Hi Dept of Public Safety Contractual Compliance Checklist for Saguaro Cc 2011
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H~lAII DEPARTMENT OF PUBLI1 SAFETY 1 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 Contract Item & Description 0 ::!: Q) C) 4 c. E c. E 0 C. ACA Accredited Facility: (RRCC & SCC to be accredited within 18 months of facility activation) 1. Mandatory (100%) 2. Non-mandatory (90%) 3. Life Safety Code/Fire Codes A. s:: 0 C'lS 20 s:: C'lS Z E Q) - X X X Comments C'lS co 0 zo Date of Accreditation (every 3 yrs): October 2008 Mandatory Score: 100% Non-mandatory Score: 100% 3. Underwear X Sprinklers operational: Feb 2010 Fire Marshall Reoort: Julv 16, 2010 Inmate receives 3 sets of uniforms during the Intake process (packed in laundry and distributed to housing units). Random uniform checks in housing units confirm that inmates have 3 sets of uniforms. Describe: Use of restricted funds may be requested and approved for winter wear and/or warmer clothing through MB; Winter jackets were issued in September 2010 for the winter season. Issued @ Intake 4. Personal Hygiene: X Issued @ Intake a. Soap b. Toothbrush X Issued @ Intake c. Toothpaste X Issued @ Intake d. Deodorant X Issued @ Intake X May exchange razors and toothbrushes on 1-for-1 basis. X Boots stored in commissary and issued for kitchen workers, maintenance and yard/landscape workers. Clothing & Supplies: 1. 2 sets of Uniforms (Males) X 2. Seasonal Clothing (Warmer clothing for colder weather; Colder clothing for warmer weather) X / Sa. Monthly Exchange (Y/N) If No, why or why not? 6. Workline Appropriate Clothing: a. Boots (as appropriate) b. Gloves (as appropriate) X 7. Linen: a. Towel b. Sheets c. Pillow Case Revised 7/1/07 X X X X H~1AII DEPARTMENT OF PUB:;6 SAFETY 2 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 d. Blanket (Wool) or e. Blanket (Cotton) Available B. 4 Laundry: 1. Weekly Laundry Service X X (Describe weekly schedule) 2. Laundry Exchange (clean, laundered replacements) Wool blanket available if 11M is allergic to cotton; medical memo required. Weekly Schedule: Posted in Units Mondays: Wkly washes - whites Tuesdays: Wkly washes - colors Wednesdays: Blankets (monthly); whites Thursdays: Uniforms; Wkly colors Fridays: Wklv washes - whites X ~ C. D. 4 45 Exchanges offered every 6 months or upon request; exchanges inoutted into OMS bookinq notes. Property disclaimer forms were once handled by the Property Officer but is now completed during intake and filed in inmate records. A log is maintained and kept in the N-Unit (N-Unit administrative clerk emails hard copies for files) N-Unit multi-purpose room is secured. 2a. Laundry Exchange every 6 mos. X Inmate Property: 1. Property Disclaimer Form X 2. Lost/Stolen Property Form X 3. Secured Property Room X 4. Property Officer X Property Officer: R. Streeter 5. Segregation Property Form & Confiscation Form X Form completed for every inmate in segregation: YES 5a. Secure Segregation Storage X Food Service (Canteen Contract Services): 1. Rice served daily Location: N-Unit multi-purpose room is secured. Programs 2 also utilized to store H-Unit inmate property. Inmates who have been transferred to Hawaii for court have property stored in Programs 2. Food Service Manager: P. Parker X 2. Fresh/Canned Fruit Weekly X Average 3x weekly 3. Menus Approved by Dietician X 10/21/10 L. LeClair, RDLD Cycle date: 1/21111 3a. Meals based on current U.S. Dietary Guidelines 3b. Copies of Cycle Menus Provided X Calorie Count per inmate: 3,200 X Date of menu: 10/21/10 X Compliance monitored daily and reports given to medical on a monthly basis 4. Medical Meals Approved by Facility's Physician (CCA Policy) Revised 7/1/07 H~kAIl DEPARTMENT OF PUB~6 SAFETY 3 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 5. Religious Meals Approved by Facility's Chaplain (CCA Policy) X Increase in Kosher diets noted 6. Special Dinner Menus: a. Prince Kuhio Day (March) b. King Kamehameha Day (June) c. Other special event X Menu for Kuhio Day: Teri chicken, beef broccoli, rice, pasta salad, mixed vegetables, haupia and banana X X Describe other: MLK Day, Independence Day, Thanksgiving & Christmas, all other religious programs are given a special meal. President's Day (2/21/11): Shoyu chicken, sausage, pasta salad, peas/carrots, rice, chocolate cake w/ frosting, banana and fruit punch Kitchen: 1. Food served compares to menu 2. Dead man trays X X 3. Alternative disaster menu 4. Food portion control 5. Workline training on sanitation/hygiene, tool/equipment safety, hand washinQ techniques 6. Sufficient hair nets available 7. Sufficient gloves available 8. Workers know location of hair nets and Qloves 9. Food handlers/Cooks wear hair nets and gloves X X X Monitored by supervisor Logs reviewed X X X 10. Appropriate footwear are used X 11. Internal inspection of kitchen, dining areas, food storage and preparation areas 12. Internal inspection of tools, equipment and liquid soap dispensers X Revised 7/1/07 Cycle week 1 meals as indicated Maintained for how many days: 72 hours X Improper use of hairnets; several inmates had to be reminded to wear hair nets All inmates wearing approved rubber foot coverinqs Clean and orderly X Gauges on hotboxes 1 and 2 inoperable, #2 hotbox not working, grills not functioning, 1 mixer switch on order, tilt skillet won't light, 1 broken soap dispenser broken (work order repaired during audit), 1 soap dispenser empty. --j-' HAWAII DEPARTMENT OF PUBLIb SAFETY 4 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 13. Adequate drainage near washing X stations 14. Dry Storaqe: Appropriate lighting X 15. Food stored at least 6' off floor X 16. Food stored at least 18" from X ceilinq 17. Food is covered, labeled and X dated 18. Separate storage for food and X non-food items 19. Emergency supply # of days _7_ X 20. Regular insect control maintenance 21. Refrigerators/Freezers thermometers operable 22. Evidence (log) shows thermometers are calibrated on a routine basis 23. Refrigerator temperature monitored and recorded 2 per day 24. Freezer temperature monitored and recorded 2 per day 25. Refrig/Freezer food is stored at least 6' off qround 26. Refrig/Freezer food is covered, labeled and dated 27. Refrig/Freezer doors are sealed, cleaned and in tact 28. Refrig/Freezer vents/fans are clean and free from dust 29. Refrig/Freezer hinges/locks/ are in good repair 30. Refrig/Freezer is clean inside and out 31. Portable Food carts in working order 32. Food prep/production areas are clean, sanitized and in qood repair 33. Grease traps are clean 34. Inventory control for sharp utencils Revised 7/1/07 Floor clean under supplies No expired dates noted Monthly service contractor X X " X Daily/3 checks on transported food: Before leaves kitchen, before serving and during serving X At each shift; 34 degrees X At each shift; 6 degrees X X X X X X X Cleaning wheels and seals are being addressed X X X Every 6 months Under lock and key and only given out and accounted for by security PUB~?C HAJvAII DEPARTMENT OF SAFETY 5 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 35. Mops, cleaning supplies and chemicals are securely stored and inventoried 36. Garbage containers covered with tiQht fittinQ lids 37. Scheduled garbage removal from kitchen after each mail 38. Adequate outside storage of garbage until trash removal 39. Dishwashing temp log (125-140 degrees) 40. Dishes/pots/pans properly scraped and free from excessive stains and caked foods X X X X 3 times weekly X 140 degrees; chemical cleansing X Food manager has begun a special workline detail to address this issue. Describe: # of Supervisors/hours per shift: 2 Breakfast 2 **There are 2 shifts daily; with the Supervisor, it makes 3 per shift. E. F. 5 5 Inmate Commissary: 1. Commissary Services a. Non-essential items (soda, candy, personal items) X 2. Commissary proceeds utilized for General Inmate Population Benefit (commissary maintenance, equipment, services, programs) X 3. Commissary Revenues (May be used to pay all operating expenses of the commissary) Recreation: 1. Indoor Activities Provided X 2. Outdoor Activities Provided X Revised 7/1/07 X Lunch 2 Dinner Vendor Name: Mid States Majority of the items distributed by Midstate distribution center in Casa Grande. Items distributed: Soda, ice cream, laundry bags, hangers, and Japanese wash cloths. Commissary best sellers are rice and iack mack. Commissary income statement and checking account statement provided by facility Business Office reflecting that the proceeds utilized for population benefit like Satellite TV in all cells. Describe indoor activities available: Pinochle, chess, checkers, dominoes, music room. Last music concert was Nov 2009. Staff looking at bands being able to perform in courtyard 2 times/year (Sprinq and Fall) Describe outdoor activities available: Basketball, sandbattle (shambattle) tournaments, strongman endurance competitions scheduled. ) -) HAWAII DEPARTMENT OF PUBL.-C SAFETY 6 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 G. 5 Library Services: 1. Recreational Library X a. Hawaii-based newspaper available in library (at cost of State) X H. I. J. 5 5 56 Visitation: 1. Visitation Room Available X 2. Video Visit Conferencing X 3. PolyCom Equipment Operable X 4. Special Visits (Pastoral, Legal and Families 300 miles or more) allowed X 4a. Non-contact visits X Grievance Procedures: X Recreational Librarian: R. Watley Recreational Library Hours: 0800-1030 hrs; 1330-1500 hrs. (Monday thru Friday); 0900 - 1000 hrs (Saturday); 0830 - 0930 hrs (Sunday). Library schedule posted in units Mainland Branch sends Saguaro 4 sets of weekly Star Advertiser newspapers. Seg inmates request a copy of HI newspaper and Segregation recreation librarian delivers newspapers to seg inmates Available for approved contact and non-contact visits. Food and drinks may be purchased from vending maohineswithpre-paidcard; cards purchased at facility entrance. Video visits are available on Saturdays and are scheduled throuqh the MB. PolyCom equipment working properly in each unit; MB successfully called into each unit durina audit. Need Warden's approval prior to visit and inmate must be 30 days disciplinary free; special visits may include military. Visitors traveling 300 miles or more may request extended visit through written request. Non-contact visits available for segregation inmates or visitors placed on restriction. Grievance Officer: J. Valenzuela Mailbox located outside dining hall for general population, segregation and H-unit. Officer checks grievance boxes daily and date stamps grievances when received. 1. Secured Grievance Boxes Mailboxes in segregation located in NB, NC, NO, NE rotunda area. 2. Informal Grievances Forms X 2a. Informal Grievance Logging & Tracking System X Revised 7/1/07 Mailboxes in H-Unit located in HB and H-unit rotunda areas. Maybe obtained through Unit Team and Grievance Officer Sent to the MB on a monthly basis PUBLf~ HA1AII DEPARTMENT OF SAFETY 7 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 K. 67 3. Formal Grievance Forms X 3a. Formal Grievance Logging & Tracking System 4. Designated time limits and filing appeals are consistent with the policy 5. Grievance Officer replying to grievances and not staff members 6. Opportunity to Appeal Decision X Access to Courts: 1. Law Library X X X X 2. Parole Hearings Conducted X 3. Attorney calls scheduled with facility X 3a. Court hearings afforded by telephone as necessary 4. Law Library Collection (KIOSKS): a. Hawaii Revised Statutes (HRS) b. Session Laws of Hawaii (SLH) c. Hawaii Reports d. Hawaii Appellate Reports e. U.S. Code Annotated f. Shepard's Hawaii Citations g. HI Court Rules (State) h. HI Court Rules (Federal) i. HI Digest j. Black Law's Dictionary k. Federal Civil Procedures & Rules I. Supreme Court Reports X Revised 711107 Obtained through the Grievance officer Sent to the MB on a monthly basis X X X X X X X X X X X X Law Librarian: R. Whatley Law Library Hours: (0830-1030 hrs; 1330-1545 hrs) - GP inmates Law library with segregation inmates is scheduled through unit staff. Segregation inmates may request law library materials through request to the librarian; materials will be delivered to segregation inmate within 3 working days. HPA sends parole hearing schedule to MB then it is facilitated with the facility. Attorney sets up calls with the MB then it is facilitated with the facility. Attorney may schedule within 24 hours of call on Tuesdays, WednesdaYs, and Thursdays. Hearings are set up through the MB then facilitated with the facility. Kiosk server in N-Unit is being replaced by vendor; server replaced as of 3/10/11 as confirmed by vendor. Available on touch-screen kiosk Available in hard copy (2001-2010) Available in Hawaii Court Rules hard copv (State 201 Q) Available in hard copy (volumes 5-50) Citations on kiosks Available in hard copy (2006, 2007, 2010) Available in hard copy (2006, 2007, 2010) Available in hard copy Available in hard copy (2011) Available in hard copy (1-126) )--) HAWAII DEPARTMENT OF PUBLIC SAFETY 8 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 L. 78 Security & Control: 1. Security Staffing Plan (to include all mandatory posts) is updated and available for review 2. Urinalysis Program: Minimum of 10% of State's Total Population X 1.71 formula (7-day post) 1.50 formula (5-day post) X CCA Policy #: 9-4 10.3% - 10.4% of pop randomly tested. na 2 test available at CCA expense 3a. Second test made available at inmate request/cost 3b. Positive Results Reported to PSD within 24-hours of Facility Receiving Results 4. Contraband Management X X CCA Policy: #9-6 4a. Policy covers definition, appropriate storage and critical areas to search 4b. Routine facility shake-down for contraband 4c. Inmates given proper written notification of contraband 5. Emergency Response Preparedness 5a. Security protocols on managing riots, disturbances, hostage situations, work stoppages, fires, escapes, bomb threats, natural disasters, etc. 5b. Appropriate agreements with the local county and law enforcement aQencies in emerQency responses 5c. Proper training of all staff in emergency response plans (i.e. Command post, Food service, etc.) 6. 5-1 Policy X CCA Policy: #9-5 X X X X X X MOU wi police, fire department and Casa Grande Hospital X Trainer: J. Marsh Initial training = 160 hrs In-Service training = 40 hrs I per yr X 6a. Investigations Completed in timely manner per policy 14 days 6a. Proper notification of Priority 1 incidents to the State 7. Formal Count on each Shift X 8. Tool & Key Control X 8a. Is there a Tool & Key Control Officer? 8b. Adequate storage of all tools & keys in the facility? X Revised 7/1/07 CCA Policy #: 8-1 Facility Investigator: S. Williamson X X X 2 day; 2 evening; 2 on swing shift Control Officer: E. Gobea / ) \ HAWAII DEPARTMENT OF PUBLIC SAFETY 9 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 8c. Proper logging system for issuance and return of tool? 8d. Proper logging system for issuance and return of keys? 8e. Proper shadow boards to provide rapid visual inventory of tools? 8f. Immediate reporting procedure for lost or damaqed tools 9. Security Inspections M. N. 8 89 O. 9 P. 9 Q. 9- 9a. Security inspections in accordance to CCA policy 9b. Security inspection checklist available 9c. Area inspections are documented and loqqed for review 9d. Security deficiencies are documented and corrected Use of Force: 1. Proper policy which governs the use of force aqainst inmates 2. Facility staff training provided in accordance with policy 3. Proper notification made to State Discipline: 1. Hearings are conducted in timely manner per policy 7 # days 2. Charqes match the offense 3. Copies of disciplinary report given to inmate to review 4. Disciplinary committee is impartial and was not involved in the original write-up 5. Disciplinary segregation not to exceed 60 days without Mainland Branch approval 6. Discipline Reports Completed & mailed out each month 7. Inmate has opportunity to appeal Inmate Trust Account: 1. Spendable/Restricted Accounts Restitution: 1. 10% Deduction of Inmate Wages TeleDhone Costs & Services: Revised 7/1/07 X X X X X X CCA Policy # 9-7 X CCA Policy #9-6 X X X Chief of Security: M. Lopez CCA Policy # 9-1 X X X Hearings Officer: Lt. Burns X X X X X X X Accounts maintained on CCA's OMS system X MB and CCA Corporate processes 10% deduction from workline wages towards restitution payment X All calls with the exception of legal )~) HAWAII DEPARTMENT OF PUBLfC SAFETY 10 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 10 R. S. 10 10 12 calls are monitored. 1. Electronic monitoring available 2. Cost of phone call/per minute X DNA Testing Program: 1. Staff trained in DNA Collection X 2. DNA test prior to Inmates return to Hawaii 3. DNA signed forms faxed to Mainland Branch prior to Inmate's return 4. DNA kits available at facility Inmate Programming: 1. Educational Ability Assessment X X MS supervisor receives DNA forms prior to inmates' return. Information inputted into Offendertrak by MS. X X Avaiable in R&D Principal: K. Sell Basic Literacy/ESL Adult Basic Education GEDlTesting Lifeskills/Breaking Barriers Vocational Training X X X X X 7. PSD SMSIV Input 8. Workline Opportunities; 2/3 Population Working X X 8a. Payscales per policy X 9. Hobby Crafts available 10. College Correspondence (at Inmate's expense) - Not required by Contract 10a. Distance Learning Satellite System (at PSD's expense) - Not required by Contract 11. Special Housing Incentive Program (SHIP) 11a. SHIP pursuant to policy 12. Hawaii Cultural Programs X X 2. 3. 4. 5. 6. 13. Faith-based unit Revised 7/1/07 Telephone Provider: ISC .25 per minute (direct calls); .35 per minute (collect calls). Collect calls not available for international calls. DNA collected by trained Saguaro staff. X Types: Wood works, plumbing, electrical, computer training 69.16% of entire popUlation is working (with the exception of seqreqation unit) .25 cents; CCA pays difference in hourly wages for inmates earning .50 cents for skilled worklines (dog proQram handlers). In-cell and hobby shop available College classes enrollment by Ohio University Re-evaluation of this program scheduled for June 2011. X X X X Types: Language, Hula, Cultural dance, House of Healinq ) ) HAWAII DEPARTMENT OF PUBLIC SAFETY 11 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10, 2011 T. 12 13 U. 13 V. 13 W. 15 19 Addictions Treatment Manager: K. Johnston, LPC, LSIC Substance Abuse Program: 1. Substance Abuse (Level 2) (SCC only) X 2. Therapeutic Community (Level 3) (SCC only) X 3. Aftercare (SCC only) X 4. PSD SMSIV Input 5. LSI-R / ASUS Certified 6. LSI-R/ASUS completions mailed to Mainland Branch Religious Programs: 1. Weekly Religious Services X X X Classification: 1. Completed Annually by the Facility Classification Officer X 2. Special Classification completed for SHIP/Administrative Segregation 3. Classification input on Offendertrak X Health Care: Operate 85% of NCCHC Standards 1. Health Services Administrator X X Health Services Administrator: P. Sells 2. Licensed Staffing X 3. Primary Care Services X 4. Chronic Care Management X 5. Medical & Specialtv Care 6. Infirmary Services 7. Routine Diagnostic Services X X X 8. Health Appraisals 9. Physical Medicine 10. Infection Control 11. Immunizations 12. Mortality & Peer Reviews X X X X X 1 vacancy (FT RN); Has been approved for hire Seen in timely manner for sick call and referrals to Providers The additional PT Provider (20hours) has resolved the backlog of chronic care since last audit. Document renal insufficiency on problem lists. Appts. timely N/A observation only Could improve on labs prior to CCC visits Up-to-date Revised 711/07 X 1:29 staff ratio 1: 12 staff ratio; 10-week program after RDAP3 completion Chaplain: C. Miller Schedules posted in pods; rosters provided; religious preference can be chanQed once every 6 months Classification Supervisor: C. Frappiea HI reclasses sent to MB for review monthlv X Classification supervisor saves draft in Offendertrak; MB staff will audit, verifv and finalize. ACA 98%; Quarterly outside pharmacy audit: 100% Infection control nurse assigned Tracked by infec. control nurse/utd Timely -"'" --~ ) . ) HAWAII DEPARTMENT OF PUBLIC SAFETY 12 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 X. 20 24 13. Dental Services 14. Mental Health Services 15. Co-payment Fees 16. Prosethesis aqreement available Personnel: 1. 24-Hour Staffing Plan X X X X X 2. Criminal History/Background Checks on all Facility Employees 3. Correctional Officer Training (160 hours basic training; 40 hours annual) X County and national background checks completed on all employees X Trainer: J. Marsh No backlog All up-to-date Amount of Co-payment: $3.00 Plan provided Staff unable to continue to work if their training requirements are not met by year's end. Randomly audited employee training records. 4. Full-Time On-Site Warden X Warden's Name: T. Thomas 5. Case Manaqers (Males) 6. LSI-R Training X X Ratio: 1: 120 7. Offendertrak Access (MIS) X 8. Quality Assurance Manager X a. b. c. d. e. f. Tracks all facility policies Schedules internal audits Coordinates external audits Tracks audit deviations Policy/procedural changes for Warden's review/approval Provides Response & Corrective Action Plan within 30 days X X X List provided QAM: T. Murrieta QAM iust started 1/3/11; All policies reviewed and tracked by policy status and tracking logs on dailv basis. Random internal audit samplings qenerated bv CCA Corporate Continually conducts internal audits. Schedules more formal internal audits as well. Cross audit teams to incorporate staff from other facilities have been implemented to audit each other's facilities. X X Y. 24 25 9. Unit Management Model X Reporting: 1. Progress Reports (Every 6 mos.) X Revised 7/1/07 Maintains an informal log, tracks internal audit plan of corrective actions which are due 30 days of report issuances. Each housing unit has a separate Unit Management plan complete with jobs information and safety inspections. MB receives progress reports. Advised staff to have it scheduled at end of each month to ensure no inmate has been missed. HAWAII DEPARTMENT OF PUBLIC SAFETY 13 MAINLAND/FDC BRANCH CONTRACTUAL COMPLIANCE CHECKLIST Saguaro Correctional Center, February 8-10,2011 Z. 2. Classification X 3. 5-1 Reports 4. Disciplinary Reports X X 5. Monthly Report X Administrative Matters: 1. Refer Inmate for Prosecution for Violating Laws of state 2. Refer Staff for Prosecution for Violating Laws of state 3. Liquidated Damages a. Is procedure in place? b. Level III Treatment c. Staffing Patterns (mandatory posts) d. 90 days initial activation before liquidated damages can be applied X Facility Population: 1. Facility Population Count X Current since last audit; extra staff assigned to assist in bringing reclasses up-to-date on new HI classification svstem. Sent to MB by Duty Officer DHO sends to MB 1s week of month Warden's secretary mails out to MB nd by the end of 2 week each month. MB uses statistics for monthly Kamakani report. Inmates involved in criminal activity in 2010 were referred for prosecution in Arizona. Last case referral in 2009. X X X X X Rated Capacity: 1896 Hawaii Count: 1699 US Marshalls: 219 FACILITY: Saguaro Correctional Center, Eloy AZ DATE OF VISIT: February 8-10, 2011 AUDIT TEAM MEMBERS: Jeanette Baltero, Contract Monitor; Heather Kimura, Contract Monitor; Carol Payne, PSD/Health Care; Lt. Daniel Mau, WCF/Acting Chief of Security. AUDIT COMPLETED BY: Shari Kimoto, MBA Audit Report Completed on 3/15/11. Plan of corrected action due 4/15/2011. Plan of corrective action received and deficiencies corrected as of 4/1/11. Revised 7/1/07