Adom v. California Department of Corrections and Rehabilitation

FOR PUBLICATION UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT BILAL ADOM, No. 24-4756 D.C. No. Plaintiff - Appellant, 4:22-cv-07150- JSW v. CALIFORNIA DEPARTMENT OF OPINION CORRECTIONS AND REHABILITATION; M. ATCHLEY, Warden; MONTEGRANDE, Doctor; SCOTT LADD, Doctor; LOTERSZTAIN, Doctor; S. SAWYER; R. MOJICA, ADA Coordinator; BIANCA RUBIO, Certified Nursing Assistant (CNA), Defendants - Appellees. Appeal from the United States District Court for the Northern District of California Jeffrey S. White, District Judge, Presiding Argued and Submitted October 23, 2025 San Francisco, California Filed September 8, 2026 2 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION Before: Richard A. Paez, Carlos T. Bea, and Danielle J. Forrest, Circuit Judges. Opinion by Judge Paez; Dissent by Judge Bea SUMMARY* Americans with Disabilities Act The panel reversed the district court’s summary judgment for the California Department of Corrections and Rehabilitation (“CDCR”), and remanded, in Bilal Adom’s action alleging, in part, that CDCR violated Title II of the Americans with Disabilities Act (“ADA”) by failing to reasonably accommodate his disabilities. Adom, an incarcerated individual at Salinas Valley State Prison, suffers from spinal pain and incontinence. For nearly a year after Adom’s incontinence symptoms emerged, prison staff provided him with incontinence supplies through CDCR’s Durable Medical Equipment and Medical Supply program. After Adom was transferred to a different housing unit, prison staff terminated his access to these supplies. Adom requested restored access, but his requests were denied for nearly five months. The panel held that a reasonable jury could find that Adom satisfied the three primary elements of his Title II * This summary constitutes no part of the opinion of the court. It has been prepared by court staff for the convenience of the reader.  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 3 claim and may therefore be entitled to declaratory relief where: (1) a reasonable jury could conclude that Adom is disabled within the meaning of the ADA by virtue of his spinal condition, incontinence, or both; (2) a jury could conclude that Adom was denied meaningful access to CDCR’s toileting and hygiene services because he needed the accommodation of adult diapers to relieve himself hygienically and with dignity; and (3) a jury could find that such denial was by reason of Adom’s disabilities, because it is his disabilities that make it harder for him to enjoy the benefits of CDCR’s toileting and hygiene services. The panel also held that Adom put forth sufficient evidence to create a triable issue regarding whether CDCR acted with deliberate indifference when it denied him the benefits of its services, which he must show to obtain damages. Rejecting CDCR’s contention that a jury could not find deliberate indifference because institutional actors determined that incontinence supplies were not medically necessary, the panel held that a public entity is not excused from its obligation to provide a reasonable accommodation solely because it determined the accommodation is not medically necessary or indicated. The panel remanded for the district court to consider in the first instance whether Adom has standing to seek an injunction ordering CDCR to grant him a permanent accommodation order. The panel addressed Adom’s additional claims in a concurrently filed memorandum disposition. Dissenting, Judge Bea wrote that Adom’s Title II claim fails as a matter of law because: (1) Adom was not qualified to receive the services in question where he did not demonstrate the medical necessity of the supplies; and 4 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION (2) even if Adom was a “qualified individual,” he was denied access to the Durable Medical Equipment services because he lacked proof of medical necessity for the original incontinence supplies, not “by reason of his disability,” as Title II requires. Judge Bea further wrote that the record presents no triable issue of fact as to whether CDCR or any member of the prison’s medical staff acted with deliberate indifference in suspending Adom’s incontinence supplies. COUNSEL Samuel Weiss (argued), Amaris Montes, and Lillian Novak, Rights Behind Bars, Washington, D.C., for Plaintiff- Appellant. Adam M. Stoddard (argued) and James J. Zenere, Zenere Cowden & Stoddard APC, Santa Clara, California; Jaime Ganson (argued), Deputy Attorney General; Neah Huynh, Supervising Deputy Attorney General; Monica N. Anderson, Senior Assistant Attorney General; Rob Bonta, California Attorney General; Office of the California Attorney General, Sacramento, California; Eric J. Miersma, Deputy Attorney General, Office of the California Attorney General, San Diego, California; for Defendants-Appellees.  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 5 OPINION PAEZ, Circuit Judge: Bilal Adom is incarcerated at Salinas Valley State Prison. He uses a wheelchair and suffers from spinal pain that is exacerbated when he moves. He also experiences incontinence and so relies on adult diapers. For nearly a year after Adom’s incontinence symptoms emerged, prison staff provided him with a weekly supply of adult diapers and other incontinence supplies. After Adom transferred to a new section of the prison, however, prison staff abruptly terminated his access to these supplies. Adom urgently requested restored access, but the prison denied his requests for nearly five months. Without these supplies Adom would soil himself and his surrounding environment, including his bed and wheelchair. Adom informed prison officials, in writing, that he was humiliated, dehumanized, and deeply distressed. In a pro se verified complaint, Adom alleged that the California Department of Corrections and Rehabilitation (“CDCR”) violated the Americans with Disabilities Act (“ADA”) by failing to reasonably accommodate his disabilities. Adom also included claims under 42 U.S.C. § 1983 against several individual defendants, alleging violations of the Eighth Amendment. The district court granted summary judgment to all defendants on both claims. Adom, with the assistance of pro bono counsel, appeals. We reverse in part and affirm in part. In this opinion, we reverse the district court’s grant of summary judgment as to Adom’s ADA claim. A reasonable jury could conclude that Adom is disabled within the meaning of the ADA by virtue of his spinal condition, incontinence, or both. A jury could 6 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION also conclude that Adom was denied meaningful access to CDCR’s toileting and hygiene services because he needs diapers to relieve himself hygienically and with dignity. Further, a jury could find that such denial was by reason of Adom’s disabilities, because it is his disabilities that make it harder for him to access these services. And a reasonable jury could conclude that CDCR repeatedly acted with deliberate indifference, as that concept is understood under the ADA. Finally, we hold that a public entity is not excused from its obligation to provide a reasonable accommodation solely because it determined the accommodation is not medically necessary or indicated. In a concurrently filed memorandum disposition, we reverse in part and affirm in part the grant of summary judgment as to Adom’s Eighth Amendment claims. And we remand for further proceedings consistent with these dispositions. I. Background A. Facts1 Bilal Adom is a fifty-seven-year-old man who is incarcerated at Salinas Valley State Prison (“SVSP”). SVSP is a state prison operated by CDCR. For the purposes of our analysis, we attribute all actions of SVSP staff to CDCR. See Duvall v. County of Kitsap, 260 F.3d 1124, 1141 (9th Cir. 2001). 1 The parties dispute many of the material facts. Because Adom appeals from a summary judgment order, and Adom was the nonmovant, we recount the facts as alleged in his verified complaint and sworn affidavit, and draw all reasonable inferences in his favor. Thomas v. Ponder, 611 F.3d 1144, 1149 (9th Cir. 2010).  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 7 Adom has a spinal condition that causes him chronic, severe pain and significantly limits his mobility. He underwent spinal surgery in 2008 and has an active recommendation for a second surgery. He is also a stroke survivor. Adom uses a wheelchair to get around and wears a prison-issued vest that signals he is mobility impaired. Since 2020, Adom has suffered incontinence. He is unable to control his urinary evacuations, particularly at night, and sometimes also involuntarily evacuates stool. In or around December 2020, Adom filed a medical request form complaining of incontinence. Shortly thereafter, CDCR began issuing Adom a weekly supply of fourteen adult diapers. In May 2021, CDCR entered a permanent order for Adom to receive these weekly supplies through its Durable Medical Equipment and Medical Supply program. The regulations governing the program require CDCR to “provide medically necessary accommodations to patients to ensure equal access to prison services, programs, and activities.” Cal. Code Regs. tit. 15, § 3999.394(a) (2026). Adom lived in SVSP’s Alpha Yard until August 2021, where he received incontinence supplies without incident. On August 16, 2021, CDCR transferred Adom to Delta Yard. Adom received his last set of incontinence supplies on September 1, 2021. By mid-September, CDCR officially terminated the order for incontinence supplies.2 Adom was 2 The record is unclear as to when Adom’s supply order was officially terminated, but prison records suggest that CDCR terminated the order upon Adom’s transfer to Delta Yard in August. Another record suggests that Adom’s supplies order expired on September 15, 2021. It appears that CDCR did not notify Adom of the termination until around September 17. 8 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION not seen by a medical professional or asked about his incontinence before CDCR terminated the order. From September 1, 2021, to January 20, 2022, Adom lived without access to adult diapers. He explained in a grievance that he “cannot function without these supplies” and that the deprivation of supplies “caused [him] to have terrible hygiene.” “[W]ithout them,” he explained, “I have no alternative but to soil myself.” The lack of incontinence supplies also aggravated Adom’s spinal condition. Adom most often experienced incontinence in the middle of the night, when the cleanup required him to move around and bend without assistance. These incidents caused him severe spinal pain, which in turn caused him to live in anxious anticipation of incontinence episodes. Adom also lived in fear of developing skin rashes and infections. Adom’s mental health “deteriorated to the point of mental anguish and deep depression.” During those nearly five months, Adom repeatedly told custodial and medical personnel at SVSP, through both informal and formal channels, that he was not receiving the incontinence supplies he needed. On September 10, 2021, on the way to a medical appointment, Adom notified Nurse Bianca Rubio that he had run out of his adult diapers and needed a new supply immediately—he wanted to put one on before he saw the doctor. Rubio told Adom that she was not assigned to distribute incontinence supplies. Adom was then seen by Dr. Faye Montegrande to follow up on an appointment with an outside ophthalmologist. Dr. Montegrande conducted an unannounced, forceful physical examination of Adom, ostensibly to test his reflexes, that caused Adom significant pain. After the pain subsided, Adom realized that he had  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 9 involuntarily urinated in his wheelchair. He notified Dr. Montegrande, told her about his incontinence, and asked about getting his supplies reinstated. Dr. Montegrande ignored his request and continued with her examination. Following this appointment, Dr. Montegrande did not take any action to restore Adom’s incontinence supplies. Adom subsequently made multiple written requests for incontinence supplies. On September 13, he filed a healthcare services request notifying CDCR that he had run out of diapers and that his supplies were not refilled on the normal schedule. On September 17, he filed another request, notifying CDCR that he was unable to control his evacuations, that he was using makeshift diapers made of torn towels, trash bags, tissues, and plastic, and that he was “humiliated and dehumanized.” On September 18, Adom submitted a Reasonable Accommodation Request, notifying CDCR that he suffered from both urinary and fecal incontinence, that his incontinence supplies were not issued the prior week, that he was soiling his linens, and that he was unable to get new linens or diapers. He requested diapers, or towels and trash bags for makeshift diapers. On September 19, Adom filed a healthcare grievance explaining that he was “in dire need” of incontinence supplies. Between September 14 and 16, Adom also informally asked “several building officers” to retrieve, or allow him to retrieve, his incontinence supplies. Adom received no accommodation at all until October 14, 2021. On that date, SVSP’s Reasonable Accommodation Panel formally denied Adom’s request for diapers. Instead, the Panel notified Adom that following future incontinence episodes, prison staff would “provide [him] a shower as soon as safety and security permits,” and ensure that his soiled clothing was properly washed. By way 10 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION of explanation, the Panel noted only that “there was no indication found for incontinence supplies.” On November 12, 2021, Adom sent a letter to Warden M. Atchley and Chief Medical Officer S. Sawyer requesting intervention. On November 19, an unnamed sergeant acting as proxy for the warden interviewed Adom regarding his letter. Adom again requested diapers or makeshift diapers. The sergeant denied Adom’s request and instead gave him three towels and three pairs of boxers. Adom received no additional towels or boxers before or after this encounter. On December 7, 2021, Adom had a medical appointment with Dr. Scott Ladd. Adom informed Dr. Ladd that he was not receiving the incontinence supplies he needed. Dr. Ladd replied that “prisoners were malingering their incontinence conditions . . . thereby abusing the prison system, and that the abuse was costly.” Adom asked Dr. Ladd to look further into his medical records to locate his prior incontinence supplies order and date of termination, but Dr. Ladd refused, saying “I think we’re done here.” Nonetheless, Dr. Ladd prescribed Adom oxybutynin, a bladder control medication. Adom was instructed to stop taking the medication one week later due to painful side effects, and Dr. Ladd did not afterwards reinstate Adom’s access to diapers or take any further action to address Adom’s incontinence. On December 29, 2021, Adom was seen by Dr. M. Lotersztain. She performed a prostate examination and diagnosed Adom with an enlarged prostate. She told Adom that she would reinstate his incontinence supplies, but he did not receive any supplies for three additional weeks. During that period, Adom filed two formal healthcare services requests again asking CDCR to reinstate his incontinence  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 11 supplies, one on January 12, 2022, and another on January 14. Nearly five months after CDCR terminated Adom’s permanent order for incontinence supplies, it reinstated Adom’s weekly regiment of incontinence supplies on January 20, 2022. CDCR logged the new order as temporary. B. Procedural History In November 2022, Adom filed a verified, pro se, handwritten complaint in the district court against CDCR and various individuals, alleging violations of the ADA and the Eighth Amendment. The district court screened the complaint under 28 U.S.C. § 1915(A) and dismissed certain claims but allowed several claims to proceed: the ADA claim against CDCR, and the Eighth Amendment claims against Defendants Warden Atchley, Chief Medical Officer Sawyer, ADA Coordinator Mojica, Dr. Montegrande, Dr. Ladd, and Dr. Lotersztain (collectively “Defendants”).3 Defendants moved for summary judgment. Adom filed a handwritten response opposing the motion. In June 2024, the district court granted summary judgment for Defendants on all claims. The district court concluded that Adom did not address or oppose CDCR’s motion for summary judgment on the ADA claim, despite the fact that Adom submitted multiple pages of ADA-specific opposition briefing. Nonetheless, the district court apparently conducted an independent review of the record. The district court determined that Adom’s request for injunctive relief was moot because CDCR, in January 2022, reinstated his 3 The screening order dismissed Adom’s Eighth Amendment claims against CDCR and Defendant Nurse Rubio. 12 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION incontinence supplies. The district court further held that Adom was not entitled to monetary damages under the ADA because he failed to establish that CDCR discriminated against him because of his incontinence. Instead, because CDCR provided testing and some alternative accommodations, the district court concluded that Adom’s evidence most reasonably indicated a disagreement about medical treatment, rather than disability discrimination. Adom timely appealed. II. Jurisdiction and Standard of Review We have jurisdiction under 28 U.S.C § 1291. We review de novo the district court’s grant of summary judgment. Updike v. Multnomah County, 870 F.3d 939, 947 (9th Cir. 2017). Summary judgment is proper only if there is “no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). In reviewing whether summary judgment was proper, we resolve all evidentiary conflicts, and draw all reasonable inferences, in favor of the nonmoving party. Updike, 870 F.3d at 947. A verified complaint may function as an opposing affidavit under Rule 56. Schroeder v. McDonald, 55 F.3d 454, 460 (9th Cir. 1995). “We construe liberally the filings and motions of a pro se inmate in a civil suit.” Thomas, 611 F.3d at 1150; United States v. Qazi, 975 F.3d 989, 992–93 (9th Cir. 2020) (noting the duty of liberal construction applies with “special force” to the filings of pro se inmates). And in reviewing whether Adom carried his burden in opposition to summary judgment, we do not strictly apply the summary judgment rules, given that Adom was proceeding as a pro se inmate when he filed his complaint and opposition papers. Thomas, 611 F.3d at 1150.  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 13 III. Discussion A. ADA Title II of the ADA provides that “no qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.” 42 U.S.C. § 12132. State prison operators, like CDCR, “fall squarely within the statutory definition of ‘public entity.’” Pa. Dep’t of Corr. v. Yeskey, 524 U.S. 206, 210 (1998) (quoting 42 U.S.C. § 12131(1)(B)). To prove that a public entity violated Title II, a plaintiff must show that “(1) he is a qualified individual with a disability; (2) he was either excluded from participation in or denied the benefits of a public entity’s services, programs, or activities, or was otherwise discriminated against by the public entity; and (3) such exclusion, denial of benefits, or discrimination was by reason of his disability.” Duvall, 260 F.3d at 1135 (internal quotation marks omitted). To recover monetary damages for a violation of Title II, the plaintiff must also show that the public entity defendant acted with deliberate indifference. Id. at 1138. The district court did not address whether Adom was a qualified individual with a disability but concluded that he could not satisfy the remaining elements of his ADA claim. We address each element in turn.4 4 In interpreting the scope of Title II, we also consider precedent interpreting Section 504 of the Rehabilitation Act, as the two laws are “interpreted coextensively.” Payan v. L.A. Cmty. Coll. Dist., 11 F.4th 729, 737 (9th Cir. 2021). 14 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 1. Qualified Individual with a Disability A trier of fact could conclude that Adom is a “qualified individual with a disability.” 42 U.S.C. § 12132. A “qualified individual” within the meaning of Title II is one who “with or without reasonable modifications . . . meets the essential eligibility requirements for the receipt of services or the participation in programs or activities provided by a public entity.” Id. § 12131(2). As we will explain, the “services” that Adom seeks are available to all those, like Adom, who are incarcerated in CDCR facilities. See infra Section III.A.2. Adom is thus qualified to receive all relevant services. See Yeskey, 524 U.S. at 210–11. A jury could also conclude that Adom is disabled within the meaning of the ADA. The ADA generally defines “disability” in two parts: first, the disability must be “a physical or mental impairment”; second, the impairment must be one that “substantially limits one or more major life activities.” 42 U.S.C. § 12102(1)(A).5 This definition must be “construed in favor of broad coverage.” Id. § 12102(4)(A). “[T]he question of whether an individual’s impairment is a disability under the ADA should not demand extensive analysis.” ADA Amendments Act of 2008, Pub. L. No. 110–325, § 2(b)(5), 122 Stat. 3553, 3554 (2008) [“ADAAA”]. Instead, “the primary object of attention in cases brought under the ADA should be whether entities covered under the ADA have complied with their obligations.” Id. 5 Alternatively, a plaintiff can establish “disability” with “a record of such an impairment” or by being “regarded as having such an impairment.” 42 U.S.C. §§ 12102(1)(B)–(C).  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 15 Adom’s spinal condition and incontinence are physical impairments. An impairment is “[a]ny physiological disorder or condition . . .affecting one or more body systems,” including the “musculoskeletal,” “digestive,” and “genitourinary” systems. 28 C.F.R. § 35.108(b)(1)(i). 6 Adom’s back pain is a “condition” that affect[s]” his “musculoskeletal” system because the pain makes it harder to move. Id. His incontinence is a “condition” that “affect[s]” his “genitourinary” and “digestive” systems because it results in a loss of control over when and how he urinates and defecates. Id. A jury could conclude that each of these impairments substantially limits Adom’s major life activities. Major life activities include “caring for oneself, . . . sleeping, walking, standing, lifting, [and] bending,” as well as “the operation of a major bodily function, including but not limited to . . . bowel [and] bladder . . . functions.” 42 U.S.C. §§ 12102(2)(A)–(B). “‘Substantially limits’ is not meant to be a demanding standard.” 28 C.F.R. § 35.108(d)(1)(i); ADAAA § 2(b)(4). The impairment need not prevent, severely restrict, or even significantly restrict the execution of a major life activity. 28 C.F.R. § 35.108(d)(1)(v); ADAAA § 2(b)(4). 6 We have previously given “controlling weight” to Department of Justice regulations interpreting Title II under a theory of agency deference. Cohen v. City of Culver City, 754 F.3d 690, 695 (9th Cir. 2014) (quoting Armstrong v. Schwarzenegger, 622 F.3d 1058, 1065 (9th Cir. 2010)). Title II requires the Department to issue such regulations to implement the statute. 42 U.S.C. § 12134(a). Because of this delegation, and because the parties do not dispute the validity of the relevant regulations, we apply the regulations as an interpretive aid in defining the scope of Title II. See Loper Bright Enters. v. Raimondo, 603 U.S. 369, 394 (2024). 16 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION Whether an impairment causes a substantial limitation may, in some cases, require an individualized determination. See Rohr v. Salt River Project Agric. Imp. & Power Dist., 555 F.3d 850, 858 (9th Cir. 2009) (pre-ADAAA). But “some impairments may invariably cause a substantial limitation of a major life activity.” Albertson’s, Inc. v. Kirkingburg, 527 U.S. 555, 566 (1999) (pre-ADAAA); see also 28 C.F.R. § 35.108(d)(2). Here, a jury could easily conclude that a spinal condition that leaves one bound to a wheelchair invariably limits one’s ability to engage in multiple enumerated major life activities, such as “walking.” 42 U.S.C. § 12102(2)(A); 28 C.F.R. § 35.108(d)(2)(iii)(D) (“[M]obility impairments requiring the use of a wheelchair substantially limit musculoskeletal function.”). Adom has also put forward more than enough evidence from which a trier of fact could conclude that his incontinence substantially limits his “bowel” and “bladder” functions. 42 U.S.C. § 12102(2)(B). He is frequently unable to control his urinary evacuations, and at times his fecal evacuations. A reasonable jury could conclude that is substantial. Adom’s incontinence qualifies as a disability notwithstanding that his doctors did not initially understand its medical basis or believe that diapers were medically necessary. Neither the statute, regulations, nor case law require a medical diagnosis or a doctor’s determination of a medical need for a condition to qualify as a disability under the ADA. See 28 C.F.R. § 35.108(d)(1)(vii) (“The comparison of an individual’s performance of a major life activity to the performance of the same major life activity by most people in the general population usually will not require scientific, medical, or statistical evidence.”).  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 17 CDCR disputes whether Adom’s spinal condition is relevant to his need for incontinence accommodation. But the ADA does not require a one-to-one analysis of impairments and substantial limitations. Construing the meaning of “disability” broadly, 42 U.S.C. § 12102(4)(A), multiple intersecting impairments may contribute to the same limitation. Here, a jury could find that Adom’s spinal condition and incontinence collectively contribute to substantial limitations in, among other things, Adom’s ability to care for himself and his hygiene. Id. § 12102(2)(A). It is reasonable to conclude that it is more difficult to manage involuntary urination and defecation when such evacuations necessitate twisting and moving around in a wheelchair to clean up, and when such movements exacerbate spinal pain. 2. Denial of the Benefits of Services Adom argues that a reasonable jury could conclude he was “denied the benefits of [CDCR’s] services”—namely, toileting and hygiene services provided to inmates. 42 U.S.C. § 12132. We agree. “[T]he ADA entitles inmates to receive the ‘benefits’ of the incarcerating institution’s programs and services without facing discrimination on account of a disability.” Armstrong, 622 F.3d at 1068. CDCR provides the services of toileting and hygiene—that is, it provides the means for inmates to urinate and defecate, as well as the means to keep themselves clean. The broad language of Title II “brings within its scope anything a public entity does.” Lee v. City of Los Angeles, 250 F.3d 668, 691 (9th Cir. 2001) (citation modified), overruling on other grounds recognized in Galbraith v. County of Santa Clara, 307 F.3d 1119, 1125– 26 (9th Cir. 2002). At least one way to identify what a prison 18 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION does, and the services it provides within the meaning of Title II, is to identify what it is required to do by contract or other formal arrangement. See Armstrong, 622 F.3d at 1068. Here, CDCR is vested with “the responsibility for the care, custody, [and] treatment” of those incarcerated in state prisons. Cal. Pen. Code § 5054. CDCR must “provide the means for all incarcerated persons to keep themselves and their living quarters clean and to practice good health habits.” Cal. Code Regs. tit. 15, § 3060 (2026). Given the “restrictions imposed by incarceration,” Armstrong, 622 F.3d at 1068, these statutes and regulations require CDCR to provide the basic services of toileting and hygiene maintenance. The “benefits” of these services are self-explanatory. 42 U.S.C. § 12132. In the words of the relevant regulations, they at least include “clean[liness]” and “good health,” Cal. Code Regs. tit. 15, § 3060 (2026), and “physical and mental well-being,” id. § 3061. CDCR has an “affirmative obligation” to provide Adom with “meaningful access” to the benefits of these services.7 7 “A disability discrimination claim may be based on ‘one of three theories of liability: disparate treatment, disparate impact, or failure to make a reasonable accommodation.’” Payan, 11 F.4th at 738 (quoting Davis v. Shah, 821 F.3d 231, 260 (2d Cir. 2016)). The parties do not clearly delineate the relevant theory of discrimination in this case, but Adom’s ADA claim is best understood as a reasonable accommodation claim because it centers on “an individualized request or need.” Id. Although we have generally applied the meaningful access standard in disparate impact cases, id., Adom urges that meaningful access is the appropriate standard in this accommodation case and CDCR does not argue otherwise. We agree that meaningful access is one standard for assessing whether a reasonable accommodation is required, and we apply it here. See Alexander v. Choate, 469 U.S. 287, 301 (1985) (“[T]o assure meaningful access, reasonable accommodations in the [] program  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 19 Updike, 870 F.3d at 949, 951. Whether Adom was granted meaningful access is measured against the access provided to inmates generally. See Crowder v. Kitagawa, 81 F.3d 1480, 1484–85 (9th Cir. 1996). That is because the purpose of the ADA is to “assure equality of opportunity” and “full participation” in society for individuals with disabilities. 42 U.S.C. § 12101(a)(7). A reasonable jury could find that Adom was denied meaningful access to the benefits of CDCR’s toileting and hygiene services because he needed the accommodation of adult diapers to enjoy those benefits on par with the rest of the SVSP population. Although Adom was technically able to relieve himself (by soiling his bed or wheelchair) and clean after himself (though with spinal pain) during the period he was not provided incontinence supplies, a reasonable jury could conclude that was not comparable to the toileting and hygiene services provided to inmates who did not suffer from Adom’s impairments. When a person with a disability can access a public entity’s services only by experiencing pain and humiliation, that access is likely not meaningful. CDCR does not contest that Adom lived without diapers for five months. Rather, CDCR argues that the termination of Adom’s incontinence supplies was not a denial of CDCR’s services because Adom still had physical access to toilets, showers, and laundry facilities. CDCR further argues that uncontrolled evacuations do not limit one’s physical access to such facilities. And CDCR argues that Adom in fact had greater access to toileting and hygiene services relative to the general prison population because he received or benefit may have to be made.”). That is, if a person lacks meaningful access, they may require a reasonable accommodation. 20 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION a commode in his cell, priority shower and laundry access, and a few extra pairs of towels and boxers. We reject CDCR’s narrow view of its obligations under the ADA. For a person with disabilities, meaningful access to the benefits of toileting and hygiene services may require more than physical access to a toilet, sink, and shower. Beyond removing “architectural, communication, or transportation barriers,” Title II instructs that the requisite access may be achieved through “reasonable modifications to rules, policies, or practices” or “the provision of auxiliary aids and services.” 42 U.S.C. § 12131(2). Although other inmates can access CDCR’s toileting and hygiene services by making use of its bathrooms, showers, and laundry facilities, Adom’s access is not so straightforward. Because he urinates involuntarily, without notice, and often in the middle of the night, structurally accessible facilities fall short of providing Adom a dignified and hygienic way to manage his bodily functions. For similar reasons, a reasonable jury could find that CDCR’s alternative accommodations did not suffice to ensure Adom meaningful access. A closer toilet, and more ways to clean up after incontinence episodes, did not make it possible for Adom to accomplish toileting and hygiene with ease and dignity comparable to that enjoyed by the rest of the inmate population, as he was still left to soil his clothes, bedding, and wheelchair. CDCR also objects that Adom had “the same access to hygiene services as other prisoners.” Along these lines, the dissent suggests that CDCR must be free of liability because it treated all prisoners “alike,” and Adom was left to live in his own waste only by the application of “neutral, generally applicable rules.” Dissent 41. But that is exactly the  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 21 problem. CDCR treated Adom the same as nondisabled inmates when the ADA required CDCR to treat him differently. See McGary v. City of Portland, 386 F.3d 1259, 1267 (9th Cir. 2004) (“The purpose of the ADA’s reasonable accommodation requirement is to guard against the façade of ‘equal treatment’ when particular accommodations are necessary to level the playing field.”); see also Crowder, 81 F.3d at 1484. Finally, CDCR and the dissent object that Adom did not allege in his complaint, or argue in the district court, that toileting and hygiene were the “services” he was denied, so the argument is forfeited. We disagree. “We construe liberally the filings and motions of a pro se inmate in a civil suit.” Thomas, 611 F.3d at 1150. And our precedent clearly establishes a pro se inmate may “refine[] and clarif[y]” an initial legal theory through subsequent filings and counseled appellate briefing. See Walker v. Beard, 789 F.3d 1125, 1133–34 (9th Cir. 2015); see also Qazi, 975 F.3d at 993 (discussing Zichko v. Idaho, 247 F.3d 1015, 1020 (9th Cir. 2001)). Adom’s handwritten complaint identified the “general theory” of his ADA claim—denial of services by reason of disability—and the “nucleus of facts” entitling him to relief—the denial of incontinence supplies and the ways in which that denial left him unable to cleanly and humanely relieve himself. See Walker, 789 F.3d at 1133. And in opposition to summary judgment, Adom expressly argued that he was “entitled to recover under the ADA” because he was “excluded from obtaining incontinence supplies,” without which he “was unable to painlessly, effectively and humanely protect himself from involuntary urinations.” 22 ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION This is the same claim, and essentially the same argument, that Adom raises in his counseled briefs on appeal.8 In the district court, Adom’s pleadings did not identify “toileting and hygiene” as the relevant “services”; rather, they identified only the “service” or “program” of CDCR’s Durable Medical Equipment program, which provides incontinence supplies. At the same time, Adom’s pleadings identified incontinence supplies—provided through the Durable Medical Equipment program—as his requested accommodation. Our precedent requires that we afford Adom the benefit of doubt regarding the nature and substance of his pleadings. Qazi, 975 F.3d at 993. Thus, we construe Adom’s complaint as seeking an accommodation of a supply order through the Durable Medical Equipment program rather than access to that program in and of itself. In resisting this straightforward application of binding law, the dissent relies on a string of cases that do not touch on the essential circumstances here: 9 a pro se inmate, to 8 The dissent, in contrast, argues at length that Adom’s requested accommodation of adult diapers is not “reasonable,” Dissent 59–60, when CDCR neither raised this defense in the district court nor briefed it on appeal. Pierce v. County of Orange, 526 F.3d 1190, 1217 (9th Cir. 2008) (providing burden shifting framework for reasonableness inquiry). Similarly, CDCR has not argued that it would have had to “violate binding regulations” to provide incontinence supplies while waiting for doctors to uncover the medical cause of Adom’s incontinence. Dissent 60, 63–65. Even if that were true, it would neither necessarily offend the ADA nor require affirmance here. A public entity may be required to make “reasonable changes in existing policies in order to accommodate individuals’ disabilities.” Townsend v. Quasim, 328 F.3d 511, 518 (9th Cir. 2003) (citation modified). 9 Beaudett v. City of Hampton, 775 F.2d 1274, 1278 (4th Cir. 1985) (affirming dismissal of a pro se complaint where plaintiff on appeal sought to introduce entirely new claims of vagueness, overbreadth, and  ADOM V. CA DEPT. OF CORRECTIONS AND REHABILITATION 23 whom the rule of liberal construction applies with “special force,” whose revised theory is squarely presented in “more focused” appellate briefing. Qazi, 975 F.3d at 993; see also Beaudett, 775 F.2d at 1278 (“Subsequent proceedings, may, at times, reveal that ambiguous fragments in the complaint represent the heart of a litigant’s concern.”). The dissent further objects that this reframing fails to review the district court’s reasoning and prejudices CDCR. Although Adom addressed his ADA claim in his opposition to CDCR’s summary judgment motion, the district court erroneously determined that Adom did not oppose summary judgment on this claim, so it did not consider, let alone liberally construe, any of Adom’s ADA arguments. Moreover, even if the dissent were correct that CDCR was not on notice as to the relevant service, we struggle to understand why CDCR would have introduced any different evidence on the reasonableness of the incontinence-supply accommodation. Dissent 55–56. CDCR did not object to the reasonableness of Adom’s requested accommodation in the district court. See supra n.8. And construing Adom’s handwritten complaint as we do is a legal issue that does not change the relevant factual allegations—that Adom sought, and was denied, incontinence supplies. selective prosecution based on passing references to free speech, equal protection, and refusal to pay fines in “sentence fragments,” and where the only claim for relief was trial by jury on a personal