A caregiver at the Lanterman Developmental Center in Pomona assists a patient.
By Ryan Gabrielson
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.
PHOTOS: California Watch investigates Office of Protective Services
Most abuse cases simply are logged but never prosecuted, including the suspicious 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 center's detective, a former nurse who'd never investigated a suspicious death, failed to identify what - or who - had caused the fatal injury.
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 they are 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.
Records indicate that caregivers have inflicted abuse on patients without facing prosecution. The precise number of times nurses, janitors or staff supervisors have been implicated is unknown - the state has censored thousands of pages of documents detailing the cases.
But federal audits and investigations by disability-rights groups, as well as hundreds of pages of case files and other data, show staff members allegedly involved in choking, shoving, hitting and sexually assaulting patients at the facilities. None of these cases were prosecuted.
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, leaving law enforcement agencies pointing the finger of responsibility at each other.
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"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.
Over the past eight months, California Watch has provided state officials with the findings of its investigation, including inspection records, activity logs, interviews with family members, case files and data on suspected abuse cases.
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 prosecuted.
Delgadillo also declined to comment on specific cases of alleged abuse or mistreatment at the developmental centers, citing patient privacy laws. Corey Smith, the former firefighter who is now police chief, said he was not permitted to speak with reporters for this story.
Abuse cases increase
The developmental centers have been the scene of 327 patient abuse cases since 2006, according to inspection data from the California Department of Public Health. Patients have suffered an additional 762 injuries of "unknown origin" - often a signal of abuse that under state policy should be investigated as a potential crime.
At the state's five centers, the list of unexplained injuries includes patients who suffered deep cuts on the head; a fractured pelvis; a broken jaw; busted ribs, shins and wrists; bruises and tears to male genitalia; and burns on the skin the size and shape of a cigarette butt.
Timothy Lazzini, a quadriplegic cerebral palsy patient at the Sonoma Developmental Center, died in 2005 after he swallowed 4-inch swabs that shredded his esophagus. After his death, Lazzini's doctor and a pathologist concluded it was highly unlikely that Lazzini could have placed the swabs in his own mouth.
But records show detectives waited too long to start their investigation.
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 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.
Thankless jobs, hidden from the public
The Office of Protective Services has existed in various forms and names since the late 19th century, when California opened its first institution for the developmentally disabled. That facility in San Jose - first known as the Agnews Insane Asylum - opened in 1885 and closed in 2009.
Interviews with current and former Office of Protective Services employees suggest the organization's structure from its beginning has contributed to its dysfunction.
Patrol officers dress much like those at any other police department. They wear tan and green uniforms with gold badges. Handcuffs are hooked to their belts. They drive marked squad cars. But there are key differences.
Officers and caregivers are confined together in a 24-hour facility monitoring an unpredictable, sometimes uncontrollable population. Beyond a paycheck, the job is mostly thankless and hidden from the public. Officers are not allowed to carry guns; many carry pepper spray instead. They often work their shifts alone.
Greg Wardwell, a sergeant who spent more than 20 years patrolling the Sonoma Developmental Center before retiring last year, said the state has undermined its own police force through neglect and incompetence.
"You can look like a cop and we'll call you a cop, but you don't really have any way of being a cop," Wardwell said. "Because we're not going to train you, we won't provide safety equipment. The salary will be so bad that we won't be able to recruit anybody of talent."
Salaries for the roughly 90 sworn officers are half of what police earn in the state's big city departments. Yet, roughly a third of officers within the Office of Protective Services are among the best compensated in California law enforcement, with much of their pay gained through overtime. One officer's income has topped $200,000 a year.
Families must rely on the Office of Protective Services to provide evidence for lawsuits when their relatives are harmed or killed at a developmental center. Records show the state paid out nearly $9 million in legal settlements - out of 68 separate lawsuits - from 2004 to 2010.
In 2005, Disability Rights California issued a report on a pattern of unexplained genital lacerations suffered by male patients at an unnamed developmental center. The cases were potentially sex assaults, but the investigations were woefully incomplete, documents show.
"Photographs were not taken," the report states. "Not all witnesses, nor all key witnesses, were interviewed. Physical evidence was not collected. Victims did not receive thorough medical workups to look for other indications of abuse."
Leslie Morrison, director of investigations at Disability Rights California, said the report showed how the developmentally disabled can be treated as second-class citizens.
"If this had happened to 3-year-old boys in a day care center, people would have been alarmed, police would have been called, there would have been an outrage," Morrison said. "It wouldn't have just been treated as just, 'Oh, look, there's a cut, we better sew that up.'"
In the case of the 50-year-old autistic man, Van Ingraham, his family received $800,000 in a 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.
Sexual assaults unprosecuted
Sex abuse cases, too, have been shelved without prosecution.
In April 2010, at the Canyon Springs Developmental Center in Riverside County, a janitor twice sexually abused a mentally disabled female patient when caregivers were out of sight. Under California law, having sex with any developmentally disabled person who is incapable of giving consent is considered rape.
The patient, who is not identified in state records, had a history of being assaulted. She was institutionalized at age 12 after her father impregnated her, a state health department citation shows.
The patient had been diagnosed with moderate mental retardation, schizoaffective disorder and 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 has been kept secret by the state, continues to work at Canyon Springs.
In another case with even fewer details available, a female patient at the Sonoma Developmental Center accused a male caregiver of sexually assaulting her during a bath in early 2000, police records show. The institution responded by assigning two men to bathe the patient.
On July 6, 2000, both caregivers allegedly raped her, again during bathing.
The institution did not inform its own police officers about the details of either incident. Records show Ed Contreras, then Sonoma's police commander, received an anonymous tip four days after the second alleged rape.
"They weren't following the law," Contreras said in an interview. "They weren't reporting it to the police department. They weren't reporting it to me."
Contreras said no arrests were made in the sex assaults. The Sonoma County district attorney's office declined to release records on the cases or any other criminal allegations from the developmental center.
Inside institutions, a different world
The Sonoma Developmental Center is 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."
Delayed notification hinders investigations
Delays by the Office of Protective Services often make investigations harder, if not impossible, 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 two days 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.
*WATCH News10 on Friday at 6 p.m. for more about this in-depth investigation*
CIR staff writers Agustin Armendariz and Emily Hartley contributed to this report. This story was edited by Robert Salladay and Mark Katches. It was copy edited by Nikki Frick.
California Watch, the state's largest investigative reporting team, is part of the independent, nonprofit Center for Investigative Reporting. For more, visit www.californiawatch.org. Gabrielson can be reached at firstname.lastname@example.org.