MEMBERS OF THE BOARD

COUNTY OF LOS ANGELES
OFFICE OF INSPECTOR GENERAL
312 SOUTH HILL STREET, THIRD FLOOR
LOS ANGELES, CALIFORNIA 90013
(213) 974-6100
http://oig.lacounty.gov

HILDA L. SOLIS
MARK RIDLEY-THOMAS
SHEILA KUEHL
JANICE HAHN
KATHRYN BARGER

MAX HUNTSMAN

INSPECTOR GENERAL

February 4, 2019

TO:

Supervisor Janice Hahn, Chair
Supervisor Hilda L. Solis
Supervisor Mark Ridley-Thomas
Supervisor Sheila Kuehl
Supervisor Kathryn Barger

FROM:

Max Huntsman
Inspector General

SUBJECT:

REPORT BACK ON ENSURING SAFETY AND HUMANE
TREATMENT IN THE COUNTY’S JUVENILE JUSTICE
FACILITIES

Introduction
On December 18, 2018, the Los Angeles County Board of Supervisors
(Board) directed the Office of the Inspector General (OIG) to investigate safety
concerns in Los Angeles County Probation Department (Department) juvenile
halls and camps, with an emphasis on use-of-force incidents involving oleoresin
capsicum (OC) spray (also known as pepper spray), and to report back with
findings and related recommendations. The Board also instructed the OIG to
address de-escalation tools and any staffing issues that impede de-escalation
efforts.
The Department maintained an open and collaborative approach
throughout the OIG’s review. Department staff, managers, and executive
leadership were accommodating and transparent, and the Department
responded to document and information requests thoroughly and quickly.
Department personnel and executives made themselves available for inquiries,
meetings, and follow-up at each step of the review. Many of the issues
addressed in this review were articulated by Department executives at the outset,
and input from Department members contributed to the development of OIG
recommendations.

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The majority of Department staff who spoke with the OIG expressed a
passion for their work and a determination to positively affect the lives of youth.
Some also shared challenges and frustrations. Conversations with youth, staff,
and managers revealed many shared opinions regarding safety concerns, lack of
resources, concerns about policies, training and practices, and the need for
improved communication and ongoing dialogue within the Department.
The OIG’s review confirms reports by Department executives, staff, and
youth that some staff have engaged in inappropriate and avoidable uses of OC
spray and have failed to properly decontaminate youth who have been exposed
to OC. In those instances where egregious acts were suspected to have been
committed, the Department reports that it has removed staff from direct contact
with youth and will be taking disciplinary action if appropriate.
In some instances, staff who have not received effective training, including
training on de-escalation techniques, may rely on OC spray as a default or as an
intermediary step to obtain compliance rather than as a last resort in potentially
or actively dangerous situations. In some instances, youth have been
ineffectively decontaminated, or decontaminated long after exposure to OC
spray.
Lack of adequate training, supervision, accountability systems, and
policies, which may be exacerbated by an apparent lack of resources, likely
contribute to out-of-policy use of and over-reliance on OC spray. In general, staff
reported feeling unsupported and ill equipped to effectively interact with youth,
especially those with acute mental health and behavioral needs. Specifically,
staff consistently identified a lack of effective policies and training that would
prepare them to attempt to de-escalate tense situations and avoid using OC
spray.
Background
The Department is composed of approximately 6,000 staff members who
work in more than eighty facilities across the county, including three juvenile
halls, seven youth camps, and the Dorothy Kirby Center, a secured, residential
facility that provides enhanced mental health services for youth. The Department
interacts with an average daily population of approximately 7,750 youth in its
camps, juvenile halls, and at-home placements, making it the largest probation
department in the nation. Throughout 2018, approximately 900 of these youth
were housed in its juvenile halls and camps on any given day.
The Department currently authorizes staff to use OC spray in its juvenile
halls (Barry J. Nidorf Juvenile Hall, Central Juvenile Hall, and Los Padrinos
Juvenile Hall) and two youth camps (Camp Ellison Onizuka and Camp Ronald

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McNair, both a part of the Challenger Memorial Youth Center). Thirty-five states
have banned the use of OC spray in juvenile facilities and California is one of six
states (in addition to Illinois, Texas, South Carolina, Indiana and Minnesota) that
allow staff in juvenile facilities to carry OC canisters.1 The OIG spoke with several
representatives from county probation departments throughout California
regarding the use of OC spray and de-escalation tactics. San Francisco County,
Santa Cruz County, Marin County, and Santa Clara County do not permit the use
of OC spray in their juvenile facilities.
Representatives from all four county probation departments shared
information regarding non-punitive alternatives to use-of-force that have
reportedly served them well and stressed the importance of policies and
practices that foster positive relationships between youth and staff. The OIG also
spoke to systems that make use of OC spray.
In March of 2018, the Department reported a significant increase in the
use of OC spray in its juvenile halls from 2015 through 2017:




Central Juvenile Hall: 338%
Los Padrinos Juvenile Hall: 214%
Barry J. Nidorf: 192%2

At the time, the Department had not analyzed OC spray figures in its camps.3 No
changes to the Department’s core use-of-force policy took place during that time.
The Department also reported an increase in youth-on-youth assaults (66%) and
youth assaults on staff (58%) from 2016 through 2017.4
In December of 2018, the Department cited a 20% decrease in the use of
OC spray in juvenile halls and camps, when compared to 2017.5 The Department
reports that it is conducting on going internal review of OC related incidents and
has generated additional data. The OIG has recommended and the Department
has agreed to increase transparency by developing a plan to regularly publish
use-of-force and violence data on the Department website.

1

Report by Legislative Counsel David Billingsley presented to the Assembly Committee on Public Safety for hearing held
April 17, 2018, pg. 4; see also Council of Juvenile Correctional Administrators, Issue Brief: Pepper Spray in Youth
Facilities (May 2011), p.2, available at http://cjca.net/wp-content/uploads/2018/02/CJCA.Issue_.Brief_.OCSpray.pdf (last
accessed January 30, 2019).
2
County of Los Angeles Probation Commission, Minutes of Regular Meeting of March 22, 2018, available at
http://file.lacounty.gov/SDSInter/probation/1039083_ProbationCommissionMinutes03-22-2018.pdf (last accessed January
22, 2019).
3
Ibid.
4
Id.
5
County of Los Angeles Board of Supervisors, December 18, 2018 Meeting Transcript, pg. 133, available at
http://file.lacounty.gov/SDSInter/bos/sop/transcripts/1048857_121818.pdf (last accessed January 22, 2019).

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The Department’s Safe Crisis Management (SCM) policy currently
governs the use-of-force (including use of OC spray) and its review in County
juvenile justice facilities. The SCM policy addresses varied topics that include
staff training requirements, reporting protocols, and the use of physical restraints
and OC spray.6 The SCM policy organizes force on a continuum, with six total
levels that progress from less to more significant physical and chemical
interventions (i.e. OC spray). It requires that force only be used as “necessary
and appropriate to restore order and/or achieve and maintain control” and not as
a form of “discipline, punishment or retaliation.”7 It also details a host of deescalation approaches and prohibits certain kinds of force techniques, including
the carotid restraint (commonly referred to as a “chokehold”).8
OC spray is the most significant force option authorized by the
Department, with the SCM policy describing it as “the final and ultimate
authorized” method to “gain control of a situation and/or subdue” youth.9 During
“controlled situations,” which the SCM policy generally defines as situations in
which youth are not actively physically aggressive, OC spray may only be used
at the discretion of a supervisor.10 In “uncontrolled situations,” which are defined
as incidents during which staff must respond immediately, officers are authorized
to rely on OC spray without supervisory approval. 11 The Department prohibits the
use of OC spray on individuals who are receiving psychotropic medications,
under the influence of stimulants, suffer from asthma or other respiratory issues,
have a history of heart disease or seizures, are pregnant, or are clinically
obese.12
The Department’s senior leadership provided the OIG with information
regarding its assessments of several force-related issues. In August of 2017, the
Department prepared a report for the Board of Supervisors outlining targeted
strategic initiatives for establishing greater accountability, rehabilitating youth,
maintaining a core workforce of professionals by promoting development and
wellness, and strengthening communities.
The Department identifies several key issues that echo concerns
communicated to the OIG during conversations with leadership, staff, and youth.
These issues, several of which are outlined below, include improving training
infrastructure, creating a robust auditing function, and implementing systemic
reform in the internal affairs processes and the grievance system, among other
efforts.
6

Probation Department Safe Crisis Management Policy Directive (SCM Directive), pg. 1.
Ibid.
8
Id. at 4.
9
Id. at 23.
10
Id. at 8.
11
Id. at 33.
12
Id. at 25-26.
7

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The Department reports that it has also conducted an in-depth selfassessment of its accountability systems and related resource needs. The selfassessment included a review of recent problematic use-of-force incidents. As a
result, the Department developed a detailed strategy to eliminate unnecessary or
excessive uses of force in its facilities. The Department’s self-assessments
indicate an institutional awareness and willingness to identify and implement
corrective measures. These fundamental qualities are critical to bringing about
positive and sustainable change through systemic reform and demonstrate the
Department’s commitment to providing youth and staff with a safe environment.
Methods
OIG staff reviewed Department policies, training materials, and
information related to particular uses of force and the reviews that followed. OIG
staff reviewed existing assessments and evaluations, from internal and external
sources, of Department organization, administration, and operations.
OIG staff visited every juvenile justice facility where the use of OC spray is
authorized, and spoke with more than forty-five incarcerated youth representing
each of the County’s juvenile halls, Camp Ellison Onizuka, and Camp Ronald
McNair. In order to ensure that applicable rights and privileges were
safeguarded, representatives of the Public Defender, Alternate Public Defender,
and the Los Angeles County Bar Association’s Independent Juvenile Defender
Program were present during conversations with youth. OIG staff also spoke with
more than thirty line-level Department staff and managers at facilities visited,
Department executive leadership including the Chief Probation Officer, facility
mental health providers, and union representatives.
In addition, OIG staff reviewed twenty-one incidents that were identified
through a Department audit of use-of-force reports and reviewed videos
generated from October 2017 through November 2018 in the juvenile halls and
camps. The Department initiated the audit following a series of troubling use-offorce incidents. The OIG reviewed available information, including reports,
closed-circuit television (CCTV) footage of the incidents, and reviews that
followed. The OIG did not conduct an independent audit of a representative
sample of all reported uses of force for a given time period, nor did the OIG
review the OC cases that the Department audit revealed were within policy. The
below analysis follows a qualitative review of a specific set of Department
identified incidents.
Regarding information provided by youth and staff, the OIG has neither
verified nor independently investigated allegations detailed in this report. To

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ensure confidentiality and safety, the OIG agreed not to document any identifying
information unless a youth threatened harm to self or others.
Use-of-force Incidents and Safety Concerns
The OIG’s onsite visits, conversations with staff and youth, and review of
force incidents reveal several problematic practices. The problematic incidents
identified by the department and reviewed by the OIG include several examples
of OC spray applications and multiple instances of improper or ineffective
decontamination practices that likely violate Department policy.13
Staff and youth interviewed detailed concerns with OC spray use, and with
staff who may not be adequately prepared to prevent uses of force. Staff and
youth recognized that strong relationships and healthy communication are crucial
to creating a safe environment. Youth praised staff who treated them with respect
and took the time to build constructive rapport. However, youth also reported that
some staff were overly harsh or retaliatory, creating a culture based on
punishment and force rather than rehabilitation and support. Safety concerns
identified by staff and youth are discussed in more detail below.
OC Spray
Based on incidents reviewed and youth and staff reporting, OC spray
appears to be a commonly used tool by some staff to obtain compliance;
however, it is not always justified or used as the final and most significant force
option consistent with Department policy. The twenty-one force incidents
reviewed suggest a consistent use of OC spray as an initial or intermediary force
option, rather than as one that follows a failure to de-escalate or the use of less
significant force. Several of the incidents also involve the use of OC spray where
there did not appear to be actual or potential threat of harm by youth. Some staff
also acknowledged the common use of OC spray, and one line-level supervisor
plainly stated that some staff were engaging in “justified overreliance” on OC
spray.
Some incidents reviewed include uses of OC spray that likely violate
Department policies, at times involving youth who appeared only passively noncompliant. In several incidents, the use-of-force reports filed by staff described
youth behaviors as aggressive or threatening, even when available video footage
showed that youth appeared to pose no threat to staff.
Other incidents involved staff who used OC spray before any attempts to
use other, less significant force techniques. Similarly, several incidents involve
13

Most incidents reviewed are currently being investigated and final determinations about policy violations or criminal
conduct are pending.

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situations in which de-escalation strategies, including the involvement of mental
health professionals, may have been fruitful but where not attempted.
Several youth reported that some staff threaten the use of OC spray or
retrieve and shake OC canisters in front of youth as the initial and sole effort to
gain compliance without first giving verbal commands. Youth reports are
consistent with video footage reviewed. While threatening the use of OC spray
may achieve compliance in some situations, it appears to have unnecessarily
escalated confrontations in others.
In some incidents reviewed, OC spray was used on youth who, under the
Department’s SCM policy, should not have been subject to OC spray unless all
other alternatives to gain compliance had first been exhausted. The OIG
reviewed incidents in which youth with identified respiratory conditions and youth
taking psychotropic medications were subjects of OC spray.
In one incident reviewed, a youth with a mental health condition was
engaging in self-harming behavior, and was OC sprayed in the groin and
buttocks. Following the use of OC spray, the youth was left in a room, which
apparently lacked running water, for approximately 20 minutes before being
decontaminated. In violation of the SCM policy, staff did not make reasonable
attempts at physical intervention before relying on OC spray during these
incidents. Furthermore, the use-of-force reports that arose from this incident were
found to be incomplete, failing to accurately describe the events that led to the
use-of-force and OC deployment. The Department reports that the involved
employee was subsequently terminated.
OC Spray Warnings
The Department’s SCM policy, which is in the process of being revised,
contains conflicting and inconsistent requirements for OC spray warnings that
staff are required to provide to youth before deploying OC spray. Some youth
detailed issues with OC spray warnings by staff, citing instances in which they
did and did not receive warnings before OC spray was deployed.
Some youth also expressed confusion over what constitutes a proper
warning, stating that some staff relied on variations of “OC Warning,” while others
only instructed youth to get down on the floor or stop their behavior. One youth,
who was recently the subject of OC use, stated the youth would have complied
with an order if one had been issued.
Other youth stated that certain staff issue blanket warnings when they
begin their shift or arrive on a unit, even if there are no incidents at that point that
would justify a warning or the use-of-force. Some youth reported that blanket or

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preemptive warnings made them uneasy, and they are unable to predict which
specific conduct might result in OC spray.
Inadvertent Exposure to OC Spray
OIG staff received reports of Department personnel inadvertently exposing
youth to OC spray. Several youth recounted being exposed to OC spray when
staff were engaging with other youth, or when staff used OC spray while chasing
youth. One youth spoke about being OC sprayed on the back, and another
stated a significant amount of OC spray hit the youth’s mouth. Both youth stated
that, following the incident, staff indicated that the OC deployments were
accidental.
Some incidents identified by the Department and reviewed by the OIG
also involve unintended OC exposure of bystanders stemming from altercations
between staff and a youth. Reports and available footage suggest that following
the confrontations, staff members appeared to deploy OC despite the fact that
the youth did not appear to pose an imminent physical threat to staff or
surrounding youth.
OC Spray Decontamination
Youth described consistently negative experiences with decontamination
in the juvenile halls and camps. The most common complaints from youth were
related to delayed decontamination and the use of hot water to decontaminate
youth. Several youth, at several facilities, reported being exposed to OC and then
placed in their rooms for upwards of thirty minutes before any attempts to
decontaminate were made.
One youth reported hearing others suffering in their rooms on several
occasions following the application of OC spray. Several youth reported staff-led
decontamination efforts that involved hot water or towels, two improper
decontamination practices that may increase the discomfort that follows OC
spray. Youth stated that staff often make use of shower facilities for
decontamination, and that staff and youth often lack the ability to control the
temperature of most showers. Others detailed being confined to their rooms for
extended periods of time after an OC spray, and receiving only a wet towel to
assist with decontamination. These practices, if true, would violate the
Department’s SCM policy.
Some use-of-force incidents identified by the Department as problematic
indicate failures to timely and effectively decontaminate youth after OC spray
exposure. Among incidents reviewed, staff appear to repeatedly place recently
sprayed, un-decontaminated youth in their rooms. In several incidents, youth

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appear to have been left in their rooms, visibly struggling, for periods exceeding
fifteen to thirty minutes, without apparent efforts to decontaminate them.
In some instances, youth were exposed to OC spray and placed in rooms
with toilet and sink units. The sink water was either not functioning or was turned
off, and youth can be seen attempting to self-decontaminate from the toilet.
Staffing Issues
Some Department staff expressed having low morale. As described in
detail below, reported morale issues may be exacerbated by a perceived lack of
sufficient staffing and a lack of trust in existing accountability structures.
Staffing and Supervision Resources
Staff interviewed frequently expressed fear regarding their personal
safety and consistently reported feeling outnumbered and overpowered by youth
in juvenile halls and camps. Several staff cited inconsistent and inadequate
staffing as a chief source of unease. Department managers and executives cited
difficulties in recruitment and retention of staff and various labor-related issues as
contributing to difficulties in maintaining ideal staffing ratios throughout its
facilities.
Line-level staff expressed frustration with sometimes having to perform
their duties without supervision. According to some staff, the lack of supervisors
may be hindering the proper use of OC spray and force, since supervisors are
required to authorize and direct force in certain situations. Some staff also
believe that the strains that come with the lack of supervisory support and
guidance contribute to low morale and performance. The Department reports that
it has added some supervisors, but anticipates additional needs.
Insufficient staffing of supervisors may also negatively impact the
Department’s ability to adequately review uses of force. For example, several of
the incidents reviewed were initially assessed by Department supervisors who
failed to identify potential policy violations and refer the incidents for further
review, despite indicators that force was inappropriate or excessive.
The Department reports that it has been working to standardize facility
staffing, but that sick leave and long-term absences de-stablize the Department’s
workforce. The Department reports that it is working with the County Department
of Human Resources to pilot new strategies for countywide leave practices that
may reduce long-term absences and facility shortages, including permanent
placement, medical retirements and other accommodation matters.

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Accountability
Overreliance on and out-of-policy OC use may also be driven by a belief
frequently communicated by staff during conversations with the OIG: physical
uses of force are more likely to lead to injuries and result in internal affairs
investigations. While policies identify OC spray as the final and most significant
force option, several staff reported fear of physical injury as a driving reason for
using OC in lieu of hands-on intervention. Some staff also stated that recent
investigations and disciplinary actions by the Department led them to conclude
that OC deployments invite less scrutiny than physical force.
Various staff and union representatives further expressed a lack of trust in
the Department’s accountability protocols. Staff interviewed routinely
communicated a belief that internal affairs is poorly staffed and trained. They
cited the length and quality of investigations as a serious concern, and a general
perception that the results of investigations suffer because of it.
Training
Several staff reported feeling inadequately trained to effectively respond to
crisis situations in a manner that may minimize the need to use force. In
particular, staff reported a lack of training in de-escalation and physical
intervention techniques. One recently hired probation officer expressed
disappointment with the Department’s new-hire training, stating that courses
involving physical force techniques were insufficient and unrealistic. Staff
recognized that de-escalation and physical intervention techniques are
“perishable skills” that require regular and frequent training to master. As a result,
staff expressed a strong desire for additional scenario-based training.
Some officers also articulated various kinds of unease or confusion in
determining when and/or how to use force. Several cited a sense of crisis
following the elimination of special housing units in County facilities, stating that
the inability to place youth in a solitary confinement setting made dealing with
problem behaviors difficult. They believed that workable alternatives were not
provided, leaving staff scrambling for other ways to address problem youth
behaviors.
The Department reports that due to significant increases in the use of OC
spray, it is implementing multiple short and long term training initiatives,
including: (1) trauma informed training, provided by the Center for the
Empowerment of Families, (2) Non-Violent Crisis Intervention de-escalation
training by the Crisis Prevention Institute, and (3) a training and technical
assistance program, Youth in Custody Practice Model, by the Council of Juvenile
Correctional Administrators and the Center for Juvenile Justice Reform at

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Georgetown University’s McCourt School of Public Policy. Lastly, the Department
reports that it completed an internal analysis and identified that 36% of staff in
the juvenile halls were responsible for most OC use and that, as of February 1,
2019, 56% of all full duty personnel in the halls, have received the refresher OC
spray training.14
Mental Health Resources
Department staff generally reported being unprepared to deal with youth
experiencing behavioral and mental health issues, which form an increasing
percentage of the County’s youth population. Several staff stated that the youth
populations housed in the County’s juvenile halls and camps suffer from more
serious mental health conditions than previous groups, and that training and
policies have not kept pace. Both Department and mental health staff also
reported that facilities lack adequate mental health resources. Department staff
reported that inadequate mental health staffing hinders de-escalation efforts.
Deficiencies were reportedly more problematic on evenings, weekends, and
holidays.
One mental health professional working at a juvenile hall stated that it was
difficult to work effectively with probation staff because of concerns about lack of
both mental health and Department staff. According to that individual, mental
health supervisors have discouraged providers from placing youth in crisis on
one-on-one supervision because it strains Department staffing resources.
Culture
Youth and staff consistently spoke with one voice on a particular topic: the
importance of relationships, interpersonal communication, and mutual respect in
improving safety and preventing force. Several staff reported never having to rely
on physical intervention or OC spray when dealing with youth, citing their “verbal
judo” or “gift of gab” as attributes that allowed them to address problem
behaviors and minimize the need to rely on force. Those staff members also
consistently stated that they felt the Department’s training did not provide them
with effective use-of-force alternatives.
Youth similarly praised staff who, in their perspective, are respectful and
willing to get to know youth. Various youth described staff members who go to
great lengths to build rapport with them, and who avoid using OC spray and other
force in interacting with them. However, several youth related stories of frequent
disrespect and verbal mistreatment by staff, which some cited as creating tense
The OIG has not verified the information provided by the Department regarding
measures it has taken to improve training.
14

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situations that might lead to aggressive behavior. Some youth reported receiving
or hearing profanity-laden taunts from staff, including criticisms of their
neighborhoods, their families, and, in some instances, threats. Youth at two
different facilities stated that staff told them that if they did not behave, they
would “join their dead homies.”
Youth also reported some potentially retaliatory actions that they cited as
creating an environment in which conflict between staff and youth is more likely
to escalate into situations that require force. Chief among these were examples
of denying access to programs. One youth stated that the youth had been denied
the opportunity to attend church services, which were described as a “privilege”
that the youth had failed to earn. OIG staff reviewed an OC spray incident that
reportedly arose from similar facts. Lastly, some youth stated that they were
occasionally subjected to group discipline, confined to their rooms for extended
periods of time, and denied access to programing. If accurate and common,
these incidents raise significant concerns regarding the legal rights of youth,
collective punishment, and general conditions in County facilities.
Finally, some youth reported being denied timely access to toilets and
having to rely on trash or other containers in their rooms to relieve themselves.
These allegations raise issues about facility infrastructure (including the
prevalence of rooms without toilets) and staffing resources (staff must escort
youth in toilet-less rooms to appropriate facilities), which may result in the neglect
of youths’ basic human needs.
Some incidents reviewed involve clear misconduct. While some
inappropriate conduct identified might be prevented through effective policy
revision and training, the most problematic incidents detailed above are
symptoms larger systemic and cultural issues that require immediate and
extensive analysis and reform.
Policies, Practices, and Training Issues
The safety concerns and problematic uses of force described above are
likely exacerbated by insufficient use-of-force policies, training, reporting, and
accountability practices. Effective use-of-force policies and training provide a
framework for officers to understand precisely how and when force can be used
and how it might be avoided. They do so by identifying applicable laws,
standards and limits, and by delineating the factors that should be considered
before and after employing force. By providing clear requirements, use-of-force
policies safeguard the well-being of both staff and youth by limiting force to
situations in which it is necessary.

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While comprehensive use-of-force policies are essential, their efficacy is
wholly dependent on thorough, effective, and frequent training. Use-of-force
training should aim to provide staff with the required knowledge, skills, and
judgment to execute their duties and responsibilities in a safe and effective
manner. Effective training should also utilize evidence-based techniques to
minimize use-of-force incidents with a focus as much on scenario-based force
prevention and de-escalation exercises.
Use-of-force and De-escalation Policies
The current SCM policy is hampered by a host of issues that likely
contribute to avoidable OC spray incidents. As described above, the SCM policy
is currently structured along a continuum. Use-of-force continuums can often
lead law enforcement staff to automatically move through increasingly more
severe force options when less severe options have proved ineffective. The
Department’s draft use-of-force policy reflects an understanding of this, and does
away with the continuum. The Department reports that the draft policy is under
review by labor unions and has committed to additional revisions based on OIG
recommendations detailed below.
The SCM policy does not currently provide workable definitions of
threshold terms that govern whether or not OC spray is authorized. For example,
the SCM policy authorizes staff to use OC spray without supervisory authority
during “uncontrolled situations,” which are described as incidents in which “a
major disturbance, fight, assault or escape attempt…occurs quickly, requiring
staff to respond immediately and employ more restrictive alternatives on an
escalating basis…”15 Other sections of the SCM policy also state that OC spray
is authorized for “serious disturbances” or “major facility disturbances.”16 The
SCM policy does not provide a definition of “a major disturbance,” requiring staff
to use their discretion to identify such instances.
The Department’s current SCM policy and draft use-of-force policy also
include inconsistent requirements for OC spray warnings, which may frustrate
their usefulness as de-escalation and force prevention tools. Department staff
often cited the warnings as a tool to gain compliance from recalcitrant youth.
Unfortunately, the required warning varies depending on the section of the SCM
policy:


15
16

Page 12: “Staff shall provide a warning to minors involved in the
incident regarding the intended use of chemical intervention by
clearly stating in a loud voice, ‘O.C. warning!’”

SCM Directive at 33.
Id. at 4 and 26.

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February 4, 2019
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



Page 25: The Department “shall advise minors that…if staff instruct
them to get down, take a knee, or use the words ‘OC spray’ they
are to [comply] immediately” or they may be sprayed.
Page 32: “[S]taff shall provide a warning regarding the intended use
of chemical intervention by clearly stating in a loud, commanding
voice: ‘O.C. spray.’”

Based on conversations with youth, these inconsistent warnings have at
times denied youth an opportunity to comply with staff instructions before being
OC sprayed. The inconsistencies may also make it difficult to hold staff
accountable when they fail to deliver appropriate warnings.
The Department is in the process of revising its SCM policy and other
policies that will govern its use-of-force reviews. The draft use-of-force policy
introduces several positive changes to the way officers are required to think
about and use force. The draft moves away from the use of a rigid force
continuum and structures all uses of force on the well-established “objectively
reasonable” standard articulated by the United States Supreme Court. The draft
use-of-force policy explains that reasonable force is “the force that an objective,
trained and competent correctional employee, faced with similar facts and
circumstances, would consider necessary and reasonable to gain compliance.”17
The draft use-of-force policy provides a non-exhaustive list of factors used to
evaluate whether the use-of-force is objectively reasonable, including: “the nature
and severity of the situation; whether the youth poses an immediate threat to the
safety of the staff and/or others; and, whether the youth is actively resisting.”18
In addition, the draft use-of-force policy delineates boundaries for how and
when force may be objectively reasonable. First, the draft use-of-force policy
eliminates the distinction between controlled and uncontrolled situations that
currently governs whether the use-of-force is authorized for a given situation and
draws a similar distinction between “directed use-of-force incidents” for “nonemergent situations” that require the presence of a supervisor to plan and direct
the use-of-force, and “immediate use-of-force incidents” for situations that
threaten the “safety and security of youth, staff and/or the public.”19 However,
unlike the SCM policy, the draft use-of-force policy does not dictate a defined list
of situations that fall within each category. Instead, it provides examples of
situations that may fall within each category and ultimately predicates the
authorized use of reasonable force on the facts of the situation at hand.

17

Draft Use-of-force Policy, pg. 3
Ibid.
19
Ibid.
18

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February 4, 2019
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Next, the draft use-of-force policy provides that “[s]taff shall only utilize
force as a last resort and shall only use that level of force which is objectively
reasonable.”20 The draft use-of-force policy requires that staff utilize, where
reasonably possible, de-escalation strategies when faced with a crisis situation
and outlines an extensive list of de-escalation strategies. However, the draft useof-force policy acknowledges that if staff “reasonably determine that deescalation techniques are ineffective or cannot be utilized due to imminent
danger,” “the use of immediate physical or chemical intervention may be
required.”21 If a use-of-force is necessary, the draft use-of-force policy prescribes
a “dignity-based approach” requiring that all youth “continually be treated with
dignity and respect” during the incident.22 The “dignity-based approach” reflects
the Department’s commitment to an overall philosophy of preventing and limiting
force.
Training
The Department’s use-of-force training curriculum aims to provide staff
with a broad range of knowledge and skills, including development and behavior
theories, effective communication, self-management, misbehavior prevention
strategies, de-escalation strategies, physical and chemical interventions, and
report writing. All incoming staff assigned to juvenile facilities are required to
participate in twenty-four hours of use-of-force training as part of their Juvenile
Corrections Officer Core Training. In addition, the Department mandates sixteen
hours of use-of-force retraining annually. The substantial increase in the use of
OC spray generally, use-of-force incidents reviewed by the OIG, and reporting by
staff and youth underscore the need to assess, revise, and bolster current
training programs.
In reviewing use-of-force training material provided by the Department, the
OIG noted a problematic slide that was included in both the new hire and annual
training presentations. The slide, titled “DID YOU REALLY MEAN WHAT YOU
WROTE?” displays an animated graphic of a masked criminal behind a red
prohibitory sign.23 The slide purports that certain terms should not be used when
writing a use-of-force incident report because the terms may “unintentionally
evoke suspicion.”24 The slide provides several examples of terms that should be
avoided, including tackled, threw, dragged, twisted hands/arms, bent arms back,
and pinned. Lastly, the slide explains that if a term is “unavoidable,” staff should
“fully describe the circumstances” and “justify” their actions.25

20

Ibid.
Id. at 8-9.
Id. at 3.
23
SCM Staff Training Presentation Slide 132, see Figure 1 (emphasis in original).
24
Id.
25
Ibid.
21
22

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February 4, 2019
Page 16 of 28

Fig. 1
A problematic example of a term the slide suggests staff avoid is “slammed.” The
Department’s current use-of-force policy explicitly prohibits slamming youth.26
Staff may interpret the slide to suggest that, if they believe a youth was slammed,
they should use less-descriptive language to recount the incident in the use-offorce report. Trainees should be encouraged to avoid specific tactics where
possible, but not to avoid accurate language in describing tactics used.
Use-of-force Reporting, Review, and Accountability Practices
The review of use-of-force incidents allows law enforcement agencies to
test not only whether individual officers complied with policies and training, but
also whether policies and training are sufficiently tailored to the needs of staff
and youth. A comprehensive use-of-force review regimen rests on accurate and
timely reporting by staff. Such reports and other available information, including
video, are then reviewed to ensure accuracy, policy compliance, and the efficacy
of policies and training. The incidents reviewed suggest serious deficiencies in
the Department’s current reporting and review procedures. The Department is
currently revising its force review policies, and is working toward creating a
standardized use-of-force review process that will seek to identify draft policy and
training failures so that they can be addressed in a timely fashion. The
Department’s draft force review policy includes various improvements to its
processes.

26

SCM Directive at 4.

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February 4, 2019
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Use-of-force Reporting
Complete, accurate, and truthful reporting maintain the integrity and
reliability of the Department’s use-of-force reporting process. According to the
SCM policy, staff who participated in a physical or chemical intervention are
required to complete a Physical Intervention Report (PIR). In addition, staff who
witness the incident, or who were assigned to the unit at the time the incident
occurred, are required to complete a Supplemental Physical Intervention Report
(SUP-PIR).
A majority of the staff-generated reports associated with the troubling
incidents reviewed were not comprehensive and appeared to omit necessary
information. Reports rarely described the events that led to the use-of-force,
making it difficult for subsequent reviewers to assess the need for the force used.
Additionally, several reports did not appear to accurately describe the youth
behavior that necessitated the use of OC spray, stating generally that the subject
youth moved aggressively in attempts to assault staff, though video shows a
passive posture and no movement.
Use-of-force Review and Accountability Practices
The SCM policy details the Department’s use-of-force report and review
process. Staff members who are involved in or observed a use-of-force are
required to prepare PIRs no later than the end of the eight-hour shift during which
the incident occurred.27 Reports must be clear and comprehensive, and staff
must memorialize a host of factors, including: de-escalation attempts, the factors
that gave rise to the need to use force, and the type of force used. Staff must
also record a “full description of O.C. spray post-deployment decontamination.”28
The SCM policy does not require staff to photograph injuries of youth who are
subjects of force.
Once submitted, PIRs and related documents are reviewed by the
presiding shift leader and duty supervisor for completeness and accuracy.29 If
they are found lacking, they are returned to the relevant staff for necessary
amendments. They are then passed on to the particular facility’s SCM
Supervising Coordinator, who reviews the documentation and conducts
interviews with involved youth and witnesses.30 If the underlying force incident
appears to violate policy, it is then forwarded either to “the facility Director, facility
Superintendent, or the Probation Department’s Special Investigations Unit.”31

27

Id. at 13.
Id. at 14.
29
Id. at 15.
30
Id. at 17.
31
Ibid.
28

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February 4, 2019
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The SCM Supervising Coordinator is not explicitly required to view relevant
videos of the incident.
The Department’s draft force review policy addresses some of these
significant issues. It calls for force reviewers to view available videos and assess
the accuracy of any written reports. It also requires that a youth reporting injuries
be photographed to ensure such necessary evidence is preserved. Significantly,
it calls for the creation of Use-of-force Data Coordinators at each Department
facility. The Data Coordinators will be tasked with ensuring that relevant force
data is collected for input into the Department’s various databases.
According to information provided by the Department and information
gathered during site visits, Department facilities lack the necessary technology
infrastructure to ensure that use-of-force incidents are captured on video. Staff
further reported that when videos of force incidents exist, they are difficult to
access and view. The Department is aware of this issue and is working to
address it.
Department policy also provides for notifying executive Department
leadership of certain force incidents that involve potentially problematic use-offorce or protocol violations or failures. The Department’s Preliminary Incident
Notification (PIN) directive requires that supervising line staff alert their superiors
of incidents that involve various factors, including when: (1) there is “any major
disturbance at the facility”; (2) an incident “may generate media interest or come
to the attention of the Board of Supervisors”; and, (3) “it is likely that the Chief
Probation Officer may be contacted.”32 The policy does not include a definition of
what constitutes a “major disturbance,” and does not provide other specific
information or examples about what kinds of incidents fall into the prescribed
categories.
In October of 2018, the Department implemented a Critical Incident
Review (CIR) protocol that creates a routine assessment of particular incidents to
“determine the effectiveness of existing policies and procedures before and after
an event, to address the root causes of an event, and to prevent the incident
from reoccurring.”33 Policies prescribe that reviews take place twice a month, and
involve various Department managers and County counsel.34 The CIR process is
triggered, generally, by an escape, a disturbance involving ten or more people, a
suicide or suicide attempt, death of an in-custody youth, and at the discretion of
the Chief Probation Officer. It can also be initiated by incidents or situations in
which it is likely the Chief Probation Officer may be contacted.

32

Preliminary Incident Notification Directive, at 1.
Critical Incident Review Process Directive (CIR Directive), at 1.
34
Id. at 4.
33

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February 4, 2019
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An effective use-of-force review process rests, in part, on developed
accountability and disciplinary infrastructure. Once spotted, actions that violate
use-of-force-related policies should be dealt with in a timely, effective, and
consistent manner. The OIG’s review of Department-provided information
suggests that Internal Affairs is understaffed and overburdened by a high
caseload, leading to extensive delays in investigations and resolutions. Drawn
out investigations by overworked staff may be a reason staff consistently
expressed a distrust and dissatisfaction with Department accountability systems.
OIG discussions suggest that the Department should continue auditing
and reviewing its force reporting practices. For example, line-level supervisors
and more senior managers reported knowing of the PIN directive — but also had
significantly different understandings of what types of incidents merit reporting.
Furthermore, the incidents reviewed for this assessment routinely contained staff
reports that failed to capture all relevant action, including particular uses of force
by staff and descriptive details of decontamination procedures.
Several staff stated that it was difficult to view video because it is not
readily accessible. Others reported losing access to the video database during
2017 and 2018. No staff assigned to work at a juvenile hall or camp reported
viewing video from other juvenile facilities.
Recommendations
Los Angeles County should evaluate whether the use of OC spray in
Department facilities aligns with the Department’s philosophical shift toward
rehabilitation and trauma informed care and its ongoing implementation of the LA
Model. Department personnel and leadership express an awareness of OC
spray’s physical and emotional harm to youth and of its negative implications for
staff-youth relationships and larger Department culture. Most also express,
however, a firm belief that absent adequate alternatives, the use of OC spray is
necessary to safeguard their personal safety.
Any plan to restrict or eliminate OC spray should prioritize institutional
safety, with meticulous attention to youth and staff perceptions about their
personal safety, and dedication of necessary resources. Any changes to the use
of OC spray in juvenile halls and camps should be incremental and balance
training and programmatic needs. The County should explore the feasibility, with
significant input from all stakeholders, of restricting or eliminating the use of OC
spray in Department juvenile facilities.
Based on the OIG review of existing safety concerns and examination of
existing and proposed reporting and accountability practices, training and
policies, the OIG makes the recommendations detailed below. While the

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February 4, 2019
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recommendations offered generally reference current policies, they have been
tailored to ensure that they are relevant to the policy changes currently being
considered by the Department.
Accountability and Reporting
Recommendation 1: The Department should dedicate appropriate resources to
finalize and implement its comprehensive use-of-force accountability
improvements including its Force Intervention Response Support Team (FIRST)
and Department Force Review Committee (DFRC) processes.
In addition to the Department’s existing CIR process, the Department is in
the planning stages of a comprehensive force review process. This process
includes a team of highly trained personnel who will be required to respond to
use-of-force incidents and assist with real-time mentorship and evaluation of deescalation efforts, tactics, reporting, among other tasks. The team is then
responsible for referral of incidents for review by the CIR or what the draft use-offorce policy refers to as the Department Force Review Committee (DFRC). The
FIRST should consist of proven effective leaders who possess operational and
tactical expertise and who demonstrate an unyielding commitment to the
rehabilitative approach. FIRST team members should be single assignment
positions.
Every use-of-force incident reviewed should include review of available
CCTV footage and should be evaluated for (1) force prevention opportunities, (2)
de-escalation efforts, (3) pre-force conduct and tactics, (4) force tactics, (5) postforce incident tactics, (6) decontamination, (7) trauma informed critical incident
counseling for and placement of youth as necessary, and (8) post-incident
reporting.
The Department’s draft use-of-force policy calls on the DFRC to review a
selection of use-of-force incidents. The DFRC should analyze every OC
deployment and the decontamination process following each incident. In
assessing the use of OC spray, the DFRC should also evaluate whether staff
exercised appropriate judgment and decontaminated youth as soon as possible
following the incident. Where decontamination was delayed allegedly due to
physical plant, staffing, or other systemic deficiencies, the DRFC should review,
identify, and report deficiencies to Department executive leadership, who should
take necessary remedial action and implement sustainable solutions as soon as
possible.
As necessary, the DFRC should also be empowered to require retraining
of particular officers, and it should be tasked with tracking completion of all
corrective action. Furthermore, force reviewers at all levels should identify staff

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February 4, 2019
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who have effectively prevented the use-of-force and de-escalated tense
situations. The Department should recognize and reward these individuals and
successes should be shared with all relevant Department personnel.
Recommendation 2: The Department should dedicate necessary resources
and training to effectively implement its Internal Affairs processes.
The implementation of an effective force review process as described
above is time and resource intensive. The Department provided information that
strongly suggests that its Internal Affairs team is understaffed and overburdened.
Department leadership should continue to work to identify and address unmet
staffing needs, and should also continue working to procure necessary tools and
training to aid its Internal Affairs staff.
Recommendation 3: PIN and CIR Directives should more clearly guide staff in
determining when to notify leadership of relevant force incidents.
The PIN Directive serves the important function of creating a conduit for
information to travel expeditiously from a juvenile hall or camp to the
Department’s senior leadership. As described above, the PIN Directive does not
currently provide staff with sufficient clarity as to when such notices are required.
Without a PIN, Department leadership may not be able to notify the Board of
particular incidents.
The Department should revise the PIN Directive so that it provides
definitions and instructive examples of factors that trigger a notice. Subjective
analysis and judgement on such matters can vary wildly, evidenced in the lack of
notices for the 2017 and 2018 incidents audited by the Department and reviewed
here. The Department should establish bright line triggers for notice and review
to ensure that policy, training, and supervision failures are identified in a timely
fashion, and that the Chief Probation Officer and the Board are aware of them.
The policy should also be amended to require notification to the DFRC and the
CIR committee.
Recommendation 4: The Department should introduce cameras in all of its
juvenile justice facilities. It should also consider updating its CIR policy to require
supervisors to view relevant videos of incidents.
The Department currently lacks sufficient information technology
infrastructure to ensure that all use-of-force incidents are captured on CCTV. It
should continue to work to address this weakness, and improve access to
existing videos by relevant supervisors and force reviewers. Department staff
who have been involved in the force incidents should continue filing any
necessary reports before viewing relevant videos.

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February 4, 2019
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In instances when videos are available, the Department’s CIR Directive
should require that CIR reports and presentations include them. Staff-generated
use-of-force reports are a necessary and effective source of information — but
videos can potentially provide reviewers with a new vantage point that might
bring relevant information to light. Videos may also serve to help assess the
efficacy of particular policies or practices.
Training
Recommendation 5: The Department should address staff concerns regarding
inadequate use-of-force training by developing comprehensive and fully
integrated training curriculums and presentations that offer effective alternatives.
Force prevention, de-escalation, and physical and chemical intervention
techniques are important tools that safeguard against unnecessary uses of force.
Poorly trained staff lack the ability to de-escalate situations, which likely
contributes to avoidable OC spray incidents. Thus, the Department should
assess staff concerns regarding insufficient training.
The Department should aim to develop comprehensive and fully
integrated use-of-force training and retraining curriculums to ensure that staff
have a complete understanding of all related policies and procedures. The
presentations should also include slides pertaining to the zero tolerance policy for
abuse and slides that encourage staff to report abuse and misconduct by other
staff.
Training should also address troubling staff conduct. Several use-of-force
incidents reviewed by the OIG involved a failure to timely decontaminate youth
following the application of OC spray. Yet, the use-of-force training presentations
reviewed lack discussion of decontamination. The Department should develop
training that clearly details decontamination procedures and any prohibited
practices, such as providing youth with hot or warm water for decontamination
purposes. Furthermore, training should clearly articulate circumstances in which
shaking a canister in the presence of youth is appropriate and when shaking
should be prohibited, with or without deployment.
Recommendation 6: The Department should assess and enhance training,
including off-post training, in interacting with youth with mental health and
behavioral needs, and youth in acute mental health crises.
Several staff reported feeling inadequately trained to care for youth with
mental health and behavioral needs. In addition, staff expressed a desire to learn
specialized de-escalation techniques for use-of-force incidents involving youth

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February 4, 2019
Page 23 of 28
with mental health needs. The Department should collaborate with the
Department of Mental Health (DMH) and, as necessary, mental health juvenile
correctional consultants to assess training deficiencies and to provide staff with
the tools they need to effectively care for the County’s most vulnerable youth
population.
Recommendation 7: The Department should ensure that staff are effectively
trained to accurately document all events that led up to the use-of-force,
including staff and youth behaviors that precipitated force, and decontamination
efforts.
Several of the reports did not contain comprehensive information
regarding the events that led up to the use-of-force. At best, they included
cursory summaries of de-escalation attempts that failed. The Department should
consider and implement strategies to ensure that its staff memorialize specific
information regarding force prevention, de-escalation, and decontamination
efforts. The Department should explicitly require probation officers to provide
detailed descriptions of the interactions between staff and youth that preceded
the use-of-force incident, including the nature of the conflict that led to the use-offorce, any and all ultimatums provided by staff to the youth that was the subject
of OC spray, and youth reactions to those ultimatums. Force reports should also
include detailed descriptions of decontamination efforts — if they do not, they
should be consistently returned to staff for revision.
Recommendation 8: The Department should revise training materials to remove
language that inadvertently encourages incomplete or inaccurate reporting.
The Department should review existing training materials and remove any
problematic language that encourages undesirable behavior. As described
above, current materials include language that may unintentionally encourage
staff to file incomplete use-of-force reports. Training should continue to
emphasize the importance of complete, accurate, and truthful reporting of use-offorce incidents, including in situations where prohibited force may be at issue.

Department Policies
Recommendation 9: The Department should establish a unified training and
policy development team.
The Department does not currently have a single designated team tasked
with developing or amending its training and policies as needed, including those
related to force. The Department has identified this need, and has worked
towards assessing the resources it would need to create one. In reviewing,

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February 4, 2019
Page 24 of 28
revising, or developing trainings and policies, the team should strongly consider
including timely input from line-level staff, outside experts, representatives of
other juvenile justice systems, and representative community stakeholders,
including formerly incarcerated youth and relatives of currently incarcerated
youth. Active participation and contribution to the policy development process
may also result in positive cultural change by enabling all interested parties to
invest in and value the rules that guide their work.
Recommendation 10: The Department should ensure that its use-of-force
policies clearly define keystone concepts.
The Department’s current and draft use-of-force policies fail to provide
clear and workable definitions for terms that relate to when staff are allowed to
use force. For example, the draft use-of-force policy states that force can be
used when staff are confronted by “ongoing defiant behavior” that leads to a
“major disturbance,” but neither factor is defined. Concrete definitions of these
terms, and others, would assist staff in determining whether or not physical or
chemical force is authorized.
Recommendation 11: The Department should consider amending its draft useof-force policy so that its force standard goes beyond the minimum requirements
of the Constitution and other applicable laws.
The Department’s draft use-of-force policy states that force used by its
staff will be assessed through the “objectively reasonable” standard established
by the U.S. Constitution and relevant case law. However, some probation
departments have chosen to go beyond the floor created by the applicable law in
guiding the use-of-force. San Francisco, for example, requires its officers to
generally apply the minimum amount of force necessary in all applications of
force. The Department’s draft use-of-force policy requires that its staff use the
minimum amount of force necessary. The Department should also consider
limiting the use of OC spray to instances in which staff are confronted by
potential or actual physically threatening behavior. The draft use-of-force policy
currently allows staff to use OC spray to gain compliance, which may contribute
to avoidable deployments.
Some law enforcement agencies require that any force used be
proportional to the risk of harm faced by the subject of that force, and that it
correspond in degree to the seriousness of the objective at issue. The concept of
proportionality is already implicit in some of the Department’s policies — for
example, the Department generally prohibits the use of OC spray when the
subject youth suffers from certain physical or mental health conditions. Such
restrictions are anchored in an understanding that OC spray results in actual and
potential harm that may not be justified given the objective of the force. The

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February 4, 2019
Page 25 of 28
Department would likely avoid unnecessary OC sprays by requiring officers to
weigh the harm caused by OC spray with the intended objective in each discrete
incident.
Recommendation 12: The Department should ensure its draft use-of-force
policy prohibits troubling decontamination practices.
Following the use of OC spray, the Department currently requires that staff
remove the youth to a safe area following the application of OC spray, apply cold
water to the face, and change clothing following an OC spray.35 It also requires
that staff present youth for a medical assessment within thirty minutes.36
Conversations with staff and youth and force incidents reviewed by the OIG
suggest that staff may be waiting up to thirty minutes or longer before initiating
decontamination procedures. The draft use-of-force policy should guide staff in
caring for recently sprayed youth who resist or refuse decontamination. Such
resistance should not result in unnecessary delays to decontamination.
The draft use-of-force policy should also explicitly prohibit the following
decontamination practices:






Confining a youth to a room without running water within thirty
minutes of an OC spray application;
Turning off water to a room occupied by a youth who was the
subject of OC spray;
Providing a wet towel to youth who are attempting to
decontaminate, and allowing those youth to rub their face;
Using facility showers or faucets to decontaminate youth when staff
lack the ability to control the temperature of the water; and
Leaving youth unattended and without supervision immediately
after the deployment of the first burst of OC spray.

Recommendation 13: The Department should assess its policies regarding
youth access to religious programming.
Conversations with youth suggest that Department staff may be denying
access to certain programs, including religious services. Some youth stated that
they were not able to attend available religious services at Department facilities
due to staff who believed they did not deserve such a privilege. The Department
should ensure that its policies effectively prohibit such acts, and that its practices
reflect policy.

35
36

SCM Directive at 28.
Id.

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February 4, 2019
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Recommendation 14: The Department should require staff to act appropriately
when observing policy violations and deviations from training.
The Department’s draft use-of-force policy requires staff to report potential
violations. The Department should consider also requiring staff to immediately
take affirmative action to try and stop inappropriate uses of force that they
observe, and to take steps to correct the situation. Several incidents reviewed by
the OIG involved staff who were passive witnesses to troubling violations of
Department policy, and who failed to intervene. Creating this requirement will
ensure that staff understand expectations regarding the use-of-force, and their
role in caring for youth.
Recommendation 15: The Department should assess its implementation of its
HOPE Centers to ensure that it aligns with intended goals.
Conversations with staff and youth suggest that the Department’s HOPE
Centers, which are designed to assist staff and youth in dealing with problem
behaviors and to mitigate the use for force, may not be achieving their intended
goals. The Department should assess its HOPE Center-related policies and
practices, with a focus on ensuring adequate staff training and supervisor and
management commitment to their effective operations.
Staffing
Recommendation 16: The Department should continue assessing its staff
resources, with an emphasis on ensuring that sufficient and effective supervision
is provided to line-staff and youth.
Conversations with staff and Department leadership revealed a consistent
concern for day-to-day staffing levels and, as a result, the availability of
experienced and effective supervisors during every shift. The Department should
ensure that its staff needs assessment takes into account the experience level of
available staff members, so that the teams that work together during shifts are
led by capable staff. Similarly, such analyses should also take into account the
potential needs of a youth population that may require one-on-one supervision.
Recommendation 17: The DMH should work with the Department to identify
specific mental health staffing needs and increase provider-to-youth ratios.
The Department’s use-of-force and de-escalation practices identify very
specific and important roles for mental health professionals. For example, the
SCM policy prohibits the use of OC spray on youth who are receiving
psychotropic medication. The SCM policy also calls on staff to enlist the
assistance of mental health professionals when attempting to de-escalate

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February 4, 2019
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situations that may lead to the need for force. Force prevention efforts that
include mental health and other service providers, such as teachers and
chaplains, tend to be more successful. Indeed, youth reported that some mental
health providers were among the few individuals they trusted in facilities. The
ability to provide adequate care, and to make good on force policy requirements,
hinges on training and sufficient mental health staffing. However, most of the
Department staff members and youth communicated strong impressions that
mental health provider availability and support is inadequate.
DMH and the Department should assess existing staffing and services,
identify any shortages or deficiencies, and rectify them. Adequate mental health
staffing should include continuous, 24-hour care that allows for timely crisis
intervention efforts, medication prescription and compliance monitoring, regular
youth counseling, and sufficient availability to proactively assist in force
prevention and de-escalation.
Culture
Recommendation 18: The Department should continue to implement measures
that ensure its practices are consistent with its core values, and to ensure that
staff at every level work to create a safer environment in the County’s juvenile
justice facilities.
The Department is led by specific and articulated core values, which
include treating youth, staff, and the public with dignity and respect, and acting
with integrity.37 Available information suggests that the Department’s values are
not consistently being practiced by all personnel.
The Department should continue to address and refine its recruitment,
hiring, training, supervision, and accountability practices to align with its stated
mission. The Department should identify and procure resources necessary to
adequately train existing personnel in effective behavior management tools that
emphasize rehabilitation over punishment. The Department should identify and
procure necessary resources to identify, recruit, and hire individuals whose
professional orientation and expertise more closely align with rehabilitative rather
than punitive principles. Department policies and procedures should establish
clear expectations for staff-youth interactions in all aspects of youth confinement.
Consequences for non-compliance and incentives for compliance should be
clearly communicated and consistently enforced.

37

Los Angeles County Probation Department Core Values.

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February 4, 2019
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Conclusion
The information and recommendations provided in this report are intended
to inform both the Board and the Department of issues related to the use-of-force
within the County’s juvenile justice facilities. During its time-sensitive and focused
review, the OIG identified several other factors that may impact the use-of-force
in County juvenile justice facilities, including: facility conditions, labor
agreements, staff morale, general resource allocation and constraints, and
organizational culture, among other issues. Further assessments of these
subjects is likely warranted.

cc: Sachi A. Hamai, Chief Executive Officer
Celia Zavala, Executive Officer
Mary C. Wickham, County Counsel
Terri McDonald, Chief Probation Officer