Job vacancies in prison and state hospital health care have grown even as California has invested hundreds of millions of dollars to fill medical and mental health positions, according to a new state audit.

The audit reviewed staffing at Atascadero State Hospital, Porterville Developmental Center, and Salinas Valley State Prison. These facilities house individuals who are incarcerated or institutionalized after being deemed dangerous to themselves or others or incompetent to stand trial.

During fiscal year 2023–24, health care vacancy rates exceeded 30% at all three facilities. At Salinas Valley State Prison, more than half of the health-related positions were unfilled.

Under federal and state law, as well as court rulings, California is required to provide adequate medical and mental health care in these settings. Most facilities are expected to maintain vacancy rates below 10%, a benchmark the state has not consistently met for more than 30 years.

Independent Voter News has previously reported that nearly every person in California’s prison system has documented medical or mental health needs, with state data identifying 90,744 incarcerated individuals requiring ongoing care.

Health Care Behind Bars - How It Really Works

Courts have ruled that “deliberate indifference to serious medical needs” violates constitutional protections for incarcerated people, placing legal obligations on the state to maintain adequate staffing and care.

In 2023, California was ordered to pay monthly fines for noncompliance with mandated mental health staffing levels. As of 2025, CDCR had more than $95 million in accumulated fines, according to the report.

The audit found that vacancy rates increased between 2019 and 2024, despite targeted wage increases and bonuses approved during the Newsom administration and through court orders. Prison psychiatrists received bonuses of up to $42,000 in a 2023 labor contract, and mental health workers later received $20,000 bonuses tied to a long-running prisoner rights lawsuit.

Some prison health care employees rank among the highest-paid public workers in California. All 55 prison employees who earned more than $500,000 in 2024 were doctors, dentists, psychiatrists, or medical executives. A board-certified psychiatrist at Atascadero State Hospital can earn more than $397,000 in base pay and receive a pension through the California Public Employees’ Retirement System. The statewide mean wage for psychiatrists is $328,560.

Even with that level of compensation, auditors found that psychiatrists had the highest vacancy rates at Atascadero and the second-highest vacancy rates at Porterville and Salinas Valley. In nearby private-sector hospitals, competition for health care workers remains strong. Auditors were told that private hospitals in Monterey County commonly offer hiring bonuses of up to $90,000.

Staffing shortages worsened across all three facilities during the audit period. Salinas Valley State Prison experienced a 62% increase in vacancies between 2019 and 2024, with more than half of medical and mental health positions unfilled in 2024. Atascadero State Hospital’s vacancy rate rose by 39% to approximately 30%, and during the final three years of the audit period, the hospital lost 90% of its staff to attrition. Porterville Developmental Center’s vacancy rate increased by 6%, leaving more than one-third of positions vacant in the final year reviewed.

Administrators told auditors that the COVID-19 pandemic contributed to higher turnover and increased reliance on contract workers. The Department of State Hospitals stated that staffing levels during the audit period were significantly affected by the pandemic and that reported salary savings were overstated. The department said its hospitals regularly meet or exceed mandated staffing minimums and described lapses as rare and tied to extraordinary circumstances.

Auditors identified multiple staffing management deficiencies. They found that the Department of State Hospitals, the Department of Developmental Services, and the Department of Corrections and Rehabilitation lacked procedures to evaluate or budget for staffing needs on an annual basis. None of the departments had a system to determine whether facilities met minimum staffing requirements during each shift. Auditors also found that many vacant positions were not filled through overtime or temporary staffing.

Over six years, the departments saved $592 million in payroll costs by carrying vacancies. Auditors reported that the agencies could not clearly track how that money was later spent. 

During the same period, the state spent $239 million on contract workers and was authorized to pay more than $1 billion to cover staffing gaps, though only a portion of that authority was used.

Contract workers accounted for less than 10% of the health care workforce, but auditors found they cost more per hour than state employees, even after accounting for benefits. 

“To help address vacancies, each facility has significantly increased its use of contract workers: Atascadero by 79 percent, Porterville by 172 percent, and Salinas Valley by 46 percent. Contract workers generally cost the State more than state employees in the same job classifications, and the shorter tenure of contract workers presents challenges for facilities because of the training necessary to ensure that the contract workers are prepared to provide appropriate care to the facilities’ patient populations.”

Labor organizations said contract workers are often paid two to three times as much per hour as state employees, based on job advertisements collected from staffing agencies.

The many staff vacancies have resulted in each facility realizing significant savings from fiscal year 2019–20 through 2024–25: about $247 million for Atascadero, $188 million for Salinas Valley, and $157 million for Porterville.

Workers told auditors that shortages affect safety and retention. “A high vacancy rate is a self-fulfilling prophecy,” said Dr. Stuart Bussey, president of the Union of American Physicians and Dentists. Labor representatives reported frequent verbal and physical assaults. “There were 2,700 assaults on staff last year. It’s not a matter of if, it’s when,” said Coby Pizzotti of the California Association of Psychiatric Technicians.

The audit included reports from employees who stated a concern for their safety.  “Several of the staff we interviewed at Porterville described working in conditions in which they are verbally and physically assaulted regularly,” the audit stated.

The auditor recommended that California conduct a statewide recruitment campaign, perform market analyses of health care positions, streamline hiring processes, and improve staffing oversight to address persistent vacancies in prison and state hospital health care.