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ACLU SoCal - Orange County Jails, 2017

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JUNE 2017


The authors of this report are Esther Lim, MSW and Daisy Ramirez, MSW.
Contributing authors and researchers: David Colker, Ruth Dawson, Peter Eliasberg, Brendan Hamme,
Tasha Hill and Ian Kysel.
Copy editor: Henry Fuhrmann.
Design and layout:
Cover photo credit: Daisy Ramirez, MSW.
We are grateful for the advice of Marcus Benigno, Jessica Farris, Eve Garrow, Michelle Ochoa, Jennie
Pasquarella, Jennifer Rojas and Hector Villagra.
Special thanks to Kate Summers.
The Orange County Jails Report is available online at
An accompanying executive summary is available online at

The ACLU of Southern California works to defend the Bill of Rights and apply them equally to all who
live in our society. Our Jails Project works to ensure that a basic standard of care is provided to
individuals who are incarcerated through advocacy, public education and litigation.



II.	 Orange County Sheriff’s Department............................................................................. 4
III.	 Methodology................................................................................................................. 11
IV.	 Findings........................................................................................................................ 13
A.	 In-Custody-Related Deaths.................................................................................................................13
B.	 Safety...................................................................................................................................................15
1.	 Deputy-on-Inmate Violence..........................................................................................................15
2.	 Deputy-Instigated Inmate-on-Inmate Violence and Failure to Protect........................................ 22
3.	 Verbal Abuse and Threats............................................................................................................. 27
4.	Searches........................................................................................................................................ 31
5.	 Housing of Lesbian, Gay, Bisexual, Transgender and Intersex Persons......................................35
6.	 Prison Rape Elimination Act (PREA) Data Collection................................................................... 37
C.	 Medical Care........................................................................................................................................ 39
1.	 Overall Medical Care..................................................................................................................... 39
2.	 Reproductive Health Needs..........................................................................................................45
3.	 Transgender-Specific Health Needs............................................................................................. 47
D.	 Mental Health Care.............................................................................................................................. 49
1.	 Overall Mental Health Care........................................................................................................... 49
E.	 Living and Physical Conditions............................................................................................................53
1.	Processing/Screening...................................................................................................................53
2.	Uncleanliness................................................................................................................................55
3.	 Showers and Plumbing................................................................................................................. 57
4.	Clothing.........................................................................................................................................58
5.	 Privacy for Transgender and Intersex Persons............................................................................60
6.	Overcrowding................................................................................................................................. 61
7.	 Recreation/Dayroom/Out-of-Cell Time........................................................................................63
8.	 Food Services................................................................................................................................65
9.	 Commissary and Indigent Packs/Welfare Kits.............................................................................68
10.	 Communications (Phones, Mail and Visitation)............................................................................70
F.	 Special Cases/Other............................................................................................................................73
1.	Discipline.......................................................................................................................................73
2.	 Grievance/Complaint Process.......................................................................................................75
3.	 American with Disabilities Act (ADA) Accommodations............................................................... 79
4.	 Religious Services.........................................................................................................................80
5.	 Propria Persona Status................................................................................................................. 81


Lawsuits....................................................................................................................... 83

VI.	 Key Players and Oversight............................................................................................ 87
VII.	 Conclusion.................................................................................................................... 92
VIII.	Appendices................................................................................................................... 93



Conditions in county jails that conform to the United States Constitution are a
prerequisite for the legitimacy and integrity of the American justice system. Under
the Eighth and 14th Amendments, jails have a duty to protect all people who are
incarcerated, whether sentenced or pretrial.
Conditions that fail to meet not only constitutional
but also state and department standards for physical
security, medical care, mental health care and living
environment are unlawful and should not be
tolerated. Discriminatory policies and practices and
noncompliance with legal standards may further
violate the rights of individuals who are incarcerated
and give rise to concerns of legal liability.
According to the Prison Policy Initiative, roughly
242,000 people in California are in custody.1 More
than 34% are incarcerated at local jails, accounting
for roughly 13% of the nation’s local jail population.2
For more than 40 years, the American Civil Liberties
Union Foundation of Southern California (ACLU
SoCal) has worked to ensure that a basic standard of
care is provided to people in jail. The ACLU SoCal is
the court-ordered monitor of conditions of
confinement within all Los Angeles County jail
facilities. Through its Jails Project, the ACLU SoCal
responds to complaints by individuals who are
incarcerated and ensures that court-ordered reforms
are implemented.3 The organization also entered into
a partnership with the Santa Barbara County Sheriff’s
Office to help monitor its jails in 2016.
In August 2015, the ACLU SoCal began to examine
the conditions inside the Orange County jail system
to determine whether a basic standard of care is
provided to all individuals in custody. Orange County

has the second-largest jail system in California, with
an average daily population of approximately 6,000
incarcerated individuals and roughly 64,000 annual
bookings.4 In 2009, the Orange County Sheriff’s
Department (OCSD) operated the ninth-largest jail
system in the United States.5
This report includes findings from interviews and
surveys of current and formerly incarcerated
individuals. Accounts on a range of issues are
incorporated and analyzed against constitutional
standards as well as policies and procedures of the
OCSD and Title 15 Regulations of the Board of State
and Community Corrections (BSCC). A discussion of
major findings is followed by recommendations. The
analysis also includes information from existing
reports and news articles as well as policy
recommendations issued by Orange County grand
The frequency and normalcy of issues identified -ranging from excessive use of force and verbal abuse
to inadequate medical treatment and deprivation of
due process — strongly suggest subpar conditions
and potential violations within the OC jail system.
The report aims to raise awareness and increase
transparency and accountability in an effort to halt
violations. Specific goals include strengthening
department policies and procedures and ensuring
appropriate implementation.


The OCSD operates five county jails: the Intake/Release Center (IRC), Central
Men’s Jail (CMJ6), Central Women’s Jail (CWJ), Theo Lacy Facility (Theo Lacy) and
James A. Musick Facility (Musick). The five facilities are used for the detention of
persons pending arraignment, during trial and upon a sentence of commitment,
which qualifies them as Type II jails.7
According to Orange County’s annual budget for
2016-2017, the sheriff-coroner budget accounts for
more than 19% of the county’s general fund.8
Incarcerating an individual in the county jail system
costs roughly $140 per day.9

Currently, Sheriff-Coroner Sandra Hutchens leads
the OCSD. Her predecessor, Mike Carona, was
indicted in October 2007 by a federal grand jury on
seven counts of public corruption; he resigned in
January 2008. In 2009, a jury acquitted Carona of five
charges related to the misuse of power. He was
convicted of witness tampering for attempting to
sway an ex-aide to lie for him in a federal
investigation of fraud.10 Hutchens was appointed as
sheriff-coroner by the Orange County Board of
Supervisors in June 2008.
Hutchens began her career with the Los Angeles
County Sheriff’s Department (LASD) as a secretary in
1976 and graduated from the academy in 1978.11 She
advanced in the department and retired in 2007 as the
division chief for the county’s Office of Homeland
Security under former LASD Sheriff Lee Baca, who
was recently sentenced to three years in federal
prison for obstruction of justice.12 Hutchens was able
to rise through the ranks despite a controversial
deadly shooting in 1980, when she fatally shot a
33-year old man. The death resulted in a $1.3 million
wrongful death suit,13 which at the time was the
largest police misconduct verdict in California.14


Hutchens was elected to serve a full term as sheriffcoroner for the OCSD in June 2010 with roughly 52%
of the vote and was re-elected in June 2014, running
unopposed.15 She also serves as president of the
Major Counties Sheriffs of America since 2016 and is
expected to seek re-election in June 2018.16

The chain of command within the OCSD is as follows:
sheriff-coroner; undersheriff; assistant sheriff/
executive director; commander/senior director;
captain/director/chief deputy coroner; lieutenant/
police services chief/manager/assistant chief deputy
coroner; and sergeant/supervisor/supervising
deputy coroner.17 There are five commands and 21
divisions in the Sheriff’s Department (see Appendix
A). The Custody and Courts Operations Command
consists of the following five divisions: Central Men’s
and Central Women’s Jails; Intake/Release Center
and Transportation; Musick Facility; Theo Lacy
Facility; and Inmate Services.18
Sheriff Hutchens and her Executive Command are
responsible for ensuring the safety and security of
all incarcerated individuals and staff in the county
jails.19 As sheriff, Hutchens is responsible for the
management and control of all OCSD facilities. She
is also responsible for all matters concerning the
selection, supervision, promotion, training and
discipline of staff. Undersheriff Don Barnes serves
as second in command of the OCSD and oversees its
day-to-day operations. Assistant Sheriff Bob
Peterson leads the Custody Operations Command
along with Commander Jon Briggs. Together they

On average, 61,117 people were booked annually into
the Orange County jail system from 2010 to 2015 (see
Figure 1). The security classification of individuals
who are incarcerated ranges from minimum security
to maximum security. Table 1 illustrates the security
classification of people who may be housed in each of
the five OCSD-operated jail facilities.

FIGURE 1. Annual Bookings, 2010 to 2015 (BSCC)

oversee the OCSD’s custody division and are
responsible for the operations of the five county jails.
New to the department’s Executive Command is the
position of constitutional policing advisor, which was
approved by the Orange County Board of Supervisors
in March 2016. Mary Izadi, a former deputy district
attorney for San Bernardino County, was selected to
fill the position in August 2016.









2010	2011	2012	2013	2014	2015

The OCSD provides patrol services to all
unincorporated areas of the county and to 17
independent entities, including 13 municipalities that
contract with the department for law enforcement
services.20 The 13 municipalities are Aliso Viejo, Dana
Point, Laguna Hills, Laguna Niguel, Laguna Woods,
Lake Forest, Mission Viejo, Rancho Santa Margarita,
San Clemente, San Juan Capistrano, Stanton, Villa
Park and Yorba Linda.

The OCSD provides jail functions to hold about 65,000
arrestees annually and custodial services to
individuals sentenced to serve time and/or awaiting
trial in Orange County. The OCSD is responsible for
housing, record keeping, recreational activity, food
services, commissary and services associated with
the secure custody of individuals.21 The jail
population also includes Immigration and Customs
Enforcement (ICE) detainees and Assembly Bill 109
realignment individuals.


Security Classification by Facility (OCSD)22




Medium- and maximum-security,
pretrial and sentenced male and
female inmates

Central Men’s

Pretrial and maximum-security
sentenced male and transgender
female inmates

Women’s Jail

Pretrial and maximum-security
sentenced female and transgender
male inmates

Theo Lacy Jail

Pretrial and sentenced minimum-,
medium- and maximum-security
male and transgender female inmates,
including weekender inmates

James A. Musick
Jail Facility

Pretrial and sentenced minimumsecurity male and female inmates


The CWJ is the third facility located in the CJX. After
being closed in 2009, the facility reopened in April
2012 in response to the increase in county jail
population prompted by the public safety realignment
legislation, Assembly Bill 109.26 The facility consists of
one-person cells, 16-single-cell housing, and 13-,
16- and 36-person dorms. The facility also includes
medical/mental health housing, corrective isolation
cells, single infirmary cells and safety cells for mental
health housing. Dental, medical, mental health, and
obstetrics and gynecology services are available at
the facility, as well as programs, religious services,
general education and pre-release rehabilitation.


The IRC is located in the Central Jail Complex (CJX)
in Santa Ana. It has a five-unit structure with
multiple stories. Arrestees are booked, processed,
classified, housed, transferred and released from
the IRC. While there, arrestees are classified to
determine a housing location assignment.23 The IRC
is responsible for booking and release, inmate
records and Module L (medical/mental health
housing unit). The Transportation Division is also
under the administration of the IRC command and is
responsible for transporting incarcerated individuals
to and from courts, work sites, hospitals, state
prisons and out-of-county mutual aid.24

The CMJ is also part of the CJX. The facility consists
of one-, four-, six- and eight-person cells as well as
corrective isolation cells and dormitory-style
housing. A court on the first floor conducts
arraignments for individuals housed within one of
the three jails within the CJX. The second floor
houses programs, religious services, general
education and pre-release rehabilitation. It also
includes regular housing, and dental, medical and
mental health clinics.25


The Theo Lacy Facility, named in honor of a former
sheriff of Orange County, is located in the city of
Orange. The facility includes units ranging from
multi-bunk dorms to one- or two-person cells. It
offers medical, dental and mental health services as
well as religious services, vocational programs and
educational classes.27 Theo Lacy consists of its own
booking and intake/release area in addition to
classification, inmate records and law library. The
facility receives and books all male and transgender
female stays of execution and administers the
Community Work Program.28 Under a contract
between OCSD and Immigration and Customs
Enforcement (ICE), immigration detainees may also be
housed at Theo Lacy.29

The James A. Musick Facility, also named after a
former OCSD sheriff, is located in Irvine. The facility,
referred to as “the Farm,” provides incarcerated
individuals access to educational programs such as
GED, ESL, substance abuse and positive parenting, as
well as religious services. ICE detainees awaiting
immigration hearings are also housed at the Farm.
Despite opposition from some local cities, the Orange
County Board of Supervisors approved an application
to build additional beds for minimum- and mediumsecurity individuals at Musick.30 According to the
county’s annual budget, the OCSD secured $100
million from the state of California for county jail

The first-phase project at Musick received State
Public Works Board (SPWB) approval in March 2013.
The first phase includes 512 new rated beds for the
County Adult Detention System. The design of the
first-phase project is nearing completion. The OCSD
also secured a second conditional award for $80
million from the state of California for county jail
funding in January 2014. The second-phase project
received SPWB approval in January 2015. The
second phase includes 384 rated beds intended for
rehabilitation, treatment and housing.32 After 10
years, the state would need county approval to lease
the beds for alternative purposes.33 The design for
the second-phase project began in February 2015
and is underway. The two phases have been
combined for construction and will be built almost at
the same time. Construction is anticipated to begin
in the spring of 2017, and the beds are expected to
be available and used beginning in late 2019.34

The OCSD custody process begins at the IRC.
Persons who have been arrested are transported to
the IRC from the local jails or directly after contact
with law enforcement. After booking at the facility,
they are temporarily housed. OCSD custody staff and
health care practitioners assess each person
admitted, provide medical care if indicated, and
interview and classify individuals as to the risk they
pose to themselves or others for the most
appropriate housing in the OCSD jail system.35


Incarcerated individuals are
classified by their past
confinement history, current
charges, criminal
“sophistication,” gang
affiliation, sexual
orientation, and physical or
mental health issues.
Incarcerated individuals are classified by their past
confinement history, current charges, criminal
“sophistication,” gang affiliation, sexual orientation,
and physical or mental health issues.36 Individuals
are assigned colored wristbands that show their
classification along with other information (see Table
2).37 Once transported to a specific facility, they are
further classified to determine suitable housing.
Factors considered in determining what compound
and barrack an individual can be safely placed into
include gang affiliation, sexual orientation, criminal
offense, and physical or mental health issues.38

Wristband Classification (OCSD)






Minimum Security

Low risk



Medium Security

Exhibiting irregular behavior or a history of mental illness



Maximum Security

Similar to yellow but higher risk




Maximum risk, present a danger to themselves or others
and are prohibited from association with others



Protective Custody

Segregated from jail population for their own safety







Currently the total rated capacity of the OCSD county
jails is 5,093; the total maximum capacity is 7,488.
The Board of State and Community Corrections uses
the term “rated capacity” for recommended
occupancy using state standards.39

The current population in OC is roughly 3.2 million. 44
On March 24, 2017, a total of 6,545 people were
incarcerated in the county’s jail system, exceeding its
rated capacity. Roughly 87% were classified as male
and 13% as female.45 About 70% of incarcerated
individuals were OC residents, while the remaining
30% were non-OC residents. Approximately 51% were
sentenced and 49% were pretrial. A majority of people
behind bars in Orange County are between 31 and 40
years old. Latinos make up the largest racial or ethnic
group in custody, accounting for 54% of the
incarcerated population.46 Figures 2 and 3 illustrate a
breakdown of the jail population by age and race and

TABLE 3: Capacity by Facility (BSCC)40






Santa Ana



Orange County
Men’s Jail

Santa Ana



Orange County
Women’s Jail

Santa Ana




	Unknown	 0%

James A. Musick Irvine



Theo Lacy



Incarcerated Population by Age, 2017 (OCSD)

Over 56	







Rated capacity is the highest number of incarcerated
individuals that a jail can house while providing a
minimum level of safety and services.41 The rated
capacity of a facility is calculated using factors like
cell square footage, number of showers, number
of toilets and several other Title 24 construction
Maximum capacity is the highest occupancy level
before the department would be required to release
incarcerated individuals.43 The OCSD describes
maximum capacity as the highest number of
occupants that a facility can house and remain in
compliance with the standards and requirements
contained in Title 15, Title 24 and/or any contractual
agreement, regulatory standard or code. Table 3
shows the current rated capacity and maximum
capacity for each OCSD jail facility.



	 Under 18	



	 0%	 10%	 20%	30%	 40%

FIGURE 3: Incarcerated Population by Race and Ethnicity,
2017 (OCSD)




American Indian


In 2015, more than half (61%) of the incarcerated
population was classified as minimum security. From
2010 to 2015, the average daily population (ADP) of
minimum-security individuals remained the largest
despite the significant increase of maximum-security
individuals after prison realignment (see Figure 4).



ADP by Security Classification, 2010 to 2015














2010	2011	 2012	2013	 2014	 2015


n Maximum

n Medium

Proposition 47 identified the California Department of
Education (CDE), the California Victim Compensation
and Government Claims Board (CalVCB) and the Board
of State and Community Corrections (BSCC) to
administer grant programs using the state savings. The
BSCC anticipates awarding more than $103 million in
June 2017.51 Projects selected for funding will enter into
a contract with the BSCC.




proposition’s passage, the jail population experienced
a decline of 9%.50 Counties with overcrowded facilities
have used some of the newly available jail space to
house people they would have otherwise had to
release early because of capacity constraints.


n Minimum

Before implementation of the prison realignment
legislation, Assembly Bill 109 (AB 109), in October
2011, county jails generally housed people with
misdemeanor sentences of one year or less, but no
individuals sentenced for felonies. As of October 1,
2011, however, the courts were required to sentence
certain categories of felony prisoners to county jails,
rather than state prisons, for terms of up to three
years.47 The shift of responsibilities for incarcerating
less serious felons from the state to the counties
was based on the premise that counties are better
situated to integrate public health and social
services that the state cannot. In 2014, there were
863 AB 109 individuals in the Orange County jail
system. Of them, 511 were housed in Theo Lacy, 107
in James Musick and 245 in the Central Jail.48

California Proposition 47 (Reduced Penalties for
Some Crimes Initiative) was approved by voters in
November 2014. The initiative reduced the
classification of most non-serious, non-sexual and
non-violent property and drug crimes from a felony
to a misdemeanor.49 In the year after the

A majority of people incarcerated in the Orange County
jail system are pretrial detainees who have not been
found guilty of any charges. In 2015, about 54% of
individuals incarcerated were pretrial detainees, while
46% were sentenced individuals. In 2015, the ADP of
5,658 consisted of 3,071 pretrial individuals and 2,587
sentenced individuals (see Table 4).
TABLE 4: Pretrial vs. Sentenced Population, 2010 to 2015








5,051 5,806 6,437 6,822 6,676





3,077 3,151 3,497 3,514 3,071

Sentenced 2,098 2,729

3,286 3,325 3,162 2,587

As Figure 5 indicates, the total pretrial population
was larger than the sentenced population in OCSD jail
facilities from 2010 to 2015. The rationale for pretrial
detention is to ensure court appearances and preserve
public safety. However, California’s high rates of
pretrial detention, like those in Orange County, have
not been linked with lower rates of failure to appear
or lower levels of felony rearrests.52 California’s
overreliance on pretrial detention may be attributed to
the state’s high bail amounts. The median bail amount
in California is $50,000, more than five times the
median amount in the rest of the country, $10,000.53




Pretrial vs. Sentenced Population, 2010 to 2015














2010	2011	2012	2013	2014	2015

n Pretrial

n Sentenced

Orange County is home to roughly 313,000
undocumented immigrants.54 The county has two
immigration detention facilities, both operated by the
Orange County Sheriff’s Department: the Musick
Facility and Theo Lacy Facility. The OCSD is the only
California law enforcement agency that still partners
with Immigration and Customs Enforcement (ICE), a
federal agency that is part of the Department of
Homeland Security (DHS), through its Section 287(g)
agreement.55 Section 287(g) of the U.S. Immigration and
Nationality Act authorizes DHS to deputize selected
state and local law enforcement officers to enforce
federal immigration law.56 The interagency partnership
with ICE authorizes OCSD deputies to interview and
process immigrant detainees in county jails for
removal.57 The agreement also requires deputies to
share arrest data, documents and supporting evidence
if ICE asks for it, essentially creating a pipeline into the
federal immigration system.58
Since 2010, both the Musick Facility and the Theo
Lacy Facility have participated in the federal
program, commonly known as “Beds for Feds,” to
house undocumented immigrants who are awaiting
deportation hearings or deportation.59 While ICE
handles all aspects of the detainees’ immigration
proceedings, the OCSD is responsible for providing
housing and services to detainees on a contract basis.
Both Musick and Theo Lacy separate pretrial and
sentenced individuals from immigration detainees.
The contract allows up to 838 detainees to be housed
in the county jail system. As a result, the county

receives funding from the federal government. Of $118
per day for each detainee, $94.15 is allocated to the
Sheriff’s Department for security and housing services
and $23.85 is allocated to the Orange County Health
Care Agency for medical and mental health services.60
In 2016, OCSD deputies also began serving warrants
and detainer requests on behalf of ICE. That year, a
total of 391 detainees were reported to ICE.61
In February 2017, Orange County Sheriff Hutchens
asked the Trump administration to provide a legal
directive for her to detain some immigrants past their
scheduled release dates to honor ICE detainers. The
California Trust Act, a state law, prohibits sheriff’s
departments from holding most incarcerated people
in county jails past their release time based on an ICE
detainer. Some federal courts have held that honoring
ICE detainers violates the Fourth Amendment of the
U.S. Constitution.62 At the beginning of March 2017, the
OCSD housed 528 ICE detainees.
A March 2017 report by the Department of Homeland
Security’s Office of Inspector General revealed
that immigrant detainees housed at the Theo Lacy
Facility are subject to serious health and safety risks.
Concerns include unsanitary food and handling;
24-hour disciplinary segregation known as solitary
confinement; poor sanitation, including mildewed
shower stalls and refuse in cells; broken phones;
faulty grievance procedures; and an inadequate
classification system.63 According to the report, two
additional inspections are scheduled for 2017.
In May 2017, despite opposition from community
organizations and several reports citing inhumane
conditions and abuse at the Theo Lacy Facility, the OC
Board of Supervisors unanimously approved Sheriff
Hutchens’ request to modify the existing five-year
inter-governmental service agreement (IGSA) with
ICE to increase bed space for detainees. The change
includes an additional 120 beds for a total of 958 beds.
If 100% of the bed capacity is utilized, the ICE annual
revenues for the Sheriff’s Department are expected
to increase by more than $5 million annually through
July 2020.
The ACLU SoCal urges the OCSD to end its Section
287(g) agreement with ICE and consider creating a
justice fund for universal representation to ensure fair
proceedings of individuals facing deportation.

This inquiry into the Orange County jail system was prompted by incarcerated
individuals’ and media accounts of abuse and misconduct. Before the study began,
the ACLU SoCal routinely received complaints and requests for assistance at its Los
Angeles and Orange County offices from people incarcerated in Orange County jails.
From August 2015 to April 2017, the ACLU SoCal
received and collected complaints and reports from
incarcerated individuals in the Orange County jail
system through letters, surveys and interviews. The
ACLU SoCal’s Jails Project administered postrelease surveys to formerly incarcerated people
upon their release from the Intake/Release Center,
mailed in-custody surveys to incarcerated individuals
at the five county jails and conducted face-to-face
interviews through general public visitation. Jail
visits were conducted at the IRC, the Central Men’s
and Women’s Jails, and the Theo Lacy Facility.
Family and friends of incarcerated individuals wrote
letters and made phone calls to the ACLU SoCal to
relay complaints on behalf of their loved ones.
Reports, policies and news media articles were also
analyzed to substantiate and lend credence to survey
and interview findings.
The Jails Project obtained information for this report
through the following efforts:
77 Reviewed seven grand jury reports (2007-2008,
2008-2009, 2010-2011, 2011-2012, 2012-2013,
2013-2014 and 2014-2015) on the conditions of
Orange County jails.
77 Reviewed relevant literature, including articles
published by the Orange County Register, OC
Weekly, Voice of OC, Prison Legal News, Los Angeles
Times, Washington Post and Huffington Post.
77 Surveyed more than 120 former incarcerated
individuals immediately after their release.
77 Conducted several jail visits, interviewed
individuals while in custody and collected
information via in-custody surveys.

77 Reviewed relevant policies and procedures,
including OCSD policies and BSCC Adult Title 15
77 Reviewed information and data secured by the
University of Michigan Law School Policy
Clearinghouse project.
77 Met with representatives from community
organizations and attended countywide meetings.
Through such methodologies, the Jails Project was
able to (a) explore the conditions inside the Orange
County jails, (b) solicit experienced opinions about
the issues in the jails, and (c) analyze the policies
governing OCSD custody operations.

The Jails Project used both quantitative and
qualitative data collection methods. We obtained
quantitative data through demographic survey
questions as well as directly from the OCSD and the
BSCC. Qualitative data was obtained through openended survey questions, department policies and
procedures, existing reports, news articles and
internet searches. Post-release surveys were
administered to individuals immediately after their
release from jail. In-custody surveys were mailed to
incarcerated individuals who (a) reached out to the
ACLU SoCal, (b) were referred by other incarcerated
individuals, (c) were referred by friends or family, or
(d) were selected randomly via the OCSD’s online
inmate locator. Based on the information collected,
we arranged follow-up in-custody visits with several
people to gather additional information on problems.




The post-release and in-custody survey served as the
primary means for collecting information about the
conditions inside the county jail system. The surveys
were available in English and Spanish. Both surveys
consisted of a series of open-ended questions that
focused on deputy misconduct, special cases, medical
issues, mental health issues and general conditions
of confinement. Areas of concern that surfaced
through survey responses and/or research were
incorporated in a revised survey. Such areas include
inmate monitoring, inmate privileges, cell and body
searches, and training of jail staff. We provided all
participating individuals with an explanation sheet
detailing the purpose of the survey, the risks and
benefits of participation, confidentiality and the
voluntary nature of the survey. The Jails Project and
trained volunteers administered the post-release
survey on Mondays, Tuesdays and Wednesdays from
10 p.m. to 3 a.m. The post-release survey typically
required 15 to 35 minutes to administer. Incarcerated
individuals self-administered the in-custody surveys.
The average time required to complete the in-custody
survey is unknown.

Issue type is the unit of analysis in this report.
Individual cases are summarized under issue
categories to substantiate the severity of problems.
Five categories were created to classify the range of
issues. The categories facilitated the analysis of data
and development of recommendations. The
categories are (a) physical security, (b) medical
treatment, (c) mental health treatment, (d) living and
physical conditions, and (e) other. Each category
consists of multiple subcategories focusing on
specific problems (see Table 5).


Issue Areas


The categories represent areas of concern that
require remediation to ensure reasonable safety and
access to protected rights. In-custody and postrelease survey participants were assigned
pseudonyms to maintain their confidentiality.
Pseudonyms were selected through an online search
of popular names. Given that some participants
reported multiple issues, pseudonyms may appear
multiple times throughout the report. Custody staff
are identified by rank followed by an initial.

Findings are based on more than 120 post-release surveys, as well as multiple
jail visits with, and correspondence from, incarcerated individuals. The accounts
detailed in this report are not exhaustive.
A varied number of the most severe post-release
accounts are briefly described under each
subcategory, as are a varied number of in-custody
accounts. Several subcategories have fewer than
10 post-release accounts because of limited
information on the issue. The number of in-custody
accounts varies because of visitation restrictions and
barriers to accessing the in-custody population. The
ACLU SoCal was granted access to conduct official
attorney room visits in April 2017.
A varied number of synopses of grievances submitted
between 2011 and 2013 are also incorporated to
provide additional information. The University of
Michigan Law School secured a grievance report
from the OCSD through a Freedom of Information Act
request. The department redacted synopses of
grievances from its previous data system for the
university’s Policy Clearinghouse project. The
university made the document available on the
project’s website. All narratives are written in the
third person. Grievances incorporated in this report
are taken verbatim from the document with the
exception of pseudonyms assigned to each account.
Preliminary findings substantiate concerns raised by
several reports. Lasting issues reveal that the OCSD
has failed to implement several recommendations
issued in the past. Findings also suggest that in some
cases the department fails to meet the standards
described in its own policies and procedures.

A total of 48 deaths occurred under the jurisdiction
and responsibility of the Orange County Sheriff’s
Department from 2010 to 2016.64 In-custody deaths
are extremely troubling and immediate steps should
be taken to prevent at all costs. The OCSD Coroner
Division is responsible for conducting medico-legal
death investigations countywide on all homicides,
suicides, accidents, and suspicious and unexplained
deaths to determine the identity of the deceased, the
medical cause of death, the manner of death, and
the date and time of death.65


In Custody Deaths, 2010–2016 (DOJ)

	0	2	4	6	8	10	

n Female

n Male


Of the people who died in custody from 2010 to 2016,
six (12.5%) were identified as female and 42 (87.5%)
as male. The average age of individuals who died in
custody was 47. Approximately 67% of people who
died in custody were awaiting trial; 54% died in an OC
jail facility. Of the 48 individuals, 29 were White, 13
were Latino,66 four were Black, one was Vietnamese
and one was identified as other (see Table 6).

constituting the largest category of manner of death.
According to U.S. Department of Justice data, the
death ruled “accidental” was due to a drug overdose.

FIGURE 7: Manner of Death, 2010 to 2016 (DOJ)



Table 6: Demographics (DOJ)




18 to 24




25 to 34




35 to 44


n Natural

n Pending Investigation

n Suicide



45 to 54



55 to 64


n Homicide Justified
(Law Enforcement Staff)

n Accidental


n Homicide Willful
(Other Inmate)






FIGURE 8: Custody Status of In Custody Deaths, 2010–
2016 (DOJ)

Table 7: Manner and Means of Death (DOJ)

Process of Arrest
Awaiting Booking






Not Applicable (22)



Hanging, Strangulation (3)
Handgun (1)
Other (1)



Drug Overdose (1)

Homicide Justified
(Law Enforcement


Handgun (2)

Homicide Willful
(Other Inmate)


Hands, Feet, Fists (1)



Pending Investigation (17)

Of the 48 deaths, 46% were declared due to natural
causes, 11% due to suicide, 6% due to homicide (4%
were reported as justified by law enforcement staff,
2% as willfully by another inmate), 2% were
accidental, and 35% are pending investigation (see
Figure 7).67 Twenty-two deaths were ruled “natural,”


No Charges Filed
Awaiting Trial


0	 5	 10	15	 20	25	 30	35

FIGURE 9: Facility Death Occurred, 2010 - 2016 (DOJ)


n County Jail

n Local Hospital

n Crime/Arrest Scene)

n Other

Table 8: Location where death occurred (DOJ)




County Jail


Medical Treatment (3)
Living (19)
Booking (1)
Not Applicable (3)

Local Hospital


Medical Treatment (10)
Living (5)
Crime/ Arrest Scene (1)
Not Applicable (2)
Other (2)

Crime/ Arrest


Crime/Arrest Scene (1)



Medical Treatment (1)

In California, local law enforcement agencies are
required to report to the Office of the Attorney
General any case in which a person dies while in the
custody of any law enforcement agency or while in
custody in a local or state correctional facility.68 The
agencies are required to write reports of deaths to
the attorney general within 10 days of the death.69
The reports are public records and are open to public
inspection. All Orange County District Attorney’s
Office reports of in-custody-related deaths available
online have determined no culpability of OCSD
staff.70 It is important to systematically capture
accurate figures and information to ensure
transparency and accountability. Although collecting
information is a needed first step, agencies must
ensure that investigations of in-custody-related
deaths are comprehensive, objective and fair. Data
can be used to improve tactics and strategies,
particularly when dealing with people who suffer
from mental illnesses.71

1.	 Deputy-on-Inmate Violence
OCSD deputies have a long history of assaulting
individuals behind bars. In the late 1980s,
deputies inside the Central Men’s Jail, known as
“the Psycho Crew,” beat mostly African American
incarcerated individuals.72 In the early 2000s,
under then-Sheriff Carona, deputies engaged in
misconduct with little or no fear of punishment.
Among several practices, staff used to regularly
discharge electronic control weapons (ECWs)
such as Tasers on individuals who were
handcuffed or otherwise restrained, fired pepper
guns in confined spaces, and used force on
people with mental illness when less restrictive
and less dangerous alternatives existed.73
Advisers to Carona recognized that he would not
end such jail abuse for fear of alienating the
deputies’ politically powerful union.

TABLE 9 : Use-of-Force in Custody Operations Facilities

(OC Annual Budget)






2010 211

5,051 60,995



2011 216

5,806 63,228



2012 240

6,437 66,400



2013 352

6,822 61,801



2014 351

6,676 59,167



In 2014, the U.S. Department of Justice’s Civil
Rights Division concluded in an investigation of
the Orange County Sheriff’s Department that
systemic deficiencies persisted with regard to
the use of force in the county jails.74 Although the
deficiencies were identified as limited in scope,
they revealed enduring systemic issues that pose
a serious risk of harm to incarcerated individuals.
Table 9 and Figure 10 illustrate the annual total


FIGURE 10: Use of Force in Custody Operations (OC Annual











Ca n
Ho n
Ca OC le
ro Sp
tid ra
Pe ont
pp ro
er l
Ba Sh l
Le ear Gre d
ss m na
Le /Sh de
al tgu
Sh n







FIGURE 12: Use of Force, First Quarter 2016

Ho n
Ca OC le
ro Sp
tid ra
Pe ont
pp ro
er l
Ba Sh l
Le ear Gre d
ss m na
Le /Sh de
al tgu
Sh n


Ca n

According to the OCSD, “The application of force is
counting the number of subjects that the force was
used against.” An example would be a deputy having to
break up a fight involving six people using pepper
spray; that would count as six in Figure 11. Table 10
indicates the total number of uses of force by incidents.
In 2014, there were 351 total incidents involving use of
force (see Table 9 and Figure 10). Figure 11 shows the
total number of individuals who were subjected to any
use of force broken down by the type of force. Figure 12
illustrates the type of force most used in the first
quarter of 2016. According to department data, custody
staff used “hands-on” force on over 350 individuals in
the first three months of 2016.



2010	2011	 2012	 2013	2014

use-of-force incidents from 2010 to 2014 relative to
average daily population and total bookings. According
to a California Public Records Act (CPRA) response
from the OCSD, the department does not have records
responsive to the number of in-custody use-of-force
case reviews in the years 2010 to 2016, nor to the
number of in-custody use-of-force case reviews that
reveal that use of force violated agency policy or the
law in the years 2010 to 2016.75






FIGURE 11: Use of Force, 2015 (OCSD)






2015 Use-of-Force Incident Details (OCSD)



































Theo Lacy








77 Anthony was transported to his cell in a wheelchair
after he saw a nurse at medical. Anthony was
unable to stand on his own. He had fainted earlier
that day, which exacerbated his chronic back pain.
Upon arriving to his cell, Anthony asked the deputy
if he could help him stand. The deputy refused to
help Anthony and “violently” threw him from the
wheelchair onto the floor of the cell. Before the
incident, Anthony had requested medical attention
repeatedly due to feeling “weak and
dizzy.” His requests were denied and he ultimately
fainted. In December 2015, a deputy told Anthony
that he was going to be placed in solitary
confinement. Anthony believed the move was
unwarranted and wanted to know why. After he
asked to see paperwork, Anthony maintains, “three
to five deputies slammed me against the wall and
twisted my arms up my back.” 
77 Freddy claims that after an incident involving two
inmates, several deputies zip-tied his wrists as he
was ordered to lie face down on the floor. Deputy N,
who walked up and down the aisles, stepped on
Freddy’s feet while he was handcuffed and shot
him and other inmates in the back with pepper
balls. Freddy maintains that he and others were
shot multiple times within close range. According
to Freddy, the deputies then proceeded to upend
the bunks and tossed inmates’ belongings to make
it look as if a riot had taken place. While Freddy
and others were still suffering from the pepper ball
wounds (and before being treated for the wounds),
they were interviewed on audio/video tape. Custody
staff denied complaint forms to Freddy and the
other inmates and told them that audio/video
interviews were enough documentation of the

the ground. Jeffrey claims that deputies broke his
lower left rib. He complained that he was denied
thorough medical examination, medication and
X-rays for several days after the assault.
77 Janet witnessed four deputies slam an inmate
against the wall for no apparent reason. She
disclosed that the inmate did not appear to be
resisting. She described the inmate as “slouching
over the stair railing.” She went on to say, “It
looked like she [the inmate] was really weak or
under the influence of something.” Janet
maintains that deputies held the inmate’s head
upward by pulling her by the hair.
77 Leslie witnessed a deputy being “unnecessarily
aggressive and forceful” with an inmate in spring
2016. A few days after the incident, she spoke to a
sergeant, who told her the matter was being
investigated. She had not received a response
several weeks after the fact.
77 Lily witnessed deputies drag an inmate who
appeared to have mental health issues down the
stairs. According to Lily, the deputies became
upset because the woman was on the second tier
of the housing module while deputies looked for
her on the first tier. Lily reported that the inmate
did not know that the deputies were looking for her
and was not combative when they told her to go
downstairs with them. On a separate occasion, Lily
saw deputies shove an inmate’s head against the
wall and twist her arms behind her back “as high
as they could go.” According to Lily, the deputies
routinely treated the woman poorly because they
disapproved of her charges. She did not disclose
the charges of the inmate.

77 Gladys shared that deputies routinely provoke and
threaten inmates. Once she witnessed a deputy
tase an inmate after the deputy had provoked the
person into becoming confrontational.

77 Michelle witnessed when Deputy G beat an inmate
the in spring 2016. Michelle claimed that Deputy G
put the inmate’s head in a bucket of dirty mop
water that week. According to Michelle, Deputy G
then “banged [the inmate’s] face two to three
times against the bucket.” Michelle disclosed that
the inmate suffered a bruised face and what
appeared to be a broken nose.

77 Jeffrey disclosed that he was assaulted by deputies.
When deputies ordered him to lie down on the floor,
he struggled to do so because of knee problems
(i.e., left knee has no ACL ligament). Six deputies
then took him into a cell. As Jeffrey knelt, four
deputies climbed on his back and slammed him to

77 Norma reported that Deputy E and Deputy C
slammed her face into a wall and then took her to
the recreation area on the roof of the jail and
twisted her arms behind her back. While on the
roof, the deputies ordered Norma to get undressed
so that they could search her. A male deputy was


present during the search. After the search,
Norma was handcuffed to a wheelchair and
“paraded” through the intake and processing area
in front of male and female inmates and deputies
while still partly undressed.
77 Robert claims several deputies slammed him to
the ground, chest first. A deputy pulled back
Robert’s hair while he was slammed onto the
ground so that his face would not hit the ground.
After being slammed to the ground, Robert passed
out. When he regained consciousness, he was
handcuffed to a wooden bench.
77 Stephanie witnessed deputies “toss up” and beat
up incoming female inmates. She maintains that
many of the “new girls” have never been in jail
before so they were unfamiliar with “in-house
rules.” Stephanie witnessed several of them being
“chicken-winged” and “pushed around” for no
apparent reason. Stephanie reported that deputies
once pushed and kicked her legs as they walked
past her.
77 Theresa claims several deputies injured her arms
and shoulders when frisking her. She claims that
deputies pulled her arms out of their socket.
Theresa also reported that she witnessed deputies
punch an inmate in the face.
77 Albert claims deputies elbowed his back multiple
times while he was handcuffed. Deputies also
pulled and twisted his arms for no apparent reason.
77 Carol was pinned to the floor by three deputies in
August of 2015. Deputies proceeded to elbow and
kick her while she was on the floor. Carol claims to
have suffered bruising on her knees, back, arms
and elbows. She was placed in solitary confinement
for one day following the attack.
77 David claims deputies slammed him against the
wall and forced his arms “all the way up” behind his
back. He was handcuffed and claims that deputies
intentionally placed the handcuffs too tight.
77 Ernest claims three deputies forced his arms
behind his back after he asked for lunch. He was
hurt without provocation or just cause. One of the
deputies then slammed the door on his fingers.
Ernest was not given any food for 24 hours
following the incident.

77 Hazel witnessed three female deputies “forcefully
storm a woman.” Hazel maintains that the deputies
“pretzeled” (twisted) the woman’s arms behind her
back and raised them up. The deputies then shoved
the female inmate against the cell. Hazel described
the woman as “not resisting” and “crying.”
77 Isaiah witnessed deputies pull a female inmate from
a holding tank at processing while he was in the
hallway. He described the woman as “having a
mental outburst.” He claims that the deputies
shoved the woman’s head “hard against the wall.”
77 Isaac witnessed a deputy shove an inmate against
the wall. He claimed that the inmate had
“accidentally turned the wrong way when walking to
chow.” Isaac believes that the inmate made an
“honest mistake” and was treated “very poorly” for it.
77 Michael told custody staff he did not want radiation
over his genitalia while he was going through the
medical screening at intake. Deputies then
“pretzeled” (twisted) his arms and wrists. Michael
shouted, “You’re going to break my wrists,” to which
the deputies responded by twisting his arms and
wrists harder. According to Michael, the deputies
continued to twist his arms until he apologized for
speaking up. He claims deputies with the mentality
of “lock you up and throw away the key” are quick to
put their hands on inmates.
77 Ulysses says a deputy closed a door on his toe.
Ulysses maintains that the act was intentional. His
toe was injured and bled. After a higher-ranking
staff member was contacted, Ulysses was
questioned in front of the deputy who closed the
door on his toe. During the interview, the deputy
involved in the incident stared at Ulysses, an act
Ulysses believes was meant to intimidate him from
saying the truth. Custody staff recorded the
interview and took pictures of Ulysses’ injured toe.
He was given an inmate health message slip.
77 Yousef claims that he witnessed deputies pick out an
inmate from a holding tank and beat him in front of
everyone as an “intimidation tactic.” Yousef reported
that the inmate was hit multiple times. He recalled
hearing the inmate yell, “I’m not resisting!”
77 Yahir witnessed a deputy pin an inmate down to the
floor. Another deputy engaged and put his foot on
top of the inmate’s back while he was already
restrained on the floor.

77 “Emma claims she had her arms twisted up, was
verbally abused and had a Taser pressed to the
side of her throat during the female booking
process.” (IRC, 6/6/2012)
77 “Noah alleged that around 0700 hours on 5-10-13
by Deputies A & A1 slammed him against the
wall. This caused a contusion on his right eye.”
(IRC, 5/16/2013)
77 “Irving said on 12-21-12 at 0505 hours that
Deputy B struck him in the head with an elbow
strike while he was, ‘Attempting to understand
and comply with his orders.’” (Theo Lacy,
77 “Benjamin alleges prior to bring transferred out
of Mod O to CMS that Deputy C twisted his hand
towards his upper back, causing pain while being
counseled for a security issue he inadvertently
caused.” (Theo Lacy, 3/14/2012)
77 “Mason alleged he was assaulted by staff
following his handcuffing in A/E by Sgt. D.” (Theo
Lacy, 2/9/2012).
77 “Jacob claims that Deputy E grabbed him by the
neck and ‘squished’ him against the wall.”
(James A. Musick, 1/3/2013)
77 “Alex claims to have been assaulted by Deputy F
and Deputy G came up to his cell and threatened
him.” (IRC, 8/27/2011)
77 “Carter complained Deputy H assaulted him in
the booking area for refusing to sign a
document.” (IRC, 1/30/2012)
77 “Julian stated Deputy I from the CJC ‘smashed’
his head into the elevator walls at least twice
before he lost consciousness. He now suffers
from frequent seizures, paralysis on the right
side of his body, and constant memory loss.”
(CMJ, 5/5/2013)
77 “Jonathan claims he was subjected to cruel and
unusual punishment when he was approached
by a deputy in the MJ 3rd floor chowhall.
Jonathan claims the deputy pushed his head into
the wall and bent his arms behind his back up
towards his head.” (Theo Lacy, 8/11/2011)

77 OCSD deputies use force that is not
proportionate to the threat presented in cases
where infractions do occur or at times when
infractions are not present. Force tends to be
either excessive or unnecessary.
Survey participants reported accounts of
excessive and unnecessary force by deputies.
Witness and personal accounts range from
handcuffs being placed on too tight to deputies
slamming incarcerated individuals against the
wall and twisting their arms behind their backs. In
cases where minor infractions did, in fact, result
in the use of force, survey participants reported
that the force utilized was not proportionate to the
threat presented by, or the need to lawfully
control, the individual in the particular situations.76
This violates the department’s policy on
“Objectively Reasonable Force.” According to OCSD
policy, “deputies shall use only that amount of
force that appears objectively reasonable, given
the facts and circumstances perceived by the
deputy at the time of the event, to effectively bring
an incident under control.”77 Several individuals
reported incidents that were never out of control,
yet excessive physical force was used. In
situations where compliance and cooperation are
present, exerting physical force is both
unnecessary and illegitimate.
77 OCSD deputies have used force against
individuals who are incarcerated with the intent
to harm, punish and intimidate. In several cases,
the infliction of pain did not serve to further a
lawful objective.
The practice of subjecting an incarcerated
individual to force without a legitimate ground is
problematic given that the infliction of pain does
not serve to further a lawful objective. In such
situations, force tends to be either excessive or
unnecessary. Department policy and BSCC
regulations prohibit the use of force for the sole
purpose of causing harm and/or as a form of
punishment. According to department policy, the
use of force “does not include the use of a firm
grip control while performing routine functions


OCSD deputies use the practice of “pretzeling” and
“chicken-winging” on individuals for arbitrary reasons
that do not pose a danger or threat.
such as searching, handcuffing or escorting.”78
Reports of willful and deliberate use of excessive
and unnecessary firm grip control in controlled
situations wherein individuals were following
directions and cooperating should be investigated.
It appears that deputies employ force as a means
of intimidating and punishing incarcerated
individuals for subjective motives. In any case, no
lasting physical injury is necessary to establish that
a violation has occurred when force is excessive.79
Several cases reported by survey participants
highlight the absence of a lawful objective when
force is employed. In such cases, many individuals
reported not resisting and following directives.
77 OCSD custody personnel routinely provoke,
instigate and threaten incarcerated individuals
into becoming confrontational.
Survey participants also allege OCSD deputies
provoke violence on a regular basis. Such claims
have been made and reported in the past.80
Examples include deputies taunting incarcerated
individuals at random and deputies issuing
inadequate clothing to people to get them to
complain. Deputies then use complaints as
pretexts to exert physical force. Several
individuals also recounted witnessing incidents in
which deputies shoved and pushed people despite
being unprovoked. According to survey
participants, deputies exert excessive force and
claim it was necessary to end a disruption that
they themselves incited. According to OCSD policy,
staff is prohibited from encouraging, provoking
and/or instigating misbehavior that would result
in the use of force. This is known as “baiting.”
Custody staff is also prohibited from encouraging
or allowing incarcerated persons to exercise force
against staff, visitors or other incarcerated


77 OCSD deputies use the practice of “pretzeling”
and “chicken-winging” on individuals for
arbitrary reasons that do not pose a danger or
The twisting of individuals’ arms behind their
backs was reported as a common practice
known as “pretzeling” and/or “chicken winging.”
In some circumstances, twisting arms behind a
person’s back might be a reasonable means to
gain control of an individual who is fighting. But
incarcerated individuals reported that the
technique is used when no force is needed and in
circumstances where far less severe force was
appropriate and sufficient. The multiple reports
of deputies “pretzeling” and “chicken-winging”
individuals for arbitrary reasons that did not
pose a danger or threat to the deputy or facility
need to be addressed.
77 OCSD deputies do not allow reasonable time for
compliance even when it is practical. In
situations wherein passive noncompliance is
present, the proportion of force exerted goes
beyond what is necessary to ensure compliance.
Several people disclosed that some deputies
exert unnecessary force in response to verbal
taunts and “passive noncompliance” or ignoring
directives in an unhostile way. A few people
witnessed or experienced deputies using
excessive force on incarcerated individuals who
did not immediately respond at count, stepped
out of the chow line, talked in the chow hall, or
walked the “wrong way” or looked at deputies
the “wrong way.” Other times, deputies exerted
force for no reason at all.
Pain-compliance techniques, according to OCSD
policy, may be effective in controlling a passive or
actively resisting individual.81 Deputies may only

apply such techniques when they reasonably
consider them necessary to further a legitimate
law enforcement purpose.82 Reports by survey
participants suggest that even in situations
wherein passivity is present, the proportion of
force exerted goes beyond what is necessary to
ensure compliance. It is problematic to require
that an injury be perceived as serious in order to
invalidate the use of pain-compliance techniques
in situations that are controlled or can be
controlled through alternative means.
Voluntary compliance, the preferred means of
achieving a resolution to potential use-of-force
encounters according to OSCD policy, is often
disregarded. In other situations, deputies did not
allow reasonable time for compliance even when
it was practical.83
77 OCSD deputies are not adequately supervised
nor held accountable when use-of-force is
According to accounts of survey participants and
various other sources, OCSD deputies employ
excessive force and violence to control and
intimidate incarcerated individuals. The sheriff
and the county have infringed the rights of
incarcerated people by permitting the use of
unnecessary physical force and failing to
adequately supervise jail deputies. Deputies are
entrusted with well-reasoned discretion in
determining the appropriate use of force in each
incident. Not monitoring such discretion raises
concerns, and not holding deputies accountable
when the discretion is mismanaged or abused
heightens the concerns. All of this, coupled with
a lack of transparency, is very problematic.
77 OCSD deputies and command staff do not
practice de-escalation tactics or intervene to
prevent unreasonable uses of force by fellow
custody staff.
The ongoing failure to halt abuse raises several
issues. Some survey participants disclosed that
“not all deputies are the same.” Others shared
that “some people are really just trying to do
their job.” Nonetheless, “turning a blind eye” to

instances of misconduct in itself points to a
systemic issue within the department. Deputies
and command staff permissiveness allows the
use-of-force to go unchecked. Whether implicit or
explicit, a code of silence within the department
overrides accountability and justice.
77 OCSD does not have records responsive to incustody use-of-force case reviews and in-custody
use-of-force case reviews that reveal that use of
force violated agency policy or the law.
Department policy defines physical force as
“striking, holding, pulling, pushing, throwing, or
exerting strength against another person.”84 Given
the absence of factors requiring the use of
physical force, deputies’ conduct in the several
aforementioned accounts was unreasonable.
Illegitimate seriousness of offenses and the lack
of legitimate law enforcement purpose need to be
investigated, reported and tracked.

77 Adopt adequate administrative safeguards on the
use of force and implement clear standards as to
when use of force is appropriate and necessary
and under what circumstances. Standards should
include clear limits on use of force on handcuffed
or restrained individuals and eliminate choke or
neck holds and head strikes.
77 Provide prompt and thorough medical attention to
individuals who are subjected to the use of force.
77 Prohibit the use of retaliatory force, such as force
used after a threat has diminished, or to punish
individuals for fleeing, resisting arrest or
disrespecting custody staff.
77 Ensure that staff is adequately and competently
trained on matters relating to the use of force on
incarcerated individuals with mental illness.
Implement specific policies handling encounters
with people with disabilities or in mental health
77 Prioritize voluntary compliance and allow
reasonable time for compliance. Custody staff
should use only force that is proportional to the
threat faced, rely on de-escalation tactics, and

emphasize deputies’ responsibility to deescalate encounters or prevent unreasonable
uses of force by other deputies and protect
incarcerated individuals. Provide training and
support to encourage staff to report abuse by
other staff.
77 Investigate allegations of abuse in a prompt and
thorough manner. Ensure that custody personnel
who fail to abide by department policy are held
accountable and appropriately disciplined. OCSD
personnel whose actions suggest poor moral
character should not be entrusted to uphold and
enforce the law. OCSD Internal Affairs files,
containing complaints of employee misconduct
and all materials relating to the investigation into
such allegations, should be accessible to the
public in a way that does not pose danger or
abridge the privacy rights of individuals.
77 Collect and report detailed and comprehensive
data on in-custody use-of-force incidents,
including the age, race, gender and sexual
orientation of people involved; unique
anonymized information on the deputies involved
and their role, training, experience and prior
involvement in use-of-force incidents; a
summary of the incident; and whether the
subject suffered from mental illness or other
disability. Make data available and accessible to
the public.
77 Audio- and videotape the processing of everyone
entering the OC jail system and install an
adequate number of video cameras throughout
all facilities to help settle allegations of abuse.
As previously recommended by several grand
juries, the OCSD should prioritize (a) adding
cameras to video- and audiotape known blind
spots and (b) upgrading the current surveillance
system to supplement supervision in the jails to
improve the safety of individuals who are
incarcerated, custody staff and visitors.85
77 Create a civilian oversight commission with
subpoena and investigatory powers to review use
of force incidents. This can further the goal of
transparency and accountability and begin to
restore and increase public trust.

2.	 Deputy-Instigated Inmate-onInmate Violence and Failure to
According to a 2005 news article, in 2000, a
journalist found evidence that jail deputies
amused themselves by instigating fights among
incarcerated people.86 A 2007 special criminal
grand jury investigation prompted by the death of
an incarcerated individual in 2006, found that
deputies routinely used incarcerated individuals
to enforce discipline at the jail by inflicting
violence (“taxing”) on other individuals.87 The
investigation revealed that deputies rewarded
shot-callers with benefits like new uniforms,
extra meals, additional hygiene products and
unrestricted movement in the facilities, among
other things.88 When shot-callers failed to get
other individuals “back in line,” deputies
intimidated the informal enforcers by destroying
their property.
According to several other news articles, custody
staff and incarcerated individuals inside the
Orange County jail system operate in a
hierarchical power structure.89 To enforce order
among the in custody population, deputies rely
on leaders, known as “shot-callers,” of three
main jail groups: “the Woods,” or Whites; “the
Southsiders” or “the Homies,” mostly Latino
gang members; and “the Paisanos” or “Paisas,”
mostly undocumented immigrants from

FIGURE 13: Inmate-on-Inmate Assaults (OCSD)



2009	2010	2011	2012*

*2012 numbers Jan. 1–July 26



Mexico.90 Shot-callers, typically the individuals
with the most time behind bars, serve the role of
enforcer for their racial group. Each shot-caller
has a “mouse,” or assistant, who is responsible
for passing along commands from shot-callers
to the rest of the incarcerated population.91
Helping the shot-callers enforce those orders
are “torpedoes,” considered the most violent
members of each group.92 As each person arrives
in jail, a representative of their racial group,
known as a “house mouse,” meets with them to
find out who they are, to learn why they are
behind bars, and to explain the rules and
regulations of the jail.93

FIGURE 14: Cameras per facility, 2016 (OCSD)








While some deputies support and perpetuate the
power structure and others oppose it, nearly all
deputies allow it to govern the facilities.
Individuals are routinely beaten for refusing to
carry out orders from shot-callers. Not acting on
orders from deputies and shot-callers can lead
to anything from serious injury to death. In 2009,
the Department of Justice’s Civil Rights Division
investigated operations of the OC jail system. The
investigation followed a series of incidents,
including the deadly stomping of John
Chamberlain by other incarcerated individuals in
October 2006 and the fatal tasering of two
individuals in 2007 and 2008.94 The investigation,
which remains open, involves all five jail facilities
operated by the OCSD.95 Since the investigation
was opened, department data reveals that
inmate-on-inmate assaults slightly increased
from 2009 to 2012 (see Figure 13).96 Such figures






tend to underreport the severity of the issue, given
undetected and overlooked assaults.
The OCSD has failed to implement
recommendations by the last six grand jury
reports, which uncovered the need to upgrade
antiquated and ineffective jail surveillance.
Previous grand juries found that all Orange
County adult jail facilities have inadequate video
surveillance equipment.97 Although a viable
upgrade plan with committed funding and
approval for implementation was established,
sufficient progress has not been made. This is
evidenced by the three escapees from the Central
Men’s Jail in January 2016. The 2011-2012 grand
jury noted that the Intake/Release Center as well
as the other facilities in the Central Jail Complex
had aging cameras and video surveillance

Table 11: Number of Assaults Reported (OC Annual Budget)

























































Deputy-Instigated Inmate-on-Inmate

FIGURE 15: Number of Assaults Reported (OCSD)










2010	2011	2012	2013	2014



systems with poor quality and limited access for
review.98 In 2014, the U.S. Department of
Justice’s Civil Rights Division concluded that
some improvements that were previously
recommended were not yet fully
institutionalized.99 It was particularly true in
regard to the need for cameras. Figure 14
indicates the number of cameras in each facility
as of June 2016. Blind spots continue to pose a
threat of risk to incarcerated people and allow for
poor accountability of staff.
Table 11 and Figure 15 reveal an increase in the
overall number of assaults reported, including
inmate-on-inmate assaults and inmate-on-staff
assaults, from 2010 to 2014. Table 11 compares
the percentage of inmate-on-inmate assaults
relative to ADP and total bookings to that of
inmate-on-staff relative to ADP and total
bookings. The data suggests that inmate-oninmate assaults are far more prevalent than
inmate-on-staff assaults. Inmate-on-inmate
assaults may be instigated by staff, as reported
by several survey respondents, and often go
unchecked because of poor supervision and
faulty surveillance.


77 Shawn claims that deputies create situations to
incite violence among inmates. He shared, “Time
goes by so slow. The little things in here [jail]
matter so much. They help you get by as best as
you can…. Deputies fuck with those things. They’ll
shut down the TV and blame it on you or someone
else. Now everyone is pissed and then things
happen.” Shawn claims that deputies blame
specific inmates for the loss of certain privileges
so that they become targets of violence.
77 James reported feeling unsafe in custody. He
disclosed that holding cells numbers 15 and 16 in
the processing area at Theo Lacy are marked “PCS”
for sex offenders and “PCM” for protective custody.
According to James, deputies marked the cells so
that inmates who pass by on their way to court can
identify sex offenders and then target them.
77 Pedro witnessed an inmate being “taxed”
(attacked) by other inmates after deputies
searched and destroyed their housing module.
According to Pedro, it is common for deputies to
“toss” (trash) tanks or housing modules and blame
the move on a particular person so they can get
“checked” (punished) by others. He said it is how
deputies pit people against one another and
described it as “divide and conquer.”
77 Victor claims deputies instigate violence “almost
every day.” He said the most common way of doing
so involves attributing cell searches — wherein
deputies scatter and throw inmates’ belongings
around — to a particular inmate.

Custody Staff’s Failure to Protect
77 James witnessed an inmate push the emergency
button to summon help because his cellmate was
hitting him. According to James, the deputies did
not respond to the inmate’s call for help; “they just
ignored him.” James pushed the medical

emergency button located by the sector door to
try to get help for the other inmate, whose safety
he believed was at risk, and still the deputies
failed to do anything.
77 Kyle reported that two inmates got into a physical
altercation after they were let out of their cell. He
claims that deputies intervened only after the
altercation was over.
77 Norma pushed the emergency button “about nine
times” when her cellmate became upset and
wanted to fight her in their two-person cell.
According to Norma, Deputy R and her partner did
not intervene or attempt to stop the altercation.
77 Hazel claims that inmates regularly tell each
other to quiet down. She maintains, “If the
deputies think we’re too loud we can end up
losing our mail for the week or have the TV shut
off.” Hazel recounted that when an inmate told
another to “Quiet the fuck down!” the demand led
to an verbal argument followed by a fistfight.
According to Hazel, deputies and custody staff
failed to intervene.
77 Daniel claims fights regularly broke out between
inmates who “bumped heads” with each other. He
said custody staff tends to “intervene” after
incidents have already broken up on their own.
Daniel disclosed that lots of blind spots in the
facility allow for fights to go unnoticed. He
suggested the need for more security checks and
77 Kevin witnessed inmates get sent to the “wall”
and get “taxed” by other inmates for not following
commands of inmate representatives. According
to Kevin, deputies allow the practice of “taxing” to
exist and oftentimes allow or encourage inmates
to fight each other.
77 Yadiel witnessed an inmate being attacked (“taken
to the wall”) by a group of inmates. According to
Yadiel, “a group of inmates shut down the showers
for a few minutes and beat up [the inmate].”
Yadiel did not know the motive behind the attack.
However, he disclosed that such “beatings” are
inflicted when inmates break program rules.
Yadiel said custody staff did not intervene.

77 Nick claims the behavior of custody staff showed
a lack of concern for the safety and well-being of
inmates. He said, “I was scared. I honestly think
they would let us kill each other in there.”
77 Sonia witnessed four incidents of inmate-oninmate violence during her time in jail. She did not
recount any of the fights specifically but
maintained they all started as “little arguments.”
She said that arguments in jail can “escalate to
pushing and shoving and full-on fights fast.”
According to Sonia, most fights take place in the
restrooms, away from cameras. She said
deputies, who are aware of the blind spots, “look
77 Zachary witnessed a group of inmates attack
another inmate who was “greenlighted” for his
charges. According to Zachary, deputies “walked
really slow to the scene as if nothing was
happening — they didn’t even pretend to rush.”
He thinks deputies’ response to such incidents
allows jail politics to govern through in-house
rules and violence.
77 Charlie disclosed that he personally beat up
another inmate who was labeled a sex offender by
other inmates. Charlie did not disclose how other
inmates learned of the charges. He claimed that
custody staff did not intervene during the attack.
77 Darrell was beaten up by two Paisano inmates
who were ordered to assault him by the
representative of the group. While Darrell rested
on his bunk, the representative of the Paisanos
yelled at him and asked him for his name. Darrell
responded to the representative in a similar tone
of voice, confirmed his name and asked “Why!?”
The representative then ordered two inmates to
attack Darrell for the way he responded. Darrell
maintains he was hit for about 16 seconds.
Custody staff did not intervene. He described the
pain as sharp and severe.
77 “Aaron [said] that while at the IRC on 3-28-12 he
was intentionally placed in a holding cell with a
Red band [maximum security] inmate. He is an
R-3 inmate. He was assaulted, but was afraid and
told the deputy and nursing staff he fell.” (Theo
Lacy, 4/12/2012)


OCSD personnel routinely instigate fights among
individuals and/or fail to intervene and protect individuals
in a timely manner.
77 OCSD personnel routinely instigate fights
among individuals and/or fail to intervene and
protect individuals in a timely manner. Whether
unintentional or deliberate, negligence
contributes to an unsafe environment.
Several accounts suggest that custody staff allow
individuals who are incarcerated to run their
programs despite knowledge of violence. Other
respondents reported that deputies routinely
instigate violence among individuals and allow
violent acts as a means to exert order and
control. This is a likely way for deputies to inflict
violence on people without directly engaging in
the act. A survey participant referred to it as a
way for deputies to “not get their own hands
dirty.” Another individual revealed the perception
of “hurt someone else or be hurt.” Such
practices violate Title 15 regulations, which
prohibit the delegation of authority to any
incarcerated person or group of people to
exercise the right of punishment over any other
individual or group of people.100 Handing control
over to individuals who are incarcerated and
willfully opting to “not see” violence is in
deliberate violation of Penal Code Section
§4019.5 and OCSD policy, which maintain that
incarcerated individuals shall never be permitted
to exercise control over other individuals and that
an individual shall not be allowed to inflict
punishment on another incarcerated individual.
Several means such as unsupported cell
searches continue to be used to incite violence
among individuals. It is important to point out
that searches performed only to harass people or
for other reasons not justified by a lawful
objective may be a violation of the Fourth


Amendment.101 Other participants reported that
deputies allow incarcerated individuals to fight
each other on a regular basis. Such accounts
suggest that deputies continue to neglect their
responsibility to safeguard the security of the jail
and the safety of individuals who are incarcerated.
77 Inmate-on-inmate assaults often go unchecked
due to poor supervision and faulty surveillance,
which creates a threat of risk to individuals and
allows for poor accountability of staff.
OCSD data reveals there was an increase in the
overall number of assaults reported, including
inmate-on-inmate assaults, from 2010 to 2014.
Such data tends to underreport the severity of
deputy-instigated inmate-on-inmate violence and
failure to protect given undetected and overlooked
assaults. According to survey accounts and several
reports, camera blind spots result in poor
supervision of certain jail populations and allow
jail violence to go unnoticed and unchecked.
Formerly incarcerated individuals disclosed that
deputies seldom conduct floor checks, which
exacerbates already poor supervision of certain
units due to housing configuration and inadequate
cameras. The department has failed to fully
implement the recommendations by the last six
grand jury reports, which uncovered the need to
upgrade antiquated and ineffective jail
surveillance. The lack of consistent floor checks
identified by several survey respondents is also
reminiscent of findings from the 2007-2008 grand
jury report,102 which revealed that deputies seldom
conducted 30-minute floor checks at Theo Lacy.103


Deputy-Instigated Inmate-on-Inmate
Violence and Failure to Protect
77 Work to change the culture inside the jails and
incorporate safeguards to protect individuals
who are incarcerated from violence instigated by
custody staff and/or other incarcerated
77 Conduct a review of complaints, including
deputies willfully failing to protect individuals
who are incarcerated and deputies instigating
violence among incarcerated individuals, and
develop a policy outlining protocol for responding
to such situations.
77 Review system for emergency requests to ensure
reliability in the response process and to protect
the well-being of individuals who are
incarcerated. Custody staff should respond to
emergency button requests and intervene in
emergency situations and altercations in a timely
77 Implement previous recommendations issued by
multiple grand juries and the Department of
Justice (DOJ) regarding jail security rounds.
Measures should require that jail staff conduct
more frequent and consistent rounds. According
to the DOJ, jail rounds should be performed (a) at
least one time every hour for the general
population, (b) at least once every half-hour for
high-security individuals (e.g., segregation and
suicide observation), and (c) even more frequent
observation for the most actively suicidal
individuals (specific number of checks would be
determined by medical staff and supervisors).104
77 Prioritize (a) adding cameras to known blind
spots and (b) upgrading the current surveillance
system to supplement supervision in the jails to
improve the safety of incarcerated people,
custody staff and visitors.

3.	 Verbal Abuse and Threats
According to former and current incarcerated
people, deputies demean, ridicule and belittle
the incarcerated population through derogatory
language and constant disrespect. Some
individuals disclosed being verbally abused on
the basis of their identity and needs. Such
behavior is unacceptable and should not be
tolerated. Verbal abuse, threats and harassment
have no relation to jail needs.

77 Ashley states she has been verbally abused by a
Deputy CO. Ashley further disclosed that
deputies mock, tease and laugh at inmates.
77 Dolores maintains that seasoned deputies trained
new deputies to treat inmates poorly when she
observed them in training. She said that “the
rookies were going the extra mile to look tough.”
77 Freddy was summoned to medical a few days
after he mailed the in-custody inmate survey to
the ACLU SoCal. He had not submitted a medical
slip. According to Freddy, he was not taken to
medical. He said that “[deputies] escorted me to
Internal Affairs.” He was questioned about
grievances he submitted against Deputy N.
Freddy informed Internal Affairs that he did not
feel comfortable answering questions on camera
without having a lawyer present. He believes
deputies might have read the contents of the
survey he mailed and thus subjected him to
questioning. He said, “I felt like they were trying
to intimidate me.” Freddy also reported that
deputies make it a point to verbally harass
inmates. He disclosed that Deputy N would tell
him and other inmate workers: “Hurry the fuck
up, you worthless pieces of shit! You
motherfuckers belong in here. I swear if you
don’t hurry, you will be fired!”
77 James reported that Deputy Z, who worked the
night shift at Theo Lacy, routinely called inmates
“bitches,” “weak” and “cowards.”
77 Louise disclosed that in late 2015 a deputy
declared her charges out loud so others could


hear. According to Louise, since losing her trial
in early 2017, deputies constantly disrespect her
and verbally harass her. She shared, “They talk
to me like I’m a piece of crap — they say I am a
menace to society.”

77 Carol claims that while at the lunchroom a deputy
asked her, “What? Are you dumb? Are you
retarded?” She described the demeanor of
deputies as “disgusting” and said, “They don’t
treat us like humans.”

77 Lily reported that deputies curse and yell at
inmates throughout the day for no apparent
reason. She said, “They make us feel worthless
all the time. It doesn’t end.” Lily recounted an
incident when she heard a deputy tell inmates
that she would punch them if they did not stand
in line. On a separate occasion, a deputy
threatened all the inmates in Lily’s housing
module, shouting, “If you all make me yell today,
I am going to go lights out and start punching
you bitches!” Lily claims the deputy also told her
and other inmates, “You druggies are all fucking
brain dead!” Lily disclosed feeling “extremely
unsafe in jail.” She shared that she has
nightmares about it and said, “I wake up scared
every morning…. I feel like I’m walking on
eggshells. I’m always afraid of being yelled at or
roughed up for no reason.”

77 Donna witnessed a White female deputy yelling at
a Latina inmate and asking her, “Motherfucker,
you don’t speak English?! For how long have you
been here?!” Donna also witnessed three female
deputies undressing a handicapped woman (who
appeared to have suffered a leg injury) and
laughing at her.

77 Michelle disclosed that deputies are “always in a
bad mood.” She said that “verbal abuse is an
everyday thing.” Deputies have told Michelle,
“Shut the fuck up” and “You aren’t worth shit.”
77 Norma reported that Deputy H curses at female
inmates and harasses them, particularly elderly
77 Stephanie heard Deputy G threaten to “fuck up”
inmates if they disrespected her. She also
reported that deputies call female inmates “hoes”
and “bitches.” According to Stephanie, “we’re
harassed from the time we wake up to the time
we go to bed.”
77 Brenda disclosed verbal abuse as a constant
occurrence. According to Brenda, most verbal
abuse is experienced in the booking area during
processing. She maintains that the abuse
includes a lot of cursing and degradation. Brenda
said, “There’s a difference between being strict
and being rude.” She went on to say that
“deputies are rude because they want to be and
can be,” “no one is going to stop them” and “they
don’t care.”


77 Eric recounted verbal abuse by deputies at all
points of contact throughout the day. He claims
that deputies attempt to provoke inmates through
“constant verbal harassment.” He said, “When we
react, deputies use violence and disguise it as
77 Henry claims deputies belittle, ridicule, curse and
taunt inmates. He maintains that verbal abuse is
the most common abuse that goes unaddressed in
the jails. He said, “Unlike getting punched in the
face, being put down doesn’t leave visible scars.”
77 Isaac witnessed a deputy threaten an inmate who
shook his head after seeing the deputy shove
another inmate for walking the wrong way. Isaac
heard the deputy tell the inmate who shook his
head, “Do you want people to get to fucking know
77 Kevin claims a deputy at James A. Musick
threatened him when he did not respond at count
immediately, and told him, “I can shut down
program and make you famous.” Kevin took the
statement to mean that the deputy would create
conflict between him and others as a way to get
him beaten up.
77 Lawrence recounted that while he was detoxing
from drugs and experiencing withdrawals, a
deputy asked him, “Are you a druggie, you
druggie?” Lawrence responded by asking the
deputy, “Are you a pig?” According to Lawrence,
the deputy then taunted him in an attempt to get
him to exit his cell to start a fight. On another
occasion, Lawrence had a seizure and was
foaming at the mouth. Throughout the incident
deputies called him a “druggie.” Lawrence said,
“We’re always talked shit to and treated like

77 Nick witnessed a male inmate who carried a bag
onto the elevator as he was on his way to be
processed out of the jail. After the inmate’s Bible
fell on the floor, two deputies kicked it. One of
the deputies told the male inmate, “Be a man
and do something!” The other deputy called the
inmate a “Fucking cunt rat!” According to Nick,
“Deputies treat us like we are less than animals.”
77 Oscar claims four deputies surrounded him and
called him a “crack baby.” The deputies
proceeded to harass him and tried to get a
reaction from him so they would have a reason to
use physical force. Oscar said, “I thought I was
going to get my ass kicked.”
77 Pedro claims a deputy threatened to beat “the
shit out” of him. As Pedro was walked back to his
cell from a Narcotics Anonymous class, a deputy
asked him, “What the fuck are you smiling
about?!” Pedro disclosed he was happy and
smiling about how the class went. The same
deputy ordered Pedro to “Stop fucking smiling!”
Pedro did not stop smiling. According to Pedro,
the deputy then claimed that he smelled like
alcohol and demanded that he strip down to his
boxers. The deputy proceeded to taunt Pedro and
tried to provoke him by pretending he was going
to punch him. Pedro was later transferred to the
CMJ. While at CMJ, Pedro witnessed deputies
mistreat Paisanos. Pedro heard a deputy tell an
inmate who did not understand or speak English,
“What the fuck, are you stupid?!” Pedro said that
“they want us to feel like we’re pieces of shit.”
77 Samuel heard deputies tell an inmate, “You’re
lucky I didn’t beat the shit out of you!” According
to Samuel, deputies scream at inmates for no
apparent reason and promote a “you’re a piece of
crap” attitude. He said, “I wouldn’t treat a guy I
hated as bad as they treated us.”
77 Tiffany claims she experienced a lot of racism by
deputies. Deputies tried to force her and other
non-English speakers to speak English. Deputies
told her, “You’re in the U.S. You should be
speaking English, you good-for-nothing idiot.”
77 Vernon claims being told “Get the fuck in line,
you fucking piece of shit!” is a regular thing. He
said non-English-speaking inmates are
discriminated against.

77 Oscar disclosed that he felt unsafe around
deputies. He said, “Basically if I would not be
their [deputies’] bitch, I would endanger my life.”
77 “Jeremiah complained that Deputy Y threatened
to allow another inmate out to do him harm.”
(IRC, 5/14/2012)
77 “Carlos alleges that Deputy J threatened him
physically, and verbally insulted him with vulgar
and degrading remarks. Furthermore, he
claimed Deputy J made derogatory remarks
about his deformed feet.” (Theo Lacy,
77 “Ralph claims on 6-29-11, after his court shower,
a staff member threatened to physically harm
him.” (Theo Lacy, 7/3/2011)
77 “Juan alleges that CST R told him to, ‘Get in the
fucking line,’ Juan stated Deputy V heard the
conversation between himself and CST R and
later denied it, warning him there could be
consequences for his actions.” (Theo Lacy,
77 “Josiah complained about ‘racist and derogatory
comments’ towards him by CST X.” (Theo Lacy,
77 “Adrian is unhappy about his cell being searched
by deputies and stated the deputies threatened
to physically assault him.” (Theo Lacy, 2/5/2013)
77 “Andrew claims deputies routinely use profanity
and insults toward inmates.” (James A. Musick,
77 “Dominic states that Deputy I spit ice water on her
as she returned from an official visit.” (James A.
Musick, 8/15/2012)
77 “Evan is alleging Deputy Y has verbally threatened
him and believes the threat to be physical in
nature because of a comment Deputy Y made to
him in regard to ‘wait and see what I do to you,
there are no cameras here.’” (IRC, 12/5/2012)
77 “Chase is very upset with the way Deputy Z
verbally degrades the inmate workers. Chase
said he uses racial slurs and profanity and spits
at glass towards them when yelling at them.”
(IRC, 11/18/2012)

77 OCSD deputies harass, taunt and threaten
individuals who are incarcerated through
derogatory language and constant disrespect.
Several survey participants reported constant
verbal abuse by deputies. An individual who is
incarcerated said, “They [deputies] ridicule and
belittle us all the time.” Such accounts suggest
that verbal abuse reigns in an atmosphere of
intimidation, threats and fear condoned by the
OCSD. Such behavior goes against department
policy requiring personnel to act with the highest
degree of integrity and good moral character.
77 OCSD custody personnel condone verbal abuse
on the basis of incarcerated individuals’ race,
mental state and medical needs.
With regard to non-English-speaking individuals,
OCSD policy requires the department to take all
reasonable steps to ensure timely and equal
access to all individuals, regardless of national
origin or primary language.105 According to OCSD
data, 21% of incarcerated individuals in the OC
jail system on March 25, 2016, were non-U.S.
citizens, while 79% were U.S. citizens.106 Survey

findings suggest that rather than taking
reasonable steps to ensure timely and equal
access to incarcerated people regardless of
primary language, OCSD personnel discriminate
against individuals whose primary language is
not English. The practice of verbal abuse and in
some cases physical force on such individuals
should not be tolerated.

77 Apply evidence-based practices on the
psychology of abuse of power and law
enforcement misconduct to further the mission
of transforming the criminal justice system to a
system of rehabilitation rather than punishment.
77 Review the hiring and eligibility criteria for
custody personnel to shed light on the role that
maturity, experience and education play within
jail operations. Enhance requirements to ensure
that people entrusted to enforce the law are
emotionally, psychologically and socially
equipped and mature to do so. Upholding and
adhering to the law is as important for law
enforcement to do as enforcing and
safeguarding it.

Several survey participants reported constant verbal
abuse by deputies. An individual who is incarcerated said,
“They [deputies] ridicule and belittle us all the time.”
Such accounts suggest that verbal abuse reigns in an
atmosphere of intimidation, threats and fear condoned by
the OCSD.


4.	Searches
OCSD deputies conduct an array of in custody
searches. Table 12 lists the types of searches
conducted by OCSD deputies as well as what
warrants them. According to a California PRA
response, the OCSD does not keep statistics
responsive to the number of searches conducted
annually from 2010 to 2016. The department
reported that it is possible to extract some of the
information from its databases with the
appropriate computer programming. Citing

California Government Code Section 6253.9(b), which
is a part of the California Public Records Act: “[T]he
requester shall bear the cost of producing a copy of
the record, including the cost to construct a record,
and the cost of programming and computer services
necessary to produce a copy of the record when … (2)
the request would require data compilation, extraction
or programming to produce the record.” The total cost
for the computer programming to extract the data
was cited at a rate of $111.98 per hour for a minimum
of four hours.

Table 12: Searches (OCSD)



Planned Search

Calculated search which involves specific steps,
timing and resources to locate drugs, weapons
or contraband which may be concealed.

Coordinated between the watch
commander and the appropriate sergeant.
Deputies are the primary searchers.

Spontaneous Search

Unscheduled search, sudden and done without Deputy discretion. Shall notify immediate
supervisor when practical.

Facility Assigned Search
Team (FAST) Search

Picking a random area (tank, series of cells,
etc.) to search once per shift.

Sergeant shall notify staff members.
Sergeant will be present during the
entire search.

Plumbing Tunnel Check

Locate signs of escape, unsafe facility
conditions and inmate observation.

Will be documented on the applicable
workstation log.

Pat Down/Grasping Hand

Search of an inmate’s clothing and body.

None required. Routine/random.

Extended Correctional Search

Requires inmates to remove all garments
down to, but not including, their

None required. Routine/random.

Strip Search

Requires an inmate to remove or arrange
some or all of his or her clothing so as to
permit a visual inspection of his/her/their
breast, buttocks or genitalia.

Reasonable suspicion.

Visual Body Cavity Search

Visual inspection of the rectal cavity of a male,
or the rectal or vaginal cavity of a female.

Reasonable suspicion.

Physical Body Cavity Search

Involves the physical intrusion into a body
Search warrant.
cavity for the purpose of discovering any object
concealed in a body cavity.

Hospital Monitoring Search

Close monitoring at the hospital of an inmate
who is suspected of ingesting or concealing
contraband in a body cavity.

Watch commander approval.



Searches of Transgender and Intersex
One area California jail systems struggle with,
including the OC jail system, is safe and
appropriate searches of transgender and intersex
As California law makes clear, a person’s gender
is their gender identity, regardless of external
genitalia or sex assigned at birth.107 Troublingly,
many transgender female and intersex
individuals are involuntarily strip-searched by
male custody staff, despite requests that a female
staff person perform the search. This practice
violates the Prison Rape Elimination Act
(PREA),108 the U.S. Constitution109 and California
state law.110 This practice also causes
unnecessary trauma and fear among transgender
and intersex persons, and can lead to sexual
assault of these vulnerable groups.111
PREA permits only three options for the
searches of transgender persons:
1)	 searches conducted only by medical staff;
2)	 searches conducted by female staff only,
especially given that there is no prohibition
on the pat-searches female staff can
perform; and
3)	 asking incarcerated individuals/residents/
detainees to identify the gender of staff with
whom they would feel most comfortable
conducting the search.112

Body Searches
77 Louise claims that she was searched in the
presence of male deputies and has witnessed the
same thing happen to other female inmates.
77 Lily claims that she was body-searched twice within
the span of 10 minutes although she was being
supervised at all times. According to Lily, she saw
medical staff after fainting due to excessive bleeding
from her menstrual cycle. Lily claims that it would
have been impossible for her to have acquired
anything on her way to medical and back to her
housing module, especially because she was
escorted and supervised by a deputy the entire time.
Lily claims that as she was being searched, blood
streamed down her thighs. Lily maintains that the
search was intended to humiliate her. She said,
“There’s no reason why they had to do it twice.” Lily
also shared that she does not participate in any
programs or classes offered at the facility because
inmates are searched in groups and often
humiliated and harassed.
77 Norma claims that she witnessed a female deputy
conduct a body search on four female inmates in a
vestibule. According to Norma, a male deputy was
present and could see the female inmates who were
instructed to take off their pants and underwear.
None available at this time.
77 “Pablo states deputies searched him when he was
brought in to mod k. During the search, Pablo
alleges unidentified white male deputy, “did rub,
touch, and grab” his penis during a clothed body
searched.” (Theo Lacy, 9/19/2012)
77 “Abel claims the Deputy pulled his underwear up
too high during a search and caused injury to his
shoulder and groin area and was denied medical
attention.” (Theo Lacy, 4/15/2012)
77 “Milo is grieving possible staff misconduct. States
unknown deputies touched his private parts while
being searched outside of the chowhall.” (Theo
Lacy, 1/18/2013)


77 “Orlando alleges inappropriate touching of his
person during a search.” (IRC, 9/18/2012)

Strip Searches

77 Theresa claims that some of her property,
including a book, diary, artwork, toiletries and
inhaler, were missing after a cell search.
None available at this time.

None available at this time.
77 Carol claims that she and other female inmates
were subject to a strip search. According to Carol,
a female deputy ordered them to strip down to their
bra and underwear. During the search, a male
deputy walked by and said, “Oh, I’m sorry. I’m
blind.” Carol claims that the female deputy
conducting the search responded to the male
deputy, “Sorry, I don’t have eye candy for you today.”
77 Karina claims that female body searches are
sometimes conducted in the presence of male
77 “Stephen complained he was physically violated
and traumatized after a grasping hand search in
which a deputy digitally penetrated his rectum.”
(Theo Lacy, 6/18/2012)
77 “Otto alleges a deputy squeezed his genitals and
put his finger into his anus while conducting a
search.” (Theo Lacy, 2/15/2012)

Cell Searches
77 Louise claims that “rookie” deputies were
ordered to trash her cell as part of their training.
According to Louise, there was no reason for the
deputies to conduct a cell search, yet they threw
her commissary and destroyed some of her
77 Lily claims that a deputy destroyed a picture of her
mother, who had recently passed during a search.
77 Michelle claims deputies conduct “unnecessary”
cell searches and destroy people’s commissary.
She said, “One time they destroyed my commissary.
I thought the point was to inspect, not destroy.”

77 “Noah claims deputies assaulted, threatened, and
molested him during a search of his cell.” (Theo
Lacy, 11/7/2011)
77 “Lee cell was searched. Lee claims numerous
items were missing following the search. Items
missing: 3 personal photos, shower shoes, pillow,
receipt for items.” (CMJ, 9/28/2011)
77 “Mason claims authorized items of commissary
were taken by deputies during a search of D cube.
He listed a pillow, toothbrush, bar of soap,
medical shampoo, and antibiotic ointment as
items taken.” (Theo Lacy, 8/17/2011)
77 “Leon alleges that during a search of his bunk
coffee grounds were ‘deliberately poured all over’
his pictures and letters.” (Theo Lacy, 4/10/2012)
77 “Elijah opinion that Deputy Y behavior while
searching his cell was ‘abusive’ ‘verbally assaultive’
and ‘overly upset.’” (Theo Lacy, 5/11/2012)
77 “Umberto personal property was purposely
damaged during a search of his cell.” (Theo Lacy,
77 “Shay claims his book of stamps and phone card
were thrown out during a barrack search on Friday
1-14-2013 at 1930.” (James A. Musick, 1/16/2013)
77 “Lucius alleges that Deputy Y destroyed his court
file folder while searching his personal property
and disposed of it.” (IRC, 9/28/2011)
77 “Alexa states that her photographs were disposed
of during a sector search.” (IRC, 12/16/2012)
77 “Jasper complained he was missing a box of soap,
toothpaste, and a deodorant stick after his cell
was searched.” (IRC, 1/12/2012)


77 OCSD fails to conduct safe and appropriate
searches of all incarcerated people.
Several incarcerated females reported being
subjected to unreasonable searches, as well as
being searched in front of male deputies and
custody staff. Many transgender female and
intersex incarcerated individuals are involuntarily
strip-searched by male custody staff, despite
requests that a female staff person perform the
77 OCSD deputies use searches to harass,
intimidate and punish people who are
Although strip searches are generally allowed,
they must be related to legitimate penological
interests and cannot be excessive.113 To determine
whether a search is reasonable the OCSD must
balance the need for the search against the
invasion of personal rights that the search
involves. A second strip search might be
unconstitutional if excessive, especially
considering that individuals are under the
constant supervision of deputies.114

77 Review protocol for conducting searches,
including body, strip and cell, and ensure that
safeguards are in place to protect the dignity of
every person.
77 Provide oversight of the process that determines
the need for searches to ensure that they are
related to legitimate penological interests. The
department should prohibit searches that are
excessive or used to harass, intimidate or punish
individuals who are incarcerated. Custody staff
should not arbitrarily destroy the personal
property of incarcerated individuals.
77 Prohibit cross gender body searches. Conduct
searches of incarcerated individuals who identify
as female by female custody staff and prohibit
such searches in the presence of male staff. Staff
conducting a body search should be of the same
gender as the person being searched.
77 Establish a threshold level of suspicion for each
type of search. The varying levels of suspicion
should determine the type of search warranted.
77 Implement a system whereby transgender and
intersex incarcerated individuals choose the
gender of the staff person conducting their search,
or only allow female staff to (respectfully) conduct
searches of these populations.

Several incarcerated females reported being subjected to
unreasonable searches, as well as being searched in
front of male deputies and custody staff.


5.	 Housing of Lesbian, Gay,
Bisexual, Transgender and
Intersex Persons
Under the Eighth and 14th Amendments, jails
have a duty to protect all incarcerated
individuals, including LGBTI people, from a
serious risk of harm.115 Transgender women
are particularly vulnerable to sexual abuse
while imprisoned in male facilities.116
Under the Prison Rape Elimination Act,
housing placement decisions must separate
“those inmates at high risk of being sexually
victimized from those at high risk of being
sexually abusive.”117 PREA requires that, at a
minimum, facilities consider “[w]hether the
inmate is or is perceived to be gay, lesbian,
bisexual, transgender, intersex [LGBTI], or
gender nonconforming.”118
Jails must conduct an individualized risk
assessment for each person to determine the
safest housing for that individual.119 For
example, this means that jails may not place a
transgender or intersex individual in a
particular facility based solely on their external
genital anatomy, and jails must allow for
housing by gender identity.120 Further, “serious
consideration”121 must be given to a
transgender or intersex person’s “views with
respect to his or her safety.”122
Automatic placement of transgender women or
intersex persons into a men’s unit, without
considering safer options, including placement
in a women’s unit, violates the law. On the
contrary, placement of a transgender woman
or intersex person in a women’s facility, where
that is what would make her/them safest, is
consistent with PREA, the Eighth and 14th
Amendments, and California law. Please note
that many transgender women and intersex
persons feel, and are in fact, safer in women’s

77 Maximiliano claims he is not afforded the same
privileges as inmates in general population
because he is gay. He said he and other gay
inmates are not granted access to school,
religious services or work credits and milestones
programs. Maximiliano said he was placed in
protective custody because of his sexual
orientation and is forced to be on lockdown 23
hours a day.
77 Roger claims he and all other LGBT inmates are
automatically placed in protective custody. He
described the classification system as
“inadequate.” According to Roger, custody staff
asked him if he was gay during the classification
screening. When he responded yes “it was pretty
much the end of it [the screening].” Roger
complained that he does not have access to the
same programming that is available to general
population inmates solely because he is gay. He
believes the department is discriminating
against him.
77 Trevor claims he was involuntary placed in
protective custody because he is gay. He is
currently housed in maximum security module
on 23 hour lockdown. Trevor complained that he
is denied access to the same programming and
jobs that general population inmates enjoy.
None available at this time.
None available at this time.


77 OCSD deputies house people based on sex
assigned at birth regardless of an individual’s
gender identity.
While the question of housing transgender and
intersex persons was not included in our survey,
we have received numerous intakes from
transgender persons incarcerated in Orange
County jails. It is our understanding from these
intakes that Orange County houses persons
based on sex assigned at birth, rather than an
individualized assessment of what placement
would be safest for a person based on their
gender identity and other factors.
77 OCSD deputies involuntarily place gay male and
transgender incarcerated individuals in
protective custody. This population has limited,
if any, access to programming that general
population people receive.
Under PREA, an LGBTI incarcerated individual
cannot be placed in involuntary segregated
housing unless: (1) an assessment of all
available alternatives is made; and (2) a
determination has been made that no alternative
means of separation is available.124 Given that
LGBTI persons housed in protective custody are
generally not able to access the full
programming that general population individuals
enjoy, such as parenting classes, NA/AA classes,
drug rehab groups, work programs, educational
programs, etc., some jails are noncompliant with
PREA regulations that specify that people
segregated for their protection must be given
access to the same programs, privileges and
opportunities available in the general population,
to the extent possible.125 Further, this lack of
equal access may also violate both the Equal
Protection clause of the 14th Amendment and
California law, Section 11135. The ACLU of
Southern California is currently litigating this
precise issue against the San Bernardino County
Sheriff’s Department.126 The case is in the
discovery phase.


House people based on
their gender identity.
Incorporate gender
identity as a key factor in
the department’s
classification system.

77 House people based on their gender identity.
Incorporate gender identity as a key factor in the
department’s classification system.127
Presumptive placement based on gender identity
should include an individualized assessment of
where an individual would be safest, seriously
taking into account the individual’s own stated
preferences and views about where they would
be safest.
77 Allow for the option for transgender women to be
placed into women’s facilities when that is where
they would be safest and what they prefer.
77 Do not automatically place LGBTI incarcerated
individuals into protective and restrictive custody
without an individualized assessment.
77 Halt the inappropriate use of the term “sexual
preference,” which is outdated and inaccurate.

6.	 Prison Rape Elimination Act
(PREA) Data Collection

FIGURE 18: Disposition of Total Reports, 2011 to 2015



According to the Department of Justice’s Bureau
of Justice Statistics, 3.2% of people incarcerated
in jails nationwide reported experiencing one or
more incidents of sexual victimization by another
incarcerated person or facility staff in 2013.128
The Prison Rape Elimination Act requires jails to
prevent sexual assault, sexual abuse and sexual
harassment. PREA covers general areas of
concern to jails, like sexual assault prevention,




n Investigation Ongoing
n Unsubstantiated

FIGURE 16: PREA Statistics, 2013 to 2015 (OCSD)

Victim refused to cooperate

	 Case Closed/No workable leads

Adult Arrest


Prosecution declined by DA


Prosecution initiated by DA


n Substantiated

medical and mental health care subsequent to
sexual assault, investigation of sexual assault
allegations and facility accountability
mechanisms. Figures and tables include annual
data for all OCSD jail facilities combined.


n Unfounded

In March 2017, the OCSD responded to a request
for California PREA records, contending, “The
Sheriff’s Department has no ‘synopsis’ of each
reported crime responsive to your request, and
declines to create a record to your request.” The
department did provide statistics that are included
in Figures 16 and 17 that illustrate the total

0	 5	 10	 15	20	25

n 2015

n 2014

n 2013

FIGURE 17: PREA Statistics, 2013 to 2015 (OCSD)









Sexual Acts

Sexual Acts

n Investigation Ongoing

Sexual Harrassment

n Unfounded

Sexual Misconduct

n Unsubstantiated

Sexual Harrassment

n Substantiated


number of reports by sexual victimization
category and include a breakdown of dispositions
per category.

77 “Vlad claims that Deputy K grabbed his crotch and
made humping motions towards him.” (CMJ,

Of all 101 sexual victimization reports made from
2011 to 2015, 34% were substantiated (see Figure
18). A plurality, 43%, were unsubstantiated as
reported by the OCSD. Table 13 illustrates a
breakdown of all substantiated reports by type.
Information on the unsubstantiated reports was
not provided. This raises concerns about the
investigation of sexual victimization, particularly
with respect to incidents in which staff members
are identified as the offenders.

77 “Kareem says he has a possible sexually
transmitted disease (STD) after being raped in
February of 2012 by another incarcerated person.
Kareem has been examined by HCA and was told
he did not have a STD. He would like a second
opinion.” (CMJ, 9/27/2012)

PREA Statistics, 2011–2015 (OCSD)
(only includes substantiated reports)







Sexual Acts






Sexual Acts

























77 “Eva claims she was berated, discriminated
against and sexually harassed by staff members.”
(CWJ, 1/14/2013)
77 “Josh alleges Deputy ‘grabbed his dick’ and asked
him to ‘suck his dick’ while he was at Western
Medical Center in Anaheim.” (IRC, 6/4/2013)
77 “Felix claims he was ‘sexually violated’ and then
‘assaulted and abused’ after he was booked into
the IRC and taken to Module L on January 18/19,
2012. Felix said the incident was captured in
video.” (Theo Lacy, 2/10/2012)


77 Reports of sexual victimization made by
individuals who are incarcerated include inmateon-inmate non-consensual sexual acts, inmateon-inmate abusive sexual acts, inmate-oninmate sexual harassment, staff sexual
misconduct, and staff sexual harassment.
According to OCSD policy, all individuals who are
incarcerated are interviewed and classified by
classification deputies.129 A factor considered in the
process is the likelihood of becoming a victim of
sexual assault. Classification and housing
decisions are made with the intent to avoid and
prevent sexual assaults. However, aforementioned
reports of sexual victimization suggest the
department needs to better protect the safety and
well-being of people who are incarcerated.

77 Comply with all PREA standards to prevent, detect
and respond to any forms of sexual abuse and
sexual harassment.130
77 Custody staff should be trained in accordance to
PREA standards.
77 Investigations into allegations of sexual abuse and
sexual harassment should be timely, thorough
and objective.
77 Custody staff found to be in violation of PREA and
department policies should be adequately


1.	 Overall Medical Care
Through a contract between the OCSD and the OC
Health Care Agency (HCA),131 the Adult
Correctional Health Services (ACHS) provides
medical, dental, nursing, infection control, health
education and pharmaceutical services at a
community standard of care to all people who are
incarcerated in the county’s five jail facilities. The
HCA contracts with hospitals for inpatient and
specialty care of individuals who are in custody.
The HCA is responsible for the 24-hour health
screening of arrestees before booking at the IRC
and Theo Lacy jails.132
Medical centers in the county jails are staffed by
physicians, nurse practitioners, registered nurses
and licensed vocational nurses, psychiatrists, as
well as dentists and opticians.133 If necessary,
people are transferred to a local hospital for
examination, and treatment is given as needed.134
All people who are incarcerated are entitled to
medical, dental, optical and mental health care at
no cost.33 Despite this, as of February 15, 2013, a
$3 charge for each appointment or treatment is
deducted from individuals’ commissary
Triage nurses, who are part of the medical team,
take medical histories and examine incoming
persons before deciding whether they should be
admitted to the county jail system.136 After the
screening, individuals continue through
fingerprinting and identification, called “the Loop,”
before being assigned to one of the county jails.
Individuals with disabilities must go to ADAcompliant housing units. Special arrangements
also have to be made for individuals on dialysis or
pregnant women on methadone.137 In addition,
individuals who are gay or transgender or have
certain mental health disabilities may be
separated from the general population.
Existing reports reveal complaints of inaccurate
and cursory screenings, as well as poor and
inadequate medical attention. The special
criminal grand jury investigation in 2007 found

that deputies routinely denied incarcerated
individuals medical treatment138 because they did
not want to fill out the required paperwork.139
Hence, it is not surprising that medical services
are the number one grievance in the Orange
County jails. In 2014, the U.S. Department of
Justice’s Civil Rights Division concluded in an
investigation that systemic deficiencies related to
medical care endure in the county jail system.140
Although the deficiencies were identified as
limited in scope, lack of remediation poses a
continuing and serious risk of harm to people
who are incarcerated. The DOJ also determined
that medical policies lacked clinical guidelines
required to meet the needs of incarcerated
people with serious chronic diseases. The jails
did not maintain a chronic care roster or have a
system for the routine monitoring of chronically
ill people.141 A limited chronic care management
system may result in individuals with chronic
illnesses being overlooked and exposed to an
undue risk of harm. For example, during the DOJ
investigation only 230 incarcerated individuals out
of 550 who possibly needed rescue inhalers
actually had them.142
FIGURE 19: Medical and Dental Care Monthly Averages,

2010 to 2015 (BSCC)





2010	 2011	2012	 2013	2014	 2015

Inmates that were seen at sick call per month
Physician/practitioner occurrences per month
Off-site medical appointments per month
Dental encounters per month
Inmates assigned to medical beds last day of the month
Avg. number of inmates in hospital(s) outside of OC
jail facilities


In-custody-related deaths associated with
medical negligence and inadequate treatment
further highlight the serious consequences of
inaction and medical delays. In September 2013,
Matthew Shawn Gordon, an individual
incarcerated at the Central Men’s Jail, died after
experiencing untreated heroin withdrawals.143
His mother filed a $15 million lawsuit against the
OCSD, alleging that jail staff failed to address
and monitor Gordon’s severe heroin withdrawal
symptoms. Despite a clear need for prompt
medical attention, in addition to Gordon and his
cellmates telling jail staff of his condition,144 he
was never under observation or seen by a doctor.
Three hours after posting bail, Gordon was found
unresponsive in his cell.145
Data collected by the BSCC shows that between
January and December 2015, there were, on
average, over 5,800 individuals at sick call each
month and over 5,800 physician/practitioner
occurrences.146 On average, about 10 individuals
were assigned to medical beds. During the same
time frame, there were, on average, over 160
off-site medical appointments each month and
over 1,050 dental encounters (see Table 14 and
Figure 19).147

77 Ashley experienced drug withdrawals when she
first arrived at the jail. She complained that
custody staff did not monitor or provide medical
attention to her when she suffered from
77 Angel had a hernia removed from his abdomen in
2000 before his incarceration. In January 2017, he
began to experience pain and discomfort around
the same area. He believes it is due to a hernia.
Angel said, “I can feel a bump when I rub and
push down on it.” He compared it to the feeling he
felt in the year 2000 when he underwent surgery.
Angel pointed to the lump and said, “You can see
it right away.” He has submitted two medical slips
relating to his pain and discomfort. Both times he
was advised that nothing could be done.
According to Angel, a nurse acknowledged that he
did in fact have a hernia; however, she told him
surgery was not an option.
77 Jeffrey maintains that he has anemia and is
supposed to receive extra food. He recounted
using the emergency button twice to request his
food, which had not been provided to him. Deputy

Medical Treatment, 2015 (BSCC)
Physician /
during this

during this

during this

assigned to
medical beds
last day of the

Avg. number
of inmates in
outside OC jail


(ADP totals)

Inmates that
were seen
at inmate
sick call this

































































September 5,917
































S then denied Jeffrey food and told him he would
be written up if he used the button again. Jeffrey
became hungry and pushed the button again. He
was placed in solitary confinement for 20 days.
77 Janet grinds her teeth involuntarily while
sleeping. One morning in 2016, she woke up with
a swollen jaw and submitted a request for
medical attention. She was transported off site
to see an orthodontist in Anaheim who
recommended jaw therapy or a brace. She
claims that custody staff told her that both
recommendations were too costly and said that
“you’re out of luck.”
77 Louise was in a car accident the day of her arrest.
She maintains that she has suffered from chronic
pain since then. She disclosed that her medical
requests have been denied with no justification.
According to Janet, if a medical need is not visible
to the attending nurse, one is “brushed off” and
sent back to housing. Janet also reported that a
nurse denied her request to see an optometrist
in December 2016 because her prescription was
not “strong enough.” She said, “I have really bad
headaches because I need my glasses.”
77 Lily claims a few inmates in her module have
open sores that she suspects are related to
“drug addiction.” Lily said, “I’m concerned for
those girls and the rest of us…. They should be
treated … but apart from general [population].”
77 Michelle has witnessed several inmates
experience withdrawal symptoms. She said most
symptoms go unattended by medical staff. She
reported that inmates withdrawing from drugs
throw up bile and defecate on themselves. She
went on to report that at least four girls in her
module had staph infections. She said most girls
had “sores and abscesses that ooze with pus.”
Michelle expressed concern that the girls with
infections use the same showers as everyone
else in the module. She complained that she and
other inmates have been denied medical slips
and cleaning supplies. Michelle also disclosed
that she and others were exposed to a lice
breakout. She said, “The lice spread quickly
because no one was quarantined.”
77 Norma suffers from seizures resulting from her
having a tumor removed in 2008. According to
Norma, a doctor recommended that she be

housed with a cellmate and assigned to a bottom
bunk. Contrary to the recommendation, Norma
was housed alone on 22-hour lockdown. Norma
also reported that an inmate with a leg injury
was denied medical attention. She witnessed
deputies ordering the inmate to squat even
though the inmate informed them that she was
unable to because of the injury. Norma
recounted a separate incident in October 2015,
when a female inmate who was sick requested
emergency medical care but was denied it. A
deputy ordered the inmate to submit a request
slip despite it being an emergency. According to
Norma, the inmate was found dead by her
cellmate the following morning.
77 Pauline heard a woman who was in solitary
confinement “begging and pleading for help” in
July 2015. According to Pauline, two deputies
ordered the inmate to stop screaming. Pauline
specifically recalls the deputies telling the
inmate, “Shut your mouth. You’re not getting the
paramedics; you’re not going to the hospital!”
The two deputies threatened to write up the
inmate if she did not stop screaming. Once the
inmate became silent, someone checked on her.
Pauline recalls the person saying, “There’s a lot
of blood.” Pauline claims that the paramedics
arrived shortly after and “wheeled someone out
from the same room covered in a dark tarp.”
Internal Affairs questioned Pauline about the
incident the following day.
77 Stephanie underwent skin graft surgery to
replace damaged skin between her right thigh
and buttock caused by excessive heroin use
before being incarcerated. She says a nurse
would go to her home to change her bandage
every day. After Stephanie was arrested, her
surgeon medically cleared her to be taken into
custody so long as she kept up with her medical
appointments, the first of which was scheduled
two days after her arrest. Stephanie was not
taken to her medical appointment. According to
her, for about the first month and a half of her
incarceration, the only medical care she received
was the re-bandaging of her wound despite
multiple requests to see a surgeon. Stephanie
was concerned that the wound would be infected,
given the unsanitary conditions of the jail. After a
month and a half in custody, Stephanie was
finally seen by a surgeon at the jail.


77 David informed a nurse during screening of his
scoliosis, leukemia, angina and neuropathy. He
claims that he was not provided with his
medication and was assigned a top bunk. He
submitted a request for a bottom bunk. David
was informed by a sergeant that the request was
being looked into, but he never received a
77 Henry suffers from low blood sugar. During his
time in jail, he felt ill and was only allowed to
take one day off a week from work as an inmate
worker. He reported that nurses told him to drink
water for his ailment, attributing his symptoms
to dehydration. According to Henry, medical slips
were sometimes denied or withheld from him.
He complained that he and others were often
told that slips were not available. When slips
were obtained, they were to drop them into a red
box. According to Henry, they had only a few
seconds to drop off the slips on their way to the
lunchroom. If they passed by the box by and did
not drop off their slips, they were not allowed to
get out of line to do so. Instead, they would be
forced to wait until the next day.
77 Karina was taken to Hoag Hospital before being
processed at the IRC. She informed custody staff
and a nurse that she suffers from seizures and
that she had a stab wound on her shoulder. She
received medication for seizures but was not
provided with antibiotics for her wound. Karina
was assigned a top bunk despite her injury.
77 Lawrence claims custody staff locked him out of
his module for about 30 minutes because he
refused to take medication that was not
prescribed to him. According to Lawrence, he
had never before taken the medication. He
claims that a few deputies threatened him and
told him they would shut down the module,
blame it on him and make him their “bitch.”
77 Monique experienced delays in the
administration of her medication. Despite
complaining to custody staff about symptoms,
she had to wait an additional day to get
77 Pedro broke his hand during a fight while in
custody. He was sent to the nurse in the Loop
barefoot and was not allowed to get ibuprofen or


an ice pack per the order of a deputy. He
submitted five or six request slips for an X-ray
but never received a response. A nurse later
informed him that he had, in fact, been
scheduled to get the X-ray. However, the notice
never reached him. Pedro believes that he was
never notified of the appointment. He said, “I was
never told. It was probably their way of punishing
me.” Pedro was in custody with a broken hand for
one week and only received ibuprofen the day of
his release.
77 Ulysses disclosed that his arm was broken a few
days before his arrest. He claims that deputies
tackled him when he was arrested. Both his
arms were twisted back, even though he
informed deputies that one of his arms was
broken. While he was being processed, Henry
also informed a deputy and a nurse of his broken
arm. He asked about getting an X-ray and was
told to wait until after he was processed. Henry
never got an X-ray and was denied medication
until he suffered a separate injury while in
custody (i.e., a toe injury inflicted by deputies).
77 Victor notified a nurse at processing that he had
a leg and hip injury. His request for a bottom
bunk was denied and he was assigned a top bunk
despite his injuries. He was not provided
medication and was unable to see a doctor. Victor
said a deputy advised him to drink water and fill
out another slip to seek care. The deputies made
Victor walk to request a slip despite his claims of
pain. He never received a response to the
77 Yahir reported having problems with insomnia
and his gallbladder. He notified the nurse during
screening and was told that medical staff could
not do anything about it. After being assigned a
bed, Yahir submitted a request for medicine, but
it was denied. He then verbally requested to see
a nurse, but that was also denied. While being
processed, Yahir witnessed an inmate undergo
an asthma attack in the hallway of the Loop.
According to him, a group of deputies around the
incident did not do anything for the person. Yahir
recounted that the deputies looked at the inmate
and said, “You’re going to be OK.” Yahir believed
that the tone of voice of the deputies was
sarcastic. He said, “You could tell they didn’t
mean it. They were basically making fun of her.”

77 “Christopher claims a deputy did not allow him to
take his medication and told him he is going to
die.” (Theo Lacy, 2/5/2012)
77 “Trinity was injured when she fell down the stairs
in the module. She was examined by triage and
given Ibuprofen for pain. She has put in several
requests for a follow up but claims she is being
denied. She feels her medical needs are not
being met.” (IRC, 3/30/2013)
77 “Kaylee is grieving that medical is denying her
seizure medication.” (IRC, 12/19/2011)
77 “Raul said he was put in a cell alone for three
hours where he had a seizure and chipped a
tooth. He said he was unable to contact a deputy
for medical attentions and was mocked when he
finally found one.” (IRC, 6/26/2012)
77 “Gerardo is grieving two times he has been sent
to booking Loop for transportation to medical
procedure. Both times he has been sent back to
housing location without going to appointed
medical visit.” (Theo Lacy, 9/18/2011)
77 “Marcos claims Dr. Y was mocking and teasing
him about his disability. Marcos also claims Dr. Y
mimicked his slow walk and then laughed as he
limped away from him.” (Theo Lacy, 9/18/2012)
77 “Kayden claims to have an emergency medical
situation. She filed one grievance and 2 inmate
message slips today. She claims to have made 25
previous grievances.” (Theo Lacy, 8/1/2011)
77 “Derrick states he was supposed to be getting an
MRI done and it has been three weeks and still
has not been done. Derrick states his condition is
getting worse and has submitted three
grievances prior to this.” (Theo Lacy, 7/4/2013)
77 “Jermaine complaining of pain from a hernia. He
saw a nurse who told him he would be referred
for further treatment, but he has not been seen.”
(Theo Lacy, 6/27/2013)
77 “Mitchell claims he is receiving inadequate
medical care. He also states he filed a grievance
against them about his care and they are
retaliating against him by making false diagnosis
and taking away his wheel chair.” (Theo Lacy,

77 “Ruben claims he has repeatedly asked to see a
Doctor about changing his pain medication.
Ruben claims he has tried to address the
medical staff (nurses) in person while at ‘sick
call.’ Ruben states nurses continue to ignore him
…” (Theo Lacy, 4/22/2012).
77 “Saul has submitted several request to be seen
by medical staff and has not been scheduled.”
(Theo Lacy, 4/10/2012)
77 “Calvin has liver problems and states he has not
received his daily shot of Interferon.” (Theo Lacy,
77 “Bernice states she is not receiving the
appropriate medication for her spinal
osteoporosis.” (IRC, 9/17/2012)
77 “Miles states he has not received his
rechargeable batteries for his hearing aid. When
he asked for them, a nurse told him they had
already been given to him, but he claims he never
received the batteries.” (Theo Lacy, 3/7/2012)
77 “Josue states he was placed on a high protein diet
for anemia and has not received it yet.” (Theo
Lacy, 3/7/2013)
77 “Donovan is grieving his medical/dental care in
jail. He allegedly submitted medical message
slips on/about Feb. 20, 22 & 27 of 2012
requesting dental care for an abscessed tooth.
He requests emergency treatment for
‘excruciating’ pain and discomfort.” (Theo Lacy,
77 “Mario believes his left shoulder/left arm are
broken. He states he is in severe pain 24/7. He
states that he saw a nurse who only gave him
Ibuprofen and Ben-Gay; although he’s been told
he will see a doctor and get x-rays taken, this
hasn’t happened yet.” (Theo Lacy, 2/25/2012)
77 “Marcelo states he broke his foot on 10-16-2011
and feels he is not getting proper medical
treatment for his foot. He claims it was never put
in a cast, properly set, and never received proper
pain medication. He also claims his foot is still
broken.” (Theo Lacy, 1/7/2012)
77 “Maxwell is grieving medical attention regarding
a hip displacement, pain meds, and being denied
a soft-shoe ‘chrono.’” (Theo Lacy, 1/9/2013)


77 “Jorge stated he has pain in his back and leg.
Inmate wrote he has turned in several medical
slips and has not seen a nurse.” (Theo Lacy,
77 “Marcus is complaining that he is not getting
medical help for a contagious skin condition.”
(Theo Lacy, 1/3/2013)
77 “Conner has Hepatitis C and states he has not
received treatment and has not seen a DR.” (Theo
Lacy, 5/9/2012)
77 “Kaleb claims he is receiving improper medical
care regarding a double knee replacement. He also
claims he is not receiving pain medication and
medical refused to provide a work chrono to place
him off work.” (James A. Musick, 12/14/2012)
77 “Jasmine believes she is in need of prescription
glasses and was told by a nurse her vision is not
bad enough. She claims she wears glasses while
not in custody.” (IRC, 8/3/2012)
77 “Ashton is alleging that on an unspecified day he
was seriously ill due to gut pain from gallstones.
He says he pushed the emergency call button and
when he did that, Deputy G told him to stop and
said if he continued to push the emergency button
…” (IRC, 2/19/2013)
77 “Sergio is grieving being given the wrong
medication to treat his psoriasis. He has submitted
several medical slips with negative results.” (CMJ,
77 “Jesus claims he has a medication problem causing
severe pain and wants to see a doctor. He claims
he has already submitted several medical slips
that have not been addressed by medical staff. He
says, ‘I am in so much pain. I can barely stand up.’”
(CMJ, 1/12/2013)
77 “Cole states he has HIV and has requested
medication via a Medical Slip but has received no
response.” (CMJ, 1/10/2013)
77 “Diego states he has Hep C and if he does not get
Interferon he will die.” (CMJ, 7/9/2013)


77 “Adam states he suffers from neuropathy and is
being refused proper medical care, a cane and
personal shoes. He further states the medical
staff refuses to provide their names when told a
grievance will be filed.” (CMJ, 2/10/2012)
77 “Devin states he fell and re-injured his back in the
2nd floor dispensary due to the medical staff
taking his wheelchair away. He states he cannot
use the walker that was issued due to a preexisting medical condition which causes spasms
with no warning.” (CMJ, 2/10/2012)

77 Deputies deny medical attention to individuals
who are incarcerated if their condition is
deemed non-serious.
One individual complained that one has to be on
the brink of death to get care. Another described
the emergency medical button as futile,
recounting a situation during which the button
was pushed to no avail. Several individuals
reported that medical requests are often denied
if deemed non-serious by custody staff.
77 Individuals who are incarcerated experience
delays in accessing medical care.
According to OCSD policy, if a person wants to
request routine, non-emergency medical
attention after booking, they must submit a
medical message slip to the medical staff. Slips
can be obtained from medical staff or a deputy.
According to department policy, completed
requests are to be deposited in the designated
collection box in each module. Many people
disclosed difficulty in accessing medical care
while others reported issues with the type and
quality of care they received. Limited access to
medical care and limited time with medical staff
raise concerns as to the well-being of
incarcerated individuals.


Overall Medical Care
77 Make medical message slips more readily
available and easier to submit.
77 Ensure that emergency buttons are responded
to promptly when activated to prevent further
medical trauma.
77 Provide drug withdrawal treatment and medical
supervision- to individuals who report
withdrawal symptoms in a timely manner to
prevent complications.
77 Ensure that all individuals who are incarcerated
receive prompt and adequate care and medical
services. Medical services should intervene
early to treat conditions before they become
more serious.
77 Collect information about the type of grievances
related to medical treatment to prioritize
specific recommendations by severity and
77 Provide necessary medical attention and
treatment to incarcerated individuals when
subject to use of force by deputies.

2.	 Reproductive Health Needs
According to an ACLU of California report,
incarcerated women are denied prenatal care,
abortion services and menstrual hygiene
products at some county jails.148 In March 2015,
women constituted 13% of the total jail
population in California. This figure includes
many transgender men, who are most often held
in women’s facilities and classified as women.
But it omits most transgender women, who are
mostly incarcerated in men’s facilities and
classified as male.

77 Lily reported that after not having her menstrual
cycle for two months, she experienced a heavy
flow in early 2016. She complained that deputies
denied her an additional pad and laughed at her
when she stained her uniform with blood.
77 Michelle claims there are eight pregnant women
in her housing module. She reported that they
are not given double mattresses until they reach
28 weeks and receive small rations of food. She
recounted an incident in which jail staff forced
two pregnant women to sweep at night because
of minor violations.
77 Amy was pregnant at the time of arrest. She
sought medical attention after irregular bleeding
but did not receive it until the next day. A doctor
notified her that she had a miscarriage and
prescribed bed rest.
77 Amanda reported that she received only three
pads a day while on her menstrual cycle. She hid
them from jail staff, who she claimed often
confiscate pads for no apparent reason and
claim hoarding as an excuse. Amanda said,
“Three pads a day is not enough — that’s why you
have girls using toilet paper all the time.” She
shared that it is common for women to use toilet
paper to avoid bleeding onto their underwear
when menstrual pads are withheld.


77 Betty reported that medical and custody staff
neglect pregnant inmates. She claims that
pregnant women do not receive enough food and
are often hungry.

77 “Sarah states she has submitted 3 pink slips a
week ago regarding dry eyes, scabbing nose,
coughing up blood and yellow vaginal discharge.”
(IRC, 11/1/2011)

77 Gina claims women do not receive menstrual
hygiene products like pads and tampons. After
being processed she received only basic hygiene
products, including a bar of soap. Gina had to ask
other inmates for pads when she needed them.

77 “Grace was told she would have a mammogram
completed in April of this year. She still has not
been seen by medical staff for her mammogram.
Medical responded on 8/7/2012 and indicated
Grace is on a waiting list to be seen and will be
soon.” (IRC, 7/30/2012)

77 Karina claims that deputies provide “about two
pads for every three to four girls” on their
menstrual cycle. She said, “It’s like they want us
to fight over them — I’m not about that.”
77 Paula claims that she was required to take off
her underwear during a search despite being on
her menstrual cycle. A deputy ordered her to
squeeze and twist her used pad in front of other
inmates before going to court. She said, “It was
really humiliating. I felt degraded.”
77 Julie claims that she received three pads a day
while on her menstrual cycle despite requesting
and needing more.
77 Joyce claims she did not receive enough pads
when she was on her menstrual cycle. She asked
a deputy twice for more pads but never received
77 Tracy was four months pregnant at the time of
arrest. She claims that being pregnant in jail
does not change anything. She was not afforded
special or additional attention. She mentioned
being housed next to the psychiatric ward and
reported a lot of yelling and screaming from
inmates with mental illnesses.
77 Xiomara witnessed female inmates requesting
pads and not receiving them. She claims that
deputies disregard women’s issues and said,
“They don’t care.” Xiomara recounted the case of
a young girl who accidentally stained her uniform
with blood and was afraid she would be
77 “Jessica claims she is not getting proper medical
care in regards to her pregnancy.” (IRC,


77 “Maria is complaining of 30 days bleeding due to
an abortion.” (IRC, 6/21/2012)
77 “Christina claims she might have a bacterial
infection. She said she has been asking for a Pap
smear since November 16th. She requests a Pap
smear.” (IRC, 2/2/2013)
77 “Brooke states her female medical needs are not
being met and needs to see an Obgyn.” (IRC,

77 OCSD custody personnel intentionally withhold
menstrual hygiene products, such as pads and
Several individuals disclosed that menstrual
hygiene products, such as pads and tampons,
are intentionally withheld by jail staff. Jails must
provide women with the personal hygiene
supplies they need to manage their menstrual
cycles. According to several personal accounts,
the OCSD fails to meet this obligation. Reports
from women point to delays in access and
insufficient supplies.
77 Pregnant women, who are incarcerated, are
subject to poor medical attention and a lack of
accommodations for their housing and dietary
Jails in California are mandated by law to provide
needed reproductive health care, information
and education on certain reproductive health
topics, and specific pregnancy-related
accommodations.149 Personal accounts of

incarcerated individuals and former incarcerated
individuals suggest that the OCSD is not
providing the care that women need and that is
required by law. Necessary accommodations
should be met when they are needed rather than
in line with an arbitrary department schedule.
Adequate and timely prenatal care is medically
necessary care that jails have a constitutional
obligation to provide.150

77 Evaluate reproductive health care policies using
the ACLU’s toolkit151 and ensure compliance with
the law and reproductive justice and medical
best practices. 152
77 Ensure incarcerated individuals receive ample
amounts of menstrual hygiene products,
including pads and tampons, as requested and
needed. Prohibit custody staff from denying
access to such products.
77 Mandate gender-responsive training for all
custody staff and adopt policies with genderneutral language.
77 Ensure that people who are pregnant receive
comprehensive, unbiased options counseling
that includes information about prenatal health
care, adoption, and abortion, and then the
medical care that corresponds to their decision
to terminate or carry to term.
77 Ensure that people who are pregnant receive the
health care they need and appropriate
accommodations for their condition. Defend and
widen existing protections for incarcerated
individuals who are pregnant such as housing
accommodations and obstetric care.
77 Ensure that people who are pregnant receive a
balanced, nutritious diet and necessary vitamins,
as approved by a doctor.

3. Transgender-Specific Health Needs
While transgender-specific questions were not
asked in our survey, we are aware through intakes
that transgender persons often receive
inadequate medical care while in California county
jails, and in Orange County jails specifically.
Gender dysphoria153 is a serious health condition,
experienced by some transgender persons, that
involves a strong and consistent cross-gender
identification and a persistent discomfort with
one’s sex assigned at birth that can cause a
person extreme psychological distress. Gender
dysphoria has long been recognized as a serious
medical condition by the leading medical and
mental health associations, and there are wellsettled, uncontroversial, internationally adopted
standards for how to treat gender dysphoria.154
Hormone therapy and access to genderappropriate clothing and grooming products are
core components of that therapy.
Courts have routinely held that gender dysphoria
is a serious medical need.155 Jails must provide
both pretrial and sentenced individuals with
individualized and appropriate medical care for
gender dysphoria. Failing to do so violates the U.S.
Constitution’s prohibition on cruel and unusual
punishment.156 A jail’s failure to appropriately
evaluate, diagnose or provide treatment for
transgender individuals’ gender dysphoria shows
the jail staff’s reckless disregard of the excessive
risk to their health and gives rise to a clear claim
for violation of people’s constitutional rights.157
Many transgender persons require hormone
treatment to treat their gender dysphoria.158
Accordingly, courts across the country have held
that refusing to provide a transgender individual
with hormone treatments is a violation of the U.S.
Constitution.159 Where jail officials have delayed
or withheld hormone therapy for transgender
individuals, they were violating the U.S.
Constitution as well as widely accepted
correctional and health care standards.160


None available at this time.

77 Incarcerated individuals who are transgender
receive inadequate medical care.
Appropriate medical care for LGBTI individuals is
required under the Eighth Amendment
prohibition on cruel and unusual punishment161
and the 14th Amendment’s due process clause.162
77 Transgender persons are often denied issuance
of gender appropriate clothing and toiletries by
jail staff, and are also not allowed to purchase
gender appropriate products through jail
Federal judges in California and other districts
have ruled that transgender women should have
access to female commissary items, as this
access is essential to the treatment of their
gender dysphoria.163 Denying transgender
persons issuance of gender-appropriate clothing
and toiletries and gender-appropriate products
through jail commissaries is a violation of the
U.S. Constitution and a failure to provide
necessary medical care for individuals’ gender
dysphoria.164 It is also a violation of the Equal
Protection clause of the 14th Amendment, since
in California, transgender women are legally
women and transgender men are legally men,
and jails are therefore prohibited from treating
them adversely compared to cisgender women
and men.165


77 Treat incarcerated people’s gender dysphoria.
This treatment should include appropriate
diagnosis by a medical professional with
expertise or experience in the treatment of
persons with gender dysphoria.
77 Provide all medically necessary care that a
professional with expertise believes that a
person requires for treatment of their gender
dysphoria, including uninterrupted hormone
therapy, gender-affirming clothing,
accessories or cosmetics, or surgical care.


1.	 Overall Mental Health Care

FIGURE 20: Mental Health Care Monthly Averages, 2010 to

The Orange County Health Care Agency is
responsible for providing mental health services
to individuals who are incarcerated with mental
illness.166 While the Adult Correctional Health
Services prioritizes suicide prevention,
stabilization of severe mental disorders and crisis
intervention, it purports to provide a wide range of
psychiatric services to people who are
incarcerated.167 Yet identifying and providing care
to people with mental illness is a challenge for
the OC Sheriff’s Department.
In 2012, the Department of Justice’s Civil Rights
Division issued a report detailing the most
problematic issues within the jails — inadequate
mental health care was one of them. The
investigation determined that a limited array of
mental health treatment and housing options
results in an overreliance on unsafe segregation
cells and more restrictive interventions in jail.168

2015 (BSCC)


2010	 2011	2012	 2013	2014	 2015

Mental health cases opened last day per month
New mental health cases opened per month
Inmates, last day of each month, receiving psych medication
Inmates assigned to mental health beds last day of the month

The 2015 grand jury tasked with examining crisis
intervention programs in the county found that a
Table 15: Mental Health Treatment, 2015 (BSCC)
















































































high number of psychiatric clients commit crimes
and are placed in county jail.169 Despite being
inappropriate treatment environments for
individuals in crisis,170 research suggests that the
prevalence rates of serious mental illnesses in
jails are three to six times higher than for the
general population.171 In Orange County, the
severely mentally ill cycle in and out of the county
When arrestees are taken to the IRC for booking,
they are first seen by a health care staff member.
Nurses conduct a medical and mental health
screening that includes questions about current
and past medical and mental health issues, past
hospitalizations, current treatments and
medications. If mental health issues are
identified in the initial screening, individuals must
undergo a more comprehensive mental health
evaluation to better determine housing and
treatment needs.172
According to data from the Board of State and
Community Corrections, the average number of
mental health cases reported each month in the
OC jail system from January 2015 through
December 2015 was over 1,170. Given that the
average daily jail population over the same period
was approximately 5,456, mental health cases in
the jail system represented over 21% of the
overall adult jail population.173 On average almost
700 incarcerated individuals received
psychotropic medication during the same period
and over 100 were assigned to mental health
beds (see Table 15 and Figure 20).
According to a 2016 grand jury report, jail is the
“primary treatment facility” for individuals dealing
with mental illness. At any given time 1 in 5
people who are incarcerated in the Orange
County jail system suffers from a documented
mental health issue — that is about 1,200
people.174 The report revealed that between
January and October 2015, 10,586 individuals
entered the OC jail system with a mental health
diagnosis and 2,962 other individuals were
diagnosed with acute mental illness.175 Of the
13,548 individuals with mental illness housed in
Orange County jails over the 10-month period,


the grand jury found that about 89% were housed
with the general jail population rather than being
assigned to mental health beds.176 Said individuals
are more likely to be sexually assaulted; attempt
suicide; and break jail rules, which oftentimes
results in severe disciplinary action.177 The grand
jury report also identified an overreliance on
isolation techniques and medication, which
suggests that the needs of most people with
mental illness are going unmet.178
The 2015 grand jury report also determined that
deputies both in custody and patrol receive
insufficient training on how to evaluate and handle
people with mental illness.179 The grand jury
recommended that all law enforcement officers
should receive at least 40 hours of comprehensive
crisis intervention training (CIT) on how to handle
and evaluate the mentally ill in the field with
periodic revision trainings. The Sherriff’s
Department disagreed and opted to not implement
the recommendation. Currently, the OCSD offers
16 to 18 hours of CIT training for patrol deputies.

77 Floyd claims that when he was housed in the
medical ward (L module) for suicide watch, he was
not seen by a doctor right away. It took three days
for medical staff to finally see him.
77 Jeffrey is diagnosed with schizoaffective disorder.
He claims that he was denied his medication while
in custody and suffered harassment from deputies.
77 James claims that he was denied mental health
treatment in spring 2016. He described the policy
of 23-hour lockdown as “cruel to the human
psyche” and responsible for exacerbating the
“mental breakdown of inmates.” According to
James, several inmates with mental health issues
are on 23-hour lockdown in the Q module at Theo
Lacy. James witnessed an inmate with mental
health issues push the emergency button to no
avail. According to James, a correctional services
assistant (CSA) on the night shift turned off all the
televisions after the inmate pushed the button.
The CSA told the other inmates to thank the

particular inmate for causing a loss of access to
the television for the remainder of the night.
James claims that the inmate was not provided
with mental health support but instead punished
and blamed. James also reported that other
inmates with mental health issues kick doors
and scream throughout the night, which he
believes adds stress to the module and makes it
nearly impossible to sleep. According to James,
because of the 23-hour lockdown, the television
is an important distraction.
77 Robert is diagnosed with bipolar disorder, ADHD,
manic depression and schizophrenia. He
disclosed his mental health issues to a nurse
during the intake process. After spending seven
days in general population, Robert was moved to
the medical module (J module), where he spent
only five days, at the Central Men’s Jail. He was
rehoused in general population. Robert claims
that he submitted a request to be moved back to
the medical module but that it was denied.
According to him, a deputy told him that he was
placed back in the general population because
he “appeared calm” and because medical beds
were needed for other people. After being in
custody for a month, Robert was transferred to
Theo Lacy; he was not provided a reason as to
the transfer. At Theo Lacy, Robert was housed in
the general population. While there, he was
beaten up twice. He claims that deputies failed to
intervene on both occasions. The first time,
Robert was beaten by the Homies180 for refusing
to take a shower when he was ordered to. On the
second occasion, the Homies,” with whom
Robert was associated through jail politics,
prohibited him from taking his mental health
medication. According to Robert, the Homies
ordered him to throw away his pills and told him
to submit a request denying his medication (i.e.,
Depakote and Ambien). After having a mental
outburst, Robert was beaten up by the Homies
and the Paisanos. He later associated himself
with the Paisanos, who despite beating him
previously allowed him to take his medication.
Robert suffered bruising on his right eye. He
described it as “lumpy” and “purple-bluish.”
After the second assault, Robert was taken to
Anaheim Medical Center. He disclosed that he
lied to medical staff out of fear and said he fell in
the shower while in custody.

77 Theresa claims that she was misdiagnosed with
mood disorder. She complained that her
evaluations did not last more than five minutes
and that mental health professionals did not
listen to what she had to say. She said the
clinician talking to her walked away while she
was in the middle of a thought.
77 Brenda was housed in the medical module next
to the mental health module. While in jail, she
witnessed and heard inmates in the mental
health module being verbally abused by staff and
other inmates. She claims that custody staff
ignored the needs of inmates who appeared to
have serious mental health conditions.
77 Jacob was diagnosed with anxiety about three
years ago. He notified custody staff at screening.
According to Jacob, staff did not provide him with
his medication. He claims that he submitted a
request and was denied without an explanation.
77 Karina is diagnosed with manic depression and
bipolar disorder. She notified a nurse at
processing. Although she received her
medication (i.e., Keppra and Effexor), she
disclosed that it took about one week to access
care. Karina said she was told that she was on a
wait list during the time she was denied access.
77 Yousef claims that about two-thirds of the people
he encountered in jail needed mental health
treatment. According to him, a lot of people in jail
suffer from schizophrenia possibly brought on by
heavy drug use. He claims that he spoke to many
inmates who also suffer from depression. Yousef
witnessed people’s needs being disregarded and
neglected. As a community mental health
worker, Yousef believes that many inmates he
encountered behind bars should be in mental
health facilities and not jail.
77 Yahir suffers from depression and anger
management issues. He notified the arresting
officer and custody staff. After being booked,
Yahir was denied Norco and Promethazine. He
requested mental health care but was told that
no one was on site to see him.


Accounts further suggest systemic issues with the overall
treatment of individuals with mental health needs within
the OC jail system.
77 “Alejandro alleges that he requested access to
mental health services and he requested to
speak to a sergeant and he was denied by Deputy
X.” (Theo Lacy, 3/21/2012)
77 “Cody is complaining he has not seen a
Psychological doctor yet and his psychological
medications are wrong.” (Theo Lacy, 4/13/2013)
77 “Colin claims that he has been without his mental
health medication for one month. Colin would
like to see a mental health doctor so he can be
prescribed his medication.” (Theo Lacy,
77 “Miguel stated he has not received his bi-polar
medication for three weeks and has put in
several medical slips.” (Theo Lacy, 2/2/2013)
77 “Felipe requests HCA for evaluation and
treatment for bipolar and anxiety disorder.”
(Theo Lacy, 1/22/2013)
77 “Carter is grieving Mental Health staff in Mod L
not treating him adequately.” (IRC, 9/17/2012)
77 “Zoey claims she is not receiving medical care for
her bi-polar disorder.” (IRC, 9/10/2011)
77 “Sean states he has been taken off needed psych
meds.” (CMJ, 10/10/2011)

77 A significant percentage of incarcerated
individuals who suffer from mental health illness
are housed with the general jail population rather
than being assigned to a mental health bed.
The current system and structure of OC jails
leads to high-risk individuals being housed in


unsafe physical settings that are neither
therapeutic nor readily supervised. A series of
incidents in 2010 involved the use of electronic
control weapons and other devices on
incarcerated individuals with mental illness.181
Several people suffering from mental illness may
not be able to effectively utilize the sick call
process, while others have conditions they
cannot monitor on their own.
77 Survey findings support existing reports that
conclude that jails are not structurally
appropriate or conducive to treatment or care
for incarcerated individuals with mental health
Accounts further suggest systemic issues with
the overall treatment of individuals with mental
health needs within the OC jail system. Among
the mental disorders reported by survey
participants were schizophrenia, bipolar
disorder, manic depression, severe anxiety and
post-traumatic stress. Many reported issues with
the lack of treatment while in custody. Individuals
with mental health needs are more susceptible
to abuse by other incarcerated individuals and
deputies, experience significantly higher rates of
jail discipline, and are two times more likely to
be injured and in a jail fight than incarcerated
individuals with no mental health needs.182
77 OCSD offers 16 to 18 hours of Crisis Intervention
Training for patrol deputies. Despite the high rate
of contact between OCSD custody personnel and
people with mental illness, the training is optional.
According to the OCSD Support Services Division,
the training that all deputies receive is in
accordance with the BSCC.183 The Sheriff’s
Department maintains that although it is not the

role of the deputy to make a clinical diagnosis,
making informed behavioral evaluations and
employing the appropriate tactics are crucial
steps when dealing with the mentally ill.184
Sheriff Hutchens claims that informed decisions
are being accomplished through basic training,
work experience and continued professional
training offered through the OCSD’s Training
Division and its regional training partners.185

77 Reduce the population of individuals who are
incarcerated with mental illness by increasing
the accessibility of community-based mental
health resources and jail prevention and
diversion programs.
77 Evaluate jail housing and treatment services for
individuals with mental illness and adopt a more
integrated and systematic therapeutic model.
Department policy should be revised to ensure
protocols are in place for the timely provision of
77 Require the least restrictive form of contact or
force when dealing with individuals who have
mental health needs. Prohibit the abuse of
individuals with mental health needs, including
the use solitary confinement.
77 Create transitional levels of care and supervision
for individuals with mental health needs who
may be more stable, however are still not able to
be housed safely in general population (as
previously recommended).186


1.	Processing/Screening
A majority of survey participants reported lengthy
delays with processing and screening. Several of
them believe that the delays are intentional
rather than as a result of understaffing or
security measures.

77 James had to wait over five hours in the holding
cells at Theo Lacy after returning from court
more than three times. He claims that the cells
smelled like feces and urine.
77 Michelle had to wait 18 to 20 hours in the Loop
anytime she returned to the jail from court.
77 Norma spent 22 to 24 hours in the Loop when
she was being processed. She complained that
inmates are not provided with blankets and
shared that deputies deny them toilet paper and
77 Stephanie claims that she spent over 17 hours in
the Loop before she was assigned a bed. She
said, “The deputies pretend to be busy, but we
catch them watching television, eating …
basically bullshitting.”

77 Monitor and track the medication of incarcerated
individuals with mental health needs. Ensure
individuals are receiving appropriate dosages in
a timely manner.

77 Steve made a verbal remark after he was shoved
by a deputy. The deputy then threatened Steve
and said, “I am going to make a project out of
you.” After the incident, Steve was held in the
Loop for over 24 hours, an act he believes was a
form of retaliation. He described the Loop as
foul-smelling and filthy.

77 Mandate comprehensive training for all OCSD
personnel in identifying mental illness and
de-escalating incidents with individuals suffering
from mental illness.187

77 Travis was held in the Loop for about 26½ hours
before being assigned a bed. He had to sleep in
the holding cell as he waited and claims that he
was provided with a sack lunch only once.
77 Daniel claims that he spent two days in the Loop.
77 Hazel claims that while she was at processing a

77 Uriel claims that he spent about 20 hours in the
77 Victor claims that he spent about 24 hours in the
Loop before he was assigned a bed. He
complained that some deputies just stand around.
77 Xavier claims that he spent 16 hours in the Loop.
According to him, people had to sleep on the floor
because the holding tanks were overcrowded.
77 Yousef claims that he spent about 20 hours at
processing. He said, “I feel like we’re left there for
so long on purpose…. [Deputies] try to make us as
uncomfortable as possible.”

77 Individuals experience lengthy delays with
processing and screening, sometimes as a form
of punishment.
female inmate placed an empty roll of toilet
paper on the window sill after she and other
inmates requested toilet paper for over four
hours. Afterward, a deputy told the group of
inmates, “Congratulations, you bitches get no
toilet paper and no beds.” Hazel said, “We didn’t
get any toilet paper, and some of us were in
there for 16 to 20 hours.”
77 Ian claims that he spent about 16 hours in the
Loop. He said, “People had to sleep on the dirty
floor.” He also said, “They expect us to eat our
lunch inside the filthy tanks. Most of us do it
because we’re in there for so long and get
77 Sonia claims that she spent a day and a half in
the Loop. She complained that because of
limited space, some inmates had to stand. She
said, “If you wanted to sleep you had to do it on a
bench or the floor.”
77 Samuel claims that he was at processing for over
24 hours. He claims that he was provided only
one sack lunch while he waited to get housed.
77 Tracy was in the Loop for “almost two days.” She
claims that she was moved back and forth from
different holding cells.


Following a court order, the department was
mandated to assign a bed to individuals within 24
hours of arrival at the IRC. The mandate, now
department policy, requires that deputies ensure
that individuals are properly processed and
assigned a bed within 24 hours after arrival on the
first floor. According to various accounts, the
department is not abiding by their own policy. In
any situation wherein a person is not properly
housed within 24 hours, the watch commander or
the operations sergeant is responsible for
resolving the matter.188

77 Monitor the intake process and revise the
classification system. Implement best practices
for classifying and housing individuals who are
incarcerated. Integrate guidelines to improve the
process and make it more efficient and effective.
77 Prohibit intentional delays sanctioned by deputies
at intake. Deputies who display such conduct
should be held accountable.
77 Do not hold people at intake for more than 12
hours and allow meals and supplies as required.

2.	Uncleanliness
Survey participants reported uncleanliness
within the facilities, particularly in the booking
and processing area. Several complained about
the unsanitary conditions in the holding tanks,
citing the smell and sight of feces and urine on
the floor and walls. Other individuals reported
unsanitary conditions of showers, including mold
and poor odors coming from the drains. Nearly
all survey participants described the Loop as
“disgusting,” “filthy” and “very dirty.”

77 Ashley described the Central Women’s Jail as
“extremely unsanitary.” She reported that the
living conditions in the jail are horrible and that
cleaning supplies are not provided to inmates.
She claims that there are “thousands of gnats”
and “larva in the drains.”
77 Michelle described the jail as “grimy, dirty and
filthy.” She reported that she has submitted
three or four requests for a new broom and
cleaning supplies. She has yet to receive a
77 Lily maintains that there are gnats in the housing
module. She also disclosed that there was a lice
breakout in H-8 and reported seeing
cockroaches in the carts that are used to move
the jail food.
77 Stephanie complained of “gnats everywhere” and
disclosed spotting cockroaches in the food.
77 Brenda described the jail as “gross.” She said
that being in jail was “awful” and that she was
treated like “a caged animal.”
77 Derek described the jail as “disgusting.” He
complained that soap, cleaning supplies and
toilet paper are not readily provided to inmates.
He stated, “What’s a dirty mop going to do except
spread dirty shit everywhere?”

77 Fernando described the housing modules and
housing area as “dirty as hell.” He claims that the
Loop is the worst and described it as “nasty, wet,
cold and damp.” He compared it to a “concrete
dungeon” and said he was uncomfortable while
waiting to get a bed.
77 Hazel described the jail as “extremely dirty.” She
claims that most of the uncleanliness is in the
processing area and holding tanks, “not so much in
the dorms.” Hazel said, “I saw dirty pads and used
toilet paper scattered in the Loop.” She described
sinks, walls and toilets as “disgusting.” Hazel
complained that deputies held her in the Loop for
several hours despite the “smell and dirty
conditions.” She claims that she saw “a huge
cockroach” on the wall in the processing area.
77 Luis said, “The Loop is the dirtiest and most
unsanitary place I have ever seen in my life.” He
claims that he saw words written with feces on the
floor and walls.
77 Monique was placed in solitary confinement at “the
hole” for a day and a half. While there she saw
feces on the door and was denied toilet paper or
cleaning supplies to wipe the area. She was given
her meals and expected to eat while confined there.
77 Paula described the holding cells as dirty. She
claims that there is a lot of urine around toilets, as
well as dirt under beds and gross residue on
shower curtains. According to Paula, inmates need
to wear sandals at all times because of the
unsanitary conditions.
77 Sonia claims that the showers and toilets are rusty
and dirty. She also said her mattress was dirty and
smelled “awful.” While in the Loop, she saw two
used pads on floor. She claims that she saw
cockroaches “here and there.”
77 Yousef described the jail as “completely disgusting.”
According to him, once inmates get through the
Loop, it is mandatory under program rules for
them to shower. He believes that it is because of
the long exposure to odor and filth.
77 Darrell claims that the Loop is “dirty” and said,
“There’s trash and food on the floor and benches.”
According to Darrell, sinks and toilets smelled bad
and looked as if they had not been cleaned for
several weeks. He also described a “trail of pee”
within one of the holding tanks.


77 Amanda claims that her mattress had bedbugs.
77 Karina reported seeing a mouse in the middle of
the night and claimed that pest control was not
contacted for several days.
77 Victor said, “There’s a bunch of cockroaches in
‘the hole.’ It’s gross.”
77 Vernon claims that he saw “baby cockroaches in
the chow hall.”
77 “Seth complains of being denied cleaning
products.” (CMJ, 12/26/2011)
77 “Jesse complained the whole tank is not getting
adequate cleaning supplies and the inmates
cannot clean their cells, the dayroom or the
shower properly. Grievance signed by 8 other
inmates.” (CMJ, 8/13/2011)
77 “Hunter states they are not getting access to the
cleaning supplies on their tier.” (CMJ, 2/10/2012)

77 Unclean and unsanitary conditions pose
potential risks to the health of individuals who
are incarcerated.
Several individuals reported uncleanliness within the
facilities, particularly in the booking and processing
area and showers. Unsanitary conditions in the
holding tanks include the smell and sight of feces
and urine on the floor and walls. Having to eat and
sleep in close confines with human waste is
degrading and unsanitary regardless of the time one
is subjected to such conditions — it should not be
allowed. Other individuals reported gnats,
cockroaches, lice and bedbugs, which are also sign
of uncleanliness. According to the BSCC, responsible
physicians shall develop a written plan for the
control and treatment of individuals who are infested
with vermin. According to the BSCC, there shall be
written policies and procedures developed by the
facility administrator to control the contamination
and/or spread of vermin.


77 Individuals are tasked with cleaning common
housing areas, including dayrooms and showers.
Individuals maintain that despite being assigned
to clean common housing areas, they are not
provided with adequate cleaning supplies.
According to the OCSD, each jail facility has
employees specifically trained and designated to
supervise work crews that are assigned to clean
specific areas of the jail during daily cleaning
duties.189 In addition to daily work crews, each
custody staff member is responsible for
inspecting his or her work area for cleanliness or
maintenance problems. The cleaning crew
supervisor conducts inspections on a weekly
basis and submits a report to the division
commander. Given the procedures described by
the OCSD, the conditions as reported by survey
participants are unacceptable.190

77 Implement sanitary and precautionary measures
against potential risks to the health of individuals
who are incarcerated.
77 Maintain sanitary conditions and implement
preventative measures to avoid creating potential
health hazards.
77 Monitor facility sanitation and maintenance and
ensure that inspections are thoroughly
conducted. Special attention should be given to
the processing area and common housing areas.
77 Notify pest control of existing problems
77 Perform routine pest inspections and control
methods to ensure a more sanitary living and
working environment.

3.	 Showers and Plumbing
Several survey participants reported issues with
toilets, showers, and plumbing. Individuals
stressed the need for maintenance and repair.

77 Amy claims the shower in her housing module
had only hot water, which made it difficult to take
a shower.
77 Frank claims that the showers are “full of bad
bacteria.” He described them as “unsanitary.”

77 Dolores claims two out of four toilets in her
housing module were broken.
77 James described the showers as filthy. He claims
that the tiles in the showers have to be replaced.
77 Janet claims the showers are “dirty” and “moldy.”
She claims that inmates are tasked with cleaning
the showers with limited supplies. In early 2017,
she submitted a request for a shower curtain
because the existing curtain was half torn due to
mildew. Janet’s request was not responded to.
She claims that she asked custody staff to dump
bleach in the showers to combat the mold and
foul smell. She said they did not do it.
77 Lily claims the showers are disgusting and at
times do not work.
77 Michelle claims that half the toilets in her
housing module are broken and that the sinks
are clogged and do not work. She described the
showers as “filthy.”
77 Norma claims that she submitted three requests
for her sink to get fixed because it was leaking.
She also complained that the toilets and showers
were clogged.
77 Stephanie claims the toilet and showers in her
housing module have plumbing issues. She said,
“Water seeps through the tile and there is a lot of
77 Theresa claims that the sinks in her module
were clogged, which caused “a bad odor.” She
also complained that the showers were not
cleaned for weeks and described them as “filthy”
and “unhealthy.”

77 Luis claims the toilets in the Loop overflowed
with urine and feces.
77 Julie claims that the toilets in the Loop were
clogged with toilet paper.
77 Joyce claims that a shower in her tank was not
77 Victor claims that toilets are unusable because of
clogs that go unattended to and end up
77 Walter claims that the water for showers was
either freezing or burning hot.
77 Will claims the sinks and toilets in the Loop do
not work. He said, “One sink just kept running. I
guess the water couldn’t get shut off.”
77 Curtis claims that a toilet in his tank started to
leak. He verbally notified deputies, but nothing
was done.
77 Yousef claims water from the upstairs tier was
leaking down to his housing.
77 Xavier claims that the showers “sucked” and
complained that most of the nozzles were broken.
77 Brendan claims that the shower heads in his
dorm did not work well. He said, “The water ran
slow so it was difficult to shower.” According to
him, there was mold in the showers.
77 “Oliver claims he did not receive his shower per
Title 15.” (Theo Lacy, 2/10/2013)
77 “Karen requesting latex gloves for sanitary
purposes.” (IRC, 7/25/2011)
77 “Rafael complaining regarding the lack of shower
mats/curtains to avoid water pooling on floor. He
has fallen in the past from slipping in the water.”
(IRC, 3/14/2012)


77 “Colby says the showers in B-9 and B-10 are not
working correctly despite previous attempts to
repair the issue by maintenance. He says it is
creating an unsanitary condition.” (CMJ,
77 “Brett states he does not have hot water in his
Dis-Iso cell.” (IRC, 11/13/2011)
77 “Anwar grieved that he was forced to take
showers in full view of jail staff including female
staff.” (CMJ, 4/2/2012)
77 “Trey stated he has not had hot or cold water in
his cell since 03-01-2013.” (Theo Lacy, 3/4/2013)

77 Several individuals reported issues with clogged
toilets and showers, as well as broken plumbing
resulting in leakages.
Reports of subpar conditions in the showers
raise several concerns, including possible
adverse health and safety risks. According to
Title 24 regulations, shower areas must be
“designed and constructed of materials which are
impervious to water and soap so they may be
easily cleaned.”

77 Ensure malfunctioning plumbing is fixed within a
reasonable time frame.
77 Maintain showers, toilets and sinks properly.

4.	Clothing
Many survey participants described the jail-issued
clothing as dirty and poorly kept. Nonetheless,
individuals who are incarcerated are to remain in
full jail-issued clothing between wake-up call and
lights out while in the dayrooms, in common areas
or outside their cells.191 Several individuals reported
rewashing their uniforms immediately after clothing
exchange. Others reported issues with the low
temperatures in the facilities, as well as issues with
ventilation. Exposure to extreme cold for different
lengths of time was highlighted.
Table 16 lists the type of jail clothing issued to
incarcerated individuals. According to OCSD policy,
alterations to jail-issued clothing may be considered
damage to jail property and the individual may be
subject to disciplinary action. This is problematic,
given that several individuals cited poor-fitting
clothing (either too big or too small) as an issue and
they needed to adjust accordingly. Regulations also
mandate that clothing be reasonably “fitted, durable,
easily laundered and repaired.”192 According to the
BSCC and department policy, outer garments,
except footwear, are to be exchanged at least once
each week.193 Undergarments and socks are to be
exchanged twice each week. Additionally,
transgender persons are to be given clothing that
comports with their gender identity, rather than
their sex assigned at birth. (See Medical Care.)
Table 16: In Custody Clothing (BSCC and OCSD)



Jumpsuit or pants
and shirt
Sweatshirt (optional)
Socks and shoes

Jumpsuit or pants and
Socks and shoes


Clean socks and
Clean outer garments
Clean undergarments
Two pairs of panties

Clean socks and
Clean outer garments
Clean undergarments

77 Allow individuals to shower at least every other
day in accordance with Title 15 regulations.


77 Ashley claims that inmates are supposed to
receive clean clothing twice a week. However,
she complained that the underwear and socks
are “never really clean.”
77 Kyle described the jail uniform as “nasty” and
said they were “smelly.” He complained that
clothing is altered and falling apart.
77 Michelle claims the jail clothing is “filthy” and
“stinky.” She said, “The clothing is so dirty that
the whites look like gray.”
77 Norma claims that the undergarments she
received were dirty and that they had stains. She
described the T-shirts as “brown because they are
so filthy” and said, “The socks have skin in them.”
77 Amy claims that the clothing she received was
filthy and had holes.
77 Brenda claims clothing exchange happens once
a week. She described the clothing she received
as filthy. Brenda said she had to wear the same
underwear for two to three days and had to wash
all of her undergarments in the sink.
77 Paula claims the uniform shirt she received was
“completely torn.” She also claims that the
underwear she received smelled and looked dirty.
77 Julie claims that her uniform was not washed
well and was given to her with stains. She
rewashed the uniform in the shower.
77 Reggie described the clothing he was issued as
dirty. He had to rewash it in the sink.
77 Sonia claims the clothing she received was thin
and dirty. She rewashed her uniform and
underwear. She said, “I wonder whether they
actually wash the clothes. I wouldn’t be
surprised if they didn’t.”
77 Tiffany claims that she received ripped socks and
had to wash her underwear in her dorm.
77 Tracy claims inmates who knew inmate workers
were the only ones who got decent clothing.

77 Victor claims he and other inmates washed their
own uniforms in the sink because they did not
trust that they had actually been washed. He said
he and others had to wait in “freezing
temperatures” until their uniforms dried.
77 Amanda claims that she and other inmates were
not provided with extra clothing or blankets
despite complaining of the temperature. She
described the temperature in the jail as “freezing
77 Yousef claims that the clothing that was provided
to him was inadequate for the temperature in the
77 “Nathaniel reported clothing exchange issues.
Not enough correct sizes, forced to wear his
used, dirty clothing.” (Theo Lacy, 5/24/2012)
77 “Francisco states he is only receiving underwear
and socks clothing exchange once per week.”
(Theo Lacy, 5/13/2013)
77 “Jared grieved that he did not get clean t-shirts
and boxers during clothing exchange.” (CMJ,
77 “Alan claims that the clothing and bedding items
issued during clothing exchange are dirty, torn,
and ‘not even worthy of exchanging.’” (CMJ,
77 “Kenneth states he was given socks with holes in
them. Kenneth also states that 2nd floor housing
received ripped clothes and sheets. The clothing
and bedding are not repaired.” (CMJ, 4/7/2013)

77 Jail issued clothing is poorly kept and
inadequate for the temperatures in the facilities.
Several individuals reported that they rewash jail
uniforms due to foul odor and stains. According
to Title 15 regulations, individuals held after
arraignment shall receive climatically
appropriate clothing, including (a) clean socks
and footwear, (b) clean outer garments, and (c)


clean undergarments — for males, shorts
and undershirt; for females, bra and two
pairs of panties.194 Furthermore, the BSCC
mandates that departments maintain a
living environment in accordance with the
heating, ventilating and air conditioning
requirements of Parts 2 and 4, and the
energy conservation requirements of Part
6, Title 24, California Code of Regulations.195
According to the OCSD, the temperature of
the jails is kept between 68 to 75 degrees.

77 Monitor the temperature of the facilities
and ensure individuals who are
incarcerated are provided adequate
clothing relative to the jail conditions.
77 Standardize ventilation and temperature
standards. Temperature should be
mechanically raised or lowered to
acceptable comfort levels. According to
OCSD policy, individuals who are
incarcerated have a right to adequate
lighting, heating and ventilation.196
77 Screen clothing before clothing exchange
to ensure cleanliness and quality.
77 Supervise clothing exchange to ensure
fairness and accuracy.
77 Ensure that transgender persons are
issued gender-identity-appropriate
clothing, including bras and panties for
transgender women, and boxers for
transgender men.

5.	 Privacy for Transgender and Intersex
While questions about shower privacy were not asked in
the survey, we have received intakes from transgender
persons in Orange County jail facilities that indicate that
they are not given privacy to shower and change clothing.
Section 115.42(f) of the Prison Rape Elimination Act
requires that transgender and intersex individuals,
regardless of housing area, be provided showers separate
from other individuals.197 This standard was adopted to
provide additional protections for these individuals, given
the unique risks these populations face while
incarcerated. Facilities must adopt procedures that will
afford transgender and intersex people the opportunity to
disrobe, shower and dress apart from other people.198

None available at this time.

77 Individuals who are transgender are not given privacy
to shower and change clothing.
All transgender and intersex individuals regardless of
housing area must be allowed to “shower, perform
bodily functions, and change clothing without
nonmedical staff of [a different] gender viewing their
breasts, buttocks, or genitalia, except in exigent
circumstances or when such viewing is incidental to
routine cell checks.”199 For purposes of this policy, “staff
of a different gender” means staff with a gender different
from the person’s gender identity, regardless of where
the individual is housed. Male staff should not observe a
transgender female, and female staff should not observe
a transgender male, while that person is disrobed.

77 Comply with the Prison Rape Elimination Act.
77 Provide transgender and intersex individuals the
opportunity to shower and change clothes in private,
away from the view of other incarcerated individuals
and cross-gender staff.


6.	Overcrowding

BSCC noted that on the dates of the June 2014
inspection, the overall combined rated capacity
of the OC adult jail facilities was 5,108, yet noted
that the population was 6,708. The
noncompliance was mainly attributed to the use
of extra beds over rated capacities in the dorm
areas, in addition to the use of single- and
double-occupancy cells.201

After the Stewart v. Gates case, the OCSD was
subject to a population cap. The court order was
issued in 1978 and included several other areas
for rectification. The order was lifted in 2005.
Crowding within Orange County jails remained a
persistent concern of the Department of
Justice’s Civil Rights Division.200 Through an
investigation, the DOJ determined that several of
the general population units cannot be easily
supervised because of the housing configuration
and because deputies are not able to easily
conduct rounds. A report issued by the California

Average daily population statistics kept by the
Sheriff’s Department’s Inmate Records date back
to 2001 (see Figures 21 and 22). According to the
department, there are no statistics related to
population totals before 2001.

FIGURE 21: Annual Bookings, 2001 to 2016 (OCSD)

65,794 66,330 66,437 65,987














2001	2002	2003	2004	 2005	2006	 2007	2008	2009	2010	2011	2012	 2013	2014	 2015	2016

FIGURE 22: Average Daily Inmate Population, 2001 to 2016 (OCSD)
















2001	2002	2003	2004	 2005	2006	 2007	2008	2009	2010	2011	2012	 2013	2014	 2015	2016


Table 17: Rated Capacity by Inspection Cycle (BSCC)


























Theo Lacy










From 2008 to 2016, the average daily population
(ADP) was over the total rated capacity each year,
respectively (see Table 17). In March 2017, the
ADP (6,545) exceeded the rated capacity (5,093)
by more than 1,450 people. Survey participants
reported that overcrowding is an issue,
particularly during intake and screening at the
Loop. Other individuals reported that crowding
was also an issue in the housing modules.

77 James reported that holding cells at Theo Lacy
are over capacity. He believes that holding cells
are usually three times their capacity because of
the long wait when returning from court.
77 Aiden claims that there was overcrowding in the
Loop. He said people in the holding tanks slept
on the floor and cement benches while waiting
for a bed. Once he was assigned a bed, he said,
his tanks held too many bunks.
77 Fernando claims the Loop was overcrowded. He
claims that the holding cell was over capacity. He
said the sign in the cell read “23” as the
maximum occupancy, yet 30 individuals were
being held inside.


77 Gabriel claims that the Loop was overcrowded.
According to him, deputies do not care about
maximum capacities. He said, “If a sign says 15
people, deputies let in 20.”
77 Hazel claims that the holding tank where she
was held during processing was overcrowded.
According to Hazel, people slept on the floor
because all the benches were occupied.
77 Lawrence claims the Loop was overcrowded. He
claims that a sign rated maximum capacity at
“12,” yet about 20 people waited inside.
77 Luis claims that he experienced overcrowding in
the holding cells. He complained that deputies fit
too many people in one cell. According to Luis, a
containment sign read “18,” but the cell held
about 25 people inside.
77 Sonia claims the entire jail is overcrowded. She
claims that the issue is most severe in the Loop
and said that she was held with over 20 inmates
in a small space for several hours.
77 Samuel claims that his housing module was
overcrowded. According to him, there were about
100 people per module and insufficient space
between bed bunks.
77 Tracy claims that the Loop was overcrowded. She
described the holding tank as “packed” and said
sleeping on the floor was her only option.
77 Zanet claims the Loop was overcrowded. She
claims that the holding cell was over capacity for
several hours.

Tracy claims that the Loop
was overcrowded. She
described the holding tank
as “packed” and said
sleeping on the floor was
her only option.

Utilize alternatives to
incarceration and
diversion programs or
tools to relieve overcrowdedness and reduce

7.	Recreation/Dayroom/Out-of-Cell
Individuals who are incarcerated reported that
recreation time is spent within the confines of
their cells. Others complained that when
recreation time on the roof was allowed, it was
mostly before 6 a.m. They considered the
practice an intentional act by deputies to
discourage people from taking advantage of it.


77 From 2008 to 2016, the average daily population
in the OC jail system was over the total rated
capacity each year, respectively.
Several individuals reported that overcrowding is
an issue, particularly during intake and
screening. The OCSD must explore alternatives
to incarceration rather than building more
facilities and/or expanding existing facilities.
Expansion is not the solution, and it will not
prevent the violations that people who are
incarcerated experience.

77 Explore overcrowding as a source for the
deprivation of incarcerated individuals’ basic
needs such as food, medical care and
77 Utilize alternatives to incarceration and diversion
programs or tools to relieve over-crowdedness
and reduce recidivism.

77 Anthony claims he has been on 23-hour
lockdown for about a year and a half.
77 James reported he is on 23-hour lockdown at
Theo Lacy and is allowed only one hour of
dayroom. James claims that his dayroom time is
cut short. He reported that when his cell is called
for dayroom before the other cells, he and other
inmates are to carry out cleaning duties that
include sweeping and mopping two tiers,
cleaning the upstairs and downstairs showers,
spraying and wiping eight tables and 32 seats,
and spraying and wiping four phones. According
to James, the time spent cleaning is subtracted
from his dayroom time. He said, “It leaves me
with very little time to shower or call a loved one.”
James said, “Being on lockdown for 23 hours a
day when I’m still fighting my case is cruel.”
According to James, who has been fighting his
case for five years, the 23-hour lockdown policy
deters people from taking their cases to trial. He
said, “It’s especially true for people who are in
jail for the first time.” He went on to say, “That’s
why you have so many people pleading guilty.”
James disclosed that he worries about his
mental stability and that of other inmates who
are subject to 23-hour lockdown.
77 Louise reported she is on 22-hour lockdown. She
claims that every four days she is on 36-hour
lockdown because of staff shift changes.
77 Steve claims he has been on 23-hour lockdown
for over two months. He disclosed that custody
personnel have not offered him recreation time


Tracy was on lockdown for
22 hours a day for seven
days. She was allowed
recreation time only twice
during the entire time she
was in jail.
for the past three to four weeks. According to
Steve, deputies allege that recreation had not
been granted because of inclement weather.
77 Derek claims that deputies call out for out-ofcell time at 5 a.m. once or twice a week when
most inmates are asleep and cannot hear it.
77 Eric claims deputies never called out for
recreation time. During his time in jail, he left his
dorm only for meals.

77 Yousef claims that he was not allowed to leave
his housing unit for recreational purposes. He
and other inmates had to create their own
recreation space within the housing unit.
77 “Alexis claims he did not receive his minimum 3
hours of roof rec for the week of 11-11-12 to
11-17-2012.” (Theo Lacy, 11/20/2012)
77 “Edward alleges that he is receiving less than two
hours of dayroom time and the law mandates he
receive a full two hours.” (Theo Lacy, 10/7/2012)
77 “Cesar is a Total Sep inmate and he is receiving
(1) one hour of dayroom per day. Cesar is
demanding that he receive (2) two hours of
dayroom each day or be removed from Total Sep
status.” (Theo Lacy, 8/7/2012).
77 “Emmanuel claimed he did not receive two hours
of dayroom and he felt it was done arbitrarily.”
(IRC, 10/29/2011)
77 “Vincent states he is not receiving his outdoor
recreation.” (CMJ, 8/27/2011)
77 “Andres claims he was offered outdoor recreation
on 06/26/2012 but was never escorted from his
cell to participate.” (CMJ, 6/27/2012)

77 Gina claims that she was allowed to leave her
dorm only for breakfast and dinner or if she had
a medical pass. She complained that actual
recreation is not available or allowed.
77 Hazel claims recreation time is spent within the
dorm. She shared that the dayroom is in the area
where inmates sleep. She said, “All we had in the
dayroom was a picnic table, TV that didn’t work,
some newspapers, two phones and a paper
77 Paula claims that she did not know there was a
recreation area. She was in a cell with 30 to 40
female inmates.
77 Joyce claims out-of-cell time is allowed once a
week on the roof at 6 a.m. She claims that most
inmates do not go because it is too early.
77 Tracy was on lockdown for 22 hours a day for
seven days. She was allowed recreation time
only twice during the entire time she was in jail.


Yousef claims that he was
not allowed to leave his
housing unit for recreational
purposes. He and other
inmates had to create their
own recreation space within
the housing unit.

77 Outdoor recreation is limited and offered only in
the early morning.
According to BSCC Title 15 Regulations, jail
administrators shall develop written policies and
procedures for an exercise and recreation
program, in an area designed for recreation.
Several individuals reported that the area
designated for recreation at the Central Jail
Complex is on a fenced-in roof. In accordance
with Title 15 regulations, the OCSD policy
requires that a minimum of three hours of
exercise be distributed over a period of seven
days (at least two separate days).202 Dayroom
access should be available to incarcerated
individuals for a minimum of one hour per day.
According to department policy, it is expected
that dayrooms will generally be available for use
from 6 a.m. to 11 p.m. at all facilities with the
exception of Musick (to 9 p.m.).
77 Several individuals reported being on lockdown
22 to 23-hours a day. Out-of-cell time for such
individuals was only allowed for showers and
phone calls.
Denial of out-of-cell and outdoor exercise for
people in isolation or segregation was common.
Such individuals are confined to their cells all
day unless they need medical care.

77 Ensure that individuals are allotted a minimum
of three hours of exercise over a period of seven
days in accordance to the Board of State and
Community Corrections Title 15 regulations.
77 Reduce the amount of restrictive housing and
consider widening opportunities for structured
and unstructured recreation and out-of-cell time.
77 Ensure that individuals have timely access to
exercise yards.

8.	 Food Services
Title 15 Regulations require that food be served
three times in any 24-hour period and that at least
one of the meals include hot food.203 It is prohibited
for entire meals to be withheld from incarcerated
individuals as a form of discipline.204 According to
OCSD policy, meal times are at approximately 4 a.m.
(breakfast), 11 a.m. (lunch) and 4 p.m. (dinner).
A report issued by the Department of Homeland
Security’s Office of Inspector General (OIG)
identified several food safety problems. Although
the report focuses on immigrant detainees, it is
important to underscore that despite incarcerated
individuals being separated from immigration
detainees, according to an OCSD spokesperson,
both groups of people are served the same food.205
The report highlights observations made during an
unannounced OIG inspection. Among them were
“slimy, foul-smelling lunch meat that appeared to be
spoiled” and meat and ground beef stored
uncovered in walk-in refrigerators.
Despite several complaints of inadequate quantities
of food (small portions, staying hungry) and poor
quality meals, the most frequent issue was the
amount of time allotted for meal consumption.

77 Gladys claims that she reported feeling sick after
eating lunch at the chow hall in the Central
Women’s Jail in early 2016. She said she and other
inmates were allotted only about five to seven
minutes to consume their meals. Gladys threw up
on her uniform shortly after returning to her cell.
She claims that deputies denied her request for a
clean uniform. Gladys said she complained for over
an hour, and was ultimately provided with a
different uniform.
77 Janet claims that she once found a cockroach in her
food. According to Janet, she complained to
custody staff, who simply laughed at the situation.
77 Anthony is on 23-hour lockdown and receives his
meals inside his cell. He complained that he has to


eat his meals no more than five feet away from the

was served peaches with a cockroach in them. She
did not eat her food.

77 Dolores claims she receives only three minutes to
consume her meals. She reported that she and
other inmates are ordered to throw away any food
that is not eaten within the three minutes.

77 Theresa claims that while she was in the Loop being
reclassified, a deputy ordered another inmate to
take away and trash her milk and lunch for no
apparent reason.

77 Jeffrey claims he received sack lunches without
meat, and was given only carrots and bread. He
complained to the deputies and was told he had
already received a lunch.

77 Travis claims that the food served is not good but
said, “You have to eat something.” He complained
about the limited time that inmates are allowed to
consume their food. In early 2017, he witnessed a
deputy snatch a pancake from an inmate’s mouth
and yell at him, “Get the fuck out of here!”

77 Lily is an inmate worker in the jails kitchen. She
claims that she and other workers serve food for
360 inmates within 15 minutes in a lunchroom that
holds only 64 people at a time. She claims that
inmates are given three to five minutes to eat.
According to Lily, meal time is a total of 15 minutes,
but the 15 minutes includes walking to and from
the lunchroom. Lily claims that she was ordered to
serve raw meat in the past. She said, “A lot of
people started getting sick and having diarrhea.”
Lily also disclosed that the packaging for the
bologna indicated “not for human consumption.”
On a separate occasion, she was ordered to serve
expired cheese. She also complained that kitchen
staffers act inappropriately and recounted when a
White cook told her, “If I ever see you here [jail]
again, I am going to have to spank you and stick my
10-inch boot in your ass.”
77 Leonard claims that a deputy tossed his apple to
the trash before handing him his meal inside his
cell. Leonard told the deputy, “That’s not cool, man,”
and the deputy responded, “You can’t win” and
tossed his entire lunch into the trash.
77 Michelle claims inmates receive no more than five
minutes to eat. She reported that she, like everyone
else, is forced by custody staff to throw away any
food that is not eaten within the five minutes.
77 Stephanie claims that she and other inmates
received only two to three minutes to consume their
food. She also disclosed that while working in the
kitchen, she spotted a cockroach in the cream of
wheat that she was stirring. A deputy ordered her
to serve the food regardless. Stephanie submitted a
grievance about the issue and spoke to Sergeant H,
who informed her that he would look further into
the complaint. According to Stephanie, Sergeant H
never got back to her. On a separate occasion, she


77 Betty claims that she was not served a sufficient
quantity of food. She mentioned that pregnant
women receive the same portion size as nonpregnant inmates.
77 Derek claims he and other inmates were given less
than five minutes to eat their meals. He also
disclosed that the previous time he was
incarcerated at an OC jail he lost 12 pounds because
of the small portions of food that are served.
77 Eric claims that inmates do not receive enough food
and are allotted too little time to eat. He said he
remained hungry after most meals.
77 Isaac claims deputies cheated him out of a hot
dinner and gave him a cold sack lunch. He claims
that he had only about five minutes to eat his food,
which he described as “nasty” and “almost inedible.”
77 Karina said, “all meals are cold by the time they
reach me in my cell.”
77 Samuel claims that the food is “horrible and greasy.”
He complained that it made him constipated.
Despite the small portions, Samuel reported that he
was unable to consume his entire meals because he
was allowed only four to five minutes to eat.
According to Samuel, “Unless you have money on
your books, you’re sure to be hungry a lot of the
77 Tiffany claims deputies rushed her to eat her food
within two to three minutes. She claims that any
food that was not eaten had to be thrown in the
trash. Tiffany said she witnessed two girls throw up
from eating too fast.

77 Ulysses claims that he was allowed only two to
three minutes to eat. He said that on a few
occasions he was forced to toss his leftovers into
the trash.
77 Walter claims the food he was served should not
be for human consumption. He compared the food
to dog food and said he and other inmates were
forced to eat it within two minutes.
77 “Ricardo claims CST was yelling at him to hurry up
and eat his meal. Ricardo claims when he failed to
move fast enough, CST tried to grab the sandwich
he was holding out of his hands.” (Theo Lacy,
77 “Max states that they are only afforded 5 minutes to
eat their meals in the chowhall.” (James A. Musick,
77 “Ty claims he is not given enough time to eat his
food in the chowhall and the deputies are rude and
‘racist’ because they let the ‘Americans eat first.’”
(Theo Lacy, 2/21/2013)
77 “Steven complained that his food was cold on
12-26-2011 and that the portions are consistently
small.” (Theo Lacy, 12/27/2011)
77 “Damian states he is receiving meat products in his
‘Vegan’ meal. Also, he states the food is often times
‘smelly’ and does not taste good. Finally, he
requests a ‘Vegan’ menu and a list of the calorie
and nutritional (protein) break down of his meals.”
(Theo Lacy, 9/10/2011)
77 “Grant is on a special diet and claims his portions
have been getting smaller and do not meet the diet
standards.” (Theo Lacy, 7/6/2012)
77 “Preston feels his food is being tampered with and
food is missing from his tray.” (Theo Lacy,
77 “George is currently housed in D-20-9 and although
he has been prescribed a special ‘Renal Diet,’ he
continues to be served a regular sack lunch.
George has submitted a request via an inmate
message slip to the Head Cook but has not
received a response.” (CMJ, 5/23/2013)

77 Individuals who are incarcerated are not allotted
sufficient time to consume their meals.
In line with state regulations, OCSD policy
mandates that a minimum of 15 minutes should
be allotted for the actual consumption of each
meal.206 Survey findings suggest that the OCSD is
in violation of its own policy with regard to time
allowed for the consumption of meals. Denying
individuals enough time to eat creates a
restrictive environment wherein people are
unable to fulfill even the minimum consumption
requirements. Rather, they are forced to throw
out uneaten food and regularly remain hungry.
The denial of such basic sustenance can pose a
potential risk to their health.
77 Several individuals reported issues with jail
meals, such as a lack of nutritious food, spoiled
and foul-smelling food, small portions and not
having enough time to eat.
The BSCC requires that kitchen facilities,
sanitation, and food preparation, service and
storage comply with standards set forth in the
California Health and Safety Code and the
California Retail Food Code.207

77 Guarantee individuals at least 15 minutes to
consume a meal per the Board of State and
Community Corrections Title 15 regulations.
Decreasing the 15 minutes by the amount of time
it takes to walk to and from the lunchroom
should be prohibited. The OCSD should revise its
policy to clearly include this stipulation.
77 Adhere to food safety guidelines set forth in the
California Health and Safety Code and the
California Retail Food Code to prevent health
risks to incarcerated individuals. The jail menu,
food items and food handling procedures should
comply with all California state standards. The
OCSD should monitor compliance and be subject
to inspections from external agencies.


9.	 Commissary and Indigent Packs/
Welfare Kits
According to OCSD policy, incarcerated individuals
may purchase commissary items three times per
week by completing an order form, which is
distributed also three times a week. Title 15
establishes the requirement that services be
available to all eligible individuals who are
incarcerated and prohibits the deprivation of
“implements necessary to maintain an acceptable
level of personal hygiene.”208 Thus, individuals
without enough funds can request a welfare pack
of hygiene and stationery items twice per week.209
In Orange County, the Inmate Welfare Fund (IWF),
financed primarily through revenue from
commissary purchases, telephone commissions
and education contracts, funds most inmate
programs without costs to taxpayers, including
welfare/indigent packs. According to the 2013
grand jury report, the IWF budget for fiscal year
2011-2012 was $7.5 million, and the actual
expenditures were $7 million.210 Salaries and
benefits accounted for $3.1 million, while $500,000
was used to fund in custody services programs.211
California Penal Code 4025 requires the money and
property deposited in the inmate welfare fund to be
expended by the sheriff primarily for the benefit,
education and welfare of the individuals confined

FIGURE 23: Inmate Welfare Fund Expenditure Report


Staff Support


Construction and



*	Fiscal Year ending June 30, 2015; Total expenditures:




within the jail. Any funds that are not needed for the
welfare of the incarcerated population may be
expended for the maintenance of county jail
Through a preliminary fiscal analysis of total
expenditures for the fiscal year ending June 30,
2015, it appears that services for incarcerated
individuals may be underfunded (see Figure 23).
In March 2017, the OC Board of Supervisors ended
a contract with a jail kiosk operator amid
concerns of overcharging. The company’s services
included posting bail money and depositing funds
electronically to individuals’ commissary
An expenditure report obtained from the OCSD
Support Services Division revealed the following:
77 Staff support, which constituted over 85%,
included (a) personnel, salaries, and benefits and
services, and (b) supplies, training and equipment.
77 General inmate welfare, at 0.27%, included a hot
water system.
77 Inmate education, 0.38%, included services,
supplies and equipment.
77 Inmate resources, 7.04%, included (a) audiovisual
(i.e., equipment purchase and maintenance); (b)
recreation (i.e., athletic supplies and equipment
and indoor games); and (c) library services (i.e.,
newspapers, books and magazines, and law
77 Inmate reentry, 6.05%, included (a) services,
supplies, training and equipment, and (b) Second
Chance Act Adult Reentry Program Grant.
77 Construction and maintenance projects, 0.15%,
included commissary warehouse maintenance
and improvements

77 Michelle claims that the hot water dispenser in
her housing module does not work. She
disclosed that she and other inmates purchase
commissary items such as coffee, oatmeal and
soup that require hot water. In summer 2016, she
submitted an inmate request slip for hot water
signed by herself and everyone else in her
housing module. According to Michelle, she
received a response saying the issue would be
fixed, but it was not. Michelle also reported that
she purchased glasses from the commissary.
When she received them, they were broken. She
claims to have submitted multiple complaints
but has not received a response.
77 Eric claims that he requested an indigent pack
but never received it. He resorted to asking other
inmates for general hygiene products like soap
and deodorant.
77 Gina claims she was provided only with a bar of
soap despite requesting a “fish kit” (indigent
pack). She complained that other jails provide
inmates with deodorant and shampoo.
77 Hector did not receive an indigent pack even
though he needed one.
77 Michael claims that he did not receive an
indigent pack.
77 Otis claims a deputy told him to put in a request
for an indigent pack. Otis claims that he did but
never received the pack.
77 Vernon claims that he had to ask other inmates
for toothpaste and soap because he did not have
money on his books and was denied an indigent
77 Xavier claims “fish kits” are not provided in the OC
jails. He claims that he has never received one.
77 Darrell claims that he did not receive an indigent
pack. He said another inmate gave him a piece of
bar soap to shower.

77 “Khalil had money withdrawn from his account by
commissary but did not make an order or receive
the items. Confirmed by cashiers.” (Theo Lacy,
77 “Corey is grieving account balance discrepancy
from commissary.” (Theo Lacy, 5/31/2012)
77 “Malcolm complained that Commissary
Personnel withdrew eighty dollars from his
account. Malcolm did not receive his commissary
or his money placed back on his account.” (Theo
Lacy, 2/9/2012)
77 “Israel stated he was missing eight (8) items from
the commissary order he received on 8-3-11.”
(James A. Musick, 8/5/2011)
77 “Austin claims he was charged for items he did
not receive from Commissary.” (CMJ,
77 “Fidencio is unhappy with the commissary being
late or not delivered at all.” (CMJ, 12/4/2011)
77 “Nestor says he ordered commissary and was
charged for the order but he has not received the
order.” (CMJ, 9/9/2012)
77 “Howard is grieving that his inmate account is
being charged for welfare packs.” (CMJ,
77 “Sam claims his commissary account balance is
incorrect.” (CMJ, 6/5/2012)
77 “Joe states he ordered commissary for 5/4/2013
and did not receive the order. He states his
account was deducted for the 5/4/2013 order.”
(CMJ, 5/21/2013)
77 “Ali claimed he submitted several message slips
to Commissary about money being deducted
from his commissary account that he did not
authorize. On 4-3-2013, he was wrongly charged
$49.55 that he wants reimbursed.” (CMJ,
77 “Ivan is claiming that Commissary’s new pricing
on commissary is price gouging, unethical, and
monopolizing.” (CMJ, 3/6/2013)


77 Several individuals reported issues with
commissary, including discrepancies with their
accounts, incomplete orders, and incorrect
The main goal of Commissary Operations is to
provide quality services and products to people
who are incarcerated in the OC jail system.
Personal accounts and grievances suggest this is
not the case.
77 Indigent packs/welfare kits are seldom provided
to incarcerated individuals who are unable to
supply themselves with essential personal care
OCSD policy in accordance with Title 15
regulations require that individuals who are held
for over 24 hours who do not have money in their
accounts are allowed to request a welfare kit
(consisting of one toothbrush, one tube of
toothpaste, one razor, one comb, two stamped
envelopes, five pieces of writing paper and one
pencil) once a week.213 Several survey
participants complained that they never received
an indigent pack despite submitting requests.

77 Review and update policy and procedures guiding
the administration of indigent packs.
77 Improve the commissary process and ensure
that problems are addressed and corrected in a
timely manner.
77 Conduct a management audit or thorough fiscal
analysis of the Inmate Welfare Fund (IWF) to
determine whether the OCSD is appropriately
allocating money from its sizable balance toward
its primary intended objective — the care and
rehabilitation of individuals who are incarcerated.
77 Allot a larger percentage of the IWF to general
welfare, education, resources and reentry, rather
than staff support.


10.	 Communications (Phones, Mail and
According to the Federal Communications
Commission (FCC), contact between people who
are incarcerated and their loved ones is
associated with lower rates of recidivism.214
High calling rates, however, have made contact
between incarcerated individuals who are
low-income and their family and friends
In the past, two Orange County supervisors
raised serious concerns about the jail phone
prices but ultimately shelved their opposition.
The change of opinion came after they received
maxed-out contributions from the prison and
jail phone contractor, Global Tel-Link.215 In 2012,
Global Tel Link contributed $2.49 million to the
Orange County Inmate Welfare Fund, which was
used primarily to pay salaries and benefits of
employees.216 In 2014, the county’s jail phones
generated about $5.5 million in revenue. The
money was divided between the Sheriff’s
Department and Global Tel-Link.217 The OCSD
received over $3.4 million from the jail phone
revenue, which again was used primarily to pay
staff salaries, training and benefits.218 In
November of the same year, incarcerated
individuals and their family members filed a
class-action lawsuit against Orange County and
three neighboring counties, declaring the prices
for calls as “unfair and excessive.”
Several survey participants complained of
dropped calls and nonfunctioning telephones.
Others reported issues with the way custody
staff handle mail. Such complaints focused on
delays with incoming and outgoing
correspondence and the reading of confidential
legal mail.

77 Dolores claims three out of four phones in her
housing module were broken. She claims that the
phone that was not broken functioned poorly. She
said, “You can hardly hear whoever you’re talking
77 Anthony’s legal mail was “lost” when he was
transported to the IRC from Theo Lacy to undergo
a psychiatric evaluation. According to Anthony,
inmates typically carry their property on the bus
with them. However, custody staff ordered him to
put his property under the bus. After arriving at
the IRC, Anthony asked for his legal mail while he
was being processed through the Loop. A few
hours later, jail staff told Anthony that his mail
was missing. Anthony filed a claim against
Orange County. The county wants to settle the
claim for $25. 
77 Freddy claims Deputy N inspected and read his
legal mail. After reading it, Deputy N asked
Freddy why the deputy’s name appeared on the
paperwork. Freddy claims that he told Deputy N
that he remained fearful since a pepper ball
shooting incident and thus was documenting
other incidents. Freddy said, “After I told him that,
he made me take off my uniform and made me
put on a dirtier one that was very worn out.” While
Freddy switched uniforms, he claims, Deputy N
told him: “Document that!” Freddy maintains that
he was fired from his in-custody job a few days
after the incident. He was not provided a reason
and was transferred to Theo Lacy.
77 Linda claims that her outgoing mail is not
reaching its destination and that incoming mail is
being withheld by custody staff. She is concerned
that her mail is being used for investigation
purposes. She has submitted several complaints
and received a response from Sergeant G, who
stated, “The only way an inmate is entitled to their
mail is if you can provide proof it arrived here.”
According to Linda, after pushing the issue she
learned that OCSD Investigator HH of the
Economic Crime Detail is “illegally seizing
evidence by withholding her mail.”
77 Michelle claims that mail addressed to her was
returned to the sender for an unknown reason.

According to Michelle, the sender resent the mail,
but she has not received it. She reported that
deputies give mail to random inmates and ask
them to distribute it among the housing module.
She also said, “Deputies threaten to not give us
our mail if they decide we’ve messed up.”
77 Tracy claims that out of 15 visit attempts made by
her family, she received only one. According to
her, her family was told that she had refused the
77 Emilio claims that making calls was difficult. He
said that instructions to get a PIN in order to
make calls were not available.
77 Karina claims the phone system is confusing. She
claims that the county number available to her
did not work.
77 Patrick claims that phones are available only to
inmates who have calling cards. He complained
that even with a calling card he was ordered to
hang up a call.
77 Amanda claims that her mail was not delivered to
its intended destination.
77 Derek, claims he received his mail with delays of
about four days. He was only able to track the
delay of incoming mail.
77 Yahir claims that deputies did not allow him to
send or receive mail. He was not offered a reason
77 “Logan claims he is only getting five minute phone
calls.” (Theo Lacy, 6/25/2011)
77 “Marshall alleges that the collect telephone
service is malfunctioning. Calls are disconnected
prior to being connected and the calls are billed
as completed and the service disconnects users
after approximately 15 minutes.” (Theo Lacy,
77 “Gregorio states he was not allowed to make legal
calls to his attorney between 08-26-11 thru
08-31-11.” (IRC, 9/2/2011)


77 “Brody said he has not been receiving his two hour
court ordered collect call since his arrival at the
I.R.C.” (IRC, 5/21/2012)
77 “Andy submitted grievance reference not
receiving his court ordered non-collect phone
calls because the phone was not working.” (IRC,
77 “Mariana claims she is not receiving court
ordered, non-collect phones calls after
submitting message slips requesting the calls.”
(IRC, 2/10/2012)
77 “Jackson alleges that his mail is being held for a
week prior to delivery and his mail is also being
incorrectly delivered on a regular basis.” (Theo
Lacy, 5/21/2012)
77 “Genesis is complaining the inmate workers are
tampering with her mail and her food. Genesis
told the deputies about the problem but states
they did nothing about it.” (IRC, 7/20/2012)
77 “Esteban says there should be log kept for
outgoing legal mail. He also says that Deputy Y is
‘molesting’ (sic) the jail procedures to obtain
confidential legal mail.” (CMJ, 4/17/2012)
77 “Jeremy is in part complaining he has not been
receiving his mail.” (CMJ, 10/26/2011)
77 “Micah complained about his mail being
‘arbitrarily held-up’ and not being sent out in a
timely manner.” (CMJ, 9/21/2011)
77 “Osmond claims staff denied his public visits the
following dates: 5-31-13, 6-1-13, 6-2-13, 6-7-13
and 6-8-2013. During my interview with Osmond
he claimed his mother came to the facility to visit
him on 6-7-2013 and 6-8-2013 and was turned
away…” (Theo Lacy, 6/15/2013)
77 “Joaquin is complaining about not being allowed
his visiting privileges.” (IRC, 9/13/2011)

77 Several people reported malfunctioning phones,
including dropped calls, and poor sound and
being denied their non-collect phone calls.
According to the Board of State and Community
Corrections, the facility administrator shall
develop written policies and procedures that allow
reasonable access to a phone beyond phone calls
that are required by Section 851.5 of the Penal
Code.219 According to OCSD policy, phones are
available for individual use during dayroom hours
at the IRC, CMJ, CWJ and Theo Lacy. At Musick,
phones are available for use during outdoor
recreation hours. According to department policy,
in emergency or court-ordered situations, people
who are incarcerated should be allowed to use the
phones in their assigned housing locations.220
77 Many individuals reported that deputies read their
legal mail and complained of delays with
incoming and outgoing mail.
According to Title 15 Regulations, deputies may
only open legal mail in the presence of
incarcerated individuals and can only be checked
for contraband. A few individuals reported not
receiving their mail at all.

77 Provide people who are incarcerated access to
functioning phones and allot sufficient time to
complete calls.
77 Ensure that mail marked as “legal mail” is opened
in front of the receiving individuals, where they can
see custody staff inspecting the correspondence
for contraband and ensure that the content is not
read. Legal mail is considered confidential and
privileged between the sender and receiver.
77 Address delays in receipt and delivery of legal mail
and communicate such to individuals who are
incarcerated. Revise visitation schedule to allow
for more visitation opportunities. Prohibit staff
from enforcing arbitrary visitation rules.



1.	Discipline
OCSD policy maintains that violation of
department rules can result in the loss of
privileges such as dayroom, recreation, phones
and visits, and in some cases may warrant
placement into isolation. Incarcerated individuals
complained that conditions calling for disciplinary
actions are imposed arbitrarily by deputies.
Survey responses suggest that deputies do not
adhere to OCSD policies and procedures but
rather subjectively determine what actions ought
to result in a loss of privileges.

77 Anthony claims, “I am written up for things like
asking to see paperwork or even just asking
questions.” On one occasion, Anthony was not
allowed to participate in his disciplinary hearing.
On the same day he was violently thrown from a
wheelchair onto his cell, a sergeant
approached his cell to conduct a hearing
regarding a complaint. Anthony was unable to
stand up and asked for help. Anthony claims that
the sergeant denied him assistance and lied by
saying he had refused to participate in the
hearing. Regarding a separate incident, Anthony
claims that jail staff attempted to discipline him
for the same thing three times. He noted that all
disciplinary actions were logged under the same
number and addressed the issue with a deputy.
According to him, the deputy said it was an
“honest mistake.”
77 Dolores claims that during a cell search,
deputies found an apple on her bunk. She was
ordered to work from 12 a.m. to 2 a.m. in spring
2016. Dolores informed custody staff that she is
disabled and cannot use her right wrist. She
claims that custody staff disregarded her
disability and forced her to work. Dolores
maintains that she injured her wrist and believes
that she will need surgery after she is released.

77 Joseph claims that he was written up for using the
medical emergency button in January 2016.
77 Kyle claims a deputy “tore up” his cell and
thrashed his commissary after he asked a
question that the deputy did not appear to like.
Kyle submitted a complaint but says it was
77 Lily claims everyone in her housing module was
denied their mail for three days because a girl
flushed the toilet past the time deputies allow
inmates to do so. Lily claims that deputies do not
like any noise.
77 Michelle was written up for having excess soap
and an orange. She claims that an inmate with
medical problems was forced to work two hours
at night folding underwear for a minor violation.
77 Mark claims deputies wrote him up the same day
he received the in-custody survey for an infraction
that had occurred about three weeks before. Mark
lost all privileges for 10 days and was placed in
solitary confinement for 20 days. He said, “Who
knows what would have happened if I would have
filled it [the in-custody survey] and sent it back.
Shit would have probably been real bad.”
77 Stephanie claims she was fired from her incustody job for washing her hands while the
deputies conducted a count. She claims that she
was moved to a different tank with 20 bunks and
40 women afterward. There, Stephanie was
assigned the bunk closest to the restroom. She
maintains that custody staff was advised by a
written notice to not move her from that bunk.
77 Aliyah claims deputies sometimes punish
everyone for the behavior of individual people. She
claims that this results in fights.
77 Darrell claims that he lost his food during meal
time after saying “bless you” to the person
handing out the food. According to Darrell, the
deputy on duty ordered him to put his tray to the
side. He was not provided with a sack lunch.
77 Pedro said he began to feel unsafe when he
witnessed deputies attempting to get inmates into
trouble. He said, “It’s as if they found it


77 “Roman claims the punishment he received for
his violation was excessive and is based on
discrimination toward him due to his race.
Roman was given 7 days in disciplinary isolation
for his violation and his cellmate did not receive
isolation time.” (Theo Lacy, 10/14/2012)
77 “Martin is grieving the number of days given to
him in Disciplinary Isolation.” (Theo Lacy,
77 “Efren claims there is no inmate orientation to let
them know what is against the rules.” (Theo
Lacy, 11/12/2012)
77 “Jacey is claiming one of the CSA’s is treating him
disrespectfully and making up violations so he
will be wrongfully punished.” (IRC, 5/24/2013)
77 “Andre is alleging that Sgt. R and a Lt. have
instructed Deputy Y to focus on he and Drew and
that he is to write them up every day until they
‘break.’” (CMJ, 2/18/2013)
77 “Byron wants to grieve that the deputy falsified a
report. Major write up.” (CMJ, 5/22/2012)
77 “Dillon grieved the fact he did not receive a copy
of the report narrative related to a major rule
violation.” (CMJ, 3/29/2012)

Incarcerated individuals
accused of breaking jail
rules are placed in solitary
confinement without
access to visits, recreation,
telephones, etc.
77 Deputies arbitrarily impose disciplinary
sanctions on individuals who are incarcerated.
According to the 2012-2013 grand jury, common
punishments for minor offenses involve revoking
commissary privileges, loss of good time and
denying visitation.221 Incarcerated individuals
accused of breaking jail rules are placed in
solitary confinement without access to visits,
recreation, telephones, etc. Most people reported
feeling unsafe and threatened inside the OC jail
system due to arbitrary rules and discipline
enforced by deputies even in the absence of
infractions or violations.

FIGURE 24: Total Grievances by Year (OCSD)






2013	2014	2015	2016

77 Be transparent about the discipline system and
prohibit the imposition of arbitrary punishment.
77 Allow individuals who are incarcerated to access
disciplinary hearings without the fear of
retaliation. The disciplinary hearing process
should be fair.
77 Ensure jail rules are posted at each facility in
common areas such as dayrooms and chow halls.


2.	 Grievance/Complaint Process
The grievance process is one of the most significant
tools for individuals who are incarcerated. It is
intended to provide people with an avenue to file
complaints regarding jail conditions as well as
potential violations of their rights. People who are
incarcerated may file grievances related to any
condition of confinement, including but not limited to
medical care; classification actions; program
participation; telephone, mail and visiting
procedures; food, clothing and bedding issues;
disability discrimination; and staff misconduct.

deputy, assignment to another sergeant, forwarding
to the facility administrative lieutenant or handling
the grievance personally.223 Currently, the chain of
command for the grievance process is as follows:
deputy, sergeant, facility administrative lieutenant
and division commander.224
Unfortunately, most people are reluctant to raise
complaints for fear of retaliation from custody staff.
Others simply do not trust the process and regard it
as more of a formality. Such individuals point to a
lack of response to issues raised, while others
disclose intimidation tactics employed by staff.
According to information obtained via a Public
Record Acts request, the total number of grievances
filed between 2013 and 2016 was 3,654.225 Figure 24
illustrates the total number of grievances reported
by the department annually from 2013 to 2016. In
2016, the top three types of grievances filed
concerned medical (296), food services (102) and
commissary (81) (see Figure 25).

According to the Office of Independent Review,
established by the Orange County Board of
Supervisors in 2008, grievance forms are placed in
central locations throughout the jail facilities and are
protected from interference by locked boxes.222
According to department policy, sergeants are
responsible for reviewing all submitted grievances
and determining the appropriate level at which to
handle them. This may include delegation to a

FIGURE 25: Grievance Type, 2016 (OCSD)

Transportation	2


Telephone	21


Staff Misconduct	



Shower/Hygiene	6


Religious Services	



Records	8


Property	43


Pro Per	



Law Library	


Food Services	



Discipline	29


Dayroom/Outdoor Recreation	


Correctional Programs	


Condition of Confinement	




Classification	40

CDCR Grievance	


Cashier	19

	 Attorney/Bonds/Public Visiting	


Clothing	3



Mail	53

0	 50	 100	150	200	250	300


Despite reported changes in 2014, including recording
grievances to identify patterns that needed to be
addressed and submitting grievance slips in locked
boxes available only to supervisors,226 additional
changes are required. Several survey participants
reported grave issues with the grievance process.

77 Anthony claims that he has submitted several
grievances. He maintains that deputies do not
always provide him with copies and that
responses to grievances often do not have a log
77 Ashley was “re-Looped” and rehoused for
submitting a grievance after her personal
information, including phone numbers, addresses
and photos of her son, was thrown away during a
cell search. Ashley said, “It was retaliation. They
sent me to the Loop for a day and rehoused me.”
According to Ashley, she was not given a copy of
her grievance. She claims that a deputy accused
her of lying and making false allegations. Ashley
shared that she has not submitted a grievance
since then because she fears further retaliation.
77 James claims complaint forms are inadequate
and have little space to detail problems. He was
directed by a sergeant to cite only one issue per
complaint form. After he requested additional
forms, the sergeant warned him that additional
complaints may be considered an abuse of the
grievance system and could result in a
disciplinary violation. He also complained that
appeals are rejected when additional pages are
77 Janet claims that she submitted a grievance at the
end of 2016. Janet disclosed that she wore hair
ties on her pants because they fit her loose. A
deputy directed her to remove the hair ties, to
which Janet complied. Even though she followed
the deputy’s directive, Janet claims, the deputy
continued to press the issue, exclaiming, “Don’t
you know how to follow the damn rules?” Janet
responded, “I got it.” According to Janet, the
deputy then claimed that she was giving her
attitude and began to search her cell. Janet
shared that her personal belongings were tossed

and scattered on the floor. She requested a
grievance slip, and when she attempted to submit
it, a male deputy asked her to hand the slip to him.
The deputy told Janet that he would place the slip
into the locked box for her. She followed the
deputy’s directive and handed the grievance over.
She claims that she stood in place waiting for the
deputy to place it in the box. The deputy told her
to “go to your cell and lock it down.” She
expressed that she wanted to make sure the slip
was submitted. At this point, Janet could see
other deputies walking toward them. Fearing
trouble, she followed his orders. As she walked
back to her cell, she claims, she turned and saw
the deputy reading the grievance. Janet never
received a response to the grievance and believes
that the deputy discarded it.
77 Lily claims that grievance forms are “too hard and
dangerous to get.” According to Lily, inmates
must verbally request slips from deputies. She
claims that she once witnessed a deputy yell at an
inmate for requesting a grievance. She described
the experience as intimidating and threatening
and complained that the process “protects
77 Michelle claims an inmate in her housing module
was moved to a two-person cell the night she
submitted a grievance about lost property.
Michelle disclosed that she is afraid to submit
grievances because of such retaliation.
77 Norma claims that she submitted a grievance
when a deputy slammed her face against the wall.
She received a response indicating that the
incident was being investigated. She complained
that obtaining the grievance form was difficult
because she had to ask a deputy for it and was
asked what she wanted it for. She said, “It’s
intimidating because you never know how the
deputy will react.”
77 Stephanie claims she had to ask a deputy for a
grievance slip to complain about the conditions in
the kitchen. She claims that although the
complaint was not about a specific deputy, the
experience of having to ask the staff for a slip was
“uncomfortable and unsafe.” She says that this is
the reason most people do not submit complaints.
She said, “People are discouraged by the process;
they’re afraid. Wouldn’t you be?”

77 Theresa claims that she submitted several
grievances about deputies and inmates “roughing
up people.” She maintains she has not received a
77 Norma reported feeling unsafe in jail. She
disclosed that she is treated unfairly and stated,
“If I speak up I will have to worry about retaliation
and physical abuse … my cell getting tossed,
pictures getting ripped and legal paper thrown.”
77 Amy claims that a deputy would not give her a
grievance slip. She said, “He just told me there
weren’t any and that was the end of it.”
77 Amanda submitted two grievances while in
custody. She was not provided with a copy of
either complaint and never received a response.
77 Carol claims that she did not feel safe submitting
a grievance although she wanted to. She said,
“They make it so hard that I think the signs are
only posted for show.”
77 Karina claims that she did not submit any
complaints because she knew she would be in
custody for only a few days. She said, “I knew I
was going to be released soon, so I didn’t want to
draw attention to myself.” According to Karina, a
lot of people are afraid to engage in the
grievance process. She said, “It can make you a
target overnight.”
77 Omar said he did not submit a complaint though
he wanted to because, as he said, “There’s a
clear understanding that if you complain, you will
be retaliated against.”
77 Samuel claims that he did not submit a
grievance because he was “too scared to make a
77 Oscar claims he did not submit a grievance
because of fear. He claims that he has witnessed
deputies harass inmates for doing so.
77 Victor claims that he witnessed a deputy mess
with another inmate’s belongings after the
inmate submitted a complaint. According to
Victor, the inmate’s letters and commissary were
thrown around by the deputy.

77 Wesley claims that he did not submit any
grievances about problems he encountered while
in custody because he does not believe it would
change anything. He said, “I don’t think it leads
to any change. If anything, it brings more
77 Walter claims that he does not have faith in the
grievance system. He said, “I don’t think they
take any of this seriously … best-case scenario I
won’t be retaliated against.”
77 Yousef claims that he did not submit a grievance
because he believes that the process is a “joke.”
He said, “Even though we have a right to
complain, I rather keep my mouth shut and not
get roughed up.”
77 “Owen claims he was unfairly moved to a singleman cell by a deputy as reprisal for submitting
several grievances in the past.” (Theo Lacy,
77 “Scott alleges he was transferred to TLF in
retaliation for a grievance filed at CJX.” (Theo
Lacy, 7/23/2011)
77 “Salvador filed a grievance reference not receiving
additional copies of a grievance from 12-6-2011.
Salvador needs the copies to file a lawsuit to
change his housing location.” (Theo Lacy,
77 “Carson claims he was given a jail write up in
retaliation for submitting a grievance.” (IRC,
77 “Tristan wishes to grieve the Grievance Procedure
and posting of jail rules in the dayrooms.” (IRC,
77 “Moses states he was not given a copy of two of
his grievances given to Sgt. Y earlier in the day.”
(IRC, 8/13/2011)
77 “Donald is grieving jail staff refusal to respond to
grievances within a reasonable time.” (CMJ,
77 “Shane claims his housing was moved in
retaliation for filing a grievance.” (CMJ,


77 Many individuals are reluctant to raise
complaints about conditions of confinement or
custody misconduct for fear of retaliation from
custody staff.
Other incarcerated individuals reported that jail
staff regularly discourage people from
submitting grievances, and in some cases
threaten them to not do so. There appears to be
an understanding among individuals who are
incarcerated that submitting a grievance will
result in retaliation and trouble. Some people
who engaged in the process despite legitimate
fear disclosed that they, in fact, did face
retaliation. Examples of such retaliation included
being fired from their trustee positions; constant
verbal harassment; unnecessary and excessive
use of force; confiscation of personal belongings,
including commissary, mail and pictures of loved
ones; and loss of privileges. Such retaliation
violates department policy.227 Department policy
prohibits staff from harassing, disciplining,
punishing or retaliating against an individual who
uses or participates in the grievance process.228 It
is unconscionable that deputies intimidate,
harass and harm incarcerated individuals who
attempt to engage in the only avenue available to
them to raise concerns. Intimidation by deputies
deters and discourages individuals from seeking
redress. Hence, department figures fail to
include all possible complaints.
77 Custody staff neglect to provide individuals with
grievance forms in a timely and professional
According to department policy, grievance forms
should be available in all housing locations.229
While some individuals claimed that forms are
not readily available, others complained that
deputies blatantly denied them access to forms.
Such complaints suggest that the OCSD is in
violation of its own policy. A few individuals
shared that they believe that completed forms
are sometimes intercepted by deputies and
disposed of. Others who were able to submit


grievances reported that they never received
responses and that the issues at hand were
never attended to. Several survey respondents
said, “Nothing ever gets done.”

77 Make the grievance system more accessible to
incarcerated individuals and integrate
safeguards to ensure people feel safe engaging
in the process. Provide education to incarcerated
individuals about their rights, access to
resources and the grievance process.
77 Guarantee accountability of custody personnel
who engage in any type of misconduct and
increase transparency on such matters. Conduct
thorough and objective investigations with
appropriate consequences for responsible staff.
77 Ensure that complaints are received, processed,
responded to, resolved and tracked in a fair and
timely manner. Ensure that incarcerated
individuals are provided with a copy of their
grievance, response and written reasons for any
denials from each level of review. Implement and
monitor an appeals process for grievances.
77 Revise and update the Grievance Process Policy.
Custody staff should be informed and trained of
any changes before implementation.
77 Outline what constitutes an invalid grievance and
incorporate guidelines such as timelines to the
policy and procedures governing the grievance
77 Prohibit deputies or any other staff involved in
complaints to manage review of the grievance
process. Safeguarding its integrity requires that
complaints are handled by unbiased and neutral
parties. For this reason, the department should
consider involving civilians and truly impartial
entities in the grievance review process.
77 Follow up with investigations of deputy
misconduct and general conditions of
confinement within a reasonably determined
time frame. Custody personnel who fail to follow
up should be held accountable and disciplined

3. American with Disabilities Act (ADA)
In 2009, a court held that continuing ADA violations
and inadequate access to exercise and religious
services for people who are incarcerated required
ongoing court oversight of the Orange County jails.230
ADA violations concerned structural barriers for
disabled individuals. Inspection of the areas used for
housing such disabled individuals also revealed
inadequate toilets, sinks, showers, hot water
dispensers, telephones and water fountains.231

None available at this time.
77 David claims that he was denied his cane despite
difficulty walking.
77 Henry witnessed an incarcerated person with a
physical disability be denied accommodations. Henry
described the person as an elderly man who limped
when walking. Henry claims that the man was denied
his cane and a wheelchair.
77 Salvador claims that his cane, which he uses as an
aid when walking, was confiscated.
77 Warren claims that he is disabled and requires a cane
to walk with. While he was in custody, Warren’s cane
was taken away.
77 “Giovanni wrote a letter to Court Appointed ADA
monitor alleging ADA violations, citing rude
“unprofessional behavior” “harassment” by medical
and non-sworn staff and an inability to clean and
refusal by CST to clean shower.” (Theo Lacy,
77 “Levi states he is an ADA patient and is not receiving
the proper care. He states he has extreme pain in his
feet and legs and needs proper pain management.”
(Theo Lacy, 7/4/2013)
77 “Armando claims he is classified as a ‘state ADA
inmate’ and as such should not be in regular housing.
He claims he has not been seen by a doctor to review
his ADA status.” (Theo Lacy, 7/3/2013)

77 “Julio claims he is an ADA inmate who is not getting
the proper medical care he is entitled to. He is
claiming he has back pain. He is also claiming the
medical staff is rude and show blatant disregard for
his medical condition.” (Theo Lacy, 1/28/2013)
77 “Leonardo states he’s ADA and requires a cane for
mobility. States he had one and was taken away from
him.” (IRC, 7/19/2012)
77 “Enrique claims to be ADA and that his hearing aid
was confiscated from him and not returned.” (IRC,
77 “Jonah states that he is ADA. He alleges that he made
a request with medical staff for an extra mattress to
help to ease his discomfort but was denied his
request.” (CMJ, 2/6/2013)
77 “Landen grieved his current housing location is not
appropriate for his status as an ADA inmate.” (CMJ,


77 Deputies confiscate and deny necessary aids,
including hearing aids and walking aids, to ADA
incarcerated individuals.
The Americans with Disabilities Act provides in
general that no disabled individual shall be excluded
from participation in or denied benefits of services,
programs or activities of a public entity based upon
the disability.232 Previously an appellate court held
that inadequate physical facilities of the Orange
County jail system and reduced programs for
disabled pretrial detainees violated the ADA.233 Other
reports highlight examples of barriers that illegally
hinder incarcerated individuals who are mobilityimpaired and dexterity-impaired.234 Such barriers
impeded and continue to impede people who are
disabled from programs and services available to
others at the jails who are abled.

77 Ensure the department is in compliance with the
American with Disabilities Act and make necessary
aids (e.g., canes, hearing devices, and wheelchairs)
available to incarcerated individuals who are
mobility-impaired, in addition to ensuring that
housing units are ADA-compliant.

4. Religious Services
The Religious Land Use and Institutionalized
Persons Act (RLUIPA) is a civil rights law that
protects the religious freedom of people confined
to jails, prisons, and other institutions.235 Courts
have found that a wide range of practices
constitute religious exercise under RLUIPA,
including attending religious services, wearing
head coverings, adhering to certain dietary
restrictions, and receiving certain religious
materials. Previous accounts of inadequate
access to religious services in the OC jail system
resulted in court oversight of the jails.236
Inadequate access involved deputies denying
people in administrative segregation access to
religious activities available to people in the
general population, such as group services and
individual visits to the chapel.237 In 2009, the 9th
U.S. Circuit Court of Appeals established that
Orange County’s claim of “security concerns”
was not sufficient to block all access to group
religious programs for individuals in
administrative segregation.238

77 James claims he is “hardly ever offered religious
services.” He claims that he was not offered
services for three months. He believes that he is
being treated unfairly because of his housing
None available at this time.
77 “Darwin claims he has requested a Kosher
Religious Diet for the last 45 days and has not
received a reply from Food Services.” (Theo Lacy,
77 “Nathan has requested to see the chaplain and has
not received any response.” (Theo Lacy, 9/29/2011)
77 “Ethan is grieving not being able to wear Torah
specified garments during his prayers.” (IRC,
77 “Dylan has not been able to attend religious
services.” (IRC, 7/20/2011)

The Religious Land Use
and Institutionalized
Persons Act (RLUIPA) is a
civil rights law that
protects the religious
freedom of people
confined to jails, prisons,
and other institutions.


77 “Caleb wants to maintain a religious diet after
Ramadan. Claims to have submitted prior requests
with no reply.” (Theo Lacy, 9/8/2011)
77 “Javier is complaining about the quantity of food in
his religious Special Diet.” (Theo Lacy, 9/4/2012)
77 “Thomas is requesting a Halal diet, and wishes to
observe Ramadan with special diet.” (Theo Lacy,
77 “Mateo is grieving Food Services inability to provide
a proper Kosher meal and wants to be transferred
back to the CJX.” (Theo Lacy, 7/27/2011)
77 “Sebastian wants a religious Halal diet because he
is a practicing Muslim.” (Theo Lacy, 6/2/2013)
77 “Abdiel stated he has submitted 6 message slips
requesting a kosher meal due to him being Jewish.
He has not received a response back.” (Theo Lacy,

77 Incarcerated individuals are not regularly
called out for religious services and are denied
religious diets without justification.
According to the department, its Correctional
Programs Unit offers religious services in
several denominations. Individual pastoral
counseling is also supposed to be available
upon request. However, incarcerated individuals’
accounts of the denial of religious diets and lack
of access to services suggest the department
may be in violation of its own policies and
RLUIPA. The department should not impose
substantial burdens on the religious exercise of
individuals who are incarcerated.

77 Ensure all individuals who are incarcerated,
regardless of classification and housing, have
timely access to religious services of their own
77 Provide religious meals, where reasonable
accommodations can be made.
77 Prohibit religious discrimination.
77 Comply with the Religious Land Use and
Institutionalized Persons Act (RLUIPA) and
make accommodations for religious exercise
consistent with regulations.

5.	 Propria Persona Status
The Sixth Amendment guarantees that a
defendant in a criminal trial has a right of selfrepresentation and that they may proceed to
defend themselves without counsel when they
“voluntarily and intelligently” opt to do so.239 A pro
per individual is “one who represents him/herself
in a legal proceeding.” Propria persona status is
granted to individuals who opt to advocate on
their own behalf before a court instead of being
represented by an attorney.
A grave concern in relation to pro per status is the
lack of physical access to a legal search area.
Rather, individuals are required to submit written
requests. Pro per individuals in the OC jail system
do not have physical access to a law library as is
customary in neighboring counties. Law library
access is crucial for individuals who are
representing themselves in legal proceedings.
According to a Public Records Act request
submitted to the OCSD, the department does not
have records responsive to the number of
individuals who have requested pro per status in
the years 2010 to 2016, nor to the number of
individuals who have been granted pro per status
in those years.

77 Angel claims the court system in Orange County
is “not fair.” Despite being granted pro per status,
Angel says, he has been denied access to
necessary legal resources for his case. He said
that to access legal information he must submit
a written request. Angel claims that on average
he has to wait one to three weeks to receive a
response. He said, “It sucks. I don’t have what I
need to fight my own case.” As a result of
delayed responses from the law library, Angel
postponed his case more than once because he
was underprepared.
77 Leonard is a pro per inmate. He claims that his
cell has been “tossed” several times and said
that deputies have thrown his legal documents

“all over the floor.” He also shared that on two
occasions certain documents “went missing.”
77 Steve claims that he submitted a request for
information to prepare for his upcoming court
hearing. According to Steve, a month has gone by
and he has not received a response. Steve said he
plans to request a public defender at his next
court date. He said, “I can’t do anything if I don’t
have what I need.”
None available at this time.
77 “Lorenzo was granted Pro-Per status on Sept. 10.
He has requested legal assistance but has not
received a reply. He is concerned his Pro-Per will
be compromised if he does not receive the
assistance that he has requested.” (CMJ,
77 “Amir writes that he had tried to use the law
library all day but was refused access.” (Theo
Lacy, 8/25/2011)
77 “Cassidy did not receive his pro per phone call
even though he submitted an inmate message
slip in the morning.” (IRC, 11/2/2011)
77 “Federico submitted a grievance reference his
pro-per non-collect phone calls were being made
in an area with little privacy where other inmates
could hear his conversations.” (IRC, 5/19/2012)
77 “Ezekiel was a pro per at Theo Lacy and was
having trouble getting information he requested
from law library. Now he is housed at the IRC (pro
per) and he is still having trouble getting all
information requested from the law library.” (IRC,
77 “Forest stated he is a pro per inmate and his
property was improperly searched. According to
him, he is missing some legal documents and
commissary items.” (IRC, 4/10/2012)
77 “Gus stated he did not receive his 2 hours access
to collected phones per his court order between
the hours of 0600 hours and 2300 hours.” (IRC,


77 “Tyson states Deputy Y would not give him an
inmate message slip for the law library.” (CMJ,
77 “Octavio claims his pro per mail is being tampered
with by the mail room, saying his mail is
important in fighting his case.” (CMJ, 12/3/2011)
77 “Karl is a Pro Per. He is complaining that the Law
Library process is ‘inadequate and does not
provide meaningful access to the courts.’ Karl
believes his limitations of accessing materials
from the Law Library has had a direct negative
impact on...” (CMJ, 2/29/2012)

77 Several incarcerated individuals who were
granted propria persona status report that
ensuing privileges, are poorly instituted.
Pro per individuals reported lengthy delays in
accessing privileges that are supposed to be
afforded to them, including access to legal
information and daily visits with their courtappointed investigator or other court-appointed
legal assistant. Many individuals reported
instances wherein requests for legal documents
were not responded to or were responded to
several weeks to months later. Feeling
underprepared, one person has had to postpone
his case on numerous occasions, while another
disclosed that he would opt to be assigned a
public defender despite having little faith and
trust in them.

77 Establish uniform procedures for the treatment
of individuals granted propria persona status.
77 Provide better access to legal resources for all
individuals who are incarcerated, particularly
individuals granted pro per status.

The OCSD has failed to reform itself despite past litigation and several
recommendations issued by the U.S. Department of Justice. Department officials
have a history of refusing to make changes despite several claims and scrutiny.
Rather than taking remedial measures to improve the OC jail system, the OCSD
has decided time and time again to settle cases or argue them before a jury.
In 1975, pretrial detainees in the Orange County jail
system filed a lawsuit (Stewart v. Gates) in the U.S.
District Court for the Central District of California,
challenging the conditions of their confinement. In
1978, the District Court found unconstitutional
conditions of confinement at the jail and issued
injunctive relief, ordering that reforms be
implemented in several areas, including telephone
access, visitation, law library access, mail, religious
exercise, administrative segregation, meals and
sleeping accommodations. Despite issues regarding
the OCSD’s compliance with the judgment,240 in 2014
the court terminated the ongoing order and injunctive
relief, finding that the injunction was no longer
necessary.241 There continues to be disagreement
about the termination of some of the reform orders.

FIGURE 26: Litigated Files, 2010 to 2016 (OC)










2010	 2011	2012	 2013	2014	 2015

FIGURE 27: Damages Amount, 2010 to 2016 (OC)










2010	 2011	 2012	2013	 2014	2015	 2016


1,855 claims for the OCSD in the amount of more than
$1.5 million (see Figure 28 and 29).243

FIGURE 28: Settled Claims, 2010 to 2016 (OC)









2010	 2011	2012	 2013	2014	 2015

Between 1997 and March 2008, the County of Orange
paid a total of $2.5 million to settle 47 claims of
injuries or abuse stemming from Orange County
Sheriff’s Department jails.242 From January 2010 to
May 2016, 212 claims filed involving the OCSD were
litigated (see Figure 26). This is not to suggest that
there were 212 lawsuits; rather, records showed 212
files dealing with lawsuits during that time. For
example, if 20 people sued the OCSD, that would
represent one lawsuit but 20 records in the system.
The total damages paid from lawsuits within the time
frame was almost $11 million (see Figure 27).From
January 2010 to August 2016, the county settled

Several cases suggest a pattern of misconduct by jail
deputies and inadequate conditions of confinement.
Settlements and lawsuits reveal that county taxpayers
pay the price for the department’s inaction.
77 Jason Gomez: Gomez died following a weeklong
coma after being shocked with a Taser by deputies
at the IRC in 2008. Having gone five days without
his medication for a psychiatric condition, Gomez
was placed in the jail’s psychiatric ward. While
there, he fractured a nurse’s arm.244 After engaging
in a scuffle with deputies, Gomez was restrained
and handcuffed on the floor outside his cell. He
was placed in leg irons, put in a wheelchair and
fitted with a spit mask.245 Deputies placed Gomez in
a physical position that prohibited him from
breathing. According to an independent autopsy
paid for by Gomez’s family, he died as a result of
direct injury to the head. The county will pay
Gomez’s father $2.1 million to settle the lawsuit.246
77 Gilbert Garcia: Garcia died of head injuries
inflicted by deputies in May 1998, after a scuffle on
a jail cell floor in the IRC. According to coroner
officials, Garcia died of internal bleeding caused by
a fractured skull.247 An autopsy found that along
with his fractured skull, three of Garcia’s ribs were
broken. The county paid Garcia’s family $650,000 to
settle the lawsuit.

FIGURE 29: Settlement Amounts, 2010 to 2016 (OC)








2010	 2011	2012	2013	2014	 2015	 2016

77 John Chamberlain: At Chamberlain’s request,
his public defender contacted the OCSD and
asked that he be placed in protective custody
given that he feared for his life.248 Soon after,
Chamberlain was beaten to death by inmates at
Theo Lacy after a deputy misidentified him as a
child molester to the shot-caller in the Woods jail
group and sanctioned that he be “taxed.” The
shot-caller falsely labeled Chamberlain a child
molester to the inmates in the jail’s F West
Barracks.249 About 20 inmates tortured,
sodomized and beat Chamberlain while deputies
in the nearby deputies’ station watched TV, sent
text messages and failed to perform required jail
walk-throughs.250 Chamberlain was dragged to a
blind spot in the unit where he was severely
assaulted.251 According to the coroner,
Chamberlain suffered 43 displaced rib fractures.
The county paid Chamberlain’s father $600,000
to settle his lawsuit.
77 Ryan Gene Epperson: Epperson was beaten by
deputies on March 14, 2002, after asking for
toilet paper. According to the lawsuit, deputies
kicked and punched Epperson. He was left with
cuts, bruises and broken bones.252 The county
paid Epperson $45,000 to settle his lawsuit.
77 German Torres: Torres was beaten in March
2002 after trying to stop deputies from beating
inmate Ryan Epperson. Torres yelled at deputies
to stop hitting Epperson. Subsequently, Torres
was taken out of his cell and beaten as well.253
The county paid Torres $75,000 to settle his
77 Joshua Wilson: Deputies sprayed Wilson with
pepper spray while he was handcuffed and
stunned him with a Taser gun in September 2005.
While still handcuffed, Wilson was punched and
kicked by deputies. He suffered a fractured nose,
ripped lip, busted eye socket and ribs, and
bruised leg and shoulder.254 The county paid
Wilson $49,999 to settle his lawsuit.
77 Jorge Soto: Soto was beaten by deputies after
being booked into the jail. He suffered
permanent injuries. The county paid Soto
$49,999 to settle his lawsuit.255
77 John Doe: A transgender inmate, who declined to
reveal his identity in court records and will be
referred to as John Doe, suffered severe bleeding

and lost more than 25 pounds after deputies
refused to administer prescribed testosterone
shots in October 2004. Deputies refused to give
Doe court-ordered medical treatment despite
being informed by Doe’s primary care physician
that failure to administer regular injections
would result in negative health consequences.256
Instead, jailers harassed Doe. The county paid
Doe $49,000 to settle his lawsuit.
77 Robert Carter: Carter’s case went to trial. A jury
awarded him $177,000 for inadequate medical
care in 2003.257
77 Greg Hall: After Hall complained about the
tightness of his handcuffs, five deputies dragged
him down a corridor, shoved his face into a cell
door frame, threw him to the floor, punched him,
kicked his ribs, stomped on his back and legs,
bent and twisted his arms and wrists, and
repeatedly slammed his face into the concrete.
During the beating, Hall defecated in his pants.
He was handcuffed, hooded and left to sit in his
own feces for 12 hours. Hall left the jail with a
concussion, broken ribs, a cut in his leg, a
bruised eye, broken veins in his feet, a shattered
front tooth, lacerations and bruises over his body,
contusions to his knee, neck pain, a fractured
right wrist and nerve damage to his left hand.258
His civil case went to court in October 2007. The
outcome of the case is unknown.
77 Leonard Mendez: Mendez was assaulted by jail
staff while being booked into the county’s IRC in
1997. His attorney, Jonathan Slipp, said that
Mendez was beaten up by deputies after he told
jailers he was worried that they would lose his
jacket. Mendez was punched and kicked
repeatedly and suffered bruises. The county paid
Mendez $95,000 to settle his lawsuit.259
77 Edward Hadley: Hadley was attacked by other
inmates at the behest of deputies. Hadley alleges
that deputies took him out of his jail cell on April
19, 2005, and ordered other inmates to beat him
up for making “smart” remarks. Inmates beat
Hadley, who suffered broken ribs. The county
paid Hadley $17,500 to settle his lawsuit.260
77 Roman Washington: Washington was beaten and
tasered by deputies at the CMJ after he refused
to answer their questions and asked to speak
with his lawyer. A deputy then ordered him to


A code of silence and cover-ups embedded in jail practices
has obstructed transparency and accountability.
77 Michael Lass: Lass died in October 2007 after
deputies stunned him with a Taser while he was
being restrained inside the jail.267 His father filed
a wrongful-death claim against the county.
77 Blaine Bowker: Bowker filed a lawsuit alleging
that a deputy kicked and punched him.268
77 David A. Elias: Jail staff negligently failed to
properly diagnose and treat Elias’ anemia.269 He
was paid $65,000 in 1995 to settle a suit.

stand up and turn around. Washington said he
complied, but then deputies pounded him and
shocked him. He received seven stitches. The
county paid Washington $15,000 to settle his
77 Matthew Ryan Fleuret: Fleuret sued the OCSD
after alleging that deputies shocked him twice
with a Taser while he was strapped to a
restraining chair in March 2006. The incident was
caught on videotape.262 A jail video showed
Fleuret being placed in a holding cell, then being
held down by at least five deputies.263 Over a
period of about 13 minutes, Fleuret’s arms were
pulled back while he was shocked with a Taser
11 times. The county paid Fleuret $750,000 to
settle the suit in March 2010.264
77 Liza Munoz: Munoz sued the OCSD after
deputies stunned her with a Taser while she was
being held down on the floor in September 2004.
A jail videotape shows a deputy threatening
Munoz with a Taser. 265 The video shows her being
restrained by deputies and screaming. Munoz’s
arms were pulled high above her back, and she
was subdued before the Taser was applied.
Munoz was awarded $25,000 by a federal jury.266


Despite evidence of abuse and misconduct for
several decades, no OCSD sheriff’s deputy has been
charged in connection with an attack or death inside
the OC jail system.270 Figure 30 illustrates the
number of custody staff disciplined for misconduct
from 2010 to 2016. In 2000, two reporters revealed
that four deputies had taken a 20-year-old individual
to an isolated area of the jail in December 1999 and
crushed his testicles.271 Although prosecutors
agreed that the person had been tortured and his
rights violated, silence among jail staff thwarted the
filing of charges. A code of silence and cover-ups
embedded in jail practices has obstructed
transparency and accountability.
FIGURE 30: Custody Staff Disciplined for Misconduct










2010	 2011	2012	 2013	2014	 2015

It is the responsibility of the Orange County Sheriff’s Department to mitigate and
fix systemic or institutional failures that lead to any and all misconduct. In an effort
to protect individual careers and appease the special interests of individuals with
political power, various entities in Orange County have turned a blind eye to deputy
abuse and misconduct.
In the midst of the informant scandal, several
concerns about potential conflict of interests relative
to OCSD oversight prevail. Orange County is one of
the few non-rural counties that combine the sheriff’s
and coroner’s offices. While the Office of the District
Attorney and the Orange County grand jury look into
allegations of abuse, currently the Sheriff’s
Department is tasked with investigating itself. Not
surprising, most cases of deputy misconduct or abuse
never get to the district attorney or grand jury. The
need for oversight that is neutral and objective is
profound. Establishing an impartial oversight body
can restore the public’s trust in the Sheriff’s
Department, and such a body could thoroughly
investigate and report allegations of transgressions or
abuses of power among OCSD deputies and decrease
the number of lawsuits.
After news of the jailhouse informant scandal, Sheriff
Hutchens requested the addition of a constitutional
policing advisor. The position was approved by the OC
Board of Supervisors in March 2016.272 Mary Izadi, a
former deputy district attorney for San Bernardino
County, was selected to fill the position in August
2016 by an outside panel of constitutional policing
experts.273 Izadi is responsible for advising Hutchens
on best practices, policies and procedures;
monitoring internal personnel investigations and
disciplinary matters; reviewing in-custody deaths and
deputy-involved shootings; and performing legal
research and analysis concerning law enforcement
and custody operations.274

Despite not being able to fill the position of executive
director for the Office of Independent Review, and
thus operating without any oversight of the OCSD for
roughly a year, the Orange County Board of
Supervisors unanimously increased spending on
deputy salaries and benefits in September 2016.275
The board approved a salary and benefits contract
with the Association of Orange County Deputy
Sheriffs (AOCDS), granting deputies an 8.8% raise
over three years, costing taxpayers an additional
$62.2 million.276 The AOCDS represents over 1,900
deputies and 100 district attorney investigators.277
The AOCDS spent almost $86,000 in October 2016 to
support an incumbent supervisor’s re-election bid.278

Sheriff-Coroner Budget
Total Final FY 2016-2017


Percent of County General Fund


Total Employees


The three-year agreement between the county and
the AOCDS distributes the raise in five steps, nearly
every six months, between September 2016 and
January 2019, and gives deputies a one-time, lumpsum payment equal to 0.5% of their base salary.279
The county will pay $37.1 million of the salary
increase, while the remaining $25 million is
expected to be covered by contract cities, state funds


and federal grants. According to the Orange County
annual budget, the sheriff-coroner budget accounts
for more than 19% of the county’s general fund (see
Table 18).280 As such a substantial cost driver of the
county budget, the OCSD should be subject to more
accountability and transparency. In the absence of
oversight, the Board of Supervisors has counted on
the judgment of Sheriff Hutchens.281 The AOCDS sued
her and the Sheriff’s Department in February 2016, a
month after three individuals escaped from the
Central Men’s Jail in Santa Ana. The suit referenced
staff reductions, unsafe jail conditions and
operational missteps.282 In June 2016, a sheriff’s
commander and an OCSD spokesman revealed that
deputies violated department policy by failing to
search contractors who worked in the jail or conduct
an inventory of the facility.283 Despite initial coverage,
the Board of Supervisors failed to publicly reexamine or resolve likely institutional problems
concerning the escape. Aside from a jail commander
retiring, little is known.284
In early May 2017, Orange County released its $6.2
billion proposed budget for the 2017-18 fiscal year.
The county estimates it will have $797 million in
general purpose funding, nearly $53 million more
than last year. More than half the $53 million is
proposed to go to the Orange County Sheriff’s
Department.285 General purpose funding, also known
as discretionary funding, is unrestricted which means
the OC Board of Supervisors may allocate the funds
to any county departments and programs under their
If the budget is approved, the department would
receive $29 million in addition to the one-percent
increase, just under $8 million, to be allocated to
each county department.286 The sheriff’s department
would receive a total of $153 million in general
purpose funding, accounting for roughly 19% of the
county’s discretionary funding. Other county
departments, including the Health Care Agency and
Social Services Agency will receive less than a million
dollar increase in discretionary funds on top of the
one-percent increase (see Table 19).287
The increase in the county’s general purpose revenue
was the result of a 4.2% increase in property tax
funds.288 The increase in the department’s


discretionary funding was driven mainly by the
$62-million, three year salary and benefits increase
for deputies and OCSD employees that was
unanimously approved by the Board of Supervisors in
September 2016.289 Of the $62 million, $37 million
was projected to come from county discretionary
funding, $11 million of which was expected this fiscal
year.290 If approved, the budget takes effect July 1.

FY 2017-18

Department Services


Standard 1%

$8 million




$29 million



Total allocation




% of county’s total




(all county

The Office of the District Attorney of Orange County
is supposed to enhance public safety and welfare
through the prosecution of criminal and civil laws.291
Although the responsibilities of the district attorney
and the sheriff require a close working relationship
between the DA’s office and OCSD deputies, that
relationship can sometimes undermine the pursuit
of justice and improperly influence how allegations
of abuse and misconduct are investigated. For
example, all DA investigation reports of in-custodyrelated deaths available online have determined that
the OCSD is not at fault.292
In March 2015, Orange County Superior Court Judge
Thomas Goethals recused the DA’s office from
continuing to prosecute Scott Dekraai, who pleaded
guilty in 2016 to killing eight people at a Seal Beach
hair salon in 2011. Judge Goethals found that the
DA’s office was unlawfully utilizing jailhouse
informants and unconstitutionally concealing the

District Attorney Tony Rackauckas himself issued a report
declaring the DA office a “rudderless” ship and called for a
complete investigation into the use of jailhouse informants.
information from defense lawyers.293 The state
Attorney General’s Office has taken over the case.
In January 2016, amid the informant scandal, a
committee of legal experts selected by District
Attorney Tony Rackauckas himself issued a report294
declaring the DA office a “rudderless” ship and called
for a complete investigation into the use of jailhouse
informants.295 The report revealed grave failings in
supervision and training in the DA’s office and cited a
“win-at-all-costs” mentality among some
prosecutors.296 The panel specifically called for the
grand jury, the state attorney general or the U.S.
Department of Justice to investigate allegations that
prosecutors and police exploited a classified network
of jail informants and deliberately withheld evidence
from defense attorneys. The network routinely
violated the constitutional rights of criminal
defendants to secure convictions or enhanced
sentences.297 Several cases in addition to the highprofile example of Dekraai highlight systemic
attempts by the Sheriff’s Department and the District
Attorney’s Office to circumvent the constitutional
protections allowed to criminal defendants.298 The
decision to conceal logs and a computerized records
system known as the TRED, which details the
handling and movements of informants, along with
Brady material299 contained within them, suggests a
willful disregard by the OCSD and the DA for due
process and the protection of rights.300
In December 2016, the U.S. Department of Justice
opened a civil rights investigation into the Sheriff’s
Department and the District Attorney’s Office.301 The
investigation follows the county’s “jailhouse snitch
scandal,”302 including allegations that prosecutors
and law enforcement routinely withhold evidence and
use jailhouse informants to illegally obtain
confessions.303 Vanita Gupta, former principal deputy
assistant attorney general and former acting head of

the Civil Rights Division at the Department of Justice,
said, “A systemic failure to protect the right to
counsel and to a fair trial makes criminal
proceedings fundamentally unfair and diminishes the
public’s faith in the integrity of the justice system.”304
The DOJ, the attorney general and the Orange
County grand jury (independent of one another) are
investigating the cover-up. The investigations point
to signs of systemic wrongdoing. The minimum
threshold to launch an investigation is that
wrongdoing is routine and ongoing.305 According to a
report from the DOJ, the Civil Rights Division has
opened 69 investigations since 1994 (when a federal
law was passed granting such probes); 40 of the
investigations resulted in reform agreements. If a
pattern and practice of misconduct is confirmed, the
Civil Rights Division will write a “findings report” and
present it at a public forum before prosecutors, law
enforcement, community stakeholders and others.
Before negotiating any court-enforceable reform
agreement with the agencies involved, the division
will seek community input. If no systemic
wrongdoing is identified, investigators will close the
file. Usually, investigations take more than a year.306
Incorporating a monitor to provide oversight and
enforcement would be paramount.

The Orange County Office of Independent Review was
established by the Board of Supervisors in 2008
through a contract with the Office of Independent
Review (OIR) Group.307 The office’s purpose is to
oversee, assist and advise the Orange County
Sheriff’s Department in investigations of alleged
officer misconduct and reviews of critical incidents,
including officer-involved shootings and in-custody
deaths.308 Although recommended and strongly
supported by OCSD Sheriff Hutchens, the director of


the office, Stephen Connolly, had trouble satisfying
the Orange County Board of Supervisors.309
From 2001 to June 2014, the Office of Independent
Review Group was employed by the Los Angeles
County Board of Supervisors.310 The task of the OIR
was to monitor the Los Angeles County Sheriff’s
Department (LASD) and provide legal advice to
ensure that investigations of allegations of useof-force incidents, officer-involved shootings, and
internal affairs and internal criminal matters were
thorough, effective and just.311 Under the leadership
of Michael Gennaco, the OIR in Los Angeles was
criticized for being overly embedded with the LASD
and then-Sheriff Lee Baca. Peter Eliasberg, then
legal director of the American Civil Liberties Union
of Southern California, said, “When the sheriff was
being criticized by the ACLU, Gennaco used to show
up at the sheriff’s press conferences and stood by
him, which added to the perception that the OIR was
not independent, and more interested in defending
the sheriff.”312 Eliasberg also pointed out that the
Commission on Jail Violence in Los Angeles County
said there was an enduring pattern of force while
the OIR existed. He questioned, “How did that
pattern happen if the OIR was providing effective
oversight?”313 The Office of Independent Review
Group became a private business after they were
disbanded at the request of Inspector General Max
Huntsman in Los Angeles.314
Similarly, the 2011-2012 Orange County grand
jury questioned Connolly’s placement in the
county organization. Although the OIR’s executive
director and professional staff were independent
contractors,315 concerns surfaced given the OIR’s
attorney-client relationship with the OCSD.316 The
relationship between the office and the department

was considered to be overly enmeshed and raised
concerns as to the objectivity of the director’s
findings317 and recommendations.318 Rather than
conducting its own investigations, the OIR monitored
and contributed to the OCSD’s protocols.
In July 2015, the OC Board of Supervisors
unanimously determined that the Office of
Independent Review oversight model was not as
effective as it could be. Yet in December 2015,
the board voted to extend the office’s purview
to include oversight of the public defender, the
district attorney, the Social Services Agency and the
Probation Department.319 In March 2016, Connolly
submitted his resignation with the OIR amid several
high-profile controversies including the informant
scandal,320 the 2016 jail escape321 and the subsequent
AOCDS deputies’ lawsuit regarding unsafe jail
conditions.322 Gennaco, who had worked with
Connolly at the OIR Group, has been working with
the Orange County Board of Supervisors to assist in
the transition of the OIR office.
In January 2017, the Board of Supervisors directed
staff to hire a new executive director for its Office
of Independent Review.323 County supervisors voted
unanimously to negotiate a contract with Gary
Schons. Schons, a seasoned prosecutor, led the
criminal division of the state Attorney General’s
Office in San Diego for 20 years and is currently
employed at Best Best & Krieger law firm.324 Two
weeks after being offered the job, Schons withdrew
his application, citing potential conflict of interests
with his law firm.325 The position will remain unfilled
indefinitely. The Board of Supervisors, which has
operated without any external law enforcement
oversight for nearly a year, will launch another
search to fill the position.326

Under the leadership of Michael Gennaco, the OIR in Los
Angeles was criticized for being overly embedded with the
LASD and then-Sheriff Lee Baca.

The OCSD should take
remedial measures and
make internal changes to
avoid future settlements.
Enduring issues suggest
that the SAFE Division is
falling short of its intended

Each California county is required by law to impanel
a body of 19 to 23 members, depending on county
population, to serve as a grand jury for a term of one
year.327 The grand jury is mandated to investigate and
report on criminal and civil matters within the county.
On the last day of the yearlong term, the grand jury
is required to submit all final reports to the presiding
judge of the Superior Court.328 The reports include
all studies and investigations conducted by the jury
during its term. The OCSD receives a copy of its
individual report with a requirement that response
to findings and recommendations be made within 90
days.329 Limitations of this oversight model include
that the grand jury is impaneled only for a year.
Hence, it has limited expertise and no institutional
continuity on oversight issues. Furthermore, the
current system of oversight for jail facilities looks
only at whether deputies follow existing laws and
policies but does not address questions surrounding
policies themselves. Previous investigations resulted
in reports detailing recommendations and changes
the department needed to make, however they were
largely ignored as we are seeing the same problems
arise year after year.

The Strategy, Accountability, Focus and Evaluation
(SAFE) Division was initiated by the Orange County
Sheriff’s Department in October 2008. The division
is composed of two bureaus: the Risk Management
Bureau and the SAFE Bureau.330
The Risk Management Bureau works with county
counsel and the county’s Management Office on
legal issues and serves as the OCSD’s liaison to
the grand jury.331 The bureau further evaluates
legislative mandates and policy and procedures,
provides training to mitigate risk to the department
and its employees, and facilitates civil litigation that
The SAFE Bureau revises and creates policies and
procedures to bring the department up to standards
through best practices.333 The SAFE Bureau aims
to reduce the department’s exposure to liability
and create a database to oversee the strengths and
weaknesses within units and divisions.334 Although
the SAFE Division purports to take a proactive
approach to minimizing the department’s liabilities
and maintaining required training up to standard, the
county has a history of settling claims and asserting
no guilt or responsibility of allegations. The division
is also tasked with tracking incidents and carrying
out administrative investigations against department
staff who engage in misconduct. The division either
poorly tracks data or fails to provide public access to
such information. The OCSD should take remedial
measures and make internal changes to avoid future
settlements. Enduring issues suggest that the SAFE
Division is falling short of its intended mission.


Failing to remedy poor conditions of confinement and hold deputies accountable for
misconduct, the Orange County Sheriff’s Department has implicitly endangered the
constitutional rights of incarcerated individuals.
The department must adequately train and supervise
custody staff, conduct thorough and just investigations
of excessive use-of-force incidents, hold custody staff
accountable for misconduct and wrongdoing, and
confront the entrenched code of silence that hinders
reform and true progress. Conditions of confinement
should be monitored on an ongoing basis to ensure
compliance with department policies, Title 15
regulations and individuals’ constitutional rights.
This report intends to encourage the Orange County
Sheriff’s Department to act to ensure that potential
violations and noncompliance issues are preemptively
corrected. Continuing the investigation into the
conditions of the Orange County jail system can
help assess whether any more systemic violations
exist. The stark similarities of narratives shared
by incarcerated individuals as well as formerly
incarcerated individuals suggest that several issues
may be the result of systemic issues rather than
isolated instances of wrongdoing.
Allegations of abuse and negligence, as well as
a shortage of accountability and transparency,
cannot and should not be ignored. Failing to correct
deficiencies may demonstrate deliberate indifference
by the department. Conversely, taking remedial
action can protect incarcerated individuals from poor
conditions of confinement, restore public confidence
in county law enforcement and release the county
from potential litigation. The department must work
with the community to effectively and sustainably
reform patterns and practices of excessive force,
subpar medical and mental health treatment, and poor
conditions of confinement.
There needs to be real accountability for an entity
that accounts for nearly 20% of the county’s general
fund. While taxpayers bear the financial costs, the
community at large must deal with the psycho-socioemotional impacts of a counterproductive criminal

justice system on children, youth and families. As
the need for a truly independent investigation by an
impartial body remains, the Orange County Sheriff’s
Department should look to an external entity to
remedy developing issues early on and monitor the
implementation of reforms to ensure sustainable
change. The department needs to start a comprehensive
review and inspection of all five OCSD jail facilities. An
objective oversight monitor with substantive power can
help release the Sheriff’s Department and the county
from legal liability and ensure that good governance
trumps political expediency in Orange County.
ACLU SoCal has outlined several recommendations,
which includes critical civil liberties that are of great
significance to the integrity of the American justice
system. We urge Sheriff Sandra Hutchens and her staff
to implement these recommendations immediately
– many of which have been recommended in the
past – and create a department that is committed
to constitutional custody and in accordance to state
and federal regulations. Discriminatory policies and
abusive actions violate the rights of individuals who are
incarcerated and can result in liability concerns for the
Department and County.
Justice in principle is not enough; the OCSD must do
more to ensure justice in practice.
We demand the OCSD to bridge the gap between
custody policies and practice as well as support the
creation of an impartial and independent oversight
body to oversee all custody operations and report
directly to the County Board of Supervisors. In order to
restore public trust, the department will finally have to
adhere and embrace transparency and accountability
over unlawful practices and adverse codes of silence.
We look forward to working with the sheriff and her
administration to act preemptively and help address
these pressing issues.



Executive Command
“The Executive Command is commanded by the Undersheriff whose
responsibility is to provide general management, direction and control
for administration related services.”
Administrative Services Command

Executive Command
Community Programs and Services
Communications and Technology

Financial/Administrative Services
“The Administrative Services Command is commanded by an Executive
Director whose primary responsibility is to provide general management, Research and Development
direction and control for administrative related services.”
Support Services
Custody Operations Command
“The Custody Operations Command is commanded by an Assistant
Sheriff whose primary responsibility is to provide general management,
direction and control for custody related operations and court related

Court Operations
Central Men’s and Women’s Jails
Intake/Release Center and Transportation
Musick Facility
Theo Lacy Facility
Inmate Services

Field Operations and Investigative Services Command
“The Field Operations and Investigative Services Command is
commanded by an Assistant Sheriff whose primary responsibility is
to provide general management direction and control for field related
operations and investigative related services.”

Airport Operations
Emergency Management
Homeland Security
North Operations
South Operations
Patrol Areas

Professional Services Command
“The Professional Services Command is commanded by an Assistant
Sheriff whose primary responsibility is to provide general management
direction and control for administrative related services in the

OC Crime Lab
Professional Standards

Source: Orange County Sheriff’s Department (January 2017). Commands and Divisions. Retrieved from



Paul D’Auria

Chris Corn

Jason Park
Theo Lacy Facility

Carl Bulanek
Theo Lacy Facility

Randy Johnson
Admin Manager II
ISD Operations

Geoff Henderson
Admin Manager II
Programs & Services

Greg Boston
Inmate Services

Buffy O’Neil
Admin Manager II
ISD Administration

Tracy Carroll
Admin Manager II
Inmate Records

Watch Commanders
Lt. M. Cataline
Lt. C. Denison
Lt. E. Larsen
Lt. G. Peloquin
Lt. J. Webb

Watch Commanders
Lt. S. Hernandez
Lt. L. Koehmstedt
Lt. K. Mittermeier
Lt. E. Nester

Watch Commanders
Lt. B. Benson
Lt. J. Cope
Lt. E. Manhart
Lt. J. Van Patten

Watch Commanders
Lt. B. Copeland
Lt. D. Lemmon
Lt. D. Missel
Lt. R. Shirakawa
Lt .Q. Vuong

Mark Gonzales
Airport Police
Services Bureau

Dave Johnson
James A. Musick

Rob Gardner
Central Jail Division

Matt Mc Daniel

Wayne Byerley
Airport Operations

Andy Stephens
Custody Intelligence

Brian Schmutz
James A. Musick

Jon Briggs
Custody Operations

Cindi Coppock
Central Jail Division

Garrett Degiorgio
ICE Coordinator

Eleanore Coplan

Bob Pe ter son
Assistant S heriff
Custod y Oper atio ns Command

Department Commander
Lt. S. Gil
Lt. W. Rehnelt
Lt. J. Roche
Lt. M. Stiverson
Lt. N. Wilson

Gene Inouye
Communications Bureau

Kenneth Binning
Mission Viejo

Roger Guevara
Security Bureau

Mike Jensen
Mass Transit Bureau

Ross Caouette

Luke South
Rancho Santa

Jarrett Kurimay
Yorba Linda

Martin Ramirez

Brad Valentine
Lake Forest

Mitch Wang
Investigations & DET

Sheryl Dubsky

Sean Howell

Jeff Puckett
North Patrol/Villa Park

Dave Sawyer
North Operations

Scott Ostash
Reserves Bureau

Chris Hays
Special Enforcement

Mark Alsobrook
Harbor Patrol Bureau

Joe Balicki
Homeland Security

Stu Greenberg
Field Operations

Scott Spalding
San Juan Capistrano

Matthew Barr
Laguna Niguel

Mike Peters
San Clemente

Roland Chacon
Laguna Hills

Russ Chilton
Dana Point

John MacPherson
Aliso Viejo

Fred Thompson
Investigations &
Laguna Woods

Jim England

Jessica Leauasoga

Lane Lagaret
Public Information

Public Affairs

Bonnie Foster
Executive Secretary

Lisa Zinn
Assistant Director
Cal-ID Bureau

Heather Pevney
Assistant Director
DNA Bureau

Jennifer Harmon
Assistant Director
Forensic Chemistry

Joseph Jaing
Assistant Director
Criminalistics Bureau
& Clerical

Kim Brown
Assistant Director

Bruce Houlihan
Crime Lab

Michelle Anderson
Deputy Director

Donna Boston

Bill Nimmo

Tracy Morris
Special Investigations

Mark Stichter
Criminal Investigations

Ken Burmood

Bruce Lyle
Assistant Chief
Deputy Coroner

Bob Osborne
Coroner Division

William Baker
Investigative Services

Identification Bureau &
Evidence Control Unit

James Guarneri
Development Unit

Don Barnes

Sandra Hutchens
Jeff Mclain
Sheriff’s Executive

Sheriff’s Advisory

Ada m Powell
Assistant S heriff
Field Oper atio ns & Inve stigative
Ser vices Command

Drug Use Is Life
Abuse (DUILA)

Orange County Sheriff-Coroner Department

North Justice Center
Civil Support Unit

Lisa Von Nordheim

Lamoreaux Justice Center

Mike McHenry
Central Justice Center

Vince Bravata
West Justice Center
Harbor Justice Center
Civil Support Unit

Jim Rudy
Court Operations

Bryan Thomas
SAFE Bureau

Janet Hayes
Admin Manager II
SAFE Bureau

Marilyn MacDougall

Richard Sanchez
Admin Manager II
HR Manager

Kevin La Pryne

Jason Danks
Standards Bureau

John Coppock
Standards Division

Dave Moodie
Field Training

Jared Dahl
Training Bureau

Brad Virgoe
Training Division

Jeff Hallock
Professional Services

Donna Muleady

Steve K ea
Assistant S heriff
Pro fessional Services Command

Andy Ferguson
SAFE Division

Mary Izadi
Policing Advisor

Delia Kraft
Admin Manager II
Program Support

Steve Miller
Assistant Director
Engineering &
Technical Services

David Fontneau
Communications &
Technology Division

Mark Mraz

Lynn Yamada
Admin Manager II
Law Enforcement
Contracts &
ASR Services

Linh Vuong
Admin Manager II
Cost/Audit Services

Ryan Van Otterloo
Admin Manager II
Budget Services

Sharon Tabata
Assistant Director

Noma Crook
Services Division

Jeff McMillan
Admin Manager II
Facilities Operations

Steve Hilleshiem
Admin. Manager II
Facilities Planning

Michael Dittenhofer
Admin Manager II
Management Section

Carol Morris
Assistant Director
Records &
Information Services
Ed Lee & Jerry Soto
Admin Manager II
Information Services

Matthew Monzon
Research &
Development Division

Kirk Wilkerson
Support Services

Robert Beaver
Senior Director
Administrative Services

Donna Muleady

Bria n Wayt
Executive Directo r
Admini strative Se rvices Co mmand

Effective: June 9, 2017



In-Custody Deaths, 2010 to 2016






04/22/1967 –

01/30/1963 –

02/21/1964 –

07/20/1981 –

01/17/1964 –

05/09/1969 –







11/17/1919 –

02/22/1980 –

08/25/1947 –

10/26/1982 –

10/08/1981 –

02/23/1960 –







07/07/1965 –

09/09/1971 –

09/03/1977 –

08/05/1962 –

09/18/1988 –

05/21/1973 –







08/19/1973 –

05/16/1967 –

09/26/1972 –

08/24/1964 –

01/08/1941 –

05/08/1948 –







10/31/1969 –

02/19/1957 –

10/26/1960 –

11/01/1955 –

08/31/1988 –

08/07/1962 –







05/05/1955 –

09/17/1965 –

12/19/1985 –

06/08/1956 –

02/01/1965 –

10/03/1947 –







03/12/1967 –

09/27/1961 –

07/20/1966 –

09/29/1947 –

09/27/1952 –

01/08/1982 –







05/02/1991 –

03/20/1988 –

01/12/1960 –

09/05/1973 –

02/28/1990 –

08/10/1951 –



Bernadette Rabuy and Peter Wagner, “Correctional Control:
Incarceration and Supervision by State,” Prison Policy Initiative,
last modified June 1, 2016,


Bernadette Rabuy and Peter Wagner, “Mass Incarceration: The
Whole Pie 2016,” Prison Policy Initiative, last modified March 14,


“The Road to Reform: Accountability in the L.A. County Jails,” ACLU


“Custody Operations Command,” Orange County Sheriff’s
Department, accessed May 9, 2017,


Jesse Bogan, “In Pictures: America’s Biggest Jails,” Forbes, last
modified July 13, 2009,


Not to be confused with Los Angeles County Men’s Central Jail (MCJ)


“New Details,” Orange County Sheriff’s Department, last
accessed December 5, 2016,



“FY 2016-2017 Annual Budget: 060 — Sheriff-Coroner,” Orange
County Executive Office, last accessed January 14, 2017, http://www.
Meghann M. Cuniff, “There’s Room in O.C. Jails, but Not Everyone
Ordered There Is Going. Here’s Why,” The Orange County Register,
last modified April 7, 2015,


Rick Reiff, “Inside OC: Sheriff Hutchens Says Likely to Run Again;
Discusses Jail Break, Informant Scandal,” Voice of OC, last modified
May 13, 2016,


“Policy 200 — Organizational Structure and Responsibility,” Orange
County Sheriff’s Department, accessed from California Public
Records Act request in 2015


“OCSD Command Staff and Division Commander’s Organization
Chart,” Orange County Sheriff’s Department, last accessed
February 8, 2017,


Refer to Appendix A to view the OCSD organizational chart

20	 “FY 2016-2017 Annual Budget: 060 — Sheriff-Coroner,” Orange
County Executive Office, last accessed January 14, 2017, http://www.
21	Ibid.
22	 “Policy 203.3 — Custody and Court Operations Command,” Orange
County Sheriff’s Department, accessed from CPRA request in 2015
23	 “Detention Facilities Report: 2011-2012.”
24	 “Policy 203.3 — Custody and Court Operations Command.”
25	 “Detention Facilities Report: 2011-2012.”
26	Ibid.


“Detention Facilities Report: Part I — Adult 2011-2012,” Orange
County grand jury, last accessed January 3, 2016, http://www.

27	 “Annual Inquiry on Jails and Juvenile Detention Facilities 2014-2015,”
Orange County grand jury, last accessed January 3, 2016, http://www.


Peggy Lowe, “New sheriff has new style,” The Orange County
Register, last modified June 20, 2008, http://www.ocregister.

28	 “Policy 203.3-Custody and Court Operations Command.”





Susan Abram, “Former L.A. County Sheriff Lee Baca sentenced
to 3 years in jail abuse scandal,” The Orange County Register, last
modified May 12, 2017,

29	 “Annual Report on Jails and Juvenile Detention Facilities 2013-2014,”
Orange County grand jury, last accessed January 3, 2016, http://www.
30	 Lauren Jow, “What You Should Know About Musick Jail Expansion,”
The Orange County Register, last modified October 8, 2013, http://

Ted Rohrlich, “Family Gets $1.3 Million in Wrongful Death Case,”
The Los Angeles Times, last modified July 24, 1986, http://articles.

31	 “FY 2016-2017 Annual Budget: 060 — Sheriff-Coroner.”

Stuart Pfeiter and Christine Hanley, “O.C.’s street cop,” The Los
Angeles Times, last modified June 22, 2008, http://articles.latimes.

33	Ibid.

Tony Saavedra and Greg Hardesty, “Sheriff Hutchens Wins Election,”
The Orange County Register, last modified June 9, 2010, http://www.

35	 “Condition of Orange County Jails 2008-2009,” Orange County grand
jury, last accessed January 3, 2016,

32	 Jow, “Musick Jail Expansion.”

34	Ibid.

36	Ibid.
37	Ibid.


38	Ibid.
39	 “Annual Inquiry on Jails 2014-2015.”
40	 “Jail Profile Survey: Rated Capacities of Type II, III, & IV Local
Adult Detention Facilities,” Board of Community and State
Corrections, last modified April 7, 2016,
41	 “Detention Facilities Report: Part I — Adult Jails,” Orange County
grand jury, 2013,
42	Ibid.
43	Ibid.
44	 “P-1: State Population Projections (2010-2060): Total Population
by County: 1-year increments,” California Department of Finance,
45	 “Inmate Profile for all Facilities on March 24, 2017,” Orange County
Sheriff’s Department, accessed from CPRA request
46	 The Orange County Sheriff’s Department uses the term “Hispanic”
47	 “Detention Facilities Report: 2011-2012.”
48	 “Annual Report on Jails 2013-2014.”
49	 “Annual Inquiry on Jails 2014-2015.”
50	 Mia Bird, Sonya Tafoya, Ryken Grattet and Viet Nguyen, “How Has
Proposition 47 Affected California’s Jail Population?” Public Policy
Institute of California, March 2016,

58	 Jordan Graham, “Orange County Sheriff Sandra Hutchens Asks
Trump Administration to Help Her Hold Undocumented Immigrants,”
The Orange County Register, last modified March 13, 2017, http://
59	 “Review of Orange County Detention Facilities,” Orange County grand
jury, 2011,
60	 “Detention Facilities Report: Adult Jails 2012-2013.”
61	 Tony Saavedra and Imran Ghori, “Orange County Sheriff: California
Bill Could Cost Department $26 Million Contract,” The Orange
County Register, last modified April 6, 2017, http://www.ocregister.
62	 Jordan Graham, “Orange County Sheriff Sandra Hutchens Asks
Trump Administration to Help Her Hold Undocumented Immigrants,”
The Orange County Register, last modified March 13, 2017, http://
63	 “Management Alert on Issues Requiring Immediate Action at
the Theo Lacy Facility in Orange, California,” U.S. Department of
Homeland Security, Office of Inspector General, https://www.oig.dhs.
gov/assets/Mga/OIG-mga-030617.pdf on March 9, 2017
64	 “Death in Custody Data, Orange County Deaths, 2010 — May 2016
(Preliminary),” State of California, Department of Justice, May 2016
65	 Orange County Sheriff-Coroner Department, Coroner Division, no
66	 “Hispanic” is the term used by the Orange County Sheriff’s
67	 “Death in Custody Data, Orange County Deaths, 2010 — May 2016.”

51	 Ricardo Goodridge, Proposition 47 funding, Board of State and
Community Corrections, February 2, 2017, accessed from PRA

68	 “Criminal Statistics Reporting Requirements,” California Department
of Justice, Criminal Justice Statistics Center, April 2014, http://oag.

52	 Sonya Tafoya, “Pretrial Detention and Jail Capacity in California,”
Public Policy Institute of California, July 2015,

69	 “Attorney General Kamala D. Harris Announces New Law
Enforcement Reporting Requirements for Officer-Involved Shootings
and Use of Force,” Office of the Attorney General, December 28, 2015,

53	Ibid.
54	 Erwin Chemerinsky, “Create a Justice Fund for Universal
Representation,” The Orange County Register, last modified March
16, 2017,
55	 Gabriel San Roman, “Santa Ana Becomes Orange County’s 1st
‘Sanctuary City,’ Moves to End ICE Jail Contract,” OC Weekly, last
modified December 7, 2016,
56	 Memorandum of Agreement, U.S. Immigration and Customs
Enforcement, Department of Homeland Security, retrieved from
57	 Grace Wyler, “Being a Sanctuary City: What It Means, What Cities
Can Do, and What They Can’t,” The Orange County Register, last
modified December 16, 2016,

70	 Reports about in custody deaths are available at http://
71	 Rob Barry, “Hundreds of Police Killings Are Uncounted in Federal
Stats,” The Wall Street Journal, last modified December 3, 2014,
72	 Nick Schou, “Blind Spot,” OC Weekly, last modified March 29, 2007,
73	 “Investigation of the Orange County Jail: Investigatory Results Letter,”
U.S. Department of Justice, Civil Rights Division, March 4, 2014,
74	Ibid.
75	 CPRA request, Orange County Sheriff’s Department, March 1, 2017
76	 “Policy Manual. Policy 300. Use of Force,” Orange County SheriffCoroner Department, 2015, retrieved from PRA request


77	Ibid.
78	Ibid.
79	 “Investigation of the Orange County Jail: Investigatory Results Letter.”
80	 Scott Moxley, “Justice Takes a Beating,” OC Weekly, last modified
August 11, 2005,
81	 “Policy Manual. Policy 300.3.3. Control Hold/Pain Compliance
Techniques,” Orange County Sheriff-Coroner Department, 2015,
retrieved from PRA request
82	 Ibid.
83	 “Policy Manual. Policy 300.3.2. Voluntary Compliance,” Orange
County Sheriff-Coroner Department, 2015, retrieved from PRA
84	 “Policy Manual. Policy 300. Use of Force,” Orange County SheriffCoroner Department, 2015, retrieved from PRA request
85	 “Annual Report on Jails 2013-2014.”
86	 R. Scott Moxley, “Justice Takes a Beating,” OC Weekly, last modified
August 11, 2005,
87	 Nick Schou, “Jared Petrovich Admits His Role in the Killing of John
Chamberlain. But Why did He Target the Guy?” OC Weekly, last
modified April 3, 2008,
88	Ibid.

100	 “Minimum Standards for Local Detention Facilities, Title 15 — Crime
Prevention and Corrections. Division 1, Chapter 1, Subchapter
4. 1038, Limitations on Disciplinary Actions,” Board of State and
Community Corrections, 2012,
101	 “Jailhouse Lawyer’s Handbook: Your Right to be Free from
Unreasonable Searches and Seizures,” no date, http://jailhouselaw.
102	 “The State of Orange County Jails,” Orange County grand jury, 2008,
retrieved from
103	 Sandra Hutchens, “Response to Orange County Grand Jury 20102011 Report, ‘Review of Orange County Detention Facilities,’ ” April
15, 2011,
104	 “Investigation of the Orange County Jail: Investigatory Results Letter.”
105	 “Policy Manual. Policy 368. Limited English Proficiency Services,”
Orange County Sheriff-Coroner Department, 2015, accessed from
Public Records Act request
106	 Inmate Profile, Orange County Sheriff’s Department, 2015, accessed
from Public Records Act request
107	 All uses of the term “sex” in the Penal Code refer specifically to
gender identity and gender expression. See Cal. Penal Code §
422.56(d) (“‘Gender’ means sex, and includes a person’s gender
identity and gender expression. ‘Gender expression’ means a
person’s gender-related appearance and behavior whether or not
stereotypically associated with the person’s assigned sex at birth.”);
see also Cal. Penal Code § 422.57 (applying the definition of “sex”
from Section 422.56 to the entire Penal Code).

89	 Nick Schou, “Blind Spot,” OC Weekly, last modified March 29, 2007,

108	 28 C.F.R. § 115.15(a).

90	Ibid.

109	 See Byrd v. Maricopa Cnty. Sheriff’s Dep’t, 629 F.3d 1135 (9th Cir.
2011) (en banc) (Fourth Amendment); Jordan v. Gardner, 986 F.2d
1521, 1531 (9th Cir. 1993) (en banc) (Eighth Amendment).

91	Ibid.
92	Ibid.
93	 Schou, “Petrovich Admits His Role in the Killing of John
94	 Tami Abdollah, “U.S. Probes Orange County’s Jail System,” Los
Angeles Times, last modified August 14, 2009, http://articles.latimes.
95	 Kelly Puente and Tony Saavedra, “Feds Launch Investigation into
Orange County D.A.’s Office, Sheriff’s Department over Jailhouse
Informants,” The Orange County Register, last modified January
6, 2017,
96	 Salvador Hernandez, “O.C. Jails Become More Dangerous, Violent,
Officials Report,” The Orange County Register, last modified
September 13, 2012,
97	 “Annual Report on Jails 2013-2014.”
98	 “Detention Facilities Report: 2011-2012.”
99	 “Investigation of the Orange County Jail: Investigatory Results Letter.”


110	 Cal. Penal Code § 422.56; Cal. Penal Code § 422.57 (applying the
definition of “sex” from section 422.56 to the entire Penal Code).
111	 See Tasha Hill, “Sexual Abuse in California Prisons: How the
California Rape Shield Fails the Most Vulnerable Populations,” 21
UCLA Women’s L.J. 89, 116 (2014).
112	 National PREA Resource Center, “Can You Please Clarify
the Parameters of Conducting a Search of a Transgender or
Intersex Inmate/Resident?” (February 7, 2013), http://www.
113	 “Jailhouse Lawyer’s Handbook: Your Right to be Free from
Unreasonable Searches and Seizures,” no date, http://jailhouselaw.
114	Ibid.
115	 Pretrial inmates are protected under the 14th Amendment, and
post-conviction inmates are protected under the Eighth Amendment,
where jails are liable for “deliberate indifference” to a “substantial
risk of serious harm” to an inmate. Castro, 2016 WL 4268955, at *4.

116	 A study of California prisons found that transgender women in
men’s prisons were 13 times as likely to be sexually abused as
other inmates. Valerie Jenness, et al., Univ. of Cal. Irvine Ctr. for
Evidence-Based Corr., “Violence in California Correctional Facilities:
An Empirical Examination of Sexual Assault,” 2 (2007), http://

135	Ibid.

117	 28 C.F.R. § 115.42(a).

137	Ibid.

118	 28 C.F.R. § 115.41(d).

138	 Marvin Mentor, “Corruption in Orange County, CA Sheriff’s
Department Revealed; Sheriff Resigns, Convicted on Criminal
Charges,” Prison Legal News, February 2009, https://www.

119	 See 28 C.F.R. § 115.42(b).
120	 National PREA Resource Center, “Does a Policy That Houses
Transgender or Intersex Inmates Based Exclusively on External
Genital Anatomy Violate Standard 115.42(c) & (e)?” (March 24, 2016),
121	 See 28 C.F.R. § 115.42(e).
122	 See Id.
123	 See Diamond v. Owens, 131 F. Supp. 3d, 1346, 1378 (M.D. Ga. 2015)
(“[A] transgender inmate’s vulnerability to assault at a closedsecurity male facility was obvious....”); A study of California prisons
found that transgender women in men’s prisons were 13 times as
likely to be sexually abused as other inmates. Valerie Jenness, et
al., Univ. of Cal. Irvine Ctr. for Evidence-Based Corr., “Violence in
California Correctional Facilities: An Empirical Examination of Sexual
Assault,” 2 (2007),
124	 28 C.F.R. § 115.43(a) (2012) (“Inmates at high risk for sexual
victimization shall not [automatically] be placed in involuntary
segregated housing ....”) (emphasis added).
125	 28 C.F.R. § 115.43(b) (2012); see also Tates v. Blanas, No. CIV S-002539 OMP P, 2003 U.S. Dist. LEXIS 26029, at *27-30 (E.D. Cal. Mar. 6,
126	 Second Amended Complaint, McKibben, et al. v. McMahon, et al., No.
14-2171-JGB-SP (C.D. Cal. May 20, 2015).
127	 “Does a policy that houses transgender or intersex inmates based
exclusively on external genital anatomy violate Standard 115.42(c) &
(e)?” National PREA Resource Center, accessed May 9, 2017, https://
128	 Allen J. Beck, Marcus Berzofsky, Rachel Caspar and Christopher
Krebs, “Sexual Victimization in Prisons and Jails Reported
by Inmates, 2011-12 — Update,” Bureau of Justice Statistics,
last modified December 9, 2014,
129	 “Inmate Jail Rules JOM Section 1600 — 1600.2(p) Cleanliness,”
University of Michigan Law School Policy Clearinghouse, Freedom of
Information Act request
130	 “Prison and Jail Standards,” National PREA Resource Center,
accessed May 9, 2017,
131	 “Law Enforcement Contract Services,” Orange County Sheriff’s
Department, no date,
132	 “Condition of Orange County Jails 2008-2009.”
133	 “Detention Facilities Report: Adult Jails.”
134	Ibid.

136	 Greg Mellen, “Triage Nurse Brings Order to Chaos During Late-Night
Shift,” The Orange County Register, last modified February 15, 2015,

139	 “The State of Orange County Jails,” Orange County grand jury, 2008,
140	 “Investigation of the Orange County Jail: Investigatory Results Letter.”
141	Ibid.
142	Ibid.
143	 Gabriel San Roman, “Federal Lawsuit Seeks $15 Million for OC
Inmate Death,” OC Weekly, last modified July 14, 2014, http://www.
144	 Claudia Koerner, “Lawsuit: O.C. Inmate Died After Untreated Heroin
Withdrawal,” The Orange County Register, last modified July 10,
145	Ibid.
146	 Board of State and Community Corrections, no date, retrieved from
147	Ibid.
148	 Melissa Goodman, Ruth Dawson and Phyllida Burlingame,
“Reproductive Health Behind Bars in California,” ACLU of California,
January 2016,
149	Ibid.
150	Ibid.
151	 Melissa Goodman, Ruth Dawson and Phyllida Burlingame,
“Reproductive Health Care in California Jails: A Tool to Assess and
Reform Policies and Practices,” ACLU of California, January 2016,
152	 Melissa Goodman, Ruth Dawson and Phyllida Burlingame,
“Reproductive Health Behind Bars in California,” ACLU of California,
January 2016,
153	 Gender Dysphoria, American Psychiatric Association (2013), http://
pdf. “For a person to be diagnosed with gender dysphoria, there
must be a marked difference between the individual’s expressed/
experienced gender and the gender others would assign him or
her.… Gender dysphoria is manifested in a variety of ways, including
strong desires to be treated as the other gender or to be rid of one’s
sex characteristics, or a strong conviction that one has feelings and
reac¬tions typical of the other gender.”


154	 Am. Med. Ass’n, “Resolution: Removing Financial Barriers to Care
for Transgender Patients” (2008),
pub/about-ama/our-people/member-groups-sections/glbt-advisorycommittee/; Am.
Psychological Ass’n, “Resolution on Transgender, Gender Identity,
& Gender Expression Non-Discrimination” (August 2008), http://; Nat’l Comm’n on Corr.
Health Care, “Position Statement on Transgender, Transsexual, and
Gender Nonconforming Health Care in Correctional Settings” (Oct.
18, 2009),; Eli Coleman et al., World Prof’l
Ass’n for Transgender Health, “Standards of Care for the Health
of Transsexual, Transgender, and Gender-Nonconforming People,”
Int’l J. Transgenderism 165, 170-74 (2011),
uploaded_files/140/files/IJT%20SOC,%20V7.pdf; see also Adams
v. Fed. Bureau of Prisons, 716 F. Supp. 2d 107, 109 (D. Mass. 2010)
(“GID is a readily diagnosable and treatable mental illness with
an established course of treatment … [including] hormones of the
desired gender.”).
155	 See, e.g., Rosati, 791 F.3d, at 1040; Allard v. Gomez, 9 Fed. Appx. 793,
794-95 (9th Cir. 2001) (citing Meriwether v. Faulkner, 821 F.2d 408,
412-13 (7th Cir. 1987)); Battista v. Clarke, 645 F.3d 449, 455 (1st Cir.
2011); White v. Farrier, 849 F.2d 322, 325 (8th Cir. 1988).
156	 See Estelle, 429 U.S., at 104.
157	 See Rosati, 791 F.3d, at 1040.
158	 The Fifth Edition of the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders in 2013 replaced the
diagnosis of “Gender Identity Disorder” with “Gender Dysphoria.”
See also Am. Psychological Ass’n, “Answers to Your Questions About
Transgender People, Gender Identity, and Gender Expression” (2011),
159	 See, e.g., Kothmann v. Rosario, No. 13-13166, 2014 U.S. App. LEXIS
4263, at *15 (11th Cir. 2014); Fields v. Smith, 653 F.3d 550, 559 (7th Cir.
2011); De’Lonta v. Angelone, 330 F.3d 630, 635 (4th Cir. 2003); Allard
v. Gomez, 9 Fed. Appx. 793, 795 (9th Cir. 2001); Phillips v. Michigan
Dep’t of Corr, 731 F. Supp. 792 (W.D. Mich. 1990), aff’d 932 F.2d 969
(6th Cir. 1991).
160	 See Rosati, 791 F.3d, at 1040; Diamond, 131 F. Supp. 3d (denying
defendant’s motion to dismiss plaintiff’s Eighth Amendment failureto-treat-claims-based denial of hormone therapy). Note that in the
Diamond litigation, which recently settled, the U.S. Department of
Justice submitted a brief on behalf of the transgender inmate being
denied care for gender dysphoria.
161	 Estelle, 429 U.S., at 103-04.
162	 Gibson, 290 F.3d, at 1187, overruled on other grounds by Castro, 2016
WL 4268955.
163	 Recently, a California magistrate judge ruled that transgender
women inmates in men’s carceral facilities must generally have
access to the same items as women in women’s carceral facilities.
Don Thompson, “Judge: Transgender California Inmates Must Get
Female Items,” U.S. News (June 9, 2016),
news/us/articles/2016-06-09/judge-transgender-california-inmatesmust-get-female-items. See, e.g., Soneeya v. Spencer, 851 F. Supp.
2d 228 (D. Mass. 2012) (holding that delay in giving transgender
inmate access to female commissary items and clothing was a
violation of the Eighth Amendment); Konitzer v. Frank, 711 F. Supp.
2d 874 (E.D. Wis. 2010) (deny summary judgment for prison officials
because there was a triable issue of fact about whether forbidding
plaintiff to have access to certain female products could be a


violation of the Eighth Amendment); Kosilek v. Maloney, 221 F. Supp.
2d 156 (D. Mass. 2002) (finding that a transgender woman in a men’s
prison had a serious medical need for gender-affirming medical and
psychological care, including access to female commissary products).
164	Id.
165	 See Cal. Gov’t Code § 11135.
166	 “Condition of Orange County Jails 2008-2009.”
167	 OC Health Care Agency, Adult Correctional Health Services, no date,
retrieved from
168	 “Investigation of the Orange County Jail: Investigatory Results Letter.”
169	 “Orange County Mental Health: Crisis Intervention Programs
2014-2015,” Orange County grand jury,
170	Ibid.
171	 “The Mental Illness Revolving Door: A Problem for Police, Hospitals,
and the Health Care Agency 2014-2015,” Orange County grand jury,
172	Ibid.
173	 Board of State and Community Corrections, no date, retrieved from
174	 “Our Brothers’ Keeper: A Look at the Care and Treatment of Mentally
Ill Inmates in Orange County Jails,” Orange County grand jury,
2016, retrieved from
175	Ibid.
176	 Thy Vo, “Grand Jury: Mentally Ill Inmates in County Jails Are Isolated
and Over-Medicated,” Voice of OC, last modified June 9, 2016, http://
177	 Terry Sforza, “Watchdog: O.C. Jails Are Unfit for Mentally Ill Inmates,
Grand Jury Says,” The Orange County Register, last modified June
13, 2016,
178	 Vo, “Grand Jury: Mentally Ill Inmates in County Jails.”
179	 “The Mental Illness Revolving Door.”
180	 “Homie/s” is a jail term for mostly Latino gang members
181	 “Investigation of the Orange County Jail: Investigatory Results Letter.”
182	 “Mental Health Problems of Prison and Jail Inmates,” United States
Dept. of Justice, Bureau of Justice Statistics, 2006
183	 Training requirements and copies of training documents are
available at
184	 Sandra Hutchens, “Response to Orange County Grand Jury 20142015 Report, ‘The Mental Illness Revolving Door: A Problem for
Police, Hospitals, and the Health Care Agency,’” August 27, 2015,

185	Ibid.
186	 “Annual Report on Jails 2013-2014.”
187	 “Annual Inquiry on Jails 2014-2015.”
188	 “Policy Manual. Policy 3000.6(a). Booking Prowler,” Orange County
Sheriff-Coroner Department, 2015, retrieved from PRA request
189	 Sandra Hutchens, “Response to Orange County Grand Jury 20102011 Report, ‘Review of Orange County Detention Facilities,’ ” April
15, 2011,
190	Ibid.
191	 “Inmate Jail Rules JOM Section 1600,” University of Michigan Law
School Policy Clearinghouse, Freedom of Information Act request
192	 “Minimum Standards for Local Detention Facilities, Title 15 — Crime
Prevention and Corrections, Division 1, Chapter 1, Subchapter 4,”
Board of State and Community Corrections, 2012, http://www.bscc.
193	Ibid.
194	 Ibid.
195	 “Title 24 Minimum Standards for Local Detention Facilities,” Board
of State and Community Corrections, 2013,
196	 “Policy Manual. Policy 1604.1. Inmate Rights,” Orange County
Sheriff-Coroner Department, 2015, retrieved from PRA request
197	 See 28 C.F.R. § 115.42(f).
198	 National PREA Resource Center, Standard 115.42, “Use of Screening
Information,” requires that transgender inmates be allowed to
shower separately. What constitutes “separate” for the purposes
of complying with this standard? (April 23, 2014), http://www.
199	 28 C.F.R. § 115.15(d).
200	 “Investigation of the Orange County Jail: Investigatory Results Letter.”
201	 “Annual Inquiry on Jails 2014-2015.”
202	 “Inmate Jail Rules JOM Section 1600 — 1600.3(m) Recreation
Programs,” University of Michigan Law School Policy Clearinghouse,
Freedom of Information Act request
203	 “Minimum Standards for Local Detention Facilities, Title 15 — Crime
Prevention and Corrections, Division 1, Chapter 1, Subchapter
4. 1240. Frequency of Serving,” Board of State and Community
Corrections, 2012,
204	 “Minimum Standards for Local Detention Facilities, Title 15 — Crime
Prevention and Corrections, Division 1, Chapter 1, Subchapter 4.
1083. Limitations on Disciplinary Actions,”
205	 Matt Hamilton, “Spoiled Food and Moldy Showers: Poor Conditions
for Immigrant Detainees in O.C. Jail, Report Says,” Los Angeles
Times, last modified March 8, 2017,

206	 “Minimum Standards for Local Detention Facilities, Title 15 — Crime
Prevention and Corrections, Division 1, Chapter 1, Subchapter 4,”
Board of State and Community Corrections, 2012, http://www.bscc.
207	Ibid.
208	Ibid.
209	 “Inmate Jail Rules JOM Section 1600 — 1600.3(o) Commissary,”
University of Michigan Law School Policy Clearinghouse, Freedom of
Information Act request
210	 “Detention Facilities Report 2012-2013.”
211	Ibid.
212	 Jordan Graham, “Orange County Ends Jail Contract Amid
Accusations of Overcharging Inmates’ Families to Send Money,” The
Orange County Register, last modified March 15, 2017, http://www.
213	 “Minimum Standards for Local Detention Facilities, Title 15 — Crime
Prevention and Corrections, Division 1, Chapter 1, Subchapter 4.
1265. Issue of Personal Care Items,” Board of State and Community
Corrections, 2012,
214	 Nick Gerda, “Orange County Sued for ‘Excessive’ Jail Phone Charges,”
Voice of OC, last modified November 19, 2015, http://voiceofoc.
215	Ibid.
216	 Cecilia Kang, “Technology,” The Washington Post, https://www.
217	Ibid.
218	Ibid.
219	 “Inmate Jail Rules JOM Section 1600 — 1600.3(o) Commissary,”
University of Michigan Law School Policy Clearinghouse, Freedom of
Information Act request
220	 “Policy Manual,” Orange County Sheriff-Coroner Department, 2015,
retrieved from PRA request
221	 “Detention Facilities Report 2012-2013.”
222	 Stephen J. Connolly, Office of Independent Review Activity Report,
October 4, 2011,
aspx?BlobID=6949; Stephen J. Connolly, Office of Independent
Review Activity Report, April 29, 2013,
223	 OCSD Policy 1600.5.9
224	Ibid.
225	 Orange County Sheriff’s Department, inmate grievances for the
period June 21, 2013 to May 16, 2016, accessed from Public Records
Act request
226	 Salvador Hernandez, “Federal Investigation Finds County Jail ‘Much
Improved,’” The Orange County Register, last modified March 28,


227	 OCSD Policy 1600.5.9
228	 “Inmate Jail Rules JOM Section 1600 — 1600.5.9 Protection from
Retaliation,” University of Michigan Law School Policy Clearinghouse,
Freedom of Information Act request
229	 OCSD Policy 1600.5.3

242	 Rachanee Srisavasdi, “Orange County Paid $2.5 Million to Settle Jail
Claims,” The Orange County Register, last modified April 18, 2008,
243	 J. Pasco, Settlement of Claims, Orange County Hall of Administration,
2016, accessed from Public Records Act request.

230	 “Ninth Circuit: Orange County Jail PLRA Injunction May Not be
Terminated as to Ongoing Violations,” Prison Legal News, February
15, 2009,

244	 Tony Saavedra, “Family Gets $2.1 Million in Jail Death,” The Orange
County Register, last modified July 1, 2011, http://www.ocregister.

231	Ibid.

246	 Marvin Mentor, “Corruption in Orange County, CA Sheriff’s
Department Revealed; Sheriff Resigns, Convicted on Criminal
Charges,” Prison Legal News, February 2009, https://www.

232	 “Inmate Jail Rules JOM Section 1600 — 1600.6(j) Disability
Discrimination Allegations,” University of Michigan Law School
Policy Clearinghouse, Freedom of Information Act request
233	 “Ninth Circuit: Orange County Jail PLRA Injunction May Not be
Terminated as to Ongoing Violations.”
234	 John E. Dannenberg, “Ninth Circuit: Orange County Jail Violated
Ad Seg Prisoners’ ADA, Religious and Exercise Rights,” Prison
Legal News, August 15, 2009,
235	 “Statement of the Department of Justice on the Institutionalized
Persons Provisions of the Religious Land Use and Institutionalized
Persons Act (RLUIPA),” Department of Justice, May 19, 2017,
236	 “Ninth Circuit: Orange County Jail PLRA Injunction May Not be
Terminated as to Ongoing Violations.”

245	Ibid.

247	 Jack Leonard, “O.C. Family to Pay Family in Inmate Death, Los
Angeles Times, June 13, 2002,
248	 Schou, “Blind Spot.”
249	 “CA Jail Deputies Allegedly Provoke Murder of Misidentified
Child Molester by Other Prisoners; Wrongful Death Suit Settled
for $600,000,” Prison Legal News, May 15, 2009, https://www.
250	 Mentor, “Corruption in Orange County.”
251	 Schou, “Blind Spot.”

237	Ibid.

252	 Christine Hanley, “Former Inmates Allege Beatings in O.C. Jail,” Los
Angeles Times, March 12, 2003,

238	Ibid.

253	Ibid.

239	 422 US 806, 95 S. Ct. 2525, 45 L. Ed. 2d 562 (1975)

254	 R. Scott Moxley, “Carona Makeover,” OC Weekly, last modified
October 6, 2005,

240	 In 2001, pretrial detainees filed a class-action lawsuit (Pierce v.
Orange County) against the Orange County jail system in the U.S.
District Court for the Central District of California, challenging
the conditions of confinement. Plaintiffs alleged that they were
detained for unreasonable periods of time after the order for their
release, denied rights under Stewart v. Gates and denied reasonable
accommodations under the ADA. In 2003, the District Court certified
one class for equitable relief and one class for injunctive relief. In
2004, the injunctive-relief class was decertified. The plaintiffs filed
several amended complaints concerning meals, overcrowded
holding cells, outdoor exercise, dayroom access, religious
services and access for people with disabilities. In 2004, the court
consolidated the case with Stewart v. Gates.
241	 At some point during the 1980s, a population cap and other remedial
orders were added. In 2004, the District Court consolidated
the case with Pierce v. County of Orange, relying upon the 1996
Prison Litigation Reform Act and case law emphasizing prison
administrators’ discretion. The court vacated the previously entered
remedial orders and dismissed the case. In 2008, plaintiffs appealed
and the U.S. Court of Appeals for the 9th Circuit partially reversed the
District Court’s decision (continued only two of the orders). The Court
of Appeals also ruled that the county was in violation of the ADA. In
2011, the court entered judgment for the plaintiffs and accepted the
county’s final proposed plan for addressing disparate programs and
services that were offered to disabled versus non-disabled inmates.


255	 Srisavasdi, “Orange County Paid $2.5 Million to Settle Jail Claims.”
256	 John F. Dannenberg, “California Jail Settles Gender-IdentityDisorder Discrimination Suit,” Prison Legal News, January 15, 2008,
257	 Mentor, “Corruption in Orange County.”
258	 Moxley, “Carona Makeover.”
259	 Srisavasdi, “Orange County Paid $2.5 Million to Settle Jail Claims.”
260	Ibid.
261	Ibid.
262	 Norberto Santana Jr. and Tony Saavedra, “Tapes Show OC Deputies
Using Tasers on Restrained Inmates,” The Orange County Register,
last modified January 24, 2008,

263	 “Former Orange County Jail Detainee Paid $750,000 to Settle Guard
Tasering Suit,” Prison Legal News, March 15, 2011, https://www.
264	Ibid.
265	 Santana and Saavedra, “Tapes Show OC Deputies Using Tasers on
Restrained Inmates.”
266	 Mentor, “Corruption in Orange County.”
267	Ibid.
268	Ibid.
269	 “Inadequate Anemia Treatment Nets California Jail Prisoner $65,000
Settlement,” Prison Legal News, December 15, 2007, https://

283	Ibid.
284	 Santana Jr., “Santana: Anatomy of a Police State.”
285	 Jordan Graham, “Sheriff’s Department is the biggest winner in
Orange County’s $6.2 billion proposed budget,” The Orange County
Register,” last modified May 10, 2017, http://www.ocregister.
286	 Nick Gerda, “County Budget Proposes Large Increase for Sheriff’s
Department,” Voice of OC, last modified May 11, 2017, http://
287	Ibid.
288	 Graham, “Sheriff’s Department is the biggest winner in Orange
County’s $6.2 billion proposed budget.”

270	 Schou, “Blind Spot.”

289	 Gerda, “County Budget Proposes Large Increase for Sheriff’s

271	Ibid.

290	Ibid.

272	 Jordan Graham, “O.C. Sheriff Hires Adviser Amid Jailhouse Snitch
Controversy,” The Orange County Register, last modified August
17, 2016.

291	 Mission Statement, Orange County District Attorney’s Office, no date,

273	 “OCSD Welcomes Constitutional Policing Advisor Mary Izadi,”
Orange County Breeze, August 17, 2016, http://www.oc-breeze.
com/2016/08/17/89575_ocsd-welcomes-constitutionalpolicing-advisor-mary-izadi/ The selection panel included Erwin
Chemerinsky, dean of the UC Irvine School of Law; Robert Gerard,
attorney and former Orange County Bar Association president; and
Laurie Levenson, professor at Loyola Law School
274	 Graham, “O.C. Sheriff Hires Adviser Amid Jailhouse Snitch
275	 Norberto Santana Jr., “Santana: Anatomy of a Police State,” Voice
of OC, February 6, 2017,
276	 Jordan Graham, “O.C. Sheriff’s Deputies Getting 8.8% Pay Raise Over
3 Years, Costing Taxpayers Extra $62.2 Million,” The Orange County
Register, last modified Sept. 7, 2016,
277	Ibid.
278	 Jordan Graham, “O.C. Sheriff’s Deputies Union Spends $86K to
Support Supervisor Andrew Do’s Reelection bid,” The Orange County
Register, last modified October 11, 2016,
279	 Tracy Wood, “County Supervisors Approve New Contract for
Deputy Sheriffs,” Voice of OC, September 6, 2016, http://voiceofoc.
280	 “OC Annual Budget FY 2016-17,” Orange County Executive Office,
281	 Santana Jr., “Santana: Anatomy of a Police State.”
282	 Graham, “O.C. Sheriff’s Deputies Getting 8.8% Pay Raise Over 3
Years, Costing Taxpayers Extra $62.2 Million.”

292	 “Officer-Involved Shootings and Custodial Death Letters,” OC District
Attorney’s Office, accessed May 9, 2017,
293	 Erwin Chemerinksy, “Chemerinsky: A Long Overdue Investigation,”
Voice of OC, December 19, 2016,
294	 Patrick Dixon, Robert Gerard, Blithe Leece, Laurie Levenson and
James Smith, “Orange County District Attorney Informant Policies
and Practices Evaluation Committee Report,” December 2015, http://
295	 Tony Saavedra, “After Scathing Report by Panel He Selected, O.C.
D.A. Tony Rackauckas Says He’s Staying Put,” The Orange County
Register, last modified January 5, 2016,
296	Ibid.
297	 Nick Gerda, “Longtime Corruption Fighter Chosen as OC’s Law
Enforcement Watchdog,” Voice of OC, last modified January 24, 2017,
298	 Joint Letter to the U.S. Department of Justice: Request for Federal
Investigation in Orange County, California, Volume 1
299	 Any evidence favorable to the defendant and material to their case
300	 Staff, “Timeline: Orange County’s Jailhouse Snitch Crisis,” The
Orange County Register, last modified Dec. 15, 2016, http://www.
301	 Matt Ferner, “DOJ Announces Investigation into Orange
County DA and Sheriff’s Department Over Informant Scandal,”
Huffington Post, last modified December 15, 2016, http://www.


302	 For a timeline of the events leading up to the investigation, visit
303	 Jordan Graham, “Orange County to Fill Vacant Watchdog Job to
Investigate Sheriff, District Attorney,” The Orange County Register,
last modified January 25, 2017,

320	 “OC Snitch Scandal,” OC Weekly, no date,
topic/oc-snitch-scandal-6437882; Matt Femer, “Another Secret
Cache of Notes on Jail Informants Surface in Orange County Snitch
Scandal,” Huffington Post, last modified December 19, 2016, http://
321	 “Three Inmates Escape from Orange County Jail,” Los Angeles
Times, last modified January 26, 2016,

304	 Kelly Puente and Tony Saavedra, “Feds Launch Investigation into
Orange County D.A.’s Office, Sheriff’s Department over Informants,”
The Orange County Register, last modified December 16, 2016,

322	 MRubio, “Stephen Connolly to Resign from the Office of Independent

305	 Tony Saavedra, “How the DOJ Will Conduct Civil-Rights Investigation
of Orange County District Attorney, Sheriff,” The Orange County
Register, last modified January 6, 2017,

323	 Jordan Graham, “Orange County to Fill Vacant Watchdog Job to
Investigate Sheriff, District Attorney,” The Orange County Register,
last modified January 25, 2017,

306	 Erwin Chemerinksy, “Chemerinsky: A Long Overdue Investigation,”
Voice of OC, December 19, 2016,

324	 Nick Gerda, “Longtime Corruption Fighter Chosen as OC’s Law
Enforcement Watchdog,” Voice of OC, last modified January 24, 2017,

307	 MRubio, “Stephen Connolly to Resign from the Office of Independent
Review,” Voice of OC, last modified February 18, 2016, http://
308	 Incidents OIR Monitors, Office of Independent Review, no date, http://

325	 Jordan Graham, “Orange County Law Enforcement Watchdog Job to
Remain Empty as Chosen Candidate Withdraws,” The Orange County
Register, last modified February 3, 2017,
326	Ibid.

309	 MRubio, “Stephen Connolly to Resign from the Office of Independent

327	 Grand jury: general information, Orange County Superior Court, no

310	 Projects, OIR Group, no date,

328	Ibid.

311	 OIR reports, Los Angeles County Sheriff’s Department, no date,
312	 Christina Villacorte, “Inspector General: End L.A. County Contracts
with Office of Independent Review, Special Counsel Merrick Bobb,”
Los Angeles Daily News, last modified March 18, 2014, http://www.
313	Ibid.
314	Ibid.
315	 Robert J. Franz, 2011-2012 Orange County grand jury, http://www.
316	 Robert J. Franz, Office of Independent Review/Orange
County Board of Supervisors Responses to Findings and
317	 OIR reports are available at
318	 MRubio, “Stephen Connolly to Resign from the Office of Independent
319	Ibid.


329	 Ibid.
330	 “SAFE — Strategy, Accountability, Focus and Evaluation,” Orange
County Sheriff’s Department, last accessed October 22, 2016, http://
331	Ibid.
332	Ibid.
333	Ibid.
334	Ibid.



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