Wasco State PrisonWasco State Prison: Its Failure to Proactively Address Problems in Critical Equipment, Emergency Procedures, and Staff Vigilance Raises Concerns About The first copy

Wasco State Prison:Its Failure to Proactively Address Problemsin Critical Equipment, Emergency Procedures,and Staff Vigilance Raises Concerns AboutInstitutional Safety and Security

October 199999118

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CALIFORNIA STATE AUDITOR

MARIANNE P. EVASHENKCHIEF DEPUTY STATE AUDITOR

BUREAU OF STATE AUDITS555 Capitol Mall, Suite 300, Sacramento, California 95814 Telephone: (916) 445-0255 Fax: (916) 327-0019

KURT R. SJOBERGSTATE AUDITOR

October 15, 1999 99118

The Governor of CaliforniaPresident pro Tempore of the SenateSpeaker of the AssemblyState CapitolSacramento, California 95814

Dear Governor and Legislative Leaders:

As requested by the Joint Legislative Audit Committee, the Bureau of State Audits presents its auditreport entitled Wasco State Prison: Its Failure to Proactively Address Problems in Critical Equipment,Emergency Procedures, and Staff Vigilance Raises Concerns About Institutional Safety and Security.

This report concludes that Wasco’s management has failed to create an atmosphere of vigilance in whichemergency equipment is adequately maintained and inmates are appropriately monitored as mandated byits policies. In addition, Wasco has not adequately prepared the prison and its staff for institution-wideemergency situations. Finally, we are concerned about the depth and the timing of the exercises Wascointends to use to test the viability of its year 2000 contingency plan. An unnecessarily risky atmospherewill remain until these problems are resolved.

Respectfully submitted,

KURT R. SJOBERGState Auditor

CONTENTS

Summary 1

Introduction 5

Chapter 1

Wasco’s Failure to Repair and MaintainCritical Equipment Jeopardizes theInstitution’s Safety 9

Recommendation 16

Chapter 2

Wasco’s Emergency Readiness HasSignificant Weaknesses 17

Recommendations 28

Chapter 3

Weak Managerial Oversight and a Lack ofStaff Vigilance Led to Inmates GainingAccess to Confidential Information At Wasco 29

Recommendations 38

Response to the Audit

California Department of Corrections andWasco State Prison 41

California State Auditor’s Commentson the Response From the CaliforniaDepartment of Corrections and WascoState Prison 47

1C A L I F O R N I A S T A T E A U D I T O R

SUMMARY

Audit Highlights . . .

Our review of Wasco StatePrison concludes that:

þ Wasco has a considerablebacklog of incompletemaintenance andrepairs on its criticalequipment.

þ Its failure to repairdefective equipmentnearly four yearsago resulted in acomplete loss ofpower in April 1999.

þ Due to a lack oftraining and specificemergency plans, duringthe recent poweroutage some of itsstaff were unprepared.

And finally, unsupervisedinmates gained access toconfidential informationbecause of poor vigilanceby staff.

RESULTS IN BRIEF

The California Department of Corrections (CDC) andthe management at Wasco State Prison (Wasco) nearBakersfield have developed many policies and procedures

to ensure the safety of Wasco’s staff and inmates. However, suchpolicies are essentially useless if not enforced. As several recentincidents demonstrate, Wasco has not followed its own policiesthat direct management to create an atmosphere of vigilance inwhich emergency equipment receives sufficient maintenanceand staff monitor inmates appropriately. By failing to enforcethese policies effectively, Wasco has needlessly endangered bothstaff and inmates.

Specifically, management at Wasco has not ensured that plantequipment undergoes adequate service and that staff completehigh-priority repairs promptly. Because it does not keep itsequipment functioning properly, Wasco suffered an electricalfailure in April 1999 that caused a total power outage lastingalmost seven hours—a problem that Wasco could have pre-vented had management made certain that staff repairedpreviously identified flaws in the electrical system. By neglectingpriority repairs and scheduled maintenance on critical emer-gency equipment, Wasco risks the occurrence of significantproblems in the future.

In spite of the fact that emergency readiness is a significantpart of Wasco’s mission, its management has not adequatelyprepared the prison and its staff for emergency situations thatcould affect the entire institution. Although Wasco trainsstaff to handle certain types of emergencies, the power outagerevealed that many employees had never received instruction inprocedures that they should follow during an emergency of thisnature. Moreover, at the time the outage occurred, neitherWasco’s management nor the CDC had developed an emergencyoperations plan which might have aided staff that were oversee-ing the prison, so employees were instead forced to rely on theirown experience. The fact that some of Wasco’s emergencysupplies were deficient only exacerbated the problems thatoccurred during the emergency. Furthermore, Wasco’s lack ofpreparedness for the power outage prompts us to question the

C A L I F O R N I A S T A T E A U D I T O R2

prison’s readiness for infrastructure or equipment malfunctionsthat might arise from year 2000 (Y2K) problems. We areconcerned about the extent and timing of the exercisesWasco intends to use to test the viability of its year 2000contingency plan.

Finally, even though Wasco’s policies and training emphasizethe importance of staff remaining constantly alert andvigilant, recent events indicate that staff have become increas-ingly complacent when supervising inmates. Circumstances alsosuggest that an absence of managerial oversight or evaluationmay be contributing to this lack of vigilance. In particular, staffand management have been lax in protecting confidentialinformation; as a result, inmates recently gained access todocuments that listed staff addresses and social security num-bers. Without a heightened sense of awareness among prisonstaff, Wasco has no guarantee that future compromisesto security will not occur. Additionally, we question the CDC’spolicy that allows inmates to use a detailed map of the institu-tion. Although these conditions have not yet caused any seriousrepercussions, an unnecessarily risky atmosphere will remainuntil Wasco resolves these problems.

RECOMMENDATIONS

To prepare for the possibility of another emergency, such as therecent power outage, that could affect the entire facility, Wascoshould take the following steps:

· First identify all the high-priority repairs and preventativemaintenance that its emergency equipment requires andthen develop a staffing plan to eliminate quickly the backlogof repair and maintenance tasks.

· Develop a specific plan for such institution-wide emergenciesas power outages and include this plan as a supplement to itsemergency operations procedures.

· Train and drill employees to make certain they understandprocedures and are prepared to act appropriately during aninstitution-wide emergency.


To ensure its readiness for possible infrastructure orequipment problems related to year 2000 (Y2K) computererrors, Wasco should do the following:

· Conduct a partial or full-scale simulation of a Y2K emer-gency in order to test the prison’s Y2K contingency plan.

· Perform as soon as possible a drill that simulates loss ofpower so that management can evaluate the feasibility ofWasco’s contingency plan and allow adequate time to correctany deficiencies or to adjust the plan.

· Complete the repair and testing of its systems that rely onmicroprocessor chips, such as Wasco’s thermostats andelectronic controls for inmate cell doors, to make sure thesystems comply with the CDC’s year 2000 requirements.

· Make certain that supplies of emergency equipment areadequate and that the equipment is fully functional.

To safeguard prison staff, Wasco’s supervisors and managersneed to cultivate an atmosphere of vigilance by setting exampleswith their own behavior and by closely monitoring staff interac-tions with inmates. When they observe staff displaying laxbehavior while they are working with inmates, managers needto intervene promptly.

To prevent future problems concerning the security of confiden-tial information, Wasco needs to take these actions:

· Incorporate into its procedure manuals management’srecent instructions about the storage and duplication ofsensitive data.

· Require staff to record in control logs any documents sched-uled for shredding.

In addition, the CDC should require each correctional facility todevelop a plan for handling institution-wide emergencies, suchas power failures, and to include this plan in its emergencyoperations manual. The CDC should also eliminate the unneces-sary risk associated with inmates access to detailed plans andmaps of its institutions by amending the policy that allowssuch access.


AGENCY COMMENTS

Both Wasco State Prison and the California Department ofCorrections concurred with our findings and recommendationsand are taking corrective actions. ■


INTRODUCTION

BACKGROUND

The California Department of Corrections (CDC) overseesthe operation of 33 prisons located throughout theState, manages various community correctional facilities,

and supervises all parolees during their reentry into society. Foreach of the 33 prisons it oversees, the CDC provides generalpolicy guidance through its departmental operations manual.In addition, each prison is responsible for supplementing

the departmental operations manual by develop-ing and formalizing certain institution-specificpolicies, such as emergency operations plans andprocedures for ensuring the security of employees’personal property and the security of computer-ized information. The CDC furnishes additionaloversight through periodic compliance reviews ofeach institution.

Wasco State Prison (Wasco) is one of the State’s33 prisons and is located about 20 miles north ofBakersfield. Wasco serves as one of the State’sreception centers, with its primary mission toprovide the short-term housing necessary toprocess, classify, and evaluate new inmatesphysically and mentally to determine where eachinmate will ultimately be incarcerated. In additionto functioning as a reception center, Wasco housesinmates who help support and maintain theprison and reception center, participate on workcrews for community service projects, and keep upthe outside perimeter of the institution. Accordingto the warden, despite its design capacities,Wasco’s actual inmate counts have historicallyaveraged close to 6,000. He stated that having apopulation that consistently exceeds designcapacity places a great burden on the equipmentneeded to operate and secure the institution.

In April 1999, several events occurred at Wasco thatraised concerns about the safety of correctional staffand inmates. One incident involved prisoners obtaining

Profile of Wasco State Prison

Warden: Randolph Candelaria(since 8/15/97)

Date Opened: February 1991

Number of Acres: 634

Square Footage of Buildings: 803,311

Number of Custody Staff: 800

Number of Support Staff: 440

Total Staff: 1,240

Annual Operating Budget: $95 million

Current ApproximateType of Design InmateFacility Capacity Count

Minimumcustody 200 400

Mediumcustody 575 1,000

Receptioncenter 2,284 4,300

Total 3,059 5,700


confidential information relating to correctional officers andadministrative staff. In the same month, Wasco also suffereda complete power outage that lasted for nearly seven hours.The failure of a single electrical transformer terminated theinstitution’s incoming utility power. Because the blown trans-former operates on the same electrical circuit as the emergencygenerators, the generators were unable to respond.

SCOPE AND METHODOLOGY

The Joint Legislative Audit Committee (committee) requestedthat the Bureau of State Audits review and evaluate Wasco’spolicies and procedures concerning the security of confidentialinformation so that we could determine whether Wasco wasplacing its correctional staff and their families at unnecessaryrisk. We were also asked to examine Wasco’s guidance, protocols,and maintenance practices to assess its readiness for emergen-cies, including those that could arise from year 2000 (Y2K)computer problems. Finally, the committee requested us toassess how management communicates its policies to staff andto evaluate corrective actions management has taken inresponse to recent events.

To analyze the adequacy of policies and procedures designedto protect correctional staff and their families, we interviewedCDC and Wasco management and staff, then examined theinstitution’s practices relating to confidential information andinformation security. We also reviewed incident reports allegingthat inmates obtained access to the personal information ofWasco staff. In our report, we discuss the details of thoseincidents that we were able to substantiate.

To assess Wasco’s readiness for emergencies, we looked at CDC’sand Wasco’s emergency operations procedures and we analyzedWasco’s Y2K plans. We also examined the adequacy of existingprocedures and emergency backup equipment by checkingincident reports and interviewing supervisors and staff presentduring the recent power outage. In addition, we interviewedplant operations staff and reviewed maintenance schedules,work orders, and other evidence related to the institution’srepair and maintenance practices.

To determine whether Wasco’s management effectivelycommunicates to staff its policies regarding emergencypreparedness and information security, we analyzed Wasco’s


training requirements, researched the content of selectedcourses, reviewed staff training records, and interviewed variousstaff members, including Wasco’s training coordinator. Further,we investigated whether Wasco uses course evaluations or someother method to obtain comments and suggestions from staffwho have participated in the institution’s training program. Wealso discussed with management its methods for ensuring thatstaff comply with policies and procedures.

Finally, we interviewed management and staff about correctiveactions that Wasco has taken in response to the recent eventsconcerning emergency safety and staff confidentiality issues. Inaddition, we reviewed the specific changes to policies andprocedures and the procurement of goods and services thatthese events prompted. ■


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CHAPTER 1Wasco’s Failure to Repair andMaintain Critical EquipmentJeopardizes the Institution’sSafety

CHAPTER SUMMARY

Wasco State Prison (Wasco) has failed to repair andmaintain adequately its regular and emergencyequipment, thus placing the reliability of this

equipment in doubt. In April 1999, a complete power outagehighlighted the importance of equipment upkeep. The poweroutage, which affected both regular power and emergencygenerators, was caused by a faulty electrical transformer—aproblem that Wasco management had identified nearly fouryears earlier but had not yet fixed. Repairing and maintainingequipment designed to provide basic services such as lightingand communications during emergencies are critical to ensuringthe safety of prison staff and inmates. Although no seriousinjuries occurred in this instance, the power outage causedunnecessary threats to the safety of Wasco’s staff and inmates.Because Wasco has not attended to some of its equipment, theprison risks experiencing similar problems in the future.

WASCO HAS NOT COMPLETED EMERGENCYREPAIRS AND SCHEDULED MAINTENANCEIN A TIMELY MANNER

According to the monthly reports Wasco submits to theCalifornia Department of Corrections (CDC), the prison has alarge backlog of repairs and maintenance that staff have not yetperformed. Although it sets reasonable maintenance andrepair goals, these reports show that Wasco falls far short of itsobjectives. Not only does it fail to complete regular preventativemaintenance according to its own schedules, but it also failsto perform promptly ordered repairs to critical emergencyequipment, often delaying repairs for months.


According to its Plant Operations Work Order Request Proce-dures manual, Wasco assigns different priorities to neededrepairs and maintenance. The institution designates as“Priority 1” those repairs, such as fixing a malfunctioning firealarm or cell door, that require immediate attention to protectthe health and safety of the institution’s staff and inmates.These repairs should take place within 24 hours after plantoperations receives the request. Regularly scheduled preventativemaintenance of critical equipment, such as generatorsand transformers, receives a “Priority 2” designation. Staff aresupposed to complete this sort of upkeep, which includestesting, inspections, cleaning, and adjustments, within 15 daysof its scheduled date. For example, Wasco schedules biweeklystart-up testing of its backup generators and schedules inspec-tions and cleaning of its electrical transformers annually. 1

Adhering to a regularly scheduled plan for preventativemaintenance is key to ensuring the smooth operation andcontinued security of the institution. However, its August 1999maintenance report indicated that, as of the end of May 1999,Wasco had a total of 34 Priority 1 repairs and 2,268 Priority 2scheduled maintenance work orders that were over 30 days pastdue. In addition, this report shows that, since January 1995,Wasco has failed to complete nearly 900 Priority 1 repairs andmore than 12,000 Priority 2 maintenance work orders within60 days of the work requests or due dates. These repairs shouldhave been completed within 24 hours and the maintenancewithin 15 days. The CDC states that it is aware of the mainte-nance backlog at Wasco and has taken some steps to address theproblem; however, the backlog remains. By not completing itsemergency repairs and scheduled maintenance in a timelymanner, Wasco cannot ensure the effective operation of itsequipment in the event of an emergency.

WASCO IGNORED CRITICAL ELECTRICALPROBLEMS THAT EVENTUALLY CAUSED ACOMPLETE POWER OUTAGE

The failure of Wasco management to maintain emergencyequipment appropriately became evident on April 12, 1999,when an electrical transformer malfunctioned at the prison,resulting in a complete power outage that lasted nearly sevenhours. Wasco had identified this transformer as defective nearly

1 Requests for repairs and/or maintenance of noncritical equipment receive a lowerpriority and longer response times.

Since January 1995,Wasco was significantlylate completing nearly900 emergency repairsand over 12,000scheduled maintenancework orders.


four years earlier, yet management had neither tracked thetransformer’s deterioration nor fixed the problem. Conse-quently, Wasco plunged into darkness and risked the safety of itsstaff and inmates.

The transformer in question was first identified as faulty inMay 1995, when Wasco performed infrared thermography(thermoscans) on all its high-voltage electrical transformers inan attempt to discover the source of electrical problems inthe institution’s laundry facility. Thermoscans use infraredimagers to detect heat radiated from electrical equipment, sinceoverheating can cause premature, costly, and irreversible deterio-ration to electrical components. Until a defective transformerreceives corrective repairs, the transformer’s temperatureand rate of deterioration will increase with time. Becausehigh-voltage transformers are completely sealed, thermoscanscan detect problems that regularly scheduled maintenance andinspections would not reveal. In this case, the 1995 thermoscanand an additional thermoscan completed in August 1996 bothindicated excessive heat in several of Wasco’s transformers,signifying the need for immediate repair.

However, Wasco management did not request subsequentthermoscans of Wasco’s transformers to monitor the heatbuildup, nor did management order corrective repairs.2 Rather,Wasco left the transformers to deteriorate until one of thosepreviously identified as faulty failed in April 1999. The failure ofthis single transformer had a number of significant conse-quences for Wasco. First, the malfunction disrupted theinstitution’s normal electrical power, which is supplied by thelocal utility company and distributed through the prison viaelectrical circuits and transformers, including the transformerthat failed. Moreover, the faulty transformer used the sameelectrical circuit connected to Wasco’s two standby generators;when the transformer failed, it not only disrupted the flow ofnormal power, but it also caused a ground fault in the emer-gency circuit that powers such key areas as the fire house andthe door controls in the buildings housing inmates. Then, eventhough the primary emergency generator started up properlywhen Wasco lost utility power, the generator immediately shutitself off to avoid damage when it sensed the ground fault.

2 According to the warden, thermoscan contractors are located throughout California,and the procedure is relatively inexpensive. For example, the cost to performthermoscans on all of Wasco’s high-voltage transformers was less than $800.

A transformer known tobe faulty failed, causinga power outage and theback-up generators toshort out.


With both its primary and emergency power lost, Wasco wasleft to rely on its other emergency backup systems to maintainmost of the institution for up to seven hours while its plantoperations staff worked to restore power.3 As discussed inChapter 2, even though the consequences of this situation werenot as serious as they could have been, the power loss unneces-sarily jeopardized the safety of both staff and inmates. Wasco’smanagement was unable to explain why no one had fixed thefaulty transformers when the thermoscans first identified theproblems. We do know that many staff members were aware ofthe thermoscan results, but it is unclear who made the decisionnot to repair the transformers; in fact, no one could provide uswith a work order or any other documentation to indicate thatmanagement had ever requested or ordered repairs to thetransformers. We found this situation indicative of Wasco’spoor repair and maintenance practices.

In response to the power outage, Wasco has finally taken actionto repair all faulty transformers and has performed additionalthermoscans to verify that repairs were successful. In addition,although the CDC does not mandate the thermoscan procedure,Wasco has recently made thermoscans a regular part of itsannual scheduled maintenance for transformers. Fortunately,no serious injuries occurred during Wasco’s power failure; none-theless, the outage illustrates the potential danger inherent in aprison’s neglect of its electrical equipment.

WASCO’S FAILURE TO MAINTAIN ITSEMERGENCY EQUIPMENT PROPERLYCOULD CAUSE FUTURE PROBLEMS

As discussed in the beginning of this chapter, defective electricaltransformers are not the only examples of Wasco’s failure tomake emergency repairs to its Priority 1 equipment. In fact,Wasco has had backlogs of emergency repairs for the past severalyears. To determine if other uncompleted repairs have placed theinstitution’s security at risk, we reviewed a number of Priority 1repair requests and Priority 2 maintenance orders, investigatingthe nature of the work requested, the length of Wasco’s delay incompleting it, and the possible consequences that the institu-tion risked by this delay.

3 The emergency generator for Wasco’s perimeter electric fence operates on its owndedicated electrical circuit. The fence generator sensed the power outage, startedwithin 10 seconds, and operated throughout the loss of normal power.

While we know thatmany staff were aware ofthe transformer testingresults, it is unclear whomade the decision not torepair the transformers.


To begin, we examined Wasco’s history of Priority 1 repairsfor two critical equipment items included in Wasco’s backlog:its emergency battery backup light systems and its fire alarmsystems. These systems are clearly critical to the safe operationof the institution, the former supplying light in the event of apower failure and the latter providing early detection of fires.When asked, Wasco furnished records that showed that18 Priority 1 repair requests for its fire alarm systems had beenmade during the past three years; however, 12 of these requestsremained incomplete as of August 16, 1999. In addition, of the23 Priority 1 work orders related to failed battery backup lightsrequested during the past two years, only 12 were completedwithin the required 24-hour period. The reports indicate that2 requests from February 1998 remain incomplete as ofAugust 31, 1999, and that some of the backup light repairs werefinished several months after the initial request date, wellbeyond the required 24-hour time frame for emergency repairs.The plant operations manager was unable to explain why staffdid not complete these critical Priority 1 work orders sooner.However, he thought staff had made many of the repairs ontime but had failed either to submit or to enter data showingrepair completion.

In addition to identifying delays in Priority 1 repairs, we foundmany examples of inadequate Priority 2 maintenance onWasco’s two emergency standby generators, the generator for itslethal electric fence, its electrical transformers, the emergencybattery backup lights, and the fire alarm systems. As previouslynoted, Wasco has carried a considerable backlog of Priority 2maintenance items; therefore, we reviewed its maintenancepractices for several of these equipment items that are particu-larly critical to maintaining safety and security at the prison.One of these items is the lethal electric fence generator, whichensures that the electric fence is able to operate properly in theevent of a power outage, thus assisting in preventing inmateescapes during emergencies. In analyzing the maintenancerecords, we found that, although Wasco schedules monthlystart-up testing and maintenance of its electric fence,it has completed this testing only eight times in the 56 monthssince the generator was installed. In fact, the records indicatethat Wasco did not perform any testing on this generator fromFebruary 1995 through November 1998. By not ensuring thatthe electric fence generator is functioning properly, Wascopotentially jeopardizes the safety of the community surroundingits facility.

Required monthlymaintenance and testingof the lethal electric fencegenerator has occurredonly eight times in nearlyfive years.


In another instance, we found that Wasco has failed to maintainand test adequately its battery backup lighting system. Thisemergency lighting system is designed to be the sole source oflight in many critical areas, such as inmate housing buildings,during a complete power outage. Proper functioning of thissystem is especially crucial in inmate dormitories, where as fewas two correctional officers, armed only with batons and pepperspray and without gun coverage, oversee up to 200 inmates.During a power failure, these officers face complete black-outconditions unless the buildings have backup lights. For thisreason, Wasco is supposed to perform both monthly testing andannual Priority 2 maintenance on its emergency lighting system.Monthly testing includes turning the lights on for a short periodto ensure proper operation. Annual maintenance includescleaning, testing the battery capacity, and inspecting the integ-rity of plugs and cords.

Because Wasco does not keep records of the monthly testing, wewere unable to determine the exact extent to which the prisonperforms this testing. However, interviews with staff indicatethat testing of backup lighting rarely occurs. Wasco’s records forPriority 2 annual maintenance of these emergency lights areinconsistent; however, the latest report we received indicatedthat although Wasco scheduled maintenance for these lights on232 occasions over the past 19 months, staff completed mainte-nance on only 23 occasions. The consequences of Wasco’sfailure to maintain and test these lights became evident duringthe April 1999 power outage, when some of these backup lightsfailed to operate or operated only for a short time. Althoughall of the lights eventually stopped working because they aredesigned only to last for up to three hours, the failure of some ofthe backup lights to function at all meant that some correctionalofficers did not have even a brief time to secure potentiallydangerous situations. Instead, the officers immediately faced acomplete black out. Because so many lights failed, Wasco hassince undertaken a project to replace and upgrade its emergencylighting system.

When asked about these Priority 2 maintenance problems,Wasco’s plant operations manager stated that he does not havesufficient staff to complete the scheduled maintenance workloadand, as a result, he has focused on completing emergencyPriority 1 work orders and assisting in the construction of newfacilities. However, as we have shown, Wasco has not consis-tently completed Priority 1 repair orders in a timely mannereither. Moreover, in reviewing Wasco’s plant operations

Wasco failed to complete90 percent of preventivemaintenance on itsemergency batteryback-up lights during thepast 19 months.


staffing records for September 1999, we noted that 27 of Wasco’s98 budgeted positions were vacant. Wasco’s business managerstated that Wasco has not filled these positions in part becausethe CDC requires each institution to maintain a 4.9 percentsalary savings and in part because the prison needs additionalsalary savings to pay for staff overtime. However, in light of itsrepair and maintenance backlog, we believe it is imperative forWasco management to identify its critical Priority 1 andPriority 2 needs and plan for the staff and budget necessary toensure that Wasco accomplishes these tasks. In fact, with theyear 2000 fast approaching, it is even more important thatWasco take immediate action toward reducing its maintenancebacklog so that it can ensure its emergency equipment is readyfor any contingencies that might occur this January.

Wasco is currently in the process of implementing a newautomated maintenance system that is intended to increase andimprove the data concerning facility maintenance and makethis data easily accessible to both Wasco’s management and theCDC. Expected to be fully implemented by October 1999,the new system should improve Wasco’s ability to track workorders and plan the most efficient use of staff time. With suchknowledge, management should be better able to monitor itsmaintenance projects and plan for the elimination ofthe backlog.

CONCLUSION

In the past few years, Wasco has neglected to perform neededrepairs and maintenance on critical emergency equipment, thuscalling into question the reliability of this equipment. In fact,Wasco’s failure to repair or replace a transformer that tests hadalready identified as faulty, led to a complete power failure thatplaced the security of the institution at risk. Although Wasco hasacted to address some of its repair and maintenance problems,we believe that it must act decisively and quickly to eliminate itsbacklog of all Priority 1 repairs and Priority 2 maintenance workorders. Without such immediate action, Wasco may furtherjeopardize the safety of its staff and inmates.


RECOMMENDATION

To prepare fully for future emergencies, Wasco State Prisonshould first identify for its emergency equipment all Priority 1repairs and Priority 2 maintenance. The institution shouldthen develop a staffing plan to eliminate quickly this repairand maintenance backlog and work to keep the equipmentready continuously. ■


CHAPTER 2Wasco’s Emergency Readiness HasSignificant Weaknesses

CHAPTER SUMMARY

As Chapter 1 explains, Wasco State Prison (Wasco) suffereda complete power outage on April 12, 1999. Eventhough no staff or inmates received serious injuries, the

incident demonstrated that Wasco’s staff are not adequatelytrained for institution-wide emergencies, no emergency opera-tions plan exists for a complete power outage, and Wasco’semergency equipment and supplies were deficient. In fact, webelieve that the absence of major injuries was due primarily tofortuitous mitigating circumstances, such as the occurrence ofthe power failure when staff members were changing shifts,rather than to Wasco’s emergency readiness.

Perhaps the most serious weakness revealed by the power outagewas the staff’s lack of training for emergencies of this nature.When we discussed the incident with Wasco staff memberspresent during the power outage, they told us of instances inwhich some individuals were generally unprepared to handlethe crisis effectively. Many staff attributed this lack of readinessto an absence of training and drills for institution-wide emer-gencies. Although Wasco has trained its staff regarding thegeneral Emergency Operations Plan (EOP) guidelines and hasconducted training and drills related to specific types of emer-gencies, such as inmate disturbances, the training and drills todate have yet to address such emergencies as an electricalpower outage.

In addition to these problems with staff training, Wasco also hasfailed to include within its EOP a strategy to guide staff in theevent of a complete power outage, despite the fact that its EOPacknowledges that backup power equipment has a high failurerate. We found that the EOP includes procedural checklists to aidin emergencies such as earthquakes, dam failures, and floods;however, it includes only vague guidelines regarding alternativesources of power and communications when primary systemsfail. Although Wasco’s officers were able to use their experience


to manage the institution during the April power outage,key officers indicated that established plans were not helpfuland that there is a need for better guidelines regardingelectrical failures.

Moreover, even if Wasco’s staff had received adequate trainingand its EOP included an appropriate emergency plan, the staff’slack of drills negated the opportunity to detect and correctproblems in advance of those that occurred on the night ofthe power outage as a result of deficiencies in the prison’s emer-gency supplies and equipment. Some officers did not haveflashlights or radios, and the central control board failed duringthe outage. Management could have been forewarned of thesesorts of problems if Wasco had engaged in institution-widedrills. Finally, although the prison appears to be on track with itsplans for addressing possible year 2000 (Y2K) complications, thedepth and timing of the exercises Wasco intends to conduct toensure that its Y2K contingency plan is viable may affectWasco’s ability to detect and correct any deficiencies it findsbefore the end of the year.

A LACK OF TRAINING AND DRILLS LEFT MANY STAFFUNPREPARED FOR WASCO’S RECENT POWER OUTAGE

To assess how Wasco responded to the April power outage, weinterviewed several correctional officers and supervisors whowere present at the institution during the emergency. Althoughsome staff indicated that the prison handled the emergencywell, others pointed out areas in which staff members weregenerally unprepared for this sort of crisis. For example, a towerguard was injured when he fell while climbing down the dark-ened stairs of one of the guard towers in an attempt to deliverkeys necessary to open a gate. However, an outside patrol officerwith the needed key was nearby but was unaware he had a key.Had the outside patrol officer been better prepared, the injury tothe officer responding from the guard tower could have beenavoided. In another instance, a Sheriff’s helicopter that wasproviding light for correctional officers during a move ofinmates from one housing building to another was asked by theemergency commander to light the perimeter fence instead. Thisaction left officers with only their flashlights and lanterns tocomplete the inmate move.

The black out revealedthat some staff did notknow how to manuallyopen gates, the locationof keys to open inmatehousing, or where tofind emergency lanternsand radios.


These are only two examples of problems caused that night by alack of staff training and preparedness. In addition, staff mem-bers told us that some staff did not know how to open gatesmanually and that some supervisors did not know the locationsof keys necessary to open manually the locks for inmate housingbuildings. We also learned that some staff did not know whereto find emergency keys, lanterns, and radios. Such examplesindicate that communication and coordination during thepower outage could have been better. Moreover, the exampleshighlight the importance of training staff in emergency proce-dures, including how to conduct operations manually andwhere to locate emergency resources.

Although the consequences of the power outage were notas serious as they could have been, several staff membersmentioned that good timing contributed at least in part to therelatively benign outcome to the emergency. When the powerfailed at 10:05 p.m., the Wasco staff were in the middle of a shiftchange. Fortunately, even though some of its staff memberswere confused and uncertain about what to do, Wasco was ableto redirect immediately most of its outgoing staff back into theinstitution to provide additional support in controlling theemergency. In contrast, if the power outage had occurred justone hour later, Wasco would have had only its nighttime skel-eton crew to contain the institution and might not have fared sowell. Under these hypothetical circumstances, Wasco wouldhave found staff training and preparedness even more necessarythan they were in April.

Nevertheless, despite the staff’s obvious need for training, Wascohad not conducted training or drills for situations such as poweroutages that require an institution-wide response. Wasco hasprovided some training related to its general emergency opera-tions procedures, such as how to man the perimeter towers andwhich staff are designated to assist in responding to emergenciesin specific areas of the institution. However, this training,though valuable, does not address what to do in the event of acomplete power failure.4 Wasco has conducted focused drillsrelated to specific types of emergencies, but these sessions dealtonly with parts of the facility, such as a hostage situation or aninmate-induced power failure in one building. In an isolateddisturbance training drill, management designates unaffected

4 In addition to furnishing classroom training, Wasco’s supervisors provide on-the-jobtraining to correctional officers. However, none of the officers we spoke to could recallreceiving any guidance from his or her supervisors about what to do during a poweroutage.

The outage occurred at ashift change providingadditional staff to controlthe emergency. Had ithappened one hour later,the nighttime skeletoncrew may not have faredso well.


parts of the institution to assist in responding to the emergencyor to staff critical posts, such as the building or perimeter guntowers. However, in an institution-wide emergency, such as apower outage, which affects all areas, such assistance would notbe as readily available.

For this reason, the training of supervisory staff is particularlyimportant. In an institution-wide emergency, most staff wouldhave to remain at their respective posts to maintain security,while the remaining supervisors would be responsible fordeciding where to lend help and what type of help to lend. Suchchoices are difficult, if not impossible, without training andpractice. Wasco was fortunate that this lack of training andpreparation did not result in any serious consequences lastApril; however, it should ensure that staff are adequately pre-pared for the possibility of a future institution-wide emergency.Although Wasco’s chief deputy warden acknowledgesthe need for additional training and drills for staff, he statedthat the high cost of training and drilling combined withbudget constraints limits the extent to which these activitiescan take place.

WASCO’S EMERGENCY OPERATIONS PLANS DO NOTADEQUATELY ADDRESS PROCEDURES FOR STAFF TOFOLLOW DURING A COMPLETE POWER FAILURE

The problem of Wasco’s inadequate staff training is com-pounded by the fact that its emergency operations proceduresdo not include a coherent plan or sufficiently detailed checklistto help supervising staff deal with a complete power outage.Wasco’s emergency procedures consist of an EmergencyOperations Plan (EOP) plus a series of supplements. Outliningpreparations for such emergencies as earthquakes, dam failures,and floods, the EOP defines staff responsibility during emergen-cies and establishes procedures for notifying management, forsharing information between various staff members, and forimplementing command and control of activities. The supple-ments provide more detailed emergency procedures in certainareas such as inmate counts, lockdowns, weapons distribution,communications, and the establishment of alternate sources ofpower. Although these sections provide guidance for certainneeded actions during a power outage, such as setting up theemergency operations center, the EOP and its supplementsdo not offer specific procedures for handling this typeof emergency.

Unlike earthquakes,dam failures, and floods,there are no proceduresspecific to poweroutage emergencies.


We also found that the supplements on “Communication” and“Alternate Sources of Power and Utilities,” which seem mostrelevant to a power outage, do not provide adequate or specificguidance. For instance, while the supplement on alternativesources of power acknowledges that utility power is critical, thepublication only mentions the standby generators as the alterna-tive to normal power. The supplement states that in the event ofa prolonged power outage, Wasco may use the services of out-side resources. However, this supplement does not containprocedures for staff to follow during the interim period whileWasco obtains alternative power sources or outside assistance.

The emergency operations supplement for communicationappears similarly ineffective. The plan specifies the use of radiosand hand-carried notes as alternative communication devices,yet it provides no guidance for implementing these alternatives,leaving open questions such as who should carry the notes andwhere the additional radios are located. Instead, another supple-ment supplies information on the number and location ofadditional radios. However, this second supplement did not listthe backup supply of radios kept by the person acting as liaisonfor Wasco’s radio communications. Although the radios wereneeded during the April power outage, they were never locatedor used because staff were unaware of the supply. Wasco hassince updated these supplements to include a procedure tocontact the radio liaison in the communications supplementand has added the location of the radios to another supplement;however, the supplements still lack integration for ready use anddo not include sufficient information to be effective.

The commanders in charge of Wasco during the April poweroutage confirmed the apparent weaknesses of the EOP’s guide-lines. Both the interim emergency commander, who has controlof an emergency until the warden or his designee arrives, andthe alternate watch commander, who oversees any portions ofthe institution not affected during an emergency, stated thatWasco’s emergency operations plans were not very helpful tothem during the emergency because the guidance related topower and communications failures is not specific enough.The commanders indicated that they had to rely on theircombined knowledge and experience rather than the emergencyoperations procedures to determine what actions to take. Eachacknowledged the need for more detailed procedures regardingthis type of emergency and recommended using the reportsfrom the April power failure as guides for similar occurrences in

The commanders incharge of Wascoduring the April poweroutage stated thatemergency operationsplans were not veryhelpful to them duringthe emergency.


the future. Although Wasco overcame the emergency in Aprilwithout serious incident, the fact that these managers stillrecommend the development of specific procedures highlightsthe importance of this critical task.

For this reason, we found it curious that although the CaliforniaDepartment of Corrections (CDC) requires each of its institu-tions to develop checklists for emergencies such as dam failures,floods, and earthquakes, the CDC does not have a similarrequirement for specific emergency procedures related to poweroutages. CDC officials explained that the department’s guidancein this area is more general than it is for other types of emergen-cies because of the unique character of the facilities and varyingrisk levels of inmates housed at each institution. Thus, the CDChas delegated development of more detailed procedures to theprison wardens. However, in light of the power outage sufferedby Wasco, it does appear that this type of procedure wouldbenefit all California correctional institutions. Without suchprocedures, institutions risk confusion and possible breaches ofsecurity during power failures.

TESTING OF EMERGENCY PLANS COULDHAVE REVEALED DEFICIENCIES IN WASCO’SEMERGENCY EQUIPMENT

In addition to revealing problems in Wasco’s staff training andemergency procedures, the power outage also exposed severaldeficiencies in Wasco’s emergency backup equipment, includingits supply of flashlights and lanterns, battery operated radios,personal alarms, and fire alarms. If Wasco had conducted train-ing and drills related to a complete power outage before anactual emergency occurred, prison management could haveuncovered these deficiencies and taken action to correct them.

For example, because battery backup lights in the buildingsfailed, staff were dependent on flashlights and lanterns toprovide illumination. However, despite Wasco guidelines, whichrequire correctional officers to carry flashlights, some staffmembers were not appropriately equipped. The problem wasfurther complicated when Wasco found its backup supply oflanterns inadequate to meet staff needs during this emergency.As a result, some correctional officers were forced to work insituations in which they had minimal or no light, and thesecircumstances created unnecessary risks to their safety. IfWasco had already conducted appropriate drills, they would

The loss of powerdisclosed deficienciesrelating to the supply offlashlights and lanterns,and radio batteries.


have shown that the supply of lanterns was inadequate andreinforced the need for each officer to carry a flashlight. Inresponse to the deficiencies noted during the black out,Wasco has since purchased 204 lanterns to supplement itsexisting supply.

In addition, the loss of power also uncovered weaknesses inWasco’s backup communications systems. The institution’sphone system has a battery backup system designed to operatein the event of a complete power outage. However, the phonesystem was significantly damaged by a power surge resultingfrom the failed transformer, leaving staff dependent uponbattery operated radios and other methods for communication.In accordance with the CDC guidelines, radios are only issued tostaff when fixed communication devices such as telephones willnot meet critical communications needs, so they are typicallynot issued to the staff of the inmate-housing buildings becausethese buildings have telephones. Therefore, once the phonesystem failed, all 30 inmate-housing buildings were left withoutimmediate communication and had to depend on messengersuntil management could issue radios.5 However, many of theradios proved unreliable because of an insufficient supply ofbatteries, further impeding the ability of some correctionalofficers to communicate problems or receive orders.

In fact, Wasco did have additional radios and batteries available,but staff were unaware of their availability and did not contactthe radio liaison, who could have advised them of the locationof the radio storage area. As a result of this unused supply,Wasco did not need to purchase additional radios or radiobatteries after the outage. Nevertheless, the person acting asliaison for Wasco’s radio communications advised us he hassince informally made appropriate staff aware of the additionalsupply and its location, and he has purchased an additional100 radio batteries to upgrade Wasco’s backup supply.

In a final example of deficiencies in Wasco’s emergency equip-ment, Wasco’s central control board, which shows the status ofpersonal alarms and fire alarms, failed during the April poweroutage. Plant operations staff later learned that the board, whichallows the coordination and supervision of the response to anemergency such as a fire or an officer’s call for help, did not

5 Several correctional officers retrieved personal cellular phones from their automobiles inthe parking lot for use by the supervisory staff to communicate with the emergencycommander.

Another example ofdeficiencies in Wasco’semergency equipment isthe failure of the centralcontrol board whichshows the status ofpersonal and fire alarms.


have an emergency battery backup. With the phone systemdown, the board’s role was even more critical for the officersinside the inmate-housing buildings who had no other immedi-ate means of communicating an emergency to supervisors. If ithad tested its emergency plans, Wasco would have discoveredthe lack of a backup battery for this important system. Wascomanagement has since connected the control board to a backupbattery designed to last up to eight hours.

WASCO’S HANDLING OF THE RECENT POWEROUTAGE RAISES CONCERNS ABOUT THE PRISON’SPREPAREDNESS FOR YEAR 2000 EQUIPMENT PROBLEMS

The problems that arose in conjunction with the recent poweroutage may foreshadow some of the possible scenarios thatcould occur when the year 2000 (Y2K) arrives. Although Wascohas been actively preparing for Y2K, the institution still has notcompleted certain steps necessary to ensure it will be ready forpotential computer problems. Specifically, it still needs toconduct a test of its Y2K contingency plan, required by theCDC, and to complete remediation and testing of some of itshigh-priority systems. In addition, it has yet to conduct aplanned disturbance control exercise that will simulate a loss ofpower throughout the whole institution similar to the electricalfailure that occurred earlier this year. Until these steps aresuccessfully completed, Wasco is not at the point it can declareitself ready for Y2K.

Wasco has prepared a Y2K contingency plan that details alterna-tive sources that Wasco could use to fill its institutional needsfor power, food, heat, water, lighting, and communicationsshould its primary sources be unavailable. For example, the planaddresses the possible loss of power to the perimeter electricfence, including depletion of the fuel supply for its backupgenerator. If this event should occur, the plan calls for theposting of armed staff in the perimeter towers, an institution-wide inmate lockdown, and both vehicle and foot patrols of theinstitution perimeter. To ensure that its contingency plan can becarried out effectively, Wasco intends to have all fuel supplies atfull capacity and a sufficient number of staff on duty to contendwith any electronic equipment or infrastructure problems causedby the Y2K date change. Although the plan seems fairly com-plete, we are concerned about the timing and depth of theexercises intended to test its viability.

Wasco has yet toconduct tests of its Y2Kcontingency plan.


To test its Y2K readiness, Wasco has planned two main exercises.First, the CDC is requiring each of its institutions to conduct atleast one exercise to test the major elements of its Y2K contin-gency plan. According to the CDC’s Year 2000 Validation andTraining Guide (guide), the objective of testing each institution’sY2K contingency plan is to determine if individual plans arecapable of providing support for the CDC’s most critical businessprocesses. Other goals described in the guide include testing tosee if each institution can implement its plan during a specifiedtime and provide the time necessary to make any neededadjustments to the plan so that it can be used if required. Theguide further specifies that testing the functional capability ofY2K contingency plans should enable a responsible officer at theinstitution to certify that the plan has been tested, training iscomplete, and the plan is ready for implementation if necessary.This certification was due by October 8, 1999.

The guide further gives each institution several options, orexercises, for testing its Y2K contingency plan and leaves thechoice of which option to use up to the individual institutions.Two of the five options suggested by the CDC—orientationlectures and desktop exercises—do not include any actual drillsto test whether critical parts of the plan will work in practice.Orientation lectures introduce a new plan to an existing groupor an existing plan to a new group. A desktop exercise ishypothetical in nature and performed by management andsupervisory staff. This type of exercise poses specific emergencyscenarios to a supervisor who then discusses how to resolve theemergency. The management team then critiques the proposedresolution. The other three options involve drilling or simula-tions. Skill enhancement drills train staff on a specific functionor reinforce an existing skill. Functional exercises simulate a realevent, usually with external communications in a real-timeenvironment. A full-scale exercise simulates reality to the high-est degree possible. However, unless Wasco intends to go beyonddiscussing and critiquing possible Y2K scenarios by actuallytesting its Y2K contingency plan, using either a functional orfull-scale exercise, there is a significant risk that any flaws in theplan will not be detected and corrected by year-end.

In addition, Wasco plans to conduct a disturbance controlexercise in which the entire institution will act out a drill, whichincludes a simulated loss of power to the prison. After the drill iscomplete, Wasco’s management and CDC observers intend to

Unless Wasco plans toactually test its Y2Kcontingency plan, there issignificant risk flaws willnot be detected.


critique the performance of supervisors and staff to assess areasin which they could improve. According to Wasco’s trainingcoordinator, this exercise is planned for the middle of December.

Although both these exercises seem valuable, we are concernedabout the depth and timing of the events. With the year 2000 soclose to the dates of the planned exercises, Wasco may notbe able to detect flaws in its plan and have adequate time toaddress any deficiencies or make needed adjustments that theexercises might reveal. For instance, if Wasco discovers signifi-cant problems with its equipment during the December drill, itmay prove impossible to replace or fix this equipment beforeWasco needs the equipment to mitigate any Y2K problems.

Moreover, in addition to testing and finalizing its contingencyplan, Wasco still has work to do before its systems and equip-ment are all Y2K compliant. The CDC is responsible forremediation and testing any deficiencies in information tech-nology systems that support Wasco and, according to the Y2Kmanager of the CDC’s Institutions Division, these systems arenow wholly Y2K compliant. According to the Y2K manager,Wasco’s responsibility lies in the remediation and testing ofits embedded chip systems, which are systems where amicroprocessor chip controls, monitors, or assists the operationof equipment or machinery. Thermostats as well as electroniccontrols for inmate cell doors are examples of equipment thatrely on embedded systems.

Wasco’s plan to assess and remediate its embedded systems hasthree phases. Phase I, which consists of testing its high priorityequipment and systems, is nearly complete, with three systemsstill noncompliant and needing repair. First, Wasco found thatthe software controlling an automated inventory of keys andtheir location was noncompliant; however, the CDC is currentlyreviewing this issue to determine by October whether repairs arenecessary or manual operations will suffice. In addition, Wasco’spersonal alarm and fire alarm computer is noncompliant, andWasco is currently considering alternatives to repair this system.Finally, Wasco’s time recorder for its fire alarm system isnoncompliant and should have received repairs bySeptember 14, 1999.6 Wasco needs to ensure that these

6 Wasco has not completed testing on four other high-priority items. One item, a missingsterilizer, could not be located, and remediation and testing will be rescheduled as soonas this item is found. The other three items are components of an X-ray system that isinoperable and will not receive remediation. Wasco has a contract with a vendor toprovide the X-ray services.

Because one Y2K exerciseis not planned untilDecember, there may notbe sufficient time toremediate problems.


high-priority systems are fully remediated and retestedquickly to allow time for Wasco to pursue alternatives if itsinitial efforts are unsuccessful.

In addition, Wasco has not yet begun testing of its Phase IIand III systems and equipment. Phase II involves testinghigh-priority systems that are duplicates or multiples of Phase Iequipment and certain important medium-priority systems,such as the computer for the electric fence emergency generatorand the medical blood cell analyzer. Phase III focuses on testingequipment and systems with lower-priority levels or functions,such as night-vision goggles and food delivery vehicles. Wascoplanned to complete its Phase II testing by October 8, 1999, andto complete its Phase III testing by the end of October or earlyNovember. However, the anticipated late completion of itstesting efforts will not leave much time for Wasco to completeany needed repairs. Wasco management needs to move quicklyto accelerate the completion of the prison’s remediation andtesting of at least its Phase I and Phase II equipment to reducethe risk of Y2K-related problems.

CONCLUSION

The April power outage at Wasco revealed a number of seriousproblems in the prison’s emergency readiness. The power outageshowed that some members of Wasco’s staff had not beenadequately trained in handling an institution-wide emergencyand were generally unprepared to deal effectively with a crisisof this nature. The problem was further exacerbated by a lackof clear and specific guidelines in Wasco’s EOP about properprocedures to follow in the case of a total power outage and bydeficiencies in Wasco’s emergency equipment. Although no staffor inmates suffered serious injuries, Wasco might not have beenso fortunate if the power outage had occurred only an hourlater, when less than half the number of staff would have beenon hand.

The problems exposed in the power outage could fore-shadow similar problems the prison might encounter onJanuary 1, 2000, if Wasco does not act promptly to ensure itsemergency readiness. The depth and lateness of Wasco’s pro-posed testing of its Y2K contingency plan and the proposedtiming of its remaining remediation and testing of its systems


and equipment that rely on embedded chips may not allowsufficient time for Wasco management to detect and make anynecessary revisions to its plan or to fix noncompliant systemsand equipment.

RECOMMENDATIONS

To prepare for the possibility of another institution-wide emer-gency such as the recent power outage, Wasco should do thefollowing:

· Develop a specific plan for institution-wide emergencies suchas power outages and include this plan as a supplement to itsemergency operations procedures.

· Conduct training and drills to ensure staff understandprocedures and are prepared to perform necessary functionsduring an institution-wide emergency.

To ready itself for possible year 2000 computer and equipmentproblems, Wasco should take these steps:

· Perform either a functional or full-scale exercise to test itsY2K contingency plan.

· Conduct its Y2K disturbance control exercise as soon aspossible to test the feasibility of its contingency plan and toallow adequate time to correct any deficiencies or to makenecessary adjustments to its plan.

· Complete the remediation and testing of its Phase I andPhase II embedded-chip systems for Y2K compliance as soonas possible.

· Ensure that the prison’s supplies of emergency equipmentare adequate and that its equipment is fully functional.

Furthermore, the California Department of Corrections shouldrequire each correctional facility to develop a plan that coversinstitution-wide emergencies such as power failures and to includethis plan in the facility’s emergency operations manual. ■


CHAPTER 3Weak Managerial Oversightand a Lack of Staff VigilanceLed to Inmates Gaining Accessto Confidential InformationAt Wasco

CHAPTER SUMMARY

The failure of management at Wasco State Prison (Wasco)to demonstrate sufficient foresight in handling potentialproblems is apparent not just in its preparation for

emergency situations, but also in its daily interactions withinmates. Specifically, in several separate instances this spring,inmates at Wasco were able to obtain the addresses and socialsecurity numbers of staff members because documents contain-ing confidential information were not adequately secured andbecause staff were lax in their supervision. In addition, aCalifornia Department of Corrections (CDC) policy givesinmates access to a detailed map of the institution that showssuch sensitive information as the location of the prison’sarmory, generators, and fuel supplies.

These conditions illustrate a general complacency on the partof Wasco’s staff members when they interact with inmates, abreakdown in staff vigilance regarding the protection ofconfidential information, and what we consider a poor policychoice on the part of the CDC. Moreover, incidents such asthese suggest that supervisors who should have detected andprevented this breakdown in security were not exercisingappropriate oversight. Although we are not aware of any specificharm caused to persons compromised by inmate access toconfidential information, these conditions put Wasco staff andtheir families at undue risk. Wasco’s management has sincetaken some positive steps to correct staff practices related to thehandling and security of confidential information; however,management needs to find ways both to engender a morevigilant attitude among staff and to ensure that staff adhere toestablished procedures.


STAFF DID NOT SAFEGUARD CONFIDENTIALINFORMATION OR SUPERVISE INMATEWORKERS APPROPRIATELY

Statements of policy by both Wasco’s management and the CDCemphasize the importance of vigilance. Yet several recent eventsand our own observations suggest that Wasco’s staff have notadequately safeguarded confidential information and thatoverall vigilance at the prison has become too lax. Because ofthese conditions, inmates recently gained access both to certainpersonal information about correctional officers and administra-tive staff and to sensitive information about the institutionitself. These incidents, which created a threat to the safety ofadministrative and correctional staff and their families, indicatethat management has failed to set a sufficiently vigilant tone atthe prison.

Several Inmates Had Access to a Closet That HeldConfidential Records

CDC policy requires institutions to strive for an inmate partici-pation rate of 98 percent in work, training, and educationalactivities. Because Wasco staff assign inmates tasks that includemaintenance, clerical, and janitorial work, inmates work in mostareas of the prison. During our visit at Wasco, we observed thatmany of these inmates appeared idle, indicating to us thatperhaps the prison does not have enough appropriate jobs for itsinmate population. If inmates have time on their hands, thestaff that supervise these inmates need to remain especially alertand cautious.

However, some recent events indicate that Wasco has not alwaysmaintained appropriate vigilance. Specifically, in April 1999, acorrectional officer discovered a list hidden among supplies in ajanitorial closet that contained such confidential information asthe names, phone numbers, social security numbers, and anaddress of current and former correctional officers and staff.Wasco investigators traced this list to an inmate who admittedpreparing it from confidential information contained in boxesformerly located in the closet. Even though the Department ofCorrections Operations Manual (DOM) requires that all confi-dential information be stored in locked areas, staff had notadhered to this requirement and had allowed inmates unfetteredaccess to the unlocked closet.

Recent incidents suggestthat management hasfailed to set a sufficientlyvigilant tone.


According to the office technician working in the area adjacentto the closet, the boxes, which contained confidential informa-tion such as time sheets, incident reports, and other documents,were moved to the janitorial closet around February 1998 due tospace constraints. The boxes remained there until March 1999,when other space became available. The inmate who preparedthe list had regular access to the closet as part of his work assign-ment as a janitor and also used the closet for taking breaks.Because of the location of her desk, the office technician respon-sible for supervising the inmate could not observe his actionswhen he was in the closet. Therefore, unless she stood at thedoor every time the inmate entered the closet, the inmatewould have had ample opportunities to peruse the contents ofthe boxes without being detected. In addition to the inmateresponsible for creating the list of confidential information,seven other inmates also worked as janitors or clerks at thislocation and had access to the closet from December 1997through April 1999, when the list was discovered.

In spite of the fact that many of Wasco’s staff and managementknew these boxes were accessible to inmate workers, no onetook extra precautions to safeguard the information containedin them. As a result of this laxness in attitude, at least oneinmate had time to look through the boxes and jot downconfidential information, thus creating a threat to the safety ofinstitution staff and their families.

An Inmate Used Information Obtained From an IncidentPackage to Threaten a Correctional Officer

In a second, unrelated incident in which staff failed tomaintain appropriate vigilance, an inmate obtained access to acorrectional supervisor’s personal information from a StateCompensation Insurance Fund form. The form was part of anincident package provided by another correctional supervisor toan inmate involved in a physical altercation with the supervisor.According to the various memos we reviewed concerning theincident, the inmate who received the insurance form then gaveit to another inmate. Although portions of the form had beenblacked out, the inmate who received the form was able todiscern most of the supervisor’s social security number and apartial home address.

The inmate subsequently used this information to threaten theofficer on an inmate appeal form he filed to request a transfer toanother prison. Specifically, the inmate threatened to provide

Despite knowing thatboxes containingconfidential informationwere accessible toinmates, no extraprecautions were takento safeguard them.


the officer’s personal information to other inmates “who wish todo harm” if he did not receive a transfer to another facilitywithin 72 hours. In response to the threat, Wasco transferred theinmate to another prison three days later and disciplined theofficer who initially provided the incident package to the firstinmate. Although the personal information the inmate garneredfrom the document was incomplete and the officer was notharmed, this incident underscores the potential danger that existswhen inmates learn personal information about institution staff.

CDC Policy Allows Inmate Access to a Detailed Map of theInstitution and the Surrounding Area

While attempting to obtain a map of Wasco’s facilities, wediscovered that inmates in the vocational education programhad access to a detailed map of Wasco and the surroundingarea. The inmates used the map during computerized draftinginstruction. This map identifies the two roads adjacent to Wascoand provides the location and description of all prison facilities,including the positions of critical equipment, armories, andhazardous materials storage areas. In our view, for inmates tohave such detailed knowledge of Wasco’s physical facilitiesrepresents a serious security threat. Furthermore, maps in thehands of inmates depicting any area within 10 miles of afacility are considered contraband and carry disciplinarypenalties according to both the DOM and the California Codeof Regulations.

When we spoke to Wasco’s warden about the inmates’possession of the map, he explained that an inmate’s map isconsidered contraband only if it delineates streets and roadwaysof communities surrounding the institution and thus suggeststhat the inmate is planning an escape. He referred to the mapwe saw as a “plot plan,” explaining that he was aware of itsgeneral use and that it is common practice for inmates to haveaccess to this type of information because they help buildstructures and conduct maintenance throughout the institu-tions. In fact, the warden stated that the CDC specificallyprovides for such access through its policy memorandums. Wereviewed these memorandums and found that the CDC restrictsinmate access only to plot plans and blueprints containingelectrical schematics of radio towers, security systems, or alarmsystems; mechanical drawings of internal locking devices;and information about key numbers or phone numbers.

Inmates have access todetailed maps of theinstitution, depictingthe position of criticalequipment, armories,and hazardousmaterials storage areas.


Nevertheless, we believe that it is unnecessarily risky and poorpolicy to allow inmates access to comprehensive facility mapsthat show the locations and descriptions of all buildings,fixtures, and weaponry.

BEFORE APRIL 1999, WASCO DID NOT STORE SECURELYITS CONVENIENCE COPIES OF CONFIDENTIAL RECORDS

In addition to finding these specific instances in which Wasco’ssecurity was compromised, we also noted a general practicepreviously pervasive throughout Wasco that increased the risk ofinmates obtaining confidential information. Specifically, someadministrative staff stated that, until April 1999, it was commonpractice to create “convenience copies” of confidential records,such as time sheets, so staff could avoid having to obtain thesedocuments from their secure location in another area of theinstitution. This practice contributed to the large volume ofconfidential documents created and stored in all areas of theprison, including the boxes stored in the janitorial closetmentioned earlier.

After the discovery that an inmate had obtained access to theseboxes, management instructed staff to shred all surplus docu-ments that contained confidential information. As a result, wewere unable to determine the exact volume and nature of all thepreviously stored documents, nor were we able to uncoverwhether or not inmates had access to other confidential orsensitive information. However, we found the practice of mak-ing convenience copies to be symptomatic of the atmosphere ofcomplacency that appears to have pervaded the prison.

WASCO’S MANAGEMENT LACKS EFFECTIVE METHODSFOR ENSURING THAT STAFF PRACTICE VIGILANCE

Even though Wasco’s policies and the training courses it offerson staff vigilance appear adequate, the institution’s managementhas not established effective ways to assess whether staff areputting into practice directives related to vigilance. In particular,Wasco does not regularly obtain evaluations from staff regardinghow well training courses prepare them to work in a correctionalsetting. Further, no other preventive measures appear to be inplace to help management assess whether its efforts to instillvigilance among staff result in adherence to Wasco’s policies.

Making conveniencecopies is symptomatic ofWasco’s past atmosphereof complacency.


The training Wasco offers its staff concerning security issuesappears adequate and appropriate. For instance, during amandatory 40-hour orientation training session given to all newemployees, Wasco staff members receive instruction about thepolicies, procedures, and regulations included in the DOM andthe California Code of Regulations, which mandate the policiesand procedures Wasco must follow regarding confidentialinformation and security. In particular, the DOM clearly defineswhat constitutes confidential information and outlines theresponsibility of staff to secure and protect all confidentialinformation and to prevent its disclosure to unauthorizedindividuals. The DOM also clarifies and limits the types ofwritten documents to which inmates may have access, and itspecifically excludes any type of confidential information.

In addition to covering these regulations, the mandatoryorientation also introduces staff to a variety of skills needed towork in a prison setting, including ways to secure informationand the importance of maintaining a heightened awarenesswhen working around inmates. These skills are reiterated andreinforced when employees complete a required combinedminimum of 40 hours of formal and on-the-job training eachyear. Many available training classes also discuss the importanceof staff vigilance: Courses cover correctional awareness, inmate/staff relations, the danger of overfamiliarity with inmates,universal precautions, and information security. In fact, theinmate/staff relations and universal precautions courses are partof the annual training required for all job classifications.

Thus, the training requirements and available courses appearto address sufficiently the need for staff vigilance at alllevels. However, with the exception of a limited number ofstate mandated courses in which course evaluations arerequired, Wasco generally leaves to the discretion of theindividual instructors the decision whether to request courseevaluations from participating staff. We feel that a formalizedprocess of course evaluations would give management a goodmechanism for feedback and for confirming that trainingcourses are adequately providing staff with the necessary toolsto work in a correctional environment.

Moreover, while we found that Wasco’s management generallyreacts well when incidents affecting the security of its staffarise, we also noted that managers do not employ preventivemeasures to ensure that staff comply with its policies andprocedures in the absence of a specific security breach. Without

A formalized process ofcourse evaluations wouldprovide managementwith valuable feedback.


such measures and monitoring, Wasco’s management may beallowing a complacent or lax atmosphere to continue amongits staff.

WASCO ACTED PROMPTLY TO RESOLVE RECENTCRISES, BUT MANAGEMENT SHOULD TAKE FURTHERACTIONS TO AVOID FUTURE PROBLEMS

After the series of incidents in which inmates gained access toconfidential information, Wasco took specific actions in order tominimize any negative impact and reiterated policies to avoidfuture recurrence. In general, we found that Wasco managementreacted in a prompt, appropriate manner to protect its staff andimprove the safeguarding of confidential information. However,even after management had taken these precautionary measures,we identified additional staff members who should have beenalerted that their personal information may have been compro-mised, and we also noted instances in which staff still failed tofollow security policies for the shredding of documents and thedistribution of inmate forms.

Because of the sensitive nature of the compromised informationfound in the storage closet and the potential threat it posed tothe safety of staff and their families, management took quickaction to mitigate potential negative ramifications. Withinthree to four working days, which is a reasonable time period,management had informed all staff included on the inmate’slist. Wasco management waited to notify those persons affecteduntil its investigators completed the fundamental elements ofthe internal investigation. Once the investigators had deter-mined the extent of the problem, the employee relations officernotified all staff included on the inmate’s list.

Nonetheless, despite Wasco’s prompt and seemingly appropriateactions, we identified additional staff that we feel Wasco man-agement should have notified. Specifically, we noted that thenames and social security numbers of two additional staffappeared on the same time sheets from which the inmate’s listappeared to be compiled. In each case, the name and socialsecurity number of the staff member were the last entries on thetime sheets; all other staff on these same time sheets appearedon the inmate’s list. We also determined that another staffmember’s time sheet was located in the same box from whichthe inmate had obtained the other information. However,

While Wasco’smanagement generallyresponds well to securitybreaches, it does notemploy proactivemeasures to ensurecompliance with itspolicies and procedures.


Wasco management did not inform these three people that theirconfidential information might have been compromised. Wefeel that, considering the financial and security risks involved,management would have been prudent to notify these staffmembers as well to provide them with the opportunity to takeany precautions they deemed necessary. After we brought thisfact to management’s attention, the warden had his staff contactthe three individuals.

After a Wasco correctional officer found the inmate’s list in thejanitorial closet, Wasco officials also conducted a series ofsearches throughout the prison to establish if other inmatespossessed confidential information and, more importantly, toidentify the inmate responsible for creating the list. To find thisindividual, Wasco management ordered cell searches of allinmates who had been assigned to work in or around the janito-rial closet between December 1997 and February 1999. This cellsearch had two goals: identifying the inmate responsible forcreating the list and ascertaining if other inmates assigned tothat area possessed confidential information. The search wassuccessful in pinpointing the responsible inmate and in deter-mining that no other inmates possessed sensitive information.7

Next, to avoid a reoccurrence of the problem, Wasco manage-ment issued a series of memorandums to all staff that reiteratedthe prison’s policies regarding the proper handling and storageof confidential information. Many of these memos highlightedthe importance of staff maintaining a vigilant attitude andappropriately safeguarding the security of sensitive information.Additionally, some memorandums outlined new policies, suchas elimination of the informal practice of creating “conveniencecopies.” Specifically, management directed all staff to ceasecopying time sheets or any other documents containing per-sonal information. Prison staff were instructed that confidentialforms could only be retained in secured areas; for example,Wasco would store time sheets in the personnel office that isaccessible only to prison staff. We believe that eliminating thepractice of making convenience copies should help to reduce theamount of sensitive information present in the prison.

7 In addition to the cell search, Wasco management also carried out two additionalsearches of the general prison population. Management conducted the first searchthe day following the list’s discovery, with an additional search performed the followingweek. These searches did not uncover any additional confidential information.

In reaction to theproblem, managementissued a series ofmemorandums on theproper handling ofconfidential information.


To further eliminate extraneous copies of confidentialinformation, Wasco management established policy guidelinesfor the shredding of confidential documents. In particular,management directed all staff to review active, supervisory, andother types of files in order to purge and shred all personalinformation concerning staff. Although we agree that Wascoshould shred unnecessary documents, we did not find evidencethat staff kept logs of the shredded documents, in spite ofmanagement’s directive to do so. Because Wasco did not retainlogs, and because the staffs’ initial shredding of existingdocuments occurred in reaction to the warden’s directive andbefore our visit, we were unable to determine the volume andnature of confidential information to which inmates had access.

Another new policy changed how time sheets identify staff.Management now requires that time sheets list only the last fourdigits of the employee’s social security number, along with theirfull name. This change in policy reduces the risk of a staffperson’s social security number being compromised.

Wasco management communicated these policy changes throughthe prison’s monthly staff training bulletins, memorandums to allstaff, and additional memorandums distributed to supervisorsand managers. These policy directives, if followed, shouldimprove the security of confidential information and reduce therisk that anyone could use this information inappropriately.

Nevertheless, in spite of these corrective actions, we still havesome concern about how management will ensure that staffcomply with its policies. Specifically, we discovered that after thewarden had issued a directive mandating the elimination of theState Compensation Insurance Fund form from any file otherthan the claim file in the health and safety office, staff contin-ued to use an old document checklist calling for a copy of thisinsurance form. This practice continued despite the fact that thechecklist had also been revised. Because staff members thatcompile the documents provided to inmates during disciplinaryhearings use this checklist to make certain inmates receive allrequired documents, use of the old checklist could potentiallylead to inmates once again receiving inappropriate information.This example highlights the need for Wasco management tomonitor whether staff put new policies into practice.

In spite of correctiveactions taken, we stillhave some concernabout how managementwill ensure compliancewith policy.


CONCLUSION

In the past, the improper storage of confidential informationcoupled with a general breakdown in staff vigilance resulted inWasco inmates obtaining confidential information that placedstaff members and their families at risk. We found that whilestaff receive appropriate training to be vigilant around inmatesand to secure and protect confidential information, few manage-ment controls are in place to ensure that they follow securitypolicies and remain vigilant around inmates. In reaction to therecent breaches of security, Wasco’s management has actedswiftly to implement various corrective actions that, if followed,should improve security and avoid a recurrence. However, theseactions will be in vain if top management does not set the tonefor vigilance by strengthening its efforts to ensure that stafffollow its policies and practices concerning staff watchfulnessand information security.

RECOMMENDATIONS

To ensure the safety of staff, Wasco’s supervisors and managersneed to cultivate an atmosphere of vigilance by setting anexample with their own behavior and by closely monitoringstaff interactions with inmates. When they observe staff exhibit-ing lax behavior, managers need to intervene promptly.

To avoid future problems involving the security of confidentialinformation, Wasco should take these measures:

· Incorporate into its procedural manuals the recent manage-ment directives concerning the storage and duplication ofconfidential information.

· Ensure that staff use control logs to record documents sched-uled for shredding.

To eliminate the unnecessary risk of allowing inmates access todetailed plans of its institutions, the CDC should amend itspolicy and restrict such access.


We conducted this review under the authority vested in the California State Auditor bySection 8543 et seq. of the California Government Code and according to generally acceptedgovernment auditing standards. We limited our review to those areas specified in the auditscope section of this report.

Respectfully submitted,

KURT R. SJOBERGState Auditor

Date: October 15, 1999

Staff: Doug Cordiner, Audit PrincipalDale A. Carlson, CGFMJohn F. Collins II, CPATyler Covey, CPA, CMALeah Northrop




Agency’s response provided as text only.

California Department of CorrectionsWasco State Prison

Memorandum

Date : October 4, 1999To : Kurt R. Sjoberg

State AuditorBureau of State Audits

Subject: RESPONSE TO BUREAU OF STATE AUDITS REPORT

This memorandum serves as Wasco State Prison-Reception Center’s (WSP) and the CaliforniaDepartment of Corrections’ (CDC) response to the issues identified in the recent Bureau ofState Audits report concerning maintenance and security at WSP. The following provides ourresponse and respective action plans to those areas of concern.

WASCO’S FAILURE TO REPAIR AND MAINTAIN CRITICAL EQUIPMENT JEOPARDIZESINSTITUTIONAL SAFETY

Audit findings revealed that: 1) Wasco has not completed emergency repairs and scheduledmaintenance in a timely manner; 2) Wasco ignored critical electrical problems that eventuallycaused a complete power outage; and, 3) Wasco’s failure to properly maintain its emergencyequipment could cause further problems in the future.

Wasco State Prison has begun a comprehensive re-evaluation of all outstanding Priority 1and Priority 2 repair/maintenance requests. Previously misclassified requests will be properlyidentified. Upon conclusion of the re-evaluation, remaining Priority 1s will be quickly addressed,with the objective being a 24-hour turnaround. Additionally, remaining Priority 2s will beaddressed with all reasonable efforts being employed to complete such requests within 15days. Future requests will be completed within these respective time frames contingent uponstaffing, budget constraints and materials. Additionally the CDC is implementing an automatedpreventive maintenance system that will help resolve many of these issues.

Effective immediately, the practice of allowing a non-supervisory/non-trades person tocategorize work orders will cease. All work order requests will be categorized daily by asupervisor skilled in Plant Operations’ equipment and maintenance requirements.


Kurt R. SjobergPage 2

The CDC will actively pursue the staffing of vacant WSP Plant Operations’ positions.Such hiring would be subject to workloads, maintenance priorities, both long andshort term, and appropriate budget constraints. Additional training will be provided tomaintenance staff through their respective area supervisors and managers. A mainfocus of this additional training will concern proper documentation of completed work.The failure to document completed work was clearly addressed in your audit.

SIGNIFICANT WEAKNESSES EXIST IN WASCO’S EMERGENCY READINESS

Audit findings revealed that: 1) Due to a lack of training and drills, many staff wereunprepared for the recent power outage; 2) Emergency operation plans do notadequately address procedures to follow in the event of a complete power failure;3) Testing of emergency plans could have revealed deficiencies in Wasco’semergency equipment; and, 4) Wasco’s handling of the recent power outage raisesconcerns about its preparedness for the Year 2000.

Upon review of the power outage incident (04/12/99), WSP found its existingoperational procedures regarding power outages to be lacking specificity. Inresponse to the lack of specific directives, WSP is undergoing an internal process toidentify and correct this deficiency. WSP is currently doing a full load emergencysimulation test twice a month. The CDC will develop and incorporate a morecomprehensive Power Outage Operational Procedure into its master emergencyresponse manual. It should be noted that WSP will continue to conduct quarterlypower outage drills. The record of all tests and drills will be kept in a logbook withinPlant Operations.

Upon completion of WSP’s Power Outage Operational Procedure, scheduled formaltraining will be undertaken by November 1, 1999. This training will ensure that allinstitutional staff understand their job responsibilities and emergency responsesduring a power outage. After this initial training, which will include live simulation, theinstitutions’ In Service Training department will schedule periodic training andfollow-up.

Additionally, the Emergency Operations Unit (EOU) of the Department of Corrections,shall prepare a format for an Emergency Operations Plan Resource Supplementspecifically relating to power failures. The EOU shall route this format to each prison,along with a directive to each warden ensuring the Power Resource Supplement isamended. This amendment is to include the specific procedures necessary at theirrespective prison to manage such an event. This initial Power Resource Supplementpreparation and routing shall be accomplished by November 1, 1999. Additionally, afinal response date from the respective wardens of December 1, 1999, for thefinalized amendment of their individual Resource Supplement shall be given.



WSP has requested and received permission from EOU to accelerate the planneddisturbance exercise for Y2K compliance at WSP to the first or second week ofNovember 1999. During this exercise there will be a functional testing of theinstitution’s Y2K contingency plan. This functional testing will be in addition to thealready scheduled desktop exercise. Any deficiencies noted will be immediatelyaddressed and resolved prior to the end of the year.

Phase I testing of time sensitive embedded computer chips and a risk assessmenthas been recently completed. Phase II testing is underway with an anticipatedcompletion date of October 8, 1999. The fire alarm system time recorder remediationwas completed September 14, 1999. A contract has been initiated for the personalalarm and fire alarm computer remediation. We recognize the urgency of addressingany remaining non-compliant item(s) from Phase I and any new issues that maysurface in the Phase II testing. Priority has been given to those systems whichprovide support for the primary security of the institution. We are committed toresolving problem areas that might arise from any Y2K embedded system failures.

In order to prepare for any possible future power losses, CDC has substantiallyupgraded its emergency lighting and power backups at WSP. Included in thispackage of additional resources are: 1) 500 KVA transformer; 2) approximately150 additional indoor battery-powered emergency lights; 3) 20 standing light systems;and, 4) approximately 50 portable battery-power lights with substantial batterybackups. All items are in the possession of WSP and are fully functional. Thefunctional aspects of these additional items will be re-tested during the emergencyexercise scheduled for November 1999.

AS A RESULT OF WEAK MANAGERIAL OVERSIGHT AND A LACK OF STAFFVIGILANCE, INMATES AT WASCO GAINED ACCESS TO CONFIDENTIAL INFORMATION

Audit findings revealed that: 1) Staff did not appropriately safeguard confidentialinformation and were lax in supervising inmate workers; 2) Several inmates hadaccess to a closet in which confidential records were stored; 3) An inmate usedinformation obtained from an incident package to threaten a correctionalofficer; 4) The CDC’s policy allows inmate access to a detailed map of the institution and thesurrounding area; 5) Prior to April 1999, convenience copies of confidential records were notstored securely as required by the CDC; 6) Although the need for vigilance is addressed inboth institution policy and staff training, Wasco’s management lacks effective methods forensuring it occurs in practice; and, 7) Although Wasco acted promptly to resolve recent crises,further actions should be taken to avoid future problems.



The CDC’s vision and philosophy has always been toward professionalism, and theDepartment encourages professional standards in all its employees. We doappreciate an outside look at policies and procedures and the recommendations ofyour office will provide the opportunity to correct any oversights that may have beenidentified.

The individual failures/oversights of a few supervisory and management employeeswere mistakes in judgement. These mistakes have been addressed via correctiveaction with the responsible individuals.

As noted in this section, CDC has taken immediate steps to remedy the identifiedareas of concern, at Wasco and all institutions. Several institutional policy memoshave been generated and implemented regarding staff personal information. Thesedirectives are now being compiled into an operational plan. This operational plan willbe formalized and made part of WSP formal procedures within 30 days.

The CDC will also be revising existing procedures regarding document retention andshredding schedules. All necessary changes will be incorporated into institutionaloperations plans. These plans will also include the implementation of shredding logs.This plan will be functional within the next 30 days.

The CDC appreciates the BSA comments in regards to institutional plot plans. CDCis currently reviewing policy and procedures to ensure that inmates are not beingallowed any inappropriate access to information which would jeopardize institutionalsecurity. Such plans, to the extent that they do not jeopardize safety, are utilized inthe facilities under the direction of staff for the maintenance of the institution and forconstruction projects.

Summary

Be assured that CDC has taken immediate steps to ensure the safety of thecommunity, its staff and inmates as it relates to the items identified in your report.Many additional policies and/or revisions have been implemented to prevent areoccurrence of the incident(s) cited. In addition to this clarification of policy,hands-on training through the institutions’ IST will be provided.

The CDC has an outstanding record in preventing disturbances and protecting publicsafety. At no time during the incidents cited was there a breach of security whichjeopardized the public, nor were there any serious injuries incurred by staff orinmates at the prison.

1

1*

* California State Auditor’s comments on this response appear on page 47.


Kurt R. SjobergState AuditorBureau of State AuditsDatePage 5

The Warden and members of his administrative staff reported to the institutionimmediately to personally observe and coordinate staff responses. Theseadministrators remained on duty until operations returned to normal. Many of theitems identified in the report as needing correction and/or clarification have alreadybeen addressed by Wasco administration prior to the initiation of this audit. Sinceinception of the audit, WSP and the surrounding community experienced alarge-scale electrical blackout. WSP’s emergency generators, electrified fenceand emergency lighting worked as designed. As such, the prison was able to function normallywithout incident while maintaining the safety of the community, its staff and inmates housedtherein.

I appreciate the opportunity to respond to the issues identified by your audit team. Iwould also like to commend your staff for the professional manner in which theyconducted the audit. Should you have any additional questions or concernsregarding this response, please contact David Tristan, Deputy Director, InstitutionsDivision, at (916) 445-5691, or Elizabeth A. Mitchell, Assistant Director, Office ofCompliance, at (916) 358-2494.

(Signed by: C.A. Terhune)

C. A. TERHUNEDirectorDepartment of Corrections

cc:David Tristan, Deputy Director, Institutions DivisionElizabeth Mitchell, Assistant Director, Office of ComplianceBill Dieball, Assistant Deputy Director, Institutions DivisionJan Polin, Chief, Institutions Maintenance UnitR. L. Candelaria, Warden, Wasco State Prison




COMMENTSCalifornia State Auditor’s Commentson the Response From the CaliforniaDepartment of Corrections andWasco State Prison

To provide clarity and perspective, we are commentingon the response to our audit report from the CaliforniaDepartment of Corrections and Wasco State Prison

(Wasco). The number below corresponds to the number we haveplaced in the response.

We acknowledge on pages 32 and 36 that Wasco reacted swiftly tobreaches in security by disciplining one officer and issuing a seriesof memorandums to all staff reiterating the prison’s policiesregarding the proper handling and storage of confidentialinformation. However, we are still concerned that these twoactions alone will not ensure that staff remain watchful and thatpolicies are followed without supervisors and managementsetting a tone for vigilance by actively monitoring staffinteractions with inmates and intervening when necessary.

1


cc: Members of the LegislatureOffice of the Lieutenant GovernorAttorney GeneralState ControllerLegislative AnalystAssembly Office of ResearchSenate Office of ResearchAssembly Majority/Minority ConsultantsSenate Majority/Minority ConsultantsCapitol Press Corps

Documents

Wasco State PrisonWasco State Prison: Its Failure to Proactively Address Problems in Critical Equipment, Emergency Procedures, and Staff Vigilance Raises Concerns About The first copy