Office of the Inspector General
Matthew L. Cate, Inspector General

Folsom State Prison
Quadrennial and Warden Audit

January 2008

State of California

Contents
Executive Summary .................................................................................................1
Institution Overview ................................................................................................3
Chapter 1: One-Year Evaluation of Warden Matthew C. Kramer
Objectives, Scope, and Methodology..........................................................6
Background of Warden ...............................................................................7
Discussion of Warden’s Strengths..............................................................7
Discussion of Criticisms...............................................................................9
Warden’s Response to Criticisms...............................................................9
Summary Discussion....................................................................................10
Chapter 2: Quadrennial Audit Findings and Recommendations
Objectives, Scope, and Methodology..........................................................11
Finding 1 .......................................................................................................14
Poor implementation of the changeover from medical technical assistants to
licensed vocational nurses left the nurses unsupervised and ill prepared to work
in a prison setting.

Finding 2 .......................................................................................................21
Folsom State Prison’s custody staff does not consistently follow critical safety
and security procedures.

Finding 3 .......................................................................................................25
Housing certain parolees and inmates together in the same treatment facility
exposes classification policy conflicts and violates department procedure.

Attachments
California Department of Corrections and Rehabilitation’s Response
Receiver’s Response

Executive Summary
This report presents the results of an audit by the Office of the Inspector General
(OIG) concerning the operations of Folsom State Prison and the performance of
its warden. The audit was performed under California Penal Code section 6126,
which requires the OIG to audit each warden of an institution one year after his or
her appointment, and to audit each correctional institution at least once every four
years. The OIG performed the audit work between March 28, 2007, and
November 30, 2007.
Our team of inspectors examined Folsom State Prison’s operations and programs
to identify problem areas and recommend workable solutions. The prison, which
houses nearly twice as many inmates as it was designed for, gave our inspectors
full access to its records, logs, and reports. Site visits allowed us to observe the
prison’s day-to-day operations and witness the unique physical plant challenges
inherent in a prison built in the late 1870s. We also interviewed various staff
members and inmates, and we sent surveys to three distinct groups: managers at
the institution and at the California Department of Corrections and Rehabilitation,
institution employees, and key external stakeholders. In all, our inspectors made
three audit findings and 11 recommendations, which are detailed in Chapter 2 of
this report.
Overall, Warden Kramer is an experienced, effective leader. As detailed in
Chapter 1 of this report, our inspectors used surveys and personal interviews
along with our audit results to evaluate Warden Matthew C. Kramer’s
performance. During this first year of his appointment at Folsom State Prison,
Kramer faced challenges requiring adverse personnel actions against members of
his management team. However, he confronted these challenges and took action
to restructure and rebuild the team. After an initial period of disruption, the
institution’s staff relations and general morale improved, and staff members credit
Kramer’s actions for this turnaround in morale.
Staff members praised Kramer’s leadership skills and dedication to inmate
rehabilitation and programming opportunities, but some members of the custody
staff criticized him for prioritizing inmate programming at the possible expense of
institutional safety and security. Nevertheless, survey results indicate that staff
members believe Kramer to be a “very good” warden, and our audit work
demonstrates that he is moving Folsom State Prison in the right direction,
especially in inmate programming.
Folsom State Prison needs to address safety and security concerns. While our
evaluation of the warden’s performance was mostly positive, our audit of Folsom
State Prison uncovered several safety and security concerns. One area of concern
involves the work of the institution’s licensed vocational nurses (LVNs). Most of
Folsom State Prison’s 22 LVNs were hired between March and June 2007 and
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had never before worked in a prison setting. However, they were unsupervised
during that four-month period for more than one-third of the time in which
medications are distributed and when most patient care occurs. As a result, some
new LVNs unintentionally compromised the safety of staff members and inmates
on many occasions by inadvertently allowing inmates access to controlled
medications and syringes.
Our inspectors also found that some members of Folsom State Prison’s custody
staff do not conduct the minimum number of daily cell searches required by
department policy, which calls for random searches of three cells daily for both
the second and third watches. In examining cell search logs for several months,
we found that significantly fewer searches were conducted than required by
policy. Without adequate cell searches, hidden weapons and contraband go
undetected, endangering the safety of staff members and inmates.
Moreover, our inspectors found that the custody staff does not require inmates to
stand during the daily standing count. Section 3274 of the California Code of
Regulations, Title 15, requires each institution to conduct a physical count of all
inmates under its jurisdiction at least four times daily, one of which must be a
standing count during which inmates are required to stand. However, our
inspectors observed custody staff members allowing many inmates to sit or lie on
their bunks, some covered with blankets, during the prison’s daily standing
count—potentially preventing ill, injured, or escaped inmates from being
detected.
Finally, we found that locating a substance abuse treatment program for parolees
at the Folsom Transitional Treatment Facility—a facility that also houses a
substance abuse treatment program for inmates—exposes inconsistencies between
the policies governing the security level for inmates housed at the facility and the
policies governing eligibility for participation in the parolee program conducted
there. These inconsistencies include the potential for housing at the facility
parolees formerly classified as “maximum custody.” The Parolee Substance
Abuse Program is a drug treatment program under the custodial jurisdiction of
Folsom State Prison and its warden, but the department’s Division of Addiction
and Recovery Services (DARS) evaluates parolees’ eligibility for the program. In
doing so, DARS does not use the same criteria as the institution uses to assign
appropriate housing to inmates. Thus, the Folsom Transitional Treatment Facility
may house parolees participating in the substance abuse program whose presence
is technically prohibited by facility operational procedures.

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Institution Overview
Folsom State Prison is one of the California Department of Corrections and
Rehabilitation’s 33 adult institutions. Opened on July 26, 1880, Folsom State
Prison is the department’s second-oldest adult institution. The prison has a design
capacity of 2,236 beds and, as of September 30, 2007, it housed 4,059 inmates.
Folsom State Prison accommodates two levels of medium-security inmates (levels
II and III) within its four general population cellblocks and its administrative
segregation unit. The prison also operates a minimum-security unit and a
transitional treatment facility within its 40-acre site.
Substance Abuse Treatment
The Folsom Transitional Treatment Facility was activated in March 2004. The
facility offers two supervised, intensive substance abuse treatment programs. The
first program is for inmates scheduled for parole and lasts 120 days. The second
program is for parolees who have violated their parole terms through certain drugrelated violations. Participants in the Parolee Substance Abuse Program may elect
to participate in a 90-day substance abuse treatment program instead of returning
to prison. Both programs strive to help participants understand substance abuse
and recovery. As of September 30, 2007, the transitional treatment facility housed
287 participants combined from both programs.
Vocational and Educational Opportunities
Folsom State Prison inmates may participate in various vocational and
educational programs. For example, the Prison Industry Authority (PIA) operates
one of the state’s best-known enterprises at Folsom, the license plate factory. The
PIA also operates a sign shop and metal fabrication, furniture manufacturing, and
maintenance enterprises at the prison. Inmates may participate in other vocational
programs, such as building maintenance, janitorial, and landscape gardening.
Inmates interested in pursing educational opportunities may enroll in adult basic
education (ABE), high school, general education development (GED), literacy,
and computer-assisted instruction programs. Finally, inmates may also participate
in community service crews, a youth diversion program, religious programs, the
Folsom Project for the Visually Impaired, and the Arts in Corrections program.
Physical Plant Challenges
Built in the late 1870s, Folsom State Prison features unique structural
characteristics, such as five-tiered housing units equipped with manually operated
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doors. As such, Folsom State Prison poses both physical and security challenges.
The institution’s age necessitates frequent inspection, preventive maintenance,
and renovation to keep it running smoothly.
Many inmates must move unescorted throughout the institution. For example,
during our review, inmates housed in Units 1, 4, and 5 had to walk through Unit 2
to access the medical clinic, posing potential security risks for both the inmates
and staff. In addition, many staff members must walk through Unit 2 to reach
their assigned work areas. Because of the institution’s physical layout, inmate
movement throughout the institution can appear to be, as one correctional officer
described it, “controlled chaos.”
Health Care
Folsom State Prison’s unique structural characteristics also challenge the
institution’s health care team. According to the health care manager and the chief
medical officer, inadequate space to conduct the institution’s medical program
when compared to community standards is the health care team’s number one
concern.
Despite the prison’s physical plant challenges, the health care team provides
inmates with several important services. For instance, the health care team
operates a medical and dental clinic, as well as a triage area, pharmacy, and
radiology area. The prison’s physicians treat about 25 to 45 patients each day,
while the triage nurses evaluate 100 to 125 patients each day. In addition, the
pharmacy staff administers 400 to 500 prescriptions daily. The institution does not
have enough space to provide inpatient hospital care; thus, the health care team
refers inmates who require hospitalization to the adjacent California State Prison,
Sacramento, or to outside hospitals as needed.
Folsom State Prison also operates a mental health unit that provides treatment for
inmates who participate in the Correctional Clinical Case Management System
(CCCMS). CCCMS is an outpatient program designed to maintain or improve
functioning of mentally disordered inmates. Approximately 800 inmates
participate in Folsom’s CCCMS program. The mental health unit refers inmates
requiring 24-hour inpatient psychiatric attention to California State Prison,
Sacramento, or to outside hospitals as needed.
On April 17, 2006, a federal court-appointed receiver assumed control of the
California Department of Corrections and Rehabilitation’s medical system. One
of the receiver’s duties is to ensure that the quality of medical services in
California prisons meets constitutional standards. To that end, the receiver
implemented several changes throughout the department, many of which affected
Folsom State Prison. For example, the receiver replaced all medical technical
assistants with licensed vocational nurses in late 2006. More recently, in May
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2007, Folsom State Prison became the first of the department’s 33 institutions to
implement the receiver’s new pharmacy operating procedures.1
Budget and Staffing
For fiscal year 2006–07, Warden Matthew C. Kramer manages an operating
budget of $114.9 million, which includes 1,078 budgeted positions, of which 654
positions (61 percent) are custody staff. The table below summarizes Folsom
State Prison’s budgeted and filled positions as of September 30, 2007. As shown
in the table, almost 94 percent of the authorized positions were filled.
Staffing Levels at Folsom State Prison*
Position

Custody
Support
Medical
Trades
Education
Management
Total

Filled
Positions

Budgeted
Positions

Percent Filled

635
130
101
90
44
10

654
149
122
97
45
11

97.1%
87.2%
82.8%
92.8%
97.8%
90.9%

1,010

1,078

93.7%

Source: California Department of Corrections and Rehabilitation,
COMPSTAT, 3rd Quarter 2007 (as of September 30, 2007), Folsom State
Prison.
* Unaudited data.

1

The Maxor National Pharmacy Services Corporation provides pharmacy management consulting services
to the receiver.
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Chapter 1:
One-Year Evaluation
of Warden Matthew C. Kramer
California Penal Code section 6126(a)(2) requires the OIG to audit each warden
one year after his or her appointment, and to audit each correctional institution at
least once every four years. To satisfy this requirement, our inspectors audited the
warden’s performance and the institution’s operations simultaneously.
Objectives, Scope, and Methodology
To understand how the staff and other stakeholders view the warden’s
performance, we surveyed three distinct groups. Specifically, we sent surveys to
19 officials at the California Department of Corrections and Rehabilitation and at
Folsom State Prison. Of those surveys, we received 11 responses. We also
delivered surveys to 204 institution employees and received 54 responses. Finally,
we sent surveys to 15 key stakeholders, including certain members of the
Legislature, representatives of unions and associations, a local district attorney,
and a court-appointed special master. However, we received only one response.
Our inspectors toured Folsom State Prison to gain insight into the environment
where the warden must perform. We also interviewed key staff members and
reviewed the prison’s records in the following areas:
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health care
inmate appeals
inmate discipline
investigative services
litigation
labor relations
inmate records
plant operations

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educational and vocational programs
inmate visiting
receiving and release
personnel assignment
perimeter security
armory
procurement
housing units

We also toured the Folsom Transitional Treatment Facility and the grounds
operated by the Prison Industry Authority (PIA). During our site visits, we asked
54 individuals throughout the institution to rate the warden’s performance. These
individuals included custody staff members, executive management team
members, union representatives, education and health care professionals, and
representatives from the Inmate Advisory Council and the Citizen’s Advisory
Committee. We also reviewed relevant logs, reports, and other documents related
to the warden’s performance over the past year, including the results of our
institutional audit contained in Chapter 2.
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Background of Warden
Folsom State Prison represents Warden Matthew C. Kramer’s second
appointment as a warden for the California Department of Corrections and
Rehabilitation. Kramer served as the warden of the Sierra Conservation Center
from March 1996 through June 2005, where he managed the institution and its 22
conservation camps. From February 1994 through March 1995, Kramer served as
the acting warden of the California Correctional Center in Susanville while he
assisted with the activation of High Desert State Prison. Governor
Schwarzenegger appointed him as Folsom State Prison’s warden on May 5, 2006.

Discussion of Warden’s Strengths
Kramer has improved staff morale, according to staff interviews. During his
first year of appointment at Folsom State Prison, Kramer faced challenges
requiring adverse personnel actions against members of his management team. He
confronted these challenges and took action to restructure and rebuild the team.
After an initial period of disruption, the institution’s general morale and relations
among staff members improved, according to staff interviews. Staff members felt
the institution was better off, and they generally approved of Kramer’s actions.
One unit supervisor said that Kramer was instrumental in rebuilding morale, while
another unit supervisor said that institution communication and morale is the best
in ten years.
Kramer has significant experience as a warden. Having served as acting
warden and warden since February 1994, Kramer has a significant amount of
warden experience. Kramer was a warden for nine years at the Sierra
Conservation Center before being appointed as warden at Folsom State Prison.
Kramer is viewed as an effective administrator. Staff members we surveyed
and interviewed described Kramer as an effective administrator who follows
sound correctional practices, listens to others’ opinions, and makes thoughtful
decisions. Others described him as an advocate for inmate programming who also
supports the medical functions at the prison. Staff members who interact directly
with Kramer said that he is personable and expresses himself well. In addition,
many mentioned his open-door policy and willingness to meet with staff
members. The local chapter representatives of two staff labor organizations also
commented favorably about Kramer’s overall performance.
Supportive of the institution’s medical function, Kramer assigned the associate
warden of health care services to attend all meetings on health care issues for
which the institution’s chief medical officer requested her assistance. Kramer also
rearranged the schedules of the correctional officers who escort inmates to
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medical appointments to coincide with medical clinic hours and thus increase
operational efficiency. Previously, those officers’ schedules differed from the
clinic’s hours of operation and from medical staff schedules, which created
conflicts for both custody and medical personnel.
Kramer supports inmate programming. Kramer has also worked to improve
inmate programming. He changed institution policy so that the inmate assignment
office now provides “priority ducats,” or passes for inmates to move between
locations, instead of general ducats to inmates scheduled to take the GED test.
Priority ducats ensure that inmates are not prevented from taking the test by
lockdowns or modified programs. Further, Kramer extended inmate visiting hours
so they start on Friday afternoon, instead of limiting visiting to weekends. Kramer
also arranged for inmates assigned to PIA jobs to attend education classes in
upstairs classrooms in PIA work areas after the regular work shift, and in doing
so, alleviated conflicts between inmates’ work and school schedules. Moreover,
representatives from the Inmate Advisory Council rated Kramer “outstanding,”
saying that Kramer made many improvements, such as helping to establish selfhelp programs and food sale events benefiting outside charity groups. Staff
members reported that Kramer emphasizes inmate programming and has
supported the use of volunteer veterans groups in inmate programs.
Kramer received a favorable overall rating from the staff and management.
Of the 54 individuals we asked to rate the warden’s performance, 31 provided an
overall rating for Kramer.
Warden’s Overall Performance Rating
The remaining 23 had no
Rating
Respondents
Percentage
direct interaction with him
Outstanding
11
35%
and did not provide a rating.
Very Good
12
39%
Twenty-three of 31
Satisfactory
7
23%
Improvement Needed
0
0%
respondents (74 percent)
Unacceptable
1
3%
rated the warden as either
Total
31
100%
“outstanding” or “very
good.”
Survey results also indicate a favorable overall rating for Kramer’s management
skills in six rating categories based on the following 1-to-5 scale, with 1 being the
highest: “outstanding,” “very
Warden Rating of Management Skills and Qualities:
good,” “satisfactory,”
Rating on a Scale of 1 to 5
“improvement needed,” and
Category
Average Response
“unacceptable.” The survey
Leadership
2.27
respondents’ average rating
Communication
2.09
Decision Making
2.45
of 2.18 corresponds most
Organization/Planning
2.00
closely with a qualitative
Relationships with Others
2.27
rating of “very good.”
Personal Characteristics/Traits
2.27
Overall Rating: Very Good

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Discussion of Criticisms
The warden needs to hold staff members accountable for critical safety and
security procedures. As discussed in Chapter 2 of this report, our audit disclosed
that some custody staff members are not conducting the minimum number of cell
searches required by department standards, and they are failing to require inmates
to stand during the institution’s daily standing count. The importance of these
procedures is unquestioned, and as the individual responsible for the overall
safety and security of the institution, the warden must hold the staff accountable
for following these procedures.
Some custody staff members criticize the warden’s stance on safety and
security. Staff surveys and interviews highlight the sometimes conflicting
concerns between the need to maintain institution safety and security versus the
need to provide inmate programming and rehabilitation. Staff members in the
areas of health care, education, vocational trades, and the PIA generally gave high
marks to Kramer for being supportive of inmate programming and their respective
areas.
In contrast, some custody staff members responding to the survey felt that the
warden initiates too few lockdowns and that the length of lockdowns is too short.
Lockdowns are implemented to gain control of dangerous conditions, such as
disruptive inmate behavior. While lockdowns are important to the institution’s
investigative process, they also interrupt inmate programming by keeping inmates
from their work assignments, educational classes, vocational training, and
rehabilitative activities. On the other hand, releasing inmates from lockdowns too
soon may lead to more disruptive behavior.
We note, however, that Kramer’s emphasis on inmate programming parallels the
department’s emphasis on rehabilitation. Further, statistical data maintained by
the department shows that Folsom State Prison’s incidents of inmate violence and
disruptive behavior are no more frequent than at other institutions to which the
department compares it for analysis. Without objective supporting evidence,
criticisms of the warden’s handling of inmate lockdowns should not negatively
affect him.
Warden’s Response to Criticisms
In his December 21, 2007, interview with the Inspector General, Kramer
acknowledged the importance that cell searches and standing counts play in
maintaining Folsom State Prison’s safety and security. Kramer further stated that
he is committed to ensuring that his staff consistently follows department
standards, adding that, to replace the various methods currently in practice, all
housing units in the institution will adopt a uniform method of documenting cell
searches.
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Kramer also responded that when lockdowns become necessary, releasing inmates
is a risk-filled process that must consider many factors—including factors that are
at odds with each other. He noted that he carefully considers each lockdown and
weighs the risks by balancing his overall responsibility for institutional safety and
security against his need to provide rehabilitative programming for the inmate
population.
Summary Discussion
Kramer has over 20 years of experience with the California Department of
Corrections and Rehabilitation, including nine years as warden at the Sierra
Conservation Center before becoming warden at Folsom State Prison. Staff
members describe him as an experienced warden and an effective administrator
who has improved staff morale. The non-custody staff praises him for being
supportive of inmate programming, while some custody staff members criticize
him for prioritizing inmate programming at the possible expense of institution
safety and security. We found that he must improve staff performance in the areas
of cell searches and standing counts to ensure the safety of the staff and inmates.
Nevertheless, Kramer continues to be a strong advocate of the department’s
emphasis on inmate rehabilitation by providing inmates with programming
opportunities. On average, Kramer scored qualitative ratings of “very good” based
on staff interviews and surveys.
In summary, Warden Matthew C. Kramer is performing his duties well, and we
are confident that he is moving the institution forward as warden at Folsom State
Prison.

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Chapter 2:
Quadrennial Audit Findings
and Recommendations
Objectives, Scope, and Methodology
We gained an understanding of Folsom State Prison’s mission and safety and
security concerns by reviewing applicable laws and regulations, department and
institution policies and procedures, and other criteria related to key facility
functions. As detailed in Chapter 1, we also visited the institution and observed its
general operations, sent surveys to staff members and key officials, and
interviewed various employees and inmates. In addition, we reviewed prior audit
reports and various statistical data reports that concern the institution.
After assessing the institution’s operations and the survey results, we focused our
audit work on the institution’s efforts to maintain a safe and secure environment.
These efforts include
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holding inmates and employees accountable for their actions and behavior;
preventing contraband from entering the institution through visiting;
ensuring custody staff properly conduct the daily standing count of
inmates;
conducting the daily minimum number of cell searches;
ensuring a secure perimeter;
supervising new nursing staff.

We also assessed awareness of methods to minimize inmate and staff exposure to
the Methicillin-resistant Staphylococcus aureus, commonly referred to as MRSA,
and the process for determining eligibility for the Parolee Substance Abuse
Program, an area of particular concern to the warden. In addition, we reviewed the
institution’s process for identifying and referring inmates needing mental health
services. Finally, we assessed whether the institution accurately reports certain
statistics to the department’s COMPSTAT2 unit.
In conducting our work, we performed the following procedures:
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To determine whether new nursing staff members are adequately oriented
in dealing with inmates and supervised to ensure their safety and the safety
of others in the institution, we studied applicable department and
institution policies and procedures, and we interviewed members of the

2

Short for Comparative Statistics, COMPSTAT tracks organizational data to determine increases or
decreases in performance in the areas of safety, security, programs, finance, and operations.
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custody staff, nurses, and other medical staff members. We also reviewed
nurse supervisor time sheets, various memorandums and reports of
incidents involving nursing staff, executive staff meeting minutes, and
employment applications for licensed vocational nurses. In addition, we
observed procedures at the nursing stations within the institution. Our
findings and recommendations in this area are discussed in Finding 1.
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To determine whether the institution conducts the minimum required
number of cell searches, we studied applicable regulations and department
policies, unit activity logs, and daily cell search logs, and we interviewed
members of the custody staff. Finding 2 discusses our findings and
recommendations in this area.

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To determine whether inmates are required to stand during the institution’s
daily standing count, we observed the standing count as it occurred in four
of the institution’s five celled housing units. Finding 2 discusses our
findings and recommendations in this area.

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To assess the process for admitting parolees to the Parolee Substance
Abuse Program at the Folsom Transitional Treatment Facility, we
familiarized ourselves with the program assignment process. We also
interviewed parole staff, parole management, custody staff, and union
representatives. In addition, we reviewed reports containing specific
information system queries from the department’s Distributed Data
Processing System. Our findings and recommendations are discussed in
Finding 3.

We also performed the following procedures; however, no significant issues came
to our attention in these areas.
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To determine whether inmates are held accountable for their actions and
behavior, we reviewed a sample of disciplinary logs, rules violation
reports, and inmate central files.

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To determine whether employees are held accountable for their actions
and behavior, we reviewed a sample of inmate appeals against employees,
the outcomes of the related inquiries and investigations, and the
subsequent disciplinary actions, when applicable.

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To assess the institution’s compliance with inmate visiting procedures, we
reviewed applicable post orders, interviewed visiting staff, and observed
visiting operations.

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To assess the adequacy of the institution’s awareness concerning methods
to minimize staff and inmate exposure to MRSA infection, we interviewed
the institution’s chief medical officer and an official at Cal/OSHA, and we

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attended an institutional staff meeting on MRSA in correctional settings.
We found that the institution and the department understand how the
infection is transmitted and are aware of the methods to prevent its spread
among the inmates and staff.
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To determine whether significant weaknesses in the institution’s security
perimeter exist, we reviewed applicable department policies and toured the
security perimeter.

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To understand and evaluate the adequacy of the process used to identify
incoming inmates who have mental health problems, we interviewed the
institution’s senior psychologist, the receiving and release sergeant, the
triage registered nurse assigned to the receiving and release unit, and
living unit staff. We also reviewed various records, forms, and documents
related to the identification process, including inmate unit health records.
Lastly, we reviewed the latest corrective action plan and other
correspondence related to the Coleman3 class action lawsuit.

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To determine the institution’s compliance with the Armstrong 4 class
action lawsuit, we attended a meeting on the institution’s compliance
status with Armstrong, and we toured the institution with the Armstrong
monitor.

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To understand and evaluate the adequacy of the process used to compile
selected data reported to the department for inclusion in its quarterly
COMPSTAT report, we interviewed institution employees. We evaluated
the accuracy of the data reported by reviewing source documentation for a
select period.

Finally, we summarized the results of our work and developed our
conclusions.

3

In Coleman v. Wilson, a federal court found that the department’s mental health system was
unconstitutional and that institution officials were intentionally indifferent to the needs of mentally ill
inmates. All California Department of Corrections and Rehabilitation institutions are now being monitored
by a court-appointed special master to assess compliance with the federal court’s order.

4

In Armstrong v. Wilson, a federal court issued an injunction to improve program access for inmates with
disabilities after ruling that the department’s prisons and parole facilities violated the Americans with
Disabilities Act and the Rehabilitation Act.
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Finding 1
Poor implementation of the changeover from medical technical assistants to
licensed vocational nurses left the nurses unsupervised and ill prepared to
work in a prison setting.

With a court order stemming from the Plata v. Schwarzenegger5 litigation, the federal
court-appointed receiver replaced medical technical assistants (MTAs) with licensed
vocational nurses (LVNs) at prisons statewide. The timing of the MTAs’ replacement
was intended to ensure the LVNs were adequately trained before the MTAs left.
However, when most of the LVNs began working at Folsom State Prison, most of the
MTAs were gone. In addition, the LVNs’ on-the-job training did not make up for the
lack of mentoring the MTAs could have provided because too few experienced nurses
were available to provide adequate training. Consequently, the LVNs were ill prepared
to function in a prison environment where safety and security consciousness is
paramount given the criminal nature of the patient population. Moreover, in their first
few months of employment, the LVNs went unsupervised for more than one-third of
the daily hours during which medications are distributed and when most patient care
occurs. As a result, LVNs inadvertently allowed inmates access to medications and
medical supplies.
Background. The receiver implemented a significant change to each institution’s
nursing department by replacing MTAs with LVNs. The MTAs were correctional
officers who also were licensed vocational nurses or registered nurses; they assisted in
the medical care of inmates, as well as maintained order and supervised inmates, much
like the correctional officers. According to the receiver, MTAs served primarily as
LVNs in the prison medical system, but their dual role as both correctional officer and
nurse caused confusion in the workplace, divided loyalties, and made recruitment of
registered nurses difficult. The institution’s MTA-to-LVN conversion began in
September 2006, and all MTA positions at Folsom State Prison were vacated by June 1,
2007.
Initially, the receiver allowed institutions to hire LVNs into temporary buffer positions
or into vacant MTA positions to create a foundation of trained LVNs prior to and
during the MTAs’ departures. At Folsom State Prison, however, the foundation of
trained LVNs did not materialize before the MTAs left. Although the prison began the
hiring process soon after receiving authorization and interviewed applicants in October
and November 2006, out of eight job offers only two LVNs were hired. Folsom State
Prison continued to have difficulty hiring LVNs during the first few months of 2007; by
5

In this class action lawsuit, inmates alleged that California Department of Corrections and Rehabilitation
officials inflicted cruel and unusual punishment by being intentionally indifferent to inmates’ medical
needs. A 2002 settlement agreement required the department to overhaul its medical care policies and
procedures, as well as ensure prompt access to adequate medical care. However, in May 2005, federal court
reports showed continued medical malpractice and neglect. Consequently, in October 2005, the judge
ordered that the department’s medical care system be placed under the control of a court-appointed
receiver.

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Page 14

mid-February 2007, only nine of the 21 MTAs working at the start of the conversion
remained at the prison, and only five permanent LVNs had started work. Between
March and June 2007, the prison eventually succeeded in hiring 17 additional LVNs.
Three of the new employees were already working at the prison as registry contract
nurses, but nine others started working between mid-May and June, leaving little or no
time to benefit from the experience of the seven MTAs who remained in their positions
until May 30, 2007.
Folsom State Prison used medical registry contracts6 to fill its nursing vacancies during
the transition. In fact, until the positions were permanently filled, they were temporarily
filled by 22 different registry contract LVNs. To compound the matter, six permanent
LVNs resigned before the end of June, and the resulting vacancies were once again
temporarily filled by registry nurses. Ultimately, most of the permanent LVNs were
hired too late to benefit from working with and learning from the experienced MTAs.
In addition, in May 2007, the receiver’s pharmacy management consultant, Maxor
National Pharmacy Services Corporation, implemented a new pharmacy operating
system at Folsom State Prison while the nursing department was still undergoing the
MTA-to-LVN transition. As a result, according to a nurse supervisor at the institution,
the confusion that employees typically experience when a new system is implemented
was exacerbated by frequent procedural changes in response to unanticipated problems,
coupled with inexperienced LVNs adjusting to those changes while being reassigned to
meet additional staffing needs.
Folsom State Prison’s LVNs distribute and administer medications to about 2,400
inmates in designated housing units throughout the prison. The LVNs must ensure that
inmates receive accurate doses of prescribed medication, and they must also safeguard
the medications and syringes in their work areas. For the LVNs, morning and evening
medication distribution begins with diabetic inmates lining up for insulin injections
that, in most cases, inmates are allowed to self-administer. Next in line are inmates with
prescriptions for medications that require administration by licensed health care staff.
For example, for drug types such as narcotics and tuberculosis medications, the nurse
must observe the inmate take the medication and verify that the medication is
swallowed by completing a visual mouth inspection and viewing the empty water cup.
When inmates receive medications, the LVNs also are required to verify the inmate’s
identity, verify that he has an active prescription, and document in the inmate’s medical
record that the medication was given.
Most of the recently hired licensed vocational nurses lacked prior correctional
experience. For 16 of Folsom State Prison’s 22 LVNs, their previous nursing
experience was limited to caring for patients in community hospitals or skilled nursing
facilities. In contrast, the patients in a prison setting are convicted criminals, many with
histories of violence or drug abuse, who move about unrestricted areas of the prison.
Moreover, the culture of prison life may also induce inmates to seek drugs or syringes
6

A medical registry coordinates the availability of temporary medical staff when the prison needs such
services.
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for abuse or sale, or to seek unsecured items to use as weapons. In comparison to
working in a community hospital, working in a prison requires new LVNs to be more
aware of their surroundings and potential dangers that can jeopardize safety and
security.
An awareness of prison culture and the development of strong security practices
are critical to the safety of the inmates and staff. Well-trained nurses in a prison
environment should know that many inmates take advantage of situations in which staff
members are inattentive or easily manipulated. For instance, the department’s Inmate
Medical Services Program Policies and Procedures manual requires licensed health care
staff to record the administered medication in the inmate’s medical record. But the
nurses do not always record the information immediately after administering the
medication. Consequently, if an inmate claims that he has not received his medication,
the nurse dispensing the medication has no evidence to indicate otherwise and risks
giving the inmate additional doses.
In one instance, nurses reported missing five tablets of Oxycodone, a narcotic typically
used for pain relief, after conducting a count of remaining medications following the
morning distribution. Folsom State Prison’s head pharmacist told us he received a
report that the LVN dispensing the narcotics had unknowingly given an inmate with
terminal cancer a double dose of medication. After receiving his prescribed dose of five
Oxycodone tablets, the inmate got back into the pill line. When later seen by a doctor,
the inmate admitted that he had noticed that the LVN had not recorded giving him the
five tablets, and he stepped back into the line hoping that she would not recall seeing
him and would give him another five tablets. The LVN apparently did not recall seeing
the inmate earlier that morning and, because she had not promptly recorded that he had
already received five tablets, she had no way to verify that fact and gave the inmate
another five tablets.
The nurses must also be diligent when observing inmates placing their used syringes
into biohazardous waste containers after self-injecting insulin. It is imperative that
syringes be properly disposed of so they are inaccessible to inmates; otherwise, the
syringes are sought by inmates to engage in illegal drug activity. For example, officers
found syringes in the cells of two inmates who recently died of suspected drug
overdoses. In June 2007, a correctional officer witnessed one LVN turn his back while
an inmate injected himself with insulin. According to the officer, rather than dispose of
the used syringe, the inmate put it in his pocket after realizing that the nurse was not
watching. When questioned by the LVN, the inmate told the LVN that he had already
placed the syringe in the disposal container. Had the officer not been observant,
prompting the inmate to dispose of the syringe, the inmate could have later used the
syringe to administer illegal drugs himself, or passed it to another inmate. In a similar
example, another LVN reported missing nine syringes in March 2007 after she briefly
turned around while handing out medications in a housing unit. According to the
minutes of an April 2, 2007, warden’s executive staff meeting, the nurse reported that
when she turned back around, she saw an inmate place an empty syringe box back
inside the window where the box had been sitting. Although the nurse was able to
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identify the inmate, who was subsequently placed into the administrative segregation
unit, staff members were unable to immediately find the syringes. Seven of the syringes
were later found in a garbage can in the housing unit.
Other lapses of security procedures have also occurred in the housing unit clinics. For
example, in June 2007, a medical security sergeant reported the padlock to the
medication locker missing. Although we found no evidence that an inmate took the
padlock, inmates have been known to insert padlocks into socks and use them as
weapons by swinging the weighted sock. As discussed in the following section, a more
experienced nurse providing on-the-job training might have noticed that the nurses
were not adequately safeguarding the padlock once they had removed it from the
medication locker—a routine precaution that they might not have had to consider until
they began working in the security-conscious environment of a prison.
LVNs did not promptly attend new employee orientation. The California
Department of Corrections and Rehabilitation requires all new employees to attend a
40-hour orientation course within the first 30 days of appointment. At Folsom State
Prison, this new employee orientation course covers 22 topics, including two topics that
are relevant to maintaining safety and security: one hour of training on inmate/staff
relations and one hour on escape prevention and key and tool control. Despite this
requirement, as of July 9, 2007, four LVNs at Folsom State Prison—all of whom had
been working for at least one month and had no prior experience working in a
correctional setting—had not attended the two sessions related to safety: inmate/staff
relations and key and tool control. Another three LVNs who had been working since
April or May 2007 had attended only one of the sessions. By not receiving the safety
and security training, these nurses were less aware of necessary safeguards that
heighten their safety and the safety of others.
Besides the prison’s 40-hour orientation course, the nursing department has its own
new employee orientation program that also covers various topics, including
overfamiliarity with inmates and key control. Moreover, the orientation manual
provided to medical personnel states that “keeping a safe and secure environment will
require that you become aware of things that can jeopardize the safety and security of
the institution.” According to Folsom State Prison’s staff development nurse, the
nurses’ orientation course consists of two days of classroom instruction followed by
eight days of on-the-job training with a more experienced nurse. The training records
indicate that all the new LVNs received the two days of classroom instruction.
However, the on-the-job training the LVNs received was ineffective because not
enough experienced nurses were available to provide the training after the MTAs left.
The information presented in either of these new employee orientation sessions should
raise an employee’s level of awareness of the correctional setting. Still, orientation is
cursory by nature, and attendance at the sessions is not enough by itself to ensure that
new employees learn how to handle inmates and what special precautions they must
consider—topics more effectively learned through on-the-job training and experience.
On-the-job training under direct supervision—when nurses encounter actual
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situations—is a necessary part of their orientation that ensures they are adequately
prepared to handle inmates and understand the special precautions inmates require.
The existing supervisory staff is unable to adequately monitor and train the new
licensed vocational nurses. Nursing activities generally occur 16 hours each day
during the second and third watches. Thus, depending on whether a month has 30 or 31
days, either 480 or 496 monthly hours are available for nursing supervisors to answer
questions from the nursing staff, communicate new information, model appropriate
behaviors, observe and correct unsafe work habits, and inspect syringe and key control
logs. We analyzed the nursing supervisors’ time sheets for April through June 2007 and
found that nursing supervisors were unavailable for a significant number of hours. This
condition diminished the supervisors’ ability to observe and monitor the new LVNs.
After accounting for factors such as sick leave, vacation leave, and training days,
the total supervising hours available was reduced by an average 168 hours each
month, or about the equivalent of a full-time employee. In addition, on many
weekends during this time, a nurse supervisor was at the prison on only one of the
days. And except for an on-call supervisor, no supervisors worked on holidays
even though the prison’s urgent care clinic, called the Triage and Treatment Area,
is open and LVNs still distribute medications in the housing units on those days.
Consequently, as shown in the following table, from April through June 2007
there was no nurse supervisor at the prison for 36 to 45 percent of the daily hours
starting from 5:00 a.m. and ending at 10:00 p.m., which is when medications are
distributed and most patient care occurs. For at least 25 percent of those hours,
there was only one nurse supervisor at the prison.
Percentage of Patient Care Hours with
Inadequate Supervisory Coverage:
April through June 2007

Percentage of patient care
hours with no supervisor
available
Percentage of patient care
hours with one supervisor
available

April

May

June

36%

45%

40%

30%

25%

27%

No specific policy requires supervisory coverage. However, given the unique
environment of a prison and the number of inexperienced LVNs, it is not
unreasonable to expect that the LVNs be under close supervision during peak
patient care hours until supervisors are satisfied that the LVNs understand and
follow procedures.
Time spent performing other duties further reduces the available hours for direct
supervision and on-the-job training of the new nursing staff. For example, nursing
supervisors must approve subordinates’ time sheets, prepare employee work
schedules, ensure positions are covered, handle employee disciplinary actions,
interview applicants for nurse positions, attend meetings, and work on special
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assignments. Supervising nurses told us that scheduling the nursing staff and
ensuring that enough LVNs are available to cover the housing unit medication
lines is a priority, but scheduling remains a chronic problem. The supervising
nurses also explained that scheduling problems were caused by the new pharmacy
services process and high turnover of LVN staff.
To compound the problem, Maxor decided to move the process for distributing
medication to inmates living in Units 3 and 5 out of Unit 2 and into the respective
housing units—a change that increased the number of inmate medication lines
and thus required more LVNs to cover the two shifts in each of the two units.
Further, LVN turnover—both permanent and temporary—and the sudden manner
in which many LVNs quit or are asked to leave also complicates scheduling. For
example, one nurse supervisor told us about a contract LVN who had called her at
home the previous night to tell her she had accepted another position and would
not be at work the following day. This same supervisor also told us that a contract
LVN was asked to leave the same day because he repeatedly displayed a poor
attitude.
Some controls designed for safekeeping medication and syringes are not adequate,
while other controls are not followed. Drugs, syringes, and other medical tools kept in
the Triage and Treatment Area are stored in lockable cabinets within a locked storage
room. The cabinets are equipped with padlocks, and signs posted on the cabinets
indicate they are to be kept locked. However, we observed several instances in which
the cabinets were left unsecured. We also learned that inmates performing janitorial
duties are allowed access to the storage room where, if supervised by an inexperienced
nurse, they could possibly open an unlocked cabinet, steal medications and syringes,
and later either take the medication or sell it to another inmate. Moreover, several staff
members, including some who are not assigned to the Triage and Treatment Area, have
keys to the storage room, which undermines the supervisors’ ability to hold staff
members accountable when medications and syringes disappear.
In addition to not locking the cabinets, we found in a review of logs that the Triage and
Treatment Area nursing staff do not always count the needles and syringes twice daily,
as required by Folsom State Prison’s operational procedures. The procedures state that
the two oncoming second watch staff members must count all needles and syringes.
Another count must be completed later in the day by one of the second watch nursing
staff members and the oncoming third watch nurse. In one example, a nurse reported
that 64 needles and syringes were missing after several consecutive counts had not been
conducted.
The court-appointed receiver’s observations parallel those of the Office of the
Inspector General. The receiver’s sixth quarterly report to the U.S. District Court,
dated September 26, 2007, discussed ongoing projects, including implementation of
Maxor’s new pharmacy operating system at Folsom State Prison. In his report, the
receiver acknowledged that implementation of the new pharmacy software system did
not go as smoothly as expected, and that the resulting problems had repercussions
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beyond the pharmacy walls and affected the medication delivery process to inmates.
The receiver’s report further explained that staff members were not trained in advance
to operate under the new system. This lack of training, coupled with the prison’s space
constraints, limited the nurses’ ability to deliver medications safely to inmates. The
receiver further acknowledged that these problems were compounded by implementing
the new pharmacy system “in the midst of the nursing staff’s transition from Medical
Technical Assistant positions to new LVN positions, resulting in a large number of new
LVNs at Folsom State Prison who were still being trained to perform medication
administration functions.” Furthermore, the receiver stated, “These new LVNs were not
prepared to handle prisoner/patients who were irate over not receiving their scheduled
medications.” However, the receiver’s report did not address the security concerns that
we raised in this finding.
Recommendations
The Office of the Inspector General recommends that the receiver and the
California Department of Corrections and Rehabilitation consider:
ƒ

Evaluating the adequacy of nursing supervision coverage at all institutions,
especially before implementing significant changes, such as the new
medication management system, and adding nursing supervisor positions
when warranted.

ƒ

Restricting access to Folsom State Prison’s Triage and Treatment Area
medication storage room to only those staff members responsible for
maintaining the counts and inventory. Staff members who have authorized
access should be held accountable when they fail to lock all medical
cabinets in the medication storage room after use.

ƒ

Ensuring that members of Folsom State Prison’s nursing staff attend
institution new employee orientation sessions relevant to safety and security
within the time frame established by the department or the receiver. The
orientation sessions should be expanded to include role-playing using actual
examples of unsafe and safe practices.

ƒ

Ensuring that members of Folsom State Prison’s nursing staff count
needles and syringes twice daily, in accordance with Triage and Treatment
Area procedures. Supervising nurses should be held accountable for
ensuring this requirement is enforced.

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Finding 2
Folsom State Prison’s custody staff does not consistently follow critical safety
and security procedures.

Among the most important procedures followed in a prison’s housing units are
daily random cell searches and daily standing counts. These procedures inhibit
inmates’ possession of potentially dangerous contraband and confirm inmates’
presence and physical welfare. However, some custody staff members at Folsom
State Prison do not consistently follow these procedures, as required by
department policy. As a result, they compromise public safety and the safety of
inmates and other staff members.
The number of daily cell searches does not meet department standards,
potentially allowing weapons and contraband to remain hidden. Some
custody staff members at Folsom State Prison are not conducting the minimum
number of daily cell searches, as required by section 52050.18 of the department
Operations Manual. The policy calls for daily searches of three cells, rooms,
dormitories, or living areas in each housing unit during both the second and third
watches, for a minimum of six searches a day. By not following this policy, the
staff’s interdiction of contraband in the housing units may suffer.
In examining housing unit cell search records, we found that Units 3 and 5
documented considerably fewer cell searches in the months we examined than
were required, as shown in the following table.
Housing
Unit

Month

Minimum Cell
Searches Required
(six each day)

No. of Cell
Searches
Recorded

Shortage

3

March 2007

186

60

126

5

March 2007

192 (includes Feb. 28)

166

26

5

April 2007

180

26

154

5

May 2007

186

8

178

Conducting searches in Unit 3 is crucial because most of the inmates housed in
Unit 3 are assigned to the Prison Industry Authority (PIA), and thus they have
access to potentially dangerous materials, such as tools and material scraps
commonly used by inmates to make weapons. Unit 3 also houses newly arrived
inmates who may pose potential threats because their behaviors or histories are
less likely to be known to the custody staff.
We recognize that correctional officers may be required to escort inmates to
programs, transport inmates to outside medical appointments, respond to
emergency incidents, write inmate disciplinary actions, and respond to inmate
appeals. Despite these other duties that officers must perform, detection of hidden
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contraband is critical to improving safety and security for the prison’s staff, as
well as in helping to reduce or prevent illicit inmate activity. For example, in May
2007, a cell search in Folsom State Prison’s administrative segregation unit
disclosed two weapons made from razor blades. Also, in June 2007, a correctional
officer conducted a cell search and discovered a green leafy substance suspected
to be marijuana. During this same search, the officer also discovered a cellular
phone charger and noticed one of the cell’s occupants holding a cellular phone.
Cell searches in Folsom State Prison’s housing units are inconsistently
recorded. The method for documenting cell searches varies not only among
housing units, but also among different shifts on the same housing unit. For
example, Unit 3’s second and third watch staff members document their cell
searches on a shared document, instead of using separate cell search logs, while
Unit 4 uses two separate formats unlike any used in other housing units. For
instance, Unit 4’s second watch staff records cell searches by cell number, while
its third watch staff records cell searches by the day of the month. The Unit 5
staff, meanwhile, uses two logs concurrently, one arranged by cell number and the
other by date.
While there is no officially mandated form or format for documenting cell
searches, recordkeeping inconsistencies make it difficult for institution managers
and supervisors to determine whether the custody staff is performing these duties
in accordance with department policy.
Although Unit 5 was deficient in the number of cell searches performed for the
months we tested, Unit 5’s method of documenting cell searches appears to be
particularly useful as a management tool. By using two parallel cell search logs,
users can determine not only that the minimum daily number of searches is
conducted, but they can also analyze the distribution of searches among cells, thus
avoiding inadvertently ignoring certain cells or focusing unnecessary attention on
others.
The custody staff allows many inmates to sit or lie on their bunks, some
covered with blankets, during the institution’s daily standing count,
potentially allowing ill or injured inmates from being detected. Contrary to
state regulations, the custody staff at Folsom State Prison does not require inmates
to stand during the daily standing count. As a result, staff members may fail to
notice safety and security problems, such as missing inmates, evidence of
criminal activity, or inmates with serious illnesses or injuries.
During one of our site visits, we observed a standing count conducted by the
custody staff. We noted that in three of four celled housing units visited many
inmates were allowed to sit or lie on their bunks, or they stood at the rear of their
cells, partially obscured behind their bunks. Section 3274 of the California Code
of Regulations, Title 15, requires each institution to conduct a physical count of

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all inmates under its jurisdiction at least four times daily, one of which must be a
standing count during which inmates are required to stand.
The intent of a standing count is to demonstrate that an inmate is present and that
the correctional officer performing the count can see that the inmate is alive, well
enough to stand, and free of obvious injuries or illnesses. The standing count thus
allows staff members to assess each inmate’s general welfare and identify serious
incidents, such as escapes and inmate violence.
The failure to require inmates to stand is, as one correctional sergeant explained, a
matter of expediency. The sergeant told us that the count numbers must be
reported in a timely manner, and asking inmates to stand would be time
consuming, especially considering the nearly 1,200 inmates in Unit 1. Thus, some
correctional officers are willing to accept verbal or physical acknowledgement
from inmates that they are well.
However, standing counts are required for a good reason. When inmates are
allowed to lie down or sit on their bunks during the standing count, as they did
during our observation, the custody staff might not notice serious injuries and
potentially miss detecting evidence of a serious incident. For example, on
September 6, 2005, at Pelican Bay State Prison, a correctional officer found an
inmate unresponsive in his cell during an institutional count. The inmate, whose
cellmate was suspected of his murder, had suffered serious facial injuries and was
pronounced dead. Further examination determined that the inmate had been dead
for about three days, undiscovered by custody staff. Had the custody staff
required the inmate to stand during the designated standing count, the inmate’s
condition and any evidence concerning the incident would have been discovered
sooner.
Recommendations
The Office of the Inspector General recommends that the management staff
at Folsom State Prison:
ƒ

Enforce the department’s Operations Manual requirements for daily
cell searches and ensure that supervisors monitor staff compliance
with those requirements.

ƒ

Develop uniform procedures throughout the institution for
documenting cell searches. The method should allow officers to easily
identify the cells searched, the date and watch of the search, and the
staff members conducting the search. The method currently employed
by Unit 5, involving the use of parallel logs, satisfies these elements.

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ƒ

Hold custody staff accountable for conducting the daily standing
count, as required by section 3274 of the California Code of
Regulations, Title 15.

ƒ

Use the inmate disciplinary system as necessary to require inmate
cooperation during the daily standing count.

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Finding 3
Housing certain parolees and inmates together in the same treatment facility
exposes classification policy conflicts and violates department procedure.

Background. Originally built in the late 1980s as a community correctional
facility operated by the City of Folsom, the 380-bed Folsom Transitional
Treatment Facility is a lower-security facility appropriate for inmates who can be
housed in its dormitory-style setting.
The facility operates under the jurisdiction of Folsom State Prison and its warden,
and it houses two separate substance abuse treatment programs. One is a prerelease program for Folsom State Prison inmates, and the other program, known
as the Parolee Substance Abuse Program, serves parolees and is under the
authority of the Division of Addiction and Recovery Services (DARS). Both
programs operate autonomously on separate yards at the facility. Inmates and
parolees, however, can be present concurrently in the facility’s administrative area
for activities such as medical treatment.
Parolees who have violated their parole terms because of actions related to drug
or alcohol dependency may participate in the substance abuse program in lieu of
parole revocation. The program reflects the department’s effort to provide
rehabilitative treatment services, and it provides an alternative to reincarcerating
these parolees. While parole violators participating in the Parolee Substance
Abuse Program retain their status as parolees, they wear the same clothing as
inmates and are restricted to the facility during the 90-day program under the
provisions of section 11561 of the Health and Safety Code.
Department policies for housing inmates in state institutions, including the
Folsom Transitional Treatment Facility, involve a classification process. The
classification process assesses inmates’ security risks and assigns them to
institutions capable of dealing with those risks. In addition, the department
considers the inmates’ degree of custody, a measure of the amount of supervision
inmates must have.
Before receiving permanent housing assignments, inmates typically undergo a
classification review in which the department considers the inmate’s background,
criminal history, and incarceration history to calculate a classification score under
guidelines outlined in section 3375.3 of the California Code of Regulations, Title
15. The resulting classification score determines the security level of the
institution to which the inmate may be permanently assigned and housed. The
following table summarizes the department’s classification scores and the
corresponding security levels.

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Classification
Score
Title 15, § 3375.1

Facility Security
Level
Title 15, § 3375.1

0 – 18

Level I

Open dormitories with a low-security perimeter

19 – 27

Level II

Open dormitories with a secure perimeter and
optional armed coverage

28 – 51

Level III

Secure perimeter, armed coverage, and celled
housing units

52 and above

Level IV

Secure perimeter, armed coverage, and cells nonadjacent to exterior walls

Facility Description
Title 15, § 3377

The Folsom Transitional Treatment Facility, with its open dormitories and lowsecurity perimeter, most closely resembles a level I or level II facility.
As the authority responsible for the safety and security of the treatment facility,
the warden is guided by Folsom State Prison’s local operating procedures, which
prohibit admitting level III and level IV inmates to the Folsom Transitional
Treatment Facility. Specifically, Operational Procedure 30 requires that parolees
received for placement in the Parolee Substance Abuse Program meet the same
placement criteria used for placing inmates in a community correctional facility.
Those standards, in turn, incorporate a policy memorandum dated May 11, 1998,
from the California Department of Corrections’ deputy director of institutions,
which states, “Effective immediately, inmates with a classification score of 28 or
greater shall not be endorsed or transferred to a [community correctional
facility].”
Besides prohibiting level III and level IV inmates, inmates labeled as “maximum
custody”7 are prohibited from direct placement in the treatment facility. Instead,
such inmates are initially segregated from the general population until further
assessment by a team of custody officials.
DARS does not focus on departmental housing criteria in determining
parolees’ eligibility to participate in the Parolee Substance Abuse Program.
Program participants currently on parole status are not subject to classification
reviews to determine their housing placement. Nonetheless, program participants’
histories are addressed by a parole agent II who screens parolees against various
eligibility criteria. For example, parolees cannot participate in the program if they
have histories of escape attempts, current gang affiliations, or convictions for
certain violent or sexually related crimes. Further, DARS prohibits program entry
to those who paroled from a security housing unit or a psychiatric services unit. If
7

The degree of custody reflects an inmate’s behavior while in custody along with other factors and
determines the amount of supervision an inmate must be assigned. For example, maximum custody inmates
must be housed in a cell in an approved segregated housing unit and be under the direct and constant
supervision of custody staff. In contrast, minimum custody inmates may be housed in either cells or
dormitories and require only supervision of their location adequate to ensure their presence. Inmates may
be designated as maximum custody irrespective of their assigned institution’s security level.

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the parole agent II finds the parolee eligible, the parolee is referred to the Board of
Parole Hearings for final approval.
Locating the Parolee Substance Abuse Program at the Folsom Transitional
Treatment Facility violates operational procedure and creates safety
problems. Because DARS’ program participation rules do not focus on
participants’ past custody classifications in the same way that the treatment
facility’s housing rules do, and because the warden has no authority over the
Parolee Substance Abuse Program, it is possible for DARS to place participants
who do not conform to the facility’s housing rules into the Parolee Substance
Abuse Program. In fact, treatment facility staff members advised Folsom State
Prison’s management that the transitional treatment facility has held program
participants who would be considered “maximum custody” if they were inmates,
and that this violates the provisions of Operational Procedure 30. The staff also
expressed concerns that this situation presents a potential safety issue.
We examined records of Parolee Substance Abuse Program participants for a 13month period from August 2006 through August 2007 and found nine program
participants whose former custody scores placed them in levels III and IV, as well
as four who were formerly designated as “maximum custody.” While we
confirmed that no violent incidents involving such parolees occurred at the
facility during the period we examined, their presence at the Folsom Transitional
Treatment Facility violates the provisions of Operational Procedure 30.
Another problem presented by locating the Parolee Substance Abuse Program in a
state correctional facility is the differing use-of-force policies applicable to
inmates versus those applicable to parolees. The department’s use-of-force policy
authorizes the use of deadly force to prevent an escape by an inmate. However,
the department’s Office of Legal Affairs confirmed that “normal escape
procedures cannot be employed during an escape or attempted escape of a parolee
participant in PSAP [Parolee Substance Abuse Program].” This opinion presents
the custody staff with a dilemma in the event of an escape attempt from the
Folsom Transitional Treatment Facility because inmates and parolees wear
identical clothing—leaving officers with no means to visually distinguish between
an escaping inmate and an escaping parolee. An officer would have to consider
that failure to use deadly force on an inmate could result in harm to the public, but
the use of deadly force on a parolee is prohibited.
Recommendations
Because of the unique issues surrounding the Folsom Transitional Treatment
Facility, the Office of the Inspector General recommends that the California
Department of Corrections and Rehabilitation consider using the facility
exclusively for one of the two treatment programs it currently houses—either

Bureau of Audits and Investigations
Office of the Inspector General

Page 27

the pre-release inmate substance abuse program or the Parolee Substance
Abuse Program.
Alternatively, if the department decides to keep inmates and parolees at the
facility simultaneously, the Office of the Inspector General recommends that
the department:
ƒ

Modify Operational Procedure 30 to eliminate current conflicts with
housing parolees at the Folsom Transitional Treatment Facility,
giving consideration to custodial safety and security needs while
advancing the department’s goals of providing rehabilitative services
to inmates and parolees.

ƒ

Consider issuing Parolee Substance Abuse Program participants
distinctive clothing to enable custody staff to distinguish them from
inmates.

Bureau of Audits and Investigations
Office of the Inspector General

Page 28

California Department of
Corrections and Rehabilitation’s
Response

Receiver’s Response