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.


The problem is that the need has outgrown the space and the current resources are outdated. . The MI population has increased but the two facilities that house them have not. We need a larger better staffed and more secure inpatient unit and probably a cell block specifically for MI added on to the jail. Yes it takes money and employees to staff them, but the time has come for expansion and state of the art resources. If we don’t dig into our pockets and do what necessary, people will continue to die, and then all our money will go to lawsuits.


Take away the Toads pension! Like he has a degree to explain his pay scale, doubt it! probably not a doctorate! Overpaid, underworked!


So the County as a whole should conscientiously object to grant money? And obtaining grants is an indication of poor performance…. still SMH

We agree that the off topic discussion was a distraction. The current jail is a dilapidated mess contributing to half the problem. Yes, I’ve been in there and not, as the speculation suggests, an employee. The other half is the Health Department shirking responsibility for mental health services – especially when dealing with law enforcement agencies. And I’m back to suggesting that the BOS has the responsibility for the lack of action on this issue. Both of those spoiled children work for us through them.


Slo turns down grant money for low income housing annually!! Lame gentrified city!

Jon Tatro

The mentally ill need to be housed until they are better. If you let them free they will kill you or themselves that is why they are called mentally ill. Yes it should be done humanely but they often make the difficult circumstances to help keep themselves safe.


Audits have a way of turning up all kinds of waste in departments where employees get generous overtime. Employees pre-arrange filling in for each other so they can rack up extra hours at time and a half or double time. An audit, and some basic rule changes prohibiting overtime beyond a certain point or only under specific exceptions to that point, might show there is money for more health staffing and at the very least save tax payer money.


If you want to have a study on this just go to any fire department. They are the experts.

In one of the local cities out of the 20 top paid employees 15 are firemen. You figure it out.


Grand Jury anyone?


Someone needs to call Dr. Butros who used to work for the county. And QUIT! 468-2000.


The only issue here is funding. The solution is easy if you have deep pockets. Provide adequate funding to Mental Health and the Sheriff’s Department and the problem is solved.

This report for the most part addresses under staffing. One just needs to go to and you can see what the costs are for additional employees in the different categories. The costs with benefits are almost impressive to say the least.

But what the real cause is that most criminals and mentally disturbed people don’t vote on their own.


Keep in mind…the lunatics are running the asylum.


Thank you for this important report.


SMH. All the talk about the Sheriff wasting money on the boat… it was a federal grant! The thing gets used like any other cop car, just on the water. Think about the fire last summer at Naci or ANY crime near our coast. The Coast guard is great, but the SO has primary responsibility for a ways (1 mile or something)

As fo the issue of this article, it’s a money thing. The BOS controls the money and should be making the decisions. BOS decision, now that’s the oxymoron at the root of the problem.


I know this may difficult for you to understand my.02, but where do you think federal grant money comes from? Do you think it simply hangs like fruit off of low hanging branches? ITS TAX MONEY that we all put into the system. Agencies throughout the country get grant money for crap they don’t need, when it could be better spent on our worn out infrastructure like highways and bridges, etc.

Considering we already have a coast guard, as well as licensed marine salvage masters, the panga tow boat was just another toy.

Anyway discussions about Parkinson’s Navy distracts from the real story here and I patiently await the rest of the story about what happened in the jail that caused death to a 36 year old man.

Please keep us updated Karen Velie


Will someone PLEEEEEEEEEEEEEEASE contact the Grand Jury?


And where did this “FREE” federal grant money come from? hint taxpayers.

Kaiser Bill

Cute, another St Ian shill. Sheriff Dept employee or spouse?