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Brief Summary of College Hospital Investigation

The May 2025 report found that patients at College Hospital (CH) experienced improper and excessive use of seclusion and restraints; that the facility failed to assess and provide patients with adequate individualized behavior plans; that it failed to provide patients with a therapeutic environment of care; and that it failed to provide adequate transition planning for patients. The report included recommendations that College Hospital could implement to improve patient treatment and care. The full report can be found here: Let Me Go: Excessive Restraint of Patients at College Hospital

CMS Complaint, CDPH Penalties

In 2024, the IU filed a Centers for Medicare and Medicaid Services (CMS) complaint on behalf of a College Hospital patient and similarly situated patients regarding College Hospital’s seclusion and restraint practices and other identified issues with treatment and care. CMS assigned the investigation to its state counterpart, the California Department of Public Health (CDPH).  On November 10, 2025, CDPH made its own findings, including a determination of immediate jeopardy, which led to CDPH imposing administrative penalties against College Hospital in the amount of $41,250. Immediate jeopardy occurs when a licensee’s (in this case College Hospital’s) noncompliance with its licensure “has caused or is likely to cause, serious injury or death to the patient.”1

Meetings with CH patients past and current

Since the release of the investigative report, the IU has continued to meet with current and former College Hospital patients. In addition to expressing a desire to leave College Hospital, patients also expressed wanting to learn vocational skills and social skills.

Watch "Let Me Go: Stephanie's Story" in ASL

Meetings with families and other advocates

Following the release of its report about the conditions at College Hospital, Cerritos, the IU hosted a series of panel-style Q&A sessions with the investigative team and experts. The events received an abundance of support and participation from community leaders, particularly parent leaders within the regional center system. Family advocates shared their lived experiences navigating through the mental health and regional center system. They spoke on the need for early behavioral intervention, crisis intervention, preventative crisis planning and individualized planning for placement and family support.

Parent leaders continue to call for individualized advocacy for patients who remain in psychiatric hospitals without appropriate discharge planning. They express significant concern regarding instances in which regional center clients are held in acute psychiatric settings for extended periods, sometimes lasting years, without clear pathways to community reintegration. This raises profound fears among parents that similar circumstances could affect their own children in the future. Consequently, they feel a strong responsibility to advocate on behalf of individuals who lack family support or representation. Community leaders expressed an interest in forming voluntary family advisory councils to help connect College Hospital patients to the local community.

They point to Disability Rights California (DRC) as a critical partner in enforcing the protections established by the Lanterman Act due to their expertise in the regional center system.

Parent leaders have gone to regional center Purchase of Service meetings to elevate concerns about individuals served experiencing psychiatric institutionalization. They provided testimony about the barriers families confront when trying to identify mental health services for individuals served by the regional centers. They spoke about the difficulty of accessing regional center services that would enhance safety in the home to eliminate the risk of losing community placement. Parents asked for person centered planning where individuals have access to regional center services that will teach them the skills to live safely and with dignity in the community. At the POS meetings, it was brought up that individuals need support beyond their qualifying IDD diagnosis as people have mental health needs as well. These examples reinforce the urgent need for both systemic reform and individualized advocacy.

Meetings with RCs and DDS

In November 2025 and March 2026, DRC hosted regional center roundtable discussions with the support of the Department of Developmental Services (DDS). During the roundtables, the regional centers identified issues with service coordination for College Hospital patients and identified practical policy solutions.

Meeting with CH Administration

In January 2026, the IU met with College Hospital’s administration to discuss then-current conditions and to inquire on how they implemented our recommendations from the May 2025 report. The IU noted a positive decrease in the number of restraint, seclusion, and involuntary medication incidents.

Over the year following the report, College Hospital has reduced incidents of restraint, seclusion, and involuntary medication from 1587 incidents from May 2024-April 2025 to 1144 incidents from May 2025-April 2026—a 28% reduction.

The IU finds this downward trend encouraging that College Hospital can continue to reduce its incidents and improve its treatment and care of patients. Even with these reductions, IU maintains concerns about restraint and seclusion incidents and patient length of stays.

DRC has also used its access authority to provide training and education to College Hospital patients. Broadly defined, access authority is the legal power to enter facilities, review records, interview individuals, and monitor conditions to ensure compliance and protect individuals’ rights. Starting in Summer 2026, DRC’s Peer Self Advocacy (PSA) Unit will be at College Hospital weekly to provide patient rights trainings to adults and youth patients.

Closing

The IU will continue to monitor College Hospital and engage all stakeholders in the service delivery system to improve experiences and outcomes for individuals with co-occurring intellectual and developmental disabilities and mental health conditions who may be placed at College Hospital.