causing the
sergeant to force the inmate to the floor. The inmate kicked the sergeant, and the sergeant punched the inmate in the
face.

DISPOSITION OF CASE

The hiring authority concluded that, based on the administrative investigation, sufficient evidence existed to sustain
allegations of neglect of duty and failure of good behavior for striking the handcuffed inmate in the face. The hiring
authority issued a letter of reprimand to the sergeant.

Case No. 06-0396

(Central Region)

Administrative Case

FACTS OF CASE

On July 14, 2005, two officers were accused of intentionally destroying and misdirecting outgoing inmate mail in
retaliation for inmates' alleged disruptive conduct during an earlier shift.

DISPOSITION OF CASE

The hiring authority sustained allegations of inexcusable neglect of duty, discourteous treatment, and dishonesty and
dismissed the officers. Subsequent to the Skelly hearings, additional information was brought forward that resulted in
settlement agreements imposing a 12 work day suspension and withdrawal of the dishonesty allegations.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0397

(Central Region)

Administrative Case

FACTS OF CASE

On July 9, 2005. two officers allegedly used excessive and unnecessary force involving the use of pepper spray and a
baton on an inmate. One officer also allegedly threatened the inmate.

DISPOSITION OF CASE

The first officer accepted a settlement agreement calling for a 5 percent reduction in salary for six months. The hiring
authority sustained the allegations against the second officer of neglect of duty and unreasonable use of force. A 10
percent reduction in salary for 12 months was imposed. This officer was also alleged to have threatened an inmate
with bodily harm. This allegation was not sustained. The second officer settled the action against him prior to the
appeal hearing for a 5 percent reduction in salary for six months.

Case No. 06-0398

(Central Region)

Administrative Case

FACTS OF CASE

It was alleged that on July 9, 2005, an officer improperly punished an inmate, then, accompanied by two other
officers, entered the inmate's cell without authorization and assaulted the inmate. None of the officers reported the
use of force.

DISPOSITION OF CASE

One officer was exonerated, and the hiring authority sustained allegations against the other two. One officer was
dismissed, and the other was given a 49-day suspension. A State Personnel Board hearing is pending.

Case No. 06-0399

(North Region)

Administrative Case

FACTS OF CASE

On July 8, 2005, a sergeant allegedly used excessive force and failed to report it as required.

DISPOSITION OF CASE

The sergeant and the department entered into a stipulated settlement of the case. During the investigation, the
sergeant was allegedly dishonest in an internal affairs interview. The charge of dishonesty was dropped, and the
sergeant received a 5 percent reduction in salary for six months for neglect of duty.

Case No. 06-0400

(North Region)

Administrative Case

On July 7, 2005, a health program coordinator allegedly observed a custodian supervisor with an inmate in the laundry
room. When the supervisor handed the health program coordinator some keys, paperwork fell on the floor that
revealed a picture of the supervisor provocatively posing in a bikini. Both the inmate and the supervisor appeared to
become very nervous. The supervisor later admitted to having a sexual relationship with the inmate. The health
program coordinator reported this incident to an associate warden, who allegedly covered his ears and said he "did not
want to hear it." The associate warden allegedly failed to report misconduct on the part of the supervisor.

DISPOSITION OF CASE

The allegations against the associate warden were not sustained, and the supervisor resigned from the department.

OFFICE OF THE INSPECTOR GENERAL

DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

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ADV

HA

BUREAU ASSESSMENT
DISPO

FACTS OF CASE

BUREAU OF INDEPENDENT REVIEW

BUREAU ASSESSMENT

INV

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BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0401

(Central Region)

Criminal Case

FACTS OF CASE

A supervising cook was accused of being overly familiar with inmates and falsifying time sheets in approximately July
and August 2005.

DISPOSITION OF CASE

The criminal investigation was closed without referral to the district attorney's office because of insufficient evidence.
An administrative investigation was opened, which the bureau is monitoring.

Case No. 06-0402

(North Region)

Criminal Case

FACTS OF CASE

On June 29, 2005, an officer allegedly allowed an inmate to enter a cell occupied by another inmate to commit an
assault. The injured inmate had reportedly whistled at another officer earlier that day. The inmate sustained an
abrasion to his lip. After the assault, the officer allegedly had another officer ask the injured inmate if he could still
whistle.

DISPOSITION OF CASE

The Office of Internal Affairs forwarded the completed investigation to the district attorney's office for prosecution.
The district attorney's office subsequently declined to file charges against the officer. The Office of Internal Affairs
opened an administrative investigation that is being monitored by the bureau.

Case No. 06-0403

(North Region)

Administrative Case

FACTS OF CASE

On June 29, 2005, an officer alleged that an investigative services unit squad sergeant had harassed other officers by
intimidating and degrading them. The officer also alleged that the sergeant threw a computer monitor at one of the
officers.

DISPOSITION OF CASE

Because of insufficient evidence, the hiring authority did not sustain the allegations in this case.

Case No. 06-0404

(North Region)

Administrative Case

FACTS OF CASE

On June 20, 2005, it was alleged that an officer was engaged in a physical relationship with an inmate who was a
validated gang member and provided contraband to that inmate.

DISPOSITION OF CASE

The hiring authority sustained the allegations, and the officer received a letter of reprimand.

Case No. 06-0405

(Central Region)

Administrative Case

FACTS OF CASE

On June 20, 2005, an officer was accused of not reporting a relationship between another officer and an inmate, being
dishonest during an investigation, and having a relationship with a parolee.

DISPOSITION OF CASE

The hiring authority sustained all the allegations against the officer and sought termination. The officer appealed the
matter to the State Personnel Board, which upheld the termination.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
DISPO

INV

ADV

HA

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0406

(North Region)

Administrative Case

FACTS OF CASE

On June 17, 2005, a lieutenant allegedly conducted an unclothed body search of an inmate, and the inmate refused to
assume a proper search position despite several orders to spread his legs and place his hands on the wall. The inmate
lowered his hands and turned toward the lieutenant, who grabbed the inmate and forced him to the ground. It was
also alleged the lieutenant failed to write his report within 24 hours of the incident, as required by department
procedures.

DISPOSITION OF CASE

The lieutenant received a letter of instruction for discourteous treatment.

Case No. 06-0407

(Central Region)

Administrative Case

FACTS OF CASE

On June 16, 2005, a confidential informant alerted staff members that a cook planned to smuggle narcotics into the
institution for inmates. Officers from internal affairs and the investigative services unit jointly confronted the subject.
Although no narcotics were discovered, investigators found the subject had previously ordered contraband for
inmates.

DISPOSITION OF CASE

The hiring authority sustained the allegations and decided to terminate the employee. The employee subsequently
resigned pursuant to a settlement agreement that included a stipulation to never re-apply for employment with the
department.

Case No. 06-0408

(North Region)

Administrative Case

FACTS OF CASE

On June 4, 2005, an officer reportedly approached two other officers and asked them to falsify their reports to match
the officer's version of events regarding the use of force against an inmate. The officer wanted them to report that
they witnessed the inmate strike the officer first.

DISPOSITION OF CASE

The hiring authority sustained the allegations against the officer for encouraging the preparation of false reports. The
officer was to be dismissed from state service for other misconduct involving dishonesty related to this case. The
penalty of dismissal was modified to a five-month suspension. The officer also agreed to attend relevant training as
deemed necessary by the hiring authority.

Case No. 06-0409

(Central Region)

Administrative Case

FACTS OF CASE

On June 4, 2005, a fight occurred between correctional officers and military personnel at an off-duty barbecue. A
civilian at the party was stabbed and severely injured, receiving 75 staples to close a head and chest injury. He also
suffered a bruised retina. Five officers were identified as having participated in the fight.

DISPOSITION OF CASE

Two of the officers agreed to cooperate in the investigation and each received a reduced penalty of a 30-day
suspension without pay. The remaining three officers received 120-day suspensions without pay.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0410

(Central Region)

Administrative Case

FACTS OF CASE

On June 1, 2005, an officer was arrested for driving under the influence, displaying signs of drug intoxication, and
admitting use of prescription narcotics. A search of the officer's residence uncovered prescription narcotic drugs,
marijuana, and drug paraphernalia.

DISPOSITION OF CASE

The allegations were sustained and combined with other pending matters, and the officer was dismissed. An appeal
before the State Personnel Board is pending.

Case No. 06-0411

(Central Region)

Administrative Case

FACTS OF CASE

It was alleged that during the period of June and July 2005, a non-sworn employee was involved in overly familiar
sexual relationships with various inmates. It was also alleged that the employee falsified the employee's record of
attendance during the same period.

DISPOSITION OF CASE

The employee resigned from the department before the administrative investigation was completed and before the
employee was interviewed. The investigation was closed without any findings on the allegations.

Case No. 06-0412

(Headquarters)

Administrative Case

FACTS OF CASE

On May 26, 2005, a religious volunteer reported that several wards disclosed that in April and May 2005 female wards
were engaging in sexual misconduct with another volunteer in exchange for money. The employee chaplain was
reportedly present when the misconduct occurred and allegedly failed to properly supervise the volunteer.

DISPOSITION OF CASE

The criminal investigation of the volunteer failed to produce sufficient evidence that the alleged conduct occurred.
Therefore, the matter was not referred to the district attorney's office. The allegations against the chaplain for failing
to supervise the volunteer were not sustained by the hiring authority.

Case No. 06-0413

(Central Region)

Administrative Case

FACTS OF CASE

On May 18, 2005, it was alleged that an officer was trafficking controlled medication and weapons into the institution
and being overly familiar with inmates.

DISPOSITION OF CASE

The officer was dismissed from state service and appealed. A State Personnel Board hearing is still pending.

Case No. 06-0414

(South Region)

Administrative Case

FACTS OF CASE

On May 18, 2005, an investigating sergeant allegedly withheld information favorable to an officer in the officer's
termination case.

DISPOSITION OF CASE

An investigation into the allegation produced insufficient evidence that the sergeant withheld information. Therefore,
the hiring authority did not sustain the allegations against the sergeant, and no disciplinary action was taken.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0415

(Central Region)

Administrative Case

FACTS OF CASE

On May 18, 2005, a medical technical assistant was accused of inappropriately disposing of non-psychotropic
medication during working hours in an institution's medical clinic. The medication was supposed to be issued to an
inmate.

DISPOSITION OF CASE

The hiring authority sustained the allegation, and a salary reduction of 5 percent for 12 months was imposed.

Case No. 06-0416

(South Region)

Administrative Case

FACTS OF CASE

On May 9, 2005, an officer allegedly had an inmate type a memo alleging staff misconduct. The officer then signed the
memo and attached it to that inmate's own complaint about the alleged misconduct.

DISPOSITION OF CASE

The hiring authority found insufficient evidence to sustain the allegation.

Case No. 06-0417

(South Region)

Administrative Case

FACTS OF CASE

On May 9, 2005, it was alleged that an officer signed a form to initiate cell moves for several inmates in violation of a
rule requiring a lieutenant or person of higher rank to sign and approve the moves. It was also alleged that the officer
was engaged in an overly familiar relationship with one of the inmates listed on the form the officer had signed. It was
further alleged that the warden covered up the wrongdoing.

DISPOSITION OF CASE

No allegations were sustained as a result of the investigation.

Case No. 06-0418

(Central Region)

Administrative Case

FACTS OF CASE

An officer was accused of falsifying his time sheet for May 2005 by inappropriately claiming family sick time and
bereavement leave. The individual allegedly cared for was not a relative of the officer.

DISPOSITION OF CASE

The hiring authority sustained the allegation and issued a letter of reprimand to the officer.

Case No. 06-0419

(North Region)

Administrative Case

FACTS OF CASE

On April 21, 2005, a registered nurse alleged that a counselor attempted to dissuade the nurse from testifying in
federal court on behalf of an inmate.

DISPOSITION OF CASE

No evidence indicated that the counselor attempted to dissuade the registered nurse from testifying. Therefore, no
action was taken.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0420

(Central Region)

Criminal Case

FACTS OF CASE

On April 18, 2005, a parole agent was accused of having sexual relations with a parolee who was not part of the
agent's caseload. Physical evidence was collected, and DNA testing was conducted.

DISPOSITION OF CASE

The district attorney's office charged the agent with having sexual relations with a parolee. The parole agent pled guilty
to the charge and was sentenced to pay a $2,500 fine and $500 restitution. An administrative investigation is pending,
which the bureau is monitoring.

Case No. 06-0421

(South Region)

Administrative Case

FACTS OF CASE

On April 12, 2005, an officer alleged that he found confidential documents with staff names and social security
numbers in an unsecured conference room. However, a personnel specialist stated that the subject officer requested
and had actually received the documents from the personnel office earlier that day.

DISPOSITION OF CASE

The hiring authority concluded that the officer was dishonest and sustained the allegation. Because the officer
voluntarily retired, no discipline was imposed.

Case No. 06-0422

(Central Region)

Administrative Case

FACTS OF CASE

On April 5, 2005, police arrived at the scene of a traffic accident and saw an off-duty correctional officer flee in a
damaged vehicle. The correctional officer was subsequently arrested for driving under the influence and hit and run.
The correctional officer pled no contest to both misdemeanors.

DISPOSITION OF CASE

The hiring authority sustained the allegations and sought to dismiss the officer. The officer appealed the matter to the
State Personnel Board, which upheld the dismissal. A further appeal of that decision is pending.

Case No. 06-0423

(Central Region)

Administrative Case

FACTS OF CASE

On April 1, 2005, a dentist refused to treat an inmate patient until the inmate withdrew a complaint that the inmate
had previously filed against the dentist. The dentist recorded this demand on the inmate's chart.

DISPOSITION OF CASE

In view of the dentist's record of persistent misconduct, the hiring authority sought dismissal. However, the matter
was settled in exchange for the dentist's resignation and agreement not to seek future employment with the
department.

Case No. 06-0424

(South Region)

Administrative Case

FACTS OF CASE

On March 14, 2005, it was alleged that a lieutenant left the institution to attend a union meeting while on duty. It was
also alleged that the lieutenant lied about this on his time sheet.

DISPOSITION OF CASE

None of the allegations were sustained by the hiring authority because of insufficient evidence.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0425

(Central Region)

Criminal Case

FACTS OF CASE

In March 2005, an inmate alleged that an officer had a sexual encounter with the inmate, removed confidential
documents from the inmate's central file, had off-duty telephone contact with the inmate, and provided tobacco
products to the inmate. Another inmate made similar allegations.

DISPOSITION OF CASE

The criminal investigation concluded with the officer's guilty plea to one misdemeanor violation of unlawful
communication with a prisoner. The subject resigned from state service before completion of the investigation and
the guilty plea.

Case No. 06-0426

(Headquarters)

Administrative Case

FACTS OF CASE

On February 26, 2005, a youth correctional counselor allegedly used excessive force on a ward by using pepper spray
and forcing the ward to the ground when the ward failed to comply with orders to return to the ward's room. It was
also alleged that the counselor was dishonest in the account of the incident. Further, three responding staff members
allegedly wrote inaccurate reports.

DISPOSITION OF CASE

The youth correctional counselor was initially served with a notice of dismissal. Pursuant to a settlement agreement,
the department ultimately imposed a 10-day suspension without pay and removed the charge of dishonesty. The youth
correctional counselor agreed not to appeal the disciplinary action. The three responding staff members received
letters of instruction related to their reports.

Case No. 06-0427

(Central Region)

Administrative Case

FACTS OF CASE

On January 31, 2005, an inmate died in custody. An autopsy revealed the cause of death was inhalation abuse of
organic solvents. It was alleged that the inmate gained access to glaze remover at the inmate's graphic arts class and
that the inmate's vocational instructor failed to properly handle the deglazer.

DISPOSITION OF CASE

The hiring authority issued a letter of instruction to the vocational instructor, although it should be noted the subject
could not have performed his job without allowing inmates limited access to the chemical substance involved in this
case.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0428

(Central Region)

Administrative Case

FACTS OF CASE

On January 21, 2005, an inmate alleged that five officers used excessive force resulting in injury to remove handcuffs
from the cell of the inmate who earlier refused to surrender them and that the officers failed to report the use of
force. The inmate also alleged that a psychological technician failed to provide medical treatment for the injury. In
addition to those involved in the use of force, a sergeant was accused of leaving the institution without reporting the
incident and falsely reporting it once advised of the charges.

DISPOSITION OF CASE

Charges for incompetence, neglect, and failure of good behavior were sustained against the sergeant. The sergeant's
case was settled for a 24-day suspension. Two of the officers involved entered a stipulated settlement for a 10 percent
salary reduction for 24 months. Two other officers involved entered a stipulated settlement for a 10 percent salary
reduction for 12 months. The fifth officer resigned pending adverse action. No charges were sustained, and no
discipline was imposed on the psychological technician.

Case No. 06-0429

(North Region)

Administrative Case

FACTS OF CASE

On January 8, 2005, an officer allegedly displayed an offensive gesture toward an inmate. When the inmate returned
the gesture, the officer assaulted the inmate. A sergeant arrived and observed the officer repeatedly striking the inmate
about the upper torso while the inmate offered no resistance. There were several officers present at the scene who
failed to intervene and stop the assault.

DISPOSITION OF CASE

There was insufficient evidence against the officers who allegedly observed the incident. The hiring authority
sustained the allegation of excessive force against the officer and imposed a 5 percent salary reduction for 24 months.

Case No. 06-0430

(North Region)

Criminal Case

FACTS OF CASE

In January 2005, a medical technical assistant allegedly became involved in a physical relationship with an inmate.

DISPOSITION OF CASE

The investigation revealed insufficient evidence of a criminal violation. No referral was made to the district attorney's
office.

Case No. 06-0431

(South Region)

Administrative Case

FACTS OF CASE

On November 30, 2004, a lieutenant conducted a hearing to determine if an inmate was guilty of possessing a weapon.
Subsequently, criminal charges were filed against the inmate for possession of the weapon, and it was discovered that
the lieutenant fabricated testimony in the hearing report. The district attorney's office reported the lieutenant's actions
to the department.

DISPOSITION OF CASE

Based on the administrative investigation, the hiring authority concluded sufficient evidence existed to sustain
allegations that the lieutenant had made false or intentionally misleading statements to the district attorney's office,
made false or intentionally misleading statements in the rules violations findings report, and gave false testimony
under oath. The hiring authority dismissed the lieutenant. The matter is scheduled for a State Personnel Board hearing.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0432

(Central Region)

Administrative Case

FACTS OF CASE

On November 2, 2004, an officer was accused of submitting fraudulent military orders to obtain unearned
compensation in excess of seven thousand dollars.

DISPOSITION OF CASE

The hiring authority sustained the allegation against the officer and sought termination. The subject resigned pending
discipline. A criminal case was filed by the district attorney's office and is pending.

Case No. 06-0433

(Central Region)

Administrative Case

FACTS OF CASE

On October 18, 2004, an inmate was assaulted on the yard for over 90 seconds without tower staff, who were
responsible for monitoring the yard, sounding an alarm. It was alleged that the officers in the tower allowed the assault
to occur and that responding officers were possibly negligent in their response.

DISPOSITION OF CASE

Allegations for neglect of duty resulting in injury were sustained against the officers in the tower. The more
experienced officer who had the primary duty in the tower received a five-day suspension. The other officer, who was
working his first shift in the tower, received a letter of reprimand. The allegations against the responding officers were
not sustained.

Case No. 06-0434

(Central Region)

Administrative Case

FACTS OF CASE

In October 2004, two officers in an administrative segregation unit were accused of providing confidential
information about new inmates to other inmates already in the unit.

DISPOSITION OF CASE

One officer admitted providing confidential information about new inmates to other inmates to determine housing
compatibility. The allegation was sustained, and the officer received a letter of instruction as well as additional training.
The allegation against the second officer was not sustained. Additional training was provided to institution employees
addressing the need to keep inmate records confidential from other inmates.

Case No. 06-0435

(South Region)

Administrative Case

FACTS OF CASE

On June 12, 2004, a parole agent married an individual who was on parole. Although the agent may not have known
at the time of the marriage that the spouse was on active parole, once the agent did find out, the agent failed to report
the marriage to the hiring authority. In addition, the agent tried to conceal the marriage by getting an annulment.

DISPOSITION OF CASE

The hiring authority concluded that the parole agent became aware of the parolee's status approximately one year after
the marriage and failed to inform the department of the marriage. The hiring authority dismissed the agent.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

BUREAU ASSESSMENT
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STATE OF CALIFORNIA

SATISFACTORY CASES
Case No. 06-0436

(Central Region)

Administrative Case

FACTS OF CASE

It was alleged that a non-sworn employee may have engaged in overly familiar conduct and sexual acts with inmates
from early 2004 through the summer of 2004.

DISPOSITION OF CASE

The hiring authority determined that the investigation was sufficient but that the allegations had not been proven by a
preponderance of the evidence. Therefore, no adverse action was imposed.

Case No. 06-0437

(North Region)

Administrative Case

FACTS OF CASE

On July 16, 2003, during a search of a parolee's residence, a parole agent allegedly hid methamphetamine found in one
of the rooms from other law enforcement officers. It was reported that the parolee had previously given a vehicle to
the agent, which prompted the agent's misconduct. The allegations were first reported to parole authorities in
November 2005.

DISPOSITION OF CASE

There was insufficient evidence to prove the allegation. However, the investigation did reveal that the parole agent
facilitated the transfer of a vehicle belonging to a recently discharged parolee to relatives of a current parolee. The
hiring authority issued the parole agent a letter of instruction as a corrective measure to encourage compliance with
department policies.

Case No. 06-0438

(Central Region)

Criminal Case

FACTS OF CASE

On June 4, 2003, five physicians were accused of "churning," a practice of scheduling inmate medical appointments at
lengthy intervals during time the physicians were on call, resulting in unnecessary and inefficient call-backs to the
institution, which increased the amount of money paid to the physicians. It was also alleged the physicians falsified
entries on time sheets.

DISPOSITION OF CASE

The Office of Internal Affairs forwarded the completed investigation against two of the physicians to the district
attorney's office for prosecution. The district attorney's office declined to file charges. As a result, the Office of
Internal Affairs did not refer the investigation against the remaining three physicians to the district attorney's office.
The department also conducted an administrative investigation into the alleged misconduct, which the bureau
monitored.

Case No. 06-0439

(Central Region)

Administrative Case

FACTS OF CASE

On June 4, 2003, five physicians were accused of "churning," a practice of scheduling inmate medical appointments at
lengthy intervals during time the physicians were on call, resulting in unnecessary and inefficient call-backs to the
institution, which increased the amount of money paid to the physicians. It was also alleged that the physicians
falsified entries on time sheets.

DISPOSITION OF CASE

The department decided not to take any disciplinary action against two of the physicians because they voluntarily
resigned when served with notices for interviews. The administrative investigation of the other three physicians is
reported in the table of deficient cases.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

CRITICAL INCIDE NTS
Case No. 06-0440

(Central Region)

FACTS OF CASE

On December 1, 2006, an inmate's index finger was cut off and two other fingers were lacerated while using a table saw in a vocational mill. No
staff misconduct was identified.

DISPOSITION OF CASE

Despite instructions to the inmate not to use any woodworking equipment, the inmate nevertheless used a table saw, resulting in the injuries.
When interviewed, the inmate assumed full responsibility for the accident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0441

(North Region)

FACTS OF CASE

On November 29, 2006, staff members responded to an altercation between two inmates in a cell. Staff dispersed pepper spray to end the fight.
One of the inmates suffered a broken jaw and was transported to an outside hospital for treatment. The other inmate was burned when a pot of
hot water was thrown in the inmate's face. After the fight, staff discovered an inmate-manufactured weapon in the cell likely used to break the
other inmate's jaw.

DISPOSITION OF CASE

The investigation revealed that none of the injuries sustained by the inmates were caused by staff but were inflicted by the inmates on each other
during the altercation. No internal affairs investigation was requested.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0442

(South Region)

FACTS OF CASE

On November 9, 2006, a partially unclothed material and stores supervisor was found embracing an inmate in the restroom. The material and
stores supervisor alleged that a rape had occurred. The institution initiated a criminal investigation against the inmate, and when interviewed, the
inmate denied the rape allegation and alleged that the relationship was consensual. The material and stores supervisor later admitted that no rape
had occurred and that they had been involved in a sexual relationship and had exchanged personal letters and that photographs had been taken
of the two together with a smuggled digital camera.

DISPOSITION OF CASE

The material and stores supervisor resigned. The bureau monitored the criminal investigation of the alleged rape. The hiring authority requested
an administrative investigation of the employee, which the bureau is not monitoring.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

CRITICAL INCIDE NTS
Case No. 06-0443

(Central Region)

FACTS OF CASE

On October 18, 2006, an inmate was taken to a hospital for treatment after ingesting approximately 100 Tylenol tablets. The inmate made prior
suicide attempts and has made additional attempts since the incident.

DISPOSITION OF CASE

The health care manager at the institution implemented a special program for the inmate after conferring with the bureau. The program
included increased supervision and the placement of sand bags in front of the cell to prevent the inmate from receiving items from other
inmates that could be used to commit suicide. The inmate's property was inspected, and a security mattress was provided to prevent future
suicide attempts. The inmate is receiving additional counseling and treatment from mental health staff. No staff misconduct was identified.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification,
but adequately consulted with the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the
matter to the Office of Internal Affairs.

Case No. 06-0444

(North Region)

FACTS OF CASE

On October 17, 2006, a riot involving more than 50 inmates occurred on a yard. The inmates refused staff orders to stop and get down on the
ground in a prone position. Staff used chemical agents and discharged non-lethal impact rounds to control the inmates and get them to comply.
Ultimately, the inmates stopped fighting. One inmate-manufactured stabbing weapon was discovered on the ground. There were no injuries to
responding staff or inmates as a result of the chemical agents and non-lethal impact rounds.

DISPOSITION OF CASE

Staff reports indicated the riot was handled appropriately. No subsequent investigation was initiated.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0445

(North Region)

FACTS OF CASE

On October 4, 2006, the Office of Internal Affairs received information from the institution's investigative services unit that a control booth
officer was allegedly engaged in an overly familiar relationship with an inmate and provided the inmate with tobacco. The officer also reportedly
received money in exchange for bringing in the contraband. The investigative services unit became aware of the situation when it intercepted
several letters from the inmate, some of which contained the officer's personal phone number and address.

DISPOSITION OF CASE

The officer resigned before the start of the investigation.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

CRITICAL INCIDE NTS
Case No. 06-0446

(Central Region)

FACTS OF CASE

On October 1, 2006, an officer found inmates performing CPR on another inmate. Rather than administer CPR, the officer left to obtain a tool
to cut a ligature the officer believed was around the inmate's neck. Other officers arrived and began performing CPR. Medical staff arrived with
an ambu-bag but did not immediately use it, nor did they relieve custody staff of performing CPR.

DISPOSITION OF CASE

The department conducted further investigation following a recommendation by the bureau. The officer who left the scene to retrieve a tool
was served with an employee counseling record, was counseled, and will be given on-the-job training on crime scene preservation. No
misconduct by other staff was identified.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except that an officer improperly left the scene while inmates provided CPR and
medical staff did not properly assume responsibility for providing medical attention upon arrival. The department provided adequate
notification and consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the
matter to the Office of Internal Affairs.

Case No. 06-0447

(North Region)

FACTS OF CASE

On September 26, 2006, officers observed an inmate kicking the door of a cell while the cellmate was facing away from the door with what
appeared to be blood on his upper back. As the officers sounded their alarms, the cellmate began washing off the blood at the sink as the inmate
was disposing unknown objects in the toilet and flushing it. Both inmates subsequently complied with orders to be handcuffed. According to
initial medical reports, the cellmate sustained approximately 27 puncture wounds to the torso area. Because of the apparent severity of the
injuries, the cellmate was airlifted to a nearby hospital but was returned to the institution the following day.

DISPOSITION OF CASE

There was no evidence of staff misconduct involved in the incident, and no administrative investigation was initiated.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0448

(Central Region)

FACTS OF CASE

On September 11, 2006, a control booth officer opened the door to an inmate's cell, and two inmates began fighting. One inmate used an
inmate-manufactured knife to stab the other inmate multiple times. The other inmate was incapacitated after his lung was punctured, and both
inmates returned to their cells. The control booth officer stated in the initial report that the cell door was inadvertently opened while the officer
let the first inmate out of the cell. The officer later recanted and said he had slipped and accidentally opened the door when he attempted to
catch himself.

DISPOSITION OF CASE

The control booth officer is the subject of a criminal investigation with the allegation of conspiracy to commit murder in addition to the
administrative elements. The bureau felt that an investigation should be initiated. The bureau is now monitoring the investigation.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

CRITICAL INCIDE NTS
Case No. 06-0449

(Central Region)

FACTS OF CASE

On September 6, 2006, an inmate was struck several times by another inmate with a cane during a fight. The inmate died on December 12,
2006, at a local hospital. The deceased inmate suffered from many ailments, including liver disease, serious kidney problems, and diabetes.

DISPOSITION OF CASE

The coroner determined that the inmate died from end-stage hepatic failure due to hepatitis-C infection and that atherosclerotic coronary artery
disease contributed to the inmate's death. In light of this, no investigation into the inmate's death was requested.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except that the department did not properly document the incident because the
report failed to explain why the inmate was in the hospital when he died. The department provided adequate notification and consultation to the
bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.

Case No. 06-0450

(North Region)

FACTS OF CASE

On September 1, 2006, an inmate was assaulted by two rival inmates on the yard. Officers could not stop the assault with verbal commands, so
they discharged six non-lethal impact rounds and used pepper spray to quell the assault and then delivered emergency medical assistance to the
inmate.

DISPOSITION OF CASE

The injured inmate was treated at a local hospital and eventually released to the institution. No subsequent internal affairs investigation was
initiated.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0451

(South Region)

FACTS OF CASE

On August 31, 2006, an officer counting inmates at night could not see an inmate because of a curtain. The officer asked the cellmate to move
the curtain. When the cellmate complied, the officer observed the inmate partially covered by a sheet. Another officer included the inmate in the
later counts but had to tell the cellmate to move aside from the window so the officer could see inside the cell. Within hours, staff found the
inmate dead in his bunk.

DISPOSITION OF CASE

An outside law enforcement agency is conducting a criminal investigation of the incident. The hiring authority also has requested that the Office
of Internal Affairs conduct an administrative investigation of the incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

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Case No. 06-0452

(Central Region)

FACTS OF CASE

On August 22, 2006, two inmates were found unresponsive in their cell. The cell was opened, and staff discovered that one inmate was not
breathing and the other was lethargic. Emergency life-saving efforts were initiated. One inmate was pronounced dead, and the other survived
after being administered a narcotic antidote. A substance believed to be heroin was discovered in the cell.

DISPOSITION OF CASE

The coroner determined the cause of death to be from an accidental self-inflicted overdose of heroin. The investigative services unit initiated a
subsequent criminal investigation to determine the source of the heroin.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0453

(South Region)

FACTS OF CASE

On August 22, 2006, a paraplegic inmate and a quadriplegic inmate were transported from the central region to a southern region institution
together in a department van that developed air conditioning problems and became lost during the transport. On arrival at the southern
institution about nine and one-half hours later, the quadriplegic inmate was unconscious, had a temperature exceeding 109 degrees, and was not
expected to live. Subsequently, the inmate died.

DISPOSITION OF CASE

The bureau is monitoring the criminal and the administrative investigations being conducted by the Office of Internal Affairs.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects, except some reports were tardy and the timeliness of the
hiring authority response is still under review. The department failed to provide adequate notification and consultation to the bureau regarding
the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs. The bureau
concurred with the Office of Internal Affairs' response to the hiring authority's referral.

Case No. 06-0454

(North Region)

FACTS OF CASE

On July 20, 2006, an inmate alleged that an officer was involved in trafficking contraband into the institution and had consumed alcohol with
inmates. On July 21, 2006, a second inmate reported that the same officer was involved in trafficking tobacco and alcohol into the institution for
monetary gain.

DISPOSITION OF CASE

The Office of Internal Affairs opened criminal and administrative cases, which the bureau monitored.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

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Case No. 06-0455

(Central Region)

FACTS OF CASE

On July 27, 2006, an inmate collapsed while playing basketball on an exercise yard. Officers initiated CPR and called for medical staff. The
inmate was transported to a hospital where he was pronounced dead. The inmate had a history of heart-related ailments.

DISPOSITION OF CASE

The coroner concluded that the death was related to natural causes from an acute cardio infarction due to atherosclerotic hypertension. The
inmate was seen by medical staff on November 23, 2005, related to high blood pressure, shortness of breath, and chest pain. Medical staff
recommended medication, but the inmate refused medication and further treatment. The hiring authority did not request an administrative
investigation.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0456

(North Region)

FACTS OF CASE

On July 25, 2006, an inmate was discovered unconscious by a cellmate. The cellmate notified an officer who immediately sounded an alarm. The
inmate was removed from the cell, and CPR was immediately initiated. The inmate was transported to the medical clinic and pronounced dead.

DISPOSITION OF CASE

The autopsy of the inmate revealed that the cause of death was end-stage hepatic cirrhosis of the liver. No administrative or criminal
investigations were opened based on this incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0457

(North Region)

FACTS OF CASE

On July 23, 2006, an inmate was discovered unresponsive in a cell and was transported to a local hospital because of a suspected drug overdose.
The inmate was returned to the institution the same day. The toxicology report indicated an overdose of barbiturates. Drugs were found in the
inmate's cell.

DISPOSITION OF CASE

There was no evidence of staff misconduct, and no investigations were opened as a result of the incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

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Case No. 06-0458

(Central Region)

FACTS OF CASE

On July 17, 2006, an inmate battered another inmate. Emergency life-saving efforts were initiated; however, the victim died after spending three
days in intensive care. Records indicated that these two inmates allegedly should not have been housed together as they were known enemies.

DISPOSITION OF CASE

The coroner determined the cause of death to be anoxic encephalopathy due to ligature strangulation. The hiring authority requested an
administrative investigation, which the bureau is monitoring.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

Case No. 06-0459

(Central Region)

FACTS OF CASE

On July 17, 2006, an inmate on contraband watch recovered a bag of white powder from a body cavity and swallowed a portion of the bag's
contents. Medical staff asked custody staff to bring the inmate to the medical facility, but transportation was delayed because inmates were being
counted and for alleged security reasons. The inmate went into respiratory arrest and died.

DISPOSITION OF CASE

An investigation was initiated into the conduct of the sergeant and the medical technical assistant who were present. The bureau is monitoring
the investigation.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except for a delayed medical response and failure to complete all reports in a
timely manner. The department failed to provide adequate notification and consultation to the bureau regarding the incident. The bureau
concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs. The bureau concurred with the Office of
Internal Affairs' response to the hiring authority's referral.

Case No. 06-0460

(North Region)

FACTS OF CASE

On July 14, 2006, an officer stumbled upon an inmate and a staff member engaged in sexual activity in a closet at the institution. The staff
member, a contract medical worker, was ordered to wait in a committee room in the medical facility while the Office of Internal Affairs sent a
team to gather evidence and conduct interviews.

DISPOSITION OF CASE

The investigation resulted in both a criminal prosecution and a disciplinary action against the contract medical worker.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

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Case No. 06-0461

(South Region)

FACTS OF CASE

On July 7, 2006, a riot involving more than 200 inmates erupted in a minimum support facility. Multiple levels of non-lethal force were used to
quell the riot. An outside patrol officer discharged a shotgun four times as a warning to stop inmate-on-inmate attacks.

DISPOSITION OF CASE

The institution's review of the incident resulted in a request for investigation. Central intake determined that there was sufficient documentation
to warrant direct adverse action by the institution. The bureau did not monitor the direct adverse action.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

Case No. 06-0462

(South Region)

FACTS OF CASE

On July 7, 2006, officers discovered an inmate unconscious and not breathing. Life-saving measures were initiated, and the inmate was
transported to the medical treatment area. Upon arrival of an outside ambulance 40 minutes later, the inmate was pronounced dead. A syringe
was discovered on the inmate's bed, and a crime scene was established.

DISPOSITION OF CASE

The institution determined during its emergency response review that an outside ambulance was not requested via 911 in a timely manner. The
institution implemented training to remedy the problem. The inmate's death was ruled by the coroner as an accidental overdose, and an outside
law enforcement agency conducted a criminal investigation. No administrative investigation was requested based on this incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except for the institution's failure to request outside medical assistance in a
timely manner. The institution's internal review identified this issue and implemented training. The department provided adequate notification
and consultation to the bureau regarding the incident. The bureau did not concur with the hiring authority's decision not to refer the matter to
the Office of Internal Affairs.

Case No. 06-0463

(South Region)

FACTS OF CASE

Late on July 5, 2006, an inmate complained to staff about not feeling well. The inmate was taken to the medical treatment area, and during the
next two hours, the inmate's condition deteriorated. An outside ambulance was requested. An hour later, the inmate was transported to an
outside hospital and pronounced dead shortly upon arrival.

DISPOSITION OF CASE

The coroner found that the death was a result of natural causes. The institution concluded that the inmate was not transported to outside
medical care in a timely manner and has implemented training to remedy the problem. No administrative investigation was requested as a result
of this incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except for the institution's failure to request outside medical assistance in a
timely manner. The institution's internal review identified this issue and implemented training. The department provided adequate notification
and consultation to the bureau regarding the incident. The bureau did not concur with the hiring authority's decision not to refer the matter to
the Office of Internal Affairs.

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Case No. 06-0464

(South Region)

FACTS OF CASE

On July 1, 2006, the bureau was notified that an inmate collapsed in a housing unit and was transported to the medical treatment area. During
the next two hours, the inmate's condition rapidly deteriorated, and an outside ambulance was requested. Shortly after the arrival of paramedics,
the outside physician pronounced the inmate dead.

DISPOSITION OF CASE

The autopsy determined that the inmate died of natural causes. During its emergency response review, the institution determined that outside
advanced medical care via 911 was not called in a timely manner and has implemented training to remedy the problem. No administrative
investigation was initiated based on this incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except for the institution's failure to request outside medical assistance in a
timely manner. The institution's internal review identified this issue and implemented training. The department provided adequate notification
and consultation to the bureau regarding the incident. The bureau did not concur with the hiring authority's decision not to refer the matter to
the Office of Internal Affairs.

Case No. 06-0465

(Central Region)

FACTS OF CASE

On June 29, 2006, a single-celled inmate housed in an administrative segregation unit was found hanging in his cell from a modified bed sheet.
CPR was initiated, but staff were unsuccessful in their attempt to revive the inmate. The inmate was placed into segregation the day before
because he had threatened his cellmate. Two suicide notes written in blood were found in the cell. The notes were to the inmate's mother, and
they indicated that the inmate could not do a term in the security housing unit and that the charges against him were false.

DISPOSITION OF CASE

The coroner determined that the death was a suicide by hanging. The department did not open a subsequent investigation.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification,
but adequately consulted with the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the
matter to the Office of Internal Affairs.

Case No. 06-0466

(Central Region)

FACTS OF CASE

On June 28, 2006, an inmate was stabbed 13 times while on the yard but survived following surgery. The inmate was previously assigned to the
"walk alone" yard but was placed on the "control compatible" yard at the time of the attack. Policy requires an explanation to support the
change, but none could be found. Also, some of the documentation appeared to contain late entries made in different handwriting.

DISPOSITION OF CASE

The hiring authority requested an internal affairs investigation only after the bureau recommended it. An investigation was opened, which the
bureau is monitoring.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except for initial reluctance by the department to completely investigate the
matters surrounding the incident. The department failed to provide adequate notification, but adequately consulted with the bureau regarding
the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs. The bureau
concurred with the Office of Internal Affairs' response to the hiring authority's referral.

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Case No. 06-0467

(North Region)

FACTS OF CASE

On June 24, 2006, approximately 150 inmates refused to exit their cells. Several cell extractions were conducted, with cell extraction teams using
pepper spray. Inmates were moved to the yard but later refused to return to their cells. Pepper spray and non-lethal rounds were then
discharged to restore order.

DISPOSITION OF CASE

The department did not initiate any administrative or criminal investigations based on this incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0468

(North Region)

FACTS OF CASE

On June 11, 2006, an inmate suffering from apparent cardiac problems was transported to a local hospital. After evaluation at the hospital, the
inmate was transported by helicopter to a regional trauma center. Medical testing indicated the inmate was suffering from sub-arachnoid
bleeding in his brain. The inmate was placed on a ventilator but eventually died.

DISPOSITION OF CASE

The coroner's report indicated the inmate died from a bacterial infection. No internal affairs investigation was requested.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0469

(Central Region)

FACTS OF CASE

On June 5, 2006, medical staff found an inmate hanging alone in a cell. Additional medical staff responded and performed CPR. The inmate was
later pronounced dead at a local hospital.

DISPOSITION OF CASE

The coroner confirmed that the cause of death was hanging. Therefore, no investigation was opened.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification,
but adequately consulted with the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the
matter to the Office of Internal Affairs.

Case No. 06-0470

(Central Region)

FACTS OF CASE

On May 30, 2006, an inmate was stabbed in the throat by another inmate while on a general population exercise yard. The inmate survived the
attack and was hospitalized for a short period.

DISPOSITION OF CASE

The case was referred to the district attorney's office, and the assailant was charged with assault with a deadly weapon. The department did not
open an administrative investigation into staff involvement.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification and
consultation to the bureau regarding the incident. The bureau did not concur with the hiring authority's decision not to refer the matter to the
Office of Internal Affairs.

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Case No. 06-0471

(North Region)

FACTS OF CASE

On May 23, 2006, 16 inmates engaged in a riot on an exercise yard. Staff used verbal commands, chemical agents, and non-lethal rounds in an
attempt to quell the riot, with negative results. One officer providing rifle coverage observed two inmates continuing to assault an inmate on the
ground, rendering the inmate defenseless. To protect the inmate from grievous bodily harm, the officer discharged a warning shot into a safe
area on the yard after issuing verbal commands to "get down." When the assaulting inmates did not respond to the warning shot and continued
to kick the inmate in the head, the officer aimed at the chest of one of the inmates and attempted to discharge a round. The rifle malfunctioned
and did not fire. At that point, the officer discharged a non-lethal round at the combative inmates. Following the use of pepper spray, the riot
was quelled.

DISPOSITION OF CASE

In the absence of any allegations of staff misconduct, no criminal or administrative cases were initiated against staff as a result of this incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0472

(Central Region)

FACTS OF CASE

On May 23, 2006, two inmates attacked another inmate with stabbing weapons in the dayroom of a housing unit. Staff responded with verbal
commands and discharged two non-lethal rounds before firing one lethal round that killed one of the aggressors. The inmates continued fighting
until subdued by use of pepper spray and baton strikes.

DISPOSITION OF CASE

A criminal investigation by the local district attorney's office is pending. A deadly force investigation by the Office of Internal Affairs is pending,
which the bureau continues to monitor.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except for failing to follow bureau advice to have all reports completed before
staff left the institution. The department provided adequate notification and consultation to the bureau regarding the incident. The bureau
concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs. The bureau concurred with the Office of
Internal Affairs' response to the hiring authority's referral.

Case No. 06-0473

(North Region)

FACTS OF CASE

On May 22, 2006, an officer discovered an inmate hanging by a bed sheet wrapped around the neck. Responding staff assisted in cutting the
inmate down and rushing the inmate to the medical treatment area. Although no CPR was performed in the cell, the inmate was at the medical
treatment area receiving CPR within three minutes. CPR was performed for at least 10 minutes until a staff physician pronounced death.

DISPOSITION OF CASE

All incident reports were properly completed and reviewed by the warden and chief medical officer. No criminal or administrative cases were
initiated as a result of this incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

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Case No. 06-0474

(North Region)

FACTS OF CASE

On May 15, 2006, staff conducted a medical cell extraction of an inmate when the inmate was discovered lying face down and was nonresponsive to verbal commands. Once removed from the cell, the inmate was taken to the medical treatment area where the inmate regained
consciousness.

DISPOSITION OF CASE

Upon review of the incident package, there were no administrative or criminal investigations opened based on this incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0475

(Central Region)

FACTS OF CASE

On May 8, 2006, an inmate was found unresponsive while in a sitting position in a cell, slumped forward, with a bed sheet tied around the neck.
Emergency medical efforts failed to revive the inmate, and the inmate was pronounced dead. The decedent's cellmate was out of the cell during
the incident.

DISPOSITION OF CASE

The coroner determined the death to be a suicide by hanging. There was no evidence of a homicide or staff misconduct; therefore, no
investigation was initiated.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0476

(Headquarters)

FACTS OF CASE

On May 6, 2006, an inmate armed with an inmate-manufactured stabbing weapon took an officer hostage, barricading the two of them inside an
office adjacent to a dining hall. Pursuant to a request by the department, the bureau assisted in the hostage negotiations as a neutral third party,
which had been requested by the inmate. Following a full day of negotiations between the inmate and department hostage negotiators, the
inmate surrendered to crisis response team members. The inmate was taken into custody without incident, medically evaluated, and transported
to another facility. The officer who had been held hostage was not injured during the incident and was released the same day following a
medical evaluation at a local hospital.

DISPOSITION OF CASE

The department did not request an administrative investigation based on this incident. The local district attorney filed felony criminal charges
against the inmate, which are now pending.

BUREAU ASSESSMENT

The department’s overall response to the critical incident was exemplary. The department’s notification via the Office of Internal Affairs was
prompt and accurate. The facility’s management team, crisis response team, negotiations management team, emergency operations center staff,
and other involved personnel performed well during the incident, resulting in a positive outcome. The bureau concurred with the hiring
authority's decision not to refer the matter to the Office of Internal Affairs for an administrative investigation.

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Case No. 06-0477

(Central Region)

FACTS OF CASE

On May 2, 2006, an inmate was shot in the back of the neck with a non-lethal round while in a physical altercation with another inmate. The
aggressor inmate was repeatedly and emphatically warned to stop his attack upon the other inmate. The inmate lost consciousness briefly and
then vomited after awakening.

DISPOSITION OF CASE

The use of force was determined to be appropriate and within department guidelines. Further investigation of the incident was deemed
unnecessary.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification,
but adequately consulted with the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the
matter to the Office of Internal Affairs.

Case No. 06-0478

(Central Region)

FACTS OF CASE

On April 30, 2006, an inmate was assaulted by another inmate. Medical staff arrived and performed CPR until outside paramedics arrived. The
inmate was pronounced dead at a community hospital.

DISPOSITION OF CASE

The responsible party is being criminally prosecuted. No administrative investigation was conducted.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0479
FACTS OF CASE

DISPOSITION OF CASE
BUREAU ASSESSMENT

(Central Region)
On April 28, 2006, a psychiatrist provided custody staff with a verbal order to place an inmate on suicide watch. The inmate was placed in an
administrative segregation holding cell pending assignment to a suicide watch bed. While in the holding cell, the inmate hung himself with a Tshirt. He was found unresponsive, but life-saving efforts were successful in keeping the inmate alive.
The hiring authority did not request an internal affairs investigation because there were no allegations or evidence of staff misconduct.
The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

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Case No. 06-0480

(Central Region)

FACTS OF CASE

On April 6, 2006, a single-celled inmate was found unresponsive in his cell. Medical staff responded to the alarm, and life-saving efforts were
initiated. The inmate was later pronounced dead by the physician at the institution.

DISPOSITION OF CASE

The coroner determined the cause of death to be acute myocardial infarction due to arteriosclerotic heart disease. No subsequent investigation
was requested.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate. However, the institution could have requested an autopsy and toxicology tests
but elected not to even though the records showed that the inmate did not receive medical attention for his conditions for a significant period
before his death. The department failed to provide adequate notification and consultation to the bureau regarding the incident. The bureau did
not concur with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.

Case No. 06-0481

(Central Region)

FACTS OF CASE

On March 28, 2006, at 0650 hours, an officer discovered a single-celled deceased inmate lying on the floor of his cell with a ligature tied around
his neck. The inmate had evidence of blunt-force trauma to the head and right elbow. Watch logs indicated that the inmate was counted as alive
at 0500 hours, however, other evidence indicated that the inmate was already dead at that time.

DISPOSITION OF CASE

The coroner's office indicated that the cause of death was suicide and that the blunt-force trauma resulted from the inmate falling to the ground
after the ligature broke. Nevertheless, the hiring authority is considering whether discipline is warranted relative to the 0500 hours count, and
the bureau is monitoring the process.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

Case No. 06-0482

(South Region)

FACTS OF CASE

On March 21, 2006, an inmate was placed on single-cell status after being assaulted by other inmates. On April 30, 2006, the inmate spoke with
a psychiatric technician but denied having suicidal thoughts. On May 1, 2006, the inmate asked staff if a specific counselor was available, but was
told the counselor was not available. Later that day, staff discovered the inmate hanging in a cell and the inmate was pronounced dead.

DISPOSITION OF CASE

The hiring authority initiated a request for an administrative investigation, and the Office of Internal Affairs approved the request. The bureau is
monitoring that investigation.

BUREAU ASSESSMENT

The department's overall response to the incident was delayed and inadequate. Custody staff did not respond to the suicide in accordance with
department policy. Responding medical staff failed to promptly initiate life-saving measures consistent with training. Among these failures was
staff members' inability to properly and efficiently use an automatic emergency defibrillator. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

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Case No. 06-0483

(North Region)

FACTS OF CASE

On March 16, 2006, custody staff discovered an inmate lying unresponsive on a bed, face down in what appeared to be a pool of blood. The
inmate's cellmate was observed sitting on the opposite side of the cell. Both inmates were housed in the special needs facility. According to the
cellmate, the deceased inmate used a razor to cut himself across the side of the neck.

DISPOSITION OF CASE

The district attorney's office conducted the criminal investigation with the assistance of the institution's investigative services unit. The
investigation revealed the cellmate had small flecks of blood on his person, while the deceased inmate was covered in his own blood. There were
cuts on the deceased inmate's hand and index finger, indicating the use of a blade. The evidence at the scene seemed to corroborate that the
deceased inmate had committed suicide. There was no evidence of staff misconduct involved in the incident. The coroner's report concluded
the inmate's death was a suicide, and no administrative investigation was opened.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0484

(Central Region)

FACTS OF CASE

On March 6, 2006, an inmate riot occurred on an exercise yard at the institution. A warning shot was fired from a rifle, and no injuries resulted
from the discharge.

DISPOSITION OF CASE

This incident was referred to the Office of Internal Affairs for investigation because the hiring authority was concerned that the officer did not
adequately explain the need to use lethal force during the riot. The incident was not investigated by internal affairs because it was determined
that the officer was within policy when he fired the warning shot and that his report sufficiently explained the need for lethal force.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau did not concur with the hiring authority's decision to refer the matter to the
Office of Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

Case No. 06-0485

(Central Region)

FACTS OF CASE

On February 17, 2006, an inmate was found dead in a cell after his cellmate called for staff. The cause of death was initially unknown.

DISPOSITION OF CASE

The coroner's report indicated the death was due to an undetermined cause resulting from complications of a longstanding seizure disorder.
There was no evidence of trauma or a homicide. The inmate was previously evaluated by a physician, and there were no indications the inmate
had a life-threatening condition at the time. The inmate death review committee is conducting an evaluation of the medical issues. The bureau is
monitoring that review.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects; however, the bureau did raise an issue regarding the
custody staff prematurely allowing the cellmate back into the cell. The department provided adequate notification and consultation to the
bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs.
The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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Case No. 06-0486

(Central Region)

FACTS OF CASE

On February 11, 2006, four inmates attacked three officers. The inmates had one officer on the ground and were repeatedly hitting the officer in
the head with a canister of pepper spray. Responding officers attempted to stop the attacks with verbal commands, pepper spray, discharging a
lethal round, and baton strikes to the body, but they were unsuccessful. An officer then struck the attacking inmate in the head with his baton,
which ended the attack. The inmate was provided with medical care and recovered.

DISPOSITION OF CASE

The hiring authority concluded there was no excessive use of force or staff misconduct. The responding officers used necessary and appropriate
force under the circumstances to stop the threat posed by the inmates, and the use of force stopped as soon as the inmates complied. No
subsequent administrative or criminal investigation was opened.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except that the incident was inadequately documented as numerous
clarifications of the initial reports were required. The department provided adequate notification and consultation to the bureau regarding the
incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.

Case No. 06-0487

(Central Region)

FACTS OF CASE

On December 27, 2005, an inmate was found unresponsive. Medical staff determined that the inmate was in respiratory arrest. Emergency
medical care was initiated, but life-saving efforts were unsuccessful. The inmate was pronounced dead by the institution's physician.

DISPOSITION OF CASE

No autopsy was performed because the attending physician volunteered to sign the death certificate. The attending physician declared the cause
of death to be from natural causes, specifically, cardiopulmonary arrest due to atherosclerotic coronary vascular disease. The inmate had a
history of high blood pressure and hepatitis-C. No internal affairs investigation was initiated, but the matter was submitted to the professional
practice executive committee for review.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except for incomplete health records and the failure to perform an autopsy. The
department failed to provide adequate notification and consultation to the bureau regarding the incident. The bureau concurred with the hiring
authority's decision not to refer the matter to the Office of Internal Affairs.

Case No. 06-0488

(North Region)

FACTS OF CASE

On October 23, 2005, staff responded to a fight and found an elderly inmate unconscious on the floor. The inmate was unresponsive and had a
pulse but was not breathing. There was no blood at the scene and no sign of trauma to the inmate, and the other inmates were silent as to what
occurred. Artificial breathing was initiated within five minutes of the incident, and the inmate was transported to an outside hospital where he
was placed on life-support but subsequently died on November 8, 2005.

DISPOSITION OF CASE

An autopsy of the inmate revealed he died of blunt-force trauma to the head. The institutional investigation concluded the department followed
policy and procedure. No internal affairs investigation was initiated as a result of this incident.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

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OFFICE OF THE INSPECTOR GENERAL

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Case No. 06-0489

(North Region)

FACTS OF CASE

On December 9, 2005, an institutional gang investigator received information that retaliatory assaults were planned against department staff in
response to a pending execution.

DISPOSITION OF CASE

The execution occurred without incident, and no retaliatory assaults were reported as a result of the execution. No subsequent investigation was
opened.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0490

(North Region)

FACTS OF CASE

On December 5, 2005, an inmate working at a food preparation station was assaulted from behind and stabbed in the neck and upper torso.
Within minutes, the inmate was transported by ambulance to an outside hospital. Custody staff established an inner and outer crime scene
perimeter, and all inmate movement was frozen until all inmates in the area were searched. Twelve inmates were identified in the area at the
time of the stabbing. After surgery, the inmate survived.

DISPOSITION OF CASE

The institutional investigation concluded that the department followed policy and procedure in response to the incident. No staff misconduct
was identified, and no internal affairs investigation was requested.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0491

(North Region)

FACTS OF CASE

On November 30, 2005, an inmate was found dead while housed at the facilities infirmary on suicide precaution watch. A report described the
inmate as being "rigid with rigor mortis, pale, cold to the touch with mottled pooled extremities because of lack of blood flow." There were no
visible signs of a suicide attempt, and CPR was not initiated due to the inmate's condition.

DISPOSITION OF CASE

The hiring authority determined that the nurse on duty did not have "suicide precaution watch" training and did not perform the regular checks
as required. In reviewing the operating procedures, the hiring authority also discovered that the policy was contradictory and required that the
inmate be awakened every half hour. The hiring authority amended the policy to correct the deficiencies. An autopsy report listed the cause of
death as heart attack. There was no evidence of staff misconduct involved in the incident, and no subsequent investigation was opened.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification,
but adequately consulted with the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the
matter to the Office of Internal Affairs.

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OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

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Case No. 06-0492

(North Region)

FACTS OF CASE

On November 29, 2005, at approximately 0615 hours, an inmate was discovered deceased in a cell. A nurse was summoned, and the inmate was
transported via wheeled gurney to the institution's emergency room. The inmate was pronounced dead by a physician at 0656 hours. The
coroner arrived and initially determined the cause of death to be unknown, but the coroner found the circumstances and inmate's injuries
suspicious. The case was initially treated as a potential homicide pending the outcome of the coroner's inquest.

DISPOSITION OF CASE

The coroner determined the cause of death to be an overdose with other significant conditions, schizophrenia and hypertension. According to
the coroner, the inmate saved his pills and took an undetermined amount rather than consuming them at the time they were dispensed; or the
inmate obtained extra pills from an unknown source; or the inmate's system was not able to metabolize the drugs effectively, resulting in a toxic
level. No subsequent investigation was initiated.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department failed to provide adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0493

(North Region)

FACTS OF CASE

On November 26, 2005, an officer passed a cell, and an inmate standing in the cell window stated, "I'm done." The officer asked the inmate
what he meant by that comment, and the inmate held his hands up in front of the window and stepped back. The officer then observed the
inmate's cellmate face down on the floor covered in blood. Staff responded and began emergency medical procedures on the unconscious
cellmate. The cellmate was pronounced dead shortly thereafter.

DISPOSITION OF CASE

Custody staff members and the investigative services unit both responded and followed the memorandum of understanding with the county
coroner applicable to custodial deaths. No internal affairs investigation was requested. The district attorney's office filed criminal charges against
the inmate, who received a 14 year and eight month sentence for killing his cellmate.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0494

(Central Region)

FACTS OF CASE

On October 16, 2005, numerous gang-affiliated inmates assaulted staff and other inmates in a dining hall, resulting in injuries to staff and
inmates.

DISPOSITION OF CASE

An administrative investigation was opened, which the bureau monitored. As a result of two use-of-force committee reviews, staff members' use
of force before, during, and after the incident was found to comply with department policy.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate except for a failure to thoroughly document the event in initial incident reports.
The department failed to provide adequate notification, but adequately consulted with the bureau regarding the incident. The bureau concurred
with the hiring authority's decision to refer the matter to the Office of Internal Affairs. The bureau concurred with the Office of Internal
Affairs' response to the hiring authority's referral.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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STATE OF CALIFORNIA

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Case No. 06-0495

(Central Region)

FACTS OF CASE

On August 2, 2005, a control booth officer discharged three non-lethal sponge rounds at inmates involved in a riot. One inmate was struck in
the back of the head, a second inmate was struck in the upper left shoulder blade, and a third inmate was struck in the head by a round that
ricocheted off a table. All three inmates showed visible injuries, and one inmate required sutures.

DISPOSITION OF CASE

A criminal investigation was conducted, which was monitored by the bureau, confirmed that no crime had been committed. Thus, the criminal
investigation was closed without referral to the district attorney's office. The department also opened an administrative investigation, which the
bureau is monitoring.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

Case No. 06-0496

(South Region)

FACTS OF CASE

On June 10, 2005, an officer attempted to take down a blanket in an inmate's cell by reaching through the food port. The inmate grabbed the
officer's arm and pulled the officer toward the cell, possibly using a weapon to stab the officer's head. The inmate was taken into custody,
allegedly resisted, and was eventually transported to an outside hospital where the inmate was found to have a broken rib and punctured lung.

DISPOSITION OF CASE

Based on its review of the incident, the department concluded there was no misconduct.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau did not concur with the hiring authority's decision not to refer the matter to the
Office of Internal Affairs.

Case No. 06-0497

(South Region)

FACTS OF CASE

On June 10, 2005, an inmate collapsed in a housing unit. Staff began CPR, and the inmate was transported to an outside hospital where the
inmate was pronounced dead.

DISPOSITION OF CASE

All of the circumstances surrounding the incident were consistent with a natural death; therefore, no investigation was requested.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau did not concur with the hiring authority's decision not to refer the matter to the
Office of Internal Affairs.

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OFFICE OF THE INSPECTOR GENERAL

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Case No. 06-0498

(North Region)

FACTS OF CASE

On May 19, 2005, custody staff delivered a food tray to a cell but were unable to get one of the inmates to respond to verbal commands. After
several unsuccessful attempts to rouse the inmate, custody staff entered the cell accompanied by medical staff who initiated CPR.
Approximately 20 minutes later, the physician arrived and declared the inmate dead at the scene. The investigative services unit secured the cell
pending the arrival of the coroner. Initially, there was no evidence of foul play or criminal activity observed at the scene.

DISPOSITION OF CASE

No internal affairs investigation was opened. An autopsy revealed that the inmate had been strangled. However, there was no evidence of staff
misconduct involved in the incident. The district attorney's office filed murder charges against the inmate's cellmate.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision not to refer the matter to the Office
of Internal Affairs.

Case No. 06-0499

(North Region)

FACTS OF CASE

On May 16, 2005, an inmate was beaten to death by a cellmate. The cellmate had been on single status for the majority of the 17 years spent in
prison until moving into the cell several days earlier.

DISPOSITION OF CASE

On August 8, 2005, the Office of Internal Affairs opened an investigation to learn whether staff complied with department policies relating to
inmate housing and if they had accurately completed a file review in determining appropriate housing needs. The bureau monitored the
investigation. The district attorney's office filed homicide charges against the deceased inmate's cellmate.

BUREAU ASSESSMENT

The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the bureau regarding the incident. The bureau concurred with the hiring authority's decision to refer the matter to the Office of
Internal Affairs. The bureau concurred with the Office of Internal Affairs' response to the hiring authority's referral.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

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Case No. 06-0500

(Central Region)

FACTS OF CASE

On August 27, 2004, after refusing an order to give up a blanket, an inmate resisted staff members' attempts to retrieve it. Staff members used
multiple canisters of pepper spray, baton strikes, and physical force to subdue the inmate. The inmate was decontaminated while uncuffed and
again resisted when staff attempted to re-cuff him. Staff members subdued the inmate again using force, including additional canisters of pepper
spray directed at his face. Staff members placed a spit mask over his head, and the inmate was taken to the medical clinic on a gurney while in
restraints. The inmate was not decontaminated a second time, nor was the spit mask ever removed despite complaints by the inmate of being
unable to breathe. The inmate stopped breathing and died at the clinic while four officers held him on a gurney.

DISPOSITION OF CASE

The coroner ruled the death to be accidental natural causes due to "excited delirium." Following this incident, the department issued two
successive memos to staff, initially restricting and then prohibiting the use of spit masks on inmates following the use of pepper spray and other
chemical agents. The bureau continues to monitor the ongoing efforts by the department in this area. The department's law enforcement
investigative unit conducted a deadly force investigation, which was never presented to a deadly force review board. An administrative
investigation was initiated by the Office of Internal Affairs, which the bureau monitored. The district attorney's office declined to file criminal
charges, and the Federal Bureau of Investigation recommended that no civil rights charges be filed.

BUREAU ASSESSMENT

The department provided adequate notification and consultation to the bureau during the incident itself. The reports resulting from the incident
were adequate; however, the bureau noted potential deficiencies in the handling of the incident, including negligent loss of evidence and a lack
of adequate training and policy. The deadly force investigation conducted by the department's law enforcement investigative unit was
inadequate, in that the investigation failed to interview all relevant parties, ask relevant questions, identify the appropriate subjects, and took an
undue amount of time. In addition, a deadly force review board analysis of the incident was canceled without consultation with the bureau, and
the matter never came before the board. As a result of this incident and other deadly force investigations, the bureau recommended that the law
enforcement investigative unit be removed from these investigations. The department has followed that recommendation. The hiring authority
failed to promptly request an internal affairs investigation after conducting the supervisory review of the incident. Instead, an internal affairs
investigation was requested only after the use-of-force review insisted upon by the bureau and the department's staff attorney. The Office of
Internal Affairs opened an investigation, and the bureau concurred with that decision. In consultation with the bureau, the Office of Internal
Affairs has rewritten their policy regarding deadly force investigations.

BUREAU OF INDEPENDENT REVIEW
OFFICE OF THE INSPECTOR GENERAL

PAGE 87
STATE OF CALIFORNIA