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Sonoma Developmental Center -- Investigations or Cover-ups?

2013
Dec. 4: Petaluma doctor fired for reporting patient abuse wins lawsuit
2005
Dec 16: Investigators Ask For More Clues In SDC Resident's Death
2004
July 27: Whistle-blowing Cop Says Exposing Institution Problems Was "Right Thing To Do"
2003
September 19: EEOC Okays Whistle-Blowing Campus Police Chief To Sue Institution & State Agency
2002
February 22: Federal jury awards SDC police chief $405,000 (Sonoma Index-Tribune)
February 26: Coroner looks into SDC client's death (Sonoma Index-Tribune)
March 7: SDC chief 'vindicated' by jury's decision (Sonoma Index-Tribune)
March 12: Editorial: Justice, but not for all (Sonoma Index-Tribune)
March 19: Editorial: Part II - Justice, but not for all (Sonoma Index-Tribune)
May 20: Resident Stabbing Not Immediately Reported
June 3: Former SDC doctor awarded $250,000 (Sonoma Index-Tribune)
June 27: Proposal Would Require Facilities To Identify Graves
October 10: Judge Rules For SDC Police Chief
October 14: Good Cop Driven Out
October 21: Overdose Death Investigation Closed, Cause Remains A Mystery
2001
March 27: Directors Play Musical Chairs As Claims Mount
March 30: Staff Members Suspended During Investigation
June 8: Campus Police Say Institution Is Unsafe For Police And Staff
August 8: Deaths And Abuses Must Be Reported, New Law Says
August 31: Family Sues Sonoma Developmental Center Over Man's Death
September 20: Janitor gets 6 years in SDC rape (Sonoma Index-Tribune)
September 24: SDC, sheriff hammer out investigation agreement (Sonoma Index-Tribune)
October 9: Agreement Brings Outside Law Enforcement Into SDC
November 12: Editorial: DDS rotten at the top (Sonoma Index-Tribune)
2000
June 19: SDC--Investigation or Cover-up?
June 23: Developmental Center Downplays Cuts
June 30: Developmental Centers to Renovate . . .or Close?
July 6: Officials Share Few Details On What To Do About Centers
November 17: Aging Institution To Be Preserved

SDC--INVESTIGATION OR COVER-UP?
June 19, 2000 through August 28, 2000

ELDRIDGE, CALIFORNIA--Sonoma Developmental Center, which houses over 800 people who have developmental disabilities, has been the focus of investigations by federal and state officials because of poor quality of care and for not protecting residents from assaults by staff and other residents.

Over a two month period, Sonoma's local newspaper looked at how investigations into those incidents were botched or covered up. Research into several recent incidents involving physical and sexual assaults and a drug overdose led some inside and outside the institution to believe that the state either does not want to know what happened or does not know how to properly investigate such incidents.

The Sonoma Index-Tribune looked at SDC's own investigative practices including the fact that they hired inadequately trained, under-qualified, unsupervised investigators; that site administrators were called into incident scenes before investigators arrived; and the conflict of interest that exists because investigators are employed by the very facility they investigate.

The paper also looked at how the center and state officials appeared to ignor recommendations that could have improved the safety and lives of SDC residents, how lawmakers failed to follow up on recommendations, and how fear of retaliation from coworkers and administrators keeps some SDC workers from reporting abuses.

The series ended up including five different installments, which can be accessed through this Inclusion Daily Express webpage:
"SDC -- INVESTIGATION OR COVER-UP?"

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DEVELOPMENTAL CENTER DOWNPLAYS CUTS
By Dave Reynolds, Inclusion Daily Express
June 23, 2000

ELDRIDGE, CALIFORNIA--Sonoma Development Center is facing up to $35 million in cuts because it has repeatedly failed to meet four of eight guidelines regarding residents' safety and treatment.

The institution has also been recently hit with a $40,000 fine for citations over an alleged rape of one client by another. Together, the cuts amount to more than one-fourth of the facility's $135 million annual budget. But institution officials downplayed the cuts Wednesday, saying there will be no negative impact on resident care or on staffing levels.

"This isn't a permanent situation, this is an interim situation," said Tim Meeker, SDC's executive director. "The funds flow from the feds to the state, and the state gives us a budget. . . The state will give us the same budget - all it means is the state picks up the difference."

The center continues to suggest that the alleged sexual assault of a 20-year-old female resident by a 60-year-old accused sex offender was possibly consensual in nature.

The Sonoma Index-Tribune, which has been decidedly pro-institution, may be starting to suspect that there is more than meets the eye, as it includes the following quote from an unnamed source: "These things are just a small part of what's wrong at SDC."
Here are four items from this week's Index-Tribune:
"SDC FACES FUNDING CUTS, FINES"

"EDITORIAL -- NO JOY AT SDC"

"QUESTIONS NEED FOR SDC"--(Letter to the editor from Bill Coffelt)

"SDC STORY - INVESTIGATION OR COVER-UP?"
Last week, the Index-Tribune ran the following article on SDC's mishandling of police files related to the death of a resident:
"DDS STRAINS BOUNDS OF CREDIBILITY"

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DEVELOPMENTAL CENTERS TO RENOVATE . . . OR CLOSE?
June 30, 2000
SACRAMENTO, CALIFORNIA--Most of the buildings on California's five institutional campuses are more than 50 years old. Some are over 100 years old.

Not only do these aging facilities, which house a total of 3,687 adults with developmental disabilities, have outdated plumbing, natural gas, ventilation and fire sprinkler systems, but they also present physical barriers to accessibility and are too crowded. A contractor told the Advisory Committee on Restructuring Developmental Center Services this week that it would cost the state between $300 million and $870 million to make the buildings safe, accessible and able to meet necessary standards.

But the state has only allocated $19 million this year, according to Bill Coffelt, an advocate for community supports. Coffelt suggests the state stop pouring money into renovating the old buildings and focus instead on shifting resources -- and residents -- into the community.

The committee is expected to come up with its final recommendations next March. More details from this article in today's Sonoma Index-Tribune:
"Panel weighs future of SDC, others"

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OFFICIALS SHARE FEW DETAILS ON WHAT TO DO ABOUT CENTERS
July 6, 2000
SONOMA, CALIFORNIA--Those who attended a two day session to discuss what to do about California's five ailing state operated institutions have yielded few details according to this updated report from the Sonoma Index Tribune:
"DDS tight-lipped on centers' future"

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AGING INSTITUTION TO BE PRESERVED
By Dave Reynolds, Inclusion Daily Express
November 17, 2000
ELDRIDGE, CALIFORNIA--Built right after the great earthquake of 1906 and vacant for the last 20 years, the Sonoma Developmental Center's old Main Building is literally falling apart.

Over the years, vandals have ruined many of the three-story building's hardwood floors. A hole in the roof has allowed weather to come inside and birds to take up residence. Sonoma Developmental Center, which began in 1891 as the "California Home for the Training and Care of Feeble Minded Children", now houses over 800 people with developmental disabilities. The institution has been losing hundreds of thousands of dollars in federal reimbursement over incidents of abuse and neglect.

Last month the Main Building, considered the oldest in the state's developmental center history, was placed on the National Register of Historic Places. This opens the door for organizers to apply for grant money to cover the $4 million cost of restoring and then preserving the decaying structure.

The state of California Department of Developmental Services, which owns the building, is already pitching in $300,000 to help get rid of asbestos and lead paint. Among other things, renovators found a safe containing old straitjackets and cuffs, according to this article from Thursday's Sonoma News:
"SDC building lands on historic list"

One group strongly supports restoring and preserving old buildings at former U.S. "asylums", many of which housed people with mental retardation and mental illness. They have put together a comprehensive website entitled
"HISTORIC ASYLUMS: THE VANISHING STATE HOSPITALS AND INSANE ASYLUMS OF AMERICA".
[Editor's Note: I found this website fascinating, but very, very sad when I stumbled onto and "bookmarked" it months ago. I will warn readers that some of the material on the site, particularly on the message boards, has a strong pro-institution bias. While the website's producers seem to be celebrating the preservation of these old facilities, I found myself torn between celebrating all of the institutions that have been closed and mourning for all of the years and lives lost behind their walls during the last century and a half. If any of these buildings need to be restored or preserved, let us do it in the same manner, and for the same purpose, that we preserve Auschwitz and other Nazi concentration camps -- so we will never again do what we, as a society, have done to people in these horrid places. -- Dave Reynolds]:
http://www.darkspire.org/asylums

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DIRECTORS PLAY MUSICAL CHAIRS AS ABUSE CLAIMS MOUNT
By Dave Reynolds, Inclusion Daily Express
March 27, 2001
ELDRIDGE, CALIFORNIA--Last year, Sonoma Developmental Center, an institution housing more than 800 people with developmental disabilities, lost millions of dollars in federal funding because of numerous documented cases of abuse and neglect. The problems were compounded by botched investigations and cover-ups by officials.

When executive director Tim Meeker announced his retirement this January, and Ruth Maples was moved from another institution to take his place, many thought SDC's troubles were over. After all, one of the first things Maples did in her new post was to demand that staff follow the institution's immediate reporting policies to the letter -- without exception.

According to Monday's Sonoma Index-Tribune, the staff are pretty much ignoring the institution's own policy and Maples' directives. So far this month, nine incidents of injuries and abuse are under official investigation -- all of which were reported over a four day span last week.

Unofficial reports from witnesses within SDC say most of those incidents were not reported, even to the campus police force, until several days after they occurred. Among other things, those sources claim that staff members teased and humiliated residents, and even held "beat down parties" during which several staff members ganged up on one specific resident.

Last Thursday, it was announced that Maples will be leaving SDC on April 10, to take the executive director position at Porterville Developmental Center, an institution near Bakersfield. Her replacement is Norm Kramer, the current director at Porterville.

Here is a story with details on the most recent abuse allegations from Monday's Sonoma I-T:
"SDC client abuse woes continue"

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STAFF MEMBERS SUSPENDED DURING INVESTIGATION
March 30, 2001
ELDRIDGE, CALIFORNIA--Five staff members at Sonoma Developmental Center, an institution housing more than 800 people with developmental disabilities, have been placed on paid administrative leave while officials investigate allegations of resident abuse.

The facility's acting chief of protective services, Gary Prince, said that since March 19 he has received nine reports of injury or abuses to residents "of an undetermined origin".

According to Thursday's Sonoma Index-Tribune, one of those reports involved what were referred to as "beat down parties", where several staff members would target one resident, then physically assault him or her. Other cases included allegations of staff members humiliating and slapping residents.

Some of those reports were not filed until several days after the incidents had taken place, in spite of a renewed emphasis by the administration on timely reporting.

Institution officials issued a list of actions taken last week to correct the problems, including revising the policy, training staff on the changes, and increased rounds by campus police, administrators, program managers and nursing staff.

In an editorial from Thursday's I-T, editor Bill Lynch lists other recent incidents of abuse, and puts the responsibility at the state level.

Here is that editorial:
"State fails to protect clients"

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Campus Police Say Institution Is Unsafe For Police And Staff
By Dave Reynolds, Inclusion Daily Express
June 8, 2001

ELDRIDGE, CALIFORNIA--"It's a time bomb waiting to go off," Officer Greg Wardwell told a reporter on Wednesday.

"It's only a matter of time before an officer or someone else in the equation is badly hurt."

Wardwell is one of six members of the Sonoma Developmental Center Police Department.

That's right, the institution which houses nearly 900 people with developmental disabilities has its very own police force.

And the officers don't feel safe.

Members of the department picketed in front of the facility, and were joined at times by other SDC employees. The offices say they need eight to 10 more officers, along with increased training and better safety equipment in order to be safe.

They also want permission to carry guns in the facility.

"We're responsible for 1,400 acres, 2 million square feet of building space, 900 clients, 2,000 staff members and we have only one officer on shift at a time, 24 hours a day, 7 days a week," Officer Larry Rhodes complained to the Santa Rosa Press Democrat.

The officers say they plan to continue the action until officials with the state's Department of Developmental Services respond to their demands. They say they can no longer work in such unsafe working conditions.

[Editor's note: Of course, this begs the question:
If it is an unsafe working condition for the police and the staff, what about the living condition for those 900 people living there -- the ones who cannot leave after their 8-hour shift?]

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Deaths And Abuses Must Be Reported, New Law Says
By Dave Reynolds, Inclusion Daily Express
August 8, 2001

ELDRIDGE, CALIFORNIA--The 3,800 Californians with developmental disabilities who are housed within the state's five institutions have a little bit more protection today than they did two weeks ago.

Legislation approved late last month by the state Assembly and signed into law by Governor Gray Davis requires the institutions, here called "developmental centers", to immediately report all resident "deaths and serious injuries of unknown origin" to their local law enforcement agency. Those local law enforcement officials can then decide on their own whether or not to conduct an independent investigation.

Under the new law, the state's Department of Developmental Services (DDS) is also required to give written information to every institution employee once a year that will explain mandatory reporting of suspected or known abuse; the rights and protections given to those who report suspected abuse (whistle-blowers); and the penalties they can expect if they fail to report abuse.

The measure was introduced this April by state Senator Wes Chesbro, following months of questionable deaths and injuries to residents of Sonoma Developmental Center, the state's largest institution that houses over 800 people with developmental disabilities. DDS has been criticized by some inside and outside the institution for the way it handled the investigations into those incidents.

A year ago the Sonoma Index-Tribune looked at SDC's own investigative practices, and learned that the facility had hired inadequately trained, under-qualified, unsupervised investigators; that site administrators were called into incident scenes before investigators arrived; and that a conflict of interest existed because investigators were employed by the same facility they were supposed to investigate. Some employees within the facility indicated that many incidents were never reported, in part because staff members were afraid of retaliation.

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Family Sues Sonoma Developmental Center Over Man's Death

August 31, 2001

ELDRIDGE, CALIFORNIA--On June 14, 1999, Raul Ochoa suddenly vomited, collapsed and died near a nursing station at Sonoma Developmental Center.

An SDC incident report two days later noted an autopsy had determined that Ochoa, 33, died of natural causes.

But three months after that, the official coroner's final report listed his cause of death as toxicity resulting from a "lethal amount of prescription medicine".

According to the Sonoma Index Tribune, Ochoa's family is now suing the institution for medical malpractice.

This link should redirect you to that story:
http://www.sonomanews.com/articles/2001/08/30/export6268.txt

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Agreement Brings Outside Law Enforcement Into SDC
By Dave Reynolds, Inclusion Daily Express
October 9, 2001

ELDRIDGE, CALIFORNIA--Administrators with Sonoma Developmental Center recently met with officials of the Sonoma County Sheriff's Department to come up with an agreement to aid the investigations of residents' deaths and suspected abuse at the institution.

Under the agreement officials at the institution that houses about 900 people with developmental disabilities would immediately report incidents to the Sheriff's Department, which may or may not decide to investigate further.

The meeting came as a result of legislation co-authored by state Senator Wes Chesbro and recently signed by Governor Gray Davis, that requires the state's five developmental centers to involve outside law enforcement agencies in such investigations.

Over the past two years, Sonoma Developmental Center has had a number of questionable deaths and injuries to its residents. Many of the investigations into those incidents were mishandled by SDC officials and state investigators to the point that many people have suggested the incidents were covered up.

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Resident Stabbing Not Immediately Reported
By Dave Reynolds, Inclusion Daily Express
May 20, 2002

ELDRIDGE, CALIFORNIA--A resident at Sonoma Developmental Center was allegedly stabbed by another resident earlier this month, an SDC spokesperson announced Thursday.

According to the Sonoma Index-Tribune, the man apparently was stabbed in the eye with a knife at 8:15 on the morning of Saturday, May 4. A physician at the institution determined that the man's wounds were serious enough to have him transferred to Santa Rosa Memorial Hospital for treatment.

Sonoma County Sheriff's Lieutenant Bruce Rochester said his department was notified about the incident at 9:54 a.m. -- more than an hour and a half later.

Last July, California lawmakers approved a measure requiring institutions, here called "developmental centers", to report to local law enforcement "immediately or as soon as practically possible" all resident "deaths and serious injuries of unknown origin". In January, SDC agreed to notify Sonoma County Sheriff's Department.

Over the past few years, Sonoma Developmental Center, which houses over 800 people who have developmental disabilities, has been the focus of investigations by federal and state officials because of poor quality of care and for not protecting residents from assaults by staff and other residents.

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Proposal Would Require Facilities To Identify Graves
By Dave Reynolds, Inclusion Daily Express
June 27, 2002

ELDRIDGE, CALIFORNIA--During the past 110 years, thousands of people have been admitted to Sonoma Developmental Center. Thousands have died there. And thousands have been buried on its grounds.

Now a bill in the state legislature would require SDC, along with the other state-run developmental centers and mental hospitals, to identify and collect accurate historical information on the people who are buried there. Introduced by Senator Wes Chesbro (D-Arcata), SB 1448 passed the Senate and last Tuesday was referred to the Assembly Appropriations Committee.

An estimated 20,000 people have died in state operated facilities in California since the 1850s. Many of those were never claimed by their families.

About 1,400 people are believed buried on the campus of SDC which opened in the 1880s as the "California Home for the Training and Care of Feeble Minded Children". Sonoma Developmental Center now houses over 800 people with developmental disabilities.

One SDC staff member says that California is only the sixth or seventh state to deal with this issue.

Freelance writer Pamela Gibson wrote this piece:
"Cemetery bill advances" (Sonoma Index-Tribune)
http://www.sonomanews.com/articles/2002/06/24/export2283.txt

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Judge Rules For SDC Police Chief
October 10, 2002
ELDRIDGE, CALIFORNIA-- Last month a judge in the U.S. District Court ordered the California Department of Developmental Services to give former Sonoma Developmental Center Police Chief Edward Contreras a pay raise based on the jury's conclusion that the department denied him a promotion in 1998 because he filed a discrimination claim.

King (Contrera's attorney) said that recently Contreras has been subjected to a series of actions that included demotion to sergeant, numerous derogatory "letters of instruction" being placed in his personnel file, being denied an opportunity to participate and interview for the senior special investigator position at SDC, being "blackballed" for other positions for which he is qualified, and threatened with disciplinary action for bringing his concerns about patient abuse to his superiors and the state legislature.

The court decision in Contreras' favor goes back to 1998, when he was denied a promotion to a position for which he was qualified. Part of his complaint was that the state was retaliating against him because he was critical of the department's failure to investigate incidents of patient abuse.

"Judge rules for SDC police chief" (Sonoma Index-Tribune)
http://www.sonomanews.com/articles/2002/10/10/export3292.txt

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Good Cop Driven Out
October 14, 2002
ELDRIDGE, CALIFORNIA--Ed Contreras, former police chief at Sonoma Developmental Center, announced last week that he is retiring. He is leaving to protect his own health because the people who should protect him won't.

He made the mistake of being critical of the state's law enforcement and investigative procedures at SDC. His criticism was valid, based on facts and supported by documentation. That didn't matter to the bureaucrats. Whistleblowers in state service are doomed. When Contreras made the decision to report his concerns to state legislators, he became a marked man.

"Editorial: Good cop driven out" (Sonoma Index-Tribune)
http://www.sonomanews.com/articles/2002/10/14/export3336.txt

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Overdose Death Investigation Closed, Cause Remains A Mystery
By Dave Reynolds, Inclusion Daily Express
October 21, 2002

ELDRIDGE, CALIFORNIA--Shortly after 8 p.m on April 2 of this year, Nicholas Turley collapsed at Sonoma Developmental Center. He was declared dead 37 hours later at a local hospital.

He was 14 years of age.

This past Wednesday, chief deputy coroner Will Wallman said toxicology results indicated that Turley died from an overdose of phenobarbital, a barbituate that is commonly used as a sedative and to control seizures. The lab report showed that Turley's system had 75 milligrams of phenobarbital per liter of blood -- nearly twice as much as what is considered safe.

"It's hard to get that level in a person's system," Wallman explained. "Phenobarbital is . . . slow to uptake and slow to release. Administered twice a day (as in Turley's case), it should balance out to about 35 milligrams per liter."

Despite an intense investigation, officials have not been able to determine how the overdose happened. The investigation is being closed.

"It could be a case of mistaken medication (or) mistaken administration (of medication)," Wallman said, adding that he couldn't rule out an intentional overdose.

"Natural, homicide, accident, suicide - we don't have enough to pin it on any of those four, so it's 'could not be determined,'" Wallman said.

The death is the latest of a string of unsolved or questionable deaths and injuries at Sonoma Developmental Center, the institution in Northern California that houses over 800 people with developmental disabilities.

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"SDC patient death unresolved" (Sonoma News-Index)
http://www.sonomanews.com/articles/2002/10/17/export3359.txt

EEOC Okays Whistle-Blowing Campus Police Chief To Sue Institution & State Agency
By Dave Reynolds, Inclusion Daily Express
September 19, 2003

ELDRIDGE, CALIFORNIA--A former campus police chief who blew the whistle on troubles with investigations of resident abuses, neglect and questionable deaths at Sonoma Developmental Center, has been given the green light by a federal agency to file a civil rights lawsuit against the institution and the state.

The U.S. Equal Employment Opportunity Commission determined on September 4 that officials at SDC and the California Department of Developmental Services retaliated against former SDC Police Chief Edward Contreras in violation of his civil rights, after he had won an earlier civil rights case against them. In that case, Contreras was awarded $412,000.

When Contreras retired last October he claimed that he was subjected to ongoing harassment and intimidation by his employers following the previous suit.

Sonoma Developmental Center, located north of San Francisco, houses over 800 people with developmental disabilities. It has been the focus of numerous state investigations surrounding questionable deaths and injuries, along with physical and sexual abuse of residents. State regulators were in charge of investigating such incidents, until an August 2001 law called for "deaths and serious injuries of unknown origin" at institutions to be reported to local law enforcement.

For more than four years Contreras complained to his superiors that investigations had been performed inadequately if at all. He also claimed that SDC administrators actively interfered with investigations to cover up mistakes made by facility staff.

When Contreras' concerns were ignored by SDC and DDS officials, he took the complaints to lawmakers. Contreras later said his employers made his workplace intolerable, forcing him out.

"They (DDS and SDC authorities) have made it so unbearable, I have to get out of there," he said at the time.

EEOC's ruling is "the latest documentation that state bureaucrats would rather harass whistleblowers than reform their corrupt system" wrote Sonoma Index-Tribune Editor Bill Lynch on Tuesday.

Lynch's reporting has been critical of SDC's handling of those investigations, including an award-winning series entitled "SDC-Investigation or Cover-up" in the summer of 2000.

Related:
"EEOC: State violated SDC chief's civil rights" (Sonoma Index-Tribune)

http://www.sonomanews.com/articles/2003/09/15/news/topstories/news04.txt
"Editorial - Corruption in state bureau costs us all" (Sonoma Index-Tribune)
http://www.sonomanews.com/articles/2003/09/19/news/editorial/letters01.txt

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