Public health abuse - Elsie Fossum photo

Abuse was suspected in Elsie Fossum’s death, but the Department of Public Health dismissed it as an accidental fall. Her case languished for seven years before it was closed.Courtesy of the Fossum family

CLAREMONT, Calif. – Sabrina Bengoa was vocal about her dislike of the messier tasks of caring for the elderly. The nursing assistant loathed changing diapers. At times, patients’ steps were too slow, and she’d grab their arms to pull them forward.

“I wish we could medicate them and tie them down when they piss me off,” Bengoa told her colleagues at the east Los Angeles County assisted living home where she worked the night shift, state records show.

Bengoa’s grievances seemed strongest against Elsie Fossum, a 95-year-old woman with wispy white hair and a reserved nature, colleagues said.“I can’t handle her,” Bengoa said.

Bengoa was the lone caregiver with Fossum during the predawn hours at Claremont Place Assisted Living, a tan two-story complex built to resemble an oversized suburban single-family house.

After sunrise July 3, 2006, Fossum lay crumpled on her bedroom floor. Her right arm was broken at the shoulder, her eyes bruising black, her upper lip cut open.

“She looked like her face had been hit by a Mack truck,” recalled Beverlee McPherson, Claremont Place’s nursing director at the time. “It was very gruesome. She was beaten to a pulp.”

Fossum, who was rushed to the hospital, died nearly three weeks later of dehydration, unable or unwilling to eat or drink through her swollen mouth. At Claremont Place, caregivers made it clear that they believed Bengoa had attacked Fossum.

But for seven years, Fossum’s death lingered in a regulatory backwater. The state Department of Public Health, which monitors and licenses nursing assistants and home health aides, did almost nothing to investigate what happened.

Fossum’s case was lost in a pileup of health care abuse cases at the department. Documents show state regulators effectively shelved more than 900 cases from Southern California, including the most alarming allegations that involved suspicious deaths.

Fossum’s case was one of them.

All along the line, Fossum’s case languished. The state Department of Social Services, which regulates assisted living facilities, produced a detailed report that sat neglected for years. The Los Angeles County coroner said the manner of her death was undetermined. With more information, the medical examiner said, the case could be reopened.

Claremont police handed over the case to the Los Angeles County Sheriff’s Department, which delayed a criminal investigation while it waited for public health regulators to determine whether Fossum died because of an accident or a beating.

The Department of Public Health finally closed its own case in February – almost seven years after Fossum’s death – calling the allegation of abuse unsubstantiated.

When the Department of Public Health delivered its report to the sheriff’s department this year, a detective there quickly opened a criminal investigation. That case – built on autopsy records, witness testimony and regulatory records – remains open. Bengoa has not been charged with a crime.

Bengoa resigned from Claremont Place a few days after Fossum was injured. She took a job at another assisted living facility about five minutes away but later was fired for lying on her application. It’s unclear where she works now, if anywhere. Her record has been erased from the state’s public licensing database.

In a Department of Social Services report on the incident, Bengoa denied harming Fossum. She did not respond to multiple requests for comment.

Fossum’s life stretched over nearly a century, much of it devoted to teaching children and service to her church. It ended in a burst of unexplained violence and indifference, as state officials failed to pursue answers about her death.

“You think safeguards are in place, and you think that staff are qualified and that this is being regulated,” said Janet Flynn, Fossum’s niece. “This I find chilling.”

Dr. Ron Chapman, California’s public health director, said the department now is repairing its investigations section. Chapman was unfamiliar with the allegations against Bengoa before an interview last month with The Center for Investigative Reporting and KQED.

“What you describe, it sounds absolutely horrible,” he said. “We should be doing investigations on all complaints. If that’s not occurring, that’s a problem and we need to address it.”

Fossum’s death should have been classified as high priority and investigated with urgency, Anita Gore, a Department of Public Health spokeswoman, acknowledged in a written statement. “We regret that did not happen.”

From farm life to teaching

Born in North Dakota, Fossum was as skinny and fair-skinned as her Scandinavian ancestors and wore her almond-brown hair in cropped curls. She grew up learning in one-room schools and helping in the fields.

Farm life didn’t hold her.

After college, she took a teaching job in 1946 at a Los Angeles-area junior high school. Fossum settled comfortably in bright Southern California. She shifted her career slightly, taking a school librarian job, and began sharing an apartment with Lula Hohensee, a teacher who became her lifelong companion.

For all her charisma, Fossum was defined by the restraint she developed on her isolated North Dakota farm. She would have a drink at gatherings, though not more than one, Flynn said. She was loath to complain.

She traveled ambitiously with Hohensee to destinations in Europe and Asia. Upon her retirement in 1973, she stopped dying her hair its original brown and let it go white, which her relatives took as a sign of relaxation.

She displayed the first signs of physical and mental decline on a flight to Minnesota in 2001, when she was 90, for her brother’s funeral. Fossum became disoriented, Flynn said, and “we decided that was her last flying trip.”

A year later, Fossum fell and injured herself while working at First Lutheran Church in Pomona. She had no relatives nearby, and regardless, she and Hohensee wanted to remain together. A move to assisted living became inevitable.

Public health abuse - Fossum family photo

Elsie Fossum (bottom left) is seen with family members Judy and Bill McLean (back row) and her longtime companion, Lula Hohensee.Courtesy of the Fossum family

They moved into Claremont Place, an airy building around a courtyard of flowers. Bandstand hits play in the background in its communal spaces. Fossum and Hohensee took rooms next door to each other.

Hohensee’s room was their preferred space, a point of frustration for some of the facility’s nighttime caregivers. McPherson, the former nursing director, said nursing assistants working that shift try to keep residents on a schedule: use the bathroom by a certain time, in bed shortly thereafter, then lights out until sunrise and the end of evening shift.

Claremont Place residents are supposed to keep their own hours. Fossum liked to be with Hohensee into the evening, as she’d done for nearly 50 years. She resented being ordered into her own room, McPherson said.

Not known for her patience

Sabrina Bengoa started her career at the Inland Valley Care and Rehabilitation Center in Pomona, where she was hired as a nursing assistant in February 2005, a couple of weeks before the state formally certified her.

She didn’t last long. The center fired her after six months for “substandard care and working outside her assigned station,” according to a state Department of Social Services report.

She joined the staff at Claremont Place Assisted Living in early 2006. Explaining why her tenure at Inland Valley was so brief, she wrote on her application, “Politics/Office Political Issues,” state records show.

Bengoa was 26 years old at the time and working Claremont Place’s least desirable shift, 11 p.m. to 7 a.m. She wasn’t fond of her assignment and made her feelings known.

Ozonna Wilson, a Claremont Place colleague, told regulators that Bengoa complained about working alone with assisted living residents, who are given more independence. Bengoa boasted to Wilson that at a previous job, she tied down patients “if they acted up.”

The nursing assistant had little patience for Fossum and regularly ridiculed her as “fucking slow,” the regulator report states.

“God, I wish she would hurry up and move,” Bengoa told Karen Morgan, another Claremont Place nursing aide.

Bengoa’s irritation also came out physically. She was rough when changing diapers and moving residents from their wheelchairs to bed and vice versa, former colleagues said.

No one reported seeing Bengoa strike or shove a resident. There is no indication she had been reprimanded for her performance prior to Fossum’s injuries.    

Emergency situation

At about 6:20 a.m. July 3, 2006, Bengoa walked out of Fossum’s room and got the attention of another caregiver.

“I need your help,” Bengoa said. “Elsie just fell on the floor.”

LaRonda Holloway, a nurse aide, stood nearby in the hallway with medication technician Michelle Molitor. Bengoa called the situation an “emergency,” regulatory records show.

In the Department of Social Services investigative report, colleagues said that Bengoa’s face was absent of alarm amid the crisis and that “she did not seem especially concerned.”

Molitor directed Holloway to call for paramedics and hustled into Fossum’s room. By then, Fossum was sitting up on the floor, clasping her black purse against her legs, blood still running from her mouth, the report said. It’s unclear who moved Fossum upright or whether she moved herself.

Bengoa grabbed towels, which Molitor used in a first attempt to stanch the blood loss. Immediately, Molitor believed Fossum had landed too far from her bed, and the physical damage appeared far too severe for her to have fallen, the report said.

If she’d landed on her face, her nose likely would have showed injuries. And it didn’t.

McPherson, the nurse director, went to her office and checked with her assistant about the frenzy of activity. The assistant said she’d heard Fossum had fallen and broken her nose. Paramedics had rushed Fossum to an emergency room, and police likely were en route.

Public health abuse - Beverlee McPherson photo

Beverlee McPherson was Claremont Place’s nursing director when Elsie Fossum suffered serious injuries in 2006. “She looked like her face had been hit by a Mack truck,” she recalled.
Adithya Sambamurthy/The Center for Investigative Reporting

“She fell out of bed, and we’re bringing in the SWAT team?” McPherson wondered aloud.

McPherson went to speak with her boss, Carol Lininger, then Claremont Place’s executive director, who had few answers about what happened. Lininger instructed McPherson not to disturb anything in Fossum’s room.

“I know not to touch a crime scene,” McPherson replied, and set off to see it for herself.

In an interview, McPherson said she saw blood sprayed across the room, marking the walls, headboard and nightstand. It pooled beneath Fossum and soaked the carpet. McPherson said there was so much blood in the bedroom, more than the carpet could absorb. She said it formed a pool of red about 3 square feet in size.

Nausea unbalanced McPherson for a moment.

She composed herself and noticed one of the paramedics remained in the room. He was studying the physical evidence.

“Do you honestly believe this was a fall out of bed?” McPherson remembers asking.

“That’s what we’re investigating,” she recalls the medic saying.

At one point that day, McPherson said Bengoa told her: “I’m not going to get blamed for her (Fossum’s) broken arm.”

Abuse suspected

Fossum was taken to the Pomona Valley Hospital Medical Center. The staff there wasn’t convinced Fossum’s injuries were accidental, regulatory records show. Fossum was disoriented and said she couldn’t remember falling.

A doctor stitched the gashes inside her mouth and on her upper lip. She received two units of blood. Her fractured arm was fitted into a shoulder brace.

Nurses discovered other bruises on Fossum’s lower back and pelvis, which raised a new complication. Did she fall on her face or her back? And if it was the latter, what or who damaged Fossum’s face?

“Although I feel that most of her injuries can be explained simply to fall,” the attending physician wrote in Fossum’s medical records, “there is some concern by the nursing staff which I must respect that this additional bruising may represent the possibility of abuse.”

The doctor alerted the state Department of Public Health and local police, according to state regulatory records.

Public health abuse - Claremont Place photo

Elsie Fossum lived at Claremont Place Assisted Living in Southern California for two years before she died.Adithya Sambamurthy/The Center for Investigative Reporting

Two days later, the hospital discharged Fossum back to Claremont Place. Her face still was swollen badly.

After Fossum returned to Claremont Place, Lininger, the facility director, called Donald Wilson, a longtime friend of Fossum and Hohensee’s, to say the injuries might signal abuse.

“This is the first notification of this possibility,” Wilson wrote in his meticulous diary of the events, which he provided to Fossum’s family.

Lininger called him again the next day. A Claremont police officer took pictures of Fossum’s face and bloodstains in her room, and Lininger put Bengoa on paid leave, the diary said, “pending further investigation.”

It’s unclear what investigation took place in the days that followed, but Bengoa decided to quit her Claremont Place job.

“The caregiver in question did resign her job when confronted with the facts,” Wilson wrote in his July 18 entry.

After she quit, Bengoa took a job at a nearby facility, Claremont Manor.

Fossum largely stopped speaking. When questioned by the Claremont police, she insisted that she’d fallen on accident. “I can’t tell you something happened when it didn’t,” Fossum said, according to the police report.

She repeated the same thing to Wilson and Claremont Place employees. They weren’t convinced. McPherson said Fossum likely feared what would happen to her longtime companion, Lula Hohensee.

“At any cost, she was protecting Lula,” McPherson said.

Hohensee died in early 2007, at age 100.

The Los Angeles County Coroner’s Department ruled the manner of Fossum’s death “undetermined,” because “allegations of assault could not be ruled out.”

Soon after she died, Claremont police deferred the investigation to the Los Angeles County Sheriff’s Department.

More than a year after Fossum died, on Aug. 1, 2007, a simple notation in the public health department’s log shows the case was assigned to Department of Public Health investigator Reginald Mitchell.

Four years later, Mitchell’s supervisor sent him an email asking about the case. In his reply, Mitchell reported only that he was “still reviewing this case.”

Reached by phone, Mitchell declined to answer questions about his investigations. “I cannot comment on allegations; state employees can’t do that,” he said. “It’s not worth my career, sir.”

Mitchell now works for the state Department of Consumer Affairs.

Last year, the California Department of Social Services issued a report on Fossum’s case, saying “the unrefuted evidence” proves Bengoa was prone to “sustained and bitter railing against her elderly charges” and her employer.

“It is an understatement that respondent was temperamentally ill-suited to render the services required of her as a nursing assistant,” the report reads.

As a result, the Department of Social Services barred Bengoa from working in the facilities it regulates, including assistant living homes like Claremont Place. 

But according to state records, Bengoa is not listed among the people banned from working in thousands of other health care facilities, including nursing homes, overseen by the Department of Public Health.

KQED reporter Mina Kim and CIR senior data reporter Agustin Armendariz contributed to this report. This story was edited by Robert Salladay and copy edited by Nikki Frick and Christine Lee.

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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.