HomeMy WebLinkAbout4.25.22 Health and Hygiene Holding Facility inspections
From:York, Danette
To:BOS
Cc:Nuzum, Danielle; Canton, David
Subject:Health and Hygiene Holding Facility inspections
Date:Monday, April 25, 2022 8:54:57 AM
Attachments:Cover Letter to Butte County Board of Supervisors.docx
Chico Police Department.docx
Juvenile Hall.docx
Oroville Courthouse.docx
Paradise Police Department.docx
Butte County Jail.docx
Chico Courthouse.docx
A Combined Itemized Summary.docx
Dear Board Members,
Per Health and Safety Code 101045 the Health Officer is responsible for conducting Health and
Hygiene inspections on the jail and holding facilities within the county. Dr. Canton and team have
completed all inspections for calendar year 2021. The inspections were not able to be conducted
within the calendar year due to various issues related to the COVID pandemic.
Please find a letter to the Board, a copy of the inspection report for each facility inspected, and a
combine summary document attached. Feel free to reach out to me or Dr. Canton with any
questions you may have.
Respectfully,
Danette York
Public Health Director
BUTTE COUNTY PUBLIC HEALTH
| F: 530.538.2164
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Public Health Administration DanetteYork, MPH, Director
David Canton, DO, MPH, JD, Health Officer, Interim
202 Mira Loma Drive T: 530.552.4000
Oroville, California 95965 F: 530.538.2164
April 14, 2022
Butte County Board of Supervisor’s
25 County Center Dr.
Oroville, CA
RE: Copy of Annual Jail and Juvenile Hall Health Inspections for Butte County Public Health.
Attached are copies of the 2021-2022 jail and holding facilities Health and Hygiene Inspection report
required per Health and Safety Code§ 101045. While the inspection was attempted to be scheduled
and conducted in calendar year 2021, the inspection could not be coordinated and conducted until
2022 due to various issues relate to the COVID pandemic.
Originals sent to Board of State and Community Corrections, FSO Division. Please contact me if you
have any questions.
Sincerely,
David B. Canton, D.O., M.P.H., J.D.
Interim Health Officer
ADULT COURT AND TEMPORARY HOLDING FACILITIES
Local Detention Facility Health Inspection Report
Health and Safety Code Section 101045
BSCC #: ___________
FACILITY NAME:COUNTY:
Police Department – City of Chico Butte
FACILITY ADDRESS (STREET, CITY, ZIP CODE, TELEPHONE):
1460 Humboldt Road, Chico, CA 95928, (530) 897-4900
CHECK THE FACILITY TYPE AS DEFINED IN TITLE 15, COURT HOLDING TEMPORARY HOLDING
SECTION 1006:
FACILITY: FACILITY: X
ENVIRONMENTAL HEALTH EVALUATION DATE INSPECTED: 02/09/2022
ENVIRONMENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Alana Kong, Registered Environmental Health Specialist II, (530) 552-3998
Leslie Roberts, Senior Registered Environmental Health Specialist, (530) 552-3872
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Jeramie Struthers, Lieutenant, (530) 897-5808
NUTRITIONAL EVALUATIONDATE INSPECTED:
NUTRITIONAL EVALUATORS (NAME, TITLE, TELEPHONE):
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
MEDICAL/MENTAL HEALTH EVALUATION DATE INSPECTED: 02/09/2022
MEDICAL/MENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Monica Soderstrom, Division Director, Public Health, (530) 552-3930
David Canton, Public Health Officer, (53) 552-3993
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Jeramie Struthers, Lieutenant, (530) 897-5808
1
This checklist is to be completed pursuant to the attached instructions.
I. ENVIRONMENTAL HEALTH EVALUATION
Police Department – City of Chico
ARTICLE/SECTIONYESNON/ACOMMENTS
Article 12. Food
Approach for Providing Food Service
If held during a meal time frozen or pre-packaged
(Not applicable to CH)
snack food that are non-potentially hazardous are
available.
x
Food served in the facility is prepared in the facility.
If "No," respond to items 1 and 2 below prior to
continuing with the checklist.
1. Food is prepared at another city or county
x
detention facility.
2. Food is contracted through a private vendor There is no contract through a private vendor. Will
who had been inspected and complies with
obtain frozen / snack foods from Costco and
x
provisions of CalCode.
Walmart who are permitted food facilities with
Butte County Environmental Health.
1245 Kitchen Facilities, Sanitation and Food
No kitchen facility or food preparation
Service
(Not applicable to CH)
x
Kitchen facilities, sanitation, and food preparation,
service and storage comply with standards set forth
in CalCode.
In facilities where inmates prepare meals for self-
consumption, or where frozen meals are pre-
prepared food from other facilities permitted
pursuant to HSC §114381 is (re)heated and served,
x
the following CalCode standards may be waived by
the local health officer.
HSC §114130-114141
HSC §114099.6, 114095-114099.5,114101-
114109, 114123 and 114125 if a domestic or
commercial dishwasher, capable of providing
x
heat to the surface of utensils of at least 165
degrees Fahrenheit, is used to clean and
sanitize multi-service utensils and multi-service
consumer utensils;
HSC §114149-114149.3 except that, regardless
of such a waiver, the facility shall provide
x
mechanical ventilation sufficient to remove
gases, odors, steam, heat, grease, vapors and
smoke from the kitchen;
HSC §114268-114269 x
2
ARTICLE/SECTION YESNO N/A COMMENTS
HSC §114279-114282 x
1246 Food Serving and Supervision No food preparation done at this facility
(Not applicable to CH)
Policies and procedures ensure that appropriate
x
work assignments are made, and food handlers are
adequately supervised. Food is prepared and served
only under the immediate supervision of a staff
member.
Article 14. Bedding and Linens
1270 Standard Bedding and Linen Issue
(Not applicable to CH)
x
The standard issue of clean suitable bedding and
linens, for each inmate entering a living area who is
expected to remain overnight, shall include, but not
be limited to:
(a) One serviceable mattress which meets the
x
requirements of Title 15 §1272;
(b) one mattress cover or one sheet; x
(c) one blanket or more depending upon climatic
conditions. Two blankets or sleep bag may be
x
issued in place of one mattress cover or one
sheet
(d) one towel x
Temporary Holding facilities which hold persons
Typically, not held longer than 4 hours but items
above are available since this facility can hold up
x
longer than 12 hours shall meet the requirements of
to 24 hours
1, 2 and 3 above.
1272 Mattresses
(Not applicable to CH)
x
Mattresses are enclosed in an easily cleaned, non-
absorbent ticking and conform to the size of the
bunk as referenced in Title 24, Part 2, §1231.3.5
Beds (at least 30" wide X 76" long).
Any mattress purchased for issue to an inmate in a
facility, which is locked to prevent unimpeded
access to the outdoors, is certified by the
x
manufacturer as meeting all requirements of the
State Fire Marshal and Bureau of Home Furnishings
for penal mattresses at the time of purchase.
3
ARTICLE/SECTION YESNO N/A COMMENTS
Article 15. Facility Sanitation and Safety
1280 Facility Sanitation, Safety and Maintenance 900.10.1 and safety checklist
Daily janitorial services.
There are policies and procedures for the
x
maintenance of an acceptable level of cleanliness,
Contracted with cleanrite / buildrite
repair and safety throughout the facility.
The plan provides for a regular schedule of Deficiency – all 7 holding cells do not have hot
housekeeping tasks and inspections to identify and water. Some holding cell’s hot water button was
correct unsanitary or unsafe conditions or work not working
practices.
Corrective action – provide hot water and fix the
x
hot water button
Deficiency – light in shower is not working
Corrective action – repair
Itemized Summary
I. Environmental Health Evaluation
Police Department – City of Chico
Page 4
Deficiency – all 7 holding cells do not have hot water. Some holding cell’s hot water button was not working
Corrective action – provide hot water and fix the hot water button
Deficiency – light in shower is not working
Corrective action – repair
Summary of environmental health evaluation: There were deficiencies with plumbing fixtures and lighting that need to
be addressed. Overall, facility appears to be clean at the time of inspection.
4
III. MEDICAL/MENTAL HEALTH EVALUATION
Adult Court and Temporary Holding Facilities
ARTICLE/SECTIONYES NO N/A COMMENTS
Article 11. Health Services
1200 Responsibility for Health Care Services
Addressed in section 905.5.3 of department policy
In court holding and temporary holding facilities, the
manual
facility administrator shall have the responsibility to
X
develop written policies and procedures which
ensure provision of emergency health care services
to all inmates.
1207 Medical Receiving Screening
Addressed in section 902.11.1 of department policy
(Not applicable to CH)
manual
A receiving screening is performed on all inmates at
the time of intake, with the exception of inmates X
transferred directly within a custody system with
documented receiving screening
This screening shall be completed in accordance
with written procedures and shall include but not be
limited to medical and mental health problems, X
developmental disabilities, tuberculosis and other
communicable diseases.
The screening shall be performed by licensed health Deficiency: Training of facility staff is lacking.
personnel or trained facility staff, with
Corrective Action: Training program is in
documentation of staff training regarding site
development per Lt Struthers. Recommend
specific forms with appropriate disposition based on
X
acceleration and implementation of training
responses to questions and observations made at
program.
the time of screening. The training depends on the
role staff are expected to play in the receiving
screening process.
The facility administrator and responsible physician Addressed in section 900.5.4 of department policy
manual
shall develop a written plan for complying with
X
Penal Code Section 2656 (orthopedic or prosthetic
appliance used by inmates).
There shall be a written plan to provide care for any
inmate who appears at this screening to be in need
X
of or who requests medical, mental health, or
developmental disability treatment.
Written procedures and screening protocol shall be
X
established by the responsible physician in
cooperation with the facility administrator.
5
ARTICLE/SECTIONYES NO N/A COMMENTS
1209 Mental Health Services and Transfer to a Addressed in section 900.3.1 of department policy
Treatment Facility manual
(Not applicable to CH)
X
(a) The health authority, in cooperation with the
mental health director and facility
administrator, shall establish policies and
procedures to provide mental health services.
These services shall include but not be limited
to:
1.Identification and referral of inmates
Per policy inmates are referred to local hospital or
X
with mental health needs;
county jail for treatment
2. Mental health treatment programs
X
provided by qualified staff, including the
use of teleheath.
X
3. Crisis intervention services;
4. Basic mental health services provided, as
X
clinically indicated;
5. Medication support services; and, X
6. The provision of health services
sufficiently coordinated such that care is
appropriately integrated, medical and
X
mental health needs are met, and the
impact of any of these conditions on each
other is adequately addressed.
(b) Unless the county has elected to implement Addressed in section 902.11.1 of department policy
the provisions of Penal Code Section 1369.1, a
manual
mentally disordered inmate who appears to
be a danger to himself or others, or to be
gravely disabled, shall be transferred for
further evaluation to a designated Lanterman
Petris Short treatment facility designated by
X
the county and approved by the State
Department of Mental Health for diagnosis
and treatment of such apparent mental
disorder pursuant to Penal Code section
4011.6 or 4011.8 unless the jail contains a
designated Lanterman Petris Short treatment
facility.
Prior to the transfer, the inmate may be No licensed health personnel on staff and no
treatment given in facility
evaluated by licensed health personnel to
determine if treatment can be initiated at the
correctional facility. Licensed health
X
personnel may perform an onsite assessment
to determine if the inmate meets the criteria
for admission to an inpatient facility, or if
treatment can be initiated in the correctional
facility.
6
ARTICLE/SECTIONYES NO N/A COMMENTS
(c) If the county elects to implement the
provisions of Penal Code Section 1369.1, the
health authority, in cooperation with the
facility administrator, shall establish policies
X
and procedures for involuntary
administration of medications. The
procedures shall include, but not be limited
to:
1. Designation of licensed personnel,
including psychiatrist and nursing staff,
X
authorized to order and administer
involuntary medication;
2. Designation of an appropriate setting
X
where the involuntary administration of
medication will occur;
3. Designation of restraint procedures
and/or devices that may be used to
X
maintain the safety of the inmate and
facility staff;
4. Development of a written plan to
monitor the inmate's medical condition
following the initial involuntary
administration of a medication, until the
inmate is cleared as a result of an
evaluation by, or consultation with, a
psychiatrist;
X
7
ARTICLE/SECTIONYES NO N/A COMMENTS
5. Development of a written plan to provide Addressed in section 900.3.1 of department policy
a minimum level of ongoing monitoring
manual directing referral of inmates requiring
of the inmate following return to facility
medication.
housing. This monitoring may be
performed by custody staff trained to
recognize signs of possible medical
problems and alert medical staff when
indicated; and
X
6. Documentation of the administration of
X
involuntary medication in the inmate's
medical record.
1212 Vermin Control
Addressed in section 902.15 of department policy
(Not applicable to CH)
manual
The responsible physician shall develop a written
X
plan for the control and treatment of vermin-
infested inmates. There shall be written, medical
protocols, signed by the responsible physician, for
the treatment of persons suspected of being
infested or having contact with a vermin-infested
inmate.
1213 Detoxification Treatment
Addressed in section 902.3.1 of department policy
(Not applicable to CH)
manual
The responsible physician shall develop written
medical policies on detoxification which shall include
X
a statement as to whether detoxification will be
provided within the facility or require transfer to a
licensed medical facility. The facility detoxification
protocol shall include procedures and symptoms
necessitating immediate transfer to a hospital or
other medical facility.
Facilities without medically licensed personnel in
Addressed in section 902.3.1 of department policy
attendance shall not retain inmates undergoing
manual
withdrawal reactions judged or defined in policy, by
X
the responsible physician, as not being readily
controllable with available medical treatment. Such
facilities shall arrange for immediate transfer to an
appropriate medical facility.
8
ARTICLE/SECTIONYES NO N/A COMMENTS
1220 First Aid Kits Addressed in section 900.5.3 of department policy
X
manual
First aid kit(s) shall be available in all facilities.
The responsible physician shall approve the Deficiency: Policy does not specify specific contents
contents, number, location and procedure for of first aid kits and there is no documentation
periodic inspection of the kit(s). In Court and supporting periodic inspection. Expired contents
Temporary Holding facilities, the facility were identified.
X
administrator shall have the above approval
Corrective Action: Update policy to list specific
authority, pursuant to Section 1200 of these
contents and locations of first aid kits. Establish
regulations.
policy and implement policy to regularly inspect first
aid kits for complete and current status of contents.
1046 Death in Custody
Addressed in section 900.9 and 900.11.2 of
(a) Death in Custody Reviews for Adults and
department policy manual
Minors.
The facility administrator, in cooperation with
the health administrator, shall develop written
policy and procedures to ensure that there is
X
an initial review of every in-custody death
within 30 days. The review team shall include
the facility administrator and/or the facility
manager, the health administrator, the
responsible physician and other health care
and supervision staff who are relevant to the
incident.
Deaths shall be reviewed to determine the
No Deaths occurred during inspection period
appropriateness of clinical care; whether
X
changes to policies, procedures, or practices
are warranted; and to identify issues that
require further study.
(b) Death of a Minor.
Addressed in section 323.7.4 and 323.13 of
In any case in which a minor dies while
X
department policy manual
detained in a jail, lockup, or court holding
facility:
(1) The administrator of the facility shall
provide to the Board a copy of the report
submitted to the Attorney General under
Government Code Section 12525. A copy
X
of the report shall be submitted within 10
calendar days after the death.
No in custody death of a minor occurred during
covered inspection period
(2) Upon receipt of a report of death of a
minor from the administrator, the Board
may within 30 calendar days inspect and
evaluate the jail, lockup, or court holding
X
facility pursuant to the provisions of this
subchapter. Any inquiry made by the
Board shall be limited to the standards
and requirements set forth in these
regulations.
9
ARTICLE/SECTIONYES NO N/A COMMENTS
1051 Communicable Diseases
Addressed in section 902.11.1 of department policy
The facility administrator, in cooperation with the
manual
responsible physician, shall develop written policies
X
and procedures specifying those symptoms that
require segregation of an inmate until a medical
evaluation is completed.
At the time of intake into the facility, an inquiry shall
be made of the person being booked as to whether or
not he/she has or has had any communicable
X
diseases, such as tuberculosis or has observable
symptoms of tuberculosis or any other communicable
diseases, or other special medical problem identified
by the health authority.
The response shall be noted on the booking form
X
and/or screening device.
1052 Mentally Disordered Inmates
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
and procedures to identify and evaluate all mentally
disordered inmates, and may include telehealth. If an
X
evaluation from medical or mental health staff is not
readily available, an inmate shall be considered
mentally disordered for the purpose of this section if
he or she appears to be a danger to himself/herself or
others or if he/she appears gravely disabled.
An evaluation from medical or mental health staff
Inmates are transferred for medical or mental
shall be secured within 24 hours of identification or
health care
X
at the next daily sick call, whichever is earliest.
Segregation may be used if necessary to protect the
safety of the inmateor others.
1055 Use of Safety Cell
Safety cell is not in place, inmates requiring safety
The safety cell described in Title 24, Part 2, Section
cell are not retained in facility
1231.2.5, shall be used to hold only those inmates
X
who display behavior which results in the
destruction of property or reveals an intent to cause
physical harm to self or others
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
and procedures governing safety cell use and may X
delegate authority to place an inmate in a safety cell
to a physician.
In no case shall the safety cell be used for
X
punishment or as a substitute for treatment.
An inmate shall be placed in a safety cell only with
the approval of the facility manager or designee, or
X
responsible health care staff; continued retention
shall be reviewed a minimum of every four hours.
10
ARTICLE/SECTIONYES NO N/A COMMENTS
A medical assessment shall be completed within a
maximum of 12 hours of placement in the safety cell
or at the next daily sick call, whichever is earliest. X
The inmate shall be medically cleared for continued
retention every 24 hours thereafter.
The facility manager, designee or responsible health
care staff shall obtain a mental health
opinion/consultation with responsible health care X
staff on placement and retention, which shall be
secured within 12 hours of placement.
Direct visual observation shallbe conducted at least
twice every thirty minutes. Such observation shall be X
documented.
Procedures shall be established to assure
administration of necessary nutrition and fluids.
Inmates shall be allowed to retain sufficient clothing,
or be provided with a suitably designed “safety
X
garment,” to provide for their personal privacy
unless specific identifiable risks to the inmate's
safety or to the security of the facility are
documented.
1056 Use of Sobering Cell
Sobering cell not in place. Inmates requiring
The sobering cell described in Title 24, Part 2,
sobering are not retained in facility per policy
Section 1231.2.4, shall be used for the holding of
inmates who are a threat to their own safety or the
safety of others due to their state of intoxication and
pursuant to written policies and procedures
developed by the facility administrator. Such
inmates shall be removed from the sobering cell as
X
they are able to continue in the processing. In no
case shall an inmate remain in a sobering cell over
six hours without an evaluation by a medical staff
person or an evaluation by custody staff, pursuant
to written medical procedures in accordance with
section 1213 of these regulations, to determine
whether the prisoner has an urgent medical
problem.
At 12 hours from the time of placement, all inmates
will receive an evaluation by responsible health care
staff. Intermittent direct visual observation of X
inmates held in the sobering cell shall be conducted
no less than every half hour.
Such observation shall be documented.
11
ARTICLE/SECTIONYES NO N/A COMMENTS
1057 Developmentally Disabled Inmates
Addressed in section 902.11.1 of department policy
The facility administrator, in cooperation with the
manual
responsible physician, shall develop written policies
X
and procedures for the identification and evaluation,
appropriate classification and housing, protection,
and nondiscrimination of all developmentally
disabled inmates.
The health authority or designee shall contact the
Inmates identified as potentially developmentally
regional center on any inmate suspected or confirmed
disabled are not retained in facility
to be developmentally disabled for the purposes of
X
diagnosis and/or treatment within 24 hours of such
determination, excluding holidays and weekends.
1058 Use of Restraint Devices Addressed in section 900.6 of department policy
manual
The facility administrator, in cooperation with the
X
responsible physician, shall develop written policies
and procedures for the use of restraint devices and
may delegate authority to place an inmate in
restraints to a responsible health care staff.
In addition to the areas specifically outlined in this
Addressed in section 306.3 of department policy
regulation, at a minimum, the policy shall address the
manual
following areas:
acceptable restraint devices;
signs or symptoms which should result in
immediate medical/mental health referral;
X
availability of cardiopulmonary
resuscitation equipment;
protective housing of restrained persons;
provision for hydration and sanitation
needs; and
exercising of extremities.
In no case shall restraints be used for punishment or Addressed in section 306.2 of department policy
X
as a substitute for treatment. manual
Restraint devices shall only be used on inmates who
Addressed in section 306.3 of department policy
display behavior which results in the destruction of
manual
property or reveal an intent to cause physical harm to
X
self or others. Restraint devices include any devices
which immobilize an inmate's extremities and/or
prevent the inmate from being ambulatory.
Physical restraints should be utilized only when it
appears less restrictive alternatives would be X
ineffective in controlling the disordered behavior.
Inmates shall be placed in restraints only with the
approval of the facility manager, the facility watch
commander, responsible health care staff; X
continued retention shall be reviewed a minimum of
every hour.
A medical opinion on placement and retention shall Since no licensed medical personnel are on staff,
be secured within one hour from the time of inmates are not retained in facility if restraints are
X
required.
placement. A medical assessment shall be
completed within four hours of placement.
12
ARTICLE/SECTIONYES NO N/A COMMENTS
If the facility manager, or designee, in consultation
with responsible health care staff determines that
an inmate cannot be safely removed from restraints X
after eight hours, the inmate shall be taken to a
medical facility for further evaluation.
Direct visual observation shall be conducted at least
twice every thirty minutes toensure that the
restraints are properly employed, and to ensure the X
safety and well-being of the inmate. Such
observation shall be documented.
While in restraint devices all inmates shall behoused
alone or in a specified housing area for restrained
X
inmates which makes provisions to protect the
inmate from abuse.
The provisions of this section do not apply to the use
X
of handcuffs, shackles or other restraint devices
when used to restrain inmates for security reasons.
1058.5 RESTRAINTS AND PREGNANT INMATES Addressed in section 306.3.2 of department policy
manual
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures for the use of restraint devices on
pregnant inmates. In accordance with Penal Code
3407 the policy shall include reference to the
following:
(1) An inmate known to be pregnant or in
recovery after delivery shall not be
X
restrained by the use of leg irons, waist
chains, or handcuffs behindthe body.
(2) A pregnant inmate in labor, during
delivery, or in recovery after delivery,
shall not be restrained by the wrists,
X
ankles, or both, unless deemed necessary
for the safety and security of the inmate,
the staff, or the public.
(3) Restraints shall be removed when a No licensed medical personnel on staff. Pregnant
professional who is currently responsible
inmates are transferred if in need of medical care
for the medical care of a pregnant inmate
and treatment.
X
during a medical emergency, labor,
delivery, or recovery after delivery
determines that the removal of restraints
is medically necessary.
(4) Upon confirmation of an inmate's
pregnancy, she shall be advised, orally or
X
in writing, of the standards and policies
governing pregnant inmates.
13
Itemized Summary
III. Medical/Mental Health Evaluation
Police Department – City of Chico
Page 5
Deficiency: Training of facility staff is lacking.
Corrective Action: Training program is in development per Lt Struthers. Recommend acceleration and implementation of training
program.
Page 9
Deficiency: Policy does not specify specific contents of first aid kits and there is no documentation supporting periodic inspection.
Expired contents were identified.
Corrective Action: Update policy to list specific contents and locations of first aid kits. Establish policy and implement policy to
regularly inspect first aid kits for complete and current status of contents.
Commendation: Facility has an Automatic External Defibrillator (AED) in place. This is noted as best practice.
Best Practice: AED should be included in the first aid inspection policy to ensure it us operational. Narcan should be
available in the facility should drug overdose occur.
Staff were open and collaborative in the inspection process. Generally, facilities complies with letter and intent of
requirements.
14
I. ENVIRONMENTAL HEALTH EVALUATION
Juvenile Halls, Special Purpose Juvenile Halls and Camps
FACILITY NAME: COUNTY:
Butte County Juvenile Hall Butte
FACILITY ADDRESS (STREET, CITY, ZIP CODE, TELEPHONE):
41 County Center Dr. Oroville, CA 95965, (530) 538-7311
CHECK THE FACILITY TYPE AS DEFINED IN JUVENILE HALLCAMP
TITLE 15, SECTION 1302:
DATE EVALUATED:
ENVIRONMENTAL HEALTH EVALUATION
DEFICIENCIES OR NON COMPLIANCE ISSUES NOTED:
YES NO
ENVIRONMENTAL EVALUATOR(S) (NAME, TITLE, TELEPHONE):
Alana Kong, Registered Environmental Health Specialist II, (530) 552-3998
Leslie Roberts, Senior Registered Environmental Health Specialist, (530) 552-3872
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Mariah Ruddy, Administration Supervisor, (530) 538-4389
JUV HEALTH ENVIRONMENT PAGE 1 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
I. ENVIRONMENTAL HEALTH EVALUATION
Juvenile Halls, Special Purpose Juvenile Halls and Camps
ARTICLE/SECTION YESNO N/ACOMMENTS
Article 9. Food
1464 Food Services Plan
Deficiency: Item (n) The Hazard Analysis Critical
Control Point Plan is out of date and was written
by previous Food Services Manager.
Facilities shall have a written site specific food
Corrective Action: The current Food Services
service plan that shall comply with the applicable
Manager is working to write a new HACCP plan for
California Retail Food Code (CalCode). In facilities
facility and using the California Retail Food Code.
with an average daily population of 50 or more,
there shall be employed or available, a trained and
experienced food services manager or designee to
complete a written food service plan. In facilities of
less than an average daily population of 50, that do
not employ or have a food services manager
available, the facility manager shall complete a
written food service plan.
The plan shall include, but not be limited to the
following policies and procedures:
(a) menu planning;
(b) purchasing;
No
(c) storage and inventory control;
(d) food preparation;
(e) food serving;
(f) transporting food;
(g) orientation and on-going training;
(h) personnel supervision;
(i) budgets and food costs accounting;
(j) documentation and record keeping;
(k) emergency feeding plan;
(l) waste management;
(m) maintenance and repair;
(n) hazard analysis critical control point plan; and,
(o) provision for maintaining three days of meals
for testing in the event of food-borne illness.
JUV HEALTH ENVIRONMENT PAGE 2 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/ACOMMENTS
1465 Food Handlers Education and Monitoring
The facility manager, in cooperation with the food
services manager, shall develop and implement
written policies and procedures to ensure that
supervisory staff and food handlers receive ongoing
x
training in safe food handling techniques, including
personal hygiene, in accordance with Section
113947 of the Health and Safety Code, California
Retail Food Code (CalCode). The procedures shall
include provisions for monitoring compliance that
ensure appropriate food handling and personal
hygiene requirements.
1466 Kitchen Facilities, Sanitation, and Food At this time no guidance has been received to
Storage waive any sections of California Retail Food Code.
Kitchen facilities, sanitation, and food preparation,
service, and storage shall comply with standards set
forth in Health and Safety Code, Division 104, Part 7,
Chapters 1-13, Sections 113700 et seq. California
Retail Food Code (CalCode). x
In facilities where youth prepare meals for self-
consumption or where frozen meals or pre-prepared
food from other permitted food facilities (see Health
and Safety Code Section 114381) are (re)heated and
served, the following applicable CalCode standards
may be waived by the local health officer:
(a) Health and Safety Code Sections 114130-
114141;
(b) Health and Safety Code Sections 114099.6,
114095-114099.5, 114101-114109, 114123, and
114125. If a domestic or commercial
dishwasher, capable of providing heat to the
surface of the utensils of a temperature of at
least 165 degrees Fahrenheit, is used for the
purpose of cleaning and sanitizing multi-service
kitchen utensils and multi-service consumer
utensils;
(c) Health and Safety Code Sections 114149-
114149.3 except that, regardless of such a
waiver, the facility shall provide mechanical
ventilation sufficient to remove gases, odors,
steam, heat, grease, vapors and smoke from the
kitchen;
JUV HEALTH ENVIRONMENT PAGE 3 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/ACOMMENTS
(d) Health and Safety Code Sections 114268-
114269; and,
(e) Health and Safety Code Sections 114279-
114282.
1467 Food Serving and Supervision
Policies and site-specific procedures shall be
x
developed and implemented to ensure that
appropriate work assignments are made and food
handlers are adequately supervised. Food shall be
prepared and/or served only under the immediate
supervision of a staff member.
Article 10. Clothing and Personal Hygiene
1480 Standard Facility Clothing Issue
The youth's personal clothing, undergarments and
x
footwear may be substituted for the institutional
clothing and footwear specified in this regulation.
The facility has the primary responsibility to provide
clothing and footwear.
Clothing provisions shall ensure that:
(a) clothing is clean, reasonably fitted, durable,
x
easily laundered, in good repair, and free of
holes and tears.
(b) The standard issue of climatically suitable
clothing for youth shall consist of but not be
limited to:
(1) socks and serviceable footwear;
(2) outer garments;
x
(3) new non-disposable underwear which
shall remain with the youth throughout
their stay, and;
(4) undergarments, that are freshly
laundered and free of stains, including tee
shirts and bras.
(c) clothing is laundered at the temperature
required by local ordinances for commercial
x
laundries and dried completely in a mechanical
dryer or other laundry method approved by the
local health officer.
(d) suitable clothing is issued to pregnant
x
youth.
JUV HEALTH ENVIRONMENT PAGE 4 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/ACOMMENTS
1481 Special Clothing
x
Provision shall be made to issue suitable additional
clothing essential for minors to perform special work
assignments where the issue of regular clothing
would be unsanitary or inappropriate.
1482 Clothing Exchange 807.6
x
The facility administrator shall develop and
implement written policies and site-specific
procedures for the cleaning and scheduled exchange
of clothing.
Unless work, climatic conditions, or illness
necessitates more frequent exchange, outer
x
garments, except footwear, shall be exchanged at
least once each week.
Tee shirts, bras, and underwear shall be exchanged
daily; youth shall receive their own underwear back x
at exchange.
1483 Clothing, Bedding and Linen Supply 807.5
There shall be a quantity of clothing, bedding, and
linen available for actual and replacement needs of
the facility population. Each facility shall have a
written procedure for acquisition, handling, storage,
x
transportation and processing of clothing, bedding
and linen in a clean and sanitary manner.
Consideration shall be given to mattress type for
pregnant youth or youth with other medical-related
needs.
804
1484 Control of Vermin in Minors’ Personal
Clothing
x
There shall be written policies and site-specific
procedures developed and implemented by the
facility administrator to control the contamination
and/or spread of vermin and ecto-parasites in all
youths' personal clothing.
JUV HEALTH ENVIRONMENT PAGE 5 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/ACOMMENTS
Infested clothing shall be cleaned or stored in a
closed container so as to eradicate or stop the x
spread of the vermin.
1485 Issue of Personal Care Items 807.9
x
There shall be written policies and site-specific
procedures developed and implemented by the
facility administrator for the availability of personal
hygiene items.
Each female youth shall be provided with sanitary
x
napkins, panty liners and tampons as requested.
Each youth to be held over 24 hours shall be
x
provided with the following personal care items:
(a) toothbrush; x
(b) toothpaste; x
(c) soap; x
(d) comb; x
(e) shaving implements; x
(f) deodorant; x
(g) lotion; x
(h) shampoo; and, x
(i) post-shower conditioning hair products.
x
Youth shall not be required to share any personal No personal care items shared
care items listed in items (a) through (d). Liquid soap
provided through a common dispenser is permitted.
Youth shall not share disposable razors. Double
edged safety razors, electric razors, and other
x
shaving instruments capable of breaking the skin,
when shared among youth, shall be disinfected
between individual uses by the method prescribed
by the State Board of Barbering and Cosmetology in
Sections 979 and 980, Chapter 9, Title 16, California
Code of Regulations.
1486 Personal Hygiene 807.12
x
There shall be written policies and site-specific
procedures developed and implemented by the
facility administrator for showering/bathing and
brushing of teeth.
JUV HEALTH ENVIRONMENT PAGE 6 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/ACOMMENTS
Youth shall be permitted to shower/bathe upon
assignment to a housing unit and on a daily basis
x
thereafter and given an opportunity to brush their
teeth after each meal.
1487 Shaving
x
Youth shall have access to a razor daily, unless their
appearance must be maintained for reasons of
identification in Court.
All youth shall have equal opportunity to shave face
and body hair. The facility administrator may
suspend this requirement in relation to youth who
x
are considered to be a danger to themselves or
others.
1488 Hair Care Services 807.10
Written policies and site-specific procedures shall be
developed and implemented by the facility
x
administrator to comply with Title 16, Chapter 9,
Sections 979 and 980, California Code of
Regulations. Hair care services shall be available in
all juvenile facilities. Youth shall receive hair care
services monthly.
Equipment shall be cleaned and disinfected after
each haircut or procedure, by a method approved by x
the State Board of Barbering and Cosmetology.
Article 11. Bedding and Linens
1500 Standard Bedding and Linen Issue
Clean laundered, suitable bedding and linens, in
x
good repair, shall be provided for each youth
entering a living area who is expected to remain
overnight, shall include, but not be limited to:
a) one mattress or mattress-pillow combinationMattress-pillow combination
x
which meets the requirements of Section 1502
of these regulations;
(b) one pillow and a pillow case unless provided Extra pillows are available for purchase
x
for in (a) above;
(c) one mattress cover and a sheet or two
x
sheets;
(d) one towel; and, x
JUV HEALTH ENVIRONMENT PAGE 7 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/ACOMMENTS
(e) one blanket or more, upon request. x
1501 Bedding and Linen Exchange 807.7
x
The facility administrator shall develop and
implement site specific written policies and
procedures for the scheduled exchange of laundered
bedding and linen issued to each youth housed.
Washable items such as sheets, mattress covers,
x
pillow cases and towels shall be exchanged for clean
replacement at least once each week.
The covering blanket shall be cleaned or laundered
x
once a month.
1502 Mattresses
x
Any mattress issued to a youth in any facility shall
conform to the size of the bed as referenced in Title
24, Section 1230.2.5 and be enclosed in an easily
cleaned, non-absorbent ticking.
Any mattress purchased for issue to a youth in a
facility, which is locked to prevent unimpeded access
to the outdoors, shall be certified by the
x
manufacturer as meeting all requirements of the
State Fire Marshal and Bureau of Home Furnishings
test standard for penal mattresses at the time of
purchase.
Article 12. Facility Sanitation and Safety
1510 Facility Sanitation, Safety and Maintenance
800-802 - Sanitation / maintenance
806 – Youth safety
The facility administrator shall develop and
Inmates are responsible to keep their own rooms
x
implement written policies and site-specific
clean. Staff have daily janitorial checklist for
procedures for the maintenance of an acceptable
facility.
level of cleanliness, repair and safety throughout the
facility.
JUV HEALTH ENVIRONMENT PAGE 8 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/ACOMMENTS
The plan shall provide for a regular schedule of Deficiency- holding cell 3, intake shower room,
housekeeping tasks, equipment, including restraint rooms E12 and F1-F8 have no hot water at the
devices, and physical plant maintenance and hand washing sinks
inspections to identify and correct unsanitary or
Corrective action – provide hot water
unsafe conditions or work practices in a timely
manner.
Deficiency – hot water button at hand wash sinks
x
in rooms E3, E13, and F11 are not working
Corrective action – repair
Deficiency – light is out in room E12
Corrective action – repair
The use of chemicals shall be done in accordance to
the product label and Safety Data Sheet which may
x
include the use of Personal Protection Equipment
(PPE).
Medical care housing as described in Title 24,
Section 13-201(c)6 shall be cleaned and sanitized
x
according to policies and procedures as established
by the health administrator.
1511 Smoke Free Environment 1211.1-1211.4
The facility administrator shall develop policies and
x
procedures that assure youth are not exposed to use
of tobacco products or electronic nicotine delivery
system devices while in the facility or in the custody
of staff.
JUV HEALTH ENVIRONMENT PAGE 9 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
Itemized Summary
I. Environmental Health Evaluation
Juvenile Halls, Special Purpose Juvenile Halls and Camps
Page 2
Deficiency - Item (n) The Hazard Analysis Critical Control Point Plan is out of date and was written by previous Food Services
Manager.
Corrective Action - The current Food Services Manager is working to write a new HACCP plan for facility and using the California
Retail Food Code
Page 9
Deficiency-holding cell 3, intake shower room, rooms E12 and F1-F8 have no hot water at the hand washing sinks
Corrective action – provide hot water
Deficiency – hot water button at hand wash sinks in rooms E3, E13, and F11 are not working
Corrective action – repair
Deficiency – light is out in room E12
Corrective action – repair
Summary of environmental health evaluation: Deficiencies were found throughout rooms for plumbing fixtures and
lighting that need to be addressed. Rooms D1-16 and Condor Pod were not being occupied. Suggested best practices:
Prior to rooms being occupied check for hot water, plumbing, and lighting to ensure it’s in good working condition. This
facility has required policies and procedures in place.
Summary of environmental health inspection: Raw shell eggs being used for juveniles. If former HACCP plan for using
raw shell eggs in meals is not found create one or cease using raw shell eggs.
JUV HEALTH ENVIRONMENT PAGE 10 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
II. NUTRITIONAL HEALTH EVALUATION
Juvenile Halls, Special Purpose Juvenile Halls and Camps
FACILITY NAME: COUNTY:
Butte County Juvenile Hall Butte
FACILITY ADDRESS (STREET, CITY, ZIP CODE, TELEPHONE):
41 County Center Dr. Oroville, CA 95965, (530) 538-7311
CHECK THE FACILITY TYPE AS DEFINED IN JUVENILE HALLCAMP
TITLE 15, SECTION 1302:
DATE EVALUATED:
JUVENILE FACILITY NUTRITIONAL HEALTH REVIEW AND EVALUATION
DEFICIENCIES OR NON COMPLIANCE ISSUES NOTED:
YES NO
NUTRITIONALEVALUATOR(S) (NAME, TITLE, TELEPHONE):
Amber McPherson, Registered Dietitian, 530-552-3917
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Patricia Norton, Food Services manager 530-538-6369
JUV HEALTH ENVIRONMENT PAGE 11 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
II. NUTRITIONAL HEALTH EVALUATION
ARTICLE/SECTION YESNON/A COMMENTS
Article 9. Food
1460 Frequency of Serving 3 meals per day and 1 snack
Meals shall be served at least three times in any 24-
X
hour period.
Hot food served at most meals
At least one of these meals shall include hot food.
Food shall be offered to youth at the time of initial
intake, shall be served to youth if more than 14
X
hours pass between meals, and shall be served to
youth on medical diets as prescribed by the
attending physician.
Snack provided q night
A snack shall be provided to all youth between 2 to 4
X
hours after the dinner meal is served.
A minimum of twenty minutes shall be allowed for
the actual consumption of each meal except for
X
those youth on medical diets where the responsible
physician has prescribed additional time.
Provisions shall be made for youth who may miss a
X
regularly scheduled facility meal.
They shall be provided with a substitute meal and
beverage, and youth on medical diets shall be X
provided with their prescribed meal.
1461 Minimum Diet
Per RD analysis on 9/28/21, rotating menus meet
Title 15 standards & meet USDA standards for
Facility meals are based on nutritional standards
breakfast and lunch
which may include the Federal Child Nutrition Meal
Program. The minimum diet provided shall be based
upon the nutritional and caloric requirements found
X
in the 2011 Dietary Reference Intakes (DRI) of the
Food and Nutrition Board, Institute of Medicine of
the National Academies; the 2008 California Food
Guide, and the 2015-2020 Dietary Guidelines for
Americans.
Facilities shall have a written process for how Deficiency: No written process for how vegetarian
vegetarian or vegan diets may be requested and or vegan diets may be requested, granted or
denied.
granted or denied. Religious diets, and when
X
provided, vegetarian or vegan diets, must conform
Corrective Action: Write process for how
to these nutrition standards.
vegetarian or vegan diets may be requested,
granted or denied.
The nutritional requirements for the minimum diet
are specified in the following subsections. Snacks
X
may be included as part of the minimum diet. A
wide variety of foods should be served.
JUV HEALTH ENVIRONMENT PAGE 12 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNON/A COMMENTS
(a) Protein Group. Includes: beef, veal, lamb,
pork, poultry, fish, eggs, cooked dry beans,
Per RD analysis on 9/28/21, 30-35 g protein served
peas, lentils, nuts, peanut butter, and textured
vegetable protein (TVP). One serving equals
qd (~210 g q week)
14 grams or more of protein; the daily
requirements shall equal two servings (a total
X
of 196 grams per week). In addition, there
shall be a requirement to serve a third serving
from the legumes three days a week, and/or
three servings from another protein group.
One serving equals, but is not limited to, one
of the following examples:
2 to 3 oz. (without bone) lean, cooked meat,
poultry or fish
2 medium eggs
1 cup cooked dry beans, peas, or lentils
4 Tbsp. peanut butter
8 oz. tofu
2 1/4 oz. dry, or 1 cup rehydrated, canned, or
frozen TVP
1/2 cup seeds
2/3 cup nuts
(b) Dairy Group. Includes milk (fluid, evaporated
or dry; nonfat; 1% or 2% reduced fat, etc.);
cheese (cottage, cheddar, etc.); yogurt; ice
X
cream or ice milk, and pudding. A serving is
equivalent to 8 oz. of fluid milk and provides
at least 250 mg of calcium.
All milk shall be pasteurized and fortified with 1% pasteurized & fortified milk serves breakfast,
vitamins A and D. For persons 9-18 years of lunch, dinner and snack
X
age, including pregnant and lactating women,
the daily requirement is four servings.
One serving equals, but is not limited to, one
X
of the following examples:
JUV HEALTH ENVIRONMENT PAGE 13 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNON/A COMMENTS
8 oz. fluid milk (nonfat, 1% or 2% reduced fat)
1 1/2 oz. natural cheese
2 oz. processed cheese
1 1/2 cups of low fat, or nonfat cottage
cheese
X
1 1/2 cups of ice milk,or ice cream
1/3 cup nonfat dry milk
1/2 cup nonfat, or low-fat evaporatedmilk
1 cup nonfat, or low fat plain yogurt
1 cup pudding
(c)Vegetable-Fruit Group. Includes: fresh, Fruit or vegetable serve q lunch and dinner, fruit
frozen, dried, and canned vegetables and
served q breakfast
fruits. One serving equals: 1/2 cup vegetable
X
or fruit; 6 oz. of 100% juice; 1 medium apple,
orange, banana, or potato; 1/2 grapefruit, or
1/4 cup dried fruit.
The daily requirement shall be at least six Six: 2 at dinner, 2 at lunch, 1 at breakfast & 1 @
servings; at least one serving per day, or snack
X
seven (7) servings per week, shall be from
each of the following three categories:
(1) One serving of a fresh fruit or vegetable. X
Vitamin C juice
(2) One serving of a Vitamin C source
containing 30 mg. or more. One serving
X
equals, but is not limited to the foods
described in the regulation.
(3) One serving of a Vitamin A source fruit or Carrots on menu frequently. If not already on
vegetable containing 200 micrograms
menu recommend adding other Vitamin A rich
X
Retinol Equivalents (RE) or more. One
sources like cantaloupe, sweet potatoes, winter
serving equals, but is not limited to the
squash, apricots, spinach, kale or collard greens
foods described in the regulation.
(d) Grain Group. Includes: bread, rolls, pancakes,
sweet rolls, ready-to-eat, or cooked cereals,
corn bread, pasta, rice, tortillas, etc., and any
food item containing whole or enriched
grains. At least four (4) servings from this
X
group must be made with some whole grains.
The daily requirement for youth shall be a
minimum of six (6) servings, or 42 servings
per week. One serving equals, but is not
limited to the foods described in the
regulation.
JUV HEALTH ENVIRONMENT PAGE 14 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNON/A COMMENTS
(e) Calories. Recommended daily caloric
allowancesfor both females and males is a
minimum of 2500calories not to exceed
X
3000. Calorie increases withthe exception of
a medical diet may occur as collaboratively
determined by the facility manager, dietitian,
food service manager and physician.
(1) Pregnant youth shall be provided with a
diet as approved by a doctor in
X
accordance with Penal Code Section
6030(e) and a supplemental snack, if
medically indicated.
(2) In keeping with chronic disease
prevention goals, total dietary saturated
fat shall not exceed 10 percent of total
calories on a weekly basis. Facility
dietitians shall consider the
X
recommendations and intent of the
2015-2020 Dietary Guidelines of
Americans of reducing overall added
sugar and sodium levels. Herbs and
spices may be used to improve the taste
and eye appeal of food served.
1462 Medical Diets Nursing communicates with dietary
X
Only the attending physician shall prescribe a
medical diet.
The medical diets utilized by a facility shall be Deficiency: Medical diets are not planned,
prepared or served with consultation of an RD.
planned, prepared, and served with the consultation
X
of a registered dietitian.
Corrective Action: Have RD plan and prepare
medical diet manual for use by facility.
The facility manager shall comply with any medical
X
diet prescribed for a youth.
Diet orders shall be maintained on file for at least
X
one year.
Deficiency: Medical diet manual not available.
The facility manager and responsible physician shall
ensure that the medical diet manual, with sample
Corrective Action: Medical diet manual will be
menus for medical diets, shall be available in both X
available in both the medical unit and the food
the medical unit and the food service office for
service office.
reference and information.
A registered dietitian shall review, and the Deficiency: Medical diet manual not available or
approved.
responsible physician shall approve the diet manual
on an annual basis.
X
Corrective Action: Medical diet manual will be
approved on an annual basis by the RD and
responsible physician.
JUV HEALTH ENVIRONMENT PAGE 15 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNON/A COMMENTS
1463 Menus
Menus shall be planned at least one month in
advance of their use. Menus shall be planned to
X
provide a variety of foods considering the cultural
and ethnic makeup of the facility, thus, preventing
repetitive meals.
Menus shall be approved by a registered dietitian
X
before being used.
If any meal served varies from the planned menu, Substitution log kept on file.
X
the change shall be noted in writing on the menu
and/or production worksheet.
Deficiency: Substitutions are not evaluated by RD.
Menus, as planned and including changes, shall be
retained for one year and evaluated by a registered
Corrective Action: Have RD evaluate substitution
X
dietitian at least annually.
logs to provide feedback on appropriate
substitutions.
1464 Food Service Plan
Facilities shall have a written site-specific food Foodservice plan from 2014, recommended
service plan that shall comply with the applicable reviewing and updating.
California Retail Food Code (CalCode). In facilities
with an average daily population of 50 or more,
there shall be employed or available, a trained and
experienced food services manager or designee to
complete a written food service plan. In facilities of
X
less than an average daily population of 50, that do
not employ or have a food services manager
available, the facility manager shall complete a
written food service plan.
The plan shall include, but not be limited to the
following policies and procedures:
(a)menu planning; X
(b) purchasing; X
(c)storage and inventory control;X
(d) food preparation;X
(e) food serving; X
(f) transporting food; X
(g)orientation and on-going training; X
(h) personnel supervision; X
(i) budgets and food costs accounting; X
(j) documentation and record keeping; X
(k) emergency feeding plan; X
(l) waste management; and, X
(m) maintenance and repair. X
JUV HEALTH ENVIRONMENT PAGE 16 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNON/A COMMENTS
(n) hazard analysis critical control point plan;
Old HACCP plan on file and staff not trained on
and,
X procedures. Recommend updating HACCP plan
and training all staff
Deficiency: No provision for maintaining 3 days of
(o) provision for maintaining three days of meals
meals for testing in the event of food-borne
for testing in the event of food-borne illness.
illness.
X
Corrective Action: Create provision for
maintaining 3 days of meals for testing.
1465 Food Handlers Education and Monitoring
Policy and procedure manual in useand ongoing
The facility manager, in cooperation with the food
training provided
services manager, shall develop and implement
written policies and procedures to ensure that
supervisory staff and food handlers receive ongoing
training in safe food handling techniques, including
personal hygiene, in accordance with Section
113947 of the Health and Safety Code, California
Retail Food Code (CalCode). The procedures shall
include provisions for monitoring compliance that
ensure appropriate food handling and personal
hygiene requirements.
All staff certified in food service
1466 Kitchen Facilities, Sanitation, and Food
Storage
Kitchen facilities, sanitation, and food preparation,
service, and storage shall comply with standards set
forth in Health and Safety Code, Division 104, Part 7,
Chapters 1-13, Sections 113700 et seq. California
Retail Food Code (CalCode).
In facilities where youth prepare meals for self-
consumption or where frozen meals or pre-prepared
food from other permitted food facilities (see Health
and Safety Code Section 114381) are (re)heated and
served, the following applicable CalCode standards
may be waived by the local health officer:
(a)Health and Safety Code Sections 114130-
114141;
(b) Health and Safety Code Sections 114099.6,
114095-114099.5, 114101-114109, 114123,
and 114125. If a domestic or commercial
dishwasher, capable of providing heat to the
surface of the utensils of a temperature of at
least 165 degrees Fahrenheit, is used for the
purpose of cleaning and sanitizing multi-
service kitchen utensils and multi-service
consumer utensils;
JUV HEALTH ENVIRONMENT PAGE 17 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNON/A COMMENTS
(c)Health and Safety Code Sections 114149-
114149.3 except that, regardless of such a
waiver, the facility shall provide mechanical
ventilation sufficient to remove gases, odors,
steam, heat, grease, vapors and smoke from
the kitchen;
(d) Health and Safety Code Sections 114268-
114269; and,
(e) Health and Safety Code Sections 114279-
114282.
1467 Food Serving and Supervision
Policies and site-specific procedures shall be
X
developed and implemented to ensure that
appropriate work assignments are made and food
handlers are adequately supervised. Food shall be
prepared and/or served only under the immediate
supervision of a staff member.
JUV HEALTH ENVIRONMENT PAGE 18 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
Itemized Summary
II. Nutritional Health Evaluation
Juvenile Halls, Special Purpose Juvenile Halls and Camps
Page 12
Deficiency - No written process for how vegetarian or vegan diets may be requested, granted or denied.
Corrective Action - Write process for how vegetarian or vegan diets may be requested, granted or denied.
Page 14
Carrots on menu frequently. If not already on menu recommend adding other Vitamin A rich sources like cantaloupe,
sweet potatoes, winter squash, apricots, spinach, kale or collard greens.
Page 15
Deficiency - Medical diets are not planned, prepared or served with consultation of an RD.
Corrective Action - Have RD plan and prepare medical diet manual for use by facility.
Deficiency - Medical diet manual not available.
Corrective Action - Medical diet manual will be available in both the medical unit and the food service office.
Deficiency - Medical diet manual not available or approved.
Corrective Action - Medical diet manual will be approved on an annual basis by the RD and responsible physician
Page 16
Deficiency - Substitutions are not evaluated by RD.
Corrective Action - Have RD evaluate substitution logs to provide feedback on appropriate substitutions.
Foodservice plan from 2014, recommended reviewing and updating.
Page 17
Old HACCP plan on file and staff not trained on procedures. Recommend updating HACCP plan and training all staff
Deficiency - No provision for maintaining 3 days of meals for testing in the event of food-borne illness.
Corrective Action - Create provision for maintaining 3 days of meals for testing.
Menus and frequency of serving meet the nutritional requirements based on nutritional standards which include the
Federal Child Nutrition Meal Program. Menus are planned well in advance and provide a variety of foods considering the
cultural and ethnic makeup of the facility. Kitchen staff receive ongoing training in safe food handling techniques.
Deficiencies were found include lack of medical diet manual, planning of vegetarian or vegan diets, proper review of
substitutions by Registered Dietitian and provision to maintaining 3 days of meals for testing
JUV HEALTH ENVIRONMENT PAGE 19 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
III. MEDICAL/MENTAL HEALTH EVALUATION
Juvenile Halls, Special Purpose Juvenile Halls and Camps
FACILITY NAME: COUNTY:
Butte County Juvenile Hall Butte
FACILITY ADDRESS (STREET, CITY, ZIP CODE, TELEPHONE):
41 County Center Drive, Oroville, CA 95965 530-538-7311
CHECK THE FACILITY TYPE AS DEFINED IN JUVENILE HALLCAMP
TITLE 15, SECTION 1302: X
DATE EVALUATED:
MEDICAL/MENTAL HEALTH EVALUATION
DEFICIENCIES OR NON COMPLIANCE ISSUES NOTED:
YES NO
MEDICAL/MENTAL EVALUATOR(S) (NAME, TITLE, TELEPHONE):
David Canton, DO, MPH, JD, Interim Health Officer, Butte County Public Health 530-552-3993
Monica Soderstrom, RN, PHN, Division Director, Community Health, Butte County Public Health (530) 552-3930
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Tarah Foster, Health Services Administrator, Wellpath 530-538-6863
Lauren Tuft, RN (530) 538-6381
Mariah Ruddy, Juvenile Hall Administrator, (530) 552-4461
JUV HEALTH ENVIRONMENT PAGE 20 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
III. MEDICAL/MENTAL HEALTH EVALUATION
Juvenile Halls, Special Purpose Juvenile Halls and Camps
ARTICLE/SECTION YESNO N/A COMMENTS
Article 8. Health Services
1400 Responsibility for Health Care Services Addressed in Wellpath policy HCD 210 Y A-01
X
The facility administrator shall ensure that health
care services are provided to all youth.
The facility shall have a designated health
administrator who, in cooperation with the
behavioral/mental health director and facility
administrator and pursuant to a written agreement,
contract or job description, is administratively
responsible to:
(a)develop policy for health care
X
administration;
(b) identify health care providers for the
X
definedscope of services;
(c)establish written agreements as necessary
X
to provide access to health care;
(d) develop mechanisms to assure that those
X
agreements are properly monitored; and,
(e)establish systems for coordination among
X
health care service providers.
When the health administrator is not a physician,
there shall be a designated responsible physician
X
who shall develop policy in health care matters
involving clinical judgments.
1401 Patient Treatment Decisions Addressed in Wellpath policy HCD 210 Y A-03
Clinical decisions about the treatment of individual
X
youth are the sole province of licensed health care
professionals, operating within the scope of their
license and within facility policy defining health care
services.
Safety and security policies and procedures that are Addressed in Wellpath policy HCD 210 Y B-04
X
applicable to youth supervision staff also apply to
health care personnel.
JUV HEALTH ENVIRONMENT PAGE 21 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
1402 Scope of Health Care Addressed in Wellpath policy HCD 210 Y E-11
(a)The health administrator, in cooperation
with the facility administrator, shall develop
X
and implement written policy and
procedures to define the extent to which
health care shall be provided within the
facility and delineate those services that
shall be available through community
providers. Each facility shall provide:
(1) at least one health care provider to
X
provide treatment; and,
(2) health care services which meet the Addressed in Wellpath policy HCD 210 Y A-01; Y E-
minimum requirements of these
07; Y E08
regulations and be at a level to address
emergency, acute symptoms and/or
conditions and avoid preventable
deterioration of health while in
X
confinement.
(b) When health services are delivered within Addressed in Wellpath policy HCD 110 D-03
the juvenile facility, staff, space,
X
equipment, supplies, materials, and
resource manuals shall be adequate to the
level of care provided.
Addressed in Butte County Probation Policy 702.12
(c) Consistent with security requirements and
public safety, written policy and procedures
for juvenile facilities shall provide for
parents, guardians, or other legal
custodians, at their own expense, to
X
authorize and arrange for medical, surgical,
dental, behavioral/mental health or other
remedial treatment of youth that is
permitted under law.
1403 Health Care Monitoring and Audits Addressed in Wellpath policy HCD 110- A-06
performed in conjunction with Butte County Jail
(a) In juvenile facilities with on-site health care
staff, the health administrator, in
X
cooperation with the facility administrator,
shall develop and implement written policy
and procedures to collect statistical data
and submit at least annual summaries of
health care services to the facility
administrator.
JUV HEALTH ENVIRONMENT PAGE 22 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
(b) The health administrator, in cooperation
with theresponsible physician and the
facility administrator, shall establish policies
X
and procedures to assure that the quality
and adequacy of health care services are
assessed at least annually.
(1) Policy and procedures shall identify a
process for correcting identified
deficiencies in the medical, dental,
X
mental health and pharmaceutical
services delivered.
(2) Based on information from these
assessments, the health administrator
shall provide the facility administrator
X
with an annual written report on
medical, dental, mental health and
pharmaceutical services.
(c) Medical, behavioral/mental and dental
services shall be reviewed at least
quarterly, at documented administrative
X
meetings between the health and facility
administrators and other staff, as
appropriate.
1404 Health Care Staff Qualifications Addressed in Wellpath policy HCD 110 Y C-09
(a) The health administrator shall, at the time
of
recruitment for health care positions,
X
develop education and experience
requirements that are consistent with the
community standard and the needs and
understanding of the facility population.
Hiring practices will take into consideration
cultural awareness and linguistic
competence.
(b) In all juvenile facilities providing on-site
health care services, the health
administrator, in cooperation with the
facility administrator, shall establish policy
X
and procedures to assure that State
licensure, certification, or registration
requirements and restrictions that apply in
the community, also apply to health care
personnel who provide services to youth.
(c)Appropriate credentials shall be accessible
for review. Policy and procedures shall
X
provide that these credentials are
periodically reviewed and remain current.
JUV HEALTH ENVIRONMENT PAGE 23 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
(d) The health administrator shall assure that
position descriptions and health care
practices require that health care staff
X
receive the supervision required by their
license and operate within their scope of
practice.
1405 Health Care Staff Procedures
Addressed in Wellpath policy HCD 210 Y A-07, HCD
110 Y C-07 & HCD 210 Y-C-06
The responsible physician for each facility providing
on-site health care may determine that a clinical
X
function or service can be safely and legally
delegated to health care staff other than a physician.
When this is done, the function or service shall be
performed by staff operating within their scope of
practice pursuant to written protocol, standardized
procedures or direct medical order.
1406 Health Care Records Addressed in Wellpath policy HCD 210 Y-H-01
In juvenile facilities providing on-site health care, the
X
health administrator, in cooperation with the facility
administrator, shall maintain individual and dated
health records that include when applicable, but are
not limited to:
(a) intake health screening form;
X
(b)health appraisals/medical examinations;
X
(c) health service reports (e.g., emergency
X
department, dental, psychiatric, and other
consultations);
(d)complaints of illness or injury;
X
(e) names of personnel who treat, prescribe,
X
and/or administer/deliver prescription
medication;
(f)location where treatment is provided;
X
(g)medication records in conformance with
X
Title 15, Section 1438;
(h)progress notes;
X
(i) consent forms;
X
(j) authorizations for release of information;
X
(k)copies of previous health records;
X
(l) immunization records;
X
(m) laboratory reports; and,
X
JUV HEALTH ENVIRONMENT PAGE 24 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
(n)individual treatment plan.
X
Addressed in Wellpath policy HCD 210Y H-02
Written policy and procedures shall provide for
maintenance of the health record in a locked area or
secured electronically, separate from the
confinement record. Access to the medical and/or
X
behavioral/mental health record shall be controlled
by the health administrator and shall assure that all
confidentiality laws related to the provider-patient
privilege apply to the health record.
Health care records shall be retained in accordance
X
with community standards.
1407 Confidentiality Addressed in Wellpath policy HCD 210Y H-02
(a) For each juvenile facility that provides on-
site health services, the health
administrator, in cooperation with the
facility administrator, shall establish policy
and procedures, consistent with applicable
laws, for the multi-disciplinary sharing of
health information. These policies and
X
procedures shall address the provision for
providing information to the court, child
supervision staff and to probation.
Information in the youth's case file shall be
shared with the health care staff when
relevant. The nature and extent of
information shared shall be appropriate to
treatment planning, program needs,
protection of the youth or others,
management of the facility, maintenance of
security, and preservation of safety and
order.
(b) Medical and behavioral/mental health Addressed in Wellpath policy HCD 210Y A-09
services shall be conducted in a private
manner such that information can be
X
communicated confidentially consistent
with HIPAA.
(c) Youth shall not be used to translate Butte County Probation Department 602.4.2
confidential medical information for other
X
non-English speaking youth.
JUV HEALTH ENVIRONMENT PAGE 25 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
1408 Transfer of Health Care Summary and Records Addressed in Wellpath policy HCD 210Y H-03
The health administrator, in cooperation with the
facility administrator, shall establish written policy
and procedures to assure that a health care
summary and relevant records are forwarded to X
health care staff in the receiving facility when a
youth is transferred to another jurisdiction, and to
the local health officer, when applicable.
Policies shall include:
(a) a summary of the health record, or
documentation that no record exists at the
X
facility, is sent in an established format,
prior to or at the time of transfer;
Addressed in Wellpath policy HCD 210Y H-02
(b) relevant health records are forwarded to
X
the
health care staff of the receiving facility;
(c) notification to health care staff of the
receiving facility prior to or at the time of
X
the release or transfer of youth with known
or suspected communicable diseases;
(d) applicable authorization from the youth
and/or parent-legal guardian is obtained
prior to transferring copies of actual health
X
records, unless otherwise provided by court
order, statute or regulation having the
force and effect of law; and,
(e) confidentiality of health records is
X
maintained.
1408.5 Release of Health Care Summary and Addressed in Wellpath policy HCD 210Y H-02
Records
X
After youth are released to the community, health
record information shall be promptly transmitted to
specific physicians or health care facilities in the
community, upon request and with the written
authorization of the youth and/or parent/guardian.
In special purpose juvenile halls and other facilities
that do not have on-site health care staff, policy and
procedures shall assure that youth supervision staff
X
forward non-confidential information on
medications and other treatment orders prior to or
at the time of transfer.
JUV HEALTH ENVIRONMENT PAGE 26 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
1409 Health Care Procedures Manual
For juvenile facilities withon-site health care staff,
the health administrator, in cooperation with the
X
facility administrator, shall develop, implement and
maintain a facility-specific health services manual of
written policies and procedures that address, at a
minimum, all health care related standards that are
applicable to the facility.
Health care policy and procedure manuals shall be
available to all health care staff, to the facility
X
administrator, the facility manager, and other
individuals as appropriate to ensure effective service
delivery.
Each policy and procedure for the health care
delivery system shall be reviewed at least every two
years and revised as necessary under the direction
X
of the health administrator. The health
administrator shall develop a system to document
that this review occurs.
The facility administrator, facility manager, health
X
administrator and responsible physician shall
designate their approval by signing the manual.
1410 Management of Communicable Diseases Addressed in Wellpath policy HCD 210Y B-01
The health administrator/responsible physician, in
cooperation with the facility administrator and the
X
local health officer, shall develop written policies
and procedures to address the identification,
treatment, control and follow-up management of
communicable diseases. The policies and procedures
shall address, but not be limited to:
(a) intake health screening procedures; X
X
(b) identification of relevant symptoms;
X
(c) referral for medical evaluation;
(d) treatment responsibilities during detention;X
(e) coordination with public and private
X
community-based resources for follow-up
treatment;
(f) applicable reporting requirements; and, X
X
(g) strategies for handling disease outbreaks.
JUV HEALTH ENVIRONMENT PAGE 27 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
The policies and procedures shall be updated as
necessary to reflect communicable disease priorities
X
identified by the local health officer and currently
recommended public health interventions.
1411 Access to Treatment Addressed in Wellpath policy HCD 210Y A-01
X
The health administrator, in cooperation with the
facility administrator, shall develop writtenpolicy
and procedures to provide unimpeded access to
health care.
1412 First Aid/AED and Emergency Response Addressed in Wellpath policy HCD 210Y H-02
X
The health administrator/responsible physician, in
cooperation with the facility administrator, shall
establish facility-specific policies and procedures to
assure access to first aid and emergency services.
(a) First aid kits shall be available in designated Addressed in Wellpath policy HCD 210Y D-07
areas of each juvenile facility. The
Deficiency: First aid kits are available but contents
responsible physician shall approve the
are not uniform or defined in policy. Process is in
contents, number, location and procedure
place for inspecting kits but has holes that allows
for periodic inspection of the kits.
X gaps in ensuring contents are current an complete.
Corrective Action: Amend policy to include
inventory list, inventory quantity, location of all
first aid kits and process for ensuring contents are
complete and up-to-date.
(b)Automated external defibrillators (AED)
shall be available in each juvenile facility.
X
The facility administrator shall ensure that
device is maintained properly per
manufacturer standard.
Addressed in Wellpath policy HCD 210Y C-04
Youth supervision and health care staff shall be
trained and written policies and procedures
X
established to respond appropriately to emergencies
requiring first aid and AED.
JUV HEALTH ENVIRONMENT PAGE 28 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
1413 Individualized Treatment Plans
With the exception of special purpose juvenile halls,
the health administrator and behavioral/mental
health director responsible physician, in cooperation
X
with the facility administrator, shall develop and
implement policy and procedures to assure that
Addressed in Wellpath policy HCD 210Y G-01 &
coordinated and integrated health care treatment
G-04
plans are developed for all youth who are receiving
services for significant medical, behavioral/mental
health or dental health care concerns.
Policies and procedures shall assure:
(a) Health care treatment plans are considered in
X
facility program planning.
(b)Health care restrictions shall not limit Addressed in Butte County Probation Department
participation of a youth in school, work
Policy 602.5
assignments, exercise and other programs,
X
beyond that which is necessary to protect the
health of the youth or others.
(c) Relevant health care treatment plan
information shall be shared with youth
X
supervision staff in accordance with Section
1407 for purposes of programming,
implementation and continuity of care.
(d)Accommodations for youth who may have
X
special needs when using showers and toilets
and dressing/undressing.
Treatment planning by health care providers shall
address:
(a) Pre-release and discharge planning for Addressed in Wellpath policy HCD 210Y E-13
continuing medical, dental and
behavioral/mental health care, including
medication, following release or transfer,
X
which may include relevant authorization for
transfer of information, insurance, or
communication with community providers to
ensure continuity of care.
(b)Participation in relevant programs upon
X
return into the community to ensure
continuity of care.
(c) Youth and family participation (if applicable
X
and available).
(d)Cultural responsiveness, awareness and Addressed in Butte County Probation Department
X
linguistic competence.
Policy 504.3&504.31
(e)Physical and psychological safety. X
(f)Traumatic stress and trauma reminders when
X
applicable.
JUV HEALTH ENVIRONMENT PAGE 29 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
1414 Health Clearance for in-Custody Work and
Program Assignments Addressed in Wellpath policy HCD 210Y C-06
The health administrator/responsible physician, in
X
cooperation with the facility administrator, shall
develop health screening and monitoring
procedures for work and program assignments that
have health care implications, including, but not
limited to, food handlers.
1415 Health Education Addressed in: Wellpath policy HCD 210Y A-01;
Butte County Probation Department Policy 702.6.4
& 6.5;
With the exception of special purpose juvenile halls,
the health administrator for each juvenile facility, in Health Annual Training Manual
X
cooperation with the facility administrator, shall
develop written policies and procedures to assure
that interactive and gender and developmentally
appropriate medical, behavioral/mental health and
dental health education and disease prevention
programs are provided to youth.
The education program content shall be updated as
necessary to address current health and community
X
priorities that meet the needs of the confined
population.
1416 Reproductive Services and Sexual Health
Addressed in:
For all juvenile facilities, the health administrator, in
Health Education Training Manual & Butte County
cooperation with the facility administrator, shall Probation Department Policy 702.6.4 & 702.6.5
develop written policies and procedures to assure
that reproductive and sexual health services are
available to all youth in accordance with current
public health guidelines
X
Such services shall include but not be limited to
those prescribed by Welfare and Institutions Code
X
Sections 220, 221 and 222 and Health and Safety
Code Section 123450.
JUV HEALTH ENVIRONMENT PAGE 30 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
Section 1417. Pregnant/Post-Partum Youth Addressed in Wellpath policy HCD 210Y G-09
With the exception of special purpose juvenile halls,
the health administrator for each juvenile facility, in
cooperation with the facility administrator, shall
X
develop written policies and procedures pertaining
to pregnant and post-partum youth as required by
Penal Code Section 6030(e) and limitations on the
use of restraints in accordance with Penal Code
Section 6030(f) and Welfare and Institutions Code
Sections 220, 221, and 222.
Written policies and procedures shall also include
the following:
X
(a) Pregnant youth will receive information
regarding options for continuation of
pregnancy, termination of pregnancy and
adoption.
(b)Pregnant youth receive prenatal care,
including physical examination, nutrition
guidance, childbirth, breast feeding and
X
parenting education, counseling and
provisions for follow up and post-partum
care,
(c) Availability of a breast pump and
X
procedures for storage, delivery or disposal
for lactating youth.
(d)Qualified medical professionals develop a
plan for pregnant youth that includes direct
communication of medical information and
X
transfer of medical records regarding
prenatal care to the obstetrician who will be
providing prenatal care and delivery in the
community.
1418. Youth with Developmental Disabilities Addressed in Wellpath policy HCD 210Y G-01
Policy and procedures shall require that any youth
who is suspected or confirmed to have a
X
developmental disability is referred to the local
Regional Center for the Developmentally Disabled
for purposes of diagnosis and/or treatment within
24 hours of identification, excluding holidays and
weekends.
JUV HEALTH ENVIRONMENT PAGE 31 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
Addressed in Wellpath policy HCD 210Y E-02
1430 Medical Clearance/Intake Health and
Screening
The health administrator/responsible physician, in
cooperation with the facility administrator and
X
behavioral/mental health director shall establish
policies and procedures for a documented intake
health screening procedure to be conducted
immediately upon entry to the facility. Policies and
procedures shall also define when a health
evaluation and/or treatment shall be obtained prior
to acceptance for booking.
For adjudicated youth who are confined in any
juvenile facility for successive stays, each of which
totals less than 96 hours, the responsible physician
X
shall establish a policy for a medical evaluation and
clearance. This evaluation and clearance shall
include screening for communicable disease.
The responsible physician shall establish criteria
defining the types of apparent health conditions that
would preclude acceptance of a youth into the
X
facility without a documented medical clearance.
The criteria shall be consistent with the facility's
resources to safely hold the youth.
Intake personnel shall ensure that youth who are
unconscious, semi-conscious, profusely bleeding,
severely disorientated, known to have ingested
substances, intoxicated to the extent that they are a
threat to their own safety or the safety of others, in X
alcohol or drug withdrawal or otherwise urgently in
need of medical attention shall be immediately
referred to an outside facility for medical attention
and clearance for booking.
Written documentation of the circumstances and
X
reasons for requiring a medical clearance whenever
a youth is not accepted for booking is required.
Written medical clearance, and when possible, a
medical evaluation with progress notes are required X
for admission to the facility.
Procedures for an intake health screening shall
consist of a defined, systematic inquiry and
observation of every youth booked into the juvenile
X
facility. The screening shall be conducted
immediately upon entry to the facility and may be
performed by either health care personnel or
trained youth supervision staff.
JUV HEALTH ENVIRONMENT PAGE 32 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ARTICLE/SECTION YESNO N/A COMMENTS
Screening procedures shall include but not be
limited to:
X
(a) Medical, dental and behavioral/mental
health concerns that may pose a hazard to
the youth or others in the facility;
(b)Health conditions that require treatment
X
whilethe youth is in the facility; and,
(c) Identification of the need for
accommodations, e.g., physical or
X
developmental disabilities, gender identity
or medical holds.
Any youth suspected to have a communicable
disease that could pose a significant risk to others in
X
the facility shall be separated from the general
population pending the outcome of an evaluation by
healthcare staff.
Procedures shall require timely referral for health
care commensurate with the nature of any problems X
or complaint identified during the screening process.
Addressed in Wellpath policy HCD 210Y G-06 , 06.A
1431 Intoxicated Youth and Youth With a
Substance Use Disorder
(a) The responsible health administrator/physician,
in cooperation with the facility administrator, shall
X
develop and implement written policy and
procedures that address the identification and
management of alcohol and other substance
intoxication. Withdrawal, and treatment of
substance use disorder in accordance with Section
1430.
JUV HEALTH ENVIRONMENT PAGE 33 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(b) Policy and procedures shall address:
(1)a medical clearance shall be obtained prior
X
to booking any youth who is intoxicated to
the extent that they are a threat to
themselves or others;
(2) designated housing, including use of any
X
intoxicated youth;
(3) symptoms known history of ingestion or
withdrawal that should prompt immediate
X
referral for medical evaluation and
treatment;
(4)determining when the youth is no longer
considered intoxicated and documenting
X
when the monitoring requirements of this
regulation are discontinued;
(5) medical responses to youth experiencing
X
intoxication or withdrawal reactions;
(6) management of pregnant youth who use
X
alcohol or other substances;
(7) initiation of substance abuse counseling Facility does not have staffing to provide MAT for
and/or treatment during confinement and
opioid use disorder.
X
referral procedures for continuation upon
release to the community consistent with
Section 1413 and Section 1355;
(8) coordination with behavioral/mental health
services in cases of substance abusing
X
youth with known or suspected mental
illness.
(9) how, when and by whom the youth will be
X
monitored when intoxicated;
(10) the frequency of monitoring and the
X
documentation required;
(11) that when a youth is intoxicated,
experiencing progressive or severe
X
intoxication or withdrawal, they shall be
immediately medically evaluated; and,
(12)that intoxication beyond four hours from
X
the time of admission shall require a
medical evaluation
1432 Health Assessment Addressed in Wellpath policy HCD 210Y E-11 & E-
04
The health administrator/responsible physician, in
X
cooperation with the facility administrator for each
juvenile hall, shall develop and implement written
policy and procedures for a health assessment of
youth and for the timely identification of conditions
necessary to safeguard the health of the youth
JUV HEALTH ENVIRONMENT PAGE 34 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(a)The health assessment shall be completed
within 96 hours of admission, excluding
holidays, to the facility and result in a
compilation of identified problems to be
considered in classification, treatment, and
the multi-disciplinary management of the
youth while in custody and in pre-release
X
planning. It shall be conducted in a location
that protects the privacy of the youth and
conducted by a physician, or other licensed or
certified health professional working within
his/her scope of practice and under the
direction of a physician.
(1) At a minimum, the health assessment
shall
include, but is not limited to, health
X
history, examination, laboratory and
diagnostic testing, and immunization
reviews as outlined below:
(A) The health history includes but is not
limited to: Review of the intake
health screening, history of illnesses,
operations, injuries, medications,
allergies, immunizations, systems
review, exposure to communicable
diseases, family health history, habits
(e.g., tobacco, alcohol and other
substances), developmental history
including strengths and supports
available to the youth (e.g., school,
home, and peer relations, activities,
X
interests), history of recent trauma-
exposure which may require
immediate attention (including
physical and sexual abuse, sexual
assault, neglect, violence in the
home, traumatic loss) and current
traumatic stress symptoms,
pregnancy needs, sexual activity,
contraceptive methods, reproductive
history, physical and sexual abuse,
neglect, history of mental illness,
self-injury, and suicidal ideation.
JUV HEALTH ENVIRONMENT PAGE 35 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(B)The physical examination includes
but is not limited to: Temperature,
height, weight, pulse, blood
pressure, appearance, gait, head and
neck, a preliminary dental and visual
acuity screening, hearing screening,
X
lymph nodes, chest and
cardiovascular, breasts, abdomen,
genital (pelvic and rectal
examination, with consent, if
clinically indicated), musculoskeletal,
neurologic.
(C)Laboratory and diagnostic testing
includes, but is not limited to:
Tuberculosis screening and testing
for sexually transmitted diseases for
sexually active youth. Additional
X
testing should be available as
clinically indicated, including
pregnancy testing, urinalysis,
hemoglobin or hematocrit.
(D) Review and update of the
immunization records within two
X
weeks in accordance with current
public health guidelines.
(2) The physical examination and laboratory
and diagnostic testing components of the
health assessment may be modified by the
health care provider, for youth admitted
with an adequate examination done
within the last 12 months, provided there
is reason to believe that no substantial
X
change would be expected since the last
full evaluation. When this occurs, health
care staff shall review the intake health
screening form and conduct a face-to-face
interview with the youth. The health
history and immunization review should
be done within 96 hours of admission
excluding holidays.
(3)Physical exams shall be updated annually
X
for all youth.
Addressed in Wellpath HCD 210 Y E-04
(b) For adjudicated youth who are confined in
any juvenile facility for successive stays, each
of which totals less than 96 hours, the
responsible physician shall establish a policy
for a medical assessment. If this assessment
X
cannot be completed at the facility during the
initial stay, it shall be completed prior to
acceptance at the facility. This evaluation and
clearance shallinclude screening for
communicable disease.
JUV HEALTH ENVIRONMENT PAGE 36 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(c)For youth who are transferred to and from Addressed in Wellpath HCD 210Y E-02
juvenile facilities outside their detention
system, the health administrator, in
X
cooperation with the facility administrator,
shall develop and implement policy and
procedures to assure that a health
assessment:
(1) is received from the sending facility at or
X
prior to the time of transfer;
(2) is reviewed by designated health care
X
staff at the receiving facility; and,
(3) is identified and any missing required
X
assessments are scheduled within 96
hours.
Addressed in Wellpath HCD 210Y E-02
(d) The health administrator/responsible
physician shall develop policy and procedures
to assure that youth who are transferred
among juvenile facilities within the same
X
detention system, receive a written health
care clearance. The health record shall be
reviewed and updated prior to transfer and
forwarded to facilities that have licensed on-
site health care staff.
1433 Requests for Health Care Services Addressed in Wellpath policy HCD 210Y H A-01
Also Wellpath policy HCD 210_Y- E-07
The health administrator, in cooperation with the
X
facility administrator, shall develop policy and
Non-emergency Services
procedures to establish a daily routine for youth to
convey requests for emergency and non-emergency
and Wellpath Policy HCD 210_Y- E-08
medical, dental and behavioral/mental health care
Emergency Services
services.
(a) Youth shall be provided the opportunity to
Addressed in Wellpath Policy HCD 210 Y-E-07,
confidentially convey either through, written
section 6.2
or verbal communications, request for
X
medical, dental or behavioral/mental health
services. Provisions shall be made for youth
who have language or literacy barriers.
(b)Youth supervision staff shall relay requests Addressed in Wellpath policy HCD-210_Y-E-07
from the youth, initiate referrals when a need
(section 6.6)
for services is observed, and advocate for the
x
And HCD-210_Y-G-04 Mental Health Services
youth when the need for medical, dental and
behavioral/mental services appears to be
urgent.
(c) Staff shall inquire and make observations of Addressed in Wellpath Policy HCD 210 Y-G-04
each youth regarding their medical, dental
x
and behavioral/mental health including the
presence of trauma-related behaviors, injury
and illness.
(d)There shall be opportunities available on a Addressed in Wellpath Policy HCD 210 Y-E-08
twenty-four hour per day basis for youth and
x
staff to communicate the need for emergency
medical and behavioral/mental health care
services.
JUV HEALTH ENVIRONMENT PAGE 37 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(e)Provision shall be made for any youth Addressed in Wellpath Policy HCD 210 Y-E-07 and
requesting medical, dental and
Y- E-08
behavioral/mental health care attention, or
x
observed to be in need of health care, to be
given that attention by licensed or certified
health care personnel.
(f)All medical, dental and behavioral/mental Facility uses a paper chart system. Charts were
x
health care requests shall be documented and
made available for inspectors to review.
maintained.
1434 Consent and Refusal for Health Care Addressed in Wellpath Policy HCD-210 _Y-I-04
Informed Consent and Right to Refuse
x
The health administrator, in cooperation with the
facility administrator, shall establish written policy
and procedures to obtain informed consent for
health care examinations and treatment.
(a) All immunizations, examinations,
Addressed inWellpath Policy HCD 210 Y-I-04
treatments, and procedures requiring verbal or
x
written informed consent in the community also
require that consentfor confined youth.
(b)There shall be provision for obtaining
Addressed in Wellpath Policy HCD 210 Y-I-04
parental consent and obtaining authorization for
health care services from the court when there is no
x
parent/guardian or other person standing in loco
parentis, including the requirements in Welfare and
Institutions Code Section 739.
(c) Policy and procedures shall be consistent
Policies consistent with minor consent laws for
with applicable statutes in those instances where
s
state of CA
the youth's consent for testing or treatment is
sufficient or specifically required.
(d)Conservators can provide consent only
Addressed in Wellpath Policy HCD 210 Y-I-04
x
within limits of their court authorization.
Youth may refuse, verbally orin writing, non-Addressed in Wellpath Policy HCD 210 Y-O-04
emergency medical, dental and behavioral/mental x
health care.
1435 Dental Care Addressed in Wellpath Policy HCD 210_Y-E-06
Oral Care
The health administrator, in cooperation with the
facility administrator, shall develop and implement
Youth sees RN first for assessment. Referred to
x
written policy and procedures to require that dental
community dental provider who takes Medi-Cal
treatment be provided to youth as necessary to
which provides continuity of care after discharge.
respond to acute conditions and to avert adverse
List of providers in Rolodex.
effects on the youth's health and require preventive
services as recommended by a dentist. Treatment
shall not be limited to extractions.
Addressed in Wellpath Policy HCD 210 Y-E-06
Annual dental exams shall be provided to any youth
x
detained for longer than one year.
JUV HEALTH ENVIRONMENT PAGE 38 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
1436 Prostheses and Orthopedic Devices Addressed in Wellpath Policy HCD 210_Y-G-14
(a)The health administrator, in cooperation withDurable Medical Equipment and Medical Supplies
the facility administrator and the responsible
x
physician shall develop written policy and
procedures regarding the provision, retention
and removal of medical and dental prostheses,
including eyeglasses and hearing aids.
(b) Prostheses shall be provided when the health Addressed in Wellpath Policy HCD 210 Y-G-14
of the youth would otherwise be adversely
x
affected, as determined by the responsible
physician.
Addressed in Wellpath Policy HCD 210 Y-G-14
(c) Procedures for retention and removal of
prostheses shall comply with the requirements
x
of Penal Code Section 2656.
1437 Mental Health Services
Addressed in Wellpath Policy HCD 210_Y-G-04
Mental Health Services and
The health administrator/responsible physician, in
Y-G-05 Suicide Prevention
cooperation with the behavioral/mental health
x
director and the facility administrator, shall establish
policies and procedures to provide
behavioral/mental health services. These services
shall include, but not be limited to:
(a)screening for behavioral/mental health
problems at intake performed by either
behavioral/mental/medical health personnel or
trained youth supervision staff; history of
x
recent exposure to trauma which may require
immediate attention (including physical and
sexual abuse, sexual assault, neglect, violence
in the home, traumatic loss), current traumatic
stress symptoms, and pregnancy needs
(b) assessment by a behavioral/mental health
x
provider when indicated by the screening
process;
(c)therapeutic services and preventive services
x
where resources permit;
(d) crisis intervention and the management of
x
acute psychiatric episodes;
(e)stabilization of persons with mental disorders
x
and the prevention of psychiatric deterioration
in the facility setting;
(f) initial and periodic medication support
x
services;
(g) assurance that any youth who displays
significant symptoms of severe depression,
suicidal ideation, irrational, violent or self-
x
destructive behaviors, shall be provided a
mental status assessment by a licensed
behavioral/mental health clinician,
psychologist, or psychiatrist.
(h) transition planning for youth undergoing
behavioral/mental health treatment, including
arrangements for continuation of medication
x
and services from behavioral/mental health
providers, including providers in the
community where appropriate.
JUV HEALTH ENVIRONMENT PAGE 39 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
Absent an emergency, unless the juvenile facility has
been designated as a Lanterman-Petris-Short (LPS)
facility, and youth meet the criteria for involuntary
commitment under the LPS Act in Welfare and
Institutions Code Section 5000 et seq., all services x
shall be provided on a voluntary basis. Voluntary
mental health admissions may be sought pursuant
to Penal Code Section 4011.8 or Welfare and
Institutions Code Section 6552.
1437.5 Transfer to a Treatment Facility
Policy 519 addresses Transportation outside of the
facility.
The health administrator/responsible physician, in
x
cooperation with the behavioral/mental health Youth are evaluated at a local hospital and are not
director and the facility administrator, shall establish usually transferred directly to a Behavioral Health
policies and procedures for the transfer of youth to treatment facility.
a treatment facility. These policies and procedures
shall include but are not limited to:
(a) Youth who appear to be a danger to
themselves or others, or to be gravely
disabled, due to a mental health condition
x
shall be evaluated either pursuant to
applicable statute or by on-site health
personnel to determine if treatment can be
initiated at the juvenile facility, and
(b)Provision for timely referral, transportation,
and admission to licensed mental health
x
facilities, and follow-up for youth whose
psychiatric needs exceed the treatment
capability of the facility.
1438 Pharmaceutical Management Addressed in Wellpath policy HCD-210_Y-D-01
Pharmaceutical Operations
For all juvenile facilities, the health administrator, in
consultation with a pharmacist and in cooperation
s
with the facility administrator, shall develop and
implement written policy, establish procedures, and
provide space and accessories for the secure
storage, controlled administration, and disposal of
all legally obtained drugs.
(a) Such policies, procedures, space and accessories Addressed in Wellpath Policy HCD 210 Y-D-01,
shall include, but not be limited to, the following: section 6.21
x
(1) securely lockable cabinets, closets, and
refrigeration units;
(2) a means for the positive identification of Addressed in Wellpath Policy HCD 21—Y-D-02
x
the recipient of the prescribed medication;
Medical Services
(3) administration/delivery of medicines to
x
youth as prescribed;
(4) confirmation that the recipient has ingested
x
the medication;
JUV HEALTH ENVIRONMENT PAGE 40 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(5)documenting that prescribed medications
x
have or have not been administered, by
whom, and if not, for what reason;
(6) prohibition of the delivery of medication
x
from one youth to another;
(7) limitation to the length of time medication
x
may be administered without further
medical evaluation;
(8) the length of time allowable for a
x
physician's signature on verbal orders, not
to exceed seven (7) days;
Addressed in Wellpath policy HCD 210_Y-C-04
(9) training by medical staff for non-licensed
personnel which includes, but is not limited
Health Training of Staff
to: delivery procedures and
documentation; recognizing common
symptoms and side-effects that should
x
result in contacting health care staff for
Addressed in Wellpath policy HCD 210_Y-C-08
evaluation; procedures for consultation for
Health Care Liaison
confirming ingestion of medication; and,
consultation with health care staff for
monitoring the youth's response to
medication;
(10) a written report shall be prepared by a The Health Services Administrator receives
pharmacist, no less than annually, on the
monthly statistics from pharmaceutical contractor
status of pharmacy services in the
x
Correct RX and has access to Correct Rx website for
institution. The pharmacist shall provide
data sooner if needed.
the report to the health authority and the
facility administrator; and,
Addressed in Wellpath Policy HCD 210_Y-D-02
(11) transition planning, including plan for
x
uninterrupted continuation of medication.
Medication Services
(b) Consistent with pharmacy laws and regulations, Addressed in Wellpath Policy HCD 210_Y-D-01
the health administrator shall establish written
x
Pharmaceutical Operations
protocols that limit the following functions to being
performed by the identified personnel:
(1) Procurement shall be done only by a
x
physician, dentist, pharmacist, or other
persons authorized by law.
(2)Storage of medications shall assure that
stock supplies of legend medications shall
only be accessed by licensed health
personnel. Supplies of legend medications
x
that have been properly dispensed and
supplies of over-the-counter medications
may be accessed by both licensed and
trained non-licensed personnel.
(3) Repackaging shall only be done by a
Addressed in Wellpath Policy HCD 210 Y-D-02,
physician, dentist, pharmacist, or other
x
Section 6.17
persons authorized by law.
JUV HEALTH ENVIRONMENT PAGE 41 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(4)Preparation of labels can be done by Correct Rx is contract pharmacy
licensed physician, dentist, pharmacist or
Crystal Pharmacy is local back-up
other personnel, provided the label is
checked and affixed to the medication
container by the physician, dentist, or
x
pharmacist before administration or
deliveryto the youth. Labels shall be
prepared inaccordance with Section 4076
and 4076.5 of the Business and Professions
Code.
(5) Dispensing shall only be done by a
x
physician, dentist, pharmacist, or other
person authorized by law.
(6) Administration of medication shall only be
done by licensed health personnel who are
x
authorized to administer medication and
acting on the order of a prescriber.
(7)Licensed health care personnel and trained
non-licensed personnel may deliver
x
medication acting on the order of a
prescriber.
(8)Disposal of legend medication shall be done in
accordance with pharmacy laws and regulations
Any controlled substances that need to be
and requires any combination of two of the
destroyed or disposed of are taken to the jail for
following classifications: physician, dentist,
x
processing.
pharmacist, or registered nurse. Controlled
substances shall be disposed of in accordance
with Drug Enforcement Administration disposal
procedures.
(c) The responsible physician shall establish policies Addressed in Wellpath policy HCD 210_Y-E-11
and procedures for managing and providing over-x Nursing Protocols and Y-D-01
the-counter medications to youth.
1439 Psychotropic Medications Addressed in Wellpath policy HCD 210_Y-I-02
Emergency Psychiatric Medications
The health administrator/responsible physician, in
x
cooperation with the behavioral/mental health
Addressed in Wellpath policy HCD 210_Y-G-02,
director and the facility administrator, shall develop
sections 6.1-6.4
and implement written policies and procedures
governing the use of voluntary and involuntary
Patients with Sepcial Health Needs
psychotropic medications.
(a) These policies and procedures shall include, but
not be limited to:
(1) protocols for health care providers written Addressed in Wellpath Policy HCD 210 Y-I-02,
and verbal orders for psychotropic
section 6.3 &
x
medications in dosages appropriate to the
Y-D-01
youth's need;
(2) the length of time medications may be
Addressed in Wellpath Policy HCD 210 Y-D-02,
x
ordered and administered before re-
section 6.7
evaluation by a health care provider;
JUV HEALTH ENVIRONMENT PAGE 42 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(3)provision that youth who are on Addressed in Wellpath Policy HCD 210Y-D-02,
psychotropic medications prescribed in the
section 6.9
community are continued on their
x
medications when clinically indicated
pending verification in a timely manner by a
health care provider
(4) re-evaluation and further determination of Addressed in Wellpath Policy HCD 210 Y-D-02
continuing psychotropic medication, if
x
needed, shall be made by a health care
provider;
Addressed in Wellpath Policy HCD 210 Y-D-02
(5) provision that the necessity for
uninterrupted continuation on psychotropic
medications is addressed in pre-release
x
planning and prior to transfer to another
facility or program including authorization
for transfer of prescriptions; and,
(6)provision for regular clinical/administrative Addressed in Wellpath Policy HCD 210 Y-D-02
review of utilization patterns for all
x
psychotropic medications, including every
emergency situation.
(b) Psychotropic medications shall not be Addressed in Wellpath policy HCD 210-Y-I-04
administered to a youth absent an emergency unless
x
Informed Consent and Right to Refuse
informed consent has been given by the legally
authorized person or entity.
(1) Youth shall be informed of the expected Addressed in Wellpath Policy HCD 210Y-I-04,
benefits, potential side effects and
x
section 6.2
alternatives to psychotropic medications.
(2) Absent an emergency, youth may refuseAddressed in Wellpath Policy HCD 210 Y-I-04
x
psychotropic medication without
disciplinary consequences.
Addressed in Wellpath Policy HCD 210 Y-I-02
(c) Youth found by a health care provider to be an
imminent danger to themselves or others by reason
of a mental disorder may be involuntarily given
psychotropic medication immediately necessary for
the preservation of life or the prevention of serious
bodily harm, and when there is insufficient time to
obtain consent from the parent, guardian, or court
x
before the threatened harm would occur. It is not
necessary for harm to take place or become
unavoidable prior to initiating treatment. All
involuntary administrations of psychotropic
medications shall be documented and reviewed by
the facility administrator or designee and health
administrator.
Addressed in Wellpath Policy HCD 210 Y-I-02
(d) Assessment and diagnosis must support the
administration of psychotropic medications.
x
Administration of psychotropic medication is not
allowed for coercion, discipline, convenience or
retaliation.
JUV HEALTH ENVIRONMENT PAGE 43 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
1452 Collection of Forensic Evidence Addressed in Wellpath Policy HCD 201_y-I-03
Forensic information
The health administrator, in cooperation with the
facility administrator, shall establish policies and
x
procedures assuring that forensic medical services,
including drawing of blood alcohol samples, body
cavity searches, and other functions for the purpose
of prosecution are collected by appropriately trained
medical personnel who are not responsible for
providing ongoing health care to the youth.
1453 Sexual Assaults
Addressed in Wellpath Policy HCD 210-Y-B-04A and
Y-B-05
Federal Sexual Abuse Policy 605x
The health administrator, in cooperation with the
x
facility administrator, shall develop and implement
policy and procedures for treating victims of sexual
assaults, preservation of evidence and for reporting
such incidents to local law enforcement.
The evidentiary examination and initial treatment of Addressed in Wellpath Policy HCD 210 Y-B-05,
victims of sexual assault shall be conducted at a section 6.11
health facility that is separate from the custodial
x
facility and is properly equipped and staffed with
personnel trained and experienced in such
procedures.
1454 Participation in Research Addressed in Wellpath policy HCD 210_Y-I-05,
section 6.3 Medical Research
The health administrator, in cooperation with the
facility administrator, shall develop site specific
policy and procedures governing biomedical or
x
behavioral research involving youth. Human
subjects' research shall occur only when ethical,
medical and legal standards for human research are
met as verified by Institutional Review Board (IRB)
approvals. Written policy and procedure shall
require assurances for the safety of the youth and
informed consent.
Addressed in Wellpath Policy HCD 210 Y-I-05
Participation shall not be a condition for obtaining
privileges or other rewards in the facility. The court,
x
health administrator, and facility administrator shall
be informed of all such proposed actions.
JUV HEALTH ENVIRONMENT PAGE 44 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
1329 Suicide Prevention Plan Addressed in Wellpath Policy HCD 210-Y-G-05
Suicide Prevention
The facility administrator, in collaboration with the
healthcare and behavioral/mental health
administrators, shall plan and implement written
x
policies and procedures which delineate a Suicide
Prevention Plan. The plan shall consider the needs of
youth experiencing past or current trauma. Suicide
prevention responses shall be respectful and in the
least invasive manner consistent with the level of
suicide risk.
The plan shall include the following elements:
Addressed in Wellpath Policy HCD 210 Y-G-05,
section 6.1
(a)Suicide prevention training asrequired in
x
Section 1322, Youth Supervision Staff
Orientation, and Training and the Juvenile
Corrections Officer Core Course.
(b)Screening, Identification Assessment and
Addressed in Wellpath Policy HCD 210 Y-G-05,
x
Precautionary Protocols
section 6.2
(1) All youth shall be screened for risk of Addressed in Wellpath Policy HCD 210 Y-G-05,
x section 6.4.2
suicide at intake and as needed during
detention.
(2) All youth supervision staff who perform
intake processes shall be trained in x
screening youth for risk of suicide.
(3) All youth who have been identified
during the intake screening process to be at
risk of suicide shall be referred to x
behavioral/mental health staff for a suicide
risk assessment.
(4) Precautionary protocols shall be
developed to ensure the youth's safety
x
pending the behavioral/mental health
assessment.
(c) Referral process to behavioral/mental health
Addressed in Wellpath Policy HCD 210 Y-G-05,
x
staff for assessment and/or services.
section 6.2.3
(d)Procedures for monitoring of youth
x
identified at risk for suicide.
(e) Safety Interventions
(1) Procedures to address intervention
protocols for youth identified at risk for
x
suicide which may include, but are not
limited to:
(A) Housing consideration x
(B) Treatment strategies including
x
trauma-informed approaches
JUV HEALTH ENVIRONMENT PAGE 45 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(2) Procedures to instruct youth supervision
staff how to respond to youth who exhibit x
suicidal behaviors.
(f)Communication
(1) The intake process shall include
communication with the arresting officer
and family guardians regarding the youth's x
past or present suicidal ideations, behaviors
or attempts.
(2) Procedures for clear and current
information sharing about youth at risk for
x
suicide with youth supervision, healthcare,
and behavioral/mental health staff.
(g)Debriefing of Critical Incidents Related to
Addressed in Wellpath Policy HCD 210 Y-G-05,
x
Suicides or Attempts
section 6.11.1
(1) Process for administrative review of the
circumstances and responses proceeding, x
during and after the critical incident.
(2) Process for a debriefing event with Addressed in Wellpath Policy HCD 210 Y-G-05,
x
affected staff. section 12.1
(3) Process for a debriefing event with Addressed in Wellpath Policy HCD 210 Y-G-05,
x
affected youth. section 12.1
(h)Documentation
(1) Documentation processes shall be
developed to ensure compliance with this x
regulation
Youth identified at risk for suicide shall not be
denied the opportunity to participate in facility
programs, services and activities which are available
to other non-suicidal youth, unless deemed
x
necessary for the safety of the youth or security of
the facility. Any deprivation of programs, services or
activities for youth at risk of suicide shall be
documented and approved by the facility manager.
Section 1357 Use of Force This is a custody policy (not health staff)
Lexipol policy 514
The facility administrator, in cooperation with the
x
responsible physician, shall develop and implement
written policies and procedures for the use of force,
which may include chemical agents. Force shall
never be applied as punishment, discipline,
retaliation or treatment.
JUV HEALTH ENVIRONMENT PAGE 46 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(a)At a minimum, each facility shall develop
policies and procedures which:
(1)restricts the use of force to that which is
x
deemed reasonable and necessary, as defined
in Section 1302 to ensure the safety and
security of youth, staff, others and the facility.
(2) outline the force options available to staff
including both physical and non-physical
x
options and define when those force options
are appropriate.
(3) describe force options or techniques that are
x
expressly prohibited by the facility.
(4) describe the requirements of staff to report
any inappropriate use of force, and to take x
affirmative action to immediately stop it.
(5) define a standardized reporting format that
includes time period and procedure for
documenting and reporting the use of force,
including reporting requirements of
management and line staff and procedures for
reviewing and tracking use of force incidents by
x
supervisory and or management staff, which
include procedures for debriefing a particular
incident with staff and/or youth for the
purposes of training as well as mitigating the
effects of trauma that may have been
experienced by staff and/or the youth involved.
(6) Include an administrative review and a
system for investigating unreasonable use of x
force.
(7) define the role, notification, and follow-up
procedures required after use of force incidents
x
for medical, mental health staff and parents or
legal guardians.
(8) describe the limitations of use of force on
pregnant youth in accordance with Penal Code
x
Section 6030(f) and Welfare and Institutions
Code Section 222.
(b) Facilities that authorize chemical agents as
a force option shall include policies and procedures
that:
x
(1) identify who is approved to carry and/or
utilize chemical agents in the facility and the
type, size and the approved method of
deployment for those chemical agents.
JUV HEALTH ENVIRONMENT PAGE 47 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(2) mandate that chemical agents only be used
when there is an imminent threat to the youth's
x
safety or the safety of others and only when de-
escalation efforts have been unsuccessful or are
not reasonably possible.
(3) outline the facility's approved methods and
timelines for decontamination from chemical
agents. This shall include that youth who have
been exposed to chemical agents shall not be x
left unattended until that youth is fully
decontaminated or is no longer suffering the
effects of the chemical agent.
(4) define the role, notification, and follow-up
procedures required after use of force incidents
x
involving chemical agents for medical, mental
health staff and parents or legal guardians.
(5) provide for the documentation of each
incident of use of chemical agents, including the
reasons for which it was used, efforts to de-
escalate prior to use, youth and staff involved,
x
the date, time and location of use,
decontamination procedures applied and
identification of any injuries sustained as a
result of such use.
(c) Facilities shall develop policies and
procedure which require that agencies provide
initial and regular training in use of force and
chemical agents when appropriate that address:
x
(1) known medical and behavioral health
conditions that would contraindicate certain
types of force;
(2) acceptable chemical agents and the methods
x
of application.
(3) signs or symptoms that should result in
immediate referral to medical or behavioral x
health.
(4) instruction on the Constitutional Limitations
x
of Use of Force.
(5) physical training force options that may
x
require the use of perishable skills.
(6) timelines the facility uses to define regular
x
training.
JUV HEALTH ENVIRONMENT PAGE 48 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
1358 Use of Physical Restraints Addressed in Wellpath Policy HCD 210_Y-I-01,
sections 6.8-6.14
Restraints and Seclusion
The facility administrator, in cooperation with the
responsible physician and mental health director,
x
shall develop and implement written policies and
Juvenile Detention Manual Custody Policy,
procedures for the use of restraint devices. Restraint
devices include any devices which immobilize a
Lexipol 515, Butte County Probation Department
youth's extremities and/or prevent the youth from
being ambulatory.
Physical restraints may be used only for those youth
who present an immediate danger to themselves or
others, who exhibit behavior which results in the
destruction of property, or reveals the intent to
x
cause self-inflicted physical harm. Physical restraints
should be utilized only when it appears less
restrictive alternatives would be ineffective in
controlling the youth's behavior.
In no case shall restraints be used as punishment or
discipline, or as a substitute for treatment. The use
of restraint devices that attach a youth to a wall,
floor or other fixture, including a restraint chair, or
through affixing of hands and feet together behind x
the back (hogtying) is prohibited. The use of
restraints on pregnant youth is limited in accordance
with Penal Code Section 6030(f) and Welfare and
Institutions Code Section 222.
The provisions of this section do not apply to the use
of handcuffs, shackles or other restraint devices
when used to restrain youth for movement or
x
transportation within the facility. Movement within
the facility shall be governed by Section 1358.5, Use
of Restraint Devices for Movement Within the
Facility.
Youth shall be placed in restraints onlywith the
approval of the facility manager or designee. The
facility manager may delegate authority to place a
x
youth in restraints to a physician. Reasons for
continued retention in restraints shall be reviewed
and documented at a minimum of every hour.
A medical opinion on the safety of placement and
retention shall be secured as soon as possible, but
no later than two hours from the time of placement. x
The youth shall be medically cleared for continued
retention at least every three hours thereafter.
A mental health consultation shall be secured as
soon as possible, but in no case longer than four
x
hours from the time of placement, to assess the
need for mental health treatment.
JUV HEALTH ENVIRONMENT PAGE 49 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
Continuous direct visual supervision shall be
conducted to ensure that the restraints are properly
employed, and to ensure the safety and well-being
x
of the youth. Observations of the youth's behavior
and any staff interventions shall be documented at
least every 15 minutes, with actual time of the
documentation recorded.
In addition to the requirements above, policies and
x
procedures shall address:
(a) documentation of the circumstances leading to
x
an application of restraints.
(b) known medical conditions that would
contraindicate certain restraintdevices and/or x
techniques.
(c) acceptable restraint devices. x
(d) signs or symptoms which should result in
x
immediate medical/mental health referral.
(e) availability of cardiopulmonary resuscitation
x
equipment.
(f) protective housing of restrained youth. While in
restraint devices, all youth shall be housed alone or
x
in a specified housing area for restrained youth
which makes provision to protect the youth from
abuse.
(g) provision for hydration and sanitation needs. x
(h) exercising of extremities.x
Custody policy (not health staff)
1358.5 Use of Restraint Devices for Movement and
Transportation Within the Facility
Restraints are not used for transportation and
The Facility Administrator, in cooperation with the movement within the facility
x
responsible physician and behavioral/mental health
director, shall develop and implement written
policies and procedures for the use of restraint
devices when the purpose is for movement or
transportation within the facility that shall include
the following:
(a) identification of acceptable restraint devices,
staff approved to utilize restraint devices and the x
required training.
(b) the circumstances leading to the application of
x
restraints must be documented.
JUV HEALTH ENVIRONMENT PAGE 50 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(c) an individual assessment of the need to apply
restraints for movement or transportation that
includes consideration of less restrictive
x
alternatives, consideration of a youth's known
medical or mental health conditions, trauma
informed approaches, and a process for
documentation and supervisor review and approval.
(d) consideration of safety and security of the
facility, with a clearly defined expectation that
x
restraint devices shall not be used for the purposes
of discipline or retaliation.
(e) the use of restraints on pregnant youth is limited
in accordance with Penal Code Section 6030(f) and x
Welfare and Institutions Code Section 222.
1359 Safety Room Procedures Addressed in Wellpath Policy HCD 210-Y-E-09A
Safety Cell Placement and Retention, &
(a) The facility administrator, and where applicable,
Custody Policy, Lexipol 507, Butte County
in cooperation with the responsible physician, shall Probation Department
develop and implement written policies and
procedures governing the use of safety rooms, as
described in Title 24, Part 2, Section 1230.1.13. The
Intake area has a safety room that has been used
s
room shall be used to hold only those youth who
approximately three times in 24 years.
present an immediate danger to themselves or
others, who exhibit behavior which results in the
destruction of property, or reveals the intent to
cause self-inflicted physical harm. A safety room
shall not be used for punishment or discipline, or as
a substitute for treatment. Policies and procedures
shall:
(1) include provisions for administration of
necessary nutrition and fluids, access to a
x
toilet, and suitable clothing to provide for
privacy;
(2) provide for approval of the facility manager,
x
or designee, before a youth is placed into a
safety room;
(3) provide for continuous direct visual
supervision and documentation of the youth's
x
behavior and any staff interventions every 15
minutes, with actual time recorded;
(4) provide that the youth shall be evaluated by
x
the facility manager, or designee, every four
hours;
(5)provide for immediate medical assessment,
x
where appropriate, or an assessment at the
next daily sick call; and,
(6) provide a process for documenting the
reason for placement, including attempts to
x
use less restrictive means of control, and
decisions to continue and end placement.
JUV HEALTH ENVIRONMENT PAGE 51 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
(b)The placement of a youth in the safety room shall
x
be accomplished in accordance with the following:
(1) safety room shall not be used before other
less restrictive options have been attempted
x
and exhausted, unless attempting those
options poses a threat to the safety or security
of any youth or staff.
(2)safety room shall not be used for the purposes
x
of punishment, coercion, convenience, or
retaliation by staff.
(3) safety room shall not be used to the extent
x
that it compromises the mental and physical
health of the youth.
Addressed in Lexipol policy 601
(c) A youth may be held up to four hours in the
safety room. After the youth has been held in the
x
safety room for a period of four hours, staff shall do
one or more of the following:
(1)return the youth to general population.
x
(2)consult with mental health or medical staff,
x
(3)develop an individualized plan that includes
the goals and objectives to be met in order
x
to reintegrate the youth to general
population.
(d) If confinement in the safety room must be
extended beyond four hours, staff shall develop an
individualized plan that includes the requirements of
x
Section 1354.5 and the goals and objectives to be
met in order to integrate the youth to general
population.
Itemized Summary
III. Medical/Mental Health Evaluation
Juvenile Halls, Special Purpose Juvenile Halls and Camps
Page 28
Addressed in Wellpath policy HCD 210Y D-07
Deficiency: First aid kits are available but contents are not uniform or defined in policy. Process is in place for inspecting kits but has
holes that allows gaps in ensuring contents are current and complete.
Corrective Action: Amend policy to include inventory list, inventory quantity, location of all first aid kits and process for ensuring
contents are complete and up-to-date
Page 34
Facility does not have staffing to provide MAT for opioid use disorder.
Commendations: (1) Facility is a Vaccines for Children (VFC) provider and RN is committed to getting immunizations up to date. New
data logger information for VFC appliances will be forwarded to the RN by local health department vaccine coordinator. (2) RN
provides Covid screening outside facility before youth enter to decrease transmission in to facility. (3) RN provides reproductive
health education to youth in facility. Local health department, health education specialist will connect with RN to coordinate
education efforts and promote birth control methods and STD testing available at Public Health clinics.
JUV HEALTH ENVIRONMENT PAGE 52 Juvenile Facilities BSCC FORM 458 (Rev.01/2019)
ADULT COURT AND TEMPORARY HOLDING FACILITIES
Local Detention Facility Health Inspection Report
Health and Safety Code Section 101045
BSCC #: ___________
FACILITY NAME:COUNTY:
Oroville - Butte County Courthouse Butte
FACILITY ADDRESS (STREET, CITY, ZIP CODE, TELEPHONE):
One Court Street, Oroville, CA 95965
CHECK THE FACILITY TYPE AS DEFINED IN TITLE 15, COURT HOLDING TEMPORARY HOLDING
SECTION 1006:
FACILITY: X FACILITY:
ENVIRONMENTAL HEALTH EVALUATION DATE INSPECTED: 02/07/2022
ENVIRONMENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Alana Kong, Registered Environmental Health Specialist II, (530) 552-3998
Leslie Roberts, Senior Registered Environmental Health Specialist, (530) 552-3872
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Robert Allen, Deputy Sheriff, (530) 532-7002
NUTRITIONAL EVALUATIONDATE INSPECTED:
NUTRITIONAL EVALUATORS (NAME, TITLE, TELEPHONE):
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
MEDICAL/MENTAL HEALTH EVALUATION DATE INSPECTED: 02/07/2022
MEDICAL/MENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Monica Soderstrom, Division Director, Public Health, (530) 552-3930
David Canton, Public Health Officer, (53) 552-3993
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Robert (Bobby) Allen, BCSO Sergeant, (530) 538-7817
Scott Miller, Courthouse Administrator
This checklist is to be completed pursuant to the attached instructions.
1
I. ENVIRONMENTAL HEALTH EVALUATION
Adult Court and Temporary Holding Facilities
ARTICLE/SECTION YESNO N/A COMMENTS
Article 12. Food
Approach for Providing Food Service
(Not applicable to CH)
x
Food served in the facility is prepared in the facility.
If "No," respond to items 1 and 2 below prior to
continuing with the checklist.
1. Food is prepared at another city or county Sack lunches will be provided by the Butte County
detention facility.
Jail in the event the prisoner is housed during the
x noon meal. No potentially hazardous foods that
need time temperature control are served. No
utensils provided for safety reasons.
2. Food is contracted through a private vendor No private vendor utilized. Butte County Jail has a
who had been inspected and complies with
x permitted kitchen with Butte County
provisions of CalCode.
Environmental Health.
1245 Kitchen Facilities, Sanitation and Food
No kitchen facility or food preparation
Service
(Not applicable to CH)
x
Kitchen facilities, sanitation, and food preparation,
service and storage comply with standards set forth
in CalCode.
In facilities where inmates prepare meals for self-
consumption, or where frozen meals are pre-
prepared food from other facilities permitted
pursuant to HSC §114381 is (re)heated and served,
x
the following CalCode standards may be waived by
the local health officer.
HSC §114130-114141
HSC §114099.6, 114095-114099.5,114101-
114109, 114123 and 114125 if a domestic or
commercial dishwasher, capable of providing
x
heat to the surface of utensils of at least 165
degrees Fahrenheit, is used to clean and
sanitize multi-service utensils and multi-service
consumer utensils;
HSC §114149-114149.3 except that, regardless
of such a waiver, the facility shall provide
x
mechanical ventilation sufficient to remove
gases, odors, steam, heat, grease, vapors and
smoke from the kitchen;
2
ARTICLE/SECTION YESNO N/A COMMENTS
HSC §114268-114269 x
HSC §114279-114282 x
1246 Food Serving and Supervision
No food preparation done at this facility
(Not applicable to CH)
Policies and procedures ensure that appropriate
x
work assignments are made, and food handlers are
adequately supervised. Food is prepared and served
only under the immediate supervision of a staff
member.
Article 14. Bedding and Linens
1270 Standard Bedding and Linen Issue Inmates never held longer than 12 hours
(Not applicable to CH)
x
The standard issue of clean suitable bedding and
linens, for each inmate entering a living area who is
expected to remain overnight, shall include, but not
be limited to:
(a) One serviceable mattress which meets the
x
requirements of Title 15 §1272;
(b) one mattress cover or one sheet; x
(c) one blanket or more depending upon climatic
conditions. Two blankets or sleep bag may be
x
issued in place of one mattress cover or one
sheet
(d) one towel x
Temporary Holding facilities which hold persons
x
longer than 12 hours shall meet the requirements of
1, 2 and 3 above.
1272 Mattresses
(Not applicable to CH)
x
Mattresses are enclosed in an easily cleaned, non-
absorbent ticking and conform to the size of the
bunk as referenced in Title 24, Part 2, §1231.3.5
Beds (at least 30" wide X 76" long).
Any mattress purchased for issue to an inmate in a
facility, which is locked to prevent unimpeded
access to the outdoors, is certified by the
x
manufacturer as meeting all requirements of the
State Fire Marshal and Bureau of Home Furnishings
for penal mattresses at the time of purchase.
3
ARTICLE/SECTION YESNO N/A COMMENTS
Article 15. Facility Sanitation and Safety
1280 Facility Sanitation, Safety and Maintenance
Policies and procedures in place but not being
adhered to.
There are policies and procedures for the
x
maintenance of an acceptable level of cleanliness,
Janitorial contract with Pro-Line Cleaning Services,
repair and safety throughout the facility. Inc.
The plan provides for a regular schedule of Deficiency – holding cell next to the attorney
housekeeping tasks and inspections to identify and visiting room and cells 42 and 43 have no hot
correct unsanitary or unsafe conditions or work water
practices.
Corrective action –provide hot water. Hot water
was turned back on during inspection, corrected
on stie.
Deficiency – lights in the holding cell (next to
x
attorney visiting room) and the attorney visiting
room were not working.
Corrective action – repair
Deficiency – A chain was hooked onto the back of
the char in the attorney visiting room
Corrective action – remove the chain
Itemized Summary
I. Environmental Health Evaluation
Oroville Courthouse
Page 4
Policies and procedures in place but not being adhered to.
Janitorial contract with Pro-Line Cleaning Services, Inc.
Deficiency – holding cell next to the attorney visiting room and cells 42 and 43 have no hot water
Corrective action – provide hot water. Hot water was turned back on during inspection, corrected on stie.
Deficiency – lights in the holding cell (next to attorney visiting room) and the attorney visiting room were not working.
Corrective action – repair
Deficiency – A chain was hooked onto the back of the char in the attorney visiting room
Corrective action – remove the chain
Summary of environmental health evaluation: Deficiencies found with plumbing fixtures and lighting within the facility that need to
be addressed. The hot water was turned off due to holding cells being unoccupied, which was then turned on during the inspection.
Have policies in place to ensure hot water is turned on when cells are going to be occupied and to check lights regularly to ensure
they are working.
Best Practices: Have soap available for inmates to wash their hands, when requested.
4
III. MEDICAL/MENTAL HEALTH EVALUATION
Adult Court and Temporary Holding Facilities
ARTICLE/SECTIONYES NO N/A COMMENTS
Article 11. Health Services
1200 Responsibility for Health Care Services
Staff was not initially aware of manual but manual
In court holding and temporary holding facilities, the
was identified during visit
facility administrator shall have the responsibility to
X
develop written policies and procedures which
ensure provision of emergency health care services
to all inmates.
1207 Medical Receiving Screening
Manual addresses cases should a prisoner be taken
(Not applicable to CH)
into custody at the court house pending transfer to
the jail where screen would occur.
X
A receiving screening is performed on all inmates at
the time of intake, with the exception of inmates
transferred directly within a custody system with
documented receiving screening
This screening shall be completed in accordance
with written procedures and shall include but not be
limited to medical and mental health problems, X
developmental disabilities, tuberculosis and other
communicable diseases.
The screening shall be performed by licensed health
personnel or trained facility staff, with
documentation of staff training regarding site
specific forms with appropriate disposition based on
X
responses to questions and observations made at
the time of screening. The training depends on the
role staff are expected to play in the receiving
screening process.
The facility administrator and responsible physician
shall develop a written plan for complying with
X
Penal Code Section 2656 (orthopedic or prosthetic
appliance used by inmates).
There shall be a written plan to provide care for any
inmate who appears at this screening to be in need
X
of or who requests medical, mental health, or
developmental disability treatment.
Written procedures and screening protocol shall be
X
established by the responsible physician in
cooperation with the facility administrator.
5
ARTICLE/SECTIONYES NO N/A COMMENTS
1209 Mental Health Services and Transfer to a Manual does address cases where person is taken
Treatment Facility into custody in the court house pending transfer to
the jail where services would occur.
(Not applicable to CH)
X
(a) The health authority, in cooperation with the
mental health director and facility
administrator, shall establish policies and
procedures to provide mental health services.
These services shall include but not be limited
to:
1.Identification and referral of inmates
X
with mental health needs;
2.Mental health treatment programs
X
provided by qualified staff, including the
use of teleheath.
3. Crisis intervention services; X
4. Basic mental health services provided, as
X
clinically indicated;
X
5. Medication support services; and,
6. The provision of health services
sufficiently coordinated such that care is
appropriately integrated, medical and
X
mental health needs are met, and the
impact of any of these conditions on each
other is adequately addressed.
(b) Unless the county has elected to implement
the provisions of Penal Code Section 1369.1, a
mentally disordered inmate who appears to
be a danger to himself or others, or to be
gravely disabled, shall be transferred for
further evaluation to a designated Lanterman
Petris Short treatment facility designated by
X
the county and approved by the State
Department of Mental Health for diagnosis
and treatment of such apparent mental
disorder pursuant to Penal Code section
4011.6 or 4011.8 unless the jail contains a
designated Lanterman Petris Short treatment
facility.
Prior to the transfer, the inmate may be
evaluated by licensed health personnel to
determine if treatment can be initiated at the
correctional facility. Licensed health
personnel may perform an onsite assessment X
to determine if the inmate meets the criteria
for admission to an inpatient facility, or if
treatment can be initiated in the correctional
facility.
6
ARTICLE/SECTIONYES NO N/A COMMENTS
(c) If the county elects to implement the
provisions of Penal Code Section 1369.1, the
health authority, in cooperation with the
facility administrator, shall establish policies
X
and procedures for involuntary
administration of medications. The
procedures shall include, but not be limited
to:
1. Designation of licensed personnel,
including psychiatrist and nursing staff,
X
authorized to order and administer
involuntary medication;
2. Designation of an appropriate setting
X
where the involuntary administration of
medication will occur;
3. Designation of restraint procedures
and/or devices that may be used to
X
maintain the safety of the inmate and
facility staff;
4. Development of a written plan to
monitor the inmate's medical condition
following the initial involuntary
administration of a medication, until the
inmate is cleared as a result of an
evaluation by, or consultation with, a
psychiatrist;
X
7
ARTICLE/SECTIONYES NO N/A COMMENTS
5. Development of a written plan to provide
a minimum level of ongoing monitoring
of the inmate following return to facility
housing. This monitoring may be
performed by custody staff trained to
recognize signs of possible medical
problems and alert medical staff when
indicated; and
X
6. Documentation of the administration of
X
involuntary medication in the inmate's
medical record.
1212 Vermin Control
Manual does address cases where individual is taken
(Not applicable to CH)
into custody in the court house and transferred to
the jail where control and treatment would occur.
The responsible physician shall develop a written
X
plan for the control and treatment of vermin-
infested inmates. There shall be written, medical
protocols, signed by the responsible physician, for
the treatment of persons suspected of being
infested or having contact with a vermin-infested
inmate.
1213 Detoxification Treatment
(Not applicable to CH)
The responsible physician shall develop written
medical policies on detoxification which shall include
X
a statement as to whether detoxification will be
provided within the facility or require transfer to a
licensed medical facility. The facility detoxification
protocol shall include procedures and symptoms
necessitating immediate transfer to a hospital or
other medical facility.
Facilities without medically licensed personnel in
attendance shall not retain inmates undergoing
withdrawal reactions judged or defined in policy, by
X
the responsible physician, as not being readily
controllable with available medical treatment. Such
facilities shall arrange for immediate transfer to an
appropriate medical facility.
8
ARTICLE/SECTIONYES NO N/A COMMENTS
1220 First Aid Kits
X
First aid kit(s) shall be available in all facilities.
The responsible physician shall approve the Deficiency: First aid kits contents are not
contents, number, location and procedure for standardized. Manual is not specific as to contents
periodic inspection of the kit(s). In Court and and quantity. While policy states kits are to be
Temporary Holding facilities, the facility inspected at least monthly, expired items were
administrator shall have the above approval found in the kits and contents varied from kit to kit.
authority, pursuant to Section 1200 of these
Corrective Action: edit manual to make specific list
regulations.
of contents and review inspection process to ensure
X
compliance with policy.
Best practice would be to have first aid kits in both
court houses mirror each other in content and
location.
1046 Death in Custody Addressed in section 2.1046 of manual
(a) Death in Custody Reviews for Adults and
Minors.
The facility administrator, in cooperation with
the health administrator, shall develop written
policy and procedures to ensure that there is
X
an initial review of every in-custody death
within 30 days. The review team shall include
the facility administrator and/or the facility
manager, the health administrator, the
responsible physician and other health care
and supervision staff who are relevant to the
incident.
Deaths shall be reviewed to determine the
appropriateness of clinical care; whether
changes to policies, procedures, or practices
X
are warranted; and to identify issues that
No in custody deaths occurred in court house
require further study.
during inspection period.
(b) Death of a Minor.
No death of in custody minor occurred in court
In any case in which a minor dies while
X
house during inspection period.
detained in a jail, lockup, or court holding
facility:
(1) The administrator of the facility shall
provide to the Board a copy of the report
submitted to the Attorney General under
X
Government Code Section 12525. A copy
of the report shall be submitted within 10
calendar days after the death.
(2) Upon receipt of a report of death of a
minor from the administrator, the Board
may within 30 calendar days inspect and
evaluate the jail, lockup, or court holding
X
facility pursuant to the provisions of this
subchapter. Any inquiry made by the
Board shall be limited to the standards
and requirements set forth in these
regulations.
9
ARTICLE/SECTIONYES NO N/A COMMENTS
1051 Communicable Diseases
Addressed in section 2.1051 of the manual
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures specifying those symptoms that
require segregation of an inmate until a medical
evaluation is completed.
At the time of intake into the facility, an inquiry shall
be made of the person being booked as to whether or
not he/she has or has had any communicable
X
diseases, such as tuberculosis or has observable
symptoms of tuberculosis or any other communicable
diseases, or other special medical problem identified
by the health authority.
The response shall be noted on the booking form
X
and/or screening device.
1052 Mentally Disordered Inmates
Addressed in section 2.1052 for Court House Policy
The facility administrator, in cooperation with the
manual.
responsible physician, shall develop written policies
and procedures to identify and evaluate all mentally
disordered inmates, and may include telehealth. If an
X
evaluation from medical or mental health staff is not
readily available, an inmate shall be considered
mentally disordered for the purpose of this section if
he or she appears to be a danger to himself/herself or
others or if he/she appears gravely disabled.
An evaluation from medical or mental health staff
shall be secured within 24 hours of identification or
X
at the next daily sick call, whichever is earliest.
Segregation may be used if necessary to protect the
safety of the inmate or others.
1055 Use of Safety Cell Safety cell is not available
The safety cell described in Title 24, Part 2, Section
1231.2.5, shall be used to hold only those inmates
X
who display behavior which results in the
destruction of property or reveals an intent to cause
physical harm to self or others
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
and procedures governing safety cell use and may X
delegate authority to place an inmate in a safety cell
to a physician.
In no case shall the safety cell be used for
X
punishment or as a substitute for treatment.
An inmate shall be placed in a safety cell only with
the approval of the facility manager or designee, or
X
responsible health care staff; continued retention
shall be reviewed a minimum of every four hours.
10
ARTICLE/SECTIONYES NO N/A COMMENTS
A medical assessment shall be completed within a
maximum of 12 hours of placement in the safety cell
or at the next daily sick call, whichever is earliest. X
The inmate shall be medically cleared for continued
retention every 24 hours thereafter.
The facility manager, designee or responsible health
care staff shall obtain a mental health
opinion/consultation with responsible health care X
staff on placement and retention, which shall be
secured within 12 hours of placement.
Direct visual observation shallbe conducted at least
twice every thirty minutes. Such observation shall be X
documented.
Procedures shall be established to assure
administration of necessary nutrition and fluids.
Inmates shall be allowed to retain sufficient clothing,
or be provided with a suitably designed “safety
X
garment,” to provide for their personal privacy
unless specific identifiable risks to the inmate's
safety or to the security of the facility are
documented.
1056 Use of Sobering Cell Sobering Cell is not available
The sobering cell described in Title 24, Part 2,
Section 1231.2.4, shall be used for the holding of
inmates who are a threat to their own safety or the
safety of others due to their state of intoxication and
pursuant to written policies and procedures
developed by the facility administrator. Such
inmates shall be removed from the sobering cell as
X
they are able to continue in the processing. In no
case shall an inmate remain in a sobering cell over
six hours without an evaluation by a medical staff
person or an evaluation by custody staff, pursuant
to written medical procedures in accordance with
section 1213 of these regulations, to determine
whether the prisoner has an urgent medical
problem.
At 12 hours from the time of placement, all inmates
will receive an evaluation by responsible health care
staff. Intermittent direct visual observation of X
inmates held in the sobering cell shall be conducted
no less than every half hour.
Such observation shall be documented. X
11
ARTICLE/SECTIONYES NO N/A COMMENTS
1057 Developmentally Disabled Inmates
Addressed in section 1.1059 of Court House Policy
The facility administrator, in cooperation with the
manual.
responsible physician, shall develop written policies
X
and procedures for the identification and evaluation,
appropriate classification and housing, protection,
and nondiscrimination of all developmentally
disabled inmates.
The health authority or designee shall contact the
Deficiency: Contacting regional center is not
regional center on any inmate suspected or confirmed
addressed in policy manual.
to be developmentally disabled for the purposes of
X
diagnosis and/or treatment within 24 hours of such
Corrective action: edit policy and train staff to
determination, excluding holidays and weekends.
contact regional center for inmates thought to be
developmentally disabled.
1058 Use of Restraint Devices
Addressed in section 2.1058 of the Court Holding
Facility Manual
The facility administrator, in cooperation with the
X
responsible physician, shall develop written policies
and procedures for the use of restraint devices and
may delegate authority to place an inmate in
restraints to a responsible health care staff.
In addition to the areas specifically outlined in this
regulation, at a minimum, the policy shall address the
following areas:
acceptable restraint devices;
signs or symptoms which should result in
immediate medical/mental health referral;
X
availability of cardiopulmonary
resuscitation equipment;
protective housing of restrained persons;
provision for hydration and sanitation
needs; and
exercising of extremities.
In no case shall restraints be usedfor punishment or
X
as a substitute for treatment.
Restraint devices shall only be used on inmates who
display behavior which results in the destruction of
property or reveal an intent to cause physical harm to
X
self or others. Restraint devices include any devices
which immobilize an inmate's extremities and/or
prevent the inmate from being ambulatory.
Physical restraints should be utilized only when it
X
appears less restrictive alternatives would be
ineffective in controlling the disordered behavior.
Inmates shall be placed in restraints only with the Deficiency: Section 2.1058(5) of Court Holding
Facility Manual allows for review every 2 hours.
approval of the facility manager, the facility watch
X
commander, responsible health care staff;
Corrective action: amend policy and procedure to
continued retention shall be reviewed a minimum of
comply with standard of every hour.
every hour.
12
ARTICLE/SECTIONYES NO N/A COMMENTS
A medical opinion on placement and retention shall Deficiency: Section 2.1058 (5) of Policy allows for
be secured within one hour from the time of medical opinion within 6 hours
placement. A medical assessment shall be
X
Corrective action: amend policy and procedure to
completed within four hours of placement.
comply with standard of within four (4) hours in
Court Holding Facility Manual
If the facility manager, or designee, in consultation Addressed in section 2.1058(6) of Court Holding
with responsible health care staff determines that Facility Manual
an inmate cannot be safely removed from restraints X
after eight hours, the inmate shall be taken to a
medical facility for further evaluation.
Direct visual observation shall be conducted at least Addressed in section 2.1058(5) of Court Holding
twice every thirty minutes to ensure that the Facility Manual
X
restraints are properly employed, and to ensure the
safety and well-being of the inmate. Such
observation shall be documented.
While in restraint devices all inmates shall be housed Addressed in section 2.1058(5) of Court Holding
alone or in a specified housing area for restrained Facility Manual
X
inmates which makes provisions to protect the
inmate from abuse.
The provisions of this section do not apply to the use
of handcuffs, shackles or other restraint devices X
when used to restrain inmates for security reasons.
1058.5 RESTRAINTS AND PREGNANT INMATES Addressed in section 2.1058(6) of Court Holding
Facility Manual
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures for the use of restraint devices on
pregnant inmates. In accordance with Penal Code
3407 the policy shall include reference to the
following:
(1) An inmate known to be pregnant or in
recovery after delivery shall not be
X
restrained by the use of leg irons, waist
chains, or handcuffs behind the body.
(2) A pregnant inmate in labor, during
delivery, or in recovery after delivery,
shall not be restrained by the wrists,
X
ankles, or both, unless deemed necessary
for the safety and security of the inmate,
the staff, or the public.
(3) Restraints shall be removed when a
professional who is currently responsible
for the medical care of a pregnant inmate
X
during a medical emergency, labor,
delivery, or recovery after delivery
determines that the removal of restraints
is medically necessary.
13
ARTICLE/SECTIONYES NO N/A COMMENTS
(4) Upon confirmation of an inmate's
pregnancy, she shall be advised, orally or
X
in writing, of the policies governing
pregnant inmates.
Itemized Summary
III. Medical/Mental Health Evaluation
Oroville Courthouse
Page 9
Deficiency - First aid kits contents are not standardized. Manual is not specific as to contents and quantity.
While policy states kits are to be inspected at least monthly, expired items were found in the kits and contents
varied from kit to kit.
Corrective Action -edit manual to make specific list of contents and review inspection process to ensure
compliance with policy.
Best practice:would be to have first aid kits in both court houses mirror each other in content and location.
Page 12
Deficiency - Contacting regional center is not addressed in policy manual.
Corrective action - edit policy and train staff to contact regional center for inmates thought to be
developmentally disabled.
Deficiency - Section 2.1058(5) of Court Holding Facility Manual allows for review every 2 hours.
Corrective action - amend policy and procedure to comply with standard of every hour.
Page 13
Deficiency-Section 2.1058 (5) of Policy allows for medical opinion within 6 hours
Corrective action-amend policy and procedure to comply with standard of within four (4) hours in Court
Holding Facility Manual
Overall, the facility seemed to be operated in an appropriate fashion. Deputies were cooperative and
forthright in assisting with and facilitating the inspection. Deficiencies are primarily related to policy edits and
.
training to the policies
14
ADULT COURT AND TEMPORARY HOLDING FACILITIES
Local Detention Facility Health Inspection Report
Health and Safety Code Section 101045
BSCC #: ___________
FACILITY NAME:COUNTY:
Town of Paradise Police Department Butte
FACILITY ADDRESS (STREET, CITY, ZIP CODE, TELEPHONE):
5595 Black Olive Dr. Paradise, CA 95969 (530) 872-6161
CHECK THE FACILITY TYPE AS DEFINED IN TITLE 15, COURT HOLDING TEMPORARY HOLDING
SECTION 1006:
FACILITY: FACILITY: X
ENVIRONMENTAL HEALTH EVALUATION DATE INSPECTED: 02/08/2022
ENVIRONMENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Alana Kong, Registered Environmental Health Specialist II, (530) 552-3998
Leslie Roberts, Senior Registered Environmental Health Specialist, (530) 552-3872
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Anthony Borgman, Lieutenant, (530) 872-6161 ext. 202
NUTRITIONAL EVALUATIONDATE INSPECTED:
NUTRITIONAL EVALUATORS (NAME, TITLE, TELEPHONE):
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
MEDICAL/MENTAL HEALTH EVALUATION DATE INSPECTED: 02/08/2022
MEDICAL/MENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Monica Soderstrom, Division Director, Public Health, (530) 552-3930
David Canton, Public Health Officer, (53) 552-3993
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Anthony Borgman, Lieutenant, (530) 872-6161 ext. 202
Officer Cameron Kovacs
This checklist is to be completed pursuant to the attached instructions.
1
I. ENVIRONMENTAL HEALTH EVALUATION
Adult Court and Temporary Holding Facilities
ARTICLE/SECTIONYESNON/ACOMMENTS
Article 12. Food
Approach for Providing Food Service 902.9.2 Prisoner Food Service
(Not applicable to CH)
x
Food served in the facility is prepared in the facility.
If "No," respond to items 1 and 2 below prior to
continuing with the checklist.
1. Food is prepared at another city or county
x
detention facility.
2. Food is contracted through a private vendor
x
who had been inspected and complies with
provisions of CalCode.
1245 Kitchen Facilities, Sanitation and Food
No kitchen facility or food preparation
Service
(Not applicable to CH)
x
Kitchen facilities, sanitation, and food preparation,
service and storage comply with standards set forth
in CalCode.
In facilities where inmates prepare meals for self-
consumption, or where frozen meals are pre-
prepared food from other facilities permitted
pursuant to HSC §114381 is (re)heated and served,
x
the following CalCode standards may be waived by
the local health officer.
HSC §114130-114141
HSC §114099.6,114095-114099.5,114101-
114109, 114123 and 114125 if a domestic or
commercial dishwasher, capable of providing
x
heat to the surface of utensils of at least 165
degrees Fahrenheit, is used to clean and
sanitize multi-service utensils and multi-service
consumer utensils;
HSC §114149-114149.3 except that, regardless
of such a waiver, the facility shall provide
x
mechanical ventilation sufficient to remove
gases, odors, steam, heat, grease, vapors and
smoke from the kitchen;
HSC §114268-114269 x
HSC §114279-114282 x
2
ARTICLE/SECTION YESNO N/A COMMENTS
1246 Food Serving and Supervision
No food preparation done at this facility
(Not applicable to CH)
Policies and procedures ensure that appropriate
x
work assignments are made, and food handlers are
adequately supervised. Food is prepared and served
only under the immediate supervision of a staff
member.
Article 14. Bedding and Linens
1270 Standard Bedding and Linen Issue Held for 6 hours max
(Not applicable to CH)
x
The standard issue of clean suitable bedding and
linens, for each inmate entering a living area who is
expected to remain overnight, shall include, but not
be limited to:
(a) One serviceable mattress which meets the
x
requirements of Title 15 §1272;
x
(b) one mattress cover or one sheet;
(c) one blanket or more depending upon climatic Blanket available
conditions. Two blankets or sleep bag may be
x
issued in place of one mattress cover or one
sheet
x
(d) one towel
Temporary Holding facilities which hold persons
x
longer than 12 hours shall meet the requirements of
1, 2 and 3 above.
1272 Mattresses
(Not applicable to CH)
x
Mattresses are enclosed in an easily cleaned, non-
absorbent ticking and conform to the size of the
bunk as referenced in Title 24, Part 2, §1231.3.5
Beds (at least 30" wide X 76" long).
Any mattress purchased for issue to an inmate in a
facility, which is locked to prevent unimpeded
access to the outdoors, is certified by the
x
manufacturer as meeting all requirements of the
State Fire Marshal and Bureau of Home Furnishings
for penal mattresses at the time of purchase.
3
ARTICLE/SECTION YESNO N/A COMMENTS
Article 15. Facility Sanitation and Safety
1280 Facility Sanitation, Safety and Maintenance 902.22
Janitorial services 3 times per week
There are policies and procedures for the
x
maintenance of an acceptable level of cleanliness,
repair and safety throughout the facility.
The plan provides for a regular schedule of Deficiency – light is out in right holding cell
housekeeping tasks and inspections to identify and
x
Corrective action – repair
correct unsanitary or unsafe conditions or work
practices.
Itemized Summary
I. ENVIRONMENTAL HEALTH EVALUATION
Paradise Police Department
Page 4
Deficiency – light is out in right holding cell
Corrective action –repair
Summary of environmental health evaluation: Overall the facility is clean and in good working condition.
4
III. MEDICAL/MENTAL HEALTH EVALUATION
Adult Court and Temporary Holding Facilities
ARTICLE/SECTIONYES NO N/A COMMENTS
Article 11. Health Services
1200 Responsibility for Health Care Services
Addressed in section 900.5.3 of the Department
In court holding and temporary holding facilities, the
Policy Manual. Policies also address staff
facility administrator shall have the responsibility to
maintaining CPR and basic first aid training and
X
develop written policies and procedures which
access to first aid kit.
ensure provision of emergency health care services
to all inmates.
1207 Medical Receiving Screening
Addressed in section 902.11.1 of the Department
(Not applicable to CH)
Policy Manual
X
A receiving screening is performed on all inmates at
the time of intake, with the exception of inmates
transferred directly within a custody system with
documented receiving screening
This screening shall be completed in accordance Medical screening form template reviewed and
with written procedures and shall include but not be stack of completed screenings done in the past year
X were available for review by inspectors.
limited to medical and mental health problems,
developmental disabilities, tuberculosis and other
communicable diseases.
Training of facility staff done every two years
The screening shall be performed by licensed health
personnel or trained facility staff, with
documentation of staff training regarding site
specific forms with appropriate disposition based on
X
responses to questions and observations made at
the time of screening. The training depends on the
role staff are expected to play in the receiving
screening process.
The facility administrator and responsible physician Addressed in section 900.5.4 of the Department
shall develop a written plan for complying with Policy Manual
X
Penal Code Section 2656 (orthopedic or prosthetic
appliance used by inmates).
There shall be a written plan to provide care for any Section 467.1 of Policy manual addresses Medical
inmate who appears at this screening to be in need Aid and Response. Section 467.4 addresses
X
of or who requests medical, mental health, or Transporting Ill and Injured Persons.
developmental disability treatment.
Written procedures and screening protocol shall be
established by the responsible physician in X
cooperation withthe facility administrator.
5
ARTICLE/SECTIONYES NO N/A COMMENTS
1209 Mental Health Services and Transfer to a Addressed in section 902.11.1 of the Department
Treatment Facility Policy Manual
(Not applicable to CH)
X
(a) The health authority, in cooperation with the
mental health director and facility
administrator, shall establish policies and
procedures to provide mental health services.
These services shall include but not be limited
to:
1.Identification and referral of inmates
Inmate requiring mental health services are not
with mental health needs;
X
maintained within the facility and transferred for
care
2. Mental health treatment programs
X
provided by qualified staff, including the
use of teleheath.
X
3. Crisis intervention services;
4. Basic mental health services provided, as
X
clinically indicated;
5. Medication support services; and, X
6. The provision of health services
sufficiently coordinated such that care is
appropriately integrated, medical and
X
mental health needs are met, and the
impact of any of these conditions on each
other is adequately addressed.
(b) Unless the county has elected to implement
the provisions of Penal Code Section 1369.1, a
mentally disordered inmate who appears to
be a danger to himself or others, or to be
gravely disabled, shall be transferred for
further evaluation to a designated Lanterman
Petris Short treatment facility designated by
X
the county and approved by the State
Department of Mental Health for diagnosis
and treatment of such apparent mental
disorder pursuant to Penal Code section
4011.6 or 4011.8 unless the jail contains a
designated Lanterman Petris Short treatment
facility.
6
ARTICLE/SECTIONYES NO N/A COMMENTS
Prior to the transfer, the inmate may be No licensed health personnel are on staff. Any
evaluated by licensed health personnel to inmates requiring evaluation are transferred to the
county jail or local medical facilities
determine if treatment can be initiated at the
correctional facility. Licensed health
X
personnel may perform an onsite assessment
to determine if the inmate meets the criteria
for admission to an inpatient facility, or if
treatment can be initiated in the correctional
facility.
(c) If the county elects to implement the
provisions of Penal Code Section 1369.1, the
health authority, in cooperation with the
facility administrator, shall establish policies
X
and procedures for involuntary
administration of medications. The
procedures shall include, but not be limited
to:
1. Designation of licensed personnel,
including psychiatrist and nursing staff,
X
authorized to order and administer
involuntary medication;
2. Designation of an appropriate setting
X
where the involuntary administration of
medication will occur;
3. Designation of restraint procedures
and/or devices that may be used to
X
maintain the safety of the inmate and
facility staff;
7
ARTICLE/SECTIONYES NO N/A COMMENTS
4. Development of a written plan to No licensed medical personnel areon staff. No
monitor the inmate's medical condition
medications are given.
following the initial involuntary
administration of a medication, until the
inmate is cleared as a result of an
evaluation by, or consultation with, a
psychiatrist;
X
5. Development of a written plan to provide Addressed in section 900.3.1 of the Department
a minimum level of ongoing monitoring
Policy Manual
of the inmate following return to facility
housing. This monitoring may be
performed by custody staff trained to
recognize signs of possible medical
problems and alert medical staff when
indicated; and
X
6. Documentation of the administration of
X
involuntary medication in the inmate's
medical record.
8
ARTICLE/SECTIONYES NO N/A COMMENTS
1212 Vermin Control
Addressed in section 902.15 of the Department
(Not applicable to CH)
Policy Manual
The responsible physician shall develop a written
X
plan for the control and treatment of vermin-
infested inmates. There shall be written, medical
protocols, signed by the responsible physician, for
the treatment of persons suspected of being
infested or having contact with a vermin-infested
inmate.
1213 Detoxification Treatment
Detoxification is not available in this facility.
(Not applicable to CH)
Addressed in section 902.3.1 of the Department
Policy Manual
The responsible physician shall develop written
medical policies on detoxification which shall include
X
a statement as to whether detoxification will be
provided within the facility or require transfer to a
licensed medical facility. The facility detoxification
protocol shall include procedures and symptoms
necessitating immediate transfer to a hospital or
other medical facility.
Facilities without medically licensed personnel in
Addressed in section 902.3.1 of the Department
attendance shall not retain inmates undergoing
Policy Manual
withdrawal reactions judged or defined in policy, by
X
the responsible physician, as not being readily
controllable with available medical treatment. Such
facilities shall arrange for immediate transfer to an
appropriate medical facility.
1220 First Aid Kits
Addressed in section 900.5.3 of the Department
X
Policy Manual
First aid kit(s) shall be available in all facilities.
The responsible physician shall approve the Deficiency: Policy is not in place with location and
contents, number, location and procedure for approved inventory list of contents of first aid kits.
periodic inspection of the kit(s). In Court and Also, Policy is not in place for consistent inspection
of kits for currency and completeness
Temporary Holding facilities, the facility
administrator shall have the above approval
Corrective Action: update policy manual to include
X
authority, pursuant to Section 1200 of these
inventory list of first aid kits, locations, and
regulations.
inspection procedure.
9
ARTICLE/SECTIONYES NO N/A COMMENTS
1046 Death in Custody
Addressed in section 900.9 of the Department Policy
(a) Death in Custody Reviews for Adults and
Manual
Minors.
The facility administrator, in cooperation with
the health administrator, shall develop written
policy and procedures to ensure that there is
X
an initial review of every in-custody death
within 30 days. The review team shall include
the facility administrator and/or the facility
manager, the health administrator, the
responsible physician and other health care
and supervision staff who are relevant to the
incident.
Deaths shall be reviewed to determine the
No in custody deaths occurred during the inspection
appropriateness of clinical care; whether
period
X
changes to policies, procedures, or practices
are warranted; and to identify issues that
require further study.
(b) Death of a Minor.
In any case in which a minor dies while
X
detained in a jail, lockup, or court holding
facility:
(1) The administrator of the facility shall
No in custody deaths of a minor occurred during the
provide to the Board a copy of the report
inspection period
submitted to the Attorney General under
X
Government Code Section 12525. A copy
of the report shall be submitted within 10
calendar days after the death.
(2) Upon receipt of a report of death of a
minor from the administrator, the Board
may within 30 calendar days inspect and
evaluate the jail, lockup, or court holding
X
facility pursuant to the provisions of this
subchapter. Any inquiry made by the
Board shall be limited to the standards
and requirements set forth in these
regulations.
1051 Communicable Diseases
Addressed in section 902.11.1 of the Department
The facility administrator, in cooperation with the
Policy Manual
responsible physician, shall develop written policies
X
and procedures specifying those symptoms that
require segregation of an inmate until a medical
evaluation is completed.
At the time of intake into the facility, an inquiry shall
be made of the person being booked as to whether or
not he/she has or has had any communicable
X
diseases, such as tuberculosis or has observable
symptoms of tuberculosis or any other communicable
diseases, or other special medical problem identified
by the health authority.
The response shall be noted on the booking form
X
and/or screening device.
10
ARTICLE/SECTIONYES NO N/A COMMENTS
1052 Mentally Disordered Inmates
Addressed in section 902.11.1 of the Department
The facility administrator, in cooperation with the
Policy Manual
responsible physician, shall develop written policies
and procedures to identify and evaluate all mentally
disordered inmates, and may include telehealth. If an
X
evaluation from medical or mental health staff is not
readily available, an inmate shall be considered
mentally disordered for the purpose of this section if
he or she appears to be a danger to himself/herself or
others or if he/she appears gravely disabled.
An evaluation from medical or mental health staff
Inmates requiring mental health are transferred to
shall be secured within 24 hours of identification or
the county jail or local medical facilities. No mental
X
at the next daily sick call, whichever is earliest.
health care or treatment is provided in this facility
Segregation may be used if necessary to protect the
safety of the inmate or others.
1055 Use of Safety Cell
Safety cell is not available in this facility. Inmates
The safety cell described in Title 24, Part 2, Section
requiring Safety cell are transferred
1231.2.5, shall be used to hold only those inmates
X
who display behavior which results in the
destruction of property or reveals an intent to cause
physical harm to self or others
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures governing safety cell use and may
delegate authority to place an inmate in a safety cell
to a physician.
In no case shall the safety cell be used for
X
punishment or as a substitute for treatment.
An inmate shall be placed in a safety cell only with
the approval of the facility manager or designee, or
X
responsible health care staff; continued retention
shall be reviewed a minimum of every four hours.
A medical assessment shall be completed within a
maximum of 12 hours of placement in the safety cell
or at the next daily sick call, whichever is earliest. X
The inmate shall be medically cleared for continued
retention every 24 hours thereafter.
The facility manager, designee or responsible health
care staff shall obtain a mental health
X
opinion/consultation with responsible health care
staff on placement and retention, which shall be
secured within 12 hours of placement.
Direct visual observation shallbe conducted at least
X
twice every thirty minutes. Such observation shall be
documented.
11
ARTICLE/SECTIONYES NO N/A COMMENTS
Procedures shall be established to assure
administration of necessary nutrition and fluids.
Inmates shall be allowed to retain sufficient clothing,
or be provided with a suitably designed “safety
X
garment,” to provide for their personal privacy
unless specific identifiable risks to the inmate's
safety or to the security of the facility are
documented.
1056 Use of Sobering Cell
Sobering cell is not available in the facility.
The sobering cell described in Title 24, Part 2,
Intoxicated detainees are transferred to local
Section 1231.2.4, shall be used for the holding of
medical facilities for treatment.
inmates who are a threat to their own safety or the
safety of others due to their state of intoxication and
pursuant to written policies and procedures
developed by the facility administrator. Such
inmates shall be removed from the sobering cell as
X
they are able to continue in the processing. In no
case shall an inmate remain in a sobering cell over
six hours without an evaluation by a medical staff
person or an evaluation by custody staff, pursuant
to written medical procedures in accordance with
section 1213 of these regulations, to determine
whether the prisoner has an urgent medical
problem.
At 12 hours from the time of placement, all inmates
will receive an evaluation by responsible health care
staff. Intermittent direct visual observation of X
inmates held in the sobering cell shall be conducted
no less than every half hour.
Such observation shall be documented.
1057 Developmentally Disabled Inmates
Addressed in section 902.11.1 of the Department
The facility administrator, in cooperation with the
Policy Manual
responsible physician, shall develop written policies
X
and procedures for the identification and evaluation,
appropriate classification and housing, protection,
and nondiscrimination of all developmentally
disabled inmates.
The health authority or designee shall contact the
Developmentally disabled detainees are transferred
regional center on any inmate suspected or confirmed
to the county jail or local medical facilities as
X
to be developmentally disabled for the purposes of
deemed appropriate
diagnosis and/or treatment within 24 hours of such
determination, excluding holidays and weekends.
1058 Use of Restraint Devices
Addressed in section 900.6 of the Department Policy
Manual
The facility administrator, in cooperation with the
X
responsible physician, shall develop written policies
and procedures for the use of restraint devices and
may delegate authority to place an inmate in
restraints to a responsible health care staff.
12
ARTICLE/SECTIONYES NO N/A COMMENTS
In addition to the areas specifically outlined in this
regulation, at a minimum, the policy shall address the
Addressed in section 306.3 of the Department Policy
following areas:
Manual
acceptable restraint devices;
signsor symptoms which should result in
immediate medical/mental health referral;
availability of cardiopulmonary
resuscitation equipment;
protective housing of restrained persons;
X
provision for hydration and sanitation
needs; and
exercising of extremities.
In no case shall restraints be used for punishment or Addressed in section 306.2 of the Department Policy
X
as a substitute for treatment. Manual
Restraint devices shall only be used on inmates who
Addressed in section 306.3 of the Department Policy
display behavior which results in the destruction of
Manual
property or reveal an intent to cause physical harm to
X
self or others. Restraint devices include any devices
which immobilize an inmate's extremities and/or
prevent the inmate from being ambulatory.
Physical restraints should be utilized only when it
appears less restrictive alternatives would be X
ineffective in controlling the disordered behavior.
Inmates shall be placed in restraints only with the
approval of the facility manager, the facility watch
commander, responsible health care staff; X
continued retention shall be reviewed a minimum of
every hour.
A medical opinion on placement and retention shall Licensed personnel are not on staff. Detainees
be secured within one hour from the time of requiring longer than short term restraints are
X
placement. A medical assessment shall be transferred
completed within four hours of placement.
If the facility manager, or designee, in consultation
with responsible health care staff determines that
an inmate cannot be safely removed from restraints X
after eight hours, the inmate shall be taken to a
medical facility for further evaluation.
Direct visual observation shall be conducted at least
twice every thirty minutes to ensure that the
X
restraints are properly employed, and to ensure the
safety and well-being of the inmate. Such
observation shall be documented.
13
ARTICLE/SECTIONYES NO N/A COMMENTS
While in restraint devices all inmates shall be housed
alone or in a specified housing area for restrained
X
inmates which makes provisions to protect the
inmate from abuse.
The provisions of this section do not apply to the use
of handcuffs, shackles or other restraint devices X
when used to restrain inmates for security reasons.
1058.5 RESTRAINTS AND PREGNANT INMATES Addressed in section 306.3.2 of the Department
Policy Manual
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures for the use of restraint devices on
pregnant inmates. In accordance with Penal Code
3407 the policy shall include reference to the
following:
(1) An inmate known to be pregnant or in
recovery after delivery shall not be
X
restrained by the use of leg irons, waist
chains, or handcuffs behind the body.
(2) A pregnant inmate in labor, during
delivery, or in recovery after delivery,
shall not be restrained by the wrists,
X
ankles, or both, unless deemed necessary
for the safety and security of the inmate,
the staff, or the public.
(3) Restraints shall be removed when a Pregnant inmates requiring medical care or
professional who is currently responsible
treatment are transferred to local medical facilities
for the medical care of a pregnant inmate
and not retained with in the Holding facilities.
X
during a medical emergency, labor,
delivery, or recovery after delivery
determines that the removal of restraints
is medically necessary.
(4) Upon confirmation of an inmate's
pregnancy, she shall be advised, orally or
X
in writing, of the standards and policies
governing pregnant inmates.
Itemized Summary
III. Medical/Mental Health Evaluation
Paradise Police Department
Page 9
Deficiency: Policy is not in place with location and approved inventory list of contents of first aid kits. Also, Policy is not in place for
consistent inspection of kits for currency and completeness
Corrective Action: update policy manual to include inventory list of first aid kits, locations, and inspection procedure.
Staff were cooperative and collaborative in completion of the inspection. Generally, the facility meets the inspection requirements.
Facility does have an Automatic External Defibrillator (AED) in hallway nearby holding facility cells with an inspection checklist.
Best Practice: Best practice would be to include Narcan with emergency medical supplies. The location should be central in the
Department facility to be available to all parts of the building and defined in the policy manual
14
ADULT TYPE I, II, III and IV FACILITIES
Local Detention Facility Health Inspection Report
Health and Safety Code Section 101045
BSCC #: ___________
FACILITY NAME:COUNTY:
Butte County Jail Butte
FACILITY ADDRESS (STREET, CITY, ZIP CODE, TELEPHONE):
33 County Center Dr. Oroville, CA 95965
(530) 538-7471
TYPE I: TYPE II: TYPE III: XTYPE IV:
CHECK THE FACILITY TYPE AS DEFINED IN TITLE 15,
SECTION 1006:
ENVIRONMENTAL HEALTH EVALUATION DATE INSPECTED: 02/08/2022
ENVIRONMENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Alana Kong, Registered Environmental Health Specialist II, (530) 552-3998
Leslie Roberts, Senior Registered Environmental Health Specialist, (530) 552-3872
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Douglas Brownfield, Compliance Sergeant, (530) 588-7940
NUTRITIONAL EVALUATIONDATE INSPECTED: 02/08/2022
NUTRITIONAL EVALUATORS (NAME, TITLE, TELEPHONE):
Amber McPherson, Registered Dietitian, Public Health Program Manager, (530) 552-3917
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Jarod Agurkis, Kitchen Operation
Gwendalen Ramirez, Food Services Director, Trinity Services Group
MEDICAL/MENTAL HEALTH EVALUATION DATE INSPECTED: 02/08/2022
MEDICAL/MENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Monica Soderstrom, Division Director, Public Health, (530) 552-3930
David Canton, Public Health Officer, (530) 552-3993
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Tarah Foster, Health Services Administrator, (530)538-6863
This checklist is to be completed pursuant to the attached instructions.
1
I. ENVIRONMENTAL HEALTH EVALUATION
Adult Type I, II, III and IV Facilities
ARTICLE/SECTION YESNO N/A COMMENTS
Article 12. Food
Approach for Providing Food Service
Food served in the facility is prepared in the
x
facility. If "No," respond to items 1 and 2 below
prior to continuing with the checklist.
1. Food is prepared at another city or county
detention facility.
2. Food is contracted through a private vendor
who had been inspected and complies with
provisions of CalCode.
1230 Food Handlers
903.4
The responsible physician, in cooperation with the
food services manager and the facility
x
administrator, shall develop written procedures for
medical screening of inmate food service workers
prior to working in the facility kitchen.
There shall be written procedures for education 901.3, 903.5
and ongoing monitoring and cleanliness of these
workers in accordance with standards set forth in x
Health and Safety Code, California Retail Food
Code.
2
ARTICLE/SECTION YESNO N/A COMMENTS
1243 Food Service Plan
Chapter 9, s. 900, 901, 902, 903, 904, 905, 906,
Facilities shall have a written food service plan that
907 and 908.
shall comply with the applicable California Retail
Food Code. In facilities with an average daily
population of 100 or more, there shall be
employed or available, a trained experienced food
services manager to prepare and implement a food
service plan. In facilities of less than an average
daily population of 100 that do not employ or have
a food services manager available, the facility
administrator shall prepare a food service plan.
The plan shall include, but not limited to, the
following policies and procedures:
(a) menu planning;
(b) purchasing;
x
(c) storage and inventory control;
(d) food preparation;
(e) food serving;
(f) transporting food;
(g) orientation and ongoing training;
(h) personnel supervision;
(i) budgets and food cost accounting;
(j) documentation and record keeping;
(k) emergency feeding plan;
(l) waste management;
(m) maintenance and repair; and
(n) three-day mainline sample tray.
3
ARTICLE/SECTION YESNO N/A COMMENTS
1245 Kitchen Facilities, Sanitation and Food Deficiency: Cold holding of dressings in staff salad
Service bar at 46 degrees F.
(a) Kitchen facilities, sanitation, and food
Corrective Action: Maintain potentially hazardous
preparation, service, and storage shall comply
food at or below 41 degrees F.
with standards set forth in Health and Safety
Code, Division 104, Part 7, Chapters 1-13,
Deficiency: Basins of mixed ingredients in walk-in
Sections 113700 et seq. California Retail Food
refrigerator to cool observed at 44 degrees F after
Code.
24 hours.
Corrective Action: Mixed ingredients must cool to
41 degrees F or colder in 4 hours. When cooling
foods maintain food depths at 2 – 3 inches to cool
quickly.
Deficiency: Not all utensils stored in clean drawer
or protected from possible contamination.
x
Corrective Action: Clean drawers or storage areas
to be use for utensil storage.
Deficiency: Colanders and bowls in one area stored
unprotected from contamination.
Corrective Action: Store all bowls, etc bottom side
up to prevent contamination of food contact
surfaces.
Deficiency: One area of floor cove and wall under
utensil washing sink broken/damaged.
Corrective Action: Repair floor cove and wall
damaged in utensil washing area.
(b)In facilities where inmates prepare meals for
At this time no guidance has been received to
self-consumption or where frozen meals or pre-
waive any sections of California Retail Food Code
prepared food from other permitted food
in this facility.
x
facilities (see Health and Safety Code Section
114381) are (re)heated and served, the following
applicable California Retail Food Code standards
may be waived by the local health officer:
1) HSC §114130-114141.
2) H & S Sections 114099.6, 114095-
Deficiency: Dish machine high temperature rinse
114099.5, 114101-114109, 114123, and
not 160 degrees F at dish.
114125, if a domestic or commercial
dishwasher capable of providing heat to the
Corrective Mitigation: Contact Technician ad
surface of the utensils of a temperature of
schedule service/repair. Until repair, mitigation to
x
at least 165 degrees Fahrenheit, is used for
wash, utensils in dish machine and use chemical
the purpose of cleaning and sanitizing
sanitizer solution in 3 compartment sink to
multi-service utensils and multi-service
complete sanitizer cycle.
consumer utensils;
4
ARTICLE/SECTION YESNO N/A COMMENTS
3) H & S Sections 114149-114149.3 except
that, regardless of such a waiver, the
facility shall provide mechanical
ventilation sufficient to remove gases,
odors, steam, heat, grease, vapors and
smoke from the kitchen;
4)HSC § 114268-114269; and,
5) HSC § 114279-114282
1246 Food Serving and Supervision 903.6
Policies and procedures shall be developed and
implemented to ensure that appropriate work
x
assignments are made and food handlers are
adequately supervised. Food shall be prepared and
served only under the immediate supervision of a
staff member.
Article 13. Inmate Clothing and Personal Hygiene
1260 Standard Institutional Clothing
The standard issue of climatically suitable clothing
x
to inmates held after arraignment in all but Court
Holding, Temporary Holding and Type IV facilities
shall include, but not be limited to:
(a) Clean socks and footwear;
x
(b)Clean outergarments; and,
x
(c) Clean undergarments;
x
1) for males - shorts and undershirt, and
2) for females -bra and two pairs of panties.
The inmates' personal undergarments and
footwear may be substituted for the institutional
undergarments and footwear specified in this
x
regulation. This option notwithstanding, the facility
has the primary responsibility to provide the
personal undergarments and footwear.
Clothing is reasonably fitted, durable, easily
x
laundered and repaired.
1261 Special Clothing
Provision shall be made to issue suitable additional
clothing, essential for inmates to perform such
x
special work assignments as food service, medical,
farm, sanitation, mechanical, and other specified
work.
5
ARTICLE/SECTION YESNO N/A COMMENTS
1262 Clothing Exchange 807.4.2
There shall be written policies and procedures
x
developed by the facility administrator for the
scheduled exchange of clothing.
Unless work, climatic conditions, illness, or
California Retail Food Code necessitates more
frequent exchange, outergarments, except x
footwear, shall be exchanged at least once each
week.
Undergarments and socks shall be exchanged twice
x
each week.
1263 Clothing Supply
There shall be a quantity of clothing, bedding, and
x
linen available for actual and replacement needs of
the inmate population.
Written policy and procedures shall specify
x
handling of laundry that is known or suspected to
be contaminated with infectious material.
805.4
1264 Control of Vermin in Inmates’ Personal
Clothing
There shall be written policies and procedures
x
developed by the facility administrator to control
the contamination and/or spread of vermin in all
inmates' personal clothing.
Infested clothing shall be cleaned, disinfected, or
x
stored in a closed container so as to eradicate or
stop the spread of the vermin.
1265 Issue of Personal Care Items 807.7
There shall be written policies and procedures
x
developed by the facility administrator for
the issue of personal hygiene items.
Each female inmate shall be provided with sanitary
x
napkins, panty liners, and tampons as requested.
Each inmate to be held over 24 hours who is
unable to supply himself/herself with the following
x
personal care items, because of either indigency or
the absence of an inmate canteen, shall be issued:
(a)Toothbrush, x
(b) Dentifrice, x
x
(c) Soap,
6
ARTICLE/SECTION YESNO N/A COMMENTS
x
(d) Comb, and
(e)Shaving implements.x
Inmates shall not be required to share any personal
x
care items listed in items “a” through “d.”
Inmates will not share disposable razors. Double
edged safety razors, electric razors, and other
shaving instruments capable of breaking the skin,
when shared among inmates, must be disinfected
x
between individual uses by the method prescribed
by the State Board of Barbering and Cosmetology
in Sections 979 and 980, Division 9, Title 16,
California Code of Regulations.
1266 Showering 807.10
There shall be written policies and procedures
x
developed by the facility administrator for inmate
showering/bathing.
Inmates shall be permitted to shower/bathe upon
x
assignment to a housing unit and at least every
other day or more often if possible.
1267 Hair Care Services
x
(a)Hair care services shall be available.
(b) Inmates, except those who may not shave
for reasons of identification in court, shall be
allowed to shave daily and receive hair care
x
services at least once a month. The facility
administrator may suspend this requirement
in relation to inmates who are considered to
be a danger to themselves or others.
(c) Equipment shall be disinfected, after each
use, by a method approved by the State
Board of Barbering and Cosmetology to
x
meet the requirements of Title 16, Division
9, Sections 979 and 980, California Code of
Regulations.
Article 14. Bedding and Linens
1270 Standard Bedding and Linen Issue
The standard issue of clean suitable bedding and
x
linens, for each inmate entering a living area who is
expected to remain overnight, shall include, but
not be limited to:
(a)one serviceable mattress which meets the
x
requirements of Section 1272 of these
regulations;
(b) one mattress cover or one sheet;x
7
ARTICLE/SECTION YESNO N/A COMMENTS
x 2 upon intake
(c) one towel; and,
(d) one blanket or more depending upon
climatic conditions.
x
Two blankets or sleep bag may be issued in place
of one mattress cover or one sheet.
1271 Bedding and Linen Exchange 807.4.1
There shall be written policies and procedures
x
developed by the facility administrator for the
scheduled exchange of laundered and/or sanitized
bedding and linen issued to each inmate housed.
Washable items such as sheets, mattress covers,
and towels shall be exchanged for clean x
replacement at least once each week.
If a top sheet is not issued, blankets or sleep bags
shall be laundered or dry cleaned at least once a
x
month or more often if necessary. If a top sheet is
issued, blankets shall be laundered or dry cleaned
at least every three months.
1272 Mattresses
Any mattress issued to an inmate in any facility
shall be enclosed in an easily cleaned, non-
x
absorbent ticking, and conform to the size of the
bunk as referenced in Title 24, Part 2, Section
1231.3.5, Beds.
Any mattress purchased for issue to an inmate in a
facility which is locked to prevent unimpeded
access to the outdoors shall be certified by the
x
manufacturer as meeting all requirements of the
State Fire Marshal and the Bureau of Home
Furnishings' test standard for penal mattresses at
the time of purchase.
Article 15. Facility Sanitation and Safety
1280 Facility Sanitation, Safety and Maintenance 208, 807.9, 807.10
The facility administrator shall develop written Inmates clean their own cells when needed under
x
policies and procedures for the maintenance of an supervision. Cells may be cleaned when inmates
acceptable level of cleanliness, repair and safety are not in their cell, for example at court, when
throughout the facility. needed.
8
ARTICLE/SECTION YESNO N/A COMMENTS
Such a plan shall provide for a regular schedule of Deficiency- In South dorm the light fixture in the
housekeeping tasks and inspections to identify and bathroom is broken
correct unsanitary or unsafe conditions or work
Corrective action- repair
practices which may be found.
Deficiency- cell K hand wash sink has a leaky pipe
Corrective action- repair
Deficiency- cells 4 and 62 have low water pressure
Corrective action – Increase water pressure so
inmates can adequately wash their hands
x
Deficiency – cells 86 and 54 have no hot water
Corrective action – provide hot water
Deficiency – cell H sink is not working
Corrective action – repair
Deficiency – cell 66 toilet is leaking
Corrective action – repair
Deficiency- cell M has lights that are out
Corrective action – repair
Medical care housing as described in Title 24, Part
2, Section 1231.2.14, shall be cleaned and sanitized
x
according to policies and procedures established by
the health authority.
9
Itemized Summary
I. Environmental Health Evaluation
Butte County Jail
Page 4
Deficiency- Cold holding of dressings in staff salad bar at 46 degrees F.
Corrective Action: Maintain potentially hazardous food at or below 41 degrees F.
Deficiency-Basins of mixed ingredients in walk-in refrigerator to cool observed at 44 degrees F after 24
hours.
Corrective Action - Mixed ingredients must cool to 41 degrees F or colder in 4 hours. When cooling foods
maintain food depths at 2 – 3 inches to cool quickly.
Deficiency-Not all utensils stored in clean drawer or protected from possible contamination.
Corrective Action-Clean drawers or storage areas to be use for utensil storage.
Deficiency - Colanders and bowls in one area stored unprotected from contamination.
Corrective Action - Store all bowls, etc bottom side up to prevent contamination of food contact surfaces.
Deficiency - One area of floor cove and wall under utensil washing sink broken/damaged.
Corrective Action - Repair floor cove and wall damaged in utensil washing area.
Deficiency - Dish machine high temperature rinse not 160 degrees F at dish.
Corrective Mitigation - Contact Technician ad schedule service/repair. Until repair, mitigation to wash,
utensils in dish machine and use chemical sanitizer solution in 3 compartment sink to complete sanitizer
cycle.
Page 9
Deficiency- In South dorm the light fixture in the bathroom is broken
Corrective action- repair
Deficiency- cell K hand wash sink has a leaky pipe
Corrective action- repair
Deficiency- cells 4 and 62 have low water pressure
Corrective action – Increase water pressure so inmates can adequately wash their hands
Deficiency–cells 86 and 54 have no hot water
Corrective action–provide hot water
Deficiency –cell H sink is not working
Corrective action–repair
Deficiency – cell 66 toilet is leaking
Corrective action – repair
Deficiency- cell M has lights that are out
Corrective action – repair
There are deficiencies with plumbing fixtures and lighting within the facility that need to be addressed.
Summary of environmental health inspection of food facility: There are deficiencies with food cold holding
temperatures, cooling ingredients, adequate sanitation of utensils using hot water rinse, some utensil storage
and one area of kitchen floor and floor cove damage that need to be addressed.
10
II. NUTRITIONAL HEALTH EVALUATION
Adult Type I, II, III and IV Facilities
ARTICLE/SECTIONYES NO N/A COMMENTS
Article 12. Food
1230 Food Handlers
The Environmental Health Inspector retains
primary responsibility to determine compliance
with Section 1230. Compliance should be assessed
(Note: Title 15, § 1230 is in Article 11, MMH, but
in consultation with the Nutrition Inspector so that
inspected under Environmental Health due to
the findings on the Environmental Health
CalCode reference.)
Evaluation reflect the observations, expertise and
Do not identify
consensus of both parties. The text of the
compliance with this
regulation is provided here for reference only.
regulation here.
The responsible physician, in cooperation with the
food services manager and the facility administrator,
See comments.
shall develop written procedures for medical
screening of inmate food service workers prior to
working in the facility kitchen.
There shall be written procedures for education and
ongoing monitoring and cleanliness of these workers
in accordance with standards set forth in Health and
Safety Code, California Retail Food Code.
1240 Frequency of Serving
In Temporary Holding, Type I, II, and III facilities, and
X
those Type IV facilities where food is served, food
shall be served three times in any 24-hour period.
At least one of these meals shall include hot food. X
Supplemental food must be served to inmates if
X
more than 14 hours pass between meals.
Supplemental food must be served to inmates on
X
medical diets in less than a 14-hour period if
prescribed by the responsible physician.
A minimum of fifteen minutes shall be allowed for
the actual consumption of each meal except for
X
those inmates on medical diets where the
responsible physician has prescribed additional time.
Provisions shall be made for inmates who may miss
a regularly scheduled facility meal.
X
They shall be provided with a substitute meal and
beverage, and inmates on medical diets shall be
provided with their prescribed meal.
11
ARTICLE/SECTIONYES NO N/A COMMENTS
1241 Minimum Diet
The minimum diet provided shall be based upon the Menus and diets meet the minimum standards for
nutritional and caloric requirements found in the local detention facilities.
2011 Dietary Reference Intakes (DRI) of the Food
3000 calories per day.
and Nutrition Board, Institute of Medicine of the
X
National Academies, the 2008 California Food Guide,
Menus analyzed by Registered Dietitian using
and the 2015-2020 Dietary Guidelines for
NetNutrition application from CBORD
Americans. Facilities providing religious, vegetarian
or medical diets, shall also conform to these
nutrition standards.
The nutritional requirements for the minimum diet
are specified in the following subsections. A daily or
> 42 grams protein per day.
weekly average of the food group's requirement is
acceptable. A wide variety of food should be served.
4-week daily summary.
(a) Protein Group. Includes beef, veal, lamb,
Pinto beans served 3 days per week.
pork, poultry, fish, eggs, cooked dry beans,
X
peas, lentils, nuts, peanut butter and textured
vegetable protein (TVP). One serving equals
14 grams or more of protein; the daily
requirements shall be equal to three servings
(a total of 42 grams per day or 294 grams per
week). In addition, there shall be a
requirement to serve a fourth serving from
the legumes three days a week.
(b) Dairy Group. Includes milk (fluid, evaporated
or dry; nonfat, 1% or 2% reduced fat, etc.);
1% Milk served qd @ breakfast.
cheese (cottage, cheddar, etc.); yogurt; ice
cream or ice milk; and pudding. A serving is
Beverage Calcium PC served at lunch and dinner.
equivalent to 8 oz. of fluid milk and provides
at least 250 mg. of calcium. All milk shall be
Sliced cheese served one x qd.
X
pasteurized and fortified with Vitamins A and
D. The daily requirement is three servings.
One serving can be from a fortified food
containing at least 150 mg. of calcium. For
persons 15-17 years of age, or pregnant and
lactating women, the requirement is four
servings of milk or milk products.
(c)Vegetable-Fruit Group. Includes fresh, frozen,
dried and canned vegetables and fruits. One
Fruit served q breakfast
serving equals: 1/2 cup vegetable or fruit; 6
ounces of 100% juice; 1 medium apple,
X
> 1 serving vegetable served at lunch
orange, banana, or potato; 1/2 grapefruit; or
1/4 cup dried fruit. The daily requirement of
Fruit or vegetable serving served at dinner
fruits and vegetables shall be five servings. At
least one serving shall be from each of the
following three categories:
(1) One serving of a fresh fruit or vegetable
X
per day, or seven (7) servings per week.
(2) One serving of a Vitamin C source
X
containing 30 mg. or more per day or
seven (7) servings per week.
12
ARTICLE/SECTIONYES NO N/A COMMENTS
(3) One serving of a Vitamin A source, fruit
Carrots served daily. Recommend adding other
or vegetable, containing 200 micrograms
Vitamin A rich sources like cantaloupe, sweet
X
Retinol Equivalents (RE) or more per day,
potatoes, winter squash, apricots, spinach, kale or
or seven servings per week.
collard greens
(d) Grain Group. Includes bread, rolls, pancakes,
sweet rolls, ready-to-eat cereals, cooked
cereals, corn bread, pasta, rice, tortillas, etc.
and any food item containing whole or
Wheat bread served at breakfast and dinner (2
enriched grains. At least three servings from
slices at breakfast, 4 slices at dinner. 2 servings at
this group must be made with whole grains.
lunch (cornbread or tortillas)
The daily requirements shall be a minimum of
six servings. Providing only the minimum
servings outlined in this regulation is not
X
sufficient to meet the inmates' caloric
requirements. Additional servings from the
dairy, vegetable-fruit, and bread-cereal
groups must be provided in amounts to meet
caloric requirements. Saturated dietary fat
should not exceed 10 percent of total calories
on a weekly basis. Fat shall be added only in
minimum amounts necessary to make the
diet palatable.
Facility diets shall consider the recommendations
and intentions of the 2015-2020 Dietary Guidelines
X
of Americans of reducing overall sugar and sodium
levels
1242 Menus
4-week rotating menus planned in advance and
approved by Registered Dietitian
Menus in Type II and III facilities, and those Type IV
facilities where food is served, shall be planned at
least one month in advance of their use. Menus shall
X
be planned to provide a variety of foods, thus
preventing repetitive meals. Menus shall be
approved by a registered dietitian before being
used.
If any meal served varies from the planned menu, Email Dietitian when substitutions need to be
the change shall be noted in writing on the menu X made
and/or production sheet.
Menus, as planned, including changes, shall be
X
evaluated by a registered dietitian at least annually.
13
ARTICLE/SECTIONYES NO N/A COMMENTS
1243 Food Service Plan
Foodservice plan by Trinity Services Group.
Facilities shall have a written food service plan that
shall comply with the applicable California Retail
Food Code. In facilities with an average daily
population of 100 or more, there shall be employed
or available, a trained experienced food services
X
manager to prepare and implement a food service
plan. In facilities of less than an average daily
population of 100 that do not employ or have a food
services manager available, the facility administrator
shall prepare a food service plan. The plan shall
include, but not limited to, the following policies and
procedures:
(a) menu planning; X
X
(b) purchasing;
(c) storage and inventory control;X
(d) food preparation;X
X
(e)food serving;
(f) transporting food;X
X
(g) orientation and ongoing training;
(h) personnel supervision; X
(i)budgets and food cost accounting; X
X
(j)documentation and record keeping;
(k)emergency feeding plan; X
(l)waste management; X
X
(m) maintenance and repair; and,
(n) three-day mainline sample tray. X
1245 Kitchen Facilities, Sanitation and Food Service
a) Kitchen facilities, sanitation, and food
preparation, service, and storage shall comply
with standards set forth in Health and Safety
Code, Division 104, Part 7, Chapters 1-13,
Sections 113700 et seq. California Retail Food
Code.
14
ARTICLE/SECTIONYES NO N/A COMMENTS
b)In facilities where inmates prepare meals for
self-consumption or where frozen meals or
pre-prepared food from other permitted food
facilities (see Health and Safety Code Section
114381) are (re)heated and served, the
following applicable California Retail Food
Code standards may be waived by the local
health officer:
(1) H & S Sections 114130-114141;
(2) H & S Sections 114099.6, 114095-
114099.5, 114101-114109, 114123, and
114125, if a domestic or commercial
dishwasher capable of providing heat to
the surface of the utensils of a
temperature of at least 165 degrees
Fahrenheit, is used for the purpose of
cleaning and sanitizing multi-service
utensils and multi-serviceconsumer
utensils;
(3) H & S Sections 114149-114149.3 except
that, regardless of such a waiver, the
facility shall provide mechanical
ventilation sufficient to remove gases,
odors, steam, heat, grease, vapors and
smoke from the kitchen;
(4) H & S Sections 114268-114269; and,
(5) H & S Sections 114279-114282.
1246 Food Serving and Supervision
Policies and procedures shall be developed and Foodservice supervisor staffed 5 days/week
implemented to ensure that appropriate work
assignments are made and food handlers are
adequately supervised. Food shall be prepared and
served only under the immediate supervision of a
staff member.
15
ARTICLE/SECTIONYES NO N/A COMMENTS
1247 Disciplinary Separation Diet
(a)A disciplinary separation diet which is
nutritionally balanced may be served to an
inmate. No inmate receiving a prescribed
medical diet is to be placed on a disciplinary
separation diet without review by the
responsible physician or pursuant to a written
plan approved by the physician.
Such a diet shall be served twice in each 24
hour period and shall consist of one-half of
the loaf (or a minimum of 19 oz. cooked loaf)
described in the regulation, or other equally
X
nutritious diet, along with two slices of whole
wheat bread and at least one quart of
drinking water if the cell does not have a
water supply.
The use of disciplinary separation diet shall
constitute an exception to the three-meal-a-
day standard. Should a facility administrator
wish to provide an alternate disciplinary diet,
such a diet shall be submitted to the Board
for approval.
16
ARTICLE/SECTIONYES NO N/A COMMENTS
(b) The disciplinary diet loaf shall consist of the
following:
2-1/2 oz. nonfat dry milk
4-1/2 oz. raw grated potato
3 oz. raw carrots, chopped or grated fine
1-1/2 oz. tomato juice or puree
4-1/2 oz. raw cabbage, chopped fine
7 oz. lean ground beef, turkey or rehydrated,
canned, or frozen Textured Vegetable
Protein (TVP)
X
2-1/2 fl. oz. oil
1-1/2 oz. whole wheat flour
1/4 tsp. salt
4 tsp. raw onion, chopped
1 egg
6 oz. dry red beans, pre-cooked before
baking (or 16 oz. canned or cooked red
kidney beans)
4 tsp. chili powder
1248 Medical Diets
The responsible physician, in consultation with the
Physician orders for medical diets
facility administrator, shall develop written policies
X
and procedures that identify the individual(s) who
are authorized to prescribe a medical diet.
The medicaldiets utilized by a facility shall be
planned, prepared and served with consultation
X
Medical diets preplanned and approved by
from a registered dietitian.
Registered Dietitian
The facility manager shall comply with any medical
X
diet prescribed for an inmate.
The facility manager and responsible physician shall
ensure that the medical diet manual, which includes
X
sample menus of medical diets, shall be available in
both the medical unit and the food service office for
reference and information.
17
ARTICLE/SECTIONYES NO N/A COMMENTS
A registered dietitian shall review, and the Deficiency: No signature of responsible physician
responsible physician shall approve, the diet manual on diet manual.
on an annual basis.
X
Corrective Action: Responsible physician shall
approve diet manual and will provide approval
annually.
Pregnant women shall be provided a balanced,
X
nutritious diet approved by a doctor.
.
Itemized Summary
II. Nutritional Health Evaluation
Butte County Jail
Page 13
Carrots served daily. Recommend adding other Vitamin A rich sources like cantaloupe, sweet potatoes, winter squash,
apricots, and spinach, kale or collard greens
Page 18
Deficiency: No signature of responsible physician on diet manual.
Corrective Action: Responsible physician shall approve diet manual and will provide approval annually.
Frequency of serving and minimum diet meet the requirements based upon the nutritional and caloric
requirements found in the 2011 Dietary Reference Intakes (DRI) of the Food and Nutrition Board, Institute of
Medicine of the National Academies, the 2008 California Food Guide, and the 2015-2020 Dietary Guidelines for
Americans. Menus are planned in advance, approved by a Registered Dietitian and provide a variety of foods.
Foodservice plan provided by Trinity Services Group and complies with the applicable California Retail Food
Code.
A deficiency was found in the approval of the diet manual by the responsible physician. No other deficiencies
were found.
18
III. MEDICAL/MENTAL HEALTH EVALUATION
Adult Type I, II, III and IV Facilities
ARTICLE/SECTION YESNO N/ACOMMENTS
Article 11. Health Services
1200 Responsibility for Health Care Services Addressed in Wellpath Policy HCD-110_A-02
In Type I, II, III and IV facilities, the facility
x
Responsible Health Authority
administrator shall have the responsibility to ensure
provision of emergency and basic health care
services to all inmates.
Medical, dental, and mental health matters involving
Addressed in Wellpath Policy HCD-110_A-03
clinical judgments are the sole province of the
x
Medical Autonomy
responsible physician, dentist, and psychiatrist or
psychologist respectively.
Security regulations applicable to facility personnel
Addressed in Wellpath Policy HCD-110_B-09.
x
also apply to health personnel.
Staff meeting annually on this topic.
Each facility shall have at least one physician
Monthly schedule and calendar of physician
x
available to treat physical disorders.
coverage shared with inspectors
In Type IV facilities, compliance may be attained by
Although this is not a Type IV facility, Wellpath
providing access into the community; however, in
policies related to this need were shared:
such cases, there shall be a written plan for the
x
treatment, transfer, or referral in the event of an
Wellpath E-09 (Continuing, coordination and quality
emergency.
of care) and D-08 (Hospitals and specialty care)
In court holding and temporary holding facilities, the
facility administrator shall have the responsibility to
x
develop written policies and procedures which ensure
provision of emergency health care services to all
inmates.
1202 Health Service Audits Addressed in Wellpath Policy HCD-110_A-06
The health authority shall develop and implement a
Continuous Quality Improvement (CQI)
x
written plan for annual statistical summaries of
health care and pharmaceutical services that are
provided.
CQI Committee meets quarterly
The responsible physician shall also establish a
x
mechanism to assure that the quality and adequacy of
these services are assessed annually.
The plan shall include a means for the correction of
x
identified deficiencies of the health care and
pharmaceutical services delivered.
Based on information from these audits, the health
CQI Committee quarterly meetings: review monthly
authority shall provide the facility administrator with
x
stats and provide annual report
an annual written report on health care and
pharmaceutical services delivered.
19
ARTICLE/SECTION YESNO N/ACOMMENTS
1203 Health Care Staff Qualifications
Addressed in Wellpath policy HCD 110_C-01
Credentials
State and/or local licensure and/or certification
requirements and restrictions, including those
x
defining the recognized scope of practice specific to
the profession, apply to health care personnel
Inspectors were shown a spread sheet used for
working in the facility the same as to those working
tracking all clinical staff licenses, TB tests, CPR
in the community.
expiration dates
Copies of licensing and/or certification credentials
Actual copies of credentials are kept at Wellpath
x
shall be on file in the facility or at a central location
home office
where they are available for review.
1204 Health Care Procedures
Addressed in Wellpath Professional Nursing
Protocols, dated January 2021 (pocket guides also
Health care performed by personnel other than a
available to staff)
x
physician shall be performed pursuant to written
protocol or order of the responsible health care Wellpath Policy and Procedure manual signed
staff.6/7/21
1205 Health Care Records Addressed in Wellpath policy HCD110_A-08
x
(a) The health authority shall maintain individual,
Health Records
complete and dated health records in compliance
with state statute to include, but not be limited to:
(1) Receiving screening form/history
x A-08 and E-02 (Receiving Screening)
(2) Health evaluation reports;
x
(3) Complaints of illness or injury;
x
(4) Names of personnel who treat, prescribe,
and/or administer/deliver prescription
x
medication;
(5) Location where treated; and,
x
A-08 (Med Admin recorded in chart)
(6) Medication records in conformance with Title
x
15 §1216.
(b)The physician/patient confidentiality privilege A-07 and A-08
applies to the health care record. Access to the
x
health record shall be controlled by the health
authority or designee.
The health authority shall ensure the
confidentiality of each inmate's health care record
file (paper or electronic) and such files shall be
x
maintained separately from and in no way be part
of the inmate's other jail records.
Within the provisions of HIPAA 45 C.F.R.,
Section 164.512(k)(5)(i), the responsible
physician or designee shall communicate
information obtained in the course of health
x
screening and care to jail authorities when
necessary for the protection of the welfare of the
inmate or others, management of the jail, or
maintenance of jail security and order.
20
ARTICLE/SECTION YESNO N/ACOMMENTS
(c) Written authorization by the inmate is necessary A-08
for transfer of health care record information
Includes Release of Information
unless otherwise provided by law or x
administrative regulations having the force and
effect of law.
(d)Inmates shall not be used for health care
x
recordkeeping.
1206 Health Care Procedures Manual Policies and procedures are reviewed annually.
The health authority shall, in cooperation with the Last signed 6/7/2021/
facility administrator, set forth in writing, policies
x
and procedures in conformance with applicable
state and federal law, which are reviewed and
updated at least every two years and include but are
not limited to:
(a)Summoning and application of proper Addressed in Wellpath policy HCD 110_ E-02
x
medical aid;
Addressed in Wellpathpolicy HCD 110-A_11
(b)Contact and consultation with other treating
x
health care professionals;
On call Provider contact
(c)Emergency and non-emergency medical and Addressed in Wellpath policy HCD 110 E-02
x
dental services, including transportation;
(d)Provision for medically required dental and Addressed in Wellpath policy HCD 110_F-01
x
medical prostheses and eyeglasses;
Pts with chronic disease & other special needs
Custody staff makes notification
(e) Notification of next of kin or legal guardian in
x
case of serious illness which may result in
death;
(f)Provision for screening and care of pregnant HAddressed in Wellpath policy CD 110_F-05
and lactating women, including prenatal and
Counseling and Care of Pregnant Patient
postpartum information and health care,
x
including but not limited to access to
necessary vitamins as recommended by a
doctor, information pertaining to childbirth
education and infant care;
(g)Screening, referral and care of mentally Addressed in Wellpath policy F-01
x
disordered and developmentally disabled
Chronic and special needs
inmates;
(h)Implementation of special medical programs; x Addressed in Wellpath policy HCD 110 F-01
(i) Management of inmates suspected of or Infection Control Manual
x
confirmed to have communicable diseases;
(j) The procurement, storage, repackaging, Addressed in Wellpath policy HCD 110_D-01
labeling, dispensing, administration/delivery
x (Pharmaceutical Ops) and E-09 (Medication
to inmates, and disposal of pharmaceuticals;
Verification)
(k) Use of non-physician personnel in providing Covered by Wellpath nursing protocols
x
medical care;
(l) Provision of medical diets; Addressed in Wellpath policy HCD 110_D-05
x
(Medical diets)
(m) Patient confidentiality and its exceptions; x Addressed in Wellpath policy HCD 110 A-08
21
ARTICLE/SECTION YESNO N/ACOMMENTS
Addressed in Wellpath policy HCD 110_E-09
(n)the transfer of pertinent individualized health
care information, or individual
Continuity of Care
documentation that no health care
information is available, to the health
authority of another correctional system,
x
medical facility, or mental health facility at
the time each inmate is transferred and prior
notification pursuant to Health and Safety
Code Sections 121361 and 121362 for
inmates with known or suspected active
tuberculosis disease.
Addressed in Wellpath policy HCD 110 E-09
Procedures for notification to the transferring
x
health care staff shall allow sufficient time to
prepare the summary.
The summary information shall identify the Addressed in Wellpath policy HCD 110 E-09
sending facility and be in a consistent format
that includes the need for follow-up care,
diagnostic tests performed, medications
x
prescribed, pending appointments, significant
health problems, and other information that
is necessary to provide for continuity of
health care.
Infection Control Manual
Necessary inmate medication and health care
information shall be provided to the
transporting staff, together with precautions
x
necessary to protect staff and inmate
passengers from disease transmission during
transport;
(o)forensic medical services, including drawing Addressed in Wellpath policy HCD 110_G-04
of blood alcohol samples, body cavity
Therapeutic Relationship, Forensic Information, and
searches, and other functions for the purpose
x
Disciplinary Action
of prosecution shall not be performed by
medical personnel responsible for providing
ongoing care to the inmates;
(p)Provisions for application and removal of Addressed in Wellpath policy HCD 110_G-01
restraints on pregnant inmates consistent
x Restraints/Seclusion.
with Penal Code Section 3407;
Section 6.15.1 Pregnant patients
(q)Other services mandated by statute; and, x
(r) provisions for timely and appropriate medical Addressed in Wellpath policy HCD 110 E-02
and mental health screenings, access to
Receiving Screening &
medical and mental health services, and no-
F-06 Response to Sexual Abuse
cost access to contraception and STD
x
treatment, for inmates who have reported
sexual abuse or sexual harassment, regardless
of the location where the incident(s)
occurred.
22
ARTICLE/SECTION YESNO N/ACOMMENTS
1206.5 Management of Communicable Diseases Addressed in Wellpath Policy HCD 110_B-02
Infectious Disease and Control
(a) The responsible physician, in conjunction with
the facility administrator and the county
x
health officer, shall develop a written plan to
address the identification, treatment, control
Infection Control Manual, July 2019
and follow-up management of tuberculosis
and other communicable diseases.
The plan shall cover the intake screening Addressed in Wellpath policy HCD 110 B-02
procedures, identification of relevant
Infection Control Manual
symptoms, referral for a medical evaluation,
treatment responsibilities during x
incarceration and coordination with public
health officials for follow-up treatment in the
community.
The plan shall reflect the current local LHD attests to ongoing communication regarding
incidence of communicable diseases which x STD testing/treatment for inmates as well as Covid
threaten the health of inmates and staff.response testing for inmates and staff
(b)Consistent with the above plan, the health Addressed in Wellpath policy HCD 110 B-02
authority shall, in cooperation with the facility
Infection Control Manual
administrator and the county health officer,
x
set forth in writing, policies and procedures in
conformance with applicable state and
federal law, which include, but are not limited
to:
(1) The types of communicable diseases to
x
be reported;
(2) The persons who shall receive the
x
medical reports;
(3) Sharing of medical information with
x
inmates and custody staff;
(4) Medical procedures required to identify
x
the presence of disease(s) and lessen the
risk of exposure to others;
x
(5) Medical confidentiality requirements;
(6) Housing considerations based upon
x
behavior, medical needs, and safety of
the affected inmates;
(7) Provision for inmate consent that address
x
the limits of confidentiality; and,
(8) Reporting and appropriate action upon
x
the possible exposure of custody staff to
a communicable disease.
1207 Medical Receiving Screening Addressed in Wellpath policy HCD 110_E-02
With the exception of inmates transferred directly
within a custody system with documented receiving
x
screening, a screening shall be completed on all
inmates at the time of intake
23
ARTICLE/SECTION YESNO N/ACOMMENTS
Addressed in Wellpath policy HCD 110 E-02
This screening shall be completed in accordance
with written procedures and shall include but not be
Receiving Screening
limited to medical and mental health problems, x
developmental disabilities, tuberculosis and other
communicable diseases.
The screening shall be performed by licensed health Addressed in Wellpath Policy HCD 110_C-01
personnel or trained facility staff, with
Credentials
documentation of staff training regarding site
x
specific forms with appropriate disposition based on
responses to questions and observations made at
the time of screening.
The training depends on the role staff are expected Addressed in Wellpath Policy HCD 110_C-02 (Clinical
to play in the receiving screening process. x
Performance Enhancement) and C-03 (Professional
Development)
The facility administrator and responsible physician Addressed in Wellpath Policy HCD 110_F-10
shall develop a written plan for complying with
x
Durable Medical Equipment and Supply
Penal Code Section 2656 (orthopedic or prosthetic
appliance used by inmates).
There shall be a written plan to provide care for any Addressed in Wellpath Polciy HCD 110 E-02
inmate who appears at this screening to be in need
x
Receiving Screening
of or who requests medical, mental health, or
developmental disability treatment.
Written procedures and screening protocol shall be Addressed in Wellpath Policy HCD 110 F-01
x
established by the responsible physician in
cooperation with the facility administrator.
1207.5 Special Mental Disorder Assessment Addressed in Wellpath Policy HCD 110 E-02
An additional mental health screening will be The receiving screening document contains this
performed, according to written procedures, on field. This is assessed on intake and at day 14
women who have given birth within the past year
x
and are charged with murder or attempted murder
of their infants. Such screening will be performed at
intake and if the assessment indicates postpartum
psychosis a referral for further evaluation will be
made.
1208 Access to Treatment Addressed in Wellpath Policy HCD 110_A-01
The health authority, in cooperation with the facility Access to Care
administrator, shall develop a written plan for
identifying and/or referring any inmate who appears
x
to be in need of medical, mental health or
Wellpath Policy HCD 110_E-09
developmental disability treatment at any time
Continuity, Coordinaiton and Quality of Care during
during his/her incarceration subsequent to the
Incarceration
receiving screening.
24
ARTICLE/SECTION YESNO N/ACOMMENTS
Addressed in Wellpath Policy HCD 110 E-02
The written plan shall also include the assessment
and treatment of such inmates as described in Title x
Receiving Screening
15, Section 1207, Medical Receiving Screening.
Addressed in Wellpath Policy HCD 110 E-02 and E-05
Assessment and treatment shall be performed by
either licensed health personnel or by persons
x
operating under the authority and/or direction of
licensed health personnel.
1208.5. Health Care Maintenance Addressed in Wellpath Policy HCD 110_B-03
For inmates undergoing prolonged incarceration, an Clinical Preventive Services
age appropriate and risk factor based health
x
maintenance visit shall take place within the
inmate's second anniversary of incarceration.
Initial Health history and exam
Annual exam
The specific components of the health maintenance
examinations shall be determined by the responsible
x
physician based on the age, gender, and health of
the inmate.
Thereafter, the health maintenance examinations
x
shall be repeated at reasonable intervals as
determined by the responsible physician.
1209 Mental Health Services and Transfer to a Wellpath Policy HCD 110_E-05
Treatment Facility
Mental Health Screening and Evaluation &
(a) The health authority, in cooperation with the
mental health director and facility
x
administrator, shall establish policies and
procedures to provide mental health services.
Wellpath Policy HCD 110_F-03
These services shall include but not be limited
to:
Mental Health Services
1.Identification and referral of inmates
x
with mental health needs;
2. Mental health treatment programs
provided by qualified staff, including the
x Addressed in Wellpath Policy HCD 110_F-03A
use of telehealth.
Mental Health Services and Telepsychiatry
3. Crisis intervention services; x
4. Basic mental health services provided, as
x
clinically indicated;
5. Medication support services; and, Addressed in Wellpath Policy HCD 110 F-03 and F-
x
03A
25
ARTICLE/SECTION YESNO N/ACOMMENTS
6. The provision of health services
sufficiently coordinated such that care is
appropriately integrated, medical and
x
mental health needs are met, and the
impact of any of these conditions on each
other is adequately addressed.
(b)Unless the county has elected to implement Inmates are transferred to local hospital emergency
the provisions of Penal Code Section 1369.1,
department for 51-50 evaluation and then to Butte
a mentally disordered inmate who appears to
County Behavioral Health Psychiatric Health Facility
be a danger to himself or others, or to be
(PHF) if not able to assess and treat at the jail.
gravely disabled, shall be transferred for
further evaluation to a designated Lanterman
Petris Short treatment facility designated by
the county and approved by the State
Department of Mental Health for diagnosis
and treatment of such apparent mental
disorder pursuant to Penal Code section
x
4011.6 or 4011.8 unless the jail contains a
designated Lanterman Petris Short treatment
facility. Prior to the transfer, the inmate may
be evaluated by licensed health personnel to
determine if treatment can be initiated at the
correctional facility. Licensed health
personnel may perform an onsite assessment
to determine if the inmate meets the criteria
for admission to an inpatient facility, or if
treatment can be initiated in the correctional
facility.
(c)If the county elects to implement the
Addressed in Wellpath Policy HCD 110_G-03 and G-
provisions of Penal Code Section 1369.1, the
03A
health authority, in cooperation with the
Emergency Psychiatric Meds
facility administrator, shall establish policies
x
and procedures for involuntary
administration of medications. The
procedures shall include, but not be limited
to:
1. Designation of licensed personnel,
including psychiatrist and nursing staff,
x
authorized to order and administer
involuntary medication;
2. Designation of an appropriate setting
x
where the involuntary administration of
medication will occur;
Separate restraint procedures
3. Designation of restraint procedures
and/or devices that may be used to
x
maintain the safety of the inmate and
facility staff;
4. Development of a written plan to
monitor the inmate's medical condition
following the initial involuntary
x
administration of a medication, until the
inmate is cleared as a result of an
evaluation by, or consultation with, a
psychiatrist;
26
ARTICLE/SECTION YESNO N/ACOMMENTS
5. Development of a written plan to provide
a minimum level of ongoing monitoring
of the inmate following return to facility
housing. This monitoring may be
x
performed by custody staff trained to
recognize signs of possible medical
problems and alert medical staff when
indicated; and
6. Documentation of the administration of
x
involuntary medication in the inmate's
medical record.
1210 Individualized Treatment Plans Addressed in Wellpath Policy HCD F-03
(a)For each inmate treated by a mental health
x
service in a jail, the responsible health care
shall develop a written treatment plan.
The custody staff shall be informed of the
Addressed in Wellpath Policy HCD 110_E-10
treatment plan when necessary, to ensure
Discharge
coordination and cooperation in the ongoing
x
care of the inmate. This treatment plan shall
include referral to treatment after release from
the facility when recommended by treatment
staff.
(b) For each inmate treated for health conditions
for which additional treatment, special
accommodations and/or a schedule of follow-
up care is/are needed during the period of
incarceration, responsible health care staff
shall develop a written treatment plan. The
x
custody staff shall be informed of the
treatment plan when necessary, to ensure
coordination and cooperation in the ongoing
care of the inmate. This treatment plan shall
include referral to treatment after release from
the facility when recommended by treatment
staff.
1211 Sick Call
Addressed in Wellpath Policy HCD 110_E-07
There shall be written policies and procedures
Non-emergency Health Care Requests
developed by the facility administrator, in
cooperation with the health authority, which
x
provides for a daily sick call conducted for all
inmates or provision made that any inmate
requesting medical/mental health attention be given
such attention.
1212 Vermin Control Infection Control Manual, Section 10
The responsible physician shall develop a written
plan for the control and treatment of vermin-
infested inmates. There shall be written, medical
x
protocols, signed by the responsible physician, for
the treatment of persons suspected of being
infested or having contact with a vermin-infested
inmate.
27
ARTICLE/SECTION YESNO N/ACOMMENTS
1213 Detoxification Treatment
Addressed in Wellpath Policy HCD 110-F_04B
The responsible physician shall develop written
Medication Assisted Treatment
medical policies on detoxification which shall include
a statement as to whether detoxification will be
provided within the facility or require transfer to a
Provide medically supervised withdrawal and
licensed medical facility. The facility detoxification
x
treatment. Will continue methadone or Suboxone if
protocol shall include procedures and symptoms
inmate comes in on either. Have policy to initiate
necessitating immediate transfer to a hospital or
MAT but do not have enough staff to implement it.
other medical facility.
Only pregnant women get started on MAT (if
indicated) to protect fetus.
Facilities without medically licensed personnel in
attendance shall not retain inmates undergoing
withdrawal reactions judged or defined in policy, by
x
the responsible physician, as not being readily
controllable with available medical treatment. Such
facilities shall arrange for immediate transfer to an
appropriate medical facility.
1214 Informed Consent
Addressed in Wellpath Policy HCD 110-G-05
The health authority shall set forth in writing a plan
X
for informed consent of inmates in a language
understood by the inmate.
Except for emergency treatment, as defined in
Business and Professions Code Section 2397 and
Title 15, Section 1217, all examinations, treatments
X
and procedures affected by informed consent
standards in the community are likewise observed for
inmate care.
In the case of minors, or conservatees, the informed
Minors are not kept in this facility. Competency is
consent of parent, guardian or legal custodian applies
dealt with in Wellpath Policy HCD 400-A-04
X
where required by law. Any inmate who has not been
adjudicated to be incompetent may refuse non-
emergency medical and mental health care.
Absent informed consent in non-emergency
situations, a court order is required before
X
involuntary medical treatment can be administered to
an inmate.
1215 Dental Care
Addressed in Wellpath Policy HCD 110-E-06
The facility administrator shall develop written
policies and procedures to ensure emergency and
X
medically required dental care is provided to each
inmate, upon request, under the direction and
supervision of a dentist, licensed in the state.
28
ARTICLE/SECTION YESNO N/ACOMMENTS
1216 Pharmaceutical Management
Last pharmacist audit done 12/6/2021
(a) The health authority in consultation with a
pharmacist and the facility administrator,
shall develop written plans, establish
procedures, and provide space and
X
accessories for the secure storage, the
controlled administration, and disposal of all
legally obtained drugs. Such plans,
procedures, space and accessories shall
include, but not be limited to, the following:
(1)Securely lockable cabinets, closets and
X
refrigeration units:
(2)A means for the positive identification of
X
the recipient of the prescribed
medication;
(3) Procedures for administration/delivery of
X
medicines to inmates as prescribed;
(4) Confirming that the recipient has Addressed in Wellpath Policy HCD 110-D-02
ingested the medication or accounting
X
for medication under self-administration
procedures outlined in Title 15, Section
1216(d);
(5) That prescribed medications have or
X
have not been administered, by whom,
and if not, for what reason;
(6) Prohibiting the delivery of drugs by
X
inmates;
(7) Limitation to the length of time
medication may be administered without
X
further medical evaluation; and,
(8) Limitation to the length of time required
X
for a physician's signature on verbal
orders.
Report dated 12/6/2021
(9) Awritten report shall be prepared by a
pharmacist, no less than annually, on the
status of pharmacy services in the
X
institution. The pharmacist shall provide
the report to the health authority and the
facility administrator.
(b)Consistent with pharmacy laws and
regulations, the health authority shall
establish written protocols that limit the
following functions to being performed by the
identified personnel:
(1) Procurement shall be done by a
X
physician, dentist, pharmacist, or other
persons authorized by law.
29
ARTICLE/SECTION YESNO N/ACOMMENTS
(2) Storage of medications shall assure that
stock supplies of legend medications shall
be accessed only by licensed health
personnel. Supplies of legend
X
medications that have been dispensed
and supplies of over-the-counter
medications may be accessed by either
licensed or non-licensed personnel.
(3) Repackaging shall only be done by a
X
physician, dentist, pharmacist, or other
persons authorized by law.
(4) Preparation of labels can only be done by
a physician, dentist, pharmacist or other
persons, either licensed or non-licensed,
provided the label is checked and affixed
to the medication container by the
X
physician, dentist, or pharmacist before
administration or delivery to the inmate.
Labels shall be prepared in accordance
with section 4076, Business and
Professions Code.
(5) Dispensing shall only be done by a
X
physician, dentist, pharmacist, or persons
authorized by law.
(6) Administration of medication shall only
be done by licensed health personnel
X
who are authorized to administer
medication acting on the order of a
prescriber.
(7) Delivery of medication may be done by
either licensed or non-licensed
X
personnel, e.g., custody staff, acting on
the order of a prescriber.
(8) Disposal of legend medication shall be Addressed in PH-100-03 Pharmaceutical Waste
done in accordance with pharmacy laws
Category A-1 Corporate Policies and Procedures by
and regulations and requires any
Department
combination of two of the following
Best Practice: Corporate Policies should be
classifications: physician, dentist,
X
incorporated into local policies and procedures.
pharmacist, or registered nurse.
Controlled substances shall be disposed
of in accordance with the Drug
Enforcement Administration disposal
procedures.
(c)Policy and procedures on “over-the-counter” Over the counter meds delivered via commissary.
medications shall include, but not be limited
X
to, how they are made available,
documentation when delivered by staff and
precautions against hoarding large quantities.
(d)Policy and procedures may allow inmate self-
administration of prescribed medications
under limited circumstances. Policies and
procedures shall include but are not limited to
the following considerations:
30
ARTICLE/SECTION YESNO N/ACOMMENTS
(1) Medications permitted for self-
administration are limited to those with
no recognized abuse potential.
Medications for treatment of
X
tuberculosis, psychotropic medication,
controlled substances, injectables and
any medications for which
documentation of ingestion is essential
are excluded from self-administration.
(2) Inmates with histories of frequent rule
violations of any type, or who are found
X
to be in violation of rules regarding self-
administration, are excluded from self-
administration.
(3) Prescribing health care staff document Addressed in Wellpath Policy HCD 400-A-04
that each inmate participating in self-
administration is capable of
X
understanding and following the rules of
the program and instructions for
medication use.
(4) Provisions are made for the secure
X
storage of the prescribed medication
when it is not on the inmate's person.
(5) Provisions are made for the consistent
Deficiency: Provision are in place for enforcement of
enforcement of self-medication rules by
self-medication but not included in formal written
both custody and health care staff, with
policies and procedures
systems of communication among them
X
Corrective Action: Incorporate processes into
when either one finds that an inmate is in
written policies and procedures to ensure consistent
violation of rules regarding self-
administration.
practice
(6) Provisions are made for health care staff Deficiency: Provision are in place for compliance
to perform documented assessments of
with self-medication but not included in formal
inmate compliance with self-
written policies and procedures
administration medication regimens.
X
Corrective Action: Incorporate processes into
Compliance evaluations are done with
written policies and procedures to ensure consistent
sufficient frequency to guard against
hoarding medication and deterioration of
practice
the inmate's health.
1217 Psychotropic Medications
The responsible physician, in cooperation with the
X
facility administrator, shall develop written policies
and procedures governing the use of psychotropic
medications.
An inmate found by a physician to be a danger to
him/herself or others by reason of mental disorders
X
may be involuntarily given psychotropic medication
appropriate to the illness on an emergency basis.
31
ARTICLE/SECTION YESNO N/ACOMMENTS
Psychotropic medication is any medication
prescribed for the treatment of symptoms of
X
psychoses and other mental and emotional
disorders
An emergency is a situation in which action to
impose treatment over the inmate's objection is
immediately necessary for the preservation of life or
the prevention of serious bodily harm to the inmate X
or others, and it is impracticable to first gain
consent. It is not necessary for harm to take place
prior to treatment.
If psychotropic medication is administeredduring an
emergency, such medication shall be only that which
is required to treat the emergency condition. The
medication shall be prescribed by a physician
X
following a clinical evaluation. The responsible
physician shall develop a protocol for the
supervision and monitoring of inmates involuntarily
receiving psychotropic medication.
Psychotropic medication shall not be administered
to an inmate absent an emergency unless the
inmate has given his or her informed consent in
accordance with Welfare and Institutions Code
Section 5326.2, or has been found to lack the X
capacity to give informed consent consistent with
the county's hearing procedures under the
Lanterman-Petris-Short Act for handling capacity
determinations and subsequent reviews.
Addressed in Wellpath Policy HCD 110-G-03(6.4.6)
There shall be a policy which limits the length of
time both voluntary and involuntary psychotropic
medications may be administered and a plan of
X
monitoring and re-evaluating all inmates receiving
psychotropic medications, including a review of all
emergency situations.
Addressed in Wellpath Policy HCD 110-G-04
The administration of psychotropic medication is not
X
allowed for disciplinary reasons.
1220 First Aid Kits
X
First aid kit(s) shall be available in all facilities.
The responsible physician shall approve the Deficiency: There was no evidence of a formalized
contents, number, location and procedure for and approved list of supplies but there is a list that is
periodic inspection of the kit(s). used for inventory and inspection is occurring
X
Corrective Action: establish and publish policy that
defines content, location & inspection of first aid
kits
32
ARTICLE/SECTION YESNO N/ACOMMENTS
ARTICLE 4, RECORDS AND PUBLIC INFORMATION
1046 Death in Custody Addressed in Wellpath Policy HCD 110-A-09
(a) Death in Custody Reviews for Adults and
Minors.
The facility administrator, in cooperation with
the health administrator, shall develop
written policy and procedures to ensure that
there is an initial review of every in-custody
X
death within 30 days. The review team shall
include the facility administrator and/or the
facility manager, the health administrator, the
responsible physician and other health care
and supervision staff who are relevant to the
incident.
Deaths shall be reviewed to determine the
appropriateness of clinical care; whether
X
changes to policies, procedures, or practices
are warranted; and to identify issues that
require further study.
(b) Death of a Minor.
Minors are not held in this facility
In any case in which a minor dies while
X
detained in a jail, lockup, or court holding
facility:
(1)the administrator of the facility shall provide
to the Board a copy of the report submitted
to the Attorney General under Government
X
Code Section 12525. A copy of the report
shall be submitted within 10 calendar days
after the death.
(2)Upon receipt of a report of death of a minor
from the administrator, the Board may
within 30 calendar days inspect and evaluate
the jail, lockup, or court holding facility
X
pursuant to the provisions of this
subchapter. Any inquiry made by the Board
shall be limited to the standards and
requirements set forth in these regulations.
ARTICLE 3, TRAINING, PERSONNEL AND MANAGEMENT
1030. Suicide Prevention Program.
Addressed in Wellpath Policy HCD 110-B-05
The facility shall have a comprehensive written
suicide prevention program developed by the facility
X
administrator, in conjunction with the health
authority and mental health director, to identify,
monitor, and provide treatment to those inmates who
present a suicide risk.
(a) Suicide prevention training for all staff that
X
have direct contact with inmates.
(b) Intake screening for suicide risk immediately
X
upon intake and prior to housing assignment.
33
ARTICLE/SECTION YESNO N/ACOMMENTS
(c) Provisions facilitating communication among
arresting/transporting officers, facility staff,
X
medical and mental health personnel in relation
to suicide risk.
(d) Housing recommendations for inmates at
X
risk of suicide.
(e) Supervision depending on level of suicide
X
risk.
(f) Suicide attempt and suicide intervention
X
policies and procedures.
(g) Provisions for reporting suicides and suicides
X
attempts.
(h) Multi-disciplinary administrative review of
suicides and attempted suicides as defined by X
the facility administrator.
ARTICLE 5, CLASSIFICATION AND SEGREGATION
1051 Communicable Diseases Addressed in Wellpath Policy HCD 110-B-02
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures specifying those symptoms that
require segregation of an inmate until a medical
evaluation is completed.
At the time of intake into the facility, an inquiry shall
Addressed in Wellpath Policy HCD 110-E-02
be made of the person being booked as to whether or
not he/she has or has had any communicable
X
diseases, such as tuberculosis or has observable
symptoms of tuberculosis or any other communicable
diseases, or other special medical problem identified
by the health authority.
The response shall be noted on the booking form
X
and/or screening device.
1052 Mentally Disordered Inmates
Addressed in WellpathPolicy HCD 110-E-05
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
and procedures to identify and evaluate all mentally
disordered inmates, and may include telehealth. If an
X
evaluation from medical or mental health staff is not
readily available, an inmate shall be considered
mentally disordered for the purpose of this section if
he or she appears to be a danger to himself/herself or
others or if he/she appears gravely disabled.
An evaluation from medical or mental health staff
Addressed in Wellpath Policy HCD 110-F-03
shall be secured within 24 hours of identification or
X
at the next daily sick call, whichever is earliest.
Segregation may be used if necessary to protect the
safety of the inmate or others.
34
ARTICLE/SECTION YESNO N/ACOMMENTS
1055 Use of Safety Cell
Addressed in Wellpath Policy HCD 110-G-02A
The safety cell described in Title 24, Part 2, Section
1231.2.5, shall be used to hold only those inmates
X
who display behavior which results in the
destruction of property or reveals an intent to cause
physical harm to self or others
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures governing safety cell use and may
delegate authority to place an inmate in a safety cell
to a physician.
In no case shall the safety cell be used for Addressed in Wellpath Policy HCD 110-G-04
X
punishment or as a substitute for treatment.
An inmate shall be placed in a safety cell only with
the approval of the facility manager or designee, or
X
responsible health care staff; continued retention
shall be reviewed a minimum of every four hours.
A medical assessment shall be completed within a
maximum of 12 hours of placement in the safety cell
X
or at the next daily sick call, whichever is earliest.
The inmate shall be medically cleared for continued
retention every 24 hours thereafter.
The facility manager, designee or responsible health
care staff shall obtain a mental health
X
opinion/consultation with responsible health care
staff on placement and retention, which shall be
secured within 12 hours of placement.
Direct visual observation shall be conducted at least Addressed in Butte County Sheriff Office Jail Policy
X 719
twice every thirty minutes. Such observation shall be
documented.
Procedures shall be established to assure
administration of necessary nutrition and fluids.
Inmates shall be allowed to retain sufficient clothing,
or be provided with a suitably designed “safety
garment,” to provide for their personal privacy
unless specific identifiable risks to the inmate's
safety or to the security of the facility are
documented.
35
ARTICLE/SECTION YESNO N/ACOMMENTS
1056 Use of Sobering Cell
Addressed in Wellpath Policy HCD 110-F-04
The sobering cell described in Title 24, Part 2,
Section 1231.2.4, shall be used for the holding of
inmates who are a threat to their own safety or the
safety of others due to their state of intoxication and
pursuant to written policies and procedures
developed by the facility administrator. Such
inmates shall be removed from the sobering cell as
X
they are able to continue in the processing. In no
case shall an inmate remain in a sobering cell over
six hours without an evaluation by a medical staff
person or an evaluation by custody staff, pursuant
to written medical procedures in accordance with
section 1213 of these regulations, to determine
whether the prisoner has an urgent medical
problem.
At 12 hours from the time of placement, all inmates
Addressed in Butte County Sheriff Office Jail Policy
will receive an evaluation by responsible health care
516
X
staff. Intermittent direct visual observation of
inmates held in the sobering cell shall be conducted
no less than every half hour.
Such observation shall be documented.
1057 Developmentally Disabled Inmates Addressed in Wellpath Policy HCD 110-E-05
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
and procedures for the identification and evaluation,
X
appropriate classification and housing, protection,
and nondiscrimination of all developmentally
disabled inmates.
The health authority or designee shall contact the
Addressed in Wellpath Policy HCD 110-E-02
regional center on any inmate suspected or confirmed
to be developmentally disabled for the purposes of
diagnosis and/or treatment within 24 hours of such
X
No evidence seen of developmentally disabled
determination, excluding holidays and weekends.
inmate or documentation of contacting regional
center.
1058 Use of Restraint Devices Addressed in Wellpath Policy HCD 110-G-01 and
Butte County Sheriff Office Policy 511
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures for the use of restraint devices and
may delegate authority to place an inmate in
restraints to a responsible health care staff.
36
ARTICLE/SECTION YESNO N/ACOMMENTS
In addition to the areas specifically outlined in this
regulation, at a minimum, the policy shall address
the following areas: acceptable restraint devices;
signs or symptoms which should result in immediate
medical/mental health referral; availability of X
cardiopulmonary resuscitation equipment;
protective housing of restrained persons; provision
for hydration and sanitation needs; and exercising of
extremities.
In no case shall restraints be used for punishment or
X
as a substitute for treatment.
Restraint devices shall only be used on inmates who
display behavior which results in the destruction of
property or reveal an intent to cause physical harm
X
to self or others. Restraint devices include any
devices which immobilize an inmate's extremities
and/or prevent the inmate from being ambulatory.
Physical restraints should be utilizedonly when it
X
appears less restrictive alternatives would be
ineffective in controlling the disordered behavior.
Inmates shall be placed in restraints only with the
approval of the facility manager, the facility watch
X
commander, responsible health care staff;
continued retention shall be reviewed a minimum of
every hour.
A medical opinion on placement and retention shall
be secured within one hour from the time of
X
placement. A medical assessment shall be
completed within four hours of placement.
If the facility manager, or designee, in consultation
with responsible health care staff determines that
X
an inmate cannot be safely removed from restraints
after eight hours, the inmate shall be taken to a
medical facility for further evaluation.
Direct visual observation shall be conducted at least
twice every thirty minutes to ensure that the
restraints are properly employed, and to ensure the X
safety and well-being of the inmate. Such
observation shall be documented.
While in restraint devices all inmates shall be housed
alone or in a specified housing area for restrained
X
inmates which makes provisions to protect the
inmate from abuse.
37
ARTICLE/SECTION YESNO N/ACOMMENTS
The provisions of this section do not apply to the use
of handcuffs, shackles or other restraint devices
X
when used to restrain inmates for security reasons.
1058.5Restraints and Pregnant Inmates Addressed in Butte County Sheriff Office Policy 511
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures for the use of restraint devices on
pregnant inmates. In accordance with Penal Code
3407 the policy shall include reference to the
following:
(1) An inmate known to be pregnant or in
recovery after delivery shall not be restrained
X
by the use of leg irons, waist chains, or
handcuffs behind the body.
(2) Apregnant inmate in labor, during delivery,
or in recovery after delivery, shall not be
X
restrained by the wrists, ankles, or both,
unless deemed necessary for the safety and
security of the inmate, the staff, or the public.
(3) Restraints shall be removed when a
professional who is currently responsible for
the medical care of a pregnant inmate during
X
a medical emergency, labor, delivery, or
recovery after delivery determines that the
removal of restraints is medically necessary.
(4) Upon confirmation of an inmate's pregnancy,
she shall be advised, orally or in writing, of
X
the standards and policies governing
pregnant inmates.
38
Itemized Summary
III. Medical/Mental Health Evaluation
Butte County Jail
Page 30
Best Practice: Corporate Policies for pharmaceutical destruction should be incorporated into local policies and procedures
Page 31
Deficiency: Provision are in place for enforcement of self-medication rules but not included in formal written policies and
procedures
Corrective Action: Incorporate for enforcement of self-medication rules into written policies and procedures to ensure consistent
practice
Deficiency: Provision are in place for assessment of inmate compliance with self-medication but not included in formal written
policies and procedures
Corrective Action: Incorporate processes for assessment of inmate compliance with self-medication into written policies and
procedures to ensure consistent practice
Page 32
Deficiency: There was no evidence of a formalized and approved list of first aid kit supplies but there is a list that is used for
inventory and inspection is occurring. There is a list of supplies for emergency bags (different than first aid kits.)
Corrective Action: establish and publish policy that defines content, location & inspection of first aid kits as required by Butte
County Sheriff Office Policy 704
Best Practice: Adding Automatic External Defibrillators and Narcan to the first aid supply list, location and inspection policy.
Medical equipment should be annually inspected for calibration and electrical safety. Butte County Sheriff Office Policy authorizes
health authority to adopt and implement policies on AED and to ensure staff are trained on the use.
39
ADULT COURT AND TEMPORARY HOLDING FACILITIES
Local Detention Facility Health Inspection Report
Health and Safety Code Section 101045
BSCC #: ___________
FACILITY NAME:COUNTY:
Chico - North Butte County Courthouse Butte
FACILITY ADDRESS (STREET, CITY, ZIP CODE, TELEPHONE):
1775 Concord Avenue Chico, CA 95928, (530) 532-7002
CHECK THE FACILITY TYPE AS DEFINED IN TITLE 15, COURT HOLDING TEMPORARY HOLDING
SECTION 1006:
FACILITY: X FACILITY:
ENVIRONMENTAL HEALTH EVALUATION DATE INSPECTED: 02/07/2022
ENVIRONMENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Alana Kong, Registered Environmental Health Specialist II, (530) 552-3998
Leslie Roberts, Senior Registered Environmental Health Specialist, (530) 552-3872
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Jake Smith, Sergeant, (530) 990-4999
NUTRITIONAL EVALUATIONDATE INSPECTED:
NUTRITIONAL EVALUATORS (NAME, TITLE, TELEPHONE):
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
MEDICAL/MENTAL HEALTH EVALUATION DATE INSPECTED: 02/07/2022
MEDICAL/MENTAL HEALTH EVALUATORS (NAME, TITLE, TELEPHONE):
Monica Soderstrom, Division Director, Public Health, (530) 552-3930
David Canton, Public Health Officer, (53) 552-3993
FACILITY STAFF INTERVIEWED (NAME, TITLE, TELEPHONE):
Jake Smith, Sergeant, (530) 990-4999
This checklist is to be completed pursuant to the attached instructions.
1
I. ENVIRONMENTAL HEALTH EVALUATION
Adult Court and Temporary Holding Facilities
ARTICLE/SECTION YESNO N/A COMMENTS
Article 12. Food
Approach for Providing Food Service
(Not applicable to CH)
x
Food served in the facility is prepared in the facility.
If "No," respond to items 1 and 2 below prior to
continuing with the checklist.
1. Food is prepared at another city or county Sack lunches are provided by the Butte County Jail
detention facility.
in the event the prisoner is housed during the
x noon meal. No potentially hazardous foods that
need time temperature control are served. No
utensils provided for safety reasons.
2. Food is contracted through a private vendor No private vendor utilized. Butte County Jail has a
who had been inspected and complies with
x permitted kitchen with Butte County
provisions of CalCode.
Environmental Health.
1245 Kitchen Facilities, Sanitation and Food
No kitchen facility or food preparation
Service
(Not applicable to CH)
x
Kitchen facilities, sanitation, and food preparation,
service and storage comply with standards set forth
in CalCode.
In facilities where inmates prepare meals for self-
consumption, or where frozen meals are pre-
prepared food from other facilities permitted
pursuant to HSC §114381 is (re)heated and served,
x
the following CalCode standards may be waived by
the local health officer.
HSC §114130-114141
HSC §114099.6, 114095-114099.5,114101-
114109, 114123 and 114125 if a domestic or
commercial dishwasher, capable of providing
x
heat to the surface of utensils of at least 165
degrees Fahrenheit, is used to clean and
sanitize multi-service utensils and multi-service
consumer utensils;
HSC §114149-114149.3 except that, regardless
of such a waiver, the facility shall provide
x
mechanical ventilation sufficient to remove
gases, odors, steam, heat, grease, vapors and
smoke from the kitchen;
2
ARTICLE/SECTION YESNO N/A COMMENTS
HSC §114268-114269 x
HSC §114279-114282 x
1246 Food Serving and Supervision
No food preparation done at this facility
(Not applicable to CH)
Policies and procedures ensure that appropriate
x
work assignments are made, and food handlers are
adequately supervised. Food is prepared and served
only under the immediate supervision of a staff
member.
Article 14. Bedding and Linens
1270 Standard Bedding and Linen Issue Inmates never held longer than 12 hours
(Not applicable to CH)
x
The standard issue of clean suitable bedding and
linens, for each inmate entering a living area who is
expected to remain overnight, shall include, but not
be limited to:
(a) One serviceable mattress which meets the
x
requirements of Title 15 §1272;
(b) one mattress cover or one sheet; x
(c) one blanket or more depending upon climatic
conditions. Two blankets or sleep bag may be
x
issued in place of one mattress cover or one
sheet
(d) one towel x
Temporary Holding facilities which hold persons
x
longer than 12 hours shall meet the requirements of
1, 2 and 3 above.
1272 Mattresses
(Not applicable to CH)
x
Mattresses are enclosed in an easily cleaned, non-
absorbent ticking and conform to the size of the
bunk as referenced in Title 24, Part 2, §1231.3.5
Beds (at least 30" wide X 76" long).
Any mattress purchased for issue to an inmate in a
facility, which is locked to prevent unimpeded
access to the outdoors, is certified by the
x
manufacturer as meeting all requirements of the
State Fire Marshal and Bureau of Home Furnishings
for penal mattresses at the time of purchase.
3
ARTICLE/SECTION YESNO N/A COMMENTS
Article 15. Facility Sanitation and Safety
1280 Facility Sanitation, Safety and Maintenance
Butte County Sheriff’s Office Court Holding Facility
Manual 2.1280- Facility Sanitation
There are policies and procedures for the
x
maintenance of an acceptable level of cleanliness,
Janitorial contract with Pro-Line Cleaning Services,
repair and safety throughout the facility. Inc.
The plan provides for a regular schedule of Deficiency- holding cell 104 has low water
pressure from hand washing sink.
housekeeping tasks and inspections to identify and
correct unsanitary or unsafe conditions or work
Corrective action –repair to provide adequate
practices.
water pressure to properly wash hands
x
Deficiency- holding cell 104 and corridor between
cells 201 and 202 have lights that are out.
Corrective action – repair,
maintenance has a work order in.
Itemized Summary
I. Environmental Health Evaluation
Chico Courthouse
Page 4
Deficiency- holding cell 104 has low water pressure from hand washing sink.
Corrective action – repair to provide adequate water pressure to properly wash hands
Deficiency- holding cell 104 and corridor between cells 201 and 202 have lights that are out.
Corrective action – repair, maintenance has a work order in.
Summary of environmental health evaluation: Some deficiencies with plumbing and lighting were seen but are being
addressed. This facility has required policies and procedures in place. Overall, facility is in good condition.
Suggested best practices: Have soap available for inmates to wash their hands, when requested.
4
III. MEDICAL/MENTAL HEALTH EVALUATION
Adult Court and Temporary Holding Facilities
ARTICLE/SECTIONYES NO N/A COMMENTS
Article 11. Health Services
1200 Responsibility for Health Care Services
Staff was not aware of Court Holding Facility
In court holding and temporary holding facilities, the
Manual but manual was presented to inspectors at
facility administrator shall have the responsibility to
start of visit
X
develop written policies and procedures which
ensure provision of emergency health care services
to all inmates.
1207 Medical Receiving Screening
Court Holding Facility Manual addresses cases
(Not applicable to CH)
should a prisoner be taken into custody at the court
house pending transfer to the jail where screen
would occur.
X
A receiving screening is performed on all inmates at
the time of intake, with the exception of inmates
transferred directly within a custody system with
documented receiving screening
This screening shall be completed in accordance
with written procedures and shall include but not be
limited to medical and mental health problems, X
developmental disabilities, tuberculosis and other
communicable diseases.
The screening shall be performed by licensed health
personnel or trained facility staff, with
documentation of staff training regarding site
specific forms with appropriate disposition based on
X
responses to questions and observations made at
the time of screening. The training depends on the
role staff are expected to play in the receiving
screening process.
The facility administrator and responsible physician
shall develop a written plan for complying with
X
Penal Code Section 2656 (orthopedic or prosthetic
appliance used by inmates).
There shall be a written plan to provide care for any
inmate who appears at this screening to be in need
X
of or who requests medical, mental health, or
developmental disability treatment.
Written procedures and screening protocol shall be
X
established by the responsible physician in
cooperation with the facility administrator.
5
ARTICLE/SECTIONYES NO N/A COMMENTS
1209 Mental Health Services and Transfer to a Manual does address cases where person is taken
Treatment Facility into custody in the court house pending transfer to
the jail where services would occur.
(Not applicable to CH)
X
(a) The health authority, in cooperation with the
mental health director and facility
administrator, shall establish policies and
procedures to provide mental health services.
These services shall include but not be limited
to:
1.Identification and referral of inmates
X
with mental health needs;
2.Mental health treatment programs
X
provided by qualified staff, including the
use of teleheath.
3. Crisis intervention services; X
4. Basic mental health services provided, as
X
clinically indicated;
X
5. Medication support services; and,
6. The provision of health services
sufficiently coordinated such that care is
appropriately integrated, medical and
X
mental health needs are met, and the
impact of any of these conditions on each
other is adequately addressed.
(b) Unless the county has elected to implement
the provisions of Penal Code Section 1369.1, a
mentally disordered inmate who appears to
be a danger to himself or others, or to be
gravely disabled, shall be transferred for
further evaluation to a designated Lanterman
Petris Short treatment facility designated by
X
the county and approved by the State
Department of Mental Health for diagnosis
and treatment of such apparent mental
disorder pursuant to Penal Code section
4011.6 or 4011.8 unless the jail contains a
designated Lanterman Petris Short treatment
facility.
Prior to the transfer, the inmate may be
evaluated by licensed health personnel to
determine if treatment can be initiated at the
correctional facility. Licensed health
personnel may perform an onsite assessment X
to determine if the inmate meets the criteria
for admission to an inpatient facility, or if
treatment can be initiated in the correctional
facility.
6
ARTICLE/SECTIONYES NO N/A COMMENTS
(c) If the county elects to implement the
provisions of Penal Code Section 1369.1, the
health authority, in cooperation with the
facility administrator, shall establish policies
X
and procedures for involuntary
administration of medications. The
procedures shall include, but not be limited
to:
1. Designation of licensed personnel,
including psychiatrist and nursing staff,
X
authorized to order and administer
involuntary medication;
2. Designation of an appropriate setting
X
where the involuntary administration of
medication will occur;
3. Designation of restraint procedures
and/or devices that may be used to
X
maintain the safety of the inmate and
facility staff;
4. Development of a written plan to
monitor the inmate's medical condition
following the initial involuntary
administration of a medication, until the
inmate is cleared as a result of an
evaluation by, or consultation with, a
psychiatrist;
X
7
ARTICLE/SECTIONYES NO N/A COMMENTS
5. Development of a written plan to provide
a minimum level of ongoing monitoring
of the inmate following return to facility
housing. This monitoring may be
performed by custody staff trained to
recognize signs of possible medical
problems and alert medical staff when
indicated; and
X
6. Documentation of the administration of
X
involuntary medication in the inmate's
medical record.
1212 Vermin Control
Manual does address cases where individual is taken
(Not applicable to CH)
into custody in the court house and transferred to
the jail where control and treatment would occur.
The responsible physician shall develop a written
X
plan for the control and treatment of vermin-
infested inmates. There shall be written, medical
protocols, signed by the responsible physician, for
the treatment of persons suspected of being
infested or having contact with a vermin-infested
inmate.
1213 Detoxification Treatment
(Not applicable to CH)
The responsible physician shall develop written
medical policies on detoxification which shall include
X
a statement as to whether detoxification will be
provided within the facility or require transfer to a
licensed medical facility. The facility detoxification
protocol shall include procedures and symptoms
necessitating immediate transfer to a hospital or
other medical facility.
Facilities without medically licensed personnel in
attendance shall not retain inmates undergoing
withdrawal reactions judged or defined in policy, by
X
the responsible physician, as not being readily
controllable with available medical treatment. Such
facilities shall arrange for immediate transfer to an
appropriate medical facility.
8
ARTICLE/SECTIONYES NO N/A COMMENTS
1220 First Aid Kits Some first aid kits are in court rooms.
X
First aid kit(s) shall be available in all facilities.
The responsible physician shall approve the Deficiency: First aid kits contents are not
contents, number, location and procedure for standardized. Manual is not specific as to specific
periodic inspection of the kit(s). In Court and contents and quantity. While policy states kits are
Temporary Holding facilities, the facility to be inspected at least monthly, expired items were
administrator shall have the above approval found in the kits and contents varied from kit to kit.
authority, pursuant to Section 1200 of these
Corrective Action: edit manual to make specific list
regulations.
of contents and review inspection process to ensure
compliance with policy.
X
Best practice would be to have first aid kits in both
court houses mirror each other in content and
location. Would recommend kits be immediately
available in closest area to cells as is done at Oroville
facility
1046 Death in Custody
Addressed in section 2.1046 of manual
(a) Death in Custody Reviews for Adults and
Minors.
The facility administrator, in cooperation with
the health administrator, shall develop written
policy and procedures to ensure that there is
X
an initial review of every in-custody death
within 30 days. The review team shall include
the facility administrator and/or the facility
manager, the health administrator, the
responsible physician and other health care
and supervision staff who are relevant to the
incident.
Deaths shall be reviewed to determine the
appropriateness of clinical care; whether
changes to policies, procedures, or practices
X
are warranted; and to identify issues that
No in custody deaths occurred in court house
require further study.
during inspection period.
(b) Death of a Minor.
No death of in custody minor occurred in court
In any case in which a minor dies while
X
house during inspection period.
detained in a jail, lockup, or court holding
facility:
(1) The administrator of the facility shall
provide to the Board a copy of the report
submitted to the Attorney General under
X
Government Code Section 12525. A copy
of the report shall be submitted within 10
calendar days after the death.
9
ARTICLE/SECTIONYES NO N/A COMMENTS
(2) Upon receipt of a report of death of a
minor from the administrator, the Board
may within 30 calendar days inspect and
evaluate the jail, lockup, or court holding
X
facility pursuant to the provisions of this
subchapter. Any inquiry made by the
Board shall be limited to the standards
and requirements set forth in these
regulations.
1051 Communicable Diseases
Addressed in section 2.1051 of the manual
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures specifying those symptoms that
require segregation of an inmate until a medical
evaluation is completed.
At the time of intake into the facility, an inquiry shall
be made of the person being booked as to whether or
not he/she has or has had any communicable
X
diseases, such as tuberculosis or has observable
symptoms of tuberculosis or any other communicable
diseases, or other special medical problem identified
by the health authority.
The response shall be noted on the booking form
X
and/or screening device.
1052 Mentally Disordered Inmates
Addressed in section 2.1052 for Court House Policy
The facility administrator, in cooperation with the
manual.
responsible physician, shall develop written policies
and procedures to identify and evaluate all mentally
disordered inmates, and may include telehealth. If an
X
evaluation from medical or mental health staff is not
readily available, an inmate shall be considered
mentally disordered for the purpose of this section if
he or she appears to be a danger to himself/herself or
others or if he/she appears gravely disabled.
An evaluation from medical or mental health staff
shall be secured within 24 hours of identification or
X
at the next daily sick call, whichever is earliest.
Segregation may be used if necessary to protect the
safety of the inmate or others.
1055 Use of Safety Cell
Safety cell is not available
The safety cell described in Title 24, Part 2, Section
1231.2.5, shall be used to hold only those inmates
X
who display behavior which results in the
destruction of property or reveals an intent to cause
physical harm to self or others
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures governing safety cell use and may
delegate authority to place an inmate in a safety cell
to a physician.
In no case shall the safety cell be used for
X
punishment or as a substitute for treatment.
10
ARTICLE/SECTIONYES NO N/A COMMENTS
An inmate shall be placed in a safety cell only with
the approval of the facility manager or designee, or
X
responsible health care staff; continued retention
shall be reviewed a minimum of every four hours.
A medical assessment shall be completed within a
maximum of 12 hours of placement in the safety cell
or at the next daily sick call, whichever is earliest. X
The inmate shall be medically cleared for continued
retention every 24 hours thereafter.
The facility manager, designee or responsible health
care staff shall obtain a mental health
opinion/consultation with responsible health care X
staff on placement and retention, which shall be
secured within 12 hours of placement.
Direct visual observation shallbe conducted at least
X
twice every thirty minutes. Such observation shall be
documented.
Procedures shall be established to assure
administration of necessary nutrition and fluids.
Inmates shall be allowed to retain sufficient clothing,
or be provided with a suitably designed “safety
X
garment,” to provide for their personal privacy
unless specific identifiable risks to the inmate's
safety or to the security of the facility are
documented.
1056 Use of Sobering Cell Sobering Cell is not available
The sobering cell described in Title 24, Part 2,
Section 1231.2.4, shall be used for the holding of
inmates who are a threat to their own safety or the
safety of others due to their state of intoxication and
pursuant to written policies and procedures
developed by the facility administrator. Such
inmates shall be removed from the sobering cell as
X
they are able to continue in the processing. In no
case shall an inmate remain in a sobering cell over
six hours without an evaluation by a medical staff
person or an evaluation by custody staff, pursuant
to written medical procedures in accordance with
section 1213 of these regulations, to determine
whether the prisoner has an urgent medical
problem.
At 12 hours from the time of placement, all inmates
will receive an evaluation by responsible health care
staff. Intermittent direct visual observation of X
inmates held in the sobering cell shall be conducted
no less than every half hour.
11
ARTICLE/SECTIONYES NO N/A COMMENTS
Such observation shall be documented. X
1057 Developmentally Disabled Inmates
Addressed in section 1.1059 of Court Holding Facility
The facility administrator, in cooperation with the
Manual.
responsible physician, shall develop written policies
X
and procedures for the identification and evaluation,
appropriate classification and housing, protection,
and nondiscrimination of all developmentally
disabled inmates.
The health authority or designee shall contact the
Deficiency: Contacting regional center is not
regional center on any inmate suspected or confirmed
addressed in Court Holding Facility Manual.
to be developmentally disabled for the purposes of
X
diagnosis and/or treatment within 24 hours of such
Corrective action: edit policy and train staff to
determination, excluding holidays and weekends.
contact regional center for inmates thought to be
developmentally disabled.
1058 Use of Restraint Devices Addressed in section 2.1058 of the Court Holding
Facility Manual
The facility administrator, in cooperation with the
X
responsible physician, shall develop written policies
and procedures for the use of restraint devices and
may delegate authority to place an inmate in
restraints to a responsible health care staff.
In addition to the areas specifically outlined in this
regulation, at a minimum, the policy shall address the
following areas:
acceptable restraint devices;
signs or symptoms which should result in
immediate medical/mental health referral;
X
availability of cardiopulmonary
resuscitation equipment;
protective housing of restrained persons;
provision for hydration and sanitation
needs; and
exercising of extremities.
In no case shall restraints be usedfor punishment or
X
as a substitute for treatment.
Restraint devices shall only be used on inmates who
display behavior which results in the destruction of
property or reveal an intent to cause physical harm to
X
self or others. Restraint devices include any devices
which immobilize an inmate's extremities and/or
prevent the inmate from being ambulatory.
Physical restraints should be utilized only when it
X
appears less restrictive alternatives would be
ineffective in controlling the disordered behavior.
Inmates shall be placed in restraints only with the Deficiency: Section 2.1058(5) of Court Holding
approval of the facility manager, the facility watch Facility Manual allow for review every 2 hours.
X
commander, responsible health care staff;
Corrective action: amend policy and procedure to
continued retention shall be reviewed a minimum of
comply with standard of every hour.
every hour.
12
ARTICLE/SECTIONYES NO N/A COMMENTS
A medical opinion on placement and retention shall Deficiency: Section 2.1058 (5) of Policy allows for
be secured within one hour from the time of medical opinion within 6 hours
placement. A medical assessment shall be
X
Corrective action: amend policy and procedure to
completed within four hours of placement.
comply with standard of within four (4) hours in
Court Holding Facility Manual
If the facility manager, or designee, in consultation Addressed in section 2.1058(6) of Court Holding
with responsible health care staff determines that Facility Manual
an inmate cannot be safely removed from restraints X
after eight hours, the inmate shall be taken to a
medical facility for further evaluation.
Direct visual observation shall be conducted at least Addressed in section 2.1058(5) of Court Holding
twice every thirty minutes to ensure that the Facility Manual
X
restraints are properly employed, and to ensure the
safety and well-being of the inmate. Such
observation shall be documented.
While in restraint devices all inmates shall be housed Addressed in section 2.1058(5) of Court Holding
alone or in a specified housing area for restrained Facility Manual
X
inmates which makes provisions to protect the
inmate from abuse.
The provisions of this section do not apply to the use
of handcuffs, shackles or other restraint devices X
when used to restrain inmates for security reasons.
1058.5 RESTRAINTS AND PREGNANT INMATES Addressed in section 2.1058(6) of Court Holding
Facility Manual
The facility administrator, in cooperation with the
responsible physician, shall develop written policies
X
and procedures for the use of restraint devices on
pregnant inmates. In accordance with Penal Code
3407 the policy shall include reference to the
following:
(1) An inmate known to be pregnant or in
recovery after delivery shall not be
X
restrained by the use of leg irons, waist
chains, or handcuffs behind the body.
(2) A pregnant inmate in labor, during
delivery, or in recovery after delivery,
shall not be restrained by the wrists,
X
ankles, or both, unless deemed necessary
for the safety and security of the inmate,
the staff, or the public.
(3) Restraints shall be removed when a
professional who is currently responsible
for the medical care of a pregnant inmate
X
during a medical emergency, labor,
delivery, or recovery after delivery
determines that the removal of restraints
is medically necessary.
13
ARTICLE/SECTIONYES NO N/A COMMENTS
(4) Upon confirmation of an inmate's
pregnancy, she shall be advised, orally or
X
in writing, of the policies governing
pregnant inmates.
Itemized Summary
III. Medical/Mental Health Evaluation
Chico Courthouse
Overall, the facility seemed to be operated in an appropriate fashion. Deputies were cooperative and forthright in
assisting with and facilitating the inspection. Deficiencies are primarily related to policy edits and training to the policies.
Page 9
Deficiency: First aid kits contents are not standardized. Manual is not specific as to specific contents and quantity.
While policy states kits are to be inspected at least monthly, expired items were found in the kits and contents varied
from kit to kit.
Corrective Action: edit manual to make specific list of contents and review inspection process to ensure compliance with
policy.
Best practice would be to have first aid kits in both court houses mirror each other in content and location. Would
recommend kits be immediately available in closest area to cells as is done at Oroville facility.
Page 12
Deficiency: Contacting regional center is not addressed in Court Holding Facility Manual.
Corrective action: edit policy and train staff to contact regional center for inmates thought to be developmentally
disabled.
Deficiency: Section 2.1058(5) of Court Holding Facility Manual allow for review every 2 hours.
Corrective action: amend policy and procedure to comply with standard of every hour.
Page 13
Deficiency: Section 2.1058 (5) of Policy allows for medical opinion within 6 hours
Corrective action: amend policy and procedure to comply with standard of within four (4) hours in Court Holding Facility
Manual
14
Combined Itemized Summary
Butte County Facilities
Butte County Jail
Itemized Summary
I. Environmental Health Evaluation
Butte County Jail
Deficiency- Cold holding of dressings in staff salad bar at 46 degrees F.
Corrective Action- Maintain potentially hazardous food at or below 41 degrees F.
Deficiency: Basins of mixed ingredients in walk-in refrigerator to cool observed at 44 degrees F after 24 hours.
Corrective Action- Mixed ingredients must cool to 41 degrees F or colder in 4 hours. When cooling foods maintain
food depths at 2 – 3 inches to cool quickly.
Deficiency- Not all utensils stored in clean drawer or protected from possible contamination.
Corrective Action- Clean drawers or storage areas to be use for utensil storage.
Deficiency- Colanders and bowls in one area stored unprotected from contamination.
Corrective Action: Store all bowls, etc bottom side up to prevent contamination of food contact surfaces.
Deficiency- One area of floor cove and wall under utensil washing sink broken/damaged.
Corrective Action: Repair floor cove and wall damaged in utensil washing area.
Deficiency- Dish machine high temperature rinse not 160 degrees F at dish.
Corrective Mitigation: Contact Technician ad schedule service/repair. Until repair, mitigation to wash, utensils in dish
machine and use chemical sanitizer solution in 3 compartment sink to complete sanitizer cycle.
Deficiency- In South dorm the light fixture in the bathroom is broken
Corrective action- repair
Deficiency- cell K hand wash sink has a leaky pipe
Corrective action- repair
Deficiency- cells 4 and 62 have low water pressure
Corrective action – Increase water pressure so inmates can adequately wash their hands
Deficiency – cells 86 and 54 have no hot water
Corrective action – provide hot water
Deficiency – cell H sink is not working
Corrective action – repair
Deficiency – cell 66 toilet is leaking
Corrective action – repair
Deficiency- cell M has lights that are out
Corrective action – repair
Itemized Summary
II. Nutritional Health Evaluation
Butte County Jail
Carrots served daily. Recommend adding other Vitamin A rich sources like cantaloupe, sweet potatoes, winter squash,
apricots, and spinach, kale or collard greens
Deficiency: No signature of responsible physician on diet manual.
Corrective Action: Responsible physician shall approve diet manual and will provide approval annually.
Frequency of serving and minimum diet meet the requirements based upon the nutritional and caloric requirements found
in the 2011 Dietary Reference Intakes (DRI) of the Food and Nutrition Board, Institute of Medicine of the National
Academies, the 2008 California Food Guide, and the 2015-2020 Dietary Guidelines for Americans. Menus are planned in
advance, approved by a Registered Dietitian and provide a variety of foods. Foodservice plan provided by Trinity Services
Group and complies with the applicable California Retail Food Code.
A deficiency was found in the approval of the diet manual by the responsible physician. No other deficiencies were found.
Itemized Summary
III. Medical/Mental Health Evaluation
Butte County Jail
Best Practice: Adding Automatic External Defibrillators and Narcan to the first aid supply list, location and inspection
policy.
Medical equipment should be annually inspected for calibration and electrical safety. Butte County Sheriff Office Policy
authorizes health authority to adopt and implement policies on AED and to ensure staff are trained on the use.
Deficiency: Provision are in place for enforcement of self-medication rules but not included in formal written policies and
procedures
Corrective Action: Incorporate for enforcement of self-medication rules into written policies and procedures to ensure
consistent practice
Deficiency: Provision are in place for assessment of inmate compliance with self-medication but not included in formal
written policies and procedures
Corrective Action: Incorporate processes for assessment of inmate compliance with self-medication into written policies
and procedures to ensure consistent practice
Best Practice: Corporate Policies for pharmaceutical destruction should be incorporated into local policies and
procedures
Deficiency: There was no evidence of a formalized and approved list of first aid kit supplies but there is a list that is used
for inventory and inspection is occurring. There is a list of supplies for emergency bags (different than first aid kits.)
Corrective Action: establish and publish policy that defines content, location & inspection of first aid kits as required by
Butte County Sheriff Office Policy 704
Chico Courthouse
Itemized Summary
I. Environmental Health Evaluation
Chico Courthouse
Deficiency- holding cell 104 has low water pressure from hand washing sink.
Corrective action – repair to provide adequate water pressure to properly wash hands
Deficiency- holding cell 104 and corridor between cells 201 and 202 have lights that are out.
Corrective action – repair, maintenance has a work order in.
Itemized Summary
III. Medical/Mental Health Evaluation
Chico Courthouse
Overall, the facility seemed to be operated in an appropriate fashion. Deputies were cooperative and forthright in
assisting with and facilitating the inspection. Deficiencies are primarily related to policy edits and training to the policies.
Deficiency: First aid kits contents are not standardized. Manual is not specific as to specific contents and quantity. While
policy states kits are to be inspected at least monthly, expired items were found in the kits and contents varied from kit to
kit.
Corrective Action: edit manual to make specific list of contents and review inspection process to ensure compliance with
policy.
Best practice: would be to have first aid kits in both court houses mirror each other in content and location. Would
recommend kits be immediately available in closest area to cells as is done at Oroville facility.
Deficiency: Contacting regional center is not addressed in Court Holding Facility Manual.
Corrective action: edit policy and train staff to contact regional center for inmates thought to be developmentally
disabled.
Deficiency: Section 2.1058(5) of Court Holding Facility Manual allow for review every 2 hours.
Corrective action: amend policy and procedure to comply with standard of every hour
Deficiency: Section 2.1058 (5) of Policy allows for medical opinion within 6 hours
Corrective action: amend policy and procedure to comply with standard of within four (4) hours in Court Holding
Facility Manual
Itemized Summary
I. Environmental Health Evaluation
Police Department – City of Chico
Deficiency – all 7 holding cells do not have hot water. Some holding cell’s hot water button was not working
Corrective action – provide hot water and fix the hot water button
Deficiency – light in shower is not working
Corrective action – repair
Itemized Summary
III. Medical/Mental Health Evaluation
Police Department – City of Chico
Deficiency: Training of facility staff is lacking.
Corrective Action: Training program is in development per Lt Struthers. Recommend acceleration and implementation of
training program.
Deficiency: Policy does not specify specific contents of first aid kits and there is no documentation supporting periodic
inspection. Expired contents were identified.
Corrective Action: Update policy to list specific contents and locations of first aid kits. Establish policy and implement
policy to regularly inspect first aid kits for complete and current status of contents.
Commendation: Facility has an Automatic External Defibrillator (AED) in place. This is noted as best practice.
Best Practice: AED should be included in the first aid inspection policy to ensure it us operational. Narcan should be
available in the facility should drug overdose occur.
Juvenile Hall
Itemized Summary
I. Environmental Health Evaluation
Juvenile Halls, Special Purpose Juvenile Halls and Camps
Deficiency - Item (n) The Hazard Analysis Critical Control Point Plan is out of date and was written by previous Food
Services Manager.
Corrective Action - The current Food Services Manager is working to write a new HACCP plan for facility and using the
California Retail Food Code
Deficiency- holding cell 3, intake shower room, rooms E12 and F1-F8 have no hot water at the hand washing sinks
Corrective action – provide hot water
Deficiency – hot water button at hand wash sinks in rooms E3, E13, and F11 are not working
Corrective action – repair
Deficiency – light is out in room E12
Corrective action – repair
Summary of environmental health evaluation: Deficiencies were found throughout rooms for plumbing fixtures and
lighting that need to be addressed. Rooms D1-16 and Condor Pod were not being occupied. Suggested best practices:
Prior to rooms being occupied check for hot water, plumbing, and lighting to ensure it’s in good working condition. This
facility has required policies and procedures in place.
Summary of environmental health inspection: Raw shell eggs being used for juveniles. If former HACCP plan for using
raw shell eggs in meals is not found create one or cease using raw shell eggs.
Itemized Summary
II. Nutritional Health Evaluation
Juvenile Halls, Special Purpose Juvenile Halls and Camps
Deficiency: No written process for how vegetarian or vegan diets may be requested, granted or denied.
Corrective Action: Write process for how vegetarian or vegan diets may be requested, granted or denied.
Carrots on menu frequently. If not already on menu recommend adding other Vitamin A rich sources like cantaloupe,
sweet potatoes, winter squash, apricots, spinach, kale or collard greens.
Deficiency: Medical diets are not planned, prepared or served with consultation of an RD.
Corrective Action: Have RD plan and prepare medical diet manual for use by facility.
Deficiency: Medical diet manual not available.
Corrective Action: Medical diet manual will be available in both the medical unit and the food service office.
Deficiency: Medical diet manual not available or approved.
Corrective Action: Medical diet manual will be approved on an annual basis by the RD and responsible physician
Deficiency: Substitutions are not evaluated by RD.
Corrective Action: Have RD evaluate substitution logs to provide feedback on appropriate substitutions.
Foodservice plan from 2014, recommended reviewing and updating.
Old HACCP plan on file and staff not trained on procedures. Recommend updating HACCP plan and training all staff
Deficiency: No provision for maintaining 3 days of meals for testing in the event of food-borne illness.
Corrective Action: Create provision for maintaining 3 days of meals for testing.
Menus and frequency of serving meet the nutritional requirements based on nutritional standards which include the
Federal Child Nutrition Meal Program. Menus are planned well in advance and provide a variety of foods considering the
cultural and ethnic makeup of the facility. Kitchen staff receive ongoing training in safe food handling techniques.
Deficiencies were found include lack of medical diet manual, planning of vegetarian or vegan diets, proper review of
substitutions by Registered Dietitian and provision to maintaining 3 days of meals for testing
Itemized Summary
III. Medical/Mental Health Evaluation
Juvenile Halls, Special Purpose Juvenile Halls and Camps
Addressed in Wellpath policy HCD 210Y D-07
Deficiency: First aid kits are available but contents are not uniform or defined in policy. Process is in place for inspecting
kits but has holes that allows gaps in ensuring contents are current and complete.
Corrective Action: Amend policy to include inventory list, inventory quantity, location of all first aid kits and process for
ensuring contents are complete and up-to-date
Facility does not have staffing to provide MAT for opioid use disorder.
Commendations:(1) Facility is a Vaccinesfor Children (VFC) provider and RN is committed to getting immunizations
up to date. New data logger information for VFC appliances will be forwarded to the RN by local health department
vaccine coordinator. (2) RN provides Covid screening outside facility before youth enter to decrease transmission in to
facility. (3) RN provides reproductive health education to youth in facility. Local health department health education
specialist will connect with RN to coordinate education efforts and promote birth control methods and STD testing
available at Public Health clinics.
Oroville Courthouse
Itemized Summary
I. Environmental Health Evaluation
Oroville Courthouse
Policies and procedures in place but not being adhered to.
Janitorial contract with Pro-Line Cleaning Services, Inc.
Deficiency – holding cell next to the attorney visiting room and cells 42 and 43 have no hot water
Corrective action – provide hot water. Hot water was turned back on during inspection, corrected on stie.
Deficiency – lights in the holding cell (next to attorney visiting room) and the attorney visiting room were not working.
Corrective action – repair
Deficiency – A chain was hooked onto the back of the char in the attorney visiting room
Corrective action – remove the chain
Summary of environmental health evaluation: Deficiencies found with plumbing fixtures and lighting within the facility
that need to be addressed. The hot water was turned off due to holding cells being unoccupied, which was then turned on
during the inspection. Have policies in place to ensure hot water is turned on when cells are going to be occupied and to
check lights regularly to ensure they are working.
Best Practices: Have soap available for inmates to wash their hands, when requested.
Itemized Summary
III. Medical/Mental Health Evaluation
Oroville Courthouse
Deficiency: First aid kits contents are not standardized. Manual is not specific as to contents and quantity. While policy
states kits are to be inspected at least monthly, expired items were found in the kits and contents varied from kit to kit.
Corrective Action: edit manual to make specific list of contents and review inspection process to ensure compliance with
policy.
Best practice: would be to have first aid kits in both court houses mirror each other in content and location.
Deficiency: Contacting regional center is not addressed in policy manual.
Corrective action: edit policy and train staff to contact regional center for inmates thought to be developmentally
disabled.
Deficiency: Section 2.1058(5) of Court Holding Facility Manual allows for review every 2 hours.
Corrective action: amend policy and procedure to comply with standard of every hour.
Deficiency: Section 2.1058 (5) of Policy allows for medical opinion within 6 hours
Corrective action: amend policy and procedure to comply with standard of within four (4) hours in Court Holding
Facility Manual
Overall, the facility seemed to be operated in an appropriate fashion. Deputies were cooperative and forthright in
assisting with and facilitating the inspection. Deficiencies are primarily related to policy edits and training to the policies.
Paradise Police Department
Itemized Summary
I. ENVIRONMENTAL HEALTH EVALUATION
Paradise Police Department
Deficiency – light is out in right holding cell
Corrective action – repair
Itemized Summary
III. Medical/Mental Health Evaluation
Paradise Police Department
Deficiency: Policy is not in place with location and approved inventory list of contents of first aid kits. Also, Policy is not
in place for consistent inspection of kits for currency and completeness
Corrective Action: update policy manual to include inventory list of first aid kits, locations, and inspection procedure.
Staff were cooperative and collaborative in completion of the inspection. Generally, the facility meets the inspection
requirements.
Facility does have an Automatic External Defibrillator (AED) in hallway nearby holding facility cells with an inspection
checklist.
Best Practice: Best practice would be to include Narcan with emergency medical supplies. The location should be central
in the Department facility to be available to all parts of the building and defined in the policy manual