The Reports are In

The 2019-2020 Civil Grand Jury weighs in on the Lawson investigation, county efforts to protect its most vulnerable charges



The Humboldt County Civil Grand Jury wrapped up its work for the year last month, issuing the last of its eight reports. The reports tackle subjects ranging from leadership in the Southern Humboldt Joint Unified School District (spoiler: there's a crisis going on) to how the Humboldt County Planning and Building Department interfaces with the cannabis industry (spoiler: there's too much cash and too little oversight) and represent a mountain of work from 17 volunteers.

Jury Foreperson Jim Glover took a few minutes to walk the Journal through the process. When the jury convenes in July, it's supposed to have 19 members, though this year's began with just 18 and later dropped to 17. The jurors then split into six committees (with individual jurors serving on as many as three), sift through complaints, discuss areas of concern that have been in the news over the past year and decide what issues they want to investigate. From there, they dive in, meeting with their respective committees on Tuesdays to interview witnesses and pore through materials before debriefing with the full jury on Wednesdays. When investigations ramp up, Glover said jurors can dedicate as many as 30 hours a week to the effort.

"There's a fine line when we're encouraging people to apply," Glover said. "We want the input but we also don't want to mislead them into thinking we're just going skating or something. It's a major commitment."

The jury has complete autonomy to look at local institutions — though state entities like Humboldt State University and the courts are beyond its purview. The only mandate is that the jury inspect local correctional facilities annually and report its findings to the public, and that all the jury's work is done in secret — with members bound to protect witnesses' identities and witnesses pledging not to discuss the interview process.

Before a report is released to the public, it undergoes two layers of legal review. First, Humboldt County counsel looks it over to assess liability concerns — not for the county as a whole but for the jury itself. Then the Humboldt County Superior Court's presiding judge is supposed to give it another look through the same lens or delegate the task to another judge. With legal feedback in hand, the jury votes on whether to release the report to the public, with 12 votes needed for a report's release. Glover said some reports — including one this year — do die on the vine, failing to get the required votes for release.

"We had one this year that we actually had to pull and I can't explain the reasons why," he said, adding that a report failing to garner the votes needed for release can be a divisive, fraught decision, as the report represents months of hard work by the committee members who generated it.

This 2019-2020 Civil Grand Jury also holds the distinction of being held in the COVID-19 age, and being the first to pivot entirely to video conferencing for deliberations and interviews. Glover said he's glad the jury began meeting in person and developed a rapport before COVID forced it to move to remote meetings in March.

"We never met again in person after March 10 and that changed the dynamics of this particular jury a great deal," he said. "You learn to know people's mannerisms, their quirks, their thought patterns and all that's a little harder to pick up on a screen when you're looking at 10 or 12 people at the same time."

Ultimately, the grand jury released reports on service and rehabilitation in Humboldt County's conservation camps, citizen complaint and feedback processes in county government, the county's Public Guardian's Office and patients' rights advocate and the investigation into the 2017 homicide of David Josiah Lawson, as well as the aforementioned reports on Southern Humboldt Joint Unified School District, the local jail and the county's cannabis program.

Below, we take a closer look at the Lawson report and the jury's investigation of complaints surrounding the Public Guardian's Office and mental health services. But you can find all the jury's reports linked to the online version of this story, inserted in last week's Journal or by visiting


The Department of Mental Health's Management of the Public Guardian Office and Patients' Rights Advocate

This report from the Civil Grand Jury is kind of a two-for-one, lumping what appear to be two very substantial investigations into two different functions of county government under a single umbrella because they are both overseen by the same department: Mental Health. But the underlying issues, findings and recommendations are very different, so we'll look at them separately.

Public Guardian's Office

Background: Deputy public guardians are county employees appointed by the Humboldt County Superior Court to manage the personal, financial and medical needs of people who have grave mental or physical illnesses or disabilities that prevent them from adequately caring for themselves. According to the report, the Civil Grand Jury began investigating the public guardian's office after learning that its staff were not "participating adequately in 'care conferences' for clients at skilled nursing facilities" and found that "the excessive caseloads carried by deputy public guardians hinder the office's fulfilment of its obligation to the conserved."

"Deputy public guardians across the state typically manage dozens of clients simultaneously, assisting them in tasks ranging from involved financial and medical decisions to the provision of basic necessities of day-to-day life," the report states. "[The Civil Grand Jury's] investigation showed that Humboldt County has been experiencing steady annual increases in both its total number of clients and the average caseloads borne by each guardian. The average caseload of each deputy public guardian dwarfs that of counties with populations two and three times the size of Humboldt."

The report begins by noting that the term "public guardian" itself "speaks to the trust, diligence, responsibility, virtue and compassion this position demands of those who are given this job," and offering a brief history, noting that the first public guardian's office in California was established in Los Angeles in 1945 to serve those unable to administer their own affairs. The offices became even more crucial in the 1970s, when California de-institutionalized mental health care.

"The clients of the public guardian, the 'conserved,' are those deemed by the Superiour Court to be unable to manage their own affairs according to the evaluation of a qualified physician or psychiatrist due to a grave mental or physical illness or disability," the report states. "They often lack the support of available and appropriate relatives or friends. Conservatorships belong to one of two primary categories. The Probate conservatorship focuses on financial and medical care decisions, usually for a lifetime. The LPS conservatorship, which must be renewed annually, requires the management and treatment of persons needing psychiatric care."

In some cases, the guardian's role is simply managing a client's finances, while others do that while also making medical care decisions and arrangements, applying for benefits on the clients' behalf, working with a variety of organizations and agencies to formulate and oversee care plans, and generally providing case management.

"Guardians have immense power over the conserved, whose financial, medical and psyschological well-being is in the hands of their public guardian," the report states. "Guardians have the authority to remove a person from their home in order to place them in an assisted living facility and the authority to make medical decisions for them. They can sell, confiscate or liquidate the entirety of a client's property and belongings. Clients are vulnerable, often elderly, commonly disabled and, by the nature of their predicament and circumstances, may lack the wherewithal to even understand their civil rights."

The report notes that such guardianships "must be held to the very highest of ethical and legal standards," which is why the Civil Grand Jury launched an investigation after receiving a complaint that deputy public guardians were failing to participate in quarterly care conferences, which play an "important role" in clients' care because they bring medical staff, the guardian, ombudsmen and facility staff together to review the client's program, go over treatment goals and register complaints where necessary. They are essentially quarterly check-ins between a client's entire care team, with the deputy public guardian theoretically there to advocate on the client's behalf.

"Moreover, the complaint noted that guardians were having trouble performing basic services for their clients, such as shopping for clothes or acquiring a cell phone, in a timely fashion," the report notes. "Frequently the task of securing such day-to-day items was falling to the staff of the facility or care home in question and, in some cases, to no one at all."

In its investigation, the Civil Grand Jury found that the Public Guardian's Office has been "chronically understaffed," leading to "excessive caseloads." These caseloads are reportedly in excess of 90 clients each, according to the report, a number far beyond the 70 or so cases workers identified as "manageable" and nearly triple the 30 to 40 considered ideal.

"To guardians often scrambling to locate their most at-risk clients, the relatively secure (skilled nursing facility) residents are deemed a lesser priority because they are safely housed and fed and often have a source of income in trust," the report states.

The report identifies a number of factors that contribute to the massive caseloads. First, Humboldt County conserves an inordinate amount of people, with per-capita rates of conserved people "far in excess of other California counties." Second, requests to the Department of Health and Human Services to fund an additional deputy public guardian position have gone "unheeded" for years, according to the report. Third, one of the county's three deputy public guardians is out on extended medical leave, with their "entire caseload" shifted to their two coworkers, the assistant public guardian and lead public guardian.

"Currently four workers serve around 700 clients of various types and needs," the report states. "Of these, some 200 or so are clients for whom the office handles just one aspect of their lives, the financial part. ... That leaves approximately 500 clients who require a staggering range of services and needs, from intervention in serious drug abuse to management of financial affairs to onerous tasks such as locating personal papers in a packed mobile home to the mundane, such as getting a client new pajamas."

Humboldt County's current caseload of 90 to 120 clients per guardian far outpaces those elsewhere in California, according to the report, which notes the ratio is 51 to one in San Mateo County, 30 to one in Santa Cruz County, 33 to one in Del Norte County and just 19 to one in Lake County.

"These numbers are startling," the report states. "Humboldt County's inordinately large population of conserved clients is a deeply concerning statistical anomaly that makes present questions about the administration's oversight of and responsiveness to the PGO even more urgent."

And there's reason to believe the problem is only going to get worse in both the long and short term, according to the report. More people will likely be conserved as Humboldt's boomer generation continues to age, and there have already been immediate impacts from COVID-19.

"Early data suggests that Humboldt County is beginning to see the effects of the present global COVD-19 pandemic on the Public Guardian's workload," the report states. "As the middle and lower classes begin to feel the economic impact of job losses, business closures and shrinking earnings, the number of those requiring help of the PGO will naturally rise."

The solution is increased staffing but that hasn't happened, as the report notes a new deputy public guardian position has not been approved in Humboldt County in 20 years. According to the report, that's partly because the Public Guardian's Office is funded out of the county's general fund, putting it in competition with myriad other county services for limited dollars.

"Yet it is still unclear why DHHS and Mental Health were so slow to respond to the increasingly dire situation with the Public Guardian's Office staffing," the report states. "When seeking some explanation for this failure to hire a new deputy, the Civil Grand Jury was told there were no obstacles to hiring additional deputies and that the problem may have been one of communication between supervisors. The Civil Grand Jury was troubled by the response that such requests for hiring were 'the responsibility of the supervisor' and that 'sometimes the supervisors do not ask loud enough.'"

At the time of the report, DHHS had communicated that it planned to seek funding in the fiscal year budget that started July 1. But even after a deputy public guardian is ultimately hired, the training process can take at least a year before they can work independently, according to the report.

Key Finding

The Public Guardian's Office is understaffed and Mental Health has failed to take sufficient steps to mitigate an increasing caseload, especially when a "key staff member" went out on extended leave. Presently, deputy public guardians are unable to meet their obligations to clients because they are "burdened with inordinately high caseloads."

Key Recommendations

1) The Board of Supervisors ensure the Public Guardian's Office is adequately funded so the Department of Health and Human Services can hire a fourth deputy public guardian.

2) That DHHS develop and implement a process to mitigate impacts of increased workloads on remaining staff and clients when a staff member has to take an extended leave.

Patients Rights Advocate

Background: During its investigation into conditions of the Public Guardian's Office, the Civil Grand Jury learned of a related concern in the office of the county's Patients' Rights Advocate.

"The origins of this office in the history of California's mental health institutions is tragic, even terrifying," the report states. "From their inception in the late 1800s, the state's 'insane asylums' were left to operate without much oversight. As a result, conditions inside such hospitals did little for patients' mental health. Persons could be committed to an asylum on nothing more than the word of a relative. Patients, who could be held indefinitely, were essentially prisoners without sentences. Shackled, beaten, abused and forgotten, patients were subjected to lobotomies, electro-shock therapy, psychotropic drugs and sterilizations at the will of asylum administrators. ... Once incarcerated in this virtually medieval system, a person had few if any rights."

Eventually, an undercover investigation by the California Department of Justice into conditions inside Mendocino State Hospital and the publication of the novel One Flew Over the Cuckoo's Nest led to intense calls for reform, and in 1967 the Lanterman-Petris-Short (LPS) Act was passed. And in 1993, the California Office of Patients' Rights was created with the goal of ensuring that each person admitted to a mental health facility in the state had access to an advocate who would fight to safeguard their basic rights. Each county in the state is now required to have at least one such advocate (PRA) on staff, according to the report.

"The PRA is an advisor, proponent, defender and counselor for any patient receiving mental health treatment in the county," the report states. "Patients are housed under various Welfare and Institutions Codes (WIC) that allow involuntary committals."

These commonly begin with a "5150" committal, which occurs when someone is deemed a danger to themselves or others, or gravely disabled, due to a mental health condition and committed to a mental institution for a 72-hour hold. But a showing of probable cause can extend these committals, first for 14 days, then an additional 14 days and then finally for another 30 days, which may lead to a court ordering that the patient be conserved. And it's the patients' rights advocate who stands between these people and the vast powers of the state to hold them against their will.

According to the report, the advocate's duties include ensuring clients are informed of their rights, advocating for clients during hearings to determine their legal status and whether they can continue to be held against their will on a mental health hold, training staff at mental health facilities about patients' rights, monitoring facilities, investigating potential rights abuses and compiling quarterly reports for the state Patients' Rights Office.

But in order to advocate, the PRA needs to know who their clients are.

"Most of the PRA's clients are those admitted to Sempervirens Psychiatric Health Facility or the long-term care facility, Crestwood Behavioral Health Center," the report states. "Each patient admitted voluntarily or involuntarily to a mental health facility should be made aware of the availability of the PRA and provided with a packet containing a brochure about the PRA's services, a release of information (ROI) and the PRA's contact information. The contact information is also posted in every facility with a statement of patients' rights."

What brought the PRA to the Civil Grand Jury's attention was a change in policy that made it more difficult for them to do their jobs. Previously, a ward clerk at Sempervirens would fax the PRA — who has signed a confidentiality agreement and undergone HIPAA trainings — a daily census listing the name, birthdate, case number, date of admission, legal status and type of hold for each patient housed in the facility. But in October of 2019, according to the report, staff at Sempervirens began to redact the name, birthdate and case number for all patients who had not signed a release of personal information form for the PRA. Staff claimed that disclosing such information would constitute a violation of privacy rights.

"The Civil Grand Jury heard from multiple sources that the new practice was, in effect, a hindrance to the performance of the PRA's advocacy duties," the report states. "Information that was previously accessible to the PRA now requires additional, time-consuming work in a job that already requires rigorous adherence to procedure for its various duties and mandated deadlines.

"... The imposition of the new policy introduced a new, even Byzantine, level of bureaucratic process," the report continues. "The advocate must now, first, visit each facility and move room-to-room to determine whether clients have been admitted who might need their services and, second, engage clients in the middle of an involuntary and even traumatic mental health hold to persuade them to make the rational, calm decision to sign the (release of information)."

The process becomes "potentially problematic," according to the report, when it occurs in the lead-up to the hearings that determine whether a patient's involuntary stay can be extended and they need an advocate well prepared to argue on their behalf.

"When gauging the added cost of the redacted census in the PRA's time and energy, one must remember that a single PRA serves all mental health clients in Humboldt County," the report states.

DHHS and Mental Health maintain, according to the report, that the new policy errs on the side of confidentiality, which the report notes is "informed by current law." However, the report notes that Mental Health is interpreting confidentiality laws as "strictly and narrowly" as possible when it comes to the PRA, which may run counter to the PRA's purpose and is out of step with the policies of some other California counties.

Another area of concern identified by the Civil Grand Jury is Mental Health's practice of excluding the PRA — "ostensibly" to protect client privacy — from continuous quality improvement meetings, which are held 10 times a year and aimed at evaluating whether the department is implementing best practices and what areas of client care could be improved, according to the report.

"The PRA's multifaceted job requires them to act as a consultant, representative, trainer, investigator and a liaison between the county and state," the report states. "The PRA's performance of this critical role is dependent on access to all pertinent information ..."

Key Finding

"The Mental Health administration's interpretations of confidentiality creates obstacles that prevent the Patients' Rights Advocate from serving clients' needs despite the Advocate's having signed a confidentiality agreement and having undergone the county's annual HIPAA training."

Key Recommendations

1) That Mental Health ensure the PRA has full access to patient information that's relevant to their duties, including an un-redacted daily census.

2) That Mental Health ensure the PRA is provided with un-redacted reports about the denial of rights to patients and be welcomed to participate in "the entirety of continuous quality improvement meetings without restrictions."

A Community Divided: The Ripples of a Homicide in Arcata, CA

Background: On April 15, 2017, David "Josiah" Lawson, a 19-year-old sophomore at Humboldt State University, was fatally stabbed at an off-campus party amid a series of fights and the case remains unsolved more than three years later. Kyle Zoellner, a McKinleyville man, was arrested at the scene and charged with Lawson's killing, but a Humboldt County Superior Court judge later ruled there was insufficient evidence to hold him to stand trial on a charge of murdering Lawson. A criminal grand jury was convened almost two years later to hear evidence against Zoellner but declined to indict anyone in the case. Lawson was Black and Zoellner is white, and allegations of racism and racial bias have surrounded the case from the very beginning, including allegations Zoellner's girlfriend spewed racial slurs at Lawson as he lay bleeding to death at the party.

Acting on a "myriad of community complaints," the Civil Grand Jury decided to investigate.

While its report does not unearth any new facts about Lawson's killing or the Arcata Police Department's investigation into it, it does give some additional context to both. It also buttresses the findings of the National Police Foundation report released in February, which found that while APD made a host of mistakes in the hours after Lawson's death that would cripple the investigation, there was no evidence that officers had acted with overt racial bias and every indication officers and first responders had worked diligently and competently when trying to save Lawson's life.

"The most difficult question the Civil Grand Jury had to evaluate was the charge of racial bias within the police response," the report states. "The Civil Grand Jury conducted many interviews and reviewed a vast array of information. Although the Civil Grand Jury found failures, ineptitudes and poorly executed police work, it did not find direct evidence of racial bias."

But Lawson's killing did not come in a vacuum, as the jury notes.

"As part of its investigation, the Civil Grand Jury interviewed members of various community groups, including African-American, First Nations, and Latinx," the report states. "All groups voiced concerns about the impact the Lawson homicide has had on their communities. Likewise, all indicated that they have felt disenfranchised, to various extents, long before the homicide occurred. There was a pervasive feeling among our interviewees that their communities face systemic bias, in education, policing, and community relations."

The report offers a long — and at this point fairly well documented — list of APD mistakes made before and during the investigation into Lawson's killing, including the elimination of its evidence technician position due to budget cuts, ineffective leadership, poor training, and inadequate supervision. All these lead to a failure to follow basic Peace Officer Standards and Training and department policy, and to secure the crime scene and identify key witnesses, as well as the repeated refusal to accept help from other local agencies on the investigation. And it notes that APD, now under the leadership of Chief Brian Ahearn, has taken numerous steps to address its deficiencies.

The report adds that the Civil Grand Jury feels it is premature to declare whether Lawson's killing may have constituted a hate crime and that determination "should be withheld until a perpetrator is charged, and the intent and motivation for Josiah's killing is fully explored."

Key Findings

1) While the jury found no direct evidence of racial bias or corruption within APD's response, it was clear APD was "not prepared to manage and investigate a large, violent crime scene" and that a lack of on-scene leadership "contributed to the discoordinated response." This led to failures to adequately secure the crime scene, detain witnesses and process evidence.

2) Former FBI Agent Tom Parker, whom the city brought in to advise the investigation but who later left the case while alleging he was being lied to and his recommendations weren't being followed, was accurate in his "assessments that the APD had poor management, lack of training, inadequate staffing and demonstrated a lack of transparency," the jury found.

3) Current APD Chief Ahearn is "focusing on strengthening community relationships, substantially increasing training and diversifying the pool of officers and staff." He has also begun community policing and leadership development programs, and created an investigations division complete with an evidence technician.

Key Recommendations

1) That the city of Arcata continue to sufficiently fund the police department so it can maintain the evidence technician position, as well as cultural bias and other trainings.

2) That the police department engage in community outreach by putting together brief biographies of its officers to post on the city's website, and that the city create "a diverse citizens advisory board" to specifically review police conduct and service. The jury further recommends that APD utilize minority interns from HSU to foster better connections and understanding.

3) That the Humboldt County District Attorney's Office has created a multi-agency Major Crimes Incident Team to investigate large or complex crime scenes. The jury recommends Arcata use it in the future.

To read all reports from the 2019-2020 Humboldt County Civil Grand Jury, visit


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