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 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 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 affect 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.