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developmentally disabled

New director to take over troubled Sonoma disability center

A former employee of the Sonoma Developmental Center has been tapped to head California’s largest full-time care facility for the severely disabled, at a time when the institution is struggling to reinvent itself in the wake of patient abuse scandals.

The Department of Developmental Services announced Wednesday that Karen Faria, who worked at the Sonoma Developmental Center from 1985 to 2005, will become the embattled facility's latest executive director starting April 1.

The appointment comes in the wake of a California Watch series that uncovered serious allegations of patient abuse at the Sonoma Developmental Center. The reported abuses included cases of rape and molestation as well as allegations that a state worker used a Taser to inflict burns on a dozen patients.

The California Watch investigation exposed these cases and focused on failures of an internal police force to get to the bottom of the abuses. One-third of the 36 alleged rapes occurred at the Sonoma board-and-care center – one of five such facilities in California that house about 1,600 patients with severe disabilities.

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CIR’s California Watch wins Polk award for second straight year

We are proud to write today that the Center for Investigative Reporting’s California Watch has won the George Polk Award for our series exposing flaws in the way a special state police force handles crimes against the developmentally disabled.

It is the second consecutive year that California Watch has won the prestigious George Polk Award. This year, we are being honored in the category of state reporting for Ryan Gabrielson’s extraordinary series “Broken Shield.”

 

The series has prompted far-reaching change, including a criminal investigation, staff retraining and new laws – all intended to bring greater safeguards and accountability.

Gabrielson was one of 14 Polk award winners announced today by Long Island University, which administers the prizes. University officials said more than 700 stories were submitted to the judges. Other winners include The New York Times, Milwaukee Journal Sentinel, Bloomberg News, CBS News, The Washington Post and Mother Jones.

The Polk award is named after a CBS newsman murdered while covering the Greek Civil War in 1948.

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Explainer: Investigating sexual abuse in California’s developmental centers

The support network for the disabled is a wide one. Find out how to get involved and share your stories.

Patients at California's five board-and-care centers for the developmentally disabled have accused caretakers and other employees of rape and molestation 36 times during the past four years.

The Office of Protective Services, the agency in charge of protecting this vulnerable population of 1,600 patients statewide, failed to order a single outside rape examinationfor any of the alleged victims, most of whom are female. These patients suffer from cerebral palsy, severe autism and other intellectual disabilities.

Under other circumstances, performing a rape examination is a routine part of a police investigation. Performed by specially trained nurses to find all manner of physical evidence, it is an important part of investigating sexual abuse allegations, identifying a suspect and solving sex crimes.

But this is often not the case at California’s developmental centers. Former detectives and patrol officers at three of the five centers say the Office of Protective Services blocked or ignored investigations into allegations of sexual misconduct.

 

In 2006, Jennifer, a patient at the Sonoma Developmental Center with severe intellectual disabilities, was found to have severe bruises across her chest, which she attributed to a caregiver at the centerwho abused her. Her mother was told by a social worker that the Office of Protective Services had thoroughly investigated Jennifer’s allegation but could not prove it.

Less than a year later, during a weekend visit to her family's home, Jennifer's family discovered she was pregnant. Records show that hospital staff either ignored or overlooked her condition.

Catch-22 in evidence collection

Four years ago, the Office of Protective Services implemented its first policy regarding the investigation of potential sex crimes. However, these guidelines often present a barrier to investigating sexual assaults, rather than helping. For example, the following requirements must be met for a “rape kit” examination to be ordered:

“A sexual assault occurred within the preceding 72 hours and there is potential for recovery of physical evidence of the recent sexual assault.”(Emphasis from original policy)

Experts on sexual assault investigations told California Watch that the phrase “potential for recovery” is problematic because detectives cannot tell what evidence exists before a patient is examined. It leaves them in a Catch-22:How do you know what evidence there is to collect if you are unable to collect it? Additionally, Roberta Hopewell, a detective at the Riverside Police Department, says the 72-hour time limit is outdated, as physical evidence sometimes can be recovered up to two weeks after an assault.

So what’s being done?

In September, Gov.Jerry Brown signed SB1522, which requires that developmental centers report alleged sexual assaults against patients to outside law enforcement. According to a statement, the law “will ensure developmental center investigators and outside law enforcement agencies work collaboratively to investigate unexplained injuries or allegations of abuse.”

How to get involved

The support network for the disabled is a wide one. These groups offer resources to find out more, as well as information on how to get involved. If you want to share your stories about developmental centers, we’d love to hear from you.

Californians for Disability Rights – California's oldest and largest organization of people with disabilities.
From the group’s website: CDR and its members fight for the independence, dignity and equality of all disabled persons.

Disability Rights Advocates – A nonprofit legal center dedicated to securing the civil rights of people with disabilities. All work is done pro bono.
From the group’s website: DRA advocates for disability rights through high-impact litigation, as well as research and education.

Disability Rights California – Provides free legal and advocacy services to low-income Californians with disabilities. All work is done pro bono.

From the group’s website: Advocate, educate, investigate and litigate to advance and protect the rights of Californians with disabilities.

Disability Rights Education and Defense Fund – A national civil rights law and policy center directed by individuals with disabilities and parents who have children with disabilities.
From the group’s website: The mission of the Disability Rights Education and Defense Fund is to advance the civil and human rights of people with disabilities through legal advocacy, training, education, and public policy and legislative development.

National Disability Rights Network – Protection and advocacy for people with disabilities.

From the group’s website: Through training and technical assistance, legal support and legislative advocacy, NDRN works to create a society in which people with disabilities are afforded equality of opportunity and are able to fully participate by exercising choice and self-determination.

If you suspect abuse at one of California's developmental centers, please share your story with California Watch via the Public Insight Network. All information is confidential and could help inform our reporting on this topic.

Get more updates from our Broken Shield investigation as we publish them. Text “OPS” to 877877 and visit californiawatch.org/brokenshield

See what we found in our ongoing Broken Shield investigation. Download our series explainer to learn more.

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Video: In Jennifer's Room

A young developmentally disabled woman just wanted to be left alone. What happened next shattered a family.

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.

Credits:

Reported and narrated by Ryan Gabrielson
Directed, produced, and edited by Carrie Ching
Illustrated by Marina Luz
Transcript of mother's interview read by Evelyn Kelsey
Music:
"Haunted" by Jamie Evans
"Winter Sunshine" by Evgeny Grinko
"From Truth" and "The Time to Run" by Dexter Britain
Sound effects by grayseraphim and pfly

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Police ignored, mishandled sex assaults reported by disabled

Developmentally disabled patients at California’s board-and-care centers have accused caretakers of molestation and rape 36 times since 2009.

Mike Kepka/San Francisco Chronicle Giant palm trees stand at the main gate of the Sonoma Developmental Center, which houses about 500 patients. The police force at California’s developmental centers failed to order a single hospital-supervised rape examination for any alleged sexual abuse victims between 2009 and 2012. 

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.”

Mike Kepka/San Francisco Chronicle A placard marks the Corcoran Unit at the Sonoma Developmental Center, which has been the site of many of the sexual abuse allegations at the state developmental centers. 

However, the Office of Protective Services quickly closed the case, the records indicate, because the suspect was not listed as having worked in the patient’s unit, called Corcoran, on the day of the alleged abuse. The accused caregiver did often work in that unit, though, internal records show.

Months later, the mother of a second patient alerted the center that her daughter had said she had licked the same caregiver’s penis.

But by then, the accused caregiver was gone. He is not identified by his full name in state records. The center’s incident log noted that the psychiatric technician suspected of the abuse was “no longer employed” but “did work on the unit.”

Sexual abuse cases reviewed

Earlier this year, Leslie Morrison, head of the investigations unit at Disability Rights California, examined dozens of case files in which a patient accused a center employee of sexual abuse from 2009 to mid-2012. Morrison performed the review at the request of the state Department of Developmental Services. She said these cases involved only patients capable of speaking and therefore able to report an assault.

Disability Rights, a protection and advocacy organization, has access to full patient files under state and federal law. Many of these records are confidential, but California Watch was able to obtain through other sources some of the documents provided to Disability Rights.

California Watch’s parent organization, the Center for Investigative Reporting, has sued the state for additional abuse records that can shed more light on these and other cases. A superior court 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.

Mike Kepka/San Francisco Chronicle Leslie Morrison, head of the investigations unit at Disability Rights California, examined the state developmental centers’ sexual abuse case files from 2009 to mid-2012 and found 36 cases in which the victims likely should have received a rape kit medical exam and interview with a trained nurse. 

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.

Early struggles in Jennifer’s care

Few cases are more disturbing than that of Jennifer, the former Sonoma Developmental Center patient who suffers from bipolar disorder and attention deficit and hyperactivity disorder, in 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.

Mike Kepka/San Francisco Chronicle A patient named Jennifer was impregnated by an unknown assailant while living at the Corcoran Unit at the Sonoma Developmental Center in 2007. Under state law, sexual intercourse with a patient lacking the intellectual capacity to consent is considered rape. 

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.

Injuries, then pregnancy

In 2006, the patient’s injuries changed. Bite marks broke her skin and bruises surfaced on her back and breasts. Court records show Jennifer accused a Sonoma caregiver of touching and bruising her. She showed the center’s employees and her mother the resulting injuries.

The mother said someone clearly had been grabbing Jennifer’s breasts with violent force. The bruises were unlike anything she had ever seen on her daughter.

“I can tell if a bruise was an accident because she bruises easily; I bruise easily,” she said. “That’s not a big deal. But I could tell when a bruise is really not a bruise, you know what I mean?”

A social worker at the Sonoma center told the mother that the Office of Protective Services had investigated the matter thoroughly, but detectives couldn’t prove Jennifer’s allegation that the caregiver had bruised her.

“Of course, it’s her word against his,” Jennifer’s mother said. “Nothing was done.”

Records show the institution’s doctors, nurses and caregivers overlooked or ignored her pregnancy until Jennifer was well into her second trimester. Jennifer’s disabilities make her incapable of giving consent to sex. Her mother discovered Jennifer’s swollen belly during a weekend visit at her family’s home in July 2007. Under state law, any sexual intercourse with a patient lacking the intellectual capacity to consent is considered rape.

Jennifer’s son was born by cesarean section in October. No one was arrested in Jennifer’s rape.

“I was a hands-on mom, and I fought for my daughter’s security,” Jennifer’s mother said. “And I still wasn’t able to protect her. Who protects these people?”

The month that Jennifer gave birth, the Office of Protective Services received a letter from a whistle-blower that named a janitor as the alleged rapist, but didn’t inform the Sonoma County Sheriff’s Office about the lead for three months, according to court records from a lawsuit Jennifer’s family filed against the state.

By then, the accused janitor had fled the country, court records said.

Regardless, the institution’s officers did not attempt to gather physical evidence through a sex assault examination that might have supported criminal prosecution of Jennifer’s assailant. And the center’s internal records show that patients have continued to allege sex abuse in the unit where Jennifer lived.

Her family settled a civil lawsuit with state Department of Developmental Services for $100,000. Jennifer now lives in her own apartment. Like all California residents with developmental disabilities, Jennifer is entitled to and receives services from the state. 

Her mother and family members and have hired a caregiver to take care of her. They are all women. 

Few sex crimes referred for prosecution

Statewide, the Office of Protective Services referred just three sex crime cases to county district attorneys for prosecution since 2009, said Morrison with Disability Rights California. In those cases, officers did not collect any physical evidence to determine whether crimes occurred. Just one of those cases led to an arrest.

In one incident from January at the Sonoma Developmental Center, caregivers noticed that two female roommates appeared to have injuries suggesting abuse – bruises on their faces and arms. The caregivers told the Office of Protective Services, but there was no detailed investigation.

In May, another employee of the center caught a longtime caregiver, Rue Denoncourt, exposing himself to one of those female patients in a bathroom. The colleague reported the incident to the Office of Protective Services, which then notified the Sonoma County Sheriff’s Office.

The sheriff’s office interviewed Denoncourt, who confessed to exposing himself and sexually abusing the victim’s roommate, forcing her to touch him while he masturbated.

Even after Denoncourt admitted to the abuse, records from the state Department of Public Health show neither the sheriff’s office nor the Office of Protective Services sent the victims to receive sexual assault examinations. If evidence of other assaults was available, it was lost.

No investigation took place into the bruises that were discovered on both women in January, although the health department raised suspicions about Denoncourt in its report.

Denoncourt pleaded no contest to a lewd conduct charge in August and is serving an eight-month prison term. The Sonoma County sheriff and district attorney declined to comment for this story.

Allegations of interference

Three former members of the Office of Protective Services allege that administrators and other employees at developmental centers have interfered with abuse investigations.

Pete Araujo, a former investigator at the Fairview Developmental Center in Orange County, said his commander refused to approve sex assault exams for victims. Araujo said his superiors provided no explanation for denying the exams, and no one within the force challenged the decisions.

“Their word was final,” said Araujo, who is now an investigator for the California State Lottery Commission. “They were the managers.”

Employees at the institutions have delayed notifying police of alleged sexual abuse for days, said Greg Wardwell, a 20-year veteran patrol officer and sergeant at the Sonoma center. The lost time can leave physical evidence open to contamination and witnesses vulnerable to coercion.

Wardwell, who retired in March 2011, said center administrators did not punish employees for withholding information about abuse.

“It’s very frustrating at the point that someone is genuinely victimized and you didn’t find out about it for four or five days,” Wardwell said. “There is no sanction at the point that somebody sits on the information.”

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

Policy hinders investigations

The Office of Protective Services’ own policy has made it difficult for officers to order sexual assault exams. For patients to receive an exam, the guidelines require that “a sexual assault occurred within the preceding 72 hours and there is potential for recovery of physical evidence of the recent sexual assault.”

 

The “and” is underlined and italicized in the written policy.

Experts on sex assault investigations said using the words “potential for recovery” threatens to shut off an investigation before it starts. Detectives cannot determine what evidence is present before a medical exam.

“That latter part shouldn’t even be in there,” said Linda Ledray, a forensic nurse and director of the Sexual Assault Resource Service in Minneapolis. “I mean, that’s crazy.”

Kim Lonsway, research director for End Violence Against Women International, agreed that the Office of Protective Services’ sex assault policy could undermine investigations.

“The tone of this is the exams are going to be the exception rather than the rule,” Lonsway said.

Further, the 72-hour time limit is outdated, said Hopewell, the Riverside police detective. Hopewell said physical evidence sometimes is recoverable two weeks after an assault. She will request a medical exam even in cases in which a victim was attacked two years earlier, because scars can be shown to support allegations.

Delgadillo, director of the state Department of Developmental Services, implemented the Office of Protective Services’ first policy on investigating sex assault four years ago. The department had no specific guidelines for police on investigating sex abuse before 2008, only that they be required to complete a state minimum of four hours of training.

Experts said many cases are hampered because some investigators, administrators and even family members distrust allegations by the intellectually disabled. Detectives investigating sex crimes against the disabled often need special training in the nuances of extracting evidence from these types of patients. Such training has never been offered to the state police force.

“Even if it is reported, the victim is often not believed or is thought to be fantasizing or to have merely misinterpreted what occurred,” Joan R. Petersilia, a criminology professor at UC Irvine, wrote in a 2001 study of disabled victims. “This leaves the person with a disability continually vulnerable to victimization, because perpetrators come to learn they may victimize them without fear of consequences.”

Listen to this story on KQED's California Report:

This story was edited by Robert Salladay and Mark Katches and copy edited by Nikki Frick and Christine Lee.

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Infographic: After claims of sexual assault, little is done

36 allegations, no rape kits

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. 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.

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 any other police department, using a “rape kit” to collect evidence would be considered routine.

Here is what our California Watch investigation found.

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Brown signs bills on developmental center abuse

UPDATE, Sept. 28, 2012: This story updates to include comment from the Department of Developmental Services.

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.

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Report slams state institution for neglect, weak oversight

California’s largest institution for the developmentally disabled risks losing millions of dollars in federal funding because of poor medical care and widespread failures to prevent abuse and thoroughly investigate when patients are harmed, state officials said in a confidential report.

The Department of Public Health inspection report presented a damning indictment of the Sonoma Developmental Center, which houses more than 500 people with cerebral palsy and other intellectual disabilities. Normally such reports are kept from the public, but California Watch obtained a copy of the 495-page document this week.

"Individuals have been abused, neglected, and otherwise mistreated and the facility has not taken steps to protect individuals and prevent reoccurrence," the report said. "Individuals were subjected to the use of drugs or restraints without justification. Individual freedoms have been denied or restricted without justification."

 

According to the report, the board-and-care institution must immediately upgrade patient care and abuse investigations to keep its federal certification. Without federal approval, the Sonoma center would lose reimbursement from the Medicare and Medicaid programs – crippling its budget and placing an even greater burden on the state.

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Questions surround handling of Taser assaults on disabled patients

With a suspect from the start, the Sonoma Developmental Center’s in-house police force made no arrest in a dozen patient assaults, choosing to handle the case administratively.

Facebook.com A photo posted Oct. 1, 2009, on Archie Millora’s Facebook page shows him posing at a firing range while holding an assault rifle. 

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. 

 

“There’s absolutely no excuse for allowing that to happen like that without any ramifications,” Assemblywoman Connie Conway, the Republican leader from Tulare, said of the stun gun assaults.

After California Watch published its initial investigation about the police force, a former state worker alerted reporters to the Taser incidents. Other whistle-blowers turned over records to the news organization, allowing the story to be told for the first time. The state Department of Developmental Services, which operates the developmental centers and in-house police force, has not responded to requests for additional documentation.

The Sonoma County district attorney’s office announced this week it would review the matter as a potential criminal abuse case after California Watch began asking questions about the Taser incidents. “We’re continuing to review the entire case; we haven’t closed the door on our investigation,” said Spencer Brady, chief deputy district attorney.

In a written statement, Terri Delgadillo, director of the state Department of Developmental Services, said the center’s investigation “included interviews of over 100 individuals, including the suspect who was interviewed on three separate occasions and terminated from employment.” She said that the department took the matter seriously and is continuing to investigate, nearly a year after the abuse occurred.

Millora was fired in November, state controller records show. He did not respond to multiple interview requests made by phone and in person at his home.

Jim Rogers, the Sonoma center’s executive director, also was fired, according to Delgadillo’s statement. In January, the department said Rogers retired voluntarily. Rogers did not return phone calls seeking comment.

The Taser incidents also raise new questions about the police force’s leadership. Key decisions were made by the agency’s top chief – a former firefighter with a limited background in criminal investigations – and a commander who had just been transferred to the Sonoma center from the Porterville Developmental Center.

Leslie Morrison, head of investigations for Disability Rights California, said she was surprised that the Office of Protective Services kept control of these abuse cases.

Police at the Sonoma center “should have immediately picked up the phone and called outside law enforcement,” Morrison said. “We’ve got a serial abuser here.”

At the same time, the police force  may have thwarted a criminal investigation by local authorities, records show.

On Oct. 5, more than a week after officials received the tip about the stun gun incidents, the Sonoma center’s top administrators met with an inspector from the state Department of Public Health investigating the injuries, according to an internal memo. The inspector, Ann Fitzgerald, asked whether the attacks were a criminal case.

“It could be,” said the center’s police commander, Bob Lewis, according to the memo.

But police at the center took steps that might have discouraged the Sonoma County Sheriff’s Office from opening its own investigation. Lewis downplayed the series of attacks against patients, telling the sheriff’s office there was an abuse allegation, not a dozen confirmed cases, the internal correspondence shows.

In the Office of Protective Services’ call to the sheriff’s office, center police disclosed they found two weapons, said Sonoma County Lt. Dennis O’Leary. Regarding the assaults against patients, O’Leary said Lewis informed them “just that there was some suspicion that there may have been some abuse to the patients.” At the time, however, the in-house police detectives at the state center still had not questioned Millora, records indicate.

Delgadillo said in her statement that the sheriff’s office decided “not to intercede and take over the investigation.”

The sheriff’s office had a different take.

“We offered to assist in their investigation, but we were told that they didn’t need our help,” said Sonoma County Assistant Sheriff Lorenzo Dueñas.

Force referred gun charge

Corey Smith, the Office of Protective Services’ police chief, oversees all criminal investigations at the state’s developmental centers. Sonoma center commander Lewis sent Smith multiple written reports after learning of the stun gun abuses. He also took instructions by phone at least once, records show.

Smith, a firefighter for most of the past two decades, has less law enforcement experience than a majority of the patrol officers beneath him. He hadn’t worked on criminal investigations until 2006, when the department made him the Sonoma center’s police commander.   

Smith became chief in 2010 after his predecessor was indicted on embezzlement charges. He did not respond to phone calls or written questions sent by email.

The Office of Protective Services did refer a criminal charge against Millora for carrying a concealed firearm, a misdemeanor, according to Sonoma County Superior Court records. He pleaded no contest to the charge in April and received 20 days of electronic monitoring, plus three years’ probation and a $190 fine.

Charges of assault against a dozen patients could have meant decades in prison.

Millora has no felony record and therefore has no legal barrier preventing him from again working with the disabled, said Tony Anderson, executive director of The Arc of California, an advocacy group.

"These guys bounce around from home to home and you just never catch them, until they do something really bad," Anderson said.

Disciplinary records not public

The abuses echo another attack at Sonoma, when a caregiver used a stun gun on a patient’s chest in 1999. The center’s detectives took months to obtain an arrest warrant, by which time the suspect had fled the state.

Millora started at the center as an assistant psychiatric technician in 1998, according to the Department of Developmental Services. In this position, he earned $50,000 a year as a primary caregiver for as many as a dozen patients. His duties involved watching over patients, bathing and grooming them, and protecting them from harm. He was not suspected in the earlier stun gun abuse case.

Psychiatric technicians must undergo training and certification in California. When psychiatric technicians violate regulations, their transgressions are in the public record. But this requirement does not extend to assistant caregivers. Their disciplinary records reside only in personnel files, which are largely confidential under state records law.

Facebook.com Millora’s Facebook page has portraits of firearms including an assault rifle, which was posted Dec. 13, 2009. A former caretaker at the Sonoma Developmental Center, he was accused of assaulting disabled patients with a Taser. 

On Millora’s Facebook page, he has posted portraits of several firearms. One photo shows an assault rifle beside a Glock, outfitted with an extended clip and sight. In another picture, Millora poses at a firing range, looking into the camera while holding an assault rifle.

The state Department of Developmental Services has not released the caregiver’s personnel file, detailing his termination or other disciplinary action. Developmental center officials have not answered repeated questions about the abuse. Delgadillo said that the families of patients were informed about the incidents, but the department has not specified exactly what families were told.

The state deems records related to developmentally disabled patients to be confidential. Regulators black out nearly every word on inspection records before releasing them to the public.

The state-run facilities in Los Angeles, Sonoma, Orange, Tulare and Riverside counties have documented hundreds of cases of abuse and unexplained injuries, almost none of which has led to arrests.

In response to California Watch’s earlier stories, lawmakers have introduced two bills that would require the state to notify outside law enforcement agencies and disability rights groups when it receives allegations of violent crimes against patients. The bills have passed the state Senate and await votes in the state Assembly.

Under current law, the centers’ police force is not required to report allegations of abuse such as the Taser incident to local authorities.

Conway, the assemblywoman from Tulare, has called for a state audit of the Office of Protective Services. The Joint Legislative Audit Committee has scheduled a hearing for Aug. 7 to consider the request.

Public health department citation

Sonoma center officials accepted responsibility for the stun gun abuses in June, when the state Department of Public Health issued the facility a “Class A” citation. The penalty included a $10,000 fine for violations that put patients at serious risk of harm or death.

The citation said 11 patients had stun gun injuries. Internal records from the Sonoma center list a dozen victims. All the victims were men, whose ages ranged from 33 to 61 years old.

The Department of Developmental Services is bringing in outside experts to upgrade patient care at the Sonoma center and prevent future abuses, Delgadillo said in her written statement. Following California Watch’s earlier stories, Gov. Jerry Brown’s administration in March hired Joe Brann, a longtime police chief, to oversee retraining of the entire Office of Protective Services and fix problems in its criminal investigations.

The stun gun allegation arrived on an answering machine in the executive director’s office sometime on Sept. 26, the Sonoma center records show.

A male voice said Millora had used the stun gun on patients living in one specific unit of the developmental center, the Judah Unit, home to 27 patients, according to records.

The Office of Protective Services received word of the abuse at 4 p.m. Sept. 26 and deployed patrol officers to the residence within 30 minutes. It was Millora’s day off, so the in-house police decided to stop the caregiver on his way in to work the following day.

However, the officers missed the start of Millora’s shift, at 6:30 a.m., according to the citation. The caregiver was on a break when police arrived shortly before 8 a.m. They intercepted Millora as he returned to the Judah Unit and received his consent to search his car, according to records.

That’s when officers discovered his weapons.

Facebook.com A photo of a Glock handgun fitted with a sight and placed next to an extended magazine was posted to Millora’s Facebook page Dec. 12, 2009. The weapon matches the description of the firearm police found in his car in September 2011. 

“The facility officer removed a black nylon handgun case from under the passenger seat,” the citation said. “The case contained a Glock semi-automatic pistol and a ‘magazine’ containing live rounds of ammunition.”

Stashed inside a compartment on the driver-side door, Millora had a Taser C2. Officers would place both weapons in an evidence locker, according to the citation.

Despite having the stun gun in their possession, the center’s police did not take the suspect into custody for questioning.

Rather, officers turned Millora over to administrators. Rogers, then executive director of the Sonoma center, put Millora on “administrative time off,” according to internal records, and the caregiver apparently left the institution about 10 a.m.

Millora’s job was in jeopardy at that stage, the licensing and administrative records show, but not his freedom.

Eleven hours later, police commander Lewis called Smith, the chief of the Office of Protective Services, for instructions, according to an internal chronology of events. Smith told Lewis to alert the California Highway Patrol, and the commander said he made the call sometime before 10 p.m.  

However, CHP officials say they have no record of being notified by the Office of Protective Services at the Sonoma center during the time period in question. And even if they had been notified, CHP does not handle patient abuse cases.

Lewis had taken command at Sonoma just four weeks earlier. He’d previously worked for several years as a detective and supervisor at the Porterville Developmental Center in Tulare County.

Reached by phone, Lewis said the Department of Developmental Services prohibits him from speaking to reporters. “I’m just going to have to refer you, buddy,” Lewis said.

The Sonoma County sheriff has jurisdiction over the developmental center and teams of investigators with experience in aggravated assault cases.

Lewis alerted the sheriff’s office the next morning, Sept. 28, about “the weapons recovered from an employee’s vehicle and the allegation of abuse,” according to the center’s chronology. The Office of Protective Services would remain the lead investigating agency.

Dueñas, the Sonoma County assistant sheriff, said Lewis never disclosed to the sheriff’s office that the center confirmed patients had been attacked.

‘Non-accidental trauma’

The investigation continued that day when center detectives provided pictures of the patients’ injuries to a forensic pathologist for analysis.

Doctors concluded that the victims who lived in the Judah Unit were injured by the same weapon, according to the citation reports.

“The pathologist further opined that the patterned injuries on seven clients were strongly suggestive of and consistent with electrical thermal burns ranging in age of 36 to 48 hours up to greater than two weeks,” the citation said.

The burn marks came in pairs, roughly a half-inch apart, the citation said, and “represented non-accidental trauma.” Some of the injuries were healing into scars, suggesting the attacker had abused the patients over the course of several days, if not weeks.

Based on the doctor’s findings, the state inspector concluded the patient injuries were "abrasions consistent with the use of an electrical thermal device (Taser Gun)," the citation said.

All of the patients were treated at the center’s own acute care clinic. It’s unclear from available records if any of the patients were hit with the Taser multiple times.

Initially, police believed only seven patients living at Judah had been assaulted, the licensing records and internal correspondence show. Nurses examined every Judah patient and discovered three others with the circular burn marks.

After reviewing Millora’s work schedule, medical staff found the caregiver had contact with patients living in three other residences. Subsequently, two more patients were identified with stun gun injuries in those units, according to records.

 

The Taser C2 found in Millora’s car is designed as a defensive weapon, able to hit targets from a distance of 15 feet, said Steve Tuttle, a spokesman for Taser International. When discharged in the device’s primary setting, two probes shoot forward and attach themselves to the target in different locations on the body, separated by a foot or more. It sends more than 1,000 volts into the target.

However, the Taser C2 has a second setting, called “drive-stun,” Tuttle said. In this mode, the probes are stationary and deliver voltage directly to the skin. “It would cause impairment and would be painful,” he said.

The precise burn marks on the victims' bodies indicate the Taser was used at close range to the victims – almost like a cattle prod.

Tuttle said Taser International finds it abhorrent that its product would be used to assault disabled patients.

“I’ve been spokesman for the company for 18 years,” he said. “That’s the very first time I’ve heard of anything similar to that.”

State licensing records and Sonoma center communications offer no detail on how the abuse occurred.  

Records show that Lewis and his detectives at the Office of Protective Services deliberately avoided asking Millora for his version of events in the first two weeks following their discovery of the abuses.

At the October meeting attended by state officials about the Taser incidents, the state inspector asked why police were delaying their interview with Millora until officers had spoken to all other potential witnesses, according to the internal memo.

Lewis responded that it was his decision to wait before interviewing Millora. Delaying the interview “is the most beneficial as far as obtaining information, possible leads that could lead to other involvement or evidence," Lewis explained, according to the memo.

The Office of Protective Services did not find other leads or witnesses in the case.

State officials won’t say what Millora eventually told them.

ABC 7 reporter Vic Lee contributed to this report. This story was edited by Mark Katches and copy edited by Nikki Frick and Christine Lee.

Watch ABC 7's coverage of this story below.

ABC 7 reporter Vic Lee contributed to this report. This story was edited by Mark Katches and copy edited by Nikki Frick and Christine Lee.

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

An unusually high number of officers at the state’s board-and-care facilities for the developmentally disabled have doubled their salaries.

The state of California operates a special police force devoted to protecting the residents of five board-and-care hospitals for the developmentally disabled.

These taxpayer-funded facilities – staffed by psychiatric technicians, nurses and doctors – are home to about 1,800 men and women with cerebral palsy, severe autism and other intellectual disabilities. They are located in Los Angeles, Sonoma, Tulare and Riverside counties.

Officers working for this police force – called the Office of Protective Services – are some of California government’s most proficient users of overtime. But even while they have boosted their paychecks, the force has been criticized for its sloppy investigations into potential crimes.

This graphic examines the force’s overtime pay from several vantage points. California Watch, which is part of the Center for Investigative Reporting, analyzed just how many hours the biggest earners claimed to have worked on their timesheets.

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