Report 2012-107 Summary - July 2013

Developmental Centers: Poor-Quality Investigations, Outdated Policies, Leadership and Staffing Problems, and Untimely Licensing Reviews Put Residents at Risk


Our audit on resident safety at the California Department of Developmental Services(department) developmental centers highlighted the following:


The California Department of Developmental Services (department) needs to improve its oversight of resident safety in its developmental centers. The department is responsible for operating state-owned developmental centers, which house and care for individuals with significant developmental disabilities (residents). Developmental centers are staffed with nurses, psychiatric technicians, and other health care professionals who support the ongoing health and safety of the residents who live there. 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 department's health care staff generally perform these reviews according to appropriate procedure, they do not always provide timely notification to the department's Office of Protective Services (OPS). OPS law enforcement officers are on-site at each developmental center and, in addition to general patrol and traffic enforcement duties, respond to alleged abuse of residents. However, OPS does not appear to routinely follow its established procedures for investigations of alleged abuse.

We reviewed 48 OPS investigations and found 54 deficiencies in 267 applicable observations. In particular, OPS often did not collect written declarations from witnesses and suspects during incident investigations, often 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. These deficiencies cast doubt on OPS's quality assurance process, which includes supervisory reviews, and cause the department to have less assurance that its OPS investigation conclusions are correct. Investigative deficiencies, such as those we observed, may allow for continued abuse at the developmental centers.

Partially as a result of frequent turnover in OPS management, the department has struggled to address longstanding resident safety issues, including updating outdated and underdeveloped OPS policies and oversight practices. The department hired law enforcement consultants in early 2012 to help it update OPS policies to strengthen areas of noncompliance and to add other best practices. As of May 2013 the department was preparing to finalize and implement the policy updates. One ongoing, unaddressed concern is the training and hiring of OPS personnel. Although OPS complies with minimum requirements concerning qualifications and training, it has not required the specialized training OPS personnel need to effectively work with residents, such as training in nonverbal communication skills. Another continuing challenge for OPS is the hiring and retention of qualified staff. One impediment is that OPS salaries are lower than those of the local law enforcement entities with which the developmental centers compete for employees. Even so, OPS has not developed a cohesive recruiting approach to attempt to counteract this disparity.

One potential consequence of its difficulties in hiring may be OPS's vacancy rate of roughly 43 percent, causing—at least partially—its high levels of overtime. Likewise, certain health care positions within the department, its psychiatric technicians in particular, have experienced high levels of overtime. In fact, we identified 62 department employees who worked so many extra hours that their overtime pay equaled or exceeded their regular pay over a five-year period. The department indicated that these staff and others who have worked significant overtime have done so out of necessity created by vacancies and other staffing issues caused by long periods of statewide budget reductions and corresponding hiring freezes. Nevertheless, research studies indicate that excessive overtime causes fatigue in health care staff and peace officers, and this fatigue can result in mistakes that put residents at risk of harm.

We noted that, although OPS overtime pay still appears to be excessive at 23 percent of regular pay in 2012, the department has reduced OPS overtime over the last three years and is now tracking the amount of overtime OPS employees work. However, another important performance measure—tracking outstanding investigative cases—was put on hold for a time as the result of OPS management turnover.

Despite a recommendation made more than 10 years ago by law enforcement consultants, the department has not created measurable short- and long-term goals for OPS. In Appendix A we list recommendations from a 2002 report by law enforcement consultants hired by the Office of the Attorney General. The lack of action to implement some of these recommendations has led to systemic issues, such as excessive OPS overtime and inconsistent implementation of practices and procedures, inappropriately putting developmental center residents at risk.

The California Department of Public Health (Public Health), which provides oversight of the developmental centers, has not consistently performed all of its required duties. We found that Public Health has failed to consistently perform prompt follow-ups on certification surveys or to perform state licensing surveys on time or at all. In addition, Public Health does not promptly perform investigations for incidents it classifies as less serious. Finally, because Public Health has not prepared a required report, the effectiveness of its enforcement practices, particularly those related to developmental centers, remains uncertain.


The department should provide a reminder to staff about the importance of promptly notifying OPS of incidents involving resident safety.

To provide adequate guidance to OPS personnel, the department and OPS should place a high priority on completing and implementing the planned updates to the OPS policy and procedure manual.

To help ensure the quality of OPS investigations, the department should revise its OPS training policy to require its law enforcement personnel to annually attend specialized trainings that address their specific needs. At least initially, the department should focus the additional trainings on communicating with residents, writing effective investigative reports, and collecting investigative evidence.

After the department has implemented a formal OPS recruiting program, if it can demonstrate that it is still unable to fill its vacant OPS positions, the department should evaluate how it can reduce some of the compensation disparity between OPS and the local law enforcement agencies with which it competes for qualified personnel.

To minimize the need for overtime, the department should reassess its minimum staffing requirements, hire a sufficient number of employees to cover those requirements, and examine its employee scheduling processes.

To improve its enforcement, each year Public Health should evaluate the effectiveness of its enforcement system across all types of health facilities, including those in developmental centers, and prepare the required annual report to the Legislature.


The department concurred with our findings and recommendations and supports the recommendations to strengthen areas that further increase protections and reduce risk to developmental center residents. The department stated that many of the recommendations have already been implemented or are underway. Public Health agreed with all but one of our recommendations and indicated that it is in the process of implementing them. Public Health disagrees with our recommendation that it should develop and implement target time frames for investigation priority levels that lack them because it believes its current process is sufficient to assign and monitor timeliness.