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Management Review Audit - NAC Youth Correctional Facility, CA OIG, 2005

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OFFICE

OF THE

INSPECTOR GENERAL

MATTHEW L. CATE, INSPECTOR GENERAL

MANAGEMENT REVIEW AUDIT
OF THE

N. A. CHADERJIAN YOUTH CORRECTIONAL FACILITY
STOCKTON, CALIFORNIA

MAY 2005

STATE OF CALIFORNIA

Matthew L. Cate, Inspector General

Office of the Inspector General

May 24, 2005
Steve Kruse, Superintendent
N. A. Chaderjian Youth Correctional Facility
7650 South Newcastle Road
Stockton, California 95213
Dear Superintendent Kruse:
Enclosed is the final report of the Office of the Inspector General’s management review audit of the N. A.
Chaderjian Youth Correctional Facility. Recognizing that you have been the Superintendent of the facility
for a short time, the purpose of the audit was to provide a baseline assessment of the institution’s
performance in carrying out its essential functions.
The audit found a significant number of serious deficiencies at the institution, affecting counseling services,
education, and mental health treatment. The deficiencies are significant enough to indicate that the facility is
failing in its core mission of providing treatment and education services to wards.
The audit also found that the safety of staff and wards at the institution is jeopardized by the facility’s
structural and design defects, by poor management practices, and by the failure of the institution to comply
with mandated security requirements.
The report presents 56 specific recommendations to remedy the deficiencies.
The written response to the audit from the California Youth Authority appears as an attachment to the report.
We look forward to receiving by July 22, 2005 the department’s comprehensive corrective action plan to
address the audit findings.
Thank you for the cooperation extended to my staff during the course of the audit.
Sincerely,

MATTHEW L. CATE
Inspector General
Enclosure
cc:

Roderick Q. Hickman, Secretary, Youth and Adult Correctional Agency
Walter Allen III, Director, California Youth Authority

MC:SC:lr
Arnold Schwarzenegger, Governor
P.O. BOX 348780, SACRAMENTO, CALIFORNIA 95834-8780

PHONE (916) 830-3600

FAX (916) 928-5974

CONTENTS
PAGE
EXECUTIVE SUMMARY ................................................................................................. 1
INTRODUCTION .......................................................................................................... 4
BACKGROUND ................................................................................................ 4
OBJECTIVES, SCOPE, AND METHODOLOGY ........................................................ 6
FINDINGS
FINDING 1. TREATMENT SERVICES ..................................................................... 7
FINDING 2. EDUCATION ................................................................................. 16
FINDING 3. SAFETY AND SECURITY ................................................................. 23
FINDING 4. MENTAL HEALTH SERVICES ........................................................... 40
RESPONSE FROM THE CALIFORNIA YOUTH AUTHORITY ................................................ 47

EXECUTIVE SUMMARY

T

his report presents the results of a management review audit of the California Youth
Authority’s N.A. Chaderjian Youth Correctional Facility, which was conducted by the
Office of the Inspector General between October 27, 2004 and April 29, 2005. The
purpose of the audit was to provide a baseline assessment of the facility’s performance in
carrying out essential functions and to provide recommendations to correct deficiencies. The
audit was performed under the authority provided to the Office of the Inspector General by
California Penal Code section 6051.
The N.A. Chaderjian Youth Correctional Facility in Stockton, along with the Heman G. Stark
Youth Correctional Facility in the southern part of the state, serves a ward population of
generally older and more serious offenders than those of other California Youth Authority
institutions. At the time of the audit, the facility held a population of 590 male wards between 17
and 24. The average age of the wards is 20, with 23 percent falling between ages 21 and 24.
Some 68 percent are gang-affiliated. Many are serving long sentences for serious crimes such as
murder, rape, armed robbery, and assault, and most have been sent to the facility because they
have failed at other California Youth Authority institutions. A small number—eight at the time
of the audit—have already served time in adult prisons and have been sent to the N.A.
Chaderjian Youth Correctional Facility to finish out a California Youth Authority confinement
term. All of the wards —except those who commit new offenses while in custody—must be
released by age 25.
In short, most of the wards at the N.A. Chaderjian Youth Correctional Facility have run out of
other options at the California Youth Authority. For these wards, the institution represents a last
chance to avoid an adult life of crime. Yet the audit found the facility to be a troubled institution
that fails to provide a safe environment for wards and staff and fails to provide wards with the
education and programs that would give them the best opportunity to lead a crime-free life once
they are released.
For example, the audit determined that the facility is not providing wards with the counseling
and mental health care they are required to receive under state law. The youth correctional
counselors, who are designated to provide most of the counseling, have almost no training in
counseling and almost no time to counsel wards because they are busy with custody and security
functions. The auditors found that the youth correctional counselors spend only about 10 percent
of their time in counseling-related activities. The audit also determined that the institution is
endangering wards by failing to consistently monitor those receiving psychotropic medications
by administering baseline and follow-up laboratory tests and providing timely psychiatric
evaluations. Finally, despite two suicides at California Youth Authority facilities last year, the
institution is not complying with all department-mandated suicide prevention procedures.
Education services are similarly lacking. The audit found that special education wards at the
facility—who represent 38 percent of the students enrolled at the facility’s high school—are not
receiving all of the special education service time they are mandated to receive. Moreover, the
auditors found that the special education service providers at the facility have consistently over-

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 1

reported the amount of services provided. At the same time, more than a third of the academic
classes scheduled at the high school end up being cancelled, mainly because teachers routinely
fail to show up for class. Teachers at the facility take so much time off that the high school
cannot provide enough substitutes to cover the absences.
The high number of cancelled classes contributes significantly to the school’s low effectiveness
rating, which measures actual, compared to potential, attendance and classes held. The
effectiveness rating of the high school is 40 percent, meaning that wards are receiving only 40
percent of their assigned education programming. And even though department procedures
require teachers and counselors to coordinate efforts to help wards by meeting in regularly
scheduled case conference committees set up for each ward, the auditors found that the teachers
seldom attend the case conferences. A review of a sample of 94 cases revealed that teachers
failed to attend 86 percent of the meetings. Instead, many teachers take advantage of the half-day
set aside each week for case conferences when no classes are scheduled by leaving the facility
early.
The facility is also a dangerous place. The Office of the Inspector General found that the
institution is not complying with numerous department-mandated security requirements and that
the facility is riddled with structural and design defects that jeopardize the safety of wards and
employees alike. For example, fences intended to separate recreation yards of different living
units to keep rival gang members apart are too low and the flat panel razor wire on top is
ineffective, [Information pertaining to fences redacted for security reasons.] The doors in one of
the living units pop open unexpectedly when electrical motors overheat, and in some of the
living units, surveillance cameras and video monitors are not working. The interior walls of the
facility were supposed to have been constructed of solid concrete, but an engineering study
found that [information pertaining to interior walls redacted for security reasons.] and wards
have discovered that they can dig holes in the floors because at least in some places the concrete
is less than two inches thick. The California Youth Authority has sought special repair funding
for some of the problems identified in this report, but the Department of Finance has denied the
requests.
Many of the employees at the facility fear for their safety every working day, and with reason—
the facility recorded 12 physical, non-gassing,1 assaults on staff in 2003 and 23 in 2004. Yet,
staffing ratios at the institution are the same as those for other California Youth Authority
facilities with younger wards exhibiting less violent behavior. Employee morale is reported to be
low and the staff vacancy rate is high, with almost a third of the youth correctional counselor
positions unfilled at the time of the audit.
One reason for these deficiencies is lack of leadership at the institution. The facility has had nine
superintendents or acting superintendents in the last five years and the present superintendent has
been on the job only since December 2004, although he has served as acting superintendent of
the facility on three other occasions. Similarly, a high turnover among school administrators and
consequent lack of oversight of the teaching staff has allowed teachers to abuse leave time and
fail to participate in case conferences. Since 2002, the high school has had four principals in
1

“Gassing” is the practice of throwing human excrement or bodily fluids.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 2

either acting or permanent positions, and the present acting principal works concurrently at
department headquarters in Sacramento and spends only about half his time at the facility.
The findings of this audit are consistent with those of the California Youth Authority
Accountability Audit issued by the Office of the Inspector General in January 2005. That audit,
which assessed the progress of the California Youth Authority in implementing
recommendations from nine previous audits, concluded that the department is failing in its core
mission of providing education, training, and treatment services to the youths in its care. As a
result, the wards at the state’s youth correctional institutions, including the wards at the N.A.
Chaderjian Youth Correctional facility, have little chance to end the cycle of criminality.
The Office of the Inspector General has presented 56 specific recommendations to address the
deficiencies identified in this audit. Those recommendations appear in the body of the report.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 3

INTRODUCTION

C

alifornia Penal Code section 6051 provides the Office of the Inspector General with
authority to conduct a management review audit of any California Youth Authority
superintendent. The purpose of a management review audit is to assess the
superintendent’s performance in carrying out the essential functions of the facility or to serve as
a baseline for newly appointed superintendents. In areas where weaknesses are noted, the Office
of the Inspector General makes recommendations to correct the deficiencies.

Pursuant to the provisions of California Penal Code section 6051, the Office of the Inspector
General conducted a management review audit of the N.A. Chaderjian Youth Correctional
Facility following a succession of nine changes in superintendents and acting superintendents
dating back to March 2000. At the beginning of the audit, Steve Kruse had been the acting
superintendent for one month. During the audit, the California Youth Authority appointed Mr.
Kruse to the superintendent’s position. This management review audit was performed between
October 27, 2004 and April 29, 2005.
BACKGROUND
The N.A. Chaderjian Youth Correctional Facility (N.A. Chaderjian) is one of eight youth
correctional institutions operated by the California Youth Authority. Along with O.H. Close and
DeWitt Nelson, it is one of three youth correctional facilities comprising the Northern California
Youth Correctional Center complex in Stockton. Constructed in 1991 with a design capacity of
600 beds, N.A. Chaderjian assists the California Youth Authority in pursuing its mission of
providing educational, training, and treatment services for youthful offenders (wards) committed
for confinement by the courts.
In addition to general population housing, N.A. Chaderjian has a variety of specialized programs
for wards, including drug and alcohol abuse treatment, intensive medical and psychiatric
treatment, parole violator programs, special counseling programs for wards who exhibit
symptoms of mild to moderate mental illness, sex offender programs, and a special management
program for violent and disruptive wards.
As of April 7, 2005 N.A. Chaderjian housed 590 wards. Many of the wards are among the most
dangerous in the California Youth Authority’s custody and are serving lengthy sentences for
crimes such as murder, rape, armed robbery, and assault. Although the crimes were committed
while the offenders were juveniles, nearly all wards at N.A. Chaderjian are between 18 and 25
years of age, with 23 percent over the age of 21. Most have transferred from other facilities,
while others are parole violators. Still others have come from California Department of
Corrections adult prisons. For example, one of the wards at the institution at the time of the audit
had spent four years as an inmate in various adult prisons, including more than 14 months in
administrative segregation units and more than three months in security housing units. He had
been remanded to N.A. Chaderjian at the age of 24 to serve time remaining on his California
Youth Authority confinement.
Not only are the wards older and more criminally sophisticated, but they are also disruptive and
dangerous. Sixty-eight percent are affiliated with gangs that are active within the facility. Many

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 4

are in Phase I, the most restrictive phase of the facility’s three-phase system of privileges.
Accordingly, they have few privileges to lose by disrupting daily operations. Ward programming
at the facility has diminished in the wake of large-scale fights and assaults on staff resulting in
lockdowns of living units. In this environment, the institution has been attempting to implement
an “open programming” model in response to the Farrell v. Allen agreement between the
California Youth Authority and the Prison Law Office. Under this agreement, the facility is
responsible for restoring safe general population programming and ensuring that wards are out of
their rooms daily for educational, vocational, and treatment programming, as well as meals and
recreation, by June 1, 2005.
For fiscal year 2004-05, N.A. Chaderjian has a budgeted staff of 352 personnel years and an
operating budget of $30.5 million. Staff positions include administrators, administrative support
personnel, youth correctional officers, and youth correctional counselors. In addition, the staff
includes academic and vocational education instructors, administrators, and support staff, all of
whom report to the California Youth Authority Education Services Branch, rather than to the
superintendent. Employees performing medical, dental, mental health, and facility maintenance
services report to the Northern California Youth Correctional Center.
Like other California Youth Authority institutions, N. A Chaderjian is subject to the “post-andbid” provisions of the state’s collective bargaining agreement with Bargaining Unit 6 of the
California Correctional Peace Officers Association. Those provisions require 70 percent of post
assignments to be governed by seniority and to be made through employee bidding. The 70-30
split allows the seniority-based preferences of staff to determine 70 percent of post appointments
and allows management to determine 30 percent of the appointments.
There are six buildings on the facility grounds (Units I through VI), each housing two living
units of 50 rooms. The living units are named for California rivers. A common wall separates the
living units, and there is an elevated control tower at the top of the common wall. The control
tower monitors ward activity in the central areas of the living units, which are known as day
rooms, and controls the movement of wards into and out of the living units. In addition, the
control tower maintains video surveillance of the outdoor recreation areas. Wards generally
receive counseling services in their living units, but they leave the living units to participate in
other programs at various locations on the institution grounds. The programs include attending
the facility’s N.A. Chaderjian High School and obtaining vocational training. Wards also leave
their living units to obtain medical and dental services at the institution’s clinic and to attend
religious services.
Superintendent Steve Kruse. This is Superintendent Kruse’s first assignment as a superintendent
with the California Department of the Youth Authority, but he has served as an acting
superintendent at N.A. Chaderjian on three occasions. Superintendent Kruse reported to N.A.
Chaderjian in October 2004 for his last assignment as acting superintendent from his position as
assistant superintendent of the DeWitt Nelson Youth Correctional Facility. The California Youth
Authority appointed him to the superintendent’s position in December 2004. A California Youth
Authority employee for 29 years, Superintendent Kruse began his career with the department as
a youth correctional officer. During his employment with the California Youth Authority, he has
held increasingly responsible positions in various institutions and camps.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 5

OBJECTIVES, SCOPE, AND METHODOLOGY
The objective of the management review audit was to conduct a baseline evaluation of N.A.
Chaderjian to identify areas of operation needing improvement. To that end, the Office of the
Inspector General reviewed the following major functions: institution safety and security; ward
treatment and mental health services; and academic education. Within these major functions, the
audit team reviewed issues related to personnel, training, investigations, and budgeting.
The Office of the Inspector General performed the following procedures in conducting the
management review audit:
•

Interviewed Superintendent Kruse, members of his administrative staff, and various
employees and wards at the institution to gain insight and perspective on various issues.

•

Administered a survey questionnaire to N.A. Chaderjian staff regarding their areas of
concern.

•

Conducted on-site visits and inspections of living units and ward programming areas,
including N.A. Chaderjian High School and administrative offices and facilities throughout
the institution.

•

Reviewed various laws, policies, and procedures and other documents related to key
institution systems, functions, and processes.

•

Gathered and reviewed institution logs, files, records, and transaction documents in various
operational areas.

•

Performed various analytical techniques, including sampling, to assess compliance with legal
and procedural requirements.

•

Formulated conclusions based on the audit methods cited above.

The audit team did not review the ward grievance process, the disciplinary decision-making
system, or the facility’s planning for and implementation of the Farrell v. Allen agreement.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 6

FINDING 1
The Office of the Inspector General found that wards at N.A. Chaderjian are not receiving
the counseling and other treatment services they are required to receive under state law.
Wards at N.A. Chaderjian are not receiving the fundamental assessments and specialized
counseling services they are required to receive under state law and regulations.2 The treatment
services they do receive are of questionable quality, largely because the youth correctional
counselors, who provide the bulk of the counseling, not only lack training, but spend only about
10 percent of their time counseling wards. The rest of their time is consumed by custody and
security tasks, such as supervising meals and showers and working in the control tower. The
failure of the institution to provide treatment services deprives the wards of the tools they need
for successful reintegration into society and puts them at greater risk of committing future
crimes.
Records reviewed by the Office of the Inspector General. To evaluate the institution’s
compliance with statutory and regulatory requirements governing treatment services, the Office
of the Inspector General reviewed a sample of living unit files and other documents comprising
the records of 94 wards in 9 of the facility’s 12 living units—approximately 17 percent of the
ward population. The review included the records of wards in four specialized program living
units and five general population units. In addition, the audit team interviewed 26 youth
correctional counselors and 26 wards regarding treatment services at the facility. Because the
review determined that poor record-keeping in the living units made those records unreliable, the
audit team also sought out and reviewed additional records, including counseling records, notes,
and small group counseling summaries.
Results of the review. The Office of the Inspector General found that the living unit files failed
to document that either general population wards or wards in specialized counseling programs
had received the required amounts of counseling. The review of records and documents outside
the living units, however, indicated that more counseling had occurred than had been
documented in the living unit files. From those secondary records, the audit team determined that
the specialized counseling programs had made available to wards more than the required amount
of counseling, but that general population wards had received less than the required amount.
Specifically, the audit team found the following:
•

Living unit files did not document that wards had received required treatment. Section
4050 of the California Youth Authority Institutions and Camps Branch Manual requires a
formal, structured counseling program that includes planned, scheduled staff time for
counseling and provides for a minimum of one hour of formal counseling (individual or
small group) per ward per week. The review of the living unit records failed to document that

2

The California Welfare and Institutions Code and Title 15, Division 4 of the California Code of Regulations
require wards of the California Youth Authority to be provided with assessment, counseling, and training services.
Accordingly, section 4000 et seq. of the California Youth Authority Institutions and Camps Branch Manual
specifies the types and frequency of treatment services wards are to receive.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 7

wards in the four specialized program units and in the five general population living units
had received the required weekly formal, structured counseling sessions. Of the 58 ward
living unit files reviewed in the four specialized program units, the documentation showed
that only 30 (52 percent) of wards had received the required counseling. Of the general
population living units, the documentation showed that only three of the 36 wards sampled (8
percent) had received the required one hour of weekly individual and small group counseling.
Because the living unit file is the department’s official record, these compliance rates would
normally indicate significant non-compliance, but the Office of the Inspector General found
that poor record keeping in both the specialized program living units and the general
population living units rendered the information in the living unit files incomplete.
Specifically:
9 Youth correctional counselors’ chronological notes frequently contained no records of
small group counseling received by the ward.
9 The youth correctional counselors often failed to update their counseling records each
week; the audit team found instances in which counselors’ chronological notes were two
or more months in arrears.
9 Rather than logging counseling sessions in the chronological notes section of the living
unit file, youth correctional counselors frequently logged counseling notes in the
facility’s management information system known as the Ward Information Network 2000
without transferring them to the living unit files.
•

Secondary records documented additional counseling. The Office of the Inspector
General’s review of counseling records and notes outside the living unit files confirmed that
more counseling had occurred than had been documented in the living unit files.
Accordingly, the audit team afforded counseling credit when possible, including giving credit
for the General Population Outpatient Program. Given the difficulty of searching multiple
locations for possible counseling information, however, the audit team could not rely on the
accuracy of the compliance rate for the ward sample tested. Therefore, the Office of the
Inspector General obtained and analyzed the small group counseling summaries for the
facility’s specialized program living units and general population living units for March 2004
through February 2005. These summaries document the counseling activity of each youth
correctional counselor assigned to the living unit. From these records, the audit team
determined that an average of 2.70 small group counseling sessions per counselor per week
had taken place in the specialized counseling programs. The audit team concluded that that
average made it possible for specialized program wards to receive more than the minimum of
one hour of individual and small group counseling per week required by section 4050.
However, the review determined that general population living units were making available
less than the one small group session per week. The review found that an average of only .77
small group counseling sessions per counselor per week were made available in the general
population living units, and that no general population living unit made available more than
.85 sessions per counselor per week. With fewer than one small group counseling session per

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 8

counselor per week available to wards, formal individual counseling of no less than one
hour’s duration must occur to achieve compliance with section 4050. Yet, the Office of the
Inspector General found—and staff confirmed—that formal, scheduled individual counseling
rarely occurs in any of the living units.
Accordingly, the Office of the Inspector General concluded that the general population living
units were not providing wards with the counseling services required by section 4050.
The counseling is of questionable quality. Even when provided, the quality of the counseling
provided to wards is questionable. During the course of this management review audit, the Office
of the Inspector General noted the following:
•

Almost no individual counseling. Formal, scheduled individual counseling rarely occurs in
any of the living units. Formal, scheduled individual counseling is designed to offer a private,
confidential setting in which the counselor and ward can discuss sensitive matters not
appropriate to a group setting. These matters include personal problems that, if discussed in a
group setting, could subject the ward to ridicule or even physical harm. All 26 youth
correctional counselors interviewed acknowledged that their individual counseling sessions
with wards were almost always brief and informal and did not qualify as formal counseling
under section 4050. These sessions generally lasted a few minutes and seldom exceeded 45
minutes.

•

Frequent counselor turnover. Youth correctional counselor positions are subject to annual
“post-and-bid” provisions of the state’s collective bargaining agreement with Bargaining
Unit 6 of the California Correctional Peace Officers Association, which requires 70 percent
of post assignments to be governed by seniority and to be made through employee bidding.
This results in frequent turnover in counselors, which in turn can hamper wards’ progress by
disrupting the continuity of established counselor-ward relationships. Moreover, the
contractual “70-30” split means that the seniority-based preferences of staff determine 70
percent of the counselor appointments, while management can appoint only 30 percent based
on institutional needs and the skills and abilities of employees. The 70-30 split applies to
specialized program living units as well as to general population living units.

•

Lack of training for counselors. Youth correctional counselors, who provide the bulk of the
counseling to the wards, are not required to have advanced or even undergraduate degrees in
counseling or any other field. Although the audit team did not review counselors’
qualifications or all training records to verify statements, there is testimonial evidence that
the counseling staff lacks training. The current superintendent and two past superintendents
said the treatment staff is not well trained. Program managers, consultants, and even the
youth correctional counselors themselves agreed. Of the 26 youth correctional counselors
interviewed by the audit team, all said they had received little or no formal counseling
training and 24 (92 percent) said they would like additional counseling training. Ten (38
percent) said they had not received even on-the-job training.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 9

The audit team was able to document a significant training deficiency in the sex offender
program. The program administrator said that 75 percent of the staff working in the sex
offender program has no training in working with sex offenders. Furthermore, the parole
agent and the casework specialist in this program commented on their small group audit
sheets that only four of the eight youth correctional counselors who regularly work in the
living unit had had training in the sex offender curriculum. The audit team reviewed the
training records for all staff who worked in the sex offender living unit in February 2005 and
found that 34 of the 42 staff members working directly with wards (81 percent) had received
no sex offender training during the two-year period ended December 2004.
•

Unavailability of interactive journals for small-group counseling. Interactive journals
covering 15 specific topics are the primary treatment modality for small group counseling in
the California Youth Authority. Wards use the journals to educate themselves about topics
discussed in small groups to record what they have learned and to actively participate in the
group’s discussions. The Office of the Inspector General found, however, that the facility
does not have enough interactive journals for small group counseling. The review determined
that the facility had run out of the journals entitled Victims Awareness, had never received
the journals entitled Responsible Thinking, and was almost out of journals entitled Substance
Abuse, Handling Difficult Feelings, and Parole Planning. The staff said administrators had
attempted to acquire the journals from department headquarters, but that an administrator in
headquarters told them there were no funds to purchase additional journals.

•

Education staff rarely participates in ward case conference committees. Pursuant to
California Youth Authority Institutions and Camps Branch Manual section 4025,
superintendents are required to ensure that each living unit has a case conference committee
consisting of the ward’s youth correctional counselor, a parole agent, and an education
representative. The requirement is intended to provide a coordinated effort among members
of the treatment staff (teachers and counselors) to increase the wards’ ability to succeed after
release from custody. The audit determined, however, that this coordinated effort seldom
occurs at the facility. The audit team found that in 86 percent of the cases reviewed (81 of
94), teachers failed to attend wards’ case conferences, and interviews by the audit team with
26 youth correctional counselors confirmed that teachers rarely attend the case conferences.

•

Initial and progress case conferences are not held within the required time limits. To get
wards into treatment promptly, the California Youth Authority Institutions and Camps
Branch Manual, section 4030 requires the initial case conference to take place within five
weeks of the ward’s arrival at the institution. Yet the audit team found that 21 of the 93 initial
case conferences held at the facility (23 percent) were conducted beyond the first five weeks
of the ward’s arrival.3 Furthermore, to keep wards focused on short-term and long-term
treatment program goals, section 4035 of the California Youth Authority Institutions and
Camps Branch Manual provides that the case conference committee is to hold a progress
case conference no more than 60 days following the initial case conference and at least every

3

At the time of the fieldwork, one ward’s initial case conference was not yet due.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 10

120 days thereafter. Again, the facility failed to consistently meet that requirement. The audit
team found that 26 of 82 files reviewed (32 percent) were late.4
•

Wards’ case files lack documentation that treatment was provided. The audit team found
that wards’ living unit files lacked sufficient documentation to demonstrate to management
that policies and procedures are being followed, that wards’ histories are current, and that the
files provide the necessary information for treatment and parole recommendations. As noted
earlier, the living unit files did not contain complete chronological notes on individual and
small group counseling, which required the audit team to seek alternative sources to verify
the extent of counseling taking place. In addition, the audit team found that ward case files
lacked documentation that staff had performed the following five important steps in the
treatment of wards:
9 Orientation on time-cut policy. Seventy-seven of the 94 case files reviewed (82 percent)
did not have documentation that the wards had received orientation regarding the timecut policy5, as required by California Youth Authority Institutions and Camps Branch
Manual, section 4003.5.
9 Assignment to an education, training, or work program within four days. Forty-four of
the 94 case files reviewed (47 percent) did not have documentation that wards had been
assigned to an academic school program, vocational training, work assignment, or any
combination of these, within four working days of their arrival on the permanent living
unit, as required by California Youth Authority Institutions and Camps Branch Manual,
section 4010.4.
9 Interview by a casework supervisor within five days. Thirty-two of the 94 case files
reviewed (34 percent) did not have documentation that wards had been interviewed
within five working days of their arrival on the permanent living unit by the casework
supervisor (parole agent), in order to establish rapport, continue orientation, and discuss
the treatment program, as required by California Youth Authority Institutions and Camps
Branch Manual, section 4010.2.
9 Orientation within 10 days of arrival. Twenty-seven of the 94 case files reviewed (29
percent) did not have documentation that wards had received orientation within 10
working days of their arrival at the institution, as required by California Youth Authority
Institutions and Camps Branch Manual, section 4015.
9 Assignment to a counseling caseload within three working days. Twenty-six of the 94
case files (28 percent) did not have documentation that wards were assigned to a
counseling caseload within three working days of their arrival on the permanent living
unit, as required by California Youth Authority Institutions and Camps Branch Manual,
section 4010.3.

4

At the time of the audit, 12 wards had not been at the facility long enough to warrant a progress case conference.

5

The “time-cut policy” refers to the ward’s ability to have his time in custody reduced for good behavior.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 11

The Office of the Inspector General identified the following factors as contributing to inadequate
ward treatment services at the facility:
•

Counseling staff members spend most of their time performing security functions. The
audit team asked the 26 youth correctional counselors interviewed to estimate the amount of
time they spend performing their various duties during the workweek. The results showed
that the youth correctional counselors surveyed spend an average of 75 percent of their time
performing daily activities associated with security and custody functions, such as
supervising meals, showers, recreation, and school movement and working in the living unit
control tower. They spend an average of 15 percent of their time performing administrative
functions, such as casework documentation and writing behavior reports. They reported
spending an average of only 10 percent of their time counseling wards. This 10 percent
represents approximately one hour a week of small group counseling and three hours of
“individual counseling,” which they usually described as brief, informal interaction with
wards and which does not meet the criteria for formal, scheduled individual counseling.

•

Shortage of treatment staff in the general population living units. The audit determined that
N.A. Chaderjian has fewer treatment staff members per general population ward than other
facilities, even though the facility has older and more violent wards. The audit team reviewed
treatment staffing levels for the general populations at each of the California Youth Authority
facilities for the 2004-05 fiscal year, as reflected in the fiscal year 2005-06 Salaries and
Wages Supplement to the Governor’s Budget. The team compared that number to the
facilities’ ward populations as of June 30, 2004. The comparison revealed that N.A.
Chaderjian has 4.0 wards per treatment staff member, which is higher than the department
average of 3.8 wards. In comparison, the Southern Youth Correctional Reception Center and
Clinic has a ratio of 1.4 wards per treatment staff member, and the El Paso de Robles Youth
Correctional Facility has a ratio of 2.8 wards per treatment staff member. Even Heman G.
Stark Youth Correctional Facility, which has a ward population comparable to that of N.A.
Chaderjian, has a ratio of 3.5 wards per treatment staff member. If N.A. Chaderjian had the
same ratio as the Heman G. Stark Youth Correctional Facility, it would have 16 more
treatment positions. The shortage of treatment staff members affects counseling services, the
documentation of casework services, and ward and staff safety.

•

Ward counseling is scheduled to meet only the minimum requirements. The facility
schedules wards in the general population living units for only the minimum amount of
counseling effort required by the California Youth Authority Institution and Camps Branch
Manual, section 4050—one small group per week. That practice does not allow for
compliance with the counseling requirements of section 4050 when events such as wardinitiated disturbances, staff sick leave, and other staff absences prevent the small group from
meeting. Even when regular counselors take scheduled vacations, the living units rarely
receive substitute counselors who have developed the necessary rapport with the wards to
effectively continue the treatment program. This scheduling problem has contributed
significantly to the fact that during the period audited, the general population living units
made available less than one (.77) small group counseling session per counselor per week. If

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 12

more time were scheduled for counseling each week, the general population living units
might be able to meet the requirements for counseling frequency provided in section 4050.
•

High vacancy rates in the counselor ranks. The facility has had difficulty filling youth
correctional counselor and senior youth correctional counselor positions. As of November 2,
33 of the facility’s 113 budgeted youth correctional counselor positions (29 percent) and 4
(29 percent) of the 14 senior youth correctional counselor positions, which supervise the
youth correctional counselors, were vacant. To compound the problem, the audit team noted
that in February 2005, there were only six youth correctional counselors in the relief pool of
substitutes, a number insufficient to cover the 113 budgeted youth correctional counselor
positions in the facility.

•

Formal and informal training are inadequate. As noted earlier, the counseling staff readily
admit that they lack training. An inadequate training budget and insufficient time to formally
train staff apparently contribute to this problem. Informal, on-the-job training can augment
formal training, yet it does not always take place. All of the 26 youth correctional counselors
interviewed by the audit team said they had received little or no formal counseling training,
and 10 (38 percent) also said they had never received on-the-job training. Furthermore, the
facility does not regularly use internal resources such as the following staff for informal
training:
9 Staff psychologists. Staff psychologists would be a valuable source of information and
training to youth correctional counselors; but according to staff members interviewed,
they spend little time helping counselors in the general population living units.
9 Staff experienced in using the Ward Information Network 2000 system. The audit team
found that some counselors have not been adequately trained on how this system works
and how it ties into documenting compliance with the counseling requirements of the
California Youth Authority Institutions and Camps Branch Manual. Technically
competent staff could help those less trained acquire necessary skills.

•

Inadequate monitoring of casework. In February 2005, to his credit, the superintendent
reinforced the need for program managers to audit the counseling staff’s casework for
compliance with the California Youth Authority Institutions and Camps Branch Manual.
Given the multiple locations of information outside the living unit files, however, this task
will be difficult until managers require and enforce strict adherence to the timely filing of all
casework in the living unit file.

•

Failure to hold teachers accountable for not attending case conferences. According to the
staff, when the institution had education advisors assigned to the living units they
participated more regularly in case conferences. Although the facility has done away with
that approach, the high school administration has created a schedule that allows for teachers
to attend case conferences in the living units. Yet, the administration is not holding teachers
accountable for failing to attend. Administrators could note a teacher’s failure to attend case

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 13

conferences in the annual performance appraisal, but as noted in Finding 2 of this report, at
present, administrators do not conduct timely performance appraisals.
•

Collective bargaining agreement provisions. The “post-and-bid” provisions of the state’s
collective bargaining agreement with Bargaining Unit 6 result in excessive turnover of youth
correctional counselors by calling for an annual shuffling of counselor assignments. The
contractual “70-30” requirement that management may appoint only 30 percent of the youth
correctional counselors, while seniority drives the other 70 percent, limits the
superintendent’s ability to effectively address the treatment needs of wards.

•

Lack of funding for interactive journals. As noted above, the facility does not have enough
interactive journals for small group counseling. When facility administrators attempted to
acquire the journals from department headquarters, a headquarters administrator told them
there were no funds for more journals. Given that interactive journals are the primary
treatment modality for small group counseling in the California Youth Authority, inadequate
funding for such journals diminishes the effectiveness of the counseling function.

•

No additional resources received for implementing Senate Bill 459. The passage of Senate
Bill 459 (Chapter 4, Statutes of 2003) caused an increased workload for key treatment staff.
Previously, wards appeared before the Youthful Offender Parole Board and if the board
denied parole, it decided on the additional confinement period. The 2003 legislation
eliminated the Youthful Offender Parole Board and replaced it with the Youth Authority
Board. Wards now appear before the Youth Authority Board for parole consideration, and if
denied parole, they must go before the facility’s new Youth Authority Administrative
Committee for a determination of additional confinement time. This new committee has
added more paperwork and casework time to the parole agents’ workload, and has added
more responsibilities and work for the parole agent III who chairs the committee. Yet the
facility received no new resources to handle the additional work.
RECOMMENDATIONS
The Office of the Inspector General recommends that the California Youth
Authority and N.A. Chaderjian administrators jointly take the following
actions to improve treatment services for wards:
● Provide adequate staffing to the facility’s general population living units by
evaluating the needs of the facility relative to the needs of other facilities and
act accordingly. If necessary, redirect resources from other facilities.
•

Fill staff vacancies by aggressively recruiting senior youth correctional
counselors and youth correctional counselors for the facility. In addition, hire
more staff for the counselor relief pool.

In addition, the Office of the Inspector General recommends that the
management of N.A. Chaderjian take the following actions:

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 14

•

As vacancies diminish and staffing levels increase, schedule more than one
hour of formal counseling per week per general population ward and ensure
that counseling for wards in all living units includes at least some formal,
individual counseling of a least one hour duration.

•

Assess the training needs of the facility’s counseling staff, particularly those
of the youth correctional counselors, and make available the funding and time
necessary to upgrade their knowledge, skills, and ability through formal
training. In addition, use in-house staff, such as psychologists, staff
experienced in using the Ward Information Network 2000 system, and the
best and most experienced treatment staff to provide structured on-the-job
training on counseling techniques, living unit file documentation methods, and
other relevant topics.

•

Improve the monitoring of casework by ensuring that living unit files are
organized and use progressive discipline to emphasize the importance of
maintaining current, accurate information in these files.

•

Regularly sample ward files for compliance with the treatment provisions of
the California Youth Authority Institutions and Camps Branch Manual.

•

Hold administrators, supervisors, parole agents, and counselors accountable
for counseling wards through timely performance appraisals and progressive
discipline.

Finally, the Office of the Inspector General recommends that the California
Youth Authority take the following actions:
•

Hold the facility’s high school administrators responsible for ensuring that a
teacher attends every case conference. Use performance appraisals and
progressive discipline to enforce compliance.

•

In future labor negotiations on behalf of the entire California Youth Authority,
consider reducing or eliminating the “70-30” split for filling youth
correctional counselor positions.

•

Provide funding for interactive journals and similar items critical to the
department’s core functions of treatment and training.

•

Evaluate the additional workload placed on treatment staff due to the passage and
implementation of Senate Bill 459, and provide budget support for the facilities as
necessary.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 15

FINDING 2
The Office of the Inspector General found that education services provided to wards at
N.A. Chaderjian are deficient.
Academic education and training for wards is integral to the California Youth Authority’s
mission of providing rehabilitation services to enable wards to return to society with the skills
necessary to succeed and to discourage future criminal behavior. Yet the Office of the Inspector
General found that the N.A. Chaderjian High School is not adequately fulfilling its responsibility
to provide wards with education services. Special education wards, who make up 38 percent of
the high school’s enrolled students, are not receiving all of their individually mandated special
education service time. Moreover, special education providers are consistently over-reporting the
amount of service provided. At the same time, more than a third of the academic classes
scheduled at the high school are routinely cancelled, mainly because teachers do not show up for
class. Class cancellations contribute significantly to the school’s low effectiveness rating, which
measures actual—versus potential— attendance and classes held. The effectiveness rating of the
high school is 40 percent, meaning that wards are receiving only 40 percent of their assigned
education programming. Poor oversight by school administrators contributes to the problems.
The school has had a succession of four principals since 2002 and the current acting principal
works concurrently at department headquarters in Sacramento and spends only about half his
time at the facility.
As a result of the deficiencies, wards’ test scores are declining and fewer wards are graduating.
The low academic achievement not only hampers the wards’ development and chances for future
success, but also jeopardizes the accreditation of N.A. Chaderjian High School. The Western
Association of Schools and Colleges granted the high school candidacy accreditation in April
2003 for a period of two years and revisited the school on January 26, 2005 for the purpose of
determining whether an extension of accreditation was warranted, and if so, for how long. As of
the date of this report, the association had not announced its accreditation decision, but a report
issued after its January 26, 2005 visit was critical of the school’s limited progress in addressing
the “critical areas of follow-up” identified in the April 2003 report. Among these critical areas
were low staff morale; teachers working out of their areas of expertise; a lack of understanding
of California academic standards; and a failure to integrate those standards into school curricula.
The Office of the Inspector General made the following specific findings as a result of the audit:
•

Wards are not receiving the appropriate amount of special education service time. Special
education wards at N.A. Chaderjian are receiving service far below the 90 percent threshold
set by the California Youth Authority Education Services Branch. Furthermore, the Office of
the Inspector General found that N.A. Chaderjian High School has been uniformly
overstating the special education services provided to wards. A review by the audit team of
three sample months in 2004 covering 40 reports prepared by service providers at the facility
found that every single one overstated the service rates provided to wards. During those
months, for example, N.A. Chaderjian High School reported an average compliance rate for
resource specialists of 76 percent, meaning that 76 percent of the special education wards

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 16

received at least 90 percent of the required resource specialist service hours. A recalculation
by the Office of the Inspector General of the data used to support the reported 76 percent
compliance rate, however, yielded an actual compliance rate of 43 percent— meaning that
the compliance rate had been overstated by 33 percentage points. Similarly, the audit team
found that Special Day Classes compliance rates were overstated by five percentage points;
Speech/Language Treatment compliance rates were overstated by four percentage points; and
School Psychologist Therapy compliance rates were overstated by ten percentage points.
In summary, the audit team determined that during the three months sampled in 2004, the
following percentages of special education wards obtained 90 percent or more of their
individually mandated special education service time:
Resource Specialist Program ........43 percent
Special Day Classes ......................11 percent
Speech/Language Treatment.........58 percent
School Psychologist Therapy........56 percent
The failure to provide special education services at the required level and obscuring the issue
by overstating special education statistics hampers decision-making for special education.
The California Youth Authority’s special education services historically have been under
scrutiny by the courts, youth advocates, and legislators. The erroneous and misleading
reports impair the department’s efforts to identify shortcomings in special education services
and develop appropriate corrective action.
•

N.A. Chaderjian High School’s standardized test scores have declined. The percentage of
wards scoring below the 25th national percentile in Standardized Testing and Reporting
(STAR) increased from 61 percent in 1998 to a high of 83 percent in 2004. This trend is also
manifested in the disparity between N.A. Chaderjian wards and statewide STAR scores for
public schools. While scores across the state improve, the wards at N.A. Chaderjian are
failing to keep pace. In 1998 N.A. Chaderjian wards performed at a rate 3.7 percentage
points below the statewide public school average. By 2003 the performance rate had
plummeted to 10.8 percentage points below the statewide average. The 2004 scores
continued the downward trend, with N.A. Chaderjian wards scoring 12.2 percentage points
below the statewide average. Overall, the 2004 STAR scores at the N.A. Chaderjian High
School ranked eighth worst among the eleven California Youth Authority institution and
camp schools reporting.

•

Fewer wards are graduating from N.A. Chaderjian High School. In 2004, N.A. Chaderjian
High School graduated 41 wards, a significant decrease from 2003, when 72 wards
graduated. While a drop in the ward population at N.A. Chaderjian High School from 2003 to
2004 contributed to the decline in the number of wards graduating, the population decrease
was only 23 percent, while the decrease in the graduation rate was 43 percent. Earning a
diploma from N.A. Chaderjian High School is difficult—a ward must earn 200 credits to
graduate from the school. The Office of the Inspector General found that the average ward at
N.A. Chaderjian has 134 credits, yet is earning only 13 credits per year. At that rate, the

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 17

average ward needs five years to earn a high school diploma at the facility; yet the average
remaining confinement time of wards is slightly more than two years.
The audit team identified the following factors as contributing to the poor special education
service rates and to the low academic achievement of wards at N.A. Chaderjian High School:
•

Failure to assign properly credentialed teachers to special education. Education
administrators at the facility have not managed the institution’s resources effectively by
assigning properly credentialed teachers to special education classes. The audit team
identified two full-time teachers at N.A. Chaderjian High School who possess special
education teaching certificates but who were not teaching special education classes. Another
credentialed, part-time teacher who was hired in August 2004 to assist in providing special
education services worked 112.25 hours from August through November 2004, yet provided
only 29 special education service hours. And although N.A. Chaderjian High School had
credentialed teachers available to provide special education classes, a teacher without special
education credentials was providing special education Resource Specialist Program services.

•

Inadequate oversight of special education by administrators. The overstated special
education service rates are the result of a lack of meaningful supervisory review of the
individual provider reports. The audit team found that administrators routinely signed
monthly reports without checking for accuracy or logic in the numbers reported. For
example, special education administrators approved reports containing illogical dates of
service, including weekends, holidays, teachers’ vacation days, and teachers’ sick leave days.
Teachers also reported service hours for wards who had already left the institution and for
periods when classes had been cancelled.

•

Classes are frequently cancelled. Perhaps helping to account for the declining STAR scores
at N.A. Chaderjian High School, the Office of the Inspector General found that a significant
amount of time is lost from academic and vocational education at the facility because classes
are frequently cancelled due to teacher absences, security issues, or other facility-initiated
purposes. A review by the audit team of a four-month period in 2004 found an average of
347 classes cancelled per month—34 percent of the total classes offered. The cancellations
contribute significantly to the high school’s relatively low effectiveness rating — the
measure used by the California Youth Authority Education Services Branch to compare
actual ward attendance and classes held to potential ward attendance and classes held. In
fiscal year 2003-04, the effectiveness rating of N. A. Chaderjian High School was 40 percent,
meaning that wards received on average only 40 percent of their assigned educational
programming.
The class cancellations at the facility can be attributed to the following:
9 Teacher abuse of leave time. Sixty-three percent of class cancellations at the high school
occur because teachers are absent and because teachers’ use of leave time at the facility is
so high that it exceeds the institution’s ability to provide substitute coverage. The Office
of the Inspector General found that teacher-induced class cancellations occur every day

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 18

of the school week and for a variety of reported reasons, including medical and dental
appointments, personal and family sick leave, training, meetings, and personal business.
Yet, the audit team found that teachers frequently did not charge their leave balances
when taking time off for medical and dental appointments, personal and family sick
leave, or personal business.
The ability of California Youth Authority teachers to take time off without charging their
leave balances is rooted in a section of the California State Employees Association
Bargaining Unit 3 contract that designates teachers as “exempt” and therefore excluded
from the Federal Fair Labor Standards Act. This designation allows teachers to take
partial days off for legitimate purposes without deducting hours from their sick leave or
vacation leave balances provided they meet their weekly performance objectives. Yet, the
very nature of scheduled classroom instruction precludes teachers from making up lost
time if they cancel a class; therefore, they cannot meet their performance objectives
during any week in which they cancel classes.
The bargaining unit contract specifically calls for teachers to try to schedule time off
during non-class hours—which at N.A. Chaderjian would be before 8:20 a.m., after 3
p.m., or during the half-hour lunch period. Nonetheless, the Office of the Inspector
General found that some teachers at the facility take advantage of the exempt status
contract provision by abusing leave time. The audit team found that in July 2004, 15
teachers out of the 43 teachers at the facility took an average of 1.8 days of uncharged
leave that resulted in class cancellations. In the worst example, one teacher took an
average of 5.3 days of uncharged sick leave per month over a three-month period in
2004. During one of those months, that teacher took off half-days on 11 of the 21 school
days available for instruction.
9 Poor oversight of teachers by education administrators. Poor oversight by school
administrators allows teachers to abuse leave time, contributing to the high number of
class cancellations. One cause of the poor oversight, in turn, is high turnover among
administrators. Since 2002, N.A. Chaderjian has had four principals in either acting or
permanent appointments. The present acting principal of the facility’s high school works
concurrently at the Education Services Branch headquarters in Sacramento, and the audit
team observed that he spends only about half his time at the facility. The lack of
continuity and disengagement of school administrators contributes to low morale among
members of the teaching staff. High turnover at headquarters has also contributed to lack
of direction from the Education Services Branch, which has had four different
superintendents in the past year alone and has numerous vacancies in key management
positions.
Poor supervision of teachers is illustrated by the following:
▪

Performance appraisals are not completed on time. The audit determined that school
administrators do not consistently complete teacher performance evaluations on time,
and that the number of overdue evaluations increased during the course of 2004. The

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 19

audit team found 16 past-due performance appraisals for the month of January 2004
and 57 overdue evaluations for December 2004. The teachers’ labor contract provides
management with the authority to enforce performance objectives, which could lessen
abuse of leave time, but to do so requires timely performance appraisals.
▪

Teachers fail to attend case conferences. The failure of teachers to attend wards’
case conferences, described in Finding 1, is further evidence of poor supervision by
school administrators. N.A. Chaderjian High School sets aside one-half day each
week as a time when no classes are scheduled, specifically to allow teachers to attend
case conferences in the living units and provide feedback to the treatment teams
concerning each ward’s educational programming. The auditors found, however, that
teachers rarely attend case conferences. A review of wards’ treatment files from
December 2004 through March 2005, showed that teachers attended the case
conferences only 14 percent of the time. Instead of attending afternoon case
conferences, many of the teachers simply took advantage of the half-day break in the
class schedule to leave the institution early. To address the problem, administrators
began scheduling meetings during the case conference time as a way of keeping
teachers on the grounds. That measure may have served the purpose of keeping
teachers from leaving the facility, but directly undermined the goal of having teachers
attend case conferences.

9 Security factors contribute to class cancellations. According to the N.A. Chaderjian
High School Student Ward Attendance Tracking system, safety and security
considerations accounted for 18 percent of class closures during the period June through
September 2004.
9 Teacher training and development. Classes are also occasionally closed for teacher
training and development and administrative meetings. According to the N.A. Chaderjian
High School Student Ward Attendance Tracking system, teacher development accounted
for 17 percent of class closures during the period June through September 2004.
•

Ward absenteeism has increased. In addition to class cancellations and failure to provide
appropriate special education services, ward absenteeism has contributed to declining STAR
scores and the low effectiveness rating of N.A. Chaderjian High School. The four-year
downward trend in STAR scores at the institution mirrors an upward trend in ward
absenteeism. The Office of the Inspector General found that in fiscal year 2003-04, ward
absenteeism averaged 23 percent—up from 18.5 percent the previous year and nearly double
the fiscal year 1999-00 ward absenteeism average of 12 percent.
Numerous factors have contributed to the heightened absenteeism, including several beyond
the control of the wards. For example:
9 Counselors keep wards out of class. The Bargaining Unit 6 contract allows counselors to
withhold wards from school during scheduled education time to attend small group

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 20

counseling sessions—a clash of priorities that demonstrates the lack of coordination
between treatment services and education.
9 Long class periods discourage attendance. In response to violence that has often
accompanied the movement of wards to classes and to reduce the number of movements,
the N.A. Chaderjian High School has instituted a schedule of two 140-minute classroom
periods per day. Although this schedule meets the minimum required instructional
minutes over a two-week period, most teachers interviewed told the audit team that the
wards’ attention spans diminish significantly after one hour, with the result that more
than half the class period is not productive. In addition, the long periods magnify the
impact of absences and cancellations. When a teacher arrives late, his or her class is
canceled for the entire 140-minute period, resulting in a loss of half the normal school
day. Wards held from school for small group sessions or other activities similarly lose a
half day of school, or even a full day, depending on the ward’s class schedule. If the
school schedule consisted of four shorter periods per day, only 25 percent of the school
day would be lost when a teacher arrives late or a ward is held out for a counseling
session or other reason.
9 Wards lack motivation to complete coursework. Because wards at the facility often have
had negative education experiences both inside and outside the California Youth
Authority, many of them believe earning a high school diploma is beyond their ability;
yet California Youth Authority policy requires wards to make “satisfactory progress”
toward high school graduation to be considered for parole. As a result, many wards enroll
in classes solely for that reason and lack the motivation to complete the courses. Wards
who might be more interested in learning a trade, meanwhile, are often denied that
opportunity because the number of vocational education programs at the facility has
shrunk from 13 to six since 1996 because of budget cuts.
9 Gang segregation limits educational opportunities. Current policy at N.A. Chaderjian
High School requires segregation of students by gang affiliation. As a result, many wards
are assigned to school for only one period and, consequently, one subject. But because
not all classes required for graduation are offered in both morning and afternoon sessions,
wards may be unable to complete graduation requirements. The Office of the Inspector
General identified one ward, for example, who needs only 5.5 credits to graduate, but the
two classes he needs are offered only in the morning, and his gang affiliation permits him
to attend class only in the afternoon.
RECOMMENDATIONS
To improve educational achievement at N.A. Chaderjian, the Office of the Inspector
General recommends that the California Youth Authority take the following
actions:
•

Expedite the appointment of a superintendent of education.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 21

•

During the next Bargaining Unit 3 negotiations, bargain for removal of the exempt
status of teachers.

•

During the next Bargaining Unit 6 negotiations, bargain to eliminate the authority of
counselors to keep wards from attending the high school classes.

The management of the Education Services Branch of the California Youth
Authority and the institution’s education administrators should take the following
actions:
•

Expedite the appointment of a permanent principal for N.A. Chaderjian High School.

•

Use performance appraisals and progressive discipline to hold teachers and
administrators accountable for their performance, including attending case
conferences, meeting performance objectives, and accurately reporting special
education services and attendance.

•

Reduce class cancellations by working with the facility superintendent to improve
scheduling and coordination between the facility staff and the high school
administration. As part of this joint effort, eliminate the scheduling conflict
between small group counseling and wards’ attendance in school.

•

For wards 18 years of age and older, consider developing alternatives to obtaining a
high school diploma as a criterion for parole consideration. While obtaining a high
school diploma should remain the primary goal for the majority of wards, alternatives
such as adult basic education and vocational programs should be considered as
appropriate options for educating wards and earning parole consideration.

•

If teachers’ attendance at case conferences does not improve, eliminate the halfday reserved for case conferences and require teachers to provide timely progress
reports to the wards’ youth correctional counselors.

•

Adjust the school schedule to provide for at least four class periods per day.

•

Study ways to lessen the negative effects of gang segregation within the high
school in order to provide all wards with equal educational opportunities.

•

Comply with all recommendations of the Western Association of Schools and
Colleges in order to obtain full accreditation for N.A. Chaderjian High School.

•

Use existing special education staff to provide special education services and ensure
that only properly credentialed special education staff are providing the services.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 22

FINDING 3
The Office of the Inspector General found that structural defects, maintenance problems,
and deficient management practices at N.A. Chaderjian jeopardize the safety of employees,
wards, and visitors.
The Office of the Inspector General found that N.A. Chaderjian has significant structural
deficiencies and that the institution is not complying with numerous security policies and
procedures required by the California Youth Authority Institutions and Camps Branch Manual.
These deficiencies, combined with maintenance problems and deficient management practices,
jeopardize the safety of staff, wards, and visitors to a degree that exceeds even the normal risks
inherent in a correctional setting.
Building deficiencies compromise security. According to the plant operations staff for the
Northern California Youth Correctional Center complex, the institution has been plagued by
structural defects since the day it opened in 1991. As an example, according to the Facilities
Planning Branch of the California Youth Authority, the construction plans for the facility called
for walls to be “solid grouted” — meaning that cement blocks were to be filled with concrete —
but the facility staff discovered that some of the walls had hollow areas. In response to that
discovery, the department contracted with a geotechnical engineering firm to conduct an
independent study of the facility. [Information pertaining to interior walls redacted for security
reasons.] The study identified other structural deficiencies, including inadequate bracing, and
recommended that further testing be conducted. The plant operations staff has found numerous
other deficiencies, including improperly installed floor tiles, gaps in the doors and food tray slots
of the wards’ rooms, and failure to properly ground water lines and electrical panels. The
California Youth Authority has sought special repair funding for some of the problems identified
in this report, but the Department of Finance has denied the requests.

Picture provided by California Youth Authority staff
illustrating a hollow area within a wall in one of the
rooms in the Kern living unit. These cement blocks
were not filled with concrete. This hole had been
repaired prior to the initiation of the audit.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 23

Metal plate installed over a hole in a room in the
Kern living unit.
___________________________________________

The Office of the Inspector General
confirmed the existence of numerous
structural deficiencies at the institution and
noted that wards are able to exploit the
deficiencies, endangering staff and other
wards. For instance, section 1802 of the
California Youth Authority Institutions and
Camps Branch Manual requires that doors
to wards’ rooms be constructed to withstand
damage. It also requires that doorjambs and
locks be constructed to be as secure and
indestructible as practicable. The section
also requires plumbing and electrical
fixtures in the wards’ rooms to have limited
potential for damage by wards and that
rooms be designed to lessen the possibility
of escape, suicide, and passing contraband.
Yet the Office of the Inspector General found that the institution does not consistently meet these
standards. For example:
•

The doors to ward rooms are in poor repair and are not secure. The Office of the Inspector
General found that construction of the doors to the wards’ rooms in at least five living units
is such that wards are able to jam the doors and prevent them from being locked by placing
objects in the doorjamb. The torsion springs in some of the doors are weak, allowing wards
to prop open doors with string or wire. The staff reported that replacement parts are hard to
find, making repairs difficult.

•

Doors to ward rooms can pop open. All of the doors in the Kern living unit are electrically
operated and have undersized motors that tend to overheat. This can cause the doors to open
unexpectedly when the motor cools and the computer memory executes the most recent
command. Doors in the other living units are manually operated and therefore do not have
this deficiency.

•

Gaps between doors and doorjambs allow wards to assault staff. Gaps between the doors
and the doorjambs and along the food tray slots in the doors provides an opportunity for
wards to “gas” employees— intentionally throw human excrement or body fluids on them. In
2003, there were 43 gassing incidents at the institution, and in 2004, there were 25 gassing
incidents. Gassing incidents usually require testing victims and perpetrators for hepatitis and
tuberculosis at state expense.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 24

A door in the Kern living unit showing gaps next to
the food tray slot that provides an opportunity for
gassing assaults.

•

Food tray slot altered by the plant operations staff to
prevent gassing assaults.

Holes in the floor. Wards have been able to dig through the cement floor of some of the
rooms into the underlying soil, revealing that the floor in some places is less than two inches
thick and raising questions about its structural integrity. The maintenance staff patches the
holes as they are discovered.

Picture provided by California Youth Authority staff
illustrating a hole dug by a ward in the floor of a
room in the Sacramento living unit. This hole had
been repaired prior to the initiation of the audit.
A hole in the floor of the Sacramento living unit
after it was patched by plant operations.

•

Wards are able to tamper with electrical fixtures. Some of the rooms are without power for
radios and television sets because wards have tampered with the electrical outlets. Because

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 25

the rooms continue to be used so long as the lights are working, wards sometimes remove
electrical outlet plates in adjoining rooms and tamper with those outlets to divert electricity to
rooms without power. This practice, referred to as “juicing,” involves tying a wire to a plug,
attaching it to metal shelving, and transferring the power to the adjacent room. Wards
camouflage the small wires with toothpaste blended to match the wall color. Other forms of
tampering involve altering light switches or light ballasts. Some of the tampering incidents
have caused plugs to conduct 220 volts instead of 110 volts, tripped circuit breakers, and
caused computers to fail. Wards sometimes divert electricity to deliberately cause electrical
shocks to the staff, and a number of staff members have received electrical shocks while
working in the rooms. Wards who are unaware of the dangers of the tampering are also at
risk of electrical shock.

An electrical outlet that was burned out due to
electrical tampering by wards.

•

Broken electrical and plumbing fixtures have rendered many rooms unusable. Many of the
rooms in the living units are unusable because wards have damaged or destroyed plumbing
and electrical fixtures and repairs have not been made. The review found that 13 (26 percent)
of the 50 rooms in the Kern living unit, for example, were unusable because of unrepaired
plumbing, doors, or electrical fixtures.

•

Wards are able to flood dayrooms. Because the floors in ground-level ward rooms are at the
same level as the floors in the central dayrooms, when wards flood their rooms, they also
flood the dayrooms, disrupting the programming activity of all wards in the area. The
flooding, together with the fact that the tiles were not properly installed, has damaged the
tiles and left them loose and in poor condition, resulting in broken pieces of tile that can be
used as weapons.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 26

Broken floor tiles in the dayroom of the Pajaro living
unit. Pieces of tile can be used as weapons or to
manufacture weapons.

The Office of the Inspector General found numerous other building deficiencies at the facility
that endanger staff and wards. Examples include the following:
•

Control panels, monitoring devices, and lights are out or malfunctioning. In some living
units, the door status lights in the control tower electrical panel mistakenly indicate that a
door is locked when it is not, or that it is open when it is not. In addition, some of the
surveillance cameras, as well as some of the video monitors in the control towers, are not
fully functioning. For example, the audit team found that three of the nine screens of a
surveillance monitor in one control tower were blacked out, and the staff reported that they
were unaware that a surveillance camera on the recreation yard was broken until a staff
member was assaulted on the yard. In addition, in some of the living units, lights in the
wards’ rooms and in the dayrooms have been out for as long as a week, making it difficult to
conduct counts or provide regular programs. Evening programs in at least one living unit
have been cut short because of inadequate lighting.

Surveillance monitor in the control tower over the
Owens and Pajaro living units showing three of the
nine screens blacked out.

•

Fences between recreation yards are inadequate. Fences separating the recreation yards of
different living units are too low and the flat panel razor wire on top does not sufficiently
discourage climbing. [Information pertaining to fences redacted for security reasons.]

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 27

•

Outdoor caged areas are in disrepair. Some of the outdoor caged areas used by the
Sacramento and Kern living units to provide wards in the lockup unit and the special
management program with large-muscle exercise are in disrepair because of damage by
wards. [Information pertaining to cages redacted for security reasons.] The maintenance
staff reported they are unable to keep up with the necessary repairs, and some of the cages
are continually unusable.

A piece of metal more than 4” long that was found on
03/08/05 behind the Sacramento living unit. The
metal appears to be broken off a fence. One of the
ends appears to have been sharpened. Because of its
location, it was likely broken off from the large cages
used as individual recreation areas.
Picture taken during the audit depicting a large cage
used as an individual recreation area outside the
Kern living unit with a hole probably created by
wards either to obtain material for weapons or to
break through the fence.

•

Electronic entry/exit tracking system is not reliable. Sections 1915 and 1920 of the
California Youth Authority Institutions and Camps Branch Manual require the use of the
electronic entry/exit system to identify all employees and certain visitors and to alert the staff
when those checking into the institution have not departed at the expected time. The Office
of the Inspector General found, however, that the bio-scan electronic entry system was not
operating properly at the time of the review. [Information pertaining to bio-scan electronic
entry system redacted for security reasons.] Those who attempted to use it often found that
the system would neither register their access card nor recognize their fingerprint. The
institution does use a manual system to identify those entering and leaving the institution, but
unlike an electronic system, that system cannot automatically alert staff when employees or

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 28

visitors fail to leave the facility at the expected time and instead relies on the staff to monitor
departure times.
•

The main entrance of the facility lacks a stationary metal-detector. Section 1805 of the
California Youth Authority Institutions and Camps Branch Manual requires a stationary
metal-detection device to be in place for screening incoming staff and visitors for contraband
such as firearms or knives. [Information pertaining to metal detector removed for security
reasons.] Although hand held metal-detection devices are available, the Office of the
Inspector General never saw them being used. The audit team did observe that stationary
metal-detection devices in the school and visiting areas were operational.

•

Youth correctional counselor stations provide minimal protection. Section 1820 of the
California Youth Authority Institutions and Camps Branch Manual requires every facility to
design youth correctional stations in living units so as to provide protection from wards
during emergencies. Whenever possible, these stations are to be enclosed with locking doors
and secure from intrusion. The audit team found, however, that the youth correctional
counselor stations on the floors of the 12 living units at the institution are open and
unsecured. While the stations can serve as a barrier from a thrown object, they provide no
protection from physical assaults.

•

Intercom system does not serve all areas. Intercoms are essential to enabling the security
staff to monitor ward activity and respond to emergencies. Section 1810 of the California
Youth Authority Institutions and Camps Branch Manual requires institutions to “have an
intercom system linking school classrooms with security staff and having an all-call
capability.” While the Office of the Inspector General found that most of the academic
classrooms and vocational education shops at the institution had operable intercom systems,
two of the vocational shops in which classes are being held (auto mechanics and building
maintenance) did not.

•

Perimeter security is deficient. Section 1813 of the California Youth Authority Institutions
and Camps Branch Manual requires all buildings that form part of the institution perimeter to
include specified features and to conform to structural specifications for fences, fence poles,
cameras, fence alarms, and other equipment necessary to secure the perimeter and prevent
escapes. Section 1813 also requires that “sallyports shall be provided with an electronic
overide lock system operable from a security control station.”
The Office of the Inspector General found that the institution’s one vehicle entry/exit
sallyport does include an electronic override lock system operable from the control tower.
But the audit revealed deficiencies in both the perimeter fence at the institution and in
security procedures at the entry gate. The bottom of the perimeter fence is not set in concrete
and the fence poles are of insufficient diameter, with the result that the fence is unstable and
sways in the wind. [Information pertaining to perimeter security redacted for security
reasons.] Although fence lighting is adequate, some of the fence cameras are not operating
and those that are operating are not useful in foggy conditions. Also, the signs identifying the
fence “zones” are so small that the staff is obliged to memorize the zone locations to be able

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 29

to respond to alarms. [Information pertaining to perimeter security redacted for security
reasons.]
•

Radio equipment is outdated and needs a replacement schedule. Section 1814 of the
California Youth Authority Institutions and Camps Branch Manual requires that radios
needed to provide secure communication and sensitive information be placed on a
replacement schedule and budgeted for accordingly. [Information pertaining to radio
equipment redacted for security reasons.]

•

The Office of the Inspector General also found that the institution is not complying with
numerous other department-mandated security policies and procedures. The California Youth
Authority Institutions and Camps Branch Manual requires the state’s youth correctional
institutions and camps to comply with specific policies and procedures intended to provide
for the safe and secure operation of California Youth Authority facilities. Policies and
procedures affecting ward, employee, and visitor safety include those found in sections 1800
through 1848 (safety and security standards); sections 1915 through 1947 (entry-exit
systems); sections 5000 through 5030 (contraband and searches); and sections 5050 through
5075 (searches of employees and visitors).

The importance placed by the California Youth Authority on compliance with sections 1800
through 1848 is demonstrated by a department requirement that the superintendent of every
institution and camp conduct an annual evaluation of the entity’s compliance with those sections.
Superintendents are required to report the results of the evaluations each November to the deputy
director of the department’s Institutions and Camps Branch. Non-compliance with any provision
requires the superintendent to submit a plan and expected date for achieving compliance. In
addition to reviewing the annual compliance reports, the deputy director is responsible for
assembling a review team to visit every camp and institution each year to conduct a security
audit of compliance with the safety and security requirements.
Despite the importance placed by the department on compliance with safety and security
requirements, the Office of the Inspector General found numerous deficiencies in N.A.
Chaderjian’s compliance with the requirements, as well as with the department’s monitoring of
that compliance. The Office of the Inspector General found the following:
Security evaluations do not identify all problems and do little to achieve change. Problems
affecting the safety and security of staff, wards, visitors, or the general public should be
identified and addressed by the institution’s annual security audit, as required by section 1800.
The Office of the Inspector General’s review of N.A. Chaderjian’s 2002, 2003, and 2004 section
1800 security evaluation reports, however, revealed the following:
•

Areas of non-compliance were missed. The evaluations overlooked significant areas of noncompliance and did not result in correction of the non-compliance they did identify. As
itemized below, the Office of the Inspector General identified non-compliance with 17 of the
sections contained in sections 1800 through 1848 of the California Youth Authority
Institutions and Camps Branch Manual pertaining to security policies and procedures.
According to staff interviews and facility records, many of the issues of non-compliance have

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 30

existed for years; yet the facility’s 2002 report identified problems with only seven sections.
Furthermore, while the 2003 report identified problems with 11 sections, 7 were the same
problems identified the previous year. And although the 2004 report identified compliance
deficiencies with 14 sections, 11 of those were the same problems identified in the previous
year, meaning that problems identified earlier had not been resolved.
•

Report errors reflect careless work and minimal effort. In the 2004 report, only two items of
non-compliance included the required estimated completion date, and both of the estimated
completion dates given were nonsensical because they had already expired —one by 12
months and the other by 11 months. The audit team noted that the staff person who prepared
the 2004 report appeared to have copied the previous years’ reports and neglected to update
the estimated completion dates. The auditors also found that the document the reviewer used
to conduct the compliance evaluation had not been updated to reflect changes in sections
1800 through 1848. For example, in August 2002, section 1815 of the manual was changed
from “restraint devices” to “ward accountability.” All three reports indicate that the
institution was in compliance with that section, but no evidence was provided to show that
ward accountability was evaluated. Also, the 2004 report addressed section 1835 (“room
extraction”), even though that section has not been part of the manual since at least March
2003.

The Institutions and Camps Branch has not conducted required security audits of the facility.
The Office of the Inspector General found that the Institutions and Camps Branch has not
conducted security audits of the facility as required by section 1800 for at least the past three
years. In December 2002, the department’s compliance review unit did conduct a three-day
management review audit at the facility that included a security component, but a three-day
review is much more limited than an in-depth review. It is noteworthy that the management
review audit criticized the Institutions and Camps Branch for neglecting to act on the facility’s
section 1800 reports, saying the reports were routinely filed without comment. Furthermore, the
errors in the institution’s section 1800 reports identified above indicate that the branch does not
review the reports or assess compliance. The failure of the Institutions and Camps Branch to
conduct required security audits and its inaction on section 1800 reports is clearly inconsistent
with the security needs of the California Youth Authority.
The Office of the Inspector General also found numerous other security deficiencies related to
the management of the institution. For example:
•

Ward movement practices are deficient. Section 1804 of the California Youth Authority
Institutions and Camps Branch Manual requires that each institution develop “controls and
written procedures for ward movement” and that the controls “be based on a system which
provides for advance communication of the movement and observation and accountability
for all wards.” According to the staff, any ward leaving a unit is issued a pass.
The Office of the Inspector General observed the following practices in ward movements at
the institution that compromise safety and security:

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 31

9 Wards were allowed to leave the culinary arts program without a pass or a phone call to
notify school security. Wards also left the administration building without a pass.
9 Staff personnel allowed ward workers in the living units to continually communicate with
wards who were secured in their rooms.
9 Staff personnel also allowed wards to go behind the youth correctional counselor station
in the living units and go unescorted into an area of the Kern living unit that is not readily
visible.
•

Multi-hazard emergency plan is outdated. Section 1807 of the California Youth Authority
Institutions and Camps Branch Manual requires the institution to update its multi-hazard
emergency plan annually and to meet annually with local law enforcement officials to plan
for any emergency, such as a disturbance or an escape. The Office of the Inspector General
found, however, that the institution’s multi-hazard emergency plan was outdated and was
told by a staff member that the 1996 version was being revised. The 2003 and the 2004
security audits both found the plan to be outdated, and both reported that the anticipated
rewrite would be completed in January 2004.

•

Hostage training is not conducted. Section 1809 of the California Youth Authority
Institutions and Camps Branch Manual requires that each institution implement procedures
for handling hostage situations and that appropriate employees be trained for handling those
situations. But the Office of the Inspector General found that the institution has not provided
hostage training. The superintendent said he was the most recently trained hostage negotiator.
The security major said the institution would rely on local law enforcement to handle any
hostage situation, but the Office of the Inspector General found no written agreement or
memorandum of understanding with a local law enforcement agency to provide for such
assistance. According to the security major, an agreement with a local law enforcement
agency to provide mutual aid was recently completed, but the agreement does not include a
formal hostage protocol. The major reported that the Youth and Adult Correctional Agency is
developing a hostage protocol for both youth and adult correctional institutions.

•

Key controls are deficient. Section 1811 of the California Youth Authority Institutions and
Camps Branch Manual requires the institution to establish a key control committee, but the
institution has not done so. Also, the facility locksmith reported that some teachers and other
staff have keys that allow them to enter the living units without going through the main
doors. This is a safety hazard because security personnel are often unaware that staff who
enter this way are inside the living units.

•

Ward accountability practices are deficient. Section 1815 of the California Youth Authority
Institutions and Camps Branch Manual requires that each institution “develop and maintain a
ward accountability system that ensures accurate counts for all wards assigned to the
facility,” and provides that the “system shall include written procedures that require a
minimum of six daily major counts of all wards.” The institution complies with the
requirements in this section by conducting six official counts of all wards throughout the day
and by conducting room checks and logging the counts at each living unit. The institution
does not have written procedures, for handling erroneous counts, however. Also, a review of

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 32

living unit logs by the Office of the Inspector General revealed that ward movements are not
documented consistently. For example, the review team noted that a count of wards taken
from the unit to attend education classes was documented in the living unit logbook, but there
was no count documented when the wards returned to the living unit, and not all the wards
returned at the same time. The logbook is the primary document for recording activity in the
living unit. As such, it should accurately record the egress and ingress of wards in each living
unit.
•

Institution operations manual is outdated. Section 1816 of the California Youth Authority
Institutions and Camps Branch Manual requires each facility to have an updated operations
manual detailing institution safety and security policies and procedures. However, the
operations manual at the institution is outdated, with many sections written in March 1999.
The section 1800 security audit noted this problem in each of the last three years, reporting
each time that a committee has been established to update the manual. As currently written,
some sections of the operations manual simply define a subject, but provide no procedures.
For example, section 1185, covering “hostile work environment,” defines the subject in one
sentence and defines “sexual harassment” in another, but provides no guidance on how to
handle or report those issues. The manual’s index also lists sections that are not included in
the manual.

•

Personal alarm system and procedures are deficient. Section 1817 of the California Youth
Authority Institutions and Camps Branch Manual requires employees working in the security
area of the institution to be trained in the use of the personal alarm system and to carry an
alarm or a two-way radio. Only volunteers or visitors escorted or supervised by staff are not
required to carry an alarm. Section 1817 also requires alarm signals to terminate in the
security control center and requires procedures to ensure timely replacement of batteries in
the personal alarms and two-way radios.
With the exception of one staff member, the employees questioned during the Office of the
Inspector General’s review reported that security staff respond to personal alarms
immediately, but the audit team noted that the personal alarm system is outdated. The section
1800 security audit reports completed in November 2003 and November 2004 reported that a
new system was being installed and was expected to be on line by December 2003. At the
completion of the Office of the Inspector General’s fieldwork, the new system had still not
been implemented. [Information pertaining to personal alarms redacted for security
reasons.] The audit team found there are often not enough alarms to provide to visitors, and
the staff reported that maintenance personnel who come from the central complex to perform
services on the institution grounds are not provided with personal alarms.

•

Annual orientation on escape procedures is not provided. Section 1818 of the California
Youth Authority Institutions and Camps Branch Manual requires every facility to establish
escape prevention procedures and to monitor ward behavior that might signal escape
tendencies. The procedures are to be included in the operations manual and every employee
is to be provided with annual orientation on those procedures. However, the Office of the
Inspector General found that the institution is not providing employees with the required

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 33

annual orientation. The major of security told the Office of the Inspector General that the last
training on escape procedures was “probably in 2002.”
•

Ward visiting room practices are deficient. Section 1830 of the California Youth Authority
Institutions and Camps Branch Manual requires ingress and egress to visiting areas to be
controlled so that visitors are identified before they enter the area and that they submit to a
metal detector scan and have their property searched for contraband. The Office of the
Inspector General found that the institution does control ingress and egress to the ward
visiting area, which is inside the administration building, and that employees screen, search,
and subject visitors to a metal detector scan. Visiting is normally monitored by two youth
correctional officers on the floor and one in the visiting tower. But the audit team noted that
the tower officer also acts as the gate-keeper for wards arriving or departing and must walk
away from the visiting area to open the doors, thereby compromising surveillance of the
visiting room. Several staff members told the Office of the Inspector General that most of the
drug contraband enters the institution from the visiting section. The audit team also found
that the duty lieutenant was unaware of a recent policy change that allows wards to leave
their seats without seeking permission from staff to use the vending machines or to retrieve
table games.

•

Post orders are not always available at work sites or included in personnel files. Section
1836 of the California Youth Authority Institutions and Camps Branch Manual requires that
all peace officers have current and signed duty statements and post orders on file. The section
also requires post orders to be updated annually and to be placed in each peace officer’s
personnel file, in the supervisor’s work file, and at each work site. The Office of the
Inspector General found, however, that post orders were not available at every post and that
some post orders were outdated. A review of a sample of personnel files also revealed that
some did not contain updated post orders and duty statements.

•

Communication with employees is inadequate. Section 1844 of the California Youth
Authority Institutions and Camps Branch Manual requires that superintendents ensure that
pertinent information is disseminated to all appropriate employees and requires a “read-andinitial” system. A “read-and-initial” system is necessary because access to computers is
limited at the institution and only a few employees in the living units have ready access to
computers to retrieve electronic mail. The Office of the Inspector General found, however,
that the institution does not appear to be using the read-and-initial system effectively to
communicate with employees. In some instances, lists of employees needing pertinent
information appear to be incomplete and out of date, and confirmation that employees have
read the information is not always timely. For example:
9 A July 8, 2004, memorandum notifying employees to discontinue the use of water rounds
as a restraint option had been initialed as read by 70 employees, but nine members of the
security staff had written their names on the list because they had been omitted, and 24
other names had not been initialed.
9 In the case of the same July 8, 2004 memorandum, 23 of the 70 initials were signed in
November 2004, more than four months later. In another instance, an April 26, 2004

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 34

memorandum concerning emergency staff accountability procedures was supposed to
have been read by employees by May 3, 2004, yet 12 of 84 initials had been signed in
November 2004, more than six months after the due date.
•

Search practices are deficient. Sections 5065 and 5070 of the California Youth Authority
Institutions and Camps Branch Manual allow for the search of employees’ and visitors’
persons, property, and vehicles as a condition of entering the facility. Section 5066 requires
searches to be conducted by at least two staff members unless a metal-detection device is
used and requires each search to be recorded with the person’s name, time, and date of
search, search results, and significant comments. The section also requires that if random
searches are conducted on groups, those who are searched are to be advised of the reasons
the others were not searched.
At the beginning of this audit, the Office of the Inspector General observed commercial and
state vehicles entering and leaving the facility without being searched. This is an especially
serious problem because the audit team also observed that personnel at the main gate of the
complex also were not searching vehicles. After the audit team reported that vehicles were
not being searched, the facility began searching vehicles.
The Office of the Inspector General did not see the property of any employee being searched
as employees entered the institution and many of the facility staff members interviewed said
they had never been searched. The major of security provided a report listing and quantifying
searches of employees for the period January 2004 to March 2005, however. The report
records the dates of the searches and the number of employees searched by civil-service
classification, but not by name. Although the property of the Office of the Inspector
General’s staff was searched, the audit team saw no searches of individuals who were not
visiting wards. The major’s report identified only two occasions on which visitors were
searched in the period covered by the report.

•

Conflict of interest in conducting inquiries. The Office of the Inspector General’s review of
staff fact-finding inquiries found an instance of conflict of interest. In the inquiry in question,
an employee in the chain of command directly under the major of security was assigned to
conduct an inquiry in which the major of security was both the complainant and primary
witness to the incident other than the subject employee. Such conflict in job assignments
compromises the integrity of the inquiry and engenders mistrust of management by line staff.
With trained staff available at neighboring facilities, it would be prudent to refer inquiries
involving management staff to them.

•

The workplace violence prevention program is almost non-existent. Failure to provide a
workplace violence prevention program to staff in an environment like N.A. Chaderjian
eliminates a tool that staff can use to help provide a safe workplace. Sections 5250 through
5255 of the California Youth Authority Administrative Manual require managers to ensure
that employees are trained in the workplace violence prevention program and that a manager
or supervisor complete the workplace violence worksheet within 24 hours of a reported
incident. The local administrator is required to forward the worksheet to the department
coordinator within 24 hours of completion of the form. The Office of the Inspector General

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 35

found that only four incidents of workplace violence have been reported to the coordinator in
the last 3½ years, and that all were reported between July 23 and September 30, 2004. None
of the forms were forwarded within the appropriate time period; instead one was forwarded
within 7 days, another in 19 days, and two in 23 days. Several staff members, including
union representatives, said in interviews that they were unaware of the program and did not
know the identity of the local administrator. A review of the facility’s operation manual
found only one sentence referring to workplace violence — which defined it as “hostile work
environment”— and no procedures to implement the program.
Employees claim that management policies and practices compromise safety. Members of the
institution’s custody and living unit staff complained particularly of management policies and
practices they said cause unsafe conditions at the facility. Line staff consistently said that the
institution management does not communicate with or provide leadership in a way that promotes
safe and secure operations and that changes in department policies have put the staff and wards
at risk. Employees said that as a result they have become hesitant to perform simple functions or
to respond to incidents for fear that if an incident arises, they could be accused of wrongdoing.
Examples cited by the staff include the following:
9 Disciplinary sanctions have been eliminated and alternatives have not been provided.
The staff said that the loss of disciplinary sanctions that were formerly available puts
them at risk in dealing with the violence-prone wards at the facility, particularly because
sufficient alternatives have not been provided. As part of reforms being implemented at
California Youth Authority institutions, programs that staff utilized to provide
disciplinary sanctions for disruptive wards, such as the 23-and-1 program and temporary
detention, are being eliminated, but have not been replaced by other disciplinary or
incentive measures. Forms of discipline such as loss of privileges are ineffective with
Phase I wards, who have few privileges left to suspend. Similarly, wards whose specified
commitment time already extends to their 25th birthday, after which they can no longer be
held by the California Youth Authority, realize that their commitment time will not
increase as a result of bad behavior and therefore have less incentive to avoid trouble.
The changes have left the staff with few disciplinary options or positive incentives that
will convince wards to curtail disruptive or assaultive behavior. In 2003, there were 12
physical, non-gassing, assaults on the staff at the facility, and in 2004, there were 23 such
assaults. Assaults on other wards also endanger staff, who must quell the incident.
9 Staffing ratios compromise safety. Required staffing levels are based on ward population
and do not take into account the ages and violent histories of wards at N.A. Chaderjian or
the configuration of the living units at the facility. Sections 24.04 (b) and (c) of the
collective bargaining unit agreement between the State of California and the California
Correctional Peace Officers Association specifies the required staffing ratios for
California Youth Authority facilities, taking into account the differences between singleroom living units and open-dorm living units. To provide the same level of safety, a
living unit primarily housing wards over age 18 who have committed violent offenses
and who have consistently displayed poor in-custody behavior would appear to justify a
higher staffing ratio than a living unit with younger wards with less-violent histories. Yet,

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 36

at N.A. Chaderjian, the living units have a lower staffing ratio than other facilities
because one of the living unit posts in each of the six buildings is actually assigned to the
control tower shared by two adjacent living units and is not available on the floor of
either unit. As a result, although one living unit can put all three of its staff members on
the living unit floor to provide additional security and ward supervision, the adjacent
living unit, with the same staffing level has only two staff members on the floor with a
third staff member manning the control tower shared with the adjacent unit.
9 Staff is uncertain what use-of-force policy is in effect. The California Youth Authority
is revising its use-of-force policy, but has not made clear to the staff whether the old or
the new policy is now in effect. The department provided training on the proposed policy
to employees throughout the California Youth Authority in May 2004 and promised to
provide staff with the new policy when it became final, but has not yet done so.
Department administrators advised the Office of the Inspector General that the new
policy is not yet in final form. In the meantime, however, facility staff are uncertain
which policy is in effect.
RECOMMENDATIONS
The Office of the Inspector General recommends that the institution
management take the following actions to improve security operations and safety
at the facility:
•

In conjunction with the plant operations staff of the Northern California Youth
Correctional Center, develop and implement a comprehensive plan to identify,
prioritize, and correct all building deficiencies that create security and safety risks.
The plan should specifically address the deficiencies identified in this report and
should have cost estimates and a schedule with target dates for completion. The
California Youth Authority headquarters should assist the facility with the plan.

•

Take steps to secure the recreation yard fences. In so doing, consider “climbresistant” fences and using wire of the appropriate gauge to lessen the possibility of
wards ripping or breaking through the fence.

•

Until a properly functioning electronic entry/exit system is installed, security staff at
the main entrance should track visitors and staff on an electronic spreadsheet. The
spreadsheet should be structured so that it can easily be sorted by estimated exit time
to track the names of individuals whose anticipated exit time has passed.

•

Hold the security major accountable for improving the thoroughness and overall
quality of the facility’s annual Section 1800 security audits. The facility should
ensure that unresolved deficiencies are resolved promptly.

•

Improve ward accountability and movement by requiring that movement of wards to
and from the living units be recorded in the unit logbooks. Recorded information
should include the time of arrival and departure for each ward and his name and
identification number. Staff from each sending area should be required to provide
prior notification to staff at the receiving area that ward movement is about to occur,

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 37

and the receiving area should be required to confirm receipt of the wards by notifying
the sending area when ward movement is completed. Staff should ensure that all
wards carry a pass during movement.
•

Develop procedures for handling erroneous ward counts, including recording each
occurrence and identifying the responsible staff member to determine whether
additional training, discipline, or procedural changes are needed.

•

Update the multi-hazard emergency plan and provide training and notification of
changes to appropriate staff as necessary.

•

Update and formalize hostage procedures and provide hostage training as necessary.

•

Require all staff entering the living units to notify the living unit control tower so that
security personnel are aware of their presence.

•

Set the bottom of the perimeter fence in concrete and, if necessary, replace fence
poles with poles of a larger diameter.

•

In conjunction with California Youth Authority headquarters, develop and implement
a radio replacement schedule and dedicate funding for that function in order to supply
facility personnel with adequate communication devices.

•

Update the facility’s operations manual and post orders. Provide post orders for every
watch on every post. Provide training on procedures requiring major changes. Use the
read-and-initial system to ensure that staff personnel receive copies of important
procedural changes and confirm receipt within a reasonable time.

•

Update escape procedures and provide training annually.

•

Improve security related to the ward visiting area by providing uninterrupted visual
coverage. Consider adding another staff person to the visiting tower so that one
person can continually monitor the visiting area while the other can operate the doors
for wards entering and leaving.

•

Augment electronic mail and the read-and-initial system by conducting quarterly
meetings involving line staff and management to enhance communication and
provide a forum to discuss issues affecting the work environment. Ensure that
meeting times are rotated so that staff from different shifts can attend.

•

Conduct more random searches of both employees and visitors and record searches
by identifying the names of those searched, the time and date of the search, and the
results of the search. Ensure that searches occur on a random and unpredictable
schedule.

•

Refer inquiries involving a management employee as a subject, complainant, or
primary witness to a neighboring institution to improve the integrity of the inquiry
and its findings.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 38

•

Develop policies and procedures to implement a workplace violence prevention
program. Train or orient staff on the program as necessary. Ensure that the policies
and procedures comply with the required time limits.

In addition, the Office of the Inspector General recommends that the California Youth
Authority take the following actions:
•

Before committing resources to implement the facility’s comprehensive plan cited
above, contract for a thorough, independent study that tests the structural integrity of
the buildings in the facility. If the contractor finds that structural deficiencies exist,
the contractor should include in the study the estimated costs to fix them. The director
should use the test results to recommend to the administration and the Legislature
whether to make the repairs and keep the facility open or close it and find a suitable
alternative for housing the wards.

•

Require the Institutions and Camps Branch to perform the annual security audit of the
N.A. Chaderjian Youth Correctional Facility and other facilities as required by
section 1800 of the California Youth Authority Institutions and Camps Branch
Manual.

•

Evaluate staffing ratios and work requirements for each living unit to determine
whether the current staffing ratios are appropriate given the types of resident wards,
the physical design of the units, and the job requirements of staff. Based on the
results, propose to the California Correctional Peace Officers Association realignment
of the staffing ratios of the living units. (This recommendation is partially addressed
in finding one, which discusses staffing in the general population living units.)

•

Explore and evaluate disciplinary measures and positive reinforcement options that
can be used with wards as disincentives to poor behavior and incentives for good
behavior. Give consideration to the fact that many wards cannot have time added to
their commitments.

•

Provide department staff with the status of the revised use-of-force policy and advise
staff on what policy to follow until the new policy is final.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 39

FINDING 4
The Office of the Inspector General found that N.A. Chaderjian is not consistently
complying with department policies and procedures governing the use of psychotropic
medications and suicide prevention, assessment, and response.
Providing mental health treatment, including the appropriate use of psychotropic medication for
wards diagnosed with mental disorders, and instituting effective suicide prevention measures are
fundamental responsibilities of the California Youth Authority. To accomplish those objectives
the department has adopted specific policies and procedures to govern the use of psychotropic
medication and to reduce the possibility of suicide by wards. Suicide prevention, assessment, and
response is critically important in California Youth Authority facilities, where suicide risk is
generally high. Since January 2004, there have been two suicides in other California Youth
Authority institutions.
The Office of the Inspector General found, however, that the suicide prevention, assessment, and
response program at N.A. Chaderjian is severely deficient. The audit also determined that wards
at the facility are receiving psychotropic medications without proper testing and monitoring. As a
result, the facility is jeopardizing the health of wards receiving psychotropic medications and is
not taking adequate measures to protect wards from suicide. The failure of the institution to
comply with required policies and procedures also exposes the department to potential lawsuits
resulting from death or injury to wards.
Psychotropic medication practices. The Office of the Inspector General found the following
deficiencies in the administration of psychotropic medication at the facility.
•

Wards on psychotropic medication are not consistently tested. Because some psychotropic
medications may cause liver toxicity or other organic damage, California Youth Authority
Institutions and Camps Branch Manual section 6275 requires that wards receiving
psychotropic medications undergo appropriate laboratory tests and be monitored regularly.
Consistent with that provision, the chief medical officer of the Northern California Youth
Correctional Center told the Office of the Inspector General that wards should receive a
baseline laboratory test before starting psychotropic medications and should undergo followup tests at least every three months. Pharmaceutical manufacturers also recommend testing.
Yet, the audit found that psychiatrists at N.A. Chaderjian do not consistently order laboratory
tests before and after dispensing psychotropic medications to wards.
At the time of the management review audit, approximately 58 wards were receiving
psychotropic medications at the facility. To determine whether wards had received baseline
and follow-up tests, the Office of the Inspector General reviewed the unified health records
of 28 wards who had a total of 52 prescriptions for psychotropic medications. The 28 wards
included all of the 13 wards in the general population who were taking psychotropic
medications and a random sample of 15 wards from two specialized program living units.
The review determined that wards did not undergo baseline laboratory tests for 34 of the 52
prescriptions (65 percent). Furthermore, of the 30 prescriptions that were at least three

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 40

months old, the auditors found that wards had received both baseline and follow-up testing in
only 23 percent of the cases—seven of the 30 prescriptions. In the other 23 prescriptions
(representing 77 percent of the 30 prescriptions), wards did not receive all of the testing. In
seven prescriptions, wards received neither baseline nor follow-up testing. In four
prescriptions, wards received a baseline test, but no follow-up tests. In the case of 12
prescriptions, wards underwent follow-up tests, but had never received a baseline test. It
should be noted that follow-up tests are of limited value without baseline data to identify
trends or progress. Baseline data is also critical for wards who arrive at the California Youth
Authority with existing prescriptions if the sending entity does not provide the data.
•

General population wards receive psychotropic medications without an evaluation.
California Code of Regulations, Title 15, section 4746(b) requires wards to receive a Special
Program Assessment Needs evaluation before receiving psychotropic medication. That
assessment is important because it identifies mental health disorders and directs wards
toward treatment, including possible placement in an intensive treatment program or
specialized counseling program. Yet the Office of the Inspector General found that four (31
percent) of the 13 general population wards at the facility who were taking psychotropic
medication prescribed by staff psychiatrists had not been given a Special Program
Assessment Needs evaluation before receiving the medication.

•

General population wards are not receiving timely follow-up psychiatric evaluations.
General population wards using psychotropic medications are not meeting with the
psychiatrists for evaluations as often as required by the California Youth Authority Health
Care Services Division. The California Youth Authority Institutions and Camps Branch
Manual section 6275 requires an evaluation of wards placed on psychotropic medications at
regular intervals consistent with good medical practice. The acting chief of the California
Youth Authority Health Care Services Division advised the audit team that the standard for
monitoring wards is a minimum of every 30 days. The Office of the Inspector General found
that six (60 percent) of the 10 general population wards who had been receiving psychotropic
medications for more than 30 days were not being seen by a psychiatrist every 30 days. For
example, of five general population wards receiving Bupropion (an anti-depressant
medication), four received an evaluation an average of every 60 days, while the fifth had not
received an evaluation for five months. In contrast, two wards in the specialized counseling
program and two wards in the intensive treatment program who also were taking Bupropion
received psychiatric evaluations an average of every 17 days.

•

Treatment plans are not prepared for wards receiving psychotropic medications. California
Youth Authority Institutions and Camps Branch Manual section 6206 requires a treatment
plan to be prepared for wards undergoing psychiatric treatment. While section 6206 does not
define treatment plans in detail, a study conducted for the department in 2001 by Stanford
University described the role of treatment planning as follows:
The process would result in a treatment plan which is as specific as possible, delineating
not just global malfunctions and symptoms, but also specifying which domains of
functioning are disturbed, appropriate treatments for these dysfunctions and when one

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 41

can expect them to resolve, along with a date for re-assessment which will then determine
further level of care.6

In addition, Section 6275 of the California Youth Authority Institutions and Camps Branch
Manual specifically requires that the administration of psychotropic medications be linked to
a diagnosis and statement of the desired benefit and approximate length of treatment time
expected. A review of the files of the 28 wards receiving psychotropic medications for this
specific information, however, determined that none included a notation of the desired
benefit or the approximate length of time expected to achieve a desired effect. The audit also
determined that 26 (93 percent) of the 28 wards reviewed who were receiving psychotropic
medications did not have a treatment plan in their unified health records. The absence of a
treatment plan, a statement of the desired benefit, and approximate length of time expected
for the outcome, deprives the medical and mental health treatment team of the information
needed to ensure proper treatment and monitoring.
•

Incoming parole violators are not receiving Treatment Needs Assessments. California
Youth Authority Institutions and Camps Branch Manual, section 6260 requires all wards,
including returning parole violators, to receive a Treatment Needs Assessment within three
weeks of admission to the California Youth Authority to identify those needing treatment for
problems such as depression, anxiety, anger, or thought disorders at the time of admission.
The absence of the assessment deprives mental health and medical personnel of complete
information about the ward and could lead to misdiagnosis, improper treatment, or lack of
treatment. The Office of the Inspector General reviewed the unified health records of 10
parole violators to determine whether they had received Treatment Needs Assessments
within three weeks of arrival and found that none had received the assessment at all, even
though they had been at the facility for between five to ten weeks.

•

Unified health records do not document informed consent. Section 6178 of the California
Youth Authority Institutions and Camps Branch Manual requires the facility to obtain
informed consent for the administration of psychotropic medication. To obtain consent, the
physician or psychiatrist must obtain signed consent after disclosing to the patient the nature
and seriousness of the illness or disorder, the reason for treatment, the nature of the
procedures, the probable degree and duration of improvement or remission, potential side
effects, any division of opinion concerning the proposed treatment, reasonable treatment
alternatives, and the fact that the ward has the right to accept or refuse the treatment. The
absence of signed informed consent exposes the department and the institution to possible
liability should a ward suffer adverse effects from the medication. A review by the Office of
the Inspector General found that the unified health records of eight (29 percent) of the 28
unified health records for wards on psychotropic medication did not include a signed consent
form.

6

“The Assessment of the Mental Health System of the California Youth Authority: Report to Governor Gray
Davis,” prepared by Principal Investigator: Hans Steiner, M. D., Co-Principal Investigator: Keith Humphreys, PhD.,
and Project Manager, Allison Redlich, PhD., Department of Psychiatry, Stanford University School of Medicine,
December 31, 2001.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 42

Suicide prevention and response. The California Youth Authority Institutions and Camps
Branch Manual requires the institution to have a comprehensive suicide prevention, assessment,
and response program to lessen the potential for suicides. Sections 6263 through 6272 of the
manual describe the program and lay out specific requirements. The requirements include:
establishing a multi-disciplinary suicide prevention, assessment, and response committee to
oversee the program; maintaining suicide risk lists in the living units; maintaining cut-down tools
to minimize the potential for suicide by hanging; and assessing and maintaining the physical
safety of living areas.
The Office of the Inspector General found the institution’s suicide prevention, assessment, and
response program to be deficient. The audit determined that cut-down tools were available in all
living units, but that overall deficiencies in the program amount to significant non-compliance
with program requirements. Specifically:
•

The program lacks leadership. Section 6263 of the California Youth Authority Institutions
and Camps Branch Manual requires the superintendent to designate a manager at the
program administrator level or above to serve as the facility’s risk management officer. That
person is also to serve as chairman of the suicide prevention, assessment, and response
committee. At N.A. Chaderjian, however, responsibility for the suicide prevention,
assessment, and response program is divided between the risk management officer and a
senior psychologist—neither of whom are program administrators. The responsibilities of the
committee chairman, which include ensuring that the committee analyzes and reports on
“lessons learned” about suicides, suicide attempts, and other suicidal behavior, have been
assigned to the senior psychologist, who has no line authority over the living unit staff. Like
the senior psychologist, the risk management officer also has no line authority over living
unit staff. Furthermore, the responsibilities of the risk management officer, which include
tracking wards on suicide watch and ensuring that they receive mandated services, are
presently not being fulfilled because the position has been vacant since February 2005.
Moreover, the two most recent risk management officers—an associate governmental
program analyst and a lieutenant —told the audit team they did not perform the tracking and
monitoring duties assigned to the risk management officer.

•

Committee meetings have been sporadic and poorly attended. The suicide prevention,
assessment, and response committee, which is comprised of staff members from various
disciplines inside the facility, has not consistently held quarterly meetings as required by
section 6263 of the California Youth Authority Institutions and Camps Branch Manual. The
committee did not meet at all for a period of more than 19 months from March 21, 2003 to
October 27, 2004. When meetings are held, committee members frequently fail to attend. For
example, only five of the committee’s 12 members attended the October 2004 meeting. At
the completion of the audit fieldwork, the most recent committee meeting had been held on
January 25, 2005 and only seven members attended.

•

Suicide risk lists were neither appropriately displayed nor routinely initialed. Section 6269
of the California Youth Authority Institutions and Camps Branch Manual requires that living
unit suicide risk lists be displayed in the living unit control center in a manner that provides

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 43

ready access to and easy review by staff, but does not allow wards to see them. The manual
also requires every member of the living unit staff to initial the list as evidence that they
reviewed it. The audit found, however, that living units were not consistently displaying the
lists and that staff members are not consistently reviewing them. The audit team found that
10 of the 12 living units (83 percent) did not have the unit’s suicide risk list appropriately
displayed and nine of the 12 (75 percent) could not verify that the staff reviewed and initialed
the suicide risk list daily as required.
•

Committee has not conducted annual room inspections. Section 6263 of the California
Youth Authority Institutions and Camps Branch Manual requires the suicide prevention,
assessment, and response committee to conduct an annual inspection of all living unit rooms
to identify problems with configuration, equipment, and supplies that could facilitate a
ward’s suicide. However, the chairman of the committee told the Office of the Inspector
General that the committee has not conducted these living unit inspections for more than two
years, since April 2003.

•

Staff members have not received training. Some staff members who have routine contact
with wards have not received the suicide prevention, assessment, and response refresher
training required by section 6263 of the California Youth Authority Institutions and Camps
Branch Manual. The Office of the Inspector General found that of a sample of 31 staff
members in routine contact with wards, only 11 (35 percent) had received the required
training annually between January 1, 2000 and February 8, 2005.

The Office of the Inspector General found that the following factors have contributed to the
facility’s failure to administer and monitor psychotropic medications consistently and to comply
with required suicide prevention, assessment, and response program procedures:
•

Psychiatrist positions are not fully staffed. According to the staff at the California Youth
Authority, the facility is budgeted for two full-time psychiatrists, which equates to 80 hours
per week, but the facility is currently staffed only with two part-time psychiatrists who
provide a combined total of approximately 18 hours per week of psychiatric services, or 23
percent of the total budgeted hours. Of the 18 hours, approximately 8 hours per week are
dedicated to general population wards and 10 hours per week are dedicated to wards in the
intensive treatment and specialized counseling programs. The chief medical officer informed
the Office of the Inspector General that he is working with the department’s Health Care
Services Division to fill these vacancies.

•

Psychotropic medication protocol has not been developed. The chief medical officer has not
developed and maintained a psychotropic medication protocol that identifies each step of the
process for prescribing, dispensing, and administering the medications. Without that
protocol, the facility lacks standardized policies and procedures for baseline testing, followup testing, monitoring, and related functions.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 44

•

Insufficient oversight by the chief medical officer. The chief medical officer has not
provided sufficient oversight to ensure that his staff appropriately performs the following
functions:
9 Consistently administer baseline and follow-up tests to wards to monitor
psychotropic medications.
9 Provide Special Program Assessment Needs evaluations of wards before
prescribing psychotropic medications.
9 Conduct timely follow-up psychiatric evaluations for general population wards.
9 Describe the desired benefit of psychotropic medications to wards and properly
documents informed consent in wards’ unified health records.
9 Develop treatment plans for each ward.
9 Conduct Treatment Needs Assessments for parole violators.

•

Insufficient priority given to suicide prevention and response. The institution management
has given insufficient priority to the suicide prevention, assessment, and response program.
The lack of priority has manifested itself in various ways. Specifically, management has not
emphasized to staff the importance of the suicide prevention, assessment, and response
committee and has not monitored attendance at the committee’s meetings. In addition,
management has not ensured that pertinent staff members receive required training.
Management also has not appointed a risk management officer at the appropriate level or
monitored that person’s work to ensure that the required duties, including ensuring that
suicide risk lists are properly posted and reviewed by the living unit staff, are performed.
RECOMMENDATIONS
To improve the administration and monitoring of psychotropic medications and the
suicide prevention, assessment, and response program, the Office of the Inspector
General recommends the following:
•

The chief medical officer should continue to work with the department’s Health Care
Services Division to fill vacancies in psychiatrist positions at the facility.

•

The chief medical officer should develop a psychotropic medication protocol and
forward a copy to the chief of the department’s Health Care Services Division for
review and approval.

•

The chief medical officer should more closely monitor the work of employees to
ensure that they comply with California Youth Authority policies and procedures and
best professional practices. When employees are not doing work correctly, the chief

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 45

medical officer should provide on-the-job training and formal training as necessary.
The chief medical officer should provide timely feedback to employees through
accurate performance appraisals and hold staff accountable for their work through
progressive discipline.
•

The chief medical officer should develop a checklist for the unified health record that
itemizes all the requirements to be met by mental health staff before administering
psychotropic medications. These requirements should include fulfilling requirements
for mental health testing and psychiatric evaluations; written informed consent;
developing treatment plans; and statements of duration of prescription time and
desired clinical effect, and performing laboratory tests.

•

The chief medical officer should ensure that incoming parole violators receive
Treatment Needs Assessments.

•

The superintendent should assign a higher priority to the suicide prevention,
assessment, and response program by emphasizing to all staff the program’s
importance. The superintendent also should stress to the members of the suicide
prevention, assessment, and response committee the importance of its duties by the
following:
9 Monitoring attendance at the committee meetings and reviewing the committee’s
quarterly reports.
9 Appointing a committee chairman and a risk management officer at the program
administrator level or above and holding those individuals accountable for the
positions’ duties, including ensuring that suicide risk lists are properly posted and
reviewed by the living unit staff.
9 Ensuring that the committee conducts annual room inspections and reports on
conclusions and recommendations as required by section 6263 of the California
Youth Authority Institutions and Camps Branch Manual.
9 Ensuring that all staff members who have routine contact with wards receive the
training required by section 6263 of the California Youth Authority Institutions
and Camps Branch Manual.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 46

RESPONSE FROM THE CALIFORNIA YOUTH AUTHORITY

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 47

STATE OF CALIFORNIA

Arnold Schwarzenegger, Governor

YOUTH AND ADULT CORRECTIONAL AGENCY
1515 K Street, Suite 520
Sacramento, CA 95814
(916) 323-6001/FAX (916) 442-2637

May 20, 2005

Matthew Cate
Inspector General
P.O. Box 348780
Sacramento, CA 95834
Attention: Sam Cochrane
Dear Mr. Cate:
The California Youth Authority (CYA) and the Youth and Adult Correctional Agency
appreciate the opportunity to respond to the draft report of the Office of the Inspector
General’s May 2005 Management Review Audit of the N.A. Chaderjian Youth
Correctional Facility, Stockton, California. The purpose of the audit was to provide a
baseline assessment of the facility’s performance in carrying out essential functions and
to provide recommendations to correct deficiencies.
We agree that there are deficiencies that must be addressed. Accordingly, the CYA will
develop a comprehensive plan, including specific timelines for implementation, to
address the deficiencies identified in your Management Review Audit. The plan will be
submitted to you by July 22, 2005.
Sincerely,
[original signed by Undersecretary G. Kevin Carruth for Roderick Q. Hickman]
RODERICK Q. HICKMAN
Secretary
Youth and Adult Correctional Agency
cc: G. Kevin Carruth
Walter Allen

 

 

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