Welfare and Institutions Code section 209 (d) Corrective Action Plan Submission, Review, and Approval Process Outline

Notice of Noncompliance

The Initial Inspection Report (IIR) is the notice to the Chief Probation Officer that noncompliance has been identified during inspection; the IIR Issuance Date starts the 60-day Corrective Action Plan (CAP) Development process.

An IIR will be electronically provided to the Facility Manager and Chief Probation Officer at the conclusion of the inspection at the Exit Briefing.
The IIR Issuance Date is the date the IIR is electronically provided to the Chief Probation Officer and the Facility Administrator.
Each facility will receive a separate IIR.
In addition to information on each item of noncompliance, the IIR will indicate:
1. IIR Issuance Date.
2. Maximum Statutory CAP Due/Approval Date
  1. This date is 60 days from the IIR issuance date.
3. Maximum Statutory Resolution Date
  1. This date is 90 days from the CAP Due/Approval date.

Corrective Action Plan (CAP) Development Process

Agencies must develop and submit their CAP to the BSCC within 60 days of the IIR Issuance Date. If the item of noncompliance has been corrected prior to submittal of the CAP, the CAP shall indicate the date the corrective action was completed.

The final CAP shall outline how the agency plans to correct the item(s) of noncompliance within a reasonable timeframe not to exceed 90 days from the date the CAP is submitted.
The final CAP shall contain the following information:
1. The date for proposed resolution of the item(s) of noncompliance, indicating either the:
  1. County Resolution Date: A reasonable date for correction that is earlier than the Maximum Statutory Resolution Date. If an agency indicates a County Resolution Date, verification of the correction will be based on this date.
  2. Maximum Statutory Resolution Date: A reasonable date for correction that is no later than 90 days from the CAP Due/Approval date.
2. A detailed description of each of the steps that will be taken to correct the item of noncompliance and when each step will be implemented, such as updates to policy, training, county counsel approval, County Board of Supervisors approval, procurement of materials, scheduling work orders, meet and confer timelines, etc.
3. A description of how each of the steps that will be taken will remedy item(s) of noncompliance and how they provide a durable and sustainable remedy.
4. A brief explanation as to why the proposed resolution date is reasonable.
  1. If short-term or interim remedies are proposed, indicate what the long-term remedy is and when implementation is expected.
Draft CAP submission.
1. Agencies are encouraged to submit a draft CAP to the BSCC; when requested, BSCC Field Representatives can provide technical assistance regarding whether the steps outlined in the CAP are likely to be approved or identify any missing items.
2. Agencies may submit draft CAPs at any time during the CAP Development Process and may submit more than one draft.

CAP Approval

By close of business on the day the final CAP is received by the BSCC, which is no later than 60 days from the issuance of IIR, the FSO Deputy Director will approve or deny the final CAP. The BSCC will provide written notice of approval or denial to the Chief Probation Officer.
1. If a CAP is not received by the 60th day from the IIR, the facility shall be deemed unsuitable for the confinement of juveniles pursuant to WIC 209 (d). Notice of unsuitability (WIC 209(a)(4)) shall be issued within three days to the Chief Probation Officer, County Board of Supervisors, County Executive Officer, County Counsel, and Presiding Juvenile Court Judge.
2. If the final CAP is denied, the facility shall be deemed unsuitable for the confinement of juveniles pursuant to WIC 209 (d). Notice of unsuitability (WIC 209(a)(4)) shall be issued within three days to the Chief Probation Officer, County Board of Supervisors, County Executive Officer, County Counsel, and Presiding Juvenile Court Judge.
The following will be considered by BSCC staff when approving a CAP:
1. The CAP contains all the required elements outlined in Section 2 (b) above.
2. The timeframe for resolution of the item(s) of noncompliance are reasonable. When determining if the timeframe for resolution is reasonable, the following factors will be considered:
  1. Severity of item(s) of noncompliance. Does the item of noncompliance pose immediate risk to the safety and health of youth or result in a deprivation of constitutional rights?
  2. Likelihood of continued risk or harm to youth if the item of noncompliance is not addressed within this timeframe.
  3. Do the steps outlined in the CAP align with a reasonable timeframe? Will planning and implementation take the stated amount of time, or can it be accomplished in less time? Are there other measures that can be taken in the short term to ensure that youth are not at risk of harm?
  4. Resources required to correct the issue. Can the agency allocate resources immediately or does implementation and planning require acquiring additional resources?
A CAP may be denied if:
1. CAP does not contain all required elements outlined in Section 2 (b) above.
2. The proposed corrective action, if completed as described, will not result in compliance.
3. The timeframe for correction is not reasonable.
4. The timeframe for correction exceeds the Maximum Statutory Resolution Date.

90 Day CAP Implementation Period and County Verification of Correction of Item(s) of Noncompliance

Agency implements CAP during the 90 days following CAP approval.

On or before the resolution date indicated on the final CAP, the Chief Probation Officer must send written verification to the FSO Deputy Director that the corrective action is complete, and the item(s) of noncompliance have been remedied.
1. This written verification of correction does not clear the item of noncompliance; BSCC staff must verify the corrective action through follow up inspection or document review before the item is considered corrected.0
If an agency’s approved CAP indicates a County Resolution Date, and during the 90 day CAP implementation time, the agency determines that the Maximum Statutory Resolution Date is a more reasonable timeframe, the agency must submit a written request to the Deputy Director of the Facilities Standards and Operations Division to change the resolution date. The agency’s request must include why the Maximum Statutory Resolution Date is reasonable and necessary.

BSCC Verification of Corrective Action

Following receipt of the County Verification of Corrective Action, BSCC staff will verify the corrective action by conducting an on-site follow up inspection or requesting documentation.
1. If the follow up inspection or document request is after the resolution date indicated in the CAP, BSCC staff will verify corrective action beginning on the resolution date going forward.
When BSCC staff has verified corrective action and compliance, the agency will be notified in writing that the items of noncompliance have been corrected and BSCC data reporting systems will be updated.
If corrective action has not been completed and/or the facility remains out of compliance following the resolution date, the agency will be given notice for determination of suitability for the next scheduled board meeting.