San Quentin, Avenal State Prison Fined Over Medical Negligence; Office of Inspector General Releases Scathing Report of CDCR Transfers


Davis Vanguard’s weekly update from CDCR’s COVID-19 Crisis

CDCR Confirmed COVID-19 Cases and Outcomes

As of Feb. 6, there have been a total of 48,104 confirmed COVID-19 cases in the CDCR system – 1,606 of them emerged in the last two weeks. 1,784 cases are active in custody while 694 were released while active. Roughly 94 percent of confirmed cases were resolved.

There have been 199 deaths within the CDCR facilities. 55 incarcerated persons are currently receiving medical care at outside health care facilities across the state.

In the past week, seven incarcerated persons have reportedly died from complications related to COVID-19 at Valley State Prison, California Men’s Colony, California Training Facility, Mule Creek State Prison, CSP Solano and California Health Care Facility.

CDCR officials have withheld their identities citing medical privacy issues. 

As of Feb. 6, 45,145 individuals have received first-round vaccines statewide. 23,365 are staff and 21,780 are patients.

In the past two weeks, Substance Abuse Treatment Facility has tested the most– 50 percent of its population.

Kern Valley State Prison has tested the least– just 9 percent of its population.

There are currently 94,306 incarcerated persons in California’s prisons – a reduction of 28,103 since March 2020, when the prison outbreaks first began.

San Quentin

After multiple workplace safety violations that contributed to the spread of COVID-19, the Division of Occupational Safety and Health (Cal/OSHA) has issued a large penalty to San Quentin.

San Quentin faces a fine of  $421,880 stemming from a June inspection by regulators from Cal/OSHA.

A $39,600 penalty was also handed to Avenal State Prison for similar violations.

“Cal/OSHA determined that San Quentin staff were not provided adequate training or equipment for working with COVID-19 infected individuals, and employees who had been exposed to COVID-19 positive inmates were not provided proper medical services, including testing, contact tracing and referrals to physicians or other licensed health care professionals,” according to a division statement.

Meanwhile, Avenal failed to maintain an effective aerosol transmissible diseases control exposure program, had an inadequate written respiratory protection plan and did not implement or enforce work practice controls to minimize COVID-19 exposure among staff members, the statement said.

In response to the citation, CDCR released a statement.

“San Quentin has made many improvements and already remedied several of the citations in the eight months since Cal/OSHA visited the institution. The visits took place last June and July, and we have worked with Cal/OSHA representatives throughout the pandemic to ensure regulations were met and concerns addressed expeditiously,” the statement reads.

The Office of the Inspector General (OIG) issued a report on Monday, Feb. 1, stating that the transfers between CA Institution for Men to San Quentin and CSP Corcoran were, “deeply flawed and risked the health and lives of thousands of incarcerated persons and staff.” 

They state that CCHCS and CDCR caused a “public disaster” especially at San Quentin after they transferred medically vulnerable incarcerated individuals from CA Institution for Men “without taking the proper safeguards.”  

Since OIG is an independent oversight body, it can only make recommendations for CDCR. Ultimately, it is up to key stakeholders and lawmakers to decide how to handle the situation. 

There have been nearly 200 deaths across CDCR, a majority of which were reported at San Quentin. It has had over 2,200 confirmed cases and 28 deaths since May. 

CDCR and CCHCS gave a joint statement explaining that there were, “many factors that contributed to the need to move medically high-risk individuals from CIM last May that are not reflected in the report.” They added that transfers were done with the intent to mitigate harm and informed by a, “thoughtful risk analysis using scientific information available.” 

The statement also said, “We have acknowledged some mistakes were made in the process of these transfers, and both CCHCS and CDCR have made appropriate changes to patient movement since that time.”

The changes they are referring to include increased testing, designated isolation and quarantine spaces, as well as better PPE. CDCR pointed out that since they made these changes, no additional outbreaks have occurred. 

However, OIG investigators suggest that CDCR insisted they had to meet a tight deadline to complete transfers from CIM to San Quentin and CSP Corcoran even though the majority had not been tested beforehand. 

Text from email conversations show that a healthcare executive from CIM, “explicitly ordered that the incarcerated persons not be retested the day before the transfers began.” OIG investigators found that with outdated test results, facilities had no way of knowing whether any of the transferees were carrying coronavirus. 

Although healthcare staff conducted verbal and temperature screenings on those being transferred, they were conducted too early in the transfer process. Authorities even packed the buses, leaving no room for social distancing. 

Prior to the outbreak at San Quentin, nurses immediately noted that two people from CIM had the virus. However, it housed almost all of the transferees from CIM in a housing unit without solid doors allowing for the air to flow in and out of cells. 

COVID-19 spread quickly not only within the housing unit, but to multiple areas across the prison. 

OIG staff visited three facilities and interviewed officials and 56 incarcerated people while also observing the prison operations. Medical staff had warned CDCR officials in writing about the dangers of transfers and recommended they slow down, but CDCR went ahead anyway stating the benefits outweigh the risks. 

For Marin County Public Defender Kathleen Boyle and other lawyers, the OIG’s report is not surprising as they have sued the Attorney General and CDCR demanding the release of 300 incarcerated individuals from San Quentin, but unfortunately, nothing has changed. 

Majority of cells inside San Quentin remain open, without solid doors and poor ventilation. These cells house two people within a 4 feet by 9 feet area, making social distancing impossible.

Effect on Public

On Sunday, Jan. 31, more than 200 cars formed a caravan in Oakland near Middle Harbor Shoreline Park demanding Gov. Newsom authorize the immediate release of non-violent offenders from CDCR facilities. 

From Oakland, the car caravan crossed the Bay Bridge creating a massive traffic slowdown before the caravan exited into San Francisco. Courtney Morris, an organizer from the grassroots organization, No Justice Under Capitalism, states,  “Today’s action is very much a direct message to Governor Newsom…We demand that Governor Newsom grant mass releases to save lives, it is the only way to prevent more deaths, and we demand that he begin with the elderly incarcerated community and the immuno-compromised community.”

Lisa Strawn, an elderly and formerly incarcerated woman released in July 2020 due to COVID-19, explains, “Sure, they’ll sing to the tune of ‘you do the crime, you do the time,’ but here I am outside of prison, and I’m doing really good, I have a job that I really like and I have an opportunity to help others when they are released from prison…I’m going to be on the front lines.”

Ryan Brett, a former CDCR counselor for mental healthcare, believes, “It’s no secret that reduction of crowds reduces the spread of the virus but what about the mental health benefits of getting to be with your family? What about the economic benefits of getting treatment in the community versus in prison?”

Case Management Conference 

The Plata v. Newsom case continued last week with a conference discussing state vaccination efforts.

On the plus side, data shows that vaccination efforts have been successful among eligible subjects— COVID-naive patients over 65, those possessing a risk score above 3, and those with a risk score above six, have accepted the first dose of the vaccine at a rate of 90 percent, 90 percent, and 86 percent, respectively.

Overall, vaccine acceptance rate sits at 84% for the 8,349 first doses offered thus far.

As is evident, vaccines are being prioritized for those who have not yet contracted COVID-19. Healthcare personnel and frontline workers (in addition to the general populations at CMF and CHCF, skilled medical facilities) were first to receive the initial vaccine doses secured by CDCR, however, CCHCS has specified that a first-come-first-serve model will be adopted for employees seeking the vaccine going forward.

Prioritization is as follows:

  1. COVID naive patients 65+ at all CDCR institutions
  2. COVID naive patients who have weighted risk score of 6+
  3. COVID naive patients who have weighted risk score of 3+
  4. Remainder of the CDCR Population

Vaccine distribution to staff and incarcerated people is being overseen by the Vaccination Planning and Implementation Committee.

CCHCS’s current stance on mandated employee vaccination is indecisive. 

So far, staff refusal for testing has remained relatively low since CDCR implemented mandatory staff testing in December, with Central CA Women’s Facility leading with 29 refused tests. 

The topic then shifted to the longstanding issue surrounding release efforts. The Plaintiff’s counsel is requesting Gov. Newsom to grant additional medical reprieves and expand early-release criteria to include those facing indeterminate sentences. The Plaintiff additionally solicited the court to allow Secretary Kathleen Allison to reimplement the more lenient early-release program present from July to September during the virus’ devastating first wave. This request specified only a select number of institutions and not the CDCR system as a whole. 

CDCR’s expansion of early-release efforts was in many ways the product of reluctant compromise. In response to the Plaintiff’s motions, the defense counsel referenced declining prison population statistics as evidence of mitigation diligence. In addition to having decreased overall population by 22% since Feb. 26, 2020, CDCR cited accomplishments such as the 7,252 individuals released under the aforementioned July program, as well as additional medical releases for at-risk individuals. 

As of Jan. 20, 2021, CDCR’s population sits at approximately 89,933. Population decline can be attributed to both early release efforts and the suspension of intakes from County Jails. However, CDCR recently announced that prisons will be accepting new individuals from County Jails to the tune of 175 during the week of Jan. 18 and 370 during the week of Jan. 25, which may counteract current pursuits. 

CDCR Staff

There have been at least 15,453 cases of COVID-19 reported among prison staff. 25 staff members have died while 14,618 have returned to work. 835 are still active.

Recently, three staff members have died from COVID-19 at Valley State Prison, California Institution for Women and Calipatria State Prison.

CDCR Comparisons – California and the US

According to the Marshall Project, California prisons rank first in the country for the highest number of confirmed cases. Federal prisons follow closely behind while Texas ranks third. 

California makes up 12.7 percent of total cases among incarcerated people and 8 percent of the total deaths in prison.

California also makes up 15 percent of total cases and 13 percent of total deaths among prison staff.

Division of Juvenile Justice

As of Feb. 6, there are six active cases of COVID-19 among youth at the Division of Juvenile Justice facilities. 197 cases have been resolved since the first case was diagnosed in June.



By Julietta Bisharyan, Nick Gardner and Jaskiran Soomal 


About The Author

Aparna Komarla leads the Covid In-Custody project, which partners with the Davis Vanguard to bring reporting on the pandemic's impact on county jails and CDCR to the public eye. See for more information.

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