Report 2013-103 Recommendation 15 Responses

Report 2013-103: Armed Persons With Mental Illness: Insufficient Outreach From the Department of Justice and Poor Reporting From Superior Courts Limit the Identification of Armed Persons With Mental Illness (Release Date: October 2013)

Recommendation #15 To: Justice, Department of

To ensure that it keeps an accurate and up-to-date list of all mental health facilities that are required to report individuals with mental illness, at least twice a year Justice should update its outreach list of mental health facilities by obtaining a list of facilities from Health Care Services.

Agency Response*

The Department is working with the Department of Health Care Services (DHCS) to receive a list of all mental health facilities on a monthly basis. The Department will review and compare its list against the list received from DHCS. If there are any discrepancies found, the Department will work with DHCS to resolve them. The manager over the Mental Health Unit will do a high-level review each month and note any concerns on the list for the analyst to address.

DHCS stated they will continue to update their website on a quarterly basis. The Department is comparing its list with the website list each quarter and noting any discrepancies. A new procedure has been added to forward the list to the unit's manager for a thorough supervisory review to ensure staff have identified and corrected all discrepancies. The manager will make any necessary notations on the spreadsheet for the analyst to explain or correct. In addition, the manager will sign and date the bottom of each page to acknowledge that the supervisory review has been completed. The Department will continue to work with DHCS to resolve any discrepancies.

  • Response Type†: Annual Follow Up
  • Completion Date: September 2015
  • Response Date: October 2015

California State Auditor's Assessment of Status: Fully Implemented


Agency Response*

DHCS provided the Department with a website link, in which they update the list of designated facilities on a quarterly basis. The Department will review the updated list twice a year, each January and June to verify that all designated facilities on the list are providing the required information. If any discrepancies are found, the Department will work with DHCS to resolve. All new designated facility information will be forwarded to the Training, Information and Compliance Section manager in order to schedule training regarding the mental health prohibition reporting process.

  • Response Type†: 1-Year
  • Completion Date: October 2014
  • Response Date: October 2014

California State Auditor's Assessment of Status: Partially Implemented

In its response regarding the status of its implementation of this recommendation after the state auditor's report was published, Justice asserted that it had fully implemented this recommendation. Based on our review of documentation provided by Justice at that time, we assessed the recommendation as fully implemented. However, during a follow-up audit, which entailed a more in-depth review of actions Justice has taken to address this recommendation, we found that Justice has not fully implemented the recommendation. The state auditor issued its follow-up audit titled Follow-Up—California Department of Justice: Delays In Fully Implementing Recommendations Prevent It From Accurately and Promptly Identifying All Armed Prohibited Persons With Mental Illness, Resulting in Continued Risk to Public Safety(Report 2015-504), in July 2015.


Agency Response*

The Department has established an open line of communication with DHCS to obtain information about all facilities required to submit mental health information to the Department.

The Department received a list of mental health facilities from DHCS at a meeting held on January 15, 2014. During this meeting, both agencies also discussed:

1) discrepancies on the list The Department will reach out to facilities to fix any discrepancies;

2) ways to work together to enhance the facility licensing process DHCS stated that the County Board of Supervisors and County Mental Health Directors designate and approve the 5150 facilities. They then notify DHCS of these facilities. DHCS will work to ensure they receive this information;

3) methods for better educating facilities The DOJ Mental Health Unit manager will forward all relevant facility information to the Training Information and Compliance Section (TICS) manager. The TICS staff will contact the facility to schedule training and forward all relevant information regarding the mental health prohibition reporting process; and

4) ways to follow up on low or non-compliance reporting facilities. The Department received information in January 2014. The Mental Health Unit then contacted all of the facilities included on the list and verified that all facilities are providing the required information to the Department. The Department will contact DHCS and request an updated list of mental health facilities in June 2014, and will continue to do so every January and June. The Department will also reach out to any new facilities on an on-going basis.

  • Response Type†: 6-Month
  • Completion Date: April 2014
  • Response Date: April 2014

California State Auditor's Assessment of Status: Partially Implemented

Justice describes its first meeting with the Department of Health Care Services and the resulting actions that Justice took after the meeting. However, it did not provide documents that would indicate the results of this meeting. As such, we continue to consider this recommendation partially implemented and anticipate reviewing the results of Justice's second meeting with Health Care Services at the one-year response.

  • Auditee did not substantiate its claim of full implementation

Agency Response*

The Department sent a letter on November 19, 2013, to Department of Health Care Services (DHCS) Director Tobey Douglas. Subsequently, we were contacted by Lanette Castleman, Chief of DHCS Oversight and Compliance Branch. Chief Castleman advised that a list of designated facilities is currently on the DHCS website. AC Buford requested DHCS review the website listing and forward a copy under agency letterhead indicating the list had been reviewed and verified to be the most current. Additionally, the Department and DHCS agreed to meet in mid-January 2014 on the following topics: 1) identify any discrepancies in the list submitted by DHCS: 2) discuss ways both agencies can work together to enhance the facility licensing process; 3) suggest methods to better educate facilities regarding state mandated reporting of danger to self/others mental health patients; and 4) conduct follow-up with facilities when facility reporting statistics indicate low or non-compliance with required reporting.

  • Response Type†: 60-Day
  • Estimated Completion Date: April 2014
  • Response Date: December 2013

California State Auditor's Assessment of Status: Partially Implemented


All Recommendations in 2013-103

†Response Type refers to the interval in which the auditee is providing the State Auditor with their status in implementing recommendations made in an audit report. Auditees must submit a response regarding their progress in implementing recommendations from our reports at three intervals from the release of the report: 60 days, six months, and one year or subsequent to one year.

*Agency responses received after June 2013 are posted verbatim.


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