Looking Back at COVID in Sac County Jails – How Staff Violated Official Protocol

This report is written by the Covid In-Custody Project — an independent journalism project that partners with the Davis Vanguard to bring reporting on the pandemic in California’s county jails and Department of Corrections and Rehabilitation (CDCR) to the public eye. Refer to our website to view and download the raw data.

By Minerva Melendrez 

SACRAMENTO, CA – Incarcerated populations across the United States have been disproportionately impacted by COVID-19 due to overcrowded correctional settings, poor healthcare and negligence by jail staff. 

In Sacramento County, an analysis of court expert reports, data and incarcerated narratives from the Main Jail and Rio Cosumnes Correctional Center (RCCC) obtained during the past year, suggest that the jail administration and staff have failed to uphold a high standard of COVID-19 mitigation strategies.

The COVID-19 protocol laid out by the Dept. of Health Services provides jail staff with guidelines on sanitation practices, quarantine requirements, medical care and virus-related data documentation. Its implementation, however, raises significant concerns. 

As of June 30, 2021, there have been 1,816 cumulative confirmed cases in the incarcerated population and 2 active cases in custody. Currently, there are 3,056 people in custody across both facilities.

The COVID-19 response in Sacramento County jails is in many ways intertwined with the consent decree entered by a federal court in Mays v. County of Sacramento— a class-action lawsuit filed in July 2018 alleging “dangerous solitary confinement conditions, failures to provide mental health and medical care, and disability discrimination” at both jails. The court-ordered remedial plan in the lawsuit has been a primary tool to ensure that the jails meet the minimum legal standard necessary to avoid suffering, injury or death.

Mays has been referred to often throughout the pandemic, serving as a reminder of the agreement that Disability Rights California and the Prison Law Office reached with the County to settle the lawsuit on alleged deficiencies in the jail’s mental health and medical care systems, overuse and misuse of  solitary confinement, and poor treatment of people with disabilities. 

For example, in May 2020, just several weeks into the COVID-19 pandemic, the plaintiffs filed a Notice of Dispute expressing concern over the failure of jail custody to wear facial coverings and the denial of showers to incarcerated people in quarantine units, arguing that it “created deficiencies that hasten the risk of mass transmission.” With a threat of court enforcement, the County agreed to stipulate to a court order that mandated face coverings for jail staff and additional showers to those in quarantine. 

Although Mays legally advocates for improved health care and safer conditions of confinement, there are conflicts between official guidelines or court orders and staff behavior. One concern highlighted by many incarcerated people and their loved ones is the lack of adequate medical care.

In an interview with the Sacramento Bee, Jasmine McFadden-Stevens alleges that her late husband, William Stevens, passed away in Feb. 2021 after not receiving medical attention while battling COVID-19. 

William had been housed in the Main Jail since Dec. 2020, and contracted the virus in Jan. 2021. His wife alleges that before testing positive, he was placed in the same unit as a COVID-positive patient. After getting tested for COVID-19, jail staff withheld William’s test results despite making at least ten requests to view them. His medical help requests were similarly ignored.

Jasmine revealed her husband was held in his cell for long periods of time, food was put on the floor to avoid physical contact and he was not allowed to shower more than twice a week. One month after he passed away, the coroner had still not determined the cause of death.

In early 2021, multiple loved ones of incarcerated people reached out to the Covid In-Custody Project alleging similar negligence by jail staff.

“He is not receiving care… He is on the verge of dying,” said a mother whose son with severe underlying medical conditions had contracted the virus.

“My brother tested positive for COVID after they placed positive inmates back into the population and refused to test symptomatic inmates. Once my brother tested positive they locked him in his cell with absolutely nothing. No medication to combat symptoms, they did not test oxygen levels nor did they even bother to check on him for days,” another woman said.

According to the Dept. of Health Services, a registered nurse must notify incarcerated individuals of positive and negative test results. Further, nurses must complete regular health checks such as symptom screening, temperature checks and oxygen checks.  

Needless to say, the reported experiences of people in custody and their families suggest significant problems with the implementation of the official health protocol. 

William and other incarcerated people faced these grim circumstances amidst a massive COVID-19 outbreak during Dec. 2020 to Feb. 2021— the first mass outbreak in the Sacramento Jails reported during the pandemic. Notably, botched transfer procedures between the Main Jail and RCCC very likely contributed to widespread COVID-19 transmission across the jail system. 

In a statement about the outbreak, the Sheriff’s Office revealed, “On 12/30/20 staff confirmed 55 recently transferred inmates tested positive for COVID-19. These inmates were transferred from Main Jail to the RCCC. Two other transports occurred during this period, tests were completed and confirmed. Contact tracing resulted in large-scale testing and confirmed positive inmates at the RCCC and Main Jail.”

Several days later, Rodney Grassmann, a Sheriff’s Office spokesman told the Sacramento Bee, “All transferred inmates were asymptomatic prior to transfer…so the assertion that the transfers came with COVID is unknown as the symptoms began several days after transfer,” apparently walking back any connection between the transfers and the outbreaks despite growing evidence to the contrary. 

During this time, the RCCC reported a 200 percent increase in active cases. Cases subsequently tripled at the Main Jail. What is clear is that the inter-facility transfer protocols were insufficient, or at a minimum insufficiently adhered to, and very likely contributed to the proliferation of COVID-19 that occurred. 

As of today, the outbreak has subsided, but the question remains– how could an outbreak occur if the protocol had been thoroughly followed?

Particularly, the protocol demands that all individuals being transferred are screened twice; once before the actual transfer and once after having arrived at the new facility. Furthermore, negative testing is required prior to facilitating the transfer and incarcerated people suspected to have coronavirus are not to be transferred at all. 

Even then, all transferred individuals must be placed in intake quarantine for ten days, with the RCCC specifically requiring fourteen days of isolation. Once integrated into the new facility, a receipt of the completed health screening must be provided no more than twenty-four hours after the arrival. 

When the Covid In-Custody Project brought concerns about these issues to the Sheriff’s Office’s attention, the Media Officer became sympathetic to the staff’s efforts, stating “in retrospect, the staff managed the COVID-19 operations in the jail facilities extremely well from March 2020 – December 2020.  Unfortunately, despite protocols, when an outbreak occurs, it spreads extremely rapidly within the jails.” 

Under the settlement in Mays, the County agreed to a Consent Decree by which health care experts would evaluate jail conditions through a series of visits and make recommendations to the jail administration on how to address any deficiencies. Court-appointed medical care expert, Madeleine L. LaMarre, submitted the First Medical Care Monitoring Report in Jan. 2021. During an on-site visit, she noticed staff failed to monitor patients in quarantine for COVID-19 symptoms and did not adhere to contact tracing guidelines.

She noted that “in early December 2020, a patient tested positive for COVID-19 on the same day he was transferred to CDCR. He transferred back to the jail the following day, but there was no documentation that staff were aware that he had tested positive or any contact tracing measures taken as a result of the transfer.” Again, this violates official protocol which states that all COVID-related processes and care must be recorded by nurses, and that close contact quarantine placement must be documented. 

Another issue is the lack of transparency on COVID-19 data for the incarcerated population and jail staff.

The Covid In-Custody Project has submitted multiple Public Records Act requests for data on the number of recovered patients in custody and patients released while positive. These data points are critical to understanding the level of immunity within the jail population, and the risk in-custody infections pose to the Sacramento County community at-large, respectively. 

While the protocol states that “nursing staff must document all processes… including placement, releases… discharge planning,” implying that resolved and released cases must be recorded, the Media Officer asserts that the data exists in individual patient records and no aggregate “statistics are kept on these indicators.”

For jail staff, no data has been disclosed regarding COVID-19 testing and positivity rates. 

The Sheriff’s Office has reported that 417 custody and healthcare staff have been fully vaccinated thus far. However, they have not provided the total number of staff who enter the jail’s premises, making it impossible to determine the degree of immunity among them.

Additionally, for staff who are asymptomatic, testing is not required but rather “highly recommended” according to the protocol. The Dept. of Health Services no longer requires custody staff to complete screenings before beginning work. This is despite numerous medical reports showing that infections among correctional officers are primary vectors for outbreaks in jails and prisons.

In Alameda County’s Santa Rita Jail, an asymptomatic deputy was identified as a possible vector that triggered a massive outbreak in Dec. 2020. The Alameda County Public Health Dept. subsequently issued a mandatory testing order for jail staff in March 2021. Bi-weekly testing is also mandatory for jail staff in Santa Clara and San Francisco counties. Sacramento County has not discussed or adopted similar guidance. 

The protocol even provides jail staff the opportunity to return to work if they are symptomatic and have not been tested. Although testing is highly recommended, clearance for return only requires that “at least 10 days have passed since symptoms first appeared; and at least 24 hours have passed since last fever without the use of fever-reducing medications; and symptoms (e.g. cough, shortness of breath) have improved.” 

Staff who are considered to be asymptomatic and untested, which the protocol defines as “workers who had close contact to a laboratory-confirmed case patient at work, home, or in the community and do not have symptoms, or workers who refuse or are unable to be tested after close contact”, can return to work upon completing a 14-day at-home quarantine. Furthermore, if untested, the LHD considers allowing a worker who had close contact to a confirmed case to continue to work on the grounds that there is a staffing shortage*.

Health care staff shortages at the jail have been a longstanding problem, leading to a situation during the pandemic in which jail leadership face a Hobson’s choice of staffing the jail with health care workers who may have COVID-19 or going without the necessary staff to provide day-to-day care to people in custody.

While Mays has served as a foundation for holding the jail system accountable during the pandemic, there are also limits to what courtroom advocacy can accomplish.

Aaron Fischer, one of the attorneys for the plaintiffs in the federal Mays case, described how his team was able to successfully advocate for a mandatory masking order for jail staff, an increase in access to showers for incarcerated people in quarantine units, and expedited rollout of vaccinations for people incarcerated at the jail. After Fischer and his team threatened legal action on the issue of vaccinating the jail population, the County issued a plan to offer COVID-19 vaccination to all incarcerated people in February 2021.

Yet overcrowding in jails also plays a critical role in spreading the virus, but many courts have been reluctant to order jail population reductions in the name of COVID-19 mitigation. Sacramento County’s Public Defender’s office sought such population reduction orders, including before the California Supreme Court, without success. 

Noticing discrepancies between the Sheriff’s Office’s COVID-19 protocol and testimonies from incarcerated individuals, activists from Decarcerate Sacramento took to criticizing the jail’s response at a Public Health Advisory Board (PHAB) meeting in March 2021.

Some compared confinement to being treated like an animal. One individual disclosed that in many instances, no testing was offered, no social distancing was enforced, no cleaning supplies were provided, and many individuals were exposed to others who were not a part of their housing unit. Another individual expressed that her loved one underwent a great deal of suffering after someone who was exhibiting a high fever and COVID-related symptoms had been placed in the same pod. 

Following these reports of protocol violations by jail staff, the PHAB decided to draft a letter to the Board of Supervisors urging them to take action on the “direct conflict” between protocol and testimonies from affected community members. In April, PHAB members dedicated their monthly meeting to discuss the draft and the jail’s efforts towards compliance with the Mays consent decree. 

Specifically, Farla Kaufman, Chair of PHAB, emphasized PHAB’s role in advising the Board of Supervisors and highlighted that sending the letter requires that board members vote on a final decision on whether or not to send it. Most of the board members were largely neutral to whether there was negligence at the jail. 

Kaufman contended the jail’s COVID-19 response is a “complex issue with a lot of moving parts and a lot of players.” She acknowledged the efforts the jail had been making so far in moving forward to satisfy the stipulations of the consent decree but ultimately stated that protocol implementation was difficult given the prior state of the jails. She argued that the facilities’ conditions act as a barrier to accomplishing full compliance, as “hundreds of changes are needed” to implement the provisions of the consent decree. 

Also maintaining a neutral stance, board member Libby called attention to the fact that the PHAB was being presented with two sides of the story, as “comments from the public and Decarcerate paint one picture of the situation while comments from County seem to counter that and show another side of the story.” She concluded that the best place for PHAB is to conduct monitoring and oversight to understand what is actually happening.  

Representing the jail’s perspective of the situation, Sandy Damiano, Adult Correctional Health Director for Sacramento County, asserted that “it’s going to be a multi-year plan to implement changes” required by the Mays consent decree, noting that a major culture change is needed that requires training and retraining staff who have been in the facilities for years. 

Damiano stressed that the jail’s COVID-19 response has been an evolving process that has forced staff to be in a constant state of revision and change. She noted that her team had made about 15 to 26 revisions to the protocols thus far, as they try to adapt to changing circumstances, knowledge about the pandemic, and vaccine availability. 

She admitted that at the beginning of the pandemic, testing and informing incarcerated people of their test results was not always occurring, but now staff are doing so.

Damiano also stated that jail staff and the Mays plaintiffs counsel are constantly in dialogue to discuss concerns, promoting a high degree of monitoring. Part of this monitoring includes having the court-appointed medical experts come on-site to review the facilities, the implementation of COVID-19 protocol, and abidance to the consent decree’s remedial plan. Damiano assured that she provides the outside experts and the Mays plaintiffs’ counsel access to the jails’ policies and procedures and electronic medical records. 

“I don’t want to diminish anyone’s experience from what they have had in the jails, nor do I want to discredit what they are reporting has happened with COVID because, I have said, the process with COVID has changed over time tremendously,” Damiano emphasized. She concluded that overall, it has been challenging to monitor coronavirus in the correctional setting since the jails are ultimately not built to be health facilities. Her hope for mitigation lies with vaccination rollout, which would work to prevent future outbreaks from occurring. 

The PHAB ultimately decided to table the letter and arrange a special meeting at a later point to continue the deliberations.

Nevertheless, their discussion raises the evergreen question of accountability and oversight for the Sheriff’s Office— who enforces the COVID-19 protocol on law enforcement besides law enforcement itself?

Attorney Fischer explained that court orders such as the masking mandate for staff, access to showers during quarantine, and vaccination of the incarcerated population do not come easily. It first requires that legal counsel, the Sheriff’s Office, and Healthcare leadership be in constant contact to discuss areas where there has been progress and where further improvement is needed. Fischer and his team are in regular contact with their clients inside the jails to learn first-hand the experiences and concerns of those impacted by detention conditions. Through this dialogue, they have the opportunity to build an evidentiary record of where standards in the consent decree are not being met, and if the jails fail to implement the remedial plan resulting in ongoing legal and constitutional violations, then a court order enforcing the consent decree could follow. 

Fischer explained that federal court enforcement generally does not involve disciplining individual staff members but ensuring that the system has adequate policies, supervision, and accountability procedures so that staff take the steps necessary to safeguard the rights of people in custody. 

However, for guidance in the official COVID-19 protocols that is not court ordered, there is little to no recourse if jail staff do not adhere to it. This ultimately leaves the Sheriff’s Office to enforce its own policies, with limited transparency and public accountability.  

Similar to other California counties, Sacramento has a long way to travel in terms of its COVID-19 protocol, implementation and data transparency. There is still much work to be done before reaching compliance to the Mays consent decree’s requirements; nevertheless, reflecting on some of the mandates that have been implemented thus far provides hope that progress is slowly being made. 

Although no correctional department exists as an ideal model due to fundamental flaws in the criminal justice system, there is still something that can be learned from other departments across our nation. By relaying tactics for improvement, Sacramento may be able to close the gap between what they state they intend to do and what is actually being done.


*The protocol states, “if testing has not occurred, the LHD may consider allowing a worker who had close contact to a confirmed case to continue to work only in a critical infrastructure industry in which the essential operations of the workplace would be compromised by quarantine of the worker and no alternate staff can perform the same role.” 

COVID-19 staff protocol references

  1. Masking policy
    1. Staff are required to wear a mask at all times in non-patient care areas. The protocol continues to say that an acceptable alternative to masking is if > 6 feet social distancing is maintained or an employee disinfects a workspace before use by another employee. County Pharmacists are given further instruction to “label masks and continue use of one mask until the mask no longer stays in place or becomes dirty” (Sacramento County, 2021).
  2. Social distancing policy 
    1. Social distance of at least six feet should be maintained unless providing direct patient care
  3. Inmate moving restrictions 
    1. The movement of inmates is restricted at all possible times. Inmates who exhibit Covid-19 symptoms may not be seen in their floor’s clinic exam room and should be transferred to COVID housing.
  4. Intake screening
    1. Arresting officers are required to both wear a mask and mask their arrestees. Anyone not given a mask by their arresting officer will be provided one by the Sacramento Sheriff’s Office. 
    2. Health care staff, wearing PPE, will do an intake assessment to screen for Covid-19 symptoms Anyone deemed UNFIT by temperature will be isolated and placed in COVID suspect isolation housing. Staff will disinfect areas where the isolated patient was placed.
  5. COVID housing populations
    1. COVID houses patients can only be released from isolation by order of physicians designated by the Medical Director
    2. Inmates are sorted into cohorts and cohorts are not allowed to mix with each other
    3. Sufficient hygienic supplies are provided
  6. Documentation
    1. Nurses are required to screen all new arrestees for COVID and notify SRNs via EHR of the condition of each patient
    2. RN’s will additionally notify patients of negative results. Positive results will be notified by providers via COVID Care Note. COVID care notes are used to document care provided in COVID housing
    3. Consent forms are required to release specific health information to the patient’s family, attorney, or others. Health staff and custody may share information to each other regarding suspected Covid-19 cases.
  7. Contact tracing
    1. Contact tracing is necessary for any inmate or staff exposed to a person who has tested positive within five days. SSO will create a full-contact tracing list for each positive COVID patient. SRNS will complete contact tracing for medical staff. 
  8. Potential outbreak
    1. The Infection Control Coordinator is the primary liaison between the County Jail and Public Health. In an outbreak, notifications are made and the ICC communicates past and future actions to Public Health.
  9. Education
    1. Medical and MH staff are required to provide inmate education regarding COVID guidelines for prevention. Staff is not allowed to provide personal opinions regarding Covid-19 procedures and transmission.
  10. Medical care 
    1. Inmates in COVID housing are not permitted to transport unless required for emergency or for medical care not available in inmate cells.
    2. RNs are required to complete health checks in COVID housing, with frequency relying on COVID status.
    3. Patients are required to be masked at all times
  11. Release of quarantine 
    1. Those being released from 10-day intake quarantine must be confirmed negative with no signs of COVID and complete documentation in the COVID Care Notes. IP team members will notify SSO staff of 11th-day releases.
    2. Those being released from 14-day close contact quarantine must be confirmed negative with no signs of COVID and complete documentation in the COVID Care Notes. IP team members will notify SSO staff of 15th-day releases.
    3. Those being released from COVID isolation housing must be appropriately documented by the Provider, following they meet the criteria for release at scheduled MD visit. They must also notify SSO and ACH staff of releases. Nurses will oversee the release from isolation housing.
  12. Transfer 
    1. Hospital transfers must have RN completed intake assessment prior to placement in housing unit. New/ in-custody patients must enter 10-day intake quarantine. Returning patients from inpatient hospitals do not need to be placed in isolation, following a negative covid test. Patients needing medical monitoring or with diagnosed COVID returning from a hospital should be placed in designated housing. 
    2. Jail Facility transfers must be screened for COVID-19 prior to their transfer. Suspected cases should not be transferred. Outer-agency transfers must also be screened prior to entrance. Suspected cases should not be accepted. Transfers for MJ to RCCC will be housed in intake quarantine for 14 days.
    3. Drug Residential Treatment transfers should have COVID test results sent to the outbound program and SRN will plan discharge.
    4. State Hospital/Prison, Other County Jail Facility, and Federal Prison transfers are required to have negative tests prior to transfer. SSO will not accept any transfers that require COVID isolation housing. All incoming transfers placed in intake quarantine for 10 days.


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 www.covidincustody.org for more information.

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