June 2004

To the People of San Luis Obispo County

This Final Report is presented to you by the 2003- 2004 San Luis Obispo County Grand

Jury. It is the compilation of the major inquiries conducted during our service.

Each July the Superior Court for the County of San Luis Obispo impanels a Grand Jury

to serve through the following June. Thirty candidates, including up to ten holdovers

from the previous jury, are nominated by Judges of the Superior Court. The names, mi-nus

holdovers, are then drawn in a lottery- type process. The first nineteen, including

holdovers, are sworn in and constitute the Grand Jury. Eleven alternates are chosen in

the order in which they are drawn. At the filing of this report, the 2003- 2004 Grand Jury

consists of seventeen jurors, including three who were originally chosen as alternates.

The 2003- 2004 Grand Jury represents a wide range of ages, from a young Cal Poly sen-ior

political science major, to residents well into their retirement. Our education and

experience includes retired teachers, farmers, executives, a social worker, an employed

technician, professionals, and a retired city manager, professor, and law enforcement

officer. Most of the county geographical areas were represented. The commonality

among jurors was the commitment and responsibility to the citizens of the county they

represented. For many of us, serving as jurors was a significant education on how local

government functions. It was also an opportunity to provide recommendations, where

appropriate, for improvements.

Each juror participated on two committees that met at least weekly, and more often as

the year progressed. The committees were: County, City, Law & Justice, and Health &

Social Services. We also held weekly general session meetings, where the committees

provided status reports and the Grand Jury deliberated on voting matters. A quorum of

at least 12 members was always present for official voting.

Our inquiries were initiated by citizen complaints or by a juror, committee, or the Grand

Jury as a whole. The 2003- 2004 Grand Jury received nearly eight hundred citizen com-plaints

concerning fifty different issues. These complaints were first referred to the

appropriate committee to review and to conduct a preliminary investigation. If the com-plaint

met the established criteria, the committee would recommend that the Grand Jury

authorize further investigation.

Many complaints did not require action beyond the initial review. In some cases these

complaints were not within our county or civil jurisdiction, or we determined that the is-sues

could best be resolved through other avenues. Other reasons we did not pursue a

complaint included: the matter was currently in the legal process, it was received too late

in our term, or, in the judgment of the Grand Jury, it was not in the best interest of the

community to pursue.

Grand Jury work was not confined to the jury offices. As you will read in our reports, ju-rors

conducted numerous on- site inspections, including the required reviews of the

California Men’s Colony and the El Paso de Robles Youth Authority. We also met with

many department heads, and visited the San Luis Obispo County Jail, Juvenile Hall, and

Office of Emergency Services. Toward the end of our term, we toured the PG& E Diablo

Canyon Power Plant.

In the course of our investigations, we interviewed more than 70 witnesses. We thank

all those who contributed their time and energy in providing important information to us.

The offices of both the District Attorney and County Counsel provided significant legal

guidance for our investigations. Their responsiveness and thoroughness was greatly ap-preciated.

The California Penal Code requires that the Grand Jury submit a Final Report to the

Presiding Judge of the Superior Court prior to the end of its term. As required, the judge

approved this report prior to its publication.

For a report that includes findings and recommendations, elected county officers and

heads of county agencies and departments must reply to the Presiding Judge within 60

days. The governing bodies of other public agencies, concerning matters under their

control, must respond within 90 days.

The required responses are specified in Penal Code § 933.05, as follows:

( a) ... as to each grand jury finding, the responding person or entity shall indicate

one of the following:

( 1) The respondent agrees with the finding.

( 2) The respondent disagrees wholly or partially with the finding, in which

case the response shall specify the portion of the finding that is disputed

and shall include an explanation of the reasons therefor.

( b) ... as to each grand jury recommendation, the responding person or entity

shall report one of the following actions:

( 1) The recommendation has been implemented, with a summary regarding

the implemented action.

( 2) The recommendation has not yet been implemented, but will be imple-mented

in the future, with a timeframe for implementation.

( 3) The recommendation requires further analysis, with an explanation and

the scope and parameters of an analysis or study, and a timeframe for the

matter to be prepared for discussion by the officer or head of the agency or

department being investigated or reviewed, including the governing body of

the public agency when applicable. The timeframe shall not exceed six

months from the date of publication of the grand jury report.

( 4) The recommendation will not be implemented because it is not warranted

or is not reasonable, with an explanation therefor.

Agency, Board of Supervisors, and other responses to Grand Jury findings and recom-mendations

are required to be on file with the clerk of the public agency, the office of the

county clerk, and the currently impaneled Grand Jury. We anticipate that the responses

to this report will be available on the Grand Jury web site by the end of this year.

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VEHICULAR MANSLAUGHTER CASE

TABLED ON DEPUTY DA’S TABLE

Synopsis

On the evening of September 7, 2002, the Grover Beach Police Depart-ment

responded to the report of an accident involving a vehicle and two

pedestrians crossing Grand Avenue at Fifth Street. This accident caused

one pedestrian fatality. The police investigated and sent their report to

the San Luis Obispo County District Attorney's Office. The District Attor-ney's

Office did not file any charges against the driver or reject the case,

and, after six months, sent the case to the Attorney General's Office for its

review. The Attorney General also declined to file charges and returned

the case to the District Attorney's Office on August 26, 2003. Later, two

deputies from the Attorney General’s Office came to our Grand Jury office

to present their reasons for declining to file charges against the driver.

This Grand Jury report examines the handling of the case by the Grover

Beach Police Department and the San Luis Obispo County District Attor-ney.

Key issues include: 1) the time taken to process the case in the Dis-trict

Attorney's Office, 2) why it was transferred to the California State At-torney

General's Office, 3) the time the case was held at the Attorney

General's Office, and 4) why and how the District Attorney finally filed the

charge after the Attorney General's rejection. California law requires the

prosecuting attorney to file charges in a misdemeanor manslaughter case

within one year of the victim's death; otherwise, the statute of limitation

prevents filing and prosecution. The Grand Jury, knowing of the ap-proaching

statute of limitation deadline, made this investigation a top pri-ority.

It was not until September 5, 2003 that the District Attorney filed

one charge of misdemeanor manslaughter.

Why the Grand Jury Investigated

In August 2003, the parents of the fatally injured girl petitioned the Grand Jury to explore

why the District Attorney's Office did not act. The family had been frustrated in their

attempts to receive information about the status of the case, and later, by the Attorney

General's decision not to file. The concerned family and others submitted 704 com-plaints

to the Grand Jury requesting an investigation, the first arriving on August 14,

2003. The family sought to motivate action because the impending September 11, 2003

expiration of the statute of limitation would prevent any subsequent criminal prosecution.

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Authority

The Grand Jury exercises its authority to investigate the San Luis Obispo County District

Attorney under Penal Code 925, which states " The grand jury shall investigate and

report on the operations, accounts, and records of the officers, departments or functions

of the county" and for the Grover Beach Police Department under Penal Code 925a,

which authorizes the investigation of city departments. The last two parts of this report

are informational only, and are included to help the reader make the bridge between the

case leaving, then returning to the county.

Background

A traffic accident occurred in Grover Beach that resulted in the death of a 17- year- old

girl. Typically, in a case of a traffic accident resulting in a fatality, the law enforcement

agency of the local jurisdiction where the accident occurred conducts a comprehensive

investigation of the accident scene, the vehicle, and any persons who were involved or

witnessed the event. After assessing the information compiled, the local agency then

forwards its report, along with any recommended charges, to the County District

Attorney's ( DA) Office for review of the file, any necessary additional investigation, and a

decision whether or not to file charges against any participants. If the DA's Office feels

that charges are appropriate and a reasonable chance exists to sustain the charges, the

DA will file the determined charges with the appropriate court of law.

The DA is elected by the voters of the county to a four- year term to lead the county's

prosecuting agency. Due to the volume of misdemeanor and felony cases forwarded to

the DA's Office by local law enforcement agencies each year, the DA employs a staff of

deputy DAs to assist with review and prosecution of cases. Among these are a chief

deputy who serves to oversee the deputies; a filing deputy responsible for case review

and filing of the less serious, or misdemeanor cases; and a filing deputy for the more

serious felony cases. The filing deputies must make the decision whether or not to file

charges before the statute of limitation expires. Once it expires, the opportunity to

prosecute ends, regardless of the merit of the charges or the ability to successfully

prosecute the case. When the filing of a case involving injury or death occurs, the Victim

Witness ( VW) Division of the DA's Office is notified. VW then assigns a staff advocate to

provide assistance and support to the victim and/ or family throughout the process of

prosecution.

When a valid or perceived conflict of interest exists, the DA's Office may request a

review by the Attorney General's ( AG) Office. The AG's Office also employs a staff of

deputies and assistants to handle the review and prosecution of cases. If, in the opinion

of the AG's staff attorneys, sufficient grounds exist to file charges and a reasonable

chance for prosecution exists, the AG's Office will file charges in an appropriate court.

Generally, if the AG's Office determines that grounds are insufficient, the case is closed

and the matter ends.

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Method of Investigation

The Grand Jury requested, in some cases subpoenaed, copies of the police file, the

driver's previous driving history, his court and probation records, and his insurance claim

pertaining to this accident. Some of the documents gathered for the investigation

include the District Attorney's Protocol Addressing Conflict of Interest and Case

Management and Complaint Filing Procedures. In addition we obtained Victim Witness

notes, various correspondence, attendance sheets, and workload records for the

Misdemeanor Filing Deputy District Attorney ( Filing Deputy). The Jury also examined

minutes of the Pension Trust Fund meetings for the past five years, Pension Trust Fund

travel and expense vouchers for that Filing Deputy and the Tax Collector who is the

father of the driver involved in the accident. We then reviewed the above materials,

which precipitated our need to question individuals on several matters.

The jury conducted interviews with police officers from the Grover Beach and Pismo

Beach departments who responded to the accident. We interviewed many District

Attorney personnel to learn what actually transpired in the District Attorney's Office after

the police report was submitted. We questioned the intake secretary, the Filing Deputy,

the Chief Deputy District Attorney, three other deputy district attorneys, the information

technology lead programmer, and three victim witness advocates including the Victim

Witness Director who had talked with the family. In all interviews conducted, the GJ

placed the witnesses under oath and admonished them not to discuss the proceedings

with anyone else. At least nine jurors were present at each interview, and the proceed-ings

were tape recorded for later reference and review by the jurors who were not able

to attend. Some of these interviews were transcribed by one of the jurors for clarification

of the facts.

Members of the Grand Jury visited the location of the accident at night, observed the

scene, the lighting, and even crossed the street using the same crosswalk. Later, two

deputies from the Attorney General's Office came to our Grand Jury Office to present

their reasons for declining to file charges against the driver.

We developed this report for the public after reviewing the information extracted from a

myriad of sources. We have organized the data chronologically within each section as

much as possible. The investigative Parts 1 and 2 detail the events by numerical order.

The informational sections, Parts 3 and 4, use the narrative form. Acronyms will be used

throughout the report for convenience. The following table of acronyms will help the

reader.

4

Acronyms Used

AG California Attorney General

AGH Arroyo Grande Hospital

DA San Luis Co. District

Attorney

GB Grover Beach

GBPD Grover Beach Police Dept

GJ San Luis Co. Grand Jury

MAIT Calif. Highway Patrol's

Multidisciplinary Accident

Investigation Team

PB Pismo Beach

SLO San Luis Obispo

VW Victim Witness

Part One: Grover Beach Police Department ( GBPD)' s accident investigation

Part Two: San Luis Obispo County District Attorney ( DA)' s Office processing and

Victim Witness ( VW) handling of the case

A) Communication within DA staff and filing conflicts:

What went on in the DA's Office?

B) Case remains in the DA's Office for six months without a decision to file or

reject: How could " shelving" of the file go unnoticed for six months?

C) Victim Witness involvement: How could the VW Office better assist the

family?

Part Three: Transfer of the case to the California Attorney General ( AG) Office

Part Four: The District Attorney reclaims the case. AG Office relinquishes the case

to the SLO DA Office and DA files the charge of vehicular manslaughter

without gross negligence.

5

PART ONE

Grover Beach Police Department Investigates

Facts:

( 1) Two teenage female pedestrians were crossing Grand Avenue northbound at 5th

Street in Grover Beach at 9: 04 p. m. on Saturday, September 7, 2002.

( 2) A 1997 Chevrolet Tahoe was traveling west on Grand Avenue at the same time.

( 3) The vehicle struck the pedestrians, causing serious injuries that resulted in the

subsequent death of one girl and minor injury to the other.

( 4) GBPD responded to the emergency call.

Findings:

( 1) The GB police officer on patrol at the time arrived within two minutes of the

accident.

( 2) The San Luis Obispo Ambulance Service was requested at 9: 06 p. m., arriving at

9: 10, to provide medical attention and to transport the seriously injured victim to

Arroyo Grande Hospital ( AGH). A second ambulance, summoned at 9: 12 p. m.,

arrived at 9: 17, took the other victim to AGH where she was treated and re-leased.

( 3) The GB responding officer interviewed and took statements from five witnesses

at the site of the accident.

( 4) The GB officer interviewed the driver and administered a preliminary alcohol

breath test, then released him.

( 5) When another GB police officer came on duty, that officer went to the driver’s

home, and at 10: 11 p. m., took him to AGH to obtain a blood sample.

( 6) Neither the first- responding GB police officer, nor his watch commander on duty

at the time of the accident, had the training required to issue a citation at the

scene of the accident unless he had witnessed the accident.

( 7) A Pismo Beach police officer with advanced traffic accident training arrived at

9: 57 p. m. and assisted with the investigation, as requested by GB police.

( 8) The GB police officer's report did not indicate any adverse weather or lighting

conditions as contributing causes of the accident.

( 9) The police report showed no tire skid marks on the pavement.

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( 10) The GBPD impounded the vehicle and arranged for a full inspection.

( 11) The GB officer and a police volunteer took photos that night, and later, during the

accident reconstruction.

( 12) On September 10, 2002, the GBPD requested that California Highway Patrol

Multidisciplinary Accident Investigation Team ( MAIT) inspect the vehicle. MAIT

inspected the vehicle on September 12, 2002.

( 13) MAIT's vehicle inspection ruled out malfunction as a cause of the accident.

( 14) September 11, 2002, four days after the accident, the seriously injured victim

died from the injuries she had sustained.

( 15) On September 24, 2002, the GBPD submitted a complete report in triplicate -

including accident details, photos, medical reports, and witness statements - to

the SLO County DA Office.

( 16) The GB police accident report recommended that the DA review the report for

possible prosecution of the driver for violation of Penal Code Section 192( C), ve-hicular

manslaughter without gross negligence, and Vehicle Code Section

21950( a), pedestrian right of way at a crosswalk.

( 17) After submitting its report to the DA's Office, GBPD considered its task complete.

Per the department’s standard operating procedure, police personnel did not

make any further inquiries about the case or the possible prosecution of the

driver.

Conclusions:

( 1) The GBPD conducted a thorough investigation of the accident.

( 2) Accident reconstruction efforts followed guidelines detailed in the Collision

Investigation Manual.

( 3) Weather, lighting, and vehicular malfunction were ruled out as causative factors.

( 4) GBPD insured that the appropriate medical reports were included in the investi-gation

package before delivery to the DA.

( 5) The initial responding officers were unable to write a citation at the scene

because they lacked the requisite training.

( 6) GBPD processed the case efficiently and effectively.

( 7) GBPD's delivery of the complete report to the DA’s office was timely.

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Recommendations:

( 1) The GBPD should make every reasonable effort to train additional field personnel

so that citations may be written at the scene, when appropriate.

( 2) In future cases involving death or serious injury, the GBPD should routinely

follow up and inquire of the DA as to the status of the case.

GBPD Response Requirement

Under Penal Code Section 933( c), the governing body of the GBPD shall comment to

the presiding judge on these findings and recommendations no later than 90 days from

this report's publication.

PART TWO

District Attorney's Office Processing

and Victim Witness Handling of the Case

A. What went on in the District Attorney's Office?

Facts:

( 1) The DA's receptionist received the file from the GBPD on September 24, 2002

and date- stamped it.

( 2) The Intake Secretary personally delivered the large file to the Deputy DA

responsible for misdemeanor filings after numbering and processing the file.

( 3) No system was in place at that time for tracking misdemeanor cases.

( 4) The file remained in the Filing Deputy's office from late September 2002 until

March 26, 2003.

( 5) The Filing Deputy did not contact GB or PB police officers about their accident

investigation, or call upon the DA investigators to conduct additional investiga-tion.

( 6) The Filing Deputy stated to the GJ that he did not discuss with his colleagues his

problem with filing.

( 7) The District Attorney received a letter from the victim's mother on March 18,

2003, questioning the delay in filing charges.

( 8) On March 26, 2003, the Chief Deputy DA told the filing deputy to file the case.

8

( 9) The Filing Deputy said he could not file the case because he could not find a

violation of the vehicle code.

( 10) This same Filing Deputy filed serious criminal charges against this same driver in

1999 which resulted in a conviction.

( 11) The Filing Deputy told the GJ that in reviewing the file in March 2003, he

discovered that the driver is the son of the County Tax Collector whom he knows.

The Filing Deputy serves with the County Tax Collector on the County Pension

Trust Fund board, which poses a possible appearance of conflict of interest.

( 12) Upon learning that the County Tax Collector is the driver's father, the Chief

Deputy took the file for transfer to the AG's Office on March 26, 2003 to avoid

any perception of conflict of interest.

Findings:

( 1) The Filing Deputy had opportunity to examine the file in late September 2002.

( 2) The file remained in the Filing Deputy's office for six months without the

knowledge of senior DA personnel due, in part, to the lack of a tracking system.

( 3) The Filing Deputy did not act on the case, to either file or decline to file, during

the six months the case remained on his desk.

( 4) He did not seek advice of the Chief Deputy DA or the DA after he read the file.

( 5) He did not discuss with other DAs, before March 26, 2003, any perceived

problem about filing.

( 6) Each time the victim's mother requested to speak to him he declined. He chose

to communicate through the victim's family’s attorney.

( 7) The Chief Deputy, on March 26, 2003, directed the Filing Deputy by saying, " You

need to file this case." It was then that the Filing Deputy said he first noticed a

document from the tax collector's office bearing the name of the driver's father.

( 8) The Chief Deputy, acting on this possible conflict, contacted the AG Office in Los

Angeles, asking that office to review the file.

( 9) The Senior Assistant AG stated that the case did not meet the usual parameters

of conflict, but would take it as a courtesy.

( 10) GJ investigation of Pension Trust Fund minutes of January 26, 1998 through July

28, 2003, travel vouchers, conference expenses, and Auditor/ Controller records

of the past five years did not expose any connections that suggested a conflict

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between the Filing Deputy and the County Tax Collector, despite their serving on

that same committee.

Conclusions:

( 1) The Filing Deputy did not act to perform his duty to file or reject this case.

( 2) The Filing Deputy withdrew from any of the alternative actions available to him.

( 3) The Filing Deputy, when questioned by the Grand Jury, had no acceptable

explanation for his inaction.

( 4) The lack of a tracking system for misdemeanors allowed this case to go

unresolved and unnoticed for six months.

( 5) The Chief Deputy DA accepted the perception of a conflict of interest and

referred the case to the AG.

( 6) The District Attorney's Office did not file or reject the case in March 2003,

causing additional extended stress to the victim's family.

( 7) Because of this case, in April 2003, the Chief Deputy DA requested two new

systems of tracking. One was to track the more serious high misdemeanor ( red

dot) pending cases; the more recent one, for pending cases neither filed nor re-jected.

( 8) This case fueled the formulation of a new procedure ( still in draft in the DA's

Office) titled Filing Procedures for Vehicular Manslaughter Cases ( and Other

Cases Involving a Fatality).

( 9) The Grand Jury found nothing to indicate to us that a conflict of interest existed

with the DA handling the case, in the interviews we conducted or the records we

reviewed.

( 10) The Grand Jury’s initial observation was that the Filing Deputy’s performance in

the handling of this case should be sanctioned. However, a closer examination

revealed that management personnel either knew, or should have known, that a

review of this fatal accident was pending. News articles, for example, were

printed at the time of the accident in local newspapers in which the driver was

named. News articles in December 2002 identified the driver as the son of the

County Tax Collector.

Recommendations:

( 1) The DA’s Office should track all cases, starting from the time a file comes to the

office, rather than when the deputy files it. [ The new Pending Cases ( Neither

Filed or Rejected) does this tracking now.]

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( 2) Encourage Deputy DAs to seek input of each other and of their superiors

regarding problematic and difficult cases.

( 3) The Grand Jury recognizes that this is a small county and therefore many people

in county government know each other. This makes it even more imperative that

the DA's Office identifies conflicts early on in their handling of criminal cases.

( 4) The DA’s Office should substantiate claims of conflict of interest more carefully

before referring cases elsewhere.

B. How could " shelving" of the file in the DA's Office go unnoticed for

six months?

Facts:

( 1) No computer program existed for tracking misdemeanors.

( 2) At that time, no system of " red flagging" existed for misdemeanors before filing a

case.

( 3) The Filing Deputy did not act or say anything to his colleagues about this case.

( 4) Management in the DA's office was not aware of the inaction.

Findings:

( 1) Only felony cases were trackable at the time.

( 2) Communication within the DA's Office regarding this file was insufficient.

Conclusions:

( 1) Tracking systems for misdemeanors could have prevented the lengthy " shelving"

of the file.

( 2) The Filing Deputy failed to make a timely decision to file or reject.

Recommendations:

( 1) The Chief Deputy should periodically evaluate the computer programs designed

and implemented for tracking high misdemeanor ( red dot) cases and the new

pending cases, now that such tracking is available.

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( 2) The Chief Deputy DA should exercise closer control/ oversight of deputies'

caseloads to monitor status of cases.

( 3) Management should take a more assertive role in supervising employees of the

DA's Office and take corrective action when needed.

C. How could the Victim Witness Office better assist the family?

Facts:

( 1) The case was delivered to the DA's Victim Witness ( VW) Division Assistant

Director's desk, but no action was initiated because a filing had not occurred yet.

( 2) No procedure was in place to require a contact with victims' families until after a

filing occurred.

( 3) The victim's mother made the first contact with VW Assistant Director on

December 23, 2002, asking to see the Filing Deputy.

( 4) The victim's mother requested the help of VW on seven occasions. She had

questions about the lack of progress of the case.

( 5) Subsequent communication between the victim's mother was with another VW

advocate. The Assistant Director assigned this advocate to the case on February

6, 2003.

( 6) VW made no other attempts to satisfy the request of the victim's mother when the

filing deputy declined to talk with her.

( 7) The VW advocate and Assistant Director did not communicate with the Director

of the VW Office concerning victim's parents' inquiries.

( 8) The first contact initiated by VW to advocate on behalf of the victim's family was

on March 10, 2003. [ The accident was in September 2002.]

( 9) The Filing Deputy advised the VW advocate on March 10, 2003, that he was

inclined not to file the case.

( 10) The Director of VW stated that she did not know of the police report until March

31, 2003.

( 11) The Director of VW and Chief Deputy DA met with the victim's mother on April

10, 2003, to inform her that the DA had referred the case to the AG's Office.

( 12) The Director of VW spoke with the DA on July 24, 2003, after victim's mother

requested the DA re- review the case.

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Findings:

( 1) At the time of the accident, Victim Witness lacked policy for discussing with

victims' family where death is involved. [ New policy addresses this.]

( 2) Communication within the VW Office was insufficient in this case.

( 3) The VW Assistant Director realized the father- son relationship of the County Tax

Collector and the driver upon his review of the file.

( 4) The victim's family did not receive support and VW advocacy until the case went

to the AG's Office.

Conclusions:

( 1) Lack of communication within the VW Division hindered effectiveness of service

to this victim's family.

( 2) VW did not reach out to the family until after filing of the case, almost seven

months later.

( 3) The VW advocate was not helpful in addressing this victim's parents' anxieties

when they repeatedly requested status reports.

( 4) Lack of initiative and responsiveness reflects negatively on staff and division.

( 5) Policy and procedures failed to address this case while the Filing Deputy

remained undecided.

( 6) The policy in existence at the time and the lack of a tracking system prevented

timely assistance to victim's family.

Recommendations:

( 1) The director should schedule regular VW Division meetings for discussion of

current cases among all advocates.

( 2) The division should develop guidelines to offer appropriate assistance to families

of victims while waiting for the DA's decision to file or reject. [ New procedure has

been drafted and instituted as of December 11, 2003 as a result of this case.]

( 3) Assistant directors should monitor DA intake data to assess need for VW

intervention. [ Also part of new procedure.]

( 4) VW advocates should promptly notify the Chief Deputy DA when filing deputies

are not responding in a timely manner to victim's requests.

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DA and VW Response Requirement

Penal Code Section 933( c) mandates that the DA shall comment within 90 days to the

presiding judge on the findings and recommendations in this report directed to the DA

Office and the Victim Witness Division.

PART THREE

Transfer of the Case to the

California Attorney General ( AG) Office

The DA's office sent the case to the Los Angeles office of the California Attorney

General on March 26, 2003, with a letter advising that

1) "... a conflict of interest exists which would preclude the prosecution of

the above- entitled matter by our office," 2) the "… case does not fit the

strict traditional definition of a conflict of interest, but better judgment

would indicate that an impartial review and prosecution of the case would

be in the public interest due to the complex net of interactions that the fa-ther

of the defendant has with members of our office," and 3) " We would

appreciate it if your office would be kind enough to handle this matter to

avoid any appearance of impropriety in the handling of this case by our

office."

The DA ' s Office sent the file, containing only material related to this incident, to the AG

after the AG agreed to take the case. The AG’s staff conducted their investigation,

holding the case four months before determining that there were not sufficient grounds

to file charges against the driver. We have incorporated in this summary the AG

representatives' explanation to the GJ of some of their investigative process.

On July 21, 2003 the AG met with the victim's family in SLO to apprise them of their

decision to reject the case. Later that week the girl's mother called VW to request the

DA re- review the case. Meanwhile the AG sent a letter to inform the DA of the decision.

On August 19, 2003 the family and others came to meet with the DA and express their

anger and frustration at the long delay of the filing decision. They also communicated

their dissatisfaction with their lack of access to the Filing Deputy. The GJ received these

same complaints in August.

On September 3, 2003, two AG representatives came to the SLO County GJ Office.

They stated this was a highly unusual action. They explained their decision to us and

described what they did in reviewing the case. The AG does not consider the character,

behavior, or prior infractions of a suspect unless it is relevant, or proves some fact, or is

evidence that is usable to support a charge.

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They stated that they had reviewed the case in light of practices typically applied to

cases reviewed in the Los Angeles urban area, where the number of such cases is

greater. They file only the most provable cases with aggravated circumstances. They

said that they did not consider the possibility of successful prosecution in a less

populous county, despite the fact that workload considerations vary greatly between the

two jurisdictions. On May 4, 2003 a Deputy AG personally visited the site of the incident

and interviewed the GB Police officer who responded to the 911 call.

The AG staff considered whether sufficient evidence existed for filing charges against

the driver. They cited these factors in making their decision:

1) the street lighting at the intersection

2) the dark clothing worn by the victims

3) conflicting evidence that both girls were within the crosswalk at the time the

vehicle struck the girls

4) that the driver’s speed was assumed to be within the posted speed limit, and

5) no evidence that the driver had consumed alcohol.

They examined the cell phone records of the driver for calls made on the evening of the

incident and determined that he was not talking on his cell phone at the time that his

vehicle struck the two girls. They believed that the two victims might have been outside

the crosswalk at the time the vehicle struck the girls.

Because of the focused involvement of the GJ, the AG investigator returned to SLO to

re- examine evidence during the week of August 25- 29. They nevertheless concluded

that, in their opinion, the driver could not have avoided striking the victims. Listening to

the AG's report, the GJ realized that the case file submitted to the AG by the DA's Office

did not include the long list of the driver's prior driving citations and prior road rage

convictions nor had they seen the accident photos.

At the conclusion of the AG's presentation, the GJ's position was that the AG’s Office

should reconsider its decision. The GJ asked the AG to review additional materials and

provided them with accident photos and documents. The jury had compiled this

supplemental information in its investigation of the matter. When the GJ apprised the AG

representatives of these prior convictions, the AG staff responded that they could not

use much of the driver’s prior traffic record because that information would not be

admissible as evidence. The AGs agreed to take the box of materials from the GJ back

to Los Angeles with them. The additional items, however, did not change the AG's

opinion, and they so informed the GJ the next day.

The AG notified the victim's mother again on September 4, 2003 that they were not

prosecuting the case, but that the DA had the option of reclaiming the case. The victim's

mother immediately called VW urging the DA to resume control and file charges against

the driver.

15

PART FOUR

The District Attorney Reclaims the Case

The Senior Assistant Attorney General informed the Chief Deputy DA in a letter dated

July 23, 2003 that the AG staff’s review of the case was completed and that the AG’s

Office decided not to file any criminal charges against the driver. The letter arrived to

the desk of the Chief Deputy DA while he was out of the office on leave. Apparently no

one was assigned to process his mail in his absence. He returned to work August 11

and immediately showed the letter to the DA. The Chief Deputy asked the AG to return

the case paperwork to the SLO DA's Office.

Meanwhile, after learning of the AG's original negative decision, the GJ wrote to the

AG’s Office on August 15, 2003, just after receiving the family's complaints. The GJ

wanted an explanation of the factors contributing to the AG's decision. The GJ advised

the AG of the extensive local news coverage generated by the case and the hundreds of

complaints the GJ had received. The AG decided to present an explanation to the GJ in

person, something rarely done by that office.

On September 3, 2003 two representatives of the Los Angeles division of the AG’s

Office met with the GJ at the GJ office in San Luis Obispo to explain their decision of

July 23. As explained in Part 3 of this report, the GJ disagreed with the AG Office’s

decision and provided the AG representatives with additional information the GJ had

compiled, including photos of the accident scene and information about prior offenses

and convictions of the driver. However, that additional information apparently did not

change the AG Office’s decision not to file charges. The day following that visit to the

SLO GJ, the AG indicated their opinion had not changed despite the input from the GJ.

On September 4, 2003 the attorney for the victim’s family sent a letter to the Chief

Deputy DA stating that “ It is our hope that… your office will now file the misdemeanor

complaint against … and pursue prosecution in this matter.”

On September 5, 2003 the Senior Assistant Attorney General sent a letter to the District

Attorney forwarding more than 300 pages of material, including “… material you have not

previously seen or requested.” She also referred information to the DA relating to a

Department of Motor Vehicles administrative hearing decision to return the driver’s

license and some information regarding the cell phone previously installed in the vehicle.

None of that information proved to be relevant to this investigation.

The AG indicated that the DA's Office was free to file if they chose to do so. That same

day, September 5, 2003, the DA assigned the case to another Filing Deputy with the

instruction to research and review the case and to recommend whether or not to file any

charges. ( Remember that on March 26 the Chief Deputy had instructed the filing deputy

to " file the case.") Later that same day the DA’s Office filed one count of misdemeanor

vehicular manslaughter against the driver.

16

Case Status:

The DA’s Office filed charges on September 5, 2003 in the San Luis Obispo County

Superior Court and counsel for defense immediately proceeded to file a series of

motions. In January 2004 a defense motion to recuse the DA’s Office from the case and

effectively end the prosecution failed in superior court. Defense counsel had requested

an April 2, 2004 hearing regarding his motion involving the prosecution’s failure to

preserve the victim’s blood sample. Arroyo Grande Hospital did not keep the victim's

blood drawn on the evening of the accident. The defense position is that the blood

sample is potentially significant in the case because a preliminary screening by hospital

staff had shown the presence of methamphetamine in the victim. The defense attorney,

however, had a conflict on April 2, and the motion was continued to April 16. A ruling on

all motions is necessary before the trial scheduling date of May 28. The SLO DA is

ready to proceed with the trial, which has been set for June 22.

17

ATASCADERO HIGH SCHOOL

MARCHING BAND PLAYS AT

POLITICAL CANDIDATE’S CAMPAIGN RALLY

On Sunday, September 28, 2003 the Atascadero High School Marching

Band played at a political rally for then candidate for governor, Arnold

Schwarzenegger. To some county residents, this appeared to be in viola-tion

of the California Education Code, which prohibits use of school

resources for political purposes. Reports of the story in local newspapers

included an opinion from the California Department of Education deputy

legal counsel indicating that, if asked, he would have advised against the

band playing. Within weeks of the event, the Grand Jury received two

complaints from citizens citing this and other news reports, and express-ing

concern that the Atascadero Unified School District had violated the

law in permitting the band to play at the rally.

Authority for the Inquiry

The authority for the Grand Jury to inquire into this matter is given in Section 933.5 of the

California Penal Code: “ The grand jury may at any time examine the books and records

of any special- purpose assessing or taxing district located wholly or partly in the county or

the local agency formation commission in the county, and, in addition to any other inves-tigatory

powers granted by this chapter, may investigate and report upon the method or

system of performing the duties of such district or commission.”

Overview

The Atascadero Unified School District ( AUSD) is responsible for the operation and su-pervision

of thirteen schools, including Atascadero High School. The schools are

located in the northern part of the county, serving the communities of Atascadero, Cres-ton

and Santa Margarita. The district is governed by a Board of Trustees consisting of

seven members who are publicly elected to four- year terms. The Board establishes the

policies that govern the operations of the schools in the district, and hires the District Su-perintendent,

who is responsible for policy implementation.

Many of the Board policies reference the California Education Code, which sets the legal

requirements for public schools in the state. The section of the code relevant to this in-quiry

is 7054( a), which states:

18

No school district or community college district funds, services,

supplies, or equipment shall be used for the purpose of urging the

support or defeat of any ballot measure or candidate, including, but

not limited to, any candidate for election to the governing board of

the district.

The applicable AUSD policy mirrors and references this section, and reads:

No district funds, services, supplies or equipment shall be used to

urge the support or defeat of any ballot measure or candidate, in-cluding

any candidate for election to the Board. ( Education Code

7054)

Section 7058 of the Education Code further clarifies 7054 as follows:

Nothing in this article shall prohibit the use of a forum under the

control of the governing board of a school district or community col-lege

district if the forum is made available to all sides on an

equitable basis.

Since the band performance in question occurred at a political rally for a gubernatorial

candidate, some residents questioned whether it violated the Education Code and AUSD

policies. The performance was requested by Assemblyman Abel Maldonado, and the

expenses for it were billed to his office. Nevertheless, some individuals question whether

this is adequate to counter the perception that AUSD resources were used to support a

political candidate.

Method

We obtained the information reported here through review of AUSD policies, correspon-dence

and an interview with the AUSD Superintendent, and an interpretation provided by

legal counsel for AUSD. The Grand Jury requested and received the applicable AUSD

policies and procedures related to the band playing at the rally, as well as information re-garding

the payment of the expenses incurred. Jurors interviewed the superintendent

and reviewed the related documents.

Description of Inquiry

In providing information on behalf of the district, the superintendent repeatedly empha-sized

that the band performance at the rally was never intended to show support for a

candidate, but was considered to be simply an opportunity for the band to perform. Given

the political nature of the rally, specific concerns included whether AUSD funds were

used, whether students were required to participate, and whether the decisions relative

to the band playing at the rally were made in accordance with district policies and public

considerations. Our findings are summarized below.

19

( 1) The AUSD Request for Transportation form details that there were two buses used

for seventy- five students and ten adults to attend the rally in Santa Maria on September

28, 2003. The charges for the two bus drivers, bus mileage, and meals are itemized in

accordance with the AUSD 2003/ 2004 Transportation Rates. The mileage rate includes

an allocation for vehicle maintenance and insurance. The listed expenses totaled

$ 718.85.

( 2) An invoice for $ 718.85 was sent to Assemblyman Maldonado at his office in San

Luis Obispo, and was paid by a check on an account of “ Californians for Schwarzeneg-ger”

dated November 18, 2003.

( 3) The band members were not required to participate. The band’s performance at the

rally was considered to be an extracurricular field trip, for which parental approval was

necessary. One family did not approve and the band member did not perform.

( 4) The decision to allow the band to perform at the rally was made by the principal of

Atascadero High School. This is the appropriate level for approval of field trips, accord-ing

to the district’s organizational delegation of authority. The principal sought additional

review because the performance had the potential for appearing to support a political

candidate. In the absence of the superintendent, the principal consulted with the Assis-tant

Superintendent of Educational Services, who concurred that the field trip was

appropriate.

( 5) The interpretation of the AUSD legal counsel, requested after the fact, supports the

decision to allow the band to perform. The legal opinion was provided in writing at the

request of the Grand Jury, and highlights the reimbursement for the AUSD expenses re-lating

to the performance. The legal counsel’s concluding remarks are as follows:

In this instance, where no District funds were expended, the activ-ity

was voluntary, it was not during school hours, and the intent of

the District administration was to provide students with an oppor-tunity

to perform publicly, there was no violation of Education

Code section 7054 ( a).

The District’s Board and administration has the discretion to de-termine

that there is an educational benefit to AUSDHS band

students performing publicly. Such a determination is appropriate

given that public performance is a natural part of learning to play a

musical instrument in any band. Had the students been provided

with the same opportunity to perform for other candidates, and the

students were able to perform, the intent and impartiality of the

District administration might be more easily understood. But the

lack of additional invitations and opportunity cannot convert the

proper intent of the administration to an improper intent.

20

While the District must avoid using District funds, services, sup-plies

and equipment for the purpose of supporting or opposing

particular candidates or issues, it is nevertheless our opinion that

the AUSDHS Band may voluntarily participate in a public perform-ance,

even at a political event, where no District funds are

expended, and the intent is not to support the candidate, but

rather to provide students with the opportunity to perform publicly.

Conclusion

The issues surrounding the band performance at the political rally appear to be a matter

of legal interpretation. A conclusive opinion would have to come through the courts or

further legislative action. The decision to allow the band to perform in this instance, how-ever,

was made within the spirit and intent of the law as interpreted by the AUSD legal

counsel and consistent with District policy. A new or changed policy that would direct a

different decision regarding marching band performances is a matter for the AUSD Board

of Trustees to consider.

Required Responses

This is an informational report. No formal response to this 2003- 2004 Grand Jury report

is required from any agency.

21

CALIFORNIA MEN’S COLONY

The California Men’s Colony ( CMC) is located on Highway 1 just north of

the San Luis Obispo city limits. It is a low and medium security prison

under the direction of the State of California Department of Corrections,

and includes two main facilities on 356 acres. The West facility houses

the lower security inmates in a barracks- type setting. The East facility,

with more traditional prison cells, primarily houses inmates with medium

security classifications. The total inmate population at CMC in March

2004 was 6,542.

The average CMC employment level is 1,673, of which 952 are custody

staff positions that include correctional officers, counselors, and medical

technical assistants. The local facility and operations are managed by a

warden who is appointed by the governor. Following the former warden’s

retirement, Assistant Warden Leslie Blanks served as acting warden for

almost two years. Current Warden John Marshall was appointed on Oc-tober

30, 2003.

Authority for the Inquiry

The California Penal Code § 919 ( b) establishes the authority for this inquiry as follows:

“ The grand jury shall inquire into the condition and management of the public prisons

within the county.”

Method

We obtained the information reported here through interviews, documents review, and

visits to the prison. Early in our term, Acting Warden Blanks presented an informational

overview to the full Grand Jury. Members of the jury toured CMC on September 30,

2003, visiting both the East and West facilities. Jurors returned on January 29, 2004, to

meet with the new warden, to visit a vocational class, and to follow up on questions

concerning the Inmate Trust Fund. We were encouraged to talk to inmates and

correctional officers during both visits.

Description and Observations

Our initial visit to the East facility included a tour of prisoner cells, the education facilities,

the operations of the Prison Industries Authority, and a “ typical” inmate lunch in an inmate

dining hall. We were driven in a CMC bus from the East to the West facility where we

observed the barracks, the recreational yards, and the Arts in Correction program.

22

Housing

Inmates are assigned to the East or West facility based on their security levels, which

consider many factors. The lower security inmates ( levels 1 and 2) housed at the West

facility typically have no history of prison disciplinary action, no prior escapes, and a

majority of their sentences served. Higher security levels 3 and 4 are assigned based on

the type of crime, post- conviction behavior, outstanding holds/ warrants, length of

commitment and balance of sentence. Inmates housed in the East facility have level 3,

or medium, security level designations. In addition to security assignments, each inmate

is given an activity assignment that typically requires him to participate in either an

education or an employment program.

Even from our brief tours, it was clear that the housing conditions at both facilities are

crowded. The inmate cells that we observed in the East facility were designed for single

occupancy, although there are currently two inmates living in each 5' X 8' cell. The

second added bunk is hinged on the wall and must be pulled up for the occupants to

move about the cell. The design capacity for the East facility is 2,425, although its

average daily inmate population in March 2004 was 3,689.

The West facility inmates are housed in military- style barracks, each holding approxi-mately

ninety bunks. We observed that there was little room to move around the barracks

even when most of the inmates were outside in the yard. The March 2004 inmate

population of 2,853 is almost double the West facility design capacity of 1,459.

Education

Educational activities primarily include adult basic and high school level academic

classes and vocational programs. Vocational courses include: machine shop, dry

cleaning, electronics, welding, auto shop, small engine/ motorcycle repair, landscaping,

and office services/ related technology. Both the academic and vocational programs are

located at the East facility.

On our second visit we observed the office services/ related technology class; both the

instructor and the curriculum were impressive. It is a self- paced program, with 30

students who use computers with standard business applications. The curriculum

progresses from basic typing and business math, through more advanced subjects such

as bookkeeping and business law. The final modules cover computer applications,

including databases, word processing, spreadsheets, and desktop publishing. It should

be noted that the instructor also includes life skills such as goal setting, self improvement

and presentation skills in the curriculum. We were encouraged to talk to the inmates in

the class and found them to be generally appreciative of the class and the instructor’s

efforts.

We also visited the Arts in Corrections program located at the West facility for lower

security inmates. Although not formally identified as an education program, activities for

inmates provide outlets for artistic expression in words, painting and music. Fifty- four

inmates attend a structured program there as their official assignment. An additional 90

23

inmates voluntarily participate in Arts and Corrections activities during their unassigned

time. We watched a video of an inmate- produced play, and listened to a live perform-ance

of a three person self- written and produced musical piece.

Employment

During our initial visit we met with the director of the CMC Prison Industry Authority ( PIA)

programs. The PIA provides jobs for inmates in the production of goods and services

used both inside and outside of the prison system. We toured the PIA shoe factory, the

T- shirt factory, and the print plant where state auto registration stickers and brochures are

produced. Other PIAs include a knitting mill, jacket factory, glove factory, laundry and

maintenance. In the generally repetitive and fairly low skilled PIA jobs, inmates earn from

$ 0.30 to $ 0.95 per hour. With the exception of those sentenced to life with no parole and

“ three- strikers,” inmates also earn one day off their sentence for each day of work.

We were interested in recidivism ( return rate) statistics for inmates who work and learn

employable skills in the PIA, as compared with those who were not involved in PIA during

their incarceration. Although the state does not currently provide statistics by facility, the

state- wide recidivism figures for the year 2000 provide insight into the influence of the PIA

program. For PIA inmates, the recidivism rates were 19 percent for the first, and 43

percent for the second year. The rate for inmates who had not held PIA jobs was more

than double in the first year ( 43 percent) and was 56 percent in the second year.

In addition to PIA, prisoners may be assigned to other work programs, such as in the

prison’s Food Services division. Other prisoners are assigned as Inmate Firefighters,

who can make from $ 32 to $ 52 per month, or to the Hazardous Materials Unit where

inmates receive $ 48 per month.

Inmate Trust Fund

We requested and received a detailed presentation on the Inmate Trust Fund during our

January visit. The Associate Warden for Business Services and the fund’s Business

Manager provided an overview of the fund’s management. Their philosophy reflects a

respect for the inmates’ right to understand and monitor their funds. The general

approach is that of a bank, and each inmate receives a monthly trust fund balance report.

Additional time is spent explaining these reports to inmates as needed. The fund is also

subject to regular state level audits, which have reported no problems in recent years.

Community Services

During calendar year 2003, CMC had 76,000 hours of inmate time, and 6,071 hours of

staff time involved in fire suppression and “ Fire Kitchen” operations. These figures include

inmates directly fighting fires as well as those involved in setting up and staffing the

kitchens that feed the firefighters. In addition, 4,000 correctional officer hours were spent

supervising these inmates. Inmates also set up a kitchen to serve all those assisting after

the December 22, 2003 San Simeon earthquake.

24

CMC provides inmate service crews to local communities to perform such services as

weed abatement, general clean- up, sandbagging, tree trimming, seaweed cleanup of

beaches, clearing culverts, trash pickup on highways, and fence repair. CMC has entered

into contracts to provide Community Service Crews to the cities of Arroyo Grande, Grover

Beach, Morro Bay and Pismo Beach, to the County of San Luis Obispo General Services

and Roads Department, and to Port of San Luis. These crews have also been provided

at no charge to Cal- Trans and San Luis Obispo School District. CMC estimates that

communities saved $ 189,594 by using the CMC crews during the last year.

Inmate groups make cash donations to community groups. In 2003, the Leisure Time

Activity Groups ( Prisoners Against Child Abuse and CMC Literacy Council) distributed

$ 13,250 in cash donations, and an additional $ 4,000 for the annual Holiday Party for

Inmates’ Children. Some other recipients of donations include: Alpha Academy, SLO

Child Development Center, County Mental Health Youth Services, North County

Women’s Shelter, SLO Literacy Council, SLO Prado Day Center, and the Good Samari-tan

Shelter.

Required Responses

This is an informational report. No formal response to this 2003- 2004 Grand Jury report

is required from any agency.

25

CALIFORNIA VALLEY

COMMUNITY SERVICES DISTRICT

Synopsis

The 2003/ 2004 San Luis Obispo County Grand Jury received several

complaints from citizens of California Valley regarding the operations of

the California Valley Community Services District ( CVCSD) Board of Di-rectors.

The Grand Jury examined the complaints, interviewed several

witnesses and reviewed the history of other complaints that had been

previously submitted to prior grand juries. After careful consideration, the

Grand Jury determined that insufficient evidence existed for an investiga-tive

report, and instead chose to prepare an informational report to draw

attention to the grievances submitted by the complainants.

Origin of the Inquiry

The complaints submitted to the Grand Jury stated that the CVCSD Board of Directors

did not conform to Brown Act meeting notification requirements or follow appropriate

procedures in handling citizen complaints. In addition, the complainants submitted to the

Grand Jury a petition signed by 73 CVCSD residents requesting that we help them

obtain the following amenities:

1. A gas station,

2. A clinic with doctors once a week,

3. Transportation into town two or three times a week,

4. A mercantile or convenience store, and

5. A water purification system for the entire valley.

Other comments submitted by the residents included unpaved roads in the district area

and the lack of garbage collection.

Authority for the Inquiry

California Penal Code § 933.5 authorizes the Grand Jury to investigate operations of a

special legislative district such as the CVCSD.

Method

Six members of the Grand Jury traveled to California Valley on Monday, February 16,

2004 for an informal meeting with the original complainant and several other subsequent

26

complainants. In addition, the Grand Jury interviewed the County District Five Super-visor,

the County Health Director, the County Director of Public Works, and the County

Auditor/ Controller. Grand Jurors also reviewed reports from previous Grand Jury investi-gations

of the CVCSD.

Setting

The CVCSD is established as a community services district under the provisions of

section 61000 et seq. of the California Government Code. The district is governed by a

five- member board of directors elected at large to four- year overlapping terms. The

district has an annual operating budget of approximately $ 400,000 and is responsible for

provision of basic services, including refuse collection.

The district board hires a general manager to administer and oversee the efficient and

effective provision of these services. During the 2003- 2004 fiscal year a large amount of

the district’s general fund reserves was determined to be missing. After a brief investi-gation,

the County District Attorney’s Office filed charges of embezzlement against the

general manager, who pled guilty to the charges. Although the mystery of the missing

funds has been solved, the fact remains that the district’s general fund reserves have

been severely depleted, leaving the board with insufficient money to continue to provide

several services, including refuse collection, to its residents.

The County Health Director advised the Grand Jury that the CVCSD, per their charter,

has the responsibility for garbage collection in the district area. The County Public

Works Director advised the Grand Jury that the unpaved roads listed in the citizen

complaints are CVCSD roads and, therefore, cannot be paved or maintained by the

county. The County Fifth District Supervisor affirmed that the CVCSD is responsible for

basic service delivery to the area, and advised the Grand Jury that the county does not

have sufficient resources to provide the other services and amenities that California

Valley citizens expect.

The Grand Jury found that CVCSD residents have previously submitted complaints

about the CVCSD Board of Directors to past grand juries. For example, the 1999- 2000

Grand Jury found a history of inefficient and inappropriate operation of the district’s

organization and service delivery.

Conclusions

This Grand Jury attempted to assist the residents of the CVCSD in resolving their

complaints and requests. However, the Grand Jury did not find any evidence of specific

Brown Act violations by the CVCSD Board of Directors. Further, the services and needs

detailed by the residents were beyond the jurisdictional reach of the Grand Jury and the

county.

27

In their report, the 1999- 2000 Grand Jury stated that, “… the CVCSD has a history of

inefficient and inappropriate operation.” The report then emphasized that:

Ultimately, voter participation is the only effective oversight for the

CVCSD. The effectiveness and responsiveness of the board of Directors

are directly related to the attendance and awareness of the electorate.

The Grand Jury urges constituents of the District to keep this in mind and

to become aware of, and involved in, the activities of their District.

This Grand Jury concurs with those conclusions.

Many of the issues in California Valley must be solved by the residents and their Board

of Directors. These issues would be costly to address and may well be beyond the

ability of the board to implement. Prioritization is even more important due to the

district’s unfortunate financial situation. The district has the authority under the

California Government Code to levy the necessary tax assessments to fund the district’s

operations, and must take the responsibility to do so.

Suggested Actions

Under Penal Code § 933.05, the CVCSD was required to respond to the aforementioned

recommendations and findings of the 1999/ 2000 Grand Jury Final Report. This Grand

Jury did not find evidence that such response was ever completed and submitted.

Accordingly, this Grand Jury recommends that the County Counsel advise the CVCSD

Board of Directors that their response to the 1999/ 2000 Grand Jury Final Report must be

submitted to the Superior Court within 90 days of issuance of this report.

The problems that were brought to this Grand Jury must be solved by the CVCSD. The

Grand Jury recognizes the district’s financial condition and understands that the

resident’s complaints and demands cannot be addressed or implemented overnight.

The Grand Jury contends that the Board of Directors must make a concerted effort to

conscientiously address each of these matters in a timely manner. Accordingly, the

Grand Jury also recommends that the CVCSD immediately contact the California

Special Districts Association for any applicable assistance, training and technical support

to prepare and implement a long- term program to address the issues raised by the

residents.

If such a long- term program cannot be implemented successfully on a timely basis due

to financial, realistic or other considerations, the Grand Jury recommends that the

residents of the CVCSD service area seriously consider disbanding the district. Under

such a dissolution, service delivery responsibility would revert to the county, and the

District’s Board of Directors would be replaced by the County Board of Supervisors.

28

Required Response

This is an informational report. No formal response to the 2003- 2004 Grand Jury report

is required from any agency.

29

EL PASO DE ROBLES

YOUTH CORRECTIONAL FACILITY

The El Paso de Robles Youth Correctional Facility ( El Paso) is one of

eight institutions operated by the California Youth Authority ( CYA) for the

detention, training and education of youthful offenders. The CYA is a de-partment

of the California Youth and Adult Correctional Agency. Recently,

the agency has been under the scrutiny of the Governor, the California

Attorney General, the Legislature, and the new Director of the Youth Au-thority.

As a result, there has been considerable press coverage of CYA

and its facilities during the first part of 2004.

The El Paso facility is located across from the Paso Robles Airport. It

houses male offenders, referred to as “ wards,” who have been committed

to CYA by the Superior or Juvenile Court for offenses that would have

been felonies if committed by adults. Under a special contract with the

Monterey County Juvenile Probations Department, some of their wards

were also located at the El Paso facility. The ward population at El Paso

has been declining in recent years, mainly due to legislative changes. In

April 2002 there were 644 CYA wards and 327 full time staff at El Paso.

The ward population and staff level in April 2004 was 300 CYA wards, 48

Monterey County juveniles, and 264 full time staff.

Authority for the Inquiry

The California Penal Code § 919 ( b) states, “ The grand jury shall inquire into the

condition and management of the public prisons within the county.”

Method

The superintendent and assistant superintendent met with the full Grand Jury in August

2003 to provide an overview of El Paso’s mission and operations. They emphasized

that the facility is open “ 24/ 7” and we were invited to visit at any time. Members of the

Grand Jury visited the El Paso facility on three occasions during subsequent months. In

addition to meetings and tours, the El Paso management and staff provided extensive

documentation about the facility and its programs.

Informational Description and Observations

Our initial visit to the El Paso facility in October 2003 included presentations by the

senior staff and department heads. They provided current program and performance

data related to their area of responsibility. The format allowed questions and interaction

30

with all attendees. We also reviewed with the staff previous Grand Jury findings,

recommendations, and CYA’s responses to them.

We then toured the ward housing units, referred to as “ cottages.” There were nine

active housing units at the time of our first visit, each named for communities in San Luis

Obispo county. The number of wards housed in each unit ranged from 13 to 75, varying

according to capacity and the program it houses. The Cambria cottage is the designated

maximum detention unit. The environment is one of discipline and close personal and

video scrutiny. We verified that there were no “ cages” utilized for restraint or punishment

of the type that had been reported in the press at some CYA facilities.

Wards are assigned to a cottage based on their program assignment, which includes

initial reception and evaluation, drug dependency, food service and firefighters ( fire-fighter

wards have since been integrated into other cottages as a result of budget cuts

detailed below). All wards assigned to a program and cottage wear colored T- shirts

specific to that unit. This allows the correctional officers to quickly identify the wards

when they are going from one area to another and to verify that they are in the proper

location.

An informative part of our tour was a demonstration by the ward firefighters. This unit,

comprised of the most trusted wards, provided significant county and state service. In

2003, the wards expended 111,772 man- hours in emergency fire fighting, controlled

burns, and brush clearance.

Other programs also allowed wards to provide community service. They contributed

over 1,000 man- hours for the December 2003 San Simeon earthquake emergency

response and clean up. An additional 30,000 man hours were dedicated to community

and state activities that included: park maintenance, road/ ground maintenance, flood

control, and general construction. A partial listing of other public service activities the

wards performed included: maintenance for Paso Robles City, Hearst Castle, Atasca-dero

City and Templeton Community Service District, Paso Robles spring clean up,

Camp Roberts weed abatement and wood cutting, and the Mid- State Fair Paso Robles

High School graduation set- up and teardown.

These disciplined service activities provided the wards with an opportunity to make

positive contributions and gave them an incentive to return to society with job- related

behaviors and skills. Nevertheless, as of the time of this report, the state budget cuts

had eliminated the firefighters and the other community service programs, effective

February 29, 2004. There are ongoing efforts to reinstate some of the programs.

Resource groups that continue to be available to wards include: victim’s awareness,

substance abuse counseling, parenting, gang awareness, anger management, and

employability skills.

Members of the Grand Jury attended a lunch meeting with the Citizens Advisory

Committee on March 1, 2004. The approximately twenty members of the Advisory

31

Council represent various volunteer and non- profit organizations that provide support

functions for the wards. The Paso Robles Police Chief is also an active member. The El

Paso senior staff members attend the monthly Council meetings and present updates in

their areas of management. In our one meeting observation, the Advisory Council

appears to function less as an advising body than as an interface between the CYA and

the local community.

At the March meeting, the assistant superintendent gave us copies of two reports

commissioned by the California Attorney General and the Youth Authority: The Review

of Health Care Services in the California Youth Authority released August 22, 2003, and

The General Corrections Review of the California Youth Authority released December

23, 2003. Both reports were the result of thorough investigations over an extended

review period, and both reports are highly critical of the central ( state) and local

management of all CYA institutions. The recommendations, if implemented, will result in

major changes to the CYA.

On March 9, 2004, members of the Grand Jury returned to the facility to observe high

school and general education classes. Our observations were that, although the

instructors were making an honest effort to provide a disciplined and educational

environment, many of the wards did not seem to be engaged in the classroom activities.

The CYA should address whether the instructional content or end results are meaningful

to the general ward population.

Investigation of Pharmacy Medications

In February 2004, The Tribune of San Luis Obispo reported that the state commission

report on health services had found that the El Paso de Robles pharmacy contained

expired medications. Based on that information, and without prior notice, we asked to

review the pharmacy during our March 1 visit. Our intent was to verify that appropriate

corrective action had been implemented. Contrary to the previously touted “ 24/ 7”

availability, the superintendent and assistant superintendent initially balked at our

request, citing various reasons that would prohibit our inspection of the pharmacy. At

our insistence they reluctantly agreed, and three jurors were escorted to the medical

building.

The pharmacy is a secured room within the clinic. We found boxes of expired medica-tions

on top of the counters and the floor covered with several boxes of new medications

that were not properly stored. Upon subsequent review we found that the August report

described a similar situation: “ the pharmacy contained boxes and bags of medications

stored on the floor. Many of the medications had expired, or were about to expire.”

( Review of Health Care Services in the California Youth Authority, p. 47)

The superintendent indicated to us that there was no effective means of disposal for

expired medication. However, jurors later performed an internet search and quickly

identified information regarding the availability of registered disposal companies, one of

which is based in California.

32

Findings

( 1) Expired medications are stored in the pharmacy.

( 2) Significant quantities of medications are not properly stored in the pharmacy.

Recommendations

( 1) The El Paso de Robles Youth Authority should take advantage of available

services to properly dispose of expired medications.

( 2) Pharmaceuticals should be ordered on an as- needed basis and should be

expeditiously inventoried and stored.

Conclusion

Although the management expressed an openness to Grand Jury inspection on a “ 24/ 7"

basis, a more closed, protective attitude surfaced when we asked for an unannounced

tour of the pharmacy. This response seems consistent with that mentioned in the

December General Corrections Review of the California Youth Authority report which

noted that middle management had referred to prior investigations at El Paso as “ the

witch hunt.” We would suggest that a less defensive posture toward authorized

inspections would better serve the institution.

Overall, El Paso de Robles Youth Authority provides a reasonably safe environment for

the wards, staff, and correctional officers under conditions that are frequently hostile and

dangerous. The effectiveness of local and state mandated policies and the state- wide

improvements that are needed are best addressed by the state CYA, the formal state

review panel, and ultimately the Legislature.

Required Response

Pursuant to Penal Code § 933 ( c), the following agencies are required to respond to the

findings and recommendations contained in this report: The El Paso de Robles Youth

Authority Youth Correctional and The California Youth Authority.

33

FLOOD CONTROL: CLOGGED BY BUREAUCRACY

AND ATTEMPTS TO TRANSFER RESPONSIBILITY

Synopsis

In March of 2001, the Arroyo Grande Channel Levee section of the San

Luis Obispo County Flood Control and Water Conservation District Zone

1/ 1a was breached following heavy rains. This resulted in the flooding of

several hundred acres of agricultural fields, businesses, residences and

mobile homes. These heavy damages led to claims against San Luis

Obispo County with costs totaling $ 1,289,000. The San Luis Obispo

County Board of Supervisors responded by reinstating a citizen advisory

committee to specifically oversee the Arroyo Grande Creek Flood Control

District. This was the first time any citizen oversight group had met in over

20 years for that purpose.

That committee was comprised of concerned residents of the county,

many of whom were directly affected by the flood breach. The committee

found the zone did not have enough funds to meet the current

maintenance requirements. The committee also recommended a study to

identify alternative means for clearing the creek and to guard against

future flooding. To this end, the Board of Supervisors appropriated

$ 150,000 for an Alternative Analysis Study to be included in the County

Public Works budget of 2002- 2003, only to later withdraw that funding.

Origin of the Inquiry

The Grand Jury received a complaint from a county resident whose property was

damaged from flooding stemming from the way in which the creek has been maintained.

Authority of the Inquiry

According to the California Penal Code § 925: " The grand jury shall investigate and

report on the operations, accounts, and records of the officers, departments, or functions

of the county including those operations, accounts, and records of any special legislative

district or other district in the county created pursuant to state law."

Method

During the course of the investigation the Grand Jury obtained its information from

several sources. The information in this report is a compilation of information received

from attending watershed forums, interviewing many county officials, both

34

elected and appointed, as well as visiting the site. Through the course of the

investigation we met with, and interviewed, the Project Manager of the Arroyo Grande

Watershed Forum, San Luis Obispo Assistant County Counsel, Executive Director of

Environment in the Public Interest, County Public Works Director, County Deputy

Director of Public Works for Engineering Services, Coastal San Luis Resource

Conservation District Board President, State Division of Flood Management Chief, and a

representative from the Environmental Defense Center. We also interviewed the

complainant on multiple occasions.

Setting

The Arroyo Grande and Los Berros Creeks, located in the South County area of Arroyo

Grande and Oceano, flow into the adjacent lowlands, much of which is, and has been,

farmland for generations. A Public Works Department map of the area is included as an

Appendix to this report. Serious floods occurred in 1969, 1983, and 1995.

For visitors, and even long time residents, the Arroyo Grande Creek is part of the charm

of the Village historical area of Arroyo Grande, but most people know very little about the

creek that flows beneath the swinging bridge on its way to the sea. The creek is one of

several that flow from higher elevations east of Arroyo Grande, in this case from Lopez

Lake. It winds naturally toward the Village with a downhill flow and levels out as it

reaches farmland in the area west of Highway 101. This relatively flat area slows the

flow of the creek. The levee, built in the 1950' s, starts in the farmland near Halcyon and

extends three miles, including lower portions of Los Berros Creek.

Early ranchers and farmers used the creek for their crops and animals, but there was

often a price to pay when flooding occurred. Documented floods go back to the year

1862 and occurred with regularity from the early 1900' s through the 1940' s. A huge crop

loss in 1952 made it apparent that a project was necessary to improve the creek's ability

to move water. In 1957, the U. S. Department of Agriculture ( USDA) coordinated

construction of the Arroyo Grande Channel Improvement Project.

The high probability of future flooding exists because over the years sedimentation and

riparian growth within the creek have restricted the capacity of the stream flow. To

monitor and protect the surrounding area, the County Board of Supervisors approved

creation of flood control districts 1 and 1/ A in the late 1950s. The county attempted to

clear the waterway from time to time as the creek channel filled with soil moved from

upstream.

Over the years the process for repairing the channel was made more difficult with the

increasing number of permits needed before work could begin, the extent of work

permitted, and the time limitations for such work. Budgetary constraints further

complicate any repair project. Permits are now required from the California Coastal

Commission, the U. S. Army Corp of Engineers, the USDA, and other agencies.

Because of the complex situation, county engineers have recently coordinated permit

applications for maintaining the channel.

35

Findings

( 1) On March 27, 2003 the San Luis Obispo County Board of Supervisors sent a

letter to the California Department of Water Resources ( DWR) advising that SLO

County was considering relinquishing responsibility for the Arroyo Grande Creek

Flood Control Channel to the state.

( 2) On March 28, 2003, a letter from Chief of the DWR Division of Flood Control

Management stated that relinquishment by San Luis Obispo County would not

resolve the issue. The letter advised that the decision on how to best proceed

should be done carefully with public dialogue.

( 3) On April 1, 2003, the San Luis Obispo County Board of Supervisors adopted

Resolution No. 2003- 105 seeking to transfer responsibility for the Arroyo Grande

Channel to the State. That item was not listed on the agenda posted at the SLO

County Board of Supervisors' website, and the item was passed as a consent

agenda item without any public input.

( 4) One week later on April 8, 2003, the Coastal San Luis Resource Conservation

District ( RCD) Board President and staff met with SLO County Public Works

representatives. A Public Works representative informed the RCD Board

President that the $ 150,000 Alternative Analysis Study was " off the table" for the

fiscal year 2002- 2003. The county, believing that it was no longer responsible

for any damage that may occur in the coming, or following rainy seasons, then

opted not to reallocate funding for the study in the next fiscal year budget,

beginning July 1, 2003.

( 5) On June 13 the DWR Chief of Flood Control Management sent a letter to the

SLO County Department of Public Works acknowledging the receipt of SLO

County Resolution No. 2003- 105. The state then told the county that such

jurisdictional transfer couldn't even be considered before July 2004, and possibly

not until 2005 due to limited resources.

( 6) Each agency says the other has the responsibility; neither is willing to do

anything now. In the meantime, probability of floods causing serious damage to

the property owners, the public, and farmers increases significantly. Future

lawsuits and any insurance claims against the county paid out will ultimately

affect the county taxpayer.

( 7) Despite the position of the county on jurisdictional transfer, they were quick to

respond after the earthquake of December 22, 2003. The following day the

County Public Works Department contracted for repair of four earthquake-damaged

locations on the Arroyo Grande channel levee. The county still

maintains that it has turned over responsibility for maintenance and repair to the

state.

36

Conclusions

Today the creek is clogged and flows slowly between the levees through the Oceano

area, emptying into the ocean south of the vehicle entrance to the beach. Anyone

wishing to see first hand the condition of the creek can do so by visiting the 22nd Street

Bridge in Oceano. From this vantage point it is possible to look toward the mesa and

see that at one time the entire area was a wetland. Nature's power is evident, both in

what was once here, and in what is occurring today.

The Grand Jury found that the problem in addressing a waterway with protected wildlife

is compounded by the numerous permit requirements found at the state level, and those

that are even more restrictive at the federal level. Even within the same agency,

whether state or federal, there often are overlapping divisions with differing processes,

programs, and priorities.

The Grand Jury determined that the number and nature of the permits required for such

a project is dependent upon the nature of the work to be done, which, in turn, is

dependent upon the results of required scientific studies. The studies themselves are

often very costly and time- consuming. A vast and complex array of mandated public

hearings and response must be completed prior to issuance of the permits necessary for

a project to address flooding in a creek channel such as Arroyo Grande Creek.

Assuming an acceptable alternative solution is identified as a result of any required

studies, the proposed project is then dependent upon the time duration of the various

permits, the cost of the project, the availability of funding, and seasonal construction

restrictions.

In short, the permit process is so difficult, complex, costly and confusing that even the

most knowledgeable government official finds it almost impossible to decipher and

implement. Even if the agency responsible for a drainage waterway is able to identify

and undertake the necessary steps, the cost of such projects must compete with many

other capital improvement projects for that government's limited budget funds, an

important consideration in the present fiscal climate.

In the opinion of the Grand Jury, by adopting Resolution No. 2003- 105, the Board of

Supervisors attempted to absolve itself of the long term expense and aggravation of the

permit process. Following this action, the Board of Supervisors removed the $ 150,000

which had been initially budgeted for the " Alternative Analysis" study. In the opinion of

the Board of Supervisors they were no longer responsible for the creek, and so there

was no need to perform that study. This action is especially disconcerting because the

Grand Jury has been told that the county actually holds an existing permit for some work

that could be done on the Arroyo Grande Creek channel. However, the county will not

proceed with the work allowed by that permit process because, in the estimation of

County Counsel, jurisdiction of the creek maintenance was immediately transferred to

the state upon adoption of Resolution No. 2003- 105, and county action on that permit

would mitigate against the county's position that the state now has responsibility for

maintenance of the Creek.

37

In the meantime, the property owners affected by creek flooding, including the original

complainant, are left waiting and wondering if anyone will help them avoid further

damage and expense. While the state disagrees that the county transferred jurisdiction

by adoption of Resolution No. 2003- 105, the one thing both entities agree on is that an

appropriate court of authority as a result of litigation could determine maintenance

responsibility. That, however, is very small consolation to the threatened property

owners.

Many federal, state, county, Coastal Commission and related environmental permits are

required for such drainage control work. Further, the cost of any logical solution to repair

or maintain the creek channel would be better borne by an agency with sufficient

authority and resources.

The U. S. Army Corps of Engineers historically has had responsibility for flood control

management in the continental United States. In 1999 the Corps of Engineers performed

a preliminary evaluation for potential solutions to the Arroyo Grande flood control

problem. Therefore, the Corps may be the appropriate agency to acquire the necessary

permits and complete the necessary work to protect the property and residents in this

area.

Recommendation

The Grand Jury recommends that the County Board of Supervisors establish a citizens’

committee to meet with the appropriate congressional representatives to obtain their

assistance in directing the Corps of Engineers to immediately undertake a flood control

remediation project to resolve the Arroyo Grande Creek channel flooding problems.

Required Response

As required by California Penal Code Section 933 ( c), within 90 days the County Board

of Supervisors shall comment to the presiding judge on the findings and recommend-ations

in this report.

38

Appendix

39

SAN LUIS OBISPO COUNTY JAIL

The county jail, located on Highway 1 between the cities of San Luis

Obispo and Morro Bay, is operated by the San Luis Obispo County Sher-iff’s

Department. The facility houses inmates who have been convicted

of misdemeanors or felonies, inmates who have not been sentenced, and

some who are awaiting transport to a state prison.

Authority for the Inquiry

Penal Code § 925 states, “ The grand jury shall investigate and report on the operations,

accounts, and records of the officers, departments or functions of the county.”

Method of Inquiry

The bases for this report include a grand jury tour of the jail and a meeting and follow- up

discussions with the sheriff. Additional information reviewed for this report include

statistical data provided by members of the Sheriff’s Department, and a summary of the

Board of Corrections Biennial Inspection Report dated February 26, 2004.

Description of the Inquiry

Grand Jurors toured the county jail on October 27, 2003, accompanied by the sheriff and

a correctional lieutenant. Issues of concern include overcrowding in the women’s

section of the jail, the prevalence of inmates requiring mental health services, and

inmate safety cells.

Jail - Women’s section

The California Board of Corrections ( BOC) conducts biennial inspections of the jail, in

accordance with Penal Code § 6031. The approved board rated capacity of the jail is for

412 male and 41 female inmates. However, there are currently 75 beds in the women’s

areas. The cells and dormitory units we observed were not only crowded, but the single

cells contained two beds and some prisoners were required to sleep on mattresses on

the floor. The average daily population of female prisoners in 2003 was 62. During the

months of October and November 2003, there were nine days when the female

population was over 80, peaking at 89 on October 23.

The February, 2004 BOC inspection of the jail found the women’s jail facilities, including

the female single cells, dorm and honor farm “... continue to remain out of compliance

with Title 24 regulations due to the beds placed in these areas” ( 2/ 26/ 04 BOC letter to

40

Sheriff Hedges). This finding was also reported in the 2001 BOC inspection. Previous

Grand Jury reports have recommended that this problem be addressed.

According to the Sheriff’s Department, funds for expansion of the women’s facilities have

been requested through the County’s Capital Improvement Project process each year

since fiscal year 1990- 91. The county budget office confirmed that expansion of the

women’s jail is included in a master plan for development of the jail site, and that

$ 694,000 was included in the 1999- 2000 budget for design work on the project. At the

start of the 2003- 2004 fiscal year, there was $ 562,000 remaining of this approved

amount.

Mental health

An increasing percentage of the jail inmate population is in need of mental health

services. The Sheriff’s Department cites the County Mental Health staff estimates that

30 percent of the inmates are receiving medication or counseling for mental health

issues. To address these issues, the Sheriff’s Department is partially funding a mental

heath therapist located at the jail. The department also reports that, in conjunction with

the Mental Health Department, it has initiated a program that provides inmates with a ten

day supply of medication upon their release from the jail. In addition, the Sheriff’s

Department is active in the county’s Homeless Task Force which is seeking to address

the problem within current systems, rather than create additional organizational

overhead and expense.

Cameras in safety cells

Previous Grand Juries have recommended that cameras be placed in the jail cells where

suicide- prone inmates are housed. The Sheriff’s Department August 2000 response to

this recommendation stated that this was not necessary since they had been successful

with their existing program for monitoring suicide- prone inmates. The department later

explained that an exposed video camera in the cell could become a suicide risk factor.

We inspected these cells during our tour of the jail and expressed concern that a small

window in the door was the only means of visually monitoring the inmate. In subsequent

discussions with the Grand Jury, the sheriff confirmed that current technology would

allow enclosed cameras to be installed in the cells, and that he is exploring funding to

acquire them.

Conclusion

The 2001- 2002 Grand Jury reported on the overcrowding in the women’s jail and

recommended that the sheriff act to correct the situation. We join them in highlighting

this unacceptable situation. Without funding and county action, however, the Sheriff’s

Department cannot expand the facility. It is the responsibility of the Board of Supervi-sors

and the county to move quickly beyond the design stage to implement a solution to

this ongoing problem.

41

The Sheriff’s Department appears to effectively operate and maintain a secure facility

with limited resources. They are to be commended for their efforts in coordinating with

the Mental Health Department to provide services to the increasing number of inmates

who require counseling and/ or medication. We also commend the sheriff for working

toward adding enclosed cameras in the safety cells. Given the increased inmate

population with mental health issues, it would be reasonable to expect that the number

of inmates with suicidal tendencies would also increase.

The jail staff, who are not trained mental health professionals, are likely to feel additional

stress in working with the mentally ill population in the jail. We encourage the depart-ment

to work with the Mental Health Department and to identify other resources in order

to provide the jail staff with appropriate training in working with mentally ill inmates.

Required Response

This is an informational report. No formal response to this 2003- 2004 Grand Jury report

is required from any agency.

43

THE SAFETY AND BEST INTEREST OF CHILDREN?

AN INQUIRY INTO CHILD WELFARE SERVICES

Synopsis

The 2003- 2004 Grand Jury received multiple complaints against the San

Luis Obispo County Department of Social Services ( DSS). These complaints

accused the Child Welfare Services ( CWS) division of failing to provide for

the safety and stability of children who are at risk of abuse and/ or neglect.

Investigation of the complaints led us to examine several CWS systems.

Our investigation focused on two areas where CWS has important responsi-bilities:

the county system for reporting and investigating suspected child

abuse, and the processes involved in the placement of children who have

been removed from their homes. We found problems in both systems that

involve lack of communication and coordination with related agencies. In re-porting

child abuse, CWS fails to provide law enforcement and the district at-torney

with required, timely information. In Juvenile Court cases concerning

the placement of children, CWS acts to keep information and other profes-sionals

who work with the children outside of the process.

While confidentiality is of the utmost importance in child welfare and court

cases, the same confidentiality that is supposed to protect these children is

used to prevent related agencies from communicating with CWS and the

court. There appears to be little or no accountability as to how CWS arrives

at many important decisions. Grand Jury members received specialized

training and were allowed access to confidential CWS case information. We

question whether the court is receiving all of the relevant information, or even

the correct information.

We also reviewed the CWS organization in our effort to understand its situa-tion.

We found an organization that is faced with enormous challenges,

many of which are inherent in the work it performs. There are currently

added pressures from California mandated changes and budgetary con-cerns.

The most difficult obstacle to overcome, however, may be the distrust

between social workers and upper management at CWS. Unless this prob-lem

is addressed, it is questionable whether CWS can effectively meet its

other challenges.

44

Origin of the Investigation

This investigation began as a result of a complaint that was accepted by the 2002- 2003

Grand Jury. The complaint alleged that the Department of Social Services, Child Welfare

Services division, failed to protect and to act in the best interest of two children. After initial

review late in its term, the 2002- 2003 Grand Jury assessed that the complaint may under-score

more serious problems within the department. Because of the time constraints, that

Grand Jury forwarded the complaint to the 2003- 2004 Grand Jury for our consideration.

Upon review of the forwarded complaint, we accepted it as the first case of the 2003- 2004

Grand Jury.

By March 2004 we had received similar complaints and allegations involving 17 CWS cases,

16 families and 38 children. The allegations against CWS cover a range of issues, including

failure to respond to reports of child abuse and neglect, and inappropriate actions in foster

care and adoption cases. As we investigated each case, several themes emerged that

shaped our investigation and this report. The central question that we address in this report

is, does CWS effectively implement systems that protect the safety and best interest of chil-dren?

Authority for the Investigation

Our authority to pursue the investigation is pursuant to Section 925 of the California Penal

Code that states, “ The grand jury shall investigate and report on the operations, accounts,

and records of the officers, departments or functions of the county.@ The Department of So-cial

Services is a county agency under the purview of the Board of Supervisors, and Child

Welfare Services is a division within that agency.

Overview: Child Welfare Services

This investigation focuses on the Child Welfare Services ( CWS) division of the San Luis

Obispo County Department of Social Services ( DSS). Within the county structure, the Board

of Supervisors appoints the DSS Director. Leland Collins has held this position since August

of 2000. DSS provides services under three main categories: Aid Programs, Adult Protec-tive

Services, and Child Welfare Services. Since the time of Mr. Collins= appointment as

DSS Director, the CWS division has been under the direction of Deputy Director Debby

Jeter.

The DSS budget derives its revenues from allocations of state and federal funds, special

grants, and county funds. The approved 2003- 2004 DSS budget includes expenditures of

$ 74.26 million, of which about 65 percent is for DSS administration and 35 percent is for di-rect

benefit payments. The county General Fund Support for the DSS 2003- 2004 budget

was originally approved at $ 3.53 million, although in January, 2004 this amount was in-creased

by nearly $ 2 million. The increases were attributed to the complex funding and state

reimbursement for CWS services. With the budget adjustments that were approved in May,

the total General Fund Support for the 2003- 2004 DSS budget was $ 6.97 million.

45

The major programs implemented through CWS are under the jurisdiction of the California

Department of Social Services and are regulated by California= s Penal Code ( PC), Welfare

and Institutions Code, and Health and Safety Code. The county receives federal funds for

CWS programs, along with the federal regulatory requirements, from the state DSS. The

California DSS Manual of Policies and Procedures, Division 31 Child Welfare Services Pro-gram,

is the primary operating manual governing CWS programs. Local CWS policies and

procedures define specific implementation and practices in San Luis Obispo County. During

the last year, CWS has been compiling local procedures as ADesk Guides@ for workers to

access via the departmental intranet.

The county= s 2003 DSS Public Information Report states, AThe goal of Child Welfare Ser-vices

is to provide for the safety and stability of children who are at risk of abuse or neglect@

( March, 2004 p. 16). CWS services are listed in the following categories: Early Intervention/

Emergency Response, Family Maintenance Voluntary/ Family Preservation, Family Mainte-nance

Court Ordered, Family Reunification, and Permanency Planning. The work of CWS

involves receiving and responding to reports of child abuse or neglect, working with families

to facilitate effective parenting and safe environments for children, and, when necessary,

removing children from their homes and finding alternative placements for them.

The Juvenile Court, a division of the California Superior Court, has jurisdiction when CWS

takes a child from parents or legal guardians. CWS must petition the court to detain, take

custody, and/ or place children in foster care or other placements. Recommendations and

placement plans are developed by CWS and submitted for court review and approval. In

this capacity, CWS plays an important role in providing the critical information on which the

court bases its decisions.

The DSS Public Information Report also describes 15 Ainnovative practices and initiatives@

that CWS has implemented in its efforts to keep children safe. Many of these initiatives

have been in response to, or in anticipation of, social work benchmarks and state priorities.

Since 1998, standards of excellence in social services have been referred to as Best Prac-tices

and CWS has sought special funding in support of local implementation. Recently,

many such standards have been incorporated as state mandates and performance goals in

the California Child Welfare Services Redesign ( generally referred to as ARedesign@). 1

This statewide Redesign, which is being implemented from 2004 through 2007, also re-quires

major systems changes in local CWS operations. The state has selected San Luis

Obispo as one of the counties that will receive special funding as Aearly implementers@ of

the Redesign. CWS will receive a total of $ 2.85 million beyond its normal allocated state

funding over the next four years. The first $ 300,000 was accepted in January 2004, and the

remaining payments are to be distributed annually through fiscal year 2007- 2008.

A central component of the Redesign is the legislatively mandated statewide accountability

and monitoring system ( Assembly Bill 636), which involves tracking performance measures.

The online California CWS Case Management System ( CWS/ CMS), which the county CWS

has been phasing in over the past five years, enables the state to track county performance.

The system can also be used to track individual social worker performance.

46

State mandates and local initiatives in recent years have required county CWS employees to

learn, implement, and adapt to a myriad of changes. They also must provide vital services

with fewer staff. DSS has had a hiring freeze in place since May 2002, resulting in more

than 70 unfilled positions in 2004. In addition, in January 2004, the Board of Supervisors

approved the elimination of temporary CWS employees and of 18.5 permanent positions,

including two of the five senior management jobs.

Methods of Investigation

Our efforts to identify actions and behaviors that led to the complaints against CWS involved

conducting interviews, reviewing CWS case files, and examining various documents. We

conducted 37 individual interviews at the Grand Jury office, each lasting from one to three

hours. Interviewees included complainants, social service professionals, mandated report-ers,

lawyers, court commissioners, and current and former CWS managers, supervisors,

and social workers. A minimum of five Grand Jury members participated in each interview,

although there were typically eight to ten jurors present. The majority of the interviews were

tape recorded for the review of other jurors and for later reference. In addition to these

Grand Jury office interviews, we visited several law enforcement agencies to talk with offi-cers

over the course of our investigation. At least two jurors participated in each of these

visits.

Because of the sensitive nature of CWS cases, confidentiality, by law, is at a high level. All

jurors received special training in confidentiality from Office of County Counsel attorneys

prior to having access to confidential information or to CWS files. Discussions of cases and

our review of CWS files was completed in accordance with a Standing Order of the Superior

Court, as revised during the period of our investigation. At least two jurors reviewed each

file. Other documents reviewed for this investigation included the California Penal Code and

Welfare and Institutions Code, state and local agency publications, presentation handouts

and budget summaries, and correspondence and documentation provided by complainants

and related parties. When information in this report is derived from public information, the

source is indicated.

The range of issues that surfaced in the course of this investigation resulted in three areas

of focus that are developed in the remainder of this report. We have identified findings and

recommendations under each section, and include our concluding remarks at the end of the

report. This report includes the following sections:

I. Suspected Child Abuse Reports

II. CWS Placement Cases and Issues

III. Organizational Issues

IV. Concluding Remarks and Response Requirements

47

l. Suspected Child Abuse Reports

The focus of this section is the system used for reporting child abuse in California and its

implementation in San Luis Obispo County. We first review the legal requirements and then

discuss local processes.

The Child Abuse and Neglect Reporting Act, California Penal Code ' 11164 et. seq., is in-tended

to protect children from abuse. Many sections of the Penal Code and the Welfare

and Institution Code support this act and in many instances the section numbers of the two

codes are the same. Both law enforcement and Child Welfare Services ( CWS) play impor-tant

roles in ensuring compliance with the law.

SCAR is the acronym for Suspected Child Abuse Report, a Department of Justice form that

is used to report suspected physical, mental, emotional, or sexual abuse, and severe or gen-eral

neglect. Any person can make a report, but mandated reporters are required by law to

complete a SCAR form. Mandated reporters generally include any person who has direct or

indirect contact with children. Penal Code ' 11165.7, included here as Appendix A, identi-fies

legally designated mandated reporters, and a copy of the SCAR form is provided in Ap-pendix

B. All employers of mandated reporters are required by law to inform their employ-ees

about the requirements for reporting child abuse.

Mandated reporters are required to submit a SCAR whenever the reporters, in their profes-sional

capacity or within the scope of employment, have knowledge of, observe, or reasona-bly

suspect a child has been the victim of abuse or neglect. These suspicions are to be re-ported

immediately or as soon as possible by telephone to any police or sheriff's department

or to the county child welfare services. The SCAR form containing information concerning

the incident must be sent to the agency that was telephoned within 36 hours. As specified in

the instructions printed on the reverse side of the form, color specific copies are to be dis-tributed

to child welfare services, the local law enforcement agency, and the district attor-ney=

s office. The fourth copy is for reporting parties to keep for their record.

The report flow shown in Figure 1 is designed to ensure that all interested agencies are noti-fied

in order to initiate their investigations. The Penal Code specifies penalties for failure to

follow the designated procedures. A mandated reporter who fails to report any suspected

child abuse or neglect A... is guilty of a misdemeanor punishable by up to six months in a

county jail or by a fine of one thousand dollars ($ 1,000) or by both fine and punishment@ ( PC

' 11166). The section further states A... any supervisor or administrator who violates or hin-ders

the distribution of the SCAR is guilty of an infraction punishable by a fine not to exceed

five thousand dollars ($ 5,000)@ ( PC ' 11166.01).

The purpose of requiring the distribution of the four part handwritten form is to ensure that all

appropriate investigative agencies are provided with original information. Any agency receiv-ing

a SCAR must accept it. When an agency receives a report for which it lacks jurisdiction,

the agency must immediately evaluate it and refer the applicable cases by telephone, fax, or

electronic transmission to the agency with proper jurisdiction.

48

Initiates

SCAR

Mandated

Reporter

CWS

Law enforcement District Attorney

Department of

Justice

Investigation

CWS/ CMS

Founded?

Yes Yes

Juvenile Court

Investigation Investigation

Suspected Child Abuse

Report ( SCAR)

Investigation

Yes

Delete

No

End

Abuse? Abuse?

No

Process flow in accordance with

Penal Code and Welfare and

Institution Codes

Law enforcement

as a Mandated

Reporter

District Attorney

as a Mandated

Reporter

CWS as a

Mandated

Reporter

Figure 1

49

The intent of the law is to ensure a multi- agency involvement process. The goal is for all in-formation

to be cross checked so that no child falls through the cracks of the process, and

that independent investigative reports are available to the courts.

SCARs in San Luis Obispo County

The issue of SCARs was brought to the Grand Jury= s attention when two mandated report-ers

filed a complaint asking us to follow up on why investigations were not initiated after they

had properly filled out and sent a SCAR to the county Child Welfare Services. This

prompted the part of this investigation that involved reviewing the distribution of SCAR forms

in our county.

In following up on the initial and subsequent complaints, we reviewed 17 CWS files involving

38 children. We found 44 SCAR forms that had been completed in the last three years,

mostly by mandated reporters. Thirty- five of the forms still included the copies intended for

distribution to law enforcement and the district attorney. In only one of the files was there

indication that the mandated reporter was sent an acknowledgment as required by the proc-ess.

Upon investigation, we learned that since August 2000, CWS has been initiating a comput-erized

CWS/ CMS version of the SCAR when they receive a report of suspected child abuse

that meets their criteria for action. Copies of that version of the SCAR are distributed to law

enforcement and the district attorney when required. A result of this practice is that in most

cases, the other agencies do not see the originally submitted SCAR that may contain infor-mation

that is not included on the CWS form. In instances when the original form is also

submitted, either by a mandated reporter or CWS, the result is that other agencies are re-ceiving

duplicate reports. An effective approach, which we found used in a few instances,

was CWS attaching the agency copy of the original SCAR to the CWS form they distribute.

Local CWS procedures are currently being developed as ADesk Guides@ for electronic distri-bution

to employees through the county DSS internal network. The working ADraft CWS

Desk Guide Subject: Intake Referral@ ( Draft Revised 7/ 17/ 03) calls for systematic distribution

of the reports as depicted in Figure 2.

We noted that the Desk Guide does not specify that a copy of the SCAR must be distributed

to the district attorney when it alleges physical or sexual abuse or severe neglect. While we

confirmed that the district attorney= s office does receive some copies of CWS generated

SCARs, it is difficult to know whether they are consistently distributed as required by law.

There is also a delay in receiving the reports from CWS. Even with the Desk Guide in place,

we identified additional areas of concern related to CWS communication with mandated re-porters

and the coordination with law enforcement.

Mandated Reporters

Many of the SCARs that we reviewed had been determined to be unsubstantiated or un-founded

by CWS. An unsubstantiated designation means that not enough evidence was

50

Initiates

SCAR

Mandated

Reporter

CWS

Investigation

CWS/ CMS

Juvenile Court

Suspected Child Abuse

Report ( SCAR)

Figure 2

Case carrying SW

SW’s Supervisor Licensing/ Approval supervisor

Placement supervisor

All CWS Division Managers

DSS SCAR

form

Case carrying SW

SW’s Supervisor Licensing/ Approval supervisor

Placement supervisor

All CWS Division Managers

Law Enforcement

Case carrying Social Worker’s ( SW) Supervisor

Licensing/ Approval supervisor

Placement supervisor

All CWS Division Managers

Law Enforcement

District Attorney

Distribution in accordance

with Desk Guide

Typical distribution

Internal distribution only

Process flow in accordance with the

San Luis Obispo CWS Desk Guide

and actual practices

51

found to support the allegation. In an unfounded determination, CWS has found no evi-dence

or basis for the accusation.

Several mandated reporters questioned how these determinations had been made. In many

cases, it appeared to this Grand Jury and to law enforcement agencies that there was

enough documentation to warrant further investigation or another conclusion. One example

is a SCAR submitted by mandated reporters that included statements and evidence from a

doctor, teachers, psychologists, and even a child= s drawing to substantiate their accusations.

Even with this supporting documentation, the SCAR was deemed to be unsubstantiated by

CWS. When asked how this conclusion had been determined, CWS told the mandated re-porters

that the information could not be shared due to confidentiality.

Law Enforcement

In our interviews with law enforcement, we learned that in some agencies the dispatchers

routinely receive calls from CWS when suspected child abuse is reported. Other agencies

reported that they do not receive calls as often as they should. This call is important be-cause

it allows the law enforcement agency to respond quickly. Failure to receive immediate

notice delays law enforcement investigations. Important evidence such as bruising and

markings may be lost, the information provided by the victim and suspect may change, and

one or the other of them may leave town.

The reporting process is designed for the telephone reports to be followed by a copy of the

CWS/ CMS version of the SCAR form in cases of physical or sexual abuse. Each law en-forcement

agency has developed its own system for matching the reports they receive by

telephone with the corresponding paper work. In cases where there was no call received,

the SCAR may be the first time law enforcement was made aware of the suspected abuse.

Problems also occur in the paper flow from CWS. SCAR forms are often distributed by

CWS to the wrong law enforcement agency. This puts an extra burden on the receiving

agency to re- route the SCAR, particularly since some receive up to 70 per month.

A related issue is the delivery time. The Penal Code is clear that a written SCAR must be

sent within 36 real ( consecutive) hours to the agency that receives a telephone report. In

many cases, we found the CWS initiated SCAR was not filled out until several days after the

initial call. After it has been processed by CWS, it was another three to five working days,

often more than a week, before the law enforcement agencies and the district attorney= s of-fice

received their copies. The county agencies that we interviewed received the written

SCARs from CWS through the county= s inter- office mail system.

Findings

( 1) CWS is not sending a written SCAR within 36 hours of receiving reports of abuse or

severe neglect to the agency to which it made a telephone report in accordance with

Penal Code ' 11165.7( h). Law enforcement and the district attorney= s office are re-ceiving

the SCARs longer than three days and frequently more than a week later.

52

( 2) Some law enforcement agencies do not receive immediate telephone calls on inci-dents

for which they later receive a SCAR.

( 3) The CWS Desk Guide instructions do not specify that a SCAR is to be distributed to

the district attorney as required in PC ' 11165.12 ( c).

( 4) When CWS determines that reports of sexual and physical abuse and severe ne-glect

are unfounded or unsubstantiated, they do not distribute the written SCAR to

the appropriate agencies. This appears to be in violation of PC ' 11166.

( 5) Some law enforcement agencies are receiving SCARs that are not within their juris-diction

and must forward them to the appropriate agency. This is a time consuming

activity and hinders the timely investigation by the appropriate agency.

( 6) Some law enforcement agencies are receiving duplicate copies of SCARs, one initi-ated

by the mandated reporter and one initiated by the CMS/ CWS. Receiving dupli-cate

SCARs for the same incident can be confusing and time consuming for the law

enforcement agency.

( 7) When a SCAR decision is made regarding a referral from a mandated reporter,

CWS does not consistently send an acknowledgment of the outcome to the reporting

party.

( 8) Training for mandated reporters of child abuse and members of the child welfare

delivery system is not regularly provided, as required in PC ' 16206.

( 9) CWS reporting and coordination is not consistent among law enforcement agencies.

Recommendations

( 1) CWS should ensure that the appropriate law enforcement agency is immediately

telephoned when CWS receives a report of child abuse or severe neglect.

( 2) CWS should ensure that SCARs are distributed to the appropriate law enforcement

agency and the district attorney. The CWS Desk Guides and internal procedures

should be corrected to reflect this.

( 3) CWS should complete and forward a written SCAR to the appropriate agencies

within 36 consecutive hours.

( 4) The law enforcement copy of a SCAR should be forwarded to the correct law en-forcement

agency.

( 5) CWS should attach the appropriate copy of the original SCAR form to CWS/ CMS

SCAR forms they distribute to law enforcement and the district attorney.

53

( 6) CWS should notify mandated reporters of the outcome of the SCARs that they sub-mitted.

( 7) CWS should take a leadership role in promoting training for mandated reporters.

( 8) CWS should review agreements on SCAR reporting with all law enforcement agen-cies

within the county to ensure consistent practices and coordination on a regular

basis.

( 9) County inter- office mail should not be used for delivery of time- sensitive information.

II. CWS Placement Cases and Issues

Perhaps the most difficult decision CWS social workers must make is to remove a child from

his or her home. This is the least preferred outcome within the context of U. S. social values.

Nevertheless, in some instances the protection of a child requires removal. This section fo-cuses

on the complaints the Grand Jury received involving the placement of these children.

When children must be taken from their homes, CWS places them in protective custody. A

Juvenile Court hearing is required within two court days requesting permission to detain the

child, and a detention hearing is held the next court day. When the court determines that

out- of- home care is necessary, the child is typically placed in foster care and placement

planning is initiated. Of the 17 cases that the Grand Jury reviewed, all but two involved

placement issues.

Child Welfare Services submits reports and recommended placement plans to the Juvenile

Court for review. A county attorney ( County Counsel) represents CWS in court, and the

court assures that all other parties to the case, including the children, have legal representa-tion.

A Juvenile Court ruling determines the placement of children. However, CWS is the

conduit and often the screener of the information that the court receives. Several of the

complaints that we received were from other agency professionals who had been frustrated

in their efforts to have their positions represented in the reports and recommendations that

CWS submitted to the court.

State and local policies are clear that the order of preference for permanent placement of

children is: family reunification, adoption, guardianship, and long term foster care. This pri-oritization

is reflected in the social work Best Practices, which have defined policy for many

CWS decisions in recent years. Currently, the state Redesign and AB 636 in effect mandate

this prioritization of placements. 2

Fifteen of the cases that we reviewed involved children who had been removed from their

homes and placed in out- of- home care for some period. In most of these cases CWS efforts

were proceeding toward the goal of family reunification. The common concern among the

complainants was that CWS continued to recommend reunification as a goal, even when it

appeared this was detrimental to the safety and the best interest of the children.

54

The cases that we reviewed provide a glimpse of the complex and difficult work of CWS and

the Juvenile Court. These cases represent a small percentage of the total CWS caseload.

They came to our attention, however, because people who were involved with the children

were so concerned for the children’s welfare and safety, and so frustrated with the place-ment

process or outcome, that they felt they had no other recourse.

Case Reviews

We present an overview of the facts and issues that led to our findings and recommenda-tions

by summarizing some of the cases we reviewed. This is sensitive information that is

protected by laws regarding confidentiality. Therefore, specific details and identifying infor-mation,

such as names, dates, and location, have been omitted. We have provided this in-formation

to the Superior Court and, with the permission of the Presiding Judge, to CWS. It

is not our intent to second guess decisions by social workers who were directly involved in

these cases.

Several of the cases, including our initial investigation, focused on children with develop-mental

disabilities. We begin with discussion of the initial case and related issues. We then

summarize additional cases with placement goals of reunification and adoption. The final

case we present involves the death of a minor while in the protective custody of CWS.

While each case is presented under a specific category for emphasis, many involve issues

from multiple categories.

Developmentally Disabled Children

The first case, discussed below, and five subsequent cases that came to our attention in-volved

developmentally disabled children. The complainants are professionals who worked

closely with these children. Each case is unique, but in all cases the concerns were that

CWS failed to understand the special needs of the children, and did not involve those with

expertise either in working with the children or in developing plans and recommendations to

the court.

The Tri- Counties Regional Center ( TCRC) is the local agency serving developmentally dis-abled

children and adults, under a contract with the state. In cases where developmentally

disabled children have been found to be neglected or abused, they are served jointly by

TCRC and CWS. According to TCRC, “ Children and adults are eligible [ for services] who

are substantially handicapped due to conditions falling within the legal definitions of ‘ devel-opmental

disability.’ These conditions are mental retardation, cerebral palsy, epilepsy, and

autism. Or the person may have a condition closely related to mental retardation which re-quires

similar treatment.” 3 TCRC case workers are experienced in working with the devel-opmentally

disabled and their families, and TCRC can pay for resources to serve them.

Developmentally disabled children often require special medical and therapeutic services to

address physical and emotional problems. Some are delayed in developing motor skills and

abilities, such as dressing, toileting, feeding, etc. Depending on the nature of their disability,

many of these children have difficulty communicating and expressing themselves. Special

education teachers and support staff within the public school systems have expertise in

55

working with developmentally disabled children. They are also most likely to notice changes

in the health and behavior of children with whom they work closely, often over several years.

Case The first complaint to this Grand Jury alleged that CWS was emphasizing a

goal of family reunification long after there was evidence that it was not in the

best interest of two developmentally disabled children. These children began

their Juvenile Court dependen