Incarcerated Narratives Describe Folsom State Prison’s Poor COVID-19 Response & Massive Outbreaks


By Julietta Bisharyan, Nick Gardner and Jaskiran Soomal 

Incarcerated Narratives

Vanguard reporter Ozge Terzioglu spoke with the mother of an incarcerated person at Folsom State Prison (FSP) — the sixth most affected CDCR institution with 1,342 confirmed cases of COVID-19. Over 1,000 of these cases were reported during the months of September and October. The woman, who will be referred to as Diana per request to remain anonymous, gave brief insight into her son’s experience battling COVID-19 at FSP, as well as the misguided safety measures that have allowed the virus to spread rapidly to more than half of the prison’s population. 

When the first major COVID-19 outbreak emerged at Folsom State Prison in mid-August, the institution mirrored CDCR’s general lack of preparedness. Makeshift quarantine areas proved ineffective, cross contamination between the prison’s sick and healthy population was widespread, and testing lacked the consistency required to ensure the safe reintegration of previously infected individuals into the general population.

Diana recalled her son’s anxiety when over 1,000 COVID-19 cases were reported at FSP in October. 

“He felt like he was living in a Petri dish.”

His encounter with COVID-19 likely began in a visitation room that had been converted to a holding area for quarantine purposes. In the absence of strong testing protocols, the makeshift lockdown unit had unknowingly become home to a mix of healthy and infected individuals. He spent two days in this isolation unit, among roughly 30 individuals, before testing positive.

Upon testing positive, Diana’s son was assigned to one of many blue tents erected in the prison’s yard to isolate sick members of the population. For two weeks, he and three others occupying the tent battled an array of symptoms, while receiving minimal medical attention.  

“When he was sick with COVID, all they gave him was Tylenol,” Diana added.

Once his symptoms subsided, he was relocated to his original cell for three days before being transported to Delano for a scheduled court appearance. He was not tested prior to his transportation, relocation or reintegration into the general healthy population.

“When they took him to court you would think they would have tested him to make sure he wasn’t still infected, and he said that they didn’t have it until they brought people in from another prison and building, it was like trying to infect everyone to achieve herd immunity,” Diana recalled. 

While her son’s COVID diagnosis was likely the result of his two-day tenure in the converted visitation room, Diana pointed to a general lack of safety protocols that puts every member of FSP’s population at risk of contracting the deadly virus. 

“When he used the phone, they were making him clean it with a dirty cloth, so cross contamination was happening,” Diane explained. 

Her son’s removal from the infected blue tents without a negative test was also not a one-off event. “When they are moving the sick, they would expose them to the healthy when they could’ve quarantined people separately.” 

Diana’s concerns are identical to those of many incarcerated persons highlighted by the Vanguard. The lack of communication by CDCR officials has left many in the dark about the status of their loved ones. Flaws in safety protocols have fostered anxiety and general uncertainty among family members.

“It was a lot of stress not knowing how sick he was or if he was dying,” Diane concluded. “This has been so hard for me.”

CDCR Confirmed COVID-19 Cases and Outcomes

As of Nov. 20, there are a total of 18,159 confirmed COVID-19 cases in the CDCR system – 1,742 of them emerged in the last two weeks. 11 percent of the cases are active in custody while 2.5 percent have been released while active. Roughly 85 percent of all confirmed cases have been resolved.

There have been 83 deaths across CDCR. 31 incarcerated persons are currently receiving medical care at outside health care facilities across the state

On Nov. 17, an incarcerated person from High Desert State Prison (HDSP) died from what appears to be complications of COVID-19. This is the first COVID-related death at HDSP.

CDCR officials have withheld the individual’s identity, citing medical privacy issues.

Cases at High Desert State Prison (HDSP) in Susanville continue to rise, as they report 167 cases this week.

“We are meeting with HDSP leadership on a daily basis at this point in the outbreak to ensure they have adequate resources and are following COVID-19 response guidelines,” said Elizabeth Gransee, the deputy director, Healthcare Communications for CDCR.

“Additionally, local institution leadership is in frequent communications with Lassen County Public Health to ensure we are coordinating with the community. We will continue to provide necessary support to help get HDSP through this outbreak with as little impact as possible to the institution population, staff and community.”

After months of zero cases, on Nov. 2, a second incarcerated individual and four staff members tested positive for COVID-19 at Pelican Bay State Prison (PBSP). A third incarcerated person also tested positive on Nov. 3.

CDCR Spokesperson Terri Hardy said PBSP follows CDCR’s Patient Movement Matrix when testing for COVID-19. 

“This includes housing inmates who have returned from an outside appointment for 14 days in quarantine. While in quarantine, incarcerated people are screened and tested multiple times,” said Hardy. “If they test positive, they are placed in isolation and contact tracing is initiated by CDCR nursing staff. If an inmate in quarantine continues to test negative, they are returned to the inmate population after 14 days.”

According to Hardy, PBSP staff are tested biweekly. 61 staff members have now tested positive for coronavirus, 40 members have returned to work after self-quarantine and 21 cases are still active. 

None of the cases have required hospitalization.

“I don’t foresee this becoming a big outbreak. The CDCR and CDPH are aware of the situation,” said Del Norte County Health Officer Dr. Warren Rehwaldt. “The experience in other prisons including San Quentin have driven the response activity for all the prisons in the system. So I think it is a very different operational picture than it was 3 or 4 months ago.”

Supervisor Roger Gitlin noted that all three new cases there were transferees. Rehwaldt clarified that one of the confirmed cases was a medical return while the other two are still being confirmed where they were transferred from.

“I think it is important for the public to know Pelican Bay has and continues to remain safe through extremely strict protocol by Warden (James) Robinson. I’m proud to say of the job he has done keeping that institution COVID free,” said Gitlin. “These three were transferees. We’ve all heard the information that transferees from San Quentin was definitely a problem spot among the COVID and the warden has indicated they expect some increase in healthy population transferred to the other 34 populations around the state.”

On Nov. 19, CDCR and CCHCS issued an updated guidance to staff regarding facial coverings and physical distancing in the Authorized Facial Coverings For All Employees, Contractors Entering CDCR Institutions And DJJ Youth Facilities memo.

The memorandum, which is effective Nov. 23, requires all employees, contractors, and visitors working, visiting or performing duties at a CDCR institution or DJJ facility, indoors and outdoors to wear a procedure mask at all times, except when eating/drinking or being in a closed room with no other individuals present.

The memo also highlights that the incarcerated population will continue to use cloth facial coverings made and maintaining physical distancing, according to California Prison Industry Authority standards. 

In the past two weeks Substance Abuse Treatment Facility (SATF) has tested the most, 78 percent of its population.

Kern Valley State Prison (KVSP) has tested the least, just 6 percent of its population.

There are currently 97,891 incarcerated persons in California’s prisons – a reduction of 24,518 since March 2020, when the prison outbreaks first began.

CDCR Staff

There have been at least 4,915 cases of COVID-19 reported among prison staff. 10 staff members have died while 4,208 have returned to work. 707 cases are still active.

CDCR Comparisons – California and the US

According to the Marshall Project, California prisons rank third in the country for the highest number of confirmed cases, following Texas and Federal prisons. California makes up 9% of total cases among incarcerated people and 5.7% of the total deaths in prison.

California also makes up 9.8% of total cases and 10% of total deaths among prison staff.

Division of Juvenile Justice

As of Nov. 20, there is one active case of COVID-19 among youth at the Division of Juvenile Justice facilities. 70 cases have been resolved.

COVID-19 Outbreak Preparedness and Management Toolkit

Established in August 2020 by the California Correctional Health Care Services (CCHCS), the COVID-19 Outbreak Preparedness and Management Toolkit provides guidelines for correctional institutions to prevent/handle COVID-19 outbreaks. It also includes multiple checklists for institutions to utilize in three domains: Primary Prevention, Outbreaks, and Outbreak Identification and Management. 

CCHCS has created instructions for correctional institutions to follow if they are experiencing an outbreak or trying to prevent an outbreak. Many of these guidelines are well-known to the public (i.e. face coverings, social distancing, frequent surface cleaning/disinfecting, etc.) as they are pertinent to reduce and slow the spread of COVID-19.

Within the Primary Prevention Checklist and guidelines, CCHCS is encouraging the education of basic COVID-19 regulations towards staff, patients and volunteers/visitors in order to prevent any virus spread. The regulations adhere to staff and patients wearing face coverings at all times. 

Staff are recommended to consider their institution’s layout to understand airflow and ventilation within buildings and cell/housing units as well as minimize movements of patients, inmates, staff, and volunteers/visitors as much as possible. Social distancing is highly encouraged by decreasing the incarcerated population.

In terms of cleaning practices, patients who test positive must be given cleaning supplies, hand sanitizer, soap, toilet paper, etc. Frequently touched surfaces, shared equipment, showers and common areas need to be cleaned often.

If an institution is experiencing an outbreak, CCHCS recommends that it continues Primary Prevention efforts along with mapping out an incident command plan. This planning should involve communication among staff, nearby hospitals, hospital providers and patients’ families. CCHCS recommends preparing staff as well as making efforts to inventory stock and procure supplies in advance. 

Supply shortages should be anticipated so institutions must plan accordingly, substitute, adapt, conserve and reuse what they can. In addition, institutions should identify vulnerable populations to see which patients are at higher risk of complications and death.

During an outbreak, institutions are expected to take immediate steps towards identifying other possible positive cases and manage accordingly. Contract tracing is very crucial to control any further spread in addition to testing to identify symptomatic and asymptomatic individuals.

Facilities are encouraged to consider lessons learned from past outbreaks across CDCR. These include – minimizing movements immediately by screening individuals entering buildings, separating symptomatic from asymptomatic cases when possible, testing before and after movement, extensive PPE training and educating patients about positive/negative test results.

Correctional institutions in California are asked to adhere to these guidelines in order to prevent the outbreak and spread of COVID-19.


About The Author

The Covid In-Custody Project partners with the Davis Vanguard to report on the pandemic's impact on California's county jails and state prisons. See for more information.

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