summary: PREA - FINAL

raw_content:
Prison Rape Elimination Act (PREA) Audit Report
Juvenile Facilities
☐ ☒
Interim Final
Date of Report June 3, 2018
Auditor Information
Name: Flora Brooks Boyd Email: flora.boyd@thecmcg.com
Company Name: Correctional Management and Communications Group, LLC
Mailing Address: 5 Rosemount Court City, State, Zip: Blythewood, SC 29016
Telephone: (803) 312-5199 Date of Facility Visit: Oct 31-Nov 1, 2017
Agency Information
Name of Agency Governing Authority or Parent Agency (If Applicable)
Florida Department of Juvenile Justice Florida State Government
Physical Address: Knight Building, 2737 City, State, Zip: Tallahassee, FL 32399-3100
Centerview Drive
Mailing Address: Same as above City, State, Zip: Same as above
Telephone: (850) 413-7313 Is Agency accredited by any organization? ☐ Yes ☒ No
The Agency Is: ☐ ☐ ☐
Military Private for Profit Private not for Profit
☐ ☐ ☒ ☐
Municipal County State Federal
Agency mission: To increase public safety by reducing juvenile delinquency through effective prevention, intervention
and treatment services that strengthen families and turn around the lives of troubled youth.
Agency Website with PREA Information: www.djj.state.fl.us/partners/prison-rape-elimination-act-(prea)
Agency Chief Executive Officer
Name: Christina K. Daily Title: Secretary
Email: Christy.Daly@djj.state.fl.us Telephone: (850) 413-7313
Agency-Wide PREA Coordinator
Name: Jeff Wenhold Title: PREA Coordinator
Email: Jeff.Wenhold@djj.state.fl.us Telephone: (850) 717-2533
PREA Coordinator Reports to: Number of Compliance Managers who report to the PREA Coordinator
None
Laura Moneyham, Residential and Correctional
Facilities
Facility Information
Name of Facility: Orange Regional Juvenile Detention Center
Physical Address: 2800 South Bumby Ave Orlando, FL 32806
Mailing Address (if different than above): Same as above
Telephone Number: (941) 741-3023
The Facility Is: ☐ ☐ ☐
Military Private for Profit Private not for Profit
☐ ☐ ☒ ☐
Municipal County State Federal
Facility Type: ☒ ☐ ☐ ☐
Detention Correction Intake Other
Facility Mission: To increase public safety by reducing juvenile delinquency through effective prevention, intervention
and treatment services that strengthen families and turn around the lives of troubled youth. Click or tap here to enter text.
Facility Website with PREA Information: www.djj.state.fl.us/partners/prison-rape-elimination-act-(prea)
☐ ☒
Is this facility accredited by any other organization? Yes No
Facility Administrator/Superintendent
Name: Paul Finn Title: Acting Superintendent
Email: paul.finn@djj.state.fl.us Telephone: (407) 897-2800
Facility PREA Compliance Manager
Name: Paul Finn Title: Acting Superintendent
Email: paul.finn@djj.state.fl.us Telephone:(407) 897-2800
Facility Health Service Administrator
Name: Dr. D. Yarin Title: Designated Health Authority
Email: david.yarin@djj.state.fl.us Telephone: 904-221-8455
Facility Characteristics
Designated Facility Capacity: 124 Current Population of Facility: 95
Number of residents admitted to facility during the past 12 months 2513
Number of residents admitted to facility during the past 12 months whose length of stay in the facility 921
was for 10 days or more:
Number of residents admitted to facility during the past 12 months whose length of stay in the facility 1198
was for 72 hours or more:
Number of residents on date of audit who were admitted to facility prior to August 20, 2012: 0
Age Range of 9-18 years
Population:
Average length of stay or time under supervision: 11 days
Facility Security Level: Secure
Resident Custody Levels: Secure
Number of staff currently employed by the facility who may have contact with residents: 147
Number of staff hired by the facility during the past 12 months who may have contact with residents: 90
Number of contracts in the past 12 months for services with contractors who may have contact with 3
residents:
Physical Plant
Number of Buildings: 1 Number of Single Cell Housing Units: 0
Number of Multiple Occupancy Cell Housing Units: 6
Number of Open Bay/Dorm Housing Units: 0
Number of Segregation Cells (Administrative and Disciplinary: 0
Description of any video or electronic monitoring technology (including any relevant information about where cameras
are placed, where the control room is, retention of video, etc.): The facility is equipped with a video surveillance system
which includes 128 cameras. The monitors are located in the Main Control room in the administrative area.
Medical
Type of Medical Facility: Maxim- Clinic/Office
Forensic sexual assault medical exams are conducted at: Victim Service Center of Central Florida
Other
Number of volunteers and individual contractors, who may have contact with residents, currently 34
authorized to enter the facility:
Number of investigators the agency currently employs to investigate allegations of sexual abuse: 0
Audit Findings
Audit Narrative
The auditor’s description of the audit methodology should include a detailed description of the following processes during
the pre-onsite audit, onsite audit, and post-audit phases: documents and files reviewed, discussions and types of
interviews conducted, number of days spent on-site, observations made during the site-review, and a detailed
description of any follow-up work conducted during the post-audit phase. The narrative should describe the techniques
the auditor used to sample documentation and select interviewees, and the auditor’s process for the site review.
Orange Regional Juvenile Detention Center (ORJDC) located in Orlando, Florida, is a 124 bed,
hardware secure facility which serves male and female juveniles detained by various circuit court(s).
ORJDC is operated by the Florida Department of Juvenile Justice (FDJJ) and serves Orange County
area youth who are detained pending adjudication, disposition or placement in a commitment facility.
The facility’s first PREA audit was completed in November 2014. The current audit was attained and
assigned to the Auditor by Correctional Management and Communications Group, LLC of Minneola,
Florida.
Prior to the onsite visit, an introductory conference call was held with the facility’s Superintendent who
also serves as the PREA Compliance Manager and the FDJJ Statewide PREA Coordinator to discuss the
overall audit process and onsite audit schedule. The notification of the onsite auditor’s visit was sent to
the facility immediately after the conference call along with specific instructions regarding documenting
the posting of the notices. The posting of the notices was verified by time-stamped photographs received
electronically from the facility six weeks prior to the first date of the on-site visit. The photographs
indicated notices were posted in various locations throughout the facility including resident housing units
and administrative areas.
The Pre-Audit Questionnaire, policies and other supporting documentation were received on October 4,
2017 nearly four weeks prior to the onsite visit. There was difficulty accessing the documents saved the
flash drive. Another flash drive was sent with the same result. Therefore, documents, were reviewed via
email and onsite. The initial review of the Pre-Audit Questionnaire, policies and other supporting
documents revealed the need for additional documentation. After providing a written summary of the
review, the Superintendent/PREA Compliance Manager, took immediate steps to address each concern
and required documentation was provided. Specific actions taken to correct deficiencies are summarized
in this report under the related standard. There was communication with the Superintendent by
telephone and email however two days prior to the onsite visit the Superintendent resigned. An Acting
Superintendent from a nearby detention facility was assigned as Acting Superintendent.
The on-site visit was conducted October 31-November 1, 2017. After meeting with the facility’s
management staff and Florida Department of Juvenile Justice, Central and North Region staff
representatives, a complete tour of the facility was conducted. During the tour, youth were observed
under constant supervision of the staff while involved in various activities however a one-to-eight staff
to resident ratio was not observed in all areas due to the facility’s 24 direct care staff vacancies.
Staff, contractors and volunteers were observed announcing themselves prior to entering the housing
area of the opposite gender. Red dots were observed over doorways indicating youth are not allowed to
enter the office/room/area because there is no camera present however the facility did not have a policy
or written directive to support this practice. Additional areas were also identified as needing red dots
during the tour.
PREA posters and notices announcing the PREA Auditor’s onsite visit were observed throughout the
facility. The brochure posted for the victims’ advocacy services (Victim Service Center of Central
Florida) appeared to be designed for the general public use. The facility staff took immediate steps to
replace the brochure with posters which provides information specific to the resident population.
During the on-site visit, Cheryl Anderson, Certified PREA Auditor assisted with conducting specialized staff,
random direct care staff and resident interviews. Direct care staff were randomly selected from the facility’s shift
roster from all three shifts for interviews. Overall, the interviews revealed staff are knowledgeable of PREA
standards and were able to articulate their responsibilities toward preventing, detecting, reporting and responding
to sexual abuse and sexual harassment. Sixteen randomly selected residents form the facility’s roster were also
interviewed and found to be informed of their right to be free from sexual abuse and sexual harassment, how to
report sexual abuse and sexual harassment however the majority of residents were not aware of the services
provided by the victim advocacy agency. Staff conducted additional education sessions to review the services
provided by the victim advocacy agency. There were no residents identified in the targeted categories. There
were no residents in the targeted population to interview.
Additional information reviewed onsite included various forms; background checks; risk screening
instruments; education and training acknowledgement forms; electronic training records; logbooks; and
other documentation relative to the residents and staff members interviewed during the onsite visit.
The interim report was completed on November 30, 2017, due to the facility’s failure to comply with staffing
ratios and failure to document deviation from the staffing plan. A corrective action plan was implemented.
On March 14, 2018, during the corrective action phase, the Auditor received and reviewed documentation
indicating the staffing ratio status for each shift was being documented on the shift report however
complying with the staffing ratios was still a challenge for the facility. On May 31, 2018, the Auditor
received shift reports from all shifts between April 1, 2018 and May 31, 2018. A comparison of the data
revealed a significant reduction in the occurrence of deviation from the facility’s staff plan, as a result of the
numerous measures implemented by the agency and the facility.
Facility Characteristics
The auditor’s description of the audited facility should include details about the facility type, demographics and size of the
inmate, resident or detainee population, numbers and type of staff positions, configuration and layout of the facility,
numbers of housing units, description of housing units including any special housing units, a description of programs and
services, including food service and recreation. The auditor should describe how these details are relevant to PREA
implementation and compliance.
ORJDC processes approximately 2,513 youth annually with average daily population of 115 and an
average length of stay for residents is 11 days.
The facility employs 119 full-time staff. The management team consists of a Superintendent, two
Assistant Superintendents, and 11 supervisors. Medical staff are contracted through Maxim Healthcare
Services and mental health services are provided by Camelot Community Care. The Florida Department
of Education provides funding to the Orange County School Board to provide residents with academic
educational services. Facility staff provides direct supervision of youth in a safe, secure and humane
environment.
ORJDC provides comprehensive mental health and substance abuse services to all detained youth, as well as
education and healthcare. Various mental health services and groups are offered to youth
throughout their confinement. The center has a full-time Licensed Clinical Social Worker (LCSW).
serving as the designated mental health authority (DMHA) responsible for the overall coordination,
implementation and supervision of all mental health and substance abuse services provided at the center.
Mental health and substance abuse services are provided seven days per week by a LCSW and a non-
licensed master’s level clinician. There are two other Licensed Mental Health Counselors (LMHC) who
fill in as needed. The DMHA also provides face-to-face clinical supervision with directions, instructions,
and recommendations to the one non-licensed clinician. Additionally, there a part-time Licensed
Psychiatrist.
The facility is high custody with controlled entrance and egress for both staff and contractors. A metal
detector and wand are used at the pedestrian entrance. There are two control centers, one in the East
Annex and one in the West Annex to control entrances and monitor the facility’s 128-camera
surveillance system. Cameras may also be accessed and viewed in the Superintendent, Assistant
Superintendents and supervisors’ offices.
There are currently three living units for males in the East Annex and one for females in the West
Annex. Some youth are single room assigned and some males are assigned to two and three-bed rooms.
Youth are screened for placement based on results from Victimization and Sexually Aggressive
Behavior (VSAB) screening tool. Rooms are equipped with toilets, but no sinks. Sinks are located
adjacent to communal showers. Youth are locked in rooms at night and direct care staff conducts and
documents ten-minute checks.
The facility also contains a medical area, cafeteria, dayrooms, classroom and a large multi-purpose
room. Living units have their own outside recreation spaces.
Summary of Audit Findings
The summary should include the number of standards exceeded, number of standards met, and
number of standards not met, along with a list of each of the standards in each category. If
relevant, provide a summarized description of the corrective action plan, including deficiencies
observed, recommendations made, actions taken by the agency, relevant timelines, and methods
used by the auditor to reassess compliance.
Auditor Note: No standard should be found to be “Not Applicable” or “NA”. A compliance
determination must be made for each standard.
Number of Standards Exceeded: 0
No standard exceeded requirements.
Number of Standards Met: 41
All standards met requirements.
Number of Standards Not Met: 0
No standards did not meet requirements.
Summary of Corrective Action (if any)
The onsite audit revealed Orange Regional Juvenile Detention Center was not in compliance with the 1:8 staff to
juvenile ratio during waking hours or 1:16 during sleeping hours and deviations from the staffing plan were not
documented. During the 180-day Corrective Action Phase, the agency and the facility took significant steps to
ensure compliance with this standard as detailed under standard 115.313 of this report.
.
PREVENTION PLANNING
Standard 115.311: Zero tolerance of sexual abuse and sexual harassment; PREA
coordinator
All Yes/No Questions Must Be Answered by The Auditor to Complete the Report
115.311 (a)
▪ Does the agency have a written policy mandating zero tolerance toward all forms of sexual abuse and
sexual harassment? ☒ Yes ☐ No
▪ Does the written policy outline the agency’s approach to preventing, detecting, and responding to sexual
abuse and sexual harassment? ☒ Yes ☐ No
115.311 (b)
▪ Has the agency employed or designated an agency-wide PREA Coordinator? ☒ Yes ☐ No
▪ Is the PREA Coordinator position in the upper-level of the agency hierarchy? ☒ Yes ☐ No
▪ Does the PREA Coordinator have sufficient time and authority to develop, implement, and oversee agency
efforts to comply with the PREA standards in all of its facilities? ☒ Yes ☐ No
115.311 (c)
▪ If this agency operates more than one facility, has each facility designated a PREA compliance manager?
(N/A if agency operates only one facility.) ☒ Yes ☐ No ☐ NA
▪ Does the PREA compliance manager have sufficient time and authority to coordinate the facility’s efforts to
comply with the PREA standards? (N/A if agency operates only one facility.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
The Florida Department of Juvenile Justice (FDJJ) Policy 1919 PREA and the ORJDC Facility Operating
Procedure (FOP) PREA mandate zero-tolerance of sexual abuse and sexual harassment and outlines how
the facility carries out its approach to preventing, detecting and responding to sexual abuse and sexual
harassment. The policy includes definitions of prohibited behaviors and sanctions for those found to have
participated in prohibited behaviors. The policy also provides strategies and responses for reducing and
preventing sexual abuse and harassment.
ORJDC is a juvenile detention facility governed and operated by the FDJJ which employs a Statewide
PREA Coordinator who is in an upper-level management position within the agency as indicated on the
FDJJ’s organizational chart. The PREA Coordinator’s interview revealed he has sufficient time and
authority to develop, implement and oversee the agency’s efforts to comply with PREA standards in all
operated and contracted facilities.
The facility’s Acting Superintendent also serves as the Acting PREA Compliance Manager as indicated
on the facility’s organizational chart. An interview with the Acting PREA Compliance Manager revealed
he has sufficient time to oversee the facility’s PREA compliance efforts and to perform his other duties.
Standard 115.312: Contracting with other entities for the confinement of residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.312 (a)
▪ If this agency is public and it contracts for the confinement of its residents with private agencies or other
entities including other government agencies, has the agency included the entity’s obligation to adopt and
comply with the PREA standards in any new contract or contract renewal signed on or after August 20,
2012? (N/A if the agency does not contract with private agencies or other entities for the confinement of
residents.) ☒ Yes ☐ No ☐ NA
115.312 (b)
▪ Does any new contract or contract renewal signed on or after August 20, 2012 provide for agency contract
monitoring to ensure that the contractor is complying with the PREA standards? (N/A if the agency does not
contract with private agencies or other entities for the confinement of residents OR the response to
115.312(a)-1 is "NO".) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
Currently, FDJJ has 82 contracts with providers for the confinement of juveniles in residential facilities
throughout the State of Florida.
A review of a signed contract revealed provider’s agreement to comply with all requirements and
standards of the Prison Rape Elimination Act 28 CFR Part 115 as outlined in FDJJ Policy 1919.
All contracts require FDJJ to monitor the contractor’s compliance with PREA standards as verified
during the FDJJ Contract Administrator’s interview.
Standard 115.313: Supervision and monitoring
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.313 (a)
▪ Does the agency ensure that each facility has developed a staffing plan that provides for adequate levels of
staffing and, where applicable, video monitoring, to protect residents against sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility has implemented a staffing plan that provides for adequate levels
of staffing and, where applicable, video monitoring, to protect residents against sexual abuse? ☒ Yes ☐
No
▪ Does the agency ensure that each facility has documented a staffing plan that provides for adequate levels
of staffing and, where applicable, video monitoring, to protect residents against sexual abuse? ☒ Yes ☐
No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: The prevalence of
substantiated and unsubstantiated incidents of sexual abuse? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: Generally accepted
juvenile detention and correctional/secure residential practices? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: Any judicial findings of
inadequacy? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: Any findings of
inadequacy from Federal investigative agencies? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: Any findings of
inadequacy from internal or external oversight bodies? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: All components of the
facility’s physical plant (including “blind-spots” or areas where staff or residents may be isolated)? ☒ Yes
☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: The composition of the
resident population? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: The number and
placement of supervisory staff? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: Institution programs
occurring on a particular shift? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: Any applicable State or
local laws, regulations, or standards? ☒ Yes ☐ No
▪ Does the agency ensure that each facility’s staffing plan takes into consideration the 11 criteria below in
calculating adequate staffing levels and determining the need for video monitoring: Any other relevant
factors? ☒ Yes ☐ No
115.313 (b)
▪ Does the agency comply with the staffing plan except during limited and discrete exigent circumstances? ☒ Yes
☐ No
▪ In circumstances where the staffing plan is not complied with, does the facility document all deviations from
the plan? (N/A if no deviations from staffing plan.) ☒ Yes ☐ No ☐ NA
115.313 (c)
▪ Does the facility maintain staff ratios of a minimum of 1:8 during resident waking hours, except during
limited and discrete exigent circumstances? (N/A only until October 1, 2017.) ☒ Yes ☐ No ☐
NA
▪ Does the facility maintain staff ratios of a minimum of 1:16 during resident sleeping hours, except during
limited and discrete exigent circumstances? (N/A only until October 1, 2017.) ☒ Yes ☐ No ☐
NA
▪ Does the facility fully document any limited and discrete exigent circumstances during which the facility did
not maintain staff ratios? (N/A only until October 1, 2017.) ☒ Yes ☐ No ☐ NA
▪ Does the facility ensure only security staff are included when calculating these ratios? (N/A only until
October 1, 2017.) ☒ Yes ☐ No ☐ NA
▪ Is the facility obligated by law, regulation, or judicial consent decree to maintain the staffing ratios set forth
in this paragraph? ☒ Yes ☐ No
115.313 (d)
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed, determined,
and documented whether adjustments are needed to: The staffing plan established pursuant to paragraph (a) of
this section? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed,
determined, and documented whether adjustments are needed to: Prevailing staffing patterns? ☒ Yes ☐
No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed,
determined, and documented whether adjustments are needed to: The facility’s deployment of video
monitoring systems and other monitoring technologies? ☒ Yes ☐ No
▪ In the past 12 months, has the facility, in consultation with the agency PREA Coordinator, assessed,
determined, and documented whether adjustments are needed to: The resources the facility has available
to commit to ensure adherence to the staffing plan? ☒ Yes ☐ No
115.313 (e)
▪ Has the facility implemented a policy and practice of having intermediate-level or higher-level supervisors
conduct and document unannounced rounds to identify and deter staff sexual abuse and sexual
harassment? (N/A for non-secure facilities) ☒ Yes ☐ No ☐ NA
▪ Is this policy and practice implemented for night shifts as well as day shifts? (N/A for non-secure facilities)
☒ Yes ☐ No ☐ NA
▪ Does the facility have a policy prohibiting staff from alerting other staff members that these supervisory
rounds are occurring, unless such announcement is related to the legitimate operational functions of the
facility? (N/A for non-secure facilities) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 and ORJDC FOP PREA requires the facility to develop, implement and document an
approved staffing plan. Documentation along with the Acting Superintendent/Compliance Manager
interviews verified the development of the facility’s staffing plan, the continual assessment of adequate
staffing levels and the need for video monitoring. The staffing plan is based upon the facility’s capacity
of 124 residents however the average daily resident population has been 115 over the past 12 months.
The Acting Superintendent’s interview confirmed there is no law, regulation or judicial decree to
maintain staffing ratios of 1:8 staff to resident ratio during waking hours or a 1:16 staff to resident ratio
during sleeping hours however the facility’s staffing plan does reflect the required ratios. Observation
during the tour revealed the staff to residents’ ratio did not meet requirements in all areas. The facility
has a “holdover” requirement for direct care staff to be assigned up to one holdover day per week to
cover for staff who may not be able to come to work however the facility had 24 direct care staff
vacancies which precludes the “holdover” plan from being fully implemented.
ORJDC FOP PREA requires the facility to document deviations from the staffing plan on the
Justifications Tracking for Deviations from the Staffing Plan form however the facility has not
documented deviations as required.
During the 180-day Corrective Action Phase, the facility took the following steps to ensure compliance with
this standard:
• Ratio compliance was added to each shift report and supervisory staff were provided additional
training regarding documenting the staff ratios.
• Residents appropriate for transfers and courtesy holds are transported to other detention facilities
• Detention review process has been enhanced to expedite committed residents’ transfer to residential
programs.
• Staff from other FDJJ detention facilities and Regional Office fill in to cover staff shortages.
• Streamlined the initial training period for new direct care staff to reduce the time before on-the-job
training is conducted on posts.
• Hired new administrative staff including a Superintendent, two Captains and added an additional
Captain.
• Implemented 12-hour shifts for direct care staff.
• Piloted cross-over positions which use certified Juvenile Probation officers on a part-time basis to
assist with direct supervision of residents during evening activities.
• Implemented new staff recognition efforts to increase staff retention.
• In the process of piloting cross-over positions which use certified Juvenile Probation officers in a
part-time capacity to assist with direct supervision of youth during evening activities.
Documentation of deviations to the staffing plan was incorporated in each shift report and supervisory staff
received training on documenting staff ratios. A review of shift reports from February 8 – March 8, 2018 and
from April 1- May 31, 2018 revealed a significant reduction in the occurrence of deviation from the facility’s
staff plan as a result of the measures implemented. The facility has made a good faith effort to comply with
its staffing plan and with continued implementation of steps to reduce direct care staff vacancies, deviations
will continue to be limited and discrete.
Documentation of the annual review of the staffing plan dated May 11, 2017 was reviewed and found in
compliance with all elements contained in (d)-1 of this standard. The FDJJ Statewide PREA Coordinator
and the Acting Superintendent reviewed the staffing plan to determine if adjustments were needed
however no adjustments were made during the review.
The facility utilizes video monitoring combined with direct staff supervision to protect residents from
sexual abuse and sexual harassment. The facility has a total of 128 cameras throughout the facility. The
annual assessment of the staffing plan was reviewed on May 11, 2017 however there were no
recommendations made regarding upgrades to the surveillance system.
FDJJ Policy 1919 PREA and ORJDC FOP PREA require intermediate or higher-level staff to conduct
unannounced rounds to deter and identify staff sexual abuse and sexual harassment. An interview with
a higher- level staff member and a review of unannounced rounds documentation revealed over time
unannounced rounds are conducted on all three shifts in all areas of the facility.
Standard 115.315: Limits to cross-gender viewing and searches
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.315 (a)
▪ Does the facility always refrain from conducting any cross-gender strip or cross-gender visual body cavity
searches, except in exigent circumstances or by medical practitioners? ☒ Yes ☐ No
115.315 (b)
▪ Does the facility always refrain from conducting cross-gender pat-down searches in non-exigent
circumstances? ☒ Yes ☐ No ☐ NA
115.315 (c)
▪ Does the facility document and justify all cross-gender strip searches and cross-gender visual body cavity
searches? ☒ Yes ☐ No
▪ Does the facility document all cross-gender pat-down searches? ☒ Yes ☐ No
115.315 (d)
▪ Does the facility implement policies and procedures that enable residents to shower, perform bodily
functions, and change clothing without nonmedical staff of the opposite gender viewing their breasts,
buttocks, or genitalia, except in exigent circumstances or when such viewing is incidental to routine cell
checks? ☒ Yes ☐ No
▪ Does the facility require staff of the opposite gender to announce their presence when entering a resident
housing unit? ☒ Yes ☐ No
▪ In facilities (such as group homes) that do not contain discrete housing units, does the facility require staff
of the opposite gender to announce their presence when entering an area where residents are likely to be
showering, performing bodily functions, or changing clothing? (N/A for facilities with discrete housing units)
☒ Yes ☐ No ☐ NA
115.315 (e)
▪ Does the facility always refrain from searching or physically examining transgender or intersex residents for the
sole purpose of determining the resident’s genital status? ☒ Yes ☐ No
▪ If a resident’s genital status is unknown, does the facility determine genital status during conversations with the
resident, by reviewing medical records, or, if necessary, by learning that information as part of a broader medical
examination conducted in private by a medical practitioner? ☒ Yes ☐ No
115.315 (f)
▪ Does the facility/agency train security staff in how to conduct cross-gender pat down searches in a
professional and respectful manner, and in the least intrusive manner possible, consistent with security
needs? ☒ Yes ☐ No
▪ Does the facility/agency train security staff in how to conduct searches of transgender and intersex
residents in a professional and respectful manner, and in the least intrusive manner possible, consistent
with security needs? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP PREA prohibit cross-gender strip searches, or pat down
searches of youth, except in exigent circumstances and there have been no such searches conducted by
direct care staff in the past 12 months as verified by random staff and random resident interviews.
ORJDC FOP 5.11 Searches states body cavity searches requires the Superintendent’s authorization and
must be conducted by licensed medical personnel in a medical establishment. There were no body cavity
searches of residents in the past 12 months
ORJDC FOP PREA states the facility must be configured to allow residents to shower, perform bodily
functions and change clothing without staff of the opposite sex viewing their bodies. Staff and resident
interviews confirm there is no cross-gender viewing. Observation of the bathrooms revealed all shower
stalls have shower curtains to allow privacy while taking showers.
FDJJ Policy 1919 PREA and ORJDC FOP PREA require opposite sex staff, volunteers and contractors
entering housing units to announce themselves. Resident and random staff interviews verified this practice
is done on consistent bases.
FDJJ Policy 1919 PREA and ORJDC FOP PREA prohibit the search of a transgender or intersex resident
solely for the purpose of determining the resident’s genital status and staff interviews verified
compliance.
One hundred percent of direct care staff have received training on cross-gender pat down searches and
searches of transgender and intersex residents as verified during interviews of random staff. Training
curriculum and training logs were reviewed and confirmed compliance.
Standard 115.316: Residents with disabilities and residents who are limited English
proficient
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.316 (a)
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity
to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who are deaf or hard of hearing? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity
to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who are blind or have low vision? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity
to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who have intellectual disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity
to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who have psychiatric disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity
to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Residents who have speech disabilities? ☒ Yes ☐ No
▪ Does the agency take appropriate steps to ensure that residents with disabilities have an equal opportunity
to participate in or benefit from all aspects of the agency’s efforts to prevent, detect, and respond to sexual
abuse and sexual harassment, including: Other? (if "other," please explain in overall determination notes.)
☒ Yes ☐ No
▪ Do such steps include, when necessary, ensuring effective communication with residents who are deaf or
hard of hearing? ☒ Yes ☐ No
▪ Do such steps include, when necessary, providing access to interpreters who can interpret effectively,
accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary?
☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that ensure
effective communication with residents with disabilities including residents who: Have intellectual
disabilities? ☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that ensure
effective communication with residents with disabilities including residents who: Have limited reading skills?
☒ Yes ☐ No
▪ Does the agency ensure that written materials are provided in formats or through methods that ensure
effective communication with residents with disabilities including residents who: Are blind or have low
vision? ☒ Yes ☐ No
115.316 (b)
▪ Does the agency take reasonable steps to ensure meaningful access to all aspects of the agency’s efforts
to prevent, detect, and respond to sexual abuse and sexual harassment to residents who are limited
English proficient? ☒ Yes ☐ No
▪ Do these steps include providing interpreters who can interpret effectively, accurately, and impartially, both
receptively and expressively, using any necessary specialized vocabulary? ☒ Yes ☐ No
115.316 (c)
▪ Does the agency always refrain from relying on resident interpreters, resident readers, or other types of
resident assistants except in limited circumstances where an extended delay in obtaining an effective
interpreter could compromise the resident’s safety, the performance of first-response duties under
§115.364, or the investigation of the resident’s allegations? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP 3.09 PREA requires steps to be taken to ensure residents with disabilities or who are
limited English proficient are provided meaningful access to all aspects of the facility’s efforts to
prevent, protect and respond to sexual abuse and sexual harassment. This policy also states the
facility will not rely on resident interpreter, resident readers or any kind of resident assistants
except when a delay in obtaining interpreters services could jeopardize a residents’ safety
FDJJ’s Central Region has a blanket purchase order with Language Line Services, Inc. to provide
interpreter services for facilities in the Central Region.
A letter from Orange County Schools confirms their ability to provide services for hearing-impaired,
visually impaired and other residents on a as needed bases to provide them with an equal opportunity to
participate in or benefit from all aspects of the agency’s effort to prevent, detect and respond to sexual
abuse and sexual harassment. Mental Health professionals are also trained to provide appropriate
explanations regarding PREA to residents, when needed.
Random staff interviews verified the facility does not use resident assistants and there were no instances
of resident interpreter or readers being used in the past 12 months.
Written material used to ensure effective communication about PREA with residents with disabilities
and residents who are limited English proficient are available for use when needed.
Standard 115.317: Hiring and promotion decisions
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.317 (a)
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with residents who: Has
engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other
institution (as defined in 42 U.S.C. 1997)? ☒ Yes ☐ No
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with residents who: Has
been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force,
overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or
refuse? ☒ Yes ☐ No
▪ Does the agency prohibit the hiring or promotion of anyone who may have contact with residents who: Has
been civilly or administratively adjudicated to have engaged in the activity described in the question
immediately above? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact with residents
who: Has engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility,
or other institution (as defined in 42 U.S.C. 1997)? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact with residents
who: Has been convicted of engaging or attempting to engage in sexual activity in the community facilitated
by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to
consent or refuse? ☒ Yes ☐ No
▪ Does the agency prohibit the enlistment of services of any contractor who may have contact with residents
who: Has been civilly or administratively adjudicated to have engaged in the activity described in the
question immediately above? ☒ Yes ☐ No
115.317 (b)
▪ Does the agency consider any incidents of sexual harassment in determining whether to hire or promote
anyone, or to enlist the services of any contractor, who may have contact with residents? ☒ Yes ☐ No
115.317 (c)
▪ Before hiring new employees, who may have contact with residents, does the agency: Perform a criminal
background records check? ☒ Yes ☐ No
▪ Before hiring new employees, who may have contact with residents, does the agency: Consult any child
abuse registry maintained by the State or locality in which the employee would work? ☒ Yes ☐ No
▪ Before hiring new employees, who may have contact with residents, does the agency: Consistent with
Federal, State, and local law, make its best efforts to contact all prior institutional employers for information
on substantiated allegations of sexual abuse or any resignation during a pending investigation of an
allegation of sexual abuse? ☒ Yes ☐ No
115.317 (d)
▪ Does the agency perform a criminal background records check before enlisting the services of any
contractor who may have contact with residents? ☒ Yes ☐ No
▪ Does the agency consult applicable child abuse registries before enlisting the services of any contractor
who may have contact with residents? ☐ Yes ☒ No
115.317 (e)
▪ Does the agency either conduct criminal background records checks at least every five years of current
employees and contractors who may have contact with residents or have in place a system for otherwise
capturing such information for current employees? ☒ Yes ☐ No
115.317 (f)
▪ Does the agency ask all applicants and employees who may have contact with residents directly about
previous misconduct described in paragraph (a) of this section in written applications or interviews for hiring
or promotions? ☒ Yes ☐ No
▪ Does the agency ask all applicants and employees who may have contact with residents directly about
previous misconduct described in paragraph (a) of this section in any interviews or written self-evaluations
conducted as part of reviews of current employees? ☒ Yes ☐ No
▪ Does the agency impose upon employees a continuing affirmative duty to disclose any such misconduct?
☒ Yes ☐ No
115.317 (g)
▪ Does the agency consider material omissions regarding such misconduct, or the provision of materially
false information, grounds for termination? ☒ Yes ☐ No
115.317 (h)
▪ Unless prohibited by law, does the agency provide information on substantiated allegations of sexual abuse
or sexual harassment involving a former employee upon receiving a request from an institutional employer
for whom such employee has applied to work? (N/A if providing information on substantiated allegations of
sexual abuse or sexual harassment involving a former employee is prohibited by law.) ☒ Yes ☐ No ☐
NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1800 Background Screening, FDJJ Policy 1919 PREA and ORJDC FOP 3.09 Hiring and
Promotions address hiring and promotion processes and decisions, including the requirement for
background checks for new hires. The collective policies and interview with the Human Resource staff
member revealed information regarding the hiring process, completion of background checks, and the
grounds for termination. The policies are aligned with the requirements of the standard and provide that
background checks are conducted every five years. A review of a sample of personnel files confirmed
compliance.
A pre-hire form requires applicants to provide information regarding previously related sexual contact
with residents and prohibit enlisting the services of any contractor who may have contact with residents
who engaged in previous sexual misconduct.
According to the Human Resource staff, the facility considers any incidents of sexual abuse or sexual
harassment in determining whether to hire a person, contract for services, or whether to promote an
employee. Policies FDJJ 1800 and FDJJ 1919 and the Human Resource interview along with the Acting
Superintendent confirms staff have a continuing duty to report misconduct and provide omissions of
misconduct or providing false information will be grounds for termination.
The PREA Coordinator provided documentation the Florida State law does not allow FDJJ or other
agencies to contact the abuse registry for the purpose of screening applicants.
A review of personnel files for a sample of staff hired in the past 12 months revealed all had criminal
records checks and a sample review of personnel files of current staff employed for more than 5 years
revealed all have had criminal background checks conducted every five years.
Standard 115.318: Upgrades to facilities and technologies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.318 (a)
▪ If the agency designed or acquired any new facility or planned any substantial expansion or modification of
existing facilities, did the agency consider the effect of the design, acquisition, expansion, or modification
upon the agency’s ability to protect residents from sexual abuse? (N/A if agency/facility has not acquired a
new facility or made a substantial expansion to existing facilities since August 20, 2012, or since the last
PREA audit, whichever is later.) ☐ Yes ☐ No ☒ NA
115.318 (b)
▪ If the agency installed or updated a video monitoring system, electronic surveillance system, or other
monitoring technology, did the agency consider how such technology may enhance the agency’s ability to
protect residents from sexual abuse? (N/A if agency/facility has not installed or updated a video monitoring
system, electronic surveillance system, or other monitoring technology since August 20, 2012, or since the
last PREA audit, whichever is later.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ has not acquired any new facilities or made any structural modifications to ORJDC since the last PREA audit
in June 2014.
ORJDC FOP PREA requires when installing or updating a video monitoring system, electronic surveillance system
or other monitoring technology, the facility will consider how such technology may enhance the ability to protect
residents from sexual abuse.
Documentation of the annual staffing plan review which was held on May 11, 2017, revealed no recommendation
and no blind spots were identified at that time.
During the facility tour, the video surveillance system was viewed in the Main Control Room. Camera upgrades
and additions since the last PREA audit in 2014 were pointed out by staff.
RESPONSIVE PLANNING
Standard 115.321: Evidence protocol and forensic medical examinations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.321 (a)
▪ If the agency is responsible for investigating allegations of sexual abuse, does the agency follow a uniform
evidence protocol that maximizes the potential for obtaining usable physical evidence for administrative
proceedings and criminal prosecutions? (N/A if the agency/facility is not responsible for conducting any form
of criminal OR administrative sexual abuse investigations.) ☐ Yes ☐ No ☒ NA
115.321 (b)
▪ Is this protocol developmentally appropriate for youth where applicable? (N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative sexual abuse investigations.) ☐ Yes ☐
No ☒ NA
▪ Is this protocol, as appropriate, adapted from or otherwise based on the most recent edition of the U.S.
Department of Justice’s Office on Violence Against Women publication, “A National Protocol for Sexual
Assault Medical Forensic Examinations, Adults/Adolescents,” or similarly comprehensive and authoritative
protocols developed after 2011? (N/A if the agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations.) ☐ Yes ☐ No ☒ NA
115.321 (c)
▪ Does the agency offer all residents who experience sexual abuse access to forensic medical examinations,
whether on-site or at an outside facility, without financial cost, where evidentiarily or medically appropriate?
☒ Yes ☐ No
▪ Are such examinations performed by Sexual Assault Forensic Examiners (SAFEs) or Sexual Assault Nurse
Examiners (SANEs) where possible? ☒ Yes ☐ No
▪ If SAFEs or SANEs cannot be made available, is the examination performed by other qualified medical
practitioners (they must have been specifically trained to conduct sexual assault forensic exams)? ☒ Yes
☐ No
▪ Has the agency documented its efforts to provide SAFEs or SANEs? ☒ Yes ☐ No
115.321 (d)
▪ Does the agency attempt to make available to the victim a victim advocate from a rape crisis center? ☒ Yes
☐ No
▪ If a rape crisis center is not available to provide victim advocate services, does the agency make available
to provide these services a qualified staff member from a community-based organization, or a qualified
agency staff member? ☒ Yes ☐ No
▪ Has the agency documented its efforts to secure services from rape crisis centers? ☒ Yes ☐
No
115.321 (e)
▪ As requested by the victim, does the victim advocate, qualified agency staff member, or qualified
community-based organization staff member accompany and support the victim through the forensic
medical examination process and investigatory interviews? ☒ Yes ☐ No
▪ As requested by the victim, does this person provide emotional support, crisis intervention, information, and
referrals? ☒ Yes ☐ No
115.321 (f)
▪ If the agency itself is not responsible for investigating allegations of sexual abuse, has the agency
requested that the investigating entity follow the requirements of paragraphs (a) through (e) of this section?
(N/A if the agency/facility is responsible for conducting criminal AND administrative sexual abuse
investigations.) ☒ Yes ☐ No ☐ NA
115.321 (g)
▪ Auditor is not required to audit this provision.
115.321 (h)
▪ If the agency uses a qualified agency staff member or a qualified community-based staff member for the
purposes of this section, has the individual been screened for appropriateness to serve in this role and
received education concerning sexual assault and forensic examination issues in general? (Check N/A if
agency attempts to make a victim advocate from a rape crisis center available to victims per 115.321(d)
above.) ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA requires staff to report allegations of sexual abuse to the Orange County Sheriff’s
Department for criminal investigations and to the Florida Central Abuse Hotline and FDJJ’s Central
Communication Center (CCC).ORJDC does not have a Memorandum of Understanding (MOU) however
the policy states when the Orange County Sheriff’s Department arrives at the facility to conduct an
investigation, facility staff will provide and request the investigative agency to follow the DJJ Inspector
General Directive 3-05 (uniform evidence protocol that maximizes the potential for obtaining usable
physical evidence for criminal prosecution and appropriate for youth).
The policy also requires resident victims of sexual assaults to have access to forensic examinations.
During the past 12 months, there were no forensic examinations conducted.
Standard 115.322: Policies to ensure referrals of allegations for investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.322 (a)
▪ Does the agency ensure an administrative or criminal investigation is completed for all allegations of sexual
abuse? ☒ Yes ☐ No
▪ Does the agency ensure an administrative or criminal investigation is completed for all allegations of sexual
harassment? ☒ Yes ☐ No
115.322 (b)
▪ Does the agency have a policy and practice in place to ensure that allegations of sexual abuse or sexual
harassment are referred for investigation to an agency with the legal authority to conduct criminal
investigations, unless the allegation does not involve potentially criminal behavior? ☒ Yes ☐ No
▪ Has the agency published such policy on its website or, if it does not have one, made the policy available
through other means? ☒ Yes ☐ No
▪ Does the agency document all such referrals? ☒ Yes ☐ No
115.322 (c)
▪ If a separate entity is responsible for conducting criminal investigations, does such publication describe the
responsibilities of both the agency and the investigating entity? [N/A if the agency/facility is responsible for
criminal investigations. See 115.321(a).] ☒ Yes ☐ No ☐ NA
115.322 (d)
▪ Auditor is not required to audit this provision.
115.322 (e)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA requires the immediate referral of all sexual abuse allegations to the Orange County
Sheriff’s Department, the Florida Abuse Hotline and FDJJ’s CCC. In the past 12 months, ORJDC received
one allegations of sexual harassment. The allegation was reported for investigation to the Florida Abuse
Hotline and FDJJ’s CCC in accordance with the facility’s policy. Interviews with the Acting
Superintendent and random direct care staff verified their knowledge of the policy’s requirements.
A review of FDJJ’s website revealed a PREA page includes investigative entities responsibilities for
conducting investigations of allegations of sexual abuse.
TRAINING AND EDUCATION
Standard 115.331: Employee training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.331 (a)
▪ Does the agency train all employees who may have contact with residents on: Its zero-tolerance policy for
sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to fulfill their
responsibilities under agency sexual abuse and sexual harassment prevention, detection, reporting, and
response policies and procedures? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: Residents’ right to be free
from sexual abuse and sexual harassment ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The right of residents and
employees to be free from retaliation for reporting sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The dynamics of sexual
abuse and sexual harassment in juvenile facilities? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: The common reactions of
juvenile victims of sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to detect and respond
to signs of threatened and actual sexual abuse and how to distinguish between consensual sexual contact
and sexual abuse between residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to avoid inappropriate
relationships with residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to communicate
effectively and professionally with residents, including lesbian, gay, bisexual, transgender, intersex, or
gender nonconforming residents? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: How to comply with relevant
laws related to mandatory reporting of sexual abuse to outside authorities? ☒ Yes ☐ No
▪ Does the agency train all employees who may have contact with residents on: Relevant laws regarding the
applicable age of consent? ☒ Yes ☐ No
115.331 (b)
▪ Is such training tailored to the unique needs and attributes of residents of juvenile facilities? ☒
Yes ☐ No
▪ Is such training tailored to the gender of the residents at the employee’s facility? ☒ Yes ☐ No
▪ Have employees received additional training if reassigned from a facility that houses only male residents to
a facility that houses only female residents, or vice versa? ☒ Yes ☐ No
115.331 (c)
▪ Have all current employees who may have contact with residents received such training? ☒ Yes
☐ No
▪ Does the agency provide each employee with refresher training every two years to ensure that all
employees know the agency’s current sexual abuse and sexual harassment policies and procedures? ☒
Yes ☐ No
▪ In years in which an employee does not receive refresher training, does the agency provide refresher
information on current sexual abuse and sexual harassment policies? ☒ Yes ☐ No
115.331 (d)
▪ Does the agency document, through employee signature or electronic verification, that employees
understand the training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ provides PREA training through SkillPro, an online E-Learning training system. At the end of the
PREA course, staff are tested and receive a score based upon their comprehension of the material
provided. A review of the ORJDC FOP PREA, the training curriculum, staff training records and random
direct care staff interviews confirms staff receive PREA training during orientation and refresher training
every two years. Specific topics as outlined in the policy and the curriculum are consistent with this
standard’s requirements and are tailored to the facility’s male and female resident population. One-
hundred percent of employees are trained as new hires regardless of their previous experience.
A sampling of employees’ training records was reviewed, and random staff interviews verified staff
comprehension of their responsibilities relating to PREA standards. Staff are required to sign an
acknowledgement form stating they have completed the training and understand FDJJ Policy 1919
PREA.
Standard 115.332: Volunteer and contractor training
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.332 (a)
▪ Has the agency ensured that all volunteers and contractors who have contact with residents have been
trained on their responsibilities under the agency’s sexual abuse and sexual harassment prevention,
detection, and response policies and procedures? ☒ Yes ☐ No
115.332 (b)
▪ Have all volunteers and contractors who have contact with residents been notified of the agency’s zero-
tolerance policy regarding sexual abuse and sexual harassment and informed how to report such incidents
(the level and type of training provided to volunteers and contractors shall be based on the services they
provide and level of contact they have with residents)? ☒ Yes ☐ No
115.332 (c)
▪ Does the agency maintain documentation confirming that volunteers and contractors understand the
training they have received? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP PREA require volunteers and contracted providers who have
contact with residents to be trained on their responsibilities on sexual misconduct prevention, detection,
reporting and responding to sexual abuse, assault or sexual harassment. The level and type training
provided to contract providers and volunteers is based upon the service they provide and the level of
contact they have with youth, but at a minimum all contract providers and volunteers will be informed of
FDJJ’s policy on zero tolerance against sexual abuse and sexual harassment as well as informed on how
to report incidents.
Interviews with contract providers along with the review of training records revealed they are given a
downloaded version of the SkillPro on-line PREA training, asked to read it and given the opportunity to
ask questions prior to signing acknowledging they understand the contents of the documents regarding
PREA.
Standard 115.333: Resident education
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.333 (a)
▪ During intake, do residents receive information explaining the agency’s zero-tolerance policy regarding
sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ During intake, do residents receive information explaining how to report incidents or suspicions of sexual
abuse or sexual harassment? ☒ Yes ☐ No
▪ Is this information presented in an age-appropriate fashion? ☒ Yes ☐ No
115.333 (b)
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to residents
either in person or through video regarding: Their rights to be free from sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to residents
either in person or through video regarding: Their rights to be free from retaliation for reporting such
incidents? ☒ Yes ☐ No
▪ Within 10 days of intake, does the agency provide age-appropriate comprehensive education to residents
either in person or through video regarding: Agency policies and procedures for responding to such
incidents? ☒ Yes ☐ No
115.333 (c)
▪ Have all residents received such education? ☒ Yes ☐ No
▪ Do residents receive education upon transfer to a different facility to the extent that the policies and
procedures of the resident’s new facility differ from those of the previous facility? ☒ Yes ☐ No
115.333 (d)
▪ Does the agency provide resident education in formats accessible to all residents including those who: Are
limited English proficient? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including those who: Are
deaf? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including those who: Are
visually impaired? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including those who: Are
otherwise disabled? ☒ Yes ☐ No
▪ Does the agency provide resident education in formats accessible to all residents including those who:
Have limited reading skills? ☒ Yes ☐ No
115.333 (e)
▪ Does the agency maintain documentation of resident participation in these education sessions? ☒ Yes
☐ No
115.333 (f)
▪ In addition to providing such education, does the agency ensure that key information is continuously and
readily available or visible to residents through posters, resident handbooks, or other written formats? ☒
Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP 3.09 PREA require during intake, residents to receive
comprehensive education regarding the facility’s zero tolerance policy and how to report sexual abuse
and sexual harassment. According to intake staff, they explain the PREA handout to residents and
residents sign verifying they received the information. Documentation of resident’s signatures were
reviewed and confirmed during resident interviews. All residents interviewed stated they received this
information the same day they arrived. The policies also require within 10 day of intake a
comprehensive training will be provided. Sample rosters of the comprehensive training were provided
for review.
Staff present the PREA information in a manner accessible to all residents. If needed, the facility has
internal and external resources to provide translation services through staff or Language Line Services
for residents who may be limited English proficient or through Hillsborough County Schools for hearing
and visual impairment services and for residents with other disabilities.
Resident interviews revealed youth have limited to no knowledge of the victim’s advocacy service
posted in each housing module however since the onsite visit documentation was provided of corrective
action taken to provide additional education regarding victim’s advocacy services provided by Victim
Service Center of Central Florida.
Standard 115.334: Specialized training: Investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.334 (a)
▪ In addition to the general training provided to all employees pursuant to §115.331, does the agency ensure
that, to the extent the agency itself conducts sexual abuse investigations, its investigators have received
training in conducting such investigations in confinement settings? [N/A if the agency does not conduct any
form of administrative or criminal sexual abuse investigations. See 115.321(a).] ☒ Yes ☐ No ☐ NA
115.334 (b)
▪ Does this specialized training include: Techniques for interviewing juvenile sexual abuse victims? [N/A if the
agency does not conduct any form of administrative or criminal sexual abuse investigations. See
115.321(a).] ☒ Yes ☐ No ☐ NA
▪ Does this specialized training include: Proper use of Miranda and Garrity warnings? [N/A if the agency does
not conduct any form of administrative or criminal sexual abuse investigations. See 115.321(a).] ☒ Yes ☐
No ☐ NA
▪ Does this specialized training include: Sexual abuse evidence collection in confinement settings? [N/A if the
agency does not conduct any form of administrative or criminal sexual abuse investigations. See
115.321(a).] ☒ Yes ☐ No ☐ NA
▪ Does this specialized training include: The criteria and evidence required to substantiate a case for
administrative action or prosecution referral? [N/A if the agency does not conduct any form of administrative
or criminal sexual abuse investigations. See 115.321(a).] ☒ Yes ☐ No ☐ NA
115.334 (c)
▪ Does the agency maintain documentation that agency investigators have completed the required
specialized training in conducting sexual abuse investigations? [N/A if the agency does not conduct any
form of administrative or criminal sexual abuse investigations. See 115.321(a).] ☒ Yes ☐ No ☐ NA
115.334 (d)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☒
Exceeds Standard (Substantially exceeds requirement of standards)
☐
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA states local law enforcement agencies and the Florida Department of Children
and Families Services conduct criminal investigations into allegations of sexual abuse. FDJJ’s Office of
Inspector General (OIG) conducts administrative and management reviews, separate and apart from any
criminal investigation.
The policy further states the OIG staff will be trained on the policies and procedures for the Department
policies and procedures related to handling of sexual misconduct incidents and reports.
Facility staff does not conduct administrative nor criminal investigations into allegations of sexual abuse and
sexual harassment.
Standard 115.335: Specialized training: Medical and mental health care
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.335 (a)
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners who work
regularly in its facilities have been trained in: How to detect and assess signs of sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners who work
regularly in its facilities have been trained in: How to preserve physical evidence of sexual abuse? ☒ Yes
☐ No
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners who work
regularly in its facilities have been trained in: How to respond effectively and professionally to juvenile
victims of sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency ensure that all full- and part-time medical and mental health care practitioners who work
regularly in its facilities have been trained in: How and to whom to report allegations or suspicions of sexual
abuse and sexual harassment? ☒ Yes ☐ No
115.335 (b)
▪ If medical staff employed by the agency conduct forensic examinations, do such medical staff receive
appropriate training to conduct such examinations? (N/A if agency medical staff at the facility do not
conduct forensic exams.) ☐ Yes ☐ No ☒ NA
115.335 (c)
▪ Does the agency maintain documentation that medical and mental health practitioners have received the
training referenced in this standard either from the agency or elsewhere? ☒ Yes ☐ No
115.335 (d)
▪ Do medical and mental health care practitioners employed by the agency also receive training mandated for
employees by §115.331? ☒ Yes ☐ No
▪ Do medical and mental health care practitioners contracted by and volunteering for the agency also receive
training mandated for contractors and volunteers by §115.332? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA requires PREA training for all employees and specialized training for all full and
part time medical and mental health staff.
Specialized Medical and Mental Health training is provided on SkillPro, FDJJ’s online E-Learning
system. Documentation of specialized training was reviewed for all medical and mental health staff and
confirmed during interviews of medical and mental health staff.
Forensic examinations are not conducted by the facility’s medical staff as verified during the medical
staff interview. Forensic examinations are conducted at the Victims Service Center of Central Florida by
SANE or SAFE certified examiners.
SCREENING FOR RISK OF SEXUAL VICTIMIZATION AND ABUSIVENESS
Standard 115.341: Screening for risk of victimization and abusiveness
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.341 (a)
▪ Within 72 hours of the resident’s arrival at the facility, does the agency obtain and use information about
each resident’s personal history and behavior to reduce risk of sexual abuse by or upon a resident? ☒ Yes
☐ No
▪ Does the agency also obtain this information periodically throughout a resident’s confinement? ☒ Yes ☐
No
115.341 (b)
▪ Are all PREA screening assessments conducted using an objective screening instrument? ☒ Yes
☐ No
115.341 (c)
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Prior sexual victimization or abusiveness? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Any gender nonconforming appearance or manner or identification as lesbian, gay,
bisexual, transgender, or intersex, and whether the resident may therefore be vulnerable to sexual abuse?
☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Current charges and offense history? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Age? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Level of emotional and cognitive development? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Physical size and stature? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Mental illness or mental disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Intellectual or developmental disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Physical disabilities? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: The resident’s own perception of vulnerability? ☒ Yes ☐ No
▪ During these PREA screening assessments, at a minimum, does the agency attempt to ascertain
information about: Any other specific information about individual residents that may indicate heightened
needs for supervision, additional safety precautions, or separation from certain other residents? ☒ Yes ☐
No
115.341 (d)
▪ Is this information ascertained: Through conversations with the resident during the intake process and
medical mental health screenings? ☒ Yes ☐ No
▪ Is this information ascertained: During classification assessments? ☒ Yes ☐ No
▪ Is this information ascertained: By reviewing court records, case files, facility behavioral records, and other
relevant documentation from the resident’s files? ☒ Yes ☐ No
115.341 (e)
▪ Has the agency implemented appropriate controls on the dissemination within the facility of responses to
questions asked pursuant to this standard in order to ensure that sensitive information is not exploited to the
resident’s detriment by staff or other residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA requires staff to complete the FDJJ’s Vulnerability to Victimization and Sexually
Aggressive Behavior (VSAB) form if youth arrives from the Juvenile Assessment Center (JAC) without a
completed form or is returning from a residential program. The JAC staff and intake staff obtain
information from court records, current charges, and interviews with the resident and his/her
parents/guardians. The intake staff interview confirmed compliance with this standard.
A review of VSAB forms in residents’ files and resident interviews revealed risk screenings are being
conducted and/or reviewed by intake staff upon arrival. The VSAB form includes each component
contained in section (c) of this standard.
Resident interviews indicated they were asked whether they identify with being gay, bi-sexual, transgender or
intersex, if they think they are in danger of sexual abuse and if they have any disabilities. Random resident
interviews verified they were asked the same questions by mental health staff during their initial interview.
Completed VSAB forms are maintained in residents’ medical and intake files and are available to staff
only on a need to know bases.
Standard 115.342: Use of screening information
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.342 (a)
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently, with the goal
of keeping all residents safe and free from sexual abuse, to make: Housing Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently, with the goal
of keeping all residents safe and free from sexual abuse, to make: Bed assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently, with the goal
of keeping all residents safe and free from sexual abuse, to make: Work Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently, with the goal
of keeping all residents safe and free from sexual abuse, to make: Education Assignments? ☒ Yes ☐ No
▪ Does the agency use all of the information obtained pursuant to § 115.341 and subsequently, with the goal
of keeping all residents safe and free from sexual abuse, to make: Program Assignments? ☒ Yes ☐ No
115.342 (b)
▪ Are residents isolated from others only as a last resort when less restrictive measures are inadequate to
keep them and other residents safe, and then only until an alternative means of keeping all residents safe
can be arranged? ☐ Yes ☒ No
▪ During any period of isolation, does the agency always refrain from denying residents daily large-muscle
exercise? ☒ Yes ☐ No
▪ During any period of isolation, does the agency always refrain from denying residents any legally required
educational programming or special education services? ☒ Yes ☐ No
▪ Do residents in isolation receive daily visits from a medical or mental health care clinician? ☒ Yes ☐
No
▪ Do residents also have access to other programs and work opportunities to the extent possible? ☒ Yes ☐
No
115.342 (c)
▪ Does the agency always refrain from placing: Lesbian, gay, and bisexual residents in particular housing,
bed, or other assignments solely on the basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency always refrain from placing: Transgender residents in particular housing, bed, or other
assignments solely on the basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency always refrain from placing: Intersex residents in particular housing, bed, or other
assignments solely on the basis of such identification or status? ☒ Yes ☐ No
▪ Does the agency always refrain from considering lesbian, gay, bisexual, transgender, or intersex
identification or status as an indicator or likelihood of being sexually abusive? ☒ Yes ☐ No
115.342 (d)
▪ When deciding whether to assign a transgender or intersex resident to a facility for male or female
residents, does the agency consider on a case-by-case basis whether a placement would ensure the
resident’s health and safety, and whether a placement would present management or security problems
(NOTE: if an agency by policy or practice assigns residents to a male or female facility on the basis of
anatomy alone, that agency is not in compliance with this standard)? ☒ Yes ☐ No
▪ When making housing or other program assignments for transgender or intersex residents, does the
agency consider on a case-by-case basis whether a placement would ensure the resident’s health and
safety, and whether a placement would present management or security problems? ☒ Yes ☐ No
115.342 (e)
▪ Are placement and programming assignments for each transgender or intersex resident reassessed at least
twice each year to review any threats to safety experienced by the resident? ☒ Yes ☐ No
115.342 (f)
▪ Are each transgender or intersex resident’s own views with respect to his or her own safety given serious
consideration when making facility and housing placement decisions and programming assignments? ☒
Yes ☐ No
115.342 (g)
▪ Are transgender and intersex residents given the opportunity to shower separately from other residents? ☒
Yes ☐ No
115.342 (h)
▪ If a resident is isolated pursuant to paragraph (b) of this section, does the facility clearly document: The
basis for the facility’s concern for the resident’s safety? (N/A for h and i if facility doesn’t use isolation?) ☒
Yes ☐ No ☐ NA
▪ If a resident is isolated pursuant to paragraph (b) of this section, does the facility clearly document: The
reason why no alternative means of separation can be arranged? (N/A for h and i if facility doesn’t use
isolation?) ☒ Yes ☐ No ☐ NA
115.342 (i)
▪ In the case of each resident who is isolated as a last resort when less restrictive measures are inadequate
to keep them and other residents safe, does the facility afford a review to determine whether there is a
continuing need for separation from the general population EVERY 30 DAYS? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA requires victimization screening information to be used to determine a resident’s
room assignment and room’s proximity to direct care staff to ensure resident’s safety. The Compliance
Manager’s interview confirmed the facility’s compliance with this standard. The facility also utilizes the
Classification Alerts to ensure that staff working directly with residents are advised if the resident is
identified as being at risk for victimization or posing a risk.
ORJDC FOP PREA precludes lesbian, gay, bi-sexual, transgender and intersex residents from being
placed in a module and states LGBTI identification or status is not an indicator of likelihood of
being sexually abusive. Transgender or intersex resident’s own view with respect to his/her safety
will be given serious consideration. The Compliance Manager’s interview also verified compliance
with this standard.
Transgender and intersex residents are given the opportunity to shower separately from other youth.
The policy also states isolation or room restriction may be used as a last resort when less restrictive
measures are inadequate to ensure youths safety and only until an alternative means of keeping all youth
safe can be arranged.
REPORTING
Standard 115.351: Resident reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.351 (a)
▪ Does the agency provide multiple internal ways for residents to privately report: Sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report: Retaliation by other
residents or staff for reporting sexual abuse and sexual harassment? ☒ Yes ☐ No
▪ Does the agency provide multiple internal ways for residents to privately report: Staff neglect or violation of
responsibilities that may have contributed to such incidents? ☒ Yes ☐ No
115.351 (b)
▪ Does the agency also provide at least one way for residents to report sexual abuse or sexual harassment to
a public or private entity or office that is not part of the agency? ☒ Yes ☐ No
▪ Is that private entity or office able to receive and immediately forward resident reports of sexual abuse and
sexual harassment to agency officials? ☒ Yes ☐ No
▪ Does that private entity or office allow the resident to remain anonymous upon request? ☒ Yes ☐
No
▪ Are residents detained solely for civil immigration purposes provided information on how to contact relevant
consular officials and relevant officials at the Department of Homeland Security to report sexual abuse or
harassment? ☒ Yes ☐ No
115.351 (c)
▪ Do staff members accept reports of sexual abuse and sexual harassment made verbally, in writing,
anonymously, and from third parties? ☒ Yes ☐ No
▪ Do staff members promptly document any verbal reports of sexual abuse and sexual harassment? ☒ Yes
☐ No
115.351 (d)
▪ Does the facility provide residents with access to tools necessary to make a written report? ☒ Yes ☐
No
▪ Does the agency provide a method for staff to privately report sexual abuse and sexual harassment of
residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the standard for the
relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the compliance
or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s conclusions. This discussion
must also include corrective action recommendations where the facility does not meet the standard. These
recommendations must be included in the Final Report, accompanied by information on specific corrective actions taken
by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA provides multiple ways internal ways for residents to privately report sexual abuse,
sexual harassment, retaliation and staff neglect including telling a trusted staff member or filling out a
PREA Reporting form and placing it in a secure drop box. Random resident interviews confirmed their
knowledge of this procedure. During the facility tour, PREA Reporting forms were not readily available
to residents in their housing modules however the facility staff took corrective action immediately to
ensure residents have unimpeded access to the forms.
The FOP PREA requires youth to have one way of reporting sexual abuse and sexual harassment to a
public or private entity or office not a part of the agency. Residents may call the Florida Abuse Hot Line
or call the victim’s advocate hotline (Victims Service Center of Central Florida). Residents may request
to use a telephone with some degree of privacy to call the hotline without having to obtain staff
permission, The FOP mandates staff not to question residents about the reason for the call. A resident can
also request writing materials write and send a letter to one of these sources. Random residents
interviewed were aware of the abuse hotline and were able to articulate how they could gain access.
A youth has the option of calling or writing his/her parent(s) or guardian or calling or writing his/her
attorney or legal representative.
The facility has available Consular Notification and Reference cards to assist residents detained solely for civil
immigration purposes.
Standard 115.352: Exhaustion of administrative remedies
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.352 (a)
▪ Is the agency exempt from this standard? NOTE: The agency is exempt ONLY if it does not
have administrative procedures to address resident grievances regarding sexual abuse. This
does not mean the agency is exempt simply because a resident does not have to or is not
ordinarily expected to submit a grievance to report sexual abuse. This means that as a matter of
explicit policy, the agency does not have an administrative remedies process to address sexual
abuse. ☒ Yes ☐ No ☐ NA
115.352 (b)
▪ Does the agency permit residents to submit a grievance regarding an allegation of sexual abuse
without any type of time limits? (The agency may apply otherwise-applicable time limits to any
portion of a grievance that does not allege an incident of sexual abuse.) (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the agency always refrain from requiring a resident to use any informal grievance process,
or to otherwise attempt to resolve with staff, an alleged incident of sexual abuse? (N/A if agency
is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (c)
▪ Does the agency ensure that: A resident who alleges sexual abuse may submit a grievance
without submitting it to a staff member who is the subject of the complaint? (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the agency ensure that: Such grievance is not referred to a staff member who is the
subject of the complaint? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (d)
▪ Does the agency issue a final agency decision on the merits of any portion of a grievance
alleging sexual abuse within 90 days of the initial filing of the grievance? (Computation of the
90-day time period does not include time consumed by residents in preparing any administrative
appeal.) (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ If the agency determines that the 90-day timeframe is insufficient to make an appropriate
decision and claims an extension of time [the maximum allowable extension of time to respond
is 70 days per 115.352(d)(3)], does the agency notify the resident in writing of any such
extension and provide a date by which a decision will be made? (N/A if agency is exempt from
this standard.) ☐ Yes ☐ No ☒ NA
▪ At any level of the administrative process, including the final level, if the resident does not
receive a response within the time allotted for reply, including any properly noticed extension,
may a resident consider the absence of a response to be a denial at that level? (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
PREA Audit Report Page 45 of 83 Facility Name – double click to change
115.352 (e)
▪ Are third parties, including fellow residents, staff members, family members, attorneys, and
outside advocates, permitted to assist residents in filing requests for administrative remedies
relating to allegations of sexual abuse? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
▪ Are those third parties also permitted to file such requests on behalf of residents? (If a third
party, other than a parent or legal guardian, files such a request on behalf of a resident, the
facility may require as a condition of processing the request that the alleged victim agree to
have the request filed on his or her behalf, and may also require the alleged victim to personally
pursue any subsequent steps in the administrative remedy process.) (N/A if agency is exempt
from this standard.) ☐ Yes ☐ No ☒ NA
▪ If the resident declines to have the request processed on his or her behalf, does the agency
document the resident’s decision? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☐ NA
▪ Is a parent or legal guardian of a juvenile allowed to file a grievance regarding allegations of
sexual abuse, including appeals, on behalf of such juvenile? (N/A if agency is exempt from this
standard.) ☐ Yes ☐ No ☒ NA
▪ If a parent or legal guardian of a juvenile files a grievance (or an appeal) on behalf of a juvenile
regarding allegations of sexual abuse, is it the case that those grievances are not conditioned
upon the juvenile agreeing to have the request filed on his or her behalf? (N/A if agency is
exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (f)
▪ Has the agency established procedures for the filing of an emergency grievance alleging that a
resident is subject to a substantial risk of imminent sexual abuse? (N/A if agency is exempt from
this standard.) ☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance alleging a resident is subject to a substantial risk of
imminent sexual abuse, does the agency immediately forward the grievance (or any portion
thereof that alleges the substantial risk of imminent sexual abuse) to a level of review at which
immediate corrective action may be taken? (N/A if agency is exempt from this standard.).
☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance described above, does the agency provide an initial
response within 48 hours? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ After receiving an emergency grievance described above, does the agency issue a final agency
decision within 5 calendar days? (N/A if agency is exempt from this standard.)
☐ Yes ☐ No ☒ NA
▪ Does the initial response and final agency decision document the agency’s determination
whether the resident is in substantial risk of imminent sexual abuse? (N/A if agency is exempt
from this standard.) ☐ Yes ☐ No ☒ NA
PREA Audit Report Page 46 of 83 Facility Name – double click to change
▪ Does the initial response document the agency’s action(s) taken in response to the emergency
grievance? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
▪ Does the agency’s final decision document the agency’s action(s) taken in response to the
emergency grievance? (N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
115.352 (g)
▪ If the agency disciplines a resident for filing a grievance related to alleged sexual abuse, does it
do so ONLY where the agency demonstrates that the resident filed the grievance in bad faith?
(N/A if agency is exempt from this standard.) ☐ Yes ☐ No ☒ NA
Auditor Overall Compliance Determination
☐ Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐ Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC FOP PREA states the facility is exempt from this standard because it does not have
administrative procedures in place for residents to report allegations of sexual abuse and sexual
harassment through the grievance procedure.
Standard 115.353: Resident access to outside confidential support services
and legal representation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.353 (a)
▪ Does the facility provide residents with access to outside victim advocates for emotional support
services related to sexual abuse by providing, posting, or otherwise making assessible mailing
addresses and telephone numbers, including toll-free hotline numbers where available, of local,
State, or national victim advocacy or rape crisis organizations? ☒ Yes ☐ No
▪ Does the facility provide persons detained solely for civil immigration purposes mailing
addresses and telephone numbers, including toll-free hotline numbers where available of local,
State, or national immigrant services agencies? ☒ Yes ☐ No
PREA Audit Report Page 47 of 83 Facility Name – double click to change
▪ Does the facility enable reasonable communication between residents and these organizations
and agencies, in as confidential a manner as possible? ☒ Yes ☐ No
115.353 (b)
▪ Does the facility inform residents, prior to giving them access, of the extent to which such
communications will be monitored and the extent to which reports of abuse will be forwarded to
authorities in accordance with mandatory reporting laws? ☒ Yes ☐ No
115.353 (c)
▪ Does the agency maintain or attempt to enter into memoranda of understanding or other
agreements with community service providers that are able to provide residents with confidential
emotional support services related to sexual abuse? ☒ Yes ☐ No
▪ Does the agency maintain copies of agreements or documentation showing attempts to enter
into such agreements? ☒ Yes ☐ No
115.353 (d)
▪ Does the facility provide residents with reasonable and confidential access to their attorneys or
other legal representation? ☒ Yes ☐ No
▪ Does the facility provide residents with reasonable access to parents or legal guardians?
☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
PREA Audit Report Page 48 of 83 Facility Name – double click to change
ORJDC FOP PREA ensures residents are provided access to outside confidential support
services. The facility has an MOU with the Victim Service Center of Central Florida to provide
the following: a 24/7 hotline staffed by certified victim advocate; certified victim advocates to
respond to requests for advocacy and accompaniment during forensic examination;
counselling; follow-up support; and referral for treatment after release or transfer to another
facility.
Brochures containing the Victim Service Center hotline number and basic information about
the service were observed throughout the facility however resident interviews revealed they
had little to no knowledge of these services. Corrective action was taken after the onsite visit
by staff conducting educational sessions in each housing module. Documentation of these
sessions included signed resident rosters and summary of information presented.
Additionally, information contained in the Victim Service Center of Central Florida’s
brochure was streamlined to give residents a better understanding of the services available
to them when needed.
Residents have access to attorneys and other legal representatives by telephone or visits
with reasonable and private access upon request. Residents may call their parents/legal
guardians and can receive visits from them three times a week.
Random resident interviews helped to verify this standard.
Standard 115.354: Third-party reporting
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.354 (a)
▪ Has the agency established a method to receive third-party reports of sexual abuse and sexual
harassment? ☒ Yes ☐ No
▪ Has the agency distributed publicly information on how to report sexual abuse and sexual
harassment on behalf of a resident? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
PREA Audit Report Page 49 of 83 Facility Name – double click to change
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ’s website provides the public with information regarding third-party reporting of
sexual abuse or sexual harassment on behalf of residents. Members of the public may call
an incident/complaint hotline number, email, fax or write the OIG to report an incident.
Resident interviews revealed their awareness of reporting sexual abuse or sexual
harassment to others outside of the facility including their parents/legal guardians.
OFFICIAL RESPONSE FOLLOWING A RESIDENT REPORT
Standard 115.361: Staff and agency reporting duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.361 (a)
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding an incident of sexual abuse or sexual
harassment that occurred in a facility, whether or not it is part of the agency? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding retaliation against residents or staff who
reported an incident of sexual abuse or sexual harassment? ☒ Yes ☐ No
▪ Does the agency require all staff to report immediately and according to agency policy any
knowledge, suspicion, or information regarding any staff neglect or violation of responsibilities
that may have contributed to an incident of sexual abuse or sexual harassment or retaliation?
☒ Yes ☐ No
115.361 (b)
▪ Does the agency require all staff to comply with any applicable mandatory child abuse reporting
laws? ☒ Yes ☐ No
115.361 (c)
▪ Apart from reporting to designated supervisors or officials and designated State or local services
agencies, are staff prohibited from revealing any information related to a sexual abuse report to
anyone other than to the extent necessary, as specified in agency policy, to make treatment,
investigation, and other security and management decisions? ☒ Yes ☐ No
115.361 (d)
PREA Audit Report Page 50 of 83 Facility Name – double click to change
▪ Are medical and mental health practitioners required to report sexual abuse to designated
supervisors and officials pursuant to paragraph (a) of this section as well as to the designated State
or local services agency where required by mandatory reporting laws? ☒ Yes ☐ No
▪ Are medical and mental health practitioners required to inform residents of their duty to report, and
the limitations of confidentiality, at the initiation of services? ☒ Yes ☐ No
115.361 (e)
▪ Upon receiving any allegation of sexual abuse, does the facility head or his or her designee
promptly report the allegation to the appropriate office? ☒ Yes ☐ No
▪ Upon receiving any allegation of sexual abuse, does the facility head or his or her designee
promptly report the allegation to the alleged victim’s parents or legal guardians unless the facility
has official documentation showing the parents or legal guardians should not be notified?
☒ Yes ☐ No
▪ If the alleged victim is under the guardianship of the child welfare system, does the facility head
or his or her designee promptly report the allegation to the alleged victim’s caseworker instead
of the parents or legal guardians? (N/A if the alleged victim is not under the guardianship of the
child welfare system.) ☒ Yes ☐ No ☐ NA
▪ If a juvenile court retains jurisdiction over the alleged victim, does the facility head or designee
also report the allegation to the juvenile’s attorney or other legal representative of record within
14 days of receiving the allegation? ☒ Yes ☐ No
115.361 (f)
▪ Does the facility report all allegations of sexual abuse and sexual harassment, including third-
party and anonymous reports, to the facility’s designated investigators? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
PREA Audit Report Page 51 of 83 Facility Name – double click to change
ORJDC meets the requirements of this standard based upon the following evidence:
All ORJDC staff are mandated reporters and are required by the ORJDC FOP PREA and FDJJ
Policy 1919 PREA to immediately report any knowledge, suspicion or information they receive
regarding sexual abuse and sexual harassment, retaliation against residents or staff who report
an incident, or any staff neglect or violation of responsibilities that may have contributed to an
incident or retaliation. Random staff interviews also helped to verify the facility’s compliance
with this standard.
Random staff interviews revealed their knowledge of mandatory reporting.
Interviews with a nurse and a mental health staff member confirmed their responsibility to
inform residents 18- years old of their duty to report and limitations of confidentiality.
Parents provide consent for residents under 18.
ORJDC FOP PREA prohibits staff from revealing any information related to a sexual abuse
report to anyone other than to the extent necessary to make treatment, investigation and other
security decisions.
Upon receiving an allegation of sexual abuse, the procedure requires the Superintendent to notify
Orange County Sheriff’s Department, FDJJ’s Central Regional Office, FDJJ’s CCC, the Florida
Abuse Hotline, the youth’s parents/legal guardian and juvenile court.
Standard 115.362: Agency protection duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.362 (a)
▪ When the agency learns that a resident is subject to a substantial risk of imminent sexual
abuse, does it take immediate action to protect the resident? ☐ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
PREA Audit Report Page 52 of 83 Facility Name – double click to change
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA requires staff to take immediate action to protect a resident when he/she
is identified as being subject to substantial risk of imminent sexual abuse.
There were no residents identified as at risk for sexual abuse in the past 12 months, as
revealed in interviews with the Acting Superintendent and random direct care staff.
Standard 115.363: Reporting to other confinement facilities
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.363 (a)
▪ Upon receiving an allegation that a resident was sexually abused while confined at another
facility, does the head of the facility that received the allegation notify the head of the facility or
appropriate office of the agency where the alleged abuse occurred? ☒ Yes ☐ No
▪ Does the head of the facility that received the allegation also notify the appropriate investigative
agency? ☒ Yes ☐ No
115.363 (b)
▪ Is such notification provided as soon as possible, but no later than 72 hours after receiving the
allegation? ☒ Yes ☐ No
115.363 (c)
▪ Does the agency document that it has provided such notification? ☒ Yes ☐ No
115.363 (d)
▪ Does the facility head or agency office that receives such notification ensure that the allegation
is investigated in accordance with these standards? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
PREA Audit Report Page 53 of 83 Facility Name – double click to change
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA requires the Superintendent to notify the head of another facility within
72 hours upon receiving an allegation a resident was sexually abused while confined at another
facility. The policy requires the notification to documented and an investigation conducted.
During the past 12 months, there were no allegations received a resident was abused while
confined to another facility nor were there allegations of sexual abuse received by ORJDC
from other facilities.
Standard 115.364: Staff first responder duties
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.364 (a)
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Separate the alleged victim and abuser?
☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Preserve and protect any crime scene until
appropriate steps can be taken to collect any evidence? ☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Request that the alleged victim not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
▪ Upon learning of an allegation that a resident was sexually abused, is the first security staff
member to respond to the report required to: Ensure that the alleged abuser does not take any
actions that could destroy physical evidence, including, as appropriate, washing, brushing teeth,
changing clothes, urinating, defecating, smoking, drinking, or eating, if the abuse occurred
within a time period that still allows for the collection of physical evidence? ☒ Yes ☐ No
115.364 (b)
PREA Audit Report Page 54 of 83 Facility Name – double click to change
▪ If the first staff responder is not a security staff member, is the responder required to request
that the alleged victim not take any actions that could destroy physical evidence, and then notify
security staff? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA requires staff to take specific steps to respond to a report of sexual
abuse including; separating the alleged victim from the abuser; preserving any crime scene
within a period of time that still allows for the collection of physical evidence; request the
alleged victim not take any action that could destroy physical evidence; and ensure that the
alleged abuser does not take any action to destroy physical evidence, if the abuse took place
within a time period that still allows for the collection of physical evidence.
Random direct care staff interviews revealed considerable knowledge of actions to be taken
upon learning a resident alleges being sexually abused.
During the past 12 months, there were no allegations of sexual harassment or sexual abuse.
Standard 115.365: Coordinated response
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.365 (a)
▪ Has the facility developed a written institutional plan to coordinate actions among staff first
responders, medical and mental health practitioners, investigators, and facility leadership taken
in response to an incident of sexual abuse? ☒ Yes ☐ No
Auditor Overall Compliance Determination
PREA Audit Report Page 55 of 83 Facility Name – double click to change
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP PREA require the development of a written plan
to coordinate actions taken in response to an incident of sexual assault among staff first
responders, medical, and facility leadership. The facility’s coordinated staff response plan
was reviewed and found in compliance with the standard.
Interviews with the Acting Superintendent and random direct care staff revealed they are
knowledgeable of their duties in response to an allegation of sexual abuse.
Standard 115.366: Preservation of ability to protect residents from contact
with abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.366 (a)
▪ Are both the agency and any other governmental entities responsible for collective bargaining
on the agency’s behalf prohibited from entering into or renewing any collective bargaining
agreement or other agreement that limits the agency’s ability to remove alleged staff sexual
abusers from contact with any residents pending the outcome of an investigation or of a
determination of whether and to what extent discipline is warranted? ☐ Yes ☒ No
115.366 (b)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
PREA Audit Report Page 56 of 83 Facility Name – double click to change
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
FDJJ is not a collective bargaining agency therefore this standard is not applicable.
Standard 115.367: Agency protection against retaliation
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.367 (a)
▪ Has the agency established a policy to protect all residents and staff who report sexual abuse or
sexual harassment or cooperate with sexual abuse or sexual harassment investigations from
retaliation by other residents or staff? ☒ Yes ☐ No
▪ Has the agency designated which staff members or departments are charged with monitoring
retaliation? ☒ Yes ☐ No
115.367 (b)
▪ Does the agency employ multiple protection measures for residents or staff who fear retaliation
for reporting sexual abuse or sexual harassment or for cooperating with investigations, such as
housing changes or transfers for resident victims or abusers, removal of alleged staff or resident
abusers from contact with victims, and emotional support services? ☒ Yes ☐ No
115.367 (c)
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct
and treatment of residents or staff who reported the sexual abuse to see if there are changes
that may suggest possible retaliation by residents or staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor the conduct
and treatment of residents who were reported to have suffered sexual abuse to see if there are
changes that may suggest possible retaliation by residents or staff? ☒ Yes ☐ No
PREA Audit Report Page 57 of 83 Facility Name – double click to change
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Act promptly to remedy
any such retaliation? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Any resident
disciplinary reports? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Resident
housing changes? ☐ Yes ☒ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Resident
program changes? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor: Negative
performance reviews of staff? ☒ Yes ☐ No
▪ Except in instances where the agency determines that a report of sexual abuse is unfounded,
for at least 90 days following a report of sexual abuse, does the agency: Monitor:
Reassignments of staff? ☒ Yes ☐ No
▪ Does the agency continue such monitoring beyond 90 days if the initial monitoring indicates a
continuing need? ☒ Yes ☐ No
115.367 (d)
▪ In the case of residents, does such monitoring also include periodic status checks?
☒ Yes ☐ No
115.367 (e)
▪ If any other individual who cooperates with an investigation expresses a fear of retaliation, does
the agency take appropriate measures to protect that individual against retaliation?
☒ Yes ☐ No
115.367 (f)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
PREA Audit Report Page 58 of 83 Facility Name – double click to change
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP PREA require the protection of residents and staff
who have reported sexual abuse or harassment or who have cooperated in a sexual abuse or
sexual harassment investigation. The policy requires the monitoring to take place for a
period of 90 days or longer, as needed.
The Captain serves the Retaliation Monitor and her interview revealed he is knowledgeable of the
position’s responsibilities. He articulated multiple measures available for victims, abusers
and staff such as housing changes, transfers, reassign staff, etc. FDJJ has developed a form to
document monitoring.
There was no retaliation monitoring in the past 12 months.
Standard 115.368: Post-allegation protective custody
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.368 (a)
▪ Is any and all use of segregated housing to protect a resident who is alleged to have suffered
sexual abuse subject to the requirements of § 115.342? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
PREA Audit Report Page 59 of 83 Facility Name – double click to change
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA states residents may only be restricted to his/her single room as a last
measure to keep a resident who alleged sexual abuse safe and then only until an alternative
means for keeping the resident safe can be arranged. The Acting Superintendent’s interview
confirmed compliance with this standard.
INVESTIGATIONS
Standard 115.371: Criminal and administrative agency investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.371 (a)
▪ When the agency conducts its own investigations into allegations of sexual abuse and sexual
harassment, does it do so promptly, thoroughly, and objectively? [N/A if the agency/facility is not
responsible for conducting any form of criminal OR administrative sexual abuse investigations.
See 115.321(a).] ☒ Yes ☐ No ☐ NA
▪ Does the agency conduct such investigations for all allegations, including third party and
anonymous reports? [N/A if the agency/facility is not responsible for conducting any form of
criminal OR administrative sexual abuse investigations. See 115.321(a).]
☒ Yes ☐ No ☐ NA
115.371 (b)
▪ Where sexual abuse is alleged, does the agency use investigators who have received
specialized training in sexual abuse investigations involving juvenile victims as required by
115.334? ☒ Yes ☐ No
115.371 (c)
▪ Do investigators gather and preserve direct and circumstantial evidence, including any available
physical and DNA evidence and any available electronic monitoring data? ☒ Yes ☐ No
▪ Do investigators interview alleged victims, suspected perpetrators, and witnesses?
☒ Yes ☐ No
▪ Do investigators review prior reports and complaints of sexual abuse involving the suspected
perpetrator? ☒ Yes ☐ No
115.371 (d)
▪ Does the agency always refrain from terminating an investigation solely because the source of
the allegation recants the allegation? ☒ Yes ☐ No
PREA Audit Report Page 60 of 83 Facility Name – double click to change
115.371 (e)
▪ When the quality of evidence appears to support criminal prosecution, does the agency conduct
compelled interviews only after consulting with prosecutors as to whether compelled interviews
may be an obstacle for subsequent criminal prosecution? ☒ Yes ☐ No
115.371 (f)
▪ Do agency investigators assess the credibility of an alleged victim, suspect, or witness on an
individual basis and not on the basis of that individual’s status as resident or staff?
☒ Yes ☐ No
▪ Does the agency investigate allegations of sexual abuse without requiring a resident who
alleges sexual abuse to submit to a polygraph examination or other truth-telling device as a
condition for proceeding? ☒ Yes ☐ No
115.371 (g)
▪ Do administrative investigations include an effort to determine whether staff actions or failures to
act contributed to the abuse? ☒ Yes ☐ No
▪ Are administrative investigations documented in written reports that include a description of the
physical evidence and testimonial evidence, the reasoning behind credibility assessments, and
investigative facts and findings? ☒ Yes ☐ No
115.371 (h)
▪ Are criminal investigations documented in a written report that contains a thorough description
of the physical, testimonial, and documentary evidence and attaches copies of all documentary
evidence where feasible? ☒ Yes ☐ No
115.371 (i)
▪ Are all substantiated allegations of conduct that appears to be criminal referred for prosecution?
☒ Yes ☐ No
115.371 (j)
▪ Does the agency retain all written reports referenced in 115.371(g) and (h) for as long as the
alleged abuser is incarcerated or employed by the agency, plus five years unless the abuse was
committed by a juvenile resident and applicable law requires a shorter period of retention?
☒ Yes ☐ No
115.371 (k)
▪ Does the agency ensure that the departure of an alleged abuser or victim from the employment
or control of the agency does not provide a basis for terminating an investigation?
☒ Yes ☐ No
PREA Audit Report Page 61 of 83 Facility Name – double click to change
115.371 (l)
▪ Auditor is not required to audit this provision.
115.371 (m)
▪ When an outside entity investigates sexual abuse, does the facility cooperate with outside
investigators and endeavor to remain informed about the progress of the investigation? (N/A if
an outside agency does not conduct administrative or criminal sexual abuse investigations. See
115.321(a).) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP 3.09 PREA states FDJJ does not conduct criminal investigations of residents’
allegations of sexual abuse. Local law enforcement (Orange County Sheriff’s Department)
and the Florida Department of Children and Families Services handle criminal
investigations. FDJJ’s Office of Inspector General (OIG) reviews allegations to identify any
misconduct by staff related to FDJJ regulatory guidance. The policy also states the agency
does not terminate an investigation solely because the source of the allegation recants the
allegation.
The agency retains all written reports of investigations pertaining to administrative and
criminal investigations.
There have been no allegations of sexual abuse or sexual harassment in the past 12 months.
Standard 115.372: Evidentiary standard for administrative investigations
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.372 (a)
PREA Audit Report Page 62 of 83 Facility Name – double click to change
▪ Is it true that the agency does not impose a standard higher than a preponderance of the
evidence in determining whether allegations of sexual abuse or sexual harassment are
substantiated? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA states the facility shall impose no standard higher than a
preponderance of the evidence in determining whether allegations of misconduct by
staff are substantiated.
Standard 115.373: Reporting to residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.373 (a)
▪ Following an investigation into a resident’s allegation that he or she suffered sexual abuse in an
agency facility, does the agency inform the resident as to whether the allegation has been
determined to be substantiated, unsubstantiated, or unfounded? ☒ Yes ☐ No
115.373 (b)
▪ If the agency did not conduct the investigation into a resident’s allegation of sexual abuse in an
agency facility, does the agency request the relevant information from the investigative agency
in order to inform the resident? (N/A if the agency/facility is responsible for conducting
administrative and criminal investigations.) ☒ Yes ☐ No ☐ NA
115.373 (c)
PREA Audit Report Page 63 of 83 Facility Name – double click to change
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The staff member is no longer posted within the resident’s unit? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The staff member is no longer employed at the facility? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The agency learns that the staff member has been indicted on a charge related to
sexual abuse in the facility? ☒ Yes ☐ No
▪ Following a resident’s allegation that a staff member has committed sexual abuse against the
resident, unless the agency has determined that the allegation is unfounded, or unless the
resident has been released from custody, does the agency subsequently inform the resident
whenever: The agency learns that the staff member has been convicted on a charge related to
sexual abuse within the facility? ☒ Yes ☐ No
115.373 (d)
▪ Following a resident’s allegation that he or she has been sexually abused by another resident,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been indicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No
▪ Following a resident’s allegation that he or she has been sexually abused by another resident,
does the agency subsequently inform the alleged victim whenever: The agency learns that the
alleged abuser has been convicted on a charge related to sexual abuse within the facility?
☒ Yes ☐ No
115.373 (e)
▪ Does the agency document all such notifications or attempted notifications? ☒ Yes ☐ No
115.373 (f)
▪ Auditor is not required to audit this provision.
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
PREA Audit Report Page 64 of 83 Facility Name – double click to change
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP PREA require at the conclusion of any law
enforcement investigation into sexual abuse, the victim or the victim’s parent(s) or legal
guardian(s) shall be notified the investigation has concluded. The FDJJ’s Statewide PREA
Coordinator will send a letter notifying residents/parents /legal guardian of charges and of
the outcome of the investigation including the identification of the investigative entity and
state the findings.
The Acting Superintendent’s interview confirmed her knowledge of the policies and the
requirements of this standard.
There were no administrative or criminal investigations completed during the past 12
months and no letters were sent.
DISCIPLINE
Standard 115.376: Disciplinary sanctions for staff
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.376 (a)
▪ Are staff subject to disciplinary sanctions up to and including termination for violating agency
sexual abuse or sexual harassment policies? ☒ Yes ☐ No
115.376 (b)
▪ Is termination the presumptive disciplinary sanction for staff who have engaged in sexual
abuse? ☒ Yes ☐ No
115.376 (c)
▪ Are disciplinary sanctions for violations of agency policies relating to sexual abuse or sexual
harassment (other than actually engaging in sexual abuse) commensurate with the nature and
circumstances of the acts committed, the staff member’s disciplinary history, and the sanctions
imposed for comparable offenses by other staff with similar histories? ☒ Yes ☐ No
PREA Audit Report Page 65 of 83 Facility Name – double click to change
115.376 (d)
▪ Are all terminations for violations of agency sexual abuse or sexual harassment policies, or
resignations by staff who would have been terminated if not for their resignation, reported to:
Law enforcement agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Are all terminations for violations of agency sexual abuse or sexual harassment policies, or
resignations by staff who would have been terminated if not for their resignation, reported to:
Relevant licensing bodies? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP 3.09 PREA require staff disciplinary sanctions up to
and including termination for violating facility’s sexual abuse or harassment policies. The
policies also mandate the violation be reported to law enforcement and states termination shall be
the presumptive disciplinary sanction for staff who engaged in sexual abuse.
No employees were terminated or disciplined in the past 12 months for violation of the
facility’s sexual abuse or harassment policies.
Standard 115.377: Corrective action for contractors and volunteers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.377 (a)
▪ Is any contractor or volunteer who engages in sexual abuse prohibited from contact with
residents? ☒ Yes ☐ No
PREA Audit Report Page 66 of 83 Facility Name – double click to change
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Law enforcement
agencies (unless the activity was clearly not criminal)? ☒ Yes ☐ No
▪ Is any contractor or volunteer who engages in sexual abuse reported to: Relevant licensing
bodies? ☒ Yes ☐ No
115.377 (b)
▪ In the case of any other violation of agency sexual abuse or sexual harassment policies by a
contractor or volunteer, does the facility take appropriate remedial measures, and consider
whether to prohibit further contact with residents? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 and ORJDC FOP 3.09 PREA require any contractor or volunteer who engages
in sexual abuse be prohibited from contact with residents. Policies also require contractors and
volunteers who engage in sexual abuse be reported to law enforcement and to relevant licensing
bodies. During the past 12 months, there were no allegations of sexual abuse or sexual
harassment regarding contractors or volunteers.
A review of training acknowledgement statements, training materials and interviews with a
contractor and volunteer revealed the facility takes measures to provide volunteers and
contractors a clear understanding sexual misconduct with a resident is strictly prohibited and
is a serious breach of conduct. The interviews confirmed participation in PREA training and
awareness of the zero-tolerance policy and how to report allegations of sexual abuse or sexual
harassment of residents.
PREA Audit Report Page 67 of 83 Facility Name – double click to change
Standard 115.378: Interventions and disciplinary sanctions for residents
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.378 (a)
▪ Following an administrative finding that a resident engaged in resident-on-resident sexual
abuse, or following a criminal finding of guilt for resident-on-resident sexual abuse, may
residents be subject to disciplinary sanctions only pursuant to a formal disciplinary process?
☒ Yes ☐ No
115.378 (b)
▪ Are disciplinary sanctions commensurate with the nature and circumstances of the abuse
committed, the resident’s disciplinary history, and the sanctions imposed for comparable
offenses by other residents with similar histories? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident is not denied daily large-muscle exercise? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident is not denied access to any legally required educational programming or special
education services? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the agency ensure
the resident receives daily visits from a medical or mental health care clinician? ☒ Yes ☐ No
▪ In the event a disciplinary sanction results in the isolation of a resident, does the resident also
have access to other programs and work opportunities to the extent possible? ☒ Yes ☐ No
115.378 (c)
▪ When determining what types of sanction, if any, should be imposed, does the disciplinary
process consider whether a resident’s mental disabilities or mental illness contributed to his or
her behavior? ☒ Yes ☐ No
115.378 (d)
▪ If the facility offers therapy, counseling, or other interventions designed to address and correct
underlying reasons or motivations for the abuse, does the facility consider whether to offer the
offending resident participation in such interventions? ☒ Yes ☐ No
▪ If the agency requires participation in such interventions as a condition of access to any
rewards-based behavior management system or other behavior-based incentives, does it
always refrain from requiring such participation as a condition to accessing general
programming or education? ☒ Yes ☐ No
115.378 (e)
PREA Audit Report Page 68 of 83 Facility Name – double click to change
▪ Does the agency discipline a resident for sexual contact with staff only upon a finding that the
staff member did not consent to such contact? ☒ Yes ☐ No
115.378 (f)
▪ For the purpose of disciplinary action does a report of sexual abuse made in good faith based
upon a reasonable belief that the alleged conduct occurred NOT constitute falsely reporting an
incident or lying, even if an investigation does not establish evidence sufficient to substantiate
the allegation? ☒ Yes ☐ No
115.378 (g)
▪ Does the agency always refrain from considering non-coercive sexual activity between residents
to be sexual abuse? (N/A if the agency does not prohibit all sexual activity between residents.)
☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP 3.09 PREA require an administrative process for
dealing with violations of resident-on-resident sexual abuse. The Acting Superintendent’s
interview confirms the formal disciplinary process however residents may also be referred to
law enforcement for charges regarding resident-on-resident sexual abuse. Sexual activity
between residents is prohibited and court or administrative processes and sanctions occur after
determination the sexual activity was coerced. Residents will be disciplined for sexual contact
with staff only when it has been determined the staff member did not consent to the sexual
contact. Isolation is not used in this facility however room restriction may be imposed for very
short periods of time.
FDJJ Policy 1919 PREA and ORJDC FOP 3.09 PREA provide anyone reporting in good faith
will not receive any repercussions. The policies and interview with the mental health staff
confirms counseling or other interventions will be offered to address and correct the underlying
reasons or motivations for abuse when the resident remains in or returns to the facility after a
PREA Audit Report Page 69 of 83 Facility Name – double click to change
sexual abuse incident. The interview also revealed any type interventions or treatment services
provided are not as a condition for the resident to access participation in the behavior
management system, education services, or other programs.
MEDICAL AND MENTAL CARE
Standard 115.381: Medical and mental health screenings; history of sexual
abuse
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.381 (a)
▪ If the screening pursuant to § 115.341 indicates that a resident has experienced prior sexual
victimization, whether it occurred in an institutional setting or in the community, do staff ensure
that the resident is offered a follow-up meeting with a medical or mental health practitioner
within 14 days of the intake screening? ☒ Yes ☐ No
115.381 (b)
▪ If the screening pursuant to § 115.341 indicates that a resident has previously perpetrated
sexual abuse, whether it occurred in an institutional setting or in the community, do staff ensure
that the resident is offered a follow-up meeting with a mental health practitioner within 14 days
of the intake screening? ☒ Yes ☐ No
115.381 (c)
▪ Is any information related to sexual victimization or abusiveness that occurred in an institutional
setting strictly limited to medical and mental health practitioners and other staff as necessary to
inform treatment plans and security management decisions, including housing, bed, work,
education, and program assignments, or as otherwise required by Federal, State, or local law?
☒ Yes ☐ No
115.381 (d)
▪ Do medical and mental health practitioners obtain informed consent from residents before
reporting information about prior sexual victimization that did not occur in an institutional setting,
unless the resident is under the age of 18? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
PREA Audit Report Page 70 of 83 Facility Name – double click to change
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP 3.09 PREA require a follow-up meeting with a
medical or mental health practitioner within 14 days when a resident discloses any prior
incidents of sexual abuse whether victim or perpetrator. Interviews with the medical and
mental health staff and a review of documentation revealed residents are generally seen by
medical and mental health staff on the same day of admission as part of the intake process.
The policies verify information related to sexual victimization or abusiveness which occurred
in an institutional setting is limited to those staff where it is based on their need to know to
make the appropriate management and security decisions.
Interviews with medical and mental health staff and observations revealed documentation of
the services provided to each resident is maintained in medical and clinical files. Medical and
mental health staff discussed their knowledge of informed consent, in accordance with policy.
The facility utilizes a consent form regarding treatment services for residents 18 years old and
up.
Standard 115.382: Access to emergency medical and mental health
services
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.382 (a)
▪ Do resident victims of sexual abuse receive timely, unimpeded access to emergency medical
treatment and crisis intervention services, the nature and scope of which are determined by
medical and mental health practitioners according to their professional judgment? ☒ Yes ☐ No
115.382 (b)
▪ If no qualified medical or mental health practitioners are on duty at the time a report of recent
sexual abuse is made, do staff first responders take preliminary steps to protect the victim
pursuant to § 115.362? ☒ Yes ☐ No
▪ Do staff first responders immediately notify the appropriate medical and mental health
practitioners? ☒ Yes ☐ No
PREA Audit Report Page 71 of 83 Facility Name – double click to change
115.382 (c)
▪ Are resident victims of sexual abuse offered timely information about and timely access to
emergency contraception and sexually transmitted infections prophylaxis, in accordance with
professionally accepted standards of care, where medically appropriate? ☒ Yes ☐ No
115.382 (d)
▪ Are treatment services provided to the victim without financial cost and regardless of whether
the victim names the abuser or cooperates with any investigation arising out of the incident? ☒
Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP 3.09 PREA mandate youth victims of sexual
abuse receive timely and unimpeded access to onsite and offsite emergency medical
treatment and crisis intervention services, the nature and scope as determined by the
judgement of medical and mental health professionals. Medical and mental health staff
interviews confirmed emergency medical care and crisis intervention services will be
provided by medical and mental health staff as required.
Processes and services are in place for a victim to receive timely access to sexually transmitted
infections prophylaxis, where medically appropriate. Observations revealed medical and
mental health staff members maintain secondary materials that document services to residents
and these staff are knowledgeable of what must occur in an incident of sexual abuse. It is
documented through policies and understood by the medical and mental health staff treatment
services will be provided at no cost to the victim, whether the victim cooperates with the
investigation.
PREA Audit Report Page 72 of 83 Facility Name – double click to change
There have been no resident victims of sexual abuse in the past 12 months however the
nurse’s interview verified documentation would be entered into the resident’s medical
record.
Standard 115.383: Ongoing medical and mental health care for sexual
abuse victims and abusers
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.383 (a)
▪ Does the facility offer medical and mental health evaluation and, as appropriate, treatment to all
residents who have been victimized by sexual abuse in any prison, jail, lockup, or juvenile
facility? ☒ Yes ☐ No
115.383 (b)
▪ Does the evaluation and treatment of such victims include, as appropriate, follow-up services,
treatment plans, and, when necessary, referrals for continued care following their transfer to, or
placement in, other facilities, or their release from custody? ☒ Yes ☐ No
115.383 (c)
▪ Does the facility provide such victims with medical and mental health services consistent with
the community level of care? ☒ Yes ☐ No
115.383 (d)
▪ Are resident victims of sexually abusive vaginal penetration while incarcerated offered
pregnancy tests? (N/A if all-male facility.) ☒ Yes ☐ No ☐ NA
115.383 (e)
▪ If pregnancy results from the conduct described in paragraph § 115.383(d), do such victims
receive timely and comprehensive information about and timely access to all lawful pregnancy-
related medical services? (N/A if all-male facility.) ☒ Yes ☐ No ☐ NA
115.383 (f)
▪ Are resident victims of sexual abuse while incarcerated offered tests for sexually transmitted
infections as medically appropriate? ☒ Yes ☐ No
115.383 (g)
PREA Audit Report Page 73 of 83 Facility Name – double click to change
▪ Are treatment services provided to the victim without financial cost and regardless of whether
the victim names the abuser or cooperates with any investigation arising out of the incident?
☒ Yes ☐ No
115.383 (h)
▪ Does the facility attempt to conduct a mental health evaluation of all known resident-on-resident
abusers within 60 days of learning of such abuse history and offer treatment when deemed
appropriate by mental health practitioners? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
ORJDC FOP PREA requires mental health evaluation and treatment, as determined by
medical/mental health staff, be offered to residents who disclose prior sexual victimization or
perpetrated sexual abuse during intake screening. Treatment services are provided at no cost to
residents.
There have been no sexual assault victims in the past 12 months however if needed,
procedures are in place as verified during staff interviews.
DATA COLLECTION AND REVIEW
Standard 115.386: Sexual abuse incident reviews
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.386 (a)
PREA Audit Report Page 74 of 83 Facility Name – double click to change
▪ Does the facility conduct a sexual abuse incident review at the conclusion of every sexual abuse
investigation, including where the allegation has not been substantiated, unless the allegation
has been determined to be unfounded? ☒ Yes ☐ No
115.386 (b)
▪ Does such review ordinarily occur within 30 days of the conclusion of the investigation? ☒ Yes
☐ No
115.386 (c)
▪ Does the review team include upper-level management officials, with input from line
supervisors, investigators, and medical or mental health practitioners? ☒ Yes ☐ No
115.386 (d)
▪ Does the review team: Consider whether the allegation or investigation indicates a need to
change policy or practice to better prevent, detect, or respond to sexual abuse? ☒ Yes ☐ No
▪ Does the review team: Consider whether the incident or allegation was motivated by race;
ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification, status, or
perceived status; gang affiliation; or other group dynamics at the facility? ☒ Yes ☐ No
▪ Does the review team: Examine the area in the facility where the incident allegedly occurred to
assess whether physical barriers in the area may enable abuse? ☒ Yes ☐ No
▪ Does the review team: Assess the adequacy of staffing levels in that area during different
shifts? ☒ Yes ☐ No
▪ Does the review team: Assess whether monitoring technology should be deployed or
augmented to supplement supervision by staff? ☒ Yes ☐ No
▪ Does the review team: Prepare a report of its findings, including but not necessarily limited to
determinations made pursuant to §§ 115.386(d)(1) - (d)(5), and any recommendations for
improvement and submit such report to the facility head and PREA compliance manager?
☒ Yes ☐ No
115.386 (e)
▪ Does the facility implement the recommendations for improvement, or document its reasons for
not doing so? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
PREA Audit Report Page 75 of 83 Facility Name – double click to change
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 PREA and ORJDC FOP 3.09 PREA require an incident review team
meeting within 30 days of the conclusion of each investigation. The policy mandates review
team participation to include the FDJJ’s Statewide PREA Coordinator, the facility’s
Compliance Manager, regional office staff, Assistant Superintendent, facility supervisor,
medical and mental health staff. The FDJJ PREA Coordinator will prepare a report of the
review team’s findings and submit the report to the Assistant Secretary for Detention Services,
regional office staff and the facility’s Superintendent. No incident review team was convened
during the past 12 months.
The interview with the Compliance Manager and a review of the form used to document the
incident review team’s findings indicate the team: consider whether the allegation or
investigation indicates a need to change policy or practice to better prevent, detect, or
respond to sexual abuse considers whether the incident or allegation was motivated by race;
ethnicity; gender identity; lesbian, gay, bisexual, transgender, or intersex identification,
status, or perceived status; gang affiliation; or other group dynamics at the facility; examine
the area in the facility where the incident allegedly occurred to assess whether physical
barriers in the area may enable abuse; assess the adequacy of staffing levels in that area
during different shifts; assess whether monitoring technology should be deployed or
augmented to supplement supervision by staff.
Standard 115.387: Data collection
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.387 (a)
▪ Does the agency collect accurate, uniform data for every allegation of sexual abuse at facilities
under its direct control using a standardized instrument and set of definitions? ☒ Yes ☐ No
115.387 (b)
▪ Does the agency aggregate the incident-based sexual abuse data at least annually? ☒ Yes
☐ No
PREA Audit Report Page 76 of 83 Facility Name – double click to change
115.387 (c)
▪ Does the incident-based data include, at a minimum, the data necessary to answer all questions
from the most recent version of the Survey of Sexual Violence conducted by the Department of
Justice? ☒ Yes ☐ No
115.387 (d)
▪ Does the agency maintain, review, and collect data as needed from all available incident-based
documents, including reports, investigation files, and sexual abuse incident reviews?
☒ Yes ☐ No
115.387 (e)
▪ Does the agency also obtain incident-based and aggregated data from every private facility with
which it contracts for the confinement of its residents? (N/A if agency does not contract for the
confinement of its residents.) ☒ Yes ☐ No ☐ NA
115.387 (f)
▪ Does the agency, upon request, provide all such data from the previous calendar year to the
Department of Justice no later than June 30? (N/A if DOJ has not requested agency data.) ☒
Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ has developed a standardized instrument with definitions to collect accurate, uniform
data for every allegation of sexual assault. The instrument includes the data necessary to
answer all questions from the most recent version of the Survey of Sexual violence conducted
by the Department of Justice. FDJJ Policy 1919 PREA requires CCC to collect all data relating
to PREA. FDJJ Policy 1919 requires the collection of data though the CCC for every allegation
of sexual misconduct which occurs in its state-operated detention centers and its contracted
PREA Audit Report Page 77 of 83 Facility Name – double click to change
residential facilities. FDJJ’s website includes annual data collected for fiscal years 2013-2014,
2014-2015, 2015-2016 and 2016-2017.
Standard 115.388: Data review for corrective action
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.388 (a)
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Identifying problem areas? ☒ Yes ☐ No
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Taking corrective action on an ongoing basis?
☒ Yes ☐ No
▪ Does the agency review data collected and aggregated pursuant to § 115.387 in order to
assess and improve the effectiveness of its sexual abuse prevention, detection, and response
policies, practices, and training, including by: Preparing an annual report of its findings and
corrective actions for each facility, as well as the agency as a whole? ☒ Yes ☐ No
115.388 (b)
▪ Does the agency’s annual report include a comparison of the current year’s data and corrective
actions with those from prior years and provide an assessment of the agency’s progress in
addressing sexual abuse ☒ Yes ☐ No
115.388 (c)
▪ Is the agency’s annual report approved by the agency head and made readily available to the
public through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.388 (d)
▪ Does the agency indicate the nature of the material redacted where it redacts specific material
from the reports when publication would present a clear and specific threat to the safety and
security of a facility? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
PREA Audit Report Page 78 of 83 Facility Name – double click to change
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ’s website includes annual data collected for fiscal years 2013-2014, 2014-2015,
2015-2016 and 2016-2017. The annual reports for the past three years are also included on
the website. The annual report contains a comparative analysis of the past three years. The
FDJJ PREA Coordinator reviews data to improve the effectiveness of its prevention,
protection and response policies, practices and training.
The report is signed and approved by the FDJJ’s Secretary.
Any information which may present a clear and specific threat to the safety and security of a
facility, staff member or resident will be redacted but must indicate the nature of the information
redacted.
Standard 115.389: Data storage, publication, and destruction
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.389 (a)
▪ Does the agency ensure that data collected pursuant to § 115.387 are securely retained?
☒ Yes ☐ No
115.389 (b)
▪ Does the agency make all aggregated sexual abuse data, from facilities under its direct control
and private facilities with which it contracts, readily available to the public at least annually
through its website or, if it does not have one, through other means? ☒ Yes ☐ No
115.389 (c)
▪ Does the agency remove all personal identifiers before making aggregated sexual abuse data
publicly available? ☒ Yes ☐ No
115.389 (d)
▪ Does the agency maintain sexual abuse data collected pursuant to § 115.387 for at least 10
years after the date of the initial collection, unless Federal, State, or local law requires
otherwise? ☒ Yes ☐ No
PREA Audit Report Page 79 of 83 Facility Name – double click to change
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
ORJDC meets the requirements of this standard based upon the following evidence:
FDJJ Policy 1919 requires the collection of data though the CCC for every allegation of sexual
misconduct which occurs in its state-operated detention centers and its contracted residential
facilities. All collected data is maintained for a ten-year period as required by the State of Florida’s
records and retention schedule.
AUDITING AND CORRECTIVE ACTION
Standard 115.401: Frequency and scope of audits
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.401 (a)
▪ During the prior three-year audit period, did the agency ensure that each facility operated by the
agency, or by a private organization on behalf of the agency, was audited at least once? (Note:
The response here is purely informational. A "no" response does not impact overall compliance
with this standard.) ☒ Yes ☐ No
115.401 (b)
▪ Is this the first year of the current audit cycle? (Note: a “no” response does not impact overall
compliance with this standard.) ☒ Yes ☐ No
▪ If this is the second year of the current audit cycle, did the agency ensure that at least one-third
of each facility type operated by the agency, or by a private organization on behalf of the
PREA Audit Report Page 80 of 83 Facility Name – double click to change
agency, was audited during the first year of the current audit cycle? (N/A if this is not the
second year of the current audit cycle.) ☒ Yes ☐ No ☐ NA
▪ If this is the third year of the current audit cycle, did the agency ensure that at least two-thirds of
each facility type operated by the agency, or by a private organization on behalf of the agency,
were audited during the first two years of the current audit cycle? (N/A if this is not the third year
of the current audit cycle.) ☒ Yes ☐ No ☐ NA
115.401 (h)
▪ Did the auditor have access to, and the ability to observe, all areas of the audited facility?
☒ Yes ☐ No
115.401 (i)
▪ Was the auditor permitted to request and receive copies of any relevant documents (including
electronically stored information)? ☒ Yes ☐ No
115.401 (m)
▪ Was the auditor permitted to conduct private interviews with inmates, residents, and detainees?
☒ Yes ☐ No
115.401 (n)
▪ Were residents permitted to send confidential information or correspondence to the auditor in
the same manner as if they were communicating with legal counsel? ☒ Yes ☐ No
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
Since August 20, 2013, FDJJ has ensured one-third of all operated detention centers and all contracted
residential facilities have been audited as evidenced by the Final Audit reports provided on the
Agency’s website.
PREA Audit Report Page 81 of 83 Facility Name – double click to change
The Auditor was provided complete access to the facility and observed all areas of the
facility’s buildings and grounds. Additionally, all relevant documents were provided upon
request.
The facility made space available for private staff and resident interviews. Residents were provided
information on the “Notice of the Auditor’s Onsite Visit” regarding how to send confidential
information to the Auditor.
Standard 115.403: Audit contents and findings
All Yes/No Questions Must Be Answered by the Auditor to Complete the Report
115.403 (f)
▪ The agency has published on its agency website, if it has one, or has otherwise made publicly
available, all Final Audit Reports within 90 days of issuance by auditor. The review period is for
prior audits completed during the past three years PRECEDING THIS AGENCY AUDIT. In the
case of single facility agencies, the auditor shall ensure that the facility’s last audit report was
published. The pendency of any agency appeal pursuant to 28 C.F.R. § 115.405 does not
excuse noncompliance with this provision. (N/A if there have been no Final Audit Reports issued
in the past three years, or in the case of single facility agencies that there has never been a
Final Audit Report issued.) ☒ Yes ☐ No ☐ NA
Auditor Overall Compliance Determination
☐
Exceeds Standard (Substantially exceeds requirement of standards)
☒
Meets Standard (Substantial compliance; complies in all material ways with the
standard for the relevant review period)
☐
Does Not Meet Standard (Requires Corrective Action)
Instructions for Overall Compliance Determination Narrative
The narrative below must include a comprehensive discussion of all the evidence relied upon in making the
compliance or non-compliance determination, the auditor’s analysis and reasoning, and the auditor’s
conclusions. This discussion must also include corrective action recommendations where the facility does
not meet the standard. These recommendations must be included in the Final Report, accompanied by
information on specific corrective actions taken by the facility.
A review of the FDJJ’s website revealed PREA Audit Reports dating back to 2014 through 2017 for
detention centers operated by FDJJ and residential facilities contracted by FDJJ are posted and can be
downloaded.
PREA Audit Report Page 82 of 83 Facility Name – double click to change
AUDITOR CERTIFICATION
I certify that:
☒ The contents of this report are accurate to the best of my knowledge.
☒ No conflict of interest exists with respect to my ability to conduct an audit of the
agency under review, and
☒ I have not included in the final report any personally identifiable information (PII)
about any resident or staff member, except where the names of administrative
personnel are specifically requested in the report template.
Auditor Instructions:
Type your full name in the text box below for Auditor Signature. This will function as your official
electronic signature. Auditors must deliver their final report to the PREA Resource Center as a
searchable PDF format to ensure accessibility to people with disabilities. Save this report document
into a PDF format prior to submission.1 Auditors are not permitted to submit audit reports that have
been scanned.2 See the PREA Auditor Handbook for a full discussion of audit report formatting
requirements.
Flora Brooks Boyd June 3, 2018
Auditor Signature Date
1 See additional instructions here: https://support.office.com/en-us/article/Save-or-convert-to-PDF-d85416c5-7d77-4fd6-
a216-6f4bf7c7c110 .
2 See PREA Auditor Handbook, Version 1.0, August 2017; Pages 68-69.
PREA Audit Report Page 83 of 83 Facility Name – double click to change

status: FINAL

program_name_raw: orange rjdc