Disabled California Residents Suffering from Lack of Procedure and Enforcement

The California Department of Developmental Services (department) is putting Californians with developmental disabilities who are cared for at state facilities at risk by failing to update policies and by conducting inadequate investigations of abuse, according to a recent report by the California State Auditor’s office. Oversight of resident safety must be improved, says the auditor. The department cares for approximately 1,480 people in five facilities throughout the state. The Office of Protective Services (OPS) was set up specifically to protect the developmentally disabled living in the state’s remaining board-and-care centers, but very few violent crime cases at the institutions have resulted in criminal charges. The auditor reviewed 48 OPS investigations and found 54 deficiencies in 267 applicable observations.

Failure to Follow Procedure

Based on its findings, the auditor noted that it is clear the OPS did not routinely follow its established procedures for investigations of alleged abuse. For example, OPS often did not collect written declarations from witnesses and suspects during incident investigations, did not take photographs of crime scenes or alleged victims, and did not always attempt to interview alleged victims, particularly residents who were said to be nonverbal. According to the auditor, these deficiencies cast doubt on the OPS’ quality assurance process, which includes supervisory reviews, and caused the department to have less assurance that its OPS investigation conclusions are correct.

Currently, the auditor’s office noted, when health care staff discover that a resident has experienced an injury or inappropriate risk of harm, they must report the incident and also initiate a review of the circumstances. Although the reviews themselves are generally completed according to appropriate procedure, they do not always provide timely notification to the OPS. Each developmental center has OPS law enforcement officers on-site, but they are not adhering to proper procedures. In addition to general patrol and traffic enforcement duties, the OPS officers are expected to respond to alleged abuse of residents. What auditors found, though, is that the OPS failed to act on allegations that residents have been raped, shot with stun guns, and otherwise abused.

Frequent Turnover

The California State Auditor’s report also said that frequent turnover in the OPS management may have contributed to a lack of action to address problems. This includes a lack of specialized training for investigators, which was first identified in 2002. There is a 43 percent vacancy rate in the OPS, auditors said, which could be due in part to the amount of overtime required to staff the facilities. Budget cuts were cited for a partial explanation for the staffing shortages.