September 2018

Correctional Officer Health
and Safety
Some State and County Correctional Facilities Could
Better Protect Their Officers From the Health Risks of
Certain Inmate Attacks
Report 2018‑106

COMMITMENT
INTEGRITY

LEADERSHIP

CALIFORNIA STATE AUDITOR
621 Capitol Mall, Suite 1200 | Sacramento | CA | 95814

916.445.0255 | TTY 916.445.0033

For complaints of state employee misconduct,
contact us through the Whistleblower Hotline:

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For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Affairs, at 916.445.0255
This report is also available online at www.auditor.ca.gov | Alternate format reports available upon request | Permission is granted to reproduce reports

Elaine M. Howle State Auditor

September 18, 2018 	

2018‑106

The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
State Capitol
Sacramento, California 95814
Dear Governor and Legislative Leaders:
As requested by the Joint Legislative Audit Committee, the California State Auditor presents this audit
report detailing our review of the health and safety of correctional staff who were subject to a particular
type of assault at three correctional facilities we visited—the California Department of Corrections
and Rehabilitation’s California Institute for Men (CIM), the Los Angeles County Sheriff ’s Department’s
Men’s Central Jail (Men’s Central), and the Alameda County Sheriff ’s Office’s Santa Rita Jail (Santa Rita).
This assault, known as a gassing attack, involves an inmate throwing bodily fluids at correctional staff.
These attacks can expose the victim to a communicable disease and cause psychological trauma. Inmates
convicted of a gassing attack can receive increases of two to four years to their current sentences. This
report concludes that the three correctional facilities we visited should improve their processes to
ensure that they provide all available aftercare to victims of gassing attacks, investigate such attacks
more quickly and thoroughly, and better prevent and respond to gassing attacks.
The three correctional facilities did not adequately inform victims immediately following the gassing
attacks of aftercare services, such as medical and counseling services. Further, these three correctional
facilities did not consistently document that they advised victims of their right to request that the inmate
who committed the gassing attack be tested for a communicable disease. In fact, CIM and Santa Rita
were aware in some cases that inmates were infected with a communicable disease at the time of gassing
attacks that occurred in 2017, but they failed to notify the victims of the exposure risk until we made
inquiries in August 2018.
Because the three correctional facilities did not consistently investigate gassing attacks in a thorough
and timely manner, only 31 percent of gassing attacks at these facilities from 2015 through 2017 resulted
in inmate convictions. In fact, district attorneys declined to prosecute four of the 45 cases we reviewed
because the three correctional facilities did not collect sufficient physical evidence of the crime—such
as the container the inmate used to throw the bodily fluids or the victim’s uniform. Additionally, the
three correctional facilities did not refer cases for prosecution in a timely manner: Men’s Central and
CIM unnecessarily extended their investigations of gassing attacks and took an average of seven months
and three months, respectively, while Santa Rita did not refer all of the cases we reviewed for prosecution.
CIM and Santa Rita often did not impose discipline on inmates, such as the loss of privileges or sentence
reduction credits, to deter them from committing future gassing attacks. Finally, the three correctional
facilities did not provide officers sufficient training about how to respond to gassing attacks.
Respectfully submitted,

ELAINE M. HOWLE, CPA
State Auditor
621 Capitol Mall, Suite 1200

S a c r a m e n t o, C A 9 5 8 1 4

916.445.0255

916.327.0019 fax

w w w. a u d i t o r. c a . g o v

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Selected Abbreviations Used in This Report
CDCR

California Department of Corrections and Rehabilitation

CIM

California Institute for Men

correctional facilities

prisons and jails

investigations unit

jail investigations unit

LASD

Los Angeles County Sheriff’s Department

Men's Central

Los Angeles County Sheriff’s Department’s Men’s Central Jail

psychological bureau

Psychological Services Bureau

Santa Rita

Alameda County Sheriff’s Office’s Santa Rita Jail

C ALIFO R N IA S TAT E AUD I TO R | Report 2018-106

September 2018

CONTENTS
Summary	

1

Introduction	

5

The Three Correctional Facilities Do Not Have Adequate Procedures
to Ensure That They Provide Care to Victims of Gassing Attacks	

13

The Three Correctional Facilities Did Not Consistently Investigate
Gassing Attacks in a Thorough and Timely Manner	

21

The Three Correctional Facilities Have Not Established Adequate
Internal Processes to Prevent and Respond to Gassing Attacks	

31

Scope and Methodology	

41

Responses to the Audit
California Department of Corrections and Rehabilitation	

45

California State Auditor’s Comment on the Response From the
California Department of Corrections and Rehabilitation	
Los Angeles County Sheriff’s Department	
California State Auditor’s Comments on the Response From the
Los Angeles County Sheriff’s Department	
Alameda County Sheriff’s Office	
California State Auditor’s Comments on the Response From the
Alameda County Sheriff’s Office	

47
49
55
57
61

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SUMMARY
Officers and staff members who work in California’s 35 state prisons and the 58 counties’ local
detention facilities (correctional facilities) face threats to their health and safety, including
being subject to a type of assault in which an inmate throws bodily fluids at them—commonly
known as a gassing attack. A gassing attack can have serious health implications for the
victim, including the potential transmission of communicable diseases from the bodily fluids
and psychological trauma from the incident. Under state law, any inmate in a correctional
facility who commits a gassing attack on an officer or employee of the facility is guilty of an
aggravated battery, and the inmate can face an increase of two to four years to his or her
current sentence. The three correctional facilities we visited—the California Department
of Corrections and Rehabilitation’s California Institute for Men (CIM), the Los Angeles
County Sheriff’s Department’s (LASD) Men’s Central Jail (Men’s Central), and the
Alameda County Sheriff’s Office’s Santa Rita Jail (Santa Rita)—oversaw 9,900 inmates as of
January 2018 and identified 111 gassing attacks during 2017. For this audit, we reviewed these
correctional facilities’ policies and responses to 45 gassing attacks that occurred between 2015
and 2017—15 at each location—to determine how the facilities protect the health and safety of
their correctional officers and staff. This report draws the following conclusions:

The Three Correctional Facilities Do Not Have Adequate Procedures
to Ensure That They Provide Care to Victims of Gassing Attacks

Page 13

Santa Rita has not consistently documented that it informed
gassing victims of all available aftercare services, including medical
evaluations for communicable diseases and workers’ compensation
benefits. None of the three correctional facilities consistently
documented that they informed gassing victims of their right to
request that the inmates involved be tested for communicable
diseases. In fact, CIM and Santa Rita were aware in some cases
that inmates had communicable diseases at the time of the 2017
attacks but they did not notify all the victims of the exposure until
August 2018 after we inquired about such notifications. Finally,
none of the correctional facilities consistently documented that they
notified victims of the availability of counseling services.

The Three Correctional Facilities Did Not Consistently Investigate
Gassing Attacks in a Thorough and Timely Manner
To deter inmates from committing gassing attacks, the Legislature
established a criminal penalty of two to four years to be added to
their current imprisonment if convicted of this crime. However, only
31 percent of gassing attacks at the three correctional facilities we
reviewed from 2015 through 2017 resulted in convictions. District
attorneys declined to prosecute a substantial number of cases that

Page 21

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CIM and Men’s Central referred from 2015 through 2017, 61 percent
and 49 percent, respectively, in part because the correctional facilities’
investigations were not always thorough or timely. Specifically, the
correctional facilities did not collect the physical evidence needed
to prosecute in four of the 45 cases we reviewed. In addition,
Men’s Central and CIM took an average of more than seven months
and more than three months, respectively, to investigate the gassing
attacks we reviewed before referring them to the district attorney,
delaying resolution of the legal process. In contrast, Santa Rita took
only 17 days on average to complete its investigations and refer the
cases we reviewed to the district attorney. However, Santa Rita
did not refer four of those 15 cases to the district attorney because
of staff oversight or because the victim did not wish to file a
criminal complaint.

The Three Correctional Facilities Have Not Established Adequate
Internal Processes to Prevent and Respond to Gassing Attacks
Page 31

We found that CIM and Santa Rita inconsistently followed their
internal discipline procedures designed to deter inmates from
committing gassing attacks, such as reducing privileges, placing
inmates into secured housing, and revoking sentence reductions
that the inmates earned. For the gassing attacks we reviewed,
Men’s Central appropriately imposed disciplinary action for all
inmates who committed gassing attacks while CIM and Santa Rita
did not always impose discipline. Further, the three correctional
facilities provided limited training to officers on how to prevent
and mitigate the harm from gassing attacks, and, as a result, their
officers may not be sufficiently prepared to react to gassing attacks. In
addition, CIM and Santa Rita do not actively track gassing attacks or
attempted attacks. Although state laws and regulations do not require
such tracking, both correctional facilities asserted they know which
inmates are most likely to commit these attacks. Nevertheless, such
tracking could help them identify the characteristics of inmates who
commit gassing incidents, inmates who are repeat offenders, and
other factors that create a higher risk of gassing attacks.

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September 2018

Summary of Recommendations
CIM
To ensure the health and safety of its employees, CIM should do
the following:
•	 Revise its policies to document that it notifies victims of
counseling services available following a gassing attack, as
well as their right to request that the inmate be tested for a
communicable disease.
•	 Develop goals for how long investigations should take and
consistently collect physical evidence of the crime.
•	 Impose internal discipline to deter inmates from committing
future gassing attacks.
•	 Provide training that is specific to preventing and responding to
gassing attacks.
•	 Consistently track all gassing attacks to use as a tool to identify
best practices for preventing future gassing attacks.

Men’s Central
To ensure the health and safety of its employees, Men’s Central
should do the following:
•	 Revise its policies to document that it notifies victims of
counseling services available following a gassing attack, as
well as their right to request that the inmate be tested for a
communicable disease.
•	 Develop goals for how long investigations should take and
consistently collect physical evidence of the crime.
•	 Provide training that is specific to preventing and responding to
gassing attacks.

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Santa Rita
To ensure the health and safety of its employees, Santa Rita should
do the following:
•	 Revise its policies to document that it notifies victims of all
medical and counseling services available following a gassing
attack, as well as their right to request that the inmate be tested
for a communicable disease.
•	 Refer all gassing attacks to the district attorney when probable
cause exists.
•	 Impose internal discipline to deter inmates from committing
future gassing attacks.
•	 Provide training that is specific to preventing and responding to
gassing attacks.
•	 Consistently track all gassing attacks to use as a tool to identify
best practices for preventing future gassing attacks.
Agency Comments
In response to the audit, CDCR and the LASD concurred
with our conclusions and generally agreed to implement our
recommendations at CIM and Men’s Central, respectively.
However, the Alameda County Sheriff ’s Office partially agreed with
our recommendations for Santa Rita, asserting that it had sufficient
procedures already in place.

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INTRODUCTION
Background
The California Department of Corrections and
Rehabilitation (CDCR) operates 35 prisons, and the
State’s 58 counties operate local detention facilities.
As of 2018, these state prisons and county jails
(correctional facilities) were confining a total of
nearly 200,000 individuals. Officers who work in
correctional facilities face threats to their health
and safety, including a type of assault known as a
gassing attack during which an inmate throws
bodily fluids at them. The text box identifies the
elements of a gassing attack. Under state law,
inmates in correctional facilities who commit
gassing attacks on officers or employees of the
facilities are guilty of an aggravated battery.

Definition of a Gassing Attack
Intentionally placing or throwing or causing to be placed
or thrown any human excrement or other bodily fluids or
bodily substances or any mixture containing human
excrement or other bodily fluids or bodily substances
(bodily fluids) that results in actual contact with the skin
or membranes of a correctional officer or employee of the
institution, by a person confined in that institution.
Source:  Penal Code sections 243.9 (b) and 4501.1 (b).

Correctional facilities have a number of responsibilities following these gassing
attacks. For example, correctional facilities provide care to employees exposed
to communicable diseases in the course of performing their job duties. This care
includes health care, access to workers’ compensation benefits, and psychological
counseling, as Figure 1 on the following page details. In addition, correctional
facilities must conduct criminal investigations to potentially file charges against the
inmates involved. Correctional facilities can also impose several types of internal
discipline on inmates, including reducing their privileges; segregating them in
disciplinary housing; and taking away their credit time, which inmates earn to reduce
their sentences. If convicted of a gassing attack, the inmates can face increases of
two to four years to their current sentences.
To determine the degree to which correctional facilities are meeting these
responsibilities, we reviewed the CDCR’s California Institute for Men (CIM),
the Los Angeles County Sheriff ’s Department’s (LASD) Men’s Central Jail
(Men’s Central), and the Alameda County Sheriff ’s Office’s Santa Rita Jail (Santa
Rita). In January 2018, these three correctional facilities were overseeing 9,900
inmates and they had identified 111 gassing attacks during 2017.

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Figure 1
Procedures After a Gassing Attack

PROCEDURES REQUIRED
AFTER AN ATTACK
OCCURS

= GASSING ATTACK

AFTERCARE
Medical

Psychological

Victim offered
• Medical treatment
• Communicable disease testing
• Inmate communicable disease testing

Victim offered
• Mental health counseling
• Peer counseling
• Employee Assistance Program

Victim can file workers’ compensation*
Victim informed of
• Facility knowledge of inmate communicable disease
• Inmate’s test results
• Personal test results

INVESTIGATION AND PROSECUTION
Correctional Facility Incident Report
Correctional facility
• Investigates and collects evidence
• Sends gassing substance for testing
• Refers case to district attorney

District Attorney
• Charges the inmate with a crime
• Declines to prosecute

Inmate
• Guilty with two, three, or four years
added to sentence
• Not guilty

INTERNAL DISCIPLINE AND PREVENTION
Facility Discipline
Correctional facility
• Notifies inmate of violation
• Conducts discipline hearing
Inmate may receive discipline
• Secured housing
• Loss of privileges
• Loss of credit time
• Disciplinary diet

Preventative Measures
Correctional facility implements
preventative measures
• Secured housing
• Door barriers
• Hand-held or portable shields
• Cell “gasser” tags
• Face shields
• Biohazard suits
• Gloves

Source:  Review of policies and procedures for each of the three correctional facilities.
*	 Workers’ compensation provides victims with services such as medical care and temporary disability benefits.

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Victims’ Right to Aftercare
Gassing attacks can have serious potential health implications for
victims, including the transmission of communicable diseases from
the bodily fluids that the inmate used. Potential communicable
diseases that a victim can contract from the bodily fluids include
human immunodeficiency virus (HIV), hepatitis B, hepatitis C, and
tuberculosis (TB). Each of these diseases can result in serious health
consequences, as Figure 2 on the following page notes. Further, the
transmission of communicable diseases can threaten not only
the health of victims of gassing attacks but also the health of the
victims’ family members, who may become unknowingly infected.
To address these risks, state law requires that correctional
facilities provide information to employees who are exposed to
communicable diseases in the course of performing their job duties.
For example, when any employee has had direct contact with the
bodily fluids of an inmate, state law requires that the correctional
facilities’ supervisory and medical personnel notify the employee
if the inmate has a communicable disease. Also under state law,
victims of gassing attacks have the right to request that the inmates
who attacked them be tested for a communicable disease. Test
results can confirm in less than a week whether the inmate involved
in the attack has an existing communicable disease, so testing the
inmate can provide the victim with timely information about
the risk of exposure.
At all correctional facilities in California, the chief medical
officer, or the facility equivalent, is responsible for ensuring
that victims of gassing attacks have access to counseling at the
time they request inmate medical tests, and when medical staff
provide the test results to them. Gassing victims may experience
psychological trauma from the attack, and counseling may help
them cope. Additionally, counseling may help victims if they
have trouble handling the uncertainty over their exposure to a
communicable disease.
State law also requires California employers—including CDCR
prisons and county jails—to provide workers’ compensation
insurance for their employees who are injured or disabled in
the course of employment. These benefits can include covering the
health care costs and providing temporary and permanent disability
payments if the employee is unable to return to work.

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Figure 2
Effects of Communicable Diseases

HIV
Weakens the immune system,
decreasing and eventually destroying
a person’s ability to fight off
infections and disease. HIV infections
can eventually lead to Acquired
Immunodeficiency Syndrome.

Hepatitis B
An inflammation of the liver caused by
a virus. Acute cases are short-term
infections that range in severity from a
mild illness to a serious condition
requiring hospitalization. Chronic
cases can lead to liver damage, liver
cancer, and death.

TB
Latent TB, which is nonsymptomatic and
noncontagious, can lead to contagious TB
disease. TB disease affects the lungs as
well as the brain, kidneys, and spine, and it
can be fatal if not treated.

Hepatitis C
An inflammation of the liver caused
by a virus. Infection can result in a
short-term illness, but for a majority of
infected people, a chronic infection
develops that can cause liver disease,
liver cancer, or death.

Source:  Centers for Disease Control and Prevention.

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Investigations and Discipline
State law further requires that correctional facilities use all
means necessary to investigate possible gassing attacks and to
refer cases for which there is probable cause to believe that a
gassing attack occurred to the local county district attorney for
prosecution. To prove that an inmate used bodily fluids in the
attack, state law requires correctional facilities to preserve and
test the substance that struck the victim in order to confirm the
presence of bodily fluids. State law does not have a statute that
specifically addresses attempted gassing attacks, that is, an incident
in which there is insufficient evidence to prove a gassing attack
occurred. Nonetheless, such an incident can be prosecuted under
one of several other statutes, based on the circumstances of each
case. For example, the district attorney can charge the inmate
who attempted to commit a gassing attack with a nonaggravated
battery. If convicted, the inmate can face up to a year of additional
imprisonment for incidents occurring in a jail, and two to four years
of additional imprisonment for incidents occurring in a prison. In
other instances, the district attorney can prosecute the case as an
assault with a penalty of a fine, an addition to the inmate’s sentence
of up to six months in jail, or both.
To ensure order within correctional facilities, the facilities can
pursue internal discipline for inmates who commit gassing attacks.
For example, if an inmate violates the rules of the correctional
facility by assaulting an officer, the correctional facility can
restrict the inmate’s privileges, such as access to the phone or the
commissary. The correctional facility also can move the inmate into
disciplinary housing, which is generally isolated housing. Sentence
reductions that inmates have earned can also be revoked as a
disciplinary measure. In these instances, state regulations require
correctional facilities to provide a written notification of a violation
to the inmate and to conduct a disciplinary hearing. Correctional
facilities also must keep a thorough record of disciplinary actions.
The three correctional facilities we reviewed have adopted policies
to evaluate the mental health and competency of an inmate when
determining whether to impose internal discipline.
Prevention and Risk Reduction
As Table 1 on the following page shows, the three correctional
facilities we visited vary in age, security levels, and other
characteristics—and these all affect the risk of gassing attacks. Some
infrastructure layouts can provide greater opportunities for gassing
attacks than others. For example, an open‑bar cell, unlike cells
with solid walls, does not provide a complete barrier between the
inmates and officers. In this type of cell, inmates can throw items,

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including bodily fluids, outside of their cells. Some correctional
facilities have a linear layout that features a straight row of cells,
which limits an officer’s ability to observe multiple cells at once and
limits the officer’s ability to see into a particular cell until he or she
is close enough to be struck by an inmate throwing a bodily fluid.
Others may use dormitory‑style housing in which a large group of
low‑security inmates are housed in one large room. In this layout,
the risk associated with the dormitory setting may be mitigated
partly by the fact that correctional facilities typically place only
low‑security inmates, who are less prone to committing gassing
attacks, in such housing.
Even when facilities have infrastructure that better protects
employees from gassing attacks, inmates can still commit them.
For example, in cells with solid doors, inmates can strike officers by
shoving bodily fluids through the gap between the cell wall and a
closed door. Inmates also can commit gassing attacks when officers
interact with them through the food or speaker port on the door, or
when officers are removing them from their cell. We discuss further
infrastructure concerns and potential gassing attack hazards in the
Audit Results.
Table 1
Characteristics of the Three Correctional Facilities
CURRENT FACILITY
CONSTRUCTED*

INMATE
POPULATION
(JANUARY 2018)

FACILITY
CAPACITY†

SECURITY LEVEL OF INMATES

CIM

1941

3,500

3,000

Largely low­‑level but temporarily
houses all levels

Both open‑bar and hard‑door
(solid metal) cells

Men’s Central

1963

4,200

4,600

Largely medium‑level

Open‑bar cells and
dormitory‑style housing, with
limited hard‑door cells

Santa Rita

1989

2,200

2,900

All levels

Both open‑bar and hard‑door
cells

FACILITY

LAYOUT FEATURES

Source:  Administrative records for the three correctional facilities we reviewed.
*	 CIM and Men’s Central have undergone renovations since their initial construction.
†	 This number represents the operational capacity of the facility as of January 2018. The design capacity for CIM is from a report that CDCR must
submit to comply with a federal court order on reducing the in‑state adult inmate population. The correctional facility capacity can change based
on the security level of inmates housed. For example, a cell that can house four low‑security inmates may hold only one high-security inmate.

Men’s Central experienced significantly more gassings than CIM
and Santa Rita from 2015 through 2017, both in total number of
incidents and when controlling for the varied population sizes at
the three facilities, as shown in Figure 3. We also compared the
rate of gassing attacks at these three correctional facilities with
the rate that occurred at other CDCR prison facilities. Specifically,
we examined 10 CDCR prison facilities with similar populations

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and security levels as Men’s Central. Based on this analysis,
Men’s Central and Santa Rita have far more gassing attacks than
any of the CDCR facilities: 19 and six attacks per 1,000 inmates on
average from 2015 through 2017, respectively. The CDCR prison
facilities, including CIM, had zero to five gassing attacks per
1,000 inmates during this same period. As we discuss later, Men’s
Central likely has experienced a higher rate of gassing incidents
partly because of its outdated infrastructure.
Figure 3
Two Correctional Facilities Have Higher Rates of Gassing Attacks Than Selected State Prisons

Average Gassing Attacks Per Year Per 1,000 Inmates
2015 Through 2017

REVIEWED
CORRECTIONAL
FACILITIES

18.9

20

15

10

5

6.3

5.3

4.0

2.6
0

0.0

2.3
0.4

0.2

0.6

1.1

2.5
0.2

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Source:  Analysis of gassing attack data from CDCR, Men’s Central, and Santa Rita.

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Me

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The Three Correctional Facilities Do Not Have
Adequate Procedures to Ensure That They Provide
Care to Victims of Gassing Attacks
Key Points
•	 Santa Rita lacks effective procedures to ensure that it immediately informs victims
of all available aftercare services—including medical evaluations for a communicable
disease and workers’ compensation benefits.
•	 None of the three correctional facilities adequately informed victims of their right to
request that inmates involved in gassing attacks be tested for a communicable disease.
•	 Although the correctional facilities had policies to provide counseling services to
victims, they did not consistently document that they notified the victims of the
availability of these services, nor did they document such notifications.
Table 2
Aftercare Scorecard
AFTERCARE PRACTICE

CIM

MEN’S CENTRAL

SANTA RITA

15/15

15/15

Undetermined*

5/6

6/7

6/6

Undetermined*

Undetermined*

Undetermined*

0/6

0/7

2/6

The facility documented whether it informed the victims of counseling
options after a gassing attack.

Undetermined*

Undetermined*

Undetermined*

The facility documented that it sought out victims for counseling following a
gassing attack.

Undetermined*

7/15

Undetermined*

4/6

2/7

2/6

Medical treatment
The facility documented whether it informed the victims of their medical
treatment options following a gassing attack.
Victims’ responses indicated that they were informed of all medical options
available following a gassing attack.†
Inmate testing
The facility documented whether it informed the victims of their right to
request that the inmate be tested for communicable disease.
Victims’ responses indicated that they were informed of their right to request
that the inmate be tested for communicable diseases.†
Counseling

Victims’ responses indicated that they were notified of the availability of
counseling services.†

Source:  Analysis of policies and procedures and attacks that occurred at CIM, Men’s Central, and Santa Rita, as well as responses to our questionnaires
by victims involved in 45 gassing attacks that we reviewed.
*	 The correctional facility does not specifically track this information, and we could not determine if it complied with its policies and procedures.
†	 A gassing attack can have multiple victims. We identified 55 victims of the 45 gassing attacks we reviewed and sent questionnaires to each victim.
We received responses from victims of 19 attacks—six from CIM, seven from Men’s Central, and six from Santa Rita.
Generally complied
Partially complied
Did not generally comply

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Santa Rita Needs to Take Additional Steps to Inform Victims of the
Medical Services Available to Them
As we discuss in the Introduction, gassing attacks pose a serious
health risk to correctional staff because of potential exposure to
communicable diseases. All three correctional facilities we visited
have policies that require supervisors to encourage victims to obtain
an immediate medical evaluation for infectious diseases following an
attack. In addition, all three correctional facilities require supervisors
to provide informational materials to the victims on available
aftercare services, including forms on medical treatment options and
communicable disease testing. State law also requires the correctional
facilities to provide victims with information on their rights to workers’
compensation benefits, which can provide them with medical benefits
if they are injured from a gassing attack. However, as indicated in
Table 2 on the previous page, we found that Santa Rita did not track
whether supervisors notified victims of their medical options following
a gassing attack. Therefore, it was not clear if Santa Rita was notifying
victims of all available medical services. In fact, we noted that victims
in 12 of the 15 gassing attacks at Santa Rita did not seek medical
evaluations. Moreover, Santa Rita could not demonstrate that victims
in these 12 attacks filed for workers’ compensation benefits. In contrast,
we noted that CIM and Men’s Central generally complied with their
process to notify victims of their medical treatment options in all cases
we reviewed.
We contacted the victims of the gassing attacks we reviewed to find
out if the correctional facilities provided them adequate information
on the medical options available to them. We received responses from
victims of 19 attacks—six from CIM, seven from Men’s Central, and
six from Santa Rita. Although we were unable to verify that Santa Rita
consistently notified victims of their medical options, because of the
lack of documentation noted above, most victims responding to our
questionnaire indicated that they were informed of medical services
following the gassing attack, as shown in Table 2.
Santa Rita acknowledged that it could improve its procedures and
indicated it will review its notification procedures and make changes to
document that it notifies victims of aftercare services. These changes
will include a requirement that supervisors record that they have
advised victims of their rights to aftercare benefits.

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The Three Correctional Facilities Do Not Have Processes to Ensure
That They Inform Victims of Their Right to Request That Inmates Be
Tested for Communicable Diseases
The three correctional facilities are not fulfilling their responsibility
to inform victims whether they were exposed to a communicable
disease. State law requires that correctional facilities notify victims
of a gassing attack when they have been exposed. At CIM, inmates
coming into custody are tested for communicable diseases and
it has the results of these tests available. However, CIM does
not actively notify victims of gassing attacks whether the inmate
involved was infected with a communicable disease. Citing federal
medical privacy law, the chief medical officer at CIM asserted that
he would not disclose to the victim whether the inmate involved
has a communicable disease. However, federal medical privacy law
provides an exception that allows correctional facilities to disclose
an inmate’s medical information to a victim in these situations. In
fact, in one of the 15 gassing attacks we reviewed, CIM was aware
that the inmate had a communicable disease at the time of the
March 2017 attack but it did not notify the victim of the exposure.

The three correctional facilities are not
fulfilling their responsibility to inform
victims whether they were exposed to a
communicable disease.

In addition to the one victim we noted in our testing, CIM failed to
inform an additional victim that was attacked by the same inmate
of the exposure to a communicable disease. When we raised
this issue with CIM’s warden, he agreed that CIM did not have
a process to notify victims of potential exposure. To address the
problem, the warden implemented a policy in June 2018 that requires
the chief medical officer to immediately notify a victim when an
inmate involved in a gassing attack is known to be infected with a
communicable disease. However, we are concerned that CIM may
not effectively implement this new policy. Even though CIM notified
the victims in August 2018 of the March 2017 exposure to a
communicable disease, the chief medical officer at CIM confirmed
he did not notify the victims until after one of the victims specifically
requested this information in August 2018. However, the chief
medical officer’s duty to notify the victim is not dependent on the
request of the victim.

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Although Santa Rita does not test inmates for communicable
diseases when they come into custody, in two of the 15 cases
we reviewed, the inmates had indicated to Santa Rita that they
were infected. Santa Rita has a process to notify the victims
of exposure to communicable diseases following a gassing
attack when the victim requests notification, but it did not
immediately notify the victims in either case following the attack
in October 2017. Specifically, one victim requested the information
at the time of the attack and Santa Rita provided the information.
However, as indicated above, Santa Rita’s duty under state law is to
immediately notify a victim when it is aware an inmate is infected
with a communicable disease and not to wait until the victim
requests the information.

In two of the 15 cases we reviewed, the
inmates had indicated to Santa Rita that
they were infected.

In the other instance, Santa Rita confirmed that it did not notify
the victim and the commanding officer could not explain why the
notification did not occur. In response to our concern, Santa Rita
notified the other victim of the exposure in August 2018. Going
forward, the commanding officer indicated that Santa Rita will
revise its policies to notify a victim immediately if an inmate
involved in a gassing attack is known to be infected with a
communicable disease.
Moreover, Men’s Central could better inform victims when the
inmate perpetrator has a communicable disease. It generally does
not test inmates for communicable disease when they come into
custody, citing the high volume of incoming inmates. However,
Men’s Central indicated that it sometimes becomes aware that
an inmate has a communicable disease. The public health nurse
at Men’s Central indicated that she would inform victims that
the inmate is infected, but that she may not always know who to
inform unless the victim files a request to have the inmate tested.
To address this problem, Men’s Central stated that it will modify
its procedures to ensure that the public health nurse is notified of
all victims in gassing attacks. In the 15 cases we reviewed at Men’s
Central, its medical records indicated that none of the inmates
involved in the gassing attacks were infected.

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None of the three correctional facilities consistently documented
whether their supervisors notified victims of their right to
request that inmates involved in gassing attacks be tested. As the
Introduction explains, state laws provide victims of gassing attacks
with the right to request such testing. However, in our review of
45 gassing attacks, none of the three correctional facilities could
provide documentation that any victims requested such testing.
Because the three correctional facilities could not provide this
information, we attempted to directly contact victims involved
in the 45 cases we reviewed. Only two of the 19 victims who
responded—both of them from Santa Rita—stated that the
correctional facility informed them that they could request the
testing. In response to our concerns, the three correctional
facilities indicated they will update their policies to ensure that
victims are notified that they can request that inmates be tested for
communicable diseases immediately following gassing attacks.
The Three Correctional Facilities Did Not Consistently Document That
They Informed Victims of Available Counseling Services
Each of the correctional facilities has counseling services available
for victims following gassing attacks, but they did not consistently
document that they notified these victims that they can use these
services. Specifically, CIM and Santa Rita do not document whether
they informed victims of counseling services. Both correctional
facilities offer victims peer support counseling to discuss the
incident with officers trained in critical incident responses, and they
provide information and resources to victims to address concerns
following the gassing attack. Both facilities also offer an employee
assistance program, which allows employees to attend a number of
sessions with a licensed counselor for any reason.
CIM policy requires officers to notify gassing attack victims of
counseling options directly after an incident. Santa Rita, in contrast,
reminds employees and supervisors about counseling options
during annual trainings. CIM stated that CDCR policy does not
require that it track whether it notifies victims of counseling
services, but it asserted that counselors do contact victims after
these incidents. Santa Rita also does not track whether victims are
notified, asserting that its employees and supervisors are well aware
of counseling services through policies and training. However, as
indicated in Table 2 on page 13, only six of the 12 victims at CIM
and Santa Rita responded that they were aware of the availability
of counseling services, suggesting that the correctional facilities’
current approaches to informing victims could be improved. If the
correctional facilities do not document these notifications, they
cannot ensure that all gassing attack victims are aware that they can
seek counseling.

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Men’s Central offers professional counseling from psychologists
within the LASD, but it lacks a process to document when it offers
the counseling services. LASD policy requires the jail to notify
all gassing attack victims of the availability of optional counseling
services through its internal Psychological Services Bureau
(psychological bureau). Moreover, following a gassing attack, an
operations sergeant has the discretion to require the employee
to attend a counseling session. However, Men’s Central does not
provide any guidance for its operations sergeants to determine when
to require counseling, and those sergeants generally do not record
their decision or if they notified the psychological bureau that an
officer was a victim of a gassing attack.

LASD lacks a process to document how
it decides to offer counseling services to
victims of gassing attacks.

Regardless of whether an operations sergeant determines that
counseling is required, LASD policy also requires the psychological
bureau to reach out to the victim to offer counseling services.
However, we found that Men’s Central informed victims of the
availability of counseling in only seven of the 15 cases we reviewed.
As a result, we could not conclude that Men’s Central consistently
refers victims to counseling. As indicated in Table 2, only two of
the seven victims who responded to our questionnaire stated that
Men’s Central made them aware that counseling services were
available. In response to our concerns, Men’s Central agreed that it
needs to better ensure that victims know about the available mental
health services. It further stated that it plans to document when
victims receive information regarding counseling services.

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Recommendations
CIM
To ensure the health and safety of its employees and hold its
supervisors accountable, CIM should revise its policies and
procedures to require documentation that its supervisors
are notifying victims of gassing attacks in a timely manner of
the following:
•	 Their right to request that the inmates involved be tested for
communicable diseases.
•	 The counseling services available to them.
To make certain that victims are aware of threats to their health,
CIM should follow state law and ensure that its medical personnel
immediately inform victims of gassing attacks of any evidence
suggesting that the inmates involved have a communicable disease.
It should further document that it has provided this information
to victims.
Men’s Central
To ensure the health and safety of its employees and hold its
supervisors accountable, Men’s Central should revise its policies
and procedures to require documentation that its supervisors
are notifying victims of gassing attacks in a timely manner of
the following:
•	 Their right to request that the inmates involved be tested for
communicable diseases.
•	 The counseling services available to them.
To make certain that victims are aware of threats to their health,
Men’s Central also should follow state law and ensure that
its medical personnel immediately inform victims of gassing
attacks of any evidence suggesting that the inmates involved
have communicable diseases. It should also document that it has
provided this information to victims.

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Santa Rita
To ensure the health and safety of its employees and hold its
supervisors accountable, Santa Rita should revise its policies
and procedures to require documentation that its supervisors
are notifying victims of gassing attacks in a timely manner of
the following:
•	 The medical services and workers’ compensation benefits
available to them.
•	 Their right to request that the inmates involved be tested for
communicable diseases.
•	 The counseling services available to them.
To make certain that victims are aware of threats to their health,
Santa Rita should follow state law and ensure that its medical
personnel immediately inform victims of gassing attacks of any
evidence suggesting that the inmates involved have a communicable
disease. It should further document that it has provided this
information to victims.

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September 2018

The Three Correctional Facilities Did Not
Consistently Investigate Gassing Attacks in a
Thorough and Timely Manner
Key Points
•	 At the three correctional facilities we reviewed, only 31 percent of gassing attacks
from 2015 through 2017 resulted in convictions, in part because district attorneys
declined to prosecute 44 percent of the cases.
•	 The three correctional facilities did not routinely collect all evidence necessary to
prosecute gassing attacks. This resulted in district attorneys declining to prosecute
four of the 45 cases we reviewed.
•	 Men’s Central and CIM extended their investigations of gassing attacks,
significantly delaying consequences for the inmates involved. Only Men’s Central
followed the state law requirement to test the gassing substance to confirm the
presence of bodily fluids, which extended its investigations by nearly five months
on average. Santa Rita did not refer four of the 15 cases we reviewed for
prosecution, primarily because staff did not follow policies and procedures.
Table 3
Investigation and Prosecution Scorecard
INVESTIGATION AND PROSECUTION PRACTICE

CIM

MEN’S CENTRAL

SANTA RITA

The facility collected physical evidence of the gassing substance.

4/15

9/15

1/15

The facility tested the physical evidence to confirm the presence of a
bodily fluid.

0/4

9/9

0/1

15/15

15/15

11/15

2/15

6/15

11/11

Evidence collection

Referral for prosecution
The facility referred gassing attacks to the district attorney.
Timeliness
The facility referred gassing attacks to the district attorney in a reasonable
time frame.

Source:  Analysis of policies and procedures and attacks that occurred at CIM, Men’s Central, and Santa Rita.
Generally complied
Partially complied
Did not generally comply

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Few Gassing Attacks Have Resulted in Successful Prosecutions
To deter inmates from committing gassing attacks, the Legislature
established criminal penalties for gassing attacks, as we discuss
in the Introduction. However, as Table 4 shows, district attorneys
were able to obtain a conviction in only 31 percent of the completed
cases that the correctional facilities referred from 2015 through
2017. Ensuring prompt consequences is an important component
of the correctional facilities’ processes to deter gassing attacks. If an
inmate commits a gassing attack on an officer without repercussion,
it conveys that committing gassing attacks may go unpunished.
Table 4
Prosecution Outcomes of Gassing Attacks From 2015 Through 2017
As of May 2018
OUTCOME OF CASES

CIM

MEN’S CENTRAL

SANTA RITA

Filed—convicted*

9

39%

66

33%

15%

80

31%

Filed—dismissed

0

0

23

12

10

30

33

14

Declined by district attorney†
Not referred by facility‡

14

61

98

49

1

3

113

44

0

0

11

6

17

52

28

11

Subtotal–Completed cases

23

 

198

 

33

 

254

 

3

 

43

 

8

 

54

 

26

 

241

 

41

 

308

 

Open cases
Totals

5

TOTAL

CONVICTION
RATE

Source:  Prosecution records from the three correctional facilities and the county district attorneys.
*	 Convictions include plea bargains for a conviction for another offense.
†	 The district attorney declined to prosecute gassing cases for insufficient evidence or prosecutorial discretion, among other reasons.
‡	 The correctional facilities did not refer cases to the district attorney for lack of probable cause, among other reasons.

As Table 4 shows, district attorneys declined to prosecute a
substantial number of cases that CIM and Men’s Central referred
from 2015 through 2017, 61 percent and 49 percent, respectively.
In contrast, the Alameda County District Attorney declined to
prosecute only 3 percent of cases that Santa Rita referred during
this same time frame. District attorneys have discretion to decide
whether to prosecute gassing attacks. For example, one district
attorney declined to prosecute a case that we reviewed because
the inmate was in state prison serving time for another crime
and the district attorney concluded that seeking an additional
sentence for the gassing attack would not substantially affect the
inmate’s current sentence. However, the correctional facilities were
responsible for the district attorneys declining to prosecute some
cases because they did not always collect sufficient evidence or
conduct timely investigations, as we discuss in the next section.

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None of the Three Correctional Facilities Consistently Collected
Sufficient Evidence to Prosecute Gassing Attacks
The correctional facilities we reviewed have not consistently met
their responsibility to ensure that their officers gather sufficient
evidence for district attorneys to prosecute
gassing attacks. As the text box shows, officers can
collect various forms of evidence at the scene of a
Types of Evidence in Gassing Attacks
gassing attack. Of the 45 attacks we reviewed, the
•	 Sample of the gassing substance
correctional facilities referred 41 cases to district
attorneys. However, those district attorneys
•	 The victim’s clothes that were struck with the
declined to prosecute four of these 41 cases because
gassing substance
the correctional facilities did not collect sufficient
•	 Victim, inmate, and witness statements
evidence. Further, as Table 4 indicates, district
•	 Video and photographs of the attack
attorneys’ offices declined to prosecute a significant
number of the total gassing attacks that CIM
•	 The container used to throw or propel the
and Men’s Central referred. Based on our review,
gassing substance
the three correctional facilities may be able to
Source:  Review of policies of the three correctional facilities.
improve the conviction rates on their cases by more
consistently collecting evidence.
None of the three correctional facilities regularly collected physical
evidence, such as the gassing substance or the container used to
throw the substance, yet state law requires correctional facilities to
use every available means to investigate a gassing attack—including
preserving and testing the substance to determine if it is a bodily
fluid. However, the three correctional facilities generally did not
collect physical evidence in gassing attacks involving an inmate
spitting on an officer. Of the 45 cases we examined, 13 involved
spitting—six at CIM, three at Men’s Central, and four at Santa Rita.
In these types of attacks, the physical evidence could have included
the officer’s uniform or the item used to clean the officer’s skin, such
as a cloth or paper tissue. Although we acknowledge that preserving
evidence of spitting can create challenges, state law still obligates
correctional facilities to use all means possible to investigate
gassing attacks.
The remaining 32 of the 45 gassing attacks involved a bodily fluid
other than spittle. In these attacks, the investigation reports from
the correctional facilities indicated that the inmate often used a
container to throw the gassing substance at the officer, with the
substance making contact with officer’s skin and uniform. The
container and contaminated clothing can provide strong evidence
that the inmate committed a gassing attack because the correctional
facilities can test them to confirm the presence of bodily fluids.
However, we found that the three correctional facilities often did
not collect and retain physical evidence, such as the container
or the contaminated uniform. For example, as shown in Table 3
on page 21, CIM collected physical evidence in only four of the

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15 gassing attacks we reviewed, despite having a memorandum of
understanding with the San Bernardino County district attorney
that requires CIM to preserve a sample of the substance that
the inmate threw as well as the victim’s clothing. Further, the
San Bernardino County district attorney chose not to file criminal
charges in one of these four cases at CIM, specifically citing that
CIM did not collect the evidence necessary to support prosecution
of the crime.
Men’s Central collected physical evidence in nine of the 15 gassing
attacks that we reviewed. In two of the six cases in which it did
not collect physical evidence, the Los Angeles County district
attorney declined to prosecute because of insufficient evidence. In
both cases, the officers did not collect the container or the soiled
uniform, and Men’s Central could not prove that the substance
was a bodily fluid. Men’s Central agreed that its officers should
collect the containers used to throw or propel the gassing substance
and that it will provide training incorporating the need for staff
to do so. Santa Rita did not collect physical evidence in 14 of the
15 gassing attacks that we reviewed and instead relied on video
footage, photographs, and witness statements. Santa Rita had the
lowest conviction rate and highest dismissal rate among the three
correctional facilities, which could be in part because it does not
collect physical evidence. However, the Alameda County district
attorney declined to prosecute only one case that we reviewed and
it did so only because the inmate faced other criminal charges.
Further, only Men’s Central follows the state law requirement
to preserve and test gassing substances to confirm that they are
bodily fluids. Of the 12 gassing attacks that did not involve spittle,
Men’s Central collected physical evidence in nine of these cases and
submitted a sample of the substance to the county crime laboratory
for testing. In contrast, CIM stated that it does not test the gassing
substance unless the district attorney requests it. However, CIM
indicated that the district attorney did not request testing for
any of the 15 cases that we reviewed. Nevertheless, CDCR stated
that it expects CIM to collect physical evidence of the gassing
substance to determine whether it is a bodily fluid. Santa Rita also
does not test the gassing substance. The Alameda County district
attorney indicated that it does not generally require Santa Rita to
test the gassing substance before it files a case because the county
crime laboratory has limited resources and the district attorney
believes that other forms of evidence—video footage, photographs,
victim testimony, and witness statements—often are sufficient to
prosecute the crime. Santa Rita’s commanding officer acknowledged
that the correctional facility should comply with the state law
requirement to test the gassing substance and stated that it plans to
do so for future gassing attacks.

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Two Correctional Facilities Took an Unreasonable Amount of Time to
Conduct Their Internal Investigations of Gassing Attacks	
Men’s Central and CIM took significantly longer than Santa Rita
to investigate the 15 gassing attacks that we reviewed at
each correctional facility, as Figure 4 shows. Men’s Central’s
investigations, including crime laboratory testing, took an average
of more than seven months, CIM’s investigation took an average of
more than three months, and Santa Rita’s investigations took an
average of just 17 days. One of the reasons for Men’s Central’s longer
investigations may be justified: it follows the state law requirement
to submit gassing substances for laboratory testing, which prolongs
the time it takes to refer cases to the district attorneys. However,
Men’s Central and CIM unnecessarily extended the time they took
to investigate cases, delaying resolution of the legal process. In fact,
the district attorney declined to prosecute one Men’s Central case
because of the length of the facility’s investigation. Nonetheless,
as Table 4 on page 22 shows, CIM and Men’s Central had higher
conviction rates than Santa Rita, indicating that the additional
time they took to investigate cases may have helped produce
better results.
Figure 4
Testing the Gassing Substance Significantly Lengthens the Investigation

STEP I

STEP II

STEP III

Facility Evidence Collection

Detective Review

Crime Laboratory Testing

70

CIM
Men’s Central

15

Santa Rita

17
0

29
70

50

140

100

150

200

250

Average Number of Days Following a Gassing Attack
Source:  Analysis of 15 gassing attacks that occurred at each of the three correctional facilities.
Note:  Santa Rita does not require a detective to review the investigation. Neither CIM nor Santa Rita submit the gassing substance for testing.
Further, Men’s Central collected and tested the gassing substance in nine of the 15 cases we reviewed.

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Men’s Central took an average of more than seven months to
complete its investigations of the 15 cases that we reviewed. In
one extreme case, its investigation took 16 months. Part of this delay
is attributable to its decision to follow state law by regularly testing
gassing substances for the presence of bodily fluids, a process that
took an average of nearly five months in the nine cases where it
was conducted. As we previously discussed, CIM and Santa Rita
have not tested the gassing substances and they rely on other forms
of evidence.

Men’s Central took an average of more than
seven months to complete its investigations
of the 15 cases that we reviewed.

Although testing the gassing substance created a delay at
Men’s Central, it appears to have merit as the correctional facility
had a conviction rate that was only slightly lower than CIM’s rate
and significantly higher than Santa Rita’s rate. However, CIM and
Santa Rita did obtain convictions without testing the gassing
substances. Both the Alameda and San Bernardino county district
attorneys told us that they generally do not require laboratory
testing of the gassing substance if the other evidence gathered
is compelling. Therefore, testing the gassing substance may be
beneficial in obtaining sufficient evidence needed for a conviction,
but it may not be necessary in all cases. For example, officers at
Santa Rita wear body cameras, which combined with a victim’s
testimony may provide clear evidence that the substance thrown
was a bodily fluid. In other cases, an inmate may admit that the
substance thrown was a bodily fluid, making testing unnecessary. If
the correctional facility can obtain sufficient evidence of the gassing
incident, a timely prosecution may promote the interest of justice
rather than to delay prosecution because it is waiting for the results
of laboratory testing.
Laboratory testing aside, Men’s Central still took nearly
three months on average to investigate gassing attacks. The
LASD jail investigations unit (investigations unit) investigates all
crimes that inmates commit in Men’s Central, including gassing
attacks, while the Men’s Central staff are responsible for notifying
the investigations unit of the crime and initially collecting the
evidence. We identified unreasonable and avoidable delays in
nine of the 15 gassing attacks at Men’s Central that we reviewed,
with one resulting in the district attorney declining to prosecute
the case. Specifically, in that case the investigations unit did not

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deliver evidence of the gassing substance to the Los Angeles County
crime laboratory until 10 months after the gassing attack occurred.
Subsequently, because of the time needed to obtain laboratory test
results, the investigations unit did not refer the case to the district
attorney until 16 months after the incident. The district attorney
declined to prosecute the inmate, citing that the inmate was now
in state prison and that the delay in receiving the crime laboratory
test results could provide the defendant with a viable defense of not
receiving a speedy trial.

Laboratory testing aside, Men’s Central still
took nearly three months on average to
investigate gassing attacks.

A sergeant from the investigations unit believes that staff members
mistakenly put this evidence into storage instead of sending it to the
crime laboratory. In another instance, the detective sent evidence
to the crime laboratory three months after the attack occurred,
but the investigations unit could not provide the reason for this
delay. When the investigations unit finally referred the case for
prosecution, the district attorney chose not to file charges because
the inmate was in state prison and a conviction would not have
substantially affected the inmate’s sentence. However, in both of
these cases, the district attorney’s comments indicate that it may
have chosen to prosecute the inmate had Men’s Central completed
its investigation in a timelier manner.
In the remaining seven cases, the delays were either because of
excessive time for Men’s Central to submit the case for investigation
or for the detective to submit the case for prosecution, or both.
Men’s Central stated that the delays were caused by multiple
steps in the incident report approval process, and to address
our concerns, it agreed to implement a general guideline of
five days to forward incident reports to the investigations
unit. The investigations unit sergeant asserted that the facts of
each case impact how quickly detectives can refer cases to the
district attorney, and that in recent years the investigations unit
has dedicated more resources to improving the timeliness of
investigations. Nonetheless, in an October 2017 investigation that
we reviewed, the detective took nearly three months to refer the
case to the district attorney because of delays in collecting witness
statements, indicating that delays continue to be present even with
additional resources.

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Although state law requires correctional facilities to immediately
investigate all gassing attacks, CIM took an average of 70 days to
complete its investigations, which included preparing an incident
report and collecting evidence. We identified unnecessary and
avoidable delays in 13 of the 15 gassing attacks we reviewed. CIM
noted that the delays in the investigations process were due to the
multiple layers of review by various staff members in approving
the incident report. In addition, when officers use force to subdue
an inmate who commits the gassing attack, CIM incorporates an
evaluation of the use of force by the officers into its investigation
process. For the seven cases we reviewed that involved the use
of force, this evaluation created a delay that averaged one month.
Although CIM’s practice is to evaluate the use of force as part of
its investigation, this evaluation is unrelated to whether the inmate
committed a criminal act. Therefore, CIM’s current approach
prolongs the investigation and delays any consequences for
the inmate.
Santa Rita completed its investigations in a more timely manner
than CIM and Men’s Central, but it did not refer four of the
15 gassing attacks that we reviewed to the Alameda County district
attorney. For three of those four cases, Santa Rita did not refer them
because staff did not follow its policies and procedures. Santa Rita
did not refer the other case because the victim did not wish to file
a criminal complaint. However, in response to our inquiry, the
commanding officer at Santa Rita indicated that the correctional
facility would review the four cases and refer them to the Alameda
County district attorney for prosecution if the required elements of
a crime are present.
Recommendations
Legislature
To shorten the time to submit cases of gassing attacks for
prosecution, the Legislature should modify state law to provide
correctional facilities the discretion to omit testing the gassing
substance for the presence of a bodily fluid when the correctional
facility, in consultation with its district attorney, finds that such
testing is unnecessary to obtain sufficient evidence of a crime.

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CIM
To ensure that it properly investigates gassing attacks and refers
cases for prosecution, CIM should do the following:
•	 Implement procedures to ensure that it collects sufficient
physical evidence and submits the gassing substance for
laboratory testing, as state law requires.
•	 Develop goals for how long investigations should take and ensure
that its officers adhere to these goals.
•	 Separate its evaluation of officers’ use of force from the
investigation process it uses to refer cases to the district attorney.
Men’s Central
To ensure that it properly investigates gassing attacks and refers
cases for prosecution, Men’s Central should do the following:
•	 Implement procedures to ensure that it collects sufficient
physical evidence.
•	 Develop goals for how long investigations should take and ensure
that its officers adhere to these goals.
Santa Rita
To ensure that it properly investigates gassing attacks and refers
cases for prosecution, Santa Rita should do the following:
•	 Implement procedures to ensure that it collects sufficient
physical evidence and submits the gassing substance for
laboratory testing, as state law requires.
•	 Develop practices to ensure that it submits all cases for
prosecution when probable cause of a crime exists. Further, it
should expedite its review of the four cases that we identified,
and if probable cause exists, submit those cases to the district
attorney for prosecution.

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The Three Correctional Facilities Have Not Established
Adequate Internal Processes to Prevent and Respond to
Gassing Attacks
Key Points
•	 Two of the correctional facilities we visited—CIM and Santa Rita—have not taken full
advantage of internal discipline procedures to deter and reduce gassing attacks. Although the
two correctional facilities have procedures for using internal discipline to maintain control
and promote desirable changes in inmate attitude and behavior, they only followed these
procedures in 13 of the 30 cases that we reviewed.
•	 The three correctional facilities provide limited training to officers on how to prevent and
mitigate the harm from gassing attacks, and as a result, their officers may not be sufficiently
prepared to react to gassing attacks. Seven of 19 victims of gassing attacks at the three
correctional facilities indicated that they were not aware of training available to them.
•	 CIM and Santa Rita do not actively track gassing attacks. However, such tracking could
help them identify inmates who are repeat offenders, inmates whose characteristics make
them more likely to commit gassing incidents, and other factors that create a higher risk of
gassing attacks.
Table 5
Internal Discipline and Prevention Scorecard
INTERNAL DISCIPLINE AND PREVENTION PRACTICE

CIM

MEN’S CENTRAL

SANTA RITA

The facility documented whether it imposed appropriate disciplinary actions in accordance
with its policies, including a consideration of the inmate’s mental health status.

12/15

15/15

1/15

Partial*

Partial*

Partial*

The facility has protective gear readily available for employees and requires its
employees to wear it when dealing with potential or known inmate gassers.

Yes

Yes

Yes

Victims’ responses indicated that they did not have concerns with the facilities’ training
to prevent and mitigate gassing attacks.†

4/6

4/7

4/6

No

Yes

No

Discipline

Training and prevention
The facility trained its employees, at least annually, how to prevent and respond to
gassing attacks.

Tracking
The facility specifically tracked gassing attacks and attempted gassing attacks.

Source:  Analysis of policies and procedures and attacks that occurred at CIM, Men’s Central, and Santa Rita, as well as responses to our questionnaires
of the victims involved in 45 gassing attacks that we reviewed.
*	 The facilities provide annual training on subjects such as the use of force and officer safety, but the training is not specific to gassing attacks.
†	 A gassing attack can have multiple victims. We identified 55 victims of the 45 gassing attacks we reviewed and sent questionnaires to each victim.
We received responses from victims of 19 attacks—six from CIM, seven from Men’s Central, and six from Santa Rita.
Generally complied
Partially complied
Did not generally comply

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Two Correctional Facilities Often Did Not Take Disciplinary Action
Against Inmates Involved in Gassing Attacks
CIM and Santa Rita are not taking full advantage of internal
discipline to deter inmates from committing gassing attacks. As
we discuss in the Introduction, internal discipline can include
actions such as reducing inmates’ privileges, placing inmates into
secured housing, and taking away credit time that inmates earn to
reduce their sentence. All three correctional facilities have policies
and procedures to use internal discipline to maintain control and
promote desirable changes in inmate attitude and behavior. In
addition, internal policies and state regulations for CDCR facilities
require that correctional facilities evaluate the mental health and
competency of an inmate when determining whether to impose
internal discipline and what method to use. However, as shown in
Table 5 on the previous page, CIM and Santa Rita imposed internal
discipline in 12 and one, respectively, of the 15 incidents we reviewed
at each correctional facility. For CIM, five of the 12 incidents
included inmates for whom it believed it was appropriate to waive
internal discipline due to the inmates’ mental health condition.
Nonetheless, because these two correctional facilities did not impose
internal discipline in the remaining cases, this may result in inmate
perpetrators not receiving any consequences for their crimes. In
fact, as Table 4 on page 22 shows, from 2015 through 2017 district
attorneys obtained convictions for only 39 percent and 15 percent of
gassing attacks at CIM and Santa Rita, respectively.

Two of the three correctional facilities do
not consistently use internal discipline to
maintain control and promote desirable
changes in inmate attitude and behavior.

CIM acknowledged that the three cases in which it did not impose
internal discipline were the result of staff not following policies and
procedures. To address this problem, CIM has developed a tracking
system to ensure that it holds inmates accountable. Santa Rita
indicated that it does not always impose internal discipline for gassing
attacks because it relies on criminal prosecution instead. Specifically,
the commanding officer of Santa Rita indicated that discipline is not
always the most effective way to prevent and deter gassing attacks
because inmates who commit these attacks often are already in
segregated housing and they have lost their privileges. Nonetheless,
we noted that some inmate attackers at Men’s Central were on similar
restrictions, yet it imposed discipline more often than Santa Rita.

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In contrast to CIM and Santa Rita, Men’s Central consistently
imposed internal discipline or determined it was appropriate to
waive discipline because of the inmate’s mental health condition
for each of the 15 gassing attacks that we reviewed. The discipline
that Men’s Central imposed was generally the loss of inmate
privileges and placement in segregated housing. For the inmates
for whom it waived internal discipline, Men’s Central transferred
them to segregated housing in another of its correctional facilities
for mental health observation. According to Men’s Central’s policy,
it consistently imposes internal discipline to make sure it holds
inmates accountable for their actions, to maintain order, and to
protect its staff.
Although the Three Correctional Facilities Have Implemented Certain
Preventative Measures, Additional Training Could Better Prepare
Officers to Respond to Gassing Attacks
To mitigate the harm of gassing attacks, the three correctional
facilities typically had available protective equipment, such as
facemasks or hand‑held shields, to block items thrown by inmates
even though this type of equipment cannot protect against all
gassing attacks. CIM and Men’s Central provide officers access
to protective gear, such as shields or helmets, when they need it.
Santa Rita requires employees to use a protective door shield that
it developed, known as a Bio‑Barrier, as pictured in Figure 5 on
the following page. It also requires, at a minimum, a face shield
and gloves when moving or interacting with inmates who have
committed previous gassing attacks. All of the correctional facilities
also make available full‑body biohazard suits. During our review,
we inspected each correctional facility’s inventory of protective
equipment and found that the gear was available to the officers.
Nevertheless, in one of the incidents we reviewed at CIM, the
victim stated that he did not wear a face shield because they were
unavailable. Gassing attacks often occur without warning, meaning
that officers may not be able to put on protective gear before
the attack. An officer’s use of protective gear can be effective in
mitigating the effects of gassing attacks, but only when the officer
can access the gear and decide to use it before an attack.

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Figure 5
Preventative Tools to Mitigate Gassing Attacks

I.

II.

Preventative
Tools
I.
II.
III.
IV.
V.

BIOHAZARD SUIT
“GASSER” TAGS
HARD-DOOR CELLS
BIO-BARRIER DOOR
FACE SHIELD

III.

IV.

V.

Source:  Photographs and policies provided by the three corrections facilities and photographs taken by audit staff.

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Officers may need protective equipment as the infrastructure at
CIM and Men’s Central can increase the risk of gassing. Most
of the holding areas in Men’s Central, and some at CIM, are
either open‑bar cells or dormitory‑style housing, as Figure 6 on
the following page shows. In this type of housing, inmates can
throw substances at officers through the bars of their cells. Both
correctional facilities mitigate these infrastructure problems
by housing inmates who are likely to commit gassing attacks—
those who have made threats or previously committed attacks—
in secured housing. Secured housing cells, which contain a
single individual, include hard‑door cells with windows to see the
inmate and a port to provide meals and personal supplies or to
handcuff inmates, as Figure 5 shows. However, CIM has 72 secured
housing cells in its outpatient housing unit in comparison to its
3,500 inmates. Men’s Central can house only up to 54 inmates in
cells with preventive measures, and it houses the vast majority of its
4,200 inmates in open‑bar cells or dormitories. In contrast to CIM
and Men’s Central, Santa Rita has 1,103 hard‑door cells throughout
the facility, and these afford better protection for officers against
gassing attacks. Nevertheless, secured housing cannot eliminate
gassing attacks. For example, 11 of the 15 gassing attacks that we
reviewed at CIM occurred in its outpatient housing unit, which is
equipped with hard‑door cells and ports.
According to its sergeant in charge of logistics, Men’s Central is
unable to modify all cells with preventive measures due to the
prohibitive cost of modifying its aging facility. In part to address
the infrastructure concerns with this correctional facility, the
Los Angeles County Board of Supervisors approved in June 2018 a
$2.2 billion plan to replace the Men’s Central facility by 2028 with
a modern correctional facility.
Although not a formal policy, CIM and Santa Rita place “gasser”
tags on the cells housing inmates who have previously committed
gassing attacks in order to warn officers of their dangerous behavior.
This facility practice may minimize the chances of the inmate
successfully committing additional gassing attacks. In our review
of 15 cases at CIM, we identified one case in which CIM did not
place a “gasser” tag on the cell of an inmate who had committed
a gassing attack. As a result, when the inmate committed another
gassing attack eight days later, the victim had no warning about the
threat that this inmate posed.

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Figure 6
Potential Hazards That Enable Gassing Attacks

I.

II.

Potential
Hazards

I.
II.
III.
IV.
V.

SPEAKER PORT
MILK CARTON AND CUP
FOOD PORT
OPEN BARS
LINEAR CELLS

III.

IV.

V.

Source:  Photographs provided by the three correctional facilities and interviews with their staff.

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Each facility provides training to officers, but that training is
about subjects such as the use of force or officer safety and not
specifically about gassing attacks. For example, CIM provides
annual training to officers on the use of force and the danger of
exposure to blood‑borne pathogens. However, the correctional
facility was unable to demonstrate that any of the training is specific
to preventing and mitigating gassing attacks. Two of the six victims
we spoke to at CIM indicated that they had not received training
to help protect themselves from a gassing attack. Additionally, the
training primarily occurs when employees begin working at
the facility rather than annually, which would ensure that all staff
receive a refresher on best practices.
New employees at Men’s Central receive training on gassings
attacks, which describes the elements of a gassing incident and how
to respond after an incident occurs. LASD’s custody training and
standards bureau also sends out instructional bulletins monthly to
all staff, although it has not issued a bulletin specific to the topic
of gassing since 2015. However, three of seven victims of a gassing
attack at Men’s Central reported that they had not received any
training or information about how to protect themselves in the
event of a gassing. A fourth respondent stated that the information
was available but that it was not easily accessible.
Similarly, two of the six victims at Santa Rita indicated that they
had not received training to help protect themselves from a
gassing attack. The commanding officer at Santa Rita indicated
that additional training dedicated to gassing is unnecessary
because existing training, including new employee training,
covers all assaults to staff—including gassing attacks. However,
he stated further that Santa Rita does not have training for its
officers specifically for how to investigate gassing attacks. Such
training would be helpful because some of the reports we reviewed
concluded that a gassing attack had occurred even though the
substances did not make skin contact. State law requires the bodily
fluid to touch the skin to be a gassing attack, so officers may not
be sufficiently informed on what a gassing attack involves. By
providing annual training specific to gassing, the three correctional
facilities could help officers be more prepared to prevent and
respond to gassing attacks.
CIM and Santa Rita Should Track Gassing Attacks to Identify High‑Risk
Situations and Deter Repeat Offenders
CIM and Santa Rita are not specifically tracking gassing attacks,
and therefore they are missing an opportunity to analyze those
attacks and reassess their current procedures to better ensure the
health and safety of their officers. State laws and regulations do not

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require correctional facilities to track gassing attacks. Nevertheless,
doing so would help the correctional facilities address the
aftercare, investigative, and disciplinary concerns that we discuss
throughout this report. Moreover, the correctional facilities could
use knowledge from the trends and common characteristics that
can become apparent from tracking gassing attacks to streamline
their prevention efforts, including the systematic identification of
inmates who commit gassing attacks and inmates who are repeat
offenders. We found that 22 of the 45 gassing attacks (49 percent)
that we reviewed at the three correctional facilities involved
repeat offenders. This count included seven cases at CIM, nine at
Men’s Central, and six at Santa Rita. Repeat offenders at Santa Rita
committed 16 of the 25 gassing attacks (64 percent) in 2017.
A correctional facility’s tracking of gassing attacks should result
in information that is consistent and readily accessible, which
is not currently the case at CIM and Santa Rita. For example,
CIM records all incidents involving inmates, including incidents
of gassing attacks, in the CDCR’s Daily Information Reporting
System database (database). However, this database cannot produce
reports that are specific to gassing attacks without significant
manual analysis. The warden indicates that CIM has not needed
to separately track gassing attacks, but rather it tracks them with
other battery offenses against officers. Santa Rita must consult
three separate databases—two that the Alameda County Sheriff ’s
Office maintains and one countywide criminal database—to
obtain information about gassing attacks at its facility, making it
difficult for Santa Rita to readily analyze gassing attacks. Santa Rita
indicated that it records information about attacks in general on
correctional staff in its internal tracking system, but this system
does not specifically track gassing attacks. Santa Rita also indicates
it is already aware of which inmates are repeat offenders and where
gassing attacks are likely to occur. Nonetheless, by systematically
tracking gassing attacks, CIM and Santa Rita would have more
information available to analyze how best to provide for the health
and safety of their officers.
In contrast to CIM and Santa Rita, Men’s Central began tracking
gassing attacks in 2015 to obtain a better understanding of why an
increase in these attacks was occurring. Men’s Central tracks data
to identify common characteristics of gassing attacks—including
the incident location, time, and date; whether the incident involved
repeat offenders or victims; and the types of inmates involved, such
as high‑security individuals, those from the general population,
and those suffering from mental illness. It uses this information to
review procedures to prevent future attacks.

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Recommendations
CIM
To better prevent gassing attacks and promote desirable changes
in inmate attitude and behavior, CIM should follow its policy
and pursue appropriate internal disciplinary actions—including
consideration of the inmate’s mental health and competency when
determining whether to impose internal discipline.
To ensure the health and safety of its officers when interacting with
inmates, CIM should do the following:
•	 Maintain a sufficient supply of preventative equipment that is
available to its officers and staff in all locations where gassing
attacks can occur.
•	 Develop a policy regarding the placement of “gasser” tags on the
cells of inmates who have committed or attempted to commit a
gassing attack.
•	 Provide annual training that is specific to preventing and
responding to gassing attacks.
To ensure that it is able to identify high‑risk situations and deter
repeat offenders, CIM should specifically track all gassing attacks
and use the tracking data as a tool to prevent future gassing attacks.
Men’s Central
To ensure the safety of its staff, Men’s Central should provide
annual training that is specific to preventing and responding to
gassing attacks.
Santa Rita
To better prevent gassing attacks and promote desirable changes
in inmate attitude and behavior, Santa Rita should follow its policy
and pursue appropriate internal disciplinary actions—including
consideration of the inmate’s mental health and competency when
determining whether to impose internal discipline.

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To ensure the health and safety of its officers when interacting with
inmates, Santa Rita should do the following:
•	 Develop a policy regarding the placement of “gasser” tags on the
cells of inmates who have committed or attempted to commit a
gassing attack.
•	 Provide annual training that is specific to preventing and
responding to gassing attacks.
To ensure that it is able to identify high‑risk situations and deter
repeat offenders, Santa Rita should specifically track all gassing
attacks and use the tracking data as a tool to prevent future
gassing attacks.

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SCOPE AND METHODOLOGY
The Joint Legislative Audit Committee (Audit Committee) directed
the California State Auditor to review the policies, procedures, and
practices in place to protect the health and safety of correctional
staff who are subject to gassing attacks at three correctional
facilities: CIM, Men’s Central, and Santa Rita. Table 6 lists the audit
objectives and the methods we used to address them.
Table 6
Audit Objectives and the Methods Used to Address Them
AUDIT OBJECTIVE

METHOD

1

Review and evaluate the laws, rules, and
regulations significant to the audit objectives.

We reviewed relevant state laws, regulations, and other background materials applicable to
gassing attacks at the three correctional facilities we visited.

2

Determine how the prison and jails track,
document, and investigate gassing attempts
and incidents perpetrated by inmates
on employees.

We interviewed personnel and reviewed policies and procedures used for tracking,
documenting, and investigating gassing attacks at each of the correctional facilities.

3

To the extent possible, determine the
magnitude of the gassing problem
at the prison and jails since 2009 by
identifying the following:

To address this objective, we performed tasks described below at the three correctional
facilities:

a.  The number of gassing attempts and
gassing incidents that occurred each
year, including:
i.  The number that were committed by
repeat gassing incident offenders.
ii.  The number that resulted in a
conviction or other punishment.
b.  The number of staff members who,
following a gassing incident, informed
their employer that they contracted a
disease as a result of the incident.
c.  Whether there was a correlation
between the number of gassing
attempts and incidents, and the
prison or jail’s infrastructure, layout, or
population overcrowding.

•	 To determine the number of gassing attacks, the number committed by repeat
offenders, and the number that resulted in a conviction or other discipline, we
reviewed and compiled data and incident report information from each of the
three correctional facilities.
•	 Men’s Central did not begin formally identifying gassing attacks until 2015. To ensure that
our review was consistent among the three locations, we focused our review on gassing
attacks that occurred from 2015 through 2017 for each of the three correctional facilities.
•	 Employees are not required to inform their employer if they contract a disease as a result
of an incident. All three correctional facilities confirmed that they do not ask employees if
they have contracted a disease.
•	 We compared the infrastructure and population of each correctional facility to identify
any correlations or conditions that could increase the risk of gassing attacks. We also
reviewed the impact of a state law that transferred certain inmates from state prisons
to county jails to relieve overcrowding, and determined that these transfers did not
substantially impact the number of gassing attacks at the three correctional facilities.

4

Review and evaluate the prison and jails’
policies and practices for handling the
aftercare of employees who have been
gassed to determine whether those policies
and practices are consistent with applicable
laws and regulations.

We obtained and reviewed policies and procedures regarding aftercare available to victims
of gassing attacks at each of the three correctional facilities—including their processes and
practices for notifying victims of their medical treatment options, psychological counseling
services, and workers’ compensation benefits—to determine whether they comply with state
and federal laws and regulations.

5

For the most recent three‑year period,
determine how many employees sought and
obtained counseling or medical treatment
through their employers following a
gassing incident.

For each of the 45 gassing attacks we reviewed as part of Objective 7 on the
following page, we determined whether the victims received medical treatment and
psychological counseling.

continued on next page . . .

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AUDIT OBJECTIVE

METHOD

6

Evaluate how the prison and jails ensure that
employees are aware of and comply with
policies and procedures related to gassing,
including those related to prevention,
response, and incident reporting.

We interviewed personnel and reviewed the processes that each of the correctional facilities
implemented to notify and train employees regarding how to prevent and respond to
gassing attacks.

7

For a selection of gassing incidents that have
occurred during the most recent three‑year
period at the prison and jails, review and
evaluate the following:

To address this objective, we judgmentally selected 15 gassing attacks that occurred from
2015 through 2017 at each of the correctional facilities—a total of 45 gassing attacks—and
performed the following procedures at the three correctional facilities:

a.  Whether the prison or jails followed
their respective aftercare policies and
procedures following each gassing
incident including whether the gassing
substance was tested for disease and, if
not, why.
b.	 Whether and how soon after the incident
affected employees were informed
of the presence of diseases in the
gassing substance.
c.	 Whether the prison and jails investigated
the incident in accordance with
requirements in state law.

8

Review and evaluate the strategies that
prisons and jails use to prevent or mitigate
the effects of gassing incidents, including
the disciplinary actions used on offenders
who have attempted or committed gassings.
To the extent possible, determine whether
disciplinary actions are effective in deterring
repeat offenders.

•	 For each of the 45 gassing attacks, we evaluated whether the correctional facilities
followed their aftercare policies and procedures—including whether it notified victims of
their medical treatment options, notified the victims of their right to request inmates be
tested for a communicable disease, and notified the victims of the outcome of the testing.
•	 We also evaluated the correctional facilities’ investigation of the gassing attacks and
whether it complied with state laws—including their processes for collecting evidence
following a gassing attack, testing the gassing substance, and referring attacks to the
district attorney for prosecution.
•	 To gain assurance that we selected a complete data set of gassing attacks from CIM and
Men’s Central, we selected 29 incident reports from these facilities and verified that they
were included in the data.
•	 We did not collect a data set of all gassing attacks from Santa Rita because it did not
track gassing attacks. Instead, we reviewed its hard‑copy log of all assaults on staff and
reviewed incident reports to identify gassing attacks.
To assess the correctional facilities’ strategies to prevent and mitigate gassing attacks, we
reviewed the following:
•	 Processes to prevent or mitigate the impact of gassing attacks, including issuing
equipment and gear such as facemasks, biohazard suits, or shields, to officers who
interact with inmates.
•	 The availability of preventative equipment at select locations within the three correctional
facilities.
•	 Processes for internal discipline to maintain control and promote desirable changes
in inmate attitude and behavior—including restricting the inmate’s privileges and
transferring the inmate to a secured housing cell.
•	 We also evaluated whether the correctional facilities consistently used internal discipline
and whether these processes deterred repeat offenders.

9

Identify any best practices for preventing,
responding to, investigating, or providing
aftercare for gassing incidents.

•	 We interviewed personnel at each of the correctional facilities to identify potential best
practices—including placing “gasser” tags on the cells of inmates who have previously
committed gassing attacks and providing victims with a packet containing all mandated
aftercare information following a gassing attack.
•	 We interviewed correctional officer union representatives to obtain their perspective on
how correctional facilities should address gassing attacks.
•	 We reviewed a U.S. Department of Justice report on practices for ensuring correctional
officer safety and wellness.

10

Review and assess any other issues that are
significant to the audit.

•	 To determine how the number of gassing attacks at the three correctional facilities
compared with other correctional facilities, we compared the rates of gassing attacks at
the three correctional facilities with 10 additional CDCR correctional facilities with similar
populations and security levels as Men’s Central.
•	 For the 45 gassing attacks that we reviewed as part of Objective 7 above, we sent
questionnaires to each victim to obtain their perspective on the gassing attack and to ask
whether the correctional facilities provided appropriate information to them following
the gassing attack. We identified 55 employees who were victims in these 45 gassing
attacks and we received responses from victims of 19 attacks—six from CIM, seven from
Men’s Central, and six from Santa Rita.

Source:  Analysis of the Audit Committee’s audit request number 2018‑106, and information and documentation identified in the table column
titled Method.

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We conducted this audit under the authority vested in the California State Auditor by Government
Code 8543 et seq. and according to generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our audit objectives specified in the Scope and
Methodology section of the report. We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Respectfully submitted,

ELAINE M. HOWLE, CPA
California State Auditor
Date: 		

September 18, 2018

Staff: 		
John Baier, CPA, Project Manager
		
Nathan Briley, JD, MPP
		
Ralph M. Flynn, JD
		
Daisy Y. Kim, PhD
		
Britani M. Keszler, MPA
		
Michaela Kretzner, MPP
		Andrew Loke
		Alex Maher
		
Itzel C. Perez, MPP
		Marye Sanchez
Legal Counsel:  J. Christopher Dawson, Sr. Staff Counsel
For questions regarding the contents of this report, please contact
Margarita Fernández, Chief of Public Affairs, at 916.445.0255.

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*  California State Auditor’s comment appears on page 47.

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COMMENT
CALIFORNIA STATE AUDITOR’S COMMENT ON THE
RESPONSE FROM THE CALIFORNIA DEPARTMENT OF
CORRECTIONS AND REHABILITATION
To provide clarity and perspective, we are commenting on the
response from CDCR regarding our review of CIM. The number
below corresponds to the number we have placed in the margin of
its response.
We look forward to receiving CDCR’s 60‑day response to this
report and identifying its progress and plans for implementing
our recommendations.

1

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*  California State Auditor’s comments begin on page 55.

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COMMENTS
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE
FROM THE LOS ANGELES COUNTY SHERIFF’S DEPARTMENT
To provide clarity and perspective, we are commenting on the
response to the audit from the LASD regarding our review of its Men’s
Central Jail. The numbers below correspond to the numbers we have
placed in the margin of its response.
During Men’s Central review of the draft audit report, it provided evidence
to demonstrate that it offered all victims medical care for the 15 cases we
reviewed. Therefore, we removed this specific recommendation for Men’s
Central. However, we were not able to do so until late in the audit process
as it did not provide documentation until August 2018. During our audit
fieldwork, Men’s Central stated that, in some cases, documentation of the
medical care did not exist. However, upon receiving our draft audit report,
the Los Angeles County Office of County Counsel, which supports the
LASD, provided the necessary documentation. Men’s Central’s practice
of using County Counsel to filter our requests likely resulted in this delay
and similar delays during the audit process. For example, beginning in
March 2018 we made repeated attempts during our audit fieldwork to
obtain complete evidence from Men’s Central regarding its efforts to
provide counseling services for victims of gassing attacks. However, Men’s
Central refused to provide access to the necessary documentation, first
through the Los Angeles County Counsel’s Office, then through outside
private counsel at an unknown additional cost to the county. Men’s
Central did not provide counseling records until July 2018, which created a
substantial delay in our ability to answer the audit questions.

1

The exhibits that Men’s Central references throughout its response
are available for inspection upon request during business hours at the
California State Auditor’s office.

2

The response by Men’s Central fails to address the concerns we
identified with its evidence collection practices. As shown in Table 3
on page 21, Men’s Central only collected physical evidence of the crime
in nine of the 15 gassing attacks we reviewed, indicating the need for
it to implement procedures to ensure that officers follow its policies
for collecting sufficient physical evidence of the gassing attacks that
inmates committed.

3

Contrary to its statement, Men’s Central’s current policy does not require
completion of investigations within 30 days. Instead, the policy it refers to
only states that it will classify an investigation as inactive and closed when
detectives make no progress after 30 days. Moreover, its investigators took
70 days on average to complete investigations for the 15 gassing attacks
we reviewed, as we display in Figure 4 on page 25. As Men’s Central’s

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investigations far exceeded 30 days on average, it should follow our
recommendation by adopting goals and ensuring officers adhere to
those goals.
5

For clarification, the training that Men’s Central refers to is part of its
new employee training and therefore is provided only once to each
employee. Moreover, we only became aware of its new training video
as part of its response to our audit. Thus, it is unclear if the training
video will ensure that officers are better prepared to prevent and
respond to a gassing attack. We look forward to learning more about
Men’s Central’s implementation of this recommendation in its 60‑day
response to this report.

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Director of Emergency Services
Coroner - Marshal

Via email: ralphf@auditor.ca.gov
(510) 272-6878
August 28, 2018
Elaine M. Howle, CPA, State Auditor *
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, California 95814
SUBJECT: RESPONSE TO THE DRAFT STATE AUDIT REPORT 2018- 106
Dear Ms. Howle:
Thank you for the DRAFT State Audit Report 2018-106. Kindly note the Alameda County
Sheriff’s Office offers the following response:
Please convey our sincere appreciation to your audit team for their hard work and
professionalism in preparing the State Audit Report 2018-106. With regards to the
recommendations that were made by your audit team, you will note the Alameda
County Sheriff’s Office partially agrees and disagrees with suggested
recommendations.
Again, thank you for the opportunity of reviewing the DRAFT State Audit Report. Please feel
free to contact me should you have any questions at (510) 272-6878.
Sincerely,

Gregory J. Ahern
Sheriff-Coroner

*  California State Auditor’s comments begin on page 61.

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Alameda County Sheriffs Office's ("ACSO") Response to the California State Audit report entitled
Correctional Officer Health and Safety: Some State and County Correctional Facilities Could Better
Protect Their Officers From the Health Risks of Certain Inmate Attacks 2018-106
ACSO thanks the California State Auditor for the opportunity to respond and for the hard work performed
in preparing this report. ACSO respectfully submits its responses to certain key findings and
recommendations below.
Finding:
Santa Rita Jail ("SRJ") does not have adequate procedures to ensure that victims of gassing
attacks are notified of aftercare medical and counseling services, and of the right to request that
inmates be tested for communicable disease
Recommendation:
SRJ should revise its policies and procedures to require documentation that its supervisors are
notifying victims of gassing attacks in a timely manner of available medical and counseling
services, workers' compensation benefits, and the right to request inmate testing.
Response:
1

ACSO partially agrees with this recommendation. ACSO's current General Orders (GO) and
Detentions and Corrections Policies and Procedures (P&P), including No. 3.15 and GO Nos.
3.16 and 3.18, which are provided to alt ACSO personnel, require that ACSO personnel who
come into contact with bodily fluids must immediately report the exposure to their supervisor.
The policies also set forth in detail a victims' rights to medical services, workman's
compensation, counseling, and the right to request that an inmate or detainee be tested for HIV
antibodies or infectious diseases. Such requests must be made in accordance with Cal. Penal
Code § 7510 which sets forth a detailed scheme for providing inmates with due process before
conducting medical testing. ACSO's Safety Manual setting forth its Illness, Injury & Prevention
Program ( U IIPP") also includes a detailed attachment (Attachment 3) and training presentation
on the risks associated with exposure to bodily fluids and associated personnel reporting
requirements. The IIPP must be carefully reviewed and signed by each ACSO employee.
ACSO also notes that state law provides that local correctional facilities may only implement a
general process of testing all inmates in custody for communicable diseases upon authorization
by the local governing body, and that only known infections can be communicated to victims.
(See Penal Code § 7505.) Alameda County has not passed a resolution authorizing such testing
and thus ACSO most often has no knowledge of an inmate's medical status that can be provided
to a gassing victim. ACSO will work with its medical provider to ensure that where infection is or
becomes known, that information is communicated immediately as required.
ACSO thanks CSA for this recommendation and will add a feature to its internal systems to
require that supervisors responding to gassing reports confirm in writing that the required
notifications have been given to the victim,

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Finding:
SRJ does not consistently investigate gassing attacks in a thorough and timely manner.
Recommendations:
SRJ should implement procedures to ensure that it collects sufficient physical evidence and
submits the gassing substance for laboratory testing; develop practices to ensure that it submits
all cases for prosecution when probable cause exists; and expedite its review of the four cases
CSA identified to determine if submission to the district attorney for prosecution is required.
Response:
ACSO partially agrees with these recommendations. ACSO notes that the findings do not appear
to take into consideration the fact that approximately half of the individually listed cases at SRJ
in 2017 were committed by one inmate, and ACSO's collaboration and responsiveness to district
attorney requests with respect to the evidence needed for prosecution in Alameda County.
ACSO works cooperatively with the district attorney to thoroughly investigate and gather
evidence as required in response to all gassing attacks. While, as noted in the report, Alameda
County has limited resources for testing gassing substances, ACSO will make every effort to test
gassing substances dependent on the crime lab's capabilities and ability to gather adequate
samples going forward. ACSO is also reviewing the four cases noted by the report to determine
whether probable cause and the required elements of a crime are present.

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Finding:
SRJ has not established adequate internal processes to prevent and respond to gassing attacks.
Recommendations:
SRJ should follow its policy and pursue appropriate internal disciplinary actions, taking mental
health and competency into account. SRJ should also develop a written policy regarding the
placement of "gasser" tags on inmate cells, and specifically track all gassing attacks and use the
tracking data as a tool to prevent future attacks. Finally, SRJ should provide annual training that
is specific to preventing and responding to gassing attacks.
Response:
ACSO does not agree with these recommendations. It is ACSO's experience that the efficacy and
propriety of inmate discipline is a highly complex and evolving issue, and one that requires an
individualized consideration of the inmate's medical and mental health as well as criminal history.
Inmate due process rights must also be respected. Inmate discipline by regulation cannot be
immediate. Inmates are afforded their right to due process thus ensuring the discipline is not
punitive and retaliatory in nature. ACSO's first priority is to maintain the safety and security of its
correctional facility for all inmates and ACSO personnel. Many inmates engaged in gassing
behavior suffer from mental health challenges which require ACSO to consult with its behavioral
health partners at the Alameda County Health Care Services Agency when contemplating internal
discipline. Many are also indigent or have already lost all privileges other than time credits. ACSO
does not agree that keeping such inmates incarcerated longer is likely to result in fewer gassing

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attacks or positively impact the safety or security of SRJ. ACSO also does not agree that
memorializing its practice of using "gasser" tags in yet another written policy would provide any
additional benefit. There is no indication that the practice developed at SRJ is inconsistently
applied.
ACSO also already requires extensive training on officer safety and defensive techniques, as well
as custodial criminal investigations, and is unaware of any gassing specific defensive tactics or
investigation training programs. As noted earlier, ACSO personnel are also trained on responding
to and mitigating the effects of exposures to bodily fluids. ACSO does not agree that it should
create a gassing specific training curriculum.
Finally, ACSO includes gassing attacks in its tracking of all inmate related incidents/assaults.
ACSO does not agree that it has the resources or ability to create a new internal tracking system
exclusive to gassing attacks. ACSO also does not agree that it has the expertise or capability to
analyze inmate characteristics, assess patterns, or come to conclusions about the factors that
lead to inmate gassing attacks. While no separate tracking system for gassing attacks exists,
ACSO's current internal systems are capable of extracting data related to gassing attacks, as is
reflected by the data provided in this report.

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COMMENTS
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE
RESPONSE FROM THE ALAMEDA COUNTY SHERIFF’S OFFICE
To provide clarity and perspective, we are commenting on the
response from the Alameda County Sheriff ’s Office regarding
our review of Santa Rita. The numbers below correspond to the
numbers we have placed in the margin of its response.
As noted on page 14, we concluded that Santa Rita had policies in
place to notify victims of the availability of aftercare services and
the right to request that an inmate be tested for communicable
diseases. However, as indicated in Table 2 on page 13, we found that
Santa Rita did not track whether it notified victims of these rights.
As a result, we were unable to determine if Santa Rita complied
with its aftercare policies and procedures.

1

Although Santa Rita indicated that it partially agrees with our
recommendation, its response confuses the issue by focusing on
a single inmate that committed repeated gassing attacks. State
law requires correctional facilities to use every available means
to investigate and refer all cases to the local district attorney
for prosecution, regardless of whether the gassing attack is
committed by the same inmate. However, as indicated in Table 3
on page 21, Santa Rita did not consistently meet its responsibility
to collect physical and evidence and did not test the evidence to
confirm the presence of a bodily fluid. Therefore, we stand by our
recommendation that Santa Rita should implement procedures to
ensure that it collects sufficient physical evidence and submits the
gassing substance for laboratory testing, as state law requires, and
regardless of whether the gassing attack is committed by inmates
who are repeat offenders.

2

Santa Rita’s disagreement with our recommendation to pursue
appropriate internal disciplinary actions is contrary to its own
policy. Specifically, as indicated on page 32, the purpose of
Santa Rita’s policy for imposing internal discipline on inmates
is to maintain control and promote desirable changes in inmate
attitude and behavior. However, as we note in Table 5 on page 31,
Santa Rita took disciplinary action for only one of the 15 gassing
incidents we reviewed. Consequently, because the Alameda County
district attorney obtained convictions for only 15 percent of the
gassing attacks, as shown in Table 4 on page 22, Santa Rita’s failure
to follow its policy to impose internal discipline has resulted in
many inmate perpetrators not receiving any consequences for those
attacks. Moreover, as noted on page 39, our recommendation for
Santa Rita to pursue appropriate internal discipline action for an

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inmate who commits a gassing attack recognizes that it must take
into consideration an inmate’s mental health and competency when
making this decision.
4

We disagree with Santa Rita’s position that memorializing its
practice of using “gasser” tags in a written policy would not provide
any additional benefit. Developing a formal policy on the use of
“gasser” tags would help ensure that all correctional staff, including
newly trained officers, are aware of the requirement and implement
it consistently.

5

We stand by our recommendation that Santa Rita should provide
annual training that is specific to preventing and responding to
gassing attacks. As we state on page 37, training specific to gassing
attacks could help officers be more prepared to prevent and
respond to these incidents. Moreover, as we indicate in Table 5
on page 31, two of the six victims at Santa Rita indicated that
they had not received training to help protect themselves from a
gassing attack—demonstrating that not all of its staff have received
adequate training.

6

A correctional facility’s tracking of gassing attacks should result
in information that is consistent and readily accessible, which is
not currently the case at Santa Rita. Specifically, as we state on
page 38, Santa Rita currently must consult three separate databases
to obtain information about gassing attacks at its facility. As a
result, staff and management are unable to easily analyze the
specific circumstances surrounding gassing attacks and to reassess
their current procedures for responding to and preventing future
attacks. Moreover, we are puzzled by Santa Rita’s statement that it
does not have the expertise or capability to analyze gassing attack
data because as a correctional facility, it is in the best position to
understand and use this information.