2012 coverage: (6.4MB PDF) - Center for Investigative Reporting

Transcription

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MARK KATCHES
EDITORIAL DIRECTOR
2130 Center St., Suite 103
Berkeley, CA 94704
510-809-3174
www.cironline.org
To the judges:
Decades ago, California created a special police force to patrol exclusively at its five state developmental centers – taxpayer-funded institutions that house patients with severe autism, cerebral palsy
and other major developmental disabilities.
But California Watch found that patients inside these centers have been beaten, tortured and raped
by staff members and that the police force has done an abysmal job bringing perpetrators to justice.
Reporter Ryan Gabrielson, a Pulitzer Prize winner, exposed the depths of the abuse while showing
how sworn officers and detectives wait too long to start investigations, fail to collect evidence and ignore key witnesses – leading to an alarming inability to solve crimes inflicted upon some of society’s
most vulnerable citizens.
Gabrielson’s 18-month investigation about the Office of Protective Services snowballed over the
course of 2012 – resulting in five major installments from February to November. He found that dozens of women were sexually assaulted inside state centers, but police investigators didn’t order “rape
kits” to collect evidence, a standard law enforcement tool. Police waited so long to investigate one
sexual assault that the staff janitor accused of rape fled the country, leaving behind a pregnant patient incapable of caring for a child. The police force’s inaction also allowed abusive caregivers to
continue molesting patients – even after the department had evidence that could have stopped future
assaults.
In one egregious physical abuse case, a caregiver was suspected of using a Taser to inflict burns on
a dozen patients. Yet the internal police force waited at least nine days to interview the caregiver,
who was never arrested or charged with abuse. In another case, a 50-year-old autistic man died after
he was discovered on his bedroom floor with a broken neck. Three doctors said someone likely had
caused the fatal injury. But critical errors by police investigators made solving the case next to impossible. Gabrielson also revealed that the force’s police chief, a former firefighter, had no training
in criminal investigations and that local police agencies were being left in the dark about potential
crimes.
Many of the victims chronicled by California Watch – including 11 of the 12 stun gun victims – are so
disabled they cannot utter a word. Gabrielson gave them a resounding voice.
“This is the type of reporting that ends up actually saving lives,” wrote Patricia L. McGinnis, executive
director of California Advocates for Nursing Home Reform, in thanking Gabrielson and California
Watch, which is part of the Center for Investigative Reporting.
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Broken Shield prompted far-reaching change, including a criminal investigation, staff retraining and
new laws – all intended to bring greater safeguards and accountability. Among the reforms that are a
direct result of our reporting:
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Gov. Jerry Brown ordered that the entire police force undergo extensive retraining, and he appointed an independent monitor to overhaul the Office of Protective Services’ policies.
The governor also signed two bills – one requiring that outside law enforcement be notified of suspected crimes inside developmental centers and another mandating that the agency be led by a law enforcement veteran.
The state took steps to revoke the license of the most troubled developmental center, in
Sonoma – the scene of one-third of the patient rapes as well as the Taser incidents.
The California Highway Patrol assumed control of the police force at the Sonoma center.
Local prosecutors launched a criminal investigation of the stun gun abuses.
State officials embarked on an audit of the entire police force’s practices.
The police force’s chief was demoted.
Gabrielson and data analyst Agustín Armendariz also found that despite their sloppy job performance, officers and detectives at the Office of Protective Services got paid more overtime than their
peers at similar-sized police agencies. Officers even collected extra pay to patrol one developmental
center long after it had been closed. As a result of our dogged journalism, the state launched yet another investigation focused on the police force’s overtime abuse.
None of the reporting came easily. Gabrielson encountered one reluctant source after another. Police
officials closed ranks. And the state health agency blacked out nearly every word contained in scores
of additional abuse cases against patients. We sued, prompting a Superior Court judge to order the
release of the uncensored documents. But the state has appealed, keeping the records hidden for
now. We will continue fighting for public access to these files.
Eight of California’s largest newspapers ran our stories on their front pages. Video producer Monica
Lam produced a broadcast segment that aired in every major market. Gabrielson and multimedia
producer Carrie Ching created two haunting videos that drilled down on specific cases – one about
the patient who was allegedly raped by the staff janitor and another that detailed the mysterious
death of the 50-year-old autistic man, a likely homicide victim. Working on every platform helped to
maximize audience reach and heighten the impact. We also hosted a jam-packed community forum
in Sonoma that drew stakeholders living near the state center threatened with license revocation.
The 1,600 patients at these five state centers deserve every ounce of our efforts. We are extremely
proud that Broken Shield spurred reforms that will ensure greater protections and justice for every
one of them.
Sincerely,
Mark Katches
Editorial Director, Center for Investigative Reporting
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TABLE OF CONTENTS
Team Biographies�� 5
MAIN ENTRY
Sloppy investigations leave abuse of disabled unsolved��7
Basic police work ignored in autistic patient’s suspicious death�� 20
Video – Manner of Death: Undetermined�� 32
Police ignored, mishandled sex assaults reported by disabled�� 33
Video – In Jennifer’s Room�� 42
Infographic – After claims of sexual assault, little is done�� 43
Questions surround handling of Taser assaults on disabled patients�� 44
Overtime pay soars for state-run police force�� 52
Infographic – How does a police officer double his salary in a year?�� 59
SUPPLEMENTAL
Response and Reaction
Reach and Outreach�� 62
Developmental centers’ police need immediate fixes, state officials say�� 64
Developmental center police investigating officer’s overtime�� 68
Developmental centers seek new police chief�� 71
State lawmakers order audit of developmental center police�� 74
Brown signs bills on developmental center abuse�� 76
Calls grow for local police to take cases at developmental centers�� 78
State threatens to shut down disability center amid patient abuse�� 80
State disability center forfeits funding over abuse�� 83
Sonoma panel invitation�� 85
Interactive Timeline – Moving the needle�� 87
Other Stories
State agency’s police chiefs lack law enforcement experience�� 89
Veteran detectives identify death investigation’s key mistakes�� 93
Video – Unexplained deaths behind closed doors�� 95
State withholds details on developmental center slaying�� 96
Report slams state institution for neglect, weak oversight�� 99
eBook – In the Wrong Hands�� 103
Commentary
Poynter commentary�� 105
USC health blog�� 108
San Diego Union-Tribune editorial�� 110
SF Gate commentary�� 112
Sacramento Bee editorial�� 114
Journalism Center on Children and Families commentary�� 116
Disability and Abuse Project�� 118
Email Responses�� 121
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TEAM BIOGRAPHIES
RYAN GABRIELSON
Ryan Gabrielson covers public safety for California Watch and the Center for
Investigative Reporting. He was a 2009-2010 investigative reporting fellow at UC
Berkeley. His reporting on an in-house police force at California’s board-and-care
institutions for the developmentally disabled exposed how officers routinely failed
to do basic work on criminal cases, including suspicious deaths. Previously, he was a
reporter at the East Valley Tribune in Mesa, Ariz. In 2009, he and Tribune colleague
Paul Giblin won a Pulitzer Prize for stories that showed immigration enforcement by the Maricopa
County Sheriff’s Office undermined investigations and emergency response. Ryan’s work has received
numerous national and state honors, including a George Polk Award, an Online Journalism Award for
investigative reporting, and a Sigma Delta Chi Award. A Phoenix native, he studied journalism at the
University of Arizona and began his career at The Monitor in McAllen, Texas. Ryan lives in Oakland
with his wife, Rachel, and two daughters.
CARRIE CHING
Carrie Ching is Senior Multimedia Producer at the Center for Investigative
Reporting. She manages and produces multimedia reports for CIR projects –
including California Watch and The Bay Citizen. Carrie has been leading CIR’s digital
storytelling initiatives since 2007, when she came on to oversee all web and
multimedia production. Her focus is now narrative multimedia storytelling and
exploring ways to use digital tools – including video, audio, photography, animation,
and interactive graphics – to push the boundaries of storytelling on the Web and other digital
platforms. Prior to joining CIR she was an editor at California magazine, Mutual Publishing, and
AlterNet.org; creator and founding editor of WireTap magazine; a reporter for the Honolulu
Advertiser and stringer for several daily and weekly newspapers; a fact-checker at Mother Jones
magazine; a freelance video journalist for Washingtonpost.com and Current TV; and a writer for
Current TV’s hosted news comedy show, Google Current. Her work has won numerous awards for
feature storytelling and explanatory journalism – including honors from the Society of Professional
Journalists, Best of the West – and was featured prominently in team awards from the Online News
Association, Investigative Reporters and Editors, and the Scripps Howard Awards. She completed a
master’s degree in journalism from UC Berkeley in 2005.
AGUSTIN ARMENDARIZ
Agustin Armendariz is the senior data analyst as CIR, hired to help start the
California Watch project. He did the mapping and analysis for the award-winning On
Shaky Ground series, and routinely works with reporters across the organization to
help advance stories. Before joining CIR, he worked at the San Diego Union-Tribune
as a database specialist on the watchdog reporting team. While there, he delved into
city finances, redevelopment projects and foreclosures. After earning his master’s
degree in journalism from American University in Washington, D.C., he worked for the Center for
Public Integrity and contributed to “The Buying of the President 2004,” which became a New York
Times bestseller.
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MONICA LAM
Monica Lam is a documentary film and television producer who has traveled on
five continents producing, reporting, and shooting for the NewsHour, Frontline,
Frontline/WORLD and other PBS programs as well as HBO, Swiss National TV and
MSNBC. Monica has followed the story of sweatshop workers in China, Uighurs
in Xinjiang, mercury poisoning in the North Atlantic, social entrepreneurship in
Paraguay, baseball in Cuba, Yanomami Indians in the Venezuelan Amazon, the
impact of Wal-Mart on small towns in America, Native American gaming in Rohnert Park, CA, crime
prevention programs in Richmond, CA, and the making of an opera written by Amy Tan. She has won
an Emmy for her work and was cinematographer of an Oscar-nominated short documentary. Monica
has written for the Daily Cal, San Francisco Chronicle, Florida Sun-Sentinel, Hyphen magazine and
was the founding editor of Berkeley Patch, a daily hyperlocal news site. She studied urban planning at
Stanford University and received her masters in journalism from the UC Berkeley Graduate School of
Journalism.
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FEBRUARY 23, 2012
Sloppy investigations leave abuse
of disabled unsolved
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Overview
C
alifornia has assembled a unique police force to protect
Where It Ran:
about 1,800 of its most vulnerable patients – men and
women with cerebral palsy, severe autism and other menThis story also appeared
in the following news outlets:
tal disabilities who live in state institutions and require
round-the-clock monitoring and protection from abuse.
• ABC 7 News
• ABC 10 News
But an investigation by California Watch has found that detec• The California Report
tives and patrol officers at the state’s five board-and-care institu• The Fresno Bee
• KPBS
tions routinely fail to conduct basic police work even when patients
• KQED News Fix blog
die under mysterious circumstances.
• KXTV News 10
• The Modesto Bee
Federal audits and investigations by disability-rights groups,
• NPR
as well as thousands of pages of case files, government data and
• Orange County Register
• The Sacramento Bee
lawsuits dating back to 2000, show caregivers and other facility
• San Francisco Chronicle
staff allegedly involved in choking, shoving, hitting and sexually
• San Diego Union-Tribune
• This Week in Northern
assaulting patients. None of these cases were prosecuted.
California
Cases investigated as possible crimes include the death of a
severely autistic man whose neck was broken. Three medical
experts said the 50-year-old patient, Van Ingraham, likely had been killed. But the developmental
center’s detective, a former nurse who’d never handled a suspicious death, failed to identify how the
fatal injury occurred.
The police force, called the Office of Protective Services, often learns about potential criminal
abuse hours or days after the fact – if they find out at all. Of the hundreds of abuse cases reported at
the centers since 2006, California Watch could find just two cases where the department made an
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arrest.
The people that the police force is sworn
to protect have profound developmental
disabilities and live in a different world from
most Californians. Some patients have spent
decades in the centers, from childhood to
death. Some cannot form words and have IQ
scores in the single digits.
The precise number of times nurses,
janitors or staff supervisors have been implicated in patient abuse cases is unknown;
the state has censored thousands of pages of
documents detailing the cases.
MONICA LAM/CALIFORNIA WATCH
California is budgeted to spend $577 mil- Donna Lazzini embraces her son, Timothy Lazzini, a resident
of the Sonoma Developmental Center who died in 2005. The
lion this fiscal year to operate the centers,
picture is part of a family photo collage celebrating his life.
or roughly $320,000 per patient. More than
5,200 people work in the institutions – roughly 2.5 staff members for each patient. The five centers
are in Los Angeles, Orange, Riverside, Sonoma and Tulare counties.
In most other states, local law enforcement or state police take the lead in conducting criminal
investigations at developmental centers.
Critics of the state Department of Developmental Services, which oversees the institutions and
the Office of Protective Services, have said the tight-knit atmosphere between the in-house police and
staff makes it difficult to create a separation between the investigators and the investigated.
In a few cases, caregivers and others with minimal police training have been hired to work as law
enforcement in the same facility. The commander at the Lanterman Developmental Center in Pomona worked there as a primary caregiver. The force’s police chief is a former firefighter at the Sonoma
Developmental Center.
The police force also suffers from a convoluted chain of command, interviews and records show.
Detectives cannot make arrests without checking with department lawyers in Sacramento. Local
police must be informed when serious injuries or deaths occur, but most defer investigations to the
Office of Protective Services.
“It seems like something is not working in California. And that’s probably a major understatement,” said Tamie Hopp, an official with the national organization Voice of the Retarded, who noted
the volume of abuse cases in California, and the lack of prosecutions, is cause for alarm.
Terri Delgadillo, director of the Department of Developmental Services, said her department has
a zero-tolerance policy that includes reporting any injuries, even those remotely suspicious, to the
state Department of Public Health. She said the department is committed to conducting thorough
investigations.
“For the department, the priority is to make sure that we’re doing the best job providing con8
sumer safety and services,” Delgadillo said in an
interview. “And if there are issues that need to be
addressed – and there’s always room for improvement – we’re looking to do that.”
She has hired a consulting group, the Consortium on Innovative Practices based in Alabama, to
review the methods and training of her police force.
The nonprofit group was recommended by the U.S.
Department of Justice, which issued a scathing critique of the department in 2006.
The department said that from January 2008
to last month, 67 developmental center employees
MONICA LAM/CALIFORNIA WATCH were fired for “client-related” offenses. But officials
Terri Delgadillo, director of the Department of Dedeclined to say how many of those, if any, were disvelopmental Services, said she has hired a consulmissed for abusing patients, where they worked or if
tant to advise her office on practices at the Office of
Protective Services.
any of them had been arrested.
Delgadillo also declined to comment on specific cases of alleged abuse or mistreatment at the
developmental centers, citing patient privacy laws. Corey Smith, the former firefighter who is now
police chief, said he was not permitted to speak with reporters for this story.
Abuse cases increase
The developmental centers have been the scene of 327 patient abuse cases since 2006, according
to inspection data from the California Department of Public Health. Patients have suffered an additional 762 injuries of “unknown origin” – often a signal of abuse that under state policy should be
investigated as a potential crime.
At the state’s five centers, the list of unexplained injuries includes patients who suffered deep
cuts on the head; a fractured pelvis; a broken jaw; busted ribs, shins and wrists; bruises and tears to
male genitalia; and burns on the skin the size and shape of a cigarette butt.
Timothy Lazzini, a quadriplegic cerebral palsy patient at the Sonoma Developmental Center, died
in 2005 after he swallowed 4-inch swabs that shredded his esophagus. After his death, Lazzini’s doctor and a pathologist concluded it was highly unlikely that Lazzini could have placed the swabs in
his own mouth.
But records show detectives waited too long to start their investigation. If any physical evidence
was left in Lazzini’s room, it had been removed by the time investigators arrived.
His death, and the slow response by the Office of Protective Services, has left Lazzini’s family
heartbroken and without a conclusive answer as to how he was killed.
“He is gone and they really haven’t given us as a family the information that we need to be at
peace,” said Stephanie Contreras, Lazzini’s sister. “There is no peace at all.”
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The rate of suspected abuse cases within the walls of the five institutions has risen – even as hundreds of developmentally disabled patients have been moved to group homes and smaller nursing
facilities.
The patient population at developmental centers dropped by 12 percent from 2008 to 2010,
state records show, but reports of abuse have increased 43 percent during those three years. Unexplained injuries jumped 8 percent in the same period.
Public health officials acknowledged the state doesn’t keep a tally of the number of times caregivers have abused patients. That information is kept hidden from the public in individual case files.
Kathleen Billingsley, director of policy and programs for the Department of Public Health, said
she also didn’t know whether inspectors were notifying law enforcement agencies when they uncover evidence of abuse. She said public health inspectors conduct thorough investigations separately
from the police.
“If there is any cross between enforcement individuals at the state facility and the work we do, I
am not familiar with that,” Billingsley said.
The Los Angeles County district attorney’s office, which oversees Lanterman, couldn’t identify a
single criminal case referred from the center’s police force. District attorneys in Tulare, Orange and
Riverside counties also reported no prosecutions for patient abuse in the past decade. Sonoma County refused to disclose its records.
On average, police in California solve about two-thirds of all homicides and about half of all aggravated assaults – or at least make an arrest and “clear” the cases. The clearance rate for the Office of
Protective Services is unknown because the department keeps the information secret.
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Thankless jobs, hidden from the public
The Office of Protective Services has existed in various forms and names since the late 19th century, when California opened its first institution for the developmentally disabled. That facility in San
Jose – first known as the Agnews Insane Asylum – opened in 1885 and closed in 2009.
Interviews with current and former Office of Protective Services employees suggest the organization’s structure from its beginning has contributed to its dysfunction.
Patrol officers dress much like those at any other police department. They wear tan and green
uniforms with gold badges. Handcuffs are hooked to their belts. They drive marked squad cars. But
there are key differences.
Officers and caregivers are confined together in a 24-hour facility monitoring an unpredictable,
sometimes uncontrollable population. Beyond a paycheck, the job is mostly thankless and hidden
from the public. Officers are not allowed to carry guns; many carry pepper spray instead. They often
work their shifts alone.
Greg Wardwell, a sergeant who spent more than 20 years patrolling the Sonoma Developmental
Center before retiring last year, said the state has undermined its own police force through neglect
and incompetence.
“You can look like a cop and we’ll call you a cop, but you don’t really have any way of being a cop,”
Wardwell said. “Because we’re not going to train you, we won’t provide safety equipment. The salary
will be so bad that we won’t be able to recruit anybody of talent.”
Salaries for the roughly 90 sworn officers are half of what police earn in the state’s big city departments. Yet, roughly a third of officers within the Office of Protective Services are among the best
compensated in California law enforcement, with much of their pay gained through overtime. One
officer’s income has topped $200,000 a year.
Families must rely on the Office of Protective Services to provide evidence for lawsuits when their
relatives are harmed or killed at a developmental center. Records show the state paid out nearly $9
million in legal settlements – out of 68 separate lawsuits – from 2004 to 2010.
In 2005, Disability Rights California issued a report on a pattern of unexplained genital lacerations suffered by male patients at an unnamed developmental center. The cases were potentially sex
assaults, but the investigations were woefully incomplete, documents show.
“Photographs were not taken,” the report states. “Not all witnesses, nor all key witnesses, were
interviewed. Physical evidence was not collected. Victims did not receive thorough medical workups
to look for other indications of abuse.”
Leslie Morrison, director of investigations at Disability Rights California, said the report
showed how the developmentally disabled can be treated as second-class citizens.
“If this had happened to 3-year-old boys in a day care center, people would have been alarmed,
police would have been called, there would have been an outrage,” Morrison said. “It wouldn’t have
just been treated as just, ‘Oh, look, there’s a cut, we better sew that up.’ ” In the case of the 50-year-old autistic man, Van Ingraham, his family received $800,000 in a set11
PHOTO BY NADIA BOROWSKI SCOTT
At his home in San Diego, Larry Ingraham constructed a memorial to his brother, Van.
tlement with the state. Ingraham died in 2007 after sustaining a broken neck while in his room at the
Fairview Developmental Center in Orange County.
Fairview officers didn’t collect physical evidence from Ingraham’s room, records show. Detectives
overlooked evidence that a caregiver last seen with Ingraham had altered the log of his activities.
And they omitted from the case file an expert’s opinion that Ingraham’s death “was likely a homicide.”
“This incompetent, horrendous organization called Office of Protective Services takes it and just
makes a mess, just a complete mangled mess of the investigation,” said Larry Ingraham, the patient’s
older brother and a veteran of the San Diego Police Department.
Sexual assaults unprosecuted
Sex abuse cases, too, have been shelved without prosecution.
In April 2010, at the Canyon Springs Developmental Center in Riverside County, a janitor twice
sexually abused a mentally disabled female patient when caregivers were out of sight. Under California law, having sex with any developmentally disabled person who is incapable of giving consent is
considered rape.
The patient, who is not identified in state records, had a history of being assaulted. She was institutionalized at age 12 after her father impregnated her, a state health department citation shows.
The patient had been diagnosed with moderate mental retardation, schizoaffective disorder and
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post-traumatic stress disorder. Canyon Springs staff had been working with her to curb any behavior
“possibly leading to sexual activity,” her file states.
The female patient, then 39 years old, told center employees she “did it” with the janitor in the
women’s bathroom and in a hallway during a fire drill. An unidentified Canyon Springs employee
notified the state Department of Public Health.
The Office of Protective Services investigated the case but made no arrests. State regulators also
investigated and ruled the incidents as sexual abuse, according to a citation issued to Canyon Springs.
In December 2010, Canyon Springs was fined $800 by public health officials for the incidents.
No criminal charges followed. The Riverside County district attorney’s office said it has no record of
receiving any case referrals from Canyon Springs, which houses about 50 patients.
Rather than placing the janitor under arrest, developmental center officials ordered him to undergo training on his “legal duty” regarding patient abuse, according to state records. The Office of Protective Services concluded that the janitor didn’t commit a crime, Delgadillo said.
She declined to answer other questions about the incident or to say whether the janitor, whose name
the state has redacted from case files, continues to work at Canyon Springs.
In another case with even fewer details available, a female patient at the Sonoma Developmental
Center accused a male caregiver of sexually assaulting her during a bath in early 2000, police records
show. The institution responded by assigning two men to bathe the patient.
On July 6, 2000, both caregivers allegedly raped her, again during bathing.
The institution did not inform its own police officers about the details of either incident. Records
show Ed Contreras, then Sonoma’s police commander, received an anonymous tip four days after the
second alleged rape.
“They weren’t following the law,” Contreras said in an interview. “They weren’t reporting it to the
police department. They weren’t reporting it to me.”
Contreras said no arrests were made in the sex assaults. The Sonoma County district attorney’s
office declined to release records on the cases or any other criminal allegations from the developmental center.
Inside institutions, a different world
The Sonoma Developmental Center is located in a quaint neighborhood in the middle of wine
country. Fairview in Costa Mesa is near the Orange County fairgrounds and surrounded by strip malls
and a golf course. Lanterman is wedged between train tracks and a highway east of Los Angeles.
Next door to a Cathedral City cemetery, tiny Canyon Springs could be mistaken for an office park.
The Porterville Developmental Center, southeast of Visalia, does have the look of an institution.
Among the 500 patients, the facility houses about 200 developmentally disabled patients who have
committed crimes or who are under arrest.
Inside, the centers feature wide hallways. Walls are decorated much the same as elementary
school classrooms, with colors and construction paper cutouts to signal upcoming holidays.
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CARLOS PUMA/CALIFORNIA WATCH
The interiors of California’s developmental centers look like nursing homes or long-term care hospitals. The state
plans to close this facility, the Lanterman Developmental Center in Los Angeles County.
Primary caregivers, called psychiatric technicians, guide patients from place to place, feeding
them and distributing medication. Each patient communicates differently, and the units are filled
with shouts, groans, shrieks and crying. Patients share bedrooms. Some are crowded with stuffed
animals, posters and family pictures. Others are empty, save for the full-sized beds and a cabinet.
Parents and siblings can visit every week for hours at a time. Fairview patients range from 15 to
94 years old, said Bill Wilson, the institution’s executive director. Most are between the ages of 40
and 60.
More than two-thirds of patients are diagnosed with profound mental disabilities, according to
research from UC San Francisco. The institutions have whole units for patients who are emotionally
volatile, prone to striking themselves and others.
The disabled population adds greater complexity to criminal investigations. For a host of reasons,
their observations can be tainted by fantasies and falsehoods. Their emotions veer from happy to
inconsolable without warning. Patients slap and punch at their faces and legs, and at each other.
“They come to us after they’ve burned every bridge in the community,” said Erinn Kanney, a program manager at Fairview.
Outside of California, local or state police most often are responsible for investigating criminal
cases at institutions. But city and county law enforcement agencies inside the state have not shown
an interest in developmental center cases and don’t have funding to expand their scope, according to
Delgadillo.
“Oftentimes, local law enforcement does not want to get involved,” said Delgadillo, who in the
past has worked for the California Department of Corrections and Rehabilitation as a manager in the
juvenile justice division.
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Local police or sheriff’s deputies can act more independently than an internal police force responsible for probes into their colleagues and bosses, said Jane Hudson, senior staff attorney for the
National Disability Rights Network, a patient advocacy organization
“If there’s a crime committed,” Hudson said, “you let the criminal investigators go in first rather
than the institution bagging the bloody shirt.”
Delayed notification hinders investigations
Delays by the Office of Protective Services often make cases harder to solve.
Although no public records exist showing how frequently the police force receives late notification of potential abuse cases, California Watch was able to identify at least a dozen incidents in which
delays from 24 hours to several days occurred.
Forensic experts say the first hours following a crime are critical. A person walking through a
crime scene can ruin fingerprints, DNA samples and other evidence, said Dennis Kilcoyne, a Los
Angeles Police Department homicide detective. Witness statements can change with time, especially
after they’ve conferred with others, he said.
“People’s emotions are in play, and they may say things that, after they’ve thought about it or consulted with an attorney, (they) won’t say a week from now,” said Kilcoyne, a 27-year veteran.
Delays have hurt criminal investigations and given the centers’ employees time to alter and destroy evidence, records and interviews show.
That’s what happened in the case of Timothy Lazzini, the 25-year-old quadriplegic patient with
cerebral palsy, who coughed up a bloody glycerin swab at the Sonoma Developmental Center. He died
from internal bleeding that night, Oct. 22, 2005.
Three swabs – each 4 inches long and twice as thick as a Q-tip – had torn Lazzini’s esophagus. He
coughed out one, but two others remained lodged in his stomach, autopsy records show.
At that point in his life, Lazzini’s disabilities had left him mostly paralyzed, and he received food
through a tube in his abdomen.
Someone at the developmental center likely put the swabs inside his mouth before he died. Dr.
Ken Christensen, Lazzini’s doctor, told Office of Protective Services investigators that it was possible
for Lazzini to swallow the swabs, but “it is unlikely for him to be able to pick it up and put it into his
mouth.” The pathologist who performed Lazzini’s autopsy noted the same thing.
The Office of Protective Services assigned the case to a detective more than 24 hours after a caregiver discovered Lazzini bleeding from the mouth, the police file shows. By then, if any evidence was
available at the scene, it was gone.
“I noted the area was cleaned up,” Rod Beck, the detective, wrote in his report. “I did not note
G-swabs in the bedroom area and none were seen in the drawers of his dresser.”
The glycerin swabs are lemon flavored and intended to moisten a patient’s mouth, but caregivers
were not supposed to use them on Lazzini, according to the case file. The patient did not have the
physical ability to remove the swabs himself, one of Lazzini’s doctors told police.
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During his interviews with caregivers, Beck learned that some technicians
had been using the glycerin swabs as a
pacifier for Lazzini, putting them in his
mouth when he “got vocal.”
Lazzini’s caregivers all denied ever
putting swabs in his mouth, however.
Only one of the seven questioned by
police admitted to using them on any
patient.
Records that might have proven
Stephanie
Contreras
reads
through
the
case file on her brother,
otherwise were destroyed, according to
Timothy Lazzini, a 25-year-old quadriplegic who died of interthe police report. Daily caregiver notes
nal bleeding in 2005. An autopsy revealed two large, Q-tip-like
swabs stuck in his stomach.
from the previous week went missing.
Someone blacked out information in two separate logs documenting patient care on the day Sonoma
employees discovered Lazzini bleeding.
“The initials were heavily lined out,” Beck wrote.
Mark Czworniak, a Chicago Police Department homicide detective, reviewed the Lazzini case file
for California Watch. He said that without records, crime scene evidence or corroborating statements
from witnesses, there is no way to link anyone to the swabs that killed Lazzini.
It might have been multiple caregivers, Czworniak wrote, “or a completely unobservant health
care worker, supplying Timothy L. with the G-swab one after another, not noticing, or caring where
each swab disappeared to, and not surmising that Timothy L. was swallowing them.”
Lazzini’s sister, Stephanie Contreras, who lives in the Sonoma County town of Windsor, and other
family members sued the state in 2006 over Lazzini’s death and settled two years later for $100,000.
The Department of Public Health also fined the Sonoma Developmental Center $90,000 in August
2007, citing “mistreatment, neglect or misappropriation of resident property” – the failure to prevent
Lazzini from swallowing the swabs.
But the Office of Protective Services closed the Lazzini case without determining what had happened.
Oversight reorganized
For much of its history, the Office of Protective Services was fragmented, with officers reporting
only to administrators at their own facility.
Then, after a series of critical stories about the Sonoma center in the local Index-Tribune newspaper, Sacramento officials took greater control of the Office of Protective Services. They created a
statewide police chief and borrowed veteran officers from the California Highway Patrol to fill the
job.
16
“If this had happened to 3-yearold boys in a day
care center, people
would have been
alarmed, police
would have been
called, there would
have been an outrage. It wouldn’t
have just been
treated as just,
‘Oh, look, there’s a
cut, we better sew
that up.’” — Leslie Morrison,
investigations
director,
Disability Rights
California
In 2006, the U.S. Justice Department’s Civil Rights Division
criticized the care at Lanterman, in Pomona, in a letter sent to
Gov. Arnold Schwarzenegger. They noted a failure to properly
collect evidence, inadequate witness interviews, delays in beginning investigations and the inability to close unsolved cases.
The audit outlined the case of a patient, identified only as
A.Z., who died on Aug. 7, 2002. The federal audit did not include
details of the case but said the patient “died of multiple blunt
force trauma after being stomped repeatedly in his bedroom at
Lanterman.”
The Office of Protective Services identified two suspects –
the patient’s caregiver and a roommate. Although there was
evidence pointing to both men, the audit said, Lanterman police
concluded the roommate had committed the crime but was too
mentally impaired to face charges.
“Regardless of who was responsible,” the auditors said, “the
fact that A.Z. suffered severe pain and ultimately died at Lanterman, in spite of the state’s obligation to keep him safe, is deeply
disturbing.”
Patricia Flannery, the state official responsible for developmental center operations, said Lanterman has remedied the
deficiencies documented by the justice department. “We haven’t
heard from them in two years,” she said.
During the Schwarzenegger administration, however, the
Department of Developmental Services hired less-experienced
candidates to run the police force.
In 2007, the department hired Nancy Irving, a longtime government labor mediator, analyst and program manager, as the
force’s interim police chief. She had not been certified as a law
enforcement officer.
The career path of Victor Davis is not unusual.
Davis started at Lanterman as a part-time psychiatric technician in 1989, working his way up to a supervising caregiver. In
1998, the Department of Developmental Services put him on the
police force as an investigator, skipping him over two ranks of
police officers despite his lack of law enforcement background.
Today, Davis is Lanterman’s commanding officer, in charge of
all criminal investigations. Davis declined to comment in detail,
and attempts to interview him during a tour of Lanterman were
17
cut off by a top-level official with the department.
The police force in 2008 added its first policies on investigating abuse and neglect, closing investigations, responding to sex assault and responding to a crime scene or emergency. But policies on
preserving evidence, managing investigations and collaborating with outside law enforcement remain unwritten to this day. Detectives have not had the authority to send investigations to prosecutors themselves. In most
police departments, officers and detectives begin working with prosecutors in the early stages of an
investigation. Some district attorneys send their prosecutors to work hand in hand with police at
crime scenes.
But the Office of Protective Services follows a different playbook. The agency’s manual states that
detectives and commanders must clear cases with administrators and civil attorneys at the Sacramento headquarters before sharing cases with local police or prosecutors.
Delgadillo, director of the Department of Developmental Services for the past five years, said the
police agency follows state standards for evidence collection.
Delgadillo said she has reorganized the force so that police commanders answer to Sacramento
rather than local administrators at the centers. This move, which was fully enacted in 2007, is intended to protect against interference by employees and officials who might be implicated in wrongdoing,
she said.
Delgadillo acknowledged the old policy had been a potential conflict of interest.
“They’re reporting directly up to us to make sure that there’s no conflict between the developmental center and the investigation that’s actually being conducted,” Delgadillo said.
The department’s legal team exists to protect the state from civil liability claims, a fact that raises
concerns among patient advocates and legal experts who say prosecutions and arrests for abuse of
patients have taken a back seat.
Delgadillo said the Office of Protective Services submits cases to department lawyers first to ensure “the investigation and the information is as complete as possible.”
Since 2006, state regulators have confirmed 21 patient abuse cases and 173 injuries of unknown
origin at the Lanterman Developmental Center in Pomona. But the Los Angeles County district attorney’s office said it is unable to find a single case referred by Lanterman investigators in the past
decade.
And the head of the district attorney’s elder abuse and dependent adult section, Robin Allen, said
she didn’t know the developmental center had its own officers and detectives. With more than 300
patients, Lanterman is one of the largest elder caregivers in Los Angeles County.
Department of Developmental Services officials provided California Watch with the case numbers
for six incidents they claim had been forwarded to prosecutors in Los Angeles County. But the district
attorney’s office said the case numbers didn’t match anything in their records.
Even cases of brazenly documented abuse have ended without criminal charges.
In 2005, a caregiver at Lanterman took a cell phone picture of her co-worker with his hands
wrapped around the neck of a 48-year-old male patient with mental disabilities.
18
In the photo, the patient’s “facial expression showed that he was not enjoying the action,” a state
Department of Public Health inspector wrote in a report about the incident.
The photograph, taken May 5, 2005, was e-mailed to the phones of multiple Lanterman employees – itself a violation of patient privacy laws. Another caregiver witnessed the choking and anonymously reported it a week later in a letter to public health officials and Lanterman administrators.
But the Office of Protective Services did not arrest the employees involved or forward the case
to prosecutors. Inspection records don’t say whether the caregivers were reprimanded or fired, but
Lanterman itself was fined $800 by the Department of Public Health.
CIR staff writers Agustin Armendariz, Emily Hartley and Michael Montgomery contributed to this
report. This story was edited by Robert Salladay and Mark Katches. It was copy edited by Nikki Frick.
19
FEBRUARY 24, 2012
Basic police work ignored
in autistic patient’s suspicious death
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Suspicious-Death
S
ix days before he died, Van Ingraham was found on the floor
Where It Ran:
of his room. His neck was broken and his spinal cord was
This story also appeared
crushed and disfigured. The injury was so severe, medical exin the following news outlets:
perts said it looked like he could have been put in a headlock
or hanged.
• San Diego Union-Tribune
But even if Ingraham knew how he’d been injured, his severe autism prevented him from revealing it. He’d never uttered a word in his
life – only his injuries could speak for him.
Solving the mystery of Ingraham’s death in the summer of 2007 was left to the detectives at the
Fairview Developmental Center, a state-run institution in Costa Mesa where Ingraham lived in a sterile room. A tiny window allowed only a sliver of light into his world.
Ingraham’s family sent him to Fairview when he was just 8 years old. He lived under the care of
the state for 42 years. Restless, he would sprint through hallways. He would urinate on himself when
upset. At his worst, he would strike at his own face, though never at his three roommates or others
around him.
The coarseness of Ingraham’s life at Fairview was matched only by the sloppiness of the investigation into his death.
The police force at Fairview failed to collect blood samples, fingerprints and other physical specimens from his room. On the day of the injury, they took one photograph – a headshot of Ingraham,
50, as he lay on a stretcher, his eyes open and glassy, an abrasion above his left brow.
Later, Fairview detectives noted that Ingraham’s caregiver had changed the institution’s log
documenting what the patient was doing at the time of the injury. But detectives never pressed the
20
PHOTO COURTESY LARRY INGRAHAM
Van Ingraham, in a 1963 photo with his brother,
Larry, lived at the Fairview Developmental
Center for 42 years.
issue.
The lead detective, a former nurse, had minimal
police training and no experience investigating suspicious deaths.
In the case file, she left out the opinion from a biomechanical specialist that Ingraham’s death “was likely
a homicide” – one of three medical experts to raise
alarms about the injury. Two of those experts concluded that Ingraham likely had been put in a headlock.
Fairview detectives eventually focused on another
patient without proof he was even near the scene. The
key testimony leading detectives down that road came
from a blind patient.
The detectives also surmised that Ingraham could
have fallen out of bed, which was about two feet off the
ground. Medical experts said that scenario was highly
unlikely given the force required to produce Ingra-
ham’s injury.
No arrests have been made in the case, and the Fairview caregiver last seen with Ingraham continues to work at the center.
Ingraham’s death illustrates how an ill-equipped, inexperienced and poorly trained police force
has dealt with a rising number of unexplained injuries and abuse cases inside facilities managed by
the Department of Developmental Services.
California Watch enlisted homicide detectives from the Seattle and Chicago police departments
to review hundreds of pages from case files on the Fairview investigation. The two investigators each
pinpointed six mistakes made by officers and detectives at Fairview – the most significant of which
came in the hours and days after Ingraham was discovered on the linoleum floor of his room.
The Seattle and Chicago detectives, who have a combined 51 years of experience in law enforcement, noted that Fairview police did not secure Ingraham’s room to protect evidence, did not
promptly interview witnesses, and did not realize that the patient’s broken neck should have been
investigated immediately. “It is my belief that the initial responders did not recognize the scene as a potential crime scene,”
Det. Al Cruise of the Seattle Police Department wrote in his review.
Even after the Office of Protective Services learned that Ingraham’s neck had been broken, they
waited five days to begin witness interviews. This “gave several people the opportunity to speak
about the events,” Det. Mark Czworniak of the Chicago Police Department wrote of the delay, which
could have potentially undermined witness statements.
The $4.5 billion Department of Developmental Services is responsible for about 1,800 patients
with cerebral palsy, mental disabilities and severe autism at five centers in Los Angeles, Orange,
21
PHOTO BY LARRY INGRAHAM
After spending six days in a Newport Beach hospital, Van Ingraham died just minutes after midnight on June 12,
2007.
Sonoma, Riverside and Tulare counties.
California Watch has found that detectives and officers working for the agency’s police force, the
Office of Protective Services, routinely mishandled reports of abuse at the facilities. Hundreds of
cases of reported abuse and unexplained injuries have been documented and then dropped without
prosecution or detailed follow-up.
Over the past six months, California Watch has provided state officials with documents, interviews and data from its investigation into Ingraham’s death. But Department of Developmental Services officials declined to comment on the case, citing patient privacy laws.
Terri Delgadillo, director of the department based in Sacramento, said overall, “If there are issues
that need to be addressed,” the department is looking into making improvements.
Key players in the case, including Fairview detectives and officials with the Orange County sheriff-coroner’s office, declined to comment or were instructed to remain silent. The circumstances of
Ingraham’s death were reconstructed based on interviews, police case files, autopsy examinations
and other public records.
Childhood diagnosis
As a baby, Van Ingraham didn’t respond to voices. His parents feared their youngest son was deaf.
Ingraham’s ears worked. His true disabilities would prove far more challenging. At 18 months,
when most children are upwardly mobile, he wasn’t walking. He made sounds, but could not form
22
words.
“Right away, I started noticing things
about him as a tiny baby,” said Jane Robert,
Van Ingraham’s mother, now 90 years old.
“He didn’t want me to hold him and cuddle
him. He would stiffen up when I would try
to hold him.”
But as he grew, Ingraham was giddy in
his love for play.
A black-and-white family picture now
fading shows him, about 6 years old, riding
PHOTO BY NADIA BOROWSKI SCOTT
piggyback on his older brother’s shoulders At his home in San Diego, Larry Ingraham constructed
in their San Diego neighborhood. Both are a memorial to his brother, Van, who died after an injury at
Fairview Developmental Center.
smiling, but Van’s mouth is open wide, like
a kid screaming joyfully on a roller coaster.
“We had a big family living in a small house,” said Jane, who stayed at home to take care of her two
sons and four daughters.
Van Ingraham’s impulses grew more difficult to tame. He suffered severe seizures. When he was
8, Jane took him to a doctor specializing in a relatively new disorder called autism.
The doctor diagnosed him as being on the severe end of the autism spectrum. The conclusion was
not so painful as the specialist’s advice, which was “put him away; forget you had him,” said Larry
Ingraham, Van’s older brother by six years.
“And that was the beginning of the nightmare,” his mother recalled. “Because my husband said,
‘Never, we’ll never do that!’ And I ran outside of the room. It was the worst day of my life.”
They tried their own methods. When he finally started to walk, and had a tendency to bolt from
the house, his family painted the walls of his bedroom yellow, his favorite color, in the hope it might
induce him to stay put.
Less than a year after the diagnosis, Ingraham became agitated one day while his mother was caring for him alone. The door to the boy’s bedroom locked only from the outside, so they could contain
him. But Ingraham ran out of the room ahead of his mother and slammed the door, locking her in.
Van Ingraham was discovered hours later, naked and running down the middle of the street, following the yellow lane dividers.
It was too much. Jane first tried placing her son in a private group home. That arrangement lasted
just 24 hours, as a distraught Van tore down curtains and nearly broke free from the facility.
Life at Fairview
The Fairview Developmental Center was a last resort and a welcome salvation from the stress of
caring for a disabled child. A doctor had recommended the facility to Ingraham’s family.
23
On a clear and cool April 20, 1964, Ingraham’s parents loaded up their car and drove
their youngest son to Costa Mesa, the suburban enclave in Orange County where five years
earlier the state’s newest institution for the
developmentally disabled had been built on
752 acres.
From outside the fenced-in campus, Fairview now looks like a school built for thousands of children, with low-slung buildings
painted blue and white. Patients wander the
drab halls and common areas, which are serviced by the institution’s own power plant and
COURTESY OF LARRY INGRAHAM
an industrial kitchen.
Van Ingraham slept in a sterile room at Fairview Developmental Center, which he shared with three other men.
Richard “Dick” Ingraham, an executive at
A handwritten sign reads, “Van’s bed.”
the defense contractor General Dynamics for
43 years, and Jane believed their son was safer at Fairview, protected and watched round the clock.
Jane co-founded the parents’ organization – Fairview Family & Friends – that assists the institution to this day and embraces a philosophy that “all people have value as human beings and as members of the human family.”
Over the years, the family would bring their son home on weekends. On one occasion when Ingraham was 9 years old, Jane said she noticed during a bath that he had “bite marks on his little penis.”
She said Fairview did not explain the marks.
The toll of institutionalizing the boy was deeply painful to the Ingrahams. Larry Ingraham said he
believes it contributed to his parents’ divorce a few years after Van Ingraham first entered Fairview.
Jane Robert said once her son became a teenager, bringing him home on weekends became too
stressful for the family.
“Finally there came a day my husband said, ‘Don’t bring him home any more,’ ” Jane said, her
voice quivering. “It was just too much for him. You know, he worked hard all week.”
Ingraham grew into a healthy man at the institution. To control his moods, Fairview physicians
prescribed him lithium and risperidone. Both medications are used to calm the behaviors of the severely autistic, according to the National Institutes of Health.
He stood 5 feet 9 inches tall, with the lean muscular build of a day laborer and full head of dark
brown hair. He was social, though he avoided physical contact with others. This made grooming him
a chore. Pictures that Larry Ingraham had taken show his brother with stubble visible along his jaw
line and chin.
His tastes and activities changed little, a 2006 assessment by Fairview caregivers shows. Ingraham guzzled soda and generally preferred sweet foods. He “likes hot cereal with LOTS of sugar and
cocoa,” the assessment states. Larry Ingraham keeps a photograph of his brother chugging a plastic
24
Van Ingraham, pictured a year before his death with his brother, Larry Ingraham, at Fairview Developmental
Center, loved to drink sugary sodas.
bottle of Sprite.
His communication skills developed, but they were basic. When Ingraham wanted someone to
leave his room, he’d nudge them toward the exit with his elbow. But impulse control would bedevil
Ingraham until the day he was paralyzed.
Predawn incident, then injury
Sometime between 4:30 and 5 a.m. on June 6, 2007, Johannes Sotingco, the Fairview caregiver
on duty that morning, found Ingraham urinating in his pants. According to Sotingco’s recollection to
police, Ingraham then pushed his pants down to his ankles to get the wetness away.
Sotingco ordered him to pull up his pants, but he refused. He said Ingraham was standing.
About this time, a supervisor down the hall said she heard Ingraham scream. The supervisor, Florens Limbong, rushed to Ingraham’s bedroom to check on the patient.
Opening the door, she saw Sotingco standing over Ingraham. The light was on in the room – it was
always on, because Ingraham was afraid of the dark. Ingraham was lying face up on the brown vinyl
floor.
Ingraham shared the room with three other patients; the roommates were asleep, accustomed to
Ingraham roaming around at night. It’s unclear from the record how Ingraham ended up on the floor.
“Is he OK?” Limbong asked.
25
“Yeah, he is OK,” Sotingco replied,
pulling the patient’s pants back up while
he was on the ground. “He doesn’t want to
wear his pants.”
Limbong turned and left without
further inquiry. She told investigators that
she saw nothing more than Ingraham on
his back, and said she trusted Sotingco’s
assertion that the patient was fine.
“No more problem, you know. I mean I
don’t hear any more screaming,” she told
the detectives.
COURTESY OF LARRY INGRAHAM AND DONOVAN JACOBS
Sotingco was on her heels, heading
Fairview’s Johannes Sotingco, shown in a video from a civil
out the door. In a later interview with
trial deposition, was Van Ingraham’s caregiver on the day of
his fatal injury.
detectives, Sotingco insisted that he hadn’t
injured the patient during the predawn incident and claimed Ingraham had stood up before he left
the room.
Ingraham, according to Sotingco, was checked again at 5:15 a.m., and was marked in a log as “R”
– resting in his bed.
Sotingco wrote in another of the center’s log – which Fairview officials labeled the Journal of
Falls – that he first discovered Ingraham’s injury when he made his rounds again. This was about
5:45 a.m.
In his interview with police, Sotingco said he found Ingraham lying face up on the floor – the
same spot where Limbong had seen him more than an hour earlier. The patient couldn’t lift his head.
There was a cut above his left brow and tears welled in his eyes.
The record shows Sotingco quickly called for help in lifting Ingraham. Another caregiver, Alvin
Tan, grabbed one side of Ingraham’s body, witness interviews show, as they pulled the patient on to
his mattress. Ingraham was dead weight.
Limbong, who had returned to the room, offered Ingraham a can of soda to see if he would respond to one of his few joys in life. But he didn’t move.
With Limbong and Tan in the room, Sotingco theorized that Ingraham had slipped and fallen from
his bed.
At 6:38 a.m., Sotingco picked up the phone and called Fairview police officer Pete Araujo. They
chatted for about 20 minutes, but Sotingco did not mention a neck injury. He reported Ingraham had
suffered an abrasion. Araujo said Sotingco did not have an urgent tone.
Investigation bungled
Araujo, the only Fairview officer on duty that morning, arrived at Ingraham’s room just as an
26
ambulance was pulling up. He quickly left to give the medics directions to the room, returning as they
were wheeling Ingraham into the hallway.
Before paramedics left, Araujo took a single picture of Ingraham’s face, Fairview police records
show. Araujo gathered no other evidence. He didn’t question possible witnesses or take custody of
the Sleep Log, which documents what patients are doing every 30 minutes throughout the night.
Ingraham was rushed to the emergency room at Hoag Memorial Hospital Presbyterian in Newport Beach. X-rays taken at the hospital documented a hyperflexion injury, akin to that inflicted on
people who’ve been hanged.
Ingraham would be paralyzed, at best, and most likely would die.
That morning, Larry Ingraham, a retired San Diego police officer, received a call from a supervisor
at Fairview saying his brother had suffered a minor injury. He walked into the hospital room to find
his brother confined
with a head brace and
with tubes running in
and out of his nose and
arms.
While there, Larry
Ingraham said a neurosurgeon took him aside
and surmised: “Somebody did this to your
brother.”
“I knew this was no
minor fall like they’d
said,” Larry Ingraham
said in an interview. “…
Because being a cop all
those years, being in the
line of work I’ve been in,
I knew there’s a person
out there right away
that had done this to
him.”
The next day, Larry
Ingraham decided to go
to Fairview. He talked
his way into the area
where his brother had
An X-ray of Van Ingraham’s neck shows a severe spinal break that two medical
lived and asked to speak experts said likely came from a headlock.
27
to a supervisor. He was told by a staff member to wait in an
office.
“She went to find the supervisor,” Larry Ingraham said, “and
I started checking through files.” He said he found the Journal of
Falls noting his brother had suffered a slip out of bed.
“And I already knew that was not true,” he said. “So I took it.”
Armed with that information, and Sotingco’s name, Larry
Ingraham filed an abuse allegation with the Office of Protective Services.
Back at Fairview, Sotingco changed the Sleep Log entries for
his rounds to reflect what he claimed was the more accurate
version.
Originally, Sotingco wrote Ingraham was using the bathroom at 4:45 a.m., and then sleeping at 5:15 a.m. He would tell
Fairview police that he changed the sleeping and bathroom
notations to say Ingraham was resting and awake in bed on both
occasions.
Fairview detectives waited five days to start interviewing
Sotingco, Limbong and other witnesses. Sotingco and Limbong
did not respond to interview requests from California Watch,
including notes left at Sotingco’s home in Anaheim and repeated
calls to Limbong.
Theresa DePue, the former nurse and Fairview’s lead detective investigating Ingraham’s death, asked Sotingco why he
changed the Sleep Log, according to the police case file. The
caregiver said he’d just tried to make it more accurate.
“So that was just a – an error?” DePue said.
Sotingco replied yes, and the detective moved on. DePue did
not investigate the alteration as potential evidence tampering.
And she didn’t press him on what Limbong had reported seeing,
records show.
Later, during a deposition in a civil lawsuit over Ingraham’s
death, Sotingco was asked if he’d put him in a headlock. He replied: “No. I don’t do that.”
Before joining Fairview, Sotingco had worked at Metropolitan State Hospital in Los Angeles County, where he’d been investigated four times in alleged patient abuse cases, police records
show. All four allegations were closed as unsubstantiated. The
state hospital would not release the details of those cases.
28
“I knew this was
no minor fall like
they’d said … Because being a cop
all those years,
being in the line of
work I’ve been in, I
knew there’s a person out there right
away that had
done this to him.”
— Larry Ingraham,
retired San Diego
police officer and
older brother
of Van Ingraham
In her interview with Limbong, DePue appeared skeptical about whether Ingraham had fallen out
of bed, as Sotingco had speculated.
“There are some pretty big concerns, because of the fact that the injury you are telling me doesn’t
really match up to the client’s injury,” DePue said.
“OK,” Limbong said.
“… Any indication that somebody physically caused these injuries? Nothing?” DePue asked her.
“No. No, I don’t. No.”
Death ‘likely a homicide,’ expert says
At the hospital, Larry Ingraham decided to take his brother off the machines that had been keeping him alive. Van Ingraham died just minutes after midnight on June 12, 2007.
At the autopsy that day, Dr. Richard Fukumoto theorized Ingraham’s shattered spine “could
have been caused by a blow to the back of the neck using a soft object,” the Fairview police case file
shows. Fukumoto was then Orange County’s chief forensic pathologist.
Another staff pathologist, Dr. Aruna Singhania, thought it looked like a whiplash injury sustained
in a car accident.
A day after Ingraham died, the Office of Protective Services finally asked for help from an outside
agency.
On June 13, Peter Mastrosimone, a Fairview detective assisting DePue, sent an e-mail to the
Orange County Sheriff’s Department asking officers to check Ingraham’s bedroom “for anything of
evidentiary value,” according to police records.
The sheriff’s office replied “that due to the time lapse and the day-to-day business in the room
(routine cleaning and presence of clients and staff) and the possibility of subsequent contamination,
no evidence could be recovered that would be of evidentiary value.”
Both Mastrosimone and DePue declined
requests for interviews from California Watch.
Ingraham’s case was DePue’s first suspicious death investigation. DePue had no police
experience when the developmental center
hired her as a detective in 2002, personnel
records show. She’d previously worked as a
Medicare inspector for the state Department
of Health Care Services.
Mastrosimone joined the Fairview police
force as a patrol officer in 1996, after more
PHOTO BY NADIA BOROWSKI SCOTT than 10 years as an unpaid volunteer reserve
Larry Ingraham (left) and friend Donovan Jacobs look
for the Alhambra Police Department, near Los
through the case files they have accumulated on Van
Angeles.
Ingraham’s death.
29
Matt Murphy, a prosecutor with the Orange County district attorney’s office, said he’s worked
with Mastrosimone multiple times over the years. While the Fairview detective doesn’t have the
skills of a city police detective, Murphy said Mastrosimone takes direction well.
“Pete is a man with no ego,” Murphy said. “He does whatever I tell him to do.”
Roughly a month into Fairview’s investigation, a tip came in from another staff member that a
patient, who was blind, had come forward. He claimed that on the morning of Ingraham’s injury, a
third patient was seen coming out of Ingraham’s room. He said this third patient came up to him and
whispered, “Don’t tell anyone.”
The detectives pursued the lead, questioning the patients, their doctors and psychologists, police
records show.
This worried Carol Risley, a patient advocate at the developmental services department.
“I am beginning to feel as though the other resident is becoming the target as it will reduce liability,” Risley wrote to department executives in an e-mail, “since he probably cannot be held responsible
for his actions.”
Detectives focused on the patient because they believed he had a violent history at Fairview. But
it turned out, he didn’t. He’d been prone to taking credit for things he’d not done, like once saying
he’d broken another patient’s arm.
The Fairview detectives subjected the two developmentally disabled men – the allegedly violent
patient and his blind accuser – to a voice stress test to determine if they were lying. The results were
inconclusive. Detectives asked Sotingco to participate in the test, but he declined.
There were other delays. It took months for a coroner’s office investigator to tell the Office of Protective Services that Fukumoto had ruled out an accidental fall as a possible cause of the injury.
In October 2007, Fairview detective Mastrosimone wrote in an e-mail to his commander to convey the autopsy results: “The injury was most likely caused by force associated with a half nelson or
some type of head lock.”
During its own investigation, the Orange County sheriff-coroner’s office was debating whether to
rule Ingraham’s death a homicide or an accident, said Jacque Berndt, the chief deputy coroner. Berndt asked Thay Lee, a biomechanical engineering professor at UC Irvine, to examine the evidence.
Berndt directed Lee not to speak with California Watch about the Ingraham case.
“It is my opinion the manner of death was likely a homicide,” Lee wrote in his report to the Orange County coroner and Office of Protective Services, which was filed in December 2007. The force
that broke the Fairview patient’s neck had to have come from another person, he ruled.
Lee’s presentation included X-ray images of Ingraham’s neck juxtaposed with the neck of a person who had jumped headfirst into a shallow pool. Ingraham was clearly in worse shape, his top
vertebrae at unnatural angles, his spinal cord a set of derailed tracks.
Regardless, Berndt listed the manner of death as “undetermined.”
DePue, the Fairview detective, noted in the file that she received Lee’s report. But she omitted
from the record his conclusion that Ingraham’s death was likely a homicide. She also failed to document that the county’s chief pathologist determined Ingraham couldn’t have broken his neck in an
30
accidental fall.
Instead, DePue wrote, “the possibility of a fall or accident could not be ruled out.” The developmental center detectives also maintained that another patient might have broken Ingraham’s neck.
In 2009, the state paid Ingraham’s family $800,000 to settle a wrongful death lawsuit Larry
Ingraham had filed two years earlier. In finally closing the case, DePue and Mastrosimone listed the
allegedly violent patient as “suspect.” Sotingco was listed as a “subject.”
As far as the Office of Protective Services was concerned, that was the end of it.
CIR staff writers Agustin Armendariz and Emily Hartley contributed to this report. This story was
edited by Robert Salladay and Mark Katches. It was copy edited by Nikki Frick.
31
FEBRUARY 24, 2012
Manner of Death: Undetermined
By Carrie Ching and Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Death-video
VIDEO
A
fter Van Ingraham was found with his neck broken at the Fairview Developmental Center, police at the state institution closed the case without answers. But the
patient’s heartbroken brother went after evidence that state investigators had
missed.
http://bit.ly/BrokenShield-Death-video
32
NOVEMBER 29, 2012
Police ignored, mishandled
sex assaults reported by disabled
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Police-ignored-sex-assaults
P
atients at California’s board-and-care centers for the developmentally disabled have accused caretakers of molestation
and rape 36 times during the past four years, but police
assigned to protect them did not complete even the simplest
tasks associated with investigating the alleged crimes, records and
interviews show.
The Office of Protective Services, the police force at California’s
five developmental centers, failed to order a single hospital-supervised rape examination for any of these alleged victims between 2009
and 2012. At most police departments, using a “rape kit” to collect
evidence would be considered routine.
The procedure, performed by specially trained nurses, is widely
regarded as the best way to find evidence of sexual abuse. Without
physical evidence, it can be nearly impossible to solve sex crimes,
especially those committed against people with cerebral palsy and
profound intellectual disabilities.
In the three dozen cases of sexual abuse, documents obtained by
California Watch reveal that patients suffered molestation, forced oral
sex and vaginal lacerations. But for years, the state-run police force
has moved so slowly and ineffectively that predators have stayed a
step ahead of law enforcement or abused new victims, records show.
State officials responsible for the police force would not com33
Where It Ran:
•
•
•
•
•
•
Bakersfield Californian
The Daily Beast
The Fresno Bee
The Press-Enterprise
San Francisco Chronicle
Santa Rosa Press Democrat
COURTESY OF NEWSEUM
Front page of the San
Francisco Chronicle on
Thursday, Nov 29, 2012.
ment about specific abuse cases but emphasized
that patient protection is the state’s top priority.
Officials also said they have ordered retraining for
officers and added new procedures to better protect patients – moves that occurred after earlier
California Watch stories.
Much of the alleged sexual abuse in the California institutions has occurred at the Sonoma
Developmental Center, where female patients
have been repeatedly assaulted, internal incident
records show. In one case, a caregiver was cleared
by the police department of assault and went on
to molest a second patient.
In another case from August 2006, caregivers
at the Sonoma center found dark blue bruises
shaped like handprints covering the breasts of
a patient named Jennifer. The patient accused
MIKE KEPKA/SAN FRANCISCO CHRONICLE
a staff member of molestation, court records
Giant palm trees stand at the main gate of the Sonoshow. Jennifer’s injuries appeared to be evidence ma Developmental Center, which houses about 500
patients. The police force at California’s developmental
of sexual abuse, indicating that someone had vio- centers failed to order a single hospital-supervised
rape examination for any alleged sexual abuse victims
lently grabbed her.
between 2009 and 2012.
The Office of Protective Services opened an
investigation. But detectives took no action because the case relied heavily on the word of a woman
with severe intellectual disabilities. A few months later, court records show, officials at the center had
indisputable evidence that a crime had occurred.
Jennifer was pregnant.
By that time, her alleged attacker had vanished.
For the parents of the 32-year-old patient, the reaction has been disbelief and anger. They are
now raising a 5-year-old boy who Jennifer is incapable of mothering. The child is precocious and
strongly resembles his maternal grandmother.
“Every time, I just imagine her being raped and screaming and crying for me,” said the woman’s
mother, whose name is being withheld to protect Jennifer’s identity. “It just kills me.”
The Office of Protective Services has not collected physical evidence to back up cases such as Jennifer’s. In situations involving developmentally disabled patients, DNA and other physical evidence
are even more important because statements from alleged victims often are treated as unreliable.
Some have IQs in the single digits and cannot speak.
Detectives at city and county police departments are trained to send sexual assault victims to an
outside hospital for the specialized rape examination. But the doctors and nurses at the state’s developmental centers – in Sonoma, Los Angeles, Orange, Riverside and Tulare counties – were not trained
34
in dealing with sexual assault victims, records and interviews show.
California Watch shared details of the developmental center sex abuse cases with two outside police detectives who specialize in such assault investigations. The detectives said they were dismayed
by the state’s actions.
“How can you do a sexual assault investigation and not do an exam?” said Roberta Hopewell, a
detective at the Riverside Police Department and president of the California Sexual Assault Investigators Association.
According to interviews with former detectives and patrol officers at three of the state’s developmental centers, the Office of Protective Services did not assign its own detectives to cases that should
have been investigated – nor did the force seek expert help from outside law enforcement.
One former patrol officer said administrators were afraid of bad publicity.
“They didn’t want anything to get out, so they handled it internally. They call the shots,” said Joe
Guardado, a former patrol officer at the Porterville Developmental Center in Tulare County who retired in 2010. In September, California Watch presented its findings about the handling of sex abuse against patients to officials at the state Department of Developmental Services, which operates the five centers
and oversees the Office of Protective Services, its 90-member police force.
Terri Delgadillo, the department’s director, declined interview requests. Instead, the department
issued a written statement saying the state is working to protect patients and ensure they receive
justice. That includes hiring “nationally recognized law enforcement experts” to train police officers
and detectives to better handle sex assault cases, the department said.
“In addition, training was provided to ensure that referrals for sexual assault examinations are
completed by thoroughly trained personnel, and that investigations are conducted appropriately and
timely,” the department said.
Studies of crimes against the developmentally disabled have found that as many as 80 percent
of women in this population are sexually assaulted during their lives. Many victims suffer repeated
attacks.
In a series of stories this year, California Watch has reported that sworn officers at the institutions
routinely failed to conduct basic police work in cases with criminal implications, including stungun assaults on multiple patients and a suspected homicide.
The facilities have documented hundreds of cases of abuse and unexplained injuries, almost none
of which have led to arrests. Despite its sloppy record, the force managed to collect more overtime
pay than other police agencies its size.
About 1,600 patients live at the five centers, which operate like board-and-care hospitals for
patients whose conditions are so challenging that they cannot live with their families or in group
homes. The population at these centers has been slowly declining. This year alone, the number of
patients has dropped more than 10 percent.
Investigating sex crimes against this vulnerable population falls to the Office of Protective Services, a unique police force that operates round-the-clock in these institutions.
35
But the detectives and patrol officers
have been unprepared to undertake such
cases, internal case files show. The records
indicate officers have lacked the skills to
competently question sex abuse victims,
particularly the developmentally disabled.
Detectives at times closed investigations when patients appeared to get the
dates and times of assaults wrong, even
though the disabled frequently struggle
with precise chronology.
At the Sonoma Developmental Center,
MIKE KEPKA/SAN FRANCISCO CHRONICLE which houses about 500 men and women,
A placard marks the Corcoran Unit at the Sonoma Developtwo patients accused a caregiver of forcing
mental Center, which has been the site of many of the sexual
abuse allegations at the state developmental centers.
them to perform oral sex on him.
The Office of Protective Services was first alerted in February 2009. “Client reported to staff that
she saw (the caregiver’s) genitals and was asked to perform oral sex for a dollar,” the records said.
“Client reports that she did.”
However, the Office of Protective Services quickly closed the case, the records indicate, because
the suspect was not listed as having worked in the patient’s unit, called Corcoran, on the day of the
alleged abuse. The accused caregiver did often work in that unit, though, internal records show.
Months later, the mother of a second patient alerted the center that her daughter had said she
had licked the same caregiver’s penis.
But by then, the accused caregiver was gone. He is not identified by his full name in state records.
The center’s incident log noted that the psychiatric technician suspected of the abuse was “no longer
employed” but “did work on the unit.”
Sexual abuse cases reviewed
Earlier this year, Leslie Morrison, head of the investigations unit at Disability Rights California,
examined dozens of case files in which a patient accused a center employee of sexual abuse from
2009 to mid-2012. Morrison performed the review at the request of the state Department of Developmental Services. She said these cases involved only patients capable of speaking and therefore able
to report an assault.
Disability Rights, a protection and advocacy organization, has access to full patient files under
state and federal law. Many of these records are confidential, but California Watch was able to obtain
through other sources some of the documents provided to Disability Rights.
California Watch’s parent organization, the Center for Investigative Reporting, has sued the state
for additional abuse records that can shed more light on these and other cases. A superior court
36
judge ruled that the state should open its
records, but the state is appealing.
Morrison said she found 36 cases in
which victims likely should have received a
rape kit medical exam and interview with
a trained nurse. But, she said, the Office
of Protective Services investigations were
incomplete and at times deeply flawed.
“We’re not sure they have the training
to do these very delicate, sensitive interviews,” Morrison said.
Disability Rights argues that outside
law enforcement and forensic nurses –
who have years of experience interviewing Leslie Morrison, head of the investigations unit at Disability
Rights California, examined the state developmental centers’
victims and identifyingphysical evidence –
sexual abuse case files from 2009 to mid-2012 and found 36
should have taken over the institutions’ sex cases in which the victims likely should have received a rape
kit medical exam and interview with a trained nurse.
crime cases.
“You’re better off referring it to the specially trained people whose job it is to do that and only
that,” Morrison said.
The Department of Developmental Services now agrees, according to its written statement.
Gov. Jerry Brown in September signed legislation requiring that the centers report alleged sex
assaults against patients to outside law enforcement. The new law, SB 1522, “will ensure developmental center investigators and outside law enforcement agencies work collaboratively to investigate
unexplained injuries or allegations of abuse,” the statement said.
The centers have a long history of sex abuse against patients, which California Watch reported in
stories earlier this year.
In one case from early 2000, police records show, a female patient at the Sonoma Developmental
Center accused a male caregiver of sexually assaulting her during a bath. The institution then assigned two men to bathe the patient, even though the facility employed many female caregivers.
Both caregivers allegedly raped her on July 6, 2000, during bathing.
Developmental center officials did not report details about the assaults to the Office of Protective
Services. Four days after the second alleged rape, the police commander at the Sonoma facility received an anonymous tip about the incident. Officials launched an investigation, but no arrests were
made.
Early struggles in Jennifer’s care
Few cases are more disturbing than that of Jennifer, the former Sonoma Developmental Center
patient who suffers from bipolar disorder and attention deficit and hyperactivity disorder, in addi37
tion to severe intellectual disabilities, the patient’s medical records show.
For most of Jennifer’s childhood, her mother said, doctors struggled to pinpoint what drove her
daughter’s outbursts. When angered, she would scream and slap herself and anyone else within
reach. Other times, she was sweet, even overjoyed when surrounded by her parents and siblings, her
mother said.
Jennifer lived peacefully enough in one group home until she was about 14. Her behavior turned
unstable, and the teenager was regularly moved among privately run homes in the community that
proved ill-equipped to care for her.
“She started (going) from group home to group home to group home,” her mother said in an interview. California Watch does not identify victims of sexual assault or their immediate family members.
Patient advocates had told her mother that the best way to diagnose and treat her daughter’s behavioral conditions would be to admit her to an institution. She would be observed at all times, they
told her; developmental center staff members are far more experienced at prescribing drugs to tame
disorders.
Her mother said she was wary and resisted the advice – initially. But she also was exhausted from
years of strain overseeing Jennifer’s care without a complete diagnosis. She relented in 2002, and
Jennifer, then 27, moved into the Sonoma Developmental Center.
“To have her on the right course of medication, that was the only reason to have her there,” Jennifer’s mother said.
At the time, the Sonoma center housed about 850 patients and was the nation’s largest institution
for the profoundly developmentally disabled. Built more than a 100 years ago in wine country, it is
an open campus, flush with green lawns and
walking paths.
From outside, Sonoma’s residences resemble single-family homes more than dormitories, featuring front stoops and yards.
Patients lounge together on porch swings.
Sonoma administrators assigned Jennifer
to the Corcoran Unit, a peach-colored building tucked in the center’s far eastern end. Its
red tile roof is covered with dead leaves and
branches from the towering oak tree that
shades the residence’s main entrance.
Everything was fine for a few years, the
A patient named Jennifer was impregnated by an unknown mother said. Her daughter came home many
assailant while living at the Corcoran Unit at the Sonoma
weekends. At times, however, her mother
Developmental Center in 2007. Under state law, sexual
noticed injuries.
intercourse with a patient lacking the intellectual capacity
to consent is considered rape.
Bruises were not necessarily alarming.
38
Jennifer would occasionally hurt herself. At one point, Jennifer cut her scalp badly. The Sonoma caregivers explained that she had been banging her head against the wall, her mother said. The center
put Jennifer in her own bedroom, padded the walls and fitted her with a helmet.
Injuries, then pregnancy
In 2006, the patient’s injuries changed. Bite marks broke her skin and bruises surfaced on her
back and breasts. Court records show Jennifer accused a Sonoma caregiver of touching and bruising
her. She showed the center’s employees and her mother the resulting injuries.
The mother said someone clearly had been grabbing Jennifer’s breasts with violent force. The
bruises were unlike anything she had ever seen on her daughter.
“I can tell if a bruise was an accident because she bruises easily; I bruise easily,” she said. “That’s
not a big deal. But I could tell when a bruise is really not a bruise, you know what I mean?”
A social worker at the Sonoma center told the mother that the Office of Protective Services had
investigated the matter thoroughly, but detectives couldn’t prove Jennifer’s allegation that the caregiver had bruised her.
“Of course, it’s her word against his,” Jennifer’s mother said. “Nothing was done.”
Records show the institution’s doctors, nurses and caregivers overlooked or ignored her pregnancy until Jennifer was well into her second trimester. Jennifer’s disabilities make her incapable of
giving consent to sex. Her mother discovered Jennifer’s swollen belly during a weekend visit at her
family’s home in July 2007. Under state law, any sexual intercourse with a patient lacking the intellectual capacity to consent is considered rape.
Jennifer’s son was born by cesarean section in October. No one was arrested in Jennifer’s rape.
“I was a hands-on mom, and I fought for my daughter’s security,” Jennifer’s mother said. “And I
still wasn’t able to protect her. Who protects these people?”
The month that Jennifer gave birth, the Office of Protective Services received a letter from a whistle-blower that named a janitor as the alleged rapist, but didn’t inform the Sonoma County Sheriff’s
Office about the lead for three months, according to court records from a lawsuit Jennifer’s family
filed against the state.
By then, the accused janitor had fled the country, court records said.
Regardless, the institution’s officers did not attempt to gather physical evidence through a sex
assault examination that might have supported criminal prosecution of Jennifer’s assailant. And the
center’s internal records show that patients have continued to allege sex abuse in the unit where
Jennifer lived.
Her family settled a civil lawsuit with state Department of Developmental Services for
$100,000. Jennifer now lives in her own apartment. Like all California residents with developmental
disabilities, Jennifer is entitled to and receives services from the state. Her mother and family members and have hired a caregiver to take care of her. They are all women. 39
Few sex crimes referred for prosecution
Statewide, the Office of Protective Services referred just three sex crime cases to county district
attorneys for prosecution since 2009, said Morrison with Disability Rights California. In those cases, officers did not collect any physical evidence to determine whether crimes occurred. Just one of
those cases led to an arrest.
In one incident from January at the Sonoma Developmental Center, caregivers noticed that two
female roommates appeared to have injuries suggesting abuse – bruises on their faces and arms. The
caregivers told the Office of Protective Services, but there was no detailed investigation.
In May, another employee of the center caught a longtime caregiver, Rue Denoncourt, exposing
himself to one of those female patients in a bathroom. The colleague reported the incident to the
Office of Protective Services, which then notified the Sonoma County Sheriff’s Office.
The sheriff’s office interviewed Denoncourt, who confessed to exposing himself and sexually
abusing the victim’s roommate, forcing her to touch him while he masturbated.
Even after Denoncourt admitted to the abuse, records from the state Department of Public
Health show neither the sheriff’s office nor the Office of Protective Services sent the victims to receive sexual assault examinations. If evidence of other assaults was available, it was lost.
No investigation took place into the bruises that were discovered on both women in January,
although the health department raised suspicions about Denoncourt in its report.
Denoncourt pleaded no contest to a lewd conduct charge in August and is serving an eight-month
prison term. The Sonoma County sheriff and district attorney declined to comment for this story.
Allegations of interference
Three former members of the Office of Protective Services allege that administrators and other
employees at developmental centers have interfered with abuse investigations.
Pete Araujo, a former investigator at the Fairview Developmental Center in Orange County, said
his commander refused to approve sex assault exams for victims. Araujo said his superiors provided
no explanation for denying the exams, and no one within the force challenged the decisions.
“Their word was final,” said Araujo, who is now an investigator for the California State Lottery
Commission. “They were the managers.”
Employees at the institutions have delayed notifying police of alleged sexual abuse for days, said
Greg Wardwell, a 20-year veteran patrol officer and sergeant at the Sonoma center. The lost time can
leave physical evidence open to contamination and witnesses vulnerable to coercion.
Wardwell, who retired in March 2011, said center administrators did not punish employees for
withholding information about abuse.
“It’s very frustrating at the point that someone is genuinely victimized and you didn’t find out
about it for four or five days,” Wardwell said. “There is no sanction at the point that somebody sits on
the information.”
40
The Department of Developmental Services did not respond to the officers’ allegations of interference.
Policy hinders investigations
The Office of Protective Services’ own policy has made it difficult for officers to order sexual assault exams. For patients to receive an exam, the guidelines require that “a sexual assault occurred
within the preceding 72 hours and there is potential for recovery of physical evidence of the recent
sexual assault.”
The “and” is underlined and italicized in the written policy.
Experts on sex assault investigations said using the words “potential for recovery” threatens to
shut off an investigation before it starts. Detectives cannot determine what evidence is present before a medical exam.
“That latter part shouldn’t even be in there,” said Linda Ledray, a forensic nurse and director of
the Sexual Assault Resource Service in Minneapolis. “I mean, that’s crazy.”
Kim Lonsway, research director for End Violence Against Women International, agreed that the
Office of Protective Services’ sex assault policy could undermine investigations.
“The tone of this is the exams are going to be the exception rather than the rule,” Lonsway said.
Further, the 72-hour time limit is outdated, said Hopewell, the Riverside police detective.
Hopewell said physical evidence sometimes is recoverable two weeks after an assault. She will request a medical exam even in cases in which a victim was attacked two years earlier, because scars
can be shown to support allegations.
Delgadillo, director of the state Department of Developmental Services, implemented the Office
of Protective Services’ first policy on investigating sex assault four years ago. The department had
no specific guidelines for police on investigating sex abuse before 2008, only that they be required to
complete a state minimum of four hours of training.
Experts said many cases are hampered because some investigators, administrators and even
family members distrust allegations by the intellectually disabled. Detectives investigating sex crimes
against the disabled often need special training in the nuances of extracting evidence from these
types of patients. Such training has never been offered to the state police force.
“Even if it is reported, the victim is often not believed or is thought to be fantasizing or to have
merely misinterpreted what occurred,” Joan R. Petersilia, a criminology professor at UC Irvine, wrote
in a 2001 study of disabled victims. “This leaves the person with a disability continually vulnerable
to victimization, because perpetrators come to learn they may victimize them without fear of consequences.”
This story was edited by Robert Salladay and Mark Katches and copy edited by Nikki Frick and
Christine Lee.
41
NOVEMBER 29, 2012
In Jennifer’s Room
By Carrie Ching and Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Jennifers-story-Video
VIDEO
I
n August 2006, caregivers at the Sonoma Developmental Center found dark blue bruises shaped like handprints covering the breasts of a patient. Jennifer accused a staff
member of molestation and her injuries appeared to be evidence of sexual abuse.
Big projects often have smaller narratives within them that can be developed into
standalone features that draw readers into the larger story. Clearly Jennifer’s story was one
of those.
Presenting this story in video format was particularly challenging because we did not
want to inadvertently identify Jennifer or her mother. We chose a graphic narrative approach, with a voice actor reading the transcript of the mother’s interview. The artist consulted photographs and diagrams of the Sonoma Developmental Center to ensure that the
drawings were accurate.
http://bit.ly/BrokenShield-Jennifers-story-Video
42
INFOGRAPHIC
After claims of sexual assault, little is done
P
By Lauren Rabaino
November 29, 2012
http://bit.ly/BrokenShield-Sex-assault-infographic
atients at California’s board-and-care centers for the developmentally disabled have
accused caretakers of molestation and rape 36 times during the past four years. Documents obtained by California Watch reveal that patients suffered molestation, forced
oral sex and vaginal lacerations.
We built an infographic for the Web highlighting our findings in an easily digestible form.
At a glance, readers could see the a stark contrast between routine police work and what happened under the Office of Protective Services, the police force at California’s five developmental
centers.
This infographic was formatted for the Web.
To view full graphic, click here:
http://bit.ly/BrokenShield-Sex-assault-infographic
43
JULY 31, 2012
Questions surround handling of Taser
assaults on disabled patients
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Taser-assaults
S
omeone using a stun gun like a cattle prod assaulted a
Where It Ran:
dozen patients at the Sonoma Developmental Center last
fall, inflicting painful thermal burns on their buttocks, arms,
legs and backs.
The center’s in-house police force, the Office of Protective Ser• ABC 7 News
• KXTV News 10
vices, had a suspect from the start. An anonymous whistle-blower
called a tip line in September 2011 and accused Archie Millora, a
• Santa Rosa Press Democrat
caregiver at the Sonoma center, of abusing several profoundly disabled men with high-voltage probes.
Detectives found burn injuries on the patients, according to internal records obtained by California Watch. The following morning, they discovered a Taser and a loaded handgun in Millora’s car
at the Sonoma center.
The facility is one of five state-run board-and-care institutions that serve roughly 1,700 residents
with cerebral palsy, mental retardation and severe autism – disabilities that make communication
difficult, if not impossible.
The one victim who is able to speak named Millora and used the word “stun” when interviewed
by a detective at the center, according to a state licensing record.
As part of an ongoing investigation, California Watch has detailed how the institutions’ internal
police force, created by the state to protect the vulnerable residents at these state homes, often fails
to conduct basic police work when patients are abused and harmed.
In case after case, detectives and officers have delayed interviews with witnesses or suspects – if
they have conducted interviews at all. The force also has waited too long to collect evidence or secure
44
crime scenes and has been accused of going easy
on co-workers who care for the disabled.
Those shortfalls again were on display in the
Taser case, records show.
After the assaults were discovered, the Office
of Protective Services made no arrest, deciding
instead to handle it as an administrative matter.
Also, at least nine days after the revelations, records show, detectives still had not interviewed
Millora, whose personal Facebook page includes
wall photos of assault weapons and handguns.
“There’s absolutely no excuse for allowing
that to happen like that without any ramifications,” Assemblywoman Connie Conway, the
Republican leader from Tulare, said of the stun
gun assaults.
After California Watch published its initial investigation about the police force, a former state
worker alerted reporters to the Taser incidents.
Other whistle-blowers turned over records to the
FACEBOOK.COM
A photo posted Oct. 1, 2009, on Archie Millora’s Facenews organization, allowing the story to be told
book page shows him posing at a firing range while
for the first time. The state Department of Deholding an assault rifle.
FACEBOOK.COM
FACEBOOK.COM
Millora’s Facebook page has portraits of firearms
including an assault rifle, which was posted Dec. 13,
2009. A former caretaker at the Sonoma Developmental Center, he was accused of assaulting disabled
patients with a Taser.
A photo of a Glock handgun fitted with a sight and
placed next to an extended magazine was posted to
Millora’s Facebook page Dec. 12, 2009. The weapon
matches the description of the firearm police found in
his car in September 2011.
45
velopmental Services, which operates the developmental centers and in-house police force, has not
responded to requests for additional documentation.
The Sonoma County district attorney’s office announced this week it would review the matter as
a potential criminal abuse case after California Watch began asking questions about the Taser incidents. “We’re continuing to review the entire case; we haven’t closed the door on our investigation,”
said Spencer Brady, chief deputy district attorney.
In a written statement, Terri Delgadillo, director of the state Department of Developmental Services, said the center’s investigation “included interviews of over 100 individuals, including the suspect who was interviewed on three separate occasions and terminated from employment.” She said
that the department took the matter seriously and is continuing to investigate, nearly a year after the
abuse occurred.
Millora was fired in November, state controller records show. He did not respond to multiple interview requests made by phone and in person at his home.
Jim Rogers, the Sonoma center’s executive director, also was fired, according to Delgadillo’s statement. In January, the department said Rogers retired voluntarily. Rogers did not return phone calls
seeking comment.
The Taser incidents also raise new questions about the police force’s leadership. Key decisions
were made by the agency’s top chief – a former firefighter with a limited background in criminal
investigations – and a commander who had just been transferred to the Sonoma center from the Porterville Developmental Center.
Leslie Morrison, head of investigations for Disability Rights California, said she was surprised that
the Office of Protective Services kept control of these abuse cases.
Police at the Sonoma center “should have immediately picked up the phone and called outside
law enforcement,” Morrison said. “We’ve got a serial abuser here.”
At the same time, the police force may have thwarted a criminal investigation by local authorities, records show.
On Oct. 5, more than a week after officials received the tip about the stun gun incidents, the Sonoma center’s top administrators met with an inspector from the state Department of Public Health
investigating the injuries, according to an internal memo. The inspector, Ann Fitzgerald, asked
whether the attacks were a criminal case.
“It could be,” said the center’s police commander, Bob Lewis, according to the memo.
But police at the center took steps that might have discouraged the Sonoma County Sheriff’s
Office from opening its own investigation. Lewis downplayed the series of attacks against patients,
telling the sheriff’s office there was an abuse allegation, not a dozen confirmed cases, the internal
correspondence shows.
In the Office of Protective Services’ call to the sheriff’s office, center police disclosed they found
two weapons, said Sonoma County Lt. Dennis O’Leary. Regarding the assaults against patients,
O’Leary said Lewis informed them “just that there was some suspicion that there may have been
some abuse to the patients.” At the time, however, the in-house police detectives at the state center
46
still had not questioned Millora, records indicate.
Delgadillo said in her statement that the sheriff’s office decided “not to intercede and take over
the investigation.”
The sheriff’s office had a different take.
“We offered to assist in their investigation, but we were told that they didn’t need our help,” said
Sonoma County Assistant Sheriff Lorenzo Dueñas.
Force Referred Gun Charge
Corey Smith, the Office of Protective Services’ police chief, oversees all criminal investigations at
the state’s developmental centers. Sonoma center commander Lewis sent Smith multiple written reports after learning of the stun gun abuses. He also took instructions by phone at least once, records
show.
Smith, a firefighter for most of the past two decades, has less law enforcement experience than a
majority of the patrol officers beneath him. He hadn’t worked on criminal investigations until 2006,
when the department made him the Sonoma center’s police commander.
Smith became chief in 2010 after his predecessor was indicted on embezzlement charges. He did
not respond to phone calls or written questions sent by email.
The Office of Protective Services did refer a criminal charge against Millora for carrying a concealed firearm, a misdemeanor, according to Sonoma County Superior Court records. He pleaded no
contest to the charge in April and received 20 days of electronic monitoring, plus three years’ probation and a $190 fine.
Charges of assault against a dozen patients could have meant decades in prison.
Millora has no felony record and therefore has no legal barrier preventing him from again working with the disabled, said Tony Anderson, executive director of The Arc of California, an advocacy
group.
“These guys bounce around from home to home and you just never catch them, until they do
something really bad,” Anderson said.
Disciplinary records not public
The abuses echo another attack at Sonoma, when a caregiver used a stun gun on a patient’s chest
in 1999. The center’s detectives took months to obtain an arrest warrant, by which time the suspect
had fled the state.
Millora started at the center as an assistant psychiatric technician in 1998, according to the Department of Developmental Services. In this position, he earned $50,000 a year as a primary caregiver for as many as a dozen patients. His duties involved watching over patients, bathing and grooming
them, and protecting them from harm. He was not suspected in the earlier stun gun abuse case.
Psychiatric technicians must undergo training and certification in California. When psychiatric
47
technicians violate regulations, their transgressions are in the
public record. But this requirement does not extend to assistant
caregivers. Their disciplinary records reside only in personnel
files, which are largely confidential under state records law.
On Millora’s Facebook page, he has posted portraits of several
firearms. One photo shows an assault rifle beside a Glock, outfitted
with an extended clip and sight. In another picture, Millora poses
at a firing range, looking into the camera while holding an assault
rifle.
The state Department of Developmental Services has not released the caregiver’s personnel file, detailing his termination or
other disciplinary action. Developmental center officials have not
answered repeated questions about the abuse. Delgadillo said that
the families of patients were informed about the incidents, but the
department has not specified exactly what families were told.
The state deems records related to developmentally disabled
patients to be confidential. Regulators black out nearly every word
on inspection records before releasing them to the public.
The state-run facilities in Los Angeles, Sonoma, Orange, Tulare
and Riverside counties have documented hundreds of cases of
abuse and unexplained injuries, almost none of which has led to
arrests.
In response to California Watch’s earlier stories, lawmakers
have introduced two bills that would require the state to notify
outside law enforcement agencies and disability rights groups
when it receives allegations of violent crimes against patients. The
bills have passed the state Senate and await votes in the state
Assembly.
Under current law, the centers’ police force is not required
to report allegations of abuse such as the Taser incident to local
authorities.
Conway, the assemblywoman from Tulare, has called for a state
audit of the Office of Protective Services. The Joint Legislative Audit Committee has scheduled a hearing for Aug. 7 to consider the
request.
Public health department citation
Sonoma center officials accepted responsibility for the stun
48
“These guys
bounce around
from home to
home and you just
never catch them,
until they do something really bad.”
— Tony Anderson,
executive director of
The Arc of California
gun abuses in June, when the state Department of Public Health issued the facility a “Class A” citation.
The penalty included a $10,000 fine for violations that put patients at serious risk of harm or death.
The citation said 11 patients had stun gun injuries. Internal records from the Sonoma center list a
dozen victims. All the victims were men, whose ages ranged from 33 to 61 years old.
The Department of Developmental Services is bringing in outside experts to upgrade patient care
at the Sonoma center and prevent future abuses, Delgadillo said in her written statement. Following California Watch’s earlier stories, Gov. Jerry Brown’s administration in March hired Joe Brann, a
longtime police chief, to oversee retraining of the entire Office of Protective Services and fix problems
in its criminal investigations.
The stun gun allegation arrived on an answering machine in the executive director’s office sometime on Sept. 26, the Sonoma center records show.
A male voice said Millora had used the stun gun on patients living in one specific unit of the developmental center, the Judah Unit, home to 27 patients, according to records.
The Office of Protective Services received word of the abuse at 4 p.m. Sept. 26 and deployed patrol officers to the residence within 30 minutes. It was Millora’s day off, so the in-house police decided to stop the caregiver on his way in to work the following day.
However, the officers missed the start of Millora’s shift, at 6:30 a.m., according to the citation. The
caregiver was on a break when police arrived shortly before 8 a.m. They intercepted Millora as he
returned to the Judah Unit and received his consent to search his car, according to records.
That’s when officers discovered his weapons.
“The facility officer removed a black nylon handgun case from under the passenger seat,” the citation said. “The case contained a Glock semi-automatic pistol and a ‘magazine’ containing live rounds
of ammunition.”
Stashed inside a compartment on the driver-side door, Millora had a Taser C2. Officers would
place both weapons in an evidence locker, according to the citation.
Despite having the stun gun in their possession, the center’s police did not take the suspect into
custody for questioning.
Rather, officers turned Millora over to administrators. Rogers, then executive director of the Sonoma center, put Millora on “administrative time off,” according to internal records, and the caregiver
apparently left the institution about 10 a.m.
Millora’s job was in jeopardy at that stage, the licensing and administrative records show, but not
his freedom.
Eleven hours later, police commander Lewis called Smith, the chief of the Office of Protective
Services, for instructions, according to an internal chronology of events. Smith told Lewis to alert the
California Highway Patrol, and the commander said he made the call sometime before 10 p.m.
However, CHP officials say they have no record of being notified by the Office of Protective Services at the Sonoma center during the time period in question. And even if they had been notified, CHP
does not handle patient abuse cases.
Lewis had taken command at Sonoma just four weeks earlier. He’d previously worked for several
49
years as a detective and supervisor at the Porterville Developmental Center in Tulare County.
Reached by phone, Lewis said the Department of Developmental Services prohibits him from
speaking to reporters. “I’m just going to have to refer you, buddy,” Lewis said.
The Sonoma County sheriff has jurisdiction over the developmental center and teams of investigators with experience in aggravated assault cases.
Lewis alerted the sheriff’s office the next morning, Sept. 28, about “the weapons recovered from
an employee’s vehicle and the allegation of abuse,” according to the center’s chronology. The Office of
Protective Services would remain the lead investigating agency.
Dueñas, the Sonoma County assistant sheriff, said Lewis never disclosed to the sheriff’s office
that the center confirmed patients had been attacked.
‘Non-accidental trauma’
The investigation continued that day when center detectives provided pictures of the patients’
injuries to a forensic pathologist for analysis.
Doctors concluded that the victims who lived in the Judah Unit were injured by the same weapon,
according to the citation reports.
“The pathologist further opined that the patterned injuries on seven clients were strongly suggestive of and consistent with electrical thermal burns ranging in age of 36 to 48 hours up to greater
than two weeks,” the citation said.
The burn marks came in pairs, roughly a half-inch apart, the citation said, and “represented nonaccidental trauma.” Some of the injuries were healing into scars, suggesting the attacker had abused
the patients over the course of several days, if not weeks.
Based on the doctor’s findings, the state inspector concluded the patient injuries were “abrasions
consistent with the use of an electrical thermal device (Taser Gun),” the citation said.
All of the patients were treated at the center’s own acute care clinic. It’s unclear from available
records if any of the patients were hit with the Taser multiple times.
Initially, police believed only seven patients living at Judah had been assaulted, the licensing records and internal correspondence show. Nurses examined every Judah patient and discovered three
others with the circular burn marks.
After reviewing Millora’s work schedule, medical staff found the caregiver had contact with patients living in three other residences. Subsequently, two more patients were identified with stun gun
injuries in those units, according to records.
The Taser C2 found in Millora’s car is designed as a defensive weapon, able to hit targets from a
distance of 15 feet, said Steve Tuttle, a spokesman for Taser International. When discharged in the
device’s primary setting, two probes shoot forward and attach themselves to the target in different
locations on the body, separated by a foot or more. It sends more than 1,000 volts into the target.
However, the Taser C2 has a second setting, called “drive-stun,” Tuttle said. In this mode, the
probes are stationary and deliver voltage directly to the skin. “It would cause impairment and would
50
be painful,” he said.
The precise burn marks on the victims’ bodies indicate the Taser was used at close range to the
victims – almost like a cattle prod.
Tuttle said Taser International finds it abhorrent that its product would be used to assault disabled patients.
“I’ve been spokesman for the company for 18 years,” he said. “That’s the very first time I’ve heard
of anything similar to that.”
State licensing records and Sonoma center communications offer no detail on how the abuse occurred.
Records show that Lewis and his detectives at the Office of Protective Services deliberately
avoided asking Millora for his version of events in the first two weeks following their discovery of the
abuses.
At the October meeting attended by state officials about the Taser incidents, the state inspector
asked why police were delaying their interview with Millora until officers had spoken to all other
potential witnesses, according to the internal memo.
Lewis responded that it was his decision to wait before interviewing Millora. Delaying the interview “is the most beneficial as far as obtaining information, possible leads that could lead to other
involvement or evidence,” Lewis explained, according to the memo.
The Office of Protective Services did not find other leads or witnesses in the case.
State officials won’t say what Millora eventually told them.
ABC 7 reporter Vic Lee contributed to this report. This story was edited by Mark Katches and copy
edited by Nikki Frick and Christine Lee.
51
MAY 18, 2012
Overtime pay soars
for state-run police force
By Ryan Gabrielson and Agustin Armendariz
California Watch
http://bit.ly/BrokenShield-Overtime-soars
A
n unusually high number of police officers at the state’s
Where It Ran:
board-and-care facilities for the developmentally disabled
have doubled their salaries with overtime, enabling some
to earn more than $150,000 a year, a California Watch
• The Fresno Bee
investigation has found.
The state-run police force, called the Office of Protective Services,
last year paid about $2 million in overtime to 80 of its officers. The
officers patrol five facilities that house about 1,800 patients with intellectual disabilities in Los Angeles, Orange, Riverside, Tulare and Sonoma counties.
The small police force is one of the most proficient in the state at accumulating overtime – the
percentage of officers boosting their salaries far exceeds the proportion at other agencies. In total, the police department’s payroll has increased 50 percent through overtime in the past
four years. For several of the officers, their overtime payouts would have required them to work 70
to 100 hours a week the entire year to earn the extra cash.
Twenty-two officers, about one-fourth of the entire police force, have claimed enough overtime
to double their salaries – a rare occurrence at other police agencies, both big and small. The average
salary for the 22 officers is about $124,000 a year.
At one point, the Office of Protective Services paid its officers overtime for patrolling a nearly empty facility. Patrol officers and detectives at the Agnews Developmental Center in San Jose
claimed hundreds of hours of overtime – months after the institution closed in March 2009, finance reports show.
One officer working at the state’s center in Tulare County acknowledged in an interview that he
52
received overtime pay for hours spent sleeping at
work. A detective there was paid during a 2008
trip to Las Vegas that officials later said was unrelated to his job, court records show.
As the Office of Protective Services has accumulated overtime, questions have been raised
about the quality of the work taxpayers have
received from the police force.
A California Watch investigation in February found that over the past decade, the Office of
Protective Services failed to conduct basic police
work even when patients died under mysterious
circumstances. State officials have documented
hundreds of cases at the facilities of abuse and
unexplained injuries, almost none of which have
led to arrests.
In March, state officials announced they had
hired an independent manager for the Office
of Protective Services to oversee new training
guidelines, and state lawmakers have introduced
RENEH AGHA/PORTERVILLE RECORDER
Porterville Developmental Center Lt. Scott Gardner
legislation that would direct serious criminal
(left) and Cmdr. Jeff Bradley make their way to Tulare
investigations to outside law enforcement, among County Superior Court in April 2010. The two were indicted for embezzling about $121,000, but the charges
other changes.
were later dropped.
No one has claimed more overtime than
Thomas Lopez, an entry-level patrolman at the Porterville Developmental Center. On top of his base
salary of $54,133, Lopez’s paychecks have included at least $80,000 in overtime every year for much
of the past decade, doubling and tripling his compensation.
In 2008, Lopez collected $208,000 in pay, including $146,000 through overtime. To achieve that
income level, Lopez would have had to work 107 hours each week for the entire year, without any
vacation or leave time.
Overtime has lifted Lopez into the same income bracket as doctors at the developmental center
where he works. He’s paid more than his boss, Terri Delgadillo, the Department of Developmental
Services director, who earns $158,000 for running the $4 billion state agency.
Even Lopez acknowledged that his paychecks are large. “If I were investigating overtime, I’d be
the top suspect,” said Lopez, who owns seven houses worth $1.2 million and two classic cars valued
at $50,000 each, according to two car auction websites.
Last year, Lopez received $150,275 – just below the salaries of Attorney General Kamala Harris
and state schools superintendent Tom Torlakson. Sixty percent of Lopez’s income was from overtime.
Lopez contends he spends every waking hour at the Porterville center. He volunteers for day
53
shifts and night shifts, weekends and holidays. The patrolman said his superiors are responsible for
his hours, not him.
“The only thing I can tell you is it was signed and allowed by a sergeant,” Lopez said. “Even people
who don’t like me will testify I was there.”
Bob Lewis, a commander with the Office of Protective Services, was responsible for police operations at the Porterville center most of the past three years and had final authority over Lopez’s
overtime hours. The office’s overtime policy directs commanders to “reduce OT whenever possible.”
Lewis declined to comment because the Department of Developmental Services does not permit
employees to talk to reporters. “I wish I could speak with you, but I can’t,” he said. Lewis received a
promotion in September and now leads the police force at the Sonoma Developmental Center.
Documents show the vast majority of extra hours at the Office of Protective Services are for patrol
shifts, with officers waiting for calls about incidents or circling the institutions’ parking lots, rather
than investigating potential abuse cases.
“At night, it gets a little bit slow. It’s hard not to doze off sometimes,” Lopez said. “You try to stay
up. But you better take your calls, and you better take your reports. It’s hard because that time
drags.”
When asked if he sometimes sleeps during overtime shifts, Lopez replied, “Yes.”
The force currently has 27 vacant jobs out of 94 positions, but most of the shifts are covered by
increased overtime and by hiring retired officers for temporary duty. Some of those officers – socalled retired annuitants – also have earned overtime pay.
Coby Pizzotti, a lobbyist for the California Statewide Law Enforcement Association, which represents the institution’s police, said the overtime payouts are a symptom of understaffing at the
developmental centers. Fairview Developmental Center in Costa Mesa and the Lanterman Developmental Center in Pomona, for example, are staffed with just four patrol officers each.
“The budgeted positions aren’t sufficient to do the job adequately without getting an incredible
amount of overtime,” he said.
The base pay for the force averages about $44,000 – relatively low compared with departments of
similar size. At the Vallejo Police Department, for example, the average base pay is $98,000.
Delgadillo, the agency’s director, declined to comment on her department’s overtime payouts. But
in a statement, the department said overtime was required “to meet the safety and security needs
of the 24-hour licensed residential health care facilities” amid a state hiring freeze and worker furloughs.
“These residents require constant and immediate law enforcement supervision for all court
hearings, community outings and medical appointments outside of the secure treatment area,” the
department said.
At the same time, the department said it has moved to curb overtime payouts. In 2009, it implemented a new policy that requires police supervisors to approve overtime requests in advance and
to assess whether officers’ workloads are reasonable.
Patricia Flannery, the official who oversees operations at California’s developmental centers, that
54
year also ordered an internal audit of
police overtime. Documents from the
audit, obtained through a public records
request, do not show any attempt to evaluate whether the officers actually worked
the hours on their timesheets.
Between 2009 and 2011, overtime
payouts at the Office of Protective Services declined about 25 percent. State
officials said their “aggressive actions”
to curb overtime – as well as using
closed-circuit cameras to monitor patients instead of security towers – has led
to the drop in overtime.
Despite the changes, seven officers at developmental centers still managed to double their pay in
2011.
City police and sheriff departments often generate large overtime bills. But the Office of Protective Services far outpaces other California law enforcement agencies in overtime, according to state
and local payroll data of five agencies reviewed by California Watch.
The developmental center police officers on average added $19,600 to their paychecks through
overtime in 2010 – $2 million in total, according to state pay data. Overtime accounted for 28 percent
of all Office of Protective Services compensation that year. Eleven officers doubled their salaries with
overtime.
By comparison, overtime was 12 percent of pay for police officers in Vallejo and at the similarly
sized Santa Cruz Police Department. And at larger agencies, such as the California Highway Patrol
and the San Jose and San Francisco police departments, the percentage of overtime hovers between 6
and 10 percent of pay, an analysis of local pay data shows.
To Loren DuChesne, former chief of investigations for the Orange County district attorney’s office,
the overtime looks suspicious. DuChesne examined the Office of Protective Services for the state
attorney general’s office a decade ago, finding shortcomings in the force’s ability to conduct criminal
investigations.
“What I’m seeing here is just a carte blanche abuse,” DuChesne said. “Given the nature of the job,
those guys on graveyard (shifts) at Sonoma or Lanterman, if you had more than one person, you had
to be the most bored person that ever worked in a law enforcement vehicle.”
Lopez is among dozens of developmental center police officers who have recorded extra hours on
their timesheets.
One patrolman at the Fairview Developmental Center in Costa Mesa, Daniel Butler, regularly collected more money from overtime than from his base pay. He worked for 14 years at the facility, but
netted at least $60,000 a year in overtime from 2007 until his retirement in March 2011.
55
Butler did not respond to repeated interview requests.
Another Porterville officer, Rick Shannon, neared Lopez’s overtime levels in 2008. His paychecks
included $114,000 from claiming extra hours.
Shannon, whose base salary was $50,000, was on pace to exceed $100,000 in total income for
at least the fourth straight year when he suffered a fatal heart attack in July 2010 in the middle of a
shift. In just seven months that year, Shannon received $44,830 in overtime.
At the Porterville center, supervisors have long approved overtime claims without verifying
the patrol officers actually showed up for the shifts, said Martin Espinoza, a former detective at the
institution. (Records show Espinoza earned $8,000 in overtime pay during the four years before he
retired, much less than many of his colleagues.)
“I couldn’t comprehend how they could allow such a thing,” Espinoza said of the overtime claims.
“These people are fairly intelligent and can figure some of this stuff out. It was so obvious.”
Indeed, a Tulare County grand jury in 2010 indicted the Office of Protective Services’ police chief
and a top detective on embezzlement charges related to overtime abuse.
The police department in the town of Porterville found evidence that Scott Gardner, the developmental center’s investigator, claimed overtime hours on days when he was in Las Vegas, said Capt.
Eric Kroutil, who conducted the investigation for the Porterville Police Department.
The detectives concluded that Jeffery Bradley, then chief of the Office of Protective Services, had
sanctioned Gardner’s overtime. Bradley and Gardner were indicted on embezzlement charges in February 2010, but the prosecution was short-lived.
A judge threw out the charges last year, saying an Office of Protective Services internal investigation into the matter violated Bradley and Gardner’s rights under the California Peace Officers’ Bill of
Rights. The internal investigation had been characterized as “administrative” rather than potentially
criminal, meaning any evidence collected could not be used in a court of law.
Gardner declined to speak with California Watch. Bradley referred questions to his attorney, W.
Scott Quinlan, who did not respond to several phone calls and e-mails. The Department of Developmental Services fired Bradley after his arrest, and Gardner resigned. Bradley has since appealed his
dismissal.
Overtime at closed facilities
Patrol officers with the Office of Protective Services have accumulated overtime even without
crimes to investigate or patients to protect.
At the Agnews Developmental Center in San Jose, which closed in March 2009, officers accumulated between 200 and 460 hours in overtime pay to patrol empty buildings in the three months after
the facility shuttered.
Agnews officers claimed 1,307 extra hours in total during those months. By comparison, that’s
twice the number of hours taken by officers and detectives at the Lanterman Developmental Center
in Pomona, which then housed 440 patients with cerebral palsy and other intellectual disabilities.
56
The Department of Developmental Services operated an
outpatient clinic at Agnews for two years after the closure. In
a written statement, state officials said the agency “remained
responsible for the safety and security” of the center as long as
it owned the property.
State officials did not provide an explanation for why the
Office of Protective Services spent more on overtime at Agnews
than at Lanterman in 2009. But they said the Agnews overtime
was necessary, “as the two full time peace officers employed
were insufficient to cover the required 24 hour schedule seven
days per week.”
Police overtime is supposed to serve a law enforcement purpose, protecting people or investigating crimes, said Leonard
Matarese, a criminal justice consultant at the International City/
County Management Association.
Matarese, a consultant and retired Florida police chief, said
departments should account for extra hours on a weekly, if not
daily, basis. The number of extra hours alone at the Office of
Protective Services – 65,000 a year on average from 2008 to
2010 – raises alarms about the institution force.
“As a police chief, I just wouldn’t allow that,” Matarese said.
“It sounds like it’s completely out of control.”
Patrolman cashes in on overtime
Lopez,the entry-level patrolman in Porterville, owns seven
houses worth a combined $1.2 million, scattered across Porterville and the Los Angeles area. Lopez lives in one of his Porterville homes – a nondescript tan structure with a well-manicured
front yard. The patrolman said he uses the house primarily to
sleep and store his belongings.
In the garage of his main residence, he keeps two pristine
1956 Chevrolet Bel Airs, collectors’ items that gleam with the
original factory paint colors of “Tropical Turquoise” and “Sierra
Gold.” Each car is worth at least $50,000, or about the same as
Lopez’s base salary.
His paychecks have included at least $80,000 in overtime
every year for much of the past decade, state data shows.
Porterville, where Lopez works, is home to more than 500
57
“What I’m seeing
here is just a carte
blanche abuse.
Given the nature
of the job, those
guys on graveyard
(shifts) at Sonoma
or Lanterman, if
you had more than
one person, you
had to be the most
bored person that
ever worked in a
law enforcement
vehicle.”
— Loren
DuChesne,
former chief of
investigations for
the Orange County
district attorney’s
office
people with developmental disabilities. About 200 of the patients are inmates, placed at the center
by courts because they are unfit to stand trial. Because of this, a majority of the Office of Protective
Services is based at Porterville.
Some days, Lopez said he earns extra hours by standing guard in the secure housing units. Other
days, the overtime calls for him to transport patients to appointments and court dates outside the
developmental center.
But many shifts don’t require him to do anything but show up – long stretches spent watching
movies on his laptop and napping, he said.
“How many times can you spin around the facility?” Lopez said of his patrol work. “You’re waiting
for a call, waiting for a help call, waiting for a report.”
Few at the Office of Protective Services have ever worked for a major law enforcement agency.
But Lopez received his basic training at the Los Angeles Police Department’s academy before signing
on with the developmental center force in 1996, personnel records show.
Judging by his training, which could have placed him at a much larger and better-paying police
force, Lopez’s decision to work at the Office of Protective Services is unusual. The department typically hires detectives from other state agencies, such as the Department of Social Services, and other
people with no law enforcement experience.
Lopez’s reported workweek is unusual, even if he spends a portion of it idling. In an interview, Lopez claimed he worked regular 12-hour shifts every week, and some days, he would work 20 hours.
In 2011, state pay data shows, Lopez’s workload averaged 85 hours a week at the Porterville center for 52 weeks to earn his $144,000 income. Of that, $90,730 was overtime.
Last year was nothing compared with 2008, when Lopez’s compensation peaked at $208,000 –
70 percent of it overtime pay. His timesheets claimed an average of 107 hours of work every week.
He claimed no sick days or vacation.
Department of Developmental Services officials would not answer questions about Lopez’s overtime, citing California law making personnel information about police officers confidential.
Martin Espinoza, the recently retired detective at Porterville, wondered how Lopez avoids crippling fatigue from putting in more than 200 overtime hours a month.
“How is that possible?” Espinoza said. “You’ve got to sleep sometimes.”
This story was edited by Robert Salladay and Mark Katches and was copy edited by Nikki Frick.
58
INFOGRAPHIC
How does a police officer
double his salary in a year?
O
By Lauren Rabaino
May 18, 2012
http://bit.ly/BrokenShield-Overtime-infographic
fficers working for the Office of Protective Services, the police force at California’s
five developmental centers, are some of the state’s most proficient users of overtime.
But even while they have boosted their paychecks, the force has been criticized for its
sloppy investigations into potential crimes.
We built an infographic for the Web examining the force’s overtime pay from several vantage
points, offering readers side-by-side comparisons with other law enforcement agencies. Our
analysis was based on how many hours the biggest earners claimed on their timesheets.
This infographic was formatted for the Web.
To view full graphic, click here:
http://bit.ly/BrokenShield-Overtime-infographic
59
SUPPLEMENTAL
60
RESPONSE AND REACTION
61
I
Reach and Outreach
n addition to reaching out to numerous news organizations, many of which published stories in
the series on their front pages, we conducted an extensive engagement campaign that included
in-person events, social media outreach and a resources guide. Some examples:
FRONT PAGES
Total California audience for this story was 12.2 million via media partners – TV,
radio, print and online. NPR’s “Morning Edition,” with 13 million daily listeners,
also featured Broken Shield.
REACT AND ACT
Handout highlighted findings, results and resources
for people to get involved.
CALIFORNIA WATCH DETAILS FAILURES OF STATE
POLICE FORCE TO PROTECT DISABLED PATIENTS
STORY SUMMARY
Decades ago, California created a unique police force to investigate crimes and unexplained injuries inflicted upon
some of society’s most vulnerable citizens – men and women with severe autism, cerebral palsy and other profound
developmental disabilities living in taxpayer-funded institutions. This police force, the Office of Protective Services,
patrols exclusively at five state developmental centers, where patients have been beaten, tortured and raped by staff
members. But the police force does a poor job bringing perpetrators to justice.
WHAT WE FOUND
Poorly trained patrol officers and detectives fail to
collect evidence, ignore key witnesses and wait too long
to start investigations – leading to an alarming inability
to solve crimes.
The force’s police chief, a former firefighter, had no
training as a law enforcement investigator.
This is the type of reporting
that ends up actually
saving lives.
—Patricia L. McGinnis, executive director of
California Advocates for Nursing Home Reform
Local law enforcement agencies often have been left in the dark about potential crimes in their own backyards.
EXAMPLES
Dozens of female patients were allegedly raped, but state police investigators didn’t order rape kits to collect
evidence, a standard tool in sexual assault cases for most police departments. Police waited so long to
investigate one sexual assault that a developmental center janitor accused of rape had time to flee the country.
A Sonoma Developmental Center caregiver used a stun gun to inflict burns on a dozen patients. But the
internal police force waited nine days to interview the caregiver, who was never arrested or charged with abuse
– and local prosecutors were not notified.
A 50-year-old autistic man died after he was discovered on his bedroom floor with a broken neck. Three
medical experts said someone likely had caused the fatal injuries. But once again, police investigators working
at the developmental center did not collect physical evidence from the scene and waited five days to begin
interviewing potential witnesses, critical errors that made solving the case next to impossible.
READ THE ENTIRE SERIES
HAVE A LOVED ONE IN A DEVELOPMENTAL CENTER?
www.californiawatch.org/broken-shield
Get updates on this investigation: Text “OPS” to 877877.
Tell us your story:
http://bit.ly/PINBrokenShield.
Page 1 of 2
!"#$%&'()'*%+)*''),%+-.)'%"$#%%/%%0'*1'2'3,%&4%567$6%%/%%8"$9:$59#";$%%/%%<<<=&42.>?*(.4<4)&@=?*A
Media partners
•
•
•
•
The Fresno Bee
KABC Los Angeles
KGO San Francisco
KGTV San Diego
•
•
•
•
•
•
•
KPBS San Diego
KQED “California Report”
KXTV Sacramento
The Modesto Bee
NPR “Morning Edition”
The Orange County Register
The Press-Enterprise
•
•
•
•
•
•
The Sacramento Bee
San Diego Union-Tribune
San Francisco Chronicle
San Luis Obispo Tribune
Santa Rosa Press Democrat
The Sonoma Index-Tribune
TWITTER
FACEBOOK PAGE
Rolled out Jennifer’s story on Twitter, highlighting prime example of abuse.
Launched our sex abuse story on Facebook with a graphic image from
our video.
62
POSTCARD
Postcards of our findings and resources were sent to disability rights groups around the state. Front
Back
California created a unique police force, the Office of
Protective Services, to investigate crimes and
unexplained injuries inflicted upon some of society’s
most vulnerable citizens – men and women who have
severe developmental disabilities living in taxpayerfunded institutions. This special police force works
exclusively at state developmental centers that have
been the scene of horrific abuses.
But – as California Watch revealed – the police force
has failed to protect and to serve.
Key things we found:
· Poorly trained patrol officers and detectives often fail
to collect evidence, ignore key witnesses and wait too
long to start investigations – leading to an alarming
inability to solve crimes.
· The force’s former police chief had no training as a
law enforcement investigator.
· Local law enforcement agencies often have been left
in the dark about potential crimes in their own
backyards.
Learn more: californiawatch.org/brokenshield
“This is the type of reporting that ends up
actually saving lives.”
- Patricia L. McGinnis, executive director of
California Advocates for Nursing Home Reform
Want to get updates on this investigation as they
develop? Text the letters OPS to 877877.
Do you have a loved one in a developmental
center? We want to hear about your experience.
Visit the following link to share your story:
http://bit.ly/PINBrokenShield
You can also contact reporter Ryan Gabrielson
at [email protected].
2130 Center St., Suite 103 | Berkeley, CA 94704 @CaliforniaWatch
63
RESULTS
MARCH 13, 2012
Developmental centers’ police need
immediate fixes, state officials say
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Immediate-fixes-prescribed
S
ACRAMENTO – Investigations of patient abuse by in-house police at California’s institutions
for the developmentally disabled have been unacceptably poor for years and must be fixed
immediately, state officials and patient advocates agreed during a hearing today.
At a hearing of the Senate Human Services Committee, witnesses and lawmakers called
for changes – ranging from improved training of police employed by the Office of Protective Services
to the outright elimination of the department, which investigates crimes at the state’s five developmental centers.
In a series of stories, California Watch has reported that detectives and patrol officers at the
state’s five board-and-care institutions – home to about 1,800 severely disabled men and women –
routinely fail to conduct basic police work even
when patients die under mysterious circumstances. The facilities have reported hundreds of cases
of abuse and unexplained injuries, almost none of
which have led to arrests.
The hearing came as the administration of
Gov. Jerry Brown announced a series of changes
for the Office of Protective Services. The overhaul includes beefed-up training for officers and
detectives, new standards for securing evidence
RANDY ALLEN/CALIFORNIA WATCH and potential crime scenes, automated tracking of
Thomas Simms, who audited the Office of Protective
injuries and other incidents, and the hiring of an
Services a decade ago, told lawmakers the agency
independent overseer.
should lose its investigative powers.
64
“Any case of abuse is unacceptable, regardless
of where the person lives,” Terri Delgadillo, director of the state Department of Developmental
Services, which oversees the Office of Protective
Services, told the Senate Human Services Committee.
Diana Dooley, secretary of the state Health and
Human Services Agency, announced in a statement today that she had hired a law enforcement
expert to oversee the changes. That consultant,
Joseph Brann, is the former chief of the Hayward
RANDY ALLEN/CALIFORNIA WATCH
Police Department and consultant to the state
State Sen. Carol Liu asked for quick action from the
attorney general monitoring reforms at the River- Department of Developmental Services to reform the
Office of Protective Services.
side and Maywood police departments.
Brann said he will push for meaningful action to ensure crimes against patients are investigated
competently. “Everyone will be operating with a sense of urgency,” he said. Brann agreed to oversee the institution police, in part, because his son lives at the Fairview Developmental Center in Orange County.
“This is not only a civic responsibility for me; it is also a personal responsibility,” he said.
After nearly a decade of scathing audits and complaints about the internal police department,
lawmakers at the hearing were demanding action. The state promised to implement reforms within
the next three months.
“We will be monitoring your progress and hoping the changes come quickly,” warned Sen. Carol
Liu, D-Glendale, chairwoman of the Human Services Committee, who has questioned whether the
standards at the Office of Protective Services had allowed people to “get away with murder.”
California is budgeted to spend $577 million this fiscal year to operate the centers, or roughly
$320,000 per patient. More than 5,200 people work in the institutions – more than 2.5 staff members
for each patient. The five centers are in Los Angeles, Orange, Riverside, Sonoma and Tulare counties.
Ric Zaharia, a consultant hired by the state to review the Office of Protective Services, said about
half of the changes offered by the Brown administration were made a decade ago in a California Department of Justice audit.
The audit recommended the department hire an experienced police executive to manage officers
and caseloads at the centers. Instead, the state hired employees with little to no law enforcement
background for the top job. The current chief, Corey Smith, was previously a firefighter. Smith hadn’t worked on criminal
investigations until 2006, when the department made him police commander at the Sonoma Developmental Center, responsible for overseeing hundreds of cases each year.
Thomas Simms, a former California Department of Justice consultant who conducted the 2002
audit, expressed frustration that little has been done to reform the Office of Protective Services since
65
then. Now, he said, the investigating authority of
the Office of Protective Services should be eliminated.
“How many more times are we going to meet
and talk about the need for fundamental reform?”
said Simms, a retired police chief who for 20
years led the Roseville and Santa Rosa departments. “If my organization had failed the way this
one has, I would’ve been fired.”
State Sen. Loni Hancock, D-Berkeley, echoed a
similar concern when she questioned whether the
RANDY ALLEN/CALIFORNIA WATCH
developmental center police are “too intertwined
Terri Delgadillo, director of the Department of Developmental Services, said she is implementing reforms to to be impartial” handling criminal investigations
the police agency.
at the institutions.
Zaharia said that potential crimes at developmental centers are best handled by a centralized
force based at the centers and trained to interview victims with intellectual disabilities. He said the
ideal model is Massachusetts, which built an independent law enforcement agency dedicated to investigate abuse of the disabled at institutions and community group homes.
Simms urged lawmakers to follow a model that separates institution officials from the police
work, though he acknowledged this wouldn’t be a simple solution. “It will not be cheap, it will not be easy, and it will not be without risk,” Simms said about disbanding the 90-officer department.
Coby Pizzotti of the California Statewide Law Enforcement Association, the union representing
the Office of Protective Services, said that rather than disbanding the department, the state needs to
separate the police force from its Sacramento management. He said Sacramento officials are more
concerned with maintaining the state’s record as good caregivers.
“You have kind of a conflict role in which the preservation of justice may not jibe with what the
licensing requirements may be,” Pizzotti said. “We believe the OPS system is one that should work
with maybe an independent chief who is experienced in law enforcement.”
Delgadillo, however, said every injury or case of potential abuse is reported to state Department
of Public Health, which licenses the developmental centers. She said the department has a zero-tolerance policy for abuse, and any staff member suspected of abuse is immediately removed from his or
her job.
Patients at the institutions are among the state’s the most vulnerable residents, sometimes unable to speak or paralyzed by cerebral palsy or other conditions.
“People with disabilities are more likely to experience more severe abuse and for long periods of
time,” said Leslie Morrison, head of investigations at Disability Rights California.
Advocates have said developmentally disabled men and women frequently are treated as second-class citizens, and they have questioned why so few people have been arrested or prosecuted for
66
abuse at California’s institutions.
“How many people went to jail for abusing patients?” Sen. Roderick Wright, D-Inglewood, asked
Kathleen Billingsley, chief deputy director of the Department of Public Health. “How many people
have been fired in the past five years for abusing patients?”
Billingsley said her department had substantiated 89 cases of abuse from the past four years at
the developmental centers, but said she did not know how many of those cases were referred for
prosecution.
Delgadillo said any investigation into potential abuse or injuries at developmental centers have
unique challenges for the police force, including difficulties communicating with patients, many of
whom have severe autism or cerebral palsy. But she said all death and serious injuries are reported
to local law enforcement.
Delgadillo nevertheless acknowledged that some investigations do not occur in a timely manner.
“I think we’ve made improvements, but I don’t think we’re good enough,” she said.
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RESULTS
JUNE 14, 2012
Developmental center police
investigating officer’s overtime
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Officer-overtime-investigated
T
he in-house police force at California’s developmental centers is investigating one of its
patrol officers for large overtime paychecks and an admission that he has slept on the job.
Thomas Lopez, an officer at the Porterville Developmental Center, has doubled and
tripled his base salary with overtime for nearly a decade, California Watch reported in
May. The force, called the Office of Protective Services, employs roughly 90 sworn police officers, 22
of whom doubled their salaries with overtime at least once during the past four years.
The state-run police force last year paid about $2 million in overtime to 80 of its officers. The
officers patrol and investigate criminal activity at five board-and-care institutions that house about
1,800 patients with severe intellectual disabilities in Los Angeles, Orange, Riverside, Tulare and
Sonoma counties.
Last week, Linda Jo Goldstein, an Office of Protective Services detective, contacted California
Watch seeking details about the news gathering process on the overtime story related to Lopez.
California Watch, part of the Center for Investigative Reporting, declined to contribute to the police examination beyond its published reports.
“News organizations should not take part in police investigations,” said Robert J. Rosenthal,
executive director of the Center for Investigative Reporting. “We stand by our work, and if it exposes
problems and issues that lead to investigations by authorities, that is not a decision or process we
participate in.”
Terri Delgadillo, director of the Department of Developmental Services, which operates the institutions, released a statement Tuesday in response to questions from California Watch.
The department “will continue to closely monitor overtime usage and thoroughly investigate
areas of potential abuse,” Delgadillo wrote in an email. “Commanders and the Chief of the Office of
68
“At night, it gets a
little bit slow. It’s
hard not to doze
off sometimes.”
— Thomas Lopez,
officer at the
Porterville
Developmental
Center
Protective Services, along with department headquarter managers, review overtime monthly to identify anomalies and validate
the appropriateness of overtime usage. This allows for timely
identification of potential issues and serves as a deterrent to
overtime abuse.”
Delgadillo did not respond to questions about the nature and
scope of the police overtime inquiry.
A previous California Watch investigation, published in February, found the Office of Protective Services failed to conduct
basic police work even when patients died under mysterious
circumstances over the past decade. State officials have documented hundreds of cases at the facilities of abuse and unexplained injuries, almost none of which have led to arrests.
The small police force is one of the most proficient in the
state at accumulating overtime. For several of the officers, their
overtime payouts would have required them to work 70 to 100
hours a week the entire year to earn the extra cash.
In 2008, Lopez collected $146,000 in overtime pay in addition to his $58,000 salary. To earn the extra pay, Lopez would
have had to work 107 hours every week of the year, according to
a California Watch analysis of state pay data.
Some of the shifts are spent idling, waiting for a call for
police assistance, Lopez said. He confirmed that he has slept
during his work hours.
“At night, it gets a little bit slow. It’s hard not to doze off
sometimes,” he said during an interview earlier this year. “You
try to stay up. But you better take your calls, and you better take
your reports. It’s hard because that time drags.”
Lopez did not return calls seeking comment Tuesday.
Although Lopez drew the most extra pay within the Office of
Protective Services the past four years, many of his colleagues
also claim large amounts of overtime. In 2011, average overtime
pay for developmental center officers was $20,981, according to
state salary data. Officers’ average base salary was $46,630.
The Porterville center, where Lopez works, also has past
experience with overtime abuse and fraud investigations.
Two years ago, a Tulare County grand jury indicted the
Office of Protective Services’ police chief and top detective on
embezzlement charges related to overtime pay. Porterville po69
lice found evidence that the detective had claimed overtime hours on days he was vacationing in Las
Vegas, which the chief knowingly approved.
A judge threw out the charges last year, ruling that the developmental center police’s internal
probe violated the officers’ rights under the California Peace Officers’ Bill of Rights.
The state attorney general’s office agreed to take over the case, though the state’s lawyers have
made no progress toward refiling criminal charges, Porterville Police Chief Chuck McMillan told The
Recorder in Porterville recently.
Lynda Gledhill, spokeswoman for the attorney general, said the state continues to investigate the
earlier Porterville overtime fraud allegations.
Officials inside the developmental center force have prepared for an inquiry, email records show.
In October, the Office of Protective Services commander at Porterville, David Montoya, directed
officers to refer questions from “the Attorney General’s Office or any other agent from another government agency” to the Department of Developmental Services’ lawyers in Sacramento.
Montoya’s instructions, obtained by California Watch, apply to requests for public records, specifically police policies and practices, “or any other information by circumventing our Chief and HQ.”
In a written statement in April, the Department of Developmental Services said the order simply
follows existing guidelines for disclosing information. It is not intended to inhibit outside investigations.
“The commander’s note is appropriate and in accordance with routine state policy for all departments in the Health and Human Services Agency,” the statement reads. “Communications to or from
department personnel especially from attorneys or law offices are supposed to be routed through the
Department’s Office of Legal Affairs office. A request from the AG’s office, on its face, would presumably involve a case or other legal matter.”
70
RESULTS
AUGUST 16, 2012
Developmental centers
seek new police chief
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-New-police-chief-sought
T
he in-house police force at California’s institutions for the developmentally disabled is
searching for a new chief as scrutiny of its work on criminal investigations intensifies.
After two years in the top job, Corey Smith received a demotion to second-in-command
for the force, the Office of Protective Services. David Montoya, police commander at the
Porterville Developmental Center, is serving as interim chief, according to the state Department of
Developmental Services’ website.
The department, which oversees the centers and the police force, has repeatedly hired police
chiefs with little to no background in law enforcement.
In its job posting, released Aug. 6, the department said applicants need “extensive management
experience directing uniformed peace officers and investigative operations.” However, the posting
does not detail how many years of police work or what level of education the next chief must have.
The personnel moves come as state lawmakers last week ordered the California State Auditor to
examine the police force’s operations [PDF]. The Office of Protective Services is responsible for
protecting nearly 1,700 patients with cerebral palsy, mental retardation and severe autism at five
state-run centers in Los Angeles, Sonoma, Orange, Riverside and Tulare counties.
In an ongoing series of stories this year, California Watch has reported that detectives and patrol officers at the institutions routinely fail to conduct basic police work, even when patients die
under mysterious circumstances.
Officers have delayed interviews with witnesses or suspects – if they have conducted interviews
at all. In case after case, the force waited too long to collect evidence or secure crime scenes and has
been accused of going easy on co-workers who care for the disabled.
Terri Delgadillo, the department’s director, did not respond to calls for comment or emails with
71
written questions regarding the chief’s position.
Delgadillo selected the past three Office of Protective Services chiefs since becoming head of the
Department of Developmental Services in late 2006. None of those hires had worked on criminal
investigations for outside police agencies.
The first, Nancy Irving, was not even a sworn officer during her time as interim police chief in
2007 and 2008. Irving worked at the developmental services department for more than three decades as a labor negotiator and government manager, before and after her stint with the police force,
until her retirement last year.
Jeff Bradley started as a security guard in 1998 and moved to the top of the force as an investigator and commander at the Lanterman and Porterville developmental centers. He succeeded Irving as
chief in June 2008, but didn’t keep the job long. In February 2010, a Tulare County grand jury indicted Bradley for his alleged involvement in
an overtime fraud scheme. A judge threw out the charges last year, saying investigators violated his
rights under the California Peace Officers’ Bill of Rights.
Smith, named chief in 2010, spent most of his career as a firefighter at the Sonoma Developmental Center. He hadn’t worked on criminal investigations until 2006, when the department made him
the Sonoma police commander, responsible for overseeing hundreds of cases each year.
It is unknown whether Smith stepped down by choice or by administrative force. He did not return calls for comment yesterday. On his voicemail message, Smith lists himself as supervising special investigator, one position below chief.
In response to California Watch’s reporting, Sen. Carol Liu, D-Glendale, introduced SB 1051,
which includes a provision mandating that the Office of Protective Services chief have significant law
enforcement experience. The legislation has passed the state Senate and awaits a vote on the floor of
the state Assembly.
Liu declined to comment on the developmental center police force’s hiring standards. “She needs
to talk to the department first,” said Robert Oakes, Liu’s spokesman.
Based on the published job requirements, Smith’s successor is likely to come from another state
agency, rather than a city or county police department.
Applicants should be current state employees, or have worked previously for the Legislature or
governor, or have been honorably discharged from the U.S. military, the posting said. Officers at city
or county law enforcement agencies can be hired only through a bureaucratic process called an “interjurisdictional exchange.”
The exchanges take place when state agencies trade employees or one agency loans an employee to another department for a set period of time, according to the California personnel operations
manual. And employees from local governments “gain no status in the California state service” while
on loan to the state agency. Tom Simms, a retired police chief who led the Roseville and Santa Rosa departments, said the
requirement would eliminate the most qualified applicants from consideration.
If the Department of Developmental Services hires its new chief from the ranks of a city police
72
agency, he or she would not become a state employee and would not earn retirement benefits.
“Oh yeah, that’s really going to encourage people to come up,” said Simms, who examined the
developmental center force a decade ago for the state Department of Justice.
Simms and Loren DuChesne, former chief of investigations for the Orange County district attorney, in 2002 wrote a report on widespread problems within the Office of Protective Services. The
report recommended the department “recruit and hire a highly qualified and experienced law enforcement candidate” for police chief.
Every commander, detective and patrol officer at the developmental centers underwent retraining in June. State officials, including Smith, also have been writing new policies and practices to
upgrade the force’s criminal investigations.
Montoya, the interim chief, started his law enforcement career with the Visalia Police Department
in 1988, according to an Office of Protective Services internal memo.
He spent 13 years with the Tulare County Sheriff’s Office, rising to the rank of sergeant, before
joining the state Department of Mental Health as an investigator at Coalinga State Hospital in Fresno
County.
73
RESULTS
AUGUST 9, 2012
State lawmakers order audit
of developmental center police
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Lawmakers-order-audit
L
awmakers directed the California State Auditor yesterday to examine the in-house police
force at the state’s board-and-care institutions for the severely developmentally disabled.
The force, called the Office of Protective Services, is responsible for protecting roughly
1,700 patients with cerebral palsy and other intellectual disabilities at five developmental
centers in Los Angeles, Orange, Riverside, Sonoma and Tulare counties. Police at the centers have
been criticized repeatedly by advocacy groups and state and federal regulators for lax work on
criminal investigations.
The review is intended to assess the training, handling of abuse cases and overtime spending by
the Office of Protective Services. The auditor plans to assess whether the police force’s procedures
comply with state law and to determine what actions the force “has taken to fulfill its responsibilities
to protect” patients at the centers. The review will cost an estimated $409,200, according to a preliminary analysis by the state auditor. It is projected to take several months of work, but there is no strict deadline for completion.
“This audit will clarify what went wrong in the past and determine how we can prevent this from
happening again,” Assemblywoman Connie Conway, R-Tulare, said in a written statement yesterday.
“Vulnerable Californians should not be put in danger by the very same hands who are responsible for
protecting them.”
State Sen. Joel Anderson, R-Alpine, and Assemblyman Jim Beall, D-San Jose, also requested the
audit of the Office of Protective Services.
The state Department of Developmental Services, which operates the centers and the police force,
did not oppose the audit.
“The health and safety of the people we serve is our highest priority regardless of whether they
74
live in a developmental center or the community,” Nancy Lungren, the agency’s spokeswoman, said in
a prepared statement. “The department has and continues to take aggressive action to improve our
internal law enforcement, and we welcome the assistance of (the state auditor) and the Legislature.”
Separately, the state Assembly Committee on Appropriations yesterday approved two measures
– SB 1051 and SB 1522 – that would require that the developmental centers report to outside law
enforcement suspicious deaths, and patient abuse and sexual assault allegations involving state employees. The bills now go to an Assembly floor vote.
The audit and legislation are in response to an ongoing series of stories this year by California
Watch, which reported that detectives and patrol officers at the institutions routinely fail to conduct basic police work, even when patients die under mysterious circumstances. In case after case,
detectives and officers have delayed interviews with witnesses or suspects – if they have conducted
interviews at all. The force also has waited too long to collect evidence or secure crime scenes and
has been accused of going easy on co-workers who care for the disabled.
These shortcomings were present late last year in a major abuse case at the Sonoma Developmental Center.
In September, the Office of Protective Services received a tip that Archie Millora, a caregiver at the
Sonoma center, had abused several profoundly disabled men with a stun gun. Internal records obtained by California Watch show detectives found burn marks on several patients and, later, discovered a Taser and a loaded handgun in Millora’s car.
After the assaults were discovered, the Office of Protective Services made no arrest and instead
handled it as an administrative matter. At least nine days after the revelations, detectives still had not
interviewed Millora, records show.
The Sonoma County district attorney’s office announced last week it would review the matter as
a potential criminal abuse case. Previously, the Office of Protective Services had only referred a misdemeanor weapons charge against Millora for possessing a concealed firearm.
The Department of Developmental Services has hired numerous people with no law enforcement
experience to handle criminal investigations. In 2007, the department hired Nancy Irving, a former
labor negotiator and government manager, as police chief despite the fact that she was not a sworn
officer. Irving led the force for a year before retiring from the department.
The current chief, Corey Smith, spent most of his career as a firefighter.
California Watch stories have also detailed how the small force is one of the most proficient in the
state at accumulating overtime. Twenty-two officers, roughly one-fourth of the force, have claimed
enough overtime to double their salaries.
In all, the state is budgeted to spend $550 million on the patients and facilities this fiscal year, or
about $314,000 per patient.
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RESULTS
SEPTEMBER 28, 2012
Brown signs bills
on developmental center abuse
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Governor-signs-bills
G
ov. Jerry Brown signed two bills yesterday to require California’s developmental centers to
alert outside police and a disability protection organization when patients die under suspicious circumstances, are abused or are seriously injured.
The state operates five board-and-care institutions for more than 1,600 people with cerebral palsy and intellectual disabilities in Sonoma, Orange, Tulare, Riverside and Los Angeles counties. An in-house police force, called the Office of Protective Services, patrols and investigates crimes
against the centers’ patients.
In a series of stories this year, California Watch has reported how the force has failed to complete basic police work, even in assault and death cases. State lawmakers drafted the measures – SB
1051 and SB 1522 – in response to the news coverage.
The bills were marked “urgent” and took effect immediately.
Advocates for the developmentally disabled praised the governor’s action as a step toward better
protecting the vulnerable.
“This package of legislation together shows a commitment by the administration to begin to
address this nightmare situation of disproportionate victimization of people with disabilities,” Tony
Anderson, executive director of The Arc of California, said in a written statement.
The state Department of Developmental Services, which operates the centers and police
force, emailed a statement about the new laws today.
“The Department of Developmental Services is pleased that the Governor has signed SB 1051
(Liu) and SB 1522 (Leno),” the statement said. “These bills are supportive of and consistent with the
administration’s priority and ongoing efforts to ensure the health and safety of developmental center
residents.”
76
The first measure introduced, SB 1051, mandates that the Department of Developmental Services
report suspicious deaths and allegations of abuse by employees to Disability Rights California, a protection group.
“It kicks the door open a little bit,” Leslie Morrison, head of investigations for Disability Rights,
said of the law.
Sen. Carol Liu, D-Glendale, and Sen. Bill Emmerson, R-Riverside, sponsored the bill.
Additionally, the new law sets minimum job requirements for the chief of the Office of Protective
Services. The chief now must be a certified peace officer “with extensive management experience
directing uniformed peace officer and investigation operations,” the legislation said.
In 2007, the department appointed Nancy Irving, a former labor negotiator and government manager without law enforcement certification or background, to work as police chief. Irving spent a
year running the Office of Protective Services. More recently, Corey Smith, a career firefighter, served
as chief despite having little experience with criminal investigations. Smith accepted a demotion to
second-in-command in August.
The companion law, SB 1522, will require that the developmental centers immediately notify an
outside law enforcement agency regarding patient deaths, sexual abuse, assaults with a deadly weapon or severe injury, and unexplained broken bones.
Detectives working at the institutions often have been the only law enforcement officials to learn
of crimes against patients.
“The governor’s signature will bring much-needed accountability and consequence to unlawful
acts at our developmental centers,” said Sen. Mark Leno, D-San Francisco, sponsor of SB 1522.
In numerous cases, investigation records show, detectives at the Office of Protective Services did
not collect physical evidence. Officers routinely delayed witness interviews and have been accused of
going easy on co-workers who care for the disabled.
The bills moved through the Legislature without public opposition.
“The issue was not considered a partisan one,” Leno said, “and a strong majority of my colleagues
recognized that the status quo was not sustainable and needed the attention of this bill.”
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RESULTS
DECEMBER 3, 2012
Calls grow for local police to take
cases at developmental centers
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Local-police-takeover-push
S
onoma County’s top prosecutor has joined with advocates for the developmentally disabled
in calling for local police to take charge of criminal investigations of patient abuse at California’s board-and-care institutions.
Cases involving reported assault and negligence have long been left to the Office of Protective Services, the police force at the five state-run developmental centers. The force’s detectives
and patrol officers have routinely failed to do basic police work even when patients die under suspicious circumstances.
The force has performed especially poorly in sexual abuse cases, California Watch reported in a
story published Thursday.
Patients have accused caretakers of molestation and rape 36 times since 2009, but the Office of
Protective Services did not order a single hospital-supervised rape examination for any of the alleged
victims. “Rape kit” exams are routinely used to collect evidence at most police departments.
Eleven of the sex abuse cases were reported at the Sonoma Developmental Center, all from female
patients living in the Corcoran Unit.
“The local law enforcement agencies have better tools than (the Office of Protective Services)
does to handle those kinds of investigations,” Jill Ravitch, Sonoma County district attorney, said in an
interview Friday. She has recommended that the county sheriff’s office take over responsibility for
potential abuse cases, including sex assaults.
The centers house roughly 1,600 patients with cerebral palsy, severe autism and intellectual disabilities in Sonoma, Los Angeles, Riverside, Tulare and Orange counties. The state spends more than
$300,000 a year to care for each patient.
The Arc and United Cerebral Palsy in California, an advocacy group for the developmentally dis78
abled, has argued for months that city and
county police agencies should investigate
patient abuse allegations at the institutions. Greg deGiere, public policy director
for the group, said the Office of Protective
Services mishandled sex assault investigations, making outside police involvement
urgent.
“This problem is out of control and warrants a much stronger response,” deGiere
said.
State officials have documented hunMIKE KEPKA/SAN FRANCISCO CHRONICLE
The Sonoma Developmental Center in Eldridge is one of five
dreds of cases of abuse and unexplained
state-run institutions for the developmentally disabled.
injuries, almost none of which have led to
arrests, California Watch has reported in a series of stories this year. The Office of Protective Services has failed to collect physical evidence in numerous potential violent crime cases.
And in the three dozen cases of sexual abuse, internal records reveal that patients suffered molestation, forced oral sex and vaginal lacerations. But for years, the state-run police force has moved so
slowly and ineffectively that predators have stayed a step ahead of law enforcement or abused new
victims, records show.
In response to reporting by California Watch, state lawmakers in August ordered the California
State Auditor to examine the force’s handling of criminal investigations and overtime spending. Gov.
Jerry Brown signed two laws that require the centers to notify outside law enforcement and Disability Rights California, a protection organization, of alleged patient abuse and certain serious injuries.
The state Department of Developmental Services operates the centers and the police force. Terri
Delgadillo, the agency’s director, said Friday in a written statement that the measures improve patients’ safety.
“The department welcomed the passage and signing of SB 1051 and SB 1522, that will further
ensure developmental center investigators and outside law enforcement agencies work more collaboratively to investigate unexplained injuries or allegations of abuse,” Delgadillo wrote.
It is unclear how prepared, or willing, local city police and sheriff’s departments are to shoulder
the additional caseload from the centers. Local law enforcement agencies across the state have long
deferred allegations of abuse at the centers to the Office of Protective Services.
Sonoma County Sheriff Steve Freitas could not be reached for comment on Friday.
Going forward, deGiere said the onus should be on outside police agencies to head up investigations of crimes against developmental center patients.
“If they don’t get involved, it’s because they choose not to get involved,” he said, “not because they
can’t.”
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RESULTS
DECEMBER 12, 2012
State threatens to shut down disability
center amid patient abuse
Sonoma Developmental Center loses certification, federal funding
By Ryan Gabrielson
The Bay Citizen
http://bit.ly/BrokenShield-State-threatens-to-shut-center
T
he state’s largest board-and-care center for the severely disabled lost its primary license to
operate today, after repeatedly exposing patients to abuse and shoddy medical care.
State regulators cited the Sonoma Developmental Center, which houses more than 500
patients, for dozens of cases where patients were put at risk of injury or death. In issuing
the citations, the state moved to shut down a major portion of the century-old institution.
The action comes after a series of stories this year from California Watch, sister site of The Bay
Citizen, documenting failures by the Office of Protective Services, an internal police force established
specifically to protect and serve patients at these board-and-care centers. The police force has failed
to perform basic tasks associated with crime investigations. In particular, the Sonoma center had
evidence of a dozen sexual assaults but police investigators failed to order a single hospital-supervised examination for the alleged victims. Those reported assaults represent a third of the 36 documented cases of sexual abuse and molestation in the past four years at the state’s five developmental
centers.
The loss of state certification in Sonoma means California taxpayers will lose tens of millions of
dollars in federal funding that is dependent on assurances the facility is properly managed. Critically,
it raises questions about how to care for hundreds of patients with cerebral palsy, mental retardation
and severe autism if the center closes. Most of the patients at the Sonoma center are unable to live
with their families or in group homes.
The state Department of Developmental Services is appealing the revocation, which was announced by state health officials who have regulatory control over the facility. The facility will remain
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operating during the appeal.
The state Department of Public Health
moved to sanction the Sonoma center
after it visited the facility in late November and early December and “documented
incidents of abuse constituting immediate
jeopardy, as well as actual serious threats
to the physical safety of female clients in
certain units.”
Terri Delgadillo, director of the developmental services department, which has
a budget of $4.5 billion, said state officials
The
Sonoma
Developmental
Center
in Eldridge is one of five
are acting to make changes.
state-run institutions for the developmentally disabled.
“We are contacting our residents’
families to assure them of our continued commitment to making improvements,” Delgadillo said in a
written statement. “We are moving quickly to fix this center and protect our residents.”
The department announced it was putting Frank Parrish, assistant chief of the California Highway
Patrol, temporarily in charge of the Office of Protective Services’ unit at the Sonoma center. The highway patrol “is in the process of evaluating the issues to ensure the delivery of appropriate services,”
the department said in a release.
The move does not impact the detectives and patrol officers operating at the state’s other four
developmental centers.
For some critics of the Office of Protective Services, installing new leadership with a strong law
enforcement background is a welcome change. For decades, state officials have hired police chiefs
with little or no experience investigating crimes.
“It’s a whole lot easier for someone who already knows how to do law enforcement, who knows
how to be a good investigator, to learn the idiosyncrasies of working with that client base,” said
Thomas Simms, a retired police chief and former California Department of Justice consultant who audited the Office of Protective Services in 2002. “You can’t take the in-house people ... and make them
good investigators.”
The state has already moved to make changes at the developmental centers, including hiring an
outside monitor to help oversee retraining of officers. The Legislature ordered a thorough audit of
the facilities, and Gov. Jerry Brown has signed two laws to strengthen oversight of the facilities. One
requires the centers report alleged sex assaults against patients to outside law enforcement. The
other requires that the Office of Protective Services chief have “extensive management experience
directing uniformed peace officer and investigation operations,” the law states.
The state is targeting the facility’s apparent inability to properly care for about 300 patients who
aren’t bedridden – the so-called intermediate care patients. An additional 200 patients under skilled
nursing supervision were not affected by the sanctions issued today.
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For the Sonoma center, the penalty would cut off reimbursements that cover about half of its
$160 million annual budget. Finance records show that the Medi-Cal program pays more than $6
million a month for patient care at the Sonoma center.
The 90-member Office of Protective Services force was created decades ago to patrol California’s
five developmental centers, which are in Los Angeles, Tulare, Riverside, Orange and Sonoma counties. The facilities house about 1,600 patients, many of them so severely disabled they cannot speak.
In a report issued in August, state regulators repeatedly faulted the Office of Protective Services
for inadequate investigations in alleged crimes against patients.
Since 2009, patients at developmental centers have accused their caregivers of sexual abuse 36
times. Documents show that patients suffered molestation, forced oral sex and vaginal lacerations,
but the Office of Protective Services moved so slowly and ineffectively that predators stayed ahead of
law enforcement or abused new victims.
Many the complaints of sexual abuse at the facilities have occurred at Sonoma. Twelve of the 36
abuse cases since 2009 – all identified by patients rights advocates as needing thorough investigation
– occurred at Sonoma. In every case, the Office of Protective Services failed to order a sexual assault
examination known as a rape kit, often the only way to gather physical evidence in sexual assault
cases.
Statewide, the Office of Protective Services referred just three sex crime cases to county district
attorneys for prosecution since 2009, said Leslie Morrison with Disability Rights California. In those
cases, officers did not collect any physical evidence to determine whether crimes occurred. Just one
of those cases led to an arrest.
Records show the Office of Investigative Services has failed to thoroughly investigate sexual assault cases at Sonoma for years. One of the most disturbing assaults involved a former patient named
Jennifer who suffered from bipolar disorder and severe mental retardation.
In 2006, caregivers at the Sonoma center found bruises shaped like handprints covering Jennifer’s breasts, suggesting an assault. She accused a staff member of molestation, but the Office of
Protective Services opened an investigation without ordering a rape kit examination.
A few months later, Jennifer was pregnant. By then, her alleged attacker had fled the country.
In another case from early 2000, a female patient at the Sonoma center accused a male caregiver
of sexually assaulting her during a bath. The institution then assigned two men to bathe the patient,
even though the facility employed many female caregivers. Both caregivers allegedly raped her
during bathing. Police made no arrests in the case.
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JANUARY 18, 2013
State disability center
forfeits funding over abuse
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Center-forfeits-funding
C
alifornia’s largest board-and-care center for the developmentally disabled will surrender
more than $1 million a month in federal funding for failures to protect patients from abuse
and provide quality medical care, state officials announced today.
In December, state regulators cited the Sonoma Developmental Center for numerous
violations that put patients with cerebral palsy and intellectual disabilities at risk of serious injury
and death. Regulators have threatened to close a major portion of the century-old institution, now
home to more than 500 patients.
The state Department of Developmental Services, which operates the institution, this week
agreed not to seek reimbursement from the Centers for Medicare & Medicaid for services provided
at its most troubled residences. The state singled out four out of 10 residential units at the Sonoma
facility.
“While there are deficiencies in the management, training, and staffing in the Sonoma (intermediate care) units generally, the problems are more significant in Corcoran, Lathrop, Bemis and Smith,”
Terri Delgadillo, director of the state’s developmental services department, wrote to the federal
agency Thursday.
The department “is committed to fixing the problems in all of the units, but addressing the problems in these four units will take additional time,” she said.
Roughly half of the center’s revenue comes from federal reimbursement. The loss of certification
in Sonoma means California taxpayers will lose millions of dollars in federal funding that is dependent on assurances the facility is properly managed.
The action comes after a series of stories this year from California Watch documenting failures
by the Office of Protective Services, an internal police force established specifically to protect and
83
serve patients at these board-and-care centers. The police force has failed to perform basic tasks
associated with crime investigations.
In particular, the Sonoma center had evidence of a dozen sexual assaults, but police investigators failed to order a single hospital-supervised examination for the alleged victims. Those reported
assaults, all from the Corcoran unit, represent a third of the 36 documented cases of sexual abuse and
molestation in the past four years at the state’s five developmental centers.
In a press release, the state Department of Public Health said it “will closely monitor each residential unit to ensure that all clients are protected from harm and the delivery of healthcare to this
vulnerable population complies with both federal and state requirements.”
The state Department of Public Health regulates California’s five developmental centers, which
house 1,600 patients in Sonoma, Tulare, Los Angeles, Orange and Riverside counties.
Sonoma has gone through two executive directors the past year; it is now looking for a permanent replacement. State officials have contracted with outside experts to upgrade care at the institution.
“The well-being of our residents at Sonoma Developmental Center is a top priority and the department has made critical improvements in the (intermediate care facility), but significant work still
needs to be done,” Delgadillo said in a written statement today.
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DECEMBER 21, 2012
Moving the needle
California Watch
http://bit.ly/BrokenShield-Moving-the-needle
INTERACTIVE TIMELINE
http://bit.ly/BrokenShield-Moving-the-needle
87
OTHER STORIES
88
FEBRUARY 23, 2012
State agency’s police chiefs
lack law enforcement experience
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Police-chiefs-lack-experience
S
tate officials hired a former labor negotiator and government
Where It Ran:
manager who lacked basic law enforcement training to overThis story also appeared
see investigations at California’s institutions for the developin the following news outlet:
mentally disabled, records and interviews show.
• The Press-Enterprise
For more than a year, during 2007 and 2008, Nancy Irving was the
police chief of the Office of Protective Services, which oversees institutions in Los Angeles, Orange, Sonoma, Riverside and Tulare counties. These centers, which house
about 1,800 severely disabled men and women, have been the scene of hundreds of abuse cases over
the past six years.
Yet California’s Commission on Peace Officer Standards and Training has no record showing that
Irving took legally required coursework that would qualify her as a law enforcement officer, officials
there said.
In nearly 36 years at the Department of Developmental Services, Irving worked in labor relations
and in various staff and management positions.
Irving’s lack of experience in law enforcement highlights a persistent theme at the Office of Protective Services, a little-known police agency that reports to the Department of Developmental Services in Sacramento. The agency has about 90 officers, many with limited training or lacking outside
law enforcement experience.
The state attorney general’s office, in a 2002 audit, directed the department to “recruit and hire
a highly qualified and experienced law enforcement candidate” for police chief. Yet, since the audit,
the department has in many cases done just the opposite.
“It really exposed a complete lack of infrastructure and control command and accountability,”
89
said former state Assemblywoman Sally
Lieber, a Mountain View Democrat, who
introduced a disability rights bill in 2008
that included provisions requiring the governor’s office to choose the developmental
centers’ police chief.
Lieber’s bill died in the Senate Appropriations Committee over cost concerns as
California’s financial woes mounted. The
Department of Developmental Services
also lobbied hard against the bill, she said,
MONICA LAM/CALIFORNIA WATCH arguing that its police force worked well.
Former Assemblywoman Sally Lieber, a Mountain View
The current police chief, Corey Smith,
Democrat, said a 2002 audit of the Office of Protective Services
spent almost all of his 19 years with the
“exposed a complete lack of infrastructure and control command and accountability.”
Department of Developmental Services as a
firefighter at the agency’s Sonoma facility. Like his two predecessors, Smith has less law enforcement
experience than most of the patrol officers below him.
None of the past three police chiefs at the Office of Protective Services have worked for another
law enforcement agency. And two of the force’s four police commanders have no experience working
on criminal investigations at other police or sheriff’s departments, records show.
Terri Delgadillo, director of the Department of Developmental Services, defended the hires, saying
the years spent working at the centers are just as crucial as years spent building criminal cases. Most
patients – called “consumers” by the state – are emotionally vulnerable and intellectually limited.
Their disabilities make it hard to clearly communicate.
“Having familiarity with the consumers that we serve and the population is very important,” she
said.
Patricia Flannery, who oversees operations at California’s developmental centers, said in a written statement that the Office of Protective Services has “undergone routine audits from POST and has
not been found in violation of the penal code requirements” in the Irving case.
But records from the Commission on Peace Officer Standards and Training show their own auditors did not check Irving’s certification status, and they have no record of her ever being listed as
police chief.
Flannery said Irving was appointed to police chief on an interim basis because of her experience
as a professional standards manager in the Sacramento headquarters, where Flannery said she supervised special investigations and internal affairs.
While she was police chief at the Office of Protective Services, “sworn law enforcement supervisors were identified to provide consultation to Ms. Irving as needed,” Flannery wrote. Irving, who
retired from state service in 2011, did not respond to interview requests.
The current police chief, Smith, ascended to his position after a Tulare County grand jury indict90
ed his predecessor, Jeff Bradley, on embezzlement charges in 2010 for his alleged involvement in
an overtime fraud scheme. A judge threw out the charges last year, saying investigators violated his
rights under the California Peace Officers’ Bill of Rights.
The office of state Attorney General Kamala Harris said it was reviewing the case and considering
whether to pursue new charges on the alleged overtime fraud. Meanwhile, Bradley is fighting to be
reinstated. He referred questions to his attorney, who did not return several calls and e-mails from
California Watch.
Bradley had landed his first developmental center job as a security guard in 1998, and he moved
up the ranks at the Porterville Developmental Center in Tulare County until the department moved
him to Sacramento to become chief in 2008.
Before Irving took over in mid-2007, the developmental services department borrowed officers
from the California Highway Patrol to work as the centers’ police chief. Janice Mulanix, an assistant
chief for the state patrol, said she spent two years leading the Office of Protective Services, more
often handling administrative tasks than criminal investigations.
Phyllis McDonald, an expert in police operations at Johns Hopkins University, said police chiefs
need first-hand knowledge of how criminal investigations operate, what can go wrong and the best
practices to keep them on track. She said hiring a police chief with no law enforcement training
shows a disregard for the police force.
“You just can’t walk in off the street and do this,” she said. “As a firefighter, you don’t have to be
so concerned about constitutional rights, and you don’t have to be so concerned about state laws or
local ordinances.”
San Diego County Sheriff Bill Gore said experience doing police work should be a prerequisite for
a police chief. Gorewas an FBI agent for 32 years before he became sheriff, working in counterterrorism and investigating all manner of violent crimes. Even still, he said, “there are times I wish I had
street experience” with a local police department.
Detectives lack experience, qualifications
In the 2002 audit, the California attorney general’s office concluded that investigators with the
Office of Protective Services “lack the training, experience and proper equipment to competently
preserve and collect crime scene evidence.”
Crimes at the centers can be more complex to solve than those committed outside. Because of privacy laws, there are no video cameras installed within the institutions. Victims might not be capable
of communicating what happened.
Instead of beefing up its force to handle these complex cases, the department employs detectives
with little to no qualifications in law enforcement, including nurses and psychiatric technicians.
Like Smith, more than a third of the 91 police personnel at the Office of Protective Services had
no prior criminal justice experience before joining the force, according to records from the California
Commission on Peace Officer Standards and Training.
91
The institutions’ investigators become certified police officers after finishing a months-long
course in basic procedures for conducting an investigation. The curriculum includes 52 hours on report writing and 72 hours on firearms and chemical agents, even though developmental center police
do not carry guns.
A dozen additional hours of instruction are devoted to crime scene evidence. Investigating sex
offenses receives four hours, a single lecture. The office largely operates without rules governing its
criminal justice work – more than half of its law enforcement manual is unwritten.
When the police force has had key command staff openings, it has tended to look to longtime employees serving in other state agencies.
Lindajo Goldstein, a Lanterman Developmental Center detective since 2007, came from the California Department of Social Services, where she worked as an inspector, according to personnel and
state certification records. Social services investigations examine regulatory violations and do not
build criminal cases.
Fairview Developmental Center’s police commander, Michael Jackson, joined the Office of Protective Services a year ago after 18 years as a social services department inspector, personnel records
show. Before that, he worked for the California Youth Authority, now known as the California Division
of Juvenile Justice.
Smith was moved from his firefighter duties to police commander of the Sonoma Developmental
Center in 2005. He worked more than a year in that job without the required training on basic criminal investigations; he was certified by the Commission on Peace Officer Standards and Training in
2007.
The chief’s limited law enforcement experience has troubled the rank and file within the Office of
Some have suggested the department is too insular and draws too frequently from its own ranks.
Greg Wardwell, a sergeant at Sonoma for 20 years before he retired in March, said a veteran police
chief from an outside department would be more likely to challenge bad practices throughout the
force.
He or she “would look at that and say, ‘Well, that’s crazy. You can’t function that way. You’ve got to
do this, this and this to make it better,’ ” he said.
One of the police union’s leading complaints is the department’s failure to follow the attorney
general’s audit report, which detailed major shortcomings in how the police department operated.
A former labor leader questioned why Smith was appointed.
“Why he got there, I have no idea,” said Lorenzo Indick, a patrolman at the Lanterman and former
president of the Hospital Police Association of California, the union representing developmental center officers. “Why don’t they put in somebody from an outside organization with a strong background
in law enforcement?”
CIR intern Emily Hartley contributed to this report. This story was edited by Robert Salladay and
Mark Katches. It was copy edited by Nikki Frick.
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FEBRUARY 24, 2012
Veteran detectives identify
death investigation’s key mistakes
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Veteran-detectives-ID-mistakes
C
alifornia Watch asked two veteran homicide detectives to review hundreds of pages from
the investigation into the death of patient Van Ingraham, who was critically injured at the
Fairview Developmental Center in Costa Mesa. Al Cruise of the Seattle Police Department
and Mark Czworniak of the Chicago Police Department – with a combined 51 years of experience in law enforcement – found six critical errors in the 2007 case:
Fairview police did not secure Ingraham’s bedroom to protect evidence.
The institution police, the Office of Protective Services, appear to have treated the case as an
accident and did not prevent Fairview staff from walking through and even cleaning the room. “It is
my belief that the initial responders did not recognize the scene as a potential crime scene,” Cruise
wrote. “It would be difficult for me to opine as to whether that was caused by incompetence, inexperience or influential situational and environmental factors at the scene.” Further, Czworniak wrote
that police should have documented how the room looked by taking photographs. “In today’s digital
era, it should always be done,” he wrote.
Fairview police failed to launch a full investigation upon learning Ingraham had suffered a broken neck.
Cruise wrote that investigators appear to have failed “to recognize the potential criminality of the
incident,” and therefore did not see cause to gather physical evidence, secure medical records and
question witnesses. Police might have overlooked the case because injuries are common at institutions, Czworniak theorized.
93
Investigators waited until five days after the injury to begin witness interviews.
The delay might have undermined the questioning, Czworniak wrote. “It gave several people
the opportunity to speak about the events.” Cruise agreed, adding that Fairview police had enough
information “several days prior to the initiation of the interviews to indicate a strong potential for a
crime.”
Officers did not collect physical evidence from the scene.
The first time a Fairview investigator considered gathering physical evidence was on June 13,
2007, the case file shows, seven days after Ingraham was found with a broken neck. “Seven days is a
long time to expect to recover any evidence, especially in a room that was not sealed from the onset,” Czworniak wrote. “In hindsight that seems to be irresponsible and negligent,” Cruise wrote. In
addition to searching Ingraham’s room, Cruise wrote that investigators should have requested DNA
samples and fingerprints from people who had come into contact with Ingraham before his death.
“Even if there is no evidence to compare to, the resulting dialog when such a request is made can be
telling,” he wrote.
The caregiver last seen with Ingraham altered records from the morning of the injury, but police did not investigate the changes.
Johannes Sotingco, a caregiver at Fairview, changed entries for Ingraham in the sleep log within
48 hours of the patient’s injury. The alteration might have been simply to correct the record, the detectives wrote. Regardless, police should have investigated the matter. “Any altering of records, especially after such an incident, is cause for concern,” Czworniak wrote.
Investigators omitted from their report a biomechanical expert’s finding that Ingraham’s death was “likely a homicide.”
Thay Lee, a biomechanical expert at UC Irvine, assessed evidence in the case at the request of the
Orange County sheriff-coroner and determined that another person probably caused Ingraham’s broken neck. “It is undoubtedly comprehensive and compelling,” Cruise wrote of Lee’s report. But Fairview police did not include any of Lee’s findings in their case file. “This may be because they believed
Thay Lee’s assessment had no merit,” Czworniak wrote. “Personally I think it’s better to include as
much information when constructing a final report, than to ‘pick and choose,’ what goes in. This is
because of exactly what happened down the road with this investigation. Someone started reviewing
it and now, because information was excluded, it has an appearance that things were being covered
up.”
This story was edited by Robert Salladay and Mark Katches. It was copy edited by Nikki Frick.
94
FEBRUARY 24, 2012
Unexplained deaths
behind closed doors
By Monica Lam and Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Unexplained-video
VIDEO
H
undreds of thousands of Californians suffer from developmental disabilities like
cerebral palsy and severe autism. Some of the most severely disabled are cared
for at state-run facilities with around-the-clock supervision. But while the state
spends about $300,000 a year on each patient, a months-long investigation has
uncovered a lack of accountability for reported abuse at the centers.
http://bit.ly/BrokenShield-Unexplained-video
95
JUNE 7, 2012
State withholds details
on developmental center slaying
By Ryan Gabrielson and Joanna Lin
California Watch
http://bit.ly/BrokenShield-State-withholds-details
I
n early 2009, a 16-year-old girl with mental retardation was
Where It Ran:
slain at the Fairview Developmental Center in Orange County.
This story also appeared in the
The state-operated institution didn’t tell the public about the
following news outlets:
deadly assault.
• North County Times
After three years, the California Department of Public Health
penalized Fairview in April for its role in the patient’s death, issuing
a written citation and a $10,000 fine for failing to protect a patient
from harm. The developmental center is required under state law to prominently display the citation
for the public to see.
But the institution couldn’t produce a copy last week, administrators told a California Watch reporter who attempted to review the citation at Fairview.
The state Department of Developmental Services on Monday physically displayed the citation at
the institution, one of five board-and-care centers for roughly 1,800 patients with cerebral palsy and
other intellectual disabilities.
However, the department initially blacked out nearly every word. The fragments of visible
text call the death an “an unusual occurrence.” On Tuesday night, state officials removed some of the
redacted sections, revealing information about when unnamed center employees began or ended
work the night of the murder.
The redactions black out details of how a teenage patient was strangled.
State public health officials contend the document must be redacted under the California Welfare
and Institutions Code to protect patient confidentiality.
Sen. Mark Leno, D-San Francisco, disagreed with that legal interpretation.
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The Department of Developmental Services initially blacked out nearly every word of the citation against Fairview
Developmental Center. It later revealed excerpts of the document.
“We’re talking about crimes; we’re not talking about medical services,” said Leno, who is sponsoring legislation this session regarding violent crimes at developmental centers. “This is an abuse of
state law.”
Fairview’s penalty is for regulatory violations on Feb. 22, 2009, according to a state database of
enforcement action, which matches the date and time of the slaying.
Late in the evening on that date, someone at Fairview assaulted Danisha Smith. Smith’s killer put
a towel over her head and tied it off with a cord, blocking oxygen from Smith’s brain, according to
her death certificate and interviews with law enforcement officials and Smith’s relatives. An assailant
repeatedly stabbed her in the chest with a pencil.
Smith died of brain swelling the next day.
The Office of Protective Services, an in-house police force at California’s developmental centers,
conducted the criminal investigation into the killing. The state Department of Developmental Services runs the force.
The Costa Mesa Police Department had jurisdiction over the crime but deferred responsibility to
Fairview’s detectives.
In a series of stories in February, California Watch reported that detectives and patrol officers at
the institutions routinely fail to conduct basic police work, even when patients die under mysterious
circumstances. The facilities have documented hundreds of cases of abuse and unexplained injuries,
almost none of which have led to arrests.
97
Fairview police arrested another patient, Latina Ford, then 15, in Smith’s death. The Orange
County District Attorney’s Office charged Ford with murder in October 2010, the criminal court file
shows.
She has pleaded not guilty. The courts ruled Ford incompetent to stand trial; the state is holding
her at the Porterville Developmental Center.
Records from a civil lawsuit filed in February 2010 by Smith’s family indicate Ford was Smith’s
roommate.
In response to California Watch’s stories, lawmakers have introduced two bills, SB 1051 and SB
1522, that would require the state to notify outside law enforcement agencies and disability rights
groups when it receives allegations of violent crimes against patients. SB 1522 – which Leno sponsored – is intended to direct investigation of serious crimes at developmental centers to outside
police agencies.
The bills have passed the state Senate and await hearings in the state Assembly.
Leno said the public should receive information about such violent crimes. “We need to learn
more to see if there’s need for further legislative attention,” he said.
The state Department of Public Health, which licenses and regulates developmental centers, first
reported Smith’s death this year, issuing a “class A” citation on April 19. To earn a class A citation,
a facility must put a patient at risk of serious harm or death; class AA citations are for incidents
where regulators determine a facility is directly responsible for a death.
Developmental centers must post class A and AA citations in “an area accessible and visible to
members of the public” for 120 days, states California Health and Safety Code 1429.
A California Watch reporter visited Fairview on May 30. In Fairview’s administration building
lobby, the institution’s only public space, a state workplace safety award plaque was on display but
not the citation.
When the reporter inquired about the violation record, Fairview administrators initially said
they were unsure they had a copy. They then required the reporter to file a records request with the
department’s media relations office in Sacramento.
The reporter pointed out that state law requires immediate public access. Robin Keller, Fairview’s
privacy officer, dismissed the argument and said a typical member of the public would not be aware
of the document or the law.
Fairview displayed the citation from April 19 to May 2, when a “plan of correction for the citation
had been implemented,” Nancy Lungren, spokeswoman for the state Department of Developmental
Services, said in a written statement.
The institution is posting a heavily redacted version of the record for 120 days to correct the error, Lungren wrote. It shows only excerpts regarding nurse shift change procedures and nighttime
inspections of patient quarters.
The only unobscured sentence indicating an act of violence occurred notes that an Office of Protective Services detective, who was “working overtime as a patrol officer, responded to the residence
on 2-22-09 at 2257 (10:57 PM).” The rest of the paragraph is blacked out.
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AUGUST 23, 2012
Report slams state institution
for neglect, weak oversight
By Ryan Gabrielson
California Watch
http://bit.ly/BrokenShield-Report-slams-institution
C
alifornia’s largest institution for the developmentally
Where It Ran:
disabled risks losing millions of dollars in federal funding
because of poor medical care and widespread failures to
This story also appeared in the
following news outlet:
prevent abuse and thoroughly investigate when patients
are harmed, state officials said in a confidential report.
The Department of Public Health inspection report presented a
damning indictment of the Sonoma Developmental Center, which houses more than 500 people with
cerebral palsy and other intellectual disabilities. Normally such reports are kept from the public, but
California Watch obtained a copy of the 495-page document this week.
“Individuals have been abused, neglected, and otherwise mistreated and the facility has not taken
steps to protect individuals and prevent reoccurrence,” the report said. “Individuals were subjected
to the use of drugs or restraints without justification. Individual freedoms have been denied or restricted without justification.”
According to the report, the board-and-care institution must immediately upgrade patient care
and abuse investigations to keep its federal certification. Without federal approval, the Sonoma center would lose reimbursement from the Medicare and Medicaid programs – crippling its budget and
placing an even greater burden on the state.
For the Sonoma center, the penalty would cut off reimbursements that cover about half of its
$160 million annual budget. Finance records show that the Medi-Cal program pays more than $6
million a month for patient care at the Sonoma center.
State regulators repeatedly faulted the in-house police force, the Office of Protective Services, for
inadequate investigations.
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“The facility failed to ensure evidence that all
alleged violations and injuries of unknown origin
were thoroughly investigated,” the report said.
The investigations “lacked significant and/or pertinent information to minimize recurrence.”
“It leads one to believe that, in certain circumstances, it’s a lawless environment,” state Sen.
Mark Leno, D-San Francisco, said of the inspection report.
In a series of stories this year, California
Watch has reported that detectives and patrol
The Office of Protective Services is an in-house police
force at California’s developmental centers.
officers at the institutions routinely fail to conduct basic police work, even when patients die under mysterious circumstances. In case after case,
detectives and officers have delayed interviews with witnesses or suspects – if they have conducted
interviews at all.
The force has also waited too long to collect evidence or secure crime scenes and has been accused of going easy on co-workers who care for the disabled.
The state Department of Developmental Services operates five centers that house nearly 1,700
patients with cerebral palsy and other intellectual disabilities in Sonoma, Tulare, Los Angeles, Orange
and Riverside counties. California is budgeted to spend about $314,000 this year per developmental
center patient.
Terri Delgadillo, director of the Department of Developmental Services, said the department
“recognizes the action necessary to ensure the health and safety of residents at the Sonoma Developmental Center.”
“Several key changes have already been made but more must be done,” Delgadillo said in a statement. “Both the executive director and the clinical director have been replaced. Several other employees have been terminated or disciplined and investigations continue which could result in additional actions.”
The report includes the Sonoma center’s plans to correct its violations, which include hiring additional caregivers and retraining employees.
Regulators have not decertified a center for more than a decade. The state Department of Public
Health, which licenses and regulates the institutions, decertified the Agnews Developmental Center
in San Jose for patient neglect in 1999. Agnews closed two years ago.
In September, someone assaulted a dozen patients with a stun gun, an incident first reported by
California Watch last month. The victims suffered severe burns on their backs, buttocks, arms and
legs.
The Office of Protective Services received a tip that a caregiver named Archie Millora had abused
patients during his shifts. Officers found a Taser in Millora’s car, along with a loaded handgun, but did
not make an arrest in the assaults.
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“Several key
changes have
already been made
but more must be
done. Both the
executive director
and the clinical
director have been
replaced. Several
other employees
have been
terminated or
disciplined and
investigations
continue which
could result in
additional
actions.”
— Terri Delgadillo,
director of the
Department of
Developmental
Services
Detectives continued to delay or overlook abuse cases in
recent months, according to the report.
On May 25, Rue Denoncourt, a psychiatric technician, took
a female patient into a bathroom and exposed his genitals.
Another employee reported the abuse and the Sonoma County
Sheriff’s Department arrested Denoncourt for lewd conduct;
he pleaded no contest earlier this month and was sentenced to
eight months in prison.
The Office of Protective Services waited weeks to review
patient records to determine whether others living on the unit
where Denoncourt worked showed signs of abuse, the report
shows.
In fact, there was another victim.
Denoncourt, who worked at the center 27 years, admitted
to sheriff’s deputies that he had also abused the victim’s roommate, forcing the second female patient to touch him while he
masturbated, the report said.
Three weeks earlier, on May 4, caregivers discovered bruises
on both women, including an injury to a patient’s left breast.
State regulators found records showing the patients had not attended a Cinco de Mayo event at the center the previous evening
and that Denoncourt was working on their unit at the time.
But the Office of Protective Services did not investigate
whether Denoncourt was alone with the victims, according to
the report.
The state Assembly yesterday unanimously approved legislation, SB 1051, to require the centers to report certain abuse and
injury cases to outside law enforcement and advocacy organizations for the disabled. The bill, which now goes to Gov. Jerry
Brown, also sets minimum qualifications for the Office of Protective Services’ chief.
Leno has sponsored legislation, SB 1522, to mandate that
centers notify outside law enforcement in cases of patient death,
sexual abuse, and assaults with a deadly weapon or severe
injury, and unexplained broken bones. The state Assembly is
expected to vote on SB 1522 today.
The Sonoma center’s nursing services were also faulted,
most notably for unsafe practices when placing feeding tubes
and failure to follow policies regarding how to read vital signs
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and assess patients’ pain.
As part of the improvements, the report said center employees would receive training on an array
of issues. One of them is handling of patients with pica, a disorder that causes people to ingest things
that are not food.
On Nov. 22, patient Jean Erquiaga consumed part of a “soft knit shirt,” according to an internal
incident report. Erquiaga had long been diagnosed with pica, swallowing disposable diapers in years
past, a concern caregivers were aware of.
Erquiaga began vomiting and, five days after eating the fabric, the center took the patient to Sonoma Valley Hospital, the internal record shows. Doctors operated on Erquiaga to remove material
that had formed a bowel blockage.
Sonoma center records show Erquiaga died of respiratory failure on Dec. 1.
The Office of Protective Services opened an investigation nearly six weeks later, on Jan. 13. If
center detectives intended to investigate potential criminal negligence, the caregiver responsible
for protecting Erquiaga was already gone, the records show.
“This individual had been working towards transferring to Coalinga (State Hospital),” a Sonoma
administrator wrote, “and is now employed there.”
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DECEMBER 21, 2012
In the Wrong Hands
California Watch
http://bit.ly/BrokenShield-Downloadable-eBook
eBook
California Watch and
the Center for
Investigative
Reporting compiled
the main Broken Shield
text stories, photos,
videos and interactive
elements into a
15,000-word eBook
published in December
under the title “In
the Wrong Hands.”
The eBook, our first,
augmented and retold
the investigation as a
single, comprehensive
narrative making the
information accessible
in a different way and
to more readers. It
is available as a free
download through
the Apple store and
also available through
Amazon Kindle.
http://bit.ly/BrokenShield-Downloadable-eBook
103
COMMENTARY
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Fewer and fewer news outlets can muster the resources to prepare stories like
the long, painstakingly reported one about the abuse and rape of a mentally
disabled patient published Thursday by the Center for Investigative Reporting’s
California Watch. But as hard as it may be to muster such resources, it’s even
harder to get people to read such a difficult tale when you’re through.
Readers “don’t want to face those conditions,” said Ryan Gabrielson, who reported and wrote the story about “Jennifer,” a former patient at the Sonoma
Developmental Center in California. “I think there’s a lot of fear in it. They don’t
know how to solve it.”
Such stories, CIR senior multimedia producer Carrie Ching agreed, “can be very
powerful for the viewer to absorb.”
A previous Gabrielson story in California Watch’s year-long “Broken Shield”
story was likewise a “tough sell” for readers, Ching said, so she and Gabrielson
produced a video to accompany the story of Van Ingraham, a severely autistic
man whose suspicious death at a different California institution was sloppily
investigated by police.
“Jennifer”‘s story was different from Ingraham’s — she’s still alive, and her family
is raising the child who resulted from her rape. They’re not identified in Gabrielson’s story, so making a video that would serve as an alternate way in to the
story would be tricky. “We decided early on against doing an animated version
because the subject matter was so heavy,” Ching said. They settled on a subtly
animated graphic novel-like approach with illustrations by Marina Luz. “It just
makes it a little more digestible for viewers,” Ching said. “It doesn’t overwhelm
them as much.”
Gabrielson’s text story opens with a hard news lede: “Patients at California’s
board-and-care centers for the developmentally disabled have accused care105
takers of molestation and rape 36 times during the past four years, but police
assigned to protect them did not complete even the simplest tasks associated
with investigating the alleged crimes, records and interviews show.”
The video, on the other hand, opens by introducing you to “Jennifer”: “I think
Jenny was 6, 7, 8 months old; I could see something wasn’t right, I knew it,”
says an actor reading a transcript of a Gabrielson interview with “Jennifer”‘s
mom. That feeling of something not being right pervades the creepy yet beautiful
video.
Gabrielson — who won a Pulitzer for local reporting in 2009 while at the (Mesa,
Ariz.) East Valley Tribune — said he and Ching worked on the script for the video over the five months he reported the story. “It wasn’t siloed at all,” he said. He
kept Ching up to date on his reporting, and every script she wrote went through
Gabrielson and his editor. “I think she did a really beautiful job of working within
the restrictions,” he said.
The story ran in the San Francisco Chronicle, in the Fresno Bee, in The Daily
Beast, and in the (Santa Rosa, Ca.) Press Democrat, said Meghann
Farnsworth, CIR’s senior manager for distribution and online engagement.
Farnsworth also rolled out the story Thursday afternoon in a series of tweets
like this one:
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“The goal isn’t necessarily for people to retweet but to follow along and talk with
us,” Farnsworth said, which is a “different goal” from the organization’s usual
approach to Twitter engagement.
A hashtag, #brokenshield, did get a little traction on Twitter Thursday.
CIR ran an explainer with links to organizations readers can contact if they want
to learn more, plus an infographic. It also took an image from the video and
made it the cover image on California Watch’s Facebook page, Farnsworth said.
“We do work to make sure regardless of what platform you’re on we make sure
that our story is there,” Farnsworth said.
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The journalists at California Watch have created a unique animation to visually present the story
of a source that couldn’t be identified.
The video is part of a series of reports on abuse allegations and mysterious deaths at California’s
homes for the developmentally disabled. Lead reporter Ryan Gabrielson found evidence that the
state’s Office of Protective Services, charged with keeping 1,600 residents at five different homes
safe, often failed to sufficiently investigate allegations, even when faced with an unexplained
death. As Gabrielson poured through 2,000 pages of state documents, one case rose to the top.
“Right in the middle of it was a story of a female who had been raped and impregnated,” says
Gabrielson. The woman’s case was one 36 accusations of rape or molestation made by residents of the
state-run homes at the hands of their caretakers in the last four years. The California Watch team
wanted to tell her story visually, knowing that they could never have Jennifer speak for herself on
camera. “Animation about rape sounds risky,” Gabrielson says. “A lot of news organizations would be hesitant to travel down that path. But I’m so glad we did.”
Before Gabrielson interviewed Jennifer’s mom, he and Senior Multimedia Producer Carrie Ching
consulted to ensure he got what they both needed. In the end, Jennifer’s mother did not want to
be identified either by name or by voice, piling on to the already challenging multimedia project. 108
So they settled on a graphic narrative with simple drawings and minimal movement.
“This approach with a graphic novel style was new for us,” explains Ching. They didn’t think a fully animated piece would set the right tone for the delicate subject matter.
The team also wanted to make Jennifer as relatable as possible. Gabrielson has learned from
working on this year-long reporting project that the public has a hard time digesting stories about
the disabled.
“They don’t want to face it. They don’t want to think about it,” says Gabrielson.
An actor reads excerpts from Gabrielson’s interview with Jennifer’s mom. The piece focuses on
Jennifer’s story, not her disability. Its visual simplicity allows the story to speak volumes. You can
see “In Jennifer’s Room” for yourself below.
“That video, I can’t believe the outrage that it produced. I can’t do that with the written word,”
says Gabrielson, who narrates the video.
It even brought their entire newsroom to tears. I asked Ching if she thinks multimedia journalism has arrived. Unlike five years ago, she now
believes it’s on everyone’s radar. Still, many newspapers lack a strong multimedia presence, she
says.
“Most of our video hits online don’t come from newspaper websites. They come from the big
online publications,” explains Ching. She puts The Huffington Post and The Daily Beast in that
category. Most of the views of “In Jennifer’s Room” came from Jezebel.com.
California Watch has a list of all the publications where Gabrielson’s story ran (in the right column). Of the six print outlets that ran the story on their websites, only one – the San Francisco
Chronicle – also published the accompanying animation. Perhaps further evidence that acceptance of multimedia journalism has a ways to go.
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The California Watch stories on patient deaths and suspicious injuries at
state facilities caring for the developmentally disabled are shocking and disheartening. We look forward to pending official investigations triggered by
this reporting. But what’s needed is immediate action by Gov. Jerry Brown.
The picture painted by the series is too grim to allow those in charge to
remain in charge until it is known whether they “let people get away with
murder,” in the words of Carol Liu, chair of the state Senate Human Services Committee.
California Watch, an investigative journalism group, found that since
2006, there have been 327 substantiated patient-abuse cases and 762 unexplained injuries at facilities run by the state Department of Development
Services, yet few prosecutions. These cases involve patients with severe
autism, cerebral palsy or other intellectual disabilities – individuals who are
often unable to articulate complaints about their treatment. So the figure of
abuses could be on the low side.
But even these numbers make it seem like abuse is common, given that
the five state board-and-care institutions for the developmentally disabled
– in Orange, Los Angeles, Riverside, Tulare and Sonoma counties – only
have 1,800 patients, whose conditions would suggest there isn’t much turnover.
The most haunting part of California Watch’s reporting dealt with
Van Ingraham, who at age 8, in 1964, was sent by his La Mesa family to
the Fairview Developmental Center in Costa Mesa because of his severe
autism. In June 2007, Ingraham, then 50, was found dead on the floor of his
room, having suffered a broken neck and crushed spinal cord. A supervisor
had witnessed a caregiver, Johannes Sotingco, standing over Ingraham.
According to the official record, Sotingco had been trying to clean Ingraham up after Ingraham urinated in his pants. An hour later, Sotingco reported he’d found Ingraham injured on the floor. Six days later, Ingraham died
after a relative had him removed from life support.
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Did this mystery – a patient suffering a broken neck and mangled spinal
cord while in his room – trigger a thorough investigation? Not at all. As
California Watch documented, it was cursory, and a medical expert’s conclusion that Ingraham’s death “was likely a homicide” was left out of the
case file. Instead, it was suggested Ingraham was injured falling out of bed –
even though Orange County’s chief pathologist said that was not possible.
Ingraham’s family wouldn’t buy the explanation or let the matter rest,
and in 2009 was paid $800,000 by the state to settle a wrongful-death lawsuit.
This is appalling. But more recent actions by the Department of Developmental Services also show a shake-up is needed. Officials told California
Watch they couldn’t comment on the Van Ingraham case because of “patient
privacy.” How absurd: In the name of protecting Ingraham’s privacy, the
department won’t assist journalists in getting to the truth of how he died at a
department facility.
We asked the governor’s office to comment on this. After an email backand-forth, we did hear some good news: Health and Human Services Secretary Diana Dooley said her department had “engaged the services of special
investigators” to probe the allegations. But we still think more must be done
in the short term. When a state agency is credibly accused of letting people
“get away with murder,” that demands a fuller response.
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Our society’s greatest obligation is to protect those
who cannot protect themselves - the very young, the
very old and people with profound disabilities. We
are failing in this duty.
Our state, county and local governments tolerate an
outrageous level of crime against Californians with
disabilities. Multiple studies show that more than 80 percent of severely disabled
women have been sexually abused. About 20 percent of men with disabilities
and 40 percent of women with disabilities have been sexually abused at least
10 times.
Residents of large institutional developmental centers are often nonverbal and
immobile or restrained. Their presence as easy victims and a record of lax investigations have made the centers a haven for abusers.
A recent report by California Watch detailed 36 accusations of rape and molestation in four years - and the failure of police on site to investigate or to even order
a single rape examination during three of these years.
In one case, authorities at the Sonoma Developmental Center failed to follow up
on accusations of sexual abuse, asserting that the case hinged on the testimony
of a resident with severe intellectual disabilities. Several months later, after her
accused rapist had fled the country, she was found to be pregnant.
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In the past year, the Brown administration has taken action on decade-old proposals. The law now requires the developmental centers to report all crimes to
local police departments or the state Department of Justice. Yet, despite these
changes, there has been little fundamental change in the centers’ policies.
Gov. Jerry Brown and the Legislature need to put in place a system in which the
centers’ staffs are held accountable for the safety of these vulnerable Californians.
Massachusetts offers a viable model. There an independent commission, answerable to the governor and the Legislature, is responsible for investigation,
oversight, public awareness and prevention. A single statewide force tracks cases
from investigation to referral to a local district attorney, creating a unified record
of types of abuse, location and whether charges are filed.
An independent agency would end California’s dysfunctions in which agencies
are expected to police themselves. The governor and Legislature should pursue
these commonsense steps:
-- Require peace officers in the centers to respond immediately to every crime
report and secure the crime scene.
-- Make rape exams available for every victim of sexual assault. Remove policies that hinder rape investigations.
-- Implement a system of gendered staffing, placing female staff in areas where
female residents are bathed.
-- Screen out abusers from working in the developmental centers and community services.
-- Require that citations for abuse be forwarded to the state Attorney General.
-- Set up a statewide confidential hotline for reporting abuse and adopt a zero-tolerance policy for mandated reporters who fail to report crimes.
We should also move to close the remaining developmental centers - following
the model of close cooperation between the state, residents and the residents’
families, developed during the closure of the Agnews Center. We can and must
do much more to protect center residents, but we can never protect them adequately as long as they are shut away into institutions segregated from society.
Every human society has accepted responsibility for caring for its young, its
elders and its disabled. California’s poor record of caring for its most vulnerable
is evidence that the state must do much more.
Sally Lieber is a former Assembly member and author of the California Crime
Victims with Disabilities Act and AB20, which provides courtroom protections
for Californians with cognitive disabilities.
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Editorial: California must make developmental
centers more transparent
By the Editorial Board
Published: Saturday, Dec. 15, 2012 - 12:00 am | Page 14A
For months, officials at California’s Sonoma Developmental Center
were unable to explain the frequent bruises one patient’s family members noticed on the body of their severely disabled adult daughter.
The woman, who had lived at the institution for years, complained
she’d been touched and bruised by a caregiver. Center officials said
their Office of Protective Services investigated the matter but could
not confirm the patient’s allegations.
The following year, evidence of abuse became irrefutable. The patient
turned up pregnant. In 2007 she gave birth to a healthy baby boy.
Her story was the centerpiece of a series of articles by investigative
reporter Ryan Gabrielson of California Watch.
The series, “Broken Shield,” documents 36 allegations of rape and
molestation of disabled patients at the state’s board and care facilities that the centers’ critics say police either ignored or mishandled.
Despite credible evidence of crimes, California Watch reports that
developmental center police “failed to order a single hospital-supervised rape examination for any of the alleged victims between 2009
and 2012.”
In the wake of the California Watch stories, and following its own
surprise visits to the facility, the California Department of Public
Health this week yanked Sonoma Developmental Center’s license to
operate. Regulators cited unspecified physical conditions at Sonoma
that posed “an immediate threat to patient health and safety.”
The center, which serves 500 severely disabled patients, remains open
pending appeal. Center officials say they are working to correct the
deficiencies.
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As Gabrielson has written, the patients at the state’s development
centers are “the most vulnerable of the vulnerable.” They suffer from
cerebral palsy and severe mental retardation. Some have IQs in the
single digits. Many cannot speak. They are helpless and easily exploitable.
In response to the California Watch stories, the governor signed a bill
into law in September that requires law enforcement officials at developmental centers to refer all allegations of sexual assault to outside
police agencies. Center law enforcement officials are being trained
how to recognize signs of sexual assault, and a high-ranking CHP
officer with investigative experience has been assigned to the Sonoma
Center.
Something more is needed – greater transparency. The Center for
Investigative Reporting, California Watch’s parent organization, sued
last year to force the developmental centers to provide uncensored
copies of abuse reports. Even though it’s clear from the case files hospital officials produced that a violation occurred, the reports turned
over were so heavily redacted that a judge who reviewed them said
the public “cannot ascertain how the violation occurred, whether it
has been corrected or whether it is likely to be repeated.”
The state has appealed the judge’s order to turn over uncensored
copies. Why? If it truly cares about correcting problems and stopping
abuses at development centers, the Brown administration should drop
the appeal and turn over the documents.
The patients at these hospitals are helpless, physically and mentally
frail and often alone, without family or friends. If the institution of
government charged with protecting them fails, the consequences are
heartbreaking. Developmental centers need more scrutiny, not less.
The Brown administration should release the files.
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Investigating Abuse and a “Broken Shield”
In mid-2011, Ryan Gabrielson, public safety reporter at California Watch and
the Center for Investigative Reporting, received a tip about a police force
he’d never heard of: The Office of Protective Services.
The tipster indicated that some members of this state-run police force were
abusing overtime. But before Gabrielson could make an effort to understand
what portion of their work was legitimate, he needed to determine what
exactly the police did.
He learned that this police force was specifically assigned to protect the
approximately 1,600 California residents who lived in the state’s five boardand-care centers for the developmentally disabled. Gabrielson immediately
noted a conflict-of-interest.
“Abuse is endemic to people with severe developmental disabilities who live
in these residential centers. And it’s potentially perpetrated by their caretakers, the centers’ employees,” he said. “It seemed like an issue, for an internal police force to report to the agency whose employees they’re potentially
investigating.”
Gabrielson began a dogged pursuit for records, data and more information.
The result? “Broken Shield,” a hard-hitting investigation into the Office of
A year and a half into the series, Gabrielson and California Watch have
found that the Office of Protective services failed to protect the state’s
vulnerable board-and-care residents. Articles documented how unexplained
injuries went uninvestigated and abuse and sexual assault cases went
unprosecuted.
Getting records from the state to support these findings was a tough slog.
A public health official pointed Gabrielson to the Health Facility Consumer
Public Information System, a database of all incidents reported to long-term
care facilities in California, but CIR had to sue California’s Department of
Public Health to receive uncensored copies of reports of physical abuse and
neglect.
“The public health department was sending back record requests with
almost every word blacked out. And the developmental centers themselves
were very slow to respond to records requests--or outright denied them,”
said Gabrielson.
Additionally, the police force was forbidden to speak to reporters--Gabrielson in particular. “It took time to build sources, lots of door-knocking and
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phone calls,” he said.
Getting details on individual cases required turning to the families who had
fought the system to find more information. “In one case, a retired San Diego police officer took on the investigation of his brother’s case because he
believed the Office of Protected Services was bungling their investigation—
or worse, that they were engaged in a cover up,” said Gabrielson.
One family’s story in particular grabbed Gabrielson. Smack in the middle of
a stack of more than 2,000 pages of litigation papers: Jennifer’s story. The
tale, which Gabrielson gleaned from court records and supplemented with
family interviews, is horrific: A woman with severe intellectual disabilities
accused a caregiver from a developmental center of molestation. Detectives
from the Office of Protective Services opened an investigation but didn’t
take additional action. A few months later, Jennifer was pregnant.
Gabrielson outlined Jennifer’s ordeal in “Police Ignore, Mishandled Sex
Assaults Reported by the Disabled.” “In Jennifer’s Room,” a haunting video
directed and produced by CIR multimedia producer Carrie Ching, appears
with the article.
“In the print version of the story, there’s no cushion from the facts,” said
Gabrielson. “The video was more of a narrative and it was more emotional.
The story worked because we hit both parts,” he said.
Gabrielson was vigilant about protecting the identity of the family. “They still
live in fear of the person who raped Jennifer and they’re very brave to even
share their story. I agreed that we would make sure they couldn’t be located
through the article.” So he opted to use solely Jennifer’s first name, but did
not use the names of her family. “Like other news organizations, we do not
disclose the names of victims of sex assault. And this whole family was a
victim of sex assault,” he said.
Response to Jennifer’s story, and the series as a whole, has been tremendous. California Watch and CIR’s print partners circulated Jennifer’s story
widely. “In Jennifer’s Room” was picked-up all over the web, posted to both
Poynter and Jezebel.
In September 2012, Gov. Jerry Brown signed two bills on developmental
center abuse. And in December 2012, California regulators moved to shut
down the state’s largest board-and-care center.
There’s more work to do, although Gabrielson is tight-lipped about what’s
next for the series. “There’s more reporting to be done, there’s always more
reporting to be done—but I can’t talk about it,” he said.
And although Gabrielson was relentless in his pursuit of records and data,
he reminds reporters that investigative work is about more than unearthing
staggering statistics.
“The details are with the people. Data can only take you so far, you need
people to tell a story.”
Read the full series.
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The Busiest Intersections
The intersection of the 101 and 405 freeways in Los Angeles is one of the
busiest in the world. Traffic never lets up in any direction. In search of relief the
city has expanded the freeway, increased access on secondary roads
around this intersection, widened the
freeway and created carpool lanes.
The congestion continues at all
hours, every day.
There’s another intersection that is
similar in nature. It’s the place where
abuse meets disability and if you
have a disability, you cross at your
own risk. Efforts to slow down the
traffic have met with limited success. As the number of people with
a disability has increased over the years, so too has the incidence of abuse. A
parallel crossing of abuse and no disability has far less traffic.
California Watch’s Shocking Report
Occasionally a news story on abuse comes along that shocks and outrages
us. Such is the report by Ryan Gabrielson of California Watch published in
February. This well-documented and thorough report raises questions about
the level of care for 1800 Californians with cerebral palsy, mental disabilities
and severe autism. It found 850 documented cases in the past three years of
patient abuse or unexplained injuries at the five Developmental Centers run by
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the state. In three years, there were only two related arrests. The report documents a sustained pattern of abuse, shoddy and non-existent investigations,
cover-ups and little to no accountability. One of the deaths is described as a
homicide of a man with autism. Internal investigators failed to protect evidence
and waited five days to interview witnesses.
This report reminds us not only of abuse’s insidious presence, but that the systems for risk reduction, intervention, treatment and accountability have failed.
When systemic failures occur we must first realize that these are real people
who lose their lives in the worst of these cases, and are shattered in many
others. Their families want and deserve answers and justice. If this report does
not cause advocates to pay attention longer than the usual news cycle, we
should expect no relief at this busy intersection.
When those ultimately responsible for protecting people with disabilities infer
that the problem isn’t all that serious, it’s under control, every incident is documented, they are holding people accountable with their zero tolerance policies
and bringing in consultants or establishing special units to fix it, we can’t help
but ask rhetorically; where and when have we heard this before? And; where
in all of these face-saving words can you find one syllable of sympathy for the
victims? And finally; if zero tolerance is the standard, why shouldn’t those in
charge at the highest level be held to the same standard?
Three Things that Contribute to this Busy Intersection
There are three things that make the intersection of abuse and disability a
busy place. Isolation – Abuse usually occurs when others are not present or
when those who would disapprove or report the behavior are not. Power that
one person has over another in close proximity – Whether it’s the workplace,
a school classroom, a group home, a ward of an institution, the hallway of a
middle or high school, the power or perceived power that one person has over
another is a key ingredient. Vulnerability — When you examine vulnerable
groups it appears that ones with less ability to defend themselves are abused
at a higher rate. Add a cognitive disability to any of these groups across the life
span and you find the highest rates. When these three things are present you
have one of the busiest intersections imaginable.
We Must Not Accept the Status Quo
The three factors above are a reality of our culture. How we live and the way
we choose that others live, means abuse will continue. The fact that we cannot
totally eliminate abuse should make us even more vigilant and diligent about
putting in place the safeguards that will expose it, investigate it, prosecute it
when warranted, and properly support the victims. Instead, our institutions
— churches, state and federal bureaucracies, schools, and prisons — speed
through the intersection with little chance of getting caught. While abuse is
certainly not limited to these larger places, they should be setting the example
for the rest of society.
When there are no consequences, these settings become breeding grounds
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for abuse. But understanding why abuse of vulnerable people continues does
not absolve advocates of the responsibility to promote risk reduction measures
and hold people accountable when it is clearly evident. Now is an important
time for the voices of outrage and compassion to be heard and to demand
change.
Victims and Their Families are Beginning to Speak Up
Thankfully, this is occurring for many vulnerable individuals and groups at a
level not previously seen. Bullies are being exposed and victims of bullying are
receiving help, workplace abuse is getting considerable attention and abuse
of gay people is discussed and condemned as never before. While awareness
for these groups is increasing, we believe that too little attention is paid to
abuse of people with intellectual and developmental disabilities.
Legislative Action on Developmental Center Abuse
In California, the Legislature is taking action on the issue of reporting and
investigation. After a hearing triggered by the California Watch report, two bills
have surfaced that address aspects of the problems in Developmental Centers. One of these is SB 1051 (Liu and Emmerson) and creates a Director of
Protective Services in each Center, and that person, a real law enforcement
officer, would report to the Secretary of California Health And Human Services.
That’s a good start. You can read that bill by going to this link http://www.leginfo.ca.gov/bilinfo.html and then typing in the bill number.
The Developmental Centers may need the most immediate action in California but addressing the reporting of abuse for one disability group does little to
reduce its incidence or ensure adequate help for abuse victims.
Abuse of people with disabilities is a problem that can no longer be swept
under the rug, partly because of social media. The National Survey on Abuse
of People with Disabilities may be a beginning step to understanding some of
the most pressing issues. Please take a few minutes to complete this online
survey. That busy intersection of abuse and disability needs to be a road less
traveled.
Click here so you can take it now.
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R
Email Responses
eaders, advocates, patient families and policymakers were among the many who reached
out to reporter Ryan Gabrielson as the stories unfolded.
Here is a sampling of their feedback:
Hi Ryan -just wanted to compliment you on the great report. This is the type of reporting that ends
up actually saving lives. Thank you.

Patricia L. McGinnis, executive director
California Advocates for Nursing Home Reform (CANHR)
Ryan:
I just finished reading the Sonoma
article. Every time a problem is pointed
out to the state, the standard response
is: we have hired outside experts, we are
writing new policies and we are providing our employees with additional
training. Yet, there is never any improvement. The reason for that is simple – a
complete lack of leadership and accountability. Thru all of these events I have
never heard of a single official being fired
or demoted. Could it be that nobody in
a position of power in state government
thinks the problems can be fixed – therefore, you can’t hold anyone responsible?
If that is the case the problems will never
be resolved. Really a shame for the patients and their families.
I don’t know how you do it, but hang
in there and at least make the bastards
sweat.
Tom Simms
Dear Mr. Gabrielson,
Thank you for your detailed report on the taser assaults at
Sonoma Developmental Center. I felt sick and nauseous from
it as I listened on my drive in to work today. I hope you will
keep following up on this case, especially as to charges, if any,
brought against Archie Millora and/or the Office of Protective
Services.
I am personally interested because my 9-year-old son is in
the client demographic for these Developmental Centers and
these stories strike fear into my heart.
Sincerely,
Anita Carey
Ryan,
I was shocked by your story and wanted to express my
gratitude to you for exposing this horrifying abuse of the most
vulnerable stratum, perpetrated with virtual impunity. How
could this rash of horrors have received so little scrutiny?
Thank you,
Vicki Laden
Supervising Deputy City Attorney in Oakland
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Mr. Gabrielson, I am appalled by the article on
today’s Union about State Care Homes. How can this
be going on? The most vulnerable people are at the
mercy of who knows what kind of sick minds. I love
to read the Watchdog columns because they bring out
in the open situations that “our government agencies”
keep from us. Some times I want to write to you with
my comments and to thank you for the job you are
doing. Keep it up. This time I had to write to you.
Going back to today’s article I think that this homes
should have a legal obligation to report immediately
to the local authorities any incident and forget about
their fake internal policing unit. Save that money.
It is like the fox having the key to the hen house. If
the Care Homes directors fail to report as I suggest
they should be held accountable for obstruction of
justice. As easy as that. I am sick of how poorly our
state agencies perform their jobs and how they are
not accountable to anyone. We give them this ridiculous budgets and no one supervises how the money is
used and who watches for the patients rights?
Very concerned and angry citizen,
Victor Ravelo
I have a ten-year old autistic son who sounds very similar to how Van
functioned at that age. I hope that your story brings about changes
on how cases of abuse and homicide are investigated for those living
in state hospitals.
— Diana Figueroa
Dear Ryan,
I just wanted to thank you for
this article, my brother is mentally
disabled and resides at the Porterville Developmental Center (PDC)
for the last 20 years. My brother is
serverley mentally disabled from
seizures he developed when he was
a baby. He cannot speak nor care
for himself, but is able to walk. My
parents were farm labor workers,
spanish speaking only, but took him
to every specialist that was recommended with hope that he would
get better. He lived with my family
until he was in his twenties until
my mom could no longer care for
him. My parents tried to put him in
group homes but they encountered
neglect and physical abuse at these
facilities. They decided to place him
at the PDC and has since resided
there.
Since his placement, my parents
and family visit my brother on a
monthly basis and have questioned
many times the quality of care that
the medical facility has provided.
On numerous occasions we have
encountered my brother with
scratches, bruises, dirty, thirsty
and hungry when we visit. My
parents and I have spoken to the
medical aids and his social worker
numerous times and no resolve
ever comes from the numerous
incidents of abuse my brother has
encountered. The hospital staff
never know who caused it or how
it happened and the incident gets
forgotten. The Central V alley
Regional Center has stepped in and
has recommended various group
homes but with the bad history my
parents encountered with them
they believe its just best for him to
stay at the hospital. Its a no-win-
situation.
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The last couple of years have
improved maybe because of all the
phone calls and meetings we have
requested to his social worker and
the medical staff requesting better care for him, I honestly do not
know .
I do know that much more
needs to be done for these poor
children, they have feelings, they
are human beings and lastly they
are someone’s child. Thank you for
writing this piece and writing about
this patient V an Ingraham, your
story really hits home, it saddens
my heart and makes me angry that
my brother and all the patients at
these facilities do not have a voice.
Its very a sad situation. This population has been forgotten and more
needs to be done for them.
Thank you again,
Lorena Mendibles
Good afternoon Ryan,
My name is Steven Pokorski. This
morning I read something in the Press Enterprise Newspaper that struck a cord. I was
born with Cerebral Palsy and the article
about Jennifer being raped while in the care
of a State Hospital really made me upset.
I want to know what is being done on her
and her five year old behalf. Is there anything I can do to help? Are the State Police
being trained to handle these situations?
I am now a successful taxpayer who
is happily married. But, as a child doctors
suggested that my parents place me in the
care of the State. I am so grateful that my
parents were able to raise me to be the man
that I am today. Someone needs to help
those who cannot help themselves.
Please email me with any suggestions
or comments.
Sincerely,
Steven Pokorski
Hi Ryan
I am so pleased to hear that
you are investigating two of our
state agencies that are supposed
to be protecting our most vulnerable citizens;; CDPH and DDS.
The current situation involving
the descprepencies in the data
between CDPH and DDS is
troubling to say the least. Something is terribly wrong. You can
be assured that both agencies are
scrambling around trying to “fix”
things before they release data to
you. THEY ARE WORKING TOGETHER TO PROTECT EACH
OTHER.
Unfortunately, it’s very difficult to hold state agencies accountable with their “legal teams”
and political practices in place.
It’s a huge buraracy that is like a
giant maze and the average citizen
doesn’t stand a chance trying to
obtain justice for their loved ones
The most
vulnerable people
are at the mercy of
who knows what
kind of sick minds.
I love to read the
Watchdog columns
because they bring
out in the open
situations that
“our government
agencies” keep
from us.
— Victor Ravelo
although many of us have tried.
These agencies protect each other
no matter what the expense. It’s
such a shame. Speaking from my
prior experience, CDPH is one of
the worst. They make excuse after
excuse for why they can’t supply
certain data and the data they do
provided is not always accurate. It
is altered. PRA requests have pertainent information redacted with
the excuse of it being “to protect
the patients rights and privacy”.
The current system has been
made it so difficult for the average
citizen that most end up giving up
because we lack the resources and
the time to jump through all the
hoops that they require. Perhaps
that is what they want us to do
-just give up. Heck, we can’t even
get phone calls returned, letters
answered, or timely responses to
PRA requests. How can we have
a regulatory agancy that conducts
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Thanks for the story you
wrote about Van Ingraham
and shedding some lite on
this issue. I have a ten-year
old autistic son who sounds
very similar to how Van
functioned at that age. I hope
that your story brings about
changes on how cases of
abuse and homicide are investigated for those living in state
hospitals. There should also
be a minimum level of experience required for law enforcement detectives assigned to
those investigations. If there
is anything that I can do, such
as write a letter, etc please let
me know. I don’t think I will
every forget Van’s story.
Thanks,
Diana Figueroa
business like this? Who holds
them accountable? Who are they
to pick and choose what they will
do and not do? What standards
are they held to? Oh yes, we all
know that “Agency” oversees these
departments. But, who do you
think these people are at agency?
They are an extension of the departments that they oversee. Some
have even been employees of the
said deparments previously. I hate
to say it but they are all in cohoots
-covering up and protecting each
other. It shouldn’t be this way.
Thank you, Ryan, for taking
on this issue. I hope you are successful. It’s only the tip of the ice
berg but we have to start somewhere. Keep digging -you will be
amazed at what you will find or in
some cases, what you won’t find.
Sincerely,
A Concerned Citizen