November 29, 2012 - Patients at California's board-and-care centers for the developmentally disabled have accused caretakers of molestation and rape 36 times during the past four years, but police assigned to protect them did not complete even the simplest tasks associated with investigating the alleged crimes, records and interviews show.
The Office of Protective Services, the police force at California's five developmental centers, failed to order a single hospital-supervised rape examination for any of these alleged victims between 2009 and 2012. At most other police departments, using a "rape kit" to collect evidence would be considered routine.
The procedure, performed by specially trained nurses, is widely regarded as the best way to find evidence of sexual abuse. Without physical evidence, it can be nearly impossible to solve sex crimes, especially those committed against people with cerebral palsy and profound intellectual disabilities.
In the three dozen cases of sexual abuse, documents obtained by California Watch reveal that patients suffered molestation, forced oral sex and vaginal lacerations. But for years, the state-run police force has moved so slowly and ineffectively that predators have stayed a step ahead of law enforcement or abused new victims, records show.
State officials responsible for the police force would not comment about specific abuse cases but emphasized that patient protection is the state's top priority. Officials also said they have ordered retraining for officers and added new procedures to better protect patients – moves that occurred after earlier California Watch stories.
Much of the alleged sexual abuse in the California institutions has occurred at the Sonoma Developmental Center, where female patients have been repeatedly assaulted, internal incident records show. In one case, a caregiver was cleared by the police department of assault and went on to molest a second patient.
In another case from August 2006, caregivers at the Sonoma center found dark blue bruises shaped like handprints covering the breasts of a patient named Jennifer. The patient accused a staff member of molestation, court records show. Jennifer's injuries appeared to be evidence of sexual abuse, indicating that someone had violently grabbed her.
The Office of Protective Services opened an investigation. But detectives took no action because the case relied heavily on the word of a woman with severe intellectual disabilities. A few months later, court records show, officials at the center had indisputable evidence that a crime had occurred.
Jennifer was pregnant.
By that time, her alleged attacker had vanished.
For the parents of the 32-year-old patient, the reaction has been disbelief and anger. They are now raising a 5-year-old boy who Jennifer is incapable of mothering. The child is precocious and strongly resembles his maternal grandmother.
"Every time, I just imagine her being raped and screaming and crying for me," said the woman's mother, whose name is being withheld to protect Jennifer's identity. "It just kills me."
The Office of Protective Services has not collected physical evidence to back up cases such as Jennifer's. In situations involving developmentally disabled patients, DNA and other physical evidence are even more important because statements from alleged victims often are treated as unreliable. Some have IQs in the single digits and cannot speak.
Detectives at city and county police departments are trained to send sexual assault victims to an outside hospital for the specialized rape examination. But the doctors and nurses at the state's developmental centers – in Sonoma, Los Angeles, Orange, Riverside and Tulare counties – were not trained in dealing with sexual assault victims, records and interviews show.
California Watch shared details of the developmental center sex abuse cases with two outside police detectives who specialize in such assault investigations. The detectives said they were dismayed by the state's actions.
"How can you do a sexual assault investigation and not do an exam?" said Roberta Hopewell, a detective at the Riverside Police Department and president of the California Sexual Assault Investigators Association.
According to interviews with former detectives and patrol officers at three of the state's developmental centers, the Office of Protective Services did not assign its own detectives to cases that should have been investigated – nor did the force seek expert help from outside law enforcement.
One former patrol officer said administrators were afraid of bad publicity.
"They didn't want anything to get out, so they handled it internally. They call the shots," said Joe Guardado, a former patrol officer at the Porterville Developmental Center in Tulare County who retired in 2010.
In September, California Watch presented its findings about the handling of sex abuse against patients to officials at the state Department of Developmental Services, which operates the five centers and oversees the Office of Protective Services, its 90-member police force.
Terri Delgadillo, the department's director, declined interview requests. Instead, the department issued a written statement saying the state is working to protect patients and ensure they receive justice. That includes hiring "nationally recognized law enforcement experts" to train police officers and detectives to better handle sex assault cases, the department said.
"In addition, training was provided to ensure that referrals for sexual assault examinations are completed by thoroughly trained personnel, and that investigations are conducted appropriately and timely," the department said.
Studies of crimes against the developmentally disabled have found that as many as 80 percent of women in this population are sexually assaulted during their lives. Many victims suffer repeated attacks.
In a series of stories this year, California Watch has reported that sworn officers at the institutions routinely failed to conduct basic police work in cases with criminal implications, including stun-gun assaults on multiple patients and a suspected homicide.
The facilities have documented hundreds of cases of abuse and unexplained injuries, almost none of which have led to arrests. Despite its sloppy record, the force managed to collect more overtime pay than other police agencies its size.
About 1,600 patients live at the five centers, which operate like board-and-care hospitals for patients whose conditions are so challenging that they cannot live with their families or in group homes. The population at these centers has been slowly declining. This year alone, the number of patients has dropped more than 10 percent.
Investigating sex crimes against this vulnerable population falls to the Office of Protective Services, a unique police force that operates round-the-clock in these institutions.
But the detectives and patrol officers have been unprepared to undertake such cases, internal case files show. The records indicate officers have lacked the skills to competently question sex abuse victims, particularly the developmentally disabled.
Detectives at times closed investigations when patients appeared to get the dates and times of assaults wrong, even though the disabled frequently struggle with precise chronology.
At the Sonoma Developmental Center, which houses about 500 men and women, two patients accused a caregiver of forcing them to perform oral sex on him.
The Office of Protective Services was first alerted in February 2009. "Client reported to staff that she saw (the caregiver's) genitals and was asked to perform oral sex for a dollar," the records said. "Client reports that she did."
However, the Office of Protective Services quickly closed the case, the records indicate, because the suspect was not listed as having worked in the patient's unit, called Corcoran, on the day of the alleged abuse. The accused caregiver did often work in that unit, though, internal records show.
Months later, the mother of a second patient alerted the center that her daughter had said she had licked the same caregiver's penis.
But by then, the accused caregiver was gone. He is not identified by his full name in state records. The center's incident log noted that the psychiatric technician suspected of the abuse was "no longer employed" but "did work on the unit."
Sexual abuse cases reviewed
Earlier this year, Leslie Morrison, head of the investigations unit at Disability Rights California, examined dozens of case files in which a patient accused a center employee of sexual abuse from 2009 to mid-2012. Morrison performed the review at the request of the state Department of Developmental Services. She said these cases involved only patients capable of speaking and therefore able to report an assault.
Disability Rights, a protection and advocacy organization, has access to full patient files under state and federal law. Many of these records are confidential, but California Watch was able to obtain through other sources some of the documents provided to Disability Rights.
California Watch's parent organization, the Center for Investigative Reporting, has sued the state for additional abuse records that can shed more light on these and other cases. A superior court judge ruled that the state should open its records, but the state is appealing.
Morrison said she found 36 cases in which victims likely should have received a rape kit medical exam and interview with a trained nurse. But, she said, the Office of Protective Services investigations were incomplete and at times deeply flawed.
"We're not sure they have the training to do these very delicate, sensitive interviews," Morrison said.
Disability Rights argues that outside law enforcement and forensic nurses – who have years of experience interviewing victims and identifyingphysical evidence – should have taken over the institutions' sex crime cases.
"You're better off referring it to the specially trained people whose job it is to do that and only that," Morrison said.
The Department of Developmental Services now agrees, according to its written statement.
Gov. Jerry Brown in September signed legislation requiring that the centers report alleged sex assaults against patients to outside law enforcement. The new law, SB 1522, "will ensure developmental center investigators and outside law enforcement agencies work collaboratively to investigate unexplained injuries or allegations of abuse," the statement said.
The centers have a long history of sex abuse against patients, which California Watch reported in stories earlier this year.
In one case from early 2000, police records show, a female patient at the Sonoma Developmental Center accused a male caregiver of sexually assaulting her during a bath. The institution then assigned two men to bathe the patient, even though the facility employed many female caregivers.
Both caregivers allegedly raped her on July 6, 2000, during bathing.
Developmental center officials did not report details about the assaults to the Office of Protective Services. Four days after the second alleged rape, the police commander at the Sonoma facility received an anonymous tip about the incident. Officials launched an investigation, but no arrests were made.
Early struggles in Jennifer's care
Few cases are more disturbing than that of Jennifer, the former Sonoma Developmental Center patient who suffers from bipolar disorder and attention deficit and hyperactivity disorder, in addition to severe intellectual disabilities, the patient's medical records show.
For most of Jennifer's childhood, her mother said, doctors struggled to pinpoint what drove her daughter's outbursts. When angered, she would scream and slap herself and anyone else within reach. Other times, she was sweet, even overjoyed when surrounded by her parents and siblings, her mother said.
Jennifer lived peacefully enough in one group home until she was about 14. Her behavior turned unstable, and the teenager was regularly moved among privately run homes in the community that proved ill-equipped to care for her.
"She started (going) from group home to group home to group home," her mother said in an interview. California Watch does not identify victims of sexual assault or their immediate family members.
Patient advocates had told her mother that the best way to diagnose and treat her daughter's behavioral conditions would be to admit her to an institution. She would be observed at all times, they told her; developmental center staff members are far more experienced at prescribing drugs to tame disorders.
Her mother said she was wary and resisted the advice – initially. But she also was exhausted from years of strain overseeing Jennifer's care without a complete diagnosis. She relented in 2002, and Jennifer, then 27, moved into the Sonoma Developmental Center.
"To have her on the right course of medication, that was the only reason to have her there," Jennifer's mother said.
At the time, the Sonoma center housed about 850 patients and was the nation's largest institution for the profoundly developmentally disabled. Built more than a 100 years ago in wine country, it is an open campus, flush with green lawns and walking paths.
From outside, Sonoma's residences resemble single-family homes more than dormitories, featuring front stoops and yards. Patients lounge together on porch swings.
Sonoma administrators assigned Jennifer to the Corcoran Unit, a peach-colored building tucked in the center's far eastern end. Its red tile roof is covered with dead leaves and branches from the towering oak tree that shades the residence's main entrance.
Everything was fine for a few years, the mother said. Her daughter came home many weekends. At times, however, her mother noticed injuries.
Bruises were not necessarily alarming. Jennifer would occasionally hurt herself. At one point, Jennifer cut her scalp badly. The Sonoma caregivers explained that she had been banging her head against the wall, her mother said. The center put Jennifer in her own bedroom, padded the walls and fitted her with a helmet.
Injuries, then pregnancy
In 2006, the patient's injuries changed. Bite marks broke her skin and bruises surfaced on her back and breasts. Court records show Jennifer accused a Sonoma caregiver of touching and bruising her. She showed the center's employees and her mother the resulting injuries.
The mother said someone clearly had been grabbing Jennifer's breasts with violent force. The bruises were unlike anything she had ever seen on her daughter.
"I can tell if a bruise was an accident because she bruises easily; I bruise easily," she said. "That's not a big deal. But I could tell when a bruise is really not a bruise, you know what I mean?"
A social worker at the Sonoma center told the mother that the Office of Protective Services had investigated the matter thoroughly, but detectives couldn't prove Jennifer's allegation that the caregiver had bruised her.
"Of course, it's her word against his," Jennifer's mother said. "Nothing was done."
Records show the institution's doctors, nurses and caregivers overlooked or ignored her pregnancy until Jennifer was well into her second trimester. Jennifer's disabilities make her incapable of giving consent to sex. Her mother discovered Jennifer's swollen belly during a weekend visit at her family's home in July 2007. Under state law, any sexual intercourse with a patient lacking the intellectual capacity to consent is considered rape.
Jennifer's son was born by cesarean section in October. No one was arrested in Jennifer's rape.
"I was a hands-on mom, and I fought for my daughter's security," Jennifer's mother said. "And I still wasn't able to protect her. Who protects these people?"
The month that Jennifer gave birth, the Office of Protective Services received a letter from a whistle-blower that named a janitor as the alleged rapist, but didn't inform the Sonoma County Sheriff's Office about the lead for three months, according to court records from a lawsuit Jennifer's family filed against the state.
By then, the accused janitor had fled the country, court records said.
Regardless, the institution's officers did not attempt to gather physical evidence through a sex assault examination that might have supported criminal prosecution of Jennifer's assailant. And the center's internal records show that patients have continued to allege sex abuse in the unit where Jennifer lived.
Her family settled a civil lawsuit with state Department of Developmental Services for $100,000. Jennifer now lives in her own apartment. Like all California residents with developmental disabilities, Jennifer is entitled to and receives services from the state.
Her mother and family members and have hired a caregiver to take care of her. They are all women.
Few sex crimes referred for prosecution
Statewide, the Office of Protective Services referred just three sex crime cases to county district attorneys for prosecution since 2009, said Morrison with Disability Rights California. In those cases, officers did not collect any physical evidence to determine whether crimes occurred. Just one of those cases led to an arrest.
In one incident from January at the Sonoma Developmental Center, caregivers noticed that two female roommates appeared to have injuries suggesting abuse – bruises on their faces and arms. The caregivers told the Office of Protective Services, but there was no detailed investigation.
In May, another employee of the center caught a longtime caregiver, Rue Denoncourt, exposing himself to one of those female patients in a bathroom. The colleague reported the incident to the Office of Protective Services, which then notified the Sonoma County Sheriff's Office.
The sheriff's office interviewed Denoncourt, who confessed to exposing himself and sexually abusing the victim's roommate, forcing her to touch him while he masturbated.
Even after Denoncourt admitted to the abuse, records from the state Department of Public Health show neither the sheriff's office nor the Office of Protective Services sent the victims to receive sexual assault examinations. If evidence of other assaults was available, it was lost.
No investigation took place into the bruises that were discovered on both women in January, although the health department raised suspicions about Denoncourt in its report.
Denoncourt pleaded no contest to a lewd conduct charge in August and is serving an eight-month prison term. The Sonoma County sheriff and district attorney declined to comment for this story.
Allegations of interference
Three former members of the Office of Protective Services allege that administrators and other employees at developmental centers have interfered with abuse investigations.
Pete Araujo, a former investigator at the Fairview Developmental Center in Orange County, said his commander refused to approve sex assault exams for victims. Araujo said his superiors provided no explanation for denying the exams, and no one within the force challenged the decisions.
"Their word was final," said Araujo, who is now an investigator for the California State Lottery Commission. "They were the managers."
Employees at the institutions have delayed notifying police of alleged sexual abuse for days, said Greg Wardwell, a 20-year veteran patrol officer and sergeant at the Sonoma center. The lost time can leave physical evidence open to contamination and witnesses vulnerable to coercion.
Wardwell, who retired in March 2011, said center administrators did not punish employees for withholding information about abuse.
"It's very frustrating at the point that someone is genuinely victimized and you didn't find out about it for four or five days," Wardwell said. "There is no sanction at the point that somebody sits on the information."
The Department of Developmental Services did not respond to the officers' allegations of interference.
Policy hinders investigations
The Office of Protective Services' own policy has made it difficult for officers to order sexual assault exams. For patients to receive an exam, the guidelines require that "a sexual assault occurred within the preceding 72 hours and there is potential for recovery of physical evidence of the recent sexual assault."
The "and" is underlined and italicized in the written policy.
Experts on sex assault investigations said using the words "potential for recovery" threatens to shut off an investigation before it starts. Detectives cannot determine what evidence is present before a medical exam.
"That latter part shouldn't even be in there," said Linda Ledray, a forensic nurse and director of the Sexual Assault Resource Service in Minneapolis. "I mean, that's crazy."
Kim Lonsway, research director for End Violence Against Women International, agreed that the Office of Protective Services' sex assault policy could undermine investigations.
"The tone of this is the exams are going to be the exception rather than the rule," Lonsway said.
Further, the 72-hour time limit is outdated, said Hopewell, the Riverside police detective. Hopewell said physical evidence sometimes is recoverable two weeks after an assault. She will request a medical exam even in cases in which a victim was attacked two years earlier, because scars can be shown to support allegations.
Delgadillo, director of the state Department of Developmental Services, implemented the Office of Protective Services' first policy on investigating sex assault four years ago. The department had no specific guidelines for police on investigating sex abuse before 2008, only that they be required to complete a state minimum of four hours of training.
Experts said many cases are hampered because some investigators, administrators and even family members distrust allegations by the intellectually disabled. Detectives investigating sex crimes against the disabled often need special training in the nuances of extracting evidence from these types of patients. Such training has never been offered to the state police force.
"Even if it is reported, the victim is often not believed or is thought to be fantasizing or to have merely misinterpreted what occurred," Joan R. Petersilia, a criminology professor at UC Irvine, wrote in a 2001 study of disabled victims. "This leaves the person with a disability continually vulnerable to victimization, because perpetrators come to learn they may victimize them without fear of consequences."
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