Report 2021-109 All Recommendation Responses

Report 2021-109: San Diego County Sheriff's Department: It Has Failed to Adequately Prevent and Respond to the Deaths of Individuals in Its Custody (Release Date: February 2022)

Recommendation for Legislative Action

To ensure that all sheriff's departments accurately report deaths that occur from incidents or conditions in county jails, the Legislature should amend state law to require sheriff's departments to report to the attorney general individuals who are released from custody after being transported directly to a hospital or similar medical facility and subsequently die in the facility. It should also amend state law to require sheriff's departments to provide the attorney general with all facts concerning the death, such as the cause and manner. The California Department of Justice should annually publish this information on its website.

Description of Legislative Action

As of March 2023, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 1-Year Status: No Action Taken

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

To ensure that the San Diego Sheriff's Department identifies individuals' medical and mental health needs at intake, the Legislature should require it to revise its policies to better align with best practices, as follows:

- Revise its intake screening policy to require mental health professionals to perform its mental health evaluations. These evaluations should include a mental health acuity level rating scale to better inform individuals' housing assignments and service needs while in custody. The Sheriff's Department should communicate the acuity level rating it assigns to individuals to all detention staff overseeing them.

- Create a policy requiring health staff to review and consider each individual's medical and mental health history from the county health system during the intake screening process.

Description of Legislative Action

AB 268 (Weber, 2023) would commence July 1, 2024 and, among other things, require the Board of State and Community Corrections (BSCC) to develop and adopt regulations pertaining to standards of care for incarcerated people with mental health issues by local correctional facilities, including requirements for training of correctional staff, requirements for mental health screening, and requirements for safety checks of incarcerated people. The bill is pending in the Assembly Appropriations Committee (3/22/2023).

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

To ensure that the Sheriff's Department provides the necessary medical and mental health care to individuals incarcerated in its facilities, the Legislature should require it to do the following:

- Revise its policy to require that nurses schedule an individual for an appointment with a doctor if that individual has reported to the nurse for evaluation more than twice for the same complaint.

- Revise its policy to require that a nurse perform and document a face-to-face appraisal with an individual within 24 hours of receipt of a request for medical services to determine the urgency of that request.

- Revise its policy to require more frequent psychological follow-up after release from the inmate safety program, including at least monthly check-ins.

- Revise its policy to require that a member of its health staff witness and sign the refusal form when an individual declines to accept necessary health care.

Description of Legislative Action

As of March 2023, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 1-Year Status: No Action Taken

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

To ensure that sworn staff properly perform safety checks, the Legislature should require the Sheriff's Department to do the following:

- Revise the safety check policy to include the requirement for staff to check that an individual is still alive without disrupting the individual's sleep.

- Develop and implement a policy requiring that designated supervising sworn staff conduct audits of at least two randomly selected safety checks from each prior shift. These audits should include a review of the applicable safety check logs and video footage to determine whether the safety checks were performed adequately. In addition, the policy should require higher-ranking sworn staff to conduct weekly and monthly audits of safety checks. The policy should also require each facility to maintain a record of the safety check audits that staff members perform.

Description of Legislative Action

AB 268 (Weber, 2023) would, among other things, commencing July 1, 2024, require the BSCC to develop and adopt regulations pertaining to standards of care for incarcerated persons with mental health issues by local correctional facilities, including safety checks of incarcerated persons that are sufficiently detailed to determine the safety and well-being of the incarcerated person, and that they are not in distress. This determination would not require facility staff to disturb or wake incarcerated persons during sleeping hours. The bill would also require jail supervisors to conduct random audits of safety checks that include a review of logs and video footage, if available, to ensure that safety checks are properly performed. Bill is pending in Assembly Appropriations Committee 3/22/2023.

SB 762 (Becker, 2023) would require the BSCC to revise standards to require a local detention facility to include a procedure for affirming that an incarcerated individual is alive during a safety check. As of 3/29/2023, the bill was referred to the Committee on Public Safety.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

To ensure that department staff promptly respond to unresponsive individuals, the Legislature should require the Sheriff's Department to revise its policies to require that sworn staff members immediately start CPR without waiting for medical approval, as safety procedures allow. The Legislature should also require that the Sheriff's Department provide sworn staff with additional training for starting CPR immediately and how to properly alert medical staff.

Description of Legislative Action

AB 268 (Weber, 2023) would, among other things, commencing July 1, 2024, require the BSCC to develop and adopt regulations pertaining to standards of care for incarcerated persons with mental health issues by local correctional facilities, including requiring that correctional officers be certified in cardiopulmonary resuscitation (CPR) and be required, when safe and appropriate to do so, to begin CPR on a nonresponsive person without obtaining approval from supervisors or medical staff. Bill is pending in Assembly Appropriations Committee 3/22/2023.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

To ensure that the Sheriff's Department properly assesses the reasons for each in-custody death and makes prompt changes as necessary in response, the Legislature should require it to revise its policy to specify the following:

- Staff will provide a written report of each 30-day medical review to its management.

- When warranted, the report should specify recommendations for changes to prevent further deaths.

- The 30-day medical review should determine the appropriateness of clinical care; assess whether changes to policies, procedures, or practices are warranted; and identify issues that require further study.

Description of Legislative Action

As of March 2023, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 1-Year Status: No Action Taken

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

To improve oversight of in-custody deaths and encourage meaningful action to prevent future deaths, the Legislature should require the Sheriff's Department to revise its policy to require that the Critical Incident Review Board review natural deaths.

Description of Legislative Action

As of March 2023, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 1-Year Status: No Action Taken

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

To increase the transparency of the Sheriff's Department's reviews of in-custody deaths, the Legislature should require the Sheriff's Department to either make public the facts it discusses and recommendations it decides upon in the relevant Critical Incident Review Board meetings or to establish a separate public process for internally reviewing deaths and making necessary changes.

Description of Legislative Action

SB 519 (Atkins) would make records relating to an investigation conducted by a local detention facility into a death incident, as defined, or relating to a subject officer, as defined, available to public inspection. As of 4/18/2023, the bill is set for hearing before the Senate Governance & Finance Committee.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

To ensure that the Sheriff's Department provides complete and prompt assistance to CLERB's investigations, the Legislature should require the Sheriff's Department to do the following:

- Revise its policy to include CLERB in its immediate death notification process.

- Revise its policy to allow a CLERB investigator to be present at the initial death scene.

- Revise its policy to encourage its staff to cooperate with CLERB's investigations, including participating in interviews with CLERB's investigators.

Description of Legislative Action

As of March 2023, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 1-Year Status: No Action Taken

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 60-Day Status: No Action Taken

Recommendation for Legislative Action

To ensure that standards of care for incarcerated individuals are adequate and consistent across the State, the Legislature should amend state law to require BSCC to amend certain regulations to address the following:

- County sheriff's departments with jails that have an average daily population of more than 1,000 must have a mental health professional perform mental health evaluations at intake.

- Safety checks must include a procedure for checking to see that each individual is alive.

Description of Legislative Action

AB 268 (Weber, 2023) would, among other things, commencing July 1, 2024, require the BSCC to develop and adopt regulations pertaining to standards of care for incarcerated persons with mental health issues by local correctional facilities, including requiring that mental health screening or evaluation be conducted at booking or intake by a qualified mental health care professional, if available. Mental health screening or evaluation that is conducted by anybody other than a qualified mental health care professional would have to be reviewed by a qualified mental health care professional as soon as reasonably practicable. The bill would also require that safety checks be sufficiently detailed to determine the safety and well-being of incarcerated persons and that they are not in distress. Bill is pending in Assembly Appropriations Committee 3/22/2023.

SB 762 (Becker, 2023) would require the BSCC to revise standards to require a local detention facility to include a procedure for affirming that an incarcerated individual is alive during a safety check. As of 3/29/2023, the bill was referred to the Committee on Public Safety.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

AB 2343 (Weber, Atkins, 2022) would require the BSCC to adopt regulations setting minimum standards for mental health care at local correctional facilities, including safety checks of incarcerated persons that are sufficiently detailed to determine that the inmate is alive. As of September 2, 2022, this bill passed the legislature and has been submitted to the Governor for signature.

California State Auditor's Assessment of 6-Month Status: Legislation Introduced

As of September 2, 2022, this AB 2343 passed the legislature and has been submitted to the Governor for signature.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken action to address these specific recommendations. However, AB 2343 (Weber, 2022) would require BSCC, commencing July 1, 2023, to develop and adopt regulations setting minimum standards for mental health care at local correctional facilities that meet or exceed the standards for health services in jails established by the National Commission on Correctional Health Care. Those regulations would be required to include a provision that a mental health screening or evaluation conducted at booking or intake be conducted by a qualified mental health care professional, if available. A mental health screening or evaluation that is conducted by anybody other than a qualified mental health care professional shall be reviewed by a qualified mental health care professional as soon as reasonably practicable. The regulations must address safety checks in sufficient detail to determinate that an inmate is alive. As of April 2022, this bill is pending in the Assembly.

California State Auditor's Assessment of 60-Day Status: Legislation Introduced

Recommendation for Legislative Action

To ensure the involvement of experts in the areas of medical and mental health care in approving BSCC's regulations and training standards related to the health and safety of incarcerated individuals, the Legislature should change the composition of BSCC to include a medical professional and a mental health professional.

Description of Legislative Action

AB 268 (Weber, 2023) would, among other things, commencing July 1, 2024, add two additional members to the BSCC, a licensed health care provider and a licensed mental health care provider, each appointed by the Governor, subject to confirmation by the Senate. The bill is pending in the Assembly Appropriations Committee 3/22/2023.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

AB 2343 (Weber, Atkins, 2022) would change the composition of the BSCC to include additional members effective July 1, 2023, including a licensed health care provider and a license mental health professional, both appointed by the Governor. As of September 2, 2022, this bill passed the legislature and has been submitted to the Governor for signature.

California State Auditor's Assessment of 6-Month Status: Legislation Introduced

As of September 2, 2022, AB 2343 passed the legislature and has been submitted to the Governor for signature.

Description of Legislative Action

AB 2343 (Weber, 2022) would increase the composition of BSCC, commencing July 1, 2023, to fifteen members which shall include a licensed health care provider and a licensed mental health care provider, appointed by the Governor and subject to Senate confirmation.

California State Auditor's Assessment of 60-Day Status: Legislation Introduced

Recommendation for Legislative Action

To ensure that BSCC's regulations, guidance, and training align with medical and mental health care best practices, the Legislature should require BSCC to evaluate and update all of its regulations and training as needed once its composition includes a medical professional and a mental health professional.

Description of Legislative Action

As of March 2023, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 1-Year Status: No Action Taken

Description of Legislative Action

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

California State Auditor's Assessment of 6-Month Status: No Action Taken

As of September 2, 2022, the Legislature has not taken action to address this specific recommendation.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken any action to address this specific recommendation. However, AB 2343 (Weber, 2022) would add a licensed health care provider and a licensed mental health care provider to BSCC, commencing July 1, 2023 and would require BSCC, commencing July 1, 2023, to develop and adopt regulations setting minimum standards for mental health care at local correctional facilities that meet or exceed the standards for health services in jails established by the National Commission on Correctional Health Care.

California State Auditor's Assessment of 60-Day Status: Legislation Introduced

Recommendation for Legislative Action

To ensure that all local correctional officers in the State receive sufficient continuing professional education, the Legislature should require BSCC to amend its regulations to require that local correctional officers working in local detention systems with an average daily population of more than 1,000, complete 40 hours of training annually and that at least four of those hours relate to mental and behavioral health.

Description of Legislative Action

AB 268 (Weber, 2023) would, among other things, commencing July 1, 2024, require the BSCC to develop and adopt regulations that provide for in-service training of correctional officers that include no fewer than four hours of training on mental and behavioral health annually. The bill is pending in the Assembly Appropriations Committee 3/22/2023.

California State Auditor's Assessment of 1-Year Status: Legislation Introduced

Description of Legislative Action

AB 2343 (Weber, Atkins, 2022) would require the BSCC to adopt regulations setting minimum standards for mental health care at local correctional facilities, including in-service training of correctional officers to include no fewer than four hours of training on mental and behavioral health annually. As of September 2, 2022, this bill passed the legislature and has been submitted to the Governor for signature.

California State Auditor's Assessment of 6-Month Status: Legislation Introduced

As of September 2, 2022, AB 2343 passed the legislature and has been submitted to the Governor for signature.

Description of Legislative Action

As of April 4, 2022, the Legislature has not taken any action to address this specific recommendation. However, AB 2343 (Weber, 2022) would require BSCC, commencing July 1, 2023, to develop and adopt regulations setting minimum standards for mental health care at local correctional facilities that meet or exceed the standards for health services in jails established by the National Commission on Correctional Health Care. Those regulations would be required to include a provision that in-service training of correctional officers include no fewer than four hours of training, developed in conjunction with the Commission on Peace Officer Standards and Training, on mental and behavioral health annually. The regulations shall also specify that health care and mental health care providers employed by, or regularly working within, a county jail shall receive no fewer than 12 hours of continuing education annually that is relevant to correctional health care and mental health care.

California State Auditor's Assessment of 60-Day Status: Legislation Introduced

Recommendation #14 To: Citizens' Law Enforcement Review Board

To ensure its investigations are independent, timely, and thorough, CLERB should, by May 2022, discuss and modify its current agreement with the Sheriff's Department and the labor organization to allow CLERB's investigators to conduct independent interviews of Sheriff's Department sworn staff.

1-Year Agency Response

San Diego County Code of Administrative Ordinances (Admin. Code) Section 340.15 mandates that "in the discharge of its duties, the Review Board shall receive complete and prompt cooperation from all officers and employees of the County. The Review Board and other public officers, including the Sheriff, the District Attorney, and the Grand Jury, shall coordinate their activities so that the other public officers and the Review Board can fully and properly perform their respective duties."

Throughout 2021 and 2022, the CLERB Executive Officer (EO), the former Deputy Sheriff's Association (DSA) President, DSA Counsel, and CLERB's Outside Counsel had several conversations pertaining to CLERB interviews of deputies. It is CLERB's position that the emphasized phrase above should be sufficient to enforce the complete and prompt cooperation of all County employees afforded CLERB in the discharge of its duties and will continue to work with the Sheriff's Department and Probation Department and applicable labor organizations to obtain such cooperation.

As of this writing, the DSA will advise deputies that an interview may be requested by CLERB staff if CLERB staff believe an interview is necessary. If the deputy decides to participate in the interview, SDSD administration, CLERB staff, and the DSA will ensure the interviews are conducted pursuant to the protections provided by the Public Safety Officers Procedural Bill of Rights Act detailed in California Government Code Sections 3300-3313 and any other applicable law, including Miranda v. Arizona, 384 U.S. 436 (1966), Lybarger v. City of Los Angeles 40 Cal.3d 822 (1985), and Garrity v. New Jersey, 385 U.S. 493 (1967). This agreement has not yet been formalized in writing but the DSA has agreed to do so.

Finally, it is my understanding that the new SDSD administration is currently assessing whether it will support CLERB interviews of SDSD personnel.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

In July 2022, the CLERB Executive Officer (EO), the Deputy Sheriff's Association (DSA) President, DSA Counsel, and CLERB's Outside Counsel continued the conversations initiated in the last quarter of 2021. The DSA will permit interviews of San Diego Sheriff's Department (SDSD) sworn staff when CLERB staff deems an interview is necessary. SDSD personnel, CLERB staff, and the DSA will ensure the interviews are conducted pursuant to the protections provided by the Public Safety Officers Procedural Bill of Rights Act detailed in California Government Code Sections 3300-3313 and any other applicable law.

California State Auditor's Assessment of 6-Month Status: Pending

CLERB has not yet documented a formal agreement in writing with the Sheriff's Department and the labor organization. We look forward to getting an update on the progress of documenting this agreement at the one-year response in February.

60-Day Agency Response

In March 2022, CLERB finalized a contract with new outside counsel, Duane E. Bennett. Now that Mr. Bennett is in place, the CLERB Executive Officer (EO), the Deputy Sheriff's Association (DSA) President, DSA Counsel, and Mr. Bennett will expand upon the initial conversations had about this topic in the last quarter of 2021 and the EO will advise the CSA of the status during its six-month update.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #15 To: Citizens' Law Enforcement Review Board

To ensure its investigations are independent, timely, and thorough, CLERB should, by May 2022, develop a comprehensive training manual for its investigators that outlines standard procedures for investigations. The manual should include a specific section dedicated to investigations of in-custody deaths, including guidance for evaluating the circumstances leading up to an in-custody death, such as the decedent's mental health history and the appropriateness of the decedent's housing assignment.

1-Year Agency Response

A comprehensive training manual containing the following topics has been completed:

o County structure

o CLERB historical perspective

o County Charter, Section 606

o County Administrative Code, Section 340

o CLERB Rules and Regulations

o Civil Service Commission Rule XV

o Case Law Including and impacting CLERB

o Public Safety Officer Procedural Bill of Rights (POBOR)

o Statutes Pertaining to Peace Officer Records

o San Diego County Grand Jury Reports Pertaining to CLERB

o Ralph M. Brown Act

o San Diego County Operational Plan Pertaining to CLERB

o CLERB's Internal Policies and Procedures

The training manual is being updated to include a specific section dedicated to investigations of in-custody deaths, to include an evaluation of the circumstances leading up to an in-custody death, and to include a review of the decedent's mental health history and the appropriateness of the decedent's housing assignment. It will also include evaluations of a trainee's performance and documentation as to his/her progress, or lack thereof. In addition to these critical topics, there will be documented instructions to evaluate the timeliness and thoroughness of welfare checks conducted on the decedent by deputies and assess whether deputies appropriately determined that a life-threatening emergency existed and responded accordingly. The updated training manual will be released on March 1, 2023.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

A comprehensive training manual containing the following topics has been completed:

o County structure

o CLERB historical perspective

o County Charter, Section 606

o County Administrative Code, Section 340

o CLERB Rules and Regulations

o Civil Service Commission Rule XV

o Case Law Including and impacting CLERB

o Public Safety Officer Procedural Bill of Rights (POBOR)

o Statutes Pertaining to Peace Officer Records

o San Diego County Grand Jury Reports Pertaining to CLERB

o Ralph M. Brown Act

o San Diego County Operational Plan Pertaining to CLERB

o CLERB's Internal Policies and Procedures

The training manual is being finalized to include a specific section dedicated to investigations of in-custody deaths, to include an evaluation of the circumstances leading up to an in-custody death, and to include a review of the decedent's mental health history and the appropriateness of the decedent's housing assignment. It will also include evaluations of a trainee's performance and documentation as to his/her progress, or lack thereof. In addition to these critical topics, there will be documented instructions to evaluate the timeliness and thoroughness of welfare checks conducted on the decedent by deputies and assess whether deputies appropriately determined that a life-threatening emergency existed and responded accordingly. The EO will advise the CSA of the final training manual status during its one-year update.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

A comprehensive training manual containing the following topics is being authored:

o County structure

o CLERB historical perspective

o County Charter, Section 606

o County Administrative Code, Section 340

o CLERB Rules and Regulations

o Civil Service Commission Rule XV

o Case Law Including and impacting CLERB

o Public Safety Officer Procedural Bill of Rights (POBOR)

o Statutes Pertaining to Peace Officer Records

o San Diego County Grand Jury Reports Pertaining to CLERB

o Ralph M. Brown Act

o San Diego County Operational Plan Pertaining to CLERB

o CLERB's Internal Policies and Procedures

o Results of CLERB's Business Process Review

The training manual will also include a specific section dedicated to investigations of in-custody deaths, to include an evaluation of the circumstances leading up to an in-custody death, and to include a review of the decedent's mental health history and the appropriateness of the decedent's housing assignment. It will also include evaluations of a trainee's performance and documentation as to his/her progress, or lack thereof. In addition to these critical topics, there will be documented instructions to evaluate the timeliness and thoroughness of welfare checks conducted on the decedent by deputies and assess whether deputies appropriately determined that a life-threatening emergency existed and responded accordingly. The EO will advise the CSA of the training manual status during its six-month update.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #16 To: Citizens' Law Enforcement Review Board

To ensure its investigations are independent, timely, and thorough, CLERB should, by May 2022, create policies and procedures to require its investigators to finish casework on in-custody death investigations within three months of receiving the homicide investigation file. These policies and procedures should also require investigators to attempt to independently verify any information they receive from the Sheriff's Department, to thoroughly review deputy statements and reports from the homicide investigation file, and to request interviews with relevant detention staff and other witnesses in all instances in which they identify discrepancies or missing information.

60-Day Agency Response

On February 3, 2022, the EO incorporated all aspects of this recommendation into existing CLERB Policy #300.5, entitled, "Death Investigations."

California State Auditor's Assessment of 60-Day Status: Fully Implemented

CLERB provided an updated policy related to death investigations that includes the required elements from our recommendation.

Recommendation #17 To: Citizens' Law Enforcement Review Board

To ensure that it fully investigates all in-custody deaths, CLERB should revise its rules and regulations by May 2022 to include the following:

- Prioritization criteria for investigating in-custody deaths above all other investigations.

- Clarification that its investigations of in-custody deaths includes those classified as natural deaths.

1-Year Agency Response

The EO and County Counsel have drafted verbiage to revise CLERB's Rules and Regulations (R&R) to prioritize death investigations over all other investigations. The EO is pursuing this change along with some other changes to the R&R and County Administrative Code (Code). Those additional changes require the assistance of Labor Relations and conferences with the affected labor associations. Once the labor relations process is complete, CLERB will review the proposed changes to the Code and R&R. If CLERB approves the changes, they will be brought before the Board of Supervisors for final approval. A summary of the proposed R&R changes, to include prioritization of in-custody deaths above all other investigations and clarification that its investigations of in-custody deaths include those classified as natural deaths, was presented to CLERB and the public on January 31, 2023. A final draft of the proposed R&R changes will be presented to CLERB and the public on February 14, 2023. The final proposed changes will then be forwarded to Labor Relations for meet-and-confer purposes.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The EO and County Counsel have drafted verbiage to revise CLERB's Rules and Regulations (R&R) to prioritize death investigations over all other investigations. The EO is pursuing this change along with some other changes to the R&R and County Administrative Code (Code). Those additional changes require the assistance of Labor Relations and conferences with the affected labor associations. Once the labor relations process is complete, CLERB will review the proposed changes to the Code and R&R. If CLERB approves the changes, they will be brought before the Board of Supervisors for final approval. The EO will advise the CSA of the Code and R&R revision status during its one-year update.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The EO and County Counsel have drafted verbiage to revise CLERB's Rules and Regulations (R&R) to prioritize death investigations over all other investigations. The EO is pursuing this change along with some other changes to the R&R and County Administrative Code (Code). Those additional changes require the assistance of Labor Relations and conferences with the affected labor associations. Once the labor relations process is complete, CLERB will review the proposed changes to the Code and R&R. If CLERB approves the changes, they will be brought before the Board of Supervisors for final approval. The EO will advise the CSA of the Code and R&R revision status during its six-month update.

California State Auditor's Assessment of 60-Day Status: Pending

Recommendation #18 To: Citizens' Law Enforcement Review Board

To ensure that it provides effective oversight of the deaths of individuals in the Sheriff's Department's custody, CLERB should perform an analysis of overall trends related to these deaths, including demographic information, and determine whether the trends suggest deficiencies in the Sheriff's Department's policies and procedures. Based on these trends, it should also identify policy recommendations for improving the safety of the individuals in the Sheriff's Department's custody. To increase transparency, CLERB should include these trends and analyses in its annual reports starting with its 2021 report, which it should publish in 2022.

1-Year Agency Response

The current EO has prioritized in-custody death investigations and the analysis of overall trends related to the deaths, to include demographic information. The current EO has committed to expanding the reporting to include an analysis of overall trends related to deaths, including demographic information and whether the trends suggest a deficiency in the SDSD's policies and procedures, in the 2021 Annual Report and all subsequent Annual and Semi-Annual Reports. In addition, all CLERB policy recommendations made in 2021 were included in the 2021 Annual Report, which was approved by CLERB in August 2022 and presented to the Board of Supervisors later that month.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

CLERB's 2021 Annual Report and 2022 Semi-Annual Report include metrics related to deaths in detention facilities, including demographic information. In its 2022 Semi-Annual Report, CLERB included recommendations based on data that indicated disparate enforcement of offenses. CLERB should continue to perform an analysis of overall trends related to in-custody deaths and identify policy recommendations for improving the safety of the individuals in the Sheriff's Department's custody.

6-Month Agency Response

The current EO has prioritized in-custody death investigations and the analysis of overall trends related to the deaths, to include demographic information. The current EO has committed to expanding the reporting to include an analysis of overall trends related to deaths, including demographic information and whether the trends suggest a deficiency in the SDSD's policies and procedures, in the 2021 Annual Report. In addition, all CLERB policy recommendations made in 2021 will be included in the 2021 Annual Report. The 2021 Annual Report will be presented to CLERB in August 2022.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The current EO has prioritized in-custody death investigations and the analysis of overall trends related to the deaths, to include demographic information. The current EO has committed to expanding the reporting to include an analysis of overall trends related to deaths, including demographic information and whether the trends suggest a deficiency in the Sheriff's Department's policies and procedures, in the 2021 Annual Report. In addition, all CLERB policy recommendations made in 2021 will be included in the 2021 Annual Report. The 2021 Annual Report is in progress. The EO will advise the CSA of the 2021 Annual Report status during its six-month update.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2021-109

Agency responses received are posted verbatim.