U.S. Department of Justice
Civil Rights Division
Assistant Attorney General
950 Pennsylvania Ave, NW - RFK
Washington, DC 20530

April 22, 2021
Keith Carson
President
Alameda County Board of Supervisors
1221 Oak Street, #536
Oakland, CA 94612
Gregory J. Ahern
Alameda County Sheriff/Coroner
Santa Rita Jail
5325 Broder Blvd.
Dublin, CA 94568
Mark Fratzke
Alameda Health System
Interim Chief Operating Officer
1411 E. 31st St.
Oakland, CA 94602
Re:

Notice Regarding Investigation of Alameda County, John George Psychiatric
Hospital, and Santa Rita Jail

Dear President Carson, Sheriff Ahern, and Interim Chief Operating Officer Fratzke:
The Civil Rights Division has completed the investigation into the conditions and
practices at Santa Rita Jail and John George Psychiatric Hospital, and into whether Alameda
County’s reliance on John George Psychiatric Hospital and sub-acute psychiatric facilities to
provide mental health services to adults with mental health disabilities violates those individuals’
right to receive services in the most integrated setting appropriate to their needs. The
investigation was conducted under the Civil Rights of Institutionalized Persons Act (CRIPA), 42
U.S.C. § 1997, and Title II of the Americans with Disabilities Act (ADA), 42 U.S.C. §§
12131−12134, and the ADA’s implementing regulation, 28 C.F.R Part 35.
Consistent with the statutory requirements of CRIPA, we provide this Notice of the
alleged conditions that we have reasonable cause to believe violate the Constitution and federal
law and the supporting facts giving rise to those violations. 42 U.S.C. § 1997b(a)(1); 42 U.S.C.
§ 1997c(b)(1). This Notice also sets forth the Department’s findings of fact and conclusions of
law under the ADA. 42 U.S.C. §§ 12131−12134; 28 C.F.R. § 35.172(c). We also notify you of
the minimum remedial measures that we believe may remedy the alleged violations.

After carefully reviewing the evidence, we conclude that there is reasonable cause to
believe that Alameda County and the Alameda County Sheriff’s Office violate the ADA and
engage in a pattern or practice of constitutional violations in the conditions at the Santa Rita Jail,
and that Alameda County violates the ADA as interpreted by Olmstead v. L.C., 527 U.S. 581,
607 (1999). Specifically, we have reasonable cause to believe that: (1) Alameda County violates
the ADA by failing to provide services to qualified individuals with mental health disabilities in
the most integrated setting appropriate to their needs by unnecessarily institutionalizing them at
John George Psychiatric Hospital and sub-acute facilities; (2) Santa Rita Jail fails to provide
constitutionally adequate mental health care to prisoners with serious mental health needs,
including those at risk of suicide; (3) Santa Rita Jail’s use of prolonged restrictive housing under
current conditions violates the Eighth and Fourteenth Amendment rights of prisoners with
serious mental illness; and (4) Santa Rita Jail violates the ADA by denying prisoners with mental
health disabilities access to services, programs, and activities because of their disabilities. 1
We thank Alameda County, Alameda Health System, and the Alameda County Sheriff’s
Office for accommodating our investigation and providing access to facilities, staff, documents,
and data. We are obligated to advise you that 49 days after issuance of this Notice, the Attorney
General may initiate a lawsuit under CRIPA to correct the alleged conditions we have identified
if Alameda County officials have not satisfactorily addressed them. 42 U.S.C. § 1997b(a)(1).
CRIPA also authorizes the Department to move to intervene in a related private suit 15 days after
issuing the Notice. 42 U.S.C. § 1997c(b)(1).
We hope, however, to resolve this matter through a cooperative approach and look
forward to working with Alameda County leadership and staff to address the violations of law
we have identified. The lawyers assigned to this investigation will, therefore, contact Alameda
County to discuss options for resolving this matter amicably. Please also note that this Notice is
a public document. It will be posted on the Civil Rights Division’s website.

The Department of Justice (Department) opened this investigation to examine five issues: (1) whether the County’s
reliance on psychiatric institutions to provide mental health services to adults with mental health disabilities violates
the ADA; (2) whether the conditions of confinement and practices at Santa Rita Jail deprive persons with serious
mental illness of their constitutional rights; (3) whether the conditions at Santa Rita Jail violate the rights of persons
with mental health disabilities under the ADA; (4) whether the practices at John George Psychiatric Hospital violate
the rights of persons with mental health disabilities under the ADA to receive services in the most integrated setting
appropriate to their needs; and (5) whether the conditions at John George Psychiatric Hospital deprive persons with
serious mental illness of their constitutional rights. This Notice Letter applies to the first four issues. With regard to
the remaining issue, the Department did not reach a conclusion as to whether there are systemic unconstitutional
conditions at John George Psychiatric hospital and is closing its investigation.

1

2

If you have any questions regarding this correspondence, please call Steven H.
Rosenbaum, Chief of the Special Litigation Section, at (202) 616-3244.
Sincerely,

Pamela S. Karlan
Principal Deputy Assistant Attorney General
Civil Rights Division

cc:

Donna Ziegler
County Counsel for Alameda County
1221 Oak Street, Suite 450
Oakland, CA 94612
Dr. Taft Bhuket, President
Alameda Health System Board of Trustees
1411 E. 31st. St.
Oakland, CA 94602
James Jackson, Interim CEO
Alameda Health System
1411 E. 31st St.
Oakland, CA 94602
Mike Moye, General Counsel
Alameda Health System
1411 E. 31st St.
Oakland, CA 94602
Stephanie Hinds
Acting United States Attorney
Northern District of California
Federal Courthouse
450 Golden Gate Avenue
San Francisco, CA 94102

Attachment: Investigation of Alameda County, John George Psychiatric Hospital, and Santa Rita
Jail
3

INVESTIGATION OF ALAMEDA
COUNTY, JOHN GEORGE
PSYCHIATRIC HOSPITAL, AND SANTA
RITA JAIL

United States Department of Justice
Civil Rights Division
April 22, 2021

TABLE OF CONTENTS
I.

INTRODUCTION .............................................................................................................. 1

II.

INVESTIGATION.............................................................................................................. 3

III.

SYSTEM OVERVIEW ...................................................................................................... 4

IV.

ALAMEDA COUNTY VIOLATES INDIVIDUALS’ RIGHT TO RECEIVE SERVICES
IN THE MOST INTEGRATED SETTING UNDER TITLE II OF THE ADA ................ 6
A. Alameda County Subjects Adults with Mental Health Disabilities to Unnecessary
Psychiatric Institutionalization and the Serious Risk of Psychiatric Institutionalization ... 7
B. People with Mental Health Disabilities in Alameda County Can Be Appropriately and
Effectively Served in the Community............................................................................... 11
1.
People Cycling Through Psychiatric Institutions Are Appropriate for CommunityBased Services…………………………………………………………………………..11
2.

Alameda County Fails to Provide Adequate Community-Based Services that
Could Prevent Needless Psychiatric Institutionalization ...................................... 12

3.

Alameda County Fails to Identify and Connect People with the Community-Based
Services Necessary to Avoid Needless Institutionalization.................................. 16

C. Most People with Mental Health Disabilities in the Psychiatric Facilities in Alameda
County Do Not Oppose Community-Based Services....................................................... 17
D. Alameda County Can Make Reasonable Modifications to Prevent Unnecessary
Psychiatric Institutionalization.......................................................................................... 18
V.

MENTAL HEALTH CARE AT SANTA RITA JAIL IS INADEQUATE IN
VIOLATION OF THE CONSTITUTIONAL RIGHTS OF PRISONERS WITH
SERIOUS MENTAL HEALTH NEEDS ......................................................................... 21
A. Many Prisoners at the Jail Have Serious Mental Health Needs, Requiring Treatment .... 23
B. Prisoners with Serious Mental Health Needs Are Subject to a Substantial Risk of Serious
Harm as a Result of Inadequate Mental Health Care........................................................ 24
1.

Prisoners with Serious Mental Health Needs Are Subject to Harm Because of a
Lack of Individualized Treatment, Including Inadequate Psychotherapy and
Programming......................................................................................................... 24

2.

Prisoners with Serious Mental Health Needs Are Subject to Harm Because of
Inadequate Treatment Planning, Including Discharge Planning........................... 28

C. Officials at the Jail Have Known of the Risk to Prisoner Health and Safety Posed by
Inadequate Mental Health Care and Disregarded It.......................................................... 29
VI.

THE JAIL’S USE OF PROLONGED RESTRICTIVE HOUSING UNDER CURRENT
CONDITIONS, INCLUDING THE FAILURE TO PROVIDE ADEQUATE MENTAL
HEALTH CARE, VIOLATES THE CONSTITUTIONAL RIGHTS OF PRISONERS
WITH SERIOUS MENTAL ILLNESS............................................................................ 31

A. Prisoners with Serious Mental Illness Are Subject to a Substantial Risk of Serious Harm
as a Result of the Jail’s Use of Restrictive Housing ......................................................... 33
B. Officials at the Jail Have Known of, and Disregarded, the Substantial Risk of Serious
Harm of Placing Individuals with Serious Mental Illness in Restrictive Housing ........... 34
VII.

THE JAIL’S TREATMENT OF PRISONERS WITH MENTAL HEALTH
DISABILITIES VIOLATES THE AMERICANS WITH DISABILITIES ACT ............ 35

VIII.

MINIMUM REMEDIAL MEASURES ........................................................................... 36

IX.

CONCLUSION................................................................................................................. 39

I.

INTRODUCTION

After an extensive investigation, the United States provides notice, pursuant to Title II of
the Americans with Disabilities Act of 1990 (ADA), 42 U.S.C. §§ 12131−12134, and the Civil
Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. § 1997, that there is reasonable cause
to believe that Alameda County and the Alameda County Sheriff’s Office violate the ADA and
engage in a pattern or practice of constitutional violations in the conditions at the Santa Rita Jail
and that Alameda County violates the ADA in its provision of public mental health services.
Specifically, we have reasonable cause to believe that: (1) Alameda County fails to provide
services to qualified individuals with mental health disabilities in the most integrated setting
appropriate to their needs, instead relying on John George Psychiatric Hospital and sub-acute
psychiatric facilities (collectively, “psychiatric institutions”) 1 to provide such services; (2) Santa
Rita Jail fails to provide constitutionally adequate mental health care to prisoners with serious
mental health needs, including those at risk of suicide; (3) Santa Rita Jail’s use of prolonged
restrictive housing under current conditions violates the constitutional rights of prisoners with
serious mental illness; and (4) Santa Rita Jail denies prisoners with mental health disabilities
access to services, programs, and activities because of their disabilities. 2
Specifically, the United States provides notice of the following findings:
•

Alameda County relies on psychiatric institutions to serve adults with mental health
disabilities who are eligible for public mental health services, rather than providing
services in the most integrated setting appropriate to their needs. On any given day
in Alameda County, hundreds of people are institutionalized for lengthy stays at one of
several large, locked, sub-acute psychiatric facilities or are hospitalized at John George
Psychiatric Hospital (John George). Depending on the facility, people live at the subacute facilities for an average of anywhere from six months to two years. Of those
hospitalized at John George, a significant subset will spend weeks or even months there;
many, lacking any alternatives, are funneled to other segregated facilities on discharge.
Even more adults with mental health disabilities are at serious risk of admission to these
psychiatric institutions.

For purposes of our findings related to the integration mandate of the ADA, we considered only psychiatric
institutional settings. See 28 C.F.R. pt. 35, App. B, at 708 (2018); 28 C.F.R. § 35.130(d) (2019); see also 42 U.S.C.
§ 12101(a)(2), (b)(1). We did not consider Santa Rita Jail to be an institutional or segregated setting in making
those findings. At the same time, for the CRIPA portion of our investigation, the Santa Rita Jail is an “institution”
as defined by CRIPA. See 42 U.S.C. § 1997.
2
The Department of Justice (Department) opened this investigation to examine five issues: (1) whether the County’s
reliance on psychiatric institutions to provide mental health services to adults with mental health disabilities violates
the ADA; (2) whether the conditions of confinement and practices at Santa Rita Jail deprive persons with serious
mental illness of their constitutional rights; (3) whether the conditions at Santa Rita Jail violate the rights of persons
with mental health disabilities under the ADA; (4) whether the practices at John George Psychiatric Hospital violate
the rights of persons with mental health disabilities under the ADA to receive services in the most integrated setting
appropriate to their needs; and (5) whether the conditions at John George Psychiatric Hospital deprive persons with
serious mental illness of their constitutional rights. This Notice Letter applies to the first four issues. With regard to
the remaining issue, the Department did not reach a conclusion as to whether there are systemic unconstitutional
conditions at John George Psychiatric hospital and is closing its investigation.
1

•

With appropriate community-based services, supports, and coordination, people
with mental health disabilities could live at home and be integrated in their
communities. Evidence-based services, such as Assertive Community Treatment and
Permanent Supported Housing, are proven effective in enabling people to live in their
own homes in the community, even for people with the highest level of need for mental
health services. Community-based crisis response services are also critical to avoid
unnecessary hospitalizations and maintain people successfully in the community. A
strong crisis system, along with other comprehensive community-based services, can
ensure that the majority of adults with mental health disabilities in Alameda County
avoid psychiatric institutionalization. Alameda County fails to make these needed
community-based services available in adequate capacity or intensity. Alameda County
also fails to ensure that people who are in institutions receive professionally-adequate
discharge planning and a connection upon discharge to needed services. Without
connection to adequate community-based services, people return to John George in crisis
again and again. Deficiencies in the community-based service system, including crisis
services, at times also contribute to the incarceration of people with mental health
disabilities in Santa Rita Jail (Jail). This incarceration further increases a person’s risk of
institutionalization in John George and the sub-acute psychiatric facilities after release,
due in part to the unconstitutional conditions described below.

•

For those who are incarcerated at Santa Rita Jail, the Jail fails to provide
constitutionally adequate mental health treatment. The Jail’s mental health program
lacks many of the hallmarks of a constitutionally adequate system. Specifically, the Jail’s
current program fails to: provide adequate psychotherapy; provide adequate treatment
planning, discharge planning, and programming; and properly treat and supervise suicidal
prisoners. As a result, prisoners with serious mental health needs can experience
worsening mental health conditions, repeated cycling for acute care at John George,
prolonged restrictive housing, and, at times, serious physical harm or death. From 2015
to 2019, at least 14 prisoners died by suicide in the Jail. Two other prisoners have died
by suicide at the Jail within the last two months.

•

The Jail’s use of prolonged restrictive housing under current conditions, which
include the failure to provide adequate mental health care, violates the
constitutional rights of prisoners with serious mental illness. The Jail subjects
prisoners with serious mental illness to prolonged periods of restrictive housing under
conditions that place them at a substantial risk of serious harm. Half of the people in
“administrative segregation” at any given time in the Jail are estimated to have serious
mental illness. On the date of our last visit to the Jail, there were 75 prisoners in
administrative segregation who had been there for over 90 days. Eleven of the 14 people
who died by suicide between 2015 and 2019 were held in restrictive housing at some
point, and half of the other instances of self-harm that we reviewed occurred while
prisoners were in restrictive housing.
2

•

The Jail denies prisoners with mental health disabilities equal access to needed
programming and services. The Jail offers an array of programming and transition
services to prisoners in the general population, but prisoners with mental health
disabilities who are held in the Jail’s segregated “mental health unit” or in administrative
segregation are denied access to these programs.

Together, these alleged violations result in a system where people with mental health
disabilities in Alameda County find themselves unnecessarily cycling in and out of psychiatric
institutions, lacking access to proven, evidence-based practices that would allow them to recover
and participate in community life. Many also have encounters with the criminal justice system
driven in part by unmet mental health needs. Those who are incarcerated at Santa Rita Jail
experience severely deficient mental health treatment, lengthy stays in restrictive housing, and
discrimination on the basis of their disabilities, all of which can result in serious harm or even
death while incarcerated, and place them at serious risk of repeated or unnecessarily lengthy
psychiatric institutional stays after release.
The Department has received multiple complaints from and on behalf of prisoners with
serious mental illness at Santa Rita Jail and people who rely on Alameda County for mental
health services and experience unnecessary psychiatric institutionalization. Alameda County has
long been on notice of the deficiencies in its mental health service system and the harmful
conditions at Santa Rita Jail, but these problems continue. Reports by County bodies, including
the Board of Supervisors’ own committees, and outside consultants have identified many of
these and other concerns as far back as at least 2015. News articles repeatedly highlight deaths
at Santa Rita Jail, the allegedly dangerous conditions that exist there, and the overcrowding in
John George’s emergency room, among other issues. Several lawsuits have been filed in recent
years alleging a litany of serious problems in the Jail, and California’s federally-designated
protection and advocacy organization, Disability Rights California, in 2019 sent the County a
“probable cause” findings letter regarding many of the same ADA violations we identify.
Advocates and family members of those who have died in the Jail have called for an audit of the
Alameda County Sheriff’s Office for years. In 2018, midway through our investigation, we
shared many of our concerns and observations with the County and Jail leadership.
The County is well-positioned to make crucial changes, with many of the needed services
already available in limited amounts in the community and with leadership that recognizes the
need for change. But today, people with mental health disabilities continue to experience
needless psychiatric institutionalization and unconstitutional, discriminatory, and harmful
treatment at Santa Rita Jail as they wait for change that still has not come.
II.

INVESTIGATION

In January 2017, the Department of Justice notified the County of Alameda, the Alameda
County Sheriff’s Office, and Alameda Health System that it was opening an ADA and CRIPA
investigation into whether the County of Alameda unnecessarily uses psychiatric institutional
settings to provide services to adults with mental health disabilities and whether the conditions of
confinement in John George Psychiatric Hospital and Santa Rita Jail subject individuals to
3

unlawful harm. Our ADA investigation focused on whether the County provides meaningful
community-based services as alternatives to, and effective discharge planning to help people
with mental health disabilities transition out of and avoid re-entering, psychiatric institutional
care.
Two nationally recognized expert consultants assisted with our investigation: a forensic
psychiatrist with over 20 years of clinical and forensic experience in a variety of academic and
correctional settings, and a community psychiatrist with experience as a medical director of a
statewide community services provider and as a bureau chief for a state mental health authority.
These experts accompanied us on site visits, participated in interviews with County and facility
staff and community members, reviewed documents, and provided their expert opinions and
insight to help inform our investigation and its conclusions.
During our investigation, we visited Santa Rita Jail, John George Psychiatric Hospital,
sub-acute psychiatric facilities, and board and care homes. During our site visits, we interviewed
staff at these facilities, as well as people who were receiving services in the facilities. We also
met with providers of community mental health services, individuals with mental health
disabilities who receive community-based services from the County, and mental health and
criminal justice advocates and other stakeholders in the County. Finally, we met with officials
from Alameda County Behavioral Health Care Services and the Alameda County Sheriff’s
Office. In addition to these visits and interviews, we reviewed the documents and information
provided by the County, reviewed publicly available data and reports, and considered the
opinions of a wide range of individuals knowledgeable about the County’s mental health system.
Following several visits, Department attorneys and experts provided briefings to County
and Sheriff’s Office staff and leadership about preliminary concerns identified by our experts. It
is evident that County and Sheriff’s Office leadership and staff took these briefings seriously.
By the time of our last visit in August 2019, the County had taken some positive steps, described
further in Sections IV.B.2 and IV.D, and leadership elaborated on its vision of and plans for
further progress. We appreciate the commitment to making these urgently needed changes, but
remain concerned that there has been little actual progress to resolve the discrimination that is
occurring in the County’s mental health system and the unconstitutional conditions and
discrimination in the Santa Rita Jail.
We thank the County for the assistance and cooperation extended to the Department of
Justice thus far and acknowledge the courtesy and professionalism of all of the County officials
and counsel involved in this matter to date. We also thank the people we met who are affected
by the violations we were investigating, especially for their willingness to share their oftendifficult experiences with us and take time away from their jobs and lives to do so.
III.

SYSTEM OVERVIEW

Alameda County administers, funds, and controls its public mental health system. Within
Alameda County, responsibility for administering public mental health and substance use
services falls primarily on Alameda County Behavioral Health Care Services (BHCS). BHCS is
4

responsible for providing mental health services for people with moderate to severe mental
health needs as well as for substance use disorder services. Alameda County residents are
generally eligible for services from BHCS if they have a mental health disability that impairs
their daily functioning. 3 California delegates responsibility to and authorizes counties to provide
an array of mental health services under Medicaid (referred to in California as Medi-Cal) and
state-only funds, including the Mental Health Services Act (MHSA). 4 In delegating
responsibility for behavioral health services to counties, California affords counties significant
flexibility in administering both Medicaid and state-only-funded programs; however, California
expects the emphasis of MHSA programs to be on evidence-based, recovery-oriented community
services, including crisis services, employment services, preventative services, supported
housing, and intensive support services. 5 Counties also fund additional mental health services,
such as long-term psychiatric institutional programs, that are not reimbursed by Medicaid or state
programs.
Alameda County provides acute inpatient hospitalization and crisis stabilization services
at John George Psychiatric Hospital, a County-owned, dedicated psychiatric emergency and
inpatient facility in San Leandro, California. BHCS contracts with Alameda Health System for
operation of and provision of services at John George. John George has three inpatient units
with a total of 69 beds, as well as an emergency room, called Psychiatric Emergency Services
(PES). PES is intended to provide crisis stabilization services. Utilization of these crisis
services routinely exceeds capacity. Alameda County also funds and provides long-term, subacute inpatient and residential services for about 200 people at a time in several “sub-acute
facilities” that range in size from 39 to 78 beds, where people regularly stay for months or
years. 6 Services provided in these locked facilities include medication management,
psychosocial rehabilitation, support groups, and assistance with some activities of daily living,
like grooming. Many more people in Alameda County are placed in “board and care” facilities
which provide residential services as well as minimal daily supports.
Many of the same or equivalent supports provided in these inpatient and segregated
settings in Alameda County are also available—but in extremely limited supply—through various
3
See CAL. WELF. & INST. CODE § 5600.3(b) (West 2019); CAL. CODE REGS. tit. 9, § 1830.205 (2020). A mental
health disability is a qualifying disability under the ADA. 42 U.S.C § 12102 (2012) (defining “disability” as a
“physical or mental impairment that substantially limits one or more major life activities”). Mental health
disabilities include serious mental illness, or SMI, which is defined as “a diagnosable mental, behavior, or emotional
disorder that causes serious functional impairment” of an individual over the age of 18 that “substantially interferes
with or limits one or more major life activities” within the last year. Mental Health and Substance Use Disorders,
SUBSTANCE ABUSE AND MENTAL HEALTH ADMIN., https://www.samhsa.gov/find-help/disorders (last visited Apr. 6,
2020).
4
Under the MHSA, California requires counties to provide safety net mental health services for people without
insurance. Cal. Welf. & Inst. Code §§ 5801–5809; Cal. Prop. 63, Mental Health Services Act, § 3 (2005, 2020
supp.).
5
CAL. WELF. & INST. CODE §§ 5801(b)(9), 5802, 5848.5; Cal. Prop. 63, Mental Health Services Act, § 3 (2005,
2020 supp.).
6
These facilities are considered Institutes for Mental Disease under Medicaid, and must be paid solely with County,
not Medicaid, funds; equivalent services provided in community-settings would instead be eligible for Federal
Medicaid funds.

5

outpatient programs. Full Service Partnerships and less intensive Service Teams use
multidisciplinary team models to provide high-intensity outpatient support services to people in
the places where they live. Alameda County also funds and operates limited integrated
residential services for people with mental health disabilities, such as permanent supported
housing. Alameda County also makes some limited crisis services available through crisis
stabilization units, crisis residential facilities, and mobile crisis services.
Alameda County also funds the Santa Rita Jail, which is administered and controlled by
the Alameda County Sheriff’s Office. Santa Rita Jail, opened in 1989, has the capacity to hold
approximately 4000 prisoners. During most of the time of our investigation, however, the actual
prisoner count has been closer to 2400. Until recently, Alameda County Sheriff’s Office also
operated the Glenn Dyer Jail in Oakland, but in mid-2019, it closed that jail and transferred its
population to Santa Rita Jail. The Jail holds both pre-trial detainees and convicted prisoners
(collectively referred to throughout this Notice as “prisoners”).
Jail officials have stated that approximately 40% of Santa Rita Jail’s population is on the
mental health caseload, and have estimated that approximately 20–25% of the population has a
serious mental illness. Mental health services at the Jail are provided by BHCS, through its
Criminal Justice Mental Health arm.
IV.
ALAMEDA COUNTY VIOLATES INDIVIDUALS’ RIGHT TO RECEIVE
SERVICES IN THE MOST INTEGRATED SETTING UNDER TITLE II OF THE ADA
Congress enacted the ADA in 1990 “to provide a clear and comprehensive national
mandate for the elimination of discrimination against individuals with disabilities.” 42 U.S.C. §
12101(b)(1) (2012). Congress found that “historically, society has tended to isolate and
segregate individuals with disabilities, and despite some improvements, such forms of
discrimination against individuals with disabilities continue to be a serious and pervasive social
problem.” 42 U.S.C. § 12101(a)(2) (2012). For these reasons, Congress prohibited
discrimination against individuals with disabilities by public entities when it provided that “no
qualified individual with a disability shall, by reason of such disability, be excluded from
participation in or be denied the benefits of the services, programs, or activities of a public entity,
or be subjected to discrimination by any such entity.” 42 U.S.C. § 12132 (2012). Accordingly,
the “ADA is intended to insure that qualified individuals receive services in a manner consistent
with basic human dignity rather than a manner which shunts them aside, hides, and ignores
them.” Helen L. v. DiDario, 46 F.3d 325, 335 (3d Cir. 1995).
One form of discrimination prohibited by Title II of the ADA is violation of the
“integration mandate.” See 28 C.F.R. § 35.130(d) (2019); see also 42 U.S.C. § 12101(a)(2),
(b)(1). That is, under the ADA, public entities must “administer services, programs, and
activities in the most integrated setting appropriate to the needs of qualified individuals with
disabilities.” 28 C.F.R. § 35.130(d). An integrated setting is one that “enables individuals with
disabilities to interact with nondisabled persons to the fullest extent possible.” 28 C.F.R. pt. 35,
App. B, at 708 (2018).
6

In Olmstead v. L.C., the Supreme Court held that public entities are required to provide
community-based services to persons with disabilities when (a) such services are appropriate; (b)
the affected persons do not oppose community-based treatment; and (c) community-based
services can be reasonably accommodated, taking into account the resources available to the
entity and the needs of other persons with disabilities. 527 U.S. 581, 607 (1999). In so holding,
the Court explained that unnecessary institutional placement “perpetuates unwarranted
assumptions that persons so isolated are incapable or unworthy of participating in community
life.” Id. at 600.
The ADA’s integration mandate applies both to people who are currently institutionalized
and to people who are at serious risk of institutionalization. Steimel v. Wernert, 823 F.3d 902,
913 (7th Cir. 2016); Davis v. Shah, 821 F.3d 231, 263 (2d Cir. 2016); Pashby v. Delia, 709 F.3d
307, 321–22 (4th Cir. 2013); M.R. v. Dreyfus, 663 F.3d 1100, 1115–18 (9th Cir. 2011), opinion
amended and superseded on denial of reh’g, 697 F.3d 706 (9th Cir. 2012); United States v.
Mississippi, 400 F. Supp. 3d 546, 553–55 (S.D. Miss. 2019). As the Tenth Circuit reasoned, the
integration mandate “would be meaningless if plaintiffs were required to segregate themselves
by entering an institution before they could challenge an allegedly discriminatory law or policy
that threatens to force them into segregated isolation.” Fisher v. Okla. Health Care Auth., 335
F.3d 1175, 1181 (10th Cir. 2003); see also Pitts v. Greenstein, No. 10-635-JJB-SR, 2011 WL
1897552, *3 (M.D. La. May 18, 2011) (“A State’s program violates the ADA’s integration
mandate if it creates the risk of segregation; neither present nor inevitable segregation is
required.”) (emphasis in original). A State’s failure to provide community services may create a
serious risk of institutionalization. Pashby, 709 F.3d at 322; see also Mississippi, 400 F. Supp.
3d at 553–55 (upholding plaintiff’s Olmstead claim that when people with serious mental illness
are discharged from state psychiatric hospitals, the state’s “ongoing lack of community-based
services means they are at serious risk of re-institutionalization”).
A. Alameda County Subjects Adults with Mental Health Disabilities to
Unnecessary Psychiatric Institutionalization and the Serious Risk of
Psychiatric Institutionalization
Alameda County relies unnecessarily on segregated psychiatric institutions to serve its
residents with mental health disabilities who need intensive treatment and long-term services and
supports and who are eligible for public mental health services. Institutions such as John George
and the sub-acute facilities in Alameda County isolate and segregate people with mental health
disabilities from those without disabilities. Cf., e.g., Benjamin v. Dep’t of Pub. Welfare, 768 F.
Supp. 2d 747, 750 (M.D. Pa. 2011) (individuals in facilities were segregated where they lived in
units ranging from 16 to 20 people, primarily received services on the grounds of the facilities
and had limited opportunities to interact with non-disabled peers); Disability Advocates, Inc. v.
Paterson, 653 F. Supp. 2d 184, 224 (E.D.N.Y. 2009) (finding that “many people with mental
illness living together in [an adult home] setting with few or no nondisabled persons contributes
to the segregation of [a]dult [h]ome residents from the community”), judgment vacated on other
grounds, 675 F.3d 149 (2d Cir. 2012); Joseph S. v. Hogan, 561 F. Supp. 2d 280, 285 (E.D.N.Y.
2008) (denying motion to dismiss in case involving plaintiffs with mental illness who were
institutionalized in nursing facilities). Residents of these facilities are exclusively people with
7

disabilities, and the facilities provide services nearly entirely within their walls. These
institutions’ doors are locked from the outside, and the facilities place restrictions on residents’
ability to leave. Even short stays in these facilities isolate people from their friends and families
and interrupt participation in community life.
Alameda County is distinct in California in that it has more beds per capita in long-term
sub-acute psychiatric facilities than any other similarly sized California county, and these beds
are nearly always full. The primary sub-acute facilities the County relies on to serve people with
mental health disabilities are Villa Fairmont, Gladman Mental Health Rehabilitation Center, and
Morton Bakar Center, a nursing facility, which have a combined 187 beds. Depending on the
facility, people may stay for months or live in these facilities for years. At Villa Fairmont, the
average length of stay in 2017 was 156 days. Most people stay at Morton Bakar for nearly two
years and the average length of stay at Gladman is between two-and-a-half and three years.
Outside of these sub-acute facilities, people with mental health disabilities in Alameda
County experience shorter, but often repeated, stays at John George Psychiatric Hospital in order
to get needed services. Based on the data provided by the County, an average of 1111 people in
need of crisis stabilization are evaluated at John George PES each month and remain there for up
to 72 hours. Of these, almost 240 people each month are then admitted into John George’s acute
inpatient units. The average length of stay is nine days in these units, and increasing, but many
stays last weeks or even months. Between August 2017 and July 2019, 844 admissions lasted
two weeks or more in John George’s inpatient unit, and 236 were for 30 days or more. Alameda
County’s utilization of John George’s inpatient unit is 6.3 times the statewide average in
California for utilization of state and county psychiatric hospitals. One complainant wrote to us
about her experiences at John George and told us that County authorities “concentrate
[M]edicaid crazies like myself there, as opposed to using clinics in the community.” She was
taken there involuntarily by law enforcement from her home after she called them to report
domestic abuse and then spent two weeks in “the closest thing to Hell I’ve encountered.” She
felt that, while there, she had no clear treatment or release plan; when she eventually was
released, she did not receive medications or other assistance, except for a bus pass with a single
fare.
A high number of people cycle through John George again and again. Nearly 1600
people experienced four or more crisis stabilization admissions to John George’s PES during the
two-year period from August 2017 to July 2019. 7 During the same period, over 1000 people
experienced at least two admissions to the inpatient units. In fiscal year 2019, nearly 11% of
individuals discharged from John George’s inpatient unit were readmitted within just 14 days.
This rate, which already far exceeds both national averages for state hospitals and statewide
averages, appears to be increasing.
A history of admissions to John George—which alone is disruptive to people’s lives and
can put people at risk of losing jobs and housing—in turn often becomes the gateway to
The County similarly reported in 2016 that roughly 17.5% of all emergency room admissions to John George came
from “high utilizers”: people with more than four emergency admissions in the previous 12 months.

7

8

segregating people for longer periods in the sub-acute facilities. John George directly refers
people needing longer-term services to the sub-acute facilities. Between 2012 and 2017, more
than 10% of admissions to John George’s inpatient units resulted in a placement in a sub-acute
facility within 14 days of discharge. The County itself plays a direct role in institutional
placements through its monthly Acute Care Coordination Committee meeting. In this meeting,
representatives from John George, the sub-acute facilities, and community providers discuss
individuals who have cycled through hospitals, and sometimes also jail, in an attempt to place
these individuals in the sub-acute facilities or, for those who have been lingering at the sub-acute
facilities, into a board and care home. However, few are connected with intensive community
services through this process.
As discussed in Section IV.B–D, our investigation determined that nearly all of the
people who are placed in the sub-acute facilities or in John George’s inpatient units could have
avoided or spent less time in these psychiatric institutions with appropriate community-based
services, and few would oppose such services, rendering Alameda County’s reliance upon
psychiatric institutions unnecessary. But because Alameda County does not make appropriate
community-based services available in sufficient capacity, people have little choice but to enter
these psychiatric institutions to get the help they need.
People with mental health disabilities incarcerated at the Santa Rita Jail face further
serious risk of institutionalization in a psychiatric facility upon their release from the Jail. Some
people are sent directly to John George upon release from the Jail, and others make their way to
the hospital soon after, because of a lack of community-based mental health services or because
the County fails to connect them to those services that do exist. Between 2012 and 2017, there
were more than 4200 instances when a person released from Santa Rita Jail was seen at John
George PES within just 30 days. Of the people who spent time in John George’s inpatient unit
between 2012 and 2017, 41% had previously been incarcerated in Santa Rita Jail. Of those with
four or more inpatient stays at John George, 53% had spent time in the Jail.
As discussed further in Sections V–VII, Santa Rita Jail denies prisoners adequate mental
health treatment, isolates people with serious mental illness for prolonged periods in restrictive
housing, and severely limits access to pre-release programming and transition services for this
population. These conditions contribute to people with serious mental illness being sent
repeatedly for brief stints to John George while incarcerated and often leads to
institutionalization upon release. The inadequate discharge planning the County provides to
prisoners with mental health disabilities at the Jail compounds this problem. The County’s
discharge and treatment planning often fails to anticipate a person’s needs in advance of release
and almost never includes goals for community stabilization. According to Jail mental health
staff and our expert’s review, prisoners commonly receive, at most, bridge medications and a list
of resources. Although Alameda County BHCS is responsible for mental health treatment at the
Jail, the County does not ensure that community providers meet with prisoners before their
release to coordinate treatment. Because of these practices, people being released from jail, a
time when they are particularly vulnerable, often do not successfully connect with community
services. A lack of successful connection to community services leads to housing instability and
9

a lack of effective mental health treatment. This results in an increased risk of additional mental
health crisis and eventual placement at John George and the sub-acute facilities.
Alameda County further places people at serious risk of psychiatric institutionalization
due to its lack of community-based behavioral health crisis services. Instead of providing
community crisis services by trained mental health clinicians, such as mobile crisis services and
crisis residential services, that are effective in preventing unnecessary hospitalizations, the
County relies heavily on law enforcement to respond to crises. The Alameda County Board of
Supervisors’ Mental Health Board observed in 2015 that “Police officers in the field responding
to individuals with mental illness have few options other than bringing them to Santa Rita or
John George. Although they may have received Crisis Intervention Training, without adequate
diversion resources, police officers must frequently use John George and/or Santa Rita Jail as
their only option.” 8 We heard from multiple stakeholders, including those who had themselves
experienced a mental health crisis, that it is typically law enforcement who respond to
psychiatric emergencies and that there is a degree of chance with respect to whether one is taken
to jail or the hospital. Multiple reports have found that the lack of access to community-based
mental health services—including crisis services, diversion mechanisms, long-term community
supports, and re-entry discharge planning—may all contribute to people with mental health
disabilities encountering law enforcement and ultimately becoming hospitalized or incarcerated
in Santa Rita Jail. Our experts’ findings and national studies also support this conclusion. 9
The death of A.A. 10 illustrates the problems that can occur due to the lack of communitybased mental health services, including crisis services. A.A. was experiencing a mental health
crisis in early June 2019. After a brief psychiatric hospitalization, nurses told his parents on
discharge to call 911 and ask for police if he needed further help, and that he would be brought
back in for mental health treatment. Days later, A.A. was still in crisis, and his parents called
911, asking for help. A.A.’s father told the police who responded that A.A. was not a danger and
that he needed to be taken for mental health treatment. This would have been an appropriate
situation in which to bring in community-based crisis services or call a mobile crisis team, but it
appears that this did not occur. Instead, police arrested A.A., and, as described in more detail
below, he was taken to Santa Rita Jail, where he sustained severe injuries and later died. A.A.’s
parents have publicly expressed deep regrets that they ever sought assistance from police for
their son. 11
Another person’s experience similarly illustrates how the lack of effective communitybased services and a history of repeated institutionalization can also result in engagement with
the criminal justice system. B.B. was well known to BHCS—she had more than 100 “episodes”
ALAMEDA CNTY. MENTAL HEALTH BD., ANNUAL REPORT TO THE ALAMEDA COUNTY BOARD OF SUPERVISORS,
FISCAL YEAR 2014–2015 at 7 (2015), http://www.acbhcs.org/mhb/Resources/MHB_Annual_Report_2015.pdf.
9
In fact, California law specifically permits pre-trial diversion to mental health treatment for individuals with mental
illness where the mental illness played a significant factor in the commission of the charged offense, excluding
certain violent and serious charges, CAL. PENAL CODE § 1001.36 (West 2020), but without community-based
treatment options, this law may have little impact on diversion.
10
To protect the identity of people, we use coded initials.
11
Despite multiple requests, Alameda County did not provide records related to A.A.’s death.
8

10

dating back to 2002. In 2016, without access to intensive community-based services, B.B.
experienced a mental health crisis, attempted to admit herself to John George, and was ultimately
arrested for trespassing after John George denied her admission without contacting a mobile
crisis team or otherwise connecting her to services. B.B. was rearrested a few months later, but
her mental health deteriorated and she was forensically admitted to a state psychiatric hospital
for nearly two years before being released back to Santa Rita Jail in July 2019.
B. People with Mental Health Disabilities in Alameda County Can Be
Appropriately and Effectively Served in the Community
People with mental health disabilities who are institutionalized or at serious risk of
institutionalization at John George or a sub-acute facility in Alameda County could avoid
placement in psychiatric institutions with appropriate integrated, community-based services, if
such services were available. Many established, evidence-based practices exist that are proven
to support people with serious mental illness or other mental health disabilities in their own
homes and community-based settings, and to reduce needless psychiatric institutionalization.
However, Alameda County has not appropriately implemented these practices, and services are
in too short supply. It is the County’s failure to provide evidence-based, community-based
treatment, including crisis services and processes to divert people from psychiatric
institutionalization, that results in and perpetuates the cycle of needless institutionalization
described above.
1. People Cycling Through Psychiatric Institutions Are Appropriate for
Community-Based Services
Most of the people who cycle in and out of John George and the sub-acute facilities in
Alameda County could be provided appropriate mental health treatment in the community. At
two points during the Department’s investigation, our consultant, a national expert in the
provision of community-based treatment to people with serious mental illness, conducted a
review of people in John George’s inpatient unit. Both times, our expert found that nearly all of
the individuals there would have avoided hospitalization altogether or spent less time in the
hospital had they been provided appropriate community-based treatment and received
professionally adequate discharge planning to connect with those services.
People regularly stay longer than is needed at John George. On any given day at John
George, a significant portion of the residents have been determined by John George professionals
to be appropriate to leave but remain in the hospital because they are awaiting a placement
elsewhere. On July 31, 2019, 24 of the 69 inpatient beds—or 35%—were occupied by
individuals whom John George had determined no longer met criteria for an inpatient stay. In
the year between August 2018 and July 2019, 123 people spent two weeks or more
institutionalized at John George after they were cleared for discharge, simply because there was
nowhere for them to go. Instead, they were held at John George, waiting for an opening in an
intensive community-based mental health program, or for space at one of the sub-acute
facilities—discussed below. John George staff estimated that in a given week, about 10 of their
inpatient residents who are ready for discharge are of enough concern to be discussed at the
11

weekly Acute Care Coordination Committee meeting in order to locate a community placement;
each week, the resources are found to support only about half of them. Staff reported that in
some cases, people have waited in the inpatient unit for months for a placement, simply because
there were no community resources available to support them outside of the hospital. Similarly,
the County has estimated that 75% of people placed on involuntary holds at John George do not
even meet medical necessity to be there. This is likely because, as one John George
administrator put it, the “dearth of resources” in the community lands far too many people in
their institution, again and again.
People living in the sub-acute facilities could also largely live in their own homes and
communities with appropriate services. Facility staff themselves stated that many of the people
living at these facilities could live in the community with appropriate services, and this opinion
was echoed by stakeholders in various roles in the County. Our expert agreed that Alameda
County overly relies on the sub-acute facilities instead of community-based treatment. Our
expert reviewed a sample of people at one sub-acute facility, Villa Fairmont, and concluded that,
like those at John George, nearly all would have avoided admission or could have spent less time
in the facility, had they been provided appropriate community-based treatment. Yet many are
stuck, waiting for slots in community service programs that simply do not exist or that are
inadequate to meet their needs.
Our expert found that people served by BHCS are often at serious risk of psychiatric
institutionalization because of a lack of available community supports. Having interviewed
individuals in and at risk of entry to many of the psychiatric institutions in Alameda County, our
expert confirmed that the people he met in Alameda County’s institutions were no different from
people he had served or observed receiving services successfully in their own homes around the
country.
2. Alameda County Fails to Provide Adequate Community-Based Services that
Could Prevent Needless Psychiatric Institutionalization
It is well-established that an appropriate array of evidence-based services can enable
people with serious mental illness or other mental health disabilities to avoid psychiatric
institutionalization and live safely in integrated, community-based settings. The County has
implemented some critical community-based services, but it has not fully funded them to ensure
they are available in sufficient capacity, adequate intensity, and with fidelity to evidence-based
practices so as to prevent individuals from cycling through psychiatric institutional stays.
Community-based mental health services and practices are necessary to enable
individuals with mental health disabilities to live in the community. These are critical, evidencebased practices that can be individually tailored to the needs of each person and minimize costly,
unnecessary, and repeated psychiatric institutionalization. These services are appropriate for
Alameda County residents who have serious mental illness and are currently in or at serious risk
of entering psychiatric institutions and, if fully developed in Alameda County, would prevent
unnecessary institutionalization. These services are also proven to reduce arrests and
incarceration and could thus further help to break the cycle of unnecessary psychiatric
12

institutionalization and incarceration. These services or their equivalents are provided in John
George and the sub-acute facilities, but do not currently exist in sufficient supply or intensity in
the community. These services include the following:
•

Crisis Services: Community-based crisis supports are a crucial component of a system
that prevents needless psychiatric institutionalization. These services include crisis
hotlines, mobile crisis teams, crisis apartments, and walk-in crisis centers. For example,
mobile crisis is an evidence-based intervention that is available 24 hours a day to respond
rapidly to people experiencing a mental health crisis at their homes or at whatever
location they may be experiencing the crisis. These services are proven to decrease
psychiatric hospitalizations, arrest rates, and incarceration. However, as of our last visit
to Alameda County, there were just two mobile crisis programs, which do not operate at
all times. Instead, law enforcement officers alone typically handle mental health crisis
calls. 12 In our expert’s review of individuals at John George and Villa Fairmont, he
found that none had had access to the kind of mobile crisis services that could have
diverted them from admission. County leadership has recognized the important role of
mobile crisis and the gaps in this service in Alameda County and is in the process of
expanding mobile crisis response. At the time of our last visit, the County described
plans to add six new mobile crisis teams, one of which would include an EMT to conduct
medical clearance so that individuals in crisis could be taken to a location other than John
George or Santa Rita Jail, expanding the options that currently are used by existing
mobile crisis teams. This is among the most promising plans for improvement in the
County. However, even if the County creates all of the crisis teams as planned, it will not
have mobile crisis services available 24 hours a day, mobile crisis response will not be
available in all areas of the County, and only one team will be able to conduct medical
clearances.
Similarly, crisis services should also include alternatives to hospitalization such as crisis
residential programs or crisis apartments, which typically contain a few beds in a homelike environment with full-time staff. These programs are intended to allow people to
stabilize in these settings and avoid going to the hospital. The County has a few crisis
residential programs, but people typically come to those settings from an acute setting,
typically John George, instead of using them to avoid hospitalization in the first place.
This is counter to the purpose of having a crisis residential program and uses up beds that
could otherwise be used as a diversion or alternative to hospitalization.13

In 74% of the involuntary holds (also known as 5150 holds) conducted by Alameda County Sheriff’s Office that
we reviewed, the individual was neither threatening nor violent. In 88% of these incidents, no restraints were used.
And this does not include mental health crisis calls that did not rise to the level of severity that resulted in an
involuntary hold.
13
In fact, the entire behavioral health system seems to be permeated by a step-down philosophy, requiring
individuals to graduate out of more restrictive care to gradually less restrictive settings, which does not comport with
the ADA’s requirement that people receive community-based services when they are appropriate. Standards in the
field today, which align with the requirements of the ADA, reject the step-down philosophy. Professional standards
instead dictate that individuals are best supported in their own homes with intensive, appropriate community-based
services.
12

13

To be effective, community-based crisis services must also include and be paired with
mechanisms specifically designed to divert people with mental health disabilities from
psychiatric institutions and the criminal justice system, which are notably absent in
Alameda County. For example, the County has acknowledged that law enforcement
overutilizes involuntary holds at John George due to the lack of alternative crisis
resources or a formal mechanism at initial detention to connect people with mental health
disabilities to community-based services, which would reduce the serious risk of
subsequent psychiatric institutionalization.
•

Full Service Partnerships: Assertive Community Treatment, or California’s model,
called Full Service Partnerships, is designed to support service recipients with the highest
mental health needs and most frequent hospitalizations to transition from institutions and
live in the community. Full Service Partnerships provide a multidisciplinary team that is
intended to help people stay in treatment, manage medication, address crises, secure and
maintain housing and employment, and engage in their communities. Teams should be
available 24 hours a day and be able to respond to crises and other needs on a flexible
basis, including assisting in the coordination of services if a client enters or is at risk of
entering an institutional setting. Both California and Alameda County have recognized
that Full Service Partnerships reduce institutionalization, criminal justice involvement,
and emergency room use, and community members in Alameda County have identified
Full Service Partnerships as the most effective mental health service in the County.
Alameda County administrators have acknowledged that the capacity is far from
sufficient, although the County has not conducted an analysis of the actual need. One
County administrator estimated the need to serve 4000 to 6000 people with the Full
Service Partnership program. At the same time, Alameda County had funded capacity to
serve only 850 adults with Full Service Partnerships and in practice serves fewer than 725
adults in a given month. 14 Alameda County also operates a forensic Full Service
Partnership that is designed to engage people with a history of significant criminal justice
involvement. Yet, based on documents provided by the County, of the 290 people whom
the County has identified to be eligible for this program, just 17 appear to have been
connected with that service. Evidence we reviewed indicates that the County fails to
effectively connect people with needed Full Service Partnership services and that, once
connected, such services are often not provided in an intensity or with the flexibility
needed to address crises and provide appropriate supports.

•

Permanent Supported Housing: Permanent supported housing is an evidence-based
mental health service that serves individuals with disabilities and provides flexible
supports including medical, behavioral health, and services to support sobriety.
Permanent supported housing promotes mental health recovery by enabling individuals to
maintain housing and avoid the inherent stress of housing instability; by helping service
recipients achieve maximum independence, positive health benefits, and overall higher

The County also offers another multidisciplinary team-based service, called Service Teams, which offers a lowerintensity of service and a higher client-to-staff ratio than Full Service Partnership teams.

14

14

quality of life; and by providing a stable place from which a person can engage with other
services. It is a cost-effective service that is proven to reduce psychiatric
institutionalization, as well as precursors to institutionalization including expensive
hospitalizations, emergency room visits, incarceration, and, of course, homelessness.
Alameda County BHCS acknowledges that there “is a direct link between housing and
behavioral health.” 15 However, Alameda County lacks sufficient supported housing
capacity to meet the needs of individuals with mental health disabilities. In fiscal year
2017–2018, 10% of the people entering County programs for people with mental health
disabilities—a total of 2702 unique individuals—were homeless. 16 This number has
steadily increased in recent years. Similarly, approximately 39% of all homeless
individuals in the County self-reported a mental health condition that year. 17 The
County’s contractor to coordinate homelessness issues explained that these and other data
points show “the considerable overlap between chronic homelessness and serious mental
illness.” In 2018, Alameda County’s contractor estimated that the County needed to
create an additional 2800 “permanent supportive housing” units to meet the need for this
service. In 2019, there was an 8000-person waitlist for the County’s system to access
housing services or subsidies, and only about a quarter of people with serious mental
illness who attempt to join the waitlist are successful in even getting their names on the
list. Unable to access this evidence-based service, many individuals go to board and care
homes instead. Board and care homes provide some minimal care and supervision, but
residents frequently lack access to needed services and meaningful community life;
further, these facilities tend to be overcrowded and highly variable in quality.
•

Peer Support Services: Peer support services are an evidence-based practice where
trained and certified individuals or family members of individuals who have lived
experience with mental health disabilities and receipt of mental health services provide
supports. Peer supports are proven to help individuals with serious mental illness engage
in treatment and to prevent or reduce hospitalization and incarceration. California’s
Council on Mentally Ill Offenders has explained that peer support services “clearly stood
out . . . as one of the most impactful and desired resources to reduce incarceration among
those with mental illness and substance use disorders.” 18 Multiple groups in Alameda
County have recommended expanding peer support services throughout the service
system. Nevertheless, we heard from several stakeholders that peer support services
remain in too short supply in Alameda County.

•

Supported Employment Services: Supported employment is an evidence-based service
that assists people with serious mental illness to obtain and maintain competitive
employment. Supported employment supports people with disabilities to live integrated
lives in their communities. Alameda County has recognized the importance of supported

Housing Service Office, ALAMEDA CNTY. BEHAVIORAL HEALTH CARE SERV., http://www.acbhcs.org/housingservices (last visited Apr. 6, 2020).
16
EVERYONEHOME, PLAN TO END HOMELESSNESS: ALAMEDA COUNTY, CA: 2018 STRATEGIC UPDATE at 31 (2018),
https://everyonehome.org/wp-content/uploads/2018/12/EveryOne-Home-Strategic-Update-Report-Final.pdf.
17
Id.
18
COUNCIL ON MENTALLY ILL OFFENDERS, 15TH ANNUAL REPORT at 17 (2016).
15

15

employment to support recovery for people with serious mental illness, but fewer than
530 people with serious mental illness received the County’s supported employment
services in fiscal year 2019.
•

Services for People with Co-occurring Diagnoses: Community-based services to
support people with serious mental illness who also have co-occurring diagnoses, such as
intellectual disability, substance use disorder, or chronic illnesses, are important to help
such individuals avoid placement in long-term institutional settings. John George staff
explained that in recent years they have seen an increase in people with co-occurring
intellectual and developmental disabilities, people with co-occurring substance use
disorders, and older adults who may have age-related disabilities—all of whom have
begun utilizing John George’s acute services more because of a lack of services in the
community to support their needs. Although there are evidence-based approaches that
have proven to decrease hospital use for most people—for example, integrated dual
diagnosis treatment—these services are largely unavailable in Alameda County.
3. Alameda County Fails to Identify and Connect People with the CommunityBased Services Necessary to Avoid Needless Institutionalization

In order to avoid needless cycling through institutions, it is crucial that individuals with
mental health disabilities have a way to access community-based mental health services.
However, Alameda County does not utilize available opportunities to identify people—whether
in the community or in institutional settings—who need to be connected to community-based
services and to connect them to those services. In particular, Alameda County does not provide
adequate discharge planning and transition services to individuals who are institutionalized in
John George and the sub-acute facilities in order to connect them to community-based services. 19
In a recent review of treatment plans at John George, our expert found that not one reflected
professionally adequate discharge planning. Discharge planning at John George is often not
informed by important clinical and practical considerations for the person, and there is
inadequate communication between treatment providers. Treatment plans also fail to promote
transition to the most integrated setting for the person or to anticipate key goals, opportunities,
and important factors for transition.
In addition, the County fails to adequately connect people to the community-based
services that could help them avoid institutionalization. For example, as noted above, while the
County operates a forensic Full Service Partnership designed to engage people with intensive
needs who have a history of significant criminal justice involvement, and has identified 290
people eligible for the program, as of September 2019, fewer than 20 of those individuals had
been connected with that service. Similarly, the County has identified the individuals who utilize
the most mental health services, as measured by the top 3% of its mental health spending.
However, fewer than one-third of those individuals were connected to Full Service Partnerships
And, as discussed above, Alameda County does not adequately provide for the discharge and transition planning
of prisoners who will be released from Santa Rita Jail. This further places people with mental health disabilities at
serious risk of psychiatric institutionalization upon release.
19

16

as of September 2019, and as of that time, the County did not track people who were eligible for
those services other than those eligible for forensic Full Service Partnerships, in order to
facilitate these linkages. Furthermore, of the top ten mental health service utilizers, all ten were
hospitalized during the year, and nine of the ten were in sub-acute facilities. Yet, only three of
those ten individuals received Full Service Partnership services during that 12-month period, and
only one was placed on a service team, all for seemingly brief periods. While the County has
started the process to identify people who need more intensive services, it has failed to take the
necessary steps to actually connect them.
The County’s failure to successfully connect people to services is hampered by lack of
community-based options. This is particularly true for people with co-occurring diagnoses, such
as intellectual and developmental disabilities, substance use disorders, and physical health needs.
Many people are discharged without adequate supports and services, resulting in frequent
readmissions to John George or sub-acute facilities or contacts with the criminal justice system.
One person who had received treatment several times at John George described discharge
planning there as: “Here’s a bus pass, now get the hell out.” Others described similar
experiences with discharge from John George.
John George staff confirmed many of these issues. Staff report that there are few good
options when they discharge patients to the community. They told us that at times, people are
discharged to shelters or other forms of homelessness. Without housing, people rapidly lose
connection with providers or with transition staff, so that the only way to get services is to return
again to John George. Additionally, staff reported challenges with informing County behavioral
health services when their clients were at the hospital and a regular failure of service providers to
meet with their clients when at John George. John George leadership admitted that being linked
to community services upon discharge is the single highest correlate with success in the
community.
C. Most People with Mental Health Disabilities in Psychiatric Facilities in
Alameda County Do Not Oppose Community-Based Services
Most people with mental health disabilities in Alameda County psychiatric institutions do
not oppose receiving community-based services. The majority of people who find themselves at
John George or the sub-acute facilities are there involuntarily, or because they had no other way
to get services they needed. In fact, Alameda County has the highest rate of involuntary holds of
adults in the state—a rate that is three-and-a-half times the statewide average. In his assessment
of individuals at John George and Villa Fairmont, our expert found that nearly all individuals
reviewed or their guardians would very likely choose to live in the community if they were fully
informed of and had access to appropriate community-based services. He found in his most
recent review that there was no recorded evidence, for any individual reviewed, that the person
or their guardian would oppose receiving services in the community. For many individuals and
their guardians, emergency room or inpatient hospitalization, or in some cases incarceration,
appeared to be the only option to get help. But, in our expert’s view, when there are viable
options for receiving treatment at home and in integrated settings, very few people or their
guardians would choose options that restrict their freedom and segregate them.
17

Our interviews with individuals at John George and the sub-acute facilities confirmed this
conclusion. Many told us of their desire to leave, or expressed interest in receiving services in
the community. One man we met at John George, who had also been to Santa Rita Jail four or
five times and was otherwise homeless as of the time of our interview, explained that he would
like a program that would help him transition out of John George and find a place to live, and not
just be discharged to the street. Another man at John George told us he “wanted to be anywhere
else,” but that after he left John George the last time, he relapsed and needed help, and so he
returned. A woman we met who was living at a sub-acute facility told us she wanted to go
home, and maybe go to college, but knew she would need support to do so. “Who is going to
support me and be with me?” she questioned. Another man at a sub-acute facility told us that he
wanted to leave as soon as possible, but felt that nobody was helping him with this. Others
echoed these sentiments. A staff member at one of the sub-acute facilities told us that residents
who want to leave the sub-acute facility sometimes “act up” in order to be sent to John George or
to jail, because they mistakenly believe that they would subsequently be released into the
community after their stay in the hospital or jail.
D. Alameda County Can Make Reasonable Modifications to Prevent
Unnecessary Psychiatric Institutionalization
Alameda County can reasonably modify its mental health service system to provide
home- and community-based services to prevent unnecessary psychiatric institutionalization.
The County already makes available a range of services that can support people with mental
health disabilities in their own homes. As discussed above, community-based services, diversion
programs, and professionally-adequate discharge planning are proven to be effective in
preventing unnecessary psychiatric institutionalization. The County has taken some positive
steps to address unnecessary psychiatric institutionalization, including, as of our last visit, the
recent funding of 100 Full Service Partnership slots for people with a history of forensic
involvement (although providers have had difficulty staffing these slots); the proposal to pilot
100 additional Full Service Partnership slots, combined with housing subsidies, for individuals
who are homeless and have co-occurring physical health or substance use disorders; and the plan
to significantly expand mobile crisis services. The County also conducts some limited in-reach
to John George and Santa Rita Jail with the goal of helping people to connect with services upon
discharge. While the supply of these services and scope of existing programs remain insufficient
to meet the need, the County can modify and expand these services to serve all individuals who
are, or are at serious risk of becoming, unnecessarily institutionalized; ensure that each person
receives an appropriate intensity and frequency of services to meet their needs; and eliminate
barriers that lead to unnecessary psychiatric institutionalization.
In addition, the County already conducted a Sequential Intercept Mapping process in
2017 and 2019 in which it identified the potential “intercepts,” such as arrest, where individuals
with mental health disabilities come into contact with the criminal justice system, but can instead
be identified and connected to community-based services. Alameda County has identified the
resources and gaps that exist at these intercepts and is well-positioned to develop the needed
mechanisms to use these intercepts to connect people who are at serious risk of psychiatric
institutionalization with services, but has not done so yet.
18

Further, County leadership has acknowledged, and studies have repeatedly shown, that
providing community-based services for people with serious mental illness is cost effective.
Alameda County currently spends disproportionately on institutional services as compared to
community-based services. For example, based on information provided by the County,
annually each individual in the County’s top 3% of mental health spending utilizers uses services
costing an average of $120,410 as of 2019. This group is largely made up of people who spend
the majority of their time in a sub-acute facility or have four or more hospitalizations and
accounts for 32% of all system costs. However, few of the people in this group received
intensive community services, which are known to cost significantly less. 20 Even including costs
for housing supports, serving these individuals in the community could dramatically reduce the
costs for the County.
Alameda County can also maximize federal and state funding opportunities to develop
community-based services. For example, most hospital and sub-acute stays are funded solely by
County funds, while community-based services are typically eligible for federal Medicaid match
dollars. Moreover, California provides a significant amount of funding through the Mental
Health Services Act funds, which can be used for critical services such as Full Service
Partnerships, permanent supported housing, and diversion programs. Yet Alameda County in
recent years has left a significant amount of its MHSA funds unspent, and these are at risk of
reverting to the state.
The lack of community-based services drives individuals with serious mental illness into
costly psychiatric facilities, but it also can lead to costly incarceration. Alameda County spent
$177.2 million in fiscal year 2016–2017 on Santa Rita Jail, not including mental health services,
with around 25% of its population having serious mental illness. The County has recognized
both its significant reliance on the Jail for people with mental illness and that appropriate mental
health treatment could address this problem. The Alameda County Board of Supervisors’ Mental
Health Board recognized in 2015 that “Santa Rita Jail has become a warehouse for people with
mental illness.” 21 The Board further explained that “since there is nowhere to place [individuals
with mental health disabilities], they languish in jail, often isolated in jail cells. We need to
develop a system so that this population can be diverted out of the criminal justice system and
into treatment.” 22 More recent County and external reports have echoed these conclusions. As
discussed above, studies have shown that evidence-based community mental health services have
been effective at reducing arrest rates and incarceration in California and across the country. For
example, a 2010 study in California found that the probability of arrest dropped by 56% for
See, e.g., SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMIN., CRISIS SERVICES: EFFECTIVENESS, COSTEFFECTIVENESS, AND FUNDING STRATEGIES (2014); SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMIN.,
ASSERTIVE COMMUNITY TREATMENT: THE EVIDENCE (2008); SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
ADMIN., PERMANENT SUPPORTIVE HOUSING: THE EVIDENCE (2010); NATIONAL COUNCIL ON DISABILITY, HOME
AND COMMUNITY-BASED SERVICES: CREATING SYSTEMS FOR SUCCESS AT HOME, AT WORK AND IN THE COMMUNITY
(2015), https://ncd.gov/publications/2015/02242015.
21
ALAMEDA CNTY. MENTAL HEALTH BD., ANNUAL REPORT TO THE ALAMEDA COUNTY BOARD OF SUPERVISORS,
FISCAL YEAR 2014–2015 at 7 (2015), http://www.acbhcs.org/mhb/Resources/MHB_Annual_Report_2015.pdf.
22
Id.
20

19

individuals who were involved in Full Service Partnerships. 23 Thus, in implementing
community-based services to prevent psychiatric institutionalization, the County will also likely
reduce incarceration and, in the process, reduce its expenditures for incarceration. The Mental
Health Board’s Criminal Justice Subcommittee has reported to the Board of Supervisors that,
according to national data, it costs two to three times more for a person with serious mental
illness to be incarcerated compared to being housed and receiving treatment in the community,
and that mental health programs that included housing led to fewer arrests and shorter jail stays
among people with mental illness. Making the needed modifications may thus also result in a
smaller population of prisoners with mental health needs at Santa Rita Jail, which could free up
funds to support community-based mental health services and potentially ease the Jail’s
implementation of remedies to address the conditions we identify in Sections V–VII.
Alameda County government has long been on notice of its needless institutionalization
of people with serious mental illness. In 2015, the Alameda County Board of Supervisors’
Mental Health Board wrote of the “dire need” for intensive outpatient services to address the
overcrowding and high readmission rates at John George, explaining that “John George remains
the single most utilized point of entry into the County mental health care system.” 24 The same
report concluded that “[f]ar too many Alameda County residents with mental illness cycle in and
out of Santa Rita Jail and John George Psychiatric Hospital,” and called for a “comprehensive,
integrated system which offers a continuum of care.” 25 In a January 2016 presentation to the
Board of Supervisors’ Health Committee, BHCS identified several concerns around the lack of
coordinated mental health and substance use services, insufficient service coordination across
settings, and a lack of 24/7 crisis service coverage, resulting in psychiatric emergency room
admissions. And several other County reports have similarly acknowledged these problems and
the needed solutions.
As described at several points above, the County has begun to develop many of the
needed services and programs: it offers too-limited mobile crisis services, crisis residential
services, Full Service Partnership teams, peer support services, permanent supported housing,
supported employment, and substance use disorder services, as described in Section IV.B.2. It
has the framework to divert people from institutions and conduct discharge planning in
institutions to help people access these community services. Yet the scope and supply of each of
these services and programs falls short of the need, in many cases as acknowledged by the
County, instead causing the County to rely on institutional services. Though the County could
use existing and available resources to rebalance its service system, and although County
officials have expressed goals of doing so, the County must complete this work to ensure an
adequate array and capacity of community-based services, including crisis services, diversion
programs, and appropriate discharge planning, in order to fulfill County residents’ right to
23
NICHOLAS C. PETRIS CENTER ON HEALTH CARE MARKETS AND CONSUMER WELFARE SCHOOL OF PUBLIC HEALTH,
UNIVERSITY OF CALIFORNIA, BERKELEY, EVIDENCE ON THE EFFECTIVENESS OF FULL SERVICE PARTNERSHIP
PROGRAMS IN CALIFORNIA’S PUBLIC MENTAL HEALTH SYSTEM (2010),
https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.172.8620&rep=rep1&type=pdf.
24
ALAMEDA CNTY. MENTAL HEALTH BD., ANNUAL REPORT TO THE ALAMEDA COUNTY BOARD OF SUPERVISORS,
FISCAL YEAR 2014–2015 at 6 (2015), http://www.acbhcs.org/mhb/Resources/MHB_Annual_Report_2015.pdf.
25
Id. at 7.

20

receive services in the most integrated setting. The minimum remedial measures necessary to
achieve this goal are described in Section VIII.
V.
MENTAL HEALTH CARE AT SANTA RITA JAIL IS INADEQUATE IN
VIOLATION OF THE CONSTITUTIONAL RIGHTS OF PRISONERS WITH SERIOUS
MENTAL HEALTH NEEDS
After making several trips to the Santa Rita Jail with our experts; speaking with Jail
management, security staff, mental health staff, and hundreds of prisoners; and reviewing
thousands of pages of documents, including numerous mental health and other records, the
Department has reasonable cause to believe that the Jail fails to provide prisoners with serious
mental health needs with adequate mental health care, in violation of their Eighth and Fourteenth
Amendment rights.
As discussed above in Section III, Alameda County funds the Jail, which is administered
and controlled by the Alameda County Sheriff’s Office. The Jail has the capacity to hold
approximately 4000 prisoners. During most of the period encompassed by our investigation,
however, the actual prisoner count has been closer to 2400. 26 The Jail holds both pre-trial
detainees and convicted prisoners. Approximately 85% of the Jail’s population is pre-trial
detainees.
While the population of the Jail is, by its very nature, constantly in flux, it includes a
large number of individuals with serious mental health needs. Although the Jail does not
specifically categorize prisoners as having “serious mental illness,” Jail representatives have
stated that approximately 40% of its population is on the mental health caseload. 27 And in our
interviews with the Jail’s chief psychiatrist and other key mental health staff, they estimated that
approximately 20–25% of the population likely has a serious mental illness. For those in various
specialized housing units, the numbers are likely even higher. According to the Jail’s chief
psychiatrist, for example, approximately 50% of the prisoners in the administrative segregation
units 28—the most restrictive in the Jail, other than short-term “safety cells” used up to 72 hours
for actively suicidal prisoners—have a serious mental illness. Our observations of prisoners we
26
While the population at the Jail had declined to approximately 1800 prisoners in May 2020 due to changes to
booking and release procedures that were instituted in response to the COVID-19 pandemic, the population has
since rebounded to 2200 prisoners as of April 5, 2021. See Covid-19 Update, ALAMEDA CNTY. SHERIFF’S OFFICE,
https://www.alamedacountysheriff.org/admin_covid19.php (visited June 19, 2020; visited April 6, 2021).
27
This estimate may undercount the number of prisoners with mental health needs. A March 25, 2021, report by the
California State Auditor found that the Jail fails to “conduct a mental health screening of every inmate, as state
regulations require” and instead “only assesses those inmates who exhibit erratic behaviors or disclose a history of
mental illness to jail staff.” The report explained that the Jail therefore lacks “sufficient data regarding whether
inmates have mental illnesses,” information which is “critical” to “minimize the risk of violence, injury, or
death.” CALIFORNIA STATE AUDITOR REPORT 2020-102, PUBLIC SAFETY REALIGNMENT REPORT at 22-25 (March
2021).
28
During the course of our investigation, the Jail changed its nomenclature in relation to these units, so that it now
uses the term “Administrative Separation,” or “Ad Sep,” instead of “Administrative Segregation,” or “Ad Seg.” For
the sake of consistency, we refer to these units as “administrative segregation.”

21

interviewed in administrative segregation suggested that the chief psychiatrist’s estimate was
accurate, if not perhaps an undercount. As discussed in other sections of this Notice, many of the
individuals with serious mental illness at the Jail cycle repeatedly in and out of the Jail, as well
as in and out of John George and other institutional settings.
There is one primary unit at the Jail—Unit 9—for male prisoners with mental health
needs with any security classification. While Jail officials refer to Unit 9 as a mental health unit,
it largely functions not as a therapeutic setting but rather, in all but name, as a restrictive housing
unit, because these prisoners are confined to their cells for the vast majority of the day, alone or
with another prisoner. 29 Within Unit 9 are different pods, based on security classification. Most
prisoners in these pods are placed in two-person cells and are locked in those cells for the vast
majority of their waking hours. Jail records show that, depending on their pod, prisoners were
limited to less than 1.5 to three hours out of their cells each day. And prisoners on most pods
received yard time outdoors for as little as one hour per week, with many receiving no yard time.
Instead of going to the clinic for mental health care, or to a classroom for educational or
other programming, prisoners in Unit 9 remain on the Unit. They have access to few group
programs on the Unit, and are prohibited from attending the many other programs available to
general population prisoners. Mental health staff meet with the prisoners on the Unit, at large
tables in the day-room-type area. Prisoners on Unit 9 must wear different color uniforms from
the rest of the population, which not only discloses sensitive health information, because staff
and other prisoners know that the uniform signifies a mental health diagnosis, but also serves to
stigmatize them and marginalize them.
Not all prisoners with serious mental health needs are housed on Unit 9. Women
prisoners are housed in a different area of the facility, and there are also men with serious mental
health needs housed throughout the facility. Significantly, a number of them are in
administrative segregation, which is another form of restrictive housing. Prisoners in
administrative segregation are, by policy, permitted at most only five hours outside of their cells
per week. Our review of a sample of records revealed many receiving only one or two hours
outside of their cells on given weeks, a fact repeatedly mentioned by prisoners in administrative
segregation in our conversations with them. When prisoners are permitted to leave their cells,
they do so alone—with no opportunity to interact with others—and are still confined to the
common indoor pod space. They may not go outdoors.

Restrictive housing, elsewhere sometimes referred to as solitary confinement, segregation, or isolation, is any type
of detention that involves three basic elements: removal from the general prisoner population, whether voluntary or
involuntary; placement in a locked room or cell, whether alone or with another prisoner; and the inability to leave
the room or cell for the vast majority of the day. Porter v. Clarke, 290 F. Supp. 3d 518, 528 (E.D. Va. 2018) (citing
U.S. DEP’T OF JUSTICE, REPORT AND RECOMMENDATIONS CONCERNING THE USE OF RESTRICTIVE HOUSING at 3
(2016)); see also, e.g., Wilkinson v. Austin, 545 U.S. 209, 214, 223–24 (2005) (describing restrictive housing as
limiting human contact for 23 hours per day); Sweet v.Tillery v. Owens, 907 F.2d 418, 422 (3d Cir. 1990)
(describing restrictive housing as being limited to a cell for 21 to 22 hours per day); Sweet v. S.C. Dep’t of Corr.,
529 F.2d 854, 867 (4th Cir. 1975) (Butzner, J., concurring) (categorizing as restrictive housing being alone in a cell
for 24 hours per day, save for two, one-hour periods a week for exercise and a shower).
29

22

The Eighth Amendment’s prohibition against cruel and unusual punishment requires jails
to provide prisoners with adequate mental health care. See Doty v. Cnty. of Lassen, 37 F.3d 540,
546 (9th Cir. 1994) (“[T]he requirements for mental health care are the same as those for
physical health care needs.”); see also Brown v. Plata, 563 U.S. 493, 503 (2011) (prisoners “with
serious mental illness” lacked access to adequate mental health care). The protections afforded
pre-trial detainees under the Fourteenth Amendment are at least as great as a convicted prisoner’s
Eighth Amendment rights. See Gibson v. Cnty. of Washoe, Nev., 290 F.3d 1175, 1187–88 (9th
Cir. 2002), overruled on other grounds by Castro v. Cnty. of Los Angeles, 833 F.3d 1060 (9th
Cir. 2016). While a pre-trial detainee may be afforded greater protections, we have conducted
our analysis under the Eighth Amendment standard, to which all prisoners at the Jail are at least
entitled, because the populations are mixed at the Jail.
The rights of any prisoner under the Eighth Amendment are violated when “officials
remain deliberately indifferent to their serious medical needs.” Id. at 1187 (internal quotation
marks omitted). The analysis examines if inadequate medical or mental health care creates a
“substantial risk of serious harm” to prisoners, incorporating the possibility of future harm as
well as present harm. See id. at 1188 (applying “substantial risk of serious harm” language in the
Eighth Amendment medical care context); see also Helling v. McKinney, 509 U.S. 25, 33 (1993)
(“That the Eighth Amendment protects against future harm to prisoners is not a novel
proposition.”).
The existence of serious systematic deficiencies can demonstrate that jail officials are
deliberately indifferent to prisoners’ medical needs, in violation of the Constitution. See Madrid
v. Gomez, 889 F. Supp. 1146, 1256 (N.D. Cal. 1995) (“[C]ourts have traditionally held that
deliberate indifference can be shown by proving either a pattern of negligent acts or serious
systemic deficiencies in the prison’s health care program.”); Casey v. Lewis, 834 F. Supp. 1477,
1543 (D. Ariz. 1993) (“In cases in which the system’s constitutionality is at issue, deliberate
indifference to the serious medical needs of prisoners may also be ‘evidenced by repeated
examples of negligent acts’ . . . or by ‘proving there are such systemic and gross deficiencies in
staffing, facilities, equipment or procedures that the inmate population is effectively denied
access to adequate medical care.’”) (internal citation omitted). Furthermore, a system-wide
policy or practice that leads to a substantial risk of serious harm may be considered holistically to
demonstrate a constitutional violation. See Brown, 563 U.S. at 505 n.3 (noting that in assertion
of system-wide deficiencies in medical and mental health care, there was no need to consider
whether specific instances violate the Constitution, because the state of medical and mental
health care “taken as a whole” created a constitutional violation).
A. Many Prisoners at the Jail Have Serious Mental Health Needs, Requiring
Treatment
Prisoners with serious mental health needs require treatment in order to ensure that their
illnesses are not exacerbated. See Madrid, 889 F. Supp. at 1205–06 (“For inmates with serious
or painful symptoms, delays lasting days or even weeks can cause unnecessary suffering,
exacerbate illness, and have life-threatening medical consequences.”). As acknowledged by Jail
staff, at least 20–25% of prisoners in the Jail have serious mental illness. By not adequately
23

addressing these prisoners’ mental health needs, the Jail places them at significant risk of harm.
At least in part as a result of the Jail’s failure to address their needs, and as described in more
detail below, these prisoners’ mental health often deteriorates; they may engage in self-harm, and
many are transferred to John George for acute mental health care. Many former prisoners are
admitted to John George or other psychiatric institutions, without ever receiving adequate mental
health treatment that could avert these admissions and break this pattern of cycling repeatedly
into segregated psychiatric institutions. Of the charts our expert reviewed, over 20% showed that
the prisoner had to be transferred to John George while in the Jail, and many more showed stays
at John George either prior to booking or after release. Of 21 prisoners known to have died in
the Jail or from injuries or other causes sustained in the Jail between January 12, 2017, when we
opened our investigation and 2020, at least 13 either had apparent indicators of serious mental
illness or died due to suicide.
B. Prisoners with Serious Mental Health Needs Are Subject to a Substantial Risk of
Serious Harm as a Result of Inadequate Mental Health Care
The Jail’s inadequate mental health care places prisoners with serious mental health
needs at substantial risk of harm. The Jail’s mental health program is inadequate because it fails
to provide essential components that have been identified by courts as being minimally necessary
for such a program, including adequate psychotherapy and individualized treatment plans that
include close supervision of the prisoner. See, e.g., Coleman v. Wilson, 912 F. Supp. 1282, 1298
(E.D. Cal. 1995); see also Braggs v. Dunn, 257 F. Supp. 3d 1171, 1188 (M.D. Ala. 2017);
Madrid, 889 F. Supp. at 1256–58; Balla v. Idaho State Bd. of Corr., 595 F. Supp. 1558, 1577 (D.
Idaho 1984); Ruiz v. Estelle, 503 F. Supp. 1265, 1339 (S.D. Tex. 1980), aff’d in part and rev’d in
part on other grounds, 679 F.2d 1115 (5th Cir. 1982). While a denial of any one of these factors
alone may not necessarily amount to a constitutional violation, courts have examined these
factors together to evaluate the constitutional adequacy of a correctional facility’s mental health
program.
1. Prisoners with Serious Mental Health Needs Are Subject to Harm Because of
a Lack of Individualized Treatment, Including Inadequate Psychotherapy and
Programming
The failure to treat mental illness can lead to a substantial risk of serious harm, including
decompensation and suicidal ideation, constituting a serious medical need under the Eighth
Amendment. See Conn v. City of Reno, 572 F.3d 1047, 1054–56 (9th Cir. 2009), judgment
vacated on other grounds by Connick v. Thompson, 563 U.S. 51 (2011); Madrid, 889 F. Supp. at
1222. Courts have found mental health care insufficient when use of psychotropic medications
supplants the use of mental health therapy. See, e.g., Braggs, 257 F. Supp. 3d at 1188 (“The
‘basic’ mental-health care that States must provide if needed by a prisoner includes not only
medication but also psychotherapeutic treatment.”) (citation omitted); Balla, 595 F. Supp. at
1577 (“[P]rescription of [psychotropic] drugs cannot supplant the necessity of psychiatric
counseling.”). Without therapy and programs that might, for example, help them learn cognitive
or emotional skills, plan for recovery from substance use disorder, and make healthy life choices,
24

prisoners with serious mental health needs are at risk of deterioration and eventual reinstitutionalization upon their release from incarceration.
The Jail, however, provides little to no individualized treatment, including
psychotherapy, to prisoners with serious mental health needs. Instead, mental health care on
Unit 9—the unit specifically designated for people with mental health needs—is generally limited
to medication administration, screenings for suicidal ideation, and brief conversations with
clinicians. Our expert found these conversations to be insufficiently frequent, as well as too
brief. In addition, these conversations are usually not held in therapeutic environments, but
rather “cell side,” or in day rooms within earshot of other prisoners and of security staff. As the
Alameda County Sheriff’s Office itself has previously acknowledged: “For those housed in high
security units, the vast majority of these meetings [for therapy or counseling] take place in the
dining area of the housing unit, providing little to no privacy, in an environment not designed for
this type of activity.” 30 Prisoners are often reluctant to disclose sensitive information necessary
to treatment where that information can easily be overheard by staff and other inmates. “[C]ellfront check-ins are insufficient as counseling and do not constitute actual mental-health
treatment,” as they fail to provide a therapeutic environment. Braggs, 257 F. Supp. 3d at 1210;
see also Robinson v. Purcell, No. 2:14-CV-0790, 2019 WL 1330874, at *6 (E.D. Cal. Mar. 25,
2019) (finding “cell-door consultations posed risks to plaintiff’s mental health” because of the
need to speak softly for privacy and the impediment plaintiff faced to “speak[ing] freely” due to
the “non-confidential nature of these visits”). Prisoners receiving cell-side visits are often
reluctant to speak freely, and therefore do not receive the treatment they need, and are thus at
risk of further harm and increased risk of poor outcomes such as self-harm, according to our
expert. During their brief conversations, clinicians generally encourage prisoners to take
medication, rather than utilizing any therapeutic techniques. Further, the Jail provides no group
therapy (only a sole educational class) to prisoners on Unit 9. Jail clinicians often are unable to
provide even a minimally adequate level of care to the large number of prisoners who need it,
resulting in serious harm, including suicide. See Conn, 591 F.3d at 1095 (“A heightened suicide
risk or an attempted suicide is a serious medical need.”). One of the most critical components of
a minimally adequate mental health treatment program is the “identification, treatment, and
supervision of inmates with suicidal tendencies.” Ruiz, 503 F. Supp. at 1339. Suicide watches at
the Jail—known as “IOL status” (referring to an intensive observation log)—feature unduly
harsh conditions, including a prohibition on access to socks, underwear, hygiene products,
sheets, reading material, and the commissary. Such punitive conditions are known to discourage
prisoners from reporting suicidality.
From 2015 through 2019, there were at least 14 suicides in the Jail, which equates to a
rate of suicides that is more than twice the national average. While there were no suicides in
2020, two other suicides occurred at the Jail in the first four months of 2021. In one instance in
2017, L.L., a 29-year-old former Marine, who had previously spent time at both the Jail and John
George, hanged himself in administrative segregation 18 days after entering the Jail. Despite his
ALAMEDA CNTY. SHERIFF’S OFFICE, MENTAL HEALTH SERVICES IN SANTA RITA JAIL at 9 (2015),
http://www.acgov.org/board/bos_calendar/documents/DocsAgendaReg_10_8_15/PUBLIC%20PROTECTION/Reg
ular%20Calendar/Mental_Health_Services_Santa_Rita_Jail.pdf.

30

25

history of previous suicide attempts, and the fact that he had been hospitalized two months prior
at John George for suicidal ideations, L.L. was only briefly placed on Inmate Observation Log
(IOL) status, a form of suicide watch employed by the Jail, before being removed from
observation later that same day by mental health staff and placed in administrative segregation.
The doctor who made this decision stated that this was appropriate because L.L. was not
expressing suicidal ideation at the time of his intake and was being cooperative. L.L. received
no follow-up mental health evaluation between the time of his intake and his suicide only a few
weeks later. Another example involves 20-year-old A.A., also described above, who police
brought to Santa Rita Jail while he was experiencing a mental health crisis. A.A.’s parents
reportedly informed the police that he was not a danger and was in need of mental health
treatment. A.A.’s parents say deputies ignored their requests that their son receive a mental
health evaluation. A lieutenant allegedly ordered A.A. chained to a cell door, in violation of the
Sheriff’s office restraint policy, while he was still experiencing severe symptoms. Left
unattended, A.A. appears to have attempted to strangle himself with the chains, and later died. 31
Other prisoners have suffered harm as a result of the Jail’s inadequate provision of mental
health care. C.C., a 38-year-old male prisoner with a with a history of bipolar disorder, was
incarcerated on January 8, 2019, on a charge of narcotics possession. Although he was assigned
to Unit 9 upon intake, he did not receive an initial evaluation until nine days after he was
admitted, and then only after his sister called the Jail to inform them that her brother was
connected to a community provider, receives injections of Haldol (a psychotropic medication),
and “decompensates quickly without medication.” C.C. started on Haldol on January 22, 2019,
but a clinician’s note indicated that he was not seen that day due to overbooking. During a
medical evaluation the next day, C.C. reported that he felt like he was in a “dream state,” “fired
up,” and “mildly hallucinating.” It also appeared that he was having seizures. Because he
reported no thoughts of self-harm, he was not placed on IOL status. The next day however, C.C.
was “acting strange, shaking, sweating, and appearing confused.” He was observed banging his
head on the wall and had a cut on his lip and forehead. When the mental health clinician saw
him, he was lying on the floor of his cell naked, picking at the floor, and talking to himself. C.C.
was sent to John George later that day, and subsequently transferred from John George to
Highland Hospital, where it was ultimately determined that he had several high impact hip
fractures.
D.D., a 22-year-old with schizophrenia and over 600 interactions with the County’s
behavioral health system, including multiple incarcerations at the Jail, and with a history of
bipolar disorder was incarcerated on February 22, 2019. He was placed on IOL “for muteness
and safety” after he refused to respond to medical or mental health questions. Clinicians did not
follow up with D.D. until four days later. Three days after that, on March 1, 2019, a deputy
reported to a clinician that D.D. had flooded his cell the day before and was naked, talking and
laughing to himself. Despite this behavior, there is no record of any specific therapeutic
treatment for D.D., other than a clinician’s note that the clinician spoke with D.D. about “coping
strategies.” The clinician made several cell-side visits while D.D. was on IOL, noting that
nothing could be seen because there was no light available to see into the cell. Despite his long
31

Despite multiple requests, Alameda County did not provide records related to this incident.

26

history of mental health needs, and behaviors that presented a clear management problem on the
unit, D.D. received only limited cell-side visits, and was not prioritized to receive therapy.
The lapses in mental health treatment for prisoners with serious mental health needs are
even more acute for such prisoners in administrative segregation. Those prisoners generally
speak with mental health staff infrequently, and only through their cell doors, which, as noted,
raises privacy concerns.
The Jail’s mental health program lacks meaningful access to substance use disorder
treatment, a deficiency that is particularly acute because prisoners with serious mental health
needs have a high rate of co-occurring substance use disorders. Over 70% of the charts our
expert reviewed indicated that the prisoner had significant substance use problems, sometimes
reflecting the use of multiple substances. Several prisoners were noted to be in distress from
opioid withdrawal at the time of their mental health assessments in the Jail. But very few charts
contained any mention of treatment plans, interventions, or referrals related to those disorders.
Typically, the most that mental health staff provides these prisoners is some information in the
form of handouts, and in some cases a single educational class, rather than any treatment.
Having enough mental health professionals is an essential part of any constitutionally
adequate correctional mental health program. Mental health staff must be employed in numbers
sufficient to identify and treat prisoners who have treatable mental illness in an individualized
manner. See Cabrales v. Cnty. of Los Angeles, 864 F.2d 1454, 1460–61 (9th Cir. 1988)
(upholding district court’s determination that understaffing of mental health personnel such that
prisoners only could receive 12 minutes of care per month created constitutionally inadequate
care), judgment vacated on other grounds, 490 U.S. 1087 (1989); Coleman, 912 F. Supp. at
1298; Madrid, 889 F. Supp. at 1256–58; Balla, 595 F. Supp. at 1577.
Several factors contribute to the lack of adequate mental health coverage at the Jail.
First, when there are not sufficient security personnel present, mental health staff are hampered
in their ability to see prisoners. In records we reviewed, it was not unusual to see notes from
mental health clinicians documenting this problem. One note regarding a prisoner in
administrative segregation, stated: “Writer spoke with [prisoner] at cell door due to shortage of
available deputies in the [housing unit].” In another example, a clinician wrote about a prisoner
with schizophrenia and schizoaffective disorder who had previously been at John George, Napa
State Hospital, and multiple other inpatient settings: “Writer interviewed [prisoner] at the door in
H[ousing] U[nit] 2 for follow up d[ue to] shortage of deputies. [Prisoner] repeatedly requested to
be taken out to the tables, even after multiple explanations from writer and Sergeant . . . that
there was not enough staffing in the HU to do so.” In fact, in over 85% of the charts our expert
reviewed for this issue, there was a notation of a deputy shortage, resulting in limitations on the
ability of mental health staff to adequately assess prisoners.
Second, on Unit 9, in a restriction imposed by security staff, mental health staff are
permitted only a two-hour window during each weekday in which to see any prisoners for
treatment. Because they have to fit visits with all of the individuals on their caseloads into a
two-hour window, mental health staff are not able to spend sufficient time treating prisoners with
27

serious mental health needs. In fact, as they explained to us, they are only able to spend
approximately 10 to 15 minutes at a time with each prisoner on their caseloads. Further, mental
health staff members with whom we spoke informed us that they do not have the time to run
treatment groups or therapeutic programs. This is borne out by notes in records such as, “unable
to see inmate due to caseload,” or “today this clinician was overbooked.” Finally, the Jail does
not have sufficient numbers of mental health practitioners for the population it serves, as the
Sheriff himself has noted publicly.
2. Prisoners with Serious Mental Health Needs Are Subject to Harm Because of
Inadequate Treatment Planning, Including Discharge Planning
The Jail fails to provide individualized treatment plans to prisoners with serious mental
health needs, which represents a substantial deviation from a constitutionally sound mental
health care program. See, e.g., Sharp v. Weston, 233 F.3d 1166, 1168–69, 1169 n.2 (9th Cir.
2000) (upholding denial of request to lift an injunction that included individualized treatment
plans as a requirement in providing constitutionally adequate mental health care); see also
Braggs, 257 F. Supp. 3d at 1206 n.34 (explaining that treatment planning is part of a minimally
adequate mental health care system). Treatment plans should be developed, implemented, and
monitored by treatment teams to provide adequate focus, purpose, and direction for the delivery
of service. Our expert observed that clinicians’ notes in the overwhelming majority of the charts
she reviewed merely indicate whether or not a prisoner is stable, and clinicians often provide
seriously mentally ill prisoners nothing more than handouts that list coping skills or describe
deep breathing techniques that may help reduce stress.
In addition, the Jail should provide bridge medications and transition planning. See
Charles v. Orange Co., 925 F.3d 73, 84–85 (2d Cir. 2019) (finding plausible the allegation that
discharge planning, including interim medication and referrals, “is an essential part of in-custody
care”); Wakefield v. Thompson, 177 F.3d 1160, 1164 (9th Cir. 1999) (state has constitutional
duty to provide medication to outgoing prisoner in a supply sufficient “to ensure that he has that
medication available during the period of time reasonably necessary to permit him to consult a
doctor and obtain a new supply”); United States v. County of Los Angeles, No. CV 15-05903DDP, 2016 WL 2885855, at * 7, n. 7 (C.D. Cal. May 17, 2016) (finding that Wakefield extends
to discharge planning for mentally ill inmates as required to provide them medical care after
release from custody, and noting that “[i]f anything, a public entity may be more responsible for
mental health treatment where the incarceration itself has aggravated or exacerbated the harmful
symptoms of mental illness”); Matysik v. Cnty. of Santa Clara, No. 16-CV-06223-LHK, 2018
WL 732724, at *12 (N.D. Cal. Feb. 6, 2018) (“[T]here is evidence from which a jury could
conclude that Defendants’ failure to adopt policies requiring greater coordination related to the
release of mentally disabled inmates amounted to a policy or custom [amounting] to deliberate
indifference.”). The Jail typically does not provide access to sufficient medication and a
connection to needed care upon release for prisoners with serious mental health needs.
The Jail also excludes prisoners with serious mental health needs from existing transition
services. The Jail has developed a transitional center where prisoners in general population can
meet community providers and a program, called Operation My Home Town, which connects
28

soon-to-be-released prisoners to community-based programs assisting with housing,
employment, drug and alcohol treatment, and other needs. However, prisoners with serious
mental health needs on Unit 9 or in administrative segregation do not have access to these
discharge services. These prisoners are among those with the greatest need for such services, in
order to ensure that they receive needed mental health treatment in the community. But they
often receive little more than a sheet of paper that lists programs in the community.
When prisoners are not provided with discharge planning that connects them to
community providers, it is unsurprising that they frequently cycle back to the hospital or the Jail.
One such prisoner is E.E., an administrative segregation prisoner who has a history of
schizoaffective disorder and polysubstance use disorder and, when not incarcerated, has been
connected with a mental health provider or admitted to the hospital at least 135 times. E.E. was
in and out of the Jail 13 times during the 13-month period from August 2018 to August 2019.
During those 13 incarcerations, the Jail’s limited efforts to prepare E.E. for reentry into the
community were inconsistent and incomplete. For example, in June 2019, E.E. himself—not his
clinician—suggested that he go to a substance use treatment program upon discharge. However,
instead of connecting him to the program, Jail staff simply provided bridge medications and a
prescription, and spoke with E.E. about the importance of medication compliance to prevent rearrest. E.E. was back at the Jail a month later. Despite his extensive contacts with the Jail and
BHCS, there is no indication that the Jail made any meaningful effort to connect E.E. with
community mental health services.
The lack of discharge planning contributes to the cycling we so often observed, as
individuals with serious mental health needs are drawn deeper into the criminal justice and public
mental health systems through relapse, re-arrest, and re-institutionalization, with fewer and fewer
opportunities to stabilize in the community. One prisoner’s mental health notes from July 2019
explain that the prisoner was made aware of the “B[ay] A[rea] C[ommunity] S[ervices] Re-entry
program” but “does not appear to have engaged.” Several lines down in the notes, the clinician
writes that this prisoner “has been incarcerated at [the Jail] 15 times since 2015.” If the Jail did
more than simply making the prisoner aware of community services—if, for instance, it reached
out to providers and set up appointments—the prisoner would have been more likely to have
engaged in treatment that could reduce his likelihood of repeated hospitalization or incarceration.
C. Officials at the Jail Have Known of the Risk to Prisoner Health and Safety Posed
by Inadequate Mental Health Care and Disregarded It
Jail officials have been put on notice that inadequacies in the Jail’s mental health system
pose a substantial risk of serious harm to prisoners. The Jail has failed to take steps to eliminate
these risks, evincing deliberate indifference to prisoner health and safety. See Farmer v.
Brennan, 511 U.S. 825, 837 (1994) (holding that a prison official may be liable under the Eighth
Amendment if he “knows of and disregards an excessive risk to inmate health or safety”).
There are numerous sources that should have put Jail officials on notice of the risks posed
by their deficient mental health care system. Alameda County has long known of the problems
related to the provision of mental health care to prisoners with serious mental health needs. In
29

July 2017, a public presentation was given to the Alameda County Board of Supervisors Health
Committee on the need to decrease the incarceration of those with mental illness in the County.
The Alameda County Mental Health Advisory Board’s Criminal Justice Subcommittee
investigation 32 noted the “revolving door between John George [and] Alameda County jails.” 33
The Criminal Justice Subcommittee identified factors that contributed to this situation including,
among other things: the Jail’s inadequate discharge planning and coordination of services;
frequent inadequate access to psychiatrists; and inadequate substance use disorder treatment.
In addition, lawsuits alleging inadequate mental health care at the Jail have put officials
on notice of the risks to prisoner health and safety. Cf. Disability Rights Mont., Inc. v. Batista,
930 F.3d 1090, 1099 (9th Cir. 2019) (finding that two prior lawsuits “complaining about
factually similar conditions at the prison” supported finding of deliberate indifference) (citing
Lemire v. Cal. Dep’t of Corr. & Rehab., 726 F.3d 1062, 1078 (9th Cir. 2013) (concluding that
plaintiffs stated a claim for deliberate indifference where “litigation specifically alerted prison
officials to the acute problem of inmate suicides”)). For instance, Babu v. County of Alameda, a
federal district court case filed in December 2018, concerns the very subject of this Notice—
deficiencies in mental health care provided by the Alameda County Sheriff’s Office. Babu v.
Cnty. of Alameda, 5:18-cv-07677 (N.D. Cal. Apr. 22, 2020), ECF No. 111-1. In the Complaint’s
first paragraph, it states, “The Alameda County Jail system is broken, especially when it comes
to the way it treats people with psychiatric disabilities. . . . Alameda County relies almost
entirely on the unconstitutional use of isolation to manage prisoners, including prisoners with
significant . . . mental health needs, resulting in horrific suffering.” 34 Although the Jail has
recently reported its commitment to improve mental health care as part of the ongoing settlement
negotiation process in Babu, it is not clear what, if any, remedial measures have been put in
place, whether they have been incorporated into the Jail’s policies and procedures, or whether
any measures actually put in place will prove durable. Likewise, Disability Rights California,
the federally-mandated protection and advocacy entity for California, issued a letter to Alameda
County in November 2019 alleging, after an investigation, that “people with mental health
disabilities regularly cycle in and out of . . . the jail system,” and noting that “people with mental
health disabilities held in jail face dangerous and damaging isolation conditions and inadequate
access to programming or meaningful mental health treatment.” 35

The Criminal Justice Subcommittee conducted interviews with Oakland Police Department officers, BART Crisis
Intervention counselors, social workers, program directors, and program managers to gather information on gaps
within the County system. The Criminal Justice Subcommittee also compared the situation in Alameda County with
national statistics on the relationship between mental illness and the criminal justice system.
33
BRIAN BLOOM & DR. NOHA ABOELETA, DECREASING INCARCERATION OF THE MENTALLY ILL IN ALAMEDA
COUNTY at 4 (2017),
http://www.acgov.org/board/bos_calendar/documents/DocsAgendaReg_7_24_17/GENERAL%20ADMINISTRATI
ON/Regular%20Calendar/Community_Mental_Health_7_24_17.pdf.
34
Complaint at ¶ 1, Babu v. Cnty. of Alameda, No. 5:18-cv-07677 (N.D. Cal. Dec. 21, 2018), ECF No. 111-1.
35
Letter from Disability Rights Cal., to Karyn Tribble, LSCW Dir., Alameda Cnty. Behavioral Health and Services,
and Donna Ziegler, Counsel, Alameda Cnty. (Nov. 1, 2019),
https://www.afsc.org/sites/default/files/documents/2019-1101%20DRC%20Findings%20Letter%20%20Access%20Requests%20Alameda%20Cty%20%20Signed%20%281%29.pdf.
32

30

Finally, numerous media reports have raised concerns about the provision of mental
health care to prisoners with serious mental health needs at the Jail. The Department’s
investigation has also provided Jail officials with notice of deficiencies in mental health care.
Department attorneys and staff, accompanied by experts, visited the Jail several times in 2017,
and again in 2019. At the conclusion of these visits, we provided Jail officials with exit
briefings, during which our experts shared their preliminary observations. Our experts expressed
their opinions that mental health care for prisoners with serious mental health needs was
deficient, and specified the various areas in which such care is inadequate, as described above.
Nevertheless, most of the conditions we identified in 2017 were still present when we returned in
2019.
VI.
THE JAIL’S USE OF PROLONGED RESTRICTIVE HOUSING UNDER
CURRENT CONDITIONS, INCLUDING THE FAILURE TO PROVIDE ADEQUATE
MENTAL HEALTH CARE, VIOLATES THE CONSTITUTIONAL RIGHTS OF
PRISONERS WITH SERIOUS MENTAL ILLNESS
The Jail’s use of restrictive housing for prisoners with serious mental illness in current
conditions—in which prisoners can spend months, if not longer, locked in their cells, with only
three to five hours out of cell per week, and with little to no mental health treatment, therapy, and
programming—places prisoners with serious mental illness at a substantial risk of serious harm
in violation of the Eighth and Fourteenth Amendments. See Disability Rights Mont., 930 F.3d at
1099 (finding plausible Eighth Amendment claim that placing prisoners with serious mental
illness in restrictive housing of 22 to 24 hours per day for months poses substantial risk of
serious harm); Palakovic v. Wetzel, 854 F.3d 209, 226 (3d Cir. 2017) (holding that, “in light of
the increasingly obvious reality that extended stays in solitary confinement can cause serious
damage to mental health,” there was a plausible claim that placing prisoner with history of
suicidality in restrictive housing for multiple 30-day stints violated the Eighth Amendment);
Hernandez v. Cnty. of Monterey, 110 F. Supp. 3d 929, 946 (N.D. Cal. 2015) (“While housed in
segregation, the mentally ill are especially vulnerable, and their mental health symptoms—
including depression, psychosis, and self-harm—are especially likely to grow more severe.”); see
also Braggs, 257 F. Supp. 3d at 1247 (noting the “consensus on the substantial risk of harm of
decompensation for these mostly severely mentally ill prisoners” from segregation); Madrid, 889
F. Supp. at 1265 (using prolonged restrictive housing on prisoners who are, because of their
serious mental illness, “at a particularly high risk for suffering very serious or severe injury to
their mental health” is “the mental equivalent of putting an asthmatic in a place with little air to
breathe”); Coleman, 912 F. Supp. at 1320–21 (adopting finding that restrictive housing can
“cause further decompensation” to prisoners with mental illness); Casey, 834 F. Supp. at 1549
(finding that an extensive use of lockdown in place of mental health care “clearly rises to the
level of deliberate indifference to the serious mental health needs of the inmates and violates
their constitutional rights to be free from cruel and unusual punishment”).
As discussed above, prisoners at the Jail with serious mental illness are regularly placed
in administrative segregation, where they spend almost every hour of their days locked in their
cells, alone or with one cellmate, with little to no treatment, therapy, or programming. When
they do get out, each prisoner is alone (or with their cellmate only), so they do not have any
31

opportunities for social interaction. Jail mental health staff have estimated that approximately
50% of the prisoners in administrative segregation have serious mental illness. As a result, these
prisoners are at increased risk of physical self-harm, extreme mental distress, and unnecessary
suffering. In fact, we have seen evidence of such harms, as discussed further below, including
prisoners swallowing objects, not eating, smearing or eating feces, banging their heads against
the wall, and attempting or completing suicide.
The Alameda County Sheriff has acknowledged that one hour per day of out-of-cell time
is not sufficient. “We do not like to keep people in those cells for any length of time,” he has
said. 36 Yet, despite his statements, until very recently the Jail continued to keep individuals
locked down with less than one hour out of cell each day for months at a time. 37 In fact, at the
time of our last visit, in July 2019, there were 75 prisoners in administrative segregation who had
been there for over 90 days, at least 75% of whom had indications of serious mental illness.
Thirteen of those prisoners with indications of serious mental illness had been in administrative
segregation for more than a year.
Jail officials say that prisoners are placed in administrative segregation if they cannot coexist with other prisoners, are violent, or need protection, among other reasons. However, our
review of classification records for prisoners placed in administrative segregation revealed many
instances of prisoners being assigned to such housing for reasons that seemed directly related to
their serious mental illness and not due to Jail officials’ stated reasons. For example, F.F. had a
history of suicide attempts in administrative segregation when a classification deputy approved
F.F.’s request to be transferred to a less restrictive pod. The deputy understood that the move
could help F.F.’s mental health: “Having a cellmate might help [F.F.] cope with being
incarserated [sic],” he wrote. But several weeks later, F.F. was returned to administrative
segregation, because of his serious mental illness. The classification deputy explained that F.F.
was being re-classified to administrative segregation “due to” his flag as “mental”. The deputy
made this recommendation despite the fact that the behavioral health professional who had just
evaluated F.F. recommended against the transfer, indicating instead that F.F. should be housed in
the less restrictive behavioral health unit. Over an approximately three-month period, two
behavioral health professionals made five separate recommendations that F.F. be moved to a less
restrictive unit. Each time, they were overruled by classification deputies. Their reasons often
explicitly cited F.F.’s mental illness. “Due to [F.F.’s] recent mental instability,” a deputy wrote,
for example, “he will remain in [administrative segregation] at this time.”
Another example is G.G., an individual who was sent to John George at least twice
during his incarceration at the Jail, and who reported to the Jail that he had previously been
housed in minimum security. His classification report from February 2019 from the Glenn Dyer
Lisa Fernandez, Death Rate at Santa Rita Exceeds Nation’s Largest Jail System as Critics Call for Reform,
KTVU (Oct. 1, 2019) https://www.ktvu.com/news/death-rate-at-santa-rita-exceeds-nations-largest-jail-system-ascritics-call-for-reform.
37
We note that, as part of the ongoing settlement negotiation process in the Babu case, the Jail reportedly has taken
steps to increase out-of-cell time for prisoners. We have not yet seen evidence of how much more time prisoners
may get, or how widespread the change is, and there is no evidence that this is memorialized in any policy.
Moreover, it is not clear whether such remedial measures will prove durable.
36

32

Jail, which was operated by the Alameda County Sheriff’s Office until it closed in 2019, notes
that he “suffers from bipolar [disorder] and is on heavy psychiatric medication that [the Glenn
Dyer Jail] doesn’t carry. The nurse said that if he missed more than one dose of his [medication]
he is likely to have a serious mental breakdown.” After several weeks at the Glenn Dyer Jail,
G.A. was observed “visibly shaking,” “making the sign of the cross,” and “displaying bizarre”
behavior, and was therefore placed in administrative segregation. A few weeks later, when he
was transferred to the Jail, a classification deputy acknowledged that G.G. had been housed in
administrative segregation “due to acting strangely during his classification interview”—in other
words, for reasons related to his mental health status. The deputy suggested that G.G. “may be
suitable for . . . the behavioral health unit.” Although two mental health professionals agreed
with that assessment and recommended on at least four separate occasions that G.G. be
transferred to the behavioral health unit, he remained in administrative segregation. At the time
of our visit to the Jail in July 2019, he had not been reclassified.
A. Prisoners with Serious Mental Illness Are Subject to a Substantial Risk of
Serious Harm as a Result of the Jail’s Use of Restrictive Housing
The Jail’s practice of subjecting prisoners with serious mental illness to prolonged
periods of restrictive housing places these prisoners at substantial risk of serious harm. As
described above, as of our last visit, prisoners in administrative segregation were, by policy,
permitted only five hours outside of their cells per week at most, and our review of a sample of
records revealed many receiving only one or two hours outside of their cells on any given week.
The lack of access to adequate mental health care is especially harmful for prisoners who
are suicidal. Instead of receiving the constitutionally adequate mental health care required, such
as intensive therapeutic interventions, they receive minimal engagement from limited
interactions with mental health staff. Notably, despite the known harms of prolonged restrictive
housing for people with serious mental illness, at least six of the prisoners who have died by
suicide at the Jail since January 1, 2014, were in restrictive housing at the time of their suicide. 38
One such example is H.H. He was arrested on April 4, 2018, and booked into the Jail
early the next morning. During his initial screening, he was observed to have “delusional
thoughts,” and as a result he was referred to mental health staff. While awaiting re-classification,
H.H. was found with fecal matter smeared on his face, and he stated to a deputy that he wanted
to be killed or would kill himself. He was moved to a safety cell and put on an IOL. The
following day, April 6, a mental health clinician determined that H.H. was no longer suicidal,
and he was moved from a safety cell to administrative segregation. There, on April 8, H.H. was
found with a bed sheet tied around his neck and tied to another sheet that was wrapped around
the top bunk. When a deputy entered his cell, he found H.H. unresponsive, with pale skin. The
cell was flooded with water and fecal matter, which had also been spread onto the floor, walls,
In addition, in February 2021, an individual in the Jail’s quarantine unit for newly booked prisoners died by
suicide. The County and the Sheriff’s Office have reported that newly-booked individuals at the Jail must complete
a 14-day quarantine upon intake, and that on average, those individuals receive approximately one hour of out-ofcell time per week. Babu v. Cnty. of Alameda, 5:18-cv-07677 (N.D. Cal. Apr. 7, 2021), ECF 239 at 7.
38

33

and window. A fellow prisoner reported that in the hours leading up to his suicide, H.H.’s
requests to see mental health staff were ignored. In addition, although according to Jail policy
H.H. was supposed to be observed every 30 minutes, he had not been observed for over an hour,
during which time he took his own life.
Other individuals suffer a variety of other significant harms. Indeed, over half of the
episodes of self-injurious behavior that our expert reviewed occurred while prisoners were in
restrictive housing. For example, I.I., a prisoner in restrictive housing with serious mental
illness, smeared his feces, wrote words on the walls with his feces, and even ate his feces. He
suffered delusions, believing himself to be Jesus Christ; engaged in head banging; and tried—
unsuccessfully—to hang himself. One clinician hypothesized that I.I. may have been in a “safer
placement” in a mental health unit in another jail, but noted that the Jail “does not have a mental
health unit,” apologizing to I.I. for this fact and “encourag[ing] him to try his best to manage in”
administrative segregation while the clinician tried to help him get “to a quieter pod.”
Other examples of people who were harmed include J.J., whose chart shows that he told a
clinician that he had instructed his wife not to visit him because he was “losing [his] mind” in
administrative segregation; F.F., who attempted to suffocate himself on several occasions,
including by wrapping clothes around his neck and putting a bag over his head; and K.K., who
swallowed pencils, a razor, a screw, and a comb. One prisoner in administrative segregation
who had returned from a short stay at John George less than two months earlier was “refusing to
lockdown, naked, urinating all over . . . , putting his bread in the urine then eating it, sticking his
finger up his rectum and threatening to kill himself by taking pills.” The experiences of these
prisoners mirror that of the many prisoners who told us during our visits to the Jail about “going
crazy” and “flipping out” in restrictive housing, due to the isolation they experienced. Chart
notes confirm that the Jail’s mental health professionals believe restrictive housing exacerbates
prisoners’ mental health issues. As one psychiatrist noted about a prisoner who reported a
history of schizophrenia, “Unfortunately patient appears to be doing worse, compared to initial
evaluation. This may be due to continuing to be in administrative segregation.”
B. Officials at the Jail Have Known of, and Disregarded, the Substantial Risk of
Serious Harm of Placing Individuals with Serious Mental Illness in Restrictive
Housing
Prisoners with serious mental illness in restrictive housing have died by suicide,
attempted suicide, or otherwise harmed themselves, as discussed above. These incidents—most
of which were known to Jail officials—should have put Jail officials on notice that they were
putting prisoners with serious mental illness at a substantial risk of serious harm by placing them
in restrictive housing for prolonged periods. Moreover, as discussed above, mental health
clinicians and other Jail staff specifically raised concerns about whether placement in restrictive
housing, such as administrative segregation, was appropriate for prisoners with serious mental
illness, further putting officials on notice of the risk to these prisoners.
Following our 2017 visits, the Jail made some changes to its restrictive housing practices,
apparently in part in response to the concerns expressed by our experts. Most notably, the Jail
34

instituted a “Maximum Separation” or “Max Sep” program, which represents a step-down from
administrative segregation, allowing prisoners more time out of cell, and allowing them to be out
with other prisoners. Nevertheless, the “Max Sep” program is available only to a small
percentage of those in administrative segregation. The Jail did not reasonably respond to reduce
the risk of serious harm to prisoners with serious mental illness until the very recent—and
limited—steps taken as part of the Babu negotiations, see supra note 37, evincing deliberate
indifference to prisoner health and safety.
VII. THE JAIL’S TREATMENT OF PRISONERS WITH MENTAL HEALTH
DISABILITIES VIOLATES THE AMERICANS WITH DISABILITIES ACT
Title II of the ADA provides that “no qualified individual with a disability shall, by
reason of such disability, be excluded from participation in or be denied the benefits of the
services, programs, or activities of a public entity, or be subjected to discrimination by any such
entity.” 42 U.S.C. § 12132; see also Pierce v. Cnty. of Orange, 526 F.3d 1190, 1214 (9th Cir.
2008). To establish a Title II claim, one “must show: (1) he is a ‘qualified individual with a
disability’; (2) he was either excluded from participation in or denied the benefits of a public
entity’s services, programs, or activities, or was otherwise discriminated against by the public
entity; and (3) such exclusion, denial of benefits, or discrimination was by reason of his
disability.” Duvall v. Cnty. of Kitsap, 260 F.3d 1124, 1135 (9th Cir. 2001) (citation omitted).
Title II has been found to “unmistakably” cover correctional institutions. See Pa. Dep’t of Corr.
v. Yeskey, 524 U.S. 206, 209–10 (1998) (applying Title II in the prison context); Bell v. Williams,
No. 18-CV-01245-SI, 2019 WL 2358971, at *3 (N.D. Cal. June 4, 2019) (applying Title II in the
jail context); see also Pierce, 526 F.3d at 1214 (noting that Title II applies to county jails’
“services, programs and activities for detainees”). The ADA offers the same protections to
prisoners with disabilities whether those disabilities stem from physical or mental impairments.
42 U.S.C. § 12102. Thus, prisoners at the Jail with mental health disabilities are entitled to this
protection. Further, the ADA applies to prisoners even if they are not in the general population.
“A prisoner’s misconduct does not strip him of his right to reasonable accommodations, and a
prison’s obligation to comply with the ADA and the RA [Rehabilitation Act] does not disappear
when inmates are placed in a segregated housing unit, regardless of the reason for which they are
housed there.” Furgess v. Pa. Dep’t of Corr., 933 F.3d 285, 291 (3d Cir. 2019).
Some prisoners are placed in administrative segregation or other restrictive housing due
to their mental health disabilities, and all prisoners in Unit 9 are placed there precisely due to
their mental health disabilities. Yet, prisoners at the Jail who are on Unit 9 or in administrative
segregation do not receive the same programming that is available to prisoners in general
population. For example, the Alameda County Sheriff’s Office provides an array of programs to
many prisoners in general population at the Jail, including, educational programs, art therapy,
culinary arts, computer coding, job readiness training, financial literacy, and hospitality. And the
Jail’s transition center allows many prisoners in general population to receive additional services
from community-based organizations in areas such as education, employment, housing, and
substance use disorder. But none of these programs and services are available to prisoners with
mental health disabilities placed on Unit 9 or in administrative segregation. The Jail provides
just one program, “Breaking the Chains,” on Unit 9, and it is limited to the topic of substance use
35

disorder. As discussed above, Jail officials place prisoners with mental health disabilities in Unit
9, the “mental health” unit, precisely because they have a serious mental illness. As also
discussed above, the Jail often places other prisoners with mental health disabilities in
administrative segregation for reasons that are directly related to their mental illness, as, for
example, with F.F. and G.G., discussed in Section VI, supra.
Thus, but for their mental health disabilities, prisoners in Unit 9 and those prisoners
placed in administrative segregation due to their mental health disabilities would be able to
access the programming provided to the general population. For example, approximately 41% of
the stays on Unit 9 over a 19-month period that we examined were classified as “Mental Min.”
This means that these individuals would have been classified as minimum custody, and housed
accordingly, with the attendant access to programming, but for their “mental health”
classification. Thus, by virtue only of their mental health disabilities, they were placed in a
housing unit where they were denied access to programs that they otherwise would have been
able to access, as minimum custody prisoners.
Denying prisoners with a mental health disability equal access to programming and
services available to those without disabilities violates Title II of the ADA. See Love v. Westville
Corr. Ctr., 103 F.3d 558, 561 (7th Cir. 1996) (affirming conclusion that prison officials
intentionally discriminated against an inmate in violation of the ADA when they excluded him
from prison programs and services on account of his disability).
VIII. MINIMUM REMEDIAL MEASURES
To remedy the constitutional and statutory violations identified in this Notice, we
recommend that the County implement, at minimum, the remedial measures listed below.
A. Providing Mental Health Services in the Most Integrated Setting
1. Provide evidence-based community-based services in the most integrated setting
that are effective at meeting the needs of eligible adults with mental health
disabilities in and at serious risk of entering psychiatric institutions in Alameda
County and preventing them from unnecessary institutionalization, including:
a. Implement a comprehensive crisis response system, including an array of
integrated crisis residential services, in sufficient capacity to serve adults with
mental health disabilities in the most integrated setting and effective mobile
crisis services that can respond to individuals wherever they experience crises
and that works with law enforcement where appropriate to de-escalate crises
and prevent unnecessary arrest and detention, involuntary commitment, or
hospitalization.
b. Implement a sufficient number of Full Service Partnership teams that can
provide sufficiently intensive community services to those who need them.
c. Implement a sufficient quantity of scattered-site, permanent supported
housing slots to ensure adults with mental health disabilities can maintain
housing in integrated settings.
36

d. Implement sufficient community-based services including case management,
personal care services to assist with activities of daily living, and supported
employment services in the amount, frequency, and duration needed by adults
with mental health disabilities in Alameda County.
e. Implement peer support services provided by trained and certified peers with
lived experience with mental illness in sufficient quantity to be integrated in
all aspects of the mental health service system.
f. Implement sufficient community-based services that can appropriately support
people who have co-occurring diagnoses, such as intellectual disability,
substance use disorder, or chronic illnesses.
2. Provide transition and discharge planning, beginning upon admission, to all
eligible adults with mental health disabilities in psychiatric institutions in
Alameda County.
3. Provide transition and discharge planning, beginning upon admission, for
prisoners with mental health disabilities in Santa Rita Jail to prevent needless
psychiatric institutionalization for those individuals following release from Jail.
4. Identify eligible individuals who may be at serious risk of psychiatric
institutionalization and connect them with appropriate community-based services,
including by using the crisis services described above, and by utilizing identified
intercepts where individuals with mental health disabilities are known to come
into contact with County services or the criminal justice system.
5. Ensure that community-based services and supports are designed to engage and
support individuals with mental health disabilities who may be involved in the
criminal justice system.
6. Implement systems, including through close coordination between Alameda
County BHCS, Alameda County Sheriff’s Office and Santa Rita Jail, that ensure
people with mental health disabilities can initiate or maintain connections with
community-based services while incarcerated and transition seamlessly into such
services upon release.
B. Jail Mental Health Care
1. Ensure that prisoners with serious mental illness receive timely treatment from
mental health professionals as clinically appropriate, in a setting that provides
privacy.
2. Ensure that appropriate, individualized treatment plans are developed for
prisoners with serious mental illness, and implement procedures whereby
treatment plans are regularly reviewed to ensure that they are being followed.
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3. Ensure that all prisoners with serious mental illness receive regular, consistent
therapy and counseling, in group and individual settings, as clinically appropriate.
4. Ensure that prisoners at risk of suicide receive appropriate mental health care.
The Jail’s suicide prevention program should include:
a. Individual assessments of prisoners to determine whether and when they
should be placed on some form of suicide watch, the individualized conditions
of that watch, and whether and when they should be removed from that watch;
and
b. Conditions in suicide watch placements that are therapeutic, rather than
punitive.
5. Provide transition and discharge planning to prisoners with serious mental illness,
including services for prisoners in need of further treatment at the time of
discharge to the community. These services should include the following:
a. Arranging an appointment with community mental health providers for all
prisoners with serious mental illness and ensuring, to the extent possible, that
prisoners meet with that community mental health provider prior to or at the
time of discharge to facilitate a warm handoff;
b. Providing a supply of bridge medications to prisoners sufficient to last until a
prescription can be refilled; and
c. Arranging with local pharmacies to have prisoners’ prescriptions renewed to
ensure that they have an adequate supply to last through their next scheduled
appointment with a mental health professional.
C. Restrictive Housing in the Jail
1. Ensure that prisoners with serious mental illness are not placed in restrictive
housing for prolonged periods, absent exceptional circumstances, and review
prisoners in restrictive housing periodically to ensure that restrictive housing
remains appropriate for them.
2. Ensure that if a prisoner shows credible signs of decompensation in restrictive
housing, the prisoner’s mental health needs are assessed by a mental health
professional and promptly addressed.
3. Ensure that prisoners expressing suicidality are not placed in restrictive housing
and instead are provided clinically appropriate mental health care.
4. Report and review data regarding lengths of stay in restrictive housing,
particularly with respect to prisoners with serious mental illness, and take
appropriate corrective action.

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D. Jail Compliance with the Americans with Disabilities Act
1. Ensure that prisoners with mental health disabilities have the opportunity to
participate in and benefit from services (including transition services), programs,
and activities available to prisoners without disabilities consistent with significant
health or safety concerns.
IX.

CONCLUSION

We have reasonable cause to believe that Alameda County and the Alameda County
Sheriff’s Office violate the ADA and engage in a pattern or practice of constitutional violations
in the conditions at Santa Rita Jail and that Alameda County violates the ADA in its provision of
public mental health services. The remedies we propose are narrowly tailored to correct the
conditions found during our investigation and seek to address changes to policies, practices,
training, supervision and accountability systems necessary for the County to overcome existing
deficiencies and to come into compliance with the Constitution and the ADA. We look forward
to working cooperatively with the County to identify appropriate responses to the violations have
identified.
We are obligated to advise you that 49 days after issuance of this letter, the Attorney
General may initiate a lawsuit pursuant to CRIPA to correct deficiencies identified in this letter if
County officials have not satisfactorily addressed our concerns. 42 U.S.C. § 1997b(a)(1). The
Attorney General may also move to intervene in related private suits 15 days after issuance of
this letter. 42 U.S.C. § 1997c(b)(1)(A). Please also note that this Notice is a public document.
It will be posted on the Civil Rights Division’s website.

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