Inspection report rips SLO County Jail’s treatment of mentally ill inmates

February 7, 2017
Sheriff Ian Parkinson

Sheriff Ian Parkinson


Editor’s Note: This is part two in a two-part series about San Luis Obispo County health services and sheriff department’s treatment of the mentally ill. Part one looked into several suspicious deaths and one injury that occurred in 2017.

Following the deaths of three jail inmates in less than a year, in late 2014 San Luis Obispo County hired inspectors from the Institute for Medical Quality to look into the jail’s compliance with Title 15. The inspection found numerous problems in inmate treatment, according to an inspector’s 2015 report acquired by CalCoastNews.

Nevertheless, most of the deficiencies continue to this day.

State law requires California jails to submit a health inspection report every two years to the state and to provide the county board of supervisors copies of the report. However, it appears the SLO County Board of Supervisors was not provided the 2015 report.

Inspectors determined that the county had failed to comply with state requirements regarding adequate staffing, policies and procedures and the proper use of restraints and rubber rooms. While the county appears to be ignoring state policies and procedures in an attempt to cut expenses, inmates have died and suffered, at least, physical traumas.

The San Luis Obispo County Jail is run by Sheriff Ian Parkinson and houses about 600 inmates per day. The county health department, led by Jeff Hamm, is charged with the medical and mental health care of the inmates.

Under Hamm’s leadership, the county mental health facility on Johnson Avenue has refused to admit more than a few mentally ill transfers from the jail at a time. As a result, inmates who have been ordered by a court into a mental health facility often languish for weeks or months in jail.

Because the county has failed to transfer mentally ill people, including some who have had their charges dropped but still remain in jail, the county is out of compliance with Title 15, according to the report.

The health department has said repeatedly that it adopted a policy of not transferring mentally ill inmates because of licensing issues. But, in Hamm’s response to the report, he said there was not a licensing issue and that the county mental health facility would begin treating more than just a few mentally ill inmates at a time.Jail bars

“It was an oversight that has been corrected,” Hamm wrote in a Dec. 5 email.

A review of records of several people in the jail awaiting transfer to the county mental health facility shows otherwise. Even though the county mental health facility is rarely at capacity, county staffers continue to use force, rubber rooms and jail cells as an alternative to treatment, according to county sources and the inspector’s report.

The failure to properly staff the jail is another bone of contention. While the inspectors and many county staffers report the jail’s medical and mental health staffing precludes giving adequate care, Hamm claims the jail is now and has been properly staffed.

Nevertheless, Public Health Director Penny Borenstein told jail medical staff at an April 19, 2016 staff meeting that the county has not properly staffed medical personnel at the jail for a decade, according to the minutes of the meeting.

“We have not been fully staffed over the last 10 years,” Borenstein said. “The leadership team is working very hard to hire enough staff to cover all the shifts and fill the vacancies.”

Inspectors asked the jail to stop the practice of having deputies, who lack medical training, do medical screenings of inmates. The county responded by announcing plans to create a position for a nurse to work in intake, according to the report.

But, after several months, the health department stopped the practice of positioning a nurse in intake, sources said.

In addition, inspectors determined that medical staffing levels at the jail were “insufficient to meet the workload.” At times, the jail has only one nurse on staff whose duties include handing out about 1,487 daily prescriptions. As a result, the county has “potential associated litigious risk issues,” the report read.

“The workload capacity of meeting the needs of the inmate medication administration program as it currently exists is prohibitive,” according to the report. “By enhancing the registered nurse full time equivalent, it removes the risk potential.”

The inspectors also found that deputies were confining mentally ill inmates in safety cells for a week or longer “which borders on using the safety cell as a substitute for treatment.” Safety cells are small concrete cells with rubber padding, no bedding and a hole in the floor for human waste.

If an inmate is still a danger to himself or others after spending three days in the cell, the inmate is transported to the county mental health facility, Hamm said.

“If after 72 hours an inmate still presents as a danger to self or others, or is gravely disabled, a team including a lieutenant and health and psychiatric staff determine if the inmate may be safely rehoused,” Hamm wrote in an email. “If the inmate is still at risk, they are referred to the psychiatric health facility.”

However, in the month before his death, 36-year-old Andrew Holland was held naked in a security cell for several weeks. On Jan. 20, Holland was stripped down and confined to the drunk tank for two days, sources who asked not to be identified because of fear of retribution said. Holland died on Jan. 22.

The jail also violates regulations because of correctional staffs failures to follow policies and procedures in their use of restraints, such as a restraint chair. According to the report, deputies have failed to document reasons for keeping inmates restrained longer than two hours and have failed to get a mental health consultation within eight hours of placement in restraints. That violates Title 15.

Throughout the report, inspectors requested that custody, mental health and environmental health staffers put policies in place regarding safety cells and the use of restraints. The county health department noted that it is working on updating its policies and procedures.

Sheriff’s spokesman Tony Cipolla said that policies and procedures are the responsibility of the county health department and not the sheriff’s department.

During the past three years, there has been a string of deaths at the county jail. From Jan. 2014 through Feb. 2017, eight people have died in county jail custody, primarily because of medical issues.

In the majority of those deaths, county staffers allegedly failed to provide medical assistance, check on inmates as required by department policy or protect inmates from abuse or neglect.


This story is not about Parkinson. The culprit here is Jeff Hamm. The new three-vote majority on the county supervisors pledged that they were going to come in and “clean house.” Fine. May I suggest they start by booting Hamm? He is incompetent, intent only on playing CYA as much as possible.

But I predict they’ll make Borenstein the scapegoat and she’ll get the axe.

This story is an outrage, but is anyone surprised?


Seriously PolyProf ?

This story is about Parkinson too. He is every bit as culpable as Hamm. At this point it is CYA and let the finger pointing begin.

NO SMOKESCREENS and NO FREE RIDES. The public deserves better !!!


Don’t let DA Dow get involved, it will take forever and if anything does come of it it will be a slap on the wrist with no real consequences. We know well how DA Dow takes care of the special people, Alex Geiger will suffer at a max 3 years 8 months for being responsible for killing someone. We don’t need anymore of DA Dow’s handling of investigations into the protected class.


What about M Daisy Ilano, MD?


Daisy Ilano has flown under the radar for many years. She is the QUEEN of passing things on. She is as useless as the day is long. She has ZERO integrity and will lie at the drop of a dime. Anything to cover her own ass. Having been around for a number of years I have been surprised her name did not come up more often. She double dips. Shows up for work at the county and also does phone consultations with her clients from her private practice in the valley where she is from. She is in charge of hiring doctors over at mental health. When a PROFESSIONAL in the medical field (doctor) are hired at MH if they are any good they leave running! The place is a MESS as far as adequate care from doctors, nurses etc…..they see the “system” under Iilano and not walk away but RUN!!!!!!! Somebody need to do a little investigating and find out why mental health goes through SO MANY psychiatrists so quickly!


Excuse me anyone ever heard of M Daisy Ilano, MD? Hamms sidekick and Director of the Psychiatric Health Facility? (MD Director) ???


Yet they put out a full blown investigation under Hamm;s direction to find out who leaked what to the media? Yes,,,calling in employees in one by one. They do not care that they have killed a couple of people and spend time investigating just WHY these people are no longer with us and what they can do to better their treatment of patients. They prefer to know how their DIRTY practices got out.Is ANYONE listening? I hope the Holland;s have a hotrod attorney! I hope hey are able to take down those in CHARGE!


You can all attack Parkinson and blame him personally, or perhaps you could wait for a proper investigation into why the jail has been obviously underfunded. Lets not play the blame game just yet. As for the boat the Sheriff has, we have needed something like that in this county for a very long time. He is the first guy I have seen that is willing to put his neck on the line and bust up the panga boat crews that bring drugs into San Luis Obispo County and elswhere through our beaches. Shame on you all for attacking this man based on his courageous action and selflessness in the war against the drug cartels in our county! This guy puts his neck on the line to stop drug dealers from selling dangerous drugs to our children. I personally salute you Mr. Parkinson. You have my support and I am sure we will see at the end of the day that you are not the main reason for the inadequacy of funding to our jails.


Did I miss something? When did we get rid of the Coast Guard? Spending money for a boat so the Sheriff dept can do the job of the Coast Guard is wasteful. Duplicitous spending is a big issue. The Sheriff dept.does not need military equipment to knock down building or boats to fight drugs offshore.

That is not their role and allowing this kind of expansion is budget busting.

Even if this equipment was free, the cost to maintain the equipment and new programs to administer it add up.

I guess we need a radar array as well to make the boat useful on the water, otherwise they’re looking for a needle in a hay stack. That will be in the next budget request.

You want to coordinate with the Coast Guard great. You want to do their job and have us pay for it –not so great. We’ve paid for it once already.

It’s great that Ian wants to take it to the bad guys. But that doesn’t mean we should not look to see if money is being spent efficiently and wisely. In this case it is not. Spend it on mental health mitigation and let’s put an end to the needless deaths in the county jail.


Forgive me Fred, but we are not talking about Drug Cartels. Seems the protection of our Mentally ill should rave a lot higher on the ladder than running on the Beaches looking for Drugs.

Although I agree busting Panga Boats is a good thing. It just doesn’t compare to properly caring for those in his custody.

Kaiser Bill

Let me guess, Frederick1337 works for the Sheriff or has a family member that does. All the crap you posted about St Ian doesn’t cover up the fat that there was a major tragedy on the Sheriff’s hands.




I’ve said it before and I’ll say it again.

SLOSD is always in hot water.

I’d love to hear from all the people that were riding the Sheriff’s nuts last week praising them for all their “good work”.

Spend one day in the county jail and you will feel, see, and even taste the corruption.

San Louie

More and more I get the feeling that Parkinson is rather naive individual who really doesn’t pack the gear to be the Sheriff of San Luis Obispo County. Sad.


The response from Bert makes me wonder what the reaction would be if this was a local hospital not followig the law or policies and procedures and deaths were occuring due to their negligence.

A person is arrested and booked into county jail presumably becaue s/he broke a law. Our California jails and prisons are full of mentally ill inmates. The judicial and mental health “systems” have failed, and continue to fail, many individuals with mental ilness incuding lack of access to mental health care even for those with insurance. The men that have died while in the custody of our local jail/Sherrif’s Department are the sons, brothers, husbands, uncles or maybe even fathers to family who loved them. Not abiding by the law is not okay but I’m not going to sit on a throne and be juror and judge. It sounds to me like the deaths of these men were due to neglect and could possibly have been prevented. Shame on those responsiblle.


We should have elected Joe Cortez as Sheriff.

Jorge Estrada

Yes I did vote for Joe but Ian won and he is our Sheriff. I give him credit for being true to his form and available to the public. His outreach is good and breeds public support for the Sheriffs office, organizations thence the needed funding to handle the growing problems our desirable area / programs attract. I would rather read about the volunteers who help rather than the complaining,

Kaiser Bill

Who ares about outreach when the Sheriff can’t even operate a safe Jail?

Kaiser Bill

But SLO City had to have their native son and golden boy as Sheriff! Never mind the fact that Parkinson had never lead a Police Department and didn’t even have a College Degree.


Meanwhile Parkinson practices for the Phyllis Madonna review & fashion show …


He is also busy playing with his toy boat.


Just SICKENING! When does it all end and people are held accountable? Are we really that much of a “good ol boy” county?


Why would anyone vote that down? Dont want people held accountable? REALLY?


Thanks to CCN for putting the spotlight on all of the injustice. Just wishing we could do something about it or is it the same old thing? These people keep getting away with killing people?


And the suits will keep coming, with more teeth because of this report. The county or those working for the county won’t lose a dime, the citizens of the county will pay, per the usual.


And Sheriff Ian Parkinson will not be held responsible or have any real consequences. Have the taxpayers pay and pay and pay and have the government employees retire with a nice pension, it’s the government way, but at least Sheriff Parkinson was able to scare the county into giving him a nice panga boat, my suggestion Sherriff, time for you to sail off into the sunset.

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