Finalist: California Watch

California has assembled a unique police force to protect about 1,800 of its most vulnerable patients – men and women with cerebral palsy, severe autism and other mental disabilities who live in state institutions and require round-the-clock monitoring and protection from abuse.

 

But an investigation by California Watch has found that detectives and patrol officers at the state’s five board-and-care institutions routinely fail to conduct basic police work even when patients die under mysterious circumstances.

 

Federal audits and investigations by disability-rights groups, as well as thousands of pages of case files, government data and lawsuits dating back to 2000, show caregivers and other facility staff allegedly involved in choking, shoving, hitting and sexually assaulting patients. None of these cases were prosecuted.

 

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 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.

 

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 – 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 consumer 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 were fired for “client-related” offenses. But officials declined to say how many of those, if any, were dismissed for abusing patients, where they worked or if 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.

 

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.”

 

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.

 

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 settlement 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.

 

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 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.

 

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.

 

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.

 

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.”

 

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.

 

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 otherwise were destroyed, according to the police report. Daily caregiver notes 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.

 

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.

 

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 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.

 

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.

Six days before he died, Van Ingraham was found on the floor of his room. His neck was broken and his spinal cord was crushed and disfigured. The injury was so severe, medical experts said it looked like he could have been put in a headlock or hanged.

 

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 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 Ingraham’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.

 

After spending six days in a Newport Beach hospital, Van Ingraham died just minutes after midnight on June 12, 2007.

 

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, 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.

 

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 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 piggyback on his older brother’s shoulders in their San Diego neighborhood. Both are 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.

 

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.

 

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 an industrial kitchen.

 

Richard “Dick” Ingraham, an executive at 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 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.

 

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.

 

“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.

 

Sotingco was on her heels, heading out the door. In a later interview with 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.

 

Araujo, the only Fairview officer on duty that morning, arrived at Ingraham’s room just as an 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 lived and asked to speak 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.

 

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.”

 

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 than 10 years as an unpaid volunteer reserve for the Alhambra Police Department, near Los Angeles.

 

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 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.

Patients 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 comment 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 a staff member of molestation, court records show. Jennifer’s injuries appeared to be evidence of sexual abuse, indicating that someone had violently grabbed her.

 

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 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 stun-gun 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.

 

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, which houses about 500 men and women, two patients accused a caregiver of forcing 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.”

 

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 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 victims and identifyingphysical evidence – should have taken over the institutions’ sex 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.

 

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 addition 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 mother said. Her daughter came home many weekends. At times, however, her mother noticed injuries.

 

Bruises were not necessarily alarming. 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.

 

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. 

 

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.

 

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.”

 

The Department of Developmental Services did not respond to the officers’ allegations of interference.

 

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.”

 

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.”

In August 2006, caregivers at the Sonoma Developmental Center found dark blue bruises shaped like handprints covering the breasts of a patient named Jennifer. She accused a staff member of molestation, court records show. Jennifer’s injuries appeared to be evidence of sexual abuse, indicating that someone had violently grabbed her.

 

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.

Someone using a stun gun like a cattle prod assaulted a 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 Services, had a suspect from the start. An anonymous whistle-blower called a tip line in September 2011 and accused Archie Millora, a 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 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. 

 

An unusually high number of police officers at the state’s 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 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 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 legislation that would direct serious criminal investigations to outside law enforcement, among other changes.

 

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.

 

 

INFOGRAPHIC:

 

How does a police officer double his salary in a year?

 

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 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 – so-called 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 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.

 

SACRAMENTO – 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 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.

 

Lawmakers 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 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. 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.

 

 

Gov. 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.

 

Sonoma 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 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 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 are acting to make changes.

 

“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.

 

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.