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.

Taser - Facebook photo

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

Detectives found burn injuries on the patients, according to internal records obtained by California Watch, a project of the Center for Investigative Reporting. 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.

Taser - rifle photo

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

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.

Taser - Glock photo

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

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.

“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.

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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.