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

QUARTERLY REPORT
JANUARY - MARCH 2005

STATE OF CALIFORNIA

INTRODUCTION

T

his quarterly report summarizes the audit and investigation activities of the Office
of the Inspector General for the period January 1, 2005 through March 31, 2005.
The report satisfies the provisions of California Penal Code sections 6129,
subdivision (c)(2), and 6131, subdivision (c), which require the Inspector General to
publish a quarterly summary of investigations completed, including the conduct
investigated and any discipline recommended and imposed. To provide a more complete
overview of the Inspector General’s activities and findings, this report reaches beyond
that requirement to also summarize audits and special reviews performed by the office
during the first quarter period. All of the activities reported were carried out under
California Penal Code section 6125 et seq., which assigns the Office of the Inspector
General responsibility for independent oversight of the Youth and Adult Correctional
Agency and its subordinate entities.

BACKGROUND
The Office of the Inspector General investigates and audits the state’s correctional
departments, programs, and institutions to uncover criminal conduct, administrative
wrongdoing, poor management practices, waste, fraud, and other abuses. Established in
its present form in 1998, the office has undergone significant change in the past five
years, and particularly in the months leading up to and extending through the first quarter
of 2005. Between 1999 and the end of 2003, the Office of the Inspector General
conducted 48 management review audits and special reviews of state correctional entities,
responded to 16,000 complaints concerning the correctional system, and conducted more
than 1,400 investigations into allegations of misconduct and other improprieties by
correctional staff and management. The office also performed quality control reviews of
more than 4,000 internal affairs investigations conducted by the investigative units of the
Department of Corrections and the California Youth Authority.
As a result of the state’s fiscal crisis, however, the Inspector General’s budget was cut 77
percent between 2001 and 2003, from $11.1 million to $2.7 million. The budget cuts
resulted in a reduction in staff from 114.9 funded positions to 23 and the closing of all
regional offices, even though the Office of the Inspector General’s statutory mandates
remained unchanged.
After months of downsizing, the Inspector General’s responsibilities dramatically
expanded in January 2004 as a result of actions by the Legislature and the U. S. District
Court, Northern District of California. As an integral part of a settlement between the
Department of Corrections and plaintiffs in a court action involving illegal use of force
by correctional officers at Pelican Bay State Prison, the Inspector General was assigned
responsibility for increased oversight of state prison internal affairs investigations. The
terms of the settlement called for the establishment of a Bureau of Independent Review
within the Office of the Inspector General to provide real-time evaluation of every
Department of Corrections abuse of force and employee ethics internal affairs case,
including all cases involving use of the correctional officers’ “code of silence.” The
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 1

settlement plan requires Bureau of Independent Review attorneys and investigators to be
co-located throughout the state with each of the three offices of the Department of
Corrections, Office of Investigative Services.
In accordance with the U. S. District Court settlement, the Legislature provided for the
establishment of the Bureau of Independent Review within the Office of the Inspector
General, effective January 1, 2005. The Legislature also set out specific audit and
investigative responsibilities for the Office of the Inspector General, including specific
new responsibilities for publicly reporting the results of its audits and investigations.
To fulfill the new mandates, the Governor appointed a new Inspector General in March
2004 and the Office of the Inspector General’s budget for 2004-05 was restored to $8.8
million.
The months following the appointment of the new Inspector General have been devoted
to a rapid reconfiguration, re-staffing, and re-building of the office. During fiscal year
2004-05, the Inspector General hired 32 new staff members, and between March and
December 2004, opened three regional offices in Rancho Cordova, Bakersfield, and
Rancho Cucamonga for attorneys and investigators assigned to the Bureau of
Independent Review. In addition, a new Bureau of Audits and Investigations was
established within the office to conduct management review audits of state prison
wardens and youth correctional facility superintendents, as well as special reviews of
correctional agencies and programs and investigations into alleged misconduct by
correctional agencies and employees. The Inspector General’s proposed 2005-06 budget
has been increased to $15.5 million and the office anticipates hiring 43 additional
employees in fiscal year 2005-06, bringing the staff total to 96.
Concurrent with re-building and re-staffing the office in 2004 and 2005, the Office of the
Inspector General has continued a vigorous schedule of investigations and audits. The
following pages summarize those activities. A separate semi-annual report summarizing
internal affairs investigations monitored by the Bureau of Independent Review, will be
published in August 2005 and will be posted on the Inspector General’s website at
http://www.oig.ca.gov/.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 2

SUMMARY OF INVESTIGATIONS
The Office of the Inspector General receives about 300 complaints a month concerning
state correctional departments and institutions. Most of the complaints arrive by mail or
through the Inspector General’s 24-hour toll-free telephone line, while others are brought
to the attention of the Office of the Inspector General in the course of audits or related
investigations. The Office of the Inspector General may also conduct investigations at the
request of agency or department officials in cases involving potential conflicts of interest
by high-level administrators. The Inspector General’s staff responds to each of the
complaints and requests for investigation, with those involving urgent health and safety
issues receiving priority attention through the Inspector General’s rapid response process.
Most often the Inspector General’s staff is able to resolve the complaints at a preliminary
stage through informal inquiry or preliminary investigation by contacting the complainant
and the institution or department involved and either establishing that the complaint is
unwarranted or bringing about an informal remedy. Some of the complaints, however,
warrant a full official investigation.
During the first three months of 2005, the Office of the Inspector General completed 12
full investigations. Following is a summary of those investigations.
Board of Prison Terms. The Office of the Inspector General investigated the case of an
independent contractor who provided part-time language interpretation services to the
Board of Prison Terms. The investigation resulted from information submitted by an
investigator from the San Diego County District Attorney’s Office, who had determined
that the employee, who also worked full-time for the San Diego County Public
Defender’s Office, was claiming full-time hours with the County of San Diego on days
she also invoiced the Board of Prison Terms for services. The investigator suspected the
employee was submitting fraudulent claims to the Board of Prison Terms.
Result: The Office of the Inspector General found that the employee had billed
the Board of Prison Terms for excessive hours and duplicate claims totaling
$11,862. The Inspector General forwarded the results of the investigation, along
with a Declaration in Support of Arrest Warrant, to the San Diego County District
Attorney for consideration. Upon completion of the investigation, the Office of
the Inspector General conducted a special review of Board of Prison Terms
interpretation services procedures. The findings of the special review are reported
elsewhere in this report.
Status: As the result of a March 1, 2005 plea agreement, the suspect pleaded guilty to a
felony count of grand theft under California Penal Code section 487 and was ordered to
pay full restitution to the Board of Prison Terms in the amount of $11,862. The court
placed the defendant on probation, suspended a 120-day jail sentence, and ordered her to
serve 160 hours of community service.
Department of Corrections, Office of Investigative Services/Office of Internal
Affairs. The Office of the Inspector General investigated a complaint that staff members,
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 3

including a supervisor, in the Department of Corrections, Office of Internal Affairs,
contrary to the instructions of a higher authority, granted administrative immunity to
witnesses during administrative investigations involving the department’s Law
Enforcement and Investigations Unit and Parole and Community Services Division. The
complaint also alleged that the staff members had been dishonest in reporting to the
assistant director of the Office of Investigative Services whether administrative immunity
had been granted to the witnesses.
Result: The Office of the Inspector General found sufficient evidence to sustain
the first allegation, but did not find sufficient evidence to sustain the second
allegation.
Recommendations: The Office of the Inspector General recommended adverse
action against the supervisory staff member for insubordination, neglect of duty,
and dishonesty. The Office of the Inspector General recommended corrective
action against two of the other staff members for violation of department policy.
In addition, the Office of the Inspector General recommended that the director of
the Department of Corrections establish clear policy and procedures governing the
use of administrative immunity and provide training to all employees assigned to
conduct internal affairs investigations.
Status: The Office of the Inspector General referred the matter to the director of
the Department of Corrections for appropriate action. The supervisory employee
was terminated. That case is scheduled for hearing before the State Personnel
Board. The Department of Corrections has established an interim policy to
prohibit the granting of administrative immunity in administrative cases unless
approved by the assistant director of the Office of Investigative Services or the
chief deputy director of Field Operations. The department is developing a policy
governing the use of immunity.
Department of Corrections, Office of Investigative Services. The director of the
Department of Corrections requested that the Office of the Inspector General investigate
allegations presented in legislative testimony that department management retaliated
against special agents of the Office of the Investigative Services as part of an attempt to
close the southern office of the Office of Investigative Services. In testimony before the
Senate Select Committee on Government Oversight and the Senate Select Committee on
the California Correctional System, special agents also testified under oath that the
former department director conspired with the California Correctional Peace Officers
Association to obstruct justice and that the agents were ordered to release evidence to the
California Correctional Peace Officers Association during an open criminal investigation.
The allegations stemmed from an attempt for the first time by the California Correctional
Peace Officers Association to use provisions of section 9.09 of the memorandum of
understanding between Bargaining Unit 6 and the State of California to obtain evidence
in an active criminal case. To avoid turning over the evidence to the California
Correctional Peace Officers Association and to protect the chain of custody in an

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 4

investigation concerning the California Institution for Men, the special agents had
contacted the Attorney General’s Office, which subsequently secured the evidence.
Result: The Office of the Inspector General found that the case did not meet the
prima facie standard for a protected activity to establish a legally cognizable
claim of retaliation. In response to the allegations that the department director
conspired with the California Correctional Peace Officers Association to interfere
with and obstruct an active criminal investigation, the Office of the Inspector
General found that no motive for personal gain, favors, or personal benefit was
discovered or provided in evidence.
Recommendations: The Office of the Inspector General recommended that the
Department of Corrections close the case without further investigation.
Status: The Office of the Inspector General referred the case to the Office of
Investigative Services for closure.
Correctional Training Facility. The Office of the Inspector General conducted an
inquiry into an allegation that a correctional officer at the Correctional Training Facility
used excessive force on an inmate. The complainant alleged the correctional officer
kicked the inside of the inmate’s knee, causing injury to his knee and wrist. The Office of
the Inspector General determined that the inmate had filed an appeal of the incident with
the institution and after interviewing the inmate, the correctional officer, and witnesses
and reviewing pertinent documents, the institution had not sustained the allegations.
Result: The Office of the Inspector General determined that the institution may
not have followed required policies and procedures for reviewing and
investigating use-of-force incidents.
Recommendations: The Office of the Inspector General requested that the
warden explain why required policies and procedures may not have been
followed.
Status: The Office of the Inspector General is awaiting response from the warden
and will take appropriate action after reviewing the response.
California State Prison, Los Angeles County. The Office of the Inspector General
investigated a complaint that California State Prison, Los Angeles County improperly
places inmates who have been recommended by mental health clinicians for single-cell
status into double cells. The complaint centered on an inmate in the mental health
treatment program who was allegedly murdered by his cellmate in the administrative
segregation unit on September 10, 2004. As a result of the investigation, the Office of the
Inspector General found that employees in the administrative segregation unit at
California State Prison, Los Angeles County violated department policy by failing to
complete a cell compatibility form before assigning the murder victim and his alleged
assailant in the same cell.
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 5

Result: The Office of the Inspector General found that the murder victim and his
alleged assailant should not have been celled together because both had long histories
of criminal violence and violent behavior toward other inmates. Both had also been
diagnosed with serious mental disorders. Investigators identified two other instances
in which institution employees failed to complete the cell compatibility form before
assigning inmates to the same cell. The Office of the Inspector General also found,
however, that the Institutional Classification Committee at California State Prison,
Los Angeles County did not violate existing policy when it assigned the murder
victim and his alleged assailant to double-cell status.
Recommendations: The Office of the Inspector General recommended that the
Department of Corrections investigate the employees who failed to complete the cell
compatibility forms in the three instances identified. In addition, the Office of the
Inspector General recommended that the Department of Corrections modify the
existing double-cell policy to include special consideration for inmates diagnosed
with mental illness and also require Institutional Classification Committees to verify
the cell status of inmates and review the cell compatibility form for accuracy and
completeness.
Status: The Office of the Inspector General referred the case to the Department of
Corrections, Office of Investigative Services for investigation of the failure of
institution employees to comply with department policy. The Inspector General’s
Bureau of Independent Review is monitoring that investigation and is also conducting
a special review of the department’s policy of housing administrative segregation
inmates in double cells.
California Institution for Men. The Office of the Inspector General investigated a series
of complaints from the family members of an inmate alleging that the inmate suffers from
ongoing problems as a result of a hernia operation performed by an outside health care
facility while he was in the custody of the Department of Corrections and that he has not
received proper treatment from the medical staff at the California Institution for Men.
The Office of the Inspector General determined that the institution opened an
investigation concerning the inmate’s medical care as a result of an appeal filed by the
inmate and that the institution has continued to provide medical care. The Office of the
Inspector General also found that the inmate has refused treatment in some instances and
that he refused a medical evaluation by an outside specialist because of his upcoming
release date. The Inspector General’s staff worked to facilitate communication between
the institution and the inmate’s family members.
Result: The Office of the Inspector General determined that the institution is
aware of and is monitoring the inmate’s medical concerns.
Recommendations: None.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 6

Status: The Office of the Inspector General has received no additional complaints
from the inmate or family members concerning this matter in more than 45 days.
Substance Abuse Treatment Facility and State Prison, Corcoran. The Office of the
Inspector General investigated a complaint from an inmate at the Substance Abuse
Treatment Facility and State Prison that a 72-year-old inmate at the prison died from an
apparent hunger strike. The complaint mirrored a complaint received from another
source.
Result: The Office of the Inspector General determined the institution had not
been monitoring the inmate for weight or fluid loss at the time of his death and
that the Department of Corrections, Office of Investigative Services has
investigated the circumstances surrounding the death.
Recommendations: The Office of the Inspector General recommended that the
Office of Investigative Services provide the Inspector General with a copy of the
investigation report when it is released.
Status: The report of the Office of Investigative Services investigation is
undergoing review by Office of Investigative Services management. The Office
of the Inspector General continues to monitor and track the progress of the Office
of Investigative Services investigation.
California State Prison, Corcoran. The Office of the Inspector General conducted an
inquiry into a complaint that a staff member at California State Prison, Corcoran used
excessive force on an inmate who had been admitted to the acute care hospital because of
suicidal ideation. The complainant alleged the inmate was placed in five-point restraints
during the incident. The Office of the Inspector General determined from institution
records that the inmate had been found to be drunk and out of control and was placed in
five-point restraints on the order of a staff psychiatrist. The inmate complained to the
medical staff of a swollen left eye and was prescribed eyewash the following day. The
inmate informed a nurse that the eye problem began when he was drunk. He was
subsequently prescribed antibiotics for an infected eye.
Result: The Office of the Inspector General found no reference to unusual
activity and no evidence of use of force. The inmate was subsequently discharged
back to the security housing unit and did not file an inmate appeal with the
institution.
Recommendations: None.
Status: Case closed.
California State Prison, Los Angeles County. The Office of the Inspector General
independently initiated an investigation into the reasons for an inmate’s self-imposed
hunger strike at California State Prison, Los Angeles County. The inmate’s weight had
STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 7

fallen from 265 pounds in April 2004 to 138 pounds on November 18, 2004. The Office
of the Inspector General determined that the inmate had a history of poor health, suffered
from diabetes and hypertension, and had told Department of Corrections staff that he no
longer wanted to live. The inmate received a court-ordered feeding tube on November 13,
2004, but the court ruled against extending the feeding tube beyond November 17, 2004,
when it had been scheduled to be removed. The inmate was transported to Antelope
Valley Hospital on November 19, 2004 pursuant to a court order to remove the feeding
tube and was returned to California State Prison, Los Angeles County after the feeding
tube was removed.
Result: The Office of the Inspector General found that the inmate’s hunger strike
did not involve a claim of unfair treatment at the institution.
Recommendations: None.
Status: The Department of Corrections advised the Office of the Inspector
General that the inmate began eating intermittently after he returned from the
hospital. The Office of the Inspector General has closed the case.
Salinas Valley State Prison. The Office of the Inspector General investigated a
complaint that correctional employees at Salinas Valley State Prison, Soledad were
setting up gladiator-type fights between inmates in one of the yards. The complaint
centered on an inmate who alleged that the staff allowed an inmate to enter his cell and
attack him. The inmate further alleged the correctional staff assaulted him after he was
attacked.
Result: The Office of the Inspector General found the allegations to be
unsubstantiated.
Recommendations: None.
Status: Case closed.
El Paso de Robles Youth Correctional Facility. The Office of the Inspector General
conducted a preliminary investigation into a complaint filed by the Youth Law Center
concerning a ward with mental health disorders who had been on extended lockdown.
The complaint, which was filed on behalf of the ward’s mother, reported that the ward
had previously attempted suicide and had been diagnosed with bipolar disorder, attention
deficit, and hyperactivity disorder. The complainant requested that the Inspector General
take immediate steps to remove the ward from extended lockdown and ensure that he
receives intensive mental health treatment.
Result: The Office of the Inspector General determined that the ward is no longer
under the jurisdiction of the California Youth Authority. He was convicted for
violation of Welfare and Institutions Code section 1768.8B and was in custody in

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 8

the San Luis Obispo County jail awaiting sentencing and subsequent transfer to
the Department of Corrections.
Recommendations: None
Status: The Office of the Inspector General has closed the case.
Deuel Vocational Institution. The Office of the Inspector General conducted a
preliminary investigation into a complaint filed by a correctional officer alleging that he
was illegally placed under surveillance and video-recorded by his sergeant. The
correctional officer alleged that a video recording camera was installed in a radio in the
office of the Investigations Services Unit security squad to determine whether he was
sleeping on duty. The correctional officer was subsequently removed from his position
with the security squad. The complainant asked the Office of the Inspector General to
review the Category II investigation by the Department of Corrections, Office of
Investigative Services into the correctional officer’s allegations to determine whether the
investigation had been proper and thorough.
Result: The Office of the Inspector General determined that the Office of
Investigative Services investigation was properly and thoroughly conducted. The
Inspector General concurred with the “not sustained” finding of the Office of
Investigative Services. The Office of Investigative Services found no evidence
that any of the parties interviewed knew of a camera installed in a radio and found
no evidence to support the officer’s allegations.
Recommendations: The Office of the Inspector General recommended the
Department of Corrections close the case with no further action.
Status: The complainant was informed that the Office of the Inspector General’s
case has been closed unless and until new evidence is produced.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 9

SUMMARY OF AUDITS AND SPECIAL REVIEWS
The Office of the Inspector General completed one audit and two special reviews during
the first quarter of 2005. The audit and special reviews are summarized below.
Accountability Audit: Review of Audits of the California Youth Authority, 20002003. In January 2005, the Office of the Inspector General issued a 200-page audit of the
California Youth Authority, which assessed the department’s progress in implementing
recommendations from nine previous audits conducted by the Inspector General. The
audit determined that the California Youth Authority had fully implemented only 43
percent of 241 previous recommendations and that many of the remaining deficiencies
were central to the department’s core mission of providing education and counseling
services to the youths in its custody. The full text of the report can be viewed by clicking
on the following link to the Inspector General’s website: Accountability Audit: Review of
Audits of the California Youth Authority, 2000-2003 (January 2005).
Special Review into the Death of Correctional Officer Manuel A. Gonzalez, Jr. In
March 2005, the Office of the Inspector General completed a special review into the
circumstances surrounding the January 10, 2005 stabbing death of Correctional Officer
Manuel G. Gonzalez, Jr. at the California Institution for Men. The review determined that
numerous security problems at the institution led up to the attack and that the failure of
correctional officers, including the victim, to follow security requirements may have
contributed to the incident. The full text of the special review can be viewed by clicking
on the following link to the Inspector General’s web page: Special Review into the Death
of Correctional Officer Manuel A. Gonzalez, Jr. on January 10, 2005 at the California
Institution for Men (March 2005).
Special Review of the Board of Prison Terms Interpretation Services Procedures. In
March 2005, the Office of the Inspector General completed a special review into the
procedures used by the Board of Prison Terms to secure the services of foreign language
interpreters. The review followed an investigation by the Office of the Inspector General
into the case of a foreign language interpreter who was found to have received payment
from the Board of Prison Terms for $11,862 in fraudulent claims. The special review
determined that the board routinely paid invoices from interpreters without confirming
that the services had been provided or checking to determine whether the invoice had
already been paid. The review also found that the board did not fully specify in writing
the terms of the agreement when it arranged for interpretation services. In response to the
special review and the Office of the Inspector General’s recommendations, the Board of
Prison Terms developed a comprehensive corrective action plan. The full text of the
special review and the corrective action plan submitted by the Board of Prison Terms can
be viewed by clicking on the following links to the Inspector General’s web page: Special
Review of the Board of Prison Terms Interpretation Services Procedures (March 2005)
and Response of the Board of Prison Terms to the March 2005 Special Review (April
2005).

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 10

CONCLUSION
A second quarterly report covering the period April through June 2005 will be released
and posted to the Inspector General’s website in July 2005, followed by a third quarterly
report in October 2005 and a 2005 annual report in January 2006.

STATE OF CALIFORNIA
OFFICE OF THE INSPECTOR GENERAL

ARNOLD SCHWARZENEGGER, GOVERNOR
PAGE 11