SAN QUENTIN (CBS SF) — CalOSHA has proposed levying $421,880 in fines against San Quentin State Prison for allegedly endangering its employees during a massive COVID-19 outbreak that sickened more than 2,000 inmates and 427 employees and claimed 29 lives including one guard.

The state agency cited 14 violations ranging from failing to report employee illnesses to state health officials to exposing staffers “to unsafe patient handling conditions” while removing ill inmates from cells on stretchers to unsafe working conditions in the prison medical lab to not enforcing mask policies.

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“Cal/OSHA determined that San Quentin staff were not provided adequate training or equipment for working with COVID-19 infected individuals, and employees who had been exposed to COVID-19 positive inmates were not provided proper medical services, including testing, contact tracing and referrals to physicians or other licensed health care professionals,” the agency said in a news release.

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The massive outbreak at the prison began when CDCR and California Correctional Health Care Services, which oversees health care within the state prison system, transferred 189 inmates from the California Institution for Men in Chino to San Quentin and Corcoran. At the time of the transfer, Chico was amid a coronavirus outbreak of its own.

“Our review found that the efforts by CCHCS and the department to prepare for and execute the transfers were deeply flawed and risked the health and lives of thousands of incarcerated persons and staff,” Inspector General Roy Wesley said in releasing his findings on Feb. 1 from an inquiry of the prison system’s actions.

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Wesley’s report argues that CCHCS being intent on transferring medically vulnerable inmates by the end of May ultimately led to the sloppy transfer and subsequent outbreaks at both San Quentin and Corcoran.

To meet that deadline, CCHCS sent the inmates to Corcoran and San Quentin without testing them for the coronavirus during the two weeks prior to the end of May, in spite of directions from CCHCS executives to test the inmates within four to six days of the transfers.

Only one of the 189 inmates was tested during that time frame and just three were tested during the two weeks prior to the transfers, according to the report.

In lieu of testing, CCHCS planned to screen all of the transferred inmates for coronavirus symptoms and check their temperatures prior to the transfer.

Once the infected inmates arrived at San Quentin, the virus spread quickly. By Thursday, 2,241 inmates have tested positive for COVID-19 since the outbreak began. There have been 28 inmate deaths including 12 fatalities among San Quentin’s death row population.

The outbreak also took a toll on prison employees and proved deadly for one. Sgt. Gilbert Polanco, a 55-year-old prison guard, died from a COVID-19 infection after battling the illness for more than a month at a San Jose hospital.

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CalOHSA also has proposed levying $39,600 in fines against officials at Avenal State Prison for employee safety violations during an outbreak where 3,106 inmates tested positive for COVID-19 and 8 died of the illness. Among the prison employees there have been 514 confirmed cases.