O FFICE OF THE I NSPECTOR G ENERAL
• PROMOTING INTEGRITY •

STEVE WHITE, INSPECTOR GENERAL

MANAGEMENT REVIEW AUDIT
WARDEN THOMAS L. CAREY
CALIFORNIA STATE PRISON, SOLANO
VACAVILLE, CALIFORNIA

MARCH 2003

GRAY DAVIS, GOVERNOR

OFFICE OF THE INSPECTOR GENERAL

MANAGEMENT REVIEW AUDIT

WARDEN THOMAS L. CAREY
CALIFORNIA STATE PRISON, SOLANO
VACAVILLE, CALIFORNIA

REPORT
MARCH 2003

•PROMOTING INTEGRITY •

CONTENTS
EXECUTIVE SUMMARY ------------------------------------------------------------------------------------------------- 3
INTRODUCTION-------------------------------------------------------------------------------------------------------------- 8
BACKGROUND --------------------------------------------------------------------------------------------------------------- 8
OBJECTIVES, SCOPE, AND METHODOLOGY --------------------------------------------------------------- 9
FINDINGS AND RECOMMENDATIONS -------------------------------------------------------------------------- 11
FINDING 1
Tuberculosis tracking --------------------------------------------------------------------------------- 11
FINDING 2
Sentence reduction credit --------------------------------------------------------------------------- 14
FINDING 3
Administrative segregation unit blind spots--------------------------------------------------- 16
FINDING 4
Housing for inmates on medication ------------------------------------------------------------- 18
FINDING 5
Inmate death reviews ---------------------------------------------------------------------------------- 18
FINDING 6
Administrative segregation retention ------------------------------------------------------------ 22
FINDING 7
Inmate dental care ------------------------------------------------------------------------------------- 25
FINDING 8
Employee disciplinary process --------------------------------------------------------------------- 26
FINDING 9
Pharmacy controls ------------------------------------------------------------------------------------- 28
FINDING 10
Medical modification orders ----------------------------------------------------------------------- 29
FINDING 11
Administrative segregation logs ------------------------------------------------------------------ 30
FINDING 12
Food service ---------------------------------------------------------------------------------------------- 31

ATTACHMENT A
RESPONSE OF THE CALIFORNIA DEPARTMENT OF CORRECTIONS --------------- 33

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 2

EXECUTIVE SUMMARY
This report presents the results of a management review audit conducted by the Office of the
Inspector General of Warden Thomas L. Carey of California State Prison, Solano. The audit was
conducted under the provisions of California Penal Code Section 6051, which assigns the Office
of the Inspector General authority to conduct a management review audit of any California
Department of Corrections warden who has held that position for more than four years or who
has been recently appointed. The management review audit of California State Prison, Solano
resulted from the July 2001 appointment of Warden Carey. A management review audit is
intended to assess the warden’s performance in carrying out the essential functions of the
facility. In the case of recent appointments, the management review audit provides a baseline
assessment of institution operations. Where deficiencies are noted, the Office of the Inspector
General makes recommendations to correct problems.
The Office of the Inspector General found Warden Carey to be well-respected by the staff and
management team at California State Prison, Solano, with the staff expressing approval of the
warden’s management ability and communication skills. But the audit also revealed a number of
matters that require the warden’s attention. The problems identified by the audit include
deficiencies in tracking inmate tuberculosis status, improper assignment of sentence reduction
credits, ineffective monitoring of the length of time inmates spend in administrative segregation,
unsafe modification to administrative segregation unit buildings, and inappropriate housing for
inmates taking psychotropic and anticonvulsant medications. The audit also revealed several
issues outside the direct control of the warden that require the attention of the Department of
Corrections. Those issues include budgetary restrictions that conflict with department
mandates relating to inmate dental care and deficiencies in procedures for conducting
inmate death reviews.
Following is a summary of findings from the management review audit. Recommendations of
the Office of the Inspector General are included in the body of the report.
FINDING 1
The Office of the Inspector General found evidence that California State Prison, Solano is
not adequately tracking inmates with tuberculosis, creating the potential of exposing
inmates throughout the state to the disease and presenting a risk to the correctional staff
and the general public.
To control outbreaks of tuberculosis in the inmate population, state law and Department of
Corrections regulations require state correctional institutions to test inmates for tuberculosis and
to document each inmate’s tuberculosis status in a statewide database. The purpose is to allow
inmates who have been exposed to the disease to be closely monitored and to receive
prophylactic medication; to prevent inmates who are receiving medication from having the
treatment interrupted; and to provide for medical precautions to be taken when inmates are
moved from one institution to another.
The Department of Corrections has developed a coding system for identifying each inmate’s
tuberculosis status and requires the information to be stored in the department’s statewide
distributed data processing system for the use of staff assigned to healthcare, classification, case
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 3

records, and transportation functions. But the Office of the Inspector General found numerous
errors associated with tuberculosis coding and tracking at California State Prison, Solano, with
the possibility that inmates infected with tuberculosis may not be receiving medication and as a
result may be exposing others to the disease.
FINDING 2
The Office of the Inspector General found that California State Prison, Solano inmates are
allowed to earn sentence reduction credit through education and training classes even when
classes are not actually held.
California state prison inmates may reduce their time in custody by earning credits through
participation in work, education, or training programs at the rate of one day of credit for each day
of participation. Like other Department of Corrections institutions, however, California State
Prison, Solano is experiencing difficulty filling teacher vacancies for education and training
classes, with the result that many classes are not being held. Yet, under a mistaken belief that
classes cannot be closed without approval from department headquarters, the institution has
continued to assign inmates to classes even when no teachers are available and classes are not
heldand even though the classes are not being held, inmates are allowed to earn sentence
reduction credit as though they attended the class.
FINDING 3
The Office of the Inspector General found that makeshift partitions in the institution’s
administrative segregation unit buildings have created blind spots that limit the view of the
control booth officers, compromising the safety and security of correctional staff and
inmates.
The Office of the Inspector General found that the institution has installed partitions in the
administrative segregation buildings beneath the control booth in order to create space for
classification committee meetings and other activities isolated from the view of inmates housed
in segregation cells. But the partitions block the view of officers on the floor and allow the
control booth officer only a limited view of the floor immediately outside the doors of the lowertier cells.
FINDING 4
The Office of the Inspector General found that a significant number of inmates taking
psychotropic medications are inappropriately housed in buildings lacking air conditioning
and that some inmates who are taking anticonvulsant medications are not assigned to lower
bunks to lessen the possibility of injury in the event of a seizure.
Psychotropic medications can increase the risk of heat-related illnesses by altering the body’s
temperature-regulating mechanisms or impairing the ability to perspire. Accordingly, patients
taking psychotropic medications are advised to avoid exposure to high ambient temperatures.
Yet, the Office of the Inspector General found that more than half of the inmates at California
State Prison, Solano taking psychotropic medication are assigned to buildings without air
conditioning. The Office of the Inspector General also found that 10 inmates taking
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 4

anticonvulsant medication for seizure disorders were assigned to upper bunks, putting them at
risk of injury in the event of a seizure.
FINDING 5
The Office of the Inspector General found that when inmate deaths occur, the cause and
circumstances surrounding the deaths are not examined in a timely manner and that those
assigned to conduct the reviews may have a direct interest in the results.
The Department of Corrections has established procedures for reviewing the cause and
circumstances surrounding inmate deaths, but the Office of the Inspector General found that the
reviews take too long to complete and that those assigned to review the cases sometimes have a
direct interest in the results. The process also does not provide for adequate coordination
between the institution’s investigative staff and the department’s Health Care Services Division.
FINDING 6
The Office of the Inspector General found that California State Prison, Solano retains
inmates in administrative segregation units longer than justified.
The Office of the Inspector General found that California State Prison, Solano does not
effectively monitor the process for determining the length of time inmates spend in
administrative segregation, with the result that inmates may be kept in administrative segregation
longer than necessary. The problem has been compounded by a recent action of the Department
of Corrections to override state regulations requiring that an inmate’s stay in administrative
segregation be re-evaluated at least every 30 days. A department directive has provided instead
that an inmate’s continued retention in administrative segregation be evaluated every 90 to 180
days, depending on the reason for the retention.
FINDING 7
The Office of the Inspector General found that California State Prison, Solano is not
complying with state regulations governing inmate dental care and as a result may be
exposed to the risk of litigation.
California Code of Regulations, Title 15 requires all newly committed inmates to receive a
complete dental examination within 14 days of arrival from the reception center. Title 15 also
requires all inmates under the age of 50 to receive a dental examination at least once every two
years and all inmates over the age of 50 to receive a dental examination every year. The chief
dentist at California State Prison, Solano acknowledges, however, that the institution is not
meeting these requirements, thereby exposing the institution to possible legal action.
FINDING 8
The Office of the Inspector General found that California State Prison, Solano does not
adequately document employee disciplinary proceedings and that the warden
inappropriately serves as the hearing officer in appeals of adverse action decisions.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 5

State law and regulations require specific procedures to be followed in disciplinary actions
involving California state government employees. The purpose of the provisions is to protect the
due process rights of employees to fair and impartial hearings and to afford them an opportunity
to appeal adverse action decisions. The Office of the Inspector General found that despite an
inherent conflict of interest, the warden of California State Prison, Solano often serves as the
hearing officer in appeals of adverse action decisions, and in that capacity often reduces the
penalty for sustained misconduct. Although the original adverse action penalty undergoes a
thorough independent review, the penalty reduction authorized by the warden does not.
Moreover, the reasons for penalty reductions made by the warden are rarely documented,
bringing into question the benefit of the process leading up to the adverse action.
FINDING 9
The Office of the Inspector General found that pharmacy record keeping and physical
controls over prescription medications stored in the infirmary and clinics are inadequate to
prevent unauthorized access and theft.
Although the Office of the Inspector General found no evidence of actual theft of
pharmaceuticals at California State Prison, Solano, the audit revealed that pharmaceutical
products at the institution are kept in an environment conducive to theft and abuse. In fiscal year
2001-02 the institution spent more than $4 million for pharmaceutical supplies, and the potential
exists for theft of even small quantities of drugs to have a significant fiscal impact.
FINDING 10
The Office of the Inspector General found that California State Prison, Solano does not
promptly implement medical modification orders and that many were significantly overdue
at the time of the audit.
The Office of the Inspector General found that a high percentage of modification orders directing
California State Prison, Solano to remedy conditions affecting inmate medical conditions were
more than seven months overdue. Delays in implementing medical modification orders can result
in serious medical consequences for inmates and expose the institution and the department to
possible lawsuits.
FINDING 11
The Office of the Inspector General found that the institution is not properly documenting
inmate activity in the administrative segregation units and that in some instances events
are logged before they occur.
State regulations and California Department of Corrections policy require that movement and
housing of inmates assigned to an administrative segregation unit be recorded in a hardbound
logbook  a CDC Form 114  which provides a single-source record of daily activity within
the administrative segregation unit. The log is formatted to include the inmate’s cell number and
bed assignment, the time of the inmate’s entry to or exit from administrative segregation, the

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 6

identity of visitors to the unit, and any unusual incidents within the unit. The CDC Form 114 is a
legal document subject to be used as evidence in a civil, criminal, or administrative proceeding.
The Office of the Inspector General found that although the administrative segregation staff at
California State Prison, Solano maintains the CDC Form 114, the information is not always
entered into the log immediately. Instead, information is entered into the logbook only once
every 24 hours by the administrative segregation unit’s first watch floor officer, using reports
from central control to record inmate housing assignments. That practice undermines the purpose
of the CDC Form 114 as a source of accurate, up-to-date information about inmate location,
diminishes the evidentiary value of the CDC Form 114, and presents a safety risk to staff and
inmates.
FINDING 12
The Office of the Inspector General found that California State Prison, Solano prepares an
excessive number of daily meals for inmates, resulting in unnecessary added costs for food
and related services.
The Office of the Inspector General found that the food service staff at California State Prison,
Solano does not effectively monitor the number of meals served and consumed each day and that
in at least some cases the number of meals prepared exceeds the inmate population. Although
preparing a certain number of extra meals may be necessary to avoid shortages, the institution
wastes resources by preparing a large number of meals that are not consumed, particularly given
that the entire inmate population is rarely present at any single meal.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 7

INTRODUCTION
Under California Penal Code Section 6051, the Office of the Inspector General is assigned
authority to conduct a management review audit of California Department of Corrections
wardens who have been recently appointed. The audit is intended to provide a baseline
assessment of institution operations and includes an assessment of issues relating to personnel,
training, communication, investigations, security, and financial matters. The management review
audit of California State Prison, Solano resulted from the recent appointment of Warden Thomas
L. Carey and was conducted from August 1, 2002 to October 1, 2002. Throughout the review
process, the audit team received excellent cooperation and assistance from Warden Carey and the
staff at California State Prison, Solano.
BACKGROUND
Thomas L. Carey was appointed warden of California State Prison, Solano by Governor Gray
Davis on July 25, 2001 and was confirmed by the Legislature on July 1, 2002. He began his
career with the State of California in 1981 as a senior accountant at Patton State Hospital in San
Bernardino. Warden Carey had previously spent twelve years in a variety of positions in
personnel management in both the private and public sectors. In 1984, Warden Carey was
appointed as an administrator of the Prison Industries Authority at San Quentin State Prison. In
1986, he transferred from the Prison Industries Authority to the California Department of
Corrections as an associate warden at Mule Creek State Prison. For four months in 1996,
Warden Carey was assigned to the Richard A. McGee Training Center before being promoted as
chief deputy warden at the Correctional Training Facility in Soledad, California. He was named
warden of the California Correctional Institution, Tehachapi in 1998. Warden Carey holds a
bachelor’s degree in communications from California State University, Fullerton, and a master’s
degree in education/communications from Whittier College.
California State Prison, Solano opened in August 1984 and is located on 146 acres in Vacaville,
California. When it opened in 1984, it was administered by the warden of the adjacent
institution, the California Medical Facility, but in January 1992, the two prisons were
administratively separated, with a warden assigned to each prison. With about 1,280 employees
and an operating budget of approximately $104 million, California State Prison, Solano was
designed to house 2,110 inmates, but regularly houses approximately 5,800 inmates in Level II
and III facilities. California State Prison, Solano provides a comprehensive work/training
program for medium-security inmates with academic and vocational training and industry
assignments. The vocational programs include auto body and mechanics, carpentry, eyewear
manufacture, landscaping and horticulture, machine shop, mill and cabinet work, and office
services. The Prison Industry Authority operates an optical program, including a lens laboratory,
as well as a laundry and a bookbindery at the institution.
Warden Carey inherited a significant budget deficit upon his appointment to California State
Prison, Solano and the institution currently lacks the resources to meet its mission and has not
been provided with an adequate budget with which to operate. Both the warden and health care
manager can be held personally liable for expenditures in excess of the budget, yet neither have
the discretion to make major policy changes to reduce operating costs. For example, the
institution is required to achieve 15 percent salary savings for all positions. Yet the majority of
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 8

the institution’s positions (63 percent) are posted custody personnel positions that cannot be held
vacant to achieve salary savings. In fact, the collective bargaining contract (Bargaining Unit 6)
prohibits the warden from imposing that level of salary savings requirement. The current
negotiated institution vacancy plan for correctional officers achieves only about 2 percent in
savings, leaving the elimination of entire programs, such as education and ancillary staff as the
warden’s only option to achieve the required savings. Yet the warden is not authorized to make
such a reduction without the approval of department headquarters.
Other factors contributing to the deficit at California State Prison, Solano are the continued
overflow of inmates requiring administrative segregation placement and increased sick leave
usage by the custody staff. The institution was designed to house up to 175 inmates in
administrative segregation, but the current administrative segregation inmate population exceeds
350. This is a statewide issue that the Department of Corrections has attempted to address
through the budget process with minimal success. The institution has also incurred excessive
overtime costs for sick leave usage by the custody staff. Sick leave usage for correctional
officers increased by 31 percent during fiscal year 2001-02 over the previous fiscal year,
resulting in additional expenditures of $750,000.
OBJECTIVES, SCOPE, AND METHODOLOGY
The objectives of the management review audit were to establish a baseline for future reviews by
evaluating the institution’s performance in the following areas:
•

Planning, organizing, directing, and coordinating all correctional, business management,
work-training incentive, education, and related programs at California State Prison, Solano;
and

•

Formulating and executing a progressive program for the care, treatment, training, discipline,
custody, and employment of inmates.

In order to accomplish these objectives, the audit team performed various procedures in the
general areas of mission focus, communications, institution safety and security, inmate
programming, personnel, training, financial management, and external relationships. Those
procedures included the following:
•

Analytical reviews of various financial information;

•

Conducting interviews with the warden, administrative staff, custody and non-custody
employees, and inmates, including representatives of the California Correctional Peace
Officers Association, California State Employees Association, California Correctional
Supervisors’ Association and the Inmate Advisory Committees for Facilities I-IV;

•

Distributing survey questionnaires to randomly selected California State Prison, Solano
employees, requesting responses regarding the warden’s effectiveness in communication;

•

Touring the facilities and observing its operations;

•

Reviewing key internal and external reports and analysis prepared by the Office of the
Inspector General, the Department of Corrections Health Care Services Division, Office

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 9

of Compliance, and Institutions Division and considering the impact of those reports on
audit procedures; and
•

Gathering, reviewing, and analyzing pertinent documents related to key systems,
functions, and processes to substantiate the observations made through on-site visits and
interviews.

In addition to performing field work at the institution between August 1, 2002 and October 1,
2002, the Office of the Inspector General met with the staff of the Department of Corrections
Institutions Division, Health Care Services Division, and Education and Inmate Programs Unit in
Sacramento to facilitate the review of departmental policies, procedures, and documentation.
The management review audit was performed in accordance with Government Auditing
Standards issued by the U. S. General Accounting Office.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 10

FINDINGS AND RECOMMENDATIONS
FINDING 1
The Office of the Inspector General found evidence that California State Prison, Solano is
not adequately tracking inmates with tuberculosis, creating the potential of exposing
inmates throughout the state to the disease and presenting a risk to the correctional staff
and the general public.
To control outbreaks of tuberculosis in the inmate population, state law and Department of
Corrections regulations require state correctional institutions to test inmates for tuberculosis and
to document each inmate’s tuberculosis status in a statewide database. The purpose is to allow
inmates who have been exposed to the disease to be closely monitored, appropriately housed,
and to receive prophylactic medication; to prevent inmates who are receiving medication from
having the treatment interrupted; and to provide for medical precautions to be taken when
inmates are moved from one institution to another.
The Department of Corrections has developed a coding system for identifying each inmate’s
tuberculosis status and requires the information to be stored in the department’s statewide
distributed data processing system for the use of staff assigned to healthcare, classification, case
records, and transportation functions. But the Office of the Inspector General found numerous
errors associated with tuberculosis coding and tracking at California State Prison, Solano, with
the possibility that inmates infected with tuberculosis may not be receiving medication or be
medically isolated, and as a result may be exposing others to the disease.
State law and regulations governing tuberculosis monitoring of inmates. Statutes concerning
testing and monitoring state prison inmates for tuberculosis are set out in California Penal Code
Sections 7570 et seq. The law requires state correctional institutions to test or evaluate inmates
for tuberculosis upon incarceration and at least annually thereafter. The California Department
of Corrections Operations Manual, in turn, requires institutions to assign codes denoting every
inmate’s tuberculosis status. The codes reflect the following tuberculosis disease stages and
associated need for medical treatment and precautions:
•

Tuberculosis infection. In this initial stage, a person has been infected with the disease, but
has no symptoms and is not contagious. A full course of prophylactic treatment with oral
medication is required for up to 12 months. Without treatment, 10 percent of cases will go on
to develop tuberculosis. Interruptions in treatment can result in development of tuberculosis
strains resistant to drugs. Under Department of Corrections regulations, inmates in this stage
of the disease can be moved from one institution to another, but the medical staff at the
receiving facility must be notified of the need for continued treatment.

•

Tuberculosis disease. In this stage, the person has the disease, is infectious, and requires
aggressive treatment for up to 24 months. Under department regulations, inmates in this stage
cannot be moved from one institution to another using regular Department of Corrections
transportation methods and cannot be transported without special respiratory precautions to
protect others. Treatment must be continued without interruption at the new institution. After
treatment, the person becomes non-infectious.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 11

Following are the most critical of the codes developed by the Department of Corrections to
denote inmate tuberculosis status and to specify treatment to be accorded:
11– Skin test administered but results not yet known. Inmate may not be transported.
21 – Tuberculosis test needed. Inmate may not be transported.
31 – Infectious tuberculosis disease suspected. Inmate may not be transported.
32 – Non-infectious, not on medication. Denotes inmates who have successfully
completed tuberculosis treatment. No additional prophylactic medication needed and
inmate may be moved by regular transportation. Evaluate annually.
33 – Tuberculosis infection, on medication, non-infectious. Identifies inmates exposed
to tuberculosis and receiving medication. Inmate may be moved by regular
transportation and medication must be transported with the inmate.
34 – Tuberculosis infection, not on medication, infectious. Identifies inmates who have
been exposed to tuberculosis but who either refuse or are unable to complete the
treatment regimen. Evaluate annually. Move by regular transportation.
43 – Tuberculosis disease, but non-infectious. Denotes inmates currently under
treatment but no longer infectious. Treatment must be continued without interruption.
Inmate medical records show tuberculosis codes inconsistent with medical treatment. To
evaluate the accuracy of tuberculosis coding, tracking, and treatment at California State Prison,
Solano, the Office of the Inspector General compared the institution’s pharmaceutical records to
inmate tuberculosis coding. The comparison revealed errors in the records of 131 inmates. Of the
131 inmates, the medical records of 122 inmates with tuberculosis codes of 33 showed no
corresponding pharmacy order for the medication (isoniazid) used to treat tuberculosis infection.
The records of the remaining nine inmates, conversely, showed active medication orders for
isoniazid, but no tuberculosis code of 33.
The 122 inmates with tuberculosis codes of 33 but without active medication orders may fall into
one of the following categories:
•

The inmates are not being monitored to ensure uninterrupted completion of the medication
regimen, and the medication order has expired.

•

The inmates tested positive for tuberculosis, but medication was never ordered, placing these
inmates at higher risk for developing active disease. Because the inmates are incorrectly
coded as 33, no transportation restrictions or respiratory precautions have been imposed.

•

The tuberculosis code was entered incorrectly as 33.

The nine inmates with active medication orders for isoniazid, but not coded as 33 fell into two
categories:

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 12

•

Four inmates showed negative tuberculosis tests and no record of a positive tuberculosis test,
yet still had active orders for isoniazid.

•

Five inmates had positive tuberculosis tests in their records and active orders for isoniazid,
but their tuberculosis codes were never changed to 33.

In addition, among the nine records for inmates with active orders for isoniazid, the Office of the
Inspector General found one inmate with a code of 34, indicating that the inmate had been
exposed to tuberculosis, but had not completed the medication. The inmate’s record inexplicably
reflected a subsequent code change to 22, indicating that he had never been exposed to
tuberculosis, yet there was no evidence of a positive tuberculosis test in the inmate’s record, and
no explanation for the code change from 34 to 22.
Coding errors may cause disease outbreaks and may result in resistant forms of the disease.
Inmates with tuberculosis codes of 33 and no associated order for medication are of particular
concern because they may expose others to the disease. Once they are coded as 33, inmates are
no longer tested for tuberculosis and have no transportation restrictions. Furthermore, because
California State Prison, Solano has inadequate quality control procedures to identify inmates
coded incorrectly, the number of inmates in this category is likely to increase. Incorrect
tuberculosis coding can also result in improper transportation of infected inmates and an
increased risk of an outbreak of tuberculosis among both inmates and staff. Coding errors may
also cause interruptions in treatment, resulting, in development of drug resistant forms of the
disease, necessitating more aggressive and expensive therapy.
Institution staffing appears to be inadequate for monitoring inmate tuberculosis status.
California State Prison, Solano employs only one full-time public health nurse and one part-time
infection control nurse who works one day a week to track the tuberculosis status of the
institution’s 5,800 inmates. The two employees work without clerical support. The public health
nurse is responsible for updating all tuberculosis codes in the system-wide database and in each
inmate’s medical record based on information taken from physicians’ progress notes and
pharmacy records.
RECOMMENDATIONS
The Office of the Inspector General recommends that California State Prison,
Solano take the following actions to improve the identification and tracking of
inmate tuberculosis status:
•

Allocate additional personnel resources to the task of monitoring and
recording inmate tuberculosis status.

•

Require the public health nurse to collect all records for inmates who have
completed a tuberculosis treatment regimen to ensure that those inmates
receive a post-treatment evaluation by a physician.

•

Require the public health nurse to ensure that tuberculosis codes are
properly updated in inmate medical records and in the department’s systemwide data base and that a Form CDC 128-C (tuberculosis chrono) is

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 13

forwarded to the central records staff for inclusion in the inmate’s central
file.
FINDING 2
The Office of the Inspector General found that California State Prison, Solano inmates are
allowed to earn sentence reduction credit through education and training classes even when
classes are not actually held.
California state prison inmates may reduce their time in custody by earning credits through
participation in work, education, or training programs at the rate of one day of credit for each day
of participation. Like other Department of Corrections institutions, however, California State
Prison, Solano is experiencing difficulty filling teacher vacancies for education and training
classes, with the result that many classes are not being held. Yet, under a mistaken belief that
classes cannot be closed without approval from department headquarters, the institution has
continued to assign inmates to classes even when no teachers are available and classes are not
heldand even though the classes are not being held, inmates are allowed to earn sentence
reduction credit as though they attended the class.
Regulations governing time credits for program participation. California Penal Code Section
2933 provides that inmates in the custody of the Department of Corrections may reduce their
time in custody by earning credits through performance in work, education, or training programs.
In general, for each day they participate in an approved work, education, or training assignment,
inmates may reduce their sentences by one day for up to 50 percent of their terms. Under
California Code of Regulations, Title 15, Section 3045.3, inmates unable to attend assigned work
or education programs may still earn sentence-reducing credit under certain circumstances.
Those circumstances include when the institution is on lockdown status, when instructors are
absent and no relief instructor is available, when emergency conditions exist, or when other
factors that are not the fault of the inmate prevent participation in the work or education
program. Time credited to inmates under such circumstances is referred to as “S” time.
Teacher shortages have limited class availability. Teacher shortages at California State Prison,
Solano have resulted in part from a statewide hiring freeze on non-custody positions imposed by
the Department of Corrections in November 2001. The education department at the institution
requested an exemption from the provisions of the hiring freeze in order to fill vacant teacher
positions, but because of the potential conversion of California State Prison, Solano to a
reception center, the institution obtained permission only to fill limited-term positions.
According to the supervisor of correctional education programs at the institution, this severely
limited the candidate pool and created further delays in filling vacant positions. The institution
presently lacks teachers to substitute for those on vacation or sick leave or who are participating
in mandatory continuing education or training, with the result that classes are often closed due to
teacher absences.
Misuse of “S” time credits. Although the “S” time credits are meant to cover situations
temporary in nature, the Office of the Inspector General found that California State Prison,
Solano has been assigning inmates to classes and allowing “S” time credits even when classes
have had no teachers available for periods ranging from several months to more than a year.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 14

Operating under the mistaken belief that classes cannot be closed without approval from the
Institutions Division of the Department of Corrections, for several years the institution has
continued to assign inmates to classes even when teachers are not available to teach the classes
and regular classes are not held. An adult basic education program at the institution continued to
receive new students in fiscal year 2001-02, for example, even though no instructor was
available to teach the class.
A review by the Office of the Inspector General of the institution’s monthly education reports
showed that 39 percent of the “S” time hours reported in fiscal year 2001-02 resulted from
teacher vacancies, training, and meetings. Lockdowns, late releases, and other custody matters
accounted for the remaining 61 percent. A chart depicting the breakdown in “S” time hours is
shown below:
Description

Academic

Vocational

Combined

%

Custody-Related Hours

533,888

470,025

1,003,913

61

Education-Related Hours

301,280

337,939

1,639,219

39

Total Hours

835,168

807,964

1,643132

100

The Office of the Inspector General also found that the absence of a teacher and resultant class
closing in fact may account for an even greater proportion of the “S” time granted to inmates
than that indicated by the monthly education reports. A review of inmate timesheets for an adult
basic education class revealed that often when a class was not held, a member of the teaching
staff had noted the reason for the inmate’s absence as “custody-related” even when the actual
reason was that no teacher had been assigned to the class. The supervisor of correctional
education programs told the Office of the Inspector General that when a lockdown is in effect,
the standard practice of the staff is to attribute inmate absences to custody reasons, even when no
teacher is available to teach the class and the class would not have been held if the lockdown had
not been in effect.
Whether inmate absences are attributed to custody-related reasons or to education reasons, the
Office of the Inspector General found that in 2001-02, inmates actually participated in academic
and vocational programs for only about 37 percent of the time scheduled for those programs.
Many of the inmates nonetheless received time reduction credits as if they had attended classes
full-time. In effect, the practices followed at the institution reduce the sentences of the inmates
without requiring commensurate performance by the inmates as intended by California Penal
Code Section 2933.
The following chart shows the percentage of time inmates participated in academic and
vocational programs for fiscal year 2001-02:

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 15

Description

Academic

Vocational

Combined

943

910

1,853

Actual Hours Spent in Classes

520,909

456,031

976,940

“S” Time Hours

835,168

807,964

1,643,132

Other Excused Absence Hours

16,144

18,985

35,129

1,372,221

1,282,980

2,655,201

38%

36%

37%

Average Inmate Enrollment

Total Hours
% of Hours Spent in Classes

According to the Institutions Division, although division approval is in fact required to close
classes, inmates can and should be removed from programs and placed on waiting lists when a
teacher’s absence is expected to last longer than 30 days. Inmates are also supposed to be
referred to a classification committee and removed from any program that is closed for more
than 30 days, even if the Institutions Division has not approved an official request for closure.
The Institutions Division issued a memorandum to all institutions on May 16, 2002 clarifying
this policy, but key management personnel at California State Prison, Solano advised the Office
of the Inspector General that they were unaware of the policy and of the memorandum. The
warden told the Office of the Inspector General at an informal meeting that the institution has
recently begun closing classes in accordance with departmental policy.
RECOMMENDATION
The Office of the Inspector General recommends that California State Prison,
Solano refer all inmates currently assigned to programs without instructors to the
classification committee for reassignment in accordance with the May 16, 2002
memorandum from the Department of Corrections Institutions Division and
discontinue awarding “S” time to these inmates. California State Prison, Solano
should also immediately identify which classes should be closed and take formal
steps to do so.
FINDING 3
The Office of the Inspector General found that makeshift partitions in the institution’s
administrative segregation unit buildings have created blind spots that limit the view of the
control booth officers, compromising the safety and security of correctional staff and
inmates.
The Office of the Inspector General found that the institution has installed partitions in the
administrative segregation buildings beneath the control booth in order to create space for
classification committee meetings and other activities isolated from the view of inmates housed
in segregation cells. But the partitions block the view of officers on the floor and allow the

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 16

control booth officer only a limited view of the floor immediately outside the doors of the lowertier cells.
The partitioned areas, located on one side of the Building 9 control booth and on both sides of
the Building 10 control booth, are used to conduct inmate classification committee meetings and
other business in addition to providing an area for custody employees to eat lunch. The partitions
are constructed from metal cabinets containing miscellaneous office supplies, along with inmate
clothing, towels, and linens. The Office of the Inspector General noted that cardboard file boxes
stacked atop the cabinets increase the vertical height of the barrier to about seven and a half feet.
Each three-sided partition, combined with the outside wall of the control booth structure, form a
rectangular area of roughly 250 square feet (seven cabinets on the longest side, with four
cabinets on each of the shorter sides). The photograph below, taken on October 1, 2002, shows
the partitioned area from the control booth.
The makeshift partitions,
which are not part of the
facility’s original design plan,
present a visual barrier to
officers on the floor of the
administrative segregation
unit. Although the officer in
the control booth has an
unobstructed view of all cell
doors in the unit, he or she is
afforded only a limited view
of the floor area immediately
outside the doors of the lower
tier cells and would be unable
to provide gun coverage
should an incident occur in
the blind spots.

When interviewed about these conditions, members of the custody staff remarked that inmates in
administrative segregation are moved only under escort and in mechanical restraints and that the
possibility of an inmate physically attacking the custody staff without being brought quickly
under control is remote. But there have been incidents in other correctional institutions in which
inmates have escaped from cells and attacked the staff, and for that reason barriers to the view of
correctional officers of inmate activity are discouraged in all parts of correctional institutions.
RECOMMENDATION
The Office of the Inspector General recommends that California State Prison,
Solano remove the makeshift barriers in the administrative segregation unit and
develop alternatives for creating meeting space.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 17

FINDING 4
The Office of the Inspector General found that a significant number of inmates taking
psychotropic medications are inappropriately housed in buildings lacking air conditioning
and that some inmates who are taking anticonvulsant medications are not assigned to lower
bunks to lessen the possibility of injury in the event of a seizure.
Psychotropic medications can increase the risk of heat-related illnesses by altering the body’s
temperature-regulating mechanisms or impairing the ability to perspire. Accordingly, patients
taking psychotropic medications are advised to avoid exposure to high ambient temperatures.
Yet, the Office of the Inspector General found that more than half of the inmates at California
State Prison, Solano taking psychotropic medication are assigned to buildings without air
conditioning. The Office of the Inspector General also found that 10 inmates taking
anticonvulsant medication for seizure disorders were assigned to upper bunks, putting them at
risk of injury in the event of a seizure.
A review of the records of 544 inmates taking psychotropic medication as of September 9, 2002
revealed that 289 (53 percent) were housed in facilities lacking air conditioning, putting them at
risk for heat-related illness as a result of the high temperatures common during the summer
months at California State Prison, Solano. Similarly, a review of housing assignments for
inmates receiving anticonvulsant medication for seizure disorders revealed that 10 were assigned
to upper bunks, even though inmates at risk of experiencing seizures are normally assigned to
lower bunk and lower tier housing.
The failure of the institution to assign inmates to medically appropriate housing not only places
inmates at risk of medical complications or injury, but also exposes the institution and the
Department of Corrections to the possibility of litigation.
RECOMMENDATION
The Office of the Inspector General recommends that the institution conduct
periodic evaluations of the housing assignments of inmates who have been
prescribed psychotropic medications or whose medical conditions indicate
particular housing needs. When a housing assignment is found to be incompatible
with an inmate’s medical condition, the institution should take immediate measures
to reassign the inmate to appropriate housing.
FINDING 5
The Office of the Inspector General found that when inmate deaths occur, the cause and
circumstances surrounding the deaths are not examined in a timely manner and that those
assigned to conduct the reviews may have a direct interest in the results.
The Department of Corrections has established procedures for reviewing the cause and
circumstances surrounding inmate deaths, but the Office of the Inspector General found that the
reviews take too long to complete and that those assigned to review the cases sometimes have a
direct interest in the results. The process also does not provide for adequate coordination
between the institution’s investigative staff and the department’s Health Care Services Division.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 18

Inmate death reporting and review requirements. The Health Care Services Division of the
California Department of Corrections has set out formal policies and procedures to be followed
in inmate deaths to determine the circumstances surrounding the death, including the cause of
death and the appropriateness of medical care provided. The policies and procedures are intended
to ensure that any necessary corrective measures are implemented to reduce the incidence of
preventable deaths and to provide for statistical analysis and research for the purpose of
improving the delivery of health care.
The procedures require institutions to send all pertinent information about the death to the Health
Care Services Division by the close of the first business day following the date of the death. The
information about the death is reviewed by a physician, who refers the case to the division’s
morbidity and mortality committee if the review identifies circumstances surrounding the death
that require investigation or further review. At that point the committee can either close the case
or request an additional peer review or an investigation. Peer reviews are typically assigned to
the chief medical officer of the institution where the inmate was incarcerated. The warden may
also initiate an investigation into the death. Investigations may be performed by either the
institution or by the Office of Investigative Services of the Department of Corrections.
The peer review process is not completed promptly. The Office of the Inspector General found
from reviewing a database listing cases in which peer reviews had been requested that the
reviews are not completed in a timely manner, and in some cases had still not been completed
even three years or longer after the death. The database reviewed listed 40 Department of
Corrections inmate death cases in which the morbidity and mortality committee had requested
peer reviews. The review revealed that 27 (68 percent) of the peer reviews had taken more than a
year to complete and that 17 (43 percent) were still incomplete at the time of the Office of the
Inspector General’s audit. Two of the cases dated back to March and June of 1999, almost four
years earlier. The problem is reflected at California State Prison, Solano, where a peer review of
nursing issues in a case in which an inmate died of a heart attack took eight months to complete,
and nine months after the death a peer review of a physician had still not been performed.
The Office of the Inspector General conducted an in-depth review of the documents pertaining to
the inmate death at California State Prison, Solano referred to above and identified a number of
issues of concern. The chronology of that case, which occurred in January 2002, is as follows:
An inmate who claimed to have had a history of cardiac problems complained to a correctional
officer of chest pains. The correctional officer conveyed the information to a nurse at the primary
clinic. At the nurse’s request, the inmate was walked to the clinic and examined. According to
the nurse’s notes, the inmate was alert, oriented, and relaxed with no pallor, fatigue, numbness or
tingling in the extremities, and “appeared to be in no apparent distress”. The nurse’s notes said
that the inmate was convinced that the pain was gastric in nature and not the result of a heart
attack. The nurse performed an electrocardiogram and discussed the symptoms and the patient’s
history by telephone with the chief medical officer, who prescribed Maalox to relieve gastric
discomfort. The inmate was released and walked back to his housing unit. About two hours later
a fellow inmate discovered him not breathing and alerted correctional officers. The correctional
officers were unable to get a response and summoned the medical staff. The medical staff
performed CPR until they were relieved by paramedics from the Vacaville Fire Department
medical rescue team, but despite all efforts, the inmate died.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 19

From reviewing the documents in the case, the Office of the Inspector General found the
following:
•

The peer reviewer had a direct interest in the review results. The morbidity and mortality
committee recommended that a supervising registered nurse employed at California State
Prison, Solano perform a peer review of nursing issues involved in the case, even though that
person’s responsibility for nursing matters at the institution provided a disincentive for a
critical and objective analysis. The Office of the Inspector General notes that conflicts of
interest are inherent in peer reviews — at least in appearance if not in fact — in that they are
referred to the chief medical officer at the institution where the death occurred or to
supervisors in charge of the staff undergoing review.

•

The peer review of nursing issues in the case was inadequate. The Office of the Inspector
General found a number of flaws in the peer review of the nursing issues surrounding the
case. Specifically:
•

The peer reviewer did not interview those knowledgeable about the death. The peer
review report does not indicate that the reviewer interviewed correctional officers,
inmates, or anyone else with knowledge about the circumstances surrounding the
inmate’s death, calling the adequacy of the review into question. The report contains no
documentation of an interview with even the attending nurse, and in fact it appears that in
conducting the peer review, the reviewer only read the attending nurse’s notes, which
were written a day after the incident. The Office of the Inspector General found that a
supervising nurse conducted an earlier peer review into the death and that that review did
not include a review of the inmate’s unit health record. That failure prompted the
morbidity and mortality committee to return the peer review to the same supervising
nurse for a further examination of the records.

•

The results of the electrocardiogram are not documented. Although an
electrocardiogram was apparently performed on the inmate, the report of the peer review
does not include the test results. An autopsy confirmed the presence of electrocardiogram
patches on the inmate’s chest, but the report of the peer review conducted by the
supervising nurse notes that the electrocardiogram results were missing. The report
contains no information about efforts to locate the results.

•

Blood sampling was not examined. The peer review report does not discuss whether the
attending nurse drew blood from the inmate or whether the doctor ordered a blood
sample.

•

The reason the inmate was required to walk to the clinic was not examined. The peer
review did not address the fact that the inmate was required to walk both to and from the
clinic even though he was experiencing chest pains and claimed a history of heart
problems, nor do the attending nurse’s notes address why she determined that it was
permissible for the inmate to walk to the clinic.

•

Failure of the correctional staff to administer CPR was not addressed. Section 51070.3
of the California Department of Corrections Operations Manual provides as follows:

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 20

An employee discovering a possible death shall immediately summon medical
assistance. Pending arrival of medical assistance, the employee shall make every
effort to preserve life. This may include first aid, CPR, and other life-saving
measures for which the employee is trained.

The department provides CPR training to correctional officers at the academy, along with
refresher training. Yet, the correctional staff did not administer CPR in this case, and the
peer review did not address that failure or the fact that the staff waited for medical
personnel to arrive and to initiate CPR even though the inmate had been found to be not
breathing. According to the records available, paramedics arrived at 1:58 p.m., six
minutes after they were summoned. The coroner’s report documents an interval of at
least fifteen minutes before CPR was started.
•

The warden did not initiate an investigation into the death. A warden may initiate an
investigation into an inmate death in addition to a peer review requested by the morbidity and
mortality committee, but in this case, the warden did not request an investigation, despite
indications that an investigation was warranted. Incident reports about the death, prepared by
correctional officers, included documentation that an inmate interviewed about the death said
the inmate had told him that “medical only gave him Maalox for indigestion and he knows it
was not indigestion.” The inmate also said that the inmate had told him that “he has had two
heart attacks in the past and knows what a heart attack feels like.” Those comments directly
conflict with the notes written by the nurse after the inmate’s death, which said the inmate
was convinced that the pain was gastric in nature and not the result of a heart attack. The
comments raise questions about the evaluation of the inmate’s condition when the medical
staff saw him just 2 1/2 hours before his death.

•

Results of the peer review were not provided to the warden. The results of the nurse’s peer
review requested by the morbidity and mortality committee were not provided to or
discussed with either the warden or the institution security and investigations unit, and, in
fact, the current process is not designed for such communication to occur. The institution
would have benefited from an investigation in this case, combining the coordinated skills of
medical professionals and investigative staff. Such an investigation might have answered
many of the questions that remain unresolved.
RECOMMENDATIONS
The Office of the Inspector General recommends that the Department of
Corrections develop procedures to require the Health Care Services Division to
take the following steps to improve review of inmate deaths:
•

Coordinate review of inmate deaths with the warden and the institution’s
chief medical officer. The procedures should provide for communication
throughout the review process to coordinate the assignment of staff and
collection of evidence by the investigative staff when necessary.

•

Forward pertinent information gathered by the investigations unit of the
institution to the morbidity and mortality review committee.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 21

•

Ensure that those conducting peer reviews are independent of the incident
and the individuals involved.

•

Ensure that peer reviews are completed in a timely manner.

FINDING 6
The Office of the Inspector General found that California State Prison, Solano retains
inmates in administrative segregation units longer than justified.
The Office of the Inspector General found that California State Prison, Solano does not
effectively monitor the process for determining the length of time inmates spend in
administrative segregation, with the result that inmates may be kept in administrative segregation
longer than necessary. The problem has been compounded by a recent action of the Department
of Corrections to override state regulations requiring that an inmate’s stay in administrative
segregation be re-evaluated at least every 30 days. A department directive has provided instead
that an inmate’s continued retention in administrative segregation be evaluated every 90 to 180
days, depending on the reason for the retention.
Reasons for confining inmates in administrative segregation. Inmates may be kept in
administrative segregation when they present an immediate threat to themselves or others or
when their presence in an institution’s general population endangers institution security. Inmates
may also be kept in administrative segregation when they are the subject of a pending criminal
prosecution, internal disciplinary proceeding, or investigation; during the resolution of a nondisciplinary issue such as an inmate’s concern for his own safety; or while awaiting
reclassification to a different custody level.
State regulations governing retention in administrative segregation. California Code of
Regulations, Title 15, Section 3335 (c), requires the institution classification committee to reevaluate an inmate’s continued retention in administrative segregation at least every 30 days
during the inmate’s stay and to refer any case involving confinement for more than 30 days to a
classification staff representative for additional review and approval. The re-evaluation process is
necessary both to protect the due process rights of inmates and because of the high cost of
keeping inmates in an administrative segregation unit. Confinement in administrative segregation
includes restriction of privileges normally granted to general population inmates. In
administrative segregation, inmates are confined to their cells for all but 10 hours a week for
exercise and showering and are handcuffed and escorted during any movement outside of cells.
Administrative segregation units thus require a higher staffing level than general population
facilities, with custody staff also required to serve meals individually to administrative
segregation inmates and to maintain the common areas of the housing unittasks that inmates
housed in general population units normally perform for themselves.
In a memorandum dated November 20, 2001, however, the deputy director of the Department of
Corrections Institutions Division, directed wardens, classification staff members, and
correctional counselors to extend the frequency of classification committee re-evaluations to 90
days for non-disciplinary matters and to 180 days in disciplinary matters. The Office of the
Inspector General found that the memorandum amounts to an “underground regulation” that
effectively amends California Code of Regulations, Title 15, Section 3335(c) and circumvents
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 22

the procedural requirements of California Government Code Section 11346 for adopting,
amending, or repealing administrative regulations.
An apparent intent of the administrative change was to reduce the time inmates spend in
administrative segregation by supplanting the 30 day-review requirement with improved tracking
of the reasons for the inmate’s placement in administrative segregation housing. The
memorandum provided as follows:
It is important that these changes not result in increased inmate ASU time. Conversely,
we expect reduced ASU retention time by allowing staff resources more time to bring
closure to the cases. Upon bringing closure to the case, staff shall schedule that inmate
within ten days for ICC to take action to release the inmate to the General Population,
establish a Security Housing Unit (SHU) term, and/or refer the inmate for transfer to an
alternate facility. None of these changes should be viewed as taking responsibility from
staff to actively pursue case closure as quickly as possible. It is paramount that each
institution audit and improve tracking systems associated with the reasons for ASU
housing.

Tracking systems for the retention of administrative segregation inmates are ineffective. The
Office of the Inspector General found, however, that at California State Prison, Solano the
tracking systems for monitoring retention of inmates in administrative segregation units are
inadequate. Because the institution has no standard tracking system for monitoring and tracking
inmates housed in administrative segregation, each unit involved in the process has developed its
own tracking system, with no single staff member having responsibility for ensuring that critical
actions are taken. Decisions to place and keep inmates in administrative segregation require
timely and accurate communication among more than half a dozen institution and department
employees. Breakdowns or delays in communication among these employees can significantly
delay the decision process, with inmates left in administrative segregation for unnecessarily long
periods as a result.
The Office of the Inspector General found several instances in which various units at the
institution failed either to communicate effectively or to complete actions relative to an inmate’s
continued retention in administrative segregation. Examples include the following:
•

Delays in gang validation review extend administrative segregation retention. The Office of
the Inspector General found two cases in which inexplicable delays in completing gang
validation reviews caused inmates to be retained in administrative segregation for long
periods. In one case, five months elapsed from the time the institution classification
committee reportedly requested a gang validation review until the results were made
available. In a second case, the gang validation review took seven and a half months. In
neither case did the institutional gang investigative unit find sufficient evidence to validate
the inmate as a member or associate of a prison gang, yet the inmates remained in
administrative segregation pending conclusion of the investigations. According to the
institutional gang investigative staff, gang validation reviews can usually be completed in
four days. A lack of documentation in the institution records makes it difficult to determine
the reason for the delays in these two cases. Because requests for gang validation reviews are
made by telephone, it is unclear when the institution classification committee actually
requested the reviews and whether the delays resulted from a failure of the committee to

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 23

request the investigations in a timely manner or from delays in the investigative process
itself.
•

Institution classification committee not notified promptly of gang review results. In two
other cases reviewed by the Office of the Inspector General, the institution classification
committee was not informed that institutional gang investigative unit investigations had been
completed and therefore deferred action until the next scheduled institution classification
committee meeting. In one of the cases, the gang validation investigation had been completed
for four months before the institution classification committee was notified of the results.

•

Referral to district attorney extends inmate retention in administrative segregation.
California Code of Regulations, Title 15, allows an inmate to suspend the internal
disciplinary process pending possible referral to the district attorney for criminal prosecution,
sometimes resulting in the prolonged retention of inmates in administrative segregation. The
Office of the Inspector General found one case in which the disciplinary process was
suspended by more than a month and a half because of delays in providing the necessary
documents to the security and investigations unit for review before referral of the case to the
district attorney. Ultimately, the case was not recommended for criminal prosecution, but in
the meantime, the inmate remained in administrative segregation.
RECOMMENDATIONS
The Office of the Inspector General recommends that the warden take the following
actions:
•

Develop a standard tracking system for use by all of the housing facilities to
monitor inmates retained in administrative segregation. The tracking system
should record all critical actions, including communication with employees and
other units within the institution to ensure that casework is completed in a
timely manner.

•

Emphasize the importance of completing casework before presenting cases at the
institution classification committee hearing or submitting cases to the
classification services representative for review and approval.

•

Provide training to correctional counselors and other members of the institution
staff to ensure that all actions required in administrative segregation cases are
completed and the results documented and communicated to the appropriate
staff.

•

Identify all cases that have been deferred pending action or returned by the
classification services representative for completion of additional case work and
monitor these cases closely to ensure that tasks are completed by the institution
staff in a timely manner.

The Office of the Inspector General further recommends that the Department of
Corrections follow the procedural requirements for amending regulations as
required by the California Government Code.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 24

FINDING 7
The Office of the Inspector General found that California State Prison, Solano is not
complying with state regulations governing inmate dental care and as a result may be
exposed to the risk of litigation.
California Code of Regulations, Title 15 requires all newly committed inmates to receive a
complete dental examination within 14 days of arrival from the reception center. Title 15 also
requires all inmates under the age of 50 to receive a dental examination at least once every two
years and all inmates over the age of 50 to receive a dental examination every year. The chief
dentist at California State Prison, Solano acknowledges, however, that the institution is not
meeting these requirements, thereby exposing the institution to possible legal action.
According to the chief dentist, the institution presently attempts to schedule eight examinations
each day for newly arrived inmates and provides dental care to other inmates according to the
urgency of need. As time allows, approximately 24 inmates a day also are scheduled for routine
care. But inmates receive routine dental services only when they themselves request
appointments, and the institution does not attempt to provide the periodic examinations required
by Title 15. At the time of the audit, the institution had a patient backlog of approximately five
months for routine dental services. The chief dentist maintains that a shortage of facilities and
staff prevent the institution from complying with regulatory requirements for periodic dental
examinations.
The institution includes a dental clinic, which is operated by the chief dentist and five staff
dentists, but has only four dental chairs and four dental assistants. A medical clinic annex under
construction at the time of the audit will add two more dental chairs, bringing the total to six.
But a planned modification of the correctional treatment center will cause the four existing chairs
to be unavailable for six to ten months, temporarily leaving the institution with only two dental
chairs. During that period, the patient backlog is likely to increase.
The standard staffing requirement for inmate dental care of the Department of Corrections is one
dentist and one dental assistant for every 950 inmates. Since the inmate population at California
State Prison, Solano fluctuates between 5,800 and 5,900, the current staffing level of one chief
dentist and five dentists complies with departmental standards, but the staff of four dental
assistants falls short of departmental standards by two positions. A recent report, “To Refine and
Improve the Delivery of Dental Care to the Inmate-Patients of the California Department of
Corrections,” indicates that the shortage of dental staff is not isolated to California State Prison,
Solano, but rather is a statewide problem. The failure of the department to comply with state
regulations for inmate dental care may also expose the state to possible legal action.
RECOMMENDATION
The Office of the Inspector General recommends that the California Department of
Corrections examine policies and regulatory requirements governing inmate dental
care and consider revising requirements to a level achievable under present
conditions.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 25

FINDING 8
The Office of the Inspector General found that California State Prison, Solano does not
adequately document employee disciplinary proceedings and that the warden
inappropriately serves as the hearing officer in appeals of adverse action decisions.
State law and regulations require specific procedures to be followed in disciplinary actions
involving California state government employees. The purpose of the provisions is to protect the
due process rights of employees to fair and impartial hearings and to afford them an opportunity
to appeal adverse action decisions. The Office of the Inspector General found that despite an
inherent conflict of interest, the warden of California State Prison, Solano often serves as the
hearing officer in appeals of adverse action decisions, and in that capacity often reduces the
penalty for sustained misconduct. Although the original adverse action penalty undergoes a
thorough independent review, the penalty reduction authorized by the warden does not.
Moreover, the reasons for penalty reductions made by the warden are rarely documented,
bringing into question the benefit of the process leading up to the adverse action.
Review of adverse action decisions. Statutes and regulations governing employee disciplinary
actions are set out in California Government Code Sections 3300-3311 and 19635, et seq.; in
California Code of Regulations, Title 15, Article 13; and in the California Department of
Corrections Operations Manual. The employee disciplinary process provides for systematic
review of decisions pertaining to proposed adverse actions against employees  and at any point
in the process, a reviewer can modify the recommended penalty. When an investigation into
possible misconduct by an employee sustains a finding of employee misconduct, the warden
makes a decision whether to proceed with an adverse action. If the decision is to proceed with
the adverse action, the institution’s employee relations officer reviews the investigation and
consults with Department of Corrections headquarters personnel staff to establish a range of
possible penalties based on recent disciplinary actions taken against other employees for similar
misconduct. The warden or one of the chief deputy wardens then confers with the employee
relations officer to develop a recommended penalty for the employee. The employee relations
officer submits the adverse action package, including a recommended penalty, to the department
headquarters personnel office for review, and the personnel office forwards the package to the
Department of Corrections regional administrator for approval. When all of the reviews have
been completed, the employee is served with a notice of adverse action. The employee may then
request that the matter be heard by an impartial reviewer in what is known as a “Skelly hearing,”
and may appeal any adverse action sustained at the Skelly hearing to the State Personnel Board.
Employee disciplinary files lack documentation of the reasons for disciplinary actions. The
Office of the Inspector General found that the institution is not adequately documenting the
reasons for decisions made in employee disciplinary actions during the review process, making it
impossible for an outside reviewer to determine what actions were taken or what information
was considered during the disciplinary process. An examination of the files in 21 adverse action
cases revealed that the majority did not document the reasoning behind the decisions and that
notes from the related Skelly hearings were often illegible or failed to provide a summary of the
information the Skelly officer considered in recommending a penalty. The files also lacked
documentation of information considered by the regional administrator in reviewing the case,
raising questions about the benefit of that review to the adverse action process.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 26

Disciplinary penalties are often reduced as a result of the Skelly hearing. The Office of the
Inspector General also found that in more than half the cases reviewed, the penalty was reduced
as a result of the Skelly hearing. Because the recommended penalty undergoes extensive review
and approval involving the warden, the department personnel office, and the regional
administrator, the high percentage of cases in which penalties are reduced suggests that either the
process leading up to the Skelly hearing was flawed or that the decision of the Skelly hearing
officer was faulty. Of the 21 adverse action cases reviewed by the Office of the Inspector
General, 14 advanced to a Skelly hearing, and of those 14, eight resulted in a reduction of the
penalty recommended during the earlier stages of the process. In one of the files reviewed, for
example, an adverse action penalty was reduced to a letter of instruction even though the original
notice to the employee of adverse action had imposed a 5 percent reduction in pay for 12 months.
Reasons for penalty reductions are not adequately documented. California State Prison, Solano
officials told the Office of the Inspector General that penalties often are reduced because the
employee admits to misconduct at the hearing and expresses sincere remorse, but the files
reviewed by the Office of the Inspector General did not support that information. In one of the
cases reviewed, for example, a correctional officer received a 5 percent reduction in pay for six
months after he was arrested for a hit and run accident and failed to notify the institution of his
arrest, but after the Skelly hearing the warden reduced the penalty to a 5 percent pay reduction
for three months. A memorandum to the employee reporting the results of the Skelly hearing said
that the penalty had been reduced because the employee had admitted guilt and repented, but the
adverse action file documented that the employee had been dishonest during the adverse action
investigation and had received a second adverse action for driving under the influence a few
months before the Skelly hearing. Of the eight files reviewed by the Office of the Inspector
General in which penalties were reduced at the Skelly hearing, only two contained
documentation describing the reasons for the penalty reduction. Although the files do contain
notes from the Skelly hearings, many of the notes are illegible and none provided a summary of
the information considered by the Skelly officer in modifying the recommended penalty.
The warden often assumes the role of the Skelly hearing officer. Despite inherent conflicts of
interest arising from his role in institution operations and his close association with many of the
individuals likely to be involved at various levels of the disciplinary process, the warden of
California State Prison, Solano often serves as the hearing officer presiding over Skelly
proceedings involving the institution. The Office of the Inspector General found adverse action
cases in which the warden had signed the request to initiate an investigation of an employee;
signed the majority of the notices of adverse action; participated in recommending the
disciplinary action brought forward by the institution; and yet also served as the hearing officer
at the Skelly hearing. That practice conflicts with State Personnel Board guidelines governing the
selection of Skelly officers. The State Personnel Board Technical Training Program Manual
provides that Skelly officers should disqualify themselves from the proceedings if they:
•

Were directly involved in the investigation of the matters leading to the personnel action;

•

Participated in the decision to refer the matter for investigation;

•

Personally reviewed the results of the investigation;

•

Recommended a specific penalty to the decision maker;

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

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•

Have a reason to be biased against the employee; or

•

Would be called as a material witness if the case goes to hearing.
RECOMMENDATIONS
The Office of the Inspector General recommends that California State Prison,
Solano take the following actions:
•

Take steps to ensure that the employee relations officer and all others involved
in possible employee disciplinary proceedings document their actions thoroughly
and completely in the adverse action files to provide a complete and accurate
history of critical steps in the disciplinary process and assist the employee
relations officer in developing consistent disciplinary recommendations in future
cases.

•

Discontinue the practice of the warden acting as the Skelly hearing officer in
personnel matters involving California State Prison, Solano.

FINDING 9
The Office of the Inspector General found that pharmacy record keeping and physical
controls over prescription medications stored in the infirmary and clinics are inadequate to
prevent unauthorized access and theft.
Although the Office of the Inspector General found no evidence of actual theft of
pharmaceuticals at California State Prison, Solano, the audit revealed that pharmaceutical
products at the institution are kept in an environment conducive to theft and abuse. In fiscal year
2001-02 the institution spent more than $4 million for pharmaceutical supplies, and the potential
exists for theft of even small volumes of drugs to have a significant fiscal impact.
Pharmaceuticals at the institution are classified as either “cold meds,” which inmates may take
without medical staff supervision, or “hot meds,” which require direct administration by the
staff. The pharmacy pre-packages “cold meds” for direct delivery to inmates. “Hot meds,”
however, are sent in the manufacturer’s original packaging to the infirmary and clinics where
they are stored on open shelves in the nurse’s station and used to refill the medical carts from
which the staff dispenses medication to inmates. The Office of the Inspector General noted that
medical personnel working in the nurse’s station have access to drugs stored on the open shelves
and on unlocked medical carts, making the items susceptible to theft. During one site visit, the
Office of the Inspector General noted that the door to the nurse’s station was open, allowing
access by other staff members. Drugs classified as narcotics were stored in a locked cabinet.
Furthermore, neither the pharmacy nor the medical clinics keep records of the quantities of
pharmaceuticals shipped or consumed, providing the staff with no objective means of
determining whether pharmaceutical products are missing.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 28

RECOMMENDATIONS
The Office of the Inspector General recommends that the health care manager at
California State Prison, Solano take the following actions to improve control over
pharmaceuticals:
•

Institute measures to ensure that medications are securely stored at all times
consistent with their value and potential for misuse. Medications in the
infirmary and clinics should be stored in secured areas under a supervisor’s
control.

•

Record the quantity of pharmaceuticals shipped to the infirmary and clinics and
periodically compare these records to the quantities prescribed by doctors.
Investigate any material variations between the two amounts. Physical
inventories of drugs should be conducted periodically and compared to
perpetual inventory records maintained by the health care manager.

FINDING 10
The Office of the Inspector General found that California State Prison, Solano does not
promptly implement medical modification orders and that many were significantly overdue
at the time of the audit.
The Office of the Inspector General found that a high percentage of modification orders directing
California State Prison, Solano to remedy conditions affecting inmate medical conditions were
more than seven months overdue. Delays in implementing medical modification orders can result
in serious medical consequences for inmates and expose the institution and the department to
possible lawsuits.
Under California Code of Regulations, Title 15, an inmate may appeal a departmental decision,
action, condition, or policy that the inmate can demonstrate may have an adverse effect upon his
or her welfare. Decisions favoring an inmate’s position may be granted in the form of a
“modification order,” a directive to remedy the issue or condition precipitating the inmate’s
appeal.
California State Prison, Solano policy, effective August 1, 2002, requires modification orders to
be completed within 30 calendar days of issuance and requires the institution’s medical appeals
analyst to track medical modification orders and to advise the inmate appeals office when they
are completed. The inmate appeals office is responsible for preparing a list of overdue
modification orders and distributing it to executive management each week.
But the Office of the Inspector General found that 38 modification orders at the institution were
overdue in August 2002 and that 32 of the 38 were medical modification orders. Twenty-five of
those 32 78 percent  were more than seven months overdue. In fact, 23 of the inmates for
whom the modification orders were written had since left the institution. The audit also revealed
that the institution’s report of overdue modification orders was inaccurate in that it omitted four
orders from 2001 that had not been implemented and included five orders that had been
completed.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

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According to the warden, as of November 13, 2002, the number of overdue modification orders
had been reduced to four.
RECOMMENDATIONS
The Office of the Inspector General recommends that the chief medical officer at
California State Prison, Solano assign a staff member to monitor the timely
completion of medical modification orders, with priority on resolving the oldest
orders first. That staff member should also periodically reconcile the information
on the overdue modification orders list to information in the inmate appeals office
records to ensure the accuracy of the list.
FINDING 11
The Office of the Inspector General found that the institution is not properly documenting
inmate activity in the administrative segregation units and that in some instances events
are logged before they occur.
State regulations and California Department of Corrections policy require that movement and
housing of inmates assigned to an administrative segregation unit be recorded in a hardbound
logbook  a CDC Form 114  which provides a single-source record of daily activity within
the administrative segregation unit. The log is formatted to include the inmate’s cell number and
bed assignment, the time of the inmate’s entry to or exit from administrative segregation, the
identity of visitors to the unit, and any unusual incidents within the unit. The CDC Form 114 is a
legal document subject to be used as evidence in a civil, criminal, or administrative proceeding.
The Office of the Inspector General found that although the administrative segregation staff at
California State Prison, Solano maintains the CDC Form 114, the information is not consistently
entered into the log immediately. Instead, information is entered into the logbook only once
every 24 hours by the administrative segregation unit’s first watch floor officer, using reports
from central control to record inmate housing assignments. That practice undermines the purpose
of the CDC Form 114 as a source of accurate, up-to-date information about inmate location,
diminishes the evidentiary value of the CDC Form 114, and presents a safety risk to staff and
inmates.
California Code of Regulations, Title 15, Section 3332 (g) (1), California Department of
Corrections Operations Manual, Section 52080.22.5, and institution post orders all require that
the CDC Form 114 be kept continually up to date. Title 15 provides as follows:
[A] Disciplinary Detention Log, CDC Form 114, will be maintained in each designated
disciplinary detention unit. Specific information required in this log will be kept current
on a daily and shift or watch basis.

California Code of Regulations, Title 15, Section 3332(g)(2) provides:
[A] separate record will be maintained on each inmate undergoing disciplinary
detention. This record will be compiled on CDC Form 114-A, Detention/Segregation
Record. In addition to the identifying information required on the form, all significant

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

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information relating to the inmate during the course of detention, from reception to
release, will be entered on the form in chronological order.

Similarly, special instructions in the post orders for post numbers 12050 and 12200, Units 9 and
10, for the administrative segregation unit housing officer (first watch), as revised January 2002,
provide:
You will complete the isolation log and keep it up to date…You will complete the CDC
Form 114-A for all inmates on both tiers, seven days per week. Information included will
be date, watch, security check, the Housing Officer’s last name, any unusual behavior or
activity, emergency cell moves, and any supplies distributed. New arrivals will be noted
as such and all items distributed upon their arrival will be noted. If an inmate departs
the unit, his destination will be noted on the CDC Form 114-A.

The Office of the Inspector General found that the administrative segregation unit staff at
California State Prison, Solano does not follow these procedures. The Office of the Inspector
General further noted that in some instances, entries on the detention/segregation records (CDC
Form 114-A) for individual inmates were filled out before the events the entries purported to
record occurred. For example, on August 21, 2002, second watch floor officers in Building 9
(administrative segregation overflow) were making entries recording that inmates had been
served dinner, even though that event would not occur until third watch later that day.
One reason for the problem is that officers assigned to administrative segregation units have
alternative records and census systems available to provide information on the status of inmate
housing assignments. Although those systems provide officers with reasonably accurate
information, they do not supplant the need to keep the CDC Form 114 up to date. The CDC
Form 114 is intended as the primary legal document for recording inmate movement and housing
assignments and, accordingly, is likely to be relied upon as evidence in criminal, civil, or
administrative hearings. CDC Form 114s with missing or incomplete information have
diminished evidentiary value.
RECOMMENDATION
The Office of the Inspector General recommends that administrative segregation
custody personnel institute a practice of recording inmate movements in CDC Form
114 and CDC Form 114-A as they occur, rather than waiting for the first watch
administrative segregation floor officer to update the movements after the fact or
recording events before they take place.
FINDING 12
The Office of the Inspector General found that California State Prison, Solano prepares an
excessive number of daily meals for inmates, resulting in unnecessary added costs for food
and related services.
The Office of the Inspector General found that the food service staff at California State Prison,
Solano does not effectively monitor the number of meals served and consumed each day and that
in at least some cases the number of meals prepared exceeds the inmate population. Although
preparing a certain number of extra meals may be necessary to avoid shortages, the institution
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 31

wastes resources by preparing a large number of meals that are not consumed, particularly given
that the entire inmate population is rarely present at any single meal.
The Office of the Inspector General found that lunches prepared for inmates at California State
Prison, Solano in August 2002 exceeded the inmate population by an average of 7.5 percent a
day, amounting to 13,526 extra lunches for the month. Applying the daily excess percentage of
7.5 percent to all meals using actual food costs for the fiscal year ended June 30, 2002 results in
excess food costs of approximately $400,000 per year, not including labor costs associated with
meal preparation. That number is likely to rise because of an expected increase in food costs
resulting from a new requirement presently being implemented that institutions provide a “heart
healthy” menu for inmates.
California Code of Regulations, Title 15, Section 1243 provides that in “facilities with an
average daily population of 100 or more, there shall be employed or available, a food manager
who has the training and experience to . . . provide a food cost accounting system.” Although
California State Prison, Solano does have a food manager and the staff maintains count sheets of
meals prepared, the institution does not have an adequate system to account for the number of
meals consumed. As a result, the institution has no formal cost information to assist the food
service management in determining whether the number of daily meals prepared is excessive or
if the costs associated with waste, recycling, and excessive meal preparation are material to the
overall cost of the institution’s feeding program. According to the food service staff, poor
controls over meals also enable inmates to take more than one sack lunch when leaving the
dining hall after breakfast and to return to feeding lines numerous times during meals in the
dining hall.
RECOMMENDATION
The Office of the Inspector General recommends that the warden and the food
manager review the food service process at the institution to identify areas in which
controls should be established or strengthened. Controls should include an accurate
cost accounting system to record actual meals served, re-cycled, and wasted to assist
in estimating future daily meal requirements and in controlling associated costs. The
institution should also strengthen custody controls over food service operations to
lessen opportunities for inmates to obtain more than one meal.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

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ATTACHMENT A

RESPONSE OF THE
CALIFORNIA DEPARTMENT OF CORRECTIONS

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

GRAY DAVIS, GOVERNOR
CONFIDENTIAL

PAGE 33