Lanterman interior photo

In 2012, a resident at the Lanterman Developmental Center in Los Angeles County was found to have blunt force trauma in her genital area. The case is unsolved.Carlos Puma for CIR

She is known in public records as Client 98, a disabled woman living at the Lanterman Developmental Center, a state-run board-and-care facility in Los Angeles County that houses roughly 100 men and women with disorders such as cerebral palsy and severe autism.

On the morning of Nov. 6, 2012, an aide was helping Client 98 from the shower to the bed when the aide noticed drops of blood on the floor. A health services specialist found that the woman had a tear in her genital area.

An on-site physician examined Client 98, whose age was not included in public records, and concluded that someone might have sexually assaulted her. She was taken to the hospital for a full examination.

“It was some type of blunt force trauma, but I cannot tell what,” said a nurse who examined her, according to public records. The nurse confirmed an assault had occurred.

The unsolved case of Client 98 was in reports by the California Department of Public Health documenting life inside Lanterman Developmental Center and another state board-and-care facility, the Fairview Developmental Center in Orange County. Totaling more than 500 pages, these reports offer a dispiriting glimpse into alleged violence and other misconduct harming severely developmentally disabled residents in these two facilities.

The violations include suspicious deaths, poor treatment and improper supervision. Inspectors visiting Lanterman in September, for example, recorded incidents of staff giving unnecessary drugs, providing incontinence care in view of others and inadequately supervising residents, during which times one person assaulted another with a wooden stick and another was suspected of ingesting foreign objects, among other incidents.

The state inspectors, who complete the compliance surveys on behalf of the federal Centers for Medicare & Medicaid Services, focused on about 30 residents at the facilities, which together house more than 400 residents. Although the reports are public, the names and other identifying information about patients were kept confidential for privacy reasons. The surveys occur no more than 15.9 months apart, according to federal guidelines. On average, they occur 12 months apart, according to a state Department of Public Health spokesman.

Both the Department of Public Health, which inspects the state’s five developmental centers, and the state Department of Developmental Services, which runs them, have been under intense scrutiny for overlooking obvious cases of abuse at the facilities, which collectively house more than 1,300 men and women. A series of reports from The Center for Investigative Reporting found the developmental centers’ on-site police force, the Office of Protective Services, has failed to conduct thorough investigations into claims of abuse.

“The fact that they’re finding all of these problems at all of these facilities now really suggests they have not been doing thorough survey investigations over a number of years at these facilities,” said Leslie Morrison, director of the investigations unit at Disability Rights California.

In response, a spokesman for the health department said all surveys are conducted according to a process laid out by the Centers for Medicare & Medicaid Services. “Each survey is dynamic, and findings from surveys stand independently,” Corey Egel said in a written statement.

Since December 2012, federal regulators have penalized all four of California’s large developmental centers, located in Sonoma, Orange, Los Angeles and Tulare counties. A fifth, smaller developmental center in Riverside County was found to have compliance violations in 2012, but it faced no state or federal penalties.  

In January, the health department began removing Medicaid funding for Fairview, Lanterman and the Porterville Developmental Center in the Central Valley for failing the compliance surveys, but recent agreements between the Department of Developmental Services and the California Department of Public Health to improve conditions halted the decertification process.

Nancy Lungren, a spokeswoman for the Department of Developmental Services, said in a written statement that the facilities “responded to each incident noted and developed plans of correction immediately to provide the necessary care and services, and to address any system issues.” In addition, Lungren said independent reviewers are expected to start visiting the facilities in April to “examine the root cause of the deficiencies” and offer an improvement plan.

The state has eight enforcement actions pending against Lanterman and Fairview, but neither facility paid any fines in 2013. And after agreeing to the plans of correction, neither faced sanctions for failing the surveys. Had the Medicare decertification actions for Lanterman, Fairview and Porterville gone through, California taxpayers would have been on the hook for about $4.1 million.

Dept. of Public Health photo

California’s Department of Public Health has been under scrutiny for overlooking obvious cases of abuse at the state’s five developmental centers.Adithya Sambamurthy/CIR

In the case of Client 98, the investigation was handed over the day after the assault to the California Highway Patrol, which has jurisdiction over potentially criminal cases that occur at Lanterman.

A CHP investigator interviewed all four staff members who had contact with the client the night of the incident. But after DNA tests returned negative, the highway patrol concluded the investigation nine months after the assault occurred. The primary suspect, an aide who was in charge of the shift on the night the client was injured, died of an unspecified medical condition during the course of the investigation.

Inspectors also found little evidence that the Office of Protective Services had followed up with its own internal investigation as required. It was unclear whether it had tracked down other clients with whom the suspected aide had contact.

“The OPS Commander was unable to provide a clear and concise answer, stating that it might have been documented in the report,” the inspectors wrote. The commander suggested at one point that the injury could have been a result of a loose arm on a chair, according to the compliance survey.

In addition to failing to protect a client from sexual assault, Lanterman was cited for neglect.

Around 4:30 p.m. Jan. 5, 2013 – about two months after the suspected sexual assault – another Lanterman resident, known as Client 97, lay down for a nap. The afternoon nap was out of character, but the aide assigned to monitor this resident at all times nonetheless left the room after a few minutes.

About 10 minutes later, the facility’s emergency notification system went off: code blue – patient in need of resuscitation.

The aide returned to the room and began CPR. More staff arrived to help. Paramedics came soon after. But by 5:15 p.m., the code was canceled.

Client 97 was dead.

Coincidentally, a surveyor from the Department of Public Health was on-site that day to conduct a compliance inspection. The surveyor noticed that Client 97 was supposed to be on enhanced supervision, so the surveyor and another employee went to check on him.

“We found Client 97 in his bed, laying on his side,” the surveyor wrote in the inspection report. He had no pulse. “I called a code and 911.”

Eight months later, the health department found that this incident – and several others relating to lack of supervision – put the Lanterman Developmental Center on track to lose its Medicaid funding.

Inspectors also found serious problems at the Fairview Developmental Center in Costa Mesa. In fact, they noted Fairview had accumulated more violations between surveys in May and August of 2013, ranging from verbal abuse to restricting access to the telephone and recreational activities to not being alert about unexplained injuries.

In one illustrative case, Client 12 “refused to move her legs” for two days. It turned out that she had a broken neck and needed surgery. Doctors also found a broken rib, a bruise on her neck and a blood clot under her scalp.

The surgery was the culmination of about a month of unexplained bruises and a hard fall after a seizure. It is unclear or unknown exactly what caused the neck fracture, but inspectors noted her worn-out, cracked helmet and heard from staff members who said she had complained of back pain at least a week before the paralysis began.

When the resident first “refused to move,” several sets of X-rays failed to reveal any injuries. However, as the radiologist later told inspectors, several vertebrae in her neck could not be scanned because of the placement of her shoulder. He recommended a CT scan, but Client 12 returned to Fairview without one.

After two days of being unable to move her legs, she received a CT scan. It showed her broken neck, as well as a broken right rib. Client 12 needed surgery. She is now paralyzed and requires a breathing tube.

Lanterman and Fairview continue to operate.

Reporter Ryan Gabrielson contributed to this story. It was edited by Robert Salladay and copy edited by Nikki Frick and Christine Lee.

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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.