Abuse, neglect and lack of supervision at California’s state-run homes for the developmentally disabled have directly caused the deaths of 13 people since 2002, newly released records from the state Department of Public Health show.

The developmental centers – which house men and women with severe autism, cerebral palsy and other debilitating conditions – bear some responsibility for the deaths of another six residents because they allowed living situations so dangerous that there was a great probability that deaths would occur, the state said.

One teenage resident smothered and eventually killed another teenager while the employee in charge skipped her normal rounds. A 48-year-old man with a history of a weak immune system died of septic shock when a facility doctor didn’t treat him for MRSA – a highly contagious, dangerous and antibiotic-resistant staph infection – even though his lab work showed he had it.

Another resident suffered for months before succumbing to an infection from a misplaced feeding tube that doctors, nurses and care staff all failed to notice.

The documents paint a disturbing portrait of life inside California’s five developmental centers, where 1,115 patients are housed at taxpayer expense because their guardians are unable to provide round-the-clock care or the patients have no family at all. Few populations are more vulnerable to abuse – many are unable to form sentences or communicate clearly – or more difficult to supervise.

For years, the details surrounding these deaths have remained hidden from public view. The Center for Investigative Reporting sued the public health department in 2012 after it refused to release the documents over patient privacy concerns. In February, the state Supreme Court sided with CIR, compelling the department to make the records public.

Together, these violation citations provide the most detailed accounting yet of the poor treatment some residents have faced inside these homes. They show that the centers often not only failed to protect residents from harm, but also had an active hand in resident mistreatment and deaths.

In total, the public health department fined developmental centers for their actions in the deaths of 22 residents since 2002.

The incidents in the documents ranged from death to verbal abuse. One nurse who noticed a resident with his hand down another resident’s pants called him a “mother fucking faggot” who needed “to be shipped out of here.” Patients were reported to have been shoved, grabbed by the hair, kicked while on the toilet, marched down the hall naked, doused with ice water and sexually abused.

The state Department of Developmental Services, which runs the facilities, didn’t respond to specific questions about the deaths. “DDS is fully aware of the need for continuous improvement in the delivery of services at the developmental centers,” spokeswoman Nancy Lungren said in an email.

On an October morning in 2005, a staff member found a 25-year-old resident vomiting blood in his bed at the Sonoma Developmental Center. In his vomit, staff found a plastic-handled cotton swab used for dry mouth. They immediately transferred him to an outside hospital.

It turned out that he had swallowed several swabs. One punctured his esophagus, then his aorta, on its way down, causing massive internal bleeding.

He died 17 hours later.

Both the autopsy and the public health department’s investigation suggest that caregivers left the swabs in his mouth.

“The decedent’s conditions of quadriplegia with body and limb deformity related to cerebral palsy render him, in my opinion, very unlikely to have introduced the swabs himself,” according to the autopsy report.

The center was fined $90,000. The 12 other citations for facilities found to have caused resident deaths ranged from $22,500 to $80,000.

One night in February 2009 at the Fairview Developmental Center in Southern California, a 16-year-old girl crept into another girl’s bedroom. The staff member who was supposed to be monitoring the hallway was nowhere to be found.

The teen woke up the sleeping girl, Danisha Smith, then smothered her face with a pillow. Then she took a radio cord and strangled Smith.

She left and went to her room to get a plastic bag. She returned and pressed it over Smith’s face.

If the staff member on hall monitor duty had been sitting in the hallway or had performed checks every 15 minutes as required, the girls would have been discovered around this time.

But instead, the girl was able to return to her room again and get a pencil. She went back to Smith’s bedroom and scratched and stabbed her chest. Then she crumpled up paper and pushed it up Smith’s nose with a pencil. She balled up a shirt and stuck it in her mouth. She covered her eyes in lotion and her body with blankets.

Then she heard the girls’ hallway door open, so she hid.

It was around 10:50 p.m. that an incoming night-shift staff member found Smith unresponsive on the floor.

She was taken to a hospital, where she died early the next morning. The cause of death was lack of oxygen to the brain due to foreign objects blocking the airway. Smith’s death was ruled a homicide.

At first, the girl said Smith had been suicidal. Later, she told a story of how another resident beat up Smith. But a few days later, she confessed.

“I don’t feel bad for what I did,” she said, according to notes in the citation.

She was arrested and deemed not competent to stand trial.

The facility in Costa Mesa was fined $10,000.

“These are really tragic deaths that raise questions about the level of care and supervision by developmental center staff at the time of the deaths,” said Leslie Morrison of Disability Rights California.

Fairview Developmental Center accounts for six of the 13 deaths that the state blames directly on developmental centers. But Smith’s homicide wasn’t one of them. It’s not entirely the facility’s fault, the state decided. Instead, it said the facility’s practices posed “imminent danger” of death or injury, but they were not the direct cause of the death.

In all, Fairview received eight citations linked to deaths of residents, with fines ranging from $10,000 (Smith’s homicide) to $80,000 (a woman fell out of bed and died because her bed railing wasn’t attached properly).

Lanterman Developmental Center in Pomona, which closed at the end of 2014, was cited in four deaths, and Porterville Developmental Center in Central California was cited in two deaths. The state’s fifth center, Canyon Springs in Cathedral City, was not cited for any deaths.

Lanterman Developmental Center, which closed at the end of 2014, was cited in four resident deaths. Credit: Carlos Puma for CIR Credit: Carlos Puma for CIR

The Sonoma Developmental Center received eight citations linked to deaths of residents, with fines ranging from $1,000 (a resident with hypothermia didn’t get immediate treatment) to $90,000 (the resident who swallowed the cotton swabs).

Sonoma has been the focus of a series of patient abuse scandals over the years. As CIR’s Broken Shield investigation revealed, its staff used stun guns on residents, and it has been the site of multiple uninvestigated cases of sexual assault.

Since the start of the Broken Shield investigation, Sonoma has been cited for three deaths and multiple new incidents of abuse and neglect, despite promises of heightened state oversight. This year, the state Legislative Analyst’s Office recommended closing the facility, and Republican lawmakers have introduced legislation to do so in an effort to save money.

The Department of Public Health, which oversees the developmental centers, employs a team of investigators to look into serious complaints. These records show the results of all those investigations going back 13 years. They are the actual citations issued to developmental centers found to be in serious violation of state or federal laws and regulations.

CIR originally requested the citation records as part of the Broken Shield project. Initially, the Department of Public Health released 55 heavily redacted documents. The reports hid the centers’ violations and the circumstances surrounding the incidents, making it impossible to know what went wrong, who was hurt and how it happened.

The department turned over the documents to CIR last week. There are more than 200 unredacted citations, spanning nearly 900 pages and detailing incidents of abuse, neglect and death. The state has withheld the names of the victims.

The full documents, with CIR notes, are available here.

Rachael Bale is a reporter and researcher for The Center for Investigative Reporting. Previously, she worked at KQED in San Francisco and The Center for Public Integrity, an investigative journalism nonprofit in Washington, D.C., where she covered campaign finance in the 2012 election. A California native, she has a bachelor's degree in political science from Reed College and a master's degree in journalism from American University.