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.
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.
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Abuse findings continue at developmental centers, despite state scrutiny