Report 2012-107 Recommendations

When an audit is completed and a report is issued, auditees must provide the State Auditor with information regarding their progress in implementing recommendations from our reports at three intervals from the release of the report: 60 days, six months, and one year. Additionally, Senate Bill 1452 (Chapter 452, Statutes of 2006), requires auditees who have not implemented recommendations after one year, to report to us and to the Legislature why they have not implemented them or to state when they intend to implement them. Below, is a listing of each recommendation the State Auditor made in the report referenced and a link to the most recent response from the auditee addressing their progress in implementing the recommendation and the State Auditor's assessment of auditee's response based on our review of the supporting documentation.

Recommendations in Report 2012-107: Developmental Centers: Poor-Quality Investigations, Outdated Policies, Leadership and Staffing Problems, and Untimely Licensing Reviews Put Residents at Risk (Release Date: July 2013)

Recommendations to Developmental Services, Department of
Number Recommendation Status

The department should provide a reminder to staff about the importance of promptly notifying OPS of incidents involving resident safety.

Fully Implemented

Within 60 days, the department should make the following amendments to its policies and procedures for OPS:
-Clarify who is responsible for deciding whether to make district attorney referrals.
-Clarify that the final decision to initiate a specialized medical examination for an alleged victim of sexual assault rests with OPS, not with health care staff.
-Require OPS investigators to document their efforts to communicate with alleged victims of abuse, including nonverbal clients, and require supervisors to verify that such efforts have been made when approving investigation reports.
-Direct its investigators to record the potential violations of law or facility policy they identify and consider during each investigation.

Fully Implemented

To ensure adequate guidance to OPS personnel, once the department has amended OPS's policies and procedures to reflect the recommendations we have included here, the department and OPS should place a high priority on completing and implementing its planned updates to the OPS policy and procedure manual.

Fully Implemented

OPS should provide additional training to its law enforcement personnel on how to conduct an initial incident investigation, particularly regarding collection of written declarations and photographs of alleged victims following an incident.

Fully Implemented

To avoid jeopardizing the integrity of its criminal investigations with compelled statements acquired through administrative admonishments, the department should require that different OPS investigators conduct the administrative investigation and the criminal investigation when they involve the same incident.

Fully Implemented

As soon as possible, the department should hire a permanent OPS director and permanent OPS commanders that are highly qualified staff capable of performing the administrative functions these positions require.

Fully Implemented

To help ensure the quality of OPS investigations, the department should revise its OPS training policy to require its law enforcement personnel to attend annually specialized trainings that address their specific needs. At least initially, the department should focus the additional trainings on communicating with residents, writing effective investigative reports, and collecting investigative evidence. To further develop the leadership skills of OPS management, the department should consider having experienced or particularly skilled members of its OPS management provide this annual training.

Fully Implemented

To ensure that it has adequate numbers of staff to properly and promptly investigate developmental center incidents, the department should address the high number of vacancies within OPS by instituting a formal recruitment program in accordance with the guidance provided in the California State Personnel Board's Merit Selection Manual, as well as using input from OPS law enforcement personnel.

Fully Implemented

After the department has implemented a formal OPS recruiting program, if it can demonstrate that it is still having trouble filling vacant OPS positions, the department should evaluate how it can reduce some of the compensation disparity between OPS and the local law enforcement agencies with which it competes for qualified personnel.

Fully Implemented

To make certain that residents receive an adequate level of care and are protected from harm, the department should encourage Human Resources—which is responsible for negotiating labor agreements with employee bargaining units—to include provisions in future collective agreements to cap the number of voluntary overtime hours an employee can work and/or require departments to distribute overtime hours more evenly among staff. If, in the next round of negotiating bargaining unit agreements, Human Resources does not include provisions to cap the number of voluntary overtime hours an employee can work, the department should continue to advocate for these changes for future agreements. In the meantime, the department should adjust its overtime scheduling and monitoring practices to strengthen, where possible, procedures designed to ensure that staff working overtime do not compromise residents' health and safety.


To minimize the need for overtime, the department should reassess its minimum staffing requirements, hire a sufficient number of employees to cover these requirements, and examine its employee scheduling processes.

Fully Implemented

To ensure that staff who work overtime are paid the correct amount, developmental center management should require all staff to submit not only overtime approvals, but also the department's standardized form showing time off and overtime hours. Additionally, the department should establish a written guide to help ensure that timekeeping staff follow the overtime provisions of the various laws, regulations, and bargaining unit agreements.

Fully Implemented

The department should create specific measurable goals for OPS that include existing and new measures associated with each one, such as staffing, overtime, and the timely completion of investigations. In addition, the department should perform a regular review of the quality of OPS's activities and investigations to achieve those goals. The department should track progress in quality measures over time and adjust its training plans to increase OPS law enforcement personnel's skill and compliance with established policies and procedures.

Fully Implemented

To allow for the creation of consistent performance measures and comparisons of resident abuse data across all developmental centers, the department should ensure that each of its centers consistently uses the same data fields in IRIS.

Fully Implemented
Recommendations to Public Health, Department of
Number Recommendation Status

To conduct licensing surveys at required intervals while minimizing additional workload, Public Health should explore further opportunities to coordinate the licensing and certification surveys. If Public Health questions the value of these surveys, it should seek legislation to modify the surveying requirements.


To ensure that the facilities Public Health monitors take timely corrective action on deficiencies, Public Health should comply with CMS's 45-day revisit requirement. If the 45-day revisit time frame is not possible due to the extent of the corrections required at particular facilities, Public Health should seek exemptions from CMS as appropriate. For facilities whose deficiencies are not severe enough to require an on-site revisit, Public Health should direct its staff to complete desk reviews within 60 days.

Fully Implemented

To ensure that investigations are conducted on a timely basis across priority levels, Public Health should develop and implement target time frames for the priority levels that lack them. Public Health should ensure that the timelines are being met and, if not, explore new ways to increase efficiency and manage its workload, thereby facilitating timely investigations.

Fully Implemented

To improve its enforcement, each year Public Health should evaluate the effectiveness of its enforcement system across all types of health facilities, including those in developmental centers, prepare the required annual report, and, if called for, recommend legislation to improve the enforcement system and enhance the quality of care.

Partially Implemented

Print all recommendations and responses.