Case 2:12-cv-00428-DDP-MRW Document 286 Filed 10/20/23 Page 1 of 51 Page ID #:6163

1 Kathleen M. Kenney
343 Sweet Grass Way
2 Richmond, KY 40475
Email: [email protected]
3

4 Monitor and on behalf of Monitors

Robert Houston and Nicholas E. Mitchell
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6 UNITED STATES DISTRICT COURT

7 FOR THE CENTRAL DISTRICT OF CALIFORNIA
8 WESTERN DIVISION
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10 Case No. 12-cv-00428 DDP (MRW)

ALEX ROSAS, et al.,
11 Plaintiffs,
v. PANEL'S TWELFTH REPORT
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LOS ANGELES COUNTY SHERIFF
13 ROBERT LUNA, in his official Hon. Dean D. Pregerson
capacity, United States District Judge
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Defendant.
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Case No. 12-cv-00428 DDP (MRW)
PANEL’S TWELFTH REPORT
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1 Pursuant to Section V of the Settlement Agreement And Release of Claims, the

2 Monitors appointed by this Court, Robert Houston, Nicholas E. Mitchell, and Kathleen Kenney

3 (collectively, the "Panel") hereby submit the attached Panel's Twelfth Report "evaluation

4 Defendant's Compliance with Action Plan" prepared by the Panel for the six-month period from

5 July 1, 2022 to December 31, 2022. This Report takes into consideration the comments from the

6 parties in accordance with Section V of the Settlement Agreement. The Panel is available to

7 answer any questions the Court may have regarding this Report as such times as are convenient

8 for the Court and the parties.

10 DATED: October 20, 2023 Respectfully Submitted,

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12 KATHLEEN M. KENNEY

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By: /S/ Kathleen M. Kenney
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Kathleen M. Kenney
17 Monitor and on behalf of Monitors
18 Robert Houston and
19 Nicholas E. Mitchell

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2 Case No. 12-cv-00428 DDP (MRW)

PANEL’S TWELFH REPORT

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PANEL’S TWELFTH REPORT

Table of Contents
Panel’s Twelfth Report .......................................................................................................................................................... 2
Action Plan Implementation Assessment ...................................................................................................................... 6
I. Administrative Provisions ......................................................................................................................... 6
A. Leadership and Accountability .......................................................................................................................................... 6
B. Management Visits ................................................................................................................................................................11
C. Rotations and Transfers .....................................................................................................................................................12
II. Use of Force Policies and Practices .................................................................................................... 14
A. Overall Use of Force Policies.............................................................................................................................................14
B. Use of Force Practices & Review of Packages ...........................................................................................................15
C. Quarterly Findings—Use of Force Provisions ..........................................................................................................19
III. Training ...................................................................................................................................................... 23
A. Use of Force Training ..........................................................................................................................................................23
B. Ethics and Professionalism Training ............................................................................................................................24
C. Mental Health Training .......................................................................................................................................................24
D. New Deputy Sheriffs and Custody Assistants ...........................................................................................................25
E. Sergeant Training ..................................................................................................................................................................27
IV. Reporting and Investigation of Force Incidents ........................................................................... 28
A. Reporting and Investigation Provisions in Force Package Reviews ...............................................................28
B. Reporting & Investigations Provisions as Reported by Department..............................................................31
C. Quarterly Findings—Reporting and Investigations Provisions........................................................................34
V. Inmate Grievances .................................................................................................................................... 36
A. Grievance Forms ....................................................................................................................................................................36
B. Emergency Grievances ........................................................................................................................................................37
C. Inmate Grievance Coordinator ........................................................................................................................................38
D. Handling of Grievances .......................................................................................................................................................39
E. Deadlines ...................................................................................................................................................................................40
F. Communications with Inmates ........................................................................................................................................42
VI. Use of Restraints ...................................................................................................................................... 43
VII. Early Warning System .......................................................................................................................... 45
Appendix A: Compliance Chart ........................................................................................................................................47

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Panel’s Twelfth Report

The Settlement Agreement and Release (the “Settlement Agreement”) between the Parties in Alex Rosas,
et al. v. Leroy Baca, Case No. CV 12-00248-DPP (the “Rosas” case) provides that the Court-appointed
Monitors (the “Panel”) will “prepare and submit to the Parties and the Court periodic reports evaluating
Defendant’s compliance with the Action Plan [developed by the Panel] (‘Reports’) at intervals the Panel
shall determine.” This Report sets forth the Panel’s assessment of the Los Angeles County Sheriff’s
compliance with the provisions of the Action Plan during the period from July 1, 2022, to December 31,
2022 (the “Twelfth Reporting Period”) and is created for the purposes of the settlement of the Rosas case.
In accordance with Paragraph V of the Settlement Agreement, it takes into consideration comments
received from the Parties on September 13, 2023.

In May 2014, the Parties retained the Panel “to develop a corrective action plan (‘Action Plan’) designed
to ensure that [inmates] are not subject to excessive force in the Jail Complex in downtown Los Angeles”
(the “Downtown Jail Complex”). The plan developed by the Panel sets forth provisions in twenty-one
areas that the Sheriff is required to implement in the Downtown Jail Complex. The plan was approved by
the Court on April 7, 2016. Under Paragraph VIII of the Settlement Agreement, “[w]hen the Panel
certifies that any recommendation of the Action Plan has been implemented it shall commence a period of
monitoring the Defendant’s compliance with respect to that recommendation (‘Compliance Period’).” As
of November 1, 2018, the Sheriff’s Department (the “Department”) has implemented 104 of the Panel’s
106 recommendations. The remaining two recommendations, Section 4.10 (expansion of conflict
resolution training) and Section 9.1 (security checks), have been superseded by the Settlement Agreement
and Stipulated Order of Resolution in United States v. County of Los Angeles, et al., CV No. 15-05903
(JEMx) (the “DOJ case”).

With the Court’s guidance, during the Status Conference held on May 12, 2022, the Parties agreed to
develop a written plan to achieve compliance with the following four key areas: (1) eliminating
impermissible head strikes; (2) the proper use of the WRAP; (3) appropriate utilization of force avoidance
and de-escalation techniques; and (4) accountability. The Court held status hearings in this matter on
February 13, 2023, April 19, 2023, June 26, 2023, and September 11, 2023. In advance of the June 26,
2023, Status Hearing, the Parties submitted extensive pleadings pertaining to the four key areas of a
written plan to achieve compliance. At the hearing, the Court directed the Parties to attempt to resolve
their differences and finalize a written plan to achieve compliance. The Parties have negotiated in good
faith throughout this process. The Parties have included the Panel in their recent discussions regarding the
WRAP and Limitations of Force policies. While they have not yet resolved their differences, they are
continuing to work towards a resolution of this matter.

The Panel’s Monitoring visit during the Twelfth Reporting Period occurred in November 2022. With
regard to the non-force related provisions in the Action Plan, the Department submitted its Twelfth Self-
Assessment Status Report (the “Twelfth Self-Assessment”) on April 27, 2023, and its Augmented Self-
Assessment Report (the “Augmented Twelfth Self-Assessment”) on May 12, 2023. During the Twelfth
Reporting Period, the Panel reviewed records posted by the Department to verify the Department’s self-
assessments of its compliance with non-force provisions of the Action Plan. The Panel’s evaluation of the
provisions of the self-assessment reports are included in this Report. The Panel’s auditors reviewed
source documents associated with the Training Provisions as well as Restraint Provisions 17.3 and 17.4.

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The Department’s overall uses of force at

USES OF FORCE the Downtown facilities continued to trend
OVER TWO YEARS downward between the Tenth and Twelfth
591 Reporting Period, as shown in Figure 1. 1 In
559 523 2021, the overall uses of force totaled 1,150
434
384 as compared to 957 in 2022, which is a
decrease of 20%. A more detailed analysis
of total number of use of force incidents by
quarter and facility is provided with
Provision 1.3 below. These continuing
1Q21 + 3Q21 + 1Q22 + 3Q22 + 1Q23 +
2Q21 4Q21 2Q22 4Q22 2Q23 decreases in the number of use of force
10TH 11TH REPORT 12TH 13TH
incidents in 2022 represent meaningful
REPORT REPORT REPORT progress by the Department at achieving
the goals of the Agreement. This trend
continues into 2023; according to preliminary data provided with the department, there is 36% decrease in
use of force incidents from the first half of 2022 (523) to the first half of 2023 (384). 2

During the Twelfth Reporting Period, the Panel reviewed a total of 50 completed force packages that
were selected from a comprehensive list of force incidents compiled by the Department. The Panel did
not select these force packages randomly or in proportion to the frequency with which various categories
of force occur. Rather, the Panel selected for review the force incidents most likely to involve problematic
uses of force. 3 In 30 of the 50 force packages reviewed, the Panel found some aspect of the force used
during the encounter that violated the force prevention principles of Section 2.2 of the Action Plan. The
percentage of 2.2 non-compliant cases (60%) is nearly double the percentage of non-compliant cases
reviewed in the Eleventh Report (33%). The improper use of head strikes continues to be a significant
factor driving the Department’s non-compliance.

Figure 2 reflects the total number of head strikes over Figure 1

three 6-month periods per facility. Similar to overall
use of force incident trends, the Department’s head
strike totals show successive decreases between the
first half of 2022 and the second half of 2022, from a
total of 30 to 22, which is a 27% decrease. 4

For the Twelfth Reporting Period, TTCF increased the

number of head strikes by one (from 9 to 10). IRC had
a decrease in head strikes from 12 to 5, a 58% decrease.
MCJ had a decrease in head strikes from 9 to 7, a 22%
decrease. Head strikes in the first half of 2023 reflect
the downward 2022 trend is maintaining.

1
The Sheriff’s Department maintains multiple data systems. Updated data was provided to the Panel that showed
revised numbers for previous reports. The charts included in this report are consistent with the most recent data
reported by the Department and reflect those updated numbers.
2
While the 2023 data is outside of the Twelfth Reporting Period (3Q22 - 4Q22), the Panel believes it is important to
provide the Court with timely data and information in its reports.
3
The Panel usually selects cases in which staff deployed/utilized the taser, WRAP, or head strikes.
4
All data in this report are for three of the Department’s facilities only: MCJ, TTCF, and IRC. Other Departmental
facilities are also subject to these provisions in United States v. County of Los Angeles, et. al, 2:15-cv-05903.
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As part of its continued focus on head strikes, the Assistant Sheriff produced a video highlighting the
three criteria that must be present prior to utilizing a head strike. Custody staff are required to view the
video. During the Panel’s July 2023 visit, staff reported they had seen the video and were aware of the
requirements of the head strike policy. In most of the Twelfth Reporting Period Use of Force packages
involving head strikes, the supervisors investigating and reviewing the incidents concluded the force was
reasonable and within Departmental policy. The Panel did not agree with the Department’s conclusions in
over 85% of these cases. The Panel was pleased to review two cases in which a supervisor correctly
concluded the use of head strikes was inappropriate. In order for the Department to achieve compliance
with Provision 2.6 (head strikes), staff must be held accountable for impermissible head strikes.

The Panel conducted a series of focus groups with staff and discussions with inmates during its March
and July 2023 Monitoring visits. The participants were randomly selected by one of the Monitors. The
Panel continues to find the focus groups and discussions beneficial.

The following ideas were expressed by custody staff during the focus groups: 5
● Staffing shortages are a concern. Staff are regularly working double shifts. Staff are exhausted.
This negatively impacts morale.
● Staff believe inmates are not held accountable for their bad behavior/actions.
● General feeling that inmates are faking being mentally ill.
● Concern about the impact of infrastructure issues on safety (e.g., gates not working)
● Staffing shortages in CHS negatively impact facility operations and can lead to force situations.
● Supervisors spend too much of their time doing paperwork.
● Need more supervisors at every level.
● Staff want to use the tools they have available (e.g., WRAP) more often.
● Force review process should be streamlined.

The following themes emerged from the group discussions with inmates: 6
● The majority indicated not feeling concerned about being subjected to excessive force by staff.
● Concerns regarding psychological abuse by staff - showers freezing cold then turned scalding hot;
not getting toilet paper; no working toilet - staff wouldn’t take him to use another bathroom.
● Communication with deputies has improved over the years.
● The grievance system is not viewed as effective.
● Contacting ACLU will get things fixed.
● Jail conditions are a significant concern - sewage issues, water not drinkable, cell and shower
temperatures a concern, ceilings falling down, etc.

During the Panel’s Monitoring visits in March and July 2023, senior Department managers cited staffing
shortages as one of the biggest challenges facing the Department. These shortages have led to staff having
to work several mandatory overtime shifts per month. Some staff have to work an additional 12 shifts per
month. Supervisory staff in the facilities are also working mandatory overtime due to the staffing
shortages at the supervisory level. The Panel observed the level of exhaustion among many staff we spoke
to during our visits. Requiring staff to work a significant amount of overtime is not sustainable and has a
negative impact on morale, retention and staff wellness. Correctional agencies across the country are also

5
In March 2023, the staff focus groups were comprised of deputies and sergeants from IRC and TTCF. In July
2023, the Panel spoke to deputies and sergeants from MCJ as well as Lieutenants and Captains from all three
facilities. The views expressed by these staff members are not necessarily reflective of the views of all members of
custody staff.
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The Panel spoke with a total of 27 inmates as part of the Focus Groups during March and July 2023. All three
facilities were represented in the focus groups. The views expressed by the focus group participants are not
necessarily reflective of all inmates.
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facing significant staffing shortages. The Panel has asked the Department to determine whether it is
possible to assess the impact of staff overtime on the number of use of force incidents. Realizing the
length of time it takes to bring new staff on board, the Panel urges the Department to consider having a
thorough staffing analysis completed to ascertain whether the existing staff can be deployed in a manner
to reduce the need for overtime.

The Panel continues to raise concerns about the Department’s use of head strikes with the Sheriff, Assistant
Sheriff, and senior leaders in the Department. On February 22, 2023, the Department issued a Limitations of
Force Directive (formerly known as the Prohibited Force Directive) that prohibits head strikes with personal
weapons unless all three of the following criteria are present: (1) the inmate is assaultive, (2) there is an
imminent danger of serious injury to personnel or others, and (3) there are no other means to avoid serious
physical injury. This policy was discussed with the Court during the June 26, 2023 Status Hearing. The
Parties and the Monitors are engaged in ongoing discussions regarding the policy.

For the Twelfth Reporting Period, the Department is found in compliance with 79 of the 100 applicable
(104 total) provisions set forth by the Action Plan. Compliance results per category are as follows:
(1) 8 out of 9 of the Administrative Provisions
(2) 16 out of 25 of the Force Provisions
(3) 11 out of 11 of the Training Provisions
(4) 17 out of 24 of the Investigations & Reporting Provisions
(5) 22 out of 24 of the Grievances Provisions
(6) 2 out of 8 of the Restraints Provisions (Note this category includes 4 not applicable.)
(7) 3 out of 3 of the Early Warning System Provisions

Provisions determined compliant for the Twelfth Reporting Period, that were found out of compliance in
the Panel’s Eleventh Report, include: 2.7 Supervisor Called to Scene, 4.1 Consult Mental Health
Professional, 4.4 Cooling Off Period, 4.5 Medical and Mental Health Provider Order, 5.2 Commander’s
Reviews, 3.6 Probation Reviews, 4.2 Mental Health Professionals, 4.7 Mentally Ill Inmates, 7.3 Prisoner-
Staff Communications, and 19.2 Review or ERS (EWS) Reports.

The Department continued to cooperate fully with the Panel during the Twelfth Reporting Period. The
Department and County Counsel responded to our inquiries and requests for documents and information.
They engaged in constructive conversations with the Panel regarding use of force incidents, policy issues
and their continuing efforts to implement the terms of the Rosas Action Plan. We appreciate their
responsiveness, transparency, professionalism, and courtesy in handling our monitoring requests.

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Action Plan Implementation Assessment

The Action Plan is divided into seven overarching categories: (1) Administrative; (2) Use of Force; (3)
Training; (4) Force Reporting and Force Investigations; (5) Grievances; (6) Restraint; and (7) Early
Warning System. Each category contains the substantive provisions with corresponding compliance
measures. The Panel’s findings towards compliance with each provision for the Twelfth Reporting Period
is provided below and organized to mirror the Action Plan.

I. Administrative Provisions
A. Leadership and Accountability
The recommendations in Sections 1.1 through 1.4 of the Action Plan require that Custody be headed by
an Assistant Sheriff with no other areas of responsibility, the Sheriff be engaged personally in the
management of the jails, the Department’s managers be held accountable for any failures to address force
problems in the Jails, and that the Department regularly reports to the Board of Supervisors on the use of
force in the jails and on its compliance with the Action Plan.

1.1 Custody Operations Headed by an Assistant Sheriff

Provision Description: Section 1.1 of the Action Plan provides that Custody Operations should continue
to be headed by an Assistant Sheriff with no other areas of responsibility assigned.

Compliance Measure Summary: Custody Operations headed by an Assistant Sheriff

with no other responsibilities for the duration of the Settlement Agreement.

Custody has been headed by an Assistant Sheriff with no other areas of responsibility since mid-2014.
Custody was under the direction of Former Assistant Sheriff Corbett from April 18, 2021 through
November 2022. Assistant Sheriff Sergio Aloma has been serving in the role of Assistant Sheriff since
December 6, 2022. The Panel found both Former Assistant Sheriff Corbett and Assistant Sheriff Aloma to
be accessible, forthright, and fully supportive of the work of the Panel.
1.1 Status: Compliance 7 As of Date: January 1, 2017

1.2 Personal Engagement of the Sheriff

Provision Description: Sheriff should be personally engaged in the management of the Department’s jail
facilities and regularly and adequately monitor the use of force policies and practices and compliance
with the Action Plan.

Compliance Measure Summary: Reports every six months on the Sheriff’s personal
involvement in managing the jail and monitoring use of force policies.

The Department has provided the Panel with a log of frequent meetings that Former Sheriff Alex
Villanueva had with Former Assistant Sheriff Corbett during the Third and Fourth Quarters of 2022.
Between July 27, 2022 and November 2, 2022, the Sheriff and Assistant Sheriff had 21 meetings in which
they discussed such topics as: use of force incidents, the use of less lethal weapons and personal weapons;
cell extractions; Category 3 incidents and associated injuries; use of force against mentally ill inmates;
gassing incidents; dorm disturbances; suicide attempts; available detox housing units; facility security

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Use of the term Compliance is a finding of compliance as of a certain date. The Panel’s findings are set forth on
the Appendix attached. For other provisions, the Department has either not achieved compliance or is no longer in
compliance during the Twelfth Reporting Period. Based upon the Panel’s findings, the Parties will determine
whether the Settlement Agreement is subject to termination pursuant to Section VIII of the Settlement Agreement.
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concerns; assaults on staff and alternate tactical approaches to address current inmate population. Sheriff
Robert Luna assumed his position on December 6, 2022. Between December 6, 2022 and December 31,
2022, the Sheriff and Assistant Sheriff Sergio Aloma met twice to discuss the issues noted above.

Compliance Measure Summary: Meet with the Monitors at least once every six months
to discuss personal involvement.

Sheriff Robert Luna met with the Panel virtually on December 21, 2022. The Panel appreciated the
Sheriff’s willingness to meet so soon after he assumed office. The Sheriff indicated he was committed to
transparency, working collaboratively with external stakeholders and finding a path to bring the
Department into compliance with the Rosas case.
1.2 Status: Compliance As of Date: January 1, 2017

1.3 Accountability for Failing to Address Policy Violations

Provision Description: Section 1.3 of the Action Plan provides that Department managers should be held
accountable should they fail to address use of force problems at the jail facilities.

Compliance Measure Summary: A quarterly report that sets forth the number and rank
of personnel found to have violated use of force policies.
Table 1: UoF Policy Violations
The Department provided a report for both quarters of the Twelfth Reporting
Period, which are summarized in Table 1. There were no founded violations TTCF MCJ IRC
of use of force policies reported in 3Q22. 8 In 4Q22, there were 8 founded 3Q22 0 0 0
violations of use of force policies–-6 at MCJ and 2 at TTCF. The resulting 4Q22 2 6 0
discipline for these violations is reflected in Table 2.

Table 2: 4Q22 Discipline Imposed by Violation

Case No. Facility Rank Discipline
1 MCJ Deputy 1-day Suspension
Deputy 1-day Suspension
2 MCJ Deputy 1-day Suspension
Deputy Written Reprimand
Sergeant Written Reprimand
3 MCJ Custody Assistant 1-day Suspension
Deputy 1-day Suspension
Deputy Written Reprimand
Deputy Written Reprimand
4 MCJ
Deputy Written Reprimand
Deputy Written Reprimand
Deputy Written Reprimand
5 MCJ
Deputy Written Reprimand
Sergeant Written Reprimand
6 MCJ
Sergeant Written Reprimand
Deputy Written Reprimand
7 TTCF
Deputy Written Reprimand
Deputy Written Reprimand
8 TTCF Deputy Written Reprimand
Deputy Written Reprimand

8
The reporting for Provision 1.3 occurs when the discipline for the founded violation occurs and not when the
policy violation occurs. In this Report, the Panel found 17 out of the 25 cases reviewed for 3Q22 in violation of the
force prevention principles of Section 2.2. Should the Department find staff involved in those cases violated policy,
those violations would not be recorded until the quarter the discipline was imposed.
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Compliance Measure Summary: Section 1.3 requires the Department to identify each
facility in which there was a 25% increase in the number of use of force incidents or
Category 3 incidents from the previous quarter.

Overall Uses of Force Figure 3

The Department provided data that reflects Total Number of UoF Incidents
the number of use of force incidents per & Percent Change by Quarter
month by facility and category. The monthly 6%
numbers have been collapsed into quarterly
totals for analysis as shown in Figure 3. For -11% -3% -5%
the Twelfth Reporting Period (3Q22 and
-30%
4Q22), there were a total of 434 use of force
incidents– 256 in 3Q22 and 178 in 4Q22, 296 263 254 269 256 178
which is a 30% decrease in incidents 3Q21 4Q21 1Q22 2Q22 3Q22 4Q22
between the two quarters. When comparing
data by half year, there is an overall decrease Eleventh Report Twelfth Report
in the number of incidents–with a 6%
decrease between the second half of 2021 and the first half of 2022 (559 to 523 incidents) and a further
17% decrease in the second half of 2022 (523 to 434). When comparing the second half of 2021 to the
second half of 2022, there was a 22% decrease over the year from 559 cases to 434.
Figure 4
Of the 434 use of force incidents for the Twelfth Reporting Period, TTCF
accounted for 147 of the incidents (34%), MCJ accounted for 185 of the
incidents (43%), and IRC accounted for 102 of the incidents (23%)—see
Figure 4. This pattern is similar to the Eleventh Report where MCJ
accounted for 39%, TTCF for 38%, and IRC for 23%.

The total uses of force by quarter and category for the Twelfth Reporting
Period are reflected in Figure 5. 9 For both quarters, the majority of the 434
incidents (72%) were Category 1. Category 1 cases involve incidents with no
injuries. This breakdown of incidents is in alignment with previous quarters where Category 1 incidents
reflect the highest number of UoF incidents. Category 1 incidents occurred at a rate over four times more
often than the next closest category, Category 2 (17%) and NCI (10%) incidents. Category 3 incidents are
the smallest percentage of incidents (1%) and are further assessed in the section below.

The Department is required to address increases of Figure 5

25% or more for all use of force categories. As noted
above in Figure 5, NCI and Category 2 incidents of
uses of force decreased between 2Q22 and 3Q22 as
well as between 3Q22 and 4Q22. Category 1
incidents increased by 2 incidents (1%) between
2Q22 and 3Q22, which does not meet the threshold
of 25%. Category 3 incidents increased by more than
25% between 2Q22 and 3Q22 and is further assessed
in the Category 3 Specific section below.

9
Incident data from 2Q22 is included in this figure to show and determine increases and decreases for 3Q22.
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In this reporting period, the increases or decreases of 25% or more in use of force incidents are as follows:
● NCI incidents decreased by 22% between 2Q22 and 3Q22 (37 to 29) and by 55% between 3Q22
and 4Q22 (29 to 13).
● Category 1 incidents decreased by 29% from 184 to 130 between 3Q22 and 4Q22.
● Category 3 incidents increased by 33% from 3 to 4 between 2Q22 and 3Q22.
● Category 3 incidents decreased by 75% from 4 to 1 between 3Q22 and 4Q22.
● Total number of UoF incidents decreased by 30% from 256 to 178 between 3Q22 and 4Q22.

Figure 6 During the Tenth Reporting Period (1Q21-2Q21)

there was a 34% increase in Category 1 incidents
between the First and Second Quarters of 2021,
increasing from 168 to 225, as shown in Figure 6.
For the Eleventh Reporting Period (3Q21 - 2Q22),
Category 1 incidents initially decreased. While
there was an 8% increase in the final quarter, the
number of incidents reflect a downward trend that
is 19% less than 2Q21. For the Twelfth Reporting
Period, there is a 29% decrease in Category 1
incidents from 184 to 130 between 3Q22 and
4Q22, which is the lowest number of Category 1
incidents in a two-year period.

Similarly, there is a downward trend in Category 2 incidents over the past two years, as shown in Figure 7.
There was a 17% decrease between 2Q22 and 3Q22 and an additional 13% decrease between 3Q22 and
4Q22. In total, there were 260 Category 2 uses of force in 2021 and 169 in 2022, which is a decrease of
35% over one year. Over this two-year period, Category 2 incidents have decreased from 68 in 1Q21 to 34
in 4Q22, which is a 50% decrease.
Figure 7

The figures below identify the number of use of force incidents by category per facility. Data is included
from both quarters of the Twelfth Reporting Period (3Q22 and 4Q22) as well as the first two quarters of
2022. Note that only the increases or decreases of 25% or more are included in the narrative below. In
addition, while 1Q22 data is included in the charts to show the annual trend, it was not included in the
percent change assessment.

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Twin Towers Correctional Facility

In 2022 TTCF had a total of 337 use of force incidents as depicted by Figure 8. The total number of
incidents from 2022 is a 25% decrease compared to 449 incidents in 2021. For the Twelfth Reporting
Period increases or decreases of more the 25% at TTCF are as follows:
● Between 2Q22 and 3Q22, TTCF decreased
NCI incidents by 67% from 15 to 5.
● Between 3Q22 and 4Q22, TTCF decreased
NCI incidents by 80% from 5 to 1.
Between 3Q22 and 4Q22, TTCF decreased
Category 1 incidents by 29% from 66 to 47.
● Between 3Q22 and 4Q22, TTCF decreased
Category 2 incidents by 25% from 16 to 12
● Between 2Q22 and 3Q22, TTCF decreased
Category 3 incidents by 100% from 1 to 0. Figure 8

Men’s Central Jail

In 2022 MCJ had a total of 376 use of force incidents as depicted by Figure 9. The total number of
incidents from 2022 is a 19% decrease compared to 464 incidents in 2021. For the Twelfth Reporting
Period increases or decreases of more the 25% at MCJ are as follows:
● Between 2Q22 and 3Q22, MCJ decreased
Category 2 incidents by 59% from 17 to 7.
● Between 2Q22 and 3Q22, MCJ increased
Category 3 incidents by 200% from 1 to 3.
● Between 3Q22 and 4Q22, MCJ decreased
NCI incidents by 44% from 16 to 9.
● Between 3Q22 and 4Q22, MCJ increased
Category 2 incidents by 143% from 7 to 17.
● Between 2Q22 and 3Q22, MCJ increased Figure 9
Category 3 incidents by 200% from 1 to 3.
● Between 3Q22 and 4Q22, MCJ decreased Category 3 incidents by 67% from 3 to 1.

Inmate Reception Center

In 2022 IRC had a total of 244 use of force incidents as depicted by Figure 10. The total number of
incidents from 2022 is a 3% increase compared to 237 incidents in 2021. For the Twelfth Reporting
Period increases or decreases of more the 25% at MCJ are as follows:
● Between 3Q22 and 4Q22, IRC decreased
NCI incidents by 63% from 8 to 3.
● Between 3Q22 and 4Q22, IRC decreased
Category 1 incidents by 40% from 43 to 26.
● Between 2Q22 and 3Q22, IRC increased
Category 2 incidents by 33% from 12 to 16.
● Between 3Q22 and 4Q22, IRC decreased
Category 2 incidents by 69% from 16 to 5.
● Between 3Q22 and 4Q22, IRC decreased
Category 3 incidents by 100% from 1 to 0. Figure 10
● IRC decreased NCI incidents by 58% between the first and second half of 2022 from
26 to 11.

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Compliance Measure: When there is a 25% or more increase from quarter to quarter, the
Unit Commander reports on his or her response to involved staff. If the Unit Commander
failed to address the matter, the Department indicates its response to hold the Unit
Commander accountable.

Overall Uses of Force

The Department is required to address increases of 25% or more for all use of force categories. As noted
above in Figure 6, NCI and Category 2 incidents of uses of force decreased between 2Q22 and 3Q22 as
well as between 3Q22 and 4Q22. Category 1 incidents increased by 1%, 2 incidents, between 2Q22 and
3Q22, which does not meet the threshold of 25%. Therefore, there were no Unit Commander reports to
review. Category 3 incidents had increases over 25% and are further assessed in the section below.

Category 3 Specific
Due to the infrequency of Category 3 incidents, a single incident results in 50% to 100% swings quarter
to quarter, which triggers CCSB to request a response from the Unit Commander on its handling of
involved staff. Between 2Q22 and 3Q22, MCJ increased Category 3 incidents by 200% from 1 to 3. In
response, the Unit Commander and Commander reportedly held briefings on each shift with line
lieutenants and sergeants. The Unit Commander and Commander reviewed the performance of each
sergeant and deputy involved and held multiple training scenarios to better prepare for future situations.

During the Twelfth Reporting Period, the Panel reviewed many cases involving violations of policy, such
as impermissible head strikes, in which the supervisory reviews failed to identify the policy violations.
The Parties are currently developing a written plan to achieve compliance with various provisions of this
Agreement, including its Accountability provisions. The plan will enhance this provision that broadly
requires Department managers to be held accountable should they fail to address use of force problems.
The Department must hold Deputies accountable for use of force violations and hold supervisory staff
accountable when they fail to identify and/or appropriately address violations.
1.3 Status: Out of Compliance As of Date: N/A

1.4 Reports to the Board of Supervisors

Provision Description: Department regularly reports to the Board of Supervisors on use of force status
and compliance with the Action Plan.

Compliance Measure: Report publicly at least every six months to the Board of
Supervisors on use of force data, training, investigation outcome summaries, and
discipline as well as overall compliance.

The Department did not report to the Board of Supervisors (BOS) on the use of force status and
compliance with the Action Plan during the Third or Fourth Quarter of 2022. The timing of the regular
reports to the BOS are triggered by the Panel’s reports filed with the Court. As a result of the changes to
the configuration of the Panel, the Eleventh Report was delayed. The Department appeared before the
BOS in July 2023 and addressed the Eleventh Report.
1.4 Status: Compliance As of Date: June 12, 2018

B. Management Visits
The recommendations in Sections 10.1 and 10.2 of the Action Plan address required tours of senior
managers and the documentation of visits on housing units.

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10.1 Senior Manager Tours

Provision Description: Senior managers ranked Unit Commanders and above should be required to
periodically tour jail facilities, including nights and weekends.

Compliance Measures Summary: 10.1(a) Unit Commanders tour at least two evenings
and one weekend day per quarter.

During the Third and Fourth Quarter of 2022, the Unit Commanders from MCJ, IRC and TTCF met the
requirements of this provision with 100% compliance.

Compliance Measures Summary: 10.1(b)–(e) Varying frequencies in visit requirements

for Department executives—Unit Commanders up to Sheriff—to tour and inspect the
Downtown Jail Complex.

These requirements were met for both quarters of the Twelfth Reporting Period. The Commanders, Chiefs
in Custody Operations, the Assistant Sheriff and the Sheriff achieved 100% compliance with the
requirements to tour and inspect the Downtown Jail Complex. In the Eleventh Report, the Panel noted
that Former Sheriff Alex Villanueva’s tours of the facilities were for very short periods of time. Sheriff
Robert Luna was sworn in as Sheriff on December 5, 2022. The Panel did not have the opportunity to
raise the issue of abbreviated tours with Sheriff Luna until their first meeting on December 21, 2022. The
Panel addressed the importance of conducting meaningful tours and inspections with Sheriff Robert Luna
and invited him to accompany the Panel during their next Monitoring Visit. Sheriff Luna accompanied the
Panel on a portion of their tour of the downtown facilities in March 2023. The Panel observed Sheriff
Luna engaging in lengthy conversations with staff and inmates. The Panel finds the Department in
Compliance with this provision.
10.1 Status: Compliance As of Date: June 30, 2018

10.2 Housing Unit Documentation

Provision Description: Housing units should document visits from department managers in electronic
records or visitor logs.

Compliance Measure Summary: Visits by Department managers to the Downtown Jail

Complex are documented and made available to the Monitors.

The visits to the jail facilities by Department managers (above the rank of Sergeant) were documented in
electronic visitor logs for the Twelfth Reporting Period. The logs in SharePoint noted only the required
number of visits to meet the threshold for Provision 10.1 compliance. For example, Provision 10.1
(a)(b)(c) requires a total of 72 inspections. At least 72 were completed and the logs for those inspections
are noted in SharePoint.
10.2 Status: Compliance As of Date: June 30, 2018

C. Rotations and Transfers

The recommendations in Sections 18.1, 18.2, and 20.1 of the Action Plan address custody-wide rotation
policies, semi-annual audits of unit compliance, and not assigning or transferring staff to custody as a
formal sanction.

18.1 Custody-Wide Rotation Policy

Provision Description: Maintain a custody-wide rotation policy and rotate staff members as often as
provided by policy.

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18.2 Semi-Annual Rotation Audit

Provision Description: Conduct an audit semi-annually for each unit’s compliance with rotation policies.

Compliance Measures Summary: Maintain facility rotation policy and audit compliance
every six months. Provide reports to the Monitors to demonstrate if at least 90% of staff
were rotated according to policy.

The Department’s posted results reflect that the Department achieved 99.6% Compliance in the Twelfth
Reporting Period. Each of the Downtown jail facilities had a current Unit Order setting forth its rotation
policy and the source documents indicate that most Department personnel are rotated in Compliance with
these policies. In the Eleventh Report, the Panel requested the Administration Commander carefully
review the list of posts exempted from the 6-month rotation rule and review future Unit Orders pertaining
to Facility Job Rotation. During the Panel’s site visit in July 2023, the Administration Commander
indicated they had reviewed the posts exempted from the 6-month rotation rule and were making
appropriate adjustments to the list of exempted posts. The Panel engaged in preliminary discussions with
management staff regarding the benefits of not rotating some staff assigned to certain mental health units.
The Panel looks forward to continuing the dialogue on this issue.
18.1 Status: Compliance As of Date: June 30, 2018
18.2 Status: Compliance As of Date: January 1, 2019

21.1 Transfers to Custody

Provision Description: Policy should provide that a staff member will not be assigned to Custody as a
formal or informal sanction for problem Deputies.

Compliance Measures Summary: On a quarterly basis, personnel records are reviewed

for staff transferred to Custody from other divisions and a report is provided to the
Monitors identifying each staff member who was transferred to Custody within six
months of a finding of misconduct or policy violation.

The Department’s Twelfth Self-Assessment reflects that it maintained 100% compliance from July 1,
2022, through December 31, 2022. The Panel has reviewed the Department’s source documents stating
the reasons for Deputy transfers to Custody during the Twelfth Reporting Period. No Department member
was transferred or assigned to Custody as a sanction for misconduct or a policy violation during the
Twelfth Reporting Period.
21.1 Status: Compliance As of Date: June 30, 2018

The chart below is a visual representation of compliance for the above provisions from the last three
reports. The shading of the boxes indicates compliance status–blue for compliance and red for out of
compliance. Where percentage of compliance is available, it is progressively noted by intensity of the
color. The “As Of” column shows date since first found compliant and the last column includes a check
mark if the date meets or exceeds three years of compliance. A chart is provided with each section.

Tenth Report Eleventh Report Twelfth Report

Administrative Provisions 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
1.1 Assistant Sheriff C C C 1/1/2017 
1.2 Sheriff C C C 1/1/2017 
1.3 Supervision X X X
1.4 Reports to Board C C C 6/12/2018 
10.1 Jail Visits C C C 6/30/2018 
10.2 Documented Visits C C C 6/30/2018 
18.1 Rotation in Custody C C C 6/30/2018 
18.2 Documentation of Rotation C C C 1/1/2019 
21.1 Transfers to Custody C C C 6/30/2018 

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II. Use of Force Policies and Practices

A. Overall Use of Force Policies
The recommendations in Sections 2.1, 8.2, 17.2, 20.1, and 20.2 of the Action Plan address the revision,
modification, and organization of policy into one logical manual.
2.1 Separate and Organized Custody Force Manual for Custody Operations
Provision Description: The Action Plan requires the Department to “have a separate, revised, free-
standing, and logically organized Custody Force Manual for Custody Operations[.]”

8.2 Complaints of Retaliation into Grievance Policy

Provision Description: Combine retaliation provisions into one grievance section to ensure a single,
consistent policy on handling grievances.

17.2 Pregnant Inmate Policy

Provision Description: Combine and conform provisions related to restraints on pregnant inmates with
medically ordered restraint provisions.

20.1 Categories of Force in Policy

Provision Description: Policy indicates only two types of force: reactive and planned.

The Department’s Supervisor’s Use of Force Investigation Form (P438) still lists various types of force
(e.g., reactive, etc.) The Panel requested that the form be revised by July 1, 2023 in order to remain in
Compliance with this provision for the Thirteenth Reporting Period.

20.2 Reactive Force Definition

Provision Description: Reactive Force is defined as force used in response to an immediate threat of
safety, destruction, or escape, and when there is no time to wait for assistance.

Compliance Measure Summary: A Custody Division Manual that includes all force
policies applicable to Custody Operations, including those outlined by 8.2, 17.2, 20.1,
and 20.2.

On October 16, 2015, the Department provided the Panel with a Custody Operations Force Manual with
separate sections on Use of Force Policy, Use of Force with Special Populations, Restraints, Escorting,
Chemical Agents, Reporting, Review, Special Weapons, and Deputy-Involved Shootings. The
Department’s Custody Force Manual satisfies Section 2.1 and includes specific provisions that satisfy
Sections 8.2, 17.2, 20.1, and 20.2 of the Action Plan.
2.1, 8.2, 17.2, 20.1, and 20.2 Status: Compliance As of Date: January 1, 2017

Tenth Report Eleventh Report Twelfth Report

Use of Force Policy Provisions 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
2.1 Custody Force Manual C C C 1/1/2017 
8.2 Complaints of Retaliation C C C 1/1/2017 
17.2 Pregnant Inmates C C C 1/1/2017 
20.1 Categories of Force C C C 1/1/2017 
20.2 Reative Force C C C 1/1/2017 

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B. Use of Force Practices & Review of Packages

The recommendations in Sections 2.2 through 2.13, 4.1 through 4.5, 9.2, 9.3, 17.5, and 20.3 have
provisions related to policy as well as application. The Panel reviewed multiple drafts of the Department’s
policies to implement these recommendations, required changes where appropriate, and certified that the
Department had implemented these policy recommendations effective December 1, 2015.

For the Twelfth Reporting Period a total of 50 packages were reviewed: 25 in 3Q22 and 25 in 4Q22. The
cases reviewed for each quarter did not necessarily occur in the quarter they were reviewed, nor was the
investigation necessarily completed during that quarter. The Panel requests at least 30 cases per quarter
for review. The Panel reviewed cases as they were received. The cases reviewed involved incidents from
January 2021 through December 2022. Overall results for the Twelfth Reporting Period by provision are
below. Findings for each quarter are provided in Section C: Quarterly Findings.

Compliance Measure Summary: (#1-7) Within 10 days of the end of each quarter the
Department will provide the Monitors with a cumulative force synopsis for each incident
in the Downtown Jail Complex showing the status of force investigations. The Monitors
will select a minimum of 25 force packages to review for compliance with the Action
Plan of all force provisions through Vertical and Horizontal Assessments. The
Department will provide each package and include a summary sheet that indicates how
the Department assessed each applicable provision. Force incidents will need to be 90%
or more compliant with each provision for the Vertical Assessments.

Vertical Assessment: Of the 50 cases reviewed, eight (8) were found compliant with Force
Provisions, which is 16% of all cases reviewed and below the 90% compliance threshold. Of the
eight (8) cases found in compliance with all Force provisions two (2) were from 3Q22 (one at
TTCF and one at IRC) and six (6) were from 4Q22 (four at MCJ and two at TTCF).

Horizontal Assessment: The findings for the twenty (20) use of force practice provisions in this
section represent the Horizontal Assessment, which determines that the Department is in
Compliance with each of the applicable Force Provisions. It takes into consideration the objective
of the provision and the nature and extent of any violations of the provision. Percentages are
calculated based on packages reviewed in both quarters. 10

2.2 Force Prevention Principles

Provision Description: Policy provides that force be used as a last resort, with minimal amount of force
necessary, terminated as soon as reasonably safe to do so, and de-escalated as resistance decreases.

Of the 50 use of force packages reviewed, 20 cases were found compliant with this provision, which
amounts to 40% compliance and is below the 90% compliance threshold. This 40% compliance rate
represents a decrease from the 67% compliance rate noted in the Eleventh Report.
2.2 Status: Out of Compliance As of Date: N/A

2.3 Inmate-on-Inmate Violence

Provision Description: Policy indicates it is a violation for staff to cause, facilitate, or provoke inmate-
on-inmate violence or to expose inmates to an unreasonable risk of assault. Further, staff are prohibited
from publicly humiliating inmates or using slurs or obscenities.

10
For the Horizontal Assessments, the Panel has determined that Compliance will require 90% of the applicable
force provisions were in Compliance. The Panel may exercise their discretion and depart from this 90% requirement
when considering the objective of the provision and the nature and extent of any violation of the provision.
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Of the applicable cases reviewed, 81% (25 out of 31) were found to be in compliance, which is below the
90% compliance threshold. The six cases deemed out of compliance involved staff’s unprofessional
behavior/use of obscenities. There were no instances in which staff caused, facilitated, or provoked
inmate-on-inmate violence.
2.3 Status: Out of Compliance As of Date: N/A

2.4 Use of Force as Discipline

Provision Description: Policy indicates use of force not be used as discipline or corporal punishment.

Of the applicable cases reviewed, 98% (48 out of 49) were found to be in compliance, which exceeds the
90% compliance threshold.
2.4 Status: Compliance As of Date: July 1, 2019
2.5 Force on Restrained Inmate
Provision Description: Policy indicates staff may not strike, use chemical agents, or Taser a restrained
inmate, unless the inmate is assaultive, presents an immediate threat, and no other reasonable means.

Of the applicable cases reviewed, 86% (30 out of 35) were found to be in compliance, which is below the
90% compliance threshold.
2.5 Status: Out of Compliance As of Date: N/A
2.6 Head Strikes or Kicks
Provision Description: It is prohibited to strike an inmate in the head, kicking an inmate who is on the
ground, or kicking an inmate above the knees if not on the ground unless the inmate is assaultive and
presents an imminent danger and there are no more reasonable means to avoid injury. Kicking an inmate
who is not on the ground below the knees is prohibited unless used to create distance between a staff
member and an assaultive inmate.

Of the applicable cases reviewed, 52% (26 out of 50) were found to be in compliance, which is below the
90% compliance threshold. The 52% compliance rate represents a decrease from the 65% compliance rate
noted in the Eleventh Report.
2.6 Status: Out of Compliance As of Date: N/A

2.7 Supervisor Called to Scene

Provision Description: A supervisor must be called to the scene in a situation where use of force may be
required as soon as time and circumstances permit.

Of the applicable cases reviewed, 90% (45 out of 50) were found to be in compliance, which meets the
90% compliance threshold.
2.7 Status: Compliance As of Date: January 1, 2023

2.8 Prevent Excessive Force

Provision Description: All members are responsible for preventing excessive uses of force and those
who witness such events have a duty to stop, reduce, or control the use of force being used.

Of the applicable cases reviewed, 86% (25 out of 29) were found to be in compliance, which is below the
90% compliance threshold.
2.8 Status: Out of Compliance As of Date: N/A

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2.9 Armed Inmates

Provision Description: When confronting an armed inmate, every effort should be made to control the
inmate at a distance.

Of the applicable cases reviewed, 88% (7 out of 8) were found to be in compliance, which is below the
90% compliance threshold. Given the small universe of applicable cases, the Panel has determined that
failing to meet the standard in one case should not remove the County from Compliance for this Provision.
2.9 Status: Compliance As of Date: July 1, 2019
2.10 Authorized Weapons
Provision Description: Department members can only use authorized weapons for which they have been
trained. Any available instrument can be used to prevent imminent loss of life or serious bodily injury if
no other means or alternative is available.

Of the applicable cases reviewed, 95% (36 out of 38) were found to be in compliance, which exceeds the
90% compliance threshold.
2.10 Status: Compliance As of Date: July 1, 2019

2.11 Planned Chemical Spray

Provision Description: After applying a chemical agent, members are required to wait a sufficient
amount of time before applying additional chemical or force in a cell extraction or planned use of force.

Of the applicable cases reviewed, 80% (8 out of 10 cases) were found to be in compliance, which is
below the 90% compliance threshold.
2.11 Status: Out of Compliance As of Date: N/A

2.12 Chemical Spray & Tasers

Provision Description: Chemical sprays, Tasers, and stun devices should not be used against an inmate
who no longer presents a danger or is no longer resisting, ones known to suffer medical conditions that
may be aggravated by use, or in a manner contradictory to manufacturer guidance or Department training.

Of the applicable cases reviewed, 95% (20 out of 21) were found to be in compliance, which exceeds the
90% compliance threshold.
2.12 Status: Compliance As of Date: July 1, 2019

2.13 Check of Medical Records

Provision Description: An inmate’s medical/mental health records should be checked prior to use of
chemical agents, Tasers, or stun devices when time and circumstances permit.

Of the applicable cases reviewed, 71% (10 out of 14) were found to be in compliance, which is below the
90% compliance threshold.
2.13 Status: Out of Compliance As of Date: N/A

4.1 Consult Mental Health Professionals

Provision Description: Require a mental health professional on-scene to attempt to resolve a situation
during a cell extraction or planned use of force.

Of the applicable cases reviewed, 90% (9 out of 10) were found to be in compliance, which meets the
90% compliance threshold.
4.1 Status: Compliance As of Date: January 1, 2023
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4.3 Spray on Mental Health Inmates

Provision Description: Discontinue use of chemical following an initial burst if the inmate is acutely
psychotic or severely mentally disabled and unable to conform behavior to commands.

Of the applicable cases reviewed, 100% (6 out of 6) were found to be in compliance, which exceeds the
90% compliance threshold.
4.3 Status: Compliance As of Date: October 1, 2019
4.4 Cooling Off Periods
Provision Description: In situations involving a mentally ill inmate who does not present as an obvious
danger to self or others is refusing to exit his or her cell, allow a reasonable cooling off period. After, a
mental health professional or supervisor can attempt compliance without use of force.

Of the applicable cases reviewed, 100% (9 out of 9) were found to be in compliance, which exceeds the
90% compliance threshold.
4.4 Status: Compliance As of Date: January 1, 2023

4.5 Medical or Mental Health Provider Order

Provision Description: When a planned use of force is precipitated by a medical or mental health
provider, such as for treatment purposes, the ordering provider, or designee, is given the opportunity to
intervene to de-escalate and ensure order should remain in effect.

Of the applicable cases reviewed, 100% (4 out of 4) were found to be in compliance, which exceeds the
90% compliance threshold.
4.5 Status: Compliance As of Date: January 1, 2023

9.2 Escorting of Inmates

Provision Description: Following a use of force, the staff member escorting the recalcitrant inmate to
medical, holding, or segregation should not be the same member involved in the confrontation.

Of the applicable cases reviewed, 90% (45 out of 50) were found to be in compliance, which meets the
90% compliance threshold.
9.2 Status: Compliance As of Date: January 1, 2020

9.3 Duty to Protect & Intervene

Provision Description: Members have a duty to protect and to intervene in inmate-on-inmate violence
when reasonably safe to do so.

Of the applicable cases reviewed, 100% (5 out of 5) were found to be in compliance, which exceeds the
90% compliance threshold.
9.3 Status: Compliance As of Date: July 1, 2022

17.5 Minimize Medical Distress

Provision Description: Avoid, to the extent possible, placing weight on an inmate’s back or shoulders in a
way that impairs breathing. Once under control, place the inmate on side to minimize breathing problems.

Of the applicable cases reviewed, 49% (24 out of 49) were found to be in compliance, which is below the
90% compliance threshold. The biggest factor driving non-compliance for this provision is the use of the
WRAP Restraint and the manner in which the inmates are placed in the device.
17.5 Status: Out of Compliance As of Date: N/A
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20.3 Planned Force

Provision Description: Planned Forces should be video recorded and include a medical professional on
scene or on standby, a supervisor on scene, and with a Shift Supervisor approval.

Of the applicable cases reviewed, 62% (8 out of 13) were found to be in compliance, which is below the
90% compliance threshold.
20.3 Status: Out of Compliance As of Date: N/A

C. Quarterly Findings—Use of Force Provisions

Combined 3Q and 4Q 2022 Results
For the Third and Fourth Quarter of 2022, the Panel reviewed 50 use of force incidents combined—20
from TTCF (40%), 21 from MCJ (42%), and 9 from IRC (18%).

The Department is not in Compliance with 10 of the 20 Use of Force Provisions as follows: (1) 2.2 Force
Prevention Principles, (2) 2.3 Inmate-on-Inmate Violence, (3) 2.5 Force on Restrained Inmate, (4) 2.6
Head Strikes or Kicking Inmates, (5) 2.8 Prevent Excessive Force, (6) 2.9 Armed Inmates, (7) 2.11
Planned Chemical Spray; (8) 2.13 Check of Medical Records, (9) 17.5 Minimize Medical Distress, and
(10) 20.3 Planned Use of Force.

Of the ten (10) Use of Force Provisions out of compliance, four (4) had compliance rates below 70% over
3Q22 and 4Q22 combined. Those provisions include the following:
● 2.2 Force Prevention Principles at 40% compliance.
● 2.6 Head Strikes or Kicking Inmates at 52% compliance.
● 17.5 Minimize Medical Distress at 49% compliance.
● 20.3 Planned Use of Force at 62% compliance.

The cases reviewed found full compliance, or 90% or above compliance, with the following ten (10) of
the twenty (20) use of force provisions: 2.4, 2.7, 2.9, 2.10, 2.12, 4.1, 4.3 - 4.5, 9.2, and 9.3.
Tenth Report Eleventh Report Twelfth Report
Use of Force Practice Provisions, Packet Review 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
2.2 Force Prevention Principles X 67% 40%
2.3 Inmate on Inmate Violence C 98% 81%
2.4 Use of Force as Discipline C 99% 98% 7/1/2019 
2.5 Force on Restrained Inmates X 84% 86%
2.6 Head Strikes or Kicks X 65% 52%
2.7 Supervisors Called to Scene X 81% 90% 1/1/2023
2.8 Prevent Excessive Force C 94% 86%
2.9 Armed Inmates C 100% 88% 7/1/2019 
2.10 Authrorized Weapons C 97% 95% 7/1/2019 
2.11 Planned Chemical Spray C 90% 80%
2.12 Chemical Spray & Tasers C 93% 95% 7/1/2019 
2.13 Check of Medical Records X 68% 71%
4.1 Consult Mental Health Professionals C 77% 90% 1/1/2023
4.3 Spray on Mental Health Inmates C 100% 100% 10/1/2019 
4.4 Cooling Off Periods C 81% 100% 1/1/2023
4.5 Medical or Mental Health Provider Order C 75% 100% 1/1/2023
9.2 Escorting of Inmate C 96% 90% 1/1/2023
9.3 Duty to Protect & Intervene C 100% 100% 7/1/2022
17.5 Minimize Medical Distress C 56% 49%
20.3 Planned Use of Force X 68% 62%

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Third Quarter 2022 Results

In the Third Quarter of 2022, the Panel reviewed 25 force incidents—10 from TTCF (40%), 7 from MCJ
(28%), and 8 from IRC (32%).

The Department is not in Compliance with 13 of the 20 Use of Force Provisions as follows: (1) 2.2 Force
Prevention Principles, (2) 2.3 Inmate-on-Inmate Violence, (3) 2.5 Force on Restrained Inmate, (4) 2.6
Head Strikes or Kicking Inmates, (5) 2.7 Calling Supervisors to the Scene Before Physically Engaging
with Recalcitrant Inmates, (6) 2.8 Prevent Excessive Force, (7) 2.11 Planned Chemical Spray, (8) 2.12
Chemical Spray and Tasers, (9) 2.13 Check of Medical Records, (10) 4.1 Consult Mental Health
Professionals, (11) 9.2 Escorting of Inmates, (12) 17.5 Minimize Medical Distress, and (13) 20.3 Planned
Use of Force.

Of the thirteen (13) Use of Force Provisions out of compliance, five (5) had compliance rates below 70%
in 3Q22. Those provisions include the following:
● 2.2 Force Prevention Principles at 32% compliance.
● 2.6 Head Strikes or Kicking Inmates at 52% compliance.
● 4.1 Consult Mental Health Professionals at 67% compliance.
● 17.5 Minimize Medical Distress at 28% compliance.
● 20.3 Planned Use of Force at 63% compliance.

The cases reviewed for 3Q22 found full compliance, or 90% or above compliance, with the following
seven (7) of the twenty (20) use of force provisions: 2.4, 2.9, 2.10, 4.3 - 4.5, and 9.3.

Fourth Quarter 2022 Results

In the Fourth Quarter of 2022, the Panel reviewed 25 force incidents—10 from TTCF (40%), 14 from
MCJ (56%), and 1 from IRC (4%).

The Department is not in Compliance with 9 of the 20 Use of Force Provisions as follows: (1) 2.2 Force
Prevention Principles; (2) 2.3 Inmate-on-Inmate Violence, (3) 2.5 Force on Restrained Inmates; (4) 2.6
Head Strikes or Kicking Inmates; (5) 2.9 Armed Inmates, (6) 2.11 Planned Chemical Spray, (7) 2.13
Check of Medical Records, (8) 17.5 Minimize Medical Distress, and (9) 20.3 Planned Use of Force.
Of the nine (9) Use of Force Provisions out of compliance, three (3) had compliance rates below 70% in
4Q22. Those provisions include the following:
● 2.2 Force Prevention Principles at 48% compliance.
● 2.6 Head Strikes or Kicking Inmates at 52% compliance.
● 20.3 Planned Use of Force at 60% compliance.

The cases reviewed for 4Q22 found full compliance, or 90% or above compliance, with the following
eleven (11) of the twenty (20) Force provisions: 2.4, 2.7. 2.8, 2.10, 2.12, 4.1, 4.3 - 4.5, 9.2, and 9.3.

Review of Force Incidents

The Action Plan requires that the Panel review selected force packages each quarter to assess whether the
use of force is in Compliance with Sections 2.2 through 2.13, 4.1 through 4.5, 9.2, 9.3, and 17.5 (the
“Force Provisions”) of the Action Plan. The Panel participated in meetings with Custody Commanders
and the Plaintiffs’ Counsel regarding Use of Force cases reviewed for the Twelfth Reporting Period. The
Panel found these meetings constructive and valued the various perspectives offered regarding proposed
ratings for specific Force Provisions for various force packages. The Panel notes the value of these
discussions would be improved if the cases at issue were recent. The Department continues to struggle to
complete its use of force investigations in a timely manner. The Panel is hopeful the timeliness of
investigations will improve with the newly formed Force Investigation Unit.
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As summarized in Provision 2.2, the four components of force are as follows: (a) must be used as a last
resort; (b) must be minimal amount of force that is necessary and objectively reasonable to overcome the
resistance; (c) must be terminated as soon as possible consistent with maintaining control of the situation;
and (d) must be de-escalated if resistance decreases. A pathway to Rosas compliance will entail a change
in force reviews, accountability, and consistent employment of ‘time and distance’ techniques. In some
cases, Deputies and Custody Assistants are not employing ‘time and distance’ or de-escalation
techniques. Noted below are three cases: one illustrates restraint by deputies, one in which the
components of Provision 2.2 were followed, and one not compliant with Provision 2.2.

In Case 1, Deputies created distance and used patience and time with an inmate aggressively blading his
body and challenging them to fight.
Investigation Report: “Inmate YY was acting erratic, yelling, making racial comments, and made verbal
threats to kill custody personnel. He ignored several verbal commands given to him and then threw a
chair in the direction of Deputies. Force mitigation and prevention efforts were utilized.”

IM YY “took off his outer shirt and white t-shirt and threw them on the floor, ‘showing he was ready to
fight’. Deputy initiated a radio broadcast requesting sergeant and additional deputy personnel to respond
to their location due to IM YY’s recalcitrant behavior. IM YY took a fighting stance toward deputy
personnel in the middle of the dayroom by blading his body and positioning his clenched fists in front of
his waist. ‘I saw muscle tension in his upper body as he challenged deputy personnel to a fight’.” When
IM YY closed the distance on the deputies, he was tased.

Deputies used great restraint in managing this tense and volatile incident. All applicable Provisions were
in Compliance with the exception of 2.10, use of a second taser (due to tactical miscommunication).

In Case 2, IM Z started two (2) fires in his cell using his suicide wrap. Deputies put out the fire with an
extinguisher. They also used MK 9 spray to facilitate an emergency cell entry. The extraction had to be
planned quickly. Deputies did the best job possible to get IM Z out of the cell for his personal safety.

This incident involved justifiable head strikes. IM Z punched a Deputy in the face and attempted to rip the
face mask off of a Deputy who was laying on the floor in a cell that had fire, smoke and MK9 spray in the
air with little to no visibility. IM Z created a risk of serious bodily injury or death and there were no other
options to stop his reckless actions during a volatile cell extraction. IM Z was punched in the face while
assaulting Deputies. IM Z created a dangerous situation for himself and the deputies. IAB took the
investigation due to a knee strike to the head.

In short, Deputies did a remarkable job bringing an end to this chaotic incident. All applicable Provisions
were in Compliance with the exception of 15.6, separation of personnel to write reports.

Case 3 - This case involved an impermissible head strike. The Panel observed the following in the video
of the incident: Inmate AA was cuffed and secured to a fixed bench placed outside 171 E pod because he
refused housing in a two-man cell. Deputy T took the initiative to visit with IM AA as he sat there.
Suddenly, IM AA kicked Deputy T from his seated position. Deputy T immediately struck IM AA in the
face knocking him backward before taking him to the floor where he was secured by multiple deputies.

Deputy T had other reasonable means to control the suspect, such as a tactical retreat. The deputies had
not requested a supervisor for IM AA’s refusal, which is a violation of the recalcitrant inmate policy.

The Watch Commander reported “Deputy T took immediate action to quell the attack and immediately
de-escalated his use of force as Suspect AA stopped his attack.”

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The Unit Commander stated “Deputy T used personal weapons to stop an unprovoked attack from
Suspect AA. Although Suspect AA was partially restrained, it appears he was attempting to cause serious
injury to Deputy T when he delivered a front kick to Deputy T's knee. Once the assault from the inmate
ceased, Deputy T and responding personnel immediately transitioned to simply restraining Suspect AA.”

The Commander assessed Deputy T actions with the following statement “consistent with Custody
Division Policy and Rosas Settlement Agreement Provisions. Deputy T utilized a personal weapon and
punched the suspect one time in the face to stop his assault. The suspect in this incident was assaultive,
his violent action had presented the imminent danger or serious injury; however, there appeared an
opportunity to retreat and reassess rather than immediately engaging the suspect, who was restrained to
the bench. While Deputy T described barriers behind him, there was an open area to his left which he
should have noticed in his tactical assessment. Additional personnel were in the immediate area, and this
coupled with the area of egress to his left would have allowed Deputy T to distance himself from the
suspect and consider other options. For these reasons, I found the force violated Custody Division Policy
related to 7-01/020.00 Authorized Use of Force and Rosas Settlement Agreement Provision 2.6, as there
appeared to be other reasonable means to avoid further injury”.

Only the Commander performed due diligence when analyzing this incident. This Force situation was in
Non-Compliance with Provisions 2.2, 2.5, 2.6, 2.7, 17.5, 12.2, 12.3, 15.3, and 15.6.

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III. Training
Sections 3.1 through 3.4 of the Action Plan require that Department members receive training on use of
force policies, ethics, professionalism, and treating inmates with respect. New Department members are
to receive six (6) weeks of specific training in Custody Operations. Sections 4.6 through 4.9 require the
Department to provide Custody-specific, scenario-based skill development training for existing and new
personnel in Crisis Intervention and Conflict Resolution and in “identifying and working with mentally ill
inmates.” Section 12.1 requires that Custody Sergeants receive training in conducting use of force
investigations.

The Panel has previously deemed the Department to be complying “as of” the date reported by the
Department for the completion of the initial training required for existing personnel. The Department’s
continuing compliance with the training provisions is determined by its compliance with the refresher
training required every year or every other year. The Department submitted its report of refresher training
compliance as part of its Twelfth Self-Assessment.

A. Use of Force Training

3.1 Use of Force Training
Provision Description: Requires use of force training for all existing Department members in Custody
Operations, which should include at a minimum, a one-time eight-hour use of force policy training course
for all members assigned to Custody and then a two-hour refresher course every year.

Compliance Measure Summary: Section 3.1(a) requires that 90% of Deputies and
Custody Assistants assigned to Custody as of July 1, 2016 completed the required
training.

As of June 30, 2018, the Department was found to be compliant with Section 3.1(a).

Compliance Measure Summary: Section 3.1(b) requires that 90% of Deputies and
Custody Assistants assigned to Custody who completed the initial training receive the
two-hour refresher course every year.

The Panel’s auditors previously verified the Department’s reported annual refresher training results, and
the Department was found to be in Compliance with Section 3.1(b) as of December 31, 2021. The
Department’s Augmented Twelfth Self-Assessment reports that it maintained compliance with Section
3.1(b) for 2022. The results were verified by the Panel’s auditors and the Department is in Compliance
with Section 3.1 for 2022.
3.1 Status: Compliance As of Date: December 31, 2021

3.4 Custody-based Use of Force Scenarios

Provision Description: Custody-based, use of force scenarios included as part of the use of force policy
training provided by the Custody Training & Standard Bureau on an in-service and refresher basis.

The use of force training approved by the Panel includes the custody-based use of force scenarios.
3.4 Status: Compliance As of Date: June 30, 2018

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B. Ethics and Professionalism Training

3.2 Ethics and Professionalism Training
Provision Description: Requires training all existing Department members in Custody Operations, which
should include at a minimum, a one-time four (4) hour training course in ethics, professionalism, and
treating inmates with respect, and then a two (2) hour refresher course every other year.

Compliance Measure Summary: Section 3.2(a) requires that 90% of Deputies and
Custody Assistants assigned to Custody as of July 1, 2016 completed the required
training.

As of June 30, 2018, the Department was found to be in Compliance with the training requirements of
Section 3.2(a).

Compliance Measure Summary: Section 3.2(b) requires that 90% of Deputies and
Custody Assistants assigned to Custody who completed the initial training receive the
two-hour refresher course every other year.

The Panel’s auditors previously verified Compliance with Section 3.2(a) as of June 30, 2018 and with
Section 3.2(b) as of December 31, 2019, through December 31, 2021. The Department’s Augmented
Twelfth Self-Assessment reports that it maintained compliance with Section 3.2(b) for 2022. These
results were verified by the Panel’s auditors and the Department is in Compliance with Section 3.2 for
2022.
3.2 Status: Compliance As of Date: June 30, 2018

C. Mental Health Training

4.6 Crisis Intervention
Provision Description: The Department should provide a minimum of 32 hours of custody-specific,
scenario-based, skill development training to all Deputy Sheriffs on Crisis Intervention and Conflict
Resolution with eight (8) hours of refresher training every other year.

4.7 Mentally Ill Inmates

Provision Description: The Department should provide a minimum of eight (8) hours of custody
specific, scenario based, skill development training on identifying and working with mentally ill inmates
to all existing Custody personnel with a four (4) hour refresher course every other year.

Compliance Measure Summary: Sections 4.6(a) and 4.7(a) requires that 90% of
Deputies assigned to Custody as of July 1, 2016 completed the required training.

As of June 30, 2018, the Department was found to be Compliant with the De-Escalation and Verbal
Resolution Training (DeVRT) 11, mentally ill inmates, and refresher training requirements of Sections
4.6(a) and 4.7(a). 12

11
One of the four key areas to be addressed in the Parties written plan to achieve compliance is the appropriate
utilization of force avoidance and de-escalation techniques. Two of the Monitors reviewed the curriculum and
observed 32 hours of the DeVRT Training in May 2023. Overall, the Monitors were impressed with the content and
delivery of the training. They met with the Department’s training staff and provided feedback regarding the
curriculum. The Department is in the process of revising the DeVRT curriculum.
12
Section 4.6 pertains to Deputies assigned to MCJ, TTCF, IRC, or assigned to work with mentally ill inmates at
CRDF (the “Designated Facilities”). Section 4.7 pertains to remaining Deputies at CRDF, and all Deputies at NCCF
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Compliance Measure Summary: Sections 4.6(b) and 4.7(b) requires that 90% of
Deputies assigned to Custody who completed the initial training receive the eight-hour
refresher course every other year.

The Panel’s auditors previously verified the Department’s Compliance with Section 4.6(a) as of June 30,
2018, and with Section 4.6(b) as of December 31, 2018 through December 31, 2021. The Department’s
Augmented Twelfth Self-Assessment reports that it maintained compliance with Section 4.6(b) for 2022.
These results have been verified by the Panel’s auditors and the Department is in Compliance with
Section 4.6 as of June 30, 2018 through December 31, 2022.

After falling out of compliance in the Eleventh Report, the Department’s Augmented Twelfth Self-
Assessment reports it regained compliance with Section 4.7(b) in 2022. These results have been verified
by the Panel’s auditors and the Department is in Compliance with Section 4.7 as of January 1, 2023.
4.6 Status: Compliance As of Date: June 30, 2018
4.7 Status: Compliance As of Date: January 1, 2023

D. New Deputy Sheriffs and Custody Assistants

3.3 Custody Training
Provision Description: Section 3.3 of the Action Plan requires training all new Deputies in use of force
and ethics, professionalism, and treating inmates with respect. Section 3.3 also requires the same for new
Custody Assistants, who have received training in these subjects during their Academy training.

Compliance Measure Summary: Section 3.3 requires that 95% of new Deputies and
Custody Assistants completed the required training.

The Department reported that since the First Reporting Period beginning on July 1, 2015, newly assigned
Deputies have been required to complete a six-week Custody Operations course that includes training in
use of force and ethics, professionalism and treating inmates with respect, and new Custody Assistants,
have received training in these subjects during their Academy training as required by Section 3.3. The
Panel’s auditors previously verified results through June 30, 2022. The Department’s posted results
reflect that the Department has met the 95% Compliance threshold through December 31, 2022. The
results have been verified by the Panel’s auditors and the Department is in Compliance with Section 3.3
as of June 30, 2018 through December 31, 2022.
3.3 Status: Compliance As of Date: June 30, 2018

4.8 Mentally Ill—New Staff

Provision Description: Provide a minimum of eight (8) hours of custody specific, scenario-based, skill
development training on identifying and working with mentally ill inmates to all new members as part of
the Jail Operations Continuum.
4.9 Crisis Intervention—New Staff
Provision Description: Provide a minimum of 32 hours of custody specific, scenario-based, skill
development training in Crisis Intervention and Conflict Resolution to new Department members in the
Academy or in Custody before they are assigned to any jail facilities.

and PDC jails. The Action Plan requires an initial eight (8) hour training course, and then a four (4) hour refresher
course every other year under Section 4.7. Deputies captured under Section 4.7 receive the same training as
Deputies under Section 4.6, which includes the training contemplated under Section 4.7.
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Compliance Measure Summary: Sections 4.8 and 4.9 requires that 95% of new Deputies
and Custody Assistants completed the required training.

The Department provides new Deputies in De-Escalation and Verbal Resolution Training (DeVRT) and
training in identifying and working with mentally ill inmates (IIMI). 13 The required DeVRT and IIMI
training takes place after Deputy Sheriffs and Custody Assistant Academy graduations and prior to
assuming duties at their unit of assignment. The Panel’s auditors previously verified the Department was
in Compliance with Sections 4.8 and 4.9 as of June 30, 2018, through June 30, 2022. The Department’s
Twelfth Self-Assessment reports that 100% of the new personnel received the required training in the
Third and Fourth Quarters of 2022. These results have been verified by the Panel’s auditors and the
Department is in Compliance with Sections 4.8 and 4.9 as of June 30, 2018 through December 31, 2022.
4.8 and 4.9 Status: Compliance As of Date: June 30, 2018

3.5 Additional Training and Mentoring

Provision Description: Requires Unit Commanders to determine “what additional training, counseling,
or mentoring may be required when a personnel complaint involving the use of force is resolved with a
finding that it ‘Appears Employee Conduct Could Have Been Better’ direct that the Department member
undergo additional training, counseling, or mentoring, and document the action taken.”

Compliance Measure Summary: Section 3.5 requires that 90% of personnel complaints
involving use of force that were resolved with a “Appears Employee Conduct Could
Have Been Better” finding reflect documentation that the Unit Commander reasonably
determined what additional training, counseling or mentoring was required.

The Department’s Twelfth Self-Assessment reports that there were no inmate grievances against staff
involving use of force where the disposition was that it “Appears Employee Conduct Could Have Been
Better.” The Department is in Compliance with Section 3.5 as July 1, 2019 through December 31, 2022.
3.5 Status: Compliance As of Date: July 1, 2019

3.6 Probation Reviews

Provision Description: Requires Unit Commanders to review new Department members within six (6)
months of being initially assigned to Custody and again before the end of their probationary period.

Compliance Measure Summary: Section 3.6 requires that 95% of the new Department
members in Custody Operations were reviewed (1) within six months after being
assigned to Custody and (2) again before their first post-probationary assignment.

The Department’s Twelfth Self-Assessment reports that it achieved 96% compliance in the Second
Semester of 2022, greater than the 95% threshold required by Section 3.6. Therefore, the Department is in
Compliance with Section 3.6 as of December 31, 2022. These results are subject to verification by the
Panel’s auditors.
3.6 Status: Compliance As of Date: January 1, 2023

13
The Panel has previously agreed that IIMI is included in the DeVRT curriculum of Section 4.9.
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E. Sergeant Training
12.1 Force Investigations Training
Provision Description: Requires that all Custody Sergeants receive an initial 16-hour block of training in
conducting use of force investigations, reviewing use of force reports, and the Department's protocols for
conducting such investigations. It also requires a two (2) hour refresher course every year.

Compliance Measure Summary: Section 12.1-1 requires that 90% of all Custody
Sergeants received the initial training and a two (2) hour refresher course every year.
Section 12.1-2 requires that 95% of new Sergeants completed the required training before
or within 90 days after they assume their duties in Custody.

The Panel approved the 16-hour initial training course required by Section 12.1 on February 24, 2017.
The Panel’s auditors previously verified Compliance with Section 12.1 as of July 1, 2019, through June
30, 2022. The Department’s Twelfth Self-Assessment reports that it maintained compliance through
December 31, 2022. These results have been verified by the Panel’s auditors and the Department is in
Compliance with Section 12.1 as of July 1, 2019 through December 31, 2022.
12.1 Status: Compliance As of Date: July 1, 2019

Tenth Report Eleventh Report Twelfth Report

Training Provisions 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
3.1 Use of Force Training X C C 12/31/2021
3.2 Ethics & Professionalism X C C 6/30/2018 
3.3 Custody Training C C C 6/30/2018 
3.4 Custody-based Scenarios C C C 6/30/2018 
3.5 Add Training and Mentoring C C C 7/1/2019 
3.6 Probation Reviews C X C 1/1/2023
4.6 Crisis Intervention X C C 6/30/2018 
4.7 Mentally Ill Inmates X X C 1/1/2023
4.8 Mentally Ill Inmates (new staff) C C C 6/30/2018 
4.9 Crisis Intervention (new staff) C C C 6/30/2018 
12.1 Force Investigations C C C 7/1/2019 

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IV. Reporting and Investigation of Force Incidents

A. Reporting and Investigation Provisions in Force Package Reviews
The findings below pertain to the application of policies into practice and are supported by the selection
of use of force cases reviewed. For the Twelfth Reporting Period a total of 50 packages were reviewed:
25 in 3Q22 and 25 in 4Q22. Overall results for each provision during the Twelfth Reporting Period are
below. Findings for each quarter are in Section C: Quarterly Findings.

Compliance Measure Summary: (#1-7) Within 10 days of the end of each quarter the
Department will provide the Monitors with a cumulative force synopsis for each incident in
the Downtown Jail Complex. The Monitors will select a minimum of 25 force packages to
review for compliance with the Action Plan of all reporting and investigations provisions
through Vertical and Horizontal Assessments. The Department will provide each package
and include a summary sheet that indicates how the Department assessed each applicable
provision. Reporting and Investigations provisions will need to be 90% or more compliant
for the Vertical Assessments.

Vertical Assessment: Of the 50 cases reviewed, four (4) were found compliant with Reporting and
Investigative Provisions, which constitutes 8% of all cases reviewed and is below the 90% compliance
threshold. Of the four (4) cases in compliance with Reporting and Investigative provisions, all were from
4Q22: two (2) from TTCF, one (1) from IRC, and one (1) from MCJ.

Horizontal Assessment: The findings for the seventeen (17) Reporting & Investigative Provisions represent
the Horizontal Assessment, which determines the Department is in Compliance with each of the applicable
Force Provisions. It takes into consideration the objective of the provision and the nature and extent of any
violations of the provision. Percentages are calculated based on packages reviewed in both quarters.

4.2 Mental Health Professionals

Provision Description: Supervisors investigating uses of force are required to interview mental health
professionals who witnessed the incident or attempted to resolve it. Record interview if consented to.

Of the applicable cases reviewed, 85% (6 out of 7) were found to be in compliance, which is below the
90% compliance threshold. However, given the small number of applicable cases and the fact the
Department was found non-compliant in only one case, the Panel has found the Department compliant.
4.2 Status: Compliance As of Date: January 1, 2023

5.2 Commander’s Reviews

Provision Description: Evaluations of force incidents by Unit Commanders are reviewed pursuant to the
category level requirement.

Of the applicable cases reviewed, 94% (47 out of 50) were found to be in compliance, which exceeds the
90% compliance threshold.
5.2 Status: Compliance As of Date: January 1, 2023

5.3 Unexplained Discrepancies

Provision Description: Any unexplained tactical decisions or discrepancies among witnesses should be
referred in writing between the reviewing Commander(s) and investigator.

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Of the applicable cases reviewed, 93% (41 out of 44) were found to be in compliance, which exceeds the
90% threshold.
5.3 Status: Compliance As of Date: July 1, 2022

12.2 Location of Inmate Interviews

Provision Description: Inmate witnesses to force incidents should be asked to be interviewed, and
interviewed, away from other inmates.

Of the applicable cases reviewed, 51% (20 out of 39) were found to be in compliance, which is below the
90% compliance threshold.
12.2 Status: Out of Compliance As of Date: N/A
12.3 Suspect Interviews
Provision Description: No Department member involved in the use of force should be present for or
participate in the interviews.

Of the applicable cases reviewed, 90% (45 out of 50) were found to be in compliance, which meets the
90% compliance threshold.
12.3 Status: Compliance As of Date: July 1, 2019

12.4 Uninvolved Supervisors

Provision Description: Force investigations should not be conducted by the direct supervisor of the staff
member involved in the use of force.

Of the applicable cases reviewed, 88% (44 out of 50) were found to be in compliance, which is below the
90% compliance threshold.
12.4 Status: Out of Compliance As of Date: N/A

12.5 Standard Order and Format

Provision Description: Use of force packages organized in a standard order and format.

Of the applicable cases reviewed, 98% (48 out of 49) were found to be in compliance, which exceeds the
90% compliance threshold.
12.5 Status: Compliance As of Date: July 1, 2019

15.1 Timeliness of Reports

Provision Description: Every staff member who uses or assists in a force incident completes a separate
and independent written report before going off duty.

Of the applicable cases reviewed, 94% (47 out of 50) were found to be in compliance, which exceeds the
90% compliance threshold.
15.1 Status: Compliance As of Date: July 1, 2019

15.2 All Department Witnesses

Provision Description: Each staff member who witnesses a use of force prepares a written report unless
the Watch Commander specifically designates a witness when a large number witnessed the same event.

Of the applicable cases reviewed, 94% (47 out of 50) were found to be in compliance, which exceeds the
90% compliance threshold.
15.2 Status: Compliance As of Date: July 1, 2019
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15.3 Force by Other Members

Provision Description: Staff member who uses force describes the type used in a written report as well
the type used by others.

Of the applicable cases reviewed, 78% (39 out of 50) were found to be in compliance, which is below the
90% compliance threshold.
15.3 Status: Out of Compliance As of Date: N/A

15.4 Description of Injuries

Provision Description: Staff members who witness a use of force incident describe visible or apparent
injuries to department members, inmates, or others involved.

Of the applicable cases reviewed, 76% (38 out of 50) were found to be in compliance, which is below the
90% compliance threshold.
15.4 Status: Out of Compliance As of Date: N/A

15.5 Clarification After Video

Provision Description: A Department member who wants to make any clarifications or changes after
viewing a video of a force incident should be required to either prepare a supplemental report or
specifically note any changes to the Department member’s initial report.

Of the applicable cases reviewed, 93% (27 out of 29) were found to be in compliance, which exceeds the
90% compliance threshold.
15.5 Status: Compliance As of Date: July 1, 2019

15.6 Separation of Deputies

Provision Description: To the extent practical, Department members should be separated until they have
completed their use of force reports and/or witness reports.

Of the applicable cases reviewed, 16% (8 out of 50) were found to be in compliance, which is below the
90% compliance threshold. The Panel has advised the Department on how to document how the Deputies
were separated to complete their reports.
15.6 Status: Out of Compliance As of Date: N/A

15.7 Individual Perceptions

Provision Description: Report reviewers ensure each report reflects individual perceptions and
recollections of the events and that they do not have common wording or phrasing.

Of the applicable cases reviewed, 90% (45 out of 50) were found to be in compliance, which meets the
compliance threshold.
15.7 Status: Compliance As of Date: July 1, 2019

16.1 Healthcare Assessment

Provision Description: A documented medical assessment of each inmate upon whom force is used as
soon as practical after the force incident.

Of the applicable cases reviewed, 98% (49 out of 50) were found to be in compliance, which exceeds the
compliance threshold.
16.1 Status: Compliance As of Date: July 1, 2019

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16.2 Photographs of Injuries

Provision Description: Supervisors investigating force incidents photograph any injury, swelling, or
redness sustained by staff members and document the absence of injury.

Of the applicable cases reviewed, 83% (38 out of 46) were found to be in compliance, which is below the
90% compliance threshold.
16.2 Status: Out of Compliance As of Date: N/A
16.3 Medical Report of Injuries
Provision Description: Medical staff treating an injured inmate report any injuries related to a use of
force or an allegation by the inmate of a use of force.

Of the applicable cases reviewed, 96% (48 out of 50) were found to be in compliance, which exceeds the
90% compliance threshold.
16.3 Status: Compliance As of Date: July 1, 2019

B. Reporting & Investigations Provisions as Reported by Department

Many of the recommendations in the Action Plan that pertain to the reporting and investigation of force
used by Department personnel in Custody Operations are assessed by the Panel through a review of the
completed force packages. Other provisions are reported by the Department as follows:

5.1 Tracking of Force Incidents

Provision Description: Requires the Department to track the status of all investigations, reviews, and
evaluations of all use of force incidents and allegations to ensure they were completed appropriately and
timely. By the end of the shift, a supervisor or Internal Affairs investigator enters incidents into a database
with a summary and an initial category classification.

Compliance Measure Summary: 5.1(2) On a quarterly basis, Monitors determine if the

completed force packages reviewed were entered into the database pursuant to 5.1(1).

The Department reports that 95% of the force incidents were timely entered into the database in the Third
Quarter of 2022 (19 out of 20 cases). In the Fourth Quarter of 2022, 100% of the 29 cases were timely
entered into the database.

Compliance Measures Summary:

5.1(1) and (4a): 95% of use of force incidents are entered into the database within two
hours of the end of shift in which the incident occurred.
5.1(4)b and c: 90% of investigations of Deputies and Custody Assistants were completed
timely and appropriately.

Pursuant to The Panel’s request, the Department began providing specific data pertaining to Compliance
Measure 4(b) and 4(c). The Department reports their compliance rate for the Third Quarter was 40% and
80% for the Fourth Quarter of 2022.
5.1 Status: Out of Compliance* As of Date: N/A
*The Panel notes the Department has been in Compliance with 5.1 (1) and 4(a) since
October 1, 2019.

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8.3 CFRC Review

Provision Description: Evaluations of grievance investigations claiming force was used to retaliate
against an inmate should be reviewed by the Custody Force Review Committee.
Compliance Measures Summary: A list of completed investigations of inmate
grievances claiming use of force was used in retaliation is provided quarterly to the
Monitors and will include the CFRC review of the investigation’s evaluation.

The Department reports, and the Panel concurs, that it achieved 100% Compliance with this provision in
the Third and Fourth Quarters of 2022. There were 10 grievances reviewed in the Third Quarter of 2022
and 3 in the Fourth Quarter of 2022.
8.3 Status: Compliance As of Date: June 30, 2021

11.1 CFRT Involvement

Provision Description: The Custody Force Rollout Team (CFRT) involvement in reviewing evaluations
should not delay the investigation.

Compliance Measure Summary: 95% of the investigations reviewed by CFRT were not
delayed and discipline imposed timely if there is a policy violation finding.

There were no force incidents reviewed by CFRT where there was a finding of a policy violation or
misconduct in the Twelfth Reporting Period.
11.1 Status: Compliance As of Date: June 30, 2018

13.1 Documenting Dishonesty

Provision Description: A firm zero tolerance policy for acts of dishonesty, use of excessive force,
failures to report uses of force, and violations of PREA. For any staff member not terminated for such an
act documentation is made as to the reason and the discipline imposed as well as placement on a
monitored performance review program.

Compliance Measures Summary: 95% compliance with all completed investigations

where there was a finding of dishonesty, failure to report uses of force, or PREA
violations as well as documentation for incidents that did not result in termination.

The Department’s Self-Assessment indicates it achieved 100% compliance in both quarters of the
Twelfth Reporting Period. The following is a summary of the data posted for each quarter.

● Third Quarter of 2022: No personnel were terminated for dishonesty during this quarter.
However, there were two incidents found to violate the zero-tolerance policy for
dishonesty: one involving a deputy and the second a sergeant. In the first case, a deputy
did not return to his assignment and left the facility prior to the end of the shift. The
deputy was suspended for 15 days without pay and placed on the Mentorship Program. In
the second case, a sergeant was found to have submitted falsified overtime work hours
and adjusted daily timecards. The sergeant retired prior to the Skelly Hearing. The
Department states had the sergeant not retired he would have been terminated.
● Fourth Quarter of 2022: There were a total of seven incidents for this quarter involving
ten staff members.
a. One Custody Assistant was arrested off-duty for domestic violence and
suspended for 15 days without pay. The Department determined discharge was
not warranted. The Custody Assistant was scheduled for ethics training and
placed in the Mentorship Program to monitor performance.

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b. One Custody Assistant falsified records and failed to conduct quality safety
checks and was suspended for 15 days without pay. The Department determined
discharge was not warranted. The Custody Assistant was removed from
conducting inmate safety checks, placed on Performance Mentorship, and
attended Custody Division Force Policy Refresher Training, ethics training, and
DeVRT refresher training.
c. One Deputy was charged with misdemeanor domestic battery and entered a 12-
month informal diversion program. An IAB investigation was completed and the
deputy was terminated.
d. One Deputy left the facility prior to the end of shift without notification or
permission. The Deputy was terminated.
e. One Deputy failed to employ use of force prevention principles to deal with and
reassess the actions of an inmate, which resulted in a Category 2 use of force.
The deputy received a one-day suspension and attended Custody Division Force
Policy Refresher Training.
f. Three Deputies failed to employ use of force prevention principles to deal with
and reassess the actions of an inmate, which resulted in a Category 2 use of force.
Two received a one-day suspension without pay and the third issued a written
reprimand. All three attended Custody Division Force Policy Refresher Training.
g. One Custody Assistant and one Deputy failed to employ use of force prevention
principles to deal with and reassess the actions of an inmate, which resulted in a Category
2 use of force. The Custody Assistant was the supervisor on scene and failed to take
appropriate action. Each received a one-day suspension without pay and attended
Custody Division Force Policy Refresher Training and DeVRT Refresher Training.

The Panel recognizes the need for accountability regarding staff’s accurate and honest reporting in force
packages. The Panel has shared a draft revised Compliance Measure for 13.1. Discussions regarding the
revision will continue as part of the Accountability portion of the written Compliance Plans being
created by the Parties.
13.1 Status: Compliance As of Date: October 1, 2019

13.2 Reports of Dishonesty and PREA

Provision Description: All findings of dishonesty, failures to report uses of force, and violations of
PREA and supporting documentation is provided to the Office of the Inspector General quarterly.

The Inspector General was advised of all the actions noted above in Section 13.1.
13.2 Status: Compliance As of Date: October 1, 2019

14.1 Review of Criminal Referrals

Provision Description: An additional review of referrals of inmates for criminal prosecution arising from
incidents involving the use of force by Department members to ensure charges are not being brought to
help justify the use of force.

Compliance Measures Summary: Requires the Department review all referrals of an

inmate for criminal prosecution for assaulting a staff member and report to the Monitors
that 95% of referrals were reviewed by the Unit Commander who verified charges were
not brought as justification for use of force.

The Department reports 96% compliance with Section 14.1 for the Third Quarter of 2022. There were a
total of 29 cases referred to the District Attorney’s Office and in 28 of those cases, the Unit Commander
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verified the charges were not brought as a justification for a use of force prior to the referral being sent to
the District Attorney’s Office. In the remaining case, the Unit Commander verified the charges were not
brought as justification for a use of force approximately two months after the referral had been made. For
the Fourth Quarter of 2022, the Department reports 100% Compliance, indicating 24 cases were reviewed
by a Unit Commander before the criminal referral was sent.
14.1 Status: Compliance As of Date: July 1, 2018

14.2 Timeliness of Criminal Referrals

Provision Description: Timely forward incidents of officer misconduct that may amount to criminal
violations to the Office of the District Attorney.

Compliance Measures Summary: Requires the Department review all referrals of a staff
member for possible prosecution for alleged misconduct and report to the Monitors that
90% of referrals were sent to the Office of the District Attorney within six months.

Source documents indicate there were no cases referred to the District Attorney for possible prosecution
of a staff member during the Third and Fourth Quarters of 2022. There was no data to assess for this
reporting period.
14.2 Status: Compliance As of Date: July 1, 2018

Tenth Report Eleventh Report Twelfth Report

Reporting & Investigations Provisions, Department Reported 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
5.1 Tracking of Force Incidents C C X
8.3 CFRC Review C C C 6/30/2021
11.1 CFRT Involvement C C C 6/30/2018 
13.1 Documenting Dishonesty C C C 10/1/2019 
13.2 Reports of Dishonesty/PREA C C C 10/1/2019 
14.1 Review of Criminal Referrals C C C 7/1/2018 
14.2 Timeliness of Criminal Referrals C C C 7/1/2018 

C. Quarterly Findings—Reporting and Investigations Provisions

Third Quarter & Fourth Quarter 2022 Results
For the Third and Fourth Quarter of 2022, the Panel reviewed 50 use of force incidents combined—20
from TTCF (40%), 21 from MCJ (42%), and 9 from IRC (18%). The Department is not in Compliance
with six (6) of the seventeen (17) Reporting & Investigations Provisions as follows: (1) 12.2 Location of
Inmate Interviews, (2) 12.4 Uninvolved Supervisors, (3) 15.3 Force by Other Members, (4) 15.4
Description of Injuries, (5) 15.6 Separation of Deputies, and (6) 16.2 Photographs of Injuries.

Of the six (6) Reporting and Investigations Provisions out of compliance, two (2) had compliance rates
below 70% in 3Q22 and 4Q22 combined. Those provisions include the following:
● 12.2 Location of Inmate Interviews at 51% compliance.
● 15.6 Separation of Deputies to Write Reports at 16% compliance.
The cases reviewed for both quarters found full compliance or 90% or above compliance with the
following eleven (11) provisions: 4.2, 5.2, 5.3, 12.3, 12.5, 15.1, 15.2, 15.5, 15.7, 16.1, and 16.3.

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Tenth Report Eleventh Report Twelfth Report

Reporting & Investigations Provisions, Packet Review 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
4.2 Mental Health Professionals C X C 1/1/2023
5.2 Commanders' Reviews X X C 1/1/2023
5.3 Unexplained Discrepancies X C C 7/1/2022
12.2 Location of Inmate Interviews X X X
12.3 Suspect Interviews C C C 7/1/2019 
12.4 Uninvolved Supervisors C C X
12.5 Standard Order & Format C C C 7/1/2019 
15.1 Timeliness of Reports C C C 7/1/2019 
15.2 All Department Witnesses C C C 7/1/2019 
15.3 Force by Other Members X X X
15.4 Description of Injuries C C X
15.5 Clarification After Video C C C 7/1/2019 
15.6 Separation of Deputies X X X
15.7 Individual Perceptions C C C 7/1/2019 
16.1 Healthcare Assessment C C C 7/1/2019 
16.2 Photograph of Injuries C X X
16.3 Medical Report of Injuries C C C 7/1/2019 

Third Quarter 2022 Results

For the Third Quarter of 2022, the Panel reviewed 25 force incidents—10 from TTCF (40%), 7 from MCJ
(28%), and 8 from IRC (32%). The Department is not in Compliance with eleven (11) of the seventeen
(17) Reporting & Investigations Provisions as follows: (1) 5.2 Commander’s Reviews, (2) 5.3
Unexplained Discrepancies, (3) 12.2 Location of Inmate Interviews, (4) 12.3 Suspect Interviews, (5) 12.4
Uninvolved Supervisors, (6) 15.1 Timeliness of Reports, (7) 15.3 Force by Other Members, (8) 15.4
Description of Injuries, (9) 15.5 Clarification After Video, (10) 15.6 Separation of Deputies, and (11) 15.7
Individual Perceptions.

Of the eleven (11) Reporting and Investigations Provisions out of compliance, two (2) had compliance
rates below 70% in 3Q22. Those provisions include the following:
● 12.2 Location of Inmate Interviews at 52% compliance.
● 15.6 Separation of Deputies to Write Reports at 4% compliance.

The cases reviewed for this quarter found full compliance or 90% or above compliance with the following
six (6) provisions: 4.2, 12.5, 15.2, 16.1, 16.2, and 16.3.

Fourth Quarter 2022 Results

In the Fourth Quarter of 2022, the Panel reviewed 25 force incidents—10 from TTCF (40%), 14 from
MCJ (56%), and 1 from IRC (4%). The Department is not in Compliance with the following Reporting &
Investigations Provisions: (1) 4.2 Mental Health Professionals; (2) 12.2 Location on Inmate Interviews;
(3) 12.4 Uninvolved Supervisors; (4) 15.3 Force by Others, (5) 15.4 Description of Injuries, (6) 15.6
Separation of Deputies to Write Reports; (7) 15.7 Individual Perceptions; and (8) 16.2 Photographs of
Injuries.
Of the eight (8) Reporting and Investigations Provisions out of compliance, two (2) had compliance rates
below 70% in 4Q22. Those provisions include the following:
● 12.2 Location of Inmate Interviews at 50% compliance.
● 15.6 Separation of Deputies to Write Reports at 28% compliance.
The cases reviewed for this quarter found full compliance or 90% or above compliance with the following
provisions: 5.2, 5.3, 12.3, 12.5, 15.1, 15.2, 15.5, 15.7, 16.1, and 16.3.

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V. Inmate Grievances
The Action Plan requires extensive changes in how the Department handles inmate grievances and
requests for service. On July 15, 2016, the Department issued a new Inmate Grievance Manual (Volume
8 of the Custody Division Manual) to implement a new grievance system. The Panel assessed the
Department’s implementation of the new grievance system in the Twelfth Reporting Period as follows:

A. Grievance Forms
6.1 Separate Grievance Forms
Provision Description: Inmate grievances and inmate requests reported on separate forms, either paper
or electronically.

6.2 Availability of Grievance Forms

Provision Description: Grievance forms are reasonably available to inmates at all times.

During the Panel’s November 2022 visit to the Downtown Jail Complex, the boxes within the housing
units contained grievance forms.

6.6 Right to Appeal Form

Provision Description: Grievance forms include a check box indicating whether the complaint was
upheld or denied and a statement regarding the right to appeal and time frame.

Compliance Measures Summary: Monitors determine the availability of forms and

requirements of 6.1 through 6.6 through onsite visits, interviews with inmates and staff,
and a review of 25 consecutive force and retaliation grievances in a month.

The Panel has previously concluded that the forms meet the requirements of the Action Plan and include
the appeals check box.
6.1, 6.2, and 6.6 Status: Compliance As of Date: January 1, 2017

7.1 Conflict Resolution Meeting

Provision Description: Inmates who submit grievances should be advised that a conflict resolution
meeting is voluntary to address the grievances without a personnel investigation. If successful, the
grievance resolution is documented accordingly.

In the randomly selected months in the Third and Fourth Quarters of 2022, no grievances against staff
were adjudicated in which a Conflict Resolution was conducted. There was no data to assess from any
facility.
7.1 Status: Compliance As of Date: January 1, 2017
6.4 Use of Force Grievances
Provision Description: Grievance forms should include “use of force” as a specific category of
“grievances against staff” and brought to the attention of Unit Commanders.

Compliance Measure Summary: 90% of force grievances reviewed were brought to the
attention of the Unit Commander within 10 days of receipt and properly handled.

The Department reports that 88% of force grievances were in Compliance with Section 6.4 in the Third
Quarter of 2022. There were a total of 9 grievances that met the criteria for Section 6.4 - 8 were

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properly handled and 1 was not. The Department achieved 100% Compliance in the Fourth Quarter of
2022. In light of the fact there was only 1 grievance that was not handled properly, the Panel finds the
Department is in Compliance with Section 6.4 for the Twelfth Reporting Period.
6.4 Status: Compliance As of Date: July 1, 2018

6.5 Grievances Against Staff

Provision Description: Grievance forms should include “retaliation” and “harassment” as specific
categories of “grievances against staff” and brought to the attention of Unit Commanders.

Compliance Measure Summary: 90% retaliation grievances reviewed were brought to

the attention of the Unit Commander within 10 days of receipt and properly handled.

The Department reports that 75% of the retaliation grievances in the Third Quarter of 2022 were brought
to the Unit Commanders attention within 10 days and handled appropriately. There were 12 grievances
that met the criteria for 6.5 - 9 were handled appropriately, 3 were not. In the Fourth Quarter of 2022,
100% of the grievances were handled appropriately.
6.5 Status: Out of Compliance As of Date: N/A

B. Emergency Grievances
6.3 Emergency Grievance Forms
Provision Description: A prominent box is placed on the form to indicate an “Emergency Grievance.”

Compliance Measure Summary: Monitors verify compliance with 6.3 through

interviews of staff and inmates and review of grievances marked “emergency.

A prominent box is located on the grievance form and confirmed through reviews and interviews.
6.3 Status: Compliance As of Date: January 1, 2017

6.7 Handling Emergency Grievances

Provision Description: Grievances marked “emergency” are given to and reviewed by a supervisor as
soon as possible to determine if immediate action is needed to protect life or safety. Provide the inmate a
written response documenting action taken to address the emergency.

Compliance Measure Summary: Monitors review 50 consecutive grievances to ensure 95%

of grievances marked “emergency” were reviewed and handled pursuant to Section 6.7.

The Department’s Twelfth Self-Assessment reflects it achieved 100% compliance in the Third and Fourth
Quarter of 2022. There were seven (7) grievances that met the criteria for Section 6.7 for the Twelfth
Reporting Period and timely notification was provided to the inmate in 6 of those cases. In the remaining
case, the inmate was released.
. 6.7 Status: Compliance As of Date: July 1, 2018

6.8 Notification of Non-Emergency

Provision Description: If the grievance is determined to be non-emergent, the inmate is notified as soon
as practical that the grievance will be handled as non-emergent with reason documented.

Compliance Measure Summary: Monitors review 50 consecutive grievances to ensure

90% of those determined non-emergent were documented and notifications to inmates
were made within five days.
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The Panel has reviewed the 50 grievances posted for the Twelfth Reporting Period in which a grievance
marked “emergency” was downgraded. For the Third Quarter of 2022, it was found that 100% of the
grievances were correctly downgraded and the inmate was timely notified that the grievance will be
handled as non-emergent. The Department achieved 96% compliance with this provision in the Fourth
Quarter of 2022. There were 2 of the 50 grievances in which the inmate did not receive timely
notification that their grievances would be handled as non-emergent.
6.8 Status: Compliance As of Date: July 1, 2018

C. Inmate Grievance Coordinator

The recommendations in Sections 6.9, 6.13, 6.14, and 6.15 of the Action Plan address expectations and
duties of the Inmate Grievance Coordinator position.

6.9 Inmate Grievance Coordinator

Provision Description: Requires all emergency grievances be forwarded to the Inmate Grievance
Coordinator (IGC) who will review for proper handling and notify the Unit Commander if not properly
handled.

The Department’s posted data pertaining to Section 6.9 indicates the IGC received the emergency
grievances for the Twelfth Reporting Period and that there was not a need to notify the Unit Commander
of improperly handled grievances. While the manner in which this data is tracked is not entirely clear,
particularly with use of the “Null” Category, the Panel is hopeful the Department’s new system for
tracking grievances will provide more clarity on this, and other Provisions.
6.9 Status: Compliance As of Date: July 1, 2018

6.13 Grievance Coordinator Tracking

Provision Description: Regularly track the handling of inmate grievances to ensure that the
investigations are completed timely and reasonably, and that inmates are notified of the results of the
investigations.

6.14 Grievance Coordinator Reports

Provision Description: Provide a monthly report to Unit Commanders on the status of grievances,
timeliness of investigations, responses to grievances and appeals, and inmate notifications.

6.15 Grievance Coordinator Analysis

Provision Description: Analyze inmate grievances monthly to identify any problematic trends and
provide that analysis in a monthly report to Unit Commanders and senior management.

Compliance Measures Summary: Provide the Monitors with one or more quarterly
report to address all requirements of the Coordinator provisions. The Inmate Grievance
Coordinator will meet with the Monitors once a quarter.
The Department’s posted documentation for the Third and Fourth Quarters of 2022 includes detailed
reports and charts for managers as required by Sections 6.13, 6.14, and 6.15.

The Panel met with the Inmate Grievance Coordinator in June and November 2022 to discuss the
Department’s implementation of its grievance policies and procedures and overall trends with respect to
the Department’s handling of inmate grievances.
6.13, 6.14, and 6.15 Status: Compliance As of Date: July 1, 2018

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6.16 Centralized Grievance Unit

Provision Description: Establish a centralized unit to collect, review, categorize, forward for
investigations, and make appropriate notifications for inmate grievances.

The Panel previously determined the Department’s structure of a Grievance Coordinator supervising the
grievance teams at all of the Downtown Jail Complex facilities was equivalent in function to a centralized
system and was acceptable, pending progress and specific results. The Panel continues to deem the
Department’s Grievance Team structure acceptable.
6.16 Status: Compliance As of Date: January 1, 2017
D. Handling of Grievances
6.10 Collection of Grievances
Provision Description: Grievances should be collected from the locked grievance boxes on each living
unit no less frequently than once per day. Collection time should be recorded in a log and reviewed within
24 hours of collection.
Compliance Measures Summary: Monitors will inspect collection boxes, verify that the
database is accurate and up-to-date, and ensure that 95% of grievances selected for
review are collected, reviewed, entered, and tracked timely.
The Department’s Twelfth Self-Assessment reports that 100% of the reviewed grievances were collected
and reviewed within 24 hours and handled as required in the Third and Fourth Quarters of 2022. The
collection logs provided by the Department yielded a 95% compliance rate for the Third Quarter of 2022
and a 97% compliance rate for the Fourth Quarter of 2022. While the overall compliance rate for
collecting and reviewing grievances as required by 6.10 is very good, the Panel is concerned with the low
collection rates in certain floors/units within the downtown facilities.

As noted in our Eighth Report, the Compliance Measure for Section 6.10 does not yield data sufficient to
assess compliance with this provision. For example, the first 25 consecutive grievances at TTCF for the
selected months were collected within the first three days of the month. The fact that TTCF timely
collected grievances from its collection boxes in those first three days does not provide a meaningful
measurement of the Department’s compliance with Section 6.10. As such, the Panel has reviewed (and
will continue to review) the Unit Collection compliance data for the entire month to assess compliance
with Section 6.10.
6.10 Status: Compliance As of Date: July 1, 2021

6.11 Failure to Handle Grievances

Provision Description: Failing to provide an inmate with a grievance form when requested, destroying or
concealing grievances, failing to respond appropriately to a grievance, attempting to intimidate an inmate
from filing a grievance, and retaliating against an inmate who has filed a grievance, may each be a cause
for disciplinary action.

Compliance Measure Summary: Provide the Monitors with a log of any inmate
grievances about the matters encompassed by Paragraph 6.11, the result of the
investigations of those grievances, and documentation that appropriate corrective action
was taken in 100% of cases.

The Department reports that no staff members have been found to have engaged in the conduct
encompassed by this Provision. In the Eleventh Report, the Panel expressed concern about the accuracy
of the Department’s methods for identifying 6.11 grievances. In March 2023, the Panel met with the
Custody Support Service Grievance Team and discussed their concerns with how the universe of 6.11
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grievances was being identified. Following those discussions, the Grievance Team amended the Third and
Fourth Quarter 2022 data posted in SharePoint. The universe of grievance was much broader than
previously reported. The Panel finds the Department in Compliance with this provision.
6.11 Status: Compliance As of Date: July 1, 2022
6.12 Tracking Inmate Grievances
Provision Description: All inmate grievances should be entered into and tracked in an inmate grievance
database that reflects the nature and status of the grievance, and personnel responsible for the
Department’s handling of the grievance.

Compliance Measures Summary: Monitors will review 25 grievances from MCJ and 25
from TTCF to ensure that 95% of grievances reviewed are collected, reviewed, entered,
and tracked timely.

The Department’s Twelfth Self-Assessment reports that 98% of the grievances at both MCJ and TTCF in the
randomly selected month in the Third and Fourth Quarter of 2022 were entered into the database as required
by Section 6.12. The source documents for these results were available to, and reviewed by, the Panel.
6.12 Status: Compliance As of Date: July 1, 2018

8.1 Anti-Retaliation
Provision Description: Prohibits Department personnel from retaliating against inmates.

Compliance Measures Summary: Department implements and enforces an anti-

retaliation policy and provides Monitors with a quarterly log of cases and findings as well
as the first 25 investigations alleging retaliation.

The Department posted the results of the investigations approved by Unit Commanders in the randomly
selected months and the number of anti-retaliation grievances received and investigated in the Third and
Fourth Quarters of 2022, which is as follows:
● Third Quarter of 2022 there were 40 anti-retaliation grievances received, nine investigations
completed, and no founded violations of the anti-retaliation policy.
● Fourth Quarter of 2022 there were 20 anti-retaliation grievances received, two investigations
completed and no founded violations of the anti-retaliation policy.
8.1 Status: Compliance As of Date: April 1, 2019

E. Deadlines
6.17 Use of Force Deadlines
Provision Description: A 30-day deadline in place for filing use of force grievances by inmates.

Compliance Measures Summary: 1(a), 95% compliance with the first 25 use of force
grievances determined by the Department to be untimely.

The Department’s source documents for this provision indicate they achieved 100% Compliance for the
Twelfth Reporting Period. There were 4 use of force grievances that were submitted beyond the 30-day
deadline. While those grievances were denied, they were still investigated.
6.17 Status: Compliance As of Date: October 1, 2019
6.18 PREA Deadline
Provision Description: There should be no deadline for filing Prison Rape Elimination Act grievances.

Compliance Measures Summary: 1(b), 95% compliance with the first 25 PREA grievances.

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There were 9 grievances filed during the Third Quarter of 2022 that met the criteria for Section 6.18.
Since 1 of the 9 grievances was not handled timely, the Department achieved 88% Compliance with this
Provision for the Third Quarter of 2022. Given the small universe of applicable grievances and the
Department’s sustained compliance with this Provision, the Panel finds the Department in Compliance for
the Twelfth Reporting Period. There were no PREA related grievances filed in the randomly selected
month of October (Fourth Quarter 2022).
6.18 Status: Compliance As of Date: July 1, 2018

6.19 Response to Inmate Grievances

Provision Description: Department should respond to inmate grievances “within 15 calendar days after
the submission of the grievance,” absent exceptional circumstances, which must be documented.

Compliance Measures Summary: 1(d and e), 90% compliance with the first 25
grievances against staff and the first 25 grievances not against staff in which the
investigation was not completed within 15 days.

The Department reports responding to the randomly selected 25 grievances that were not against staff,
within the 15-day deadline, 100% of the time for the Twelfth Reporting Period. For the 25 randomly
selected grievances against staff, the Department’s documents indicate they met the 15-day deadline in
84% of the cases in the Third Quarter of 2022 and 92% of the cases in the Fourth Quarter of 2022. The
84% Compliance rate represents 4 out of the 25 grievances that were untimely. The Department’s Twelfth
Self-Assessment indicates they achieved an overall 92% Compliance rate for the Third Quarter of 2022.

The Panel’s review of the source documents for this provision found the Department is providing an
inmate with either an extension or an interim response within 15 days. For example, out of the 25
grievances identified for 6.19 (d) for the Fourth Quarter of 2022, there were 16 extensions given and 3
interim responses. Since the extensions and interim responses were provided within the 15-day deadline,
the Department was compliant. The purpose of this provision is to ensure inmates receive a substantive
response to their grievance in a timely manner. The provision contemplates responses beyond the 15-day
deadline to be rare occurrences, which is not what the data shows. The Panel recognizes that providing an
extension or an interim response to the inmate within the 15-day deadline has qualified as compliance and
will find the Department Compliant for this Reporting period. However, to remain in Compliance of this
Provision, the Panel will require the Department to provide inmates with a substantive response to their
grievance within 15 calendar days, absent exceptional circumstances. The Panel will begin applying this
standard on January 1, 2024.

6.19 Status: Compliance As of Date: July 1, 2022

6.20 Appeals of Grievances

Provision Description: Inmates should have 15 days from receipt of a denial of a grievance (or from
release from segregations) to file an appeal of the grievance.

Compliance Measures Summary: 1(c), 95% compliance with the first 25 appeals of
grievances determined by the Department to be untimely.

According to the Department’s source documents, there were no appeals that met the criteria for this
provision during the Twelfth Reporting Period.
6.20 Status: Compliance As of Date: July 1, 2018

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F. Communications with Inmates

7.2 Notification of Results
Provision Description: Inmate should be advised of the results of the investigation of grievances against
personnel, but not any sanction imposed, within 10 days of adjudication.

Compliance Measures Summary: 1(f), 90% compliance with the first 25 completed
grievances against staff, including the inmate notifications.

The Augmented Twelfth Self-Assessment reports the Department out of Compliance with this provision
in the Third Quarter of 2022. Specifically, in 8 out of the 25 grievances against staff that were reviewed,
the inmate was not notified of the adjudication of the grievance within the required 10-day timeframe.
The Compliance Measure requires 90% Compliance and the Department achieved 68% Compliance for
the Third Quarter of 2022. MCJ was issued a Corrective Action Plan and implemented new measures to
ensure notifications were sent promptly. The Department’s Compliance rate for the Fourth Quarter of
2022 was 92%. The Department respectfully requested the Panel find them in Compliance with this
provision since they had been in Compliance since July 1, 2018. In considering the totality of the
circumstances, the Panel has determined that a 68% Compliance rate cannot be deemed in Compliance.
7.2 Status: Out of Compliance As of Date: N/A

7.3 Prisoner-Staff Communications

Provision Description: The Department should ensure that there are adequate avenues for constructive
prisoner-staff communication, such as Town Hall meetings.

Compliance Measures Summary: Maintain logs of Town Hall meetings and report to the
Monitors that each jail facility has conducted Town Hall meetings for a randomly
selected month per quarter. Monitors interview inmates and staff to assess the adequacy
of communications.

The Department’s Twelfth Self-Assessment reports that the Department was in Compliance with Section
7.3 during both the Third and Fourth Quarters of 2022. The Department provided 10% of the recorded
prisoner-staff communications that occurred during Town Hall meetings at MCJ and TTCF during the
randomly selected months during the Twelfth Reporting Period that included Town Hall meetings in
special housing units as well as in General Population housing units.
7.3 Status: Compliance As of Date: January 1, 2023

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Tenth Report Eleventh Report Twelfth Report

Grievance Provisions 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
6.1 Separate Grievance Forms C C C 1/1/2017 
6.2 Availabililty of Grievance Forms C C C 1/1/2017 
6.3 Emergency Grievances Forms C C C 1/1/2017 
6.4 Use of Force Grievances C C C 1/1/2017 
6.5 Grievances Against Staff C C X
6.6 Right to Appeal Form C C C 1/1/2017 
6.7 Handling Emergency Grievances C C C 7/1/2018 
6.8 Notification of Non-Emergency C C C 7/1/2018 
6.9 Grievance Coordinator Review C C C 7/1/2018 
6.10 Collection of Grievances C C C 7/1/2021
6.11 Failure to Handle Grievances X C C 7/1/2022
6.12 Tracking Inmate Grievances C C C 7/1/2018 
6.13 Grievance Coordinator Tracking C C C 7/1/2018 
6.14 Grievance Coordinator Reports C C C 7/1/2018 
6.15 Grievance Coordinator Analysis C C C 7/1/2018 
6.16 Centralized Grievance Unit C C C 7/1/2017 
6.17 Use of Force Deadline C C C 10/1/2019 
6.18 PREA Deadline C C C 7/1/2018 
6.19 Response to Inmate Grievances X C C 7/1/2022
6.20 Appeals of Grievances C C C 7/1/2018 
7.1 Conflict Resolution Meeting C C C 1/1/2017 
7.2 Notification of Results C C X
7.3 Prisoner-Staff Communications C X C 1/1/2023
8.1 Anti-Retaliation C C C 4/1/2019 

VI. Use of Restraints

17.1 Restraint Provisions
Provision Description: Custody Force Manual must include “a separate section that sets forth the general
principles governing the use of restraints.”

The Panel concludes that the Department included such a separate section in the Manual.
17.1 Status: Compliance As of Date: December 1, 2015

17.3 Safety Chair Procedures

Provision Description: Requires immediate medical examinations of inmates placed in Safety Chairs
with a use of force, or if the inmate struggles against the Safety Chair restraints. Section 17.3 also requires
that inmates’ vitals are checked every hour while in the Safety Chair.

Compliance Measures Summary: Department to provide the Panel “with a list of incidents
in which inmates were placed in a Safety Chair, restrained to a fixed object for more than
twenty minutes, or subjected to security restraints for an extended length of time” in the
Downtown Jail Complex. The Monitors conduct a Vertical and Horizontal Assessment of
approximately 25 incidents to determine at least 90% compliance with restraint provisions.

During the Twelfth Reporting Period, the Department provided the Inmate Safety Chair Security Check
Logs for use of the safety chair and Fixed Restraint Logs at the Downtown Jail Complex for the Third and

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Fourth Quarters of 2022. 14 The Panel’s auditors continue to note there is no indication that medical
professionals, or any Custody personnel, are performing vitals checks even though inmates are often in
the safety chairs for several hours while in transport to and from court and during court proceedings.
Periodic vitals checks are necessary to establish compliance even if the inmate does not struggle and force
is not used to place the inmate in the Safety Chair. Out of the 16 and 19 safety chair records provided for
the Third and Fourth Quarters of 2022, the Panel’s auditors note that there were no uses of force to place
an inmate into the chairs. However, due to vital checks not occurring as required the Department remains
out of Compliance with Section 17.3.
17.3 Status: Out of Compliance As of Date: N/A
17.4 Safety Checks
Provision Description: Requires safety checks of inmates in fixed restraints every twenty minutes to
verify and document the inmate is not in indue pain or that restraints are not creating injury.

Compliance Measures Summary: Department to provide the Panel “with a list of

incidents in which inmates were placed in a Safety Chair, restrained to a fixed object for
more than twenty minutes, or subjected to security restraints for an extended length of
time” in the Downtown Jail Complex. The Monitors conduct a Vertical and Horizontal
Assessment of approximately 25 incidents to determine at least 90% compliance with
restraint provisions.

The Inmate Safety Chair Security Check Logs and Fixed Restraint Logs reflect that Department personnel
are generally conducting safety checks on many inmates every twenty minutes, as required by Section
17.4. 15 However, fixed restraint logs provided for the one inmate during the Third Quarter of 2022 and
seven during the Fourth Quarter of 2022 provided did not explicitly document personnel verifying that the
inmate is not in undue pain or that the restraints are not causing injury. 16 One of the seven records from
the Fourth Quarter of 2022 does not reflect a reason for the use of fixed restraints (handcuffs). 17
Therefore, for these reasons, the Department remains Out of Compliance with Section 17.4.
17.4 Status: Out of Compliance As of Date: N/A
17.6 – 17.9 Multi-Point Restraints
Provision Descriptions: The provisions in these sections are specific to the use and application of multi-
point restraints. The Department does not employ the use of multi-point restraints and these provisions
are therefore not applicable.
17.6 – 17.9 Status: Not Applicable As of Date: N/A

14
The Panel’s auditors continue to observe that the logs provided are often inconsistent from one log to the next in
documenting the placement in or removal of an inmate from the safety chair. The logs provided continue to not
contain a field for hourly vitals checks to be recorded, a requirement of Section 17.3.
15
While the use of safety chairs for transportation are not subject to Section 17.4, it should be noted that the
Department’s policy requires safety checks to be recorded every 15 minutes. Based on the Department’s posted
results, all safety chair records provided for the Third and Fourth Quarters of 2022 are related to transportation. The
Department did not provide any WRAP Restraint/WRAP Cart Security Check Logs for this Reporting Period. The
Parties are working on a policy to govern the use of the WRAP restraint. Once the policy is finalized the Panel will
draft an appropriate Compliance Measure to assess compliance with the Action Plan.
16
While no uses of the safety chair during this Reporting Period are subject to Section 17.4, unlike the Inmate
Safety Chair Security Check Logs contain a field verifying whether or not there were “any visible signs of injury or
complaint of pain caused by safety chair[,]” the Fixed Restraint Logs do not contain a similar field.
17
In the field for “Inmate’s Initial Behavior and Reason for Fixed Restraint Application,” the only notation by the
Department is “cooperative,” appearing to be in response to the inmate’s initial behavior and not the reason for the
use of handcuffs.
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17.10 Involuntary Medications

Provision Description: The Department’s Custody use of force policies should provide that medication
may not be used solely for security purposes.

Compliance Measures Summary: Department will provide a log documenting the

administration of involuntary medications and the reason for it. Monitors will review the
log and interview involved medical and mental health professionals to verify medication
was not used solely for security purposes.

The Department’s posted results reflect that every administration of involuntary medications was pursuant
to court order and there were no instances in which medication was used solely for security purposes in
the Twelfth Reporting Period. According to the log of Administration of Involuntary Medication, 430
inmates in the Third Quarter of 2022 and 441 inmates in the Fourth Quarter of 2022 received involuntary
medication.
17.10 Status: Compliance As of Date: July 1, 2018

Tenth Report Eleventh Report Twelfth Report

Restraint Provisions 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
17.1 Restraint Provisions C C C 12/1/2015 
17.3 Safety Chair Procedures X X X
17.4 Safety Checks X X X
17.6 Multi-Point Restraint Procedures X N/A N/A
17.7 Approval of Multi-Point Restraints N/A N/A N/A
17.8 Continued Use of Restraints N/A N/A N/A
17.9 Supervisor Approval of Restraints N/A N/A N/A
17.10 Involuntary Medications C C C 7/1/2018 

VII. Early Warning System

19.1 Development of EWS
Provision Description: Develop a system to identify potentially problematic Department members based
upon objective criteria, such as number of force incidents, inmate grievances, allegations of misconduct,
performance reviews, and policy violations.

Compliance Measure Summary: The system identifies potentially problematic

employees upon objective criteria.

The Panel approved the Employee Review System (“ERS”) in July 2018, and it was implemented by the
Department as a pilot program in the Downtown Jail Complex on August 1, 2018, and in the rest of the
jail facilities as of November 1, 2018.
19.1 Status: Compliance As of Date: August 1, 2018

19.2 Review of EWS Reports

Provision Description: Compliance Lieutenants review reports monthly to identify potentially
problematic Department members and promptly notify the Unit Commander and the Assistant Sheriff for
Custody Operations in writing.

Compliance Measure Summary: Unit Commanders make notifications within ten days
90% of the time and within thirty days 95% of the time.

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For the Third Quarter of 2022, the Department’s posted results indicate the Compliance Lieutenant
notified the appropriate Unit Commander and the Assistant Sheriff for Custody Operations in writing of
potentially problematic employees within 10 days of receiving the monthly reports 93% of the time, and
within thirty days 100% of the time. The Department achieved 100% compliance for both the 10 day and
30 day notification requirements for the Fourth Quarter of 2022.
19.2 Status: Compliance As of Date: January 1, 2023

19.3 Performance Mentoring Programs

Provision Description: Unit Commanders required to determine whether problematic employees should
be placed on a performance mentoring program. For each potentially problematic Department member
identified through the EWS, the Unit Commander must consult with the appropriate Chief and document
the reasons why any problematic members are not placed on a performance mentoring program.

Compliance Measure Summary: Chief is consulted 95% of the time to determine if a

non-disciplinary performance program is appropriate. If so, specific performance metrics
were in place and the reason for the decision was provided 95% of the time.

For the Twelfth Reporting Period, the Department’s posted results reflect 100% compliance with this
provision. The posted source documents for these results were available to, and reviewed by, The Panel.
19.3 Status: Compliance As of Date: July 1, 2022

Tenth Report Eleventh Report Twelfth Report

Early Warning System Provisions 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
19.1 Development of EWS C C C 8/1/2018 
19.2 Review of ERS (EWS) Reports X X C 1/1/2023
19.3 Performance Mentoring Programs X C C 7/1/2022

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Appendix A: Compliance Chart

Eleventh
Tenth Report Report Twelfth Report
Administrative Provisions 1Q21 - 2Q21 3Q21 - 2Q22 3Q22 - 4Q22 AS OF 3YR+
1.1 Assistant Sheriff C C C 1/1/2017 
1.2 Sheriff C C C 1/1/2017 
1.3 Supervision X X X
1.4 Reports to Board C C C 6/12/2018 
10.1 Jail Visits C C C 6/30/2018 
10.2 Documented Visits C C C 6/30/2018 
18.1 Rotation in Custody C C C 6/30/2018 
18.2 Documentation of Rotation C C C 1/1/2019 
21.1 Transfers to Custody C C C 6/30/2018 
8 OF 9
Use of Force Policy Provisions
2.1 Custody Force Manual C C C 1/1/2017 
8.2 Complaints of Retaliation C C C 1/1/2017 
17.2 Pregnant Inmates C C C 1/1/2017 
20.1 Categories of Force C C C 1/1/2017 
20.2 Reactive Force C C C 1/1/2017 

Use of Force Practice Provisions, Packet Review

2.2 Force Prevention Principles X X X
2.3 Inmate on Inmate Violence C C X
2.4 Use of Force as Discipline C C C 7/1/2019 
2.5 Force on Restrained Inmates X X X
2.6 Head Strikes or Kicks X X X
2.7 Supervisors Called to Scene X X C 1/1/2023
2.8 Prevent Excessive Force C C X
2.9 Armed Inmates C C C 7/1/2019 
2.10 Authorized Weapons C C C 7/1/2019 
2.11 Planned Chemical Spray C C X
2.12 Chemical Spray & Tasers C C C 7/1/2019 
2.13 Check of Medical Records X X X
4.1 Consult Mental Health Professionals C X C 1/1/2023
4.3 Spray on Mental Health Inmates C C C 10/1/2019 
4.4 Cooling Off Periods C X C 1/1/2023
4.5 Medical or Mental Health Provider Order C X C 1/1/2023
9.2 Escorting of Inmate C C C 1/1/2023
9.3 Duty to Protect & Intervene C C C 7/1/2022
17.5 Minimize Medical Distress C X X
20.3 Planned Use of Force X X X
16 OF 25

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Training Provisions
3.1 Use of Force Training X C C 12/31/2021
3.2 Ethics & Professionalism X C C 6/30/2018 
3.3 Custody Training C C C 6/30/2018 
3.4 Custody-based Scenarios C C C 6/30/2018 
3.5 Add Training and Mentoring C C C 7/1/2019 
3.6 Probation Reviews C X C 1/1/2023
4.6 Crisis Intervention X C C 6/30/2018 
4.7 Mentally Ill Inmates X X C 1/1/2023
4.8 Mentally Ill Inmates (new staff) C C C 6/30/2018 
4.9 Crisis Intervention (new staff) C C C 6/30/2018 
12.1 Force Investigations C C C 7/1/2019 
11 OF 11
Reporting & Investigations Provisions, Packet Review
4.2 Mental Health Professionals C X C 1/1/2023
5.2 Commanders' Reviews X X C 1/1/2023
5.3 Unexplained Discrepancies X C C 7/1/2022
12.2 Location of Inmate Interviews X X X
12.3 Suspect Interviews C C C 7/1/2019 
12.4 Uninvolved Supervisors C C X
12.5 Standard Order & Format C C C 7/1/2019 
15.1 Timeliness of Reports C C C 7/1/2019 
15.2 All Department Witnesses C C C 7/1/2019 
15.3 Force by Other Members X X X
15.4 Description of Injuries C C X
15.5 Clarification After Video C C C 7/1/2019 
15.6 Separation of Deputies X X X
15.7 Individual Perceptions C C C 7/1/2019 
16.1 Healthcare Assessment C C C 7/1/2019 
16.2 Photograph of Injuries C X X
16.3 Medical Report of Injuries C C C 7/1/2019 

Reporting & Investigations Provisions, Department Reported

5.1 Tracking of Force Incidents C C X
8.3 CFRC Review C C C 6/30/2021
11.1 CFRT Involvement C C C 6/30/2018 
13.1 Documenting Dishonesty C C C 10/1/2019 
13.2 Reports of Dishonesty/PREA C C C 10/1/2019 
14.1 Review of Criminal Referrals C C C 7/1/2018 
14.2 Timeliness of Criminal Referrals C C C 7/1/2018 
17 OF 24

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#:6213

Grievance Provisions
6.1 Separate Grievance Forms C C C 1/1/2017 
6.2 Availabililty of Grievance Forms C C C 1/1/2017 
6.3 Emergency Grievances Forms C C C 1/1/2017 
6.4 Use of Force Grievances C C C 1/1/2017 
6.5 Grievances Against Staff C C X
6.6 Right to Appeal Form C C C 1/1/2017 
6.7 Handling Emergency Grievances C C C 7/1/2018 
6.8 Notification of Non-Emergency C C C 7/1/2018 
6.9 Grievance Coordinator Review C C C 7/1/2018 
6.10 Collection of Grievances C C C 7/1/2021
6.11 Failure to Handle Grievances X C C 7/1/2022
6.12 Tracking Inmate Grievances C C C 7/1/2018 
6.13 Grievance Coordinator Tracking C C C 7/1/2018 
6.14 Grievance Coordinator Reports C C C 7/1/2018 
6.15 Grievance Coordinator Analysis C C C 7/1/2018 
6.16 Centralized Grievance Unit C C C 7/1/2017 
6.17 Use of Force Deadline C C C 10/1/2019 
6.18 PREA Deadline C C C 7/1/2018 
6.19 Response to Inmate Grievances X C C 7/1/2022
6.20 Appeals of Grievances C C C 7/1/2018 
7.1 Conflict Resolution Meeting C C C 1/1/2017 
7.2 Notification of Results C C X
7.3 Prisoner-Staff Communications C X C 1/1/2023
8.1 Anti-Retaliation C C C 4/1/2019 
22 OF 24
Restraint Provisions
17.1 Restraint Provisions C C C 12/1/2015 
17.3 Safety Chair Procedures X X X
17.4 Safety Checks X X X
17.6 Multi-Point Restraint Procedures X N/A N/A
17.7 Approval of Multi-Point Restraints N/A N/A N/A
17.8 Continued Use of Restraints N/A N/A N/A
17.9 Supervisor Approval of Restraints N/A N/A N/A
17.10 Involuntary Medications C C C 7/1/2018 
2 OF 8
Early Warning System Provisions
19.1 Development of EWS C C C 8/1/2018 
19.2 Review of ERS (EWS) Reports X X C 1/1/2023
19.3 Performance Mentoring Programs X C C 7/1/2022
3 OF 3
TWELFTH REPORT COMPLIANT WITH 79 OF 100
COMPLIANT FOR 3 OR MORE YEARS 60 OF 100

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