REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
January 27, 2026
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical
Center
SUBJECT
Title
Security Department Policy and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revision of Arrowhead Regional Medical Center Security Department Policy and Procedure Manual, included and summarized in Attachments A through C.
(Presenter: Andrew Goldfrach, ARMC Chief Executive Officer, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Improve County Government Operations.
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of this item will not result in the use of Discretionary General Funding (Net County Cost). Revisions of the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manual are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manual are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all manuals are reviewed and revised, as necessary, a minimum of every one, two, or three years, depending on the type of manual, and require Board of Supervisors (Board) acceptance and approval.
The manual and policies are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in these manuals improve County government operations and provide for the safety, health, and social service needs of County residents by ensuring policies and procedures are in place for hospital operations and quality patient care.
ARMC manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Security Department Policy and Procedure Manual (Manual) contains policies and procedures required by regulation or determined by ARMC Administration that pertain to the department. The Manual contains 147 policies of which one is new. The new Electronic Immobilizing Devices (EID) policy is needed by ARMC to establish clear guidelines for the safe, appropriate, and lawful use of conducted energy devices by security personnel. This policy ensures that EID is only used as a last resort to protect patients, staff, and visitors from imminent harm while maintaining a therapeutic and professional healthcare environment.
The Security Department recommends the revision summarized in Attachment A.
The new policy, set forth in Attachment B, is as follows:
• Policy No. 101.871 v1, EID - The EID, is used to safely close the gap, when physical intervention is needed, and reduce the incidence of injury.
On January 13, 2026 (Item No. 9), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment C.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on December 5, 2025; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on January 2, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on January 7, 2026.