Monica Lam/The Center for Investigative Reporting

SACRAMENTO – The in-house police force at California’s developmental centers has frequently neglected to interview victims of abuse, photograph crime scenes or collect statements from suspects and witnesses, according to a state audit released today that confirms the key findings detailed in a series by The Center for Investigative Reporting.

In a 76-page report, the California State Auditor detailed numerous shortcomings in how the force, called the Office of Protective Services, protects roughly 1,500 patients with cerebral palsy and other intellectual disabilities at five board-and-care institutions in Los Angeles, Orange, Riverside, Sonoma and Tulare counties.

“Investigative deficiencies, such as those we observed, may allow for continued abuse at the developmental centers,” the report stated. Auditors said they reviewed 48 investigations by the department and found 54 deficiencies in its police methods.

State lawmakers ordered the audit last year in response to stories by CIR detailing how the force routinely failed to do basic police work when patients were abused, including suspicious death and sexual assault cases. The Office of Protective Services was set up specifically to protect the developmentally disabled living in the state’s remaining board-and-care centers, but few violent crime cases at the institutions have resulted in criminal charges.

CIR, through its California Watch project, detailed that dozens of women were sexually assaulted inside state centers, but police investigators didn’t order “rape kits” to collect evidence, a standard law enforcement tool. Police waited so long to investigate one sexual assault that the staff janitor accused of rape fled the country. The police force’s inaction also allowed abusive caregivers to continue molesting patients – even after the department had evidence that could have stopped future assaults.

The Office of Protective Services’ records indicate the force sent 82 patient abuse cases to district attorneys for possible prosecution. However, auditors determined much of the data on the entire caseload was “not sufficiently reliable for the purposes of this audit” to verify that number.

The auditors faulted management of the facilities for failing to provide specialized training for officers in interviewing the developmentally disabled patients, many of whom cannot speak or communicate clearly.

“Despite a recommendation made more than 10 years ago by law enforcement consultants, the department has not created measurable short- and long-term goals for OPS,” the report concluded.

The Department of Developmental Services, which operates the centers and police force, agreed with the findings and said many of the prescribed fixes are already underway. The department declined to comment and referred to its formal response in the audit.

“The department recognizes that despite significant progress to date, more can be done to improve the safety of individuals residing at the facilities,” Terri Delgadillo, the department’s director, wrote in her response to the auditors’ findings.

State Sen. Carol Liu, D-Glendale, said the audit findings are disappointing, though not surprising.

“It doesn’t seem, as far as I’m concerned, that much has changed,” said Liu, who sponsored legislation last year to upgrade criminal investigations at the institutions. “I don’t know whether or not this can change behavior.”

While hailing the auditors’ work, Greg deGiere, public policy director for The Arc of California, which advocates for the developmentally disabled, said the police force should be completely independent from the Department of Developmental Services.

“The whole thing is clearly still under the department’s thumb,” he said. “There is a code of silence (at the centers), from both the top and the bottom.”

Among the force’s most pressing problems is a shortage of manpower, as 43 percent of its officer positions were vacant in 2012. 

“The use of overtime can be partially explained by staffing shortages due to budget cuts,” auditors said. “However, the amount of overtime in some cases is excessive and could endanger staff and developmental center residents.”

The audit also criticized the state Department of Public Health, which has regulatory authority over the developmental centers, saying the agency has not “consistently performed all of its required duties.” The department has failed to promptly investigate less-serious incidents or perform site inspections of the facilities in a timely manner.

In its formal response, the public health department agreed with most of the report’s conclusions. But the agency disagreed with the auditors’ recommendation that it set deadlines for incidents that do not involve serious risk or harm to patients.

Ryan Gabrielson

Ryan Gabrielson is a reporter for ProPublica covering the U.S. justice system. In 2013, his stories for the Center for Investigative Reporting on violent crimes at California’s board-and-care institutions for the developmentally disabled were a finalist for the Pulitzer Prize for Public Service.

Previously, he was a reporter at the East Valley Tribune in Mesa, Ariz. In 2009, he and Tribune colleague Paul Giblin won a Pulitzer Prize for stories that exposed how immigration enforcement by the Maricopa County Sheriff's Office undermined investigations and emergency response. Gabrielson's work has received numerous national honors, including two George Polk Awards, an Alfred I. duPont-Columbia Silver Baton, the Al Nakkula Award for Police Reporting, and a Sigma Delta Chi Award. He was a 2009-2010 investigative reporting fellow at UC Berkeley.

A Phoenix native, Gabrielson studied journalism at the University of Arizona and now lives in Oakland with his wife and two daughters.