Sacramento County

2002- 2003 Grand Jury

Final Report

June 30, 2003

Drawings done by Grand Juror Ed Hoefling

Sacramento County Grand Jury June 30, 2003

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TABLE OF CONTENTS

Letter from the Grand Jury Foreman iii

2002 – 2003 Grand Jurors v

Grand Jury Committee Assignments vii

The Year in Review – The Grand Jury Perspective ix

Reports and Investigations

·   Death Investigation in Sacramento County: The Coroner’s Office 1

·   Elk Grove Unified School District’s Failure to Recognize Fiscal

Irresponsibility Prompting a Second Grand Jury Investigation 17

·   Letter Grades for Restaurants 29

·   Misuse of Appointive Power by the Galt City Council 35

·   Recommendations for Improving Public Water Districts’ Accountability 37

·   School Safety in Jeopardy 49

Ten- Year Index of Final Reports 55

How to Contact the Grand Jury 61

Sacramento County Grand Jury June 30, 2003

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June 10, 2003

Honorable Richard K. Park

Advisor Judge to the Grand Jury

Sacramento Superior Court

720 Ninth Street, Department 39

Sacramento, CA 95814

Dear Judge Park:

In compliance with Penal Code Section 933, the Sacramento County Grand Jury is

pleased to submit to you its 2002- 2003 Final Report.

It has been my honor and pleasure to serve as Foreman of the Grand Jury. Thank

you for giving me this opportunity. This Final Report is the result of the nineteen

members working many hours researching, interviewing, investigating, writing

and deliberating over a number of issues. The members of this Jury worked as a

team that came together early in our term. They accepted their duty and set about

the business of the Grand Jury with enthusiasm and a spirit of cooperation. Each

member brought a unique attribute to the team. It was a pleasure to work with

them and to get to know them.

The Grand Jury is grateful for the sincere dedication of all the public officials with

whom we spoke. The cooperation this Jury received from staff, directors and

public officials was commendable. In addition to our mandated tours, this Jury

asked to be briefed by and had presentations from many agencies and departments

within Sacramento County administration. All who came before us were generous

with their time. They were professional, knowledgeable and were able to provide

the information we needed concisely and in an understandable manner.

Members of the public brought many issues to our attention. In addition, the Jury

initiated some investigations as a result of our observations and from other

sources. Although every complaint submitted to the Grand Jury received our

consideration, many did not result in formal action. Therefore, much of the work

the Jury undertook is not reflected in this report.

We relied on the advice of County Counsel, the District Attorney’s Office and the

Department of Justice Attorney General’s Office. Our requests for opinions were

answered in a timely manner. The Jury expresses its sincere appreciation to all

who gave so generously of their time.

Sacramento County

GRAND JURY

Barry T. Heilman, Foreman

Donald E. Bunn

C. Russell Campbell, Jr.

Gonzales Cannon

Diane Chikasawa

James Connick

Elsie S. Corbin

Linda K. Cummings

Sally C. Gibson

Edward J. Hoefling

Gwendolyn Jackson Tucker

Ralph E. Keys

Frederick Kuhl

Rees L. Lee

Robert T. Olmstead, Jr.

Miquel Rodriguez

Marty Shepherd

David C. Smith

Naomi Toyooka

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We also thank you, Judge Park, for the advice and support you provided as our Advisor Judge. You have

been at our side from the beginning of our term to the completion of our work. The advice you provided

to me and the Jury enabled us to come to the right conclusions. Thank you for your generous time

commitment and your dedication to grand jury process in Sacramento County.

Finally, all of us on the Jury express our heartfelt thanks to Michelle Park, Executive Secretary of the

Grand Jury. Michelle provided valuable guidance and knowledge throughout the year. This report

reflects her professionalism and outstanding work.

The members of the 2002- 2003 Grand Jury are honored to have served our community and hope our

efforts are a positive contribution towards better government.

Sincerely,

Barry T. Heilman, Foreman

2002- 2003 Sacramento County Grand Jury

Sacramento County Grand Jury June 30, 2003

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2002- 2003 SACRAMENTO COUNTY GRAND JURY

Donald E. Bunn

Supervising Health Physicist

Dept. of Heath Services ( retired)

Sacramento

C. Russell Campbell, Jr.

Executive, GTE Corporation

( retired)

Rancho Cordova

Gonzales Cannon

Telecommunication Technician

SBC- Pacific Bell ( retired)

North Highlands

Diane Chikasawa

Data Processing Manager

State of California

Sacramento

James Connick

Insurance Broker

Teacher ( retired)

Sacramento

Elsie S. Corbin

State Controller’s Office ( retired)

Sacramento

Linda K. Cummings

Large Systems Capacity Planner

State of California

Health & Human Services Data

Center

Sacramento

Sally C. Gibson

Management

Travel

Physical Therapist

Sacramento

Barry T. Heilman

Pharmaceutical Sales

and Marketing

Folsom

Edward J. Hoefling

Executive Director, California

State Board of Chiropractic

Examiners ( retired)

Citrus Heights

Gwendolyn Jackson Tucker

California Youth Authority

Administrator

Sacramento

Ralph E. Keys

Hospital Linen/ Laundry

Manager ( retired)

Sacramento

Frederick Kuhl

Teacher of Journalism & English

American River College ( retired)

Rancho Cordova

Rees L. Lee

High School Principal

( retired)

Carmichael

Robert T. Olmstead, Jr.

Professor of English

( retired)

Sacramento

Miquel Rodriguez

Federal Prosecutor

Elk Grove

Marty Shepherd

Accountant

Fair Oaks

David C. Smith, M. D.

Physician– Cardiovascular

Diseases

Sacramento

Naomi Toyooka

Training & Development H. R.

Specialist

U. S. Postal Service

Sacramento

Sacramento County Grand Jury June 30, 2003

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2002- 2003 Grand Jury

Committee Assignments

Officers:

Barry T. Heilman, Foreman Ralph E. Keys, Sergeant- at- Arms

Linda K. Cummings, Foreperson Pro Tempore Edward J. Hoefling, Parliamentarian

Naomi Toyooka, Secretary C. Russell Campbell, Jr. Provisioner

Administrative & Municipal Affairs Criminal and Juvenile Justice

C. Russell Campbell, Jr., Chair James Connick, Chair

Gonzales Cannon Gonzales Cannon

Elsie S. Corbin Diane Chikasawa

Sally C. Gibson Edward J. Hoefling

Edward J. Hoefling Gwendolyn Jackson Tucker

Frederick Kuhl Ralph E. Keys

Rees L. Lee Frederick Kuhl

Miquel Rodriguez Robert T. Olmstead, Jr.

Marty Shepherd Marty Shepherd

David C. Smith

Naomi Toyooka

Continuity Edit

Edward J. Hoefling, Chair Robert T. Olmstead, Jr., Chair

Donald E. Bunn Donald E. Bunn

C. Russell Campbell, Jr. James Connick

James Connick Edward J. Hoefling

Sally C. Gibson Frederick Kuhl

Rees L. Lee Rees L. Lee

Robert T. Olmstead, Jr.

Education Environment, Public Works

& Special Districts

Rees L. Lee, Chair Donald E. Bunn, Chair

Donald E. Bunn C. Russell Campbell, Jr.

Diane Chikasawa James Connick

Elsie S. Corbin Linda K. Cummings

Linda K. Cummings Edward J. Hoefling

Sally C. Gibson Ralph E. Keys

Ralph E. Keys Rees L. Lee

Robert T. Olmstead, Jr. Miquel Rodriguez

Miquel Rodriguez David C. Smith

Naomi Toyooka

Health and Human Services

Sally C. Gibson, Chair

Gonzales Cannon

Diane Chikasawa

James Connick

Elsie S. Corbin

Linda K. Cummings

Gwendolyn Jackson Tucker

Frederick Kuhl

Marty Shepherd

David C. Smith

Naomi Toyooka

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The Year in Review

The Grand Jury Perspective

Traditionally, a section detailing the history of the grand jury has preceded the final

reports. This year the jury decided to replace the history with a summary of events that

took place during our term. Yo u are welcome to view the history of the grand jury on our

web site www. sacgrandjury. org where you will find a general history of the grand jury

system as well as how it evolved in California.

We would like to share with you the state laws and codes from which the grand jury

derives its authority and reason for existence. Article I, Section 23 of the California State

Constitution states that “ a grand jury shall be drawn and summoned at least once a year in

each county.” The rules governing the makeup, organization, powers and duties of grand

juries in California are found in the California Penal Code Sections 888- 939. California

grand juries are for the most part civil grand juries. They look into the activities and

procedures of governmental agencies within the county. This also includes the cities and

special districts within the county. Recipients of our reports need to know that our

investigations have led to our findings. It is our responsibility to issue a report of our

findings and recommendations just as it is their responsibility to provide services to the

citizens of Sacramento County. It should be noted that while the duties of the grand jury

are primarily civil in nature, the jury might be called upon by the District Attorney to

issue criminal indictments. This was the case for the 2002– 2003 Grand Jury.

The 2002- 2003 Sacramento County Grand Jury completed its term on June 30, 2003. In

this report readers will see the specific investigations leading to recommendations for the

named county and city agencies. These investigations, however, do not completely cover

the scope of the activities this jury pursued. We received over 70 complaints. All were

reviewed and those we chose are included in this report, which is an effort to provide

information not contained in our formal findings.

One of the Grand Jury- mandated functions is to tour each correctional facility within the

county. To that end this Grand Jury toured the following facilities:

1. California State Prison, Sacramento

2. Folsom State Prison

3. Folsom Community Correctional Facility

4. Sacramento County Main Jail

5. Rio Cosumnes Correctional Center ( RCCC)

6. Sacramento County Work Release Center Facility

7. Sacramento County Juvenile Hall

8. Warren E. Thornton Youth Center

9. Sandra Larson Youth Facility at RCCC

10. Sacramento County Boys Ranch

11. Sacramento Assessment Center

12. Department of the Youth Authority Northern Youth Correctional

Reception Center- Clinic

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In addition to the mandated tours, we received presentations or were given tours of the

following facilities:

1. Sacramento County Airport System– Sacramento International Airport

2. Sacramento County Coroner’s Office

3. Sacramento County Crime Laboratory

4. Sacramento County Planning Department

5. Sacramento County Voter Registration and Elections

6. Sacramento Municipal Utilities District

7. Sacramento County Public Health Officer

The Grand Jury expresses its sincere appreciation to all those who assisted us on the tours

and who gave presentations. We are very impressed with their dedication and

professionalism.

Certain agencies warrant special comment from this Grand Jury. Folsom State Prison

deserves our commendation for its work with Folsom Project for the Visually Impaired.

These inmates devote thousands of hours to converting reading material into Braille and

recording books, including previous grand jury final reports, on tape for the visually

impaired.

The principal at Carson Creek Junior and Senior High School deserves special

recognition for her efforts to meet the educational needs of wards at the Sacramento

County Boys Ranch. She requests the school records of each boy that comes to the

facility so that he may be placed in the appropriate grade and subject level. Some of the

wards receive education in specific skills while others receive GED training. The

principal is particularly proud of the wards who earn their high school diplomas while at

the Boys Ranch. Because the wards are only at the facility for a short period of time, we

ask every school district in the county to give particular attention to her requests for

records as a prompt reply allows the boys to be placed in the appropriate educational

environment. Delay in fulfilling these request results in loss of valuable learning time.

Some graduates from Carson Creek High School wrote impressive letters of appreciation.

We believe that those receiving their diplomas or GED at the Boys Ranch seem less

likely to return to the penal system.

We also commend the work being done by the Sacramento Assessment Center ( S. A. C.),

a program being run by the county Probation Department under a grant provided by the

California Board of Corrections. It is a residential assessment program for wards of the

Juvenile Court between the ages of 11 and 17, who are identified as needing out- of- home

placement for the first time. The purpose of the program is to determine and to meet the

residential needs of minors in the areas of education, social skills, daily living, vocation

and therapy. The Jury concluded that such an intens ive evaluation could lead to a more

positive placement and outcome of juveniles entering the system.

Also, the Grand Jury commends the effort made by the Sacramento County Sheriff’s

Department in improving the educational, recreational, and social conditions for women

Sacramento County Grand Jury June 30, 2003

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incarcerated at the Main Jail. Last year, the 2001- 2002 Grand Jury recommended the

women in the Main Jail be returned to RCCC. We are aware these changes will take time

and planning. However, the Sheriff and his staff immediately implemented some

programs and made changes to others. As a result the women at the Main Jail have more

educational opportunities and recreational activities and more time out of their cells.

The officers and staff of the Sacramento County Work Release Program deserve special

recognition for efforts they are making in utilizing the skills of those sentenced to the

work release program, such as restoring toys donated to the needy during the holiday

season.

During our term, we asked the Sacramento County Planning and Community

Development Department to give us a presentation on the plans for growth and

development in the southeast section of the county. We were and are concerned what

unrestricted growth would do to this area and to the county as a whole. The director and

his staff gave us a lengthy and detailed presentation.

What we learned from this presentation was that because of the attractiveness of our

county, it is inevitable that our population will double within the next 50 years. That

amount of growth requires planning for the housing, schools, and the infrastructure that

such growth dictates. We believe that the Planning Department has done a very good job

in planning for this growth, while allowing for nature preserves and maintaining

agricultural land s. However, our concern is that as the population moves to the southeast

section the agencies responsible will be tempted to recommend changes to zoning and

other restrictions that will allow development of these identified nature preserves and

agricultural lands. We are also concerned that there is not enough planning for

transportation. Lack of planning here could lead to even greater gridlock and longer

commute times.

We also had a presentation by the director and staff of the Sacramento County Airport

System and toured the Sacramento International Airport facility. We were impressed

with the dedication and professionalism of those involved with the system from Public

Relations to the Fire and Rescue Department.

Members of the Jury visited the Sacramento Municipal Utility District headquarters.

During our tour we were shown some of programs that SMUD uses to encourage

conservation. We were also provided with brochures that listed the many programs that

SMUD provides for both residential and commercial customers.

We would also like to thank the Director of the Sacramento County Crime Lab for his

informative briefing and tour.

As one can see, the Jury was briefed by dozens of dedicated city, county and state

employees. To those we met and talked with, our sincere appreciation for your efforts

and presentations. To those thousands of employees you represent, thank you for all you

do.

Sacramento County Grand Jury June 30, 2003

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Sacramento County Grand Jury June 30, 2003

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Death Investigation in Sacramento

County: The Coroner’s Office

Issue

The 2002- 2003 Sacramento County Grand Jury has become aware of significant issues

regarding death investigation in Sacramento County.

Death investigation has evolved to a medical subspecialty directed by medically qualified

people. Nationwide there is a movement to replace coroner systems with medical examiner

systems directed by forensic pathologists independent and unrelated to law enforcement and

prosecutorial agencies and responding directly to the governing body.

In Sacramento County death investigation is conducted by the Sacramento County Coroner,

defined as an administrative and law enforcement position, appointed by the Board of

Supervisors. The coroner and his deputy staff are not required to have formal medical training.

The coroner’s pathology staff does not have medical autonomy or final authority, and their

medical judgments can be overruled.

Recent organizational changes within the coroner’s office have potentially further compromised

medical autonomy. Conflict of interest issues with respect to investigation of in- custody deaths

have been raised.

Method of Investigation

The Grand Jury drew information from the following:

·   Seventeen physician interviews

·   Eleven non- physician principal interviews

·   Correspondence conducted with at least eight other principals, twenty seven other

physicians and eighteen professional organizations

·   Sixty- three scientific papers, documents and transcripts

·   Eight other jurisdictions’ coroner/ medical examiner deputy staff qualifications

The jury visited the Sacramento County Coroner’s Office on two occasions and the San

Francisco County Medical Examiner’s Office.

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Background and Facts

A. General Considerations of Death Investigation

Current Status of Death Investigation in the United States and California:

There are no national death investigation laws, and systems are left to the states to establish.

There has been a continuing trend to replace coroner systems with medical examiner ( ME)

systems since the late 1800s. ME systems tend to be found in larger jurisdictions and it has

been estimated that the minimum population required to support a ME system of full time death

investigation is 200,000.1 Thirty- eight states have some type of ME system and MEs currently

serve 48 percent of the United States’ population.

Five of the largest California counties have a ME system. 2 They have an average population of

2.9 million and serve 40 percent of California inhabitants. 3

Sacramento County, with a current population of 1.95 million ( projected to be 3.65 by 2050) 4

is one of the largest California counties to continue with a coroner system. 5

Medical Considerations of Death Investigation:

With the dramatic advance of medical science, it has become clear that all deaths, natural and

otherwise, require medical direction for competent investigation and interpretation of

information. Medical expertise in death investigation is also required because the quality of

patient management by physician and healthcare workers often is at issue.

The California Medical Association policy states: “ CMA endorses the concept that medical-legal

investigation of deaths should be directly under the administration and jurisdiction of a

physician, preferably a pathologist, whether these officials be titled coroners or medical

examiners.” 6

The vast majority of decedents handled by the coroner die from natural causes, i. e., disease

entities. In 2001, homicides in Sacramento County constituted only 2 percent of deaths

reportable to the coroner and homicide, suicide, accidental, and undetermined combined were

only 13 percent. 7

Along with the Office of Public Health the medical examiner/ coroner is an early responder in the

management of biological, chemical and other emergencies.

Death certification is a healthcare issue. Many government agencies are interested parties in this

process. 8 Allocation of resources for healthcare and research are in part a function of cause of

death. Despite these considerations neither autopsy performance nor death certification is

reimbursed through healthcare financing. Although there is a national death certificate form, it is

seldom used, and state- to- state certificate variation hinders national mortality analysis. The

Sacramento County Grand Jury June 30, 2003

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situation is such that death certificates are not generally used as defining endpoints for medical

research clinical studies because they are notorious for error. Placing medically qualified people

in charge of this process would lead to improvement.

Coroners and medical examiners operate outside of the healthcare delivery system and are not

subject to the usual sources of medical scrutiny, e. g. the Joint Committee on Accreditation of

Health Care Organizations or the Health Care Financing Administration. Therefore, they face

no threat of loss of funding or reimbursement for poor performance. There are no national

standards for quality assurance or continuing education unless the individual ME/ Coroner

department volunteers for accreditation and periodic review by an organization such as the

National Association of Medical Examiners ( NAME) or the American Board of Medical Legal

Death Investigators ( ABMLDI). For these reasons it is desirable to establish a strong affiliation

with a local university medical center for joint development of quality assurance parameters.

These affiliations may be facilitated by medically qualified people heading departments.

Law Enforcement Considerations. Independence and Authority for Death

Investigation:

Death investigation and the coroner system evolved as a part of law enforcement. However,

many current observers believe death investigations should be performed by an independently

funded, autonomous office not tied to law enforcement or any prosecutorial agency. The goal is

an objective agency with clear separation of scientific medical duties and decisions from

influence and control by non- qualified individuals, and political interests.

Defenders of the coroner system state that law enforcement training is essential for death

investigation. However, death scene investigation is an integral and extensive part of the

forensic pathology ( FP) fellowship- training program and is subject to the certification

examination. 9 In Sacramento County the authority for death investigation would come to the

medical examiner through creation of the office. In counties which create a medical examiner’s

office, that office performs “ the powers and perform the duties of the coroner” ( Government

Code Section 24010). 10

General Qualifications of Coroners and Medical Examiners:

Coroners tend to be lay elected or appointed individuals with no medical qualifications or

background. Only 7 of 28 states with coroners require medical training of any kind, and only

four states require coroners to be physicians. 11

Medical examiners are physicians licensed to practice by their respective states and generally

are forensic pathologists who in addition to medical school have completed three to five years of

residency in general pathology and one year of forensic pathology fellowship. They are certified

by the American Board of Pathology in anatomic pathology ( the study of body tissues), clinical

pathology ( the study of body fluids) and are also separately certified in forensic pathology ( the

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application of medical science to legal problems). Qualifications of MEs in the United States

vary somewhat from jurisdiction to jurisdiction.

B. Death Investigation in Sacramento County

Organization:

In Sacramento County the Office of Coroner is within the Public Protection Agency along with

six other agencies. 12 This agency reports to the County Executive and the Board of

Supervisors.

The Sacramento County Coroner position is defined as an administrative position and peace

officer status is required ( see below). It has historically been held by career county employees,

frequently in concert with other county positions, as a part- time job.

Specific Qualifications and Duties of the Coroner and Staff in Sacramento County:

Coroner:

Qualifications: In Sacramento County the qualifications for the office of coroner include “ any

combination of training or experience equivalent to graduation from college and 3 years of

progressively responsible administrative experience”. There are also “ knowledge of”

provisions that are undefined objectively. 13 An interview- examination is given, the details of

which are not available to the Grand Jury. 14

Penal Code Section 830.35 states that the coroner and deputy coroners are peace officers.

Duties: The coroner is charged with determining the circumstances ( events temporally related),

manner ( natural, undetermined, homicide, suicide, accidental) and cause ( the actual vital organ

injury or disease process) of death. These duties fall to his assistants as noted below.

Assistant Coroner:

Qualifications: Possession of a Peace Officer Standards and Training ( POST) certificate and

either 3 years as deputy coroner in Sacramento County or 3 years experience in a California

public law enforcement agency performing death investigation duties equivalent to those of a

Sacramento County deputy coroner.

Duties ( among others): “ Directs Pathology Staff as to level of medical inquiry into Coroner

cases. Plans, develops and implements the policies and procedures of the department.

Determines final classification of manner and cause of death in Coroner Investigations. Meets

regularly with the Pathology staff to determine management of cases. Represents Coroners

office as liaison to other law enforcement agencies, e. g. the district attorney ( DA), attorneys,

physicians, hospitals, and contract service providers.” 15

Deputy Coroner Level I:

Qualifications: Candidates must have a 2- year college degree or 60 semester hours with

undefined “ coursework in anatomy, criminal justice, science, health science, or closely related

field.” 16 An 80- hour Coroner’s Death Investigation course originating in Orange County is

required. ( POST Plan III, CC # 2060- 31200)

Sacramento County Grand Jury June 30, 2003

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Duties: Same as level II below but investigations are less complex, and there is more

supervision. 17

Deputy Coroner Level II:

Qualifications: Possession of Peace Officer Standards and Training Regular Basic or

Specialized Basic certificate and either 1 year experience as deputy level I or 2- year degree or

60 college units as above and 1 year experience in California public law enforcement agency

performing death investigations, crime scene investigations or related duties. Several undefined

“ knowledge of” and “ ability to” sections are also required. The formal continuing education

requirement is 24 hours every other year. These courses tend to be weighted toward law

enforcement topics. From July 2000 to July 2003, twenty- three courses were scheduled and

six or possibly seven were on medical topics. 18 Deputies must qualify with firearms three times

yearly.

Duties: Investigates death scenes for evidence relating to the cause and manner of death,

including taking possession of the body and appropriate evidence and interviewing witnesses.

Confers with law enforcement to coordinate investigations of deaths resulting from criminal acts.

Confers with decedents, physicians, hospitals, and other medical personnel and reviews medical

records to determine medical background information for investigation. Photographs and

fingerprints the decedent, notifies next of kin, assists in autopsies by accepting labeling and

safeguarding evidence. And others. 19

Currently a large majority of deputy coroners have law enforcement background. 20

Pathology Staff:

Currently the Chief Forensic Pathologist is a contractual employee. His contract calls for

performance of autopsies, external exams and medical record reviews, supervising other

forensic pathologists, developing policies and procedures for clinical functions, attending county

and community meetings. 21 The other two pathologists are county employees.

Deaths in Sacramento County. Chain of Events. Authority for Direction of Death

Investigation. Issues of Medical Autonomy.

Systemic Compromise of Medical Autonomy:

In Sacramento County a deputy coroner with qualifications outlined above and no formal

medical training authorizes the signature of death certificates in 4500 reportable deaths without

consultation with or knowledge of the department forensic pathologists. The assistant coroner

determines the level of death investigation and the final manner of death and cause of death of

the 1400 decedents transported to the office for evaluation. This can include overruling the

pathologist.

Under Health and Safety Code Section 102850, the coroner must be notified when a death

occurs ( a) without medical attendance ( b) during the continued absence of the attending

physician and surgeon ( c) where the attending physician and surgeon or the physician assistant is

unable to state the cause of death ( d) where suicide is suspected ( e) following an injury or an

Sacramento County Grand Jury June 30, 2003

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accident ( f) under circumstances as to afford a reasonable ground to suspect that the death was

caused by the criminal act of another. These circumstances are stated in more detail in

Government Code Section 27491.

In approximate numbers there are 10,000 deaths annually in Sacramento County. Of those,

4000 occur under medical supervision with death certification by the attending physician. The

coroner is not involved. The remaining 6000 are reportable to the coroner by statute as noted

above. 22 Of the reported deaths, 4500 are resolved by the deputy coroner discussing the case

with those involved in the care of the decedent and by the deputy authorizing the last physician

in attendance to sign the death certificate. These cases are sometimes clear- cut and sometimes

not. The coroner’s pathologist is not involved in these discussions and decisions and has no

knowledge of their disposition. Consultation is not required.

At the deputy coroner’s order, approximately 1400 decedents are delivered to the morgue for

further study per year. The assistant coroner determines the extent of evaluation to be

performed. This may include record review, external examination, and autopsy. Annually,

approximately 900 autopsies and 300 external exams with medical record review are

performed. The pathologist performs the autopsy and states his / her opinion as to cause of

death but the assistant or deputy coroner makes the final determination of and manner of death

and signs the death certificate as the coroner designee.

Case- Specific Compromise of Medical Autonomy:

Not only is it possible for the pathologist to be excluded from case management decisions and

the final determination of manner and cause of death, his/ her specific medical recommendations

may also be overruled by the coroner and theoretically by the executive levels between him and

the Board of Supervisors, namely the Public Protection Agency, and the County Executive.

An illustrative situation arose in 2001 with the disposition of an apparent Sudden Infant Death

Syndrome ( SIDS) victim who died after brief hospitalization at University of California Davis

Medical Center ( UCD). The diagnosis of SIDS is exclusionary and requires a full autopsy and

other investigation that fail to reveal another cause of death.

A primary aim is to exclude child abuse. 23 This position was confirmed and expanded by the

American Academy of Pediatrics Policy statement in 2001.24 Therefore, by definition, death

scene investigation, interview of family, review of family social case records, review of medical

records, and performance of full autopsy is required to support the diagnosis of SIDS.

In the instance in question the examining pathologist made the written recommendation for

autopsy, but the coroner overruled the pathologist, and the office signed off without autopsy.

Reasons given for this decision included religious beliefs of family, backlog of bodies in the

coroner’s office awaiting autopsy, and the fact that the infant received medical diagnostic

evaluation before death. However, it should be noted that the family’s religious objections had

been addressed by UCD staff, making autopsy acceptable to them. Also, it has been well

documented that ante mortem diagnostic studies can miss trauma later found at autopsy.

Prioritization of this autopsy was offered by the pathologists to resolve the backlog problem, but

was refused by the coroner’s staff. 25

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A controversial “ loophole” in the law does allow for omission of autopsy in suspected SIDS

cases if the attending physician signs the death certificate. It is true that a second year pediatrics

resident certified the death; however, documents and interviews indicate that the resident had

the understanding an autopsy was to be performed. 26

The Sacramento Sierra Valley Medical Society ( SSVMS) registered a complaint with the

Board of Supervisors stating this case was “ mishandled in that there was no autopsy performed.

The forensic pathologists advised that such an autopsy was the community standard and

required in all instances of SIDS.” 27 The Child Death Review Team28 expressed their objection

by classifying the cause of death and manner of death in this case as “ undetermined.” 29 The

coroner has acknowledged that another SIDS disposition without autopsy has occurred in

recent years. 30

This case demonstrates that the current system allows non- medical authorities to overrule not

only their own pathologists, but the recommendations of national experts and academic

associations as well.

C. 2002 Conversion of Coroner Pathology Staff to County Employees.

Potential Further Compromise of Medical Autonomy:

On September 11, 2001 the Board of Supervisors heard a proposal by the coroner and the

administrator of the Public Protection Agency to terminate the contractor pathologists and

contractor morgue staff that had been serving the county for 12 and 27 years respectively and

recruit similar personnel as county employees. As justification for the changeover the coroner

wished “ control over the process as opposed to buying the product.” Enhanced customer

service was also a stated goal.

The coroner said dysfunction existed between pathologists and morgue attendants; others said

the disharmony was primarily between coroner and pathologists because of medical autonomy

issues. Usually this disagreement was about the extent of death investigation performed by the

deputy and the availability of medical records, information thought to be extremely important to

determination of cause of death and need for autopsy. There were safety issues cited as well.

On occasion the absence of medical records failed to alert staff to the presence of potentially

fatal infectious disease.

Cost considerations were not an issue because negligible savings were projected. With respect

to “ customer service,” no change was proposed of the liaison to all customers or the assistant

coroners, who were already county employees.

Many in the medical community saw the proposed conversion to county employees as a step

backward for medical autonomy. 31 32 33 34 This contravention of physician medical autonomy

was repeatedly denied by the Public Protection Agency administrator and the coroner. But this

denial was at odds with a published quote of the coroner: “ It’s the difference between being

Sacramento County Grand Jury June 30, 2003

8

able to say “ Doctor, you shall do it” versus “ Doctor, will you please do it?” 35 and testimony by

the administrator regarding gaining total control within the coroner’s office.

The Chief Deputy District Attorney stated in the hearing that there was a history of excellent

quality of pathology work in the coroner’s office since 1989. Others concurred with this

opinion. 36 Several expert observers emphasized the difficulty of finding qualified pathologists in

the proposed Sacramento situation when they would be reporting directly to a non- physician. 37

The time- lines relative to the proposed conversion raised questions as well. Notice of

termination effective December 31, 2001 was given the pathologists on June 22, 2001.

However, the issue was not presented to the Board of Supervisors until September 11, 2001.

This brief execution interval rendered recruitment of replacement pathologists problematic and

refusal by the board essentially impossible. Notice of the hearing was given very late.

The supervisors voted unanimously to accept the coroner’s conversion proposal, with an

alteration, if possible, to extend the existing pathology contract to June 2002. This proviso was

highly unlikely, as the pathologists in question had been seeking other positions since their June

2001 notification.

It is interesting to note that the result thus far has been to replace one contractual forensic

pathologist with another. The new Medical Director- Chief Forensic Pathologist is a contractual

employee with a county commitment of three years.

The manpower concern also proved significant. The coroner hired the only three pathologists

who applied, including one physician who because of personal legal problems is restricted from

performing autopsies which might become the subject of court testimony. According to the

District Attorney’s office this restriction is permanent. 38

D. Correctional Health and the Coroner. Conflict of Interest.

On December 11, 2001 the Board of Supervisors established the Department of Coroner and

Correctional Health Services, adding medical and dental care for detainees at county

correctional facilities ( Main Jail, Juvenile Hall, Rio Cosumnes Correctional Center, Boys Ranch,

Warren E. Thornton Youth Center) to the Office of Coroner. This action relegated both

positions to part- time status. It also created an obvious conflict of interest which has been

noted on more than one occasion by the local medical society and others, i. e. the person in

charge of inmate medical care is also in charge of investigation of in- custody deaths. 39 40 The

Sacramento Sierra Valley Medical Society described the Supervisors’ decision as “ curious” and

noted, “ there were several other logical choices that would have avoided potential conflicts.” 41

The conflict was said to be mitigated by a contract for autopsy of in- custody decedents with the

San Joaquin County Coroner’s Office and by transfer of numbered, sealed body bags.

However, death scene investigation, of equal or greater importance, continued under the

Sacramento County Coroner’s office in concert with Sheriff’s homicide detectives, adding two

conflicts of interest to one another. An additional problem is that the body and associated

Sacramento County Grand Jury June 30, 2003

9

evidence are in the custody of the coroner’s office until the “ next business day” which can be as

long as 60 hours.

This discussion highlights the compromised position of the county inherent in such an

arrangement. There is pending litigation which originated during the tenure of this conflict. It

would appear that the conflict is partially resolved by transfer of correctional health to the

Sheriff’s Department on January 10, 2003 and would be completely resolved by conversion to

an independent ME system answering only to the governing board of the county. That office

would perform in- custody death investigation, perhaps in concert with a district attorney

investigator.

E. Conversion to Medical Examiner System in Sacramento County.

Operational Considerations:

Most principals knowledgeable of the local situation were of the opinion that conversion to a

ME system in Sacramento County would be fairly straightforward from the perspective of

department operation. The coroner’s staff would not have to be replaced en masse, but rather

the change to medical emphasis would permeate rapidly via policies, procedures and continuing

education of medical nature.

Dr. Randy Hanzlick42 has made the following operational recommendations for Sacramento

County. Encourage diversity of background of investigators and change emphasis of

recruitment to medical from law enforcement. A department forensic pathologist should make

all case- related decisions on reportable deaths and subsequently confirm that the required

investigation has been completed and that necessary autopsy or external exam has been

performed. Such scrutiny is advisable, as studies have shown discrepancy between death

investigator and pathologist with respect to the manner of death in a significant number of

cases. 43 The supervising forensic pathologist should sign the death certificate and all death

certificates should be reviewed by the chief ME- department head.

All department pathologists should be board certified in forensic pathology. All investigator-deputies

should be required to take the Registry Certification examination of the American

Board of Medical Legal Death Investigators and board certification should be encouraged.

Continuing education should have medical emphasis and department meetings should be of

educational value for the deputies.

A strong affiliation with the UCD Department of Pathology is desirable and is attainable. Dr.

W. E. Finkbeiner, chief of Anatomic Pathology at UCD, stated, “ There are many opportunities

and areas of mutual interest between the University and Sacramento County in the area of

forensic science, forensic pathology and death investigation. I believe that with the proper

planning and cooperation we can build a model program in these fields that will meet both the

service and educational needs of our county and state.” 44

Sacramento County Grand Jury June 30, 2003

10

Sacramento County currently has the assets for development of a model, state of the art, death

investigation program. These include an excellent physical plant and nearby university medical

center. All that is required is an administrative organization assuring medical autonomy.

The Grand Jury has reviewed a comparative financial analysis of the current coroner system

versus a medical examiner system for the county and has concluded there would be no

additional funding necessary.

Process of Conversion to ME System in Sacramento County

Sacramento is a charter county. Section 27 of the Charter provides for certain appointive

officers, including the Coroner. According to County Counsel, in order for this county to

abolish the coroner and replace that office with another, a charter amendment would be

required. The same procedure would be necessary to provide different qualifications or a

different job description for the same office. A charter amendment must be proposed by

initiative, a charter commission, or the board of supervisors and then approved by a majority

vote of the electors within the county. 45 The Voter Registration and Elections office estimates

the cost of adding a charter measure to the ballot to be approximately $ 5000.

F. Death Certification, Local Problem.

The Grand Jury is aware of physician complaints regarding undue pressure from deputy

coroners to assign a cause of death even when the physician had not seen the patient for many

months and had no knowledge of the cause of death. In at least one instance, a misdemeanor

charge was threatened if the doctor did not comply. The California Medical Association has

also noted similar complaints. 46 Pertinent is Government Code Section 27491 and Health and

Safety Code Sections 102850, 102855, and 12860. Review of this issue by County Counsel

concluded that the coroner is required to sign death certificates for deaths reported for

investigation pursuant to the above codes including instances where the attending physician is

unable to state the cause of death. The latter statutes ( 102850, et seq.) were amended and

reorganized in 1995.

This problem appears to be resolved, and advice to that effect is available through the CMA

website. The Sacramento County Department of Health and Human Services has distributed

through various channels47 a letter of instruction to physicians to assist in accurate death

certificate completion. The public health officer is available for consultation at any time, day or

night. 48

Findings and Recommendations

Finding # 1. Death investigation historically has been folded into law enforcement duties. This

combination is inappropriate in the face of advanced medical knowledge in the diagnosis of

Sacramento County Grand Jury June 30, 2003

11

unnatural and violent deaths. Death investigation is a medical science and should be performed

by medically qualified people. Death certification is a healthcare issue.

Finding # 2. In the United States there has been a trend in large population centers to convert

to a medical examiner system of death investigation. Such a system now serves 48 percent of

the population of the United States and 40 percent in California.

Finding # 3. Coroners with few exceptions are administrators and/ or peace officers with no

medical qualifications or training. Very few are physicians. Medical Examiners are licensed

physicians who have completed medical school, four to six years of postgraduate training in

pathology, including forensic pathology fellowship. They are board certified in anatomic,

clinical, and forensic pathology.

Finding # 4. Death investigation should be performed by an independently funded, autonomous

office unrelated to law enforcement or prosecutorial agencies, answering only to the governing

board of the jurisdiction. There should be clear separation of scientific medical decisions from

non- qualified individuals, agencies and political interests.

Finding # 5. The performance of death investigation does not require law enforcement

background. Forensic pathology fellowship includes this training, and forensic board

certification requires this knowledge.

Finding # 6. There is no legal impediment to a medical examiner discharging all functions of

death investigation. In Sacramento County the authority for death investigation would be

conveyed by creation of the Office of Medical Examiner.

Finding # 7. In Sacramento County the Office of the Coroner is within the Public Protection

Agency and operates under the administrator of that agency and the county executive. It is

defined as an administrative position with no formal medical qualifications required. It is

frequently combined with other county positions.

Finding # 8. In Sacramento County, on an annual basis, a deputy coroner with no formal

medical qualifications authorizes the signature of death certificates in approximately 4500

reportable deaths without consultation or knowledge of the department forensic pathologists.

The assistant coroner, also with no formal medical training, is empowered to determine the

extent of death investigation and the final manner of death and cause of death of the

approximately 1400 decedents transported to the office for evaluation. This provision can

include overruling the judgment of the pathologist. The compromise of medical autonomy is not

just theoretical; cases confirming have been documented.

Finding # 9. On September 11, 2001 the Board of Supervisors authorized change in the

coroner’s office from contractual pathology and morgue services to county employees, further

compromising medical autonomy and discharging a pathology group that by all accounts was

professionally excellent. The transition may have created problems with respect to recruitment

Sacramento County Grand Jury June 30, 2003

12

of pathologists and homicide testimony. The decision was made despite significant opposing

written advice and testimony from the local medical community. The chief forensic pathologist

continues to be a contractual employee.

Finding # 10. On December 11, 2001 the Board of Supervisors created a conflict of interest in

the investigation of in- custody deaths by placing the coroner in charge of correctional health.

This conflict was in place at a time of intense scrutiny regarding inmate deaths/ suicides. There is

pending litigation. The conflict was only partially resolved by an autopsy contract with San

Joaquin County and the very recent transfer of correctional health to the Sheriff ‘ s Department.

This action was also the subject of major objection in the medical community. Investigation of

in- custody deaths by an independent medical examiner’s office in concert with a district

attorney’s investigator will resolve this conflict.

Finding # 11. Coroner and Medical Examiner systems operate outside the usual medical

oversight and control. There are no national standards or guidelines. Therefore voluntary

review and certification by organizations such as NAME and ABMDI are desirable. Affiliation

with the UCD Department of Pathology would facilitate subspecialty consultation, development

of policy and quality assurance.

Finding # 12. With the above review and affiliation, the excellent physical plant already in place

and conversion to a medical examiner system assuring medical autonomy, Sacramento County

will attract excellent forensic pathologists and be in position to develop a state of the art death

investigation program.

Finding # 13. Conversion to a medical examiner system would not be difficult from an

operational standpoint. The coroner’s staff would not have to be replaced and would adapt

quickly to medical emphasis and supervision.

Finding # 14. A financial analysis of the transition has been reviewed by the jury and thought to

be neutral, with no additional funding necessary for the operation of a medical examiner system.

Finding # 15. Change to a medical examiner system requires a charter amendment and

electorate participation.

Finding # 16. There have been complaints of inappropriate pressure by deputy coroners

placed upon attending physicians to certify deaths when the physicians had inadequate

knowledge as to the cause of death. This problem appears resolved.

Recommendation # 1. The citizens of Sacramento County should be served by a medical

examiner system headed by a board certified forensic pathologist appointed by the governing

board. The Office of the Medical Examiner is autonomous, independently funded, and

responds only to the Board of Supervisors.

Recommendation # 2. To establish this office the Board of Supervisors should propose and

place on the ballot a charter amendment to abolish the Office of Coroner and replace it with the

Sacramento County Grand Jury June 30, 2003

13

Office of Medical Examiner. Failing that, the board should propose and place on the ballot a

charter amendment to require the coroner to be a forensic pathologist. Failing that, the board

should appoint a forensic pathologist to be coroner at the earliest opportunity.

Recommendation # 3. The Chief Medical Examiner should be selected by a search committee

of medical experts utilizing non- political and strictly professional criteria, including prior

administrative experience. All staff pathologists should be board certified in forensic pathology.

They can be contractual or county employees.

Recommendation # 4. The Medical Examiner System of Sacramento County should establish

a strong relationship with the UCD Medical Center for development of lines of consultation,

quality assurance and continuing education programs. The system should utilize professional

organizations for review, certification and guidelines of operation. There should be medical

emphasis in the recruitment and continuing education of staff. A forensic pathologist should

supervise each reported decedent investigation and sign the death certificate of all those studied

in the medical examiners office. A pathologist should supervise all morgue functions.

Recommendation # 5. The investigation of in- custody deaths should be separate from

correctional health and the Sheriff’s Department. It should be performed by an independent

medical examiner and district attorney investigator.

Response Required

Penal Code Section 933.05 requires that specific responses to both the findings and

recommendations contained in this report be submitted to the Presiding Judge of the

Sacramento Superior Court by September 30, 2003 from:

·   Sacramento County Public Protection Agency

·   Sacramento County Coroner’s Office

1 Randy Hanzlick, Grand Jury communication, October 23, 2002

2 Los Angeles, San Diego, San Francisco, Santa Clara, Ventura

3 Randy L. Hanzlick, “ Medical Examiner and Coroner Systems,” Journal of the American Medical

Association, Vol. 279, 1998, pp. 870- 874

4 L. Kalb, “ Region’s On Track to Grow,” The Sacramento Bee, October 19, 2002, D- 1, quotes S. Levy,

director of the Palo Alto- based Center for Continuing Study of the California Economy

5 Four California counties have a greater population than Sacramento and still have a coroner system:

Alameda, Orange, Riverside and San Bernardino

Sacramento County Grand Jury June 30, 2003

14

6 California Medical Association Policy, “ Coroner Functions,” HOD 29- 66

7 Sacramento County Coroner’s Office: An overview of functions and services, November 2002

8 The Consumer Product Safety Commission, Food and Drug Administration, Occupational Safety and

Health, Bureau of Labor Statistics, Federal Bureau of Investigation, Center for Disease Control and

Prevention, National Highway Traffic Safety Administration, National Institute of Health, Department of

Justice, and state and local departments of organ and tissue procurement.

9 The Accreditation Council for Graduate Medical Education

10 County Counsel, Grand Jury communication, December 31, 2002

11 Randy L. Hanzlick, “ On the Need for More Expertise in Death Investigation,” Arch Pathol Lab Med, Vol.

120, 1996, pp. 329- 332

12 Child Support Services, Conflict Criminal Defenders, Correctional Health, Health and Human Services,

Human Assistance, Probation and Public Defender

13 Sacramento County Coroner, Grand Jury communication, September 5, 2002

14 Director of Personnel Services, Grand Jury communication, May 21, 2003

15 Sacramento County Series Specification, April 12, 1996

16 Ibid.

17 Ibid.

18 Sacramento County Assistant Coroner, Grand Jury communication, December 3, 2002

19 Sacramento County Series Specification, April 12, 1996

20 Sacramento County Assistant Coroner, Grand Jury communication, November 15, 2002

21 Contract for Chief Forensic Pathologist in the Coroner’s Office, December 11, 2001

22 Sacramento County Coroner’s Office: An overview of functions and services, November 2002

23 Centers for Disease Control and Prevention. Guidelines for Death Scene Investigation of Sudden

Unexplained Infant Deaths: Recommendations of the Interagency Panel on Sudden Infant Death Syndrome.

MMWR Morb Mortal Weekly Rep., No. 45, 1996, pp. 1- 22

24 Policy Statement. Distinguishing Sudden Infant Death Syndrome From Child Abuse Fatalities ( RE0036)

Pediatrics, No. 107, 2001, pp. 437- 441

25 G. Reiber, letter to Sacramento County Coroner, December 21, 2001

26 R. C. Midgley, President, Sacramento Sierra Valley Medical Society, letter to Supervisor Roger Niello,

November 27, 2001

Sacramento County Grand Jury June 30, 2003

15

27 Ibid.

28 The Sacramento County Board of Supervisors in 1988 directed the Child Abuse Prevention Council by

resolution to establish Child Death Review Team authorized by Penal Code Section 11166.7 and the Welfare

and Institutions Code Sections 830 and 10850.1

29 A. Nakamura letter to Public Health Officer, December 19, 2001

30 Sacramento County Coroner, letter to Public Health Officer, December 13, 2001

31 R. C. Midgley letter to Supervisor Niello and the Board of Supervisors, November 27, 2001

32 R. C. Midgley letter to Penelope Clarke, September 5, 2001

33 R. Ikeda letter to Supervisor Roger Niello, September 10, 2001

34 W. E. Finkbeiner, Director of the division of Anatomic Pathology at UCD letter to Penelope Clarke, Coroner

Smith, cc to the Board of Supervisors, Septemb er 4, 2001

35 C. Garvin, “ Dead Wrong,” Sacramento News and Review, March 14, 2002, p. 16

36 Penelope Clarke, Board of Supervisors’ hearing, September 11, 2001; John O’Mara, Grand Jury

communication, November 15, 2002, January 8, 2003, R. Ikeda, letter to Supervisor Roger Niello, September

10, 2001,

37 P. W. Herrmann, letter to Supervisor Roger Niello, September 5, 2001; P. Rooney, letter to Supervisor Roger

Niello, September 5, 2001; B. G. Stephens letter to Supervisor Roger Niello, September 5, 2001

38 C. Bessemer, J. O’Mara, Grand Jury communication/ interview November 15, 2002 and January 8, 2003

39 R. C. Midgley letter to Supervisor Roger Niello, November 27, 2001

40 C. Garvin, “ Dead Wrong,” Sacramento News and Review, March 14, 2002, p. 19

41 R. C. Midgley letter to Penelope Clarke, September 5, 2001

42 Chief Medical Examiner, Fulton County, Georgia; Associate Professor, Forensic Pathology, Emory

University, Forensic Pathologist with the Centers for Disease Control and Prevention, Past President,

National Association of Medical Examiners ( NAME)

43 J. L. deJong, “ Level of agreement between opinions of medical examiner investigators and forensic

pathologist medical examiners regarding the manner of death,” American Journal Forensic Medical

Pathology 2000, Vol. 21, No. 1, March, pp. 11- 20

44 W. E. Finkbeiner letter to Penelope Clarke and Coroner , cc to the Board of Supervisors, September 4, 2001

45 County Counsel, Grand Jury communication, October 15, 2002 and October 17, 2002

46 CMA on Call: www. cmanet. org, Document No. 1305

47 Sacramento County Vital Records, Coroner’s Office, and funeral directors

Sacramento County Grand Jury June 30, 2003

16

48 Public Health Officer, letter to physicians, March 27, 2002

Sacramento County Grand Jury June 30, 2003

17

Elk Grove Unified School District’s Failure

to Recognize Fiscal Irresponsibility

Prompting a Second Grand Jury

Investigation

Issue

The 2001– 2002 Grand Jury received a complaint filed by the Citizens of the Elk Grove Unified

School District for Responsible Planning alleging that the Elk Grove Unified School District

( EGUSD) failed to exercise prudent fiscal responsibility when it purchased the property now

designated as school site # 8, located at the corner of Bond and Bradshaw Roads. The Grand Jury

reported their investigation findings on this case in their June 30, 2002 report, which is Attachment

1. EGUSD’s response to the Grand Jury report is Attachment 2. The 2002- 2003 Grand Jury is

not satisfied with the response.

Method of Investigation

·   Review of 2001- 2002 Grand Jury materials

·   Review of EGUSD’s response to 2001- 2002 Grand Jury report

·   Meetings with District Superintendent

·   Meetings with original complainants

·   Meeting with Deputy Attorney General

·   Meeting with California Department of Education, School Facilities Planning Division

Background and Facts

Facts uncovered by the 2001- 2002 Grand Jury and published in their report dated June 30, 2002

are as follows:

·   Staff of EGUSD did not follow set policies and procedures when selecting land for purchase

to construct schools.

·   EGUSD staff notified a select group of five agents ( land developers/ real estate brokers) that

EGUSD was looking to purchase land in a specific area for the construction of school site # 8.

·   EGUSD staff did not engage in a search for sites, but rather relied on the agents to find

available property to consider for purchase.

Sacramento County Grand Jury June 30, 2003

18

·   One of the agents located a site that met the district’s criteria and took an option to purchase

the property on March 27, 2000 from the original owner for $ 37,000 an acre. The property

had been advertised for sale for eighteen months with a large sign with the agent’s name

clearly posted. The site was less than a mile from EGUSD offices.

·   The agent notified EGUSD staff that he had located property they might be interested in, and

the staff recommended to the EGUSD Board of Education that the district purchase the

property soon after. On May 15, 2000 the board authorized the Assistant Superintendent to

conduct a review process preliminary to the property purchase.

·   An Assistant Superintendent ordered two appraisals of the property to be made by two

different agents. One established the value at $ 41,000 per acre and the other at $ 65,000 per

acre. EGUSD staff did not question the discrepancy in the two appraised values and agreed to

pay the higher price without further negotiations with the agent.

The EGUSD’s response to the 2001- 2002 Grand Jury report indicates that the district has failed to

recognize significant fiscal irregularities by their staff with regard to the purchase of this property.

They explain that they were constrained by numerous legal requirements and could not enter into

negotiations until preliminary items were completed. Granted, there are legal requirements that

must be adhered to. However, if the district staff had noticed the “ For Sale” sign on the property

themselves and not told the real estate agent of their intent to purchase land in the immediate area,

then the legal requirements would have likely taken place with the original owner and not the real

estate agent. This fact is significant because the original owner sold the property for $ 37,000 an

acre in March 2000. The original owner may have asked for more from the district six months

later, but it is doubtful that he would have sought $ 65,000 an acre, the amount that the real estate

agent was paid.

The EGUSD maintains that they were constrained by numerous requirements from the California

Department of Education ( CDE). The CDE does not determine land acquisition per se, but rather

the suitability of the land for educational purposes and safety requirements. However, the district

may negotiate an option on the property contingent upon final approval of the CDE. The EGUSD

did not place an option on the property. They could have “ locked up” the property in February or

March 2000. They were not delayed by the California Department of Education’s rules and

procedures.

The EGUSD is correct that appraisals are required by the Office of Public School Construction,

an arm of the State Allocation Board. Only one appraisal is necessary, although the school district

may request more. Since the district pays a significant portion of the construction cost, a

reasonable assumption is they would use the lowest appraisal, or ask for a third appraisal. In this

case, the highest appraisal was used. The EGUSD argues that a public agency must pay “ fair

market value” and judged the higher appraisal to be more realistic. This is a specious argument.

By providing advance notice to an agent that the district was looking for property in the general

area, the district gave the agent an advantage, and the district lost the opportunity to negotiate with

the original owner and purchase the property for a lower price. The EGUSD staff demonstrated

negligence and fiscal irresponsibility.

Sacramento County Grand Jury June 30, 2003

19

Findings and Recommendations

The 2002- 2003 Grand Jury concurs with the 2001- 2002 Grand Jury findings and

recommendations. Further, the 2002- 2003 Grand Jury finds that the actions taken to acquire the

subject property are sufficiently questionable that EGUSD should consider appropriate disciplinary

action.

Finding # 1. The EGUSD gave insider information to a real estate agent which allowed the agent

to make a profit in excess of $ 2 million on school site # 8.

Recommendation # 1a. The EGUSD should take immediate disciplinary action against

responsible staff.

Recommendation # 1b. The Superintendent and Board of Education should provide oversight to

the staff responsible for the purchase of school sites.

Finding # 2. The EGUSD failed its fiduciary responsibility to the taxpayers by paying $ 2.4 million

more than the fair market value for school site # 8.

Recommendation # 2a. The district should require staff members responsible for the purchase

of property, supplies, or services to sign a fiduciary responsibility statement. District staff should

also be accountable under the EGUSD conflict of interest policy.

Recommendation # 2b. The district should develop policies and procedures for the purchase of

school sites that protect the financial interests of taxpayers.

Finding # 3. The EGUSD failed to perform due diligence in the search for school site # 8.

Recommendation # 3. The district should require staff to do their own research on potential

school sites and not rely solely on agents and developers.

Finding # 4. The EGUSD refuses to admit a mistake was made and to take responsibility for its

actions.

Recommendation # 4. The district should take responsibility for its actions and implement

policies and procedures to make sure this situation never happens again.

Sacramento County Grand Jury June 30, 2003

20

TO THE CITIZENS IN THE ELK GROVE UNIFIED SCHOOL DISTRICT:

The Elk Grove Unified School District is accountable to you. Apparently they do not agree. The

Grand Jury can investigate, write a report, and receive an inadequate reply year after year. The

EGUSD can obfuscate, delay, and refuse to talk without a subpoena, hoping to drag out the

process long enough so that we will go away. This process cannot work for them if you, the good

citizens in the Elk Grove Unified School District, demand better leadership from your elected

officials.

Response Required

Penal Code Section 933.05 requires that specific responses to both the findings and

recommendations contained in this report be submitted to the Presiding Judge of the

Sacramento Superior Court by September 30, 2003 from:

·   Board of Education, Elk Grove Unified School District

Sacramento County Grand Jury June 30, 2002

21

Attachment 1

Elk Grove Unified School District Fails

Fiduciary Responsibilities

Reason for Investigation

The Grand Jury received a complaint alleging that the Elk Grove Unified School District paid more

than twice the fair market value for a property located at the intersection of Bond and Bradshaw

Roads.

Method of Investigation

Members of the Grand Jury interviewed the District Superintendent and members of his staff, the

Elk Grove Unified School District Board President, the complainants and other interested parties.

Because of the reluctance of some witnesses to appear before the Grand Jury and the sensitive

issues involved, the Grand Jury requested the assistance of the Attorney General's office.

Subpoenas were prepared and served, and on April 24, 2002, under questioning from a Deputy

Attorney General, sworn testimony was received from additional witnesses.

Background

The Elk Grove Unified School District ( District) encompasses an area that includes the southern

portion of the City of Sacramento as well as the recently incorporated City of Elk Grove. The

City of Elk Grove has experienced phenomenal growth over the past decade, and for that reason

the District has had to construct new schools at a rapid pace.

A four year school construction bond measure was passed by the State of California in 1998.

During the first several months of 2000, the District attempted to purchase property for the

construction of a mega- school to be located in the area of Elk Grove Florin and Gerber Roads.

The District met with considerable resistance from residents who objected to a school in that area,

and decided to look for property elsewhere. In order to take full advantage of the bond issue the

District had to move quickly in purchasing an alternate site.

Sacramento County Grand Jury June 30, 2002

22

Facts

One of the areas the District identified as a possible school site was in the vicinity of the

intersection of Bond and Bradshaw Roads. To locate available parcels of land in the area, the

District contacted several well- known land developers/ real estate brokers.

One land developer identified a 106 plus acre parcel that was for sale on the northwest corner of

Bond and Bradshaw Roads. The Grand Jury understands that neither the previous owner of this

land nor his real estate broker was aware of the District's interest in purchasing land in the area.

The land developer purchased the parcel of land for $ 4,000,000 ( roughly $ 37,000 an acre).

Within days of entering into this purchase contract, the land developer informed the District that

he had property for sale at the corner of Bond and Bradshaw Roads. The District entered into

negotiations with the land developer for the purchase of this property.

Two independent appraisals were commisssioned by the District to determine the fair market

value of the land. The first appraisal placed the value of the land at $ 4,350,000 ( roughly $ 41,000

per acre). The second appraisal placed the value at $ 6,942,000 ( roughly $ 65,000 an acre). Both

appraisers used the same standards, but differed as to which properties were to be compared.

Although the two appraisals differed greatly, District staff did not question the value set by the

second appraisal. The Grand Jury was told the difference between the two appraisals was

probably caused by the volatility of the real estate market during this time, July 2000.

According to testimony received by the Grand Jury, the District is required by law to base its sales

price negotiations on the appraised value of the land plus or minus 10%. The Grand Jury also

learned the District had the opportunity to negotiate a price with the seller of the property based

on either appraisal. The District accepted the higher appraisal because it believed that it more

accurately reflected the market value of the land. The District purchased the property for

$ 6,928,400 ( roughly $ 63,000 an acre).

The District admits that it was unaware the parcel had previously been for sale over a year at

approximately $ 4,000,000. The District staff did not canvass the area looking for property for sale

but instead turned to a select group of real estate agents and land developers to locate desirable

property. District staff also admitted that the original broker for this piece of property was not

among the group contacted. Had District staff members responsible for property acquisition

driven by the corner of the property, a short distance from District Headquarters, they would have

seen a large broker's sign advertising the property. Also, had the District advertised its interest in

purchasing property in the area, the original broker for the property told the Grand Jury he would

have contacted the District.

Finding and Recommendation

Finding # 1. District staff members exhibited a very careless attitude toward their fiscal

responsibilities when negotiating the purchase of property. The Grand Jury also concluded that

had the District been more diligent in its search for school property, it might have purchased the

property for a price closer to the lower appraised value of $ 4,350,000. The Elk Grove Unified

School District failed in its fiduciary responsiblity to taxpayers in the purchase of property located

Sacramento County Grand Jury June 30, 2002

23

at the intersection of Bond and Bradshaw Roads. This failure resulted in a loss to taxpayers of

approximately $ 2.4 million.

Recommendation # 1. The Elk Grove Unified School District should:

a. develop formal policies and procedures for the purchase of school site property that

protect financial interests of the taxpayers and eliminate the appearance of favoritism

to any landowner, land developer or real estate agent;

b. publish in a newspaper of general record an official notice of any decision by the

District to establish a new school or seek a new site location. An offical notice should

also be delivered to the local Board of Realtors;

c. direct staff to use all available resources for the selection of property for school

construction including physical inspection of properties for sale within the area of

interest as well as Multiple Listing and newspaper ads.

Response Required

Penal Code Section 933.05 requires that specific responses to both the finding and

recommendation contained in this report be submitted to the Presiding Judge of the

Sacramento Superior Court by September 30, 2002 from:

·   Board of Education, Elk Grove Unified School District

The following grand jurors recused themselves from any particpation in the

investigation, discussion, preparation editing or approval of this report:

·   Rhea Brunner

·   A. Michael Koewler

·   James M. Moose, Jr.

·   Jimmie E. Ward

The Grand Jury Advisor Judge also recused himself from providing legal advice on this

report.

24

BEST BEST & KRIEGER LLP

A CALIFORNIA LIMITED LIABILITY PARTNERSHIP INCLUDING

RIVERSIDE PROFESSIOLNAAWLY CEORSRP ORATIONS ONTARIO

( 909) 686- 1450 400 CAPITOL MALL, SUITE 1650 ( 909) 989-

8584

SACRAMENTO, CALIFORNIA 958 14 - BBKLAW. COM

ORANGE COUNTY

JAMES E. THOMPSON ( 949) 263- 2600

JETHOMPSON@ BBKLAW. COM

September 30, 2002

The Honorable Michael T. Garcia

Presiding Judge

Sacramento County Superior Court

720 Ninth Street, Dept. 47

Sacramento, CA 95814

Re: Elk Grove Unified School District's Response to Finding and

Recommendation of Grand Jurv Report

Dear Judge Garcia:

Transmitted herewith pursuant to sections 933- 933.05 of the Penal Code is the

Specific Response of the Elk Grove Unified School District to Finding and Recommendation

of Grand Jury Report.

JET: plm

Enclosure

mes E. Thompson

BEST BEST & KRIEGER LLP

SACRAMENTOUET\ 2367

Attachment 2

25

Specific Response of Board of Education of Elk Grove Unified School

to Finding and RecommDenisdtartiicotn of Grand Jury Report

RESPONSE TO FINDING NO. 1:

The Elk Grove Unified School District asserts that its acquisition of the

Bond/ Bradshaw site ( Site) was in the public interest and did not result in any waste or

unnecessary use of taxpayer dollars entrusted to the District. The price paid by the

District for the Site was based on a qualified, professional appraisal of the fair market

value of the property. Due to procedures that the District was first required by law to

follow, the District could not have purchased the property at a substantially lower price.

As a result, there was no loss to the taxpayers. This District has a history of sound fiscal

management and has been praised many times in past years by the Grand Jury.

The assertion that the District paid more than twice the fair market value of the

Site is not true. The District was required by law to offer to pay the fair market value of

the property established at that time. The District's approved appraisal showed that the

fair market value of the property was $ 65,000 per acre in September 2000.

Any alleged " delay" in the District making an offer to purchase the property was

due to the District having to first follow numerous procedures required by law. It was not

due to any lack of diligence by District staff to discover the availability of the property;

nor did the District deliberately choose to pay more than the appraised fair market value

of the property. In late February 2000, the Board made a decision to begin a new search

for a school site. At that time, apparently the original owner listed the. Site for sale at a

price of $ 45,000 per acre as documented by statements made by the broker who sold the

property on behalf of the original owner. The seller the District purchased the property

from later told the District that he purchased the land without an appraisal. The Grand

Jury report asserted that it was purchased for $ 37,000 per acre. There was no way that

the District could simply " tie the property up" at that price in February 2000 because the

District's site selection process for this property had not begun, the necessary approvals

had not been obtained, and the required fair market value appraisal of the property had

not been determined.

Before offering to purchase the property, the District had to obtain approvals from

the Facilities Planning Division of the California Department of Education, and the

( EGUSDGrandJuryResponse092702a) 1

26

Department of Toxic Substances Control. In addition, under the California Environmental

Quality Act, the District was required to do a study to identify any potentially significant

environmental impacts, and to determine what measures could be taken to offset those

impacts. The site evaluation process required the District to hire consultants, conduct

physical inspections of the property, and prepare numerous environmental documents.

Also, before making an offer to purchase the property, the District was required to

appraise the property. The District is obligated by statute to assure that the property owner

is justly compensated based on a " highest and best use" valuation. In this instance, the

" highest and best use" was for General Plan Map Classification of " Low Density

Residential" ( 1- 12 dwelling units per acre). All of these steps, except certification of the

Environmental Impact Report ( EIR), had to be completed before the District's staff could

start the negotiations to buy this property for a school site

The Grand Jury ignored a basic premise of real estate purchases - it is the seller,

not the buyer, who determines what price will be accepted for the property. In this

instance, the seller would only accept a price close to the highest appraised value.

An initial feasibility study of the Site was completed in May 2000, and staff made a

favorable finding regarding the feasibility of the Bond/ Bradshaw site. After taking public

comments at a District Board meeting on May 15, 2000, the Board authorized staff to

begin the formal review process of the Site, which involved all of the steps described

above. District staff notified the owner of the Site that although the District was pursuing a

purchase of that property, the actual purchase could only take place after the District

concluded the necessary CEQA certification and California Department of Education

approvals. If the District decided to purchase the property, the amount offered would be

the Board approved appraisal of the fair market value. Two appraisal reports were

completed for the District by September 2000 utilizing current zone designation of AR- 5

and General Plan Map Classification of " Low Density Residential" ( 1- 12 dwelling units

per acre). The Board of Education, in a regularly scheduled meeting, authorized District

staff to make an offer for the purchase of the property. Pursuant to Code, the offer is to be

no less than the approved appraised amount, and subject to the certification of an

Environmental Impact Report ( EIR).

Although the Site may have been available for sale to the public in February 2000,

the District had not completed the mandatory site selection steps, environmental review,

( EGUSDGrandJuryResponse092702a) 2

27

or appraisal process. There was no legal way that the District could have simply purchased the property

for a school site at that time. Although the District staff proceeded swiftly, they could not complete all

steps necessary to begin negotiations for the purchase of the Site at its fair market value until

September 18, 2000. By that time, the fair market value appraisal of the property at " highest and best

use" was $ 65,000 per acre. For the reasons stated above, the District disagrees with Finding No. 1.

RESPONSE TO RECOMMENDATION NO. 1:

The Board of Education will continue to routinely examine its procedures and practices on

building future schools, including school site acquisitions. The District was already in the process of the

review before the Grand Jury investigation and will continue to examine its process in the future.

Response to Recommendation No. 1( a):

The District believes that it has implemented this Recommendation. The District believes that it

can further carry out Recommendation No. 1 through ( 1) continued compliance with State laws with

respect to public acquisitions; and ( 2) broadening its procedures related to the Grand Jury's

Recommendation Nos. 1( b) and 1( c).

Response to Recommendation No. 1( b):

The District will broaden its current notification procedures, beginning with the next occasion

in which the District's Board of Education decides to establish a new school or seek, through

purchase, a new site location not within a pending or approved subdivision

Response to Recommendation No. 1( c):

The District will broaden its current selection procedures, beginning with the next occasion in

which the District's Board of Education decides to establish a new school or seek, through purchase,

a new site location not within a pending or approved subdivision.

( EGUSDGrandJuryResponse092702a) 3

28

Re: Elk Grove Unified School District's Response to Findinand

Recommendation of Grand Jury Report

CERTIFICATE OF SERVICE

I declare that I am employed in the County of Sacramento, California. I am over the

age of eighteen years and not a party to the within action. My business address is c/ o Best

Best & Krieger LLP, 400 Capitol Mall, Suite 1650, Sacramento, California 95814. On

September 27, 2002, I caused to be served the within:

SPECIFIC RESPONSE OF THE ELK GROVE UNIFIED

SCHOOL DISTRICT TO FINDING AND RECOMMENDATION

OF GRAND JURY REPORT

on the following persons:

The Honorable Michael T. Garcia Presiding Judge

Sacramento County Superior Court 720 Ninth Street, Dept. 47 Sacramento, CA 95814

[ X] By causing a true copy thereof to be delivered to the party or parties at the

address( es) listed below, by and/ or through the services of Capitol Mall Courier

Services.

and on

Clerk, Board of Education

Elk Grove Unified School District 9510 Elk Grove - Florin Road

Elk Grove, CA 95624

[ X] ( BY MAIL) I caused such envelope with postage thereon fully prepaid to be placed

in the United States mail at Sacramento, California. I am familiar with my

company's practice whereby the mail, after being placed in a designated area, is

given the appropriate postage and is deposited in a U. S. mail box in Sacramento,

California, in the ordinary course of business.

I declare under penalty of perjury under the laws of the State of California that the

foregoing is true and correct. Executed on September 30, 2002, at Sacramento, California.

Sacramento County Grand Jury June 30, 2003

29

Letter Grades for Restaurants

Issue

The Grand Jury received a complaint regarding Sacramento County Environmental

Management Department’s failure to conduct restaurant inspections at least annually. The

complaint alleged that the Environmental Management Department had made poor management

decisions that led to staffing shortages and long- term increased risk to the public health. Several

news articles in The Sacramento Bee also cited the failure of the county to live up to its policy

of annual inspections.

Method of Investigation

·   Meetings with the Director, Environmental Management Department; Chief, Environmental

Health Division, and two Supervising Environmental Health Specialists

·   Accompanying Environmental Specialists on actual inspections of several restaurants

·   Reviewing The Sacramento Bee articles, including Health Inspections Database link

http:// www. sacbee. com/ cgi- bin/ sacbee/ news/ inspections. cgi

·   Teleconferences with County of Los Angeles, Environmental Health Department, and

County of San Diego, Department of Environmental Health, Food and Housing Division

Background and Facts

Under state law each county is required to fund a program to inspect restaurants to ensure they

meet state standards for cleanliness and safety. Counties have wide discretion in how often they

conduct inspections and how they enforce state standards. Sacramento County has established

a policy of inspection for all food preparation establishments to be inspected at least annually.

State law also requires that food inspectors must be registered Environmental Health Specialists

with the State Department of Health Services.

The inspection program in Sacramento County costs about $ 1.5 million a year and is funded by

restaurant permit fees. Sacramento County has approximately 5,000 food preparation

businesses, including 2,690 restaurants and 758 mobile food units, each of which must be

inspected at least once a year. The Chief of the Environmental Health Division indicated he

Sacramento County Grand Jury June 30, 2003

30

would like to inspect each restaurant twice a year with immediate re- inspection for a restaurant

having a critical violation.

In the past, restaurant inspections have lapsed from 18 to 36 months. The director cited staffing

shortages as the main reason the division did not meet its annual inspection goal. At various

times, the division had only 11 or 12 inspectors on the job. In addition to monitoring

restaurants, inspectors check on 10,000 other facilities having permits to prepare and serve

food, including fair booths, ice cream vendors, and delicatessens operating in grocery stores.

Also, mobile facilities by their nature are difficult to inspect causing the inspectors a further delay

in these annual inspections. At present, only 5 of the 13 inspectors have access to an

automated tracking system for inspections that are due or overdue.

Repeat violators rarely faced a harsher penalty than re- inspection. When critical violations were

found, restaurant owners were told to call and leave a message when the problem was fixed, or

to fax a receipt showing the repair was made. There was no re- inspection.

The Environmental Health Division has fallen behind with its inspection workload because of

additional environmental health issues. Because of these issues, inspectors were required to

perform extra duties. The division currently has a backlog of more than 400 inspections.

The Environmental Health Division receives 300 calls a year regarding food- borne illnesses and

200 complaints a week involving minor infractions. The director said that critical violations

could lead to food poisoning. At the least, this is unpleasant to all but can be fatal to young

children, pregnant women, the elderly, or those with a weakened immune system. Given this

danger, counties such as Los Angeles and San Diego have taken a very hard- line approach with

restaurants— sometimes allowing them only hours to fix a problem or face being shut down.

These counties have policies requiring restaurants to post the results of its last inspection on

large, brightly colored signs at restaurant entrances. The signs indicate the letter grade of A, B,

or C.

The first year the grade signs were posted in Los Angeles County, 57 percent of the restaurants

received an “ A” rating. By 2002, 83 percent of the restaurants scored an “ A” rating.

Conversely, restaurants receiving a “ C” rating decreased from 5 percent to 0.2 percent during

the same period of time. Complaints of food borne illnesses dropped approximately 30

percent.

In Sacramento County, the only way the public knows the result of an inspection is to ask the

restaurant for a copy. There is no policy of grade posting that the public can see readily when

entering a restaurant.

According to the director, Sacramento restaurants and grocery- industry members continue to

oppose any rating system or the public posting of health inspection reports; consumers and their

advocates are overwhelmingly in favor. The director and some inspection staff are not

Sacramento County Grand Jury June 30, 2003

31

convinced posting inspection grades would work or be fair as they are still struggling to bring

timely mandatory inspections and re- inspections.

Rather than focus on tougher enforcement policies, the director says Sacramento County

prefers to emphasize education. He noted that restaurant operations are complex with good

and bad days. He believes one inspection may not be a true indicator of the performance of a

restaurant.

The Environmental Health Division is in the process of improving the food inspection program.

The Environmental Management Department solicited comments from both the regulated

community ( restaurants, markets, food carts, etc.) and the public. Comments were received

through November 30, 2002. Four areas are currently identified for potential improvement.

They include the following:

1. Risk- based Inspection Frequency— Base the frequency of inspection on the type and

amount of food being handled ( level of risk associated with same).

2. Education— Increase education of food workers at retail food facilities.

3. Enforcement— Develop aggressive enforcement activities at facilities with continuous and

repeat violations.

4. Public Notification— Improve methods used to notify public of food facility inspection

results.

The first three areas of food program enhancements received almost 100 percent of consumer

and industry support. The fourth received over 90 percent consumer support for notification

either by letter grading or the onsite posting of the full inspection report. Industry did not

support grading but favored giving an “ Award for Excellence” to facilities found to be

consistently in compliance with the regulations.

At the March 11, 2003 meeting of the Board of Supervisors, the Environmental Health Division

requested the following changes in the food inspection program:

·   To change and prioritize the frequency of inspections for most food facilities from

1 per year to 2 or 3 per year

·   To hire additional health inspectors and increase fees

·   To require operators with numerous health code violations to attend “ food school”

·   Beginning July 1, 2003, to publicly display entire health inspection reports

Sacramento County Grand Jury June 30, 2003

32

The Board of Supervisors unanimously approved the changes. There was little opposition to

the first three recommendations. However, industry representatives opposed the public display

of health inspection reports objecting to a grade based on a single inspection.

A comparison of Sacramento County to San Diego and Los Angeles Counties:

Sacramento County San Diego County Los Angeles County

Inspection Goal Non risk- based

Goal 1/ yr for full service

restaurants

Risk- based

4/ yr for full service

restaurants

Risk- based

High risk— 3/ yr

Moderate risk— 2/ yr

Low risk— 1/ yr

Repetitive problems --

+ 1/ yr

Prioritizing No prioritizing Extensive food

preparation, potentially

hazardous inspected

more frequently

Based on risk

assessment

Grading System No grading system

Considering “ award of

excellence”

A, B, C

200- point grading

system

A, B, C

3 consecutive A’s

receives “ Certificate of

Excellence”

Public Satisfaction Public is not aware of

inspection results

Limited access through

The Sacramento Bee

website

Public is aware of

grading system

Restaurants quickly

correct violations and

request/ pay for

immediate re- inspection

Public is aware and

participates by calling

hotline

Most recognized

program in health

services

Facilities 5,000 food preparation

businesses

7,000 full service

restaurants/ limited food

preparation

37,000 retail food

establishments

Staffing 15 positions, 11 full time

equivalents

5000/ 11 = 454/ inspector

63 positions, 33 staff

years

7000/ 33 = 212/ inspector

283 field inspectors

37,000/ 283= 131/

inspector

Sacramento County Grand Jury June 30, 2003

33

Findings and Recommendations

Finding # 1. In the past the Environmental Health Division has been very lax in its responsibility

to provide mandated food inspections in a timely manner. In comparison, San Diego and Los

Angeles both have established risk- based programs, which led to more inspections where

extensive food preparation occurs and could be potentially hazardous. Sacramento inspectors

have to waste time trying to track down mobile food carts who list only their main distribution

address but not their site location, causing a backlog of these inspections.

Recommendation # 1a. Give priority to inspections based on risk assessment, putting

resources to work where the risk is highest. Increase inspections to 2 or 3 per year for full food

service establishments with complex menus where large amounts of food are prepared.

Recommendation # 1b. Require owners of mobile food carts to come to the County office for

their inspections during a single month of the year, e. g., January. Schedule them all during that

month.

Finding # 2. The Environmental Health Division needs more staff devoted to food preparation

inspections and needs to allocate tasks to maximize the staff they have.

Recommendation # 2. Staff should be increased from 11 to at least 22 full time inspectors.

Each inspector should be provided personal digital assistant devices ( palm pilots) to enter timely

results of their inspections. All inspectors should have access to the automated database.

Increased inspection fees from risk- based inspections and mandatory re- inspection fees should

cover the cost of increased staffing.

Finding # 3. The Environmental Health Division is not disseminating its inspection results

effectively to the public.

Recommendation # 3a. Give the public what it wants and issue letter grades to restaurants

inspections, which must be prominently displayed. Certificates or awards of excellence could

also be given to restaurants consistently receiving a letter grade of A over 3 consecutive

inspections.

Recommendation # 3b. The county Environmental Health Division should establish its own

Web site to post all food inspections results including grades, enforcement or closure actions,

follow- up inspections, and complaint remedies.

Finding # 4. The county Environmental Health Specialists ( inspectors) displayed a high degree

of professionalism during inspections. The inspectors took time to explain violations and to train

restaurant employees.

Recommendation # 4a. The county Environmental Health Division should encourage

inspection staff development by allowing staff to attend training programs sponsored by

government agencies and leaders in the food safety industry.

Sacramento County Grand Jury June 30, 2003

34

Recommendation # 4b. The County Environmental Health Division should consider

establishing an apprenticeship program to encourage recent college graduates to enter the field.

Such a program would allow these individuals to move up to staff positions after they become

registered Environmental Health Specialist.

Finding # 5. The Environmental Health Division does not provide sufficient penalties for food

service establishments to improve.

Recommendation # 5a. Enforcement actions with severe implications should require

immediate closure of the facility and mandatory re- inspections, paid for by the violator.

Increase education for minor violations.

Recommendation # 5b. Increased enforcement should lead to administrative hearings for

repeat violators with ultimate license revocation.

Commendation

The Grand Jury commends the Sacramento County Environmental Health Division for the

substantive progress it has made over the last year in increased inspections, enforcement,

education, and disclosure of health inspection results. Although more work certainly needs to

be done, it is reassuring to know that those in charge are capable and dedicated to making the

changes necessary to provide the citizens of Sacramento County with the quality food inspection

program they deserve.

Response Required

Penal Code Section 933.05 requires that specific responses to both the findings and

recommendations contained in this report be submitted to the Presiding Judge of the

Sacramento Superior Court by September 30, 2003 from:

·   Director, Sacramento County Environmental Management Department

Sacramento County Grand Jury June 30, 2003

35

Misuse of Appointive Power by the

Galt City Council

Issue

The Grand Jury received a complaint that the Galt City Council had 1) bypassed its own

resolutions and applicable law in appointing a city council member in January 2002, and 2)

failed in its ethical responsibilities to the electorate in January 2002.

Method of Investigation

·   Interviews with members of the Galt City Council

·   Interviews with community members

·   Review of audio and video tapes of Galt City Council meetings

·   Review of written minutes of Galt City Council meetings

·   Review of appropriate legal citations

·   Correspondence with the Galt City Attorney

Background and Facts

In June 2001, the Galt City Council was comprised of its full complement of five council

members.

On June 13, 2001, a council member resigned. The remaining four council members

deadlocked on an appointed replacement, and the vacancy was carried over to the primary

election in March 2002.

Between June 2001 and January 2002, the Galt City Council functioned with four members.

The council members did not agree on the course of economic development for the community

and often deadlocked on matters regarding growth.

During the period between June 2001 and through January 2002, the rule governing the Galt

City Council’s ability to transact business was clear. Specifically, Council Resolution 2000- 65,

Sacramento County Grand Jury June 30, 2003

36

Section 6, second paragraph states, “ Three council members shall constitute a quorum for the

transaction of business.” This resolution was in effect in January 2002. On January 7, 2002, a

second vacancy occurred with the death of a council member. Thus, in order for the Galt City

Council to take action “ for the transaction of business” all three remaining members were

required to be present.

On January 29, 2002, the council met to appoint a replacement for the death- caused vacancy.

Per Resolution 2000- 65, Section 6, a quorum of all three remaining members was required to

exercise appointive power and to select a new member. However, one member of the council

did not attend the January 29, 2002 public meeting to vote on the filling of the latest vacancy

because, as he explained in a written statement, he believed that the other two members of the

council had unlawfully pre- selected an appointee.

At the January 29, 2002 public meeting, the two council members in attendance were barraged

with complaints and concerns regarding the propriety of filling the vacancy upon a vote of only

two members. The community pointed out that the two council members present were

insufficient to constitute a quorum. After hearing from the Galt City Attorney, the two members

concluded in direct contradiction of Resolution 2000- 65 that they comprised a quorum and

could transact business, i. e. vote to fill the vacancy. The two members did select a candidate

and filled the vacancy.

The action of the two members raised ethical concerns: first, that the two council members

violated existing Resolution 2000- 65; second, that the two council members ignored the

concerns of the community; and, third, that they had circumvented the efforts of a fellow council

member to prevent action by not attending and thus preventing a quorum.

Finding and Recommendation

Finding # 1. The Galt City Council misused its appointive power.

Recommendation # 1. The Galt City Council should follow its own resolutions in effect at the

time a course of action is pursued. In this case, Galt should transact business by using its

appointive power by proper quorum vote. In the alternative, the Galt City Council should

correct any inconsistencies in its own resolutions prior to pursuing a course of action.

Response Required

Penal Code Section 933.05 requires that specific responses to both the findings and

recommendations contained in this report be submitted to the Presiding Judge of the

Sacramento Superior Court by September 30, 2003 from:

·   The Galt City Council

Sacramento County Grand Jury June 30, 2003

37

Recommendations for Improving Public

Water Districts’ Accountability

Issue

The Grand Jury received several complaints about managers and directors of the public water

districts serving the residents of Sacramento County. In addition, the Sacramento Bee

published newspaper articles and letters to the editor regarding various abuses found within

some districts. As a result, the Grand Jury decided to selectively investigate autonomous water

districts.

Method of Investigation

·   Newspaper articles and letters to the editor

·   January 8, 2003 Grand Jury letter to eight water districts requesting specific information

regarding their fiscal operations

·   Team visits to each of eight water districts requesting further information

·   March 20, 2003 Grand Jury letter requesting copies of information provided to the

Sacramento Bee

·   Analysis of water district responses

·   Meeting with the Sacramento County Director of Finance

·   Water Purveyors, a report of the Sacramento County Department of Finance

·   Meetings with district managers and board members of selected water districts

Background and Facts

From the Water Purveyors report:

“ Water for domestic, incidental and irrigation uses is supplied by 25 different purveyors that are

basically classified into 5 different categories: dependent water districts, autonomous water

districts ( which are independent special districts), cities, private, and mutual water companies.

The operational structure among water agencies is very similar. Each generally has a system of

wells or surface water source and distribution system designed to serve the needs of the service

area.”

Sacramento County Grand Jury June 30, 2003

38

The Grand Jury focused only on independent special water districts.

“ Autonomous Water Districts

There are … ( various) types of autonomous water districts in Sacramento County: irrigation

districts, …, community service districts, and County water districts.

Irrigation Districts

There are 4 irrigation districts located partially or wholly in Sacramento County. They include

Carmichael Water District, Fair Oaks Water District, Citrus Heights Irrigation District, and Galt

Irrigation District. The enabling legislation for irrigation districts is found in Section 20500 et

seq. of the Water Code ( California Irrigation District Act).

Community Services Districts

The San Juan Suburban Community Services District provides retail and wholesale water to the

northeastern sector of Sacramento County. Rancho Murieta Community Services District

provides its own water system. Water is taken from the Cosumes River, is stored, treated and

reclaimed for irrigation.

County Water Districts

Five county water districts were formed pursuant to the California Water District Act ( Water

Code Section 30000 et seq.). They are the Northridge Water District, Arcade Water District

( consolidated into Sacramento Suburban Water District on February 1, 2002), Florin County

Water District, Del Paso Manor County Water District, and the Rio Linda Water District.

The name ‘ county water district’ is a misnomer because it implies a dependent district of the

county government. However, all are completely autonomous with elected governing bodies.”

The eight autonomous water districts selected for investigation by the Grand Jury are as follows:

·   Carmichael Water District

·   Fair Oaks Water District

·   Citrus Heights Water District

·   San Juan Water District

·   Sacramento Suburban Water District

·   Florin County Water District

·   Del Paso Manor Water District

·   Rio Linda/ Elverta Community Water District

Sacramento County Grand Jury June 30, 2003

39

On January 8, 2003, the Grand Jury sent a letter to each of these districts requesting the

following specific information on their fiscal operations:

1. Does your district have written policies on staff travel? Please provide a copy of that

policy.

2. Who has the responsibility to audit travel records to assure compliance with those

policies?

3. How are district directors compensated for time spent on district business? Please

include forms of compensation other than cash, i. e., meals, use of vehicles, etc.

4. What authority determines which water district industry conferences directors will

attend? When more than one director attends a conference, what justification is needed

to provide for more than one participant?

5. What practices exist for directors’ travel? Please provide a copy.

6. When was the last travel audit performed on your district? Please provide a copy of

that audit.

7. Are directors attending water industry conferences required to submit reports to the

water district? Is the report written or oral? Is the item placed on the district’s meeting

agenda?

8. What is the district’s policy on the acceptance of gifts by district directors and staff

personnel? Please provide a copy of the policy.

9. What is the district’s policy on the payment of overtime to management personnel?

Please provide a copy of that policy.

After reviewing the responses, Grand Jurors interviewed the general managers and/ or directors

to elicit additional information. The following is a summary of what the Grand Jury found:

Carmichael Water District

Carmichael Water District is an urban water supply serving 11,063 customers in the Carmichael

area with a population of 40,000 in a 6 square mile area. Water sources include 9 ground

water wells ( 37%) and surface water supplied from the American River ( 63%). The average

monthly rate for unlimited water is $ 39.80 for one connection of a ½ acre or less. The district’s

operating budget for 2002- 2003 is $ 7.9 million. The general manager’s annual salary is

$ 100,614 and the assistant manager’s annual salary is $ 82,000.

The district’s written response to questions by the Grand Jury:

1. Carmichael Water District has a written travel policy for staff and the board of directors

( Policy # 4080).

2. The district’s Finance Office reviews travel receipts and expense reports.

3. Board members receive $ 144.70 per meeting with a maximum of 10 meetings per

month. In 2001, compensation for board members varied from $ 2,459 to $ 8,826,

including travel reimbursements for conference attendance. Board members do not

receive fringe or retirement benefits.

Sacramento County Grand Jury June 30, 2003

40

4. The board of directors annually reviews a list of water industry conferences and training

seminars and approves attendance of them at a public board meeting. Meetings not

previously reviewed are placed on the board’s agenda of a regularly scheduled meeting.

5. Board members are required to follow Policy # 4080, which includes a “ Conference

Expense Policy,” adopted on September 2, 1986 requiring a written or oral report be

made to the board at a public meeting.

6. The district has no separate travel audit, but includes travel as part of the general annual

audit.

7. Board members are required to follow Policy # 4080.

8. The district has a conflict of interest policy for employees ( Policy # 2170); board

members are not specifically mentioned in the policy. The omission is to be remedied

and included in Policy # 2170.

9. Management employees do not receive overtime pay. However, they receive

“ administrative leave” of one day per month as compensation for hours worked in

excess of 40 hours per week ( Policy # 2040).

It appears that Carmichael Water District has well defined travel policies and financial oversight.

The board of directors meets twice a month and is actively involved in the water industry.

There appears to be no personal use of district funds. The district does not use credit cards and

has established accounts with its vendors.

Fair Oaks Water District

Fair Oaks Water District is a medium- sized water district within Sacramento County. Although

referred to as an irrigation district, it’s actually an urban water supplier serving 39,191

customers in the Fair Oaks and Orangevale areas. Its service area is 9.45 square miles and the

source is primarily surface water from the American River and 7 ground water wells. The

district purchases treated water from San Juan Suburban Water District. The average monthly

residential rate for one connection and unlimited water is $ 35.83. The district’s operating budget

is $ 6,963,900.00. The general manager’s annual salary is $ 160,551.14.

The district’s written response to questions by the Grand Jury:

1. Fair Oaks Water District has a written travel policy for staff and the board of directors

( Policy # 2060 and Policy # 2070).

2. The district manager, accounts payable, and controller audit the travel receipts and

expense reports. Accounts Payable is responsible for reviewing expense

reimbursement forms and credit card statements for receipt documentation and business

purpose.

3. Board members receive $ 100 per meeting with a maximum of one meeting per day and

10 meetings per month. In 2001, compensation for board members varied from

$ 3,385.42 to $ 6,200.00, which included travel reimbursements for conference

attendance. Board members do not receive fringe or retirement benefits.

4. According to Policy # 2070, the board authorizes travel for the general manager; the

general manager authorizes travel for the district staff.

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5. Some board members are committee members of various water associations and attend

more meetings than other board members.

6. The district controller audits all travel expense claims. Receipts are required for all

travel related expenses; in addition, credit cards are issued to board members and

charges must be verified each month.

7. After attending water association meetings, board members are required to report back

at the next meeting.

8. Board members are prohibited from accepting gifts by the district’s Business Ethics and

Conduct Policy.

9. District managers do not work overtime and are expected to complete all necessary

duties.

Minutes of the board meetings indicate they meet monthly. They have policies and procedures

addressing staff and management conduct that are updated frequently. Board members are

active in regional and national associations.

Citrus Heights Water District

The Citrus Heights Water District covers 12.16 square miles and serves a population of

65,135. It has 19,118 service connections. The district provides 17,000- acre feet of treated

surface water from the Suburban Community Services District and 2296 acre feet of ground

water from 3 wells. The average monthly rate is $ 21.67. The 2002- 2003 operating budget is

$ 5,611,925 and the capital budget is $ 3,565,689. The general manager’s annual salary is

$ 122,280. The board of directors consists of 3 members serving 4- year terms.

The district’s written response to questions by the Grand Jury:

1. Citrus Heights Water District has a written policy on travel that applies to both directors

and officers. Travel is limited to education and training functions that are beneficial to

the district. Within those limits, board members attend meetings of their choosing. The

board must approve attendance to out- of- region meetings.

2. The district’s treasurer is responsible for auditing travel records.

3. Each director receives $ 127.33 per diem with a maximum of 10 days per calendar

month.

4. Directors determine their need to attend specific conferences.

5. Travel by air, train or bus is permitted and shall not exceed or is reimbursed beyond the

cost of an unrestricted round trip coach air fare plus associated ground transportation

and parking expenses.

6. The last audit was performed in January 2003.

7. Written or verbal reports on conferences attended are required to be presented at

public meetings.

8. Policy is consistent with standards of the Fair Political Practices Commission.

9. Management is considered “ exempt” and is not entitled to overtime pay.

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San Juan Water District

San Juan Water District serves eastern Sacramento County and western Placer County.

It sells wholesale water to Fair Oaks Water District, Citrus Heights District, Orangevale Water

District and to the City of Folsom. The district supplies water to approximately 160,350

customers in the northeast area including Orangevale, Citrus Heights, Fair Oaks and South

Placer County and the City of Folsom. Its service area is 46.6 square miles, with 33,000 acre

feet of water rights, a 24,000 acre feet contract with the Bureau of Reclamation, and a 25,000

acre feet contract with Placer County Water Agency. The average monthly gravity rate is

$ 36.66. In April 2003, the cost increased by 8 percent and in June 2003, an additional 12

percent increase was scheduled. The district’s operating budget is $ 9,517,839. The general

manager’s annual salary is $ 127,000 and the assistant manager’s annual salary is $ 111,000.

The district’s written response to questions from the Grand Jury:

1. San Juan Water District has written policies for travel for staff and the board of

directors. Reimbursement for use of personal vehicles is limited to a 200- mile radius of

the district. Beyond that, travel reimbursement may not exceed the cost of the

equivalent round- trip airfare to the same destination, except as approved by the general

manager for a specific trip ( Policy, Chapter Eleven 11.1).

2. The department manager to the general manager approves travel reimbursement

expenses submitted with an expense report and appropriate receipts. Travel/ hotel

expenses are reimbursed by statement or receipt. Meals are reimbursed at per diem

rates.

3. Board members receive $ 100 per meeting, with a maximum of 10 meetings per month.

In 2001, compensation for board members varied from $ 4,200 to $ 6,877, including

travel reimbursements for conference attendance. Board members do not receive fringe

or retirement benefits. If they use their private car, board members are reimbursed for

mileage. Board members do not use district cars.

4. The board of directors authorizes conference attendance through Resolution

92- 04.

5. The board of directors complies with Chapter 11 of the district’s policy manual

regarding “ Employee Business Expenses.” In addition, Resolution 92- 04 authorizes

conference attendance.

6. The district does not have a specific process for auditing travel other than the annual

audit and the policy requirements which require the financial office to review employee

expenses.

7. Board members are not required to submit written reports, but oral reports are given at

regularly scheduled board meetings. The board of directors is currently reviewing a

revision of policies about conference and workshop reporting.

8. The district is bound by the Fair Political Practices law, which is incorporated into its

policy regarding “ Standards of Conduct and Employee Discipline.”

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9. Payment of overtime is not allowed for management personnel. There is a program

termed “ pay for performance” available to management, supervisory, confidential, and

professional employees. It is a yearly incentive program which has the potential of being

a bonus of up to 10 percent of base wages for the assistant general manager,

supervisors, confidential and professional employees. The general manager’s bonus is

determined by the board of directors.

An area of Grand Jury concern is employee retirement. The district pays the entire cost for all

regular employees. Retirement is computed on the highest earning year and is based on three

percent at age 60 as of September 2002. These figures represent an increase of 50 percent

over the previous policy of two percent at age 55 and will cost the district approximately

$ 450,000 the first year.

Sacramento Suburban Water District

The Sacramento Suburban Water District was formed in February 2003 with the consolidation

of Northridge Water District and Arcade Water District. It covers 36 square miles, serves a

population of 180,000, and has 46,000 customers. The district has rights to 26,064- acre feet

from the City of Sacramento water entitlement and has a contract with Placer County Water

Agency to purchase up to 29,000 additional acre- feet of surface water per year. In 2002, the

district’s 87 wells produced 25,121 acre- feet of water, and it purchased 16,923- acre feet.

Fiscal Data:

2002- 03 Budget: $ 19,072,055

2003- 04 Budget: $ 19,204,463

Monthly Rates:

Arcade Service Area: $ 41.88 ( average residential for 1” connection,

10,000 sq. ft. parcel, unlimited water)

$ 22.34 ( average residential for ¾ ” connection,

10,000 sq. ft. parcel, unlimited water)

Northridge Service Area: $ 28.61 ( average residential for 1” connection,

10,000 sq. ft. parcel, unlimited water)

$ 26.27 ( average residential ¾ ” metered service)

The district’s written response to questions from the Grand Jury:

1. The Sacramento Suburban Water District recently adopted a new manual, which

includes staff travel policies.

2. Staff expense reports are submitted to the direct supervisor, who, in turn, submits the

report to the general manager for approval. The district’s auditors may further examine

travel records during year- end audits.

3. Each director is entitled to $ 100 per day for meetings or other district related functions,

up to 10 days per month.

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4. The district encourages directors to attend conferences, seminars, and other meetings of

interest to the district. The board has given its members the discretion to determine

which industry conferences they attend.

5. In December 2002, the district adopted a policy for directors’ compensation and

expense reimbursement.

6. An independent auditor completed two reports dated January 9, 2003 and March 10,

2003, which have been made available to the public.

7. Directors are not required to submit formal written reports of water industry

conferences they attend; however, a list of meetings they attend is included on the

agenda, and directors may give informal reports at that meeting.

8. The district has adopted the Fair Political Practices Commission Code.

9. The general manager does not receive overtime compensation.

The newly created Sacramento Suburban Water District has undergone close scrutiny by

investigative reporting in the local newspaper, independent auditors, the newly formed board of

directors. It appears that the consolidation was difficult and sometimes painful; however,

members of the Grand Jury who met with the interim manager, the recently appointed new

general manager and others, were impressed with their response to the auditor’s reports and to

the new policies and procedures being implemented.

Florin County Water District

Florin County Water District in the southern part of Sacramento County serves a population of

fewer than 10,000, with approximately 2250 customers. The district has ten wells to serve their

clients. Residential accounts are not metered; all commercial accounts are metered. The

residential rate is $ 7.50 per month billed bi- monthly. The district’s annual budget is just under a

half million dollars, with a total revenue for 2002- 2003 estimated at $ 543,650.

The budgeted positions are General Manager, Billing Clerk/ Receptionist, Office Manager, and a

Certified Grade II Distribution Operator. The pay scale for the general manager is $ 60,000

annually. The district’s annual payroll budget is $ 160,000. The board of directors consists of

five members. Board members are local businesspersons compensated at the rate of $ 100 per

meeting once per month. District credit cards are used for buying small hand tools and parts for

backhoes, trucks, and other district equipment and pumps.

The Grand Jury received a complaint regarding nepotism within the district, and in fact, three

relatives are employed by the district. However, the Grand Jury found no evidence that the

district’s operations were negatively affected by this situation.

The district’s written response to the questions of the Grand Jury is as follows:

1. Florin County Water District has no written policy regarding staff travel; however, a

“ travel expense report,” with expense receipts, was used to report the general

manager’s travel expenses for attendance to the National Rural Water Association

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Conference and board meeting, of which he is a member. The National Rural Water

Association reimbursed these expenses to the district.

2. Travel records are audited by an independent auditor during the district’s annual audit.

3. District directors are compensated $ 100 per meeting, with a maximum of three meetings

per month. Florin County Water District does not provide any other compensation.

4. A board member wishing to attend a specific conference has their request placed on the

meeting agenda and it is voted on at that time. For the past seven years, no board

member has attended any industry conferences.

5. The district does not have a travel policy.

6. The district does not have a travel policy.

7. The district does not have a travel policy.

8. The district complies with the requirements of the Fair Political Practices Commission

Reform Act concerning the acceptance of a gift or gratuity.

8. Florin County Water District has only one management employee, the general manager.

The general manager is an “ at- will” exempt employee; he receives no pay for overtime.

Although the general manager told the Grand Jury the district had no travel policy, review of the

submitted materials did include a policy on travel. Apparently the general manager is not aware

of this policy.

Del Paso Manor Water District

The Del Paso Manor Water District is located north of the American River and almost

completely surrounded by the Sacramento Suburban Water District. The district takes up

about one square mile and has 1790 residential and commercial customers. The average water

bill for a residential customer is $ 11.15 per month. There are five members on the board of

directors. The district’s general manager earns a salary of $ 74,441, plus benefits.

The district’s written response to the Grand Jury’s questions follows:

1. Del Paso Manor Water District has a written travel policy.

2. The general manager audits the monthly travel and meeting expenses, which are

confirmed by the annual audit.

3. Directors receive $ 200 per meeting, with a maximum of 10 meetings per month.

4. Upcoming meetings are presented as an item on the board’s meeting agenda. The

board discusses the meetings and decides on attendance.

5. The district has defined travel procedures and practices.

6. The general manager audits each travel reimbursement requests, followed by full board

review at the next regular meeting, in addition to the annual independent audit.

7. Directors and staff are required to report on all conferences attended at the next regular

board meeting.

8. The board has adopted the Fair Political Practices Commission codes.

9. There is no overtime pay for management personnel.

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Board of Directors’ meeting reimbursement is $ 200 per meeting. This amount is high when

compared to other water districts. The reimbursement for meeting expenses through September

2002 is $ 9,000. The previous year’s meeting reimbursement was $ 12,000.

The district has a policy of paying the $ 200 daily meeting reimbursement for one board member

only to attend a conference. Other board members attending the same conference are

reimbursed for their expenses and do not receive the $ 200. In fact, the 2002- 2003 budget of

$ 17,000 for professional meetings exceeds the entire year’s budget of $ 14,500 for director

fees.

Rio Linda/ Elverta Community Water District

The Rio Linda/ Elverta Community Water District covers 17.7 square miles and serves a

population of 13,100. The water supply and distribution facilities consist of 11 wells and 58.82

miles of distribution mains. The district pum