April 9, 2003

Ms. Yvonne B. Burke
Chair
Los Angeles County Board of Supervisors
500 West Temple Street, Suite 866
Los Angeles, CA 90012
Re:

Los Angeles County Juvenile Halls

Dear Ms. Burke:
We write to report the findings of our investigation of
conditions at the Los Angeles County Juvenile Halls (“the
juvenile halls”). On November 8, 2000, we notified you of our
intent to investigate the juvenile halls pursuant to the Civil
Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C.
§ 1997, and 42 U.S.C. § 14141.
Between February 12 and June 7, 2001, we conducted on-site
inspections of the facilities with expert consultants in juvenile
corrections, medical care, mental health care, sanitation,
education and educational services for speakers of other
languages. We visited Central Juvenile Hall February 12, 13
and 16, April 2-5, and May 21-24, 2001. We visited Barry J.
Nidorf Juvenile Hall February 14-15, February 27 - March 1, and
June 4-7, 2001. We visited Los Padrinos Juvenile Hall April 1619 and May 7-10, 2001. While at the juvenile halls, we
interviewed staff at all levels, resident youth, medical and
mental health care providers, food service and sanitation
personnel, teachers and school administrators. Before, during
and after our visits we reviewed an extensive number of
documents, including policies and procedures, incident reports,
medical and mental health records, grievances from youth
residents, suspected child abuse reports, unit logs, orientation
materials and school documents. Consistent with the statutory
requirements of CRIPA, we write to advise you of the results of
this investigation.
We commend the staff of the facilities and County
administrators for their helpful and professional conduct
throughout the course of the investigation. Staff and
administrators cooperated fully with our investigation, made

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exceptional efforts to be hospitable during our visits, and have
provided us with substantial assistance. In addition, subsequent
to our visits and the County’s further production of documents,
the County provided us with updates of remedial efforts it has
made since the time of our visits.
The County reports having gathered task forces and response
teams to coordinate remedies for all items our expert consultants
raised during their informal exit presentations at the end of
their facility visits. We have not yet confirmed the
effectiveness of those efforts through further on-site or
document reviews, but will do so in the near future. We
appreciate the County’s responsiveness to our experts’ on-site
recommendations, and look forward to seeing the improvements the
County reports it has made. We commend the County’s effort to
begin systemic change across the many departments responsible for
the halls and hope that lasting improvement of conditions of
confinement will be the long-term result of this reported
collaboration. This letter will describe the conditions as we
determined them to be through our facility visits and document
review, and also acknowledge where the County reports it has
undertaken remedial efforts in many of these areas.
As described more fully below, based on our documentary
review and on-site investigations, we conclude that certain
conditions at the juvenile halls violated the constitutional and
federal statutory rights of the youth residents. We find that
persons confined suffered harm or the risk of serious harm from
deficiencies in the facilities’ medical and mental health care,
sanitation, use of chemical spray, and insufficient protection
from harm. In addition, we conclude that failure to provide
proper rehabilitation, education, opportunities to use the
telephone and participate in religious programming, insufficient
provision of translation services for Limited English Proficient
(LEP) youth, and an ineffective grievance system also violated
residents’ rights under the 14th Amendment and other applicable
laws.
I.

BACKGROUND
A.

FACILITY DESCRIPTIONS

All three facilities house both pre- and post-adjudicated
youth, including those awaiting placement or transportation to
a youth camp and some who have returned from unsuccessful
placements or camp stays. Youth generally range in age from 11

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to 19, though the facilities have housed youth as young as nine
years old. While the average length of stay at the halls is 16
to 24 days, some youth are released in a matter of hours and some
youth remain at the halls for months or even as long as a year.
Youth who have been adjudicated or who have returned from an
unsuccessful placement remain at the halls awaiting placement in
an appropriate facility.
Youth are supervised by officers from the Los Angeles County
Probation Department (“probation staff”). Mental health services
are provided by employees of the County Department of Mental
Health. Medical services at the halls are provided by contract
with Los Angeles County - University of Southern California (LAUSC) Department of Pediatrics. All medical clinicians, medical
support staff, and health administrative staff work for the
contractor. Most maintenance at the halls is completed by a
separate County agency, the Internal Services Department (ISD).
Finally, the Los Angeles County Office of Education (LACOE), a
subdivision of the California Department of Education, provides
educational services. Coordination of these varied county and
state agencies to provide safe, appropriate and integrated
services at the halls is a significant challenge for managers of
these facilities.
Central Juvenile Hall (“Central”), located in the Lincoln
Heights section of the City of Los Angeles, is the oldest of the
juvenile halls. Construction dates of various buildings at the
facility range from 1924 to 1978, with some construction
currently underway. The average daily population at the time of
our visits was approximately 5751/, although the rated capacity
was 440.2/ Central is the location for overnight stays for youth
needing outside medical treatment, occasionally houses INS and
U.S. Marshals Service youth detainees and has an average length
of stay of 23 days.3/ Some youth awaiting trial in adult court
1


/Populations at all the facilities fluctuate throughout the day
as youth enter the facilities, attend their court hearings and
are moved between the halls or to other facilities.

2


/The Los Angeles County Probation Department (“Probation
Department”) reports that the population at the three halls since
the time of our tours has declined from an average of 1970 to
just over 1600 youth.

3


/Average length of stay numbers cited in this letter are those
provided by the County. In calculating those numbers, the County

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were housed at this facility at the time of our visits.
Barry J. Nidorf Juvenile Hall (“Nidorf”), located in Sylmar,
California, was constructed in 1978, with a significant expansion
of housing space between 1994 and 1998. Average daily population
was 712 during our visits, though rated capacity was 675. At the
time of our tours, the movement control office and other
structures had been closed following the Northridge earthquake in
1994, and were awaiting repair. Alternative temporary structures
served in their stead. Youth who await transfer to one of the
County’s “camp” placements are housed at Nidorf, where they
complete the first phase of the camp program. Average length of
stay is 24 days.
Los Padrinos Juvenile Hall, located in Downey, California,
dates from 1957, with buildings built through 1975. Average
daily population was approximately 547 during our visits, though
rated capacity was 421. In addition to pre-and post-adjudication
youth, Los Padrinos also holds status offenders and some alien
youth by contract with the United States Immigration and
Naturalization Service (INS). Los Padrinos houses all hearing
impaired youth confined at the juvenile halls. Average length of
stay is 16 days.
Each facility has housing units, administrative areas,
school buildings, a gymnasium, a pool, a medical observation
building, a kitchen and a chapel. Juvenile courts are located on
site at each of the juvenile halls. Youth residents in
disciplinary confinement and those with challenging behavioral or
mental health needs are housed in the Special Handling Units
(SHU’s). Youth are generally housed in either single or double
rooms, though there are a few units with one or two larger rooms
that sleep approximately three to seven youths. The INS
detention units at Los Padrinos are dormitory-style, and the
County had plans to refurbish two dormitory-style units for use
at Central. At all three halls, some youth were assigned to a
unit, even though there was no bed available for the youth in
that unit. In those circumstances, youth either slept on cots in

includes all youth who pass through the halls, including those
who are only kept for a few hours while being processed. Thus
the average length of stay for minors actually detained pending
trial or placement is longer than the numbers reported here. The
County does not compile separate statistics including only the
youth held more than a few hours.

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the day room or brought their belongings to another unit with bed
space at night. Such youth are called “sleepers” at the halls.
B.

LEGAL BACKGROUND

CRIPA gives the Department of Justice authority to
investigate and take appropriate action to enforce the
constitutional rights and the federal statutory rights of
juveniles in juvenile facilities. 42 U.S.C. § 1997.
Section 14141 of the Violent Crime Control and Law Enforcement
Act of 1994, 42 U.S.C. § 14141, makes it unlawful for any
governmental authority with responsibility for the incarceration
of juveniles to engage in a pattern or practice of conduct that
deprives incarcerated juveniles of constitutional or federal
statutory rights. Section 14141 grants the Attorney General
authority to file a civil action to eliminate the pattern or
practice. The Religious Land Use and Institutionalized Persons
Act (RLUIPA), 42 U.S.C. § 2000cc, prohibits governmental
imposition of substantial burdens on institutionalized
individuals’ religious exercise, unless the government
demonstrates that imposition of the burden is the least
restrictive means of furthering a compelling governmental
interest. RLUIPA applies to programs or activities receiving
federal funding, or when the substantial burden affects
interstate or international commerce, or commerce with Indian
tribes.
The Due Process clause of the Fourteenth Amendment to the
U.S. Constitution governs the standards for conditions of
confinement of juvenile offenders and those awaiting juvenile
justice hearings. Gary H. v. Hegstrom, 831 F.2d 1430 (9th Cir.
1987). Confinement of youth in conditions that amount to
punishment, or in conditions that represent a substantial
departure from accepted professional judgment violate the Due
Process clause. Youngberg v. Romeo, 457 U.S. 307 (1982); Bell v.
Wolfish, 441 U.S. 520 (1979); Alexander S. v. Boyd, 876 F. Supp.
773, 796-799 (D.S.C. 1995), aff’d in part and rev’d in part on
other grounds, 113 F.3d 1373 (4th Cir. 1997), cert. denied, 118
S. Ct. 880 (1998). The Fourteenth Amendment prohibits imposing
on incarcerated persons who have not been convicted of crimes
conditions or practices not reasonably related to the legitimate
governmental objectives of safety, order, and security. Bell v.
Wolfish, 441 U.S. at 539-540.
The County has an obligation to assure the reasonable
health, safety, and freedom from undue restraint of the youths in

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its custody. See Youngberg v. Romeo, 457 U.S. 307 (1982); Gary
H. v. Hegstrom, 831 F.2d 1430 (9th Cir. 1987); Alexander S. v.
Boyd, 876 F. Supp. at 786-7; Santana v. Collazo, 793 F.2D 41
(1st Cir. 1984); D.B. v. Tewksbury, 545 F. Supp. 896 (D. Or.
1982). Youth must be provided adequate medical and mental health
care. H.C. v. Jarrard, 786 F.2d 1080 (11th Cir. 1986); Morgan v.
Sproat, 432 F. Supp. 1130 (S.D. Miss. 1977); Thomas v. Mears,
474 F. Supp. 908 (E.D. Ark. 1979); Ahrens v. Thomas, 434 F. Supp.
873 (W.D. Mo. 1977), aff’d in part, 570 F.2d 286 (8th Cir. 1978).
Because the purpose of the juvenile justice system is
rehabilitative and not penal, incarcerated juveniles have a Due
Process right to rehabilitative services including adequate
education, counseling, vocational training, individual mental
health treatment and programming reasonably geared towards
helping juveniles correct their conduct. Gary H., 831 F.2d at
1433; A.J. v. Kierst, 56 F.3d 849, (8th Cir. 1995); Nelson v.
Heyne, 491 F.2d 352, 358-60 (7th Cir. 1974); Reaves v. Peace,
1996 WL 679396 at *8 (E.D.Va. March 21, 1996); Alexander S. v.
Boyd, 876 F. Supp. 773, 798 (D. S.C. 1995); Miletic v. NatalucciPersichetti, 1992 WL 1258522 at *4 (S.D. Oh. February 6, 1992);
Morgan v. Sproat, 432 F. Supp. 1130, 1140-41 (S.D. Miss. 1977).
Youth are entitled to seek redress with the government for
their grievances, without fear of punishment for doing so.
Bradley v. Hall, 911 F. Supp. 446 (D.Or. 1994); aff’d, 64 F.3d
1276 (9th Cir. 1995). Incarcerated youth have a right to access
to telephones, subject to reasonable security limitations.
Strandberg v. City of Helena, 791 F.2d 744, 747 (9th Cir. 1986).
In addition, as applicable to this investigation, juvenile
detainees also possess federal statutory rights under the
Individuals with Disabilities Education Act ("IDEA"), 20 U.S.C.
§ 1400 et seq., Section 504 of the Rehabilitation Act of 1973,
29 U.S.C. § 794 (“Section 504"), and the Americans with
Disabilities Act, 42 U.S.C. § 12101 et seq. (“ADA”.)
Recipients of federal financial assistance may not
discriminate on the basis of national origin. Services must be
provided in ways that allow Limited English Proficient (“LEP”)
individuals to have meaningful access to benefits and services,
and to have the information they need for their health and safety
while detained. Title VI of the Civil Rights Act of 1964,
42 U.S.C. 2000d; 28 CFR § 42.104.
II.

FINDINGS

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A.

MENTAL HEALTH

At the time of our tours, both our investigative team and
County staff agreed that the juvenile halls were failing to meet
the serious mental health needs of detained youth. Los Angeles
County had completed a study under which it determined that 50%
of the youth entering the system needed mental health services,
and staff estimated that perhaps one quarter of those in need
actually received care. At the time of our tours, the County was
making plans for reform and awaiting secured funds for additional
staff and other improvements.
1.

Screening and Initial Assessment

The screening and initial assessments conducted by staff as
youth were admitted to the juvenile halls failed to meet accepted
professional standards. The information collected by
correctional and nursing staff was insufficient to identify
serious emotional disturbance, substance abuse disorders and/or
mental retardation, and make an appropriate disposition for these
youth. If conducted, the brief screening form completed by
probation staff did not appear in any of the charts we reviewed;
thus the information was not available to treatment providers who
might need it later. Although the County reported that it had
instituted a new intake form and procedure during our visits to
the halls, intake staff we observed and interviewed were unaware
of a new system and continued to use the old form.
The initial medical histories completed by nursing staff
were not sufficiently detailed to screen for problems the
facilities need to identify immediately upon intake in order to
keep youth safe. For instance, nurses identified daily drug use
in a newly admitted youth, but did not determine whether he had
any signs or symptoms of potential withdrawal. Some medical
history information contradicted others in the file, suggesting
that either nurses were not reviewing earlier forms or the charts
were unavailable at the time the history forms were completed.
Likewise, information collected during mental status exams was
often insufficient. These problems contributed to an
underidentification of youth with mental health needs at the
facilities.
Furthermore, areas of the facilities where intake interviews
and also nursing rounds in the housing units occurred lacked
confidentiality. Staff questioned youth about sensitive medical

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and mental health issues in areas where arresting officers or
other youth could hear. Presence of police officers or other
youth discourages youth from fully disclosing their medical and
mental health histories and symptoms and prevents youth from
receiving timely and adequate care.
The places where youth are held awaiting intake interviews
presented safety and suicide risks. Some had blind spots that
prevented staff from monitoring youth effectively. Others lacked
a means for youth to communicate with staff while they were held
in these waiting areas. These spaces presented various suicide
risks, including live electrical outlets and hanging risks. This
is especially problematic because the first 72 hours in which a
youth is detained represent the greatest threat of suicide and
withdrawal. The County remedied a number of these safety risks
before we completed our visits.
At some point in the intake process, a staff member should
exercise discretion in determining whether a youth whose serious
psychiatric symptoms are not under control should be admitted to
the juvenile halls at all, or be immediately hospitalized. If
the halls are not equipped to handle a particular youth’s present
symptoms, then other arrangements should be made for care. One
youth we encountered in the population at Nidorf was exhibiting
psychotic behavior and hospitalized only after the intervention
of a County psychiatrist who was accompanying us on our visits.
This youth had been so unstable at the time of his admission that
officers could not interview him or read him his rights. This
youth should not have been at the halls, as the staff were not
equipped to manage his mental illness. Someone in the intake
process should be responsible for interceding in such cases.
Another example of a youth who did not belong at the halls
was a young woman who had been there for over one year. In the
course of her stay she was treated with at least 16 different
medications for a variety of mental health diagnoses. Her head
banging had occurred enough to result in “discoloration in the
center of her forehead that may be permanent.” She was on one to
one observation most of her time. Despite this level of
observation, staff frequently found the need to use physical and
chemical restraint with her. The halls were not equipped to
handle this young woman’s mental health needs.
Numerous other youth whose mental health needs far exceeded
the capacity of the juvenile halls to provide services remained
at the halls. These youth never received appropriate forensic

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evaluation, which could have determined an accurate diagnosis and
placement recommendations based on the youths’ needs, community
safety considerations and available placement options.
The County reports that a new screening/assessment form has
been in use since July of 2001, and that an interagency training
committee is developing curricula under the direction of the
Probation Department’s staff training office, with a target date
for completion of curriculum development in late 2002. The
County reportedly has budgeted funds for additional space for
mental health assessments. We plan to assess the implementation
and adequacy of these reforms.
2.

Specialized Mental Health Assessment and Referral

Some youth entering a detention system will need specialized
assessments to diagnose mental illness, substance abuse disorders
and mental retardation. The County’s written descriptions and
policies provide for adequate assessments, but none of the
records we reviewed contained examples of adequate assessments.
We found that the County was not routinely providing
psychological testing and gathering past treatment and school
records. We found that no meaningful substance abuse assessments
were conducted, and that staff did not complete most mental
health assessment forms. In addition, staff failed to ask
sufficient questions about symptoms such as hallucinations,
suicidality, functioning and cognitive ability to make reliable
decisions about diagnosis and care in many instances. In the
small percentage of records where youth had received an estimate
of functioning in their evaluations, most scored at a level
indicating serious impairment, requiring highly structured mental
health services. Nonetheless, there was no evidence that such
structured services were provided to youth residents of the
juvenile halls.
Our psychiatry consultant also found that many diagnoses in
the files she reviewed did not match the information in the
records of individual youth. For example, a youth experiencing
auditory hallucinations including commands to commit suicide was
diagnosed with depression and conduct disorder, which failed to
reflect that the youth was actively psychotic and was being
treated with medication for psychosis. Many of these diagnoses
were determined without the review and approval of a medical
doctor or Ph.D.-level practitioner, despite the County’s policy
requiring M.D. or Ph.D. review.

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In other cases, the lack of availability of psychological
testing limited the County’s ability to identify mental
retardation or other cognitive impairment in youth. Files we
reviewed documented examples such as a 14-year-old who had not
progressed beyond second grade level, and another teenager who
could not read. No evaluations for cognitive impairment had been
completed for such youth, even though such limitations may
indicate existence of mental retardation.
Youth who commit self-harm may develop serious medical
illnesses as a result of such behavior. Staff must assess and
follow up with appropriate care for physical complaints from such
youth. For example, one youth who engaged in self-injurious
behavior frequently threw up blood, refused to eat and complained
of abdominal pain was diagnosed as having bacteria that cause
stomach ulcers, but was never treated for the infection.
In many instances, youth were referred for assessment but
waited days or weeks for evaluations that referring staff thought
should be done immediately. For example, youth experiencing
suicidal thoughts or even making suicide attempts might wait
three days or longer to be seen by a mental health provider.
In another example, the medical director requested that a
psychiatrist re-evaluate a youth’s medication due to side effects
including vomiting, dizziness, blurred vision and headache,
noting that he should be seen that day. He waited nearly one
month to see a psychiatrist.
Finally, an integral part of a complete assessment is
acquiring records from other providers to develop a fuller
understanding of a child’s history. In most cases files we
reviewed had no indication that the County ever requested such
important records. Even when youth were hospitalized during the
course of their juvenile hall detention, discharge summaries,
pertinent laboratory results and results of specialized
assessments were not in the records, nor was there any notation
that the records had been requested.
New funding reportedly has allowed the County to hire
several additional mental health care providers. Such staffing
may improve some of the problems identified above. We will
assess whether such additional staffing has remedied the
identified problems.
3.

Treatment Planning, Consent and Case Management

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Individual treatment plans are necessary to ensure that
treatment goals for youth with serious needs are identified and
addressed, and that service among various systems is coordinated.
Case management ensures that treatment plans are implemented.
While the Probation Department’s manual indicates that “an
assessment and plan is prepared for each minor detained for a
period of 30 days or more,” none of the records we reviewed
contained such an assessment and plan, despite lengthy stays of
the youth. No staff asked were aware of any interdisciplinary
treatment planning at the halls. In the two charts we received
that did contain a service plan, the plans did not address some
of the youths’ most salient symptoms such as self-harming
behavior or psychoses, and neither youth received the services
promised in the plan.
The various agencies at the halls need to be able to work in
a coordinated way from the same goals and information about a
youth to meet needs effectively. For example, a minor was unable
to attend school because of lengthy suspensions. Medications
were insufficient to control her mood swings and she was not
receiving counseling, but there was no notation in her records to
suggest that further treatment or placement options were
examined. In another case, mental health staff ordered that a
youth be weighed by the medical staff every morning, since she
had been hospitalized a week earlier for dehydration related to
her “not eating or drinking due to psychosis.” There is no
indication in her records that she was ever weighed except at her
initial physical. Proper case management would ensure that such
interdepartmental collaborative needs were addressed.
Professional standard of care requires informed consent for
treatment. At the halls there was no documented process for
obtaining consent for treatment from youth or from a parent or
guardian. Youth must understand the risks and benefits of
treatment and the limits of confidentiality for a system to
obtain informed consent.
In some cases, we found that mental health staff knew that
a child had a mental retardation diagnosis, but the probation
department staff responsible for his daily care did not know. We
saw probation department notes wondering if youth were mentally
retarded, or noting concern that youth did not appear to
understand directions given to them. Mental health staff should
provide guidance to probation staff as to what modifications of
daily routine may be needed by someone who is cognitively
impaired. Youth with mental retardation may not be able to read

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and understand intake informational forms, unit orientation and
rules forms, or complex commands. Without such guidance, youth
may be disciplined and confined more than would otherwise be
necessary.
For example, a 17-year-old youth with attention
deficit/hyperactivity disorder, adjustment disorder, and mild
mental retardation whose offense of record was “loitering on
private property” accompanied by another youth with an air gun,
was ordered into placement in September 2000, but remained at the
halls “pending placement” until September 2001. During that
time, she sometimes ended up on “modified program,” an informal
disciplinary status that requires youth to remain in their rooms
except for school and physical training, due to her difficulty
following directions. Probation staff were unaware of her mental
retardation and lacked the knowledge to deal with her
effectively.
Disabled youth, including those with mental illness, should
not be housed in especially restrictive settings within the halls
unless safety and security needs require such restriction. We
found that youth with mental illness were frequently placed in
settings within the halls that were more restrictive than would
have been necessary if their mental illnesses had been adequately
treated. Many youth with mental illness were housed in the SHU’s
and/or received some form of close supervision which might have
been avoided through adequate service delivery. Appropriate
programming by probation staff and appropriate counseling and
other mental health services should be available to assist such
youth in developing skills to succeed in less restrictive
settings within the institution.
Furthermore, discharge summaries were not evident in most
charts we reviewed. Those that existed did not document the need
for medication or mental health follow-up, or had incorrect
information. Such summaries are needed for sufficient treatment
planning and follow-up.
The County reports that it is developing a
discharge/aftercare policy. It reportedly has implemented an
interagency coordinating committee and on-site facility-based
committees, which meet to resolve issues of mutual concern. We
plan to assess the implementation and adequacy of these reported
reforms.
4.

Mental Health Counseling

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We found that the halls were failing to comport with
professional standards with regard to counseling. Staff did not
create treatment plans or document progress toward stated goals.
Much counseling was focused on crisis response, and many
interventions for youth seriously in crisis were unacceptably
delayed. Treatment often was too infrequent to meet the serious
mental health needs of the youth at the halls.
For example, one youth had been transferred to the halls
from a hospital, with a long history of psychotic thought
disorder, bipolar disorder, poor impulse control and chronic
suicidality. Despite a note by a social worker who assessed her
that she should receive individual therapy twice a week, she
primarily received mental health attention only after attempted
self harm or disruptive behavior and received no regular
therapeutic interventions during her two-month stay.
Another youth had an entry in his chart that indicated he
refused to eat, was hallucinating and unable to ignore the voices
in his head, and was self-injuring in response to internal
stimuli. Rather than evaluate this youth on a daily basis and
provide counseling, he was left under watch by probation staff
for a week to await the next psychiatrist’s visit with no other
mental health support.
Another youth with a long history of self-injury was seen by
mental health staff and found to be suicidal. The worker noted
that the youth’s primary therapist would follow up, but four days
later, without receiving any further mental health attention, he
swallowed a razor, engaged in other self-mutilation and reported
auditory hallucinations telling him to harm himself. He still
did not receive mental health attention until another day had
passed.
Many youth engaged in self-harming behavior without
appropriate interventions. Staff labeled much of this behavior
as “manipulative,” without mental health professionals talking
with the youth to address their behavior and underlying emotional
issues.
Doctors wrote orders for a number of youth who engaged in
self-harming behaviors to receive behavior modification plans.
In a number of files we determined that such plans were never
written or carried out. The “Behavior Modification Contract of
the Special Handling Unit” is not a behavior modification
contract in any therapeutic sense. It is merely the list of

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rules youth sign upon entering the SHU.
Youth often missed appointments to see mental health staff
due to “population balancing,” a daily occurrence at the halls in
which youth are moved between the three halls in an attempt to
ease overcrowding at a particular location. During the course of
our tours we were told that mental health and medical staff could
put a “hold” on a child to prevent his transport for population
balancing, but we continued to hear stories of missed
appointments due to sudden transport of a child to a different
facility. This practice damaged any therapeutic relationships
that might have been built with counselors, requiring that youth
start over with a new worker at the next facility. While medical
appointments and court appearances make some movement inevitable,
administrators should find a way to minimize disruption of
therapeutic relationships.
The County reports that it has enacted an effective system
of therapeutic “holds” to prevent population balancing of youth
in medical or mental health treatment or with special school or
court needs, without Superintendent approval. The County also
reports that various agencies have reviewed and augmented the
behavioral management protocols, upgraded the delivery of mental
health, health and educational services, screening and
assessment, increased staffing levels, and trained staff in the
behavior management system. Appropriate mental health staff
reportedly have been provided with pagers and/or cell phones for
24-hour access. We plan to assess the implementation and
efficacy of these reforms.
5.

Management of Psychotropic Medication

We found that the juvenile halls were failing to manage
psychotropic medications properly and safely. Nursing staff did
not monitor the side effects of medications they administered.
Sometimes staff failed to provide prescribed medications to
youth. Psychiatrist availability was limited and
interdisciplinary communication with medical staff was poor in
most cases. Critical laboratory results were frequently
unavailable.
Nurses did not have sufficient time or training to monitor
properly the effects of psychotropic medications administered to
youth. Abnormal movements such as tardive dyskinesia and
dystonias both may become permanent disfiguring conditions and
must be monitored regularly when youth are taking certain

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psychotropic medications. Muscle weakness and lack of
coordination must also be monitored. Many nurses responsible for
administering medications were unaware of the potential side
effects of these medications, and nurses and social workers were
unfamiliar with standard tests for monitoring side effects.
Staff and youth widely reported medication errors and
failures to maintain continuity in medications. We found files
in which youth waited as long as weeks to be restarted on
medications they reported taking before their detention.
Illustrating the systemic nature of the delay in care, one youth
was referred for mental health care after a mother called to
express her concern that her son had not had Ritalin for months.
A week later a note in the file said that mental health
appointments were “backlogged for about two weeks...mother will
call to expedite her son’s referral...[she states] meds make all
the difference in his behavior.” This youth had experienced
great difficulty complying with rules and was accordingly
disciplined while off his medications.
We were told that a two to three day suspension of a child’s
medications was not uncommon when a child changed housing units.
Such suspension of medication can cause harm to youths’ physical
and mental health. For instance, a psychiatrist’s note in one
patient’s file indicates that the youth “switched to different
units and missed two days of his medication with resultant
withdrawal symptoms of depressed mood, headache, loss of appetite
and disturbed sleep.” Delays in medication administration were
in some cases the results of clerical or administrative error
(see Medical Care, Part 1, below), but the delays in restarting
medications upon intake are attributable in large part to
insufficient psychiatrist staffing.
Lack of psychiatric consultants and difficulty in
communication between medical and mental health staff put the
medical staff in the awkward position of having to respond to
youth experiencing newly developed symptoms without knowing the
full clinical picture of a patient. Also, because they had many
days between visits to a facility, psychiatrists might order lab
work, but not be able to review the results for a week or more
after the work was completed, thus delaying potentially needed
adjustments in medications.
When psychiatrists wished to review lab results, the results
were frequently unavailable. Neither Nidorf nor Los Padrinos was
equipped with computer terminals with access to laboratory

- 16 ­

results. The failure to follow through on lab work and obtain
results as ordered interrupts patient care and places youth at
risk of life threatening side effects. For example, the chart of
a youth prescribed mood stabilizing drugs lacked blood analysis
for blood cell production and renal function. The medications he
was on could cause immunosuppression and kidney damage if not at
the proper levels. Another chart revealed that the psychiatrist
had such a hard time getting the results of ordered lab work that
he discontinued the patient from a medication because without lab
results it would be unsafe to continue this medication.
In order for treatment records to provide sufficient
guidance for future care, some documentation is essential.
Medication administration must be recorded, and explanations
(i.e. patient refusal, lack of availability, youth in court,
etc.) must be written when medications are not administered as
ordered. Psychiatrists should be informed when youth refuse
medication so that the reasons for refusal can be addressed.
Proper documentation and informing of psychiatrists were not
occurring in the records we reviewed. Furthermore, reasons for
changes of dosage or type of medication must be recorded so that
treatment providers understand what medications have been tried
and the reasons they were stopped. The files we reviewed lacked
such explanations. They revealed youth who had been on twelve or
sixteen different psychotropic medications, and as many as five
at one time, without clear rationale for treatment. Medications
were sometimes stopped before efficacy could be established.
The County reports that training regarding drug side effects
and interactions is ongoing and will be included in yearly inservice training protocols, and reference materials in the
medical units have been updated. The County reports that it
hopes to research and develop a central medical records system,
though the funding has not been allocated. In the meantime,
short-term manual systems solutions reportedly have been
implemented. Additional hiring reportedly has been occurring.
We will assess the implementation and efficacy of these reforms.
6.

Custodial interference with mental health

Probation staff sometimes impeded access to mental health
services by failing to communicate youth needs for services to
mental health staff. For example, one youth reported that he
told staff he was hearing voices and wanted to see the nurse but
his requests were not communicated to the nurse. Another youth
explained that she told probation staff that she had been

- 17 ­

experiencing dizziness for three months after starting her
psychotropic medications. She reported that when she asked to be
placed on the nurse sick call list, probation staff told her that
the dizziness was normal. Youth should be able to make a
confidential request for mental health care in writing with the
expectation that the request will be triaged by a professional
with mental health training.
We received reports from youth and staff that probation
staff on many occasions made inappropriate comments about youths’
medication status or told youth not to take their medications.
One mental health worker reported that probation staff told a
youth to stop taking his psychotropic medications, he did so and
became psychotic. Mental health staff heard comments from
probation staff such as, “What are you seeing psych for? They
are going to make you crazy.” One youth reported being told,
“Come up so you can take your psych meds, you psycho,” and others
were told to “take your crazy meds.”
Although management staff of the facilities had been
attempting to address the problem of staff using abusive language
with youth, we found that many line staff still engaged in
dialogue with youth that would be harmful to their mental health.
Many staff yelled at and cursed youth, and at times demeaned a
youth’s family or made fun of a youth’s legal predicament, sexual
orientation or mental illness. Others used inappropriate words
with sexual connotations while talking with youth, including
those who had histories of sexual abuse. Such conduct by staff
is inappropriate, violates professional standards of behavior,
and may exacerbate mental illness in youth.
The County reports that it continues to reinforce existing
policy prohibiting such conduct and has identified and written to
individual employees where appropriate. We plan to assess the
effectiveness of these reforms.
7.

Crisis Management

All facilities caring for youth must have a plan for
emergency medical and mental health care and adequate support to
implement that plan. The plan must address suicide prevention,
the use of physical restraints and the use of chemical
restraints. We found that the halls were not managing mental
health crisis situations according to their own policies, and the
response to youth with serious emotional disturbance who were
experiencing crises did not meet professional standards of care.

- 18 -

(For discussion of use of chemical sprays at the facility, see
Juvenile Justice and Detention Practices, Section 1, Use of
Force.)
a.

Suicide Prevention

The County does routinely conduct staff training to
recognize youth at risk of suicidal behavior, an important
component of suicide prevention. One notable absence in staff
training, however, was the procedure for cutting down a youth who
might be found hanging. Hanging is the most common method of
suicide in detention facilities. The majority of staff we
questioned did not know where they might find a cut-down tool in
the event of a hanging.
We also encountered delay in the assessment of youth
identified as at risk for suicidal behaviors. In several files
we reviewed, youth who had made statements of intent to commit
suicide waited one to three days to be seen by a mental health
practitioner. In one egregious case, a youth “talked about
killing himself all night.” He was not seen right away, and did
cut his wrist the following day. Despite a staff request for
mental health attention for this youth on the day of his initial
statements, followed by a serious suicide attempt, no one in
mental health came to see this youth until six days later, at
which point he required hospitalization.
Once youth were finally evaluated, their suicide assessments
were frequently incomplete. Assessments we reviewed did not
contain documentation of past suicide attempts nor exploration of
the youth’s risk and protective factors.
Once youth were placed on suicide watch, they did not
receive the care that they needed. Mental health staff did not
follow up on a daily basis to counsel youth or assess their
needs, even for very high risk youth. For example, one mental
health assessment found that the youth was anxious, depressed,
self injurious (deep scratches to both arms), and unable to agree
not to hurt himself. Although mental health staff indicated that
follow-up the following day was necessary, the youth was not seen
for five days.
At times, because of staff shortages in the SHU’s, contrary
to the agency’s own policies, one staff member would supervise
more than one youth placed on one-to-one supervision due to selfharming behavior or suicidal ideation. Sometimes youth were

- 19 ­

watched directly, and at other times by camera. In these
situations, suicidal youth who staff determined to be in need of
constant supervision for their safety might not receive it. We
found that at Nidorf in the Boys’ SHU, rooms where youth were
placed to be viewed by camera did not allow staff to view parts
of the room, so that a boy could remain outside view while he
should have been on camera observation. Staff shortages might
also mean that staff not qualified for some tasks were assigned
to them anyway. A superintendent’s report from January 2001
read, “Heavy 1:1 and hospital coverage created an artificial
staff shortage. Staff were not trained to handle minors with
severe mental and/or emotional problems.”
In addition, allegedly constant supervision by staff were
not always effective. Youth placed on constant watch by staff
succeeded in numerous acts of self-harm, including taking 27
pills, ingesting hair relaxer and Windex, swallowing staples and
inserting staples in wounds.
Staff of various disciplines should work together to ensure
that suicidal youth receive appropriate supervision and care.
Some probation staff appeared to lack the information and skills
necessary for such a role. We received reports that probation
staff sometimes tried to talk mental health staff out of putting
a youth on close watch. Probation staff sometimes ridiculed
youth for being on suicide watch, which may increase self-harming
behaviors and suicide risk. Records reveal no effort to assist
probation staff in understanding the psychiatric diagnoses of
individual youth, recognizing target symptoms or implementing
interventions designed to address the root causes of self-harming
behaviors and promote healthy development. Finally,
documentation of suicide attempts and communication with
administrators, outside officials and family members after a
suicide attempt was insufficient.
The County reports that it has established “need to know”
protocols, casework conferences in the units, and a system for
sharing assessment and screening data. It has reportedly
increased mental health providers’ presence in the living units,
including the SHU, and increased other types of interdisciplinary
communication. New suicide prevention policies and staff
training reportedly are in effect, and the mental health
department reportedly was designing behavior and treatment
planning policies. We plan to assess the implementation and
adequacy of these reforms.

- 20 ­

b.

Physical restraint

Mentally ill youth experiencing crisis may be restrained for
the time necessary to prevent them from harming themselves or
others, when other less restrictive responses would be
insufficient. Uses of restraint must be promptly followed by
evaluation to ensure that restraints have been applied safely and
last only as long as necessary. Los Angeles County policy
requires referral to mental health staff within 15 minutes of
initial application of restraints, and an assessment completed
within eight hours of the time of the restraint. Records
indicate that mental health staff did not evaluate most
restrained youth within eight hours. Documentation of restraints
was also inadequate.
We were especially concerned about a restraint we observed
while visiting Los Padrinos. Probation staff placed restraints
on a boy’s ankles and wrists with his wrists behind his back and
the boy lying on his stomach. Restraint in this position
increases the risk of asphyxiation, and has contributed to deaths
of youth and adults in institutions around the country. The
probation staff member was asked to put the youth on his side and
refused until a psychiatrist explained the reasons for not
restraining people on their stomachs. The nurse who came to
check restraints found them to be too tight, and the probation
staff member was unable to loosen the restraint because it was
too small. The restraint was then removed at the psychiatrist’s
request. The psychiatrist had to ask security staff to monitor
the youth in restraints, because there was confusion as to who
was responsible for the boy. During this episode youth locked in
other rooms in the medical unit were not monitored by staff. The
probation staff member who conducted the restraint stated that he
had not received training on the use of physical restraints for
two years. We learned that other youth have been restrained in
the same position at the halls.
The County reports that crisis related issues are discussed
in on-site weekly meetings, and training protocols on crisis
response are pending. We plan to assess the implementation and
adequacy of these reforms.
B.

JUVENILE CONFINEMENT PRACTICES
1.

Use of Force

We found that staff at the facilities were using Oleoresin

- 21 ­

Capsicum (OC) spray excessively and without sufficient warning.
Staff sprayed youth in situations in which such uses of force
were not necessary, including situations that did not present
serious threats of bodily harm, circumstances in which youth had
already complied with staff’s directives, and circumstances in
which staff already had control of the youth.
For example, staff wrote in one incident report that they
had placed a minor in handcuffs and she began sobbing and
screaming over and over that she would kill herself. When the
minor did not stop sobbing and threatening self-harm after being
instructed by staff to calm down, they warned her she would be
sprayed. Staff tried to spray the youth and she attempted to
push the staff member, after which two staff members held the
girl while the other staff member sprayed her. Because staff
were able to hold her, the use of pepper spray in this case was
unwarranted. In addition, the minor’s behavior, which did not
pose an imminent danger to herself or others (as long as she was
not permitted to act on her stated desires of self-harm) was not
a circumstance that warranted use of pepper spray. We found in
other cases that staff sprayed youth for talking back or
“disrespecting” staff, standing up when ordered to be seated,
yelling or banging on doors, circumstances that do not warrant
this high level use of force.
In other incidents, relatively minor conflicts, such as a
resident possessing a piece of paper he should not have, ended in
staff spraying youth once the youth became hostile or aggressive.
While in the end the spray might have been necessary in some of
these cases once the situations had escalated, staff lacked the
skills to de-escalate incidents in which youth failed to comply
with orders, causing minor problems to become major
confrontations that otherwise would not have required spray.
Staff also inappropriately used OC spray on youth who should
not be sprayed for health or mental health reasons, including
pregnant girls, suicidal youth, youth on psychotropic medications
and youth who physicians had ordered exempted from chemical spray
use due to respiratory problems. In one example that is
representative of several in which staff relied on pepper spray
to intervene in head-banging incidents, staff sprayed a young man
who was banging his head against a wall and threatening to kill
himself after he failed to comply with an order to stop banging
his head. The youth was cognitively impaired, psychotic and
receiving psychotropic medications. In other cases, staff
sprayed a young woman who had begun to cut herself with a plastic

- 22 ­

fork, and a young man who was trying to tie a shirt around his
neck. In these examples it is likely that lower levels of force,
coupled with mental health intervention, would have been more
appropriate to intervene in the residents’ harm to themselves.
Several files we reviewed showed examples of youth who were
asthmatic and/or on psychotropic medications, who were subjected
to OC spray in violation of both Probation Department policy and
doctors’ instructions. In one case of a youth who was asthmatic
and had a heart murmur, the youth was OC sprayed only one week
after probation staff had noted in his file that he could not be
sprayed.
Staff also failed to provide proper warning and opportunity
to comply with an order before spray was used on them. For
example, some staff gave a “blanket” warning intended to be in
place for an entire shift or activity, warning all youth that if
they acted out in any way they could be sprayed. Other staff
would give the warning immediately before use without waiting for
youth to respond. Such warning methods do not allow youth the
opportunity to comply with staff members’ requests.
In addition, we learned that staff were using hot or warm
water to wash faces and bodies of youth after spraying. This
practice increases the pain and suffering from OC spray use,
intensifying the burning sensation the spray causes. After our
consultants brought this problem to their attention, officials
promptly issued a new policy providing clearer guidance to staff
for OC spray decontamination and appropriate use. However, this
lack of knowledge by staff reflects the inadequacy of their
previous training in use of OC spray.
Furthermore, management failed to keep proper control of OC
spray use, by allowing all staff to carry OC spray and simply
request more when a canister ran out, rather than weighing
canisters after each use. In a detention setting in which use of
spray inside locked units may cause pain to other residents who
are not involved with harmful behavior, due care should be taken
to restrict its use and the quantity of use to those situations
in which it is necessary.
The county reports having instituted a new use of force data
collection system and a more thorough investigation process for
uses of OC spray. In addition, there are reportedly new policies
with regard to uses of force and specifically OC spray. Noncriminal INS and status offender detainees may not be sprayed

- 23 ­

under this policy. The County informs us that it has updated
staff training to reflect new policies it issues, and that newly
hired probation staff currently receive four hours of OC spray
training. We plan to assess the implementation and adequacy of
these reforms.
2.

Protection from Harm

At Central, youth-on-youth fights occur routinely, some
resulting in significant injury. This problem appears to be
attributable, in part, to the lack of sufficient staffing at the
facility. Low staffing levels left staff with too many
responsibilities, limiting their ability to detect problems and
attempt to resolve them before violence erupted. At Los
Padrinos, staff members’ logs included comments such as, “Very,
very, very, very, extremely, totally unsafe again,” describing a
staff member’s frustration at what he believed to be insufficient
staff numbers to supervise safely the youth on his unit. Staff
from all three halls expressed their concern regarding
insufficient staff to youth ratios on the units.
Units operated with more youth than bedspace, requiring some
youth to be “sleepers,” on cots in the dayrooms or in other less
crowded units. Such practice, paired with understaffing,
prevents staff from being able to develop understanding of
individual youths’ needs and relate to them in meaningful ways
that can help reduce tensions and control behavior.
The system we encountered of reporting and investigating
allegations of child abuse failed to protect the youth held in
the halls. There was no independent, consistent, objective and
thorough system in place to report, investigate and follow up
allegations of child abuse. Reports often lacked specific
information, leaving out accurate detailed descriptions of the
events or injuries, or failing to mention by name the staff
alleged to be involved in the incidents. The facilities were
inconsistent in their attempts to interview staff or youth who
might have witnessed the incidents. Although staff of the
Department’s Ombudsman’s office attempted to respond to the
specific complaints they received from youth who called the toll
free number, the office had insufficient staff to respond
adequately to complaints coming from the three detention
facilities and the County’s probation camps.
On July 31, 2002, an unfortunate incident occurred at
Central Juvenile Hall, reflecting security lapses. Late at

- 24 ­

night, a youth being held in the Special Handling Unit was
allowed out of his cell to get water, and pulled out a handgun.
He and two other youths handcuffed the three officers on duty,
locked them in a utility closet, stole their keys and escaped,
aided in part by a ladder left accessible by workers doing
repairs. During our visits we also noted that building and
maintenance contractors were leaving supplies and debris such as
pieces of metal that breached security. County officials are
investigating how a handgun made its way into the facility, and
developing new protocols to prevent further such incidents.
The County reports that it has made progress toward reducing
the average daily population in the halls, including increased
use of electronic monitoring, daytime school and work programs
that allow youth to live at home, and expedited release of youth
to their post-disposition placements. Plans are reportedly
underway to develop additional institutional and noninstitutional options for youth placements. The use of such
options should allow the County to improve its staff to youth
ratio and reduce the need to have youth sleep in dayrooms or away
from their units. We plan to assess the implementation and
adequacy of these reforms.
3.

Opportunity to attend religious programs

We learned that the halls were not accommodating many
youth’s desires to participate in worship services due to staff
and space limitations. RLUIPA requires that actions by officials
which impose a substantial burden on an institutionalized
person’s religious exercise must be justified by a compelling
governmental interest and must be the least restrictive means
available to achieve that interest.
The County reports that minors are now assured access to
religious services of their choice if they wish to attend. We
plan to assess the implementation and adequacy of this reform.
4.

Programming

In order for the juvenile halls staff to meet the needs of
at least the adjudicated youth in their care they must have in
place a meaningful structured program, including an effective
behavior management program. The juvenile halls attempt to
provide life skills and personal responsibility education through
their EXCEL program. The EXCEL manual describes a “high
intensity” approach to education of youth regarding social issues

- 25 ­

that may have contributed to delinquent behavior, such as
substance abuse, self esteem, personal hygiene, negative social
influences and other topics. The program is supposed to
incorporate pressure from a therapeutic community of peers and
staff, and infuse all aspects of the youth’s detention, from oneon-one counseling from the time a youth enters a housing unit,
through “a busy daily schedule, punctuated with formal education
sessions, informal educational opportunities, community meetings,
physical training, and situations allowing minors to practice
newly acquired skills....” While in policy and written manuals
the halls professed to provide therapeutic structure based on the
EXCEL program, the reality for the general population at the time
of our visits was far from that goal. Staff reported to us and
we observed that the EXCEL program was not consistently in
operation. Even staff who made an effort to conduct discussions
about behavior, self-esteem, personal hygiene or other relevant
topics varied widely in their abilities to conduct these
activities in a productive manner. Medical and mental health
staff reported that they had attempted to inform management that
the lack of activities and programming for youth contributed to
mental health problems experienced by youth, but that this
communication had not resulted in improved programming.
Programming for girls was not meeting their rehabilitative
needs. Their programming gave inadequate attention to issues
that disproportionately affect girls, such as health issues,
mental health needs as a result of histories of abuse, parenting
and other gender-specific needs. While staff had begun planning
for more gender-specific programming, no plans had been completed
nor programs implemented as of the time of our visits. Planned
opportunities for youth who were parents to have visits from
their children were sometimes cancelled due to insufficient
staffing.
Some staff engaged in inappropriate group punishment. For
example, if one youth persisted in talking when she was not
allowed, the entire unit would lose the evening activity, or
might not be allowed to make telephone calls for some number of
days. The practice of group punishment that does not address
exigent security concerns violates professional standards and
gives residents a sense that following rules will not result in
fair treatment.
Due in part to thin staffing on the weekends, youth spent
large blocks of time in their cells on the weekends, with little
opportunity for stimulation while in their cells. While some

- 26 ­

youth were allowed to keep books among their personal belongings,
in many units they were not allowed to have books in their rooms
during various times of day when youth were locked down.
Although some units had an extra supply of reading materials,
they often did not make them available to youth during times when
youth were confined to their rooms. When asked, many staff were
unaware whether they had any books to lend to youth in the unit
at all.
The County reports that it has revised its EXCEL program,
drafted a new behavioral management model and is working on
training staff. Girls’ program content was being evaluated for
improvement. The County reports that it already had procedures
in place for minors’ visits with their children but is
reinforcing them. Additional reading materials reportedly have
been procured and distributed. The County further reports that
it has created additional policies and training with regard to
rules for youth conduct, in an effort to standardize expectations
throughout the halls. We plan to assess the implementation and
adequacy of these reforms.
5.

Language

The juvenile halls detain a number of youth who do not speak
or understand English well. With the exception of the detainees
housed by contract with the INS, almost all youth at the halls
with limited English skills speak Spanish. Detention facilities
must provide sufficient opportunity for Limited English
Proficient (LEP) individuals to have meaningful access to
programs and services, especially those that affect health and
safety, length of stay or discipline. Facilities should not rely
solely on written translations if the youth cannot read and
understand them. Using other residents to translate is generally
not appropriate unless the topic of communication is not
sensitive, confidential, important or technical and the other
resident is competent in the skill of interpreting. At the
juvenile halls, opportunities for youth who could not read or
understand English well to communicate with staff about important
matters in reliable ways were not provided sufficiently.
We found that youth with limited English proficiency
generally had not received sufficient orientation to understand
how to access essential services such as medical or mental health
care if they needed them. Some Spanish-speaking youth had been

- 27 ­

provided a written handbook in Spanish and others had not.4/
Youth who could not communicate in English reported that they
learned rules from asking other detained youth, and if they
needed things they asked other youth to translate or waited for
another shift when there might be a staff member who spoke their
language. Grievance forms were not available in Spanish.
Although administration officials told us that telephone
translation services were available as staff needed them to deal
with speakers of other languages, none of the staff members we
interviewed who supervised youth had any idea that youth and
staff would be permitted to use telephone translation services if
they needed them. The medical department did seem to use
telephone translation services as needed, and facility
administrators made an effort to educate staff about the
availability of this resource following our visits.
One example of the communication problems staff have
involves a Chinese youth who was being disciplined and moved to
the SHU. He was instructed to remove his pants and shoes but did
not do so, so staff removed them. He kicked a staff member, was
given an OC spray warning, but began banging on his cell door
once in the SHU. He was subsequently pepper sprayed and remained
agitated. The nurse involved in his decontamination and
examination found it necessary to contact an interpreter in order
to explain the effects of OC spray, but the rest of the
discipline process to that point had been carried out without
translation. It is quite possible that his agitation was
attributable to not understanding all of what was happening to
him. Furthermore, he may not have understood all the orders
staff gave him.
A Spanish-speaking youth who could not communicate in
English was notably upset at the time we met with him. He told
us that he had been moved from one hall to another several days
before and had been unable to ask staff for the opportunity to
use the telephone to tell his family where he was. Another
Spanish-speaking youth reported he felt hopeless and in despair,

4

/We encountered youth detained by the INS from a number of other
countries, including China, Sri Lanka and others. No written
materials were available in languages other than English or
Spanish, and these youth varied in their English proficiency from
little to no comprehension to functional understanding and
communication abilities.

- 28 ­

but did not know how to get mental health help.
Youth who did not speak English had a harder time receiving
necessary evaluations and care. While Nidorf did have a Spanishspeaking social worker, Central’s bilingual counselor left, and
no Spanish-speaking replacement had been identified during the
time of our tours. We reviewed records of non-English-speaking
youth who had not received needed mental health assessments or
counseling.
The County reports that it has surveyed staff to determine
non-English language capabilities, is working to deploy bilingual
staff more effectively, and has identified community volunteers
to translate less frequently encountered languages. The County
reports that it has revised the orientation procedure and
booklet, providing language interpretation where needed, and that
youth with special needs reportedly now receive individual
orientation. The County also reports that it issued a policy in
February 2001 regarding the availability of telephone translation
services for non-English speakers. We question the effectiveness
of this policy, since staff we interviewed after February did not
know of its existence. We plan to assess the implementation and
adequacy of the reform efforts above.
6.

Grievance system

We found that the facilities lacked an effective grievance
system. The orientation process at the halls was insufficient to
provide youth with the information they needed in order to
understand the grievance system and how to access it. While a
form was in existence and administrators were able to show us
some forms that had been completed by youth, the system was not
operating in a meaningful way at the time of our visits. In
order for youth to file a grievance, they first had to ask staff
for a form and for a pencil (for security reasons, writing
implements are strictly controlled at the halls). Once youth
completed grievances they had to turn them in to staff.
Interviews with staff and youth confirmed that staff did not
always maintain confidentiality of these forms and in some cases
did not process them or tore them up. Furthermore, youth feared
retaliation by staff for filing grievances. One mental health
staff member reported, “I hear [from youth that staff say]‘We can
lie because they will believe us before they believe you’ enough
for it to be disturbing,” suggesting that staff threatened youth
that they should not file grievances because they would not be
believed anyway.

- 29 ­

Furthermore, there was no system for ensuring that a
grievance that had been “granted” was ever remedied. The results
were not consistently documented or reported to youth, further
undermining confidence in the system, as youth could not tell
what had been done about their complaints. The halls need to
ensure that a working, confidential system is in place for youth
to seek timely redress of their grievances.
The County reports that the grievance process has been
revised, including new forms and a new logging procedure.
Management reportedly will monitor to ensure that grievances
against staff are answered in a timely fashion. We plan to
assess the implementation and adequacy of these reforms.
7.

Telephone access

Detained youth are entitled to reasonable access to
telephones. In the halls, some youth were able to use telephones
as many as four times in a week, while others went a week or more
without any access. Staff denied access to telephones as a means
of group punishment when one youth acted out. Such punishment is
not reasonable, and is contrary to accepted professional
standards.
Some youth reported having trouble gaining permission to
telephone their attorneys. They have no opportunity to make such
calls in a private location. We witnessed one youth attempting
to talk on the phone with his attorney crouched under a table in
a busy staff area with youth and staff walking in and out.
Another youth was forced to discuss her concerns with her lawyer
while three staff members sat within two feet of her, watching
and listening. While some staff would occasionally allow youth
to use the facility’s telephones to call their families free of
charge, there were no consistent provisions for youth whose
families could not accept collect calls to have telephone contact
with their families.
C.

ACCESS TO MEDICAL CARE

For the most part, Los Angeles County is meeting its
obligation to address the serious medical needs of its
incarcerated youth. However, our investigation uncovered the
following deficiencies:
At all three facilities, youth were, at times, denied timely
services for both specialized and routine medical needs.

- 30 ­

Specifically, youth with special health care needs such as
diabetes, epilepsy, unstable asthma, pregnancy, and HIV/AIDS
("medically fragile youth") often missed appointments for outside
medical consultations due to a lack of transportation. In
addition, at Central Juvenile Hall, the facility failed to track
and monitor adequately the medical needs of its medically fragile
youth. As a result, medically fragile youth missed important
follow-up appointments with physicians and treatment plans were
not developed in a timely fashion. Finally, Los Angeles County
did not have a system for transferring medical records from one
facility to another at the same time the youth was transferred.
Laboratory reports were hard to track down and often absent from
patients’ charts. The inability of staff to review prior health
records in a timely fashion delays medical treatment and places
medically fragile youth at risk of harm.
With regard to routine medical care, we found that barriers
existed which had the effect of discouraging and/or denying
access to timely medical care. For example, at all three
facilities, the medical request log the youth use to request
medical services was referred to as the "complainer's list," a
term which discourages the use of sick call because it suggests
that youth seeking medical care are inappropriately complaining.
In addition, youth were, at times, required to explain their need
for care to probation staff in order to get on the list. The
screening of medical care by probation staff may deter youth from
seeking needed medical and mental health treatment. Finally,
some youth did not even know how to access the medical care
system, a deficiency that appears attributable to the orientation
process.
The County reports that it will create additional patient
examination space at all three halls and may have funding to
computerize its recordkeeping system in 2003-2004. There are
reported plans for nurses to receive additional training in
communication with patients, and new policies have been drafted
to govern youth requests for medical care. A treatment plan
monitoring system is now reportedly in place, and a new policy
requires that doctors write treatment plans at the time of
initial evaluation of patients if such plans are needed. The
County also reports that additional staff were added to the
budget beginning fiscal year 2001-02. The County reports that it
has revised the orientation procedure and booklet, providing
language interpretation where needed. Youth with special needs
reportedly now receive individual orientation. We will assess
the implementation and adequacy of these reforms.

- 31 ­

D.

EDUCATION
1.

Special Education
a.

Screening and initial identification

School systems have a responsibility to locate, identify and
evaluate all eligible students with learning disabilities to
determine their need for special education and related services.
The screening systems used by the Halls to identify youth in need
of special education were insufficient to meet these
requirements. The schools identified youth needing special
education services in three ways: (1) through self-reporting;
(2) through records of prior detention at the Halls when a
special education need was verified; and (3) through teacher
identification and then follow-up testing. The schools did not
identify a significant portion of students who appeared to need
special education through these three systems and thus were not
consistently providing the special education services to which
youth are entitled under the Individuals with Disabilities
Education Act (IDEA).
The school system did not conduct intake interviews in a
manner that could produce reliable information. Staff completed
the intake interviews we observed in less than one minute. When
a youth is interviewed, probing and follow-up questions are often
necessary to obtain an accurate special education history from a
youth. Concern over current legal difficulties, misunderstanding
of the services youth had received previously, fear of their new
environments at the Halls or simple inability to comprehend the
screening questions are factors that prevent recently detained
youth from accurately reporting their education histories. The
one-minute or shorter interviews we observed at the Halls could
not overcome these barriers. Assessment personnel reported to us
that they were unable to conduct longer interviews due to
staffing shortages.
The school system maintains a database to record students’
receipt of special education services at the Halls. However,
youth who previously self-identified as having received special
education services in the community, but whose special education
needs had never been verified through record retrieval, did not
appear in this database. Thus, unless a youth self-reported
again at a later admission to the Halls and staff retrieved the
student's records from the school where he or she received the

- 32 ­

special education services, the youth was not likely to receive
the needed services while at the Halls.
The school system took insufficient steps to gather youth
education records needed to determine special education
eligibility and guide services. Cut-backs in staff slowed record
retrieval from students' community schools to a trickle. Until
the Halls received verification that a student did need special
education, either through prior school records identifying that
need or through testing at the Halls, the student received no
special education services.
In addition, medical and mental health staff sometimes
failed to convey to education staff necessary information that
might assist in developing appropriate education programs for
individual youth. For example, although vision and hearing
screenings are required for youth referred for special education
eligibility determination, the medical staff performed only about
half of the vision and hearing screenings the schools requested.
The practice of population balancing between the three Halls
also impeded completion of special education assessments as well
as other education goals such as planning for high school
equivalency examinations. Staff moved youth between the Halls to
even out the number of youth detained at each Hall, disrupting
testing and examination preparation.
Finally, staff at Central Juvenile Hall provide no education
services to youth aged 19 to 21, despite youth entitlement to
special education through age 21.
The County Office of Education reports that it has improved
both its screening system and its referral process to identify
students in need of special education, resulting in an increase
in referrals for assessment. The County reportedly has made
efforts to avoid moving youth between Halls when it would disrupt
ongoing testing or high school equivalency examination
preparation. The County Office of Education also reports that it
has worked with juvenile court judges, school principals and
other juvenile court leadership to enhance the retrieval of prior
education records, and has enhanced its database as well as
increased computer storage of documents. We plan to assess the
implementation and adequacy of these reforms.
b.

Delivery of special education services

- 33 ­

The Halls were providing students identified as needing
special education services with inadequate services in
insufficient quantities. General education teachers were
expected to provide special education services for the students
in their classrooms identified as special education students.
Often, the general education teachers had no idea which of their
students had been identified as needing special education. At
the time of our tours, special codes on the classroom rosters
identified special education students, but none of the teachers
we interviewed knew what the codes meant. Additionally, even if
a teacher knew that a particular student was in need of special
education, the teacher often did not know what the identified
student's disability was or what special education was needed to
address that disability.
Many general education teachers did not participate in
meetings regarding the student’s Individualized Education Program
(IEP), despite the IDEA’s requirement that they participate in
such conferences. The teachers reported that either staff did
not invite them to attend the meetings or they could not locate
coverage for their classes in order to attend. Most general
education teachers we interviewed had not read the IEPs for their
students. The schools also made inadequate efforts to ensure
meaningful parent participation in IEP conferences through use of
alternative methods such as speakerphones and scheduling of IEP
conferences to coincide with facility visitation schedules.
Delivery of special education services outside the classroom
by resource specialists also failed to meet the IDEA’s
requirements. While these services should be provided by
certified special education providers, unqualified paraeducators
attempted to provide services. The halls lacked proper spaces
for youth to work one on one in a private setting. Instead they
had to carry on individual services in noisy, shared offices that
interfered with youths’ concentration. Furthermore, due to
staffing shortages, the Halls did not provide youth the amount of
services required in the youths’ IEPs.
Counseling and speech services were limited at the Halls due
to lack of staff. Space to conduct exams and provide counseling
also lacked appropriate privacy.
The County Office of Education reports that it has hired
additional special education staff, provided extensive training
to teachers, involved special education service providers more in
classrooms and engaged in monitoring of outcomes and training

- 34 ­

needs. New management reportedly focus on instructional
leadership and strategies, and schools have developed procedures
for obtaining appropriate representation and input at IEP team
meetings. We will assess the implementation and adequacy of
these reforms.
c.

Behavior Management

The IEP teams for learning disabled youth who have
behavioral problems that interfere with their learning or that of
others must consider and implement appropriate strategies that
can address the behavioral concerns. Such strategies may include
positive behavioral interventions and supports, with correlating
behavior intervention plans. At the Halls, many youth are
confined in the special handling units (SHUs) or returned to
their units from school as a result of “refusal to attend school”
or “behavior referrals” from school. A substantial portion of
these youth have identified special education needs. The schools
did not review these youths’ IEPs to consider their need for more
intensive supports and interventions, or include positive
behavior intervention plans in their IEPs.
While behavior management assistants (BMAs) saw some youth
with emotional disturbances, these paraeducators had little
specific training in special education or in positive behavior
management strategies.
The County Office of Education reports that it has increased
training on behavior intervention, and that vice principals are
routinely involved in disciplinary procedures to ensure
consistency. We plan to assess the implementation and adequacy
of these reported reforms.
d.

Transition services

The IDEA requires education programs to provide transition
services to teenage special education students to help them move
from school to employment, higher education or other goals. The
Halls showed little evidence of providing individualized
transition services to special education students.
The County Office of Education reports that it has enhanced
transition training for the staff and increased youth
opportunities for transition skills development. We will assess
the implementation and adequacy of these reforms.

- 35 ­

2.

Exclusion from Classroom Instruction

At the time of our tours, the Halls did not have enough
teacher positions to provide the entire student population with
consistent, daily instruction. Teachers' contracts limit the
classroom size to no more than 17 students. Students who arrived
to a classroom once that maximum capacity had been reached were
sent to overflow classrooms. Substitute teachers ran the
overflow classrooms. From our observations, very little
educational instruction took place in the overflow classrooms.
Staff did not assign youth to overflow classes based on
educational criteria such as reading or grade level; teachers
were often unaware of youths’ instructional and special education
needs; overflow classes did not have appropriate instructional
materials or equipment; and the classes were held in dayrooms or
gymnasiums which provided inappropriate environments for teaching
and learning.
Furthermore, we observed many days when the overflow
classrooms also reached capacity. Students who encountered this
situation were sent back to their units and received no
educational instruction for the morning (or the afternoon unless
the situation had resolved itself). Likewise, in the residential
units where students stayed for their daily classroom education,
those classrooms often exceeded their 17 student capacity as
well, in some cases preventing youths from attending those
assigned classes.
The County Office of Education reports that students are now
consistently receiving 300 minutes a day of education at all
three halls. We look forward to assessing the implementation and
adequacy of these reported reforms.
3.

Classroom Placement

Staff assess students’ math and reading skills as they
arrive at the Halls. The schools use the results of these
assessments to determine appropriate classroom placement.
However, at the time of our review, rational classroom placement
decisions were compromised. First, the schools gave assessment
tests in English only. Students whose primary language was
Spanish were not assessed adequately. Second, due to the lack of
teachers, the schools often shuffled students between classes to
keep the classroom numbers balanced, ignoring the students'
assessed levels.

- 36 ­

The County Office of Education reports that it allows
parents, students and teachers to request changes of placement
for youth throughout their enrollment, and that changes in
instructional strategies allow all students’ skill improvement.
We will assess the implementation and adequacy of these reforms.
4.

Guidance Counselors

Guidance counselors serve important functions in juvenile
incarceration facilities, including planning and tracking of
students’ academic goals and progress toward high school
graduation or receipt of equivalency certificates. They help
students determine courses they need to graduate, and help
prepare youth for equivalency examinations. In recent years, all
guidance counselor positions were eliminated from the juvenile
halls. This cancellation of previously provided services
resulted in fewer students at the Halls receiving high school
diplomas and equivalency certificates.
The County Office of Education reports that it has placed
guidance counselors back at the schools within the Halls, numbers
of graduates and high school equivalency recipients increased in
the past school year, and more funds were available to provide
college scholarships to graduates. We will assess the
implementation and adequacy of these reported reforms.
5.

Homework and Classwork

Teachers wished to assign homework to students in their
classes, but were unable to do so due to security policies.
Though the rules varied between units, many staff did not permit
students to bring paper from school back to their residential
units, and did not provide access to writing implements in the
units. Some students reported that teachers assigned them
letters to write as classroom exercises, but they would not be
permitted to mail them.
In addition, we noted that students did not receive feedback
on many classroom assignments. In reviewing work folders, we
noted work that had inappropriate language as well as coded notes
between students, evidencing the lack of instructor review of the
material in the folders. Assignments several weeks old had no
correction or other teacher’s markings, and many youth complained
that they did work on which they never received feedback.
The County and Office of Education report that they have

- 37 ­

coordinated to resolve homework impediments, and that teachers
now assign homework on a standardized schedule, with time and
pencils available in the living units for homework completion.
In addition, the County Office of Education reports newly
restructured approaches to the curriculum to maximize instruction
in shorter modules, greater instructional guidance and more
after-school extended learning opportunities. Principals and
vice principals reportedly observe classrooms regularly, and
there are plans to more appropriately assess the merits of the
instructional program. Through grants and other efforts, the
County reportedly has acquired more books and computers for
instructional purposes. We plan to assess the implementation and
adequacy of these reported reforms.
6.

Instruction to Speakers of Other Languages

School districts must provide educational services in a
manner that allows language minority youth to participate
meaningfully in the educational program. While there are a
variety of acceptable ways in which schools can provide
meaningful access to the educational program for speakers of
other languages, we found that the Halls were failing to provide
such access.
Youth who could not understand English did not receive
information on school rules or how to access special educational
services while at the Halls. They were asked to sign papers
written in English, which they did not understand.
Staff assigned many limited English proficient youth to
classrooms in which the teachers did not engage techniques in
reading, writing or discussion assignments that could aid those
youth in understanding the lessons. In many classrooms teachers
overrelied on bilingual youth translating for limited English
proficient youth. Many youth with only limited English
proficiency reported that they did not know what was going on in
their classes and that they had to depend on another student in
the class to know what to do. We observed classrooms in which
teachers were not even aware of students’ limited English
proficient designations.
Furthermore, classes had insufficient reading materials at
appropriate instructional levels for youth, and lacked other
instructional materials needed to adapt the program effectively
for speakers of other languages.

- 38 ­

The County Office of Education reports that it has adopted
and is implementing a new policy for education of English
language learners, that it has held numerous trainings and has
acquired additional recreational and instructional materials in
Spanish. In addition, the school system reports that translation
services are available where appropriate. We plan to assess the
implementation and adequacy of these reforms.
E.

SAFETY AND SANITATION
1.

Fire and Life Safety

Our investigation found inadequate fire safety measures that
compromised residents' safety at all three halls. These
deficiencies included: absent, inaccessible and improperly
maintained fire suppression equipment; excessive and improperly
stored combustible materials; inadequate smoke and fire alarm
detection equipment; substandard evacuation routes and
procedures; and an overloaded and substandard electrical system.
a.

Fire extinguishers and sprinkler system

Fire extinguishers were present throughout the three halls
but the extinguishers were not always accessible or properly
maintained at Los Padrinos and at Nidorf. These deficiencies
were most apparent in the schools, housing units, and maintenance
areas. Some fire extinguishers were outdated or were not being
properly inspected. Others were not accessible to staff in the
event of a fire. Some staff did not know where to find the
closest extinguisher.
There were few automatic sprinkler systems in any of the
three halls. The few areas that were sprinklered were not
properly maintained. Leaking or dusty or misused sprinkler heads
were found at both Central and Los Padrinos.
The County reports having inspected, replaced or recharged,
and marked all of the fire extinguishers at all three halls, and
repaired fire hoses. We will assess the effectiveness of these
reported reforms.
b.

Combustibles and electrical hazards

Many of the maintenance/mechanical areas at Central and Los
Padrinos contained combustible materials that were not properly
stored, such as gasoline and oily rags. This problem was

- 39 ­

especially severe at Los Padrinos. Many of these same areas
contained flammable debris or were otherwise cluttered. These
maintenance/mechanical areas did not appear to be routinely
inspected for fire safety.
Overloaded electrical outlets and unsafe electrical
appliances were a problem throughout the halls. Staff have
brought to the facility electrical appliances that are not
grounded or polarized. We found such appliances plugged into
extension cords not suitable for high amperage appliances. These
fire hazards were especially severe in the classrooms, and most
notably at the Los Padrinos school where the electrical system
was outdated and unsafe. Other electrical hazards included
unsecured electrical cabinets and substandard or damaged
electrical outlets.
The County reports having inspected all electrical systems,
boxes, and sockets for safety compliance in all three halls, and
instituted a maintenance housekeeping policy. We will assess the
effectiveness and adequacy of these reported reforms.
c.

Fire and evacuation preparedness

Exit signs and other emergency lighting were missing or not
working along evacuation routes throughout the halls. It was
unclear whether emergency generators would supply power to
essential functions at the halls in the event of a power outage
because maintenance and supervisory staff at the halls did not
know and had no documents to show which items at the facility
were covered by the generators. Emergency exits were blocked in
some locations due to furniture arrangements. Some of the
housing units at Los Padrinos had blocked exits or faulty door
locks to the residents' rooms, which could make evacuation
difficult in the event of an emergency.
There were no smoke detection systems in some areas at Los
Padrinos. Non-working smoke detectors were found in at least one
housing unit at Nidorf. The halls' fire alarm systems were not
connected directly to the local fire stations.
The County reports having posted fire evacuation plans in
all areas, and inspected and repaired or replaced all faulty
doors, locks, and keys. We will assess the effectiveness and
adequacy of these reported reforms.
2.

Food service

- 40 ­

The food service operations at the three halls did not meet
sanitation requirements and put residents at risk of developing
food borne illness. In addition, there was inadequate control of
medical/special diets at two of the three halls.
We found numerous examples where foods were kept at unsafe
temperatures, which could allow for growth of food borne
bacteria. At all three halls, some of the freezers were not
working properly. At Central, frozen food deliveries were not
handled safely to maintain freezing.
The food temperature and safety were further compromised
because the closed carts that were used to transport meals from
the kitchen to individual units did not maintain safe
temperatures until the food was served.
Food service staff were also storing, preparing, and serving
food in unsanitary conditions at the three halls. At Central,
food was sometimes stored unlabeled and undated risking unsafe
food rotation. Our investigation identified food stored in
soiled containers and prepared and/or served with soiled
utensils/equipment. Food and food utensils were stored with
cleaning supplies. At Los Padrinos, food contact surfaces,
utensils and equipment were not kept in sanitary conditions.
Staff in the kitchens were seen using bare hands on food contact
surfaces. Some food was stored in a bathroom. At Nidorf, some
food was stored unlabeled and undated risking unsafe food
rotation. Equipment and utensils were being stored in an
unsanitary manner.
Other unsanitary conditions in the kitchens compromised safe
food preparation at all three halls. These included: water,
plumbing and sewage problems at Central; water, sewage, plumbing,
bathroom, garbage, rodent, and insect problems at Los Padrinos;
and garbage problems at Nidorf.
A percentage of residents at all three halls are on special
diets (medical or religious). At Central and Nidorf, we saw
evidence that residents who were supposed to be on special diets
did not always receive those meals. In addition, many of the
housing units' pantries contained no or minimal snacks necessary
for special needs children (i.e. pregnant youth, diabetic youth,
etc.) for occasions when medically ordered snacks were not
delivered.

- 41 ­

The County reports having put weekly kitchen inspection
protocols in place to determine if food in freezers is properly
labeled, decreased meal service delivery time by 15 minutes, and
repaired many kitchen appliances in need of repair. The County
also reports the development and implementation of several more
kitchen inspection protocols. We plan to assess the
implementation and adequacy of these reforms.
3.

Plumbing, ventilation, and lighting

All three halls had deficient plumbing, ventilation, and
lighting. We found broken or uncleanable toilets, urinals,
showers, and sinks at all three halls. Some sinks had on/off
valves too hard to operate, or that would not allow for proper
hand washing.
All three halls lacked proper ventilation in some locations.
There was no evidence that the ventilation systems had been
cleaned or rebalanced. Uncomfortable temperatures, moldencouraging humidity, disease transmission potential, and foul
odors existed in some areas at all three halls due to the failure
of any adequate inspection, maintenance, and repair programs for
the ventilation systems. Temperature control on the housing
units and in the classrooms varied greatly. Some ventilation
grills were plugged or blocked in each of the halls. Many
individual classrooms and residents' rooms had no intake air
circulating or no working exhaust and, in some cases, both were
not working.
Adequate lighting must be provided for reading, to ensure
security, and allow for good sanitation and proper personal
hygiene. All three halls had numerous instances of inadequate or
unsafe lighting. Unprotected lights, which can lead to food
contamination, were found in the food service areas at Central
and Los Padrinos. Many housing units at all three halls had
broken, blocked or inadequate lighting for reading and personal
hygiene. Emergency lighting and security lighting were not
working or inadequate at some locations in all three halls. Some
of the classrooms at Central and Los Padrinos were not adequately
lit. In addition, medical facilities at all three facilities
lacked adequate lighting.
The County reports having developed and implemented a
physical plant maintenance inspection system and made all
necessary repairs. In addition, the County reports having
inspected and repaired all plumbing in the bathroom/shower

- 42 ­

areas and kitchens and lighting in selected areas. An overhaul
of the three halls' HVAC systems was expected to be completed in
August 2002. We plan to assess the implementation and adequacy
of these reforms.
4.

Medical areas

There were several environmental health deficiencies in the
medical areas at the three halls, in addition to the plumbing,
lighting and fire safety problems outlined above. At Central,
the dental clinic had no means to dispose of bio-hazardous
materials, was experiencing an ant infestation, and had a dirty,
unorganized pharmacy. After hearing our grave concerns regarding
environmental health and safety conditions in the pharmacy (risk
of contamination of both medical and non-medical products), staff
quickly cleaned and reorganized the pharmacy.
At Los Padrinos, the pharmacy was poorly lit and non-medical
items were stored in the room. Uncovered waste containers and
soiled rooms and furniture were evident.
The medical areas at Nidorf were especially problematic.
Lighting in the storage area and admission exam room was poor.
Medications were stored on dirty floors and in dirty containers.
Sterile supplies were stored with non-sterile supplies. Plumbing
fixtures were broken and dirty. Patient rooms were soiled.
Staff invited us back during our later visits to see improvements
they made after our initial feedback, and many of the problems,
but not all, had been addressed. Inadequate lighting in the
medical storage area and admission examination room had not been
corrected. Broken and poorly maintained plumbing fixtures had
not been repaired.
The County reports having installed a temperature alarm on
the medical refrigerator at Central, repaired a drainage problem
in the medical area at Central, and added biohazard and sharps
buckets in each medical services room at all three halls. The
County also reports having been allocated money for additional
space, and having instituted additional training for nurses. All
three halls have implemented pharmacy inspection plans and staff
training, according to the County. We plan to assess the
implementation and adequacy of these reforms.
5.

Personal hygiene and laundry

Facility practices interfered with residents' personal
hygiene in several respects. At all three halls, security

- 43 ­

practices did not allow for necessary handwashing at appropriate
times. Stains were not always removed from clothing by the
laundry service. Female residents especially complained of
"freshly laundered" yet stained undergarments. We saw mattresses
with splits in their coverings, which prevent them from being
sanitized properly. In many units there were not enough clean
sets of clothing and towels to supply all residents.
Some housing units had an insufficient number of working
toilets and/or showers. Residents' access to toilets, especially
at night, was sometimes limited. Although management had been
attempting to improve the toileting problem, we received reports
of youth having to relieve themselves in their towels,
pillowcases, or corners of their rooms when they were not allowed
out of their rooms to use the lavatories. Some pregnant girls
reported not being allowed out to use the bathroom as frequently
as they needed to.
The County reports having increased allotments of clothing
and towels and having tried new stain eliminating products, as
well as having instituted laundry inventory, inspection and
sorting procedures. We plan to assess the implementation and
adequacy of these reported reforms.
III.

REMEDIAL MEASURES

In order to rectify the deficiencies we identified and to
protect the constitutional and statutory rights of the
facilities’ juvenile residents, the County should implement, at
a minimum, the following measures:
A.

MENTAL HEALTH CARE

1)

Provide sufficient mental health, probation and medical
professional staff to meet the serious mental health
needs of the juvenile halls population. Ensure that
professionals’ time is used efficiently and that there are
adequate means of communication to provide for appropriate
response to crises.

2)

Develop and implement policies, procedures and practices for
initial mental health screening to allow the identification
of previously diagnosed and potentially existing mental or
substance abuse disorders, including potential suicidality.

3)

Develop and implement policies, procedures and practices
for specialized mental health assessments to timely and

- 44 ­
accurately diagnose mental illness, substance abuse
disorders and mental retardation, including potential
suicidality.
4)

Develop and implement policies, procedures and practices for
interdisciplinary treatment planning for youth with serious
mental health needs, which would allow for the ongoing
identification, goal setting and monitoring of youths’
target symptoms in a detailed and organized fashion.

5)

Develop and implement policies, procedures and practices for
case management which would allow for the implementation of
the treatment plan and ensure that treatment planning
follows each youth from facility to facility and into the
community.

6)

Develop and implement policies, procedures and practices
to ensure the availability of sufficient and adequate
counseling services that meet the goal of ameliorating
target symptoms of identified mental illness.

7)

Institute an adequate information management system to allow
adequate tracking of laboratory results and response to
medication including side effects, adequate documentation of
mental health services and compilation of complete records.
This should include documentation of the goals of mental
health counseling and progress toward those goals.

8)

Develop and implement special individualized behavior
modification programs for individual youth where needed.

9)

Develop and implement policies, procedures and practices to
ensure that mental health counseling services address
substance use disorders appropriately.

10)

Develop and implement policies, procedures and practices to
ensure that psychotropic medications are prescribed,
distributed and monitored properly and safely. Provide inservice training to nursing staff regarding the side effects
of psychotropic medication and require nursing staff to
document the side effects that youth are experiencing.

11)

Revise policies, procedures and practices to limit uses of
restraints for mental health crises to circumstances
necessary to protect the youth and other individuals, for
only as long as is necessary, and to accomplish restraint in
a safe manner.

- 45 ­
12)

Provide annual suicide prevention training to all staff,
which includes practical matters such as how to access and
use a cut down tool for youth who attempt to hang
themselves.

13)

Develop and implement policies, procedures and practices to
ensure that arresting officers, probation, medical and
mental health staff share appropriate information regarding
potentially suicidal or self-harming youth.

14)

Ensure that mental health staff provide timely assessment
and daily reassessment of youth deemed at risk for suicidal
behaviors, as well as appropriate follow-up assessment once
youth are discharged from suicide precautions.

15)

Develop and implement policies, procedures and practices to
ensure that mental health staff are sufficiently involved
with probation staff in the management of youth exhibiting
suicidal behaviors, including creation of individual
behavior modification programs and decisions about
appropriate clothing, bedding and housing.

16)

Develop a continuum of services and responses to meet the
needs of self-harming youth, including revised supervision
practices to minimize incidents of self-harm, and increased
access to hospital services, specialized residential
facilities and intensive community services.

17)

Notify appropriate outside officials and family members
following a suicide attempt.

18)

Develop and implement policies, procedures and practices
that allow youth to access mental health services without
interference from custody staff, except as dictated by
institutional safety needs and due process rights of youth.

19)

Train custody staff in appropriate interactions with and
needs of mentally ill youth.

20)

Develop and implement policies, procedures and practices to
ensure that youth with disabilities at the halls are not
housed in more restrictive settings than safety and security
require.
B.

JUVENILE CONFINEMENT PRACTICES

- 46 ­

21)

Provide sufficient staff supervision to keep residents safe
from harm and allow rehabilitative activities to occur
successfully.

22)

Provide sufficient sleeping spaces in individual units for
the number of youth assigned to each unit.

23)

Develop and implement policies, procedures and practices to
restrict use of OC spray to appropriate circumstances,
enable supervisors to maintain tighter controls over spray
use and storage, restrict the carrying of OC spray to only
those individuals who need to carry and use it, prevent
wherever possible the use of OC spray on populations for
whom its use is contraindicated or contrary to doctors’
instructions, and ensure that decontamination occurs
properly.

24)

Improve training to all staff in de-escalation techniques,
crisis counseling, youth development, supervision, building
positive relationships with youth, using appropriate
language when communicating with youth, and specific writing
skills aimed at improving the clarity and specificity of
incident reports written after uses of force.

25)

Develop and implement a system for timely, thorough and
independent investigation of alleged child abuse.

26)

Develop and implement a system for review of uses of force
and alleged child abuse by senior management so that they
may use the information gathered to improve training and
supervision of staff, guide staff discipline and/or make
policy or programmatic changes as needed.

27)

Ensure adequate rehabilitative programming, access to
reading materials, especially during non-programmed time, a
reasonable behavioral management system, and gender-specific
programming, where appropriate.

28)

Ensure that youth have the opportunity to attend religious
programming in the faith of their choice if they so desire.

29)

Ensure that group punishment is not used unless there are
exigent security concerns.

30)

Develop and implement a strategy for reducing youth on youth
violence that includes training staff in appropriate
behavior management and violence reduction techniques.

- 47 ­

31)

Minimize the movement of youth from facility to facility and
unit to unit.

32)

Improve orientation to communicate important information
such as how to access the grievance system, medical care and
mental health services to new residents.

33)

Assess the needs of the facilities’ LEP residents and
develop and implement a method for providing meaningful
access to programs and services for that population, as well
as provide for their health and safety.

34)

Develop and implement policies, procedures and practices to
ensure reasonable telephone access.

35)

Develop an effective grievance system to which youth have
access when they have a complaint, ensure that grievances
may be filed confidentially and ensure that they receive
appropriate follow-up, including informing the author of the
grievance about its outcome and tracking implementation of
resolutions.
C.

MEDICAL CARE

36)

Develop and implement a system to monitor the medical needs
of medically fragile youth to ensure that these youth
receive timely and adequate medical care.

37)

Ensure that medically fragile youth are transported to
community medical appointments in a timely fashion and that
they are seen by a physician on a scheduled basis.

38)

Develop and implement an effective system for transferring
medical records from one facility to another so that youth
receive timely and consistent medical services.

39)

Develop and implement policy, procedures and appropriate
training of medical and correctional staff to ensure privacy
and confidentiality in all medical encounters, except as
dictated by institutional safety needs and due process
rights of youth.

40)

Develop and implement policy, procedures and practices to
ensure that probation staff do not deter youth from
requesting medical care.

- 48 ­
D.

EDUCATION

41)

Develop and implement a systematic, comprehensive process to
locate, screen, identify and provide appropriate services to
all youth through age 21 with disabilities who require
special education services.

42)

Staff schools to support adequate education and special
education services, including guidance counselors.

43)

Provide adequate counseling and other related services to
special education students with those needs.

44)

Utilize alternative methods to facilitate parent
participation in IEP meetings.

45)

Provide adequate transition planning and services for all
eligible youth with disabilities.

46)

Eliminate the use of overflow classes and the associated
exclusions of youth from educational programs.

47)

Provide sufficient and appropriate instructional materials,
space and equipment for all classes.

48)

Implement a positive behavior management and support system
for the education programs.

49)

Implement a professional development program for teachers,
emphasizing research-based instructional strategies that are
effective for detained youth with disabilities in the
general education classroom.

50)

Consider education needs in determining whether to transfer
youth among the halls. Consider whether youth are in the
middle of special education assessment or preparation for
high school equivalency examination.

51)

Develop and implement means for including limited English
proficient youth meaningfully in educational programming,
including acquiring adequate educational materials.
E.

52)

SAFETY AND SANITATION

Complete necessary repairs to kitchen appliances, plumbing,
ventilation, fixtures, temperature controls and lighting.

- 49 ­
53)

Complete cleanup of food service and medical areas.

54)

Institute a maintenance system that ensures prompt response
to needed repair work and incorporates preventive
maintenance.

55)

Ensure that staff and contractors do not leave debris or
tools that may be used as weapons or escape devices.

56)

Ensure adequate smoke and fire alarm coverage, which
communicates with appropriate entities.

57)

Eliminate electrical hazards.

58)

Institute a plan for food preparation, storage and service
that eliminates risk of food borne illness.

59)

Provide medical and therapeutic diets as required.

60)

Develop and implement policies, procedures and practices to
provide youth with adequate hygiene opportunities, and
needed personal hygiene products, linens, bedding and
clothing that are sanitary and in good repair.

61)

Provide adequate ventilation and appropriate temperature in
all areas where youth are present.

62)

Provide adequate lighting to perform needed tasks.

63)

Minimize fire-loading in all areas, especially the school
buildings.

64)

Establish a comprehensive Infection Control and Surveillance
Program in the medical facilities.

65)

Inventory all equipment that should be powered by emergency
generators and ensure that the generators function and power
necessary equipment.
E.

66)

QUALITY ASSURANCE

Institute quality assurance and improvement systems that
cover all areas outlined above.
*

*

*

In light of the County’s cooperation in this matter, under

- 50 ­

separate cover we will send you our experts’ reports. Although
the experts’ reports and work do not necessarily reflect the
official conclusions of the Department of Justice, their
observations, analyses and recommendations provide further
elaboration of the issues discussed above, and offer practical
assistance in addressing them.
Pursuant to CRIPA, the Attorney General may institute a
lawsuit to correct deficiencies of the kind identified in this
letter forty-nine days after appropriate officials have been
notified of them. 42 U.S.C. Section 1997b(a)(1). We would
prefer, however, to resolve this matter by working cooperatively
with you, and we have every confidence that we will be able to
do so.
Sincerely,
/s/ Ralph F. Boyd, Jr.

Ralph F. Boyd, Jr.
Assistant Attorney General
cc:

	Richard Shumsky
Chief Probation Officer
Lloyd Pellman

County Counsel

Gordon Trask

Principal Deputy Counsel

Special Services Division

Shirley Alexander

Superintendent

Central Juvenile Hall

Ron Barrett

Superintendent

Los Padrinos Juvenile Hall

Bill Gerth

Superintendent

Barry J. Nidorf Juvenile Hall


- 51 ­

Darlene Robles
Superintendent
Los Angeles County Office of Education
Shari Kim Gale
General Counsel
Los Angeles County Office of Education
The Honorable Debra W. Yang
United States Attorney for the
Central District of California
Alex M. Azar, II
General Counsel
Department of Health and Human Services
Tommy G. Thompson
Secretary
Department of Health and Human Services
Dr. Van Hanh Nguyen
Director
Office of Refugee Resettlement
Department of Health and Human Services
Lydia Blakey
Acting Assistant Director
Prisoner Services Division
U.S. Marshals Service
Gerald Auerbach
Acting General Counsel
U.S. Marshals Service
Benigno G. Reyna
Director
U.S. Marshals Service