State investigators said Thursday that inhumane conditions and incompetence at a Stockton youth correctional facility may have contributed to the suicide of an 18-year-old inmate who was locked in his room alone nearly 24 hours a day for two months.
In a blistering report, the state Office of the Inspector General admonished prison officials for denying the mentally unstable ward the ability to see family, meet with mental health counselors or take a walk while in lockdown.
The report said officials at N.A. Chaderjian Youth Correctional Facility put the ward in an impossible situation: Either renounce a violent prison gang -- making himself vulnerable to beatings by inmates -- or remain alone in his room around the clock.
The ward, who has been identified as Joseph Maldonado, eventually hanged himself with a bedsheet. And despite signs that something was wrong in Maldonado's cell -- the inmate had covered the windows and was unresponsive -- prison officials did not check on him for nearly 40 minutes, investigators said.
The latest findings come amid continued calls by activists to shut down Chaderjian, the most controversial of the state's youth prisons.
Maldonado, whom state investigators said was denied access to mental health counselors despite repeated requests, was one of three wards to die at the prison over a two-year span.
His death came after the inspector general's office had issued two reports earlier in the year that called for the facility to stop putting wards in nearly 24-hour lockdowns for months at a time.
"What's so tragic about this is that the issues that contributed to this young man's suicide are the ones we have been talking about for at least five years," said Sue Burrell, a staff attorney at the San Francisco-based Youth Law Center, which has sued the prison system over various issues.
State prison officials said they have since stopped the practice of locking down prisoners for extended periods.
"While we are continuing to investigate this incident, this report is an indictment of the violent and tense conditions that existed at the facility at a particular time," said Bernard Warner, chief deputy secretary for juvenile justice at the state Department of Corrections and Rehabilitation. (Until a name change earlier this year, the agency was known as the California Youth Authority.)
Warner said his department was committed to moving "beyond incarceration to a more rehabilitative model."
But officials at the inspector general's office questioned whether the department was moving fast enough.
"If there are not substantial changes made, the inspector general may call for the state to close this facility down," Chief Deputy Inspector General Brett Morgan said.
Morgan said the inspector general's office had warned multiple times before Maldonado's death that Chaderjian lacked an effective suicide prevention program.
"And here we are again," he said.
Maldonado was 5 feet 5 inches tall and weighed 120 pounds. Though a member of a Latino gang that had attacked prison officials, he was not involved in the attacks. Prison officials said he was a follower in the gang, not a leader.
Even so, Maldonado was among several of the gang members who refused to renounce their affiliations with the gang.
"This resulted in a deadlock between administrators and the gang members," the report said. That left Maldonado "in the position of either renouncing his gang and facing violent retribution as a result, or continuing to live in what for him appeared to be increasingly intolerable conditions."
The report said that depriving wards of social services was "inconsistent with the mission of the Division of Juvenile Justice."
During his time at the facility, Maldonado had asked to be seen by mental health counselors four times but never got that help. Prison officials, the report said, "failed several times to properly assess the ward's mental health."
At 6:15 p.m. on Aug. 31, staff at the correctional facility noticed that Maldonado "had covered his windows, could not be seen in his room, and was not responding to attempts to communicate with him."
Prison staff waited 15 minutes to report that information to a sergeant, the report said. It wasn't until 23 minutes later that an "escort team" arrived to check on the ward and found him not breathing and without a pulse.
"This 38-minute period resulted in a response so prolonged it could not be expected to successfully prevent the suicide of a ward," the report said. At the same time, investigators said, it was not possible to determine if a faster response would have saved his life.
Maldonado was pronounced dead an hour later at San Joaquin General Hospital.
The inspector general's full report can be viewed at http://www.oig.ca.gov/.