CA Guard Killing, IG Review 03-17-05

• Topics: Wrongful Death

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OFFICE OF THE INSPECTOR GENERAL
MATTHEW L. CATE, INSPECTOR GENERAL

SPECIAL REVIEW INTO THE DEATH
OF CORRECTIONAL OFFICER MANUEL A. GONZALEZ, JR.
ON JANUARY 10, 2005
AT THE CALIFORNIA INSTITUTION FOR MEN

MARCH 16, 2005
STATE OF CALIFORNIA

CONTENTS
EXECUTIVE SUMMARY ----------------------------------------------------------------------------------------------------------- 3
INTRODUCTION

---------------------------------------------------------------------------------------------------------------- 10

OBJECTIVES, SCOPE, AND METHODOLOGY------------------------------------------------------------------------- 10
BACKGROUND

---------------------------------------------------------------------------------------------------------------- 13

FINDINGS AND RECOMMENDATIONS
FINDING 1

----------------------------------------------------------------------------------------------------------------- 19

Alleged Assailant was inappropriately housed at the reception center.
FINDING 2

----------------------------------------------------------------------------------------------------------------- 26

Reception center processing was delayed by alleged assailant’s case
factors.
FINDING 3

----------------------------------------------------------------------------------------------------------------- 29

The victim and other correctional officers violated security protocols.
FINDING 4

----------------------------------------------------------------------------------------------------------------- 37

Poor maintenance at the institution gave inmates access to weapons.
FINDING 5

----------------------------------------------------------------------------------------------------------------- 42

The institution delayed issuing protective vests.
FINDING 6

----------------------------------------------------------------------------------------------------------------- 49

The medical clinic was ill-prepared to handle the emergency.
FINDING 7

----------------------------------------------------------------------------------------------------------------- 64

Emergency response was disorganized.
FINDING 8

----------------------------------------------------------------------------------------------------------------- 71

Crime scene was contaminated and evidence was lost.
FINDING 9

----------------------------------------------------------------------------------------------------------------- 79

Institution did not adequately address inmates’ mental health needs.
FINDING 10

----------------------------------------------------------------------------------------------------------------- 80

Alleged assailant was allowed access to an attorney before the
indictment.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 2

EXECUTIVE SUMMARY

his report presents the results of a special review conducted by the Office of the
Inspector General into the circumstances surrounding the January 10, 2005
stabbing death of Correctional Officer Manuel A. Gonzalez, Jr. at the California
Institution for Men. A criminal investigation into the incident was conducted by the San
Bernardino County Sheriff’s Department and resulted in criminal charges of murder
against Jon Christopher Blaylock, an inmate at the California Institution for Men.
The purpose of the Office of the Inspector General’s review was to identify systemic
procedural and policy deficiencies, procedural violations, and other factors that may have
contributed to Officer Gonzalez’ death. In its review, the Office of the Inspector General
examined the Department of Corrections incident report and attendant documents;
reviewed policies and procedures governing safety and security, reception center housing
placement and processing, inmate mental health diagnosis and placement, emergency
incident response, medical response, and crime scene management. The Office of the
Inspector General also examined the department’s recent procurement and distribution of
protective vests to correctional officers.
As a result of the review, the Office of the Inspector General identified a number of
issues that played a critical role in the incident. The review determined that Blaylock had
a long history of in-prison violence before he arrived at the California Institution for Men
for reception center processing. He had most recently paroled from an indeterminate term
in the security housing unit at California State Prison, Corcoran, where he had been
placed in a single cell and on walk-alone yard status as a safety and security risk because
of his numerous enemies and history of fighting with other inmates. At the time of his
parole in 2002, he was classified as a Level IV maximum security inmate with 376
custody points, and he had been designated as requiring placement in a 180-design Level
IV prison with internal and external armed coverage—the most secure configuration of
the state’s Level IV prisons. Less than four months after he paroled in 2002, Blaylock
was arrested for shooting at a police officer. He remained in jail in Los Angeles County
until his conviction in 2004 for attempted murder of a peace officer, whereupon he was
sentenced to a 75-year state prison term. He arrived at the California Institution for Men
for reception center processing on June 23, 2004 and remained there until the fatal
stabbing on January 10, 2005.
The Office of the Inspector General found that despite Blaylock’s history of in-prison
violence, he was kept in a general population cell during nearly all of the seven months
he spent at the California Institution for Men. Many of the state’s other reception centers
reported that — as a returning inmate who had most recently paroled from a security
housing unit — he would have been automatically placed in an administrative
segregation unit. After he allegedly assaulted another inmate at the reception center, he
spent seven weeks in administrative segregation pending disciplinary action, but the
assault charge was reduced to “mutual combat” and he was returned to the general
population, where he remained until the stabbing of Officer Gonzalez.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 3

The review also determined that correctional officers assigned to the living unit where
Blaylock was housed, including Officer Gonzalez, routinely violated standard security
protocols, as well as extra security restrictions that had been imposed in response to
several other violent incidents at the facility. The Office of the Inspector General found
that the fatal stabbing may have been prevented if Officer Gonzalez and other officers
had adhered to those security requirements.
The Office of the Inspector General found in addition that the housing unit where the
stabbing occurred is in such disrepair and tool controls so lax that inmates are able to
easily obtain and hide materials for making weapons.
The Office of the Inspector General also found that the California Institution for Men
unduly delayed issuing protective vests to correctional officers and instead stored them in
a warehouse while updating its policies on vest distribution and waiting to receive
enough vests for all officers designated to receive them in an effort to avoid complaints
of unfairness. A vest assigned to Officer Gonzalez was in the warehouse when the
stabbing occurred.
The following summarizes the Office of the Inspector General’s findings:
FINDING 1
The Office of the Inspector General found that the California Institution for Men
inappropriately housed Blaylock in a general population unit despite his recent
parole from a security housing unit and his demonstrated violence toward other
inmates.
As an inmate with a history of in-prison violence who had most recently paroled from an
indeterminate term in a security housing unit, Blaylock should have been placed in
administrative segregation when he arrived at the California Institution for Men. That
action would have been consistent with California Code of Regulations, Title 15 and with
the procedures followed at five other reception centers for males operated by the
Department of Corrections. Yet, when Blaylock arrived at the California Institution for
Men, he was assigned instead to a general population cell, where he remained throughout
nearly all of his seven-month stay at the institution. The Office of the Inspector General
found, in fact, that the California Institution for Men regularly places inmates who have
paroled from administrative segregation and security housing units into general
population housing.
Blaylock was involved in a violent altercation with another inmate six weeks after his
arrival at the reception center and he was held in administrative segregation for seven
weeks pending disciplinary action. He was then again released to the general population
despite repeated notations in his files about his potential for violence and extensive
information about his history of security housing and administrative segregation
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 4

confinement during earlier prison terms. On the day he allegedly stabbed Officer
Gonzalez, he was still assigned to a general population cell.
FINDING 2
The Office of the Inspector General found that Blaylock’s reception center
processing was delayed due to complex case factors that severely limited his options
for transfer to another institution.
Blaylock was housed at the California Institution for Men for seven months. The
departmental guidelines state that reception centers will normally process inmates for
transfer within 60 days. Blaylock’s case, however, was far from normal. The
complexities of his case, combined with his conduct, resulted in extending his
confinement at the California Institution for Men. The Office of the Inspector General
reviewed each aspect of Blaylock’s reception center processing and found no delays
resulting solely from staff inefficiency or misconduct.
FINDING 3
The Officer of the Inspector General found that the stabbing of Officer Gonzalez
might have been prevented if officers on the second watch at Sycamore Hall,
including the victim, had followed security protocols and additional security
restrictions imposed in response to earlier incidents in the housing unit.
The Office of the Inspector General found that correctional officers on the second watch
at Sycamore Hall, including Officer Gonzalez, in an attempt to calm racial tensions on
the unit and return the tier to regular programming, consistently failed to follow post
orders and standard security protocols. They also repeatedly violated additional security
measures imposed after violent incidents between Black, Hispanic, and White inmates at
the facility in December 2004. Tragically, the stabbing of Officer Gonzalez on January
10, 2005 was directly linked to the violation of those security requirements.
In interviews conducted by the Office of the Inspector General and the San Bernardino
County Sheriff’s Department, Sycamore Hall correctional staff and inmates consistently
reported that policies and procedures designed to provide safety and security were not
followed on second watch when Officer Gonzalez was on duty. The officers said, for
instance, that in direct violation of security protocols, they frequently released inmates
they believed were influential with other inmates out onto the tier to try to calm racial
tensions. In particular, they reported that Gonzalez allowed Blaylock out of his cell on
numerous occasions before the fatal stabbing, because he believed Blaylock to be a “shot
caller,” who could influence other Black inmates. On the day he was stabbed, Gonzalez
not only directed that Blaylock be released from his cell, but also entered the tier alone to
speak to Blaylock, in direct violation of established security protocols. Earlier that
morning, a fellow officer warned Gonzalez that this conduct was dangerous and could
result in a stabbing. By ignoring this warning, Gonzalez placed himself and other
officers in harm’s way.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 5

In addition, the Office of the Inspector General found that second-watch correctional
officers at Sycamore Hall did not perform required cell searches —as evidenced both by
cell search logs and by approximately 35 weapons found during a comprehensive search
of the housing unit conducted immediately after the fatal stabbing. Nor did they follow
extra security measures imposed after racial violence in the unit that called for keeping
inmate workers off the tier and racial groups separated during inmate movements. The
correctional staff on a different watch also failed to report verbal threats made by inmates
toward officers. Finally, the supervisory staff and management of the institution failed to
adequately supervise the officers or hold them accountable for the lax security practices.
FINDING 4
The Office of the Inspector General found that Sycamore Hall inmates were able to
obtain and hide weapons because of lax tool controls, poor building maintenance
and the consistent failure of the correctional staff to conduct required cell searches.
The California Institution for Men was built in 1941. A lack of preventive maintenance at
the aging facility has left Reception Center Central, and specifically Sycamore Hall and
Madrone Hall, in a serious state of disrepair. The disrepair and structural defects provide
inmates with a source of weapons stock and provides spaces for inmates to hide inmatemanufactured weapons. Compounding the disrepair and structural defects is the
institution’s failure to adhere to departmental policy requiring consistent and accurate
inventory counts of tools legitimately used by inmates, thus hindering staff from
detecting theft of tools and metal stock by inmates for use as weapons or in their
manufacture.
FINDING 5
The Office of the Inspector General found that the California Department of
Corrections procured and distributed protective vests to the institutions consistent
with its budget change proposal and its agreement with the California Correctional
Peace Officers Association; however, delays in issuing vests at the California
Institution for Men were unwarranted.
In fiscal year 2001-02, the Department of Corrections received both one-time and
ongoing funding to procure stab-resistant protective vests for its custody employees. The
Office of the Inspector General determined that in the ensuing years, the department
actually spent more than budgeted to procure these vests and distributed them to its
institutions according to priorities outlined in the agreement with the California
Correctional Peace Officers Association. At the time of the stabbing of Officer Gonzalez,
however, the California Institution for Men had been holding in its warehouse 362 vests
it had received on September 9, 2004. While the failure of the institution to distribute the
vests immediately may not have violated the agreement with the union, depending upon
the interpretation of the relevant sections of the Memorandum of Understanding,
distributing the vests expeditiously would certainly have improved employee safety,
including that of Officer Gonzalez, whose personally fitted vest was in the warehouse
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 6

when he was stabbed. Further, holding the vests in the warehouse for four months
considerably shortens their useful life. The reasons the institution provided for not
distributing the vests until the day following Gonzalez' death reflect a lack of urgency,
and inadequate planning.
FINDING 6
The Office of the Inspector General found that the medical clinic at the California
Institution for Men reception center where the victim was taken after the stabbing
was poorly equipped and ill-prepared to handle the emergency.
The reception center clinic where Officer Gonzalez was first taken was not properly
equipped, supplied or organized to deal with his medical emergency, nor was the clinic’s
medical staff prepared to cope with it. The deficiencies may not have contributed to the
death of Officer Gonzalez, given the extreme severity of his wounds, but the evidence
establishes that the care provided by the clinic staff was very deficient.
FINDING 7
The Office of the Inspector General found that the management of the California
Institution for Men did not set up an Emergency Operations Center or institute an
Emergency Operations Plan in the wake of Officer Gonzalez’ stabbing due to
ambiguous protocols. As a result, there was some confusion in the chain of
command, emergency operations policies were not implemented, the crime scene
was destroyed, and an incident log was never initiated.
The California Department of Corrections Operations Manual governs appropriate
responses to disturbances at an institution, while individual institutions’ own Emergency
Operations Procedures address ancillary policies unique to each institution. However,
these documents do not specifically address whether an Emergency Operations Center
should be set up or an Emergency Operations Plan implemented following an assault on
an officer resulting in serious injury or death. In the wake of the attack on Officer
Gonzalez, the institution’s management neither set up an Emergency Operations Center
nor implemented an Emergency Operations Plan. As a result, there was some confusion
in the chain of command that led to institutional staff’s failure to follow critical
emergency operations policies, destruction of the crime scene, and a failure to record
events in an incident log. Despite these shortcomings, correctional officers were able to
transport the wounded officer to a medical care facility quickly, effectively regain control
of the housing unit, and take the suspect into custody without further serious injury to
inmates or staff.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 7

FINDING 8
The Office of the Inspector General found that the California Institution for Men
did not implement important emergency procedures in response to the incident,
leading to contamination of the crime scene and the loss of important evidence.
California Institution for Men staff failed to preserve the crime scene and physical
evidence, including the clothing worn by Officer Gonzalez’ alleged assailant. As a result,
potentially important corroborative evidence, such as forensic evidence potentially
linking the assailant and the victim was lost. As such, the State’s case against inmate
Blaylock must rely more heavily on eyewitness accounts than otherwise necessary.
Institution staff did not follow established procedures for preserving crime scenes and
physical evidence because some were traumatized by the assault and failed to do their
duties, Investigative Services Unit officers lacked adequate training and experience, and
there was inadequate command and control over the incident. Specifically, the warden
did not implement the prison’s Emergency Operations Procedures. Because these
procedures provide detailed steps and checklists for myriad tasks including crime scene
and evidence preservation, implementing them may have facilitated a more structured,
systematic response by the institution.
FINDING 9
The Office of the Inspector General made confidential findings related to the
adequacy of mental health care for particular inmates at the California Institution
for Men.
The investigation of the Office of the Inspector General found that the California
Institution for Men failed to adequately assess and address particular inmates mental
health needs. However, due to state and federal medical privacy laws, those findings
cannot be presented in a public document. Accordingly, pursuant to Penal Code section
6131 (b) the information in this section has been presented only to the Governor and the
Youth and Adult Correctional Agency.
FINDING 10
The Office of the Inspector General found that Blaylock was permitted to conduct a
telephone conference with an attorney before he was indicted for the murder of
Officer Gonzalez and even though the attorney’s request for the conference was not
properly submitted in writing.
The Office of the Inspector General found that Corcoran State Prison, where Blaylock
was transferred following the incident, allowed Blaylock to speak to an attorney by
telephone before he was indicted for the murder of Officer Gonzalez and therefore before
he had a right to counsel in the matter under the Sixth Amendment. The prison’s
litigation coordinator allowed the telephone conference even though the attorney’s
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 8

request was not properly submitted in writing. The Office of the Inspector General found,
however, that the litigation coordinator acted reasonably in granting the request.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 9

INTRODUCTION

The mental health diagnostic, screening, and placement processes in place at the
California Institution for Men at the time of the incident.

•

Reception center policies and procedures in place at the California Institution for Men
at the time of the incident, particuarly those affecting the suspect’s initial and
continued placement in the reception center general population.

•

Safety and security policies, procedures, and conditions at Sycamore Hall, the
reception center general population living unit in which the suspect was incarcerated
and to which Correctional Officer Gonzalez was assigned, as they existed at the time
of the fatal stabbing.

•

The history of the procurement by the Department of Corrections of stab-resistant
protective vests; the department’s negotiations with the California Correctional Peace
Officers Association with regard to the vests; the policies and procedures governing
the fitting and distribution of the vests; and the decision to not immediately distribute
vests to the correctional staff at the California Institution for Men, including
Correctional Officer Gonzalez.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 10

•

Incident and crime scene management policies, procedures, and practices before,
during, and after the fatal stabbing, with emphasis on preparedness, response, medical
care of the victim, crime scene preservation, and interaction with local law
enforcement.

In reviewing these issues, the Office of the Inspector General conducted the following
procedures:
•

Assigned a team of 12 auditors, investigators and attorneys to conduct the inquiry.

•

Toured Reception Center Central at the California Institution for Men on multiple
occasions.

•

Interviewed personnel of the Youth and Adult Correctional Agency, the Department
of Corrections, and the California Institution for Men, including management staff,
custody staff, medical personnel and other employees, as well as officials of
Bargaining Unit 6 of the California Correctional Peace Officers Association and
inmates.

•

Interviewed investigators and other employees of the San Bernardino County
Sheriff’s Department, and attorneys and staff from the San Bernardino County
District Attorney’s Office.

•

Reviewed investigative reports, incident reports, and other documents related to the
stabbing provided by the entities listed above.

•

Reviewed pertinent statutes and regulations; sections of the California Department of
Corrections Operations Manual; and operational policies and procedures of the
California Institution for Men.

•

Reviewed post orders, living unit logs, inmate central files, classification committee
notes, inmate medical and mental health records and evaluations, and other pertinent
documents. Because of the inadequacy of documentation in many instances, the
Office of the Inspector General supplemented this review with interviews of
employees responsible for particular institution functions.

•

Reviewed the collective bargaining agreement between the State of California and
Bargaining Unit 6 of the California Correctional Peace Officers Association.

•

Using information gathered from these procedures, analyzed and evaluated
Department of Corrections and California Institution for Men policies, procedures,
and practices with respect to the issues cited above, and formulated recommendations
accordingly.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 11

The Office of the Inspector General did not conduct a criminal investigation into the
stabbing death of Correctional Officer Gonzalez and did not evaluate the quality of the
investigation conducted by the San Bernardino County Sheriff’s Department.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 12

BACKGROUND

epartment of Corrections Correctional Officer Manuel A. Gonzalez, Jr., 43, was
fatally stabbed at 10:57 a.m. on January 10, 2005 on Tier 1 of Sycamore Hall at
the California Institution for Men in Chino. The assailant was identified by law
enforcement as Jon Christopher Blaylock, 35, an inmate who had been at the institution’s
reception center for more than six months awaiting permanent institution placement. The
San Bernardino County Sheriff’s Department investigated the incident and the San
Bernardino County District Attorney’s Office charged Blaylock with first-degree murder
with special circumstances.
Blaylock has a history of violent behavior toward correctional employees and other
inmates. Blaylock arrived at the California Institution for Men on June 23, 2004 to
undergo reception center processing after receiving a 75-year prison sentence for the
August 2002 attempted murder of a police officer, a crime committed shortly after he was
released on parole from an earlier prison term. He had served two earlier state prison
sentences in 1990 and 1993 for attempted burglary, and a ten-year prison term for
robbery from which he paroled in 2002.
At the time of his 2002 parole, Blaylock was serving an indeterminate term in the
security housing unit at Corcoran State Prison as a maximum security Level IV inmate
with a classification score of 376 points.1 He had been placed in a single cell and on
walk-alone yard status as a safety and security risk because he had a history of fighting
with other inmates and was believed to have numerous enemies.2 He was therefore
transferred from the security housing unit at Corcoran State Prison to a single cell in the
administrative segregation unit at California State Prison, Los Angeles and paroled four
days later, on April 23, 2002.
1

Classification scores are used to determine inmate custody level and institution placement. Scores are
based on such factors as prison sentence; stability indicators such as age, employment history, and
education level; and behavior in prison, including physical assaults, possession of deadly weapons, and
serious rule violations. Under California Code of Regulations, Title 15, Section 3375.1, inmates are to be
assigned to facilities with a classification level corresponding to the classification score, as follows:
0-18
Level I
19-27
Level II
28-51
Level III
52 and >
Level IV
2
Because of acute overcrowding at Department of Corrections facilities, most inmates in secured housing
and administrative segregation are double-celled. Single cells are reserved for inmates with a history of incell violence and predatory behavior. Administrative segregation is intended as a temporary placement
pending a ruling or other action for inmates whose presence in the inmate general population poses a
danger to themselves, others, or the security of the institution or could jeopardize the integrity of serious
misconduct or criminal investigations. Secured housing may be assigned for either a determinate or
indeterminate period and is designated for inmates whose conduct endangers the safety of others or the
security of the institution. Inmates assigned to secured housing are designated either Maximum A or
Maximum B security level. Inmates in both administrative segregation and secured housing are placed in
full restraints when they come into contact with correctional staff and are allowed out of their cells only
one hour a day.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 13

On August 11, 2002, less than four months after he was released, Blaylock fired three
shots at a police officer who had stopped him for riding a bicycle without a front
headlight. The officer returned one shot. No injuries were reported. Blaylock was arrested
and remained in county jail until his conviction in June 2004 for attempted murder of a
police officer. He was sentenced to a 75-year term.
Blaylock was sent to the reception center at the California Institution for Men for
processing on June 23, 2004 and was placed in a general population cell at Sycamore
Hall. He remained in general population housing for nearly all of the seven months he
spent at the reception center.
The California Institution for Men. The California Institution for Men, built in 1941,
serves as a prison for Level I, II, and III inmates and as a reception center for male felons
newly committed to the Department of Corrections from Los Angeles, San Bernardino,
Riverside, San Diego, and Orange counties. With a design capacity of 2,778, the
institution presently houses 6,298 inmates. Custody and support staff number 1,771.
The reception center at the California Institution for Men is one of seven reception
centers for males operated by the Department of Corrections, along with High Desert
State Prison, Wasco State Prison, Richard J. Donovan Correctional Facility, North Kern
State Prison, Deuel Vocational Institution, and San Quentin State Prison. Known as
Reception Center Central, the reception center is one of four facilities at the California
Institution for Men. Arriving inmates consist of new commitments to state prison, parole
violators being returned to custody, parolees-at-large extradited from other states, inmates
enroute to other institutions, inmates returning to prison from court, and inmates
scheduled for parole into the community from prisons throughout the state. The facility
receives an average of 700 inmates a week and operates 24 hours a day, seven days a
week.
Reception Center Central has a design capacity of 618 and a current inmate population of
1,465, seventy-eight of whom are designated as permanent work crew inmates. The rest
of the inmate population consists of inmates undergoing reception center processing. The
reception center is configured into two wings: Reception Center Central East, which
consists of Birch Hall, Cypress Hall, and Palm Hall; and Reception Center Central West,
which consists of Madrone Hall and Sycamore Hall. Reception Center Central Control is
situated between Reception Center Central East and Reception Center Central West,
adjacent on one side to the main entrance to the building and on the other side to the
facility lieutenant’s office.
Birch Hall, with 154 cells, including 49 single cells, houses inmates with sensitive needs
who are not compatible with other general population inmates. Cypress Hall, with 102
cells, is used for administrative segregation overflow. Palm Hall, which is comprised of
102 cells (68 double cells and 34 single cells) is designated as the administrative
segregation unit.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 14

Sycamore Hall. Sycamore Hall and Madrone Hall, each with 102 cells, house general
population inmates. Sycamore Hall is comprised of a west side and an east side, isolated
from each other except through the guard spaces. Each side is made up of three tiers
accessible by open staircases inside the tiers and by locked staircases inside the guard
spaces.
On January 10, 2004, the day of the stabbing, 213 inmates were housed in Sycamore
Hall, with four correctional officers responsible for inmate supervision and escort. The
building was on modified lockdown because of earlier incidents in which an Hispanic
inmate stabbed a Black inmate and a Black inmate stabbed an Hispanic inmate.
Following is a chronology of events leading up to the incident:
1990 to 1992

Blaylock serves a three-year term for robbery.

1993 to 2002

Blaylock serves a 10-year term for robbery with a
firearm. At the California Men’s Colony, he is found in
possession of a weapon and is sent to California State
Prison, Corcoran to serve a 10-month determinate
sentence in the security housing unit. At the end of the
10-month term, he is given an indeterminate term in the
security housing unit as a threat to the institution’s safety
and security. He is placed in a single cell on walk-alone
yard status and is classified as a Level IV inmate with a
custody point score of 376, indicating he requires
confinement in a Level IV, 180-design prison. In April
2002 he is paroled.

April 23, 2002

Blaylock is transferred from the security housing unit at
California State Prison, Corcoran to the administrative
segregation unit at California State Prison, Los Angeles
and released on parole.

August 11, 2002

Blaylock is stopped on a bicycle for riding without a
front headlight and fires three shots at a police officer.
There are no injuries. He is arrested.

August 2002 - June 2004

Blaylock remains in Los Angeles County jail until he is
convicted of attempted murder of a peace officer, and
sentenced to a 75-year prison term.

June 23, 2004

Blaylock arrives at the reception center at the California
Institution for Men. The same day, Department of
Corrections records printed at the California Institution
for Men indicate that he paroled from the administrative
segregation unit at California State Prison, Los Angeles
County after transferring from the security housing unit
at California State Prison, Corcoran. The California

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 15

Institution for Men places him in a general population
cell at Sycamore Hall.
June 24, 2004

More Department of Corrections records arrive, showing
Blaylock had been classified as a Level IV inmate with
376 custody points and was designated as requiring
“maximum custody” at the time of his parole. He
remains in a general population cell at the reception
center.

July 9, 2004

Blaylock’s central file arrives at the reception center.
The file contains information that he had been in and out
of segregated housing and administrative segregation
since 1990 because of more than 20 incidents of serious
misconduct, including several incidents involving
violence toward staff and other inmates and the
possession and use of weapons. He remains in a general
population cell at the reception center.

July 13, 2004

Blaylock’s central file is audited and his earliest possible
release date is calculated to be January 23, 2071.

July 27, 2004

The reception center medical department classifies
Blaylock.

July 31, 2004

Blaylock was involved in a violent altercation with
another inmate and is placed in administrative
segregation. He is charged with assault.

August 2, 2004

A correctional captain reviews Blaylock’s placement in
administrative segregation and determines he is a threat
to the safety and security of the institution and should
remain in administrative segregation pending completion
of the disciplinary process.

August 4, 2004

The Institutional Classification Committee meets with
Blaylock and elects to retain him in administrative
segregation pending completion of the disciplinary
process. The committee changes his custody level to
“MAX-S,” meaning maximum security, single-cell, due
to past violence.

September 9, 2004

A senior hearing officer adjudicates the rules violation
resulting from the July 31, 2004 assault and reduces the
charge to mutual combat.

September 22, 2004

The Institutional Classification Committee meets to
consider whether Blaylock should continue in
administrative segregation. The committee notes that
Blaylock is serving a life term for attempted murder of a

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 16

peace officer; notes that the rules violation was reduced
to “mutual combat;” and releases him to the general
population. The psychologist who assessed Blaylock is a
member of the committee.
September 25, 2004

A reception center medical clearance chrono is
completed for Blaylock’s central file, clearing the way
for classification personnel to complete the casework for
transfer.

October 12, 2004

A correctional counselor I completes the reception center
readmission summary, but the summary contains
numerous errors and omissions. It reports that Blaylock
paroled with “close B” custody, rather than the higher
“MAX-S” custody. The section listing disciplinary
history notes the 2000 weapons possession that result in
a security housing unit term at California State Prison,
Corcoran and omits the July 31, 2004 assault at the
reception center.

October 14, 2004

The Institutional Staff Recommendation Summary,
which must be completed before an inmate is transferred
from the reception center, is completed. It omits the July
31, 2004 assault of the other inmate. The summary
recommends that Blaylock be sent to California State
Prison, Corcoran. The counselor notes that the interview
with Blaylock had to be cut short because his behavior
was “bizarre and confusing,” and “he became very
agitated, stating that staff were out to kill him.”

November 17, 2004

The Institutional Classification Committee refers
Blaylock’s case to the chief deputy warden,
recommending that the case be referred to the
Departmental Review Board for placement guidance
because of the difficulty of finding placement for
Blaylock.

December 1, 2004

Blaylock appears before the Unit Classification
Committee for a special review because of difficulty in
placing him due to his medical and custody needs. The
committee refers the case to the Departmental Review
Board with a recommendation that he be endorsed for
either the California Medical Facility-III or the
California Men’s Colony-E, both Level III facilities that
allow only inmates with 51 custody points or fewer.

December 2, 2004

A staff psychologist submits a form to the senior
supervising social worker requesting a referral to the
Department of Mental Health for Blaylock.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 17

December 6, 2004

The Departmental Review Board report dated November
19, 2004 is sent to the Department of Corrections
headquarters.
Sycamore Hall is placed on a modified program after a
piece of metal is discovered missing from a light fixture,
raising fears that it might be used as weapons material.
The modified program calls for increased cell searches
and caution during inmate movements.

December 19, 2004

A riot between Black and Hispanic inmates occurs in the
Sycamore Hall culinary area in which several Hispanics
sustain puncture wounds.

December 20, 2004

The modified program at Sycamore Hall is expanded to
a modified lockdown with cell feeding, no recreational
yard, escorted inmate movement, and a requirement that
Black inmates be escorted separately from White and
Hispanic inmates.

December 28, 2004

A Sycamore Hall correctional officer violates the
modified program by opening the first-tier grill gate and
allowing a Black inmate to enter while a White inmate
porter is sweeping. The White inmate stabs the Black
inmate from behind. The modified program is further
expanded to prohibit inmate workers from entering
Sycamore Hall. Blaylock tells a correctional officer and
a correctional lieutenant that Black inmates blame the
officer for the stabbing and want to “get him.” The threat
is not reported.

January 9, 2005

Blaylock becomes angry in a dispute with a correctional
officer over his legal mail and reportedly shouts, “Then
you wonder why motherfuckers get stabbed!” Again, the
threat is not reported.

January 10, 2005

The fatal stabbing of Correctional Office Gonzalez
occurs on the first tier of Sycamore Hall.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 18

FINDINGS AND RECOMMENDATIONS
FINDING 1
The Office of the Inspector General found that the California Institution for Men
inappropriately housed Blaylock in a general population unit despite his recent
parole from a security housing unit and his demonstrated violence toward other
inmates.
As an inmate with a history of in-prison violence who had most recently paroled from an
indeterminate term in a security housing unit, Blaylock should have been placed in
administrative segregation when he arrived at the California Institution for Men. That
action would have been consistent with California Code of Regulations, Title 15 and with
the procedures followed at five other reception centers for males operated by the
Department of Corrections. Yet, when Blaylock arrived at the California Institution for
Men, he was assigned instead to a general population cell, where he remained throughout
nearly all of his seven-month stay at the institution. The Office of the Inspector General
found, in fact, that the California Institution for Men regularly places inmates who have
paroled from administrative segregation and security housing units into general
population housing.
Blaylock was involved in a violent altercation with another inmate six weeks after his
arrival at the reception center and he was held in administrative segregation for seven
weeks pending disciplinary action. He was then again released to the general population
despite repeated notations in his files about his potential for violence and extensive
information about his history of security housing and administrative segregation
confinement during earlier prison terms. On the day he allegedly stabbed Officer
Gonzalez, he was still assigned to a general population cell.
Procedure for inmates who paroled from determinate terms in security housing.
California Code of Regulations, Title 15, section 3341.5 requires that inmates returning
to the Department of Corrections who paroled from a determinate sentence in security
housing be evaluated by an Institutional Classification Committee to determine whether
the determinate sentence should be reimposed. The section reads as follows:
When an inmate is paroled while serving a determinate term, the remaining time on the
term is automatically suspended. When an inmate returns to prison, either as a parole
violator or with a new prison commitment, ICC shall evaluate the case for reimposition
of the suspended determinate term.

That practice recognizes that inmates with a history of confinement in administrative
segregation or security housing have exhibited conduct in the past that posed a threat to
the safety of themselves or others or to the security of the institution. While Title 15 does
not specify a similar procedure for inmates returning to custody who parole from
indeterminate sentences in a segregated housing unit, it does provide that prison inmates
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 19

assigned to a security housing unit at an institution for either a determinate or
indeterminate term may be released to the general population only upon review by a
classification committee.
Department of Corrections inmate records provide security housing history.
Information about whether an inmate was previously confined in specialized housing —
including administrative segregation or a security housing unit — appears in various
department records to which the reception center staff has access. The Offender-Based
Information System, which reports the inmate’s most recent prison housing before he
paroled or discharged from custody is typically available to the reception center staff as
soon as the inmate arrives at the institution. The Distributed Data Processing System,
which gives the inmate’s placement score and custody level before parole, is available the
day after the inmate arrives at the institution. The inmate’s central file, which contains
detailed information about past in-custody conduct, identified enemies, and other
classification information, including security housing history, typically arrives at the
reception center between one and three weeks after the inmate’s arrival.
Housing placement procedures at other reception centers. The Office of the Inspector
General found that, consistent with Title 15, all of the other Department of Corrections
reception centers for males automatically place into administrative segregation inmates
who, according to the Offender-Based Information System, paroled from administrative
segregation or security housing. The inmates are retained in administrative segregation
pending review by an Institutional Classification Committee. Although the OffenderBased Information System does not specify whether a segregated housing term was for a
determinate or an indeterminate sentence, the procedures assume a determinate term and
therefore mandatory compliance with Title 15, section 3341.5. The procedures at those
reception centers do not allow the staff discretion to place inmates who paroled from
security housing into general population cells.
Reception center housing placement at the California Institution for Men. According
to the receiving and release staff, at the time Blaylock arrived at the California Institution
for Men, a check of the Offender-Based Information System to determine an inmate’s
most recent prison housing was typically performed within 48 hours of the inmate’s
arrival.3 In a procedure still in effect, once the previous housing information is obtained
from the Offender-Based Information System, the receiving and release supervisors at the
California Institution for Men are allowed discretion about whether to place an inmate
3

Until this review by the Office of the Inspector General, to obtain information from the Offender-Based
Information System, the receiving and release staff was obliged to submit a list of incoming inmates to the
institution’s records office, where the Offender-Based Information System terminal was located. Because
the records office is staffed only during business hours and because the reception center must accept parole
violators 24 hours a day, seven days a week, the check of the Offender-Based Information System was
often delayed for inmates arriving during non-business hours. Until the staff could obtain the previous
housing information, inmates could be placed in general population housing. As a result of the review by
the Office of the Inspector General, the California Institution for Men has remedied this problem by placing
an Offender-Based Information System terminal in the receiving and records office, allowing the staff 24hour access to the information.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 20

who paroled from segregated housing or an administrative segregation unit into the
general population. And in making that decision, the staff simply relies upon what the
inmate says about why he was confined in segregated housing or administrative
segregation. The process calls for a correctional sergeant to review the information from
the Offender-Based Information System and to interview inmates who paroled from a
segregated housing or administrative segregation unit to determine the reason for the
specialized placement. If the inmate says the placement was for an offense that would
usually carry a short term, such as participating in a riot or battery on an inmate, he is
typically assigned to the general population, under the assumption that the time
remaining on the term would likely be short. If the inmate reports that the specialized
housing placement was for an offense carrying a longer term, the correctional lieutenant
on duty interviews him to decide whether administrative segregation placement is
necessary. The lieutenant has discretion to place the inmate in administrative segregation
pending further review by the Institutional Classification Committee or to assign him to
the general population.
Blaylock’s general population placement at the California Institution for Men. The
records show that the receiving and release staff at the California Institution for Men
obtained the Offender-Based Information System information for Blaylock on the day he
arrived at the institution, June 23, 2004, and that a correctional sergeant reviewed it. The
Offender-Based Information System revealed that at the time Blaylock paroled in 2002,
he had been in the security housing unit at California State Prison, Corcoran and had been
transferred to the administrative segregation unit at California State Prison, Los Angeles
County in Lancaster just before he was released. Yet, after the Offender-Based
Information System review at the California Institution for Men, Blaylock was placed in
the general population, which allowed him to leave his cell for meals and to come into
closer contact with the staff and other inmates. Except for a one-page sheet documenting
that the Offender-Based Information System process was carried out, the files include no
information to explain why Blaylock was not placed into administrative segregation.
Blaylock remained in general population even after more information arrived. Because
the reception center process does not provide for a routine re-evaluation of the initial
housing decision after the Offender-Based Information System review, Blaylock
remained in the general population even after more information about his background
became available. On the day after his arrival, information from the Distributed Data
Processing System arrived. That information showed that Blaylock had been a Level IV
inmate with 376 custody points and was designated as requiring “maximum custody” at
the time of his parole. On July 9, 2004, his central file, which contained more complete
information about his background, also arrived. The central file revealed he had been in
and out of security housing units and administrative segregation since 1990 because of an
extensive pattern of serious misconduct. The file showed his disciplinary history included
more than 20 incidents of serious misconduct, including several incidents involving
violence. According to the file, during his then-most recent prison term, he had been sent
from the California Men’s Colony to California State Prison, Corcoran to serve a 10month determinate sentence in the segregated housing unit for possession of a weapon.
Classified as a maximum security inmate, he was on single-cell, walk-alone yard status as
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 21

a safety and security risk because of his history of violence toward other inmates and his
numerous enemies — a designation that restricted him from physical contact with other
inmates and required that he be placed in restraints whenever he left his cell or came into
contact with correctional employees.
The central file reported that when he completed the 10-month determinate sentence in
the security housing unit at California State Prison, Corcoran, the Institutional
Classification Committee determined his high classification score and history required he
be confined to one of the most secure of the state’s Level IV institutions —a 180-design
facility, rather than one of the less-secure 270-design Level IV facilities. The committee
concluded he was therefore not eligible for placement in Corcoran’s 270-design Level IV
facility. The committee referred his case to a classification services representative with a
recommendation that he be given an indeterminate sentence in the security housing unit.
The classification services representative endorsed the security housing unit
indeterminate sentence, noting:
Placement is necessary due to the high number of enemies and their placement which
makes alternate housing not feasible. Indeterminate placement will address the inmate’s
safety needs as well as his health needs.

The records show that the California Institution for Men audited Blaylock’s central file
on July 13, 2004 for the purpose of determining his earliest possible release date. The
release date was calculated at January 23, 2071, but no action was taken to alter
Blaylock’s placement in a general population cell and no note appears to have been taken
of his history of violence and security housing confinement.
The California Institution for Men lacks adequate administrative segregation space.
Blaylock’s placement in the general population may have been influenced by the shortage
of administrative segregation beds at the California Institution for Men. With just 102
beds designated for administrative segregation, the institution lacks the capacity to
provide security housing for all of the high-security inmates processing through the
reception center. The classification staff reported that at the time of the Inspector
General’s review, Palm Hall, the administrative segregation unit at the institution, was
completely full and all but four cells in Cypress Hall were being used as administrative
segregation overflow. The staff told the Office of the Inspector General that the
constantly revolving inmate population and the high number of inmates with safety
requirements results in the constant need to move inmates into the general population
beds to free up space in administrative segregation. Yet the general population housing
units at the institution are poorly equipped to accommodate high-security inmates and
control violence.
Sycamore Hall is inadequate for high-security inmates. The California Institution for
Men uses Sycamore Hall as general population housing for its worst offenders, other than
those in administrative segregation, but Sycamore Hall cannot provide the security
required for inmates with high-security needs. The facility is a three-tiered housing unit
of antiquated design with traditional bars on cells doors controlled by a recently installed
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 22

electronic bar box. It lacks gun coverage and has numerous blind spots that allow
incidents to occur without detection. The facility is also in deteriorated physical
condition, providing inmates with access to weapon-making materials and numerous
locations for concealing weapons.
Blaylock was temporarily sent to administrative segregation after a serious altercation
with another inmate. On July 31, 2004, six weeks after he arrived at the California
Institution for Men, Blaylock was involved in a serious altercation with another inmate
and was placed in administrative segregation pending disciplinary action. Following an
investigation and a disciplinary hearing, the violation was reduced from assault on an
inmate to mutual combat.
Blaylock was released from administrative segregation following the hearing. On
September 22, 2004, about two weeks after disposition of the rules violation, the
Institutional Classification Committee met to consider whether Blaylock should continue
to be confined in administrative segregation. At that hearing, the committee took note of
the fact that Blaylock was serving a life term for attempted murder of a peace officer;
noted that he had been placed in administrative segregation because of the rules violation;
and made the following ruling:
Committee notes the above RVR [rules violation] was heard and reduced to mutual
combat, therefore Committee acts to release subject to general population.

Blaylock remained in the general population for the rest of his stay at the California
Institution for Men until the stabbing of Officer Gonzalez on January 10, 2005.
The institution failed repeatedly to put Blaylock in administrative segregation. In
making the September 22, 2004 decision about whether to return Blaylock to the general
population, the Institutional Classification Committee had the opportunity, as well as the
obligation, to thoroughly review his central file, note his violent tendencies and previous
segregated housing placement, and retain him in administrative segregation, regardless of
the outcome of the rules violation. Blaylock’s central file clearly documents his long
history of in-prison violence, his maximum security classification, and the fact that he
paroled from security housing unit.
Yet, the Institutional Classification elected to release Blaylock from administrative
segregation on September 22, 2004 without mentioning his potential for violence. There
is no documentation that in making the decision to return him to the general population
the committee noted his previous security housing placement; examined the evidence and
circumstances surrounding the altercation with the other inmate; or otherwise took into
account the danger Blaylock represented to the staff and other inmates.
The California Institution for Men had numerous other opportunities to recognize and act
upon Blaylock’s violent history by putting him in administrative segregation, but each
time failed to do so. The records show that the Institutional Classification Committee,
chaired by the warden, has ultimate responsibility for ruling on administrative
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 23

segregation placement at the institution, reviewed Blaylock’s case on at least four
occasions between August 4, 2004 and November 17, 2004 without ever directing that he
be placed in administrative segregation for the duration of his stay. Similarly, the Unit
Classification Committee reviewed Blaylock’s case on December 1, 2004 in connection
with efforts to resolve difficulties in finding him a suitable institution placement, and also
failed to question his placement in a general population cell.
It is also noteworthy that even though an August 21, 1998 memorandum from the deputy
director of the Department of Corrections Institutions Division advised all wardens that it
is mandatory for them to chair Institutional Classification Committee meetings on a
“routine, rather than an exceptional basis,” neither the warden nor the chief deputy
warden at the California Institution for Men attended any of the classification committee
meetings concerning Blaylock.
RECOMMENDATIONS
The Office of the Inspector General recommends that the California
Institution for Men take the following actions:
•

Use the Offender-Based Information System to carefully screen all
incoming inmates and assign them to administrative segregation if
the offender paroled from an indeterminate security housing unit
term or if the offender’s history otherwise merits such placement. 4

•

Continue the newly adopted practice of using an Offender-Based
Information System terminal 24 hours per day in lieu of placing
unscreened inmates into the general population.

•

Stress to line and supervisory staff the importance of carefully
following prescribed classification regulations and procedures,
including supervisory review of subordinates’ work; use periodic
audits by executive staff and progressive discipline to enforce
compliance. Provide remedial training as necessary.

•

Emphasize to all staff the need to charge inmates with the crimes
the evidence demonstrates they committed while in custody, and
use periodic audits by executive staff and progressive discipline to
enforce compliance. Provide remedial training as necessary.

In addition, the Office of the Inspector General recommends that the
Department of Corrections take the following actions:
4

During its investigation, the Office of the Inspector General recommended that the California Institute for
Men install an Offender-Based Information System terminal within the Reception Center Central Receiving
and Release area. The following week, the California Institute for Men installed the terminal and during
the first week in operation staff discovered five maximum security inmates that would not have been
discovered using the old screening method.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 24

•

Consider establishing a pre-parole designation that would allow
parole regions and county jails to route parole violators with
specific custody designations to the reception centers most suitably
designed to handle them.

•

Work with the California Institution for Men to develop more
administrative segregation beds. If this is impractical to do,
evaluate modifying the prison’s mission to preclude the need for
more beds or prepare and submit a budget change proposal for
the necessary funding.

•

Work with the California Institution for Men to either phase out
Sycamore Hall as a living unit for high-security inmates or to
upgrade it to meet safety and security standards. If the latter,
prepare and submit a budget change proposal for the necessary
funding.

•

Update the August 21, 1998 memorandum advising wardens that
it is mandatory for them to chair Institutional Classification
Committee meetings on a routine, rather than an exceptional,
basis. Hold wardens accountable for doing so.

•

Amend California Code of Regulation, Title 15, section 3341.5(8)
to mandate that when an inmate returns to prison either as a
parole violator or as a new commitment, having paroled from a
security housing unit, the inmate be placed in administrative
segregation pending an evaluation by the Institution Classification
Committee.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 25

FINDING 2
The Office of the Inspector General found that Blaylock’s reception center
processing was delayed due to complex case factors that severely limited his options
for transfer to another institution.
Blaylock was housed at the California Institution for Men for seven months. The
departmental guidelines state that reception centers will normally process inmates for
transfer within 60 days. Blaylock’s case, however, was far from normal. The
complexities of his case, combined with his conduct, resulted in extending his
confinement at the California Institution for Men. The Office of the Inspector General
reviewed each aspect of Blaylock’s reception center processing and found no delays
resulting solely from staff inefficiency or misconduct.
The Office of the Inspector General’s review of Blaylock’s central file disclosed several
case factors that severely restricted the number of institutions capable of adequately
addressing his housing needs. Blaylock was restricted based upon his custody, mental
health, and medical needs. No single institution in the California Department of
Corrections has the resources to accommodate Blaylock’s cumulative case factors.
Blaylock’s extensive list of enemies precluded staff from housing him even at an
institution that could accommodate most of those factors.
Blaylock’s history of misconduct and the nature of his new commitment offense resulted
in a placement score of 376 points. Blaylock would have been designated for placement
in a 180-design housing unit because of his life sentence, prior security housing unit
status, and gang affiliation. Based upon this combination of case factors, staff from both
the Department of Corrections Classification Services Unit and the California Institution
for Men were attempting to facilitate endorsement to an institution best suited to handle
him.
Blaylock’s central file arrived at the reception center within three weeks of his arrival.
Blaylock arrived at the California Institution for Men on June 23, 2004 as a parole
violator with a new term. His central file was received at the California Institution for
Men within three weeks, and on July 13, 2004, the case records office conducted an audit
of his file.
Blaylock’s own actions resulted in a seven-week delay in processing. On July 31, 2004,
Blaylock was placed in administrative segregation as a result of a serious rules violation
report originally charging him for battery with a weapon on an inmate. Since this serious
rules violation report could result in confinement in a security housing unit, the
institution’s classification staff was unable to refer Blaylock for transfer until the issue
was resolved. Blaylock’s disciplinary hearing was held on September 9, 2004, and on
September 22, 2004, after the charges against him were reduced to “mutual combat,” the
Institutional Classification Committee released him from the administrative segregation
unit.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 26

The appropriateness of the decisions to reduce the charges against Blaylock and release
him from administrative segregation unit are addressed elsewhere in this report. Setting
these issues aside, the Office of the Inspector General found that the California Institution
For Men staff processed these actions within reasonable time limits.
The institutional staff recommendation summary was completed three weeks later.
An “institutional staff recommendation summary” is prepared by the inmate’s
correctional counselor to assist in determining the inmate’s placement. This document
contains a brief description of the case factors and an evaluation of the inmate’s potential
adjustment in prison. Based on these factors, the counselor recommended two institutions
to the classification staff representative. This document was completed on October 14,
2004 in Blaylock’s case. Although there is no specific documentation available from the
classification staff representative, Blaylock’s counselor documented that she received
direction on or before October 20, 2004 from the department’s Classification Services
Unit concerning an enemy of Blaylock at the California Medical Facility. This aspect of
Blaylock’s processing took approximately six days, which is not an unreasonable amount
of time.
Blaylock’s transfer was further delayed by his extensive list of enemies. A review of
Blaylock’s form CDC-812, “Notice of Critical Case Information – Safety of Persons,”
reveals that inmate Blaylock had enemies documented at all of the institutions capable of
accommodating most of his case factors. Beginning on October 14, 2004, institution staff
documented several attempts to resolve enemy concerns at the identified institutions.
These attempts included staff conducting interviews with the enemies to determine
whether their issues could be set aside to allow Blaylock to transfer. In addition, staff
considered whether they could transfer some of his enemies elsewhere to accommodate
Blaylock.
On November 17, 2004 Blaylock’s case was presented again to the classification staff
representative, who instructed the California Institution for Men to forward the case to
the Departmental Review Board5 because of its complexity.
The Departmental Review Board referral process requires an institution to prepare
additional classification reports citing the inmate’s case factors and history and a
description of the issues to be addressed by the Departmental Review Board. The
department’s Classification Services Unit is responsible for conducting research and
facilitating Departmental Review Board committees. The Office of the Inspector General
learned that the Classification Services Unit had been working with staff at the California
Institution for Men to locate suitable housing for Blaylock, but were severely hampered
by his numerous restrictive case factors and enemies.
In this case, the Departmental Review Board report dated November 19, 2004 was sent to
the California Department of Corrections headquarters on December 6, 2004. Records
5

The Departmental Review Board is the highest level of classification committee within the department,
and is the final arbiter regarding classification issues.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 27

there indicated that the Classification Services Unit received the institution’s referral on
December 7, 2004. The Classification Services Unit staff told the Office of the Inspector
General that Departmental Review Board cases are normally reviewed within three to
four months of receipt. Reception center cases are usually given priority due to the urgent
need to transfer inmates to appropriate institutions. At the time of the incident on January
10, 2005, the Classification Services Unit had still not been able to find an institution
suitable for Blaylock.
RECOMMENDATION
The Office of the Inspector General recommends that the California
Department of Corrections initiate a peer review audit with subject matter
experts to identify any discrepancies in the processing of reception center
inmates at the California Institution For Men.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 28

FINDING 3
The Office of the Inspector General found that the stabbing of Officer Gonzalez
might have been prevented if officers on the second watch at Sycamore Hall,
including the victim, had followed security protocols and additional security
restrictions imposed in response to earlier incidents in the housing unit.
The Office of the Inspector General found that correctional officers on the second watch
at Sycamore Hall, including Officer Gonzalez, in an attempt to calm racial tensions on
the unit and return the tier to regular programming, consistently failed to follow post
orders and standard security protocols. They also repeatedly violated additional security
measures imposed after violent incidents between Black, Hispanic, and White inmates at
the facility in December 2004. Tragically, the stabbing of Officer Gonzalez on January
10, 2005 was directly linked to the violation of those security requirements.
In interviews conducted by the Office of the Inspector General and the San Bernardino
County Sheriff’s Department, Sycamore Hall correctional staff and inmates consistently
reported that policies and procedures designed to provide safety and security were not
followed on second watch when Officer Gonzalez was on duty. The officers said, for
instance, that in direct violation of security protocols, they frequently released inmates
they believed were influential with other inmates out onto the tier to try to calm racial
tensions. In particular, they reported that Gonzalez allowed Blaylock out of his cell on
numerous occasions before the fatal stabbing, because he believed Blaylock to be a “shot
caller,” who could influence other Black inmates. On the day he was stabbed, Gonzalez
not only directed that Blaylock be released from his cell, but also entered the tier alone to
speak to Blaylock, in direct violation of established security protocols. Earlier that
morning, a fellow officer warned Gonzalez that this conduct was dangerous and could
result in a stabbing. By ignoring this warning, Gonzalez placed himself and other
officers in harm’s way.
In addition, the Office of the Inspector General found that second-watch correctional
officers at Sycamore Hall did not perform required cell searches —as evidenced both by
cell search logs and by approximately 35 weapons found during a comprehensive search
of the housing unit conducted immediately after the fatal stabbing. Nor did they follow
extra security measures imposed after racial violence in the unit that called for keeping
inmate workers off the tier and racial groups separated during inmate movements. The
correctional staff on a different watch also failed to report verbal threats made by inmates
toward officers. Finally, the supervisory staff and management of the institution failed to
adequately supervise the officers or hold them accountable for the lax security practices.
The Office of the Inspector General found that the serious security violations on the
second watch were not corrected because the correctional sergeant and lieutenant
responsible for supervising Sycamore Hall during second watch failed to consistently
provide that supervision.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 29

The Office of the Inspector General found in addition that the California Institution for
Men’s warden, the chief deputy warden, the associate warden responsible for the
reception center, the facility captain and the unit’s correctional lieutenants and sergeants
all failed to monitor compliance with the directives specified in the modified program —
the extra security measures imposed in response to violent incidents in the housing unit
— between December 6, 2004 and January 9, 2005.
Modified program requirements. Sycamore Hall was placed on a modified program on
December 6, 2004 after a piece of metal was discovered missing from a light fixture,
raising fears that it might be used as weapons material. The modified program
instructions directed the staff to increase cell searches and to “exercise caution” during
inmate movements. On December 20, 2004, after a riot between Black and Hispanic
inmates, the security restrictions were expanded to a modified lockdown, with cell
feeding, no recreational yard, escorted inmate movement, and a requirement that Black
inmates be escorted separately from White and Hispanic inmates. In a weekly program
status report to the regional administrator dated December 20, 2004, the warden
explained the reasons for the restrictions and said the incident would be investigated:
During the last modification period the White inmates were restricted to their cells
during feeding and no recreational yard. On 12-19-04 a riot occurred in the Sycamore
Culinary between Blacks and Hispanic inmates. Chemical agents were deployed. Several
Hispanic inmates sustained puncture wounds. An investigation to determine the cause of
the incident will be on going. Several weapons were discovered during the search of the
culinary.

The weekly modified program status report of December 27, 2004 reiterated the
requirements, repeated that an investigation into the December 19, 2004 “will be
ongoing,” and emphasized the need for separated escort:
Escort all movement. White & Hispanics Together, Blacks Separately.

Additional modified program requirements imposed. During the second watch at
Sycamore Hall on December 28, 2004, a correctional officer violated the modified
program by opening the first-tier grill gate and allowing a Black inmate returning from a
medical visit to enter while a White inmate porter was sweeping. When the Black inmate
entered his cell, the White inmate stabbed him from behind, inflicting two puncture
wounds. In response to that incident, the modified program status report of January 3,
2005, which was in effect on January 10, 2005, and which was signed by the correctional
captain and by the chief deputy warden for the warden, provided the additional directive
that no inmate workers were to be allowed in Sycamore Hall. The report read in part:
On 12-28-04, a White porter stabbed a Black inmate returning from a ducat on the first
tier. The Black inmate sustained two puncture wounds. This incident worsened the
already increased racial tensions in Sycamore Hall.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 30

…Staff are to conduct increased searches of inmates living in common areas. Exercise
caution during inmate movement. This procedure will not be changed without permission
of the RCC Captain. Staff will separate White and Hispanic inmates from Black inmates.
…There will be no inmate workers in Sycamore Hall, the officers will cell feed and clean
all areas within their housing unit. … The workers will be confined to the culinary.

The modified program requirements came in addition to existing post orders governing
cell searches, release of inmates from cells, and other security protocols. Post orders for
Sycamore Hall correctional officers include the following requirements:
• Releasing inmates from cells. Post orders for all correctional officers and supervisory
staff assigned to Sycamore Hall strictly limit the release of inmates from cells. The
post orders read:
Except for regular program activities which require the release of inmates from cells,
such as meals, showers, clothing exchange and cell searches, cell doors will remain
locked unless permission has been obtained from a Sergeant or Lieutenant. Inmates will
only be released from their cells for authorized activities. [Emphasis added]

•

Required cell searches. Post orders for Sycamore Hall housing unit correctional
officers require officers on second and third watches to conduct a minimum of three
cell or bed area searches for weapons and contraband on every shift. Officers are also
required to search a cell after an inmate vacates the cell and to note any
“discrepancies.” The results of the searches to be entered in two places: on the unit
cell search log and on the housing unit daily audit sheet, which is submitted to
supervisors each day.

•

Reporting threats and other information. Post orders require housing unit
correctional officers to inform the next watch of any important occurrences. The post
orders state:
Record all unusual occurrences or noteworthy information in the unit log book
and sign the log. Pass on any pertinent information to the relieving officer.

•

Officers may not enter a tier alone or open a grill gate if front door is unlocked.
Post orders for Sycamore Hall housing unit officers require the following:
In the event there is a need to enter the tier, there will be no less than two (2)
officers on the tier at a time. With the exception of inmate movement during yard
release/recall, and an emergency evacuation of the unit, the front door to the
housing unit will be locked before any unit grill gate is unlocked. A serious
breach in security will exist if both the housing unit front door and any unit grill
gate are unsecured at the same time. It is the responsibility of all housing unit
staff to maintain the security of the unit at all times and to prevent any situation

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 31

which would allow uncontrolled inmate movement. All inmate movement will be
strictly controlled by staff.

•

General supervisory responsibilities. Post orders for the Sycamore Hall correctional
sergeant and correctional lieutenant, under “general duties and responsibilities”
specify the following:
On a frequent and regular basis, you are to inspect all designated housing units.
Inspect post orders.

•

Supervisory responsibility for making post orders available. Post orders for the
Sycamore Hall second and third watch housing unit sergeant specify as follows:
Post orders must be available at the assigned positions and the current post
order acknowledgement sheet will be signed by the assigned staff.

• Supervisory responsibility for incident investigations. Post orders for supervisors
require them to review all incident reports and conduct investigations if necessary.
The post orders provide:
Review all incident reports, form CDC 837, for completeness and accuracy.
Interview and conduct informal investigations when necessary. Conduct and
prepare Investigative Reports.

• Supervisory responsibility for cell searches. Sergeants assigned to second and third
watch at Sycamore Hall are required by post orders to sign the housing unit daily
audit sheets after verifying that the information is accurate.
The Office of the Inspector General found that Officer Gonzalez, other correctional
officers on second watch at Sycamore Hall, and Sycamore Hall supervisors consistently
violated both post orders and modified program requirements. Specifically:
•

Required cell searches were not performed. The Office of the Inspector General
found that cell searches required by post orders were not properly conducted.
Although Sycamore Hall officers on the second watch did regularly document the
three required daily searches on the housing unit daily audit sheet, they did not
document the searches in the unit cell search log. As a result, officers had no way of
knowing each day which cells had already been searched, effectively nullifying any
genuine search effort. In fact, the Office of the Inspector General found that unit cell
search records at Sycamore Hall had not been maintained since February 2000.
In addition, there is almost no evidence that the increased search efforts directed by
the modified program requirements in effect between December 6, 2004 and January
10, 2005 were performed. A review by the Office of the Inspector General of unit
search logs, housing unit logbooks, sergeant and lieutenant logbooks, housing unit

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 32

daily audit sheets and program status reports found only a single piece of
documentation to suggest that searches of Sycamore Hall were increased. That
notation, which appeared in the program status report signed on December 17, 2004
stated:
During the last modification period the housing unit has been searched at least
once. Ongoing searches have produced only minor contraband.

Yet after the stabbing of Officer Gonzalez on January 10, 2005, mass searches of
Sycamore Hall yielded approximately 35 weapons.
•

Investigations were not conducted. Even though modified program status reports in
December 2004 and January 2005 indicated that recent incidents of violence would
be investigated, the Office of the Inspector General found no evidence that
investigations or inquiries were conducted. The program status report dated January
3, 2005 also failed to direct staff to investigate the cause of the December 28, 2004
incident, which clearly resulted from officers violating written directives to keep
Black and White inmates separated. In violation of his post orders, the Sycamore Hall
correctional captain failed to request an inquiry into the violation of written directives
that directly contributed to the stabbing of the inmate on December 28, 2004, even
though he signed off on the crime incident report. Asked about the policy violations
surrounding the incident, the chief deputy warden said neither the warden nor the
chief deputy warden reviewed the incident because if did not involve use of force by
staff. The chief deputy warden said the reception center associate warden is normally
the final reviewer on incidents that do not involve use of force. But when the Office
of the Inspector General asked for the post orders or duty statement of the associate
warden position, investigators were told that none exist. The chief deputy warden
acknowledged that no investigation or inquiry into the incident was requested or
conducted by anyone at the institution, although both the warden and the chief deputy
warden acknowledged that an investigation or preliminary fact-finding inquiry should
have been initiated.

•

Inmate workers were allowed on the tiers during movement of other races. In
violation of modified program restrictions, officers on second watch frequently
allowed inmate porters to remain on the tiers during movement of inmates of other
races. Instead of securing the porters during the movement, officers typically sent the
porters to a different tier until the movement was completed.

•

Permanent work crew inmates allowed on tier without supervision. Second-watch
correctional officers allowed permanent work crew inmates to be on the tiers to carry
out repairs without direct supervision so long as they had signed work orders.
Officers also allowed them to be on the tiers during movement of inmates of other
races, in direct violation of both modified program restrictions and post orders.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 33

•

Managers did not adequately communicate permanent work crew restrictions. The
warden and chief deputy warden agreed that the modified program was intended to
restrict all inmate workers from Sycamore Hall. Yet the directives in the modified
program status report were ambiguous, leaving room for the interpretation that
permanent work crew inmates were not included in the restrictions. The Sycamore
Hall correctional captain, the second-watch correctional lieutenant, and the secondwatch correctional sergeant told the Office of the Inspector General that permanent
work crew inmates were routinely allowed into units to make necessary repairs during
modified programs and lockdowns. Supervisors, staff, and inmates all noted that they
believed permanent work crew inmates were not involved in the racial politics within
the reception center.

•

Inmates were released from cells without supervisory approval. Officer Gonzalez
and other correctional officers on the second watch released inmates they believed to
be influential with other inmates from their cells without authorization from
supervisory or managerial staff, in violation of post orders and modified program
restrictions. Blaylock was one of these inmates.

•

Threats were not reported. The Office of the Inspector General found that on two
occasions in the days preceding the fatal stabbing of Officer Gonzalez, Sycamore
Hall officers on third watch did not report threats made by inmates against the staff.
The first instance occurred during third watch on December 28, 2004. On that date,
according to staff, Blaylock told a Sycamore Hall correctional lieutenant and a thirdwatch correctional officer that Black inmates blamed the officer for the stabbing that
had occurred that day and wanted to “get him.” On January 19, 2005, after the fatal
stabbing of Officer Gonzalez, another third-watch officer told the San Bernardino
County Sheriff’s Department that on January 9, 2005, Blaylock became angry over a
dispute with an officer about his legal mail, and had yelled, “Then you wonder why
motherfuckers get stabbed!” Because in both instances the staff failed to notify
institution management of the threats, Blaylock was not rehoused in Administrative
Segregation Unit and no investigation was initiated to evaluate whether the threats
were credible and to take appropriate action.

• Blaylock was repeatedly allowed out of his cell. Officer Gonzalez routinely allowed
Blaylock, in particular, to move about unsupervised on the Sycamore Hall west-side
tiers to calm other Black inmates and relieve racial tensions because he believed him
to be a “shot caller.” Witnesses made the following statements with respect to this
practice:
The guard would let him out when everyone else is in lock-down and treated him as a
“shot caller.”
Gonzalez would let Blaylock out on the tier to talk to people. I did not know why the
officers would let Blaylock out on the tier to talk to people….

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 34

I would see Blaylock out on the tier running the tier for his people doing favors and that
it was a common practice. I was curious about why Officer Gonzalez was inside the tier
area with Blaylock out because usually when the inmates were out on the tier the officers
were always on the other side of the bars.

•

Sycamore Hall supervisors failed to provide adequate supervision. Despite post
orders requiring them to inspect all designated housing units “on a frequent and
regular basis,” it appears that the Sycamore Hall correctional sergeant and
correctional lieutenant failed to provide required supervision. Although the unit
logbook indicates that supervisory staff regularly toured the unit during first and third
watches, it does not document similar inspections by the supervisory staff regularly
assigned to second watch. Numerous statements by Sycamore Hall correctional
officers also indicate that the second-watch correctional sergeant and correctional
lieutenant remained in the dark about the serious violations of security protocols that
regularly occurred during the second watch.

•

Management did not monitor compliance with modified program requirements.
Management at the California Institution for Men allowed non-compliance with
search requirements and did not monitor compliance with other modified program
requirements. Management acknowledged they were aware that Sycamore Hall
correctional officers were not conducting the cell searches required by post orders and
modified program requirements. They told the Office of the Inspector General that
the staff lacked the time to search cells being vacated and to keep up the unit logbook
because of the high turnover of inmates at the institution and increased court
mandates. The Office of the Inspector General also found no documented evidence
that staff complied with modified program directives issued by management. The
warden and chief deputy warden also said they had not documented staff compliance
with the modified program requirements, but made a commitment to developing a
chronological summary of actions taken during modified programs.

On January 10, 2005, a number of these security violations culminated in the fatal
stabbing of Officer Gonzalez. On that day, Gonzalez directed another officer to unlock
Blaylock’s cell so he could have access to the tier and try to calm racial tensions. The
officer refused, asking Gonzalez how they would explain it “if he stabs somebody.”
Gonzalez said no one would get stabbed and opened the cell himself. He subsequently
returned Blaylock to his cell while other officers released White and Hispanic inmates for
medical appointments. After the White and Hispanic inmates left, other officers working
in the unit released eight Black inmates from their cells for medical appointments and had
those eight inmates wait in the guard space. At that point, Gonzalez directed that
Blaylock again be released from his cell and onto the tier. Shortly thereafter, two
Hispanic permanent work crew inmates arrived unsupervised to make plumbing repairs at
Sycamore Hall in a cell occupied by two Black inmates. Even though modified program
restrictions were still in effect, and even though the front door of the housing unit was
open, Gonzalez opened the grill gate to allow one of the two Hispanic permanent work
crew inmates to enter the tier.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 35

The two Black inmates who were occupying the cell needing the plumbing repair should
have been moved to a secure area while the repairs were made, instead officers told them
to come out of the cell and stand on the tier against the wall. An officer then opened the
front door of the housing unit to release the eight Black inmates to medical appointments.
At that moment, and while the door was open, a White inmate returned from a medical
appointment unannounced and walked up the corridor toward the entrance to Sycamore
Hall. One officer then left the guard space to control the White inmate, leaving three
officers in the guard space, including Gonzalez, to watch the eight Black inmates, the
Hispanic plumber, the two Black inmates who had been released from their cell because
of the plumbing repair, and Blaylock. Meanwhile, Blaylock and the two Black inmates
who had been released for the plumbing repair began roaming up and down the stairs to
all three tiers of the living unit. At that point, one of the three officers was distracted by a
telephone call and, simultaneously, Blaylock called to Gonzalez, asking him to enter the
tier. In response, Gonzalez again opened the grill gate, with the front door to the housing
unit still open, and went onto the tier alone to speak to Blaylock, all in direct violation of
security protocols —risking not only his own safety, but also the safety of the other
officers standing in the guard space and posted throughout the reception center.
Immediately after Gonzalez entered the tier, the stabbing took place.
RECOMMENDATIONS
The Office of the Inspector General recommends that the California
Institution for Men take the following actions:
•

Remind all custody staff of the importance of carefully reading and
following post orders, including those requiring supervisory staff to
monitor subordinates’ work and to frequently inspect living units.
Exercise progressive discipline to enforce compliance and provide
remedial training as necessary.

•

Management staff should monitor custody supervisors’ adherence to
important security-related directives and post orders, ensuring to hold
supervisory staff accountable for compliance.

•

Ensure that all security-related directives are as clear and specific as
possible in order to avoid misinterpretation by staff.

The Office of the Inspector General also recommends that the director of the
Department of Corrections hold the warden and her executive staff
accountable for ensuring that they comply with the above recommendations.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 36

FINDING 4
The Office of the Inspector General found that Sycamore Hall inmates were able to
obtain and hide weapons because of lax tool controls, poor building maintenance
and the consistent failure of the correctional staff to conduct required cell searches.
The California Institution for Men was built in 1941. A lack of preventive maintenance at
the aging facility has left Reception Center Central, and specifically Sycamore Hall and
Madrone Hall, in a serious state of disrepair. The disrepair and structural defects provide
inmates with a source of weapons stock and provides spaces for inmates to hide inmatemanufactured weapons. Compounding the disrepair and structural defects is the
institution’s failure to adhere to departmental policy requiring consistent and accurate
inventory counts of tools legitimately used by inmates, thus hindering staff from
detecting theft of tools and metal stock by inmates for use as weapons or in their
manufacture.
A lack of preventive
maintenance has left
Reception Center Central
in a serious state of
disrepair. During visits to
the California Institution
for Men between January
10, 2005 and February 9,
2005, the Office of the
Inspector General noted
numerous maintenance
problems throughout
Reception Center Central.
During interviews with
staff and inmates, the
Madrone Hall
Office of the Inspector
General repeatedly heard complaints about the lack of preventive maintenance, timely
repairs, and insufficient maintenance staff necessary to maintain the aging physical plant.
The Office of the Inspector General found the lack of preventive maintenance at the
California Institution for Men has left Sycamore Hall and Madrone Hall in a serious state
of disrepair. This condition contributes to an increased availability of weapons stock,
while structural defects allow weapons to be hidden within the cellblock or passed
outside the building through broken cell windows. For example, at the time of the
homicide Sycamore Hall had been on a modified program in which inmates were
substantially restricted to their cells for five weeks due to missing metal from a light
fixture. The metal can be cut and fashioned into a stabbing or slashing weapon.
Illustrating the serious structural defects, a subsequent search for weapons found multiple
weapons stored in the space between the toilets and the cell wall. Maintenance staff from
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 37

other institutions were eventually called in to assist in removing the toilets to check for
other weapons and to reseal the toilets to prevent inmates from hiding contraband there
again.
The state of disrepair at Madrone Hall also provides inmates with the ability to transport
weapons or contraband from cell to cell. Many of the cell windows on the back side of
Madrone Hall are broken, permitting inmates to “fish” an item from one cell to another
by lowering or swinging the item on a string or other type of line. The Office of the
Inspector General observed “wear marks” in an arcing pattern on the back side of
Madrone Hall indicative of items having been repeatedly swung back and forth from cell
to cell.

Madrone Hall

Maintenance storage areas were in disarray. In an effort to determine why such a large
number of inmate manufactured weapons were present in Sycamore Hall on the date of
the incident, the Office of the Inspector General toured the maintenance areas located in
Reception Center Central at the California Institution for Men. The tour, conducted on
February 9, 2005, included the boiler room, conex boxes (room-sized metal containers)
and a storage area inside the secured perimeter directly behind the reception center.
These areas were toured, in part, because
of concern that inmate permanent work
crews, such as the plumbing crew
working in Sycamore Hall on the day
Officer Gonzalez was murdered, were
possibly providing inmates with weapons
stock and tools to manufacture weapons.
The Office of the Inspector General
found each area to be in total disarray.
Within the boiler room area there were
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 38

unsecured tools in a five-gallon bucket, unsecured
lockers containing welding rods and propane cylinders,
and numerous unsecured bins containing noninventoried replacement parts kept on hand for electrical
and plumbing repairs. Many of these non-inventoried
replacement parts could easily be used to manufacture
weapons. The Office of the Inspector General asked
maintenance staff if inmates had access to this area.
Staff replied that one inmate was allowed into the boiler
room area.
Tool inventories were non-existent or could not be
located. The California Department of Corrections
Operations Manual contains several provisions requiring staff to regularly inventory
tools stored and used within the institutions. Because tools are used legitimately by some
inmates, such as those assigned to permanent work crews, the most obvious purpose for
tool inventory records is to allow for quick and accurate detection of missing or stolen
tools. Section 52040.6 of the Department of Corrections Operations Manual provides
that each institution shop, work area, or building where tools are used and stored shall
have methods to account for issuance, storage, and key control of tools. Section 52040.6
also requires that each storage area include an inventory count permitting custody staff to
conduct an immediate and accurate count of tools stored in that area.
In addition, section 52040.8 of the Department of Corrections Operations Manual
provides that inventory listings of all tools shall be kept and checked prior to the
beginning and ending of each work or class period. These checks must also be conducted
before all breaks, including lunch. More specifically, section 52040.13.9 provides, in
part, that all tools used by inmate work crews inside the security area shall be controlled
and inventoried daily by the inmates’ supervisor.
The Office of the Inspector General viewed the plumbing cart used by the permanent
work crew inmates inside Reception Center Central and found that the cart contained
numerous tools and replacement parts. Maintenance staff said the tools were inventoried
daily, but were unable to locate the inventories on the day of the tour. None of the
replacement parts had been inventoried. The cart did not contain a tool inventory card to
allow for an immediate and accurate count of the tools as required by Department of
Corrections Operations Manual section 52040.6. Staff explained that the institution’s
Investigative Services Unit confiscated the toolbox normally kept on top of the cart on
January 10, 2005, following the homicide. The Office of the Inspector General contacted
Investigative Services Unit staff to view the contents of the toolbox. Staff confirmed the
toolbox had been secured in the Investigative Services Unit office since January 10,
2005. The Office of the Inspector General viewed the contents of the toolbox and found it
contained the required listing of all its tools.
The Office of the Inspector General also viewed a yellow hazardous materials storage
locker adjacent to the conex storage unit inside the secured perimeter directly behind the
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 39

reception center. The locker was unsecured and full of containers that had leaked their
contents, causing corrosion on the shelves. There was also no inventory of the chemicals
being stored as required by state mandate. The Office of the Inspector General advised
management at the California Institution for Men of this safety hazard.
The Office of the Inspector General was informed that the maintenance shop within the
corridor of the reception center was relocated to an area behind the minimum support
facility on January 20, 2005 because the space was needed for the medical department to
comply with court mandates.
Before leaving the California Institution for Men, the Office of the Inspector General
requested copies of all Reception Center Central tool inventories for December 2004 and
January 2005. On February 14, 2005, the Office of the Inspector General received from
the utility shop supervisor a facsimile of some of the requested tool inventories. The
facsimile contained a copy of a document entitled “Daily Inventory Tool Records” for
January 2005 for “Toolbox #1,” “Toolbox #2,” and the “Staff Toolbox.” The facsimile
also contained the two-page inventory of the toolbox and cart used by the inmate
plumbers inside the security area of the reception center. The sender noted that the
December 2004 tool inventory had not been located.
On February 17, 2005, the utility shop supervisor sent the Office of the Inspector General
the December 2004 Daily Tool Inventory Record; however, there is no indication on the
form which tools corresponded with the inventory. On the facsimile cover sheet the
sender wrote, “[W]e tore the place up and found the only inventory for 04 period. How
lucky this was the one in question.”
The Office of the Inspector General conducted a thorough review of the tool inventory
records submitted as evidence that maintenance staff were conducting daily inventories
as required by the Department of Corrections Operations Manual. In reviewing the
documents received on February 14, 2005, the Office of the Inspector General found the
following:
•

The Daily Tool Inventory Record utilized by maintenance staff at the California
Institution for Men reads, in part, that the staff member “counted and witnessed the
listed items in this (tool locker/tool crib/tool boxes) on the date and time I have
indicated.”

•

The three forms for January 2005 each contain 20 work days with three separate
inventory counts per day for a total of 60 inventories per sheet and a cumulative total
of 180 separate signature boxes. All 180 boxes contained the same individual’s
initials and handwriting apparently written with the same type of pen. The appearance
of the forms suggests that one person signed off on all 180 separate spaces at the
same time.

•

The inventory documents record that three inventories were conducted per day
between January 11, 2005 and January 31, 2005. However, the inmate plumber tool
box used in Sycamore Hall on January 10, 2005 was seized as potential evidence that

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 40

day by Investigative Services Unit staff and held until it was released to a
maintenance worker in the presence of the Office of the Inspector General on
February 9, 2005. The maintenance worker who initialed the Daily Tool Inventory
Record indicating that he inventoried the items in the tool box could not have had
access to that tool box between January 11 and January 31, 2005, although his initials
indicate that he did.
RECOMMENDATIONS
The Office of the Inspector General recommends that the California
Institution for Men require staff to timely and accurately complete tool
maintenance inventories.
In addition, the Office of the Inspector General recommends that the
California Department of Corrections assemble an experienced team and
conduct a thorough inspection of the California Institution for Men. This
inspection should identify all maintenance problems and result in a
corrective action plan. In addition, the team should identify staffing
requirements and resources necessary to complete repairs and maintain the
physical plant.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 41

FINDING 5
The Office of the Inspector General found that the California Department of
Corrections procured and distributed protective vests to the institutions consistent
with its budget change proposal and its agreement with the California Correctional
Peace Officers Association; however, delays in issuing vests at the California
Institution for Men were unwarranted.
In fiscal year 2001-02, the Department of Corrections received both one-time and
ongoing funding to procure stab-resistant protective vests for its custody employees. The
Office of the Inspector General determined that in the ensuing years, the department
actually spent more than budgeted to procure these vests and distributed them to its
institutions according to priorities outlined in the agreement with the California
Correctional Peace Officers Association. At the time of the stabbing of Officer Gonzalez,
however, the California Institution for Men had been holding in its warehouse 362 vests
it had received on September 9, 2004. While the failure of the institution to distribute the
vests immediately may not have violated the agreement with the union, depending upon
the interpretation of the relevant sections of the Memorandum of Understanding,
distributing the vests expeditiously would certainly have improved employee safety,
including that of Officer Gonzalez, whose personally fitted vest was in the warehouse
when he was stabbed. Further, holding the vests in the warehouse for four months
considerably shortens their useful life. The reasons the institution provided for not
distributing the vests until the day following Gonzalez' death reflect a lack of urgency,
and inadequate planning.
The California Department of Corrections introduced protective vests in the mid-1980s
for custody staff working in its administrative segregation and security housing units,
also referred to as lock-up units. The original vests were worn outside of the uniform and
consisted of a cover with titanium plate inserts. Custody personnel working in lock-up
units would retrieve a vest along with their other assigned security equipment prior to
each shift and return the vest at the end of the shift. The vests came in limited sizes and
over the years the technology for stab resistant vests greatly improved. According to the
Department of Corrections, as vest technology progressed, the Department of General
Services began testing protective vests and eventually developed standards for vendors to
follow. Later, the National Institute of Justice began performing scientific tests on
protective vests nationwide for law enforcement and certified vests that met certain
standards of resistance to stabbing instruments. The Department of General Services
eventually adopted the National Institute of Justice certification and now all protective
vests purchased by the Department of Corrections must meet the National Institute of
Justice certification.
In fiscal year 2001-02, the California Department of Corrections received $4.6 million in
one-time funding to purchase protective vests for its high security-level facilities. The
budget change proposal included $1.3 million in ongoing funding for vest maintenance
and replacement.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 42

The department spent more than budgeted to procure protective vests. In its review, the
Office of the Inspector General compared the budgeted amounts with the expenditures for
protective vests to ensure funds were expended as intended. The following table
represents the amount budgeted and expended on protective vests from fiscal year 200102 to present:
Fiscal Year
2001-02
2002-03
2003-04
2004-05*
Totals

Budgeted
$4,625,000
1,308,000
1,308,000
1,308,000
$8,549,000

Expended
$5,141,352
481,536
3,308,856
33,579
$8,965,323

Surplus/Deficit
-$516,352
826,464
-2,000,856
1,274,421
-$416,323

*In the process of ordering for FY 2004-05.

The department adhered to its labor union agreement in issuing the vests to the
institutions. The department followed the protective vest requirements outlined in its
agreement with the California Correctional Peace Officers Association. Section 7.05 I of
the labor agreement stipulates that as additional protective vests become available, they
shall first be offered to employees working in Level IV facilities, then to employees in
Level III facilities, then to employees in Level II facilities, and finally to employees in
Level I facilities. Although the language is silent on reception centers, the California
Department of Corrections determined in its fiscal year 2001-02 budget change proposal
that reception centers fall between the Level III and Level II institutions for priority
purposes. Inmates are technically unclassified during the reception center process but can
have classification scores ranging from Level I through Level IV. The Office of the
Inspector General determined that the department procured protective vests according to
the following priorities:
1.
2.
3.
4.
5.
6.
7.

Level IV-180 Design Facilities
Level IV-270 Design Facilities
Level III Facilities
Reception Centers
Administrative Segregation Units (replace expired vests)
Level II Facilities (future purchases)
Level I Facilities (future purchases)

The initial budget change proposal approved for fiscal year 2001-02 estimated funding
for providing protective vests to Level IV facilities, Level III facilities, and reception
centers, but erroneously excluded the California Institution for Men from its schedule.
The error was caught later, but it was too late to add funding to the budget. The
department, however, ran into additional problems that prevented the procurement of
protective vests as originally planned. First, the price of protective vests had increased by
more than 25 percent since the preparation of the budget change proposal. Second, the
original estimate assumed custody staff would share vests in a fashion similar to the
existing practice in its lock-up units. Last, the type of vest used to formulate the original
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 43

estimate was no longer available for purchase and the department was required to
purchase specific vests meeting standards set by the Department of General Services,
which required vests that are individually fitted for staff. As a result, the department was
limited to purchasing protective vests for its Level IV and Level III facilities during fiscal
year 2001-02 and fiscal year 2002-03. The department continued ordering vests for the
remaining Level III facilities and its reception centers, including the California Institution
for Men, during fiscal year 2003-04.
Due to the changes cited above, the original omission of the California Institution for
Men does not appear to have delayed the prison from receiving the vests beyond the time
other reception centers received them.
Protective vests could have been provided to employees earlier. The California
Institution for Men could have provided protective vests to correctional employees in
September 2004. Notwithstanding that the Department of Corrections was in compliance
with the budget change proposal, correctional employees could have benefited if the
protective vests had been distributed upon their arrival at the institution. Although the
Office of the Inspector General found no specific requirement for protective vests to be
issued immediately upon their arrival, distributing the vests in a reasonable time period
would have enhanced employee safety, including that of Officer Gonzalez, whose
personally fitted vest remained in the warehouse at the time of his death.6 There is no
guarantee that Officer Gonzalez would have survived the stabbing had he been wearing a
protective vest, since the inmate could have chosen to attack other vital areas of the body.
However, providing protective vests to staff shortly after arrival would at least provide
additional safety for those employees. Further, the fact that the institution began issuing
vests to officers within a few days of the incident demonstrates that the prison was
capable of distributing the vests.
In addition to the safety aspects, there are economic benefits to distributing the vests
upon their arrival. According to the California Department of Corrections, the protective
vests have a useful life of approximately five years regardless of whether they are worn
or stored in a warehouse. As a result, the 362 protective vests delivered to the California
Institution for Men on September 9, 2004 had expended nearly 7 percent, or $8,188, of
their useful life sitting in the warehouse awaiting distribution.
The institution cited several reasons for not distributing the vests. The reasons the
institution provided for not distributing the vests until a few days following Gonzalez'
death reflect a lack of urgency, inadequate planning, and a concern for not jeopardizing
employee relations. According to the California Institution for Men, management had
meetings to discuss whether to issue protective vests to its employees but failed to take
action for the following reasons:
6

The associate warden for business services said he removed Officer Gonzalez’ protective vest from the
warehouse on January 11, 2005 in order to not further traumatize the staff. At the request of the Office of
the Inspector General, the institution placed the vest in the custody of its Investigative Services Unit. The
Office of the Inspector General subsequently examined the vest and verified that the manufacturer’s label
identified it as being assigned to Officer Gonzalez.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 44

•

California Institution for Men Operational Supplement 33020.16 for protective
vests needed to be updated. The current policy was based on the lock-up units
only and did not address some of the issues unique to the new, individually fitted
vests. The existing policy was based on the staff exchanging pooled vests rather
than having individually assigned vests. The California Institution for Men
reported it is still in the process of updating this operational supplement.

•

The California Institution for Men had only 362 vests on hand, but needed more
than 900 to cover all staff. Prison management was concerned that there could be
issues of fairness with officers who had vests working alongside officers who did
not. In addition, the institution had a second purchase order for 578 additional
vests, only 100 of which had arrived by December 29, 2004, and was in the
process of scheduling additional fittings.

•

Management was concerned about the impact of “post and bid.” Like all
institutions, the California Institution for Men has continuous post and bid that
allows staff with seniority to bid for vacant post assignments as they occur.
Therefore, an officer who may require a vest one day could end up working a post
the next day that no longer requires a vest.

Distribution of vests at the institution lagged behind other reception centers. The
timeliness of vest delivery to the California Institution for Men was average compared to
that of other reception centers, but distribution to officers lagged behind. For comparison
purposes, the Office of the Inspector General reviewed the protective vest orders of five
reception centers, including the California Institution for Men. The following table
compares the number of vests required, number of vests received, percentage of vests
received, and number of days elapsed to initiate distribution of vests as of January 11,
2005:

Reception Center
California Institution for Men
Deuel Vocational Institution
North Kern State Prison
R.J. Donovan Correctional
Facility7
Wasco State Prison8

Vests
Required
940
657
813
727

Vests
Received
462
480
733
0

%
Received
49.2%
73.1%
90.2%
0

Days to
Distribute
124
6
14
NA

833

As shown above, the California Institution for Men had received only about half its vests
— far behind North Kern State Prison and the Deuel Vocational Institution. However,
7

R.J. Donovan ordered 515 vests on November 24, 2004. The vests were delivered to the institution on
February 18, 2005. According to the Department, these vests have been distributed.
8
Wasco State Prison ordered 496 vests on November 10, 2004. The vests were delivered to the institution
on January 21, 2005. According to the Department, these vests have been distributed.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 45

neither the R. J. Donovan Correctional Facility nor the Wasco State Prison had received
any vests. In distributing to its employees, the California Institution for Men lagged
behind the reception centers that had received their vests. Both the Deuel Vocational
Institution and North Kern State Prison distributed the majority of its vests to employees
within 14 days of receipt, whereas the California Institution for Men took four months.
These facilities informed the Office of the Inspector General that neither of them had
updated their local policies concerning protective vests. Further, since issuing the vests to
employees, the institutions have not received a grievance concerning the vests.
According to records provided by the protective vest supplier, 588 employees from the
California Institution for Men had been fitted prior to January 10, 2005. After employees
are fitted, the contractor provides a list to the institution’s contact person for final
approval of the order. The contractor’s records showed the ordering process varied from
institution to institution, with some taking only a few days and others, such as the
California Institution for Men, taking more than two months for final approval. Once the
contractor receives final approval, the vests are shipped within about 60 days according
to the contract. In reviewing the records, it appears the California Institution for Men has
not approached issuing protective vests with a sense of urgency. If the California
Institution for Men had waited until all vests arrived, the vests would still be in the
warehouse because additional fittings were still in process at the time of this review.
The department’s protective vest policy has not been updated. The Department of
Corrections has not updated its protective vest policy since adopting the new fitted vests
in September 2002. According to the Department of Corrections, neither its central office
nor the institutions had finalized the policies and procedures for distribution of new
protective vests at the time of this review. Lack of a new policy was cited as one of the
main reasons for delaying vest distribution to staff at the California Institution for Men.
The Office of the Inspector General was informed that the Emergency Operation Unit in
Sacramento was in the process of revising California Department of Corrections
Operations Manual section 33020.16 to address the new protective vest policies and
procedures. The California Institution for Men was also in the process of updating its
local policies and procedures. Generally, the local policies are required to only address
institution-specific issues that are not addressed in the broader departmental policy.
Because institution-specific policies follow departmental policies, the California
Institution for Men and other institutions might have been more efficient in updating their
policies had the Department of Corrections been more proactive in updating the
California Department of Corrections Operations Manual.
Potential employee relations problems should not have delayed issuing the vests.
The California Institution for Men’s concerns about post and bid and potential employee
issues should not have prevented the issuance of protective vests. As cited previously, the
California Institution for Men expressed concerns that providing protective vests to some
officers and not to others would create inequities among its staff. In addition, post and bid
was an ongoing concern because staff who may require a vest today may not require one
tomorrow. However, the institution could have addressed some of these concerns by
prioritizing vest distribution to employees working in certain housing units. For example,
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 46

staff working in a housing unit with the highest number of incidents the past twelve
months could have received priority over those in another housing unit. The California
Institution for Men and the contractor told the Office of the Inspector General that initial
vest fittings completed from May 11 through May 14, 2004 were not based on the
employee's job assignment but rather on who happened to be working that day and
decided to stop by for a fitting. The California Institution for Men could easily have
justified its distribution to officers if it had developed priority-based distribution criteria.
The California Institution for Men told the Office of the Inspector General that it was not
in the process of negotiating with the union concerning these issues, but was trying to
address these concerns through a new policy.
The Office of the Inspector General met with the local CCPOA chapter president to get
his perspective on the issuance of protective vests. According to the chapter president, he
has had no formal discussions with the California Institution for Men concerning the
issuance of protective vests. He said he “heard through the grapevine” over the summer
of 2004 that more than 300 vests had arrived at the institution, but he was never officially
informed by the prison administration. The chapter president said he had a few informal
conversations with the employee relations officer and a facility captain about how many
vests had arrived, what type they were, and who was going to receive them, but he was
not provided with specifics about the institution’s plan for distribution. He said he was
told that the prison administrators were working on a new protective vest policy that
would address the new procedures. The chapter president informed the Office of the
Inspector General that he was concerned about inequities in distribution, training on
proper use, vest maintenance, and lack of vest policies. The chapter president said he
planned to address these issues through the grievance process once the vests were issued.
To date, the chapter president said he has not received a copy of the new policy or even
discussed the protective vest issue with the management of the California Institution for
Men. The chapter president said that, "at no time did the union suggest the California
Institution for Men delay issuing vests to its officers."
The department must improve accountability for protective vests. California
Department of Corrections Operations Manual, section 33020.16.4 requires each
institution to prepare quarterly protective vest inventory reports utilizing CDC Form 1405
(Protective Vest Quarterly Inventory Summary). As part of its review, the Office of the
Inspector General requested copies of these reports for the California Institution for Men,
but found the prison does not prepare such reports. In fact, the unit responsible for
coordinating the reports was unaware of the requirement and had never seen a CDC Form
1405.
As noted earlier, the protective vests have a useful life of only about five years.
Therefore, the California Department of Corrections needs an inventory system to track
protective vests to ensure they are replaced once their useful life has expired. The CDC
Form 1405, if utilized, is a start toward such a system. The Department of Corrections
said it is working on an automated system that will track all safety equipment, including
protective vests.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 47

RECOMMENDATIONS
The Office of the Inspector General recommends that the California
Department of Corrections do the following:
•

Issue protective vests to correctional employees expeditiously upon
arrival of the vests at the institution.

•

Update California Department of Corrections Operations Manual section
33020.16 to address new policies and procedures for protective vests.

•

Require facilities to report quarterly vest inventory using CDC Form
1405, and develop and implement an inventory tracking system to ensure
all protective vests are adequately accounted for and replaced according
to manufacturer's standards.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 48

FINDING 6
The Office of the Inspector General found that the medical clinic at the California
Institution for Men reception center where the victim was taken after the stabbing
was poorly equipped and ill-prepared to handle the emergency.
The reception center clinic where Officer Gonzalez was first taken was not properly
equipped, supplied or organized to deal with his medical emergency, nor was the clinic’s
medical staff prepared to cope with it. The deficiencies may not have contributed to the
death of Officer Gonzalez, given the extreme severity of his wounds, but the evidence
establishes that the care provided by the clinic staff was very deficient.
Relationship of reception center clinic to the institution hospital. Reception Center
Central is a large building located several hundred yards south of the institution’s
hospital. The institution’s hospital is a general acute care hospital licensed by the State of
California, and its primary purpose is to meet the health and emergency medical needs of
inmates. Despite its physical distance from the hospital, the clinic located at the reception
center is considered an out-patient facility of the hospital, and has a pharmacy from
which medications are dispensed to inmates housed at the reception center. The clinic’s
primary purpose is to provide medical, psychiatric, and psychological screenings of
reception center inmates. Although it typically provides certain health care services not
requiring hospital attention, the clinic’s staff is sometimes called upon to respond to
medical emergencies at the clinic and in other areas of the institution’s reception center.
Medical summary of the stabbing incident. Officer Gonzalez was stabbed just before
10:57 a.m. in Sycamore Hall. Four correctional officers carried him to the reception
center medical clinic and laid him on the floor of the clinic’s interview room where
medical personnel, including licensed vocational nurses, registered nurses and physicians
were present. All of their reports were consistent in describing multiple stab wounds to
Officer Gonzalez, accompanied by profuse bleeding.
Clinic staff initially applied direct pressure to the wounds, attached an automated external
defibrillator to Officer Gonzalez, began cardiopulmonary resuscitation (CPR), and
attempted to establish an airway to begin ventilation. The clinic staff did not defibrillate
because the automated external defibrillator initially indicated that CPR should be
initiated. Staff did not establish an intravenous line, nor did they administer cardiac
medications. A member of the clinic staff called 911 at 11:02 a.m.
At 11:03 a.m., a medic engine from the fire district began its response from
approximately 2.5 miles away. At the same time, an ambulance from American Medical
Response also initiated its response. The medic engine was first on scene and initiated
treatment at 11:10 a.m. by providing ventilation with a bag valve mask. The fire
paramedics established an intravenous line at 11:12 a.m. and re-intubated Officer
Gonzalez at 11:15 a.m. Paramedics performed defibrillation and at 11:15 a.m.,
administered medications, including epinephrine, atropine, and lidocaine. At 11:20 a.m.,
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 49

a needle thoracostomy9 was performed, Officer Gonzalez was defibrillated again and
additional epinephrine administered. Additional atropine was administered at 11:26 a.m.
The ambulance transporting Officer Gonzalez departed the prison at 11:20 a.m., arriving
at Chino Valley Medical Center at 11:30 a.m. Doctors pronounced Officer Gonzalez dead
at 11:52 a.m. The San Bernardino County Sheriff’s Department homicide investigator’s
report says that the medical examiner who performed the autopsy determined that the
first stab wound penetrated the chest cavity and the heart, causing major bleeding inside
the chest cavity.
The clinic’s emergency equipment and supplies are not kept together. The clinic’s
equipment and supplies for use in respiratory, cardiac and other medical emergencies
includes airway equipment, oxygen, some intravenous access supplies, an automatic
external defibrillator, medications, dressings and related material. These items are not
kept together for immediate access in an emergency. For example, the advanced airway
equipment and drugs are kept in a case in a locked closet down the hall in a different
room from the oxygen, an automated external defibrillator, and other emergency first-aid
supplies.
While the oxygen, an automated external defibrillator, and first-aid box are available in
the same room of the clinic where Officer Gonzalez was initially taken, these items are
not kept together. The oxygen tanks are routinely stored behind the main door of the
clinic’s interview room, while the other equipment is located a short distance away in that
room. During its review, the Office of the Inspector General visited the clinic at various
times on five different days. On two of those days, the automated external defibrillator,
the box of first-aid supplies and an additional container of items were kept together,
while on the other days they were sometimes separated and moved to other locations to
accommodate other work in cramped quarters. The Office of the Inspector General noted
that at times some of this emergency equipment was partially hidden from view by
sweaters, snack food, and other items.
The manner in which the equipment and supplies were located and stored in the clinic at
the time of the incident involving Officer Gonzalez required clinic personnel to go to
different locations to obtain or search for necessary equipment and supplies, wasting
valuable time.
Clinic staff suggested to the Office of the Inspector General that the clinic needs a crash
cart for providing emergency medical care. The cart would keep all necessary equipment
together and could be easily taken to the location of any emergency in the large facility

Thoracostomy is done to drain fluid, blood, or air from the space around the lungs. Severe injuries to the
chest wall can cause bleeding around the lungs. A punctured lung allows air to gather outside the lung,
causing its collapse (called a pneumothorax). Chest tube thoracostomy (commonly referred to as “putting in
a chest tube”) involves placing a hollow plastic tube between the ribs and into the chest to drain fluid or air
from around the lungs.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 50

served by the clinic. It would also assure that all necessary equipment would be
immediately available should a patient be brought to the clinic.
The institution’s Hospital Policy & Procedure No. C-14, which provides guidance for
assuring crash cart availability in the hospital’s emergency room, requires that crash carts
be fully equipped with emergency medical equipment, and that they be operational at all
times. The policy sets forth an inventory list of equipment and supplies and provides for
their security. The clinic does not comply with the policy and there is no alternative
policy applicable to the clinic.
Some equipment and supplies were not in ready-to-use condition. Two oxygen tanks
are kept in the clinic room where Officer Gonzalez was taken. Both tanks have the
required regulators, but only one has attached to it the handle or key necessary to activate
the flow of oxygen. There was a delay in providing Officer Gonzalez with oxygen at the
time of the incident because the only tank with the required key did not have the
necessary “tree” attached to the regulator to allow oxygen tubing to be attached. A
member of the clinic staff had to remove the tree from the tank that did not have a key,
and attach it to the tank that did have a key before oxygen could be provided to Officer
Gonzalez, costing valuable time in a critical situation. Clinic staff told the Office of the
Inspector General that an additional delay occurred when staff could not immediately
locate a face mask.
Missing equipment and supplies hampered treatment. Clinic medical staff had to
abandon efforts to establish intravenous access on Officer Gonzalez when they
discovered they did not have the required tubing with which to connect fluid to a catheter.
Establishing intravenous access in a trauma victim permits medical staff to infuse a
bleeding patient with replacement fluid and to establish a means of delivering
medications to that patient. Typical equipment needed to establish intravenous access
includes a catheter, an IV start kit, tubing, and fluid solution.
When the Office of the Inspector General inspected equipment and supplies almost a
month after the incident, endotracheal tubes were found in a case containing medications.
There was no stylet to assist in the intubation of a patient, or a syringe that could be used
to inflate the balloon cuff of the endotracheal tube following intubation. Clinic staff told
the Office of the Inspector General that a stylet and syringe were not available at the time
of Officer Gonzalez’ emergency.
At the time of the Office of the Inspector General’s inspection there was no device
present in the clinic that could be used to prevent an endotracheal tube from being
dislodged accidentally following intubation. The Office of the Inspector General’s postincident interviews with clinic staff have determined that the tube used on Officer
Gonzalez became dislodged at some point. The Office of the Inspector General did not
observe an esophageal detector device, suction device, or suction catheter with the airway
equipment during its inspections. Clinic staff told the Office of the Inspector General that
such equipment was not available at the time of the incident. The continued absence of
these supplies leaves the clinic unprepared should a similar medical emergency occur.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 51

Other equipment and supplies, though available, are inadequate. The emergency
supplies set aside in the clinic include a single 20-gauge catheter. A larger supply of
catheters is required to enable the clinic staff to establish IV access in patients during
medical emergencies. Catheters with a larger bore are also needed for trauma victims.
Medical professionals expecting to encounter emergency situations typically equip
themselves with a plentiful supply of fluids in large-volume bags, yet only a single 500ml bag (approximately 16 fluid ounces) of normal saline was in the clinic’s emergency
supplies at the time of the Office of the Inspector General’s tour.
The institution’s ambulance stationed at the institution hospital has large-volume bags of
normal saline, tubing and start kits, but is not stocked with catheters. Under these
circumstances, establishing IV access in a patient at the clinic will be delayed by the
necessity of waiting for an ambulance to deliver the additional supplies.
Some available equipment and supplies were not used. The Office of the Inspector
General’s interviews of clinic staff revealed that an end-tidal CO2 detector or measuring
device was available to provide capnometry or capnography10 during endotracheal
intubation, but was not used on Officer Gonzalez. Such a device assists in confirming
that the endotracheal tube has been properly placed and is being maintained while the
patient is being ventilated.
Though a pulse oximetry device to measure the level of oxygen in a patient’s blood was
available, it does not appear to have been utilized to determine that Officer Gonzalez was
being properly ventilated. A pulse oximeter can be used whether or not an artificial
airway is used and can be used regardless of the type of airway utilized.
Oropharyngeal airways11 were available to assist in maintaining a patient airway, in the
absence of an endotracheal intubation. The Office of the Inspector General’s interviews
of clinic staff found a substantial probability that staff did not successfully intubate
Officer Gonzalez with an endotracheal tube, and did not resort to use of an oropharangeal
airway after encountering problems with achieving proper intubation. Although available,
clinic staff did not administer cardiac medications to Officer Gonzalez because of their
inability to establish IV access and because they did not know such medications could be
administered through a properly placed endotracheal tube.
The very presence of such supplies at the clinic reflects the institution’s recognition that
their use can be reasonably anticipated. However, the fact that these supplies were not

Capnography is the continuous analysis and recording of carbon dioxide concentrations in air expelled
from the lungs. Although the terms capnography and capnometry are sometimes used synonymously,
capnometry suggests measurement or analysis alone without a continuous written record or graph.

Oropharangeal airways are used to maintain the airway in the unconscious patient during assisted
breathing, and do not extend deeply into the trachea (“windpipe”) as do endotracheal tubes.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 52

used suggests that staff is not properly trained in their use, which was confirmed through
the Office of the Inspector General’s interviews with clinic staff.
The clinic lacks standardized inventory control for emergency supplies and equipment.
Although such procedures exist for medications, there are no established inventory
control procedures for other emergency equipment and supplies at the clinic. The clinic
staff is not provided with a written list of supplies that must be included in the first-aid,
airway, and IV supplies cases. The Office of the Inspector General learned that even a
month after the incident, some of the supplies used on Officer Gonzalez still had not been
replaced, and during inspections conducted at that time, no bag valve mask or AMBU
bag were included with the emergency medical supplies. Clinic staff were confused as to
what supplies were used in treating Officer Gonzalez and just as confused about what
should typically be included among the clinic’s emergency medical equipment and
supplies.
The Office of the Inspector General’s inspections noted that the case containing airways,
intubation equipment, medications, and many other items was quite disorganized, with
most equipment and supplies placed haphazardly in the case, making it difficult for staff
to find a particular item rapidly during an emergency.
During the Office of the Inspector General’s first inspection of the airway equipment
case, there was no security seal on the outside of the case. On the following day, there
was a seal on the case, requiring someone from the pharmacy staff to break the seal for a
second inspection and reseal it afterwards. During a third inspection, this process was
repeated. None of these precautions were exhibited the first time the equipment case was
inspected.
Unless improved, the clinic’s current practices with respect to inventories will leave it
unprepared to address future emergencies. One of the clinic’s staff informed the Office of
the Inspector General that the clinic treats as many as 20 to 30 stab wounds per month.
The institution’s Hospital Policy & Procedure No. C-14 provides that crash carts be
available and operational in the hospital’s emergency room, fully equipped with
emergency medical equipment and supplies. The policy prescribes an inventory list of
equipment and supplies and provides for their security. While this policy does not
explicitly apply to the clinic, it can still serve as a valuable guideline until clinic-specific
policies are developed.
Regular inspections of supplies and equipment are not performed. The clinic’s medical
staff has no procedure requiring regular inspections of emergency equipment to ensure
that all necessary equipment is available and ready to use when needed. There is no
policy requiring re-stocking and replacement of missing and consumed materials when an
emergency is over.
While the institution’s Hospital Policy & Procedure No. C-14 requires that emergency
equipment and supplies in the hospital’s crash cart be audited at the beginning of each
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 53

shift, no such requirement exists for the clinic. As a result, missing or inoperable
equipment and supplies may not be discovered until needed during an actual emergency.
The absence of policies, training, and supervision in this area is demonstrated by the fact
that, at the time of the Office of the Inspector General’s review, items consumed in the
effort to save Officer Gonzalez had not been replaced, and items unavailable when
critically needed had not been added to the emergency supplies. Unless corrected, the
absence of a policy requiring regular inspections will contribute to the clinic being
unprepared for future emergencies.
Orientation of new clinic staff is inadequate. The Office of the Inspector General’s
interviews with clinic staff revealed that staff members are not adequately briefed on the
location of emergency equipment when first assigned to the clinic. Some staff members
believed the only key available to turn on the flow of oxygen is attached to one of the
tanks, while others thought the key is kept in a desk drawer. During interviews, a number
of staff members were unable to locate basic equipment, such as a bag valve mask,
AMBU bag, and airway adjuncts.
In addition to a lack of initial orientation, the institution does not conduct drills or offer
periodic in-service training in responding to emergency medical situations to clinic staff.
There is evidence that such training existed at one time — a written examination
administered to medical staff at the institution in May 2000 tested staff on their
knowledge of emergency drills at the institution. The Office of the Inspector General’s
interviews of clinic staff disclosed confusion and a lack of uniform understanding as to
the extent and type of emergency medical services that clinic staff should provide. For
example, some of the clinic staff believe it appropriate for them to administer
medications to a patient experiencing cardiac arrest, while others believe such
medications should be administered at the institution’s hospital or by paramedics
responding from outside the facility. The clinic staff members are unaware of any
guidelines providing clarity or guidance on this issue. Without proper training, the
clinic’s staff cannot be expected to perform adequately during an emergency.
Lack of specialized training in emergency medicine. The institution does not conduct or
otherwise provide sufficient specialized training in emergency medicine for its medical
staff. All medical staff who assisted in the attempt to save Officer Gonzalez’ life held the
appropriate professional licenses. Those requiring certification in cardiopulmonary
resuscitation (CPR) were currently certified.12
The institution does not currently require that any of its clinic personnel maintain
certification in advanced cardiovascular life support. Medical staff interviewed by the
Office of the Inspector General stated that advanced cardiovascular life support
certification was required for emergency room employees in the past, but that the
institution no longer imposes such a requirement. One member of the clinic staff told the

Physicians are not required to be certified in CPR.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 54

Office of the Inspector General that he had not received any “code blue” training in eight
years.
Both physicians present when Officer Gonzalez was brought to the clinic knew that
epinephrine, atropine, and lidocaine could benefit a patient experiencing cardiac arrest.
But the lack of advanced cardiovascular life support training and certification may
explain why one physician did not know, while the other would not state, that
epinephrine, atropine, and lidocaine could all be administered through a properly placed
endotracheal tube after intubation. These medications and others are included in the case
containing the endotracheal tubes and IV fluid. One of these physicians also works shifts
in the institution hospital’s emergency room where the protocols refer to the use of such
medications. The Office of the Inspector General determined during interviews with these
physicians that neither has received any specialized training or certification in emergency
medicine, although one has continuing education credits in heart failure and coronary
syndromes as recently as December 2002. One of the physicians advised the Office of the
Inspector General that he had not worked in an emergency room in approximately 25
years, and the other said that the only emergency medical experience he has comes from
working shifts in the institution’s emergency room.
As an example of the confusion among clinic staff members as to procedures, a nurse
with significant administrative responsibilities initially told the Office of the Inspector
General that there were no cardiac medications in the clinic’s supplies. This nurse later
said the medications were intended for use in responding to emergencies involving
inmates, but 911 is to be called for medical emergencies involving employees. Still later,
this nurse said that use of these medications is to be directed by the physicians.
Clinic staff do not routinely perform some of the skills associated with providing
emergency medical services. Intubation is one example. One of the physicians told the
Office of the Inspector General that staff members are required to train or demonstrate
ability to perform oral intubations on a mannequin every six months, but the institution
could not produce evidence of such a practice, nor could other clinic staff members recall
such a practice. The nurse who claims to have intubated Officer Gonzalez told the Office
of the Inspector General that such periodic training is not required.
The lack of specific training in emergency procedures, supplemented by periodic
refresher courses, can result in the delivery of inadequate care during future emergency
situations.
Insufficient direction and leadership during the emergency. Several of the Office of the
Inspector General’s interviews with clinic staff revealed that at least two physicians were
present when Officer Gonzalez arrived in the clinic. Some clinic staff stated that
physicians failed to provide substantial assistance, direction, and leadership during the
attempts to save the officer’s life. Interviews of the two physicians reveal they have little,
if any, significant training and no substantial experience in dealing with significant
medical emergencies.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 55

Without at least one medical staff member providing directions acknowledged by the rest
of the staff, there can be a lack of focus and coordination in delivering emergency
medical services.
The institution’s Hospital Policy & Procedure C-11 states that the Medical Officer of the
Day or other physicians working in the hospital are to direct the medical care team when
a “code blue” is called in response to a patient who is not breathing or has no pulse. The
fact that this policy statement is directed to hospital operations does not diminish its value
in providing guidance to clinic procedures in the absence of policies specific to that area.
Inadequate documentation of events during the emergency. Clinic staff members
involved in treating Officer Gonzalez prepared incident reports on California Department
of Corrections Form 837 as required. These reports are the only written documentation of
emergency medical care that clinic staff prepared, and are inadequate in describing the
assessment, care and treatment of Officer Gonzalez.
Based on interviews with the Office of the Inspector General, some clinic staff indicated
the belief that standard medical charting is not required for emergency medical treatment
provided at the clinic, while others believe that such charting is required only if
emergency treatment is provided to inmates.
The institution’s Hospital Policy & Procedure No. C-11 includes by reference a
“Cardiopulmonary Resuscitation Form” that must be completed during treatment of a
patient experiencing cessation of breathing or pulse. The form requires that hospital staff
record pertinent information concerning medical assessment and care, as well as the
patient’s response to treatment. The clinic staff created no such record concerning Officer
Gonzalez.
Additional policies and procedures directly requiring, or indirectly referring to, charting
or other documentation of medical care provided in the hospital include Hospital Policy
and Procedures A-10, C-5, C-6, C-15, and E-10. These policies and procedures require
charting as a means of avoiding errors and to aid in diagnosis, treatment, and care of both
inmates and employees. Clinic staff complied with none of these policies and procedures
in connection with Officer Gonzalez.
Proper documentation minimizes or eliminates ambiguity about what occurred, and who
performed particular procedures. Proper charting has the added advantage of providing
evidence that appropriate medical care was provided and further assists by improving
future medical care and in managing risk.
In contrast with the documentation produced by the institution’s clinic staff, the fire and
ambulance paramedics did a much more thorough job of providing medical
documentation on their standardized patient care reports.
As a result of the clinic staff’s failure to document the incident adequately, there remain
discrepancies in critical details of Officer Gonzalez’ treatment:
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 56

•

The fire paramedics defibrillated Officer Gonzalez shortly after their arrival because
he was experiencing ventricular fibrillation. If clinic staff had pressed the “analyze”
control on the automated external defibrillator that they attached earlier to Officer
Gonzalez, the device would have recognized such a heart rhythm and recommended
defibrillation. However, because clinic staff did not maintain charts of the incident
there is no way to tell precisely how long Officer Gonzalez was attached to the
clinic’s automated external defibrillator or how frequently someone activated the
“analyze” control. Further, there is no way to tell how long Officer Gonzalez had a
heart rhythm in need of defibrillation prior to the fire paramedics’ arrival.

•

Though the 837 reports record clinic staff’s attempt to establish an intravenous line,
there is no mention as to whether the attempt was successful. The Office of the
Inspector General learned only during subsequent interviews with clinic staff that the
attempt to establish an intravenous line was unsuccessful because supplies to
accomplish the task were inadequate. The critical missing item was the tubing for
connecting the catheter to fluids. None of the clinic staff’s 837 reports mention the
reason an intravenous line could not be established. The necessary intravenous line
tubing had still not been added to the intravenous line supplies and other emergency
equipment at the clinic a month after the problem was first encountered.

•

The Office of the Inspector General’s examination of the 837 reports revealed
significant discrepancies in identifying the type of airway used in attempting to
ventilate Officer Gonzalez. One registered nurse wrote in his 837 report that he “was
able to insert the trach tube.” His oral statement indicated the tube had a balloon cuff.
Another nurse wrote in her 837 report that she advised fire paramedics that Officer
Gonzalez needed to be re-intubated, suggesting that the clinic staff’s attempts at this
procedure were unsuccessful or that the tube had been dislodged while the patient
was being moved. The same nurse was clear in stating that she handed a packaged
endotracheal tube, equipped with a balloon cuff, to the physicians.
One of these physicians told the Office of the Inspector General he intubated the
patient with an endotracheal tube about six inches long having no balloon cuff, and
that he does not know what an oropharyngeal airway is.13
Two of the medical technical assistants (MTA’s) directly involved in providing care
to Officer Gonzalez stated during their interviews that an endotracheal tube was not
used, but that an oropharyngeal airway was. When shown an oropharyngeal airway
the same MTA told the Office of the Inspector General that it did not look like the
airway used on Officer Gonzalez. Another of the MTA’s described an airway to

The difference between an oropharyngeal airway and an endotracheal tube is significant. The
oropharyngeal airway, when properly sized, does not extend past the pharynx when inserted and is rather
easily inserted in an unresponsive patient with an absent gag reflex. In contrast, the endotracheal tube is
actually inserted in the trachea with great care given to avoid placing it in the esophagus.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 57

which the AMBU bag was attached after insertion. However, there is nothing on an
oropharyngeal airway to which an AMBU bag can be attached.
•

Only one of the 837 reports suggests any sort of problem with the airway, recording
that paramedics were advised of a need to re-intubate Officer Gonzalez. Interviews
of clinic staff by the Office of the Inspector General a month later disclosed the
airway used on Officer Gonzalez became dislodged at some point. There is no written
record as to when or how the airway became dislodged, how long staff took to
recognize the airway was dislodged, or how long, if at all, effective ventilation was
provided.14 In fact, there is insufficient evidence to conclude the airway was properly
placed.

•

There is no documentation discussing the adequacy of the ventilation provided at any
time. Interviews of some clinic staff indicate that Officer Gonzalez’ chest was
observed to rise and fall after intubation and ventilation, which if true suggests
tracheal and not esophageal placement of the endotracheal tube. However, the nurse
who claims to have performed the intubation said there was no rise and fall of the
chest following intubation. There is no written documentation describing Officer
Gonzalez’ response to ventilation. In addition, clinic staff have offered no testimony,
oral or written, regarding any definitive primary or secondary assessments verifying
that the endotracheal tube was properly placed in the trachea as opposed to the
esophagus. The “Cardiopulmonary Resuscitation Form” used in the California
Institution for Men Hospital, but apparently not used at the clinic, calls for such
information.

The clinic staff’s collective omission of these critical details from official written reports
deprives management and staff alike of the ability to conduct an objective critique of the
handling of Officer Gonzalez’ emergency.
No staff debriefing or incident critique conducted. The medical staff was appropriately
offered stress debriefing for psychological benefit following the incident. However, there
was no attempt to evaluate or debrief the handling of the medical emergency or the
adequacy of available equipment and supplies. Some clinic staff indicated in interviews
with the Office of the Inspector General that they desired to speak with someone about
what had actually happened, because they felt there had been problems and they wanted
to contribute to better preparation in the future. Specific incident debriefing is an essential
part of quality improvement.
The institution’s Hospital Policy & Procedure No. C-11 requires that a hospital nursing
supervisor or lead nurse prepare a written critique after medical services have been
provided to a patient experiencing a cessation of breathing or pulse. Several items on that
14

If an endotracheal tube was actually used, there are no incident reports mentioning whether someone
attempted to secure it, even with nothing more than tape, to guard against dislodging. Subsequent
interviews, however, revealed there was no attempt to secure the endotracheal tube before lifting the officer
to a gurney and wheeling him out of the building.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 58

critique form would apply in this case. For example, one of the questions addresses
whether the crash cart was adequately stocked. It appears, however, that clinic staff
believe this policy was never intended to apply outside of the hospital.
Hospital Policy & Procedure No. Q-1 describes a quality assurance program.15 Its
purpose is to systematically monitor and evaluate the quality and appropriateness of
nursing care, pursue opportunities to improve nursing care and clinical performance and
resolve problems. No such policy and procedure is in place for the clinic, however. One
of the questions on a test administered by the institution in May 2000 indicates that all
emergency medical responses involving an ambulance shall be reviewed monthly to
identify procedural or training issues requiring correction. The institution made no
apparent attempt to review the quality of the care provided to Officer Gonzalez until the
Office of the Inspector General’s inquiry was initiated.
Key members of the clinic staff provided conflicting information about critical details.
One of the nurses reported in his 837 report that he personally intubated Officer
Gonzalez, and further confirmed this during an interview with the Office of the Inspector
General. The nurse’s written 837 report that he inserted a “trach tube” into the patient is
corroborated by testimony of the other medical staff present during the event, except for
one of the physicians who claims that he, and not the nurse, intubated Officer Gonzalez.
This physician who claims to have intubated Officer Gonzalez told the Office of the
Inspector General he personally listened to Officer Gonzalez’ heart and lung sounds
when the officer was first brought to the clinic and that both were absent. However, one
of the MTA’s in the clinic during the incident reports that Officer Gonzalez’ carotid pulse
was initially palpable and the chest was seen rising and falling before clinic staff initiated
ventilation. At least one member of the clinic staff told the Office of the Inspector
General that the physician who claims to have attempted to listen to heart and lung
sounds simply opened the officer’s uniform and walked away.
The physician claiming to have intubated Officer Gonzalez told the Office of the
Inspector General the following:
•

He was unable to identify by name the instrument normally used to assist in the
intubation of patients.

•

He performed a blind intubation without the assistance of a light source. The Office
of the Inspector General observed two fully functional disposable laryngoscopes16
inside the case containing a small supply of endotracheal tubes.

•

He could not and did not confirm that the endotracheal tube was in the trachea.

Many health care providers have moved to a quality improvement program instead of a quality assurance
program.
16
This instrument permits visual confirmation that the endotracheal tube been inserted through the vocal
cords and into the trachea and not into the esophagus.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 59

•

A pulse oximeter was not used and that he does not know what an end-tidal CO2
monitor is. This physician was not familiar with the terms capnometry or
capnography.

•

The only way to secure an endotracheal tube after intubation is to either hold the tube
in place with the fingers or to inflate the balloon cuff at the distal end of the tube to
hold the tube against the interior wall of the trachea. Neither is an adequately reliable
method of securing a tracheal tube. The physician confirmed that the endotracheal
tube he used did not have a balloon cuff. All of the other endotracheal tubes seen by
the Office of the Inspector General on subsequent inspections at the clinic have
inflatable balloon cuffs. Typically, only endotracheal tubes for infants and small
children have no inflatable balloon cuffs.

•

He held the tracheal tube in place with his fingers but could not explain how or when
the endotracheal tube became dislodged.

•

There was no stylet present among the supplies, or if there was, that he did not see it.
He also said there is no suction device available at the clinic and further stated that he
did not know how suction might be needed during an intubation procedure.17

•

He did not know what an oropharyngeal airway was, insisted that the carina18 was the
portion of the anatomy separating the esophagus from the trachea, and was unfamiliar
with the Glasgow Coma Scale; terms commonly known to those familiar with
performing intubations.

•

He personally saw on the small screen of the automated external defibrillator/cardiac
monitor four or five ECG waves that changed to a straight line, indicating Officer
Gonzalez’ heart rhythm was asystole (cardiac standstill). The physician said he
administered no cardiac medications, and that the four or five ECG waves he
observed were insufficient for him to determine the exact type of heart rhythm before
he recognized Officer Gonzalez was asystole.

Nonetheless, this same physician wrote an 837 report failing to mention his having
intubated the patient, the method used to provide an airway, how placement of the
endotracheal tube was confirmed, and that he read and assessed ECG waves on a cardiac
monitor while Officer Gonzalez was in the clinic. This physician’s 837 report further
describes that he issued various orders to other medical personnel.
The policies and protocols governing emergency medical procedures lack coordination.
The policies and protocols governing emergency medical procedures create confusion
among staff because they lack coordination. The California Institution for Men has three
17

Suction is necessary to remove blood and other liquids that can block visual inspection of endotracheal
tube placement, or that may be aspirated into the patient’s lungs.
18
The carina trachaea is a projection of the lowest tracheal cartilage, forming a prominent semi lunar ridge
running antero posteriously between the openings of the two bronchi. The carina trachaea is below the
portion of the anatomy separating the esophagus from the trachaea.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 60

separate sets of health care protocols. The first are policies and procedures for the
medical/surgical unit of its hospital. The second are the hospital’s emergency medical
policies and procedures. The third are policies and procedures intended only for the
clinic and are outpatient protocols concerning the care to be provided inmates.
While the institution’s emergency operations plan contains a resource supplement19
concerning emergency medical treatment, it applies only in the event of a major
disturbance and provides guidance for transporting those injured in such disturbances
without providing specific treatment protocols. The institution has no written policies
and procedures for providing emergency medical care to its employees outside of its
hospital.
There are no emergency medical care protocols available to the staff in the clinic. While
there are medical protocols located in the institution’s hospital, these do not specifically
and comprehensively address emergency care to be provided by clinic staff. Some clinic
staff believe the hospital protocols do not apply to the clinic, while others do not know
whether they apply.
The institution’s general practice is to call a private ambulance company to transport
seriously ill or injured employees to an outside medical facility. This is the written policy
to be applied during a major disturbance. In contrast, inmates experiencing a medical
emergency are usually transported by the facility ambulance to the institution’s hospital.
These policies do not preclude employees from being taken to the institution’s hospital or
inmates from being transported to outside hospitals.
The same equipment and staff assigned to provide first-response emergency medical
services to inmates at the clinic are the same that would be used for employees
experiencing an emergency. Neither inmates nor employees will be well served by the
state of emergency-preparedness that the Office of the Inspector General observed at the
institution’s clinic.
Information in the institution’s emergency operations procedures is incorrect. The
institution’s emergency operations procedures list a phone number to an ambulance
substation in Chino to contact for emergency medical transportation off institution
grounds, but that phone number is no longer in service. The 800 central dispatch number
for the ambulance company, however, is valid. Fortunately the clinic staff simply called
911 when seeking assistance for Officer Gonzalez, activating a response by not only
American Medical Response, but Chino Valley Fire whose number is not listed in the
procedures.
The emergency procedures identify a list of hospitals as providers of emergency medical
services, but Loma Linda University Medical Center, the only Level I trauma center in
the region, is not listed.

Resource Supplement Number 17, Providing Emergency Medical Treatment for All Staff and Inmates.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 61

Employees and inmates at the institution’s central unit are isolated from the traditional
911 community for obvious safety and security reasons. They are also isolated, to some
extent, from the services of the facility’s ambulance and hospital emergency room,
further underscoring the need to plan and prepare clinic staff for medical emergencies in
the clinic or at other locations. That planning and preparation is inadequate at this time.
RECOMMENDATIONS
While the primary function of the reception center’s clinic is to perform
inmate medical evaluations, it is also common for clinic staff to provide
emergency medical care, and specialized equipment and supplies have been
provided to it for that purpose. Indeed, the very environment of the
institution provides strong reason for it to be properly prepared to respond
to medical emergencies since other alternatives may be delayed or
inaccessible due to security concerns.
Accordingly, the Office of the Inspector General recommends that the
California Institution for Men take the following actions with respect to its
central reception center clinic:
•

Develop comprehensive procedures specific to the clinic that focus on
delivery of emergency medical services.

•

Assess the clinic’s needs with respect to emergency medical supplies and
equipment and assure that the clinic is adequately stocked with them.
The chief medical officer should institute a practice of conducting regular
inventories and inspections of these supplies and restock those that have
been consumed or lost to spoilage or obsolescence.

•

Ensure that the emergency supplies are ready to use and are immediately
accessible. A crash cart would address this purpose within the clinic, and
could also be easily taken to any emergency in the facility served by the
clinic.

•

Provide specialized training in emergency medical procedures for clinic
staff and other employees as appropriate. This may include courses
leading to advanced cardiovascular life support certification. Further,
management should conduct regular emergency drills for clinic staff.
Management should provide additional training in medical charting and
proper documentation of emergency medical incidents.

•

The insitution’s medical staff should engage in thorough debriefing
following incidents of medical emergencies. California Evidence Code,
section 1157 encourages a frank evaluation of quality of care issues by
prohibiting discovery of such information. The California Institution for
Men should take full advantage of this statute by engaging in candid and

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 62

complete self-assessments after significant medical events, whether
involving inmates or employees.
•

The institution should consider retaining the services of a consultant in
emergency medicine to provide a comprehensive review of its policies,
protocols, procedures, staffing, training, quality assurance/improvement
program, supply and equipment requirements and to provide guidance
on implementing improvements. The consultant should be
knowledgeable and experienced in establishing and maintaining
emergency medical clinics outside of a traditional hospital setting.

In addition, the Department of Corrections should review the emergency
preparedness of its other institutions to ensure that the deficiencies found at
the California Institution for Men do not exist elsewhere.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 63

FINDING 7
The Office of the Inspector General found that the management of the California
Institution for Men did not set up an Emergency Operations Center or institute an
Emergency Operations Plan in the wake of Officer Gonzalez’ stabbing due to
ambiguous protocols. As a result, there was some confusion in the chain of
command, emergency operations policies were not implemented, the crime scene
was destroyed, and an incident log was not initiated.
The California Department of Corrections Operations Manual governs appropriate
responses to disturbances at an institution, while individual institutions’ own Emergency
Operations Procedures address ancillary policies unique to each institution. However,
these documents do not specifically address whether an Emergency Operations Center
should be set up or an Emergency Operations Plan implemented following an assault on
an officer resulting in serious injury or death. In the wake of the attack on Officer
Gonzalez, the institution’s management neither set up an Emergency Operations Center
nor implemented an Emergency Operations Plan. As a result, there was some confusion
in the chain of command that led to institutional staff’s failure to follow critical
emergency operations policies, destruction of the crime scene, and a failure to record
events in an incident log. Despite these shortcomings, correctional officers were able to
transport the wounded officer to a medical care facility quickly, effectively regain control
of the housing unit, and take the suspect into custody without further serious injury to
inmates or staff.
Emergency response procedures in Sycamore Hall. Sycamore Hall is located in
Reception Center Central, one of four facilities at the institution. While all correctional
officers with radios use the same frequency there, Reception Center Central Control
personnel scan all institutional radio frequencies for emergency situations. Reception
Center Central Control also maintains and dispenses personal alarms for officers on duty,
as well as protective equipment and less-than-lethal weapons for Code 2 emergency
responders. Alarm response drills are conducted monthly. There are an estimated 20 to
25 Code 1 alarms weekly on Sycamore Hall, 15 of which are potentially dangerous
situations to staff or inmates. There are approximately five Code 2 alarms weekly
(requiring the need for additional officers or ballistic impact weapons) and one Code 3
alarm every two months (requiring officers to respond from all parts of the institution).
When a correctional officer activates a personal alarm, an audible and visible emergency
signal activates in the main corridor outside that officer’s unit. The activation of either a
personal alarm or a telephonic alarm triggers an automatic entry on the computer log at
Reception Center Central Control. No log entries of other communications are made and
radio traffic is not recorded.
Response to attack on Officer Gonzalez. Four correctional officers were responsible for
supervision and escort of the 213 inmates housed in Sycamore Hall on January 10, 2005,
the date of the incident. Two officers were in the first tier guard space of Sycamore Hall
at the time, while a third was just outside the tier. The assault occurred on the west side
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 64

of Sycamore Hall’s first tier, approximately 15 feet from the grill gate separating the
guard space from the tier.
Immediately after the assault, Officer Gonzalez made his way into the guard space with
the aid of a fellow officer and collapsed. The gate to the tier was then closed and one
officer activated his personal alarm while another gained control of several inmates who
were in the guard space awaiting medical appointments.
Code 1 responders from Madrone Hall were the first to arrive. One of those officers
broadcast an “officer down” call, and with the assistance of three other officers, carried
Officer Gonzalez to the medical clinic. Additional Code 1 responders from Reception
Center Central East moved down the central corridor and were directed to Sycamore Hall
by Reception Center Central Control, where they formed a skirmish line in the guard
space at the gate.
The facility lieutenant at Reception Center Central assumed responsibility as incident
commander and immediately radioed for a Code 2 response. The designated Code 2
responders proceeded to Sycamore Hall equipped with 37 mm and 40 mm launchers.
Reports estimate that as many as 25 correctional officers assembled in the tier 1 guard
space and that five or six officers assembled in the tier 2 guard space in front of the gate.
Before senior command staff arrived, the situation in the tier 1 guard space was described
by witnesses as “pandemonium.” Eventually, two facility captains arrived and took
control. A lieutenant (not the incident commander) then returned to Reception Center
Central Control and called for a Code 3 response, which was transmitted to all other
facilities in the institution. In another building adjacent to the front gate, the security
administration building lieutenant heard the initial radio traffic. Under the Emergency
Operations Plan, that lieutenant would have been the interim emergency commander.
Acting independently and without contact from the incident commander on scene, that
lieutenant had already initiated a Code 3 response by telephone. By the time Code 3
responders arrived at Sycamore Hall, the three inmates who had been at large were in
custody, so the Code 3 responders were assigned various search and coverage tasks until
ordered to stand down.
At the time of the stabbing, the warden and her executive staff were meeting in another
building in the institution. After being notified, the warden and her staff moved quickly to
Reception Center Central, arriving as Officer Gonzalez was being carried into the
medical clinic. The warden never declared herself the emergency commander, nor did she
receive a debriefing from the acting emergency commander. The warden did assign
facility captains to supervise the apprehension of inmates still at large on the tier. The
warden then remained on site at Reception Center Central to deal with issues arising from
the assault on Officer Gonzalez, sent her chief deputy warden to follow the ambulance to
the hospital, and assigned an associate warden to run the routine affairs of the institution.
Once the inmates were restrained and escorted out of Sycamore Hall, the incident
commander conducted a briefing for all responders and ordered a search of the inmates
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 65

and formation of teams to search all the cells on the west side of Sycamore Hall. After the
search was complete, the incident commander declared the incident over.
Emergency Operations Center and Emergency Operations Plan are not specifically
required. Following an inmate attack on an officer, establishing an Emergency
Operations Center and implementing the Emergency Operations Procedures is not
specifically required by the California Department of Corrections Operations Manual.
The language of the California Department of Corrections Operations Manual
establishes the conditions under which the Emergency Operations Plan is to be applied.
The Department of Corrections Operations Manual states that the Emergency Operations
Plan is to be implemented “in the event of an inmate initiated disturbance which
significantly disrupts routine institutional operations or programs [section 55010.3,
emphasis added].”
Department training materials distinguish between an “incident,” defined as an isolated
event, and a “disturbance,” defined as an event that disrupts normal institutional
operations. While an “incident” will not trigger the application of the Emergency
Operations Plan, a “disturbance” will.
Unquestionably, institutional operations were disrupted when Officer Gonzalez was
stabbed. As a result of events on Sycamore Hall’s west side, responders throughout the
institution were called to the scene, and the whole institution was placed on lock down.
The command staff, however, told the Office of the Inspector General that they regarded
the events of January 10, 2005 as an “incident,” rather than a “disturbance.” In various
interviews, they pointed out that the disruption of institutional operations following the
stabbing arose strictly as a result of the administration’s response to the incident, rather
than from the incident itself.
Institutional staff interviewed by the Office of the Inspector General further suggested the
Emergency Operations Procedures were never intended to apply to a one-on-one assault
because the disturbances mentioned in the introductory language of the California
Department of Corrections Operations Manual “include, but are not limited to, general
riots, sit-down or hunger strikes, large scale demonstrations, taking of hostages, multiple
attacks on persons, or attempts by inmates to incite others to participate in any of the
aforementioned actions” (California Department of Corrections Operations Manual,
section 55010.3). Staff further noted that the resource supplements likewise address
concerns of a more global or large-scale nature, such as widespread rioting, a major
escape, or a natural disaster. A third reason staff gave for not applying the Emergency
Operations Procedures is that the stabbing was a unique, critical situation demanding a
rapid response that would have been impeded by establishment of centralized authority in
the form of a command center.
In sum, the California Department of Corrections Operations Manual does not provide
clear-cut guidance defining an attack on an officer resulting in serious injury or death as
an occasion triggering implementation of the Emergency Operations Procedures.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 66

Emergency Operations Procedures could have improved the response. If the institution
had implemented Emergency Operations Procedures, its response to the assault on
Officer Gonzalez would have been improved. The principal advantages of following the
procedures are: (1) it establishes a clear chain of command in situations where the usual
chain of command may become confused; (2) it facilitates communication with outside
agencies by requiring activation of an Emergency Operations Center; (3) it clearly
establishes procedures to be followed, including evidence and crime scene preservation,
and provides checklists; and (4) it requires the creation of an incident log, which is
valuable in recreating events and as a training tool.
If the Emergency Operations Procedures are triggered, they provide the chain-ofcommand for handling the emergency. The EOP provide that the lieutenant who is the
on-duty watch commander at the security administration building is the interim
emergency commander and that the warden is the emergency commander.
Following the stabbing of Officer Gonzalez, the facility lieutenant at Sycamore Hall
assumed control of the scene as the incident commander. Perhaps as many as 25
correctional officers crowded into the guard space on the first tier of Sycamore Hall,
where eight inmates were on the floor and the air was contaminated with pepper spray.20
The area was also a crime scene. Numerous impact munitions were fired down the tier
without result. The incident commander attempted to transmit cease-fire orders to the
upper tiers by messenger, rather than by radio. As noted above, before senior command
staff arrived, the situation in the tier 1 guard space was described as “pandemonium.21”
The situation calmed down after senior officers arrived, effective cease-fire orders were
given, and inmates who were at large soon submitted to custody.
In the course of the Office of the Inspector General’s inquiry, executive staff frequently
responded that the nature of the command response was justified by the uniqueness of the
incident and its unforeseen nature. An EOP’s purpose is to prepare in advance for, and to
provide structure and guidance during, unpredictable incidents. Sections of the
Emergency Operations Procedures addressing a number of concerns arising following the
stabbing of Officer Gonzalez should have been consulted. For example, the Emergency
Operations Procedures sets forth a notification grid (Resource Supplement Number 1);
the emergency chain of command (Resource Supplement Number 2); procedures for
securing an emergency area (Resource Supplement Number 8); procedures for
20

Pepper spray is authorized for use inside CIM housing units. (Resource Supplement 9, at 9-16.)

The breakdown of the chain of command was exacerbated because on-site responders and control
elements were all monitoring the same open radio frequency and undertook to operate independently. As
many as 25 responders gathered in the first tier guard space. This disorder likely contributed to the IC’s
decision to relay cease-fire orders to Code 2 responders on the upper tiers by sending a messenger through
the locked staircase. Not only does the institution not have facility-targeted communications, it does not
have the means of recording radio traffic in emergencies, or at any time. Today, even relatively small
organizations have found it economical to acquire “trunking” radio systems. Such systems provide for a
master radio channel, but still allow users to be assigned to one or more “talk groups,” providing targeted
communications. All radio traffic can be recorded on such a system. Some system vendors offer methods
of indexing, time-stamping, and archiving communications.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 67

establishing an Emergency Operation Center (Resource Supplement Number 15 of the
Emergency Operation Procedures, which states that “effective control of a major
disturbance/emergency situation requires the activation of an Emergency Operation
Center (EOC)”); procedures for conducting mass searches (Resource Supplement
Number 24); procedures for crime scene preservation and preservation of evidence
(Resource Supplement Number 28); and procedures for incident reporting (Resource
Supplement Number 30).
When command staff arrived on scene, according to one senior officer, a cease-fire was
ordered, control was established, and the developing situation was “slowed down.”
Instructions to surrender were communicated to the three inmates at large on the tier and
they complied. Had procedures provided in the EOP been followed, fewer Code 1
responders would have gathered in the Sycamore Hall tier 1 guard space, communication
with Code 2 responders in the upper tiers would likely have been more effective, senior
staff could have promptly exerted control, and the situation may have been brought under
control sooner and more effectively.
The Emergency Operation Procedures further provide specific instructions regarding
summoning and coordinating mutual aid (Resource Supplement Numbers 5, 6 and 19).
The plan provides that the Emergency Operations Center shall have a mutual aid liaison
and an institution operations administrator, whose duties include summoning local law
enforcement and summoning emergency medical services and coordinating transportation
of injured staff to outside medical facilities. The Emergency Operations Center and the
mutual aid liaison would have provided clear points of contact for outside agencies. The
procedures require that outside agencies be contacted, even if they are not summoned.
Had senior staff, operating through an EOC, elected to become involved in evidence
collection and crime scene preservation, or if the required notifications had been made,
the San Bernardino County Sheriff’s Department could have been notified immediately,
the crime scene preserved to the extent possible and evidence collected in a systematic
manner.
In this instance, the warden assigned senior officers to assemble an extraction team.
After the situation on Sycamore Hall was contained, those officers focused on the
security and transportation of the three inmates involved. On Sycamore Hall, the incident
commander ordered comprehensive inmate body and cell searches. As described fully in
Finding 8 of this report, those searches destroyed the immediate crime scene and
disrupted the chain of evidence.
Implementation of the Emergency Operations Procedures concerning crime scene and
evidence preservation would have made a dramatic difference. The scene could have
been subjected to less contamination and destruction; the evidence recovered could have
been collected in an efficient and systematic manner; and evidence of any forensic value
could have been clearly identified. Following those procedures could have made it more
likely that the murder weapon, Blaylock’s clothing, and the clothing of the other inmates
on the tier would have been identified and recovered.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 68

These problems would have been minimized had staff consulted Resource Supplement
Number 28, which makes it a priority for first responders “to preserve evidence and to
protect the crime scene from destruction or contamination” (subsection A). Among
other things, Resource Supplement 28 also requires the first custody supervisor on scene
to remove all but essential and authorized persons from the scene and to designate a staff
member to note and record all persons entering the scene (subsection A.2.c.); record the
crime scene by photographing the entire area, including any and all evidence, using
distance and close up photos of each item to show spatial relationships within the crime
scene (subsection A.2.e.); measure the placement of all evidence from fixed standard
points (subsection A.2.f.); and to designate no more than two officers to collect all
evidence systematically (subsection A.3.b.1.). Resource Supplement 28 is so specific as
to instruct evidence collectors to enter the scene from the left side and collect all evidence
by moving clockwise around the area (subsection A.3.a.).
A type of log was created at the incident commander’s direction. However, that log
recorded only minimal information. The Security Administration Building watch
commander also regularly keeps a log. Literally dozens of reports were written by
officers and non-sworn staff within a day of the incident. Yet even after analyzing those
logs and the reports of various investigators who followed, the Office of the Inspector
General discovered it difficult to determine definitively what information was gathered or
broadcast, who responded, when they arrived on scene, what orders were given and
when, and who was notified of the incident. All such information should have been
recorded in an incident log, a form for which is provided in the resource supplements.
Neither that form, nor any of the accompanying checklists, was used.
Incidents such as the one involving Officer Gonzalez are rare and unpredictable. The
information that should have been collected in an incident log would have been valuable
in developing policies and training curricula to address future situations.
To their credit, emergency responders efficiently accomplished their primary mission.
The situation on Sycamore Hall was contained and controlled safely for both officers and
inmates. Notwithstanding the highly emotional circumstances, officers did not enter the
tiers, use of force was within policy and legal limits, and Officer Gonzalez was promptly
evacuated. However, because centralized control was never effectively established,
actions were taken that had the potential to adversely affect the criminal prosecution or
the liability of the institution.
RECOMMENDATIONS
The Office of the Inspector General recommends that the Department of
Corrections take the following actions:
•

Reinforce with institutional executive staff the intent, objective, and
purpose of implementing the Emergency Operations Plan when an
inmate initiated disturbance significantly disrupts routine institutional
operations or programs.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 69

•

Update section 55010 of the California Department of Corrections
Operations Manual so that it (1) clarifies ambiguities such as the
circumstances under which the Emergency Operations Plan should be
implemented, and (2) incorporates changes in technology that have
occurred since the manual’s last revision in 1989.

In addition, the Office of the Inspector General recommends that the
California Institution for Men reinforce, through training, the responsibility
of supervisors and management to direct employees to provide leadership
and direction in the face of emotionally devastating situations such as a staff
murder to ensure that all objectives specified under the Emergency
Operations Procedures are met. These objectives include, but are not limited
to, consideration of crime scene preservation and evidence collection to
enhance potential criminal prosecutions.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 70

FINDING 8
The Office of the Inspector General found that the California Institution for Men
did not implement important emergency procedures in response to the incident,
leading to contamination of the crime scene and the loss of important evidence.
As referenced in Finding 7, California Institution for Men staff failed to preserve the
crime scene and physical evidence, including the clothing worn by Officer Gonzalez’
alleged assailant. As a result, potentially important corroborative evidence, such as
forensic evidence potentially linking the assailant and the victim was lost. As such, the
State’s case against inmate Blaylock must rely more heavily on eyewitness accounts than
otherwise necessary. Institution staff did not follow established procedures for preserving
crime scenes and physical evidence because some were traumatized by the assault and
failed to do their duties, Investigative Services Unit officers lacked adequate training and
experience, and there was inadequate command and control over the incident.
Specifically, the warden did not implement the prison’s Emergency Operations
Procedures. Because these procedures provide detailed steps and checklists for myriad
tasks including crime scene and evidence preservation, implementing them may have
facilitated a more structured, systematic response by the institution.
Responsibility for crime scene preservation begins with the first responding officer who
arrives at a scene where a crime may have been committed. Once the first responder
identifies that the severity of the crime and/or the need for a crime scene investigation
exists, that officer must preserve the scene so that physical evidence at the scene is not
moved, destroyed, or otherwise contaminated by the subsequent intrusion of other parties.
This can be accomplished by numerous means, including using crime scene tape,
barriers, or other means to isolate the area. Physical evidence is any and all physical
objects or recorded observations and measurements of events, which may aid
investigators or a court in reaching a conclusion about the crime. In a stabbing, the crime
scene may contain physical evidence such as blood on the floor or elsewhere that can be
used in forensic testing to link the DNA of the victim to the assailant. This is especially
significant when both the victim and suspect are bleeding. Other physical evidence may
include the stabbing instrument or the clothing of a suspect or the victim, which may
yield fingerprints, the blood of the victim and/or the assailant, transferred clothing fibers,
and other items capable of being analyzed forensically.
The Department of Corrections recognizes the importance of crime scene preservation by
making it a four-hour component of its basic correctional officer academy training
program. In addition, the Office of the Inspector General found that the California
Institution for Men provided three hours of correctional officer training in crime scene
preservation and evidence preservation between February 19, 2001 and November 23,
2003. This training was part of the in-service training curriculum required by the nowdefunct section 7K of the State’s collective bargaining agreement with the California
Correctional Peace Officers Association. (Following the death of Officer Gonzalez, the
prison conducted two one-hour sessions on crime scene preservation.) Crime scene
preservation and evidence preservation are also part of the post orders for the prison’s
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 71

five-member Investigative Services Unit, and are an integral part of the institution’s
Emergency Operations Procedures.
Last revised in 1989, section 55010 of the California Department of Corrections
Operations Manual requires that each warden have in effect at all times an Emergency
Operations Plan for meeting emergencies and disturbances which may significantly
disrupt routine institutional operations or programs. The purpose of the plan, a
confidential document located in specific secure areas of the prison, is to specify
institutional procedures in the event of an emergency or inmate-initiated disturbance. The
California Institution for Men’s plan is entitled Emergency Operations Procedures, and it
contains 50 resource supplements that identify policies and procedures for a variety of
possible events ranging from riots and escapes through natural disasters. Included in
these resource supplements are checklists for command and control, duties of the incident
commander, the interim emergency commander, the emergency commander, and other
key staff, and specific procedures to be followed for mass searches and crime scene
preservation and evidence preservation. Resource Supplement Numbers 4, 5, and 6 task
the incident commander, the interim emergency commander, and the emergency
commander with crime scene preservation and evidence preservation, among other
duties. Resource Supplement Number 24 provides procedures for mass searches and
evidence preservation, while Resource Supplement Number 28 specifies detailed
procedures for crime scene preservation and evidence preservation. As shown in Finding
7, section 55010 of the California Department of Corrections Operations Manual and the
California Institution for Men’s Emergency Operations Procedures can facilitate an
orderly response to a surprising, stressful event. However, neither document specifies all
circumstances under which the emergency procedures should be implemented.
The California Institution for Men failed to preserve the crime scene and physical
evidence. Notwithstanding the requirements for and the importance of crime scene
preservation and evidence preservation, the Office of the Inspector General found
significant failures on the part of institution staff to carry out their duties in the aftermath
of the stabbing. Specifically, the Office of the Inspector General found:
•

Failure by Investigative Services Unit staff to seal off the crime scene at the south
stairwell. Within minutes of the 10:57 a.m. assault on Officer Gonzalez at the south
staircase of the first tier in Sycamore Hall-West, numerous correctional staff
responded to the Code I and Code II alarms. Among the early responders to
Sycamore Hall-West and Reception Center Central were four of the five members of
the Investigative Services Unit. The responders remained outside the tier area until
inmate Blaylock and the two other inmates were restrained about 43 minutes after the
assault. Although this represented the first opportunity to seal off the reported scene
of the stabbing at the south staircase and begin the criminal investigation, no one,
including Investigative Services Unit staff did so. In fact, at that time, most of the
Investigative Services Unit’s staff was monitoring inmate Blaylock, who had been
moved to Palm Hall. During the cell extractions and the mass search for weapons that
followed, foot traffic contaminated the crime scene making subsequent forensic
analysis difficult, if not impossible. The Office of the Inspector General’s review of

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 72

the physical configuration of Sycamore Hall-West determined that the crime scene at
the south staircase could have been sealed off without hindering the mass search and
cell extractions. This is because there are alternative access and egress points the
search team and escort officers could have used. The only effort to preserve any
portion of Sycamore Hall-West occurred at 12:25 p.m. when an Investigative
Services Unit sergeant ordered the cordoning off of three cells with crime scene tape,
including Blaylock’s, at 12:25 p.m.
•

Failure to treat Sycamore Hall-West as a crime scene. Once staff had searched and
removed the inmates from Sycamore Hall, they had established control over the area
of the crime scene. However, instead of preserving the scene to the extent possible,
staff began their cell-by-cell search of Sycamore Hall. As they searched, staff heaped
linen, inmate jumpsuits, and other laundry items in huge piles in the main corridor.
Despite the fact that Sycamore Hall-West was now in the institution’s control, the
staff failed to consider cordoning off the housing unit as a crime scene. Had this
occurred the homicide investigators could have ordered a forensic examination of key
areas such as the guard space where Officer Gonzalez collapsed, the main corridor,
and the medical unit where he was taken for critical corroborative evidence.

•

Clean up of blood evidence. Rather than wait for the arrival of a forensics team, staff
cleaned up blood evidence around Sycamore Hall-West and Reception Center
Central, thus eliminating the possibility of locating and identifying blood from a
reported cut on the assailant’s hand. This cleanup effort was evidently an emotional
response to Officer Gonzalez’ death. One correctional sergeant reported that he
initiated a decontamination of Officer Gonzalez’ blood by spraying the affected floor
area with cleaner and wiping the floor area with towels. The sergeant reportedly acted
out of concern that inmates would defile, disrespect, and dishonor the blood of
Officer Gonzalez if it remained on the floor. Although the Office of the Inspector
General sympathizes with the feelings of institution staff, disturbing or destroying
potential evidence that could aid in the criminal prosecution of the assailant cannot be
allowed.

•

Failure to preserve the alleged assailant’s clothing as physical evidence. Based on
the probable close quarters in which inmate Blaylock allegedly attacked and stabbed
Officer Gonzalez, Blaylock’s clothing may have had trace blood, fiber or DNA
evidence to support a criminal prosecution. When inmate Blaylock surrendered to
institution staff, they ordered him to strip down to his underwear before being taken
into custody. However, correctional officers did not recover his clothing. As staff
searched and secured the remaining inmates and searched Sycamore Hall for the
murder weapon, they tossed trash, debris and the contents of the cells onto the tier
floor. Linen and jumpsuits removed from the cells were piled in the main corridor of
Reception Center Central. When staff realized several hours later that Blaylock’s
clothing had not been recovered, what should have been a simple recovery of
potential evidence became impossible, and Blaylock’s clothing was never located.
Even if staff could have identified his clothing in the piles of linen and clothing in the
main corridor, the integrity of that evidence would have been compromised because

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 73

of the commingling of the clothing with other items and the resulting contamination
of possible trace evidence.
•

Failure to examine and preserve blood on the alleged assailant’s hands. On January
10, 2005 at 12:45 p.m. after inmate Blaylock was taken into custody, a medical
technical assistant examined inmate Blaylock because force had been used in his
apprehension. The medical technical assistant documented the examination on a
Form C7219 (Medical Report of Injury or Unusual Occurrence). On the form, the
medical technical assistant reported that Blaylock had an abrasion or a scratch and
blood on one of his hands. Although staff photographed and videotaped Blaylock
following his capture, it is unclear whether those images captured the blood evidence
on the hand. Further, it appears that samples of the blood were not obtained prior to
Blaylock’s being transferred to Corcoran State Prison. The presence of blood on the
suspect’s hand in a stabbing case is clearly of evidentiary value.

•

Poor evidence collection, storage, and chain of custody practices. Collecting,
storing, and establishing the chain of custody of physical evidence is foundational to
presenting evidence in court and is critical in defeating defense challenges of bias,
evidence altering, evidence contamination, and other issues. The Office of the
Inspector General reviewed department and institution policies and procedures for
collecting, storing, and transferring evidence and found them generally consistent
with accepted policies and procedures within the law enforcement profession.
Further, review of the staff’s collection of approximately 35 stabbing and slashing
instruments during the mass search indicated that most officers appropriately
maintained sole custody of the evidence until booking the item into the Security
Administration Building evidence locker room. However, in addition to the evidence
collection problems previously discussed, the Office of the Inspector General found
that the actual practices of custody staff within the Security Administration Building
and in the Investigative Services Unit were not always compliant. Specifically, the
Office of the Inspector General found:
•

In collecting stabbing and slashing instruments, staff did not attempt to preserve
the weapon for forensic examination, including latent and blood trace evidence.
Such evidence is directly relevant in establishing possession when inmates are
double-bunked, as is the case with most inmates in Sycamore Hall-West.
Moreover, rather than placing the instruments into paper bags, some staff
temporarily stored the recovered weapons in their vests and cargo pants, without
considering the presence of trace evidence.

•

The Evidence Locker Register, used to record evidence in the Security
Administration Building, is not formatted to keep a complete record when there
are multiple movements of the evidence. Instead, there is space for only one entry
without having to resort to ad hoc recording. Additionally, the Evidence Locker
Register consists of loose-leaf pages in a binder. As such, the possibility of
adding or eliminating pages exists, threatening the integrity of the document.
Further, the Investigative Services Unit has two additional sites in the

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 74

Administration building used to store evidence without logs, registers or any other
tracking system for the evidence stored there.
•

Entries in the Evidence Locker Register pertaining to the mass search for weapons
cited above contained numerous irregularities. Some did not record the quantities
of weapons found, and the dates of the entries for fourteen weapons are not
chronological, suggesting that some weapons were turned in before the
contemporaneous recording of entries required by sound chain of custody
procedures. At least seven entries were made in the handwriting of someone
other than that of the officer who secured the evidence despite a requirement that
the booking officer complete the entry. The date of the transfer, and the identity
of the San Bernardino County Sheriff’s Department employee who received the
weapons are not recorded in the register as required by sound chain of custody
practices.

•

Investigative Services Unit staff does not consider forensic examination of
evidence in its criminal investigations. When the Office of the Inspector General
inquired how evidence requiring further forensic examination is handled at the
institution, Investigative Services Unit staff stated that correctional officers rarely,
if ever, request forensic examination of evidence. The Investigative Services Unit
officer responsible for the evidence function stated that he could not remember
when a request for forensic examination was made on an item of evidence booked
by staff. The Investigative Services Unit officer stated that because the vast
majority of criminal prosecutions involved crimes that were witnessed by staff,
there was no need for examination of evidence for latent prints or blood evidence
except when requested by a prosecutor.

•

Correctional staff who recover evidence such as weapons take the evidence to the
Security Administration Building’s evidence locker room, where the Office of the
Inspector General observed numerous unsecured paper bags of evidence stacked
on top of the locked evidence lockers. Although these bags appeared to be closed
and sealed, any person in the evidence room would have access to the evidence.

•

Although Security Administration Building personnel monitor access to the
evidence locker room, it is possible for an officer inside the room to work
unobserved. Failing to limit access to booked evidence to specified property
custodians could bring into question the chain of custody. Further, the locker
door cards describing the booking of the evidence indicated that their contents had
been booked up to two years before. The fact that evidence has remained in
lockers for up to two years while other evidence was stored on top of those
lockers suggests that evidence initially booked into the Security Administration
Building’s evidence room is not moved to more secured locations for long-term
storage.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 75

Inadequate command and control over the incident. When the Office of the Inspector
general asked the warden and her executive staff why crime scene preservation and
evidence protection and collection procedures were ignored or poorly implemented, the
response was direct and to-the-point: the assault on Officer Gonzalez was a one-on-one
act that was unique and horrific. The nature of the incident completely overwhelmed
staff. Consequently, the warden and her staff gave priority to issues that immediately
became apparent and ignored those issues that did not immediately become apparent.
One executive staff member explained that, “The main priority was to save the officer’s
life. Everything was emotion-based. All bets were off.”
Despite the shift in priorities brought on by Officer Gonzalez’ death less than an hour
after the stabbing, the warden and her staff still did not implement the Emergency
Operations Procedures. By not doing so, they lost the value of the checklists and the
myriad policies and procedures for command and control, crime scene preservation and
evidence preservation, and other functions addressed by the procedures. To their credit,
the warden and her staff responded immediately to provide medical aid to Officer
Gonzalez. They also moved swiftly to isolate and take into custody three inmates whom
they reasonably believed were involved in the assault. They also provided for the safety
of the suspected assailant by placing him in Palm Hall, with staff guarding him, and
arranging to transport him to another institution within hours of the incident.
Simultaneously, staff moved to prevent destruction of the unaccounted for murder
weapon by searching and removing the inmates from Sycamore Hall-West and
conducting mass searches of the tiers and cells.
However, prison management did not consider coordinating the staff’s efforts to find the
murder weapon with an effort to preserve the crime scene, with the result that the crime
scene was irreparably altered and contaminated, and critical evidence was destroyed or
lost.
Moreover, institution management did not use the considerable outside investigative
expertise available or consider forensic crime scene analysis until 2:05 p.m., more than
three hours after the assault, when detectives from the Chino Police Department arrived
at the request of Investigative Services Unit staff to provide investigative advice. Prior to
their arrival, three investigators from the department’s Law Enforcement Investigations
Unit had shown up within one and one-half hours of the assault. However, because
investigative responsibility remained with the Investigative Services Unit, the Law
Enforcement Investigations Unit staff provided only investigative support. With the
arrival of a deputy director from the Department of Corrections the status of the criminal
investigation was revisited in the early evening. After an assessment of the state of the
investigation, investigative responsibility was transferred to Law Enforcement
Investigations Unit.
The following day, after further discussion regarding the investigative expertise and
resources available to the department, including Law Enforcement Investigations Unit,

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 76

investigative responsibility was ultimately transferred to the San Bernardino County
Sheriff’s Department.
As a result of the preceding conditions identified by the Office of the Inspector General,
important forensic and other physical evidence was lost. Further, the admissibility of
other evidence such as stabbing instruments may be challenged in future legal
proceedings. Lack of this evidence may make it more difficult to successfully prosecute
inmate Blaylock or to obtain a conviction.
Staff at the crime scene failed to preserve the crime scene and preserve evidence for the
following reasons:
•

Traumatized staff. Some correctional staff assigned to Sycamore Hall-West and
Reception Center Central, as well as other institution staff, were traumatized by the
incident, and their academy training and institutional training were inadequate for
them to respond automatically.

•

Investigative Services Unit shortcomings. The investigation of criminal acts by
inmates at the California Institution for Men is the responsibility of the Investigative
Services Unit. However, staff in the Investigative Services Unit had neither the
training nor the experience to respond adequately to a staff homicide. Of two
lieutenants, one sergeant, and two correctional officers in the unit, only the two
correctional officers had had training in homicide investigations and none had ever
investigated a staff homicide. Moreover, the two lieutenants had not attended the
basic investigation course. None of the five was familiar with forensic examination
techniques, there was no crime laboratory support, and the Investigative Services Unit
did not practice sound evidence collection, storage, and transfer techniques.

•

No memorandum of understanding for lead agency in staff homicide
investigations. Although the institution has various memoranda of understanding with
local law enforcement and the district attorney for deadly force investigations and
prosecution of certain types of inmate offenses, there is no memorandum of
understanding with a competent local law enforcement agency by which that agency
would assume the lead role in investigating the murder or attempted murder of a staff
member. Given the limitations of the prison’s Investigative Services Unit cited in this
report, such an agreement would be appropriate.

•

Failure to learn from a 2003 incident. During its review, the Office of the Inspector
General learned of an officer-involved shooting in 2003 in the Palm Hall exercise
yard. In that incident, a correctional officer used deadly force to stop an inmate-oninmate attack. Both the department’s Office of Investigative Services and the
department’s Law Enforcement Investigation Unit reviewed the incident; both entities
criticized the lack of crime scene preservation and evidence collection. The two
investigative organizations found little coordination between Palm Hall correctional
staff and the Investigative Services Unit staff responding to the incident. As a result,
the crime scene was disturbed to the point where the two organizations personally

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 77

contacted the institution and recommended that the institution establish a “squad” of
trained correctional staff to respond to crime scenes and either cordon them off or
collect evidence as necessary.
RECOMMENDATIONS
The Office of the Inspector General recommends that the Department of
Corrections take the following actions:
•

Evaluate the need for a memorandum of understanding or protocols
governing when an outside agency should take primary responsibility for
the criminal investigation of a crime against a staff member. In doing so,
consider the limited resources of institutional investigative units and the
emotional impact that a crime against staff may have on the institution’s
ability to react properly.

•

Reevaluate and assess the scope and responsibility of institutions’
Investigative Services Units as the primary criminal investigative entity
given their manpower, training, and resource limitations.

•

Clearly define the role and expectations of Investigative Services Units in
identifying and securing potential crime scenes, identifying and
preserving evidence and, if they remain the primary investigative entity,
proper collection and processing of the crime scene and evidence.

•

Evaluate the need for training at the correctional officer, sergeant, and
Investigative Services Unit levels regarding the identification and
collection of physical evidence with potential forensic examination in
mind, including but not limited to the manner of collection, processing
and documentation.

•

Develop a “lessons learned” instructional curriculum by which all
institutions can learn what went right and what went wrong in the events
leading up to and following the death of Officer Gonzalez.

In addition, the Office of the Inspector General recommends that the
California Institution for Men take the following actions:
•

Evaluate whether the “squad” concept of correctional officers specially
trained in crime scene investigation and crime scene and evidence
preservation is appropriate for the California Institution for Men under
existing conditions.

•

Using departmental policies and procedures, as well as the best practices
of the law enforcement profession, develop better methods for processing,
booking, and transferring evidence. These methods should include a

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 78

“chain of custody” that will satisfy legal and operational requirements of
both the transferring and receiving entities.
FINDING 9
The Office of the Inspector General made confidential findings related to the
adequacy of mental health care for particular inmates at the California Institution
for Men.
The investigation of the Office of the Inspector General found that the California
Institution for Men failed to adequately assess and address particular inmates mental
health needs. However, due to state and federal medical privacy laws, those findings
cannot be presented in a public document. Accordingly, pursuant to Penal Code section
6131 (b) the information in this section has been presented only to the Governor and the
Youth and Adult Correctional Agency.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 79

FINDING 10
The Office of the Inspector General found that Blaylock was permitted to conduct a
telephone conference with an attorney before he was indicted for the murder of
Officer Gonzalez even though the attorney’s request for the conference was not
properly submitted in writing.
The Office of the Inspector General found that Corcoran State Prison, where Blaylock
was transferred following the incident, allowed Blaylock to speak to an attorney by
telephone before he was indicted for the murder of Officer Gonzalez and therefore before
he had a right to counsel in the matter under the Sixth Amendment. The prison’s
litigation coordinator allowed the telephone conference even though the attorney’s
request was not properly submitted in writing. The Office of the Inspector General found,
however, that the litigation coordinator acted reasonably in granting the request.
The Office of the Inspector General found that after Blaylock was transferred from the
California Institution for Men to California State Prison, Corcoran, an attorney called
Corcoran State Prison’s litigation coordinator and requested to speak with Blaylock. The
attorney told the litigation coordinator that she currently represented Blaylock in an
appellate case and that she wanted to speak to him to advise him not to speak with police.
The litigation coordinator obtained the attorney’s name and contact information,
terminated the call, and then confirmed the attorney’s name and contact information
through the California State Bar’s web site. The litigation coordinator called the attorney
back at the phone number listed on the California State Bar’s web site and informed her
that a teleconference would be arranged. With the litigation coordinator’s approval, the
teleconference between Blaylock and the attorney was completed within the next hour.
The litigation coordinator said that at the time the attorney contacted her, she was
unaware of Blaylock’s alleged involvement in the murder of Officer Gonzalez.
Under the Sixth Amendment of the United States Constitution, Blaylock had no right to
counsel regarding the murder of Officer Gonzalez because that right attaches only “at the
time adversary judicial proceedings are initiated against the accused, such as when the
defendant is indicted or arraigned” [People v. Frye (1998) 18 Cal. 4th 894, 897]. Thus,
Blaylock had no Sixth Amendment right to counsel regarding the murder of Officer
Gonzalez because he had not yet been indicted or arraigned on that charge. Accordingly,
criminal investigators were free to approach Blaylock, provide his Miranda warnings and
attempt to interrogate him regarding that crime, at which time Blaylock could invoke his
Fifth Amendment right to remain silent and request the presence of an attorney.
The litigation coordinator informed the Office of the Inspector General that requests from
attorneys to conduct confidential telephone calls are a routine part of her duties and that
she can authorize such calls once she is satisfied that the caller is a bona fide attorney.
The litigation coordinator further stated that approving such calls is within her authority
and that she does not need to obtain approval from her superiors or the warden. In this
case, she told the Office of the Inspector General that this attorney’s request was handled
in the same fashion as all other such requests, that granting the request was entirely her
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 80

decision, and that she did not request approval from the warden or others before granting
the request.
The Office of the Inspector General confirmed through the California Appellate Court
web site that the attorney in question is, in fact, the attorney of record in People v.
Blaylock, California Appellate Court Case No. B176178 (a matter unrelated to the murder
of Officer Gonzalez).
Telephone calls between an attorney and an inmate-client are governed by Title 15 of the
California Code of Regulations, section 3282(g). Under Title 15, section 3282(a)(2), a
telephone call between an inmate and an attorney is considered a “confidential call.”
According to Title 15, section 3282 (g)(1):
[C]onfidential calls may be approved on a case-by-case basis by the institution head or
designee only upon written request from an inmate’s attorney on the attorney’s office
letterhead stationery. The date, time duration, and place where the inmate will make or
receive the call, and manner of the call are within the discretion of the institution head. A
confidential call from an inmate shall be made from a prison telephone or, with
appropriate authentication of the call, may be received from the attorney. [Emphasis
added.]

Section 3282(g)(2) of Title 15 states as follows:
[I]t is within the discretion of the institution head or designee to approve or deny a
confidential call, provided that the attorney/client communication privilege is not
violated. Thus, an institution head or designee may deny a confidential call based on a
determination that normal legal mail or attorney visits were the appropriate means of
communications and were not utilized by the inmate or attorney. If the demand for
confidential calls seriously burdens institutional operations, the institution head or
designee may prioritize confidential calls.

The Department of Corrections Correctional Law Unit told the Office of the Inspector
General that although these sections may be somewhat confusing, they probably allow
individual institutions a degree of flexibility on how to handle requests for “confidential
calls” from attorneys. The Correctional Law Unit said that many institutions were never
set up for accepting and coordinating confidential calls, noting that where some attorneys
may request telephone conferences with inmate-clients weekly, such requests would be
burdensome on the institution.
Based on its interview of the litigation coordinator at Corcoran State Prison, the Office of
the Inspector General found that the attorney’s request for a confidential call with
Blaylock was not based on a written request on the attorney’s office letterhead stationery
as required by Title 15, section 3282(g)(1). Further, the Office of the Inspector General
found that the requesting attorney advised the litigation coordinator that she intended to
tell Blaylock not to speak with the police. As Blaylock’s Sixth Amendment right to
counsel attached only as to the offense for which he was being represented (and not to
any and all future crimes), there is an argument that the attorney’s telephone conference
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 81

with Blaylock was granted prematurely. However, the Office of the Inspector General
questions whether it is appropriate for the litigation coordinator to inquire about the
purpose or substance of any attorney’s confidential call to a client.
A representative of the Department of Corrections Correctional Law Unit told the Office
of the Inspector General that the Title 15 provisions controlling confidential calls is
somewhat confusing and appears to allow individual institutions leeway in its
implementation. Although the litigation coordinator did not adhere strictly to the Title 15,
section 3282 (g)(1) requirement that attorneys’ requests to confer by telephone with
clients be written on the attorney’s letterhead, she made reasonable efforts to establish
that the caller was, in fact, a licensed attorney.
RECOMMENDATIONS
The Office of the Inspector General recommends that the Department of
Corrections take the following actions:
•

Evaluate and, if necessary, modify regulations governing “confidential
calls” between inmates and their attorneys. Such modifications may
address (1) permitting verification through independent sources that the
requesting attorney is licensed to practice, (2) verifying that the attorney
actually represents the inmate in question and (3) balancing inmates’
right to counsel with the institution’s need to validate such calls and its
resources available to facilitate them.

•

Develop procedures for wardens and chief deputy wardens to
communicate with key institutional staff members (such as the litigation
coordinator and the public information officer) when inmates requiring
special handling enter their institutions. Such communications should
include instructions to staff that all external inquiries concerning these
inmates be referred to the attention of the warden or warden’s designee.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 82