Santa Barbara Grand Jury Probes Myriad Problems Around County

Santa Barbara Grand Jury Probes Myriad Problems Around County

This Year’s Final Reports Include Investigations
into In-Custody Deaths and Mental-Health Issues,
Cybersecurity in School,
and Water District’s Lack of Transparency

by Jack Magargee | August 18, 2023

Every year, Santa Barbara County’s Civil Grand Jury releases its final reports to the public, with evaluations and recommendations for several county agencies stemming from investigations over the previous year. In 2023, these reports included investigations into deaths and problems with mental-health resources in Santa Barbara County jails, issues with cybersecurity in area schools, and a lack of transparency with the Santa Maria Valley Water Conservation District.

This week, the Independent breaks down the 2022-2023 Grand Jury Final Reports, which are also available in full online here.

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‘Every Death in Custody Is a Failure’

In July 2021, a Santa Maria man died by suicide while in custody at the Santa Barbara County Main Jail. According to the grand jury report, 35-year-old Kean Ardie San Juan Pinon (identified as “KP” in the report) hung himself in his jail cell just one day after his cellmate’s attempted suicide. The investigation discovered that Pinon had been rehoused in the same cell, alone, where he had watched his cellmate’s failed suicide attempt. 

The report described Pinon as a recidivist criminal who’d been incarcerated several times and suffered from mental disorders and “suicidal ideations.” Wellpath Healthcare, which is one of the largest health-care providers for prisoners around the county, provided mental-health support for Pinon during his stints at Santa Barbara County Jail. However, Wellpath “did not share this mental health history with the Sheriff’s Office custody staff” because Wellpath believed that sharing such information was illegal on the grounds of doctor/client privilege. 

The report stated that “highly relevant, critical data was not shared with the very officials who were to decide where KP should be housed.” The Grand Jury asserted that the Sheriff’s Office custody staff should have known Pinon’s mental-health fragility. Furthermore, the jury found “that had KP’s mental health history been known, KP would not have been placed back into the same cell, especially alone, and without constant observation.”

In its conclusion, the Grand Jury recommended that the Santa Barbara County Counsel undergo a legal review of the processes and legalities of the “present coordination and communication between Wellpath (or its successors).” Additionally, the report determined that the Santa Barbara Sheriff’s Custody staff disclose inmates’ serious mental health and medical information on a “need to know basis to the custody staff responsible for making housing and program decisions.” 

‘A Vicious Cycle: Incarceration of the Severely Mentally Ill’

The 2022-2023 Grand Jury investigated two deaths that occurred at the county’s Northern Branch Jail in Santa Maria, which began operating in January 2022. The inmates — 37-year-old Edgar Estrada Amezcua, a k a Edgar Mescua Estrada (referred to as “EEA” in the report) and Kristina Marie Chermak (referred to as “KC” and described as 34 years old in the report but 35 in the Sheriff’s Office’s public notice of her death) — were housed in Northern Branch Jail, where each died as a result from fentanyl overdoses. Both Chermak and Amezcua were diagnosed with severe mental illness and drug addiction and at separate times were determined to be incompetent to stand trial (IST), meaning they did not have the mental wherewithal to understand the charges or cooperate cogently with their attorneys. 

According to the report, Chermak and Amezcua had been “multiple times convicted, and sentenced to jail and/or probation” over a period of longer than a decade. Jail custody officers identified Chermak’s and Amezcua’s mental-health status as severely mentally ill (SMI), and they were referred to jail mental-health professionals for treatment. It was after their last arrests that they overdosed on fentanyl and died at the Northern Branch Jail.

The Grand Jury acknowledged the challenges Santa Barbara community encounters when tasked with providing effective mental health treatment “for the mentally ill in place of the arrest-jail-court-arrest cycle.” The report stressed that county officials and the Santa Barbara Sheriff’s Office devote resources to inmates with mental-health challenges, especially those with severe mental illnesses, to “divert individuals into comprehensive community treatment and services” and to “keep the non-violent mentally ill out of jail.”

Therefore, the Grand Jury recommended from its analysis that the Santa Barbara Sheriff’s Office work with the county and its jails’ health/mental-health-care provider to develop and publish data on the number of inmates with mental-health issues; the county create cost comparison data between arrest-jail-court-arrest cycles and appropriate mental-health diversion programs; and the county provide adequate resources for mental-health programs for Assisted Outpatient Treatment (Laura’s Law) and the CARE Act (Community Assistance, Recovery, and Empowerment Act), which will be implemented in Santa Barbara County no later than December 2024.

‘A Death in Custody: Lessons Learned’

Jonathan Paul Thomas, 45, (referred to as “JT” in the report) died in a Santa Barbara County Main Jail safety cell after engaging in a physical struggle with Santa Barbara Sheriff’s Office Custody Staff, 20 minutes after he was booked. The 2022-2023 Grand Jury investigated the circumstances of Thomas’s arrest, incarceration, and the events leading up to and causing his death. 

Thomas was arrested on the night of January 11-12 on a charge of non-injury domestic violence. According to the report, at the time of his arrest, he was morbidly obese, had a history of drug abuse, and suffered from severe mental health crises, specifically multiple suicide threats and ideation. The report detailed that Thomas’s arresting officers, Wellpath medical staff (mental-health providers on duty at the jail), and custody officers were aware that Thomas was suffering from a mental-health crisis. However, none of the personnel involved attempted to “provide crisis intervention that could have avoided the custody officers’ use of force that night,” the report states.

Two parts of the report were released concerning different aspects of Thomas’s arrest, incarceration, and death, including an investigation into the custody staff personnel. Part One found that “the law enforcement and health care systems failed to provide JT with much needed urgent mental health care intervention.” 

Part 1 of the report recommended the Santa Barbara Sheriff’s Office and Jail Custody Staff  improve delivery of on-site, 24/7 professional mental-health services in the Main Jail and Northern Branch Jail; and broadly improve law enforcement officer and jail medical service providers’ mental-health crisis prevention training and interagency communication skills.

Part Two of the report reviewed the investigation conducted by the Sheriff’s Office and Coroner’s Office into the actions of the personnel involved. The report explicitly states that Thomas “was forced into an on-stomach prone restraint hold that he vigorously resisted,” while the autopsy showed Thomas was obese, suffered from a heart condition, and had a history of substance abuse. The Coroner’s Office determined that the custody staff’s on-stomach restraint hold and Thomas’s struggle with custody staff was an “indirect cause” of his death, compounded by his obesity and drug use.

However, two independent out-of-county medical experts interviewed by the Grand Jury stated that subjects like Thomas — who suffer from obesity and other comorbidities — are at an increased risk of cardiac arrest when in prone restraint holds and resistance. According to the Grand Jury’s report, “neither the Coroner’s Office nor the Santa Barbara District Attorney’s Office discussed or considered whether the on-stomach prone restraint was a direct cause of JT’s cardiac arrest.”

Therefore, the Grand Jury recommended in Part Two of the report that the Santa Barbara County, Sheriff’s Office, and Coroner’s Office submit Thomas’s case to the State Attorney General’s Office for “reinvestigation as to whether, from a medical perspective, the custodial officers’ use of the prone restrain and JT’s resistance was an indirect or direct cause of JT’s death” and “legal consequences that stem from the Attorney General’s reinvestigation.”

‘Death on Electronic Monitored Home Release’

Per the California Penal Code Section 919(b), the Grand Jury has the authorization to “inquire into the condition and management of the public prisons within the county.” As a result, the 2022-2023 Grand Jury investigated the death of a 40-year-old Santa Barbara man Nathaniel Montross (referred to as “NM” in the report), who died while participating in the Alternative Sentencing Bureau Electronic Monitored Home Release Program (EM Home Release). Operated by the Santa Barbara County Sheriff’s Office, the EM Home Release program is used to reduce jail overcrowding by allowing nonviolent offenders to serve their jail sentences outside of jail facilities while still in custody and under jurisdiction of the Sheriff’s Office.

Montross, who, according to the report, had a history of incarceration in Santa Barbara County dating back to 2014, also suffered from mental-health struggles, including substance abuse, all of which was noted in his medical file with the Sheriff’s Office. When Montross applied and was accepted for home release by custody staff, custody officials were not made aware of his “substantial history of mental health issues,” the report states. The jail’s contracted medical provider, Wellpath, did not share Montross’s medical and mental-health history with custody staff, which the Grand Jury found is “critical to determine inmate housing, programming, and suitability for the EM Home Release Program.” While Montross was released with a list of clinical providers, the Grand Jury stated that he was not monitored to see whether he contacted any of those providers. 

According to the report, on September 23, 2021, Montross was found at his home dead from a fentanyl overdose, 21 days away from completing his sentence.

‘Cybersecurity in Schools: The Need for Central Authority’

The Grand Jury investigated and reviewed the previous history of cybersecurity issues and current cybersecurity preventative measures for Santa Barbara County school districts and discovered that more needs to be done to address cybersecurity countywide. According to the Grand Jury’s report, “Santa Barbara County school districts are regularly targeted by cybersecurity threats, placing students and teachers directly in harm’s way.”

The 2022-2023 Grand Jury report succeeded the 2021 Grand Jury analysis titled “Cybersecurity for Special Districts and County Service Areas in Santa Barbara County,” which focused on the present conditions and effectiveness of cybersecurity programs in county schools. The most recent report determined that better practices need to be implemented in county schools to combat cyber-attacks. These practices include instituting multi-factor authentication (MFA) and formal cybersecurity training for students and/or teachers. 

The report concluded that mandating MFA and formal training are not impractical for implementation by the Santa Barbara County Education Office (SBCEO). The Grand Jury stated such efforts “should be centralized within the authority of the SBCEO to formalize policies and procedures in a more cost-effective manner, thereby placing all County school districts on equal footing.” 

‘Lack of Transparency in the Water Conservation District’

A formal complaint was filed about governance at the Santa Maria Valley Water Conservation District. The Santa Maria Valley Water Conservation District operates and maintains the Twitchell Dam and Reservoir located in northern Santa Barbara County and a small section in southern San Luis Obispo County. According to the Grand Jury’s report, the water district is considered an independent special district and is therefore governed by its own elected board of directors “that operates independently of a city or county oversight.”

The Grand Jury investigated alleged violations against the water district, specifically that there is a lack of strong leadership, directors are not properly trained in open meeting laws and parliamentary procedures, staffing is inadequate, conflicts of interest exist, there is questionable appropriation of resources at Twitchell Reservoir, and there is questionable use of district-owned vehicles and equipment. 

While the Grand Jury’s inquiry did not yield “sufficient factual support for the allegations expressed in the complaint regarding California Water Code Violations,” the jury recommended that the water district “improve its management, professionalism, accountability, and transparency.” The review found the water district’s transparency, or lack thereof, created a vacuum in the flow of communication and information significance to public knowledge. 

The jury also called for greater financial due diligence regarding the district’s failure to vet the “financial capacity and capabilities of parties of all contracts,” specifically regarding the weak financial condition of Mitigation Solutions LLC (which was hired to stabilize the dam and increase the reservoir’s capacity) and its parent company, “penny stock” Western Sierra Resource Corporation.

‘Grand Jury Response Compliance Report’

Local citizens had the opportunity to bring to the attention of the 2020-2021 Grand Jury specific important issues they believed impacted the county in a significant way. In total, 10 substantive reports were filed by the Grand Jury expressing different agencies’ responses covering a wide range of topics. 

The 2020-2021 investigations included remote learning during COVID, unfunded accrued pension obligations, overpopulation and inmate deaths in county jails, homelessness in Santa Barbara County, cybersecurity in Special Districts, the fiscal solvency of pensions in the county, impact of budget cuts on the Lompoc Police Department, governance at Allan Hancock College, idle oil wells off the coasts, and zoning and permitting issues in the City of Santa Barbara. 

The 2022-2023 Grand Jury press release encouraged readers interested in specific contents to read the full reports on the Grand Jury website at sbcgj.org.