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Investigations Unit (IU)

Cover of Victimized Twice: Abuse of Nursing Home Residents, No Criminatl Accountability for Perpetrators - person in a wheelchair sitting in a long hall
Photo by Ricardo Jauregui
Our Investigations Unit (IU) looks into allegations of abuse and neglect involving people with disabilities. The victims may be children, adults or elders with a disability of any type, including developmental, psychiatric, physical, and traumatic brain injury. The IU investigates incidents occurring in any imaginable setting, from abuse in large state institutions to public schools to incidents occurring in a private residence, if the individuals receive disability-related services there.

Areas of focus include:

  1. Abuse or neglect occurring in institutions or facilities including hospitals, state run institutions, skilled nursing facilities, licensed residential care facilities, and jails, prisons, and other correctional institutions;
  2. Abuse or neglect occurring in community settings including schools, day programs and vocational training settings, unlicensed facilities and community living arrangements, and out in the community;
  3. Excessive or inappropriate restraint or seclusion,
  4. Failure of responsible agencies to recognize or respond timely to reports of abuse or neglect and take prompt action to address the incident and prevent future occurrences.

Based on the outcome of an investigation, the IU develops and implements public policy initiatives to prevent similar incidents in the future. This may involve:

  • issuing a report to publicize a problem,
  • working directly with involved entities and oversight agencies to address the issue and
  • developing corrective action to prevent similar occurrence, or drafting legislation in areas where protections do not yet exist.

How can I report abuse?

People with disabilities are given special protections when they have been abused, neglected or targeted for a crime because of their disability.

If you see or hear of an incident of abuse or neglect involving an elder or someone whose disability limits his or her ability to carry out normal activities or to protect his or her rights (including yourself), you can and should notify to appropriate authorities.

If the abuse or neglect occurred in the community, such as in a home, or at a hotel, hospital, clinic or training program, you should contact:

And also contact:

If the abuse or neglect occurred a facility, such as a group home, a nursing home, or residential facility (like assisted living or board and care home), you should contact:

And also contact:

You may also report the incident on an abuse/neglect report form, also known as a SOC 341, and fax it to APS, the LTCO, or the local police or sheriff’s department.

Other state agencies that investigate incidents of abuse or neglect are state agencies responsible for licensing residential and health care facilities.

If you are interested in knowing more about our investigations, click here to see our publications.


Media Coverage

Other

  • An Ounce of Prevention: Law Enforcement Training and Mental Health Crisis Intervention (Pub #CM51.01) (pdf) (Accessible version)
  • DRC testimony to March 13 Senate Human Services Committee hearing on "Law Enforcement Practices within the CA Developmental Centers" - In response to California Watch investigations of abuse of people living in the state developmental centers, Senator Carol Liu, chair of the Human Services Committee, called a hearing to review practices of the internal police force administered by the Office of Protective Services. Among presenters was Leslie Morrison, directing attorney of the DRC Investigations Unit, to testify about her just concluded review of selected issues and make some recommendations for change.

Investigations Unit Success Stories:

DRC Investigation Resident of State Hospital Whose Ankle was Broken in Restraint Gone Wrong:  DRC’s IU staff investigated the actions of staff at a state hospital who attempted to use a chemical restraint to stop a resident from “making rap music” by “beating on the walls”. When the resident refused to submit to the injection, he was surrounded by nine staff members, struggled, and was ultimately physically restrained on the ground. The resident claims while restrained on the ground, he was punched repeatedly in the face. One of the staff members stomped on his ankle, breaking it in two places. Despite the resident screaming and telling staff that his ankle was broken, he was placed in a five-point mechanical restraint for the next six hours before receiving medical treatment.

Facility law enforcement officers immediately launched two successive investigations: (1) into staff abuse of the resident, and (2) into the resident’s assault/battery on the staff. DRC’s Investigations Unit (IU) researched the investigation by the facility and found that it was cursory and biased. Staff members who were involved in the incident were not removed from duty pending the outcome of the abuse investigation, and were not interviewed about their abusive actions, only about the resident’s actions and his injuries.

Although the records did not show whether the staff tried any less restrictive intervention, the investigating officer determined the staff did not intend to hurt the resident, and the resident should have complied with the use of injection/chemical restraint. Staff reported that when they approached the resident, he took a fighting stance, broke his plastic mug and swung the broken handle like a weapon. The resident told investigators that he believed the fracture was an accident, and the records show that he refused any medical care until he was released from restraints the following morning. However, DRC’s investigation revealed that restraint training of the staff member who stepped on the resident’s ankle had expired. The facility and a Department of State Hospital representative agreed that all staff must complete the refresher training annually and committed to ensuring that staff are removed from duty pending the outcome of an abuse investigation.

 

Archive of Past Investigations Unit Success Stories