EDMUND G. BROWN JR. 4- 0f Calzfarnia Attorney General DEPARTMENT OF JUSTICE I RONALD REAGAN BUILDING 300 SOUTH STREET, SUITE 5212 LOS ANGELES, CA 90013 Public: (213) 897-2000 Facsimile: (213) 897-2810 (213) 897-2099 March 27, 2009 Donovan J. Jacobs, Esq. 1347 Tavern Road Suite #18 - PMB 201 Alpine, CA 91901 I Re: Ingraham v. State of California, et al. Orange County Superior Court Case No. 00100844 Dear Mr. Jacobs: Pursuant to your request, enclosed please find the Office of Protective Services - investigation regarding l\/Ir. Ingraham. Qnceney, . D.L. HELFAT Deputy Attorney General *0r EDIVIUND G. BROWN JR. General 1 Enclosures {wif A . t/J a is 2*9 ?~Me . hn tt jawn [2 Cl. 2 5 gi gut/lot 6/?tvseo 1 EDMUND G. BROWN JR. i-aw .. of California Affvm?y Genera! - 3 DEPARTMENT OF JUSTICE RONALD REAGAN BUILDING . Public: (2l 897-2000 Facsimile: 2213; 213 897-2099 March 27, 2009 Donovan J. Jacobs, Esq. . 1347 Tavem Road Suite #18 - PMB 201 Alpine, CA 91901 - Re: Ingraham v. State of California, etal. Orange County Superior Court Case No. 00100844 Dear Mr. Jacobs: Pursuant to your request, enclosed please find the Oftice of Protective Services investigation regarding Mr. IngrahamD.L. HELFAT Deputy Attorney General For EDMUND G. BROWN JR. Attorney General - Enclosures State of Califomia Department of Developmental Services Memorandum - Date: . February 21, 2008 To: . MARYBETH KELLER . Director of Quality Assurance Quality Assurance Fairview Developmental Center Re: INVESTIGATION DISPOSITION REPORT - Case Name: Van _Ingraham, (Client/Deceased) (Residence 441) (Program 4) Death Investigation (DS07-06-F-086-F) Johannes Sotingco, Technician Injury of Unkown Origin/Allegation of Abuse (DS07-06-F-081-F) Allegation of Dependent Adult Abuse (PC 368 Crime Incident Report Case No.: DS07-06-F-081-F DS07-06-F-086-F - Theresa DePue, Senior Special Investigator I Special Investigations Unit I FINDINGS: Unfounded -- No evidence that a violation or crime was committed Unsubstantiated -- Insufficient evidence to support the allegation Substantiated y- Evidence supports the allegation (Administrative Violation) OTHER: Information Only Report Injury of Unknown Origin Abuse Allegation Injury of Known Origin Client Assault Workplace Violence Theft Death Investigation RECOMMENDATION: Administrative Case OPSIHQ Management Review Costa Mesa Police Department District Attorney Review (Pending Criminal Report) COMMENTS: - I The investigation findings are included inthe attached Crime Incident Report dated February 21, 2008 completed by the Office of Protective Senrices. This Report is fonrvarded to executive and program management staff for review and disposition. The Coroner's Bio--mechanical Report- and the Orange County's Death Certihcate are pending. . DON ACKERMANN, COMMANDER . tl Office of Protective Services -- Fairview Developmental Center - - "Building Partnerships, Supporting Choices" 5 STATE OF CAUFORNIA HEALTH AND SERVICES AGENCY DEPARTMENT OF DE SERVICES zinc 3 CRIME INCIDENT REPORT Us mm I 1 Fairview Developmental Center 3fI0fl 8 l?I? Special investigations Administrative D307-O6-F-086-F Code SGCti0r1iSt 4519.5 WI Death of DDS Client I Case Status CLOSED incident Location Hoao Memorial Hosoilal Presbvf IRNIA Number Date Time Deaih 7441 25 6/12/2007 Date and Time occurred 6/12/2007 Date and Time Regoneu 5/12/zoov Role involved Name ilasl Gender Victim lngraharn_ \/an 6213370 Male ADDRESS (street city zigcodel Classification 2501 Harbor :1956 50 Chem Costa Mesa CA 92626 Role Involved Name ilasf firstl Gender Suspect 6906108 Male ADDRESS (street city zigcodel Classification 2501 Harbor -/1955 50 Client Costa Mesa CA 92626 Role Involved Name (lasl irstl Gender I "`?hieci Sotingco_ Johannes Male aj istreef cify zigcodel Classification Hafbof 'ees 39 TECHNICIAN Costa Mesa CA 92626 U95-L _i&?lY unspecified or nla Role Involved Name glasl first) QQ Gender Reporter lngraham, Lawrence Male ADDRESS street oily zigcodel Classification 3567 Hartzel Drvie -1975 30 Spring Valley CA 91977 Wire CLIENT DEATH CASES Autogsy Performed Examiner Deguty Coroner Yes No Aruna Singhania Ernesto Collazo Involved in case I Involved in case El Yes No lj Yes No Executive Director Head District/Kllorney fi /\dulfPro1ecIive Services fl LTC Ombudsman i Admin, Services Dir. Personnel Officer Medical Direcfor Child Protective Services District Attorney Clinical Director OIS Headquarters California Highway Patrol Omer Costa Mesa piE?ce Deganmeni Ll Other Agency Evaluation Director 5_9 re I na Theresa Depue QQIQDQQ Repan Dale 2/21/zoos I 1 Date Printed' 2/2 State of California - Health and Hum an Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 1 ?r 109 os me new zrzoos l_ 4.CASE NUMBER - DS07-06-F-081-F OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT 5? ECTED (714) 9576077 s. ouur - CMPD 07-9361 1. Injury of Unknown _Origin - 2. Death Investigation 3. Homicide - Penal Code 187 - 4. Dependent Adult Abuse -- Penal Code 368 . 5. Dependent Adult Elder Abuse - Welfare and Institutions Code 15656 6. FDC Policy 1.6 -- Treatment of Clients . 7. FDC Policy 5.6.2 Changes in Client's Medical Condition 8. FDC Procedure 6.8.1 - 6.8.4 First Aid . INVESTIGATION SUMMARY On or about 06-06-07 at approximately 0640 hours, Pete Araujo, Peace Officer for Police . Services with the Ofhce of Protective Services (OPS) at Fairview Developmental Center (FDC) received a telephone call from Johannes Sotingco, TechnicianlNOC ,5 (nocturnallnight) shift staff member on Residence 41 at FDC. Sotingco reported an injury of unknown origin (redness near the corner of client's outer left and unable to bear weight) for Van client who lived on Residence 41 at FDC. On or about 06-07-07 at 1400 hours, I received notification of an incident of an injury of unknown origin that allegedly occurred on Residence 41 at FDC. On 06-07-07, I received this injury of unknown origin assignment from Don Ackermann, Commander for OPS at FDC. I reviewed the OPS Police Services Incident Report (No. 07-06-357) written by Officer Araujo. Sotingco informed Officer Araujo that while conducting rounds on Residence 41 on - 06-06-07 at approximately 0530 hours, he found Van lying on the floor with his pants down to his ankles and Van's pants were wet with what appeared to be urine. Sotingco said he believed Van fell, resulting in an area of redness near the corner of Van's left outer eye. Officer Araujo interviewed Sailaja Reddy, MLD., Physician and Surgeon at FDC and the Medical-Officer-of-the-Day (MOD) on 0.6-06-07. Dr. Reddy told Officer Araujo that she received notification of an injury to Van on 06-06-07 at approximately 0645 hours and she arrived on Residence 41 shortly thereafter to assess Van. Van was stiff, in pain, and would not move his neck. Dr. Reddy suspected a possible neck injury and ordered for Van to be transferred to an acute care hospital for further medical evaluation and treatment. Dr. Reddy . believed Van's injury was consistent with a fall on the floor.- On or about 06-06-07, Central Nursing Services notified OPS that Van had sustained a fracture of the vertebrae. Officer Araujo notified Commander Ackermann that Van had a fracture to the and vertebrae. State of California - Health and Human Senrices Agency Department of Developmental Services CRIME I INCIDENT REPORT Page nav zrzooai . 4.cAsE NUMBER OFFICE OF PROTECTIVE SERVICES OF REPORT Special Investigations Unit 1. ci Felony misdemeanor gi mrmuon 5_ CONRECTEO REPORT ops Psa?-os-357 . OPS Ps07-06-372 0MPD 07-9361 On or about 06-08-07 at 1450 hours, Lawrence Ingraham (L. Ingraham), brother to Van, made an allegation of abuse against Sotingco. On 06-10-07, Commander Ackermann notified the Costa Mesa Police Department of an "injury of unknown origin" to Van. On 06-12-07, the OPS at FDC received notification that Van had expired at Hoag Hospital on 06-12-07 at 0015 hours. The Orange County Sheriff-Coroner's Office had been notified and Ernesto Collazo, Coroner Investigator with the Orange County Sheriff-Coroner's Office was assigned to the case. On 06-12-07 at 0900 hours, attended the autopsy of Van. The autopsy was conductedby Aruna Singhania, Forensic Pathologist with the Orange County Sheriff-Coroner's Office. Peter Mastrosimone, Acting Senior Special Investigator with the Special Investigations Unit at OPS FDC was present for the autopsy, Detective Derek Trusk and Detective Sergeant Robert Phillips with Costa Mesa Police Department were also present at the autopsy. Dr. Singhania stated Van had a broken neck, but found no extemal bruising or marks. Dr. Singhania clarified that the type of injury was similar to an injury caused by a motor vehicle accident (MVA) as evidenced by a "whiplash" type of injury. Dr. Singhania said this type of injury most likely required some type of accelerated force. Dr. Singhania and Dr. Fukumoto, a Pathologist with the Orange County Sheriff-Coronefs Office, speculated the injury could have been caused by a blow to the back of the neck using a soft object. On or about 06-12-07 at 1400 hours, a meeting was conducted between the staff at OPS and members of Costa Mesa Police Department. A mutual determination was made for . OPS to be the lead investigative agency with assistance from Costa Mesa Police Department. The three staff members present during the NOC shift on 06-05-07 (shift hours were 2230 hours on 06-05-07 through 0630 hours on 06-06-07), were Sotingco; Alvin Tan, Technician; and Florens Limbong, Senior Technician and designated charge person on 06-05-07. Separate interviews were conducted with the three staff members present during the NOC shift on 06-05-07. Three separate interviews were conducted with Sotingco. Sotingco said during the night on 06-06-07, he saw Van up in the hallway frequently. Van was exhibiting his usual behaviors of running out of his room and in the hallway and on occasion Van had his pants down around his ankles. Sometime between 0430 hours and 0500 hours, Sotingco entered Van's room and saw Van standing with his pants pulled down around his ankles. Sotingco directed Van to pull up his pants, but Van got upset and started yelling and hitting himself on the head (a documented self-injurious behavior). Limbong heard the noise and went to Van's room. Van calmed down, Sotingco pulled up Van's pants, which were not wet, and Limbong and State of California - Health and Human Services Agency Depaitrnent of Developmental Sen/ices INCIDENT REPORT Page 3 of109 ii. NUMBER 1 OFFICE OF PROTECTIVE SERVICES TYPE Op 1 Special Investigations Unit 1. ci Felony ci ivisuemeanm oi - "rc" rf Fairview Developmental Center . (714) 957-5077 I OPS 3 ij miin Www" CM 07-9361 I Sotingco left Van's room. \/an followed them to the door of his bedroom and then went back into his room. Sotingco said Van did not have any apparent change in condition at that time, Sometime afterward, Limbong requested Sotingco and Tan to help clean a client on Residence 41, who had smeared feces. Sotingco said that he and Tan cleaned-in -s bedroom, and as a result started 0530 rounds later than usual. Sotingco estimated it took Eve to ten minutes to clean Sotingco said at approximately 0545 hours, he entered Van's room and found Van lying on the floor. Van was lying supine with his feet toward the footboard of his bed and his head toward the footboard of the bed opposite his. Van was lying in the center of the room, his pants were wet, there was some urine on the floor underneath him, his pants were down around his ankles and he was wearing his shoes. Sotingco said Van's bed was wet. V\lhen Sotingco entered the room, Van turned his head toward Sotingco. Sotingco instructed Van to get up, but \/an only raised his arm up in the air.. Sotingco thought \/an was requesting assistance, so he pulled on Van's arm and raised Van's torso, but Van was unable to get up. Sotingco said this was unusual for Van. Sotingco went to the doorway of Van's room and called Tan for assistance. Sotingco then went to change Van's pants while Van was on the floor. . Tan arrived and changed Van's bed. Sotingco described Van as appearing tired, sleepy, or "drunk" Van was not able to bear weight. Sotingco and Tan lifted \/an by standing on either side and using their arms underneath Van's armpits to lift Van up to a standing position. Van was not able to bear weight, but he did make steppingmotions with his feet. Sotingco and Tan placed Van back in his bed. Sotingco said he made a visual assessment of \/an while he was lying on the floor, but did not identify any injuries to Van. After Van was placed back in bed Sotingco and Tan continued to make their rounds on the clients. Sotingco said he recalled an incident a month or two prior when Van had also seemed especially tired in the morning and the AIVI shift staff had complained that the NOC shift staff did not write an Incident Report. Sotingco went back to check on Van approximately five minutes after he and Tan placed Van in bed. Van was in bed and was moaning and had tears in his eyes. Sotingco reported Van's condition totimbong. Limbong went to Van's room and assessed \/an and then decided to notify the Limbong instructed Sotingco to write an Incident Report. The AIVI shift staff started to arrive and were requested to assist with Van. An attempt to stand Van at the bedside, revealed Van was unable to bear weight. Sotingco said Dr. Reddy arrived on the Residence and assessed Van. Reddy ordered for Van to have a cervical collar applied due to a possible neck injury. Sotingco said a "222" was called to transfer Van to an acute hospital. Sotingco was requested to go to the hospital with Van. Sotingco drove his personal vehicle and arrived at Hoag Hospital Emergency Room (ER) after Van and Jason Bruch, a Pre-Licensed Technician who was also assigned to accompany Van to Hoag Hospital. State of California Health and Human Services Agency INCIDENT REPORT Department of Developmental Sen/ices Page 4 of 109 DS 214 R6 _Mv ini* A `_Wk 4 CASENWBER I I I OFFICE or PROTECTIVE SERVICES OF REPORT Speciat Investigations Unit 1. r:i Er rerun Er Nrsdemeanur Er rnrraui an I Fairview Developmental Center 2- EI ADMINISTRATIVE I (714) 9576077 r: rNEoi=s injury occurred. Tan was offered the opportunity to take a Voice Stress Analysis test with Costa Mesa Police Department, but did not take the test, interviewed Limbong_ Limbong said she obsen/ed Van up in the hallway in his usual condition during the night on O6-O6-07. Limbong said she observed Van in his room State of California - Health and Human Services Agency Department of Developmental Services INCIDENT REPORT Page ur 1os os 214 is (nav fn" rlirr as ii77Y" 7 ii Muff, 7 ir" i ?s_oA5E -- DS07-05-F-081-F OFFICE OF PROTECTIVE SERVICES 1-YRE OF REPORT i Special Investigations Unit 1, i;i cniiviinnt Felony ci Misdemeanor inrracirmi Qi?gg mn REPORT I i ii OPS PSOMG-357 OPS PS07--06-372 D, 07*9%* between approximately 0400 and 0430 hours, and Van was exhibiting his usual behavior at that time. Limbong said at around 0420 hours- smeared feces and she requested help from Sotingco and Tan to clean- According to Limbong, Sotingco requested her to check on Van at approximately 0550 hours. Van was lying in bed with tears in his eyes and he just looked at her. Limbong said Van loved soda, so she got a soda thinking Van would get up for a soda Limbong said she knew something was wrong because Van didn't even try to reach for the soda Limbong decided to notify the Health Services Specialist and the MOD. Dr, Reddy, the MOD sent Van to Hoag Hospital via the Paramedics. Limbong was offered the opportunity to take a Voice Stress Analysis test with the Costa Mesa Police Department, but did not take the test, Interviews were conducted with the staff members on Residence 41 that did not work the NOC shift on 06-05-07. All staff members denied being present on Residence 41 between the hours of midnight and 0630 hours on 00-06-07. All interviewed staff members denied if current practice of marital arts. None of the interviewed staff witnessed the injury to Van. Interviews with staff revealed that none of the staff suspected Sotingco, Tan or Limbong of causing the injury to Van. None of the interviewed staff knew how the injury to Van occurred. The interviewed staff indicated that Van had behaviors of running and urinating in the hallway, he liked to open and shut doors and he was not an aggressive client. Interviews with the Residence 41 staff revealed that there were clients on the Residence with physically aggressive behaviors. Clients that were repeatedly mentioned were-, a client on Residence 41 who exhibited behaviors of striking others using a double handed downward striking motion and- who exhibited behaviors of hitting others. -was described as a client who identified more with the staff than his peers, considered himself a superhero (Superman) and enjoyed watching wrestling on television. - often imitated what he observed on television. On 07-12-07 at 0847 hours, I interviewed Kathy Kastelz, the Unit Supervisor on Residence 41 at the time of Van's injury. Kastelz informed me that-., a client who lived on Residence 41 at the time of Van's injury, reported to her that on the morning that Van went to Hoag Hospital,-exited Van's bedroom and told- 'Don't say anythingf Kastelz added that- is blind and when she asked how he knew it was- -replied that he knew -- Kastelz added that L. Ingraham informed her that he had spoken to Dr. Meyers, Dr. Krutzik /1 and Dr. Hong at Hoag Hospital and these physicians informed him that it was their opinion that Van's injuries were caused intentionally and the physicians had completed a report based on their opinion. State of California - Health and Human Sen/ices Agency Department of Developmental Services REPORT Page6of10Q DS 214 (Rev 2/2003 i Mr "7 7 7777 7 M7 7 47; 7777777777 NUMBER V7 i gsifice or eetoregrive senvices OF REPORT . i ECIE nvesti 3 IODS l'1l 1. CRIMINALU I ll] Fgirview Develgpmental Center (Sc Ion i lm) 9576077 oes Psov-06,372 gr 07-93Qi~_ On or about 1"l~06~O7 at 1030 hours, lnvestigators with OPS at FDC met with members of the Orange County District Attorneys Office to discuss the investigation of \/an's injury. interviewed clearly stated that at approximately 0400 hours on the morning that \/an went to the hospital- exited Van's bedroom and said, 'Don't say anything' -said seemed "afraid" because he was stuttering and- usually doesn't stutter_ said he thought that- had something to do with Van`s death. inten/iewed four physicians (Dr. David Meyers, ER Physician; Dr. Michael Krutzik, Intensive Care Unit Physician, Dr. Derrick Hong, lnternist; and Dr. William Dobkin, Neurosurgeon) who cared for Van while at Hoag Hospital. All of these physicians said they did not Know if the injury to Van resulted from an accident, neglect or intentional cause. All of the interviewed physicians said that they could not determine if any movement of Van following the initial injury would have exacerbated the injury. An inten/iew of-was conducted by the Costa Mesa Police Department. -did not provide any definitive information about the cause of \/an`s injury. -did admit to being in Van`s bedroom and seeing \/an in his bedroom on the morning \/an was transferred to Hoag Hospital. did not answer direct questions pertaining to his possible involvement with the cause of Van's injury. During the course of the investigation, two meetings were held with OPS, representatives of Costa Mesa Police Department and representatives of the Orange County Sheriff-Coroner's Office. All relevant aspects of Van's injury, possible causes and investigative Endings were reviewed and discussed. reviewed \/an's Clinical Record at FDC and the Medical Record for \/an's hospitalization at Hoag Hospital. Van was a 5O>>year-old male admitted to FDC on O4-20-64 with diagnoses including profound mental retardation (IQ Score of 8), autism, pervasive developmental disorder and bipolar disorder. Van was physically fit, well developed and of medium stature. He was non-verbal. Van had behaviors of urinating in inappropriate places and running in the hallway. Van had self-injurious behaviors of banging his hands on hard surfaces and slapping himself in the face, but he didn't have any aggressive behaviors toward others. Van was transferred to Hoag Hospital via the Paramedics on the morning of O6-O6-07, after he was found on the floor unable to bear weight. Van was admitted to Hoag Hospital ER on the morning of Van presented with change in level of consciousness, lethargy and unable to bear weight. At 0805 hours, shortly after arrival, the ER staff removed Van`s cervical collar and backboard. \/an later had an x- ray that revealed he had a dislocation of C5-C6 with bilateral facet block resulting in C4-C6 spinal cord compression. While at Hoag Hospital, L. lngraham opted against heroic State of California Health and Human Services Agency Department of Developmental Services CRIME INCIDENT REPORT P399 7 M109 DS 214 Rev _kv _k NUMBER 1 I I OFFICE OF PROTECTIVE SERVICES TypE Oi: Rgpogy to I . (714) 9575077 3. INFORMATION orvu/ OPS pS07'06'372 i - -if -ee; Vw; 'ig measures for \/an and signed the do not resuscitate papen/vork. Van expired and was pronounced dead on O6-12-O7 at 0015 hours, . reviewed the Clinical Record for- at FDC. Documentation in the Individual Program Plan revealed had previously admitted to breaking a clients arm. The Amended Autopsy Report dated 1_2-21-07, revealed that the cause of death was identified as acute bronchopneumonia due to status post fracture of cervical vertebra with traction Halo due to blunt force trauma, back of neck. The manner of death is undetermined. FINDINGS There were no FDC staff witnesses to the cause of Van`s injury. The staff members working at the time of Van's injury deny any actions that may have caused Van's injury. Sotingco's statements are consistent with those of interviewed witnesses, particularly his account that he and Tan had to clean resulting in a delay of 0530 hour rounds. Sotingco's reference to a previous incident regarding Van's lethargy was corroborated in the Interdisciplinary Notes in Van's Clinical Record. Based on these facts, the allegation that Sotingco abused \/an in violation of the Penal Code 368 is unsubstantiated. -said he saw- leave Van's room and then-told-, 'Don't say anything' During a subsequent interview, admitted he was in Van`s room and he saw Van on the morning of Van's injury. However, the interview with-did not reveal any further information regarding the cause of Van's injun/. There are numerous clients with aggressive behaviors on the Residence, but no clients were obsen/ed to have caused the injury to Van. \/an was found lying supine with his pants down around his ankles and wet with urine. Van had a behavior of running with his pants down, oftentimes after an episode of urinary incontinence. interviews with Hoag Hospital physicians indicated they did not rule out a fall and that they were unable to determine the cause of Van's injury. Additionally, the Orange County Coroner's staff were not able to determine the cause of Vans injury; the possibility of a fall or accident could not be ruled out. The autopsy revealed the manner of Van's death is undetermined. ADDITIONAL FINDINGS Sotingco stated that he assessed Van prior to moving him, but did not identify any external injuries and did not suspect skeletal injury. While Van had a change of condition and was unable to bear weight, the staff attending Van at FDC suspected that Van was tired and did not attribute the change in Van's condition to be the result ot a skeletal injury. Van`s condition was reported to the MOD immediately and \/an was transferred to an acute care State of Califomia - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 9 of 109 os 2148 aw I . 4.CASE NUMBER DS07-06-F-081-F OFFICE OF PROTECTIVE SERVICES OF REPORT r= I rar te an a. ruroamnon crux CMPD 07-9361 REPORT OF INVESTIGATION - DETAILS OF INVESTIGATION I Office of Protective Services Notification I On 06-06-07 at approximately 0640 hours, Pete Araujo, Peace Officer I for Police Services with the Office of Protective_ Services (OPS) at Fairview Developmental Center (FDC) with the Department of Developmental Services (DDS) received a telephone call from Johannes Sotingco,? Technician/NOC (nocturnal/night) shift staff-member on Residence 41 at FDC. Sontingco reported an injury of unknown origin (redness near the. corner of his outer left and unable to,bear weight) for Van I., a client who lived on Residence 41 at FDC On 06-07-07 at 1400 hours, I received notification of an incident of an injury of unknown origin that allegedly occurred on Residence 41 at FDC. On 06-07-07, I received this injury of unknown origin assignment from Don Ackermann, Commander for the OPS at FDC. OPS Police Services' Crime Incident Report (CIR) (Case No. 07-06-357) On or about 06-07-07, I received the Crime Incident Report (CIR) dated 06-06-07 (Attachment No. 1) completed by Pete Araujo, Peace Officer for Police Services with the OPS at FDC. The following is a summary of the information obtained: Officer Araujo wrote that he was notified by Johannes Sotingco, a Technician, on 06-06-07 at 0640 hours, that Van sustained an injury of unknown origin. Officer Araujo interviewed Sotingco on 06-06-07 at 0640 hours. Sotingco told Officer Araujo that while conducting rounds on 06-06-07 at approximately 0530 hours, he found Van lying on the floor with his pants down to his ankles. Van's pants were wet with what appeared to be urine. Sotingco said he believed Van fell, resulting in an area or redness near the corner of his outer left eye. . Officer Araujo interviewed Jason Deats, Senior Technician on Residence 41, on 06-06-07 at 2100 hours. Deats told Officer Araujo that he received information from the ANI shift staff during report that Van was found on the floor with his pants down around his ankles and he had urinated on himself. Sotingco found Van on the floor during rounds. Van - was unable to bear weight and was crying due to pain. Deats said that Van had a documented history of urinating on himself, pulling his pants down around his ankles and running in the hallway. . Officer Araujo interviewed Sailaja Reddy, and Surgeon, and the Medical- - Officer-of-the--Day (MOD) on 06-06-07 at approximately 0735 hours. Dr. Reddy informed Officer Araujo that at approximately 0615 hours she received notification of Van's injuryand State of Califomia - Health and Human Services Agency Department of Developmental Services CRIME INCIDENT REPORT Page 10 of 109 DS 214 Rev 2/2003) . 4.cAsE . DS07-06-F-081-F OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. CRIMINAL Felony E1 ueuemeamr mrracuon CONNECTED REPORT Fairview Developmental Center gi OPS 957'5?" ops psu?-oe-srz CMPD 07-9361 at approximately 0645 hours, she arrived on Residence 41 to assess Van. Van was stiff, in pain and would not move his neck. Dr. Reddy believed that Vanhad sustained a neck injury - and ordered for Van to be-transferred to an acute hospital for further medical treatment. Dr. Reddy told Officer Araujo that she believed Van's injurywas consistent with Van falling on the floor. OPS Police Services' Police Activity Log - On 06-06-07, Officer Araujo made log entries into the OPS Police Services' Police Activity . Log regarding the injury to Van. The following is a summary of the information obtained: Log Entry on 06-06-07 at 0640 hours (Attachment No. 2): Officer Araujo wrote that he received a call from Sotingco on Residence 41. Sotingco told Ofhcer Araujo that at approximately 0530 hours, while making rounds, he saw Van on the floor wearing pants that were wet due to Van urinating on himself. Sotingco said he believed Van wet his pants and 5 when he got up to infomi the staff, he fell on the floor causing redness near the corner of his out left side area. At approximately 0645 hours, Dr. Reddy treated Van. At approximately 0715 hours, Officer Araujo responded to Residence 41 to photograph Van. Officer Araujo was informed that a "222" had been called for Van. Costa Mesa Fire Department (CMFD) arrived to Residence 41 at approximately 0720 hours. At approximately 0737 hours, Schaefer Ambulance escorted Van to Hoag Memorial Presbyterian Hospital (Hoag Hospital) for further medical treatment. . At approximately 2000 hours, Officer Araujo reviewed his Groupl/Wse e-mail and noted that Jose Rodriguez, Peace Officer I for Police Services with the OPS at FDC, had forwarded him new information regarding Van's injury. Ofhcer Rodriguez wrote that Alex Tortes, Senior Technician on Residence 41, informed Officer Rodriguez that Van sustained a fracture to the and vertebrae. A Police Services Case (No. 07-06-357) was opened for this report. Log Entry on 06-06-07 at 2020 hours: Officer Araujo wrote that he notified Don Ackermann, OPS Commander at FDC, regarding new information received about Van's injury. Officer Araujo advised Commander Ackermann that Van sustained a fracture to the and vertebrate. . - Log Entry on 06-08-07 at 1450 hours (Attachment No. 3): Oscar Pinon, Peace Ofhcer for Police Senrices with the OPS at FDC, wrote that he received a call on the "888" abuse . reporting line from Margo McLaughlin, Program Assistant for Program 4 at FDC, regarding . an allegation of abuse made by Mr. Lawrence Ingraham (L. Ingraham), brother of Van. Officer Pinon interviewed L. Ingraham at approximately 1455 hours. Officer Pinon wrote that L. Ingraham informed him that he had received information from different physicians relative . . State of Califomia - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 11 or 109 os 214 a nor zrzoos . NUMBER . OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. cr Felony infraction 5 CONNECTED REPCRT Fairview Developmental Center gl REPORT OPS pS07_06__357 ops OMPD 07-9361 . to the status of Van's injuries that indicated Van's injuries were not consistent with Van falling to the floor accidentally. L. Ingraham filed an allegation of abuse against Sotingco. L. Ingraham requested that the sleep logs for the period of 12 hours prior to the discovery of Van's injury until 12 hours following the discovery of Van's injury be preserved in their original format. (Refer to OPS Police Services Supplemental Report [Attachment Abuse- Allegation.) Log Entry on 06-12-07 at 0023 hours (Attachment No. 4): Daniel Butler, Pe_ace Officer 1 for Police Services with the OPS at FDC, wrote that he was advised by Deborah Williams, Program Director for Program 4, that Van had passed away at Hoag Hospital. Commander Ackermann was advised. Log Entry on 06-12-07 at 0025-0050 hours: Officer Butler wrote that he confiscated all medical documents and medication for Van (Case No. 07-06-372). Log Entry_on 06-12-07 at 0346: Officer Butler wrote that he received information from Ernesto Collazo, Coroner Investigator with the Orange County Sheriff-Coroner Department. Investigator Collazo reported the death of Van and informed Officer Butler that Van's body was at the Coronefs Office (DR `No. 07-03422CO). . - Tour of Room 59 on Residence 41 I On 06-07-07 at 1450 hours, I toured Room 59, Van's bedroom on Residence 41, with L. Ingraham. Also present were Michelle Taylor, Registered Nurse (RN) and Alvin Tan, Technician, both Residence 41 staff members. I received information from Tan during the tour. The following is a summary of the information obtained: Tan stated that at approximately 0500 hoursnon 06-06-07, Sotingco found Van lying supine on the floor in his bedroom. According to Tan, Van had been incontinent of urine and he was able to bear weight. Tan said he changed Van's bed and Van was put back to bed. Florens Limbong, Senior Technician (SPT) NOC shift staff member on `Residence 41, was not-in Van's room at that time. - Taylor stated that Limbong found Van on the floor at approximately 0530 hours when she was doing her 30--minute rounds. Taylor said when Limbong found Van on the floor he was not able to bear weight. I 2 I I State of California Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT - Page 12 ?r me os 214 Rev zrzooa - 4.CASE NUMBER - DS07-06-F-081-F OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. 1:1 Mlsderneanor mrraeuon 5_ OONNEOTEO REPORT DeVeIOpl'\'lel'\laI Center gl OPS 557'5?77 ops Psor-os-srz . CMPD 07-9361 - Hoag Memorial Presbyterian Hospital- Medical Record Delivered by Lawrence . Ingraham On 06-07-07, L. Ingraham delivered Hoag Hospital Medical Records for Van (Attachment - No. 5) and provided a CD of diagnostic tests from Hoag Hospital for Van, from which a copy was made (Evidence Item No. 2). -Documentation from the records provided revealed Van had sustained a fracture of the and vertebrae. OPS Police Services CIR -- Supplemental Reportl R-41 Sleep Logs On 06-08-07, Officer Butler obtained the Sleep Logs on Residence 41 for 06-01-07 through 06-07-07 (Evidence Item No. 3). The following is a summary of the information obtained: . The Sleep Logs dated 06-05-07 to 06-06-07 (Attachment No. 1-B), revealed Van was in the - hallway at 0245 hours, Van was- in the bathroom at 0315 hours and Van was resting in bed, 5 awake at 30-minute intervals, from 0345 hours through 0615 hours. (NOTE: The original entries dated 06-06-07 at 0445 and 0515 hours, indicated that Van was in the however, those entries were written over to reflect that Van was resting in bed.) Notification of the Costa Mesa Police Department - On 06-10-07, Comma_nder Ackermann notified the.Chief of Police, Detective Bureau, Watch Commander and the Records Bureau at the Costa Mesa Police Department (CMPD) via a facsimile of an injury that was originally reported as an "injury of known origin" for Van (Attachment No. 6). The OPS Police Services' Report (07-06-357) was attached. The Special Investigations Unit's investigation (Case was assigned to Theresa DePue, Senior Special Investigator. On 06-09-07 at 1640 hours, Joanne Aguirre, Nurse--on-Duty (NOD) with Central Nursing Services at DC, telephoned OPS regarding Van. Aguirre reported that she received a telephone call sometime on the morning of 06-09-07, from Janet Schearer, Deputy Coroner with the Orange County Sheriff Coroner's Office. Schearer advised Aguirre that she had received a call from Detective Sergeant Bob Phillips with the. Costa Mesa Police Department, who called to report the impending death of Van. As a result of this notification, Investigator DePue rescheduled the interviews of the three . staff members working the night (NOC) shift on 06-06-07, for Monday moming and afternoon and offered Costa Mesa Police Department personnel the opportunity to participate in these . interviews. Contact information for Investigator DePue was provided. Stale of Califomia - Health and Human Services Agency Department of Developmental Services INCIDENT REPORT page is 0f109 os me nevzrzuos 5 4.CASE NUMBER - uso?-06-F-081-F . OFFICE OF PROTECTIVE SERVICES TTRE OF REPORT Special Investigations Unit 1. CRIMINAL Felony Misdemeanor infraction 5_ CCNNECTEC RERCRT Fairview Developmental Center g- OPS pS07_06_357 . ops Psov-os-372 CMPD 07-9361 . (NOTE: Derek Trusk, Detective with the Costa Mesa Police Department, deferred to OPS Special Investigations Unit as the lead agency for this investigation and was not present at these interviews.) Autopsy - Orange Coungg Sheriff Coroner Office On or about 06-12-07 at 0900 hours, I attended the autopsy of Van at the Orange County Sheriff-Coroner`s Office. The autopsy was conducted by Dr. Aruna Singhania, Forensic Pathologist with the Orange County Sheriff-Coroner Department. Peter Mastrosimone, Acting Senior Special Investigator with the DDS OPS at FDC was present during the autopsy. Also present from Costa Mesa Police Department were Detective Trusk and Detective Sergeant Phillips. During the course of the autopsy, Dr. Singhania stated that Van had a broken neck, but no external bruising or markings. Dr. Singhania clarified that the type of injury was similar to an TD injury caused by a motor vehicle accident (MVA) as evidenced by the "whipIash" type of injury. Dr. Singhania said this type of injury most likely required some type of accelerated force. Dr. Richard_ Fukumoto, Forensic Pathologist with the Orange County Sheriff-Coroner Department, also consulted during the autopsy. Both Dr. Singhania and Dr. Fukumoto - speculated that the injury could have been caused by a blow to the back of the neck using a soft object. Dr. Fukumoto hypothesized that possibly a "karate chop" type of blow could - result in this type of injury. Dr. Singhania stated that pulling on Van's arm after the injury occurred would likely not have exacerbated the injury to Van's neck. Crime Incident Report (Case No. 07-06-357) - Supplemental Report - Ronald Lizardo, Peace Officer Il/Sergeant for Police Services with OPS at FDC, completed the Supplemental Report to OPS Police Services Report No. 07-06-357 dated 10-17-07 (Attachment No. 1-C). The following is a summary of the information obtained: On .06-12-07 at 1300 hours, Officer Araujo; Officer Pinon; and Sergeant Lizardo obtained photographs and measurements of Room No. 59 on Residence 41 at FDC. Measurements of the room, furniture and fixtures in Room No. 59 were obtained and a diagram was made. The Photographs and Diagram are attachments for this Police Services' Supplemental -- Report. . State of California - Health and Human Services Agency Department ol Developmental Services CRIME I INCIDENT REPORT Page 14 of 109 rt os 2148 (Rev zrzuusi I r" TT mr r" DS07--06-F-081-F I OFFICE OF PROT ECTNE SERVICES (WE OF REPORT I Ei Ea"?1 (714) 9576077 3. INFORMATION ONLY OPS me WM Additionally, photographs were obtained ofthe following clients on Residence 41 at Ya Y., amt Photographs were obtained ofthe following staff members: Sotingco, Tan and Limbong. OPS Police Services Death Investigation Preliminary Report -- (Case No. 07-06-372) On 06-12-07, Officer Butler completed the Death Investigation Preliminary) Report for the death of Van (Case No. 07-06-372) (Attachment No. 7). The following is a summary of the information obtained: On 06-12-07 at 0025 hours, Officer Butler was notified that Van was pronounced dead by Derrick Hong, MD., at Hoag Hospital on 06-12-07 at 0025 hours. The Orange County Sheriff-Coroner Department had been notified and Coroner's Case DR No. 07-03422CO was assigned. Officer Butler wrote that he secured Van's FDC Clinical Record (Evidence Item No. 4 with referenced medications [Evidence Item Nos. SK-1 through in the OPS Office on 06-12-07 at 0030 hours. Meeting with Costa Mesa Police Department On 06-12-07 at 1400 hours, a meeting between FDC OPS and Costa Mesa Police Department took place in the Conference Room at OPS at FDC. Those present from OPS at FDC included Commander Ackermann, Investigator Mastrosimone, and myself, Investigator DePue. Those present from Costa Mesa Police Department included Tom Curtis, Lieutenant, Detective Bureau; DetectiveTrusk and Detective Sergeant Phillips. The following is a summary of the meeting; The meeting resulted in a determination that FDC OPS would be the lead investigative team working in conjunction with both the Costa Mesa Police Department and the Orange County Sheriff-Coroner Department. Costa Mesa Police Department expressed their desire to have continued discussion regarding the case and offered assistance as needed. Notification of Costa Mesa Police Department On 06-13-07, Commander Ackermann at OPS FDC notified the Watch Commander at Costa Mesa Police Department of the death of Van. In accordance with AB 430 and Code 4427.5, this report of a death at FDC was forwarded to (Attachment No. 8). I . State of California - Health and Human Services Agency Department of Developmental Senrices . CRIME I INCIDENT REPORT page 15 or 109 os 2`14 a narzrzooa 4.CASE NUMBER OFFICE OF PROTECTIVE SERVICES ORE OF REPORT I Special Investigations Unit 1. CRIMINAL Feral-ry cl Misoemeamr infraction CORRECTEO REPORT F8il'Vl0W CBIIKBT 3- mggm?3mE$PORT 957'5?" ops eso?-06-972 CMPD 07-9361 Reguest for Assistance from the Crime Lab at the Orange County Sheriff Coroner Department Forensic Services Division On or about 06-13-07, Investigator Mastrosimone requested the assistance of the Crime Lab with the. Orange County Sheriff-Coroner Department (OCSD) Forensic Science Services Division to complete a schematic representation of Van's bedroom at FDC. Investigator Mastrosimone provided Lenora Pena-Sanchez with the Orange County Sheriff Department, Forensic Science Services, a Floor Plan of Residence 41 upon her request. Additionally,.on or about 06-13-07 at 1830 hours, Investigator Mastrosimone requested that Pena-Sanchezwith OCSD evaluate Van's bedroom at FDC for anything of evidentiary value (forensic evidence). Pena-Sanchez informed Investigator Mastrosimone that due to the time lapse and the day-to--day business in the room (routine cleaning and presence of clients and staff) and the possibility of subsequent contamination, no evidence could be recovered that would be of any evidentiary value. Review of the Orange County Sheriff-Coroner Department Forensic Science Services - Division Crime Lab Report On or about 10-17-07, the OPS at FDC received the crime Lab Reportfrom the Orange County Sheriff Coroner Department, Forensic Science Services Division (Attachment No. 9). The following is a summary of the information obtained: Pena-Sanchez, L.F.S with the Orange County Sheriff Coroner Department wrote that she responded to FDC and met with Investigator Mastrosimone. Investigator Mastrosimone informed her that Van was found lying on the floor of his bedroom (Room No. 59) on Residence 41. ?Van had a broken neck. Van was taken to Hoag Hospital where he later died. . Pena-Sanchez wrote the following entries: observed the following: Residence 41 was a large multi-story building located at the south end of the compound._ Inside the building there was dorm style housing, recreation facilities and offices. I was told that the building stays locked at all times. Upon our entry, it was locked behind us." I -. . "In the victimls room, there were four beds and three lockers. There were no obvious signs of disturbances." complete sketch and photo list are available upon request. Senior Forensic Specialist K. . Cogert was present." (FR No. 07-49538.) State of California - Health and Human Services Agency Department of Developmental Services CRIME INCIDENT REPORT . - . Page r6?r-109 5 I os 214 new zrzoosi . . - 4.CASE NUMBER - . Osor-06-F-081-F OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. cr F6i0|'lY rlrrauemaanor rnrracrron CONNECTRO REPORT FBINIBW C8l'It8l' ops Psor-os-372 . - CMPD 07-9361 Omar Lazo, L. F. S. with the Orange County Sheriff Coroner Department wrote that on 06-14-07 at 2120 hours, he took 12. post-embalming photographs of Van at the Coroner's Division Facility. A list of photographs was taken at the direction of Forensic Assistant Bames. The report was dated-07-20-07 (FR No. 07-49538-3). Orange Coungg SheriffICoroner Office -'Reguest for Autopsy Photographs On or about 06-13-07, Investigator Mastrosimone requested copies of the autopsy photographs from the Orange County SherifflCoroner Office ID Unit for Van (Coroner's Case DR No. 07-03422-CO). . On or about 08-10-07, I received a CD containing "all images on tile with the OCSD Forensic Science Services Photo Lab" for Van (Evidence Item No. 5). Costa Mesa Fire Department Incident Report (No. 2007-0704028-000) On 06-21-07 at 0845 hours, I received a copy of the Costa Mesa Fire Department Incident Report (No. 2007--0704028-000) dated 06-06-07 (Attachment No. 10) from Detective Trusk with the Costa Mesa Police Department. The following is a summary of the information obtained: The Report revealed that the Costa Mesa Fire Department was initially notified of Van's injury at 0712 hours on 06-06-07 and their arrival time at FDC was 0718 hours on 06-06-07. Unit MME81 responded tothe call. The team included Lenny Goodsir, Captain; Michael Barnes, Engineer; William Moss, Firefighter/Paramedic; and Chris Holmes, Firefighter! Paramedic. The Incident Report documented that on 06-06-07 at 0712 hours, Unit MME81 responded to an Emergency Medical System (EMS) call at FDC. The client that was treated was a 50- year--oId white male. The client's chief complaint was The onset time was documented as 0700 hours. The cause of the illnesslinjury was identified as a fall. The cIient's signs and included unresponsiveness and weakness. The primary tasks performed at the scene by responding personnel were to provide advanced life support (ALS). The client was noted to have abnomial findings of lethargy and an abrasion was noted over . the client's left eye. Treatment included vital signs, an electrocardiogram identifying sinus bradycardia (low heart rate), oxygen saturation rate of 94%, a dextrose stick identifying a blood sugar level of 113 and the client was placed in trendelenberg position (feet elevated above the level of the heart). The client was transported to Hoag Hospital. I State of California - Health and Human Services Agency I Department of Developmental Services CRIME I INCIDENT REPORT Page 17'of 109 us 214 Rev amos) . 5 . 4.CASE NUMBER . osu?-06-F-081-F OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT 2: I (714) 9515077 3. INFORMATION ON OPS - CMPD 07-9361 DOCUMENT REVIEW FAIRVIEW DEVELOPMENTAL CENTER -- INCIDENTIUNUSUAL OCCURENCE REPORTS I lncidentIUnusual Occurrence Report (IR) (No. 07-06-31) I I On or about 06-09-07 at 0900 hours,-I received the Incident Report (IR) No. 07-06-31 that was written by Sotingco and dated 06-06-07 at 0550 hours (Attachment No. 11). The following is a summary of the information obtained: The following changes were noted to the original Incident Report: Section 6 Time of Incident I 0545 was lined out to "unknown" and "error 6-7-07" was written. Section 9 Type of Incident! Injury lined out and changed to Fracture. Section 10 Cause of Incident I Accident lined out and changed to Unknown. and (NOTE: The above noted changes were made by Margo McLaughlin, Assistant Program Manager for Program 4 at FDC.) - Sotingco wrote that he found Van lying on the floor of his room with wet pants down to his knees. Staff assisted Van back to his bed, there was slight redness to Van's left eye, and Van refused to bear weight. Dr. Reddy completed Section 17 of the IR (Description and Location of Injury and CareITreatment Given) on 06-06-07 at 0725 hours. Dr. Reddy wrote that the client (Van) was found down on the.floor refusing to move and bear weight. The client was crying and appeared to be in pain. The client was lying supine on the gumey and crying secondary to mild discomfort. Wtal signs were: temperature 98.8, pulse 55, respirations 18, and blood pressure 104/65:. An examination of the cIient's head, ears, eyes, neck and throat (HEENT) revealed a 3 cm reddened area over the client's left upper eyelid. The client's . pupils were 3 cm, round and reactive to light equally and bilaterally. There was questionable neck swelling. Lungs were clear. Heart rate and were regular. The client's abdomen was negative for distention, soft with positive bowel sounds. Dr. Reddy's assessment and plan identified status post and to rule out head traumalneck trauma and to transfer th client to the Emergency Room (ER) for further evaluation. Called "222" (Paramedics) for transfer to the ER. - The Level I Review was completed by Alex Tories, Jr., Senior Technician_and -- Acting Unit Supervisor on Residence 41. The Level I Review was dated 06-07-07 at 1050 hours. Tortes wrote that he interviewed Sotingco, who found Van, and he also attempted to interview Van, who could not relay what happened as he was non-verbal. At 0545 hours, - State of Califomia - Health and Human Senrices Agency Department of Developmental Services CRIMEI INCIDENT REPORT Page 2!2003) 4.CASE NUMBER OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT - Special Investigations Unit 1. cnrurrunt 1:1 Felony rnrracrion CORRECTED REPORT Fairview Developmental Center gi OPS (mi 95"5?" - ops Psov-os-xm CMPD 07-9361 Van was noted .to be lying on the floor in his bedroom with his pants partially removed. When Van was assisted to get up, Van had trouble bearing his own weight. Van was assisted to bed and assessed by staff. Van displayed less responsiveness as evidenced by a lack of resistance toward staff, lying quietly on_ the bed and moving-his arms slowly. This was unusual for Van who was generally resistive and very active. The Nurse-on-Duty (NOD) and the Medical-OfHcer--of-the-Day (MOD) were notified immediately. Van's vital signs were low. Due to Van's quiet demeanor, decrease in motion, and low blood pressure and pulse rate, "222" was activated at 0715 hours. Van was transported to Hoag Hospital viathe - Paramedics and two staff (Jason Bruch, a Pre--Licensed Technician and Tan). While at the ER, Van had an x--ray, which revealed a cervical fracture to the and vertebra. - - Tortes wrote that Van was last seen without injury at 0515 hours, ?during rounds, sleeping in his bed. Van required 30-minute checks during the night. Tortes wrote that staff followed - Van's level of supervision. Van had an open behavioral plan for urinating on the floor. Van 5 usually wet himself in his bed in the early morning. Van did not have any contributing factors noted for fractures. All required notincations were made in a timely manner. Van's brother - was informed by Tortes and was thankful that the incident was well handled and that prompt medical attention was sought. The Level ll Review was completed by McLaughlin on 06-07-07. McLaughlin wrote that a Special Conference was to be held upon Van's return to FDC, that staff were to continue to . document on the 24-Hour Report and to continue to discuss at intershift report, staff to continue to provide emotional support to Van and L. Ingraham, and for staff to continue to . follow all physician's orders. lncidentlUnusuaI Occurrence Report (IR) (N0. 07-06-46) On or about 06-11-07 at 0900 hours, I received the IR No. 07-06-46, written by McLaughlin and dated 06-08-07 at 1455 hours (Attachment No. 12). The following is a summary of the information obtained: McLaughlin wrote that L. Ingraham came to her oflice to report that he felt that Van's injury was not an accident. L. Ingraham said that reports from Hoag Hospital stated that Van's injury was consistent with a severe jerking motion, not a fall. L. Ingraham stated that his allegation was against Sotingco. L. Ingraham wanted the (sleep) logs preserved in original format 12 hours before and after Van's injury was discovered. The Level I Review was completed by Tortes on 06-11-07. Tortes wrotethat this incident involved a previous and Police Log #07-06-357). The initial incident . State of Califomia - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 19 ?r 109 5 214 is Rev zrzoosi . 4.CASE NUMBER OFFICE OF PROTECTIVE SERVICES TYPE OF Special Investigations Unit 1. crumiwxt. Felony Mlsdemeanor cr Inrracuon 5 CCNNECTEC NEPCNT Fairview Developmental Center 2- REPORT (SPS pS07_06_357 . (714) 9576077 3. ORMATION ONL . CMPD 07-9361 I has been under investigation `since 06-07-07. Until further notice, Sotingco has been assigned to an alternate work location. - The Level ll Review was completed by John Padilla, the Nursing Coordinator for Program 4. Padilla wrote that in consultation with the Clinical Director, there will be an alternate . assignment pending the outcome of the investigation, the case was referred to OPS and Residence staff were to provide support as needed. I lncidentIUnusual Occurrence Report (lR) (No. 07-06-43) On or about 06-12-07 at 0800 hours, I received the IR No. 07-06-43, written by Limbong and dated 06-12-07 at 0100 hours (Attachment No. 13). This IR was written after Van was transferred to Hoag Hospital. The following is a summary of the information obtained: Limbong wrote she received a telephone call from Michaelina "Mickey" William--Mensah, a Senior Technician on Residence 41, from Hoag Hospital, informing her that Van became unresponsive at 2336 hours on 06-11-07, with no breathing, no pulse, and pale color per Van's brother, L. Ingraham. Dr. Hong arrived at 0015 hours at which time he pronounced Van dead. Dilip Patel, M.D., Physician and Surgeon at FDC, completed Section 17 (Description and Location-of Injury and Care/Treatment Given) of the IR on 06-13-07_at 1540 hours. Dr. Patel wrote that the staff were notified that Van was hospitalized at- Hoag Hospital and noted with no respirations. Van was pronounced dead at 0015 hours, the cause was pending. The Level I Review was completed by Tortes and dated 06-12-07. Tortes wrote that he was - notified by the Clinical Liaison at FDC that Van had expired at 0012.hours. On 06-06-07 at 0735 hours, Van was transported to Hoag Hospital Emergency Room (ER) due to being physically unresponsive, unable to bear weight and a lowering blood pressure and pulse. Van was admitted to Hoag Hospital Intensive Care Unit (ICU) on 06-06-07 at 1100 hours. Do Not Resuscitate (DNR) status was initiated on 06-08-07 by L. Ingraham, who was also Van's Conservator. The Level II Review was completed by IVIcLa?ughIin on 06-12-07 at 1230 hours. McLaughlin - wrote that the case was referred to the OPS at FDC and that staff were to post on the 24- Hour Report. The staff wereto discuss this at the meeting and were to provide support as needed to Van's family. I Is., In State of Califomia - Health and Human Senrices Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 20 or 109 os 214 Rev zrzooa . 5 4.CASE NUMBER -- DS07-06-F-081-F OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT meanor I IN ION Om ops PS07-06-372 CMPD 07-9361 FDC RESIDENCEI41 DOCUMENTS I I The following documents were requested and obtained from Residence 41 for Van: . . 24-Hour Report June 5, 2007 June 6, 2007 (Attachment No. 14) Attendance Report - June 2007 (AM, PM NOC) (Attachment No. 15) Staff Assignments (Attachment No. 16) Journal of Falls (Attachment No. 17). List of Staff Assigned to Van while at Hoag Hospital (Attachment No. 18) FDC DISPATCH LOG I reviewed the FDC Dispatch Log dated 06-06-07 (Attachment No. 19). The following is a summary of the information obtained: - I 06-06-07 0638 hours: Radioed for an IR on Residence 41 06-06-07 0700 hours: Dispatch advised of a "222" Residence 41 I 06-06-07 0719 hours: Fire Department arrived at front entrance to FDC 06-06-07 0720 hours; Fire Department escorted to Residence 41 I 06-06-07 0733 hours: Schaefer Ambulance escort client Van l. to? Hoag Hospital SCHAEFER AMBULANCE SERVICE -- TRIP SHEET On or about o1-24-08, I reviewed the Schaefer Ambulance Service transport record for Van dated 06-06-07 (Attachment No. 20). The following is a summary of the information obtained: . Documentation revealed that Unit 52-32 (H. Brittain #9105 and L. Garcia #8916) was dispatched to FDC for Van on 06-06-07 at 0715 hours, arrived to FDC at 0732 hours, arrived on scene at 0733 hours. Van was transported from FDC at 0745 hours and arrived to Hoag . Hospital at 0801 hours on 06-06-07. The chief complaint was that the client was lethargic and hypotensive from a fall. The client was transported with a backboard and cervical collar In place. State of Califomia - Health and Human Senrices Agency Department of Developmental Services CRIME 1 INCIDENT REPORT Page 21 of_109 5 us 214 Rev 2I2003 4.CASE NUMBER osor-oe-F-061-F OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. cr Fam ci Misuemeamr rnrracuon CONNECTEO REPORT ops psu?-oe-372 GMPD 07-9361 FDC CLINICAL RECORD REVIEW VAN I. CLIENT On 06-07-07, I received the FDC Client Record for .Van. The following is a summary of the` I information obtained: - Van was a 50-year-old client admitted to 04-20-64. Van's diagnoses included profound mental retardation, unspecified_birth trauma, IQ Score of 8, pervasive developmental disorder and bipolar disorder. A roaches and Strate ies -Au ust 10 2006 The Approaches and Strategies dated 08-10-06 (Attachment No. 21), identified Van was at risk for attempts to elope, actual elopement, banging his hands on hard surfaces and slapping himself in the face. Van's level of supervision was close supervision (requiring an assigned staff member to` be within 25 feet of Van during waking hours and for checks every T) 15 minutes at night). - . Van had an identified behavior of urinafing in inappropriate places such as the bedroom, hallway, and when outdoors. Staff were to encourage Van to urinate in the toilet at frequent intervals throughout the day and night, discuss with Van the importance/need to urinate in the toilet for social and health reasons, and to reinforce Van for_compliance, accepting assistance, following directions and for completing the task. Van stripped his clothes when soiled. Van was capable of being very resistive to grooming tasks. Van had total skills in gross motor activities, however his fine motor skills were somewhat limited. Van used facial expressions, purposeful reach, body signals, and maladaptive behaviors, lead others by the hand, and was able to imitate the manual sign for tplease." He was able to respond to simple one-step requests. Van disliked structure in wor1<, living and social settings and he disliked being confined. Van took a long time to develop trusting relationships and responded morefavorably to people with- whom he was familiar and had developed a rapport. Van would move his peers and staff around by nudging them with his arm. Van preferred to remain physically active in the hallway or periphery of the group living room rather than participating in activities which required him to remain seated. . Individual Program Plan (IPP) Special Conference April 20, 2007 The IPP Special Conference dated 04-20-07 (Attachment No. 22) stated Van's supervision level was changed from every 15 minute checks at night to every 30 minute checks at night and increased rounds/heightened supervision on the Residence and while being escorted; i 513 I State of Califomia - Health and Human Services Agency Department of Developmental Services INCIDENT REPORT Page asv zrzous I 4.CASE NUMBER or=i=rcE OF PROTECTIVE SERVICES wp; OF Rgpogr Special Investigations Unit 1. Felony cr rnrracum 5 CONNECTED REPORT I Fairview Developmental Center GPS (Y1 4* . ops Psomo-372 CMPD 07-9361 A - Individual Program Plan Review Conference - August 10, 2006 I The Individual Program Plan Review Conference dated 08-10-06 (Attachment No. 23) stated, Van was a physically fit, well developed male of medium stature. Van had a long history of elopement. He was often seen walking, spinning or bouncing balls in the - hallway as well as rolling a small ball in his hand. He was playful in nature and would smile when spoken to or as a means to express happiness. Van enjoyed pushing/guiding others about (both peers and staff), however this was not aggressive and only a means to usher one past his preferred personal space in the hallway. Van enjoyed running in open areas as well as outdoor activities, playing ball, going in and out of his bedroom and spending time there. Van had clothing preferences including polo type shirts and shirts with sleeves rolled up. He also preferred to wear blue jean elastic waist pants. Van disliked conhnement, structure, demands, shirts with button down collars or sweatshirts, jackets, most grooming activities, invasive medical treatments, prolonged . physical contact, and having his spaceinvaded. . Van did not communicate verbally, but was able to communicate_ with gestures, body . language, protesting by leaving the areas or being loud or disruptive. He expressed wants and needs through facial expressions, leading by the hand to the desired item and purposeful reach and body signals interpreted by familiar staff. Van made facial grimaces and slammed his hand against a hard surface when angry or frustrated. Van was capable of responding to simple one-step requests. . Van was able to dress himself, but required staff assistance to complete. most dressing tasks. Van immediately stripped his clothing when wet. He used the toilet independently and he urinated in the hallway even after using the toilet. Van had maladaptive behaviors of slapping himself in the face, banging his hands on hard I surfaces and attempting to elope. - Van had as history of seizure activity, harm to self, and elopement. Van was 5 feet, 7 inches and weighed between 150-160 pounds. Interdisciglinagj Notes - .. I reviewed the below referenced Interdisciplinary Notes (lDNs). The following is a summary . of the information received: 04-08-07 0820 hours (Attachment No. The Health Service Specialist (HSS) wrote I that the AM shift staff reported that Van was "groggy." "Van is usually very hyperactive as State of California -- Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 23 or ros 214 Rev zrzoosi NUMBER . DS07-06-F-081-F OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT - Special Investigations Unit 1. Felony Mrsoomoaoor cr rormouorr CONNECTEO REPORT Fairview Developmental Center OPS 957'5?" . ops psor-os-372 CMPD 07-9361 indicated by walking/running/circling in the hallway. He sits in the chair under supervision to prevent falls." The physician was notified to see Van. 06-06-07 0545 hours (Attachment No. 25): Sotingco wrote that Van was in bed resting during change of shift, he got up before 0100 hours, soaking wet from urine, with his pants down. Staff changed Van's clothes and had his foot treatment without any problem. While he was up, he's been in and out fromthe toilet and dorm. He was redirected 4-5 times for taking his pants off before going back to bed around 0330 hours. During 4-5 AM rounds he remained in bed resting and when staff doing the 0530 hour rounds, Van was on the floor with his wet pants down to his knee and refused to get up. Staff assisted Van back to bed andwhen staff rechecked Van he seems he's not on his normal behavior. Staff notified Lin, HSS and Dr. Reddy and at 0715 hours, "222" was called. 06-06-07 2300 hours (late entry for 06-06-07 0550) (Attachment No. 26): Limbong -5 wrote that staff reported to this writer regarding an incident as stated above. Staff went into the room. to assess Van and saw Van lying on his bed in a supine position, awake. He was crying and appeared to be in pain. Vital signs were obtained and neurochecks were initiated . per protocol. The HSS and MOD were notified and came to assess Van. At approximately 0715 hours, "222" was called by the HSS per the MOD's request. Van was escorted to Hoag Hospital ER with two staff (Bruch and Tan). . 06-12-07 0900 hours (Attachment No. 27): Kathy Kastelz, Unit Supervisor on Residence 41 wrote Van was admitted to Hoag Hospital ICU on 06-06-07. Van expired on 06-12-07 at 0015 hours. Van was pronounced dead by Dr.'Hong at Hoag Hospital. Van's diagnosis upon admission was cervical fractures of the C5, C6 and C7 per the NOD. A preliminary diagnosis of respiratory failure secondary to pneumonia possibly caused by the fracture was provided. The Deputy Coroner was notified and provided Coroner Case DR No. 07-03422- CO. The Program Director was notified who in turn notified- the Medical Director, Clinical Director, Executive Director, the OPS and the physician. Residence staff notified the . Individual Plan Coordinator, the and the social worker who were to inform the Regional Center and remain in contact with Van's brother, who was the conservator. . 06-1_4-07 0235 _hours (Attachment No. 28): Post Mortem Entry for 06-12-07. Received a call from Deb Williams, Program Director for Program 4, on 06-12-07 at 0035 hours, regarding Van's death at Hoag Hospital. Called Hoag Hospital at once and spoke with Maresha, RN, Van was pronounced expiredon 06-12-07 at 0015 hours by Dr. Hong. Van's . brother was at the bedside and the Coroner was notified by Hoag Hospital staff. The Coroner's Case No. 07-03422-CO with diagnoses of respiratory failure due to pneumonia. Van was admitted to Hoag Hospital on 06-06-07, for treatment of a cervical fracture of C5, C6 and C7. All appropriate FDC disciplines were notified per protocol of Van's death. State of California - Health and Human Services Agency Department of Developmental Services . CRIME I INCIDENT REPORT page 24 or ms DQMB Rev 2/2003777777, rr 7-t rn NUMBER DS07-06-F-061-F OFFICE OF FRDTECTIVE SERVICES TYPE OP REPORT EI I3 infraction I 3 (714) 3. Cl INFORMATION ONLY OPS P.P-P PP..PP EPP. . -..2..- . it QLQEQI Pi Physicians Progress Notes On 06-06-07 at 0650 hours, Dr. Reddy wrote the following note (Attachment No. 29): Client (Van) was found down on the floor with pants down to his knee. Client refusing to move or bear weight. Also crying and appears to be in pain. The client was lying supine on the gurney crying secondary to mild distress. Vital signs were temperature 98.8 degrees Fahrenheit, pulse rate 55, respiratory rate 18, and blood pressure 104/65. Van's head, eyes, ears, nose and throat (HEENT) were examined and revealed a 3 cm reddish over the left upper eyelid. The pupils were 3 mm round, reactive to light equally and bilateral. There was questionable neck swelling. The lungs were clear. The heart had a regular rate and The abdomen was negative for distention, soft with positive bowel sounds. The extremities did not have any apparent swelling. Wound with dressing in place over the great toe. Van was assessed to be status post a fall or trauma. Rule out head injury or neck trauma. Apply cervical collar if available. Van was sent to the ER at Hoag Hospital for further evaluation. Death Summagg -- June 28 2007 On or about 07-05-07, received the Death Summary dated 06-28-07 for Van (Attachment No. 30). The Death Summary was written by James Ferguson, D.O. (Doctor of Osteopathy), Physician and Surgeon at FDC. The following is a summary of the information obtained; \/an was a 50-year-old developmentally disabled white male. He died on 06-12-07 at Hoag Hospital. Van was born on -56, and atdelivery there was premature separation of the placenta with some bleeding. At the age of three years, Van was diagnosed with mental retardation. ln 1963, Van was observed demonstrating autistic Van was admitted to FDC on 04-20-64, at the age of eight years. Van remained at FDC for the remainder of his childhood and for his adult life. Van was diagnosed with profound mental retardation, IQ Score of 8, pervasive developmental disorder and bilpolar disorder. Van had evaluation diagnoses including autism; profound mental retardation; hypothyroidism, rule out tardive dyskinesia and moderate behavior. \/an was physically strong, active, ambulatory and self--directed. He was not considered to harm others, although he would touch others in an attempt to move them along or to take them where he wanted to go to obtain what he needed. Van had many self-injuries due to accidents and self-injurious behaviors. Van frequently had skin lesions 1 and injuries in the area of his head, limbs and body due to running into things. He pounded on windows very hard. He eloped when doors were left open. He had no regard for his physical safety. State of Califomia - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT page 25 or ros os 214 (Rev zrzoos 5 4.CASE NUMBER OFFICE OF PROTECTIVE SERVICES WTYPE OF REPORT if 5- EPORT I I (714) 9576077 . s. cr INFORMATION ONLY CMPD 07-9361 . Van's past medical history included increased QTC interval on EKG, gastritis, upper gastrointestingal (Gl) bleed, contusions, wounds, head injuries, sprained left knee, and elevated blood urea nitrogen. Van's medical problems at the time of his death included harm to self, bipolar disorder (autistic features), mittens used as needed, treatment with - risperidone and lithium carbonate (in the process of downward titration at the time of his death). Van had no apparent side effects noted from the use of these medications. Tinea pedis was treated with tolnaftate. Hypothyroidism was treated successfully with levothyroxine. Van had a history of thrombocytopenia, for which recent labs and platelet counts have been normal; Van had profound mental retardation, etiology birth trauma. Van was treated with structured daily activities. He had socially undesirable behaviors defined as generally pushing people and urinating in the hallway. Van had chronic cellulites of his left foot which was treated with multiple antibiotics and debridement. Van had insomnia, which was treated with trazodone. Van received a bone density study in 2001, which showed normal bone density. . - At the time leading up to his death, Van had no significant medical problems, which affected his behavioral or physical dexterity, including cellulites of the left foot which he largely ignored and apparently had very little discomfort from. The Residence to which he was - assigned routinely checked all clients on the night shift every 30 minutes. Van was found on the floor with his underwear around his.ankles. Staff attempted to assist him off the floor, however it became apparent that he was not weight-bearing with his lower extremities. The physician was notified and came to examine the client. The physician's evaluation included a possible neck injury. Paramedics were called. Prior to moving Van, the- Paramedics provided a neck brace and placed him on a backboard. Van was then transported _to Hoag Hospital with these precautions, preventing further injury to the neck. Van died on 06-12-07, while an inpatient at Hoag Hospital. HOAG MEMORIAL PRESBYTERIAN HOSPITAL- RECORD REVIEW - VAN I., PATIENT History and Physical On or about 06-25-07, I received the History and Physical for Van, written by Dr. Hong at Hoag Hospital, and dated 06-06-07 (Attachment N0. 31). The following is a summary of the information obtained: Van presented to the Hoag Hospital emergency department with altered level of consiousness. Van was a 50-year-old gentleman with severe mental retardation. He has been a longstanding resident at FDC. The patient was in his usual state of health until the moming of 06-06-07 at approximately 0530 hours, when he was found down on the floor of - his room incontinent of urine. The waist of the patient's pants was at the level of his ankles. The patient was unable to get up off the floor on his. own. He was assisted to a chair and State of Califomia - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page zs ?r 109 . osz14a 2I20D3) - . 4.0ASE NUMBER DS07-06-F-081-F OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT Special Investigations Unit 1. cruwnnt Felony In nreuemeamr infraction 5_ CONNECTED REPORT Center ?j ops PS01-06-ss? - . OPS CMPD 07-9361 was unable to sit upright. He was also unable ?to stand. Per his caregivers, the patient at baseline was very active and restless. He was often seen at FDC running around the hallways. Currently, the patient is non-verbal. He does not follow simple commands, which according to the caregivers is a change from his baseline. -- The physical examination revealed the patient was in no acute distress and the patient moved all four extremities purposefully. He did not follow commands. He was nonverbal. The impression revealed that Van had an altered level of consciousness of unclear etiology, possibly secondary to urinary tract infection versus a postictal state from seizure; severe mental retardation, nonverbal at baseline; history of hypothyroidism and sinus bradycardia. - The plan was to admit the patient to a medical-surgical bed with a sitter for observation and neurologic checks; and electroencephalogram to rule out seizures, urinalysis and urine culture, the patient's C-spine had been cleared by the ER physician. Plans included to obtain a C-spine x--ray to definitively rule out fracture, diet and to check TSH and ,5 free T4 and a physical therapy evaluation in the moming. Discharge Summag; - On or about 6-25-07, received the Discharge Summary for Van written by Derrick Hong, . M.D. at Hoag Hospital, and dated 06-12-07 (Attachment No. 32). The following is a summary of the information obtained: Dr. Hong wrote that Van expired on 06-12-07 at 0015 hours. Van's diagnoses included dislocation of C5--C6 with bilateral facet block resulting in C4 through C6 spinal cord compression; cervical spine stenosis and spondylosis, respiratory failure due to dislocation of C5-C6 with bilateral facet block resulting in C4 through C6 spinal cord compression as well as aspiration pneumonia; mental retardation; and history of hypothyroidism. . Diagnostic Imaging Studies were obtained and included the following: Portable chest x-ray 06-06-07, normal study. Cervical spine x-ray 06-06-07, a 11 mm of anterolisthesis of C5 on C6 with findings consistent with facet block. Cervical- spine x-ray 06-06-07, partial blunting and complete reduction of C5-C6 facet block. Cervical spine x-ray 06-06-07, marked anterolisthesis of C5 on C6"has not been reduced. There is still widening of the interval between the posterior spinous processes of C5-C6. C-spine x-ray 06-06-07, the degree of posterior anterior vertebral widening at C5 and C6 is less prominent than on prior study. CT scan of brain 06-06-07, normal study. CT of the cervical spine 06-06-07, bilateral C5 anterior facet dislocation with tiny bone fragments at the site of impact, central stenosis from C4 through C6, fracture posterior superior aspect of C4. State of Califomia - Health and Human Services Agency I Department of Developmental Services . CRIME I INCIDENT REPORT page zv 0f109 214 a nav zzoosi - . 4.CASE NUMBER OFFICE OF PROTECTIVE SERVICES TTPE OP REPORT - Special Investigations Unit 1. Felony Cl Misdemeanor Inrmorion 5_ OONNEOTRO REPORT 3; . ops OPS PS07-06-372 . CMPD 07-a361 Magnetic Resonance Imaging (MRI) of cervical spine without contrast 06-06-07, dislocation of C5 on C6 with bilateral --facet block, severe central stenosis and cord compressions through C4 through C6, disruption of ligamentum nuchae in C6-C7, prevertebral and epidural hematoma underlying congenital spinal stenosis. Mulitple chest x-rays performed between the dates of 06-07-07 and 06-11-07, all showing varying degrees of bibasilar consolidation and opacitication of the left hemithorax. Van was a 50-year--oId FDC resident with developmental delay who presented to Hoag Hospital after he was found down by FDC staff. The patientvvas unable to get up off the floor on his own. He was assisted to a chair and was unable to sit upright. He was also . unable to stand. The patient at baseline was very active and ambulatory. Given this change, FDC was alarmed and called 911. The patient was brought to Hoag Hospital by Paramedics. - . RD While in the emergency department, Van had x-rays performed of his cervical spine (results listed above). Dr. William Dobkin, M.D. and Neurosurgeon, was called stat by the ER physician, and Dr. Dobkin performed application of Halo traction after intravenous analgesics were administered. Multiple subsequent x-rays were performed and revealed reduction of the patient's dislocation. Additional imaging studies were performed and revealed the patient had severe cord compression between C4--C6. The patient was admitted to ICU with . a critical care medicine consultation. Van was started?on a high-dose of IV Solu-Medrol. On the morning after admission, discussions were held with the patient's brother, who was the patient's durable power of attomey for healthcare. Van's brother stated Van's two joys in life were eating and walking/running around the confines of FDC. The patient's brother felt that if \/an was not able to enjoy these two things, his quality of life would be very poor. The patient's brother requested that no feeding tubes be placed. He also requested a full do not resuscitate (DNR) status. The patient was subsequently transferred to the sub-intensive care unit. While in sub-ICU, the patient's pulmonary status would deteriorate. The patient was treated with empiric antibiotic therapy intravenously as well as bronchodilator therapy - per respiratory therapy staff. The patient continued to deteriorate and the brother opted for comfort measures. The patient was placed on 'a palliative care pathway. The patient was pronounced dead on 06-12-07 at 0015 hours. The patient's? brother was present at the time ofthe patient's passing. Given that the patient's injury may have been sustained by a mechanical fall, this was determined to be a coroner's case. . 7 I Stale of California -- Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 28 er 109 V, D5 214 Rev 2/2003) Wim wif WW WW 4.cAsE nuivis??i Wl DS07-06-F-081-F OFFICE OF IJROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. r1 in Felony Miguel-leaner ci inrraerrun rr EO TEEQEPO Fairview Developmental Center OPS 957*5077 I ops PS07--06-372 I . . as am. FDC CLINICAL RECORD REVIEW - CLIENTS LIVING ON RESIDENCE 41 FDC Clinical Record Review--., Client On or about 09-20-07, reviewed the Clinical Record for-., a client on Program 4 at FDC. The following is a summary of the information obtained: -is a 50?year--old male admitted to FDC with diagnoses including severe mental retardation (IQ Score of 26), conduct disorder and delusional disorder. -is able to verbally communicate his wants, needs and feelings and follow multi--step commands. - has a hearing impairment and his speech may be difficult to understand. - has behaviors of hitting others and usin weapons as objects. -is ambulatory with a steady gait and full use of his extremities. is able to form and maintain friendships although usually with staff and not peers, - has conditions/factors that impact his decision A making ability. 4} By history, in 2004,- broke a peer's arm. When questioned as to how he had done this, he demonstrated by clasping his hand around the Unit Supervisors wrist and twisting her arm in a rotating fashion, turning her arm outward to the right side. When. asked why he did il, he replied that he was Superman and his peer had "bugged" him. When -was again asked why he had hurt his peer, his response was "cause I watch World Wrestling Team and they do that." "l'm Superman." -demonstrated how he had grabbed and twisted his peers arm followed these remarks. A review of the lnterdisci linary Notes (lDNs) for the morning of 05-06-07, revealed there was no entry regardingh. -is approximately 5'5" tall and l5O pounds. FDC Clinical Record Client On or about 09-20-07, I reviewed the Clinical Record for --, a client living on Residence 4l at FDC. The following is a summary of the information obtained; -is a 48-year--old male admitted to FDC with diagnoses that include profound mental retardation (IC) Score of 16). - uses vocalizations and gestures to communicate. - has aggressive behaviors including overturning furniture. - prefers to be called - is 5'8" tall and weighs approximately 170 pounds. State of California - Health and Human Services Agency CRIME I INCIDENT REPORT Department ot Developmental Services Page 29 of 109 DS 214B 4.CASE NUMBER DSO7-O6-F-O81-F OFFICE OF PROTECTIVE SERVICES OF I Special Investigations Unit 1. El CRIMINAL Ei Felony Ci Misdemeanor I fact TED Fairview Developmental Center 2~ V3 REPORT (714) 9576077 ci INFORMATION oiitv OPS P597 G5 357 OPS PSO7-O6-372 - W. -. . -. _.og . 9 07- . FDC Clinical Record Review- . Client On or about 09-20-07, reviewed the Clinical Record for- a client living on Residence 41 at FDC. The following is a summary of the information obtained: is a 31-year-old male admitted to FDC with diagnoses including moderate mental retardation (IQ Score of 50), disorder and intermittent explosive disorder. -is Spanish dominant with limited receptive and expressive skills in English. has behaviors of uncontrollable aggression and impulse aggression on strangers, staff, and peers and property destruction. -is 5'8" tall and weighs approximately 150 pounds. FDC Clinical Record Review - Client On or about 09-20-07, reviewed the Clinical Record for-., a client living on Residence 41 at FDC. The following is a summary of the information obtained: is a 27-year-old male admitted to FDC with diagnoses including severe mental retardation (IQ Score of 37) and autistic disorder, is capable of communicating his basic needs and wants through verbal communication. It is difficult to carry on a conversation with -clue to his echolalic verbalizations. had identified behaviors of harm to self, including elopement and head banging. 5'8" tall and weighs approximately 170-180 pounds. FDC Clinical Record Review - Client On or about 09-20-07, i reviewed the ciiniooi Record for-., living on Residence 41 at FDC. The following is a summary oi the information obtained: is 19-year-old more admitted to Foo on li-O8-04, with diagnoses including moderate mental retardation (iQ Score of 50) and autistic disorder. does not use speech to communicate, and he makes his wants and needs known using vocalizations, gestures, facial expressions, and body language. -exhibits behaviors of slapping or hitting his face or head and hitting others. has restrictive interventions including wrist~to~waist restraints. In 2006, had an increase in aggressive behaviors to others especially in the early morning hours. is 5'9" tall and weighs approximately 160 pounds. State of California - Health and Human Services Agency Department of Developmental Services CRIME INCIDENT REPORT Page so or me i DS 214 (Rev 2/2 3 i i if Aw iwi ifrr 4.CASE NUMBER I ., . . DS07-06-F-081-F OFFICE OF PROTECTIVE WPE OF REPORT I rnur egg; 9576077 ops eso?-os-FDC Clinical Record Review Client On or about 09-20-07, reviewed the Clinical Record for-., a client living on Residence 41 at FDC. The following is a summary of the information obtained: . -is a 53--year-old male admitted to FDC on 05-23-00, with diagnoses including mild mental retardation (IO Score of 70), bipolar disorder and Klinerfelter (a sex chromosome abnormality). -is 6'4" tall and weighs approximately 216 pounds. - had a documented history of making false allegations and a history of aggression toward staff and peers. -has medical conditions including chronic obstructive pulmonany disease, a chronic tremor and diabetes. -is legally blind and he has good blind coping skills. - communicates at normal conversation level. He understands others and is understood by others. - is currently on a provisional placement in the community. FDC Clinical Record Client On or about 09-20-07, reviewed the Clinical Record for-., a client living on Residence 41 at FDC, The following is a summary of the information obtained: -is a 38-year-old male admitted to FDC with diagnoses including profound mental retardation (IQ Score of 18), autistic disorder, intermittent explosive disorder and bipolar disorder. - has behaviors of grabbing others, pulling hair, biting others and smearing feces/rectal digging. - mostly communicates in one to two word phrases. - is 6'1" tall and weighs approximately 211 pounds. A review ofthe interdisciplinary Notes (lDNs) for 06-06-07, revealed there was no documented entry for that date. . MEETINGS AND LETTERS REVIEWED interview with Florens Limbong, Senior Technician on Residence 41 On 06-11-07 at 1012 hours, intenriewed Limbong in the Conference Room at OPS at FDC. Jason Trujillo, a Representative with the California Association of Technicians . (CAPT) was also present during the interview. Limbong stated she has been employed as a Senior Technician on Residence 41 for approximately 10 years. I administered the Criminal Admonishment referred to as Beheler. This admonishment advises that the interviewee is not under arrest, is free to leave at any time, and is not required to answer any questions asked. Limbong stated she would provide a voluntary statement for the criminal investigation. The intenriew was audio recorded with the knowledge of all parties present for State of California - Health and Human Services Agency Depanrnent of Developmental Services INCIDENT REPORT Page 31of109 DS 214 (Rev 2/2003) 7 77 77 7w7")r BER OFFICE OF PROTECTIVE SERVICES OPE OF REPORT I Special Investigations Unit 1, Cl Feldnyu Misdemeanorll 5_ I ops PS07-0G--357 9576077 7 ops kn . note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: 7 Limbong stated she began her NOC shift on 06-05-07 at 2245 hours and she was the shift lead that night, Tan and Sotingco worked the NOC shift with Limbong that night. Limbong said there were 25 clients on the Residence and there are some clients awake at night, including-., -., van - and van roamed inthe hallway at and exhibited behaviors including banging on the window of the Nurses' Station and urinating in the hallway, usually in the main hallway near the medication room. Limbong stated she received report from the PM shift staff on 06-05-07, and there was nothing unusual reported. Limbong recalled there were incident reports on both the All/I and Pll/l shifts, but nothing that involved Van, There were no medical or behavioral incidents reported that night. Limbong stated that the assignments for the NOC shift staff included medication cart exchange and the staff had to verify all medications were received from the pharmacy and the staff had to verify the correct medications were received, the staff helped to sort the pills and to make rounds, paying extra attention to the clients that were awake. - Limbong stated she arrived and received report. All the NOC shift staff made rounds, room to room. Each staff member was responsible for one hallway. The initial rounds took approximately 15 minutes to account for all the clients, ensure there were no injuries or -- A changes in condition and to ensure that safety measures were in place. There was nothing out ofthe ordinary that night. The NOC shift staff then began sorting the medications. Limbong stated that the staff started to sort the medications. When the medication task was com leted, Limbong went to the Nurses Station, Tan went to Group 1 to pay attention to and Sotingco was seated in the main hallway between -'s room and Van's room, Limbong said at approximately 0100 hours, Van got up and his pants were wet, Sotingco changed Van, Limbong said after she was done with the medication cart, she completed the necessary papenxvork in the office. Tan remained in the hallway near Group 1 and Sotingco remained sitting in the main hallway between -'s and Van's rooms, completing rounds every 30 minutes. . Limbong stated she saw Van going in and out of his room during the NOC shift. Van was banging on the Nurses' Station window to get her attention Limbong said sometime around 0400 hours or 0430 hours, she heard Van scream. Limbong explained that Van sometimes screams when he is getting dressed because he doesn't like to wear clothes. Limbong went to Van's room and found Van with Sotingco in the room. Van was kind of sitting on the floor with his pants down Limbong asked Sotingco, "ls he olt want to wear his pants} Limbong told me that sometimes when staff is State nt California -- Health and Human Services Agency Department of Developmental Services REPORT Page 32 of109 2 A ME r_rr mise NUMBER i OFF OF SERVKJES TYPE OE REPORT gz i lm) g57'5?" i oss PP PEPA al assisting Van to get dressed, Van will sit on the floor to put his pants on. Limbong was not sure if Van was lying on the floor or sitting on the floor, but Van was in a supine position at that time, Limbong did not suspect that anything was wrong because that was Van's usual behavior. Limbong clarified that Van was wet with urine at the time she walked in his room. Van does not use diapers. Urinating is one of Van's behaviors. Limbong sketched a diagram of Van's bedroom and Van's location in his room (Attachment . No. 33). Limbong said she only opened the door to Van's bedroom, .but she didn't enter into Van's room at that time. Van's head was toward the cabinets and his face was toward the door. Van was afraid of the dark and he slept with the lights on. The lights were on when Limbong opened the door. Limbong said-., known as one of Van's roommates was in bed, but- Van's second roommate, was not in the room when she opened the door. Limbong said she was only at Van's room for a very short period of time. Limbong stated that she went back to complete her paperwork and then she made rounds and checked all the clients. Around 0420 a client, opened the door and she saw that he had feces on his hand. Limbong requested help from Sotingco and Tan to clean him, and they put him on the toilet. Tan and Sotingco stayed with -because he has a history of seizure activity. After that, the staff made rounds. Each staff member went to a different hallway. Limbong went side. According to Limbong, everything was "smooth." Limbong said woke up around 0530 hours, and started to aggress on the staff. Limbong thought that - aggressed on Tan. -was placed in wrist- to--waist restraints and Tan stayed with Limbong said that she and Sotingco continued to make rounds. After rounds were completed, Sotingco put away the barrels and Limbong returned to complete her paperwork. Limbong stated at approximately 0550 hours, Sotingco came to her and asked her to check on Van, Limbong went to Van's room and he was already lying in bed. Van's eyes were open and she asked him if he was okay. \/an had tears in his eyes and he just looked at Limbong. Van was able to follow Limbong's hand with his eyes Limbong said she got a soda thinking that Van would get up for soda. Limbong said she knew something was wrong because Van wasn't even trying to reach for the soda. Van loved soda. Limbong said they started to assess Van's vital signs and perform a neurological check. Limbong said that while assessing Van,- started acting out. -went to the bathroom and started to bang his head. At the same time, a lab technician cameto draw blood on two clients. Limbong stayed with Van while Sotingco went with the lab technician to?draw -'s blood and blood. Limbong said \/an's vital signs were within normal range, but she was worried because Van was able to move his right hand a little bit but he could not get up. Limbong stated she told Sotingco that he would have to write an incident Report. Limbong asked Sotingco what happened. Limbong said Sotingco told her, 'l found him on the floor' at State of California Health and Human Services Agency Department of Developmental Services CRIME INCIDENT REPORT Page sa ?r ros DS 214 (Rev 2/2003OFFICE OF PROTECTIVE SERVICES TYPE OE REPORT I ia an rr rac`0n meme"' gz gg?gi;E;g;Qgg7;g; tm) 957**077 A ops eso?-as-372 approximately 0545. Sotingco asked for Tan's help to get him back to bed. Sotingco told Limbong that Van could kind of stand up but he was weak and lethargic. Sotingco said \/an was able to bear weight. Tan and Sotingco told Limbong that they had cleaned up the urine and had changed his bedding. Limbong said she didn't do an investigation at that time because she wanted t0 notify the physician and the nurse. Limbong notified Dr. Reddy and the HSS. Limbong stated that Van was kind of moaning, which is his usual sound for crying. Limbong said she was shocked when she heard that Van had a neck fracture. Limbong said she suspected a problem with his feet. Limbong said Van sat on the floor for the staff when he was being cleaned up after an incident of incontinence. Limbong said no one witnessed any falls. Sotingco never told her that the client had a fall. Limbong said Van had cellulitis to both feet and was receiving antibiotics. Van's gait was steady prior to this incident. 2 Limbong stated Van was a strong guy. Van was taller than Limbong and he was muscular. Limbong said that the staffjust watched Van and dealt with his behaviors. Van was not an aggressive client. Van liked to be naked. Van was up in the hallway frequently during the night shift. That was not unusual for Van. At the time, Limbong didn't think that Van had a fall, but looking back she thought something like a fall might have happened. Limbong said that she didn't hear any other unusual noises coming from Van's bedroom during the night. Prior to Sotingco hnding Van on the floor, Limbong did not hear any unusual noises coming from Van's bedroom. Limbong said if a client aggressed on Van, he didn't fight back. \/an usually didn't scream, but he cried and moaned if he was in pain. Van usually screamed to be annoying. Limbong stated that- has aggressed on Van previously. Limbong stated that the clients on Residence 4'lexhibit numerous behaviors. For example, is aggressive to staff. Limbong told me that Van had two roommates: -- and -. also?known as Limbong said that Van and his roommates did not have any problems. Limbong said that- has a behavior of flipping beds. - has a behavior of smearing feces. Van and his roommates required checks every 30 minutes. According to Limbong, \/an and his roommates were non--verbal. i Limbong stated she has worked with Tan previously on another Residence. Limbong said she has also worked with him on the NOC shift on Residence 41 and he is a very nice guy and he is caring. Tan is not easily frustrated. Tan is always calm. Limbong said she has never seen Tan be inappropriate with a client. Limbong said she does not socialize personally with Tan and she only knows him from the workplace. -- CID State of Califomia - Health and Human Services Agency Department of Developmental Services CRIME 1 INCIDENT REPORT page 34 of109 . DS 214B Rev Zl'2003 4.cAse nuiusen - . DS07-06-F-081-F 3 5- (714) 9576077 2..1:1 luronmnou cms: -- CMPD 07-9361 Limbong stated she has only worked with Sotingco since she started on Residence 41- Sotingco is good with the clients and the clients listen to-him. Limbong said Sotingco does not appear frustrated by the clients. Limbong said she has never seen Sotingco be inappropriate with any client. Limbong denied any personal relationship with Sotingco. Limbong said she has a good working relationship with Sotingco. Limbong stated she didn't know if Tan had any direct physical contact with Van during the night. Limbong said Sotingco had direct physical contact with Van during the night. Limbong said she did not witness Sotingco cause any injury to Van. The interview was stopped between 1105 hours and 1107 hours. The interview commenced again at 1107 hours. - Limbong stated Van was supine in bed when she saw him (at approximately 0550 hours). Limbong said Sotingco did not tell her what position he found Van in and she didn't ask. Limbong denied any knowledge about how Van's injuries occurred. Limbong said she ?didn't witness anything that could have caused Van's injuries or heard anything about the cause of Van's injuries. Limbong stated that when she worked in the office that night, the door was open when the staff were cutting the medications. Limbong added that when Van was up in the hallway she closed the door. Limbong would occasionally open the door. . Limbong stated that she heard Van had a fracture to the neck area and that he had developed pneumonia. Limbong stayed with Van one night at Hoag Hospital and she met L. Ingraham. Limbong stated she is 5'1" tall and approximately 159 pounds. Interview with Johannes Sotingco, Technician on Residence 41 On 06-11-07 at 1241 hours, interviewed Sotingco in the Conference Room at OPS at FDC. Trujillo was also presentduring the interview. I administered the Beheler Admonishment to Sotingco. Sotingco agreed to provide a voluntary statement-for the criminal investigation. Sotingco stated he has been employed as a Technician on Residence 41 for approximately tive years. Sotingco previously worked at Metropolitan State Hospital for approximately 14 years. The interview was audio recorded with the knowledge of all parties present for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: Slate of California -- Health and Human Services Agency Department of Developmental Services CRIME INCIDENT REPORT Page as or 109 214 (Rev 2/2003Aoerice or eaorecrive seavices OR Special Investigations Unit . rm cruiviiwai. ci Felony in misdemeanor rn lnrrammn 57 CCNNECTED REPORT Fairview Developmental Center ii EI OPS 957'5'"7 ops eso?-oe-srz Sotingco stated he started his shift at 2245 hours 0n 06-05~07. Sotingco said he worked mandated overtime because he escorted Van to the ER at the acute hospital on 06-06-07. Sotingco left the hospital at approximately 1300 hours on Sotingco stated he initially made rounds before the PM shift left for the night. Sotingco said the three NOC shift staff members split up the hallways to make rounds. Sotingco said Van's bedroom is located off the long hallway. Sotingco didn't remember if he saw Van during the initial rounds. Sotingco worked with Limbong, the shift lead, and Tan, who was working overtime that night. Sotingco said there was nothing unusual on rounds. After the rounds, the PM shift asked if everything was clear and it was, so the PM shift went home. Sotingco stated usually after rounds he will start the laundry and he gets the white cart for linen supplies during rounds. Sotingco said he and the other staff then toileted any clients that needed to betolleted. Sotingco sald-- -,-and sometimes -are the clients that are usually toileted. Sotingco said Van is usually incontinent of urine,. but the staff do not wake him at night to toilet him. Sotingco said Van is unique because he lies in bed with his eyes open and the lights on. Sotingco said after the clients were toileted, he along with Tan, separated the medications for the clients. Every other Tuesday the staff have to separate medications that have been sent to the Residence. Sotingco said it took approximately 30--4O minutes to complete the medications and they hnished at approximately 0045 to 0050 hours. Sotingco stated that while working on the medications, Van came out of his bedroom soaking wet. Van's pants were down around his feet, pulled over his shoes. \/an was making a loud noise (his usual noises) and he was running. Sotingco said heand Tan stopped their medication task and they changed Van. Usually Van sat down in the hallway to be changed. \/an wore shoes that he was unable to remove himself. Van's shoes were removed and Sotingco noticed that the dressing to his big toe was wet and needed to be changed. Sotingco notified Limbong and the staff changed Van's dressings. Sotingco said he, Limbong and Tan did the treatment to Van's toes. Limbong was the medication nurse as well as shift lead on that night. After the treatment, the staff put \/an's shoes back on. Sotingco said he had seen Van fall in the past. Sotingco said he didn't know if Van was having any gait problems due to his foot condition because Van's usual gait involved a kind of dragging of his feet. Sotingco said Van had an unsteady gait at times. Sotingco stated that Van stayed in the hallway after his foot treatment. Sotingco said he was seated in the hallway near the Nurses' Stationthe hallway near Group 1. Sotingco said the door to the Nurses' Station was open that night. Sotingco said for the majority of time, Van couldvisually be seen. \/an went in and out of the bathroom during the night. Other clients were up at various times throughout the night. Sotingco said State of California - Health and Human Services Agency Department of Deveioprnental Services CRIME INCIDENT REPORT Page 35 of 109 DS QALB i(Re\/ 2/2003) *im ASE BER OFFICE OF PROTECTIVE 13/pg OF REPORT Special investigations Unit i CRIMINALD I El vi' ci Cl infa ron 55 5 mt 2 ADMINISTRATIVE REPORT Cm' 3 my OPS P807 06 357 OPS P807 O6 372 EOI1 Em BUOY 5 he kept busy assisting clients and making rounds. Sotingco said between 0330 hours and 0400 hours, \/an returned to his bedroom. Sotingco said he was the primary staff making rounds on \/an during the night and every 30 minutes that he checked him, Van was lying in bed. Sotingco said the last time he saw Van get up, between approximately 0430 hours and 0500 hours, Van was running toward Tan with his pants down and he was making his usual sounds. Sotingco didn't know if \/an was wet at that time. Tan pulled up Van's pants. Van returned to his room. Van had been removing his pants on and off during the night. Van wasn't wearing a shirt because he preferred not to wear a shirt. Van only wore a shirt for the dining room and if it was very cold. Sotingco stated that when he was making his rounds close to 0500 hours, he opened Van`s door and stood at the entrance to the room. Van was standing in the middle of the room in front ofthe closet, standing up bent over and facing his bed. Van was trying to take oft his pants. Sotingco told Van to pull up his pants. Sotingco directed Van twice. Sotingco said Van started to get upset and started to hit himself on the side of his head and was making a noise like According to Sotingco, this was a usual sound for Van. At that point, Sotingco entered the room to assist Van. \/an sat on the floor to be changed, as was his usual behavior. Sotingco pulled up his pants because Van's pants didn't need to be changed. Limbong came to the room and asked if everything was okay. Sotingco told Limbong that \/an was fine. Sotingco stated he went back to the hallway. Sotingco said Van got up and kicked on the door, which is also a usual behavior for Van. \/an looked out the hallway and then went back to bed. Sotingco sketched a diagram of Van's bedroom (Attachment No. 34). Sotingco stated he left Van's room at the same time that Lirribong left. Sotingco said he didn't remember if Van came out of his room, but he didn't see him again until 0530 rounds. Sotingco said morning rounds were delayed because- one the clients, had smeared. Sotingco was preparing for his morning rounds, when Limbong called he and Tan to assist with After- was cared for, Sotingco said he and Tan started making morning rounds. Sotingco stated was already awake and started acting up and tried to hit staff. Sotingco said this was usual behavior for-. Sotingco and Tan continued with rounds. Tan was changing- in the group room. Sotingco said he was ahead of Tan on the rounds. Sotingco said -got up during rounds to to the bathroom. Sotingco said this further delayed the rounds. Sotingco said that 's behaviors were escalating and he was placed in restraints. Sotingco stated that at approximately 0545 hours, he went to Van's bedroom and he opened \/an's door. Sotingco found Van supine on the floor with his head toward the bed opposite his own and lying between the two beds in the middle of the room. Van was moaning, Van State ot California - Health and Human Services Agency Department of Developmental Services CRIIVIEI INCIDENT REPORT Page 37 Orme . 2li4.CASE NUMBER -- OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT cial nvesti i ns i 1 len ivir dem swim ,,tr .. .- Cl"f' #97?9?6l.. looked at Sotingco. Sotingco told \/an to get up, but he didn't. Sotingco said Van was moving, but he wasnt getting up, so Sotingco went to Van's side. Sotingco made a visual assessment of Van and didn't notice anything unusual. Sotingco took hold of Van's left hand and tried to assist him to get up. Sotingcc said, "Come on Van, get up." Sotingco said Van was trying to move but he was a little bit resistive. Sotingco said \/an was wet and so was Van's bedding. Sotingco said Van remained on the floor and Sotingco called Tan for assistance. Sotingco said he changed Van on the floor and Tan changed the bed linens. . Sotingco said he and Tan got Van up, but Van was very weak. Sotingco said Van was still moving his upper body, his neck and his arm. Sotingco told me that he and Tan assisted Van back to bed. Sotingco described Van's demeanor as "groggy," "tired" and "drunl<." Sotingco said Tan had never seen Van like that before. Sotingco said after Van was put back to bed, he and Tan left and finished rounds. Sotingco stated that he recalled that approximately one to two months prior to this incident he found Van on the floor next to his bed. At that time, Van was moaning and having I difficulty getting up. At that time he and another staff member assisted Van back to bed. On that occasion, Van wasn't able to get back on his own. said the Al\/l shift complained about the NOC shift and the HSS was called. Sotingco said he remembered that incident and thought he better check Van again. Sotingco stated he returned to Van's bedroom and did a quick assessment and Van was awake but was not moving. Sotingco said he even removed Van's shoes to see what had happened. Sotingco said Van's behavior was very unusual for him, so he called Limbong to Van's bedroom. Limbong arrived and started an assessment on the client. Sotingco said while Limbong assessed Van, he had to assist the lab technician to draw lab work on- and . After the lab work was drawn, Sotingco returned to Van's bedroom. Limbong was checking Van`s vital signs and she asked Sotingco what happened. Sotingco told Limbong that he had found Van on the floor and that he and Tan had assisted Van back to bed. Sotingco said Limbong got a soda to see if Van would attempt to get it. Sotingco said Van waved his right hand very slowly, but was not able to get the soda. Sotingco said Limbong told him this is an injury of unknown cause and told Sotingco an Incident Report had to be completed. . I Sotingco stated he and Limbong started to make the appropriate notifications. Sotingco said Limbong called Dr. Reddy and the HSS. Two HSSs came to the Residence. Sotingco said he called the Unit Supervisor, but she was on vacation. Limbong told Sotingco to call Tortes, the Acting Unit Supenxisor. Sotingco said while he was writing the IR, the physician and ,2 nurses assessed Van. Sotingco said the physician ordered a neck brace for Van. Sotingco didn't know why the physician wanted a neck brace. The staff had to go to Central Supply for a neck brace. Dr. Reddy requested a blood sugar on Van and Sotingco obtained Van's blood sugar. Van`s blood sugar was normal between 120 and I30. Sotingco then went back State of California -- Health and Human Services Agency Department of Developmental Services CRll\/lE/ REPORT Page as arms os zu (Rev Ti TT orrice or erzorecrive seevices WPE OF REPORT i i Special investigations Unit H. i;1 cauviinat i;i Feiohy ci misdemeanor inrraciron RT Fairview Developmental Center is El OPS i ops i cc,. as - . We . .--.-.- eere to his papenivork. A decision was made to call "222." Sotingco said Tortes requested two staff accompany Van to the hospital because when Van was awake he was very strong. Sotingco said he and Bruch accompanied Van to the hospital. The ambulance could only take one person, so Bruch went with Van in the ambulance. Sotingco met them at the ER later. Sotingco said he didn't know what time Van was transferred to Hoag Hospital. Sotingco stated when he arrived to the ER, Bruch was already present with Van. Sotingco said he was present when the ER nurse removed the neck brace and the backboard. A CT scan was done. The backboard and neck brace were never replaced on Van. The ER staff attempted to obtain a blood pressure in lying, sitting, and standing position, but when Van sat up he was very weak and they laid \/an back down. Sotingco said later after the lab results and the CT results were back, one ofthe physicians at Hoag Hospital told him that the CT results were negative and Van's white blood count was a concern. The physician told Sotingco that Van was going to be admitted for further testing. Sotingco said he called Tortes to update him and Tortes asked if an x--ray had been done. Sotingco told Tories that no x-rays had been taken. Sotingco requested an x-ray per Tories. The physician ordered an x-ray. Sotingco said he took a break and then while he was on a break at approximately 1300 hours, Tories called him and said he could go home. Sotingco stated that most clients require rounds every 30 minutes at night, but there are a couple of clients that require rounds every 15 minutes at night. and- require rounds every 15 minutes. Sotingco said Van and his roommates, - and- required rounds every 30 minutes at night. Sotingco stated he didrrt see anyone going into Van's room that night. Sotingco said only . was in Van's bedroom that night. Sotingco said.f|ips mattresses, even when clients are lying on a mattress. Sotingco said -. has aggressive behaviors toward his peers and- was up during rounds, but Sotingco didn't see enter Van's bedroom. Sotingco said -will hit peers and staff and Eniured staff in the past Sotingco said -also has aggressive behaviors, but he didn't see-in Van's room. Sotingco stated that both Limbong and Tan had direct hands on with \/an during the night. Sotingco denied any direct physical contact with Van that could have resulted in Van's injuries. Sotingco said he didn't see any other staff have direct physical contact with Van that could have resulted in Van's injuries. Sotingco said he has never seen Tan or Limbong be rough with the clients. Sotingco stated Van is not aggressive toward the staff, but he does aggravate his peers. Stale of California - Health and Services Agency Department ol Developmental Services INCIDENT REPORT Page 39 of109 -- _r DS 214B (Rev 2/2003) Wm wv A__ii i frr_ . r_rr_r 4.CASE NUMBER DS07-oe-F-oai-F i OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT ?c 'aC' i (714) 3. Cl INFORMATION ONLY OPS -2.. MFG Ul? 07*93 Sotingco stated he is 5'8" tall and approximately 185-190 pounds; Sotingco said he is taller than Interview with Alvin Tan Ps chiatric Technician on Residence 41 On 06-11-07 at 1424 hours, I interviewed Tan in the Conference Room at OPS at FDC. Trujillo was also present during the interview. I administered the Beheler Admonishment to Tan. Tan declined to provide a statement for the criminal investigation I administered the Administrative Admonishment. This admonishment advises that the interviewee is compelled to answer all questions honestly and thoroughly. An Administrative interview was conducted. The interview was audio recorded with the knowledge of all parties present for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: Tan stated he was assigned to work the ANI shift and he also worked overtime on other shifts. Tan said he worked the NOC shift beginning 06-05-07 at 2240 hours and ended his shift on 06-06-07 at approximately 0730 hours. Tan said he worked with Sotingco and Limbong during that shift. Limbong was in charge on the NOC shift. Tan stated upon arrival he conducted his rounds, did laundry, and separated medications with Sotingco around 2400 hours. Tan said after that Van got up and he was wet. That was the time Tan saw Van wet that night. Tan and Sotingco changed Van and at the same time they did a foot treatment due to an old lesion or cellulitis to Van's foot. Van was up in the hallway and in and out of his room. Tan usually sat by Group 1 at the end of the hallway near the Nurses' Station. Tan was acting as hallway monitor. Sotingco was making rounds on the clients. Tan was with- a client, near the Group 1 group room. Limbong was in the Nurses' Station completing paperwork. Tan was not sure if the door to the Nurses Station was open or closed. At one point, approximately 0400 hours or 0500 hours, Van ran towards Tan with his pants down around his ankles. Van wasn't wet. Tan pulled up Van's pants and Van went back toward his room. Tan stated that sometime after that, between 0500 hours and 0545 hours, Tan remained with- in the Group 1 group room. Tan said Sotingco called him at approximately 0540 hours. Tan went to Van`s room. Tan noticed Van on the floor with his pants wet. Tan went to change the bed right away. Sotingco changed Van on the floor. According to Tan, Sotingco was calm, he wasn't panicked or nervous. Tan said it seemed as though Van was sleeping on the floor. Van appeared to be tired or sleepy, kind of like he was drunk. Van . was moving his arms, neck, and legs. Tan said he and Sotingco got \/an up off the floor and got him back to bed. Usually when Van is on the floor, he would sit up, but he was lying flat A on his back. Van was making attempts to get up off the floor but he couIdn't get up by himself. Tan said he didn't consider that Van had a back or neck injury. Tan said he visually State of California - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 40 ?r tos DS 214 (Rev 2/2003) 7 -- 2 osov-os-F-ost-F I OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT EEIQI i (714) 3. IN ORMA ION ONLY OPS - - Ec E. C. checked Van's neck and head, but didn't see anything unusual. Tan said Van had decreased weight bearing and was assisted by Sotingco and himself, each of them held Van under an arm. Tan said after Van was put back to bed, he went back to Group 1. Tan said from 0550 hours until 0630 hours he stayed with another client who required restraints. Tan stated Van was ambulatory. Tan said Van's gait was not affected by his foot condition. Van had self--injurious behaviors of hitting himself. Van liked to run in the hallway, hit the -- walls, and he urinated in the hallway. Van was non-verbal. Tan wasn't sure if Van was aggressive toward others. Tan said Van would most likely exhibit self-injurious behavior if someone tried to attack him. Tan stated the only direct physical contact he had with Van during the NOC shift on 06-05- 07, was when he pulled up his pants, during the treatment to his foot, and when assisting him back to bed. Tan denied pushing or having any direct physical contact that could have MK caused Van's injury. Tan didn't see any clients go into Van's room or witness any clients have direct physical contact with Van. Tan stated he has worked with Limbong on a previous Residence. Limbong is a good worker, and she is not easily frustrated. The only direct physical contact that Tan saw between Van and Limbong was when Limbong helped with the treatment to Van's foot. Tan stated Sotingco was okay with the clients and treated them with respect. Tan said that Sotirigco is low key and mellow. Tan said Sotingco is appropriate with the clients. Tan said he never saw Sotingco have any direct physical contact with Van that could have caused Van's injury. Tan stated that- one of Van's roommates, has a behavior of flipping furniture such as chairs and beds, Tan said he has never seen .be aggressive with other clients. Tan said - another of Van's roommates, was not an aggressive client. Tan stated he did not know how Van's injury occurred. Tan said he didn't suspect that any of the staff caused Van's injury. Interview with Lawrence Mitchell Ingraham, Brother to Van I. On 06-14-07 at 1117 hours, I interviewed L. Ingraham in the Conference Room at OPS at FDC. Investigator I\/lastrosimone was also present during the interview. The interview was audio recorded with the knowledge of all parties present for note taking purposes and for the record (Evidence Item No. 1), The following is a summary of the information obtained; i""I State of California - Health Senrices Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 41 or109 os me Rev mans; I I OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT Special Investigations Unit r. cnmiiuin Felony misuemeamr rnrmeum CONNECTED REPORT ops (ml 957'5?" Ops Psov-os-svz CMPD 07-9361 L. Ingraham revealed that he had an attorney, Donovan Jacobs, for the civil side of the issue involving Van. L. Ingraham said he usually visited Van two times per year at Fairview. Van was healthy, physically fit and good-natured. Van was constantly moving. Van liked to play with balls and run in the hallway. Van was not violent. Van had a history of falls, which resulted in slight injuries- Van also exhibited minor seIf--injurious behaviors including slapping his face. L. Ingraham stated that he was in New Mexico when he received a call from the staff on Residence 41, informing him that Van had sustained an injury and had-been admitted to the hospital. L. Ingraham said he and his wife drove straight through to Costa Mesa, California - from New Mexico. L. Ingraham said he arrived at Hoag Hospital between 0300 hours and 0330 hours on 06-07-07. L. Ingraham stated that he met Dr. Krutzik, the physician caring for Van in the Neurological Intensive Care Unit (ICU) at Hoag Hospital. Van had a Halo harness attached to his skull with full traction; L. Ingraham was informed that Van had sustained a severe spinal/neck -. injury that was probably not an accident. Dr. Krutzik did not elaborate any further about the nature of Van's injury at that time. L. Ingraham stated that he was referred to Dr. Dobkin, a Neurosurgeon at Hoag Hospital. Dr. Dobkin informed L. Ingraham that Van had an x-ray and an MRI. According to L. Ingraham, he was shown computer images that were "disturbing." Van had bilateral dislocation of_the C5-C6, the vertebrae had separated due to a clear break. L. Ingraham said Dr. Dobkin told him that he had seen many types of injuries like this. L. Ingraham said that Dr. Dorbkin informed him that in this type of injury, the head was pushed forward and the body was pushed back with a force great enough to dislocate the vertebrae. According to L. Ingraham, Dr. Dobkin said it was not likely that the injury was caused by a fall or self inflicted due to the severity of the dislocation. Dr. Dobkin drafted a letter. Dr. Hong, a surgeon at.Hoag Hospital, also drafted a letter concurring with Dr. Dobkin. L. Ingraham stated that Tan was assigned to watch Van at Hoag Hospital. L. Ingraham said he found this "amazing." L. Ingraham said he talked to Tan for approximately eight hours. According to L. Ingraham, Tan told him that he was worried that he had caused Van's injury. Sotingco had called Tan into Van's bedroom to request assistance to move .Van from the floor to the bed. Van was not able to move and that was unusual. L. Ingraham said that Tan told him that he and Sotingco put Van back to bed, they had to drag his feet to get him to the bed. L. Ingraham said that Tan told hime that it appeared that Van had been drugged, he was tiredand not-able to walk. Van had no affect. Additionally, L. Ingraham said that Tan told him that Van was only sleeping for approximately four hours during the night. At approximately 0400 hours to 0500 hours, Van was up in the hallway. Van urinated in the hallway. Van also urinated on the side of his bed on the floor. Van was found supine on his State of California Health and Human Services Agency Department of Developmental Services REPORT Page 42 ut tos -. l5?.iBsv 2/2003l . jr 7777 4.CASE NUMBER DSO?-os-F-oat -F I ir;2.2r.rr.rsrw M., D., . $0 6* I Fgirview Develipmental Center Zi mac On I (714) 95-/25077 3. El INFORMATION ONLY OPS PSO7-06-372 be ree, . - -, r,ee. Mr etigzazei I back, not moving as he normally did. According to L. Ingraham, Tan told him that Sotingco removed Van's pants while he was still on the floor and changed him on the floor. Sotingco requested that Tan change the bed sheets. L. Ingraham stated that Tan told him Sotingco initially found Van and called Tan into Van's bedroom for assistance. L. Ingraham stated on 06-09-07, he made an allegation of abuse against Sotingco to the staff at FDC because Sotingco was the sole person in charge of and caring for Van at the time of the injury. L. Ingraham said he had not spoken to Sotingco or to Limbong. L. Ingraham said he only had access to the staff members that were assigned to Van's care at Hoag Hospital. Interview with Nhut Ta, Senior Laboratory Assistant On 06-14-07 at 1400 hours, I interviewed Nhut Ta, a Senior Laboratory Assistant, in the 4. Conference Room at OPS at FDC. Ta stated he has been employed at FDC for 5 approximately 14 years. Investigator I\/lastrosimone was present during the interview. The 'ill interview was audio recorded with the knowledge of all parties present for note taking purposes and for the record (Evidence Item No. 1). The following is a summary ofthe information obtained: Ta stated he arrived on Residence 41 at approximately 0600 hours on 06-06-07. At 0600 hours, he drew blood on client-. At 0605 hours, he drew blood on client- Ta said he had to awaken both clients because they were both asleep when he arrived. Initially Ta didn't recall Van, but then he said that Van was often in the hallway and liked to touch others. Van was not aggressive and did not hit. Van was compliant. Ta said he didn't recall seeing Van on the morning of 06-06-07. Ta said he couldnt remember which staff were working that morning and he did not hear anything about Van's condition the morning of 06-06-07. Ta said two staff members helped him while he was drawing blood that morning. One of the staff members was a male. The staff members held the clients' arms while Ta drew blood. Ta denied having any contact with Van on the morning of 06-06-07. Interview with Jason Bruch, Pre-Licensed Technician On 06-15-07 at 0937 hours, I interviewed Bruch in the Conference Room at OPS at FDC. Bruch stated he has been employed at FDC for approximately 18 months. Bruch has been working the PIVI shift on Residence 41 for the majority of his employment at FDC. Bruch said. on 06-06-07, he started working the All/I shift on Residence 41. I administered the Beheler Admonishment to Bruch. Bruch elected to provide a voluntary statement for the criminal i investigation. The inlenxiew was audio recorded with the knowledge of all parties present for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: x" ar} State of Califomia - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 43 or 109 os 2148 Rev zrzoual 5 -- tense Numan . OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT Special Investigations Unit r. r.1 cnimiwu. Felony Misdemeanor mrracum CONNECTEO REPORT DBVGIODHIBIKBI 2- ADMINISTRATIVE REPORT CMPD 07-9361- . '_Bruch stated he started the AM shift on Residence 41 on 06-06-07. Bruch arrived to work at 0630 hours. Bruch denied being on Residence 41 between the hours of 2400 hours and 0630 hours on 06-06-07. Bruch said he walked to work that day, so he entered the Residence from the backside. As he walked onto the Residence, Bruch noted that the two Group 1 group leaders were not in the Group 1 group room that moming. Bruch said he saw Van in his bedroom on a gurney and he asked what happened. Bruch was told by Rene- Montes, Technician Assistant on Residence 41 and Jerry Arnold, - Technician on Residence 41, the two Group 1 AM shift staff members, that the NOC shift staff found Van on the floor and he was not responding. Bruch clarified that Van's eyes were open, but Van could not bear weight. Bruch said the Paramedim arrived approximately 10 minutes after he arrived to work. Bruch said that he was told to get Van's Clinical Record. Bruch said he and Sotingco were asked to accompany Van to the hospital. According to Bruch, he rode in the ambulance with Van and Sotingco followed behind in his personal vehicle. Bruch said he left the Residence with Van shortly after he arrived to work, probably prior to 0700 hours. Bruch added that Limbong and Tan werealso present on the morning of 06-06-07. Bruch said he didn't speak to Tan or Limbong about Van's condition`. Bruch stated that Sotingco told him he found Van on the floor and Van was not responsive, he could not stand and could not bear weight. Bruch said Sotingco told him that Van was not far from the bed, next to the bed with his pants down. Bruch didn't know if Van had urinated and he didn't know if Van was in a supine or prone position when found. Bruch said it was very unusual for Van to be inactive because Van was always up in the hallway. Bruch stated that he believed Van was wearing elastic type pants and his special orthopedic boots. Bruch couldn't recall if Van was wearing a shirt. Bruch said Van was not able to express any facial emotion and that was very uncommon for Van. Bruch didn't know what happened to Van. Bruch said Van had a behavior of urinating, then pulled his pants down around his ankles and ran in the hallway. Bruch said he believed that Van possibly sustained his injury by running with his pants down around his ankles. Bruch stated that upon arrival to Hoag Hospital, Van had a slight reddened area above his left eye. That was the only mark that Bruch observed to Van's face. Bruch said he remained with Van at Hoag Hospital on 06-06-06 until 1630 hours. Bruch said the Paramedics had placed a cervical collar on Van's neck, but upon arrival to Hoag Hospital the ER staff removed Van's cervical collar. Bruch said he questioned the reason that Van's cervical collar was removed. Bruch could not remember if Van had a backboard in place during transport to the hospital. . Bruch stated that Van had an intravenous line placed, a catheter, and had some testing done. Bruch said Van was able to move his right arm, but he wasn't moving his left arm. Bruch said Van had very limited movement to his lower extremities. Van was able to make State of California - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 44 or 109 os 214 Rev zrzoos . 4.CASE NUMBER .. DS07-06-F-081-F OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. cnmiiwu. Felony masuemeamro imraurm CONNECTEO REPORT I ops PSM-06-35Y OPS PS07-06-372 . CMPD 07-9361 some very quiet noises, not his usual noises. Van was very expressive and to see him not expressing his emotions was unusual. Bruch said he was also concerned when the ER nurse requested assistance to sit Van up, because the emergency staff had already removed Van's cervical collar. Bruch said the nurse informed him that the physician wanted Van's blood pressure while he was lying, sitting and standing. Bruch said he and Sotingco did assist Van to sit upand .Van's neck fell forward. Bruch said they told-the ER nurse that they had concerns_ about sitting Van up, but the nurse instructed them to sit Van up so they could obtain a sitting blood pressure. Bruch said Sotingco requested.that the ER physician obtain an x-ray of Van's neck. _Bruch said at approximately 1000 hours,-the hospital staff started the CT Scan, the neck x-ray, and the MRI. Bruch said prior to noon,. it was detennined that Van had a fracture to his neck or spine. Bruch stated that once it was determined that Van had a fracture to his spine, there was a lot of activity in the ER. Van had the cervical collar replaced and he was put on a backboard. Additionally, the halo traction device was applied. Following the application of the halo traction, Van was started on pain medication. Later a specialist came to discuss Van's - condition with Bruch and told Bruch that Van was in really bad shape and might need surgery. Bruch stated that while he was in the ER, he tried to contact L. Ingraham on his home phone - and cellular phone and left numerous messages. Bruch said that he-never did get hold of him on 06-06-07. Bruch said prior to Van's injury, he never met L. Ingraham. Bruch didn't know how often L. Ingraham visited Van. Bruch said he did get to meet L. Ingraham a couple days later when L. Ingraham came by the Residence at FDC. Bruch stated that Sotingco remained in the ER until approximately 1100 hours or 1200 hours,_and then Sotingco took a break. Bruch said he heard from Tortes that Sotingco could go home, so Bruch called Sotingco to let him know. Bruch kept Tortes and Taylor awa_re of Van's condition at the hospital. Bruch was relieved by Dennis Lanting, Technician on Residence 41 for the PM shift. Bruch stated that he heard that Van's condition was as usual for most of the night on 06-06-07. Sotingco found Van sometime prior to 0630 hours. Bruch said Sotingco seemed very concerned about Van's condition, and Sotingco was not acting unusual. Bruch said that he and a few other staff members went to visit Van in the hospital a few days after Van was admitted. Bruch described Van as a person with a lot of character, especially for someone who was not able to verbalize. Van exhibited a lot of emotion. Van would make noise and slap his hands together or on an object when he needed something. Van occasionally exhibited a - self-injurious behavior of slapping his thigh or his face when he was upset. State of California -- Health and Human Services Agency Department of Developmental Services CRIME INCIDENT REPORT Page 45 of109 DS 214 (Rex W, _j I OFFICE OF PROTECTIVE SERVICES NRE OF REPORT Special investigations Unit 1. i;i CRIMINAL I: Felony E1 Misdemeanur infraction TED REPORT ra Fairview Developmental Center gig OPS 77*4) 957*5077 ops eso?-oe-372 was CEE. .. . E- et,4 . Bruch described Van. Bruch stated that Van did not like to have people in his personal space, so he would nudge people out of his space with a hand gesture. l\/lost clients reacted by giving Van his space. Van was not aggressive toward others. Bruch said Van was also very charming. Bruch said - was a very aggressive client, he flips and throws furniture. Bruch said is one of Van's roommates. Bruch said Van's other roommate,-, was not aggressive at all. Bruch said when he saw Van on the morning of 06-06-07, he didn't see any of Van's roommates in Van's room. Bruch stated that Van had good rapport with the staff, but Van was "difticult" at times. Bruch said most of the staff gave Van his space and that allowed Van to relax. Bruch said he had worked with Tan, Limbong and Sotingco on occasion. Bruch said he didn't know what the relationship was between the three staff members working the NOC shift on 06-05-07. Bruch said Tan is a great team member. Tan will help out in many areas. Tan is a mellow guy who is not easily frustrated. Bruch said he has never seen any of these staff members be inappropriate with a client. Bruch said these three staff members are "pretty mellow." Bruch said he wasn't aware of any staff that trained in martial arts or self- /7 defense. Interview with Michael Tuckness, Technician on Residence 41 On 06-18-07 at 1323 hours, interviewed Michael Tuckness, a Technician, in the Conference Room of Building 33 at OPS at FDC. Tuckness stated he has been employed at FDC for approximately 10 years and he has been working on Residence 41 for the entire time. Tuckness said he has been working the AM shift on Residence 41 for the past two years. Investigator Nlastrosimone was present during the interview. administered the Beheler Admonishment to Tuckness. Tuckness elected to provide a voluntary statement for the criminal investigation. The intenriew was audio recorded with the knowledge of all parties present for note taking purposes and forthe record (Evidence Item No. 1). The following is a summary of the information obtained: Tuckness stated he was not on Residence 41 between the hours of 2400 hours and 0630 hours on 06-06-07. Tuckness stated Van has been on Residence 41 since he started working on the Residence. Tuckness said Van was always awake in the hallway in the morning. Van usually made a gentle gesture with his hand to move people along in the hallway. Van exhibited self- injurious behavior of hitting his thigh or face with his open hand, he would tear his clothes off and he urinated in the hallway. Van had a steady gait when ambulating in the hallway. Van was capable of using the toilet, but he still would urinate in the hallway. Van would wet himself, pull his pants down and then ambulate with a shuffling gait. Tuckness said he was not aware of any specific falls as a result of this behavior. Van was not aggressive toward State of California Health and Human Services Agency Department of Developmental Sen/ices REPORT Page 46 of ios . DS 2li.?l - Wai we - was .-.-.- .- . - NUIVISER 1 i OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT I Special investigations Unit ci cniivunni. ci Felony Misderneanor i?rra?ti?? EC "rr* Fairview Developmental Center OPS 957"5ttee . - e,ee A as - -- eeree -. ee,e s. QBE others. Van had a behavior of stripping his clothes. Van loved playing with balls. According to Tuckness, Van was healthy except for a recurring foot infection or other type of problem. Van wore special boots due to problems with his feet. Tuckness said he worked in Group i with Van on occasion. Tuckness stated he worked with Van during the ANI shift on O6--O5-07, and Van did not have any change in condition on that day. Upon return to work on the shift on O6--O7--07, Tuckness learned that Van had been injured and was transferred to Hoag Hospital. Tuckness said he went to visit Van in the hospital with some other staff after work one day. Tuckness said Van had halo traction applied and he was connected to a lot of machinery. Tuckness said Van seemed to know that the staff were present and his eyes appeared to be watery. Van didn't seem to be able to move his left hand, but he was able to move his right hand a little bit. Tuckness didn't see Van move his lower extremities. Tuckness didn't speak to any physicians while visiting Van. Tuckness said he dicln't' see any of Van's relatives when he went to visit Van at the hospital. Tuckness stated that the other clients tolerated Van's behaviors. Tuckness said he has seen aggress on others including Van. - has a behavior of "tapping" on others wit an open hand, sometimes hard, sometimes not hard. - is approximately 5'8" and approximately 158 pounds. - used a two handed over the head smack to other clients, either to the back or front or on the arms. -required mittens and wrist--to-- waist restraints for his behavior of hitting others. Van had two roommates. -was not an aggressive client toward others. - has a history of prope destruction, elopement, and was aggressive by lunging at others. Tuckness as not seen lunge at others recently. - did not have behaviors of hitting or kicking. ihas a behavior of flipping furniture. Tuckness stated he heard that Van sustained a fractured neck. Tuckness hasn't heard anything else about Van's injury. Tuckness said it was a big surprise. Tuckness stated that the staff had a good rapport with Van. Reinforcements worked very well with Van, particularly with snacks or soda. Tuckness said he is not aware of any staff members that have martial arts training or self--defense training. - Tuckness stated he knows Tan, but has not worked with him often. Tan is a quiet guy. Tuckness said Tan is very polite and did his job. Tan seemed to be able to do his job correctly and was caring of the clients. Tuckness said he has never seen Tan be inappropriate or frustrated with the clients. Tuckness said he has not worked with Limbong and he has very limited personal interaction with her. Tuckness said Sotingco is a happy, go-lucky guy. Tuckness said none of the staff that worked the NOC shift staff on raised any alarms as far as client care. State of California - Health and Human Services Agency Department of Developmental Services CRIME INCIDENT REPORT Page 47 of 109 os_zi4g ev zrznosr i r_r_ 7 vvwimd TT rr 0. NUMBER I I OF PRQTECTIVE SERVICES irypg Or: . Special Investigations Unit 1. CI EI Felony Misdemeanor EI infraction 5 7 Fairview Developmental Center 3; Ops ops PS07-06-372 ,_ee G- Goss- Al__ Interview with Kenton Goodrich, Technician on Residence 41 On 06-18-07 at 1410 hours, I interviewed Kenton Goodrich, Technician, in the Conference Room at OPS at FDC. Goodrich stated he has been employed at FDC for approximately 10 years. Goodrich has been working the All/I shift on Residence 41 for over five years. Investigator l\/lastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: Goodrich stated he was not on Residence 41 between the hours of 2400 hours and 0630 hours on 06-06-07. Goodrich stated that he worked the AIVI shift on Residence 41 on 06-06-07. Goodrich said he didn't recall seeing Van that morning. Goodrich said when he arrived he heard that Van was found on the floor and was not able to move. Goodrich said Van was a strong guy, who would walk up and down in the hallway. Goodrich heard that L. Ingraham accused Sotingco of pushing Van and causing Van's injury. Goodrich also heard that Sotingco said he found Van on the floor when he entered Van's room. Goodrich said Tan told him that he knew nothing about how the injury occurred because he was in the hallway when Sotingco called him in for help. Goodrich didn't talk to Sotingco or Limbong directly about the incident. Goodrich stated that he had limited interaction with Van, because he didn't work in Van's group. Van exhibited a behavior of slamming doors and tapping people when he wanted them out of his way. Van occasionally walked in the hallway with his pants down around his ankles, usually after he urinated in the hallway. Van would usually pull his pants up when prompted. Goodrich didn't know if Van had falls as a result of walking with his pants down around his ankles. Van made noises, but was not verbal. Goodrich stated that there might have been some issue between and Van, but Goodrich added that he had never seen any altercations between the two clients, Goodrich was not aware of any aggressive behaviors by Van. Goodrich said Van seemed to be in good health overall. Van had special shoes for an issue with his feet. Goodrich stated he was aware that Tan, Limbong and Sotingco worked during the NOC shift on 06-05-07. Goodrich said he has worked with all three staff members. Goodrich said Limbong is great, and she helped out a lot when he has worked with her in the past. Goodrich said Tan is a real quiet guy who does his job well and seems caring. Goodrich said Sotingco seemed like a quiet, easy going guy. Goodrich said none ofthe staff raised any concerns with him regarding their work or care of the clients and that was one of the reasons this injury to Van was such a surprise. State of California -- Health and Human Services Agency Department of Developmental Services REPORT Page 48 orioe @5214 (Rev_2/20037*7777 if MQ AMW 4.cAsE NUMBER i i I I Eanu aclcn $1 .5 . .2.-., . . CM Goodrich stated-. is a roommate of Van's. When Goodrich came on that morning, he found-in bed in the room across the hallway. Goodrich said it is not uncommon for -to sleep in another room. Goodrich said he thought someone or something was probably bothering -and that was the reason -went into another room to sleep. Goodrich stated he was not aware of any staff that were involved in martial arts training or self-defense classes. The only person he has ever heard claim that he knows martial arts is _ia client on the Residence. Goodrich said he has observed - attempt to use martial arts on clients in an effort to defend himself. Goodrich said that didn't have a realistic knowledge of martial arts based on Goodrich's observation. Goodrich stated he doesn't know how the injury to Van occurred. Interview with Alex Torts, Jr., Senior Technician on Residence 41 On 06-19-07 at 0822 hours, I interviewed Tortes in the Conference Room at OPS at FDC. Investigator lvlastrosimone was present during the interview. Tortes stated he has been employed at FDC for approximately 20 years. I administered the Beheler Admonishrnent to Tortes. Tortes elected to provide a voluntary statement for the criminal investigation. Tortes said he has been working on Residence 41 for 11 months on the ANI shift. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained; Tortes stated he was not on Residence 41 between 2400 hours on 06-05-07 and 0630 hours on 06-06-07. Tortes was not aware of anyone who practiced martial arts. Tortes said he used to take martial arts and he boxed, but it had been many years since he had practiced any martial arts. A Tortes stated he arrived to work at 0632 hours on 06-06-07, and there was a little commotion in Van's room. When Tortes entered the room, Van was lying supine on his bed. Tortes asked Limbong if the physician had been called because Van's behavior was not usual. Limbong said the physician had already been called. \/an was able to move his right arm, able to move his left arm a little bit and he could move his legs only a little tiny bit. Montes called to Van from across the room to get up, but Van could not get out of bed. Usually Van would jump out of bed and start running. Tortes stated when he saw Van on the morning of 06-06-07, Van wasn't wearing a shirt and he dicln't have his shoes on. jr Tortes asked what happened and was told the staff found Van on the floor and went to get help to get him up, but Van could not bear weight so they put him back to bed. Tortes made some telephone calls and then Dr. Reddy arrived and assessed Van. Dr. Reddy decided to send Van to the hospital immediately. Dr. Reddy called "222" to expedite Van's transfer. State of Califomia - Health and Human Services Agency . Department of Developmental Services CRIME I INCIDENT REPORT Page 49 of109 os 2148 . 5 4.CASE OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT D&VEURl0pm&I'll8l CBHISF OPS 95"5?" ops psu?-os-372 CMPD 07-9361 Tortes stated that Dr. Reddy responded to the fact that Van was physically unresponsive and this was not the norm for Van. Dr. Reddy checked Van's reflexes, but he didn't know the results. Tortes said Van was- a very strong guy, and Van's physical responses on that morning were extremely weak. Tortes said the HSS that saw Van that morning was Siketha Henderson, Registered Nurse (RN) with Central Nursing Services at FDC. Tortes stated the Paramedics arrived approximately 10-15 minutes later. The Paramedics were informed that Van was found on the floor with decreased physical movement. Report was provided to the Paramedics. The FDC staff assisted the Paramedics to transfer Van onto their gurney with the application of a neck brace and backboard. Van was transferred very carefully by rolling him and placing the backboard under him. Tortes stated he noticed_ - that Van's neck was bulging a little at the base of his neck, and he mentioned to the Paramedics to make sure that Van got an x-ray. Tortes directed two staff to accompany Van. to the hospital. Tortes stated that Van was transferred off the Residence approximately 35 minutes after the physician arrived. Tortes stated Tan was watching the clients in Group 1. p) Tortes stated Sotingco found Van in his bedroom on the floor with his pajama bottoms wrapped around his leg- Tortes said Sotingco told him that he asked Van to get up. Van was lying on the floor face up and he was waving his hand in the air. He tried to help Van up, but according to Sotingco, Van was 'dead weight.' Sotingco then called Tan to assist. Sotingco and Tan changed Van's wet clothes. Tortes stated that Sotingco told him that there - was a discoloration to the area around the and an IR was done. The staff thought that . the discoloration around Van's could have been the result of a fall. Tortes said Van had a high tolerance for pain. Tortes said Van's vital signs were blood pressure around 90- 110/70, pulse 70 and respirations around 20. Tortes stated the speculation was that Van was wrapped up in his pajamas and fell on his head. Tortes found out around 1130 hours from Hoag Hospital that Van had a necklinjury. Tortes said the staff that accompanied Van to Hoag Hospital later reported that the hospital staff indicated Van's injury was consistent with a surfing type of injury where the there is a forceful impact of the head against a surface with some type of force that twists the neck. Based on the information provided, the staff thought maybe Van fell face down on his head, injured his eye, and then flipped himself over. Tortes stated that if a client was found on the floor and was reaching toward a staff member with his hand, it would not be unusual for a staff member to assist the client up off the -- ground. Tortes said it would depend on the situation. Tortes said if a client was - unconscious and was not able to move or in a strange position, he wouldn't move that client. Tortes said the staff would rely on their standard first aid training. Tortes was not aware of any specific policy regarding moving a client who was found on the floor. State of California - Health and Human Services Agency Department of Developmental Services CRIME REPORT - page E..LE . . -. 5 4.CASE NUMBER 1 DSo7~0o-F-oa1~F OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT 55*5577 Tortes stated one of Van's roommates, was walking out of Van's bedroom as he arrived on the Residence and Van's other roommate, was not in \/an's bedroom that morning. Tortes said - -and Van had been roommates for years. -is very active and an AWOL risk. -is partially verbal with some decreasing seIf--in]urious behavior. - does not have aggressive behaviors. .is non--verbal and has a history of self--irrjurious behavior. . has occasional outbursts of frustration and he flips furniture. Tortes said all the beds in Van's room are bolted down. Tortes said he has never seen .flip a mattress. For I the most pait,.liked to flip his own furniture. Tortes said the three roommates seemed to get along very well. Tortes added that- and Van were in the same group. Tortes said that -will occasionally be found sleeping in a bed across from his own bedroom, but Tortes didn't know the reason for this. Tories stated Van was an AWOL (absence without leave) risk, he liked to walk around without his shirt, and he had self-injurious behaviors of hitting himself in the head and slamming his hand into stuff. Van was very happy--go--lucky. Van was non--verbal. His preferred staff were Montes, Arnold, and a previous shift lead Duc Phan, a Senior if Technician who now works on another Residence. Van urinated on the floor, pulled his pants down, stripped his clothing (without bending over to remove his pants), when sleepy he was very groggy, he was extremely active and enjoyed playing with balls. Van was always by a door, if he saw a door open he would close it, if he saw a door closed he would open it and if he saw someone in the doorway, he wanted that person out of it. Tortes stated Van required generalsupervision and was not sure whether Van was to be checked every 15 or every 30 minutes at night. Tortes said Van had a toe injury for which he was receiving treatment. Tortes stated Tan is a very good worker and a good Technician. Tan is always on time to work, he knows his job, he knows how to work well with the clients, and he is very tolerant of the clients and their behaviors. Tan knows how to protect himself as far as putting his hands up and staying away from the clients. Tortes said he has never seen a client aggress on Tan. Tan shows respect to the clients and the clients respect him in return. Tan follows directions well, has never had a problem being mandated to work overtime, doesn't complain and works a lot of overtime. Tan is very professional. Tories told methat he (Tortes) is an instructor for Adaptive Training and Restrictive intervention (ATARI) and Tan is very quick and has done things correctly in behavioral situations. Tan is very professional and does things by the book. Tories said it is a pleasure to work with Tan. Tories stated he doesn't know Sotingco as well as Tan, but Sotingco has always arrived to work on time and works very hard and very well when he is mandated to work overtime. Sotingco is respectful of the clients and he has never seen Sotingco raise his voice to the clients or react in a negative fashion. The clients in Sotingco's care are always well-- Stateof California Health and Human Services Agency I REPORT Department of Developmental Services Page 51 of 109 ircixse NUMBER DS07-O6-F-08 1 -F DSO7-O6-F-086-F (Rev 2 3) Wihg i ii__W_VW_i?iAVn" 1 OF PROTECTIVE SERVICES Wm; OF I Special investigations Unit 1. El CRIMINAL I El de Fairview Developmental Center 2 REPORT (714) 957 5077 3 ONLY OPS P807 O6 357 CMPD O7 9361 5i?" I IS ITIEBTIDY groomed. Sotingco will ask questions that are appropriate. Sotingco is calm and smooth in a behavioral situation. Tortes stated Lirnbong is a good Senior Technician. Limbong has a good, quiet, low-key personality in working with the clients and dealing with behaviors. Limbong is a very positive and calm person. Tortes stated there are some aggressive clients on the Residence. is a large client with a ressive behaviors. also exhibits aggressive behaviors toward others. will run up and down the halls and will hit anybody. has self~injurious behaviors and exhibits aggression toward others. Tortes said -is usually up in the morning and he is aggressive. -will go into other clients' rooms to hit another client. -will hit in any manner and then will leave. Tortes described an open-handed over the head hit. hits with a lot of force. Tortes said that has injured staff and even hit a client hard enough to make them fall to the floor. is a "dangerous guy." -is very unpredictable. -will vocalize during aggressive periods. Tones said is aggressive, but not very ambulatory and unsteady on his feet. Tortes said -is more aggressive toward the staff. Tortes said it is possible for a client to get into another clients room, but the staff usually listen for any unusual noises, especially doors opening and closing at night. Tortes stated he has spoken to L. lngraham. Tortes made the initial contact to L. lngraham to notify him of \/an's injury. Tortes said L. lngraham was out of the state and was driving to FDC. Tortes said Friday, 06-08-07, was the first time he met L, lngraham in person. Tortes saw L. lngraham outside Residence 41 and explained to L. lngraham that he Was not allowed on the Residence. Tortes stated that L. lngraham told Tortes that he believed a staff member had injured Van. Tortes asked if he was reporting abuse and L. lngraham said he was. Tortes said he was going to go report the abuse, but L. lngraham said he was going to report it himself. Tones took L. lngraham to the Program Office to make the abuse report and left him with l\/lcLaughlin. Tortes asked who L. lngraham thought hun Van. L. l.ngraham told \/an it was Sotingco. Tortes took Sotingco off the schedule and reported the information to his supervisor and made the appropriate notifications. Tortes said he heard that L. lngraham came back onto the Residence on Saturday at around 1500 hours. One of the staff members had L. lngraham sign in. Tortes heard that L. lngraham spoke with William~ l\/lensah on 06-O9-07. Tortes asked why she let L. lngraham on the Residence and told Tortes she let lngraham on the Residence because he was Van's conservator. Tortes pointed out that \/an wasn't on the Residence. State of California Health anciliurnan Services Agency Department of Developmental Services CRIME INCIDENT REPORT Page 52 ofioe DS 214 _i _Ag _iWi_i NUMBER i OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT . Special Investigations Unit 1, CRIMINAL Felonylj ri/lisaemeanorti infraction pjafwf I Fairview Developmental Center 2- IE ADMINISTRAWVE REPORT i (714) 95725077 3. i3 INFORMATION oNLv i OPS O7-9361 I Tortes stated that later on Monday, 1-07, he heard that L. lngraham received some papen/vork from a staff member. Tortes was upset because he didn't find out about L. lngraham`s Saturday visit until the following Monday. Tortes said the Program Office was going to handle this issue. Tortes didn't know what paperwork lngraham received or who L. lngraharri received the paperwork from. Tortes said either on 06-11-07 or L. lngraham came back to the Residence and the janitor let him in. Tortes saw L. lngraham on the Residence and escorted him off the Residence. L. lngraham asked who gave Tortes the authority to prevent him from being on the Residence. Tortes said there were confidentiality issues and that was the protocol. L. lngraham wanted to know where this was written, Tortes told him that it was included in the Facility's conndentiality clause. Tortes explained to L. lngraham that he needed to go through the proper channels to obtain paperwork or come onto the Residence, particularly because Van wasn't on the Residence. Tortes escorted L. lngraham tothe Program Ofhce to see Kathy Kastelz, the Unit Supervisor on Residence 41. L. lngraham apologized and then said he was sorry that the staff were involved. Tortes said he was offended that he thought a staff member was involved. Tortes said L. lngraham told him that the physician at Hoag Hospital told him that someone came from behind Van, broke his neck and then pushed him to the ground. L. lngraham also told Tortes that Van's injury was the result of whiplash due to staff throwing Van back and forth. Tortes said it took three people to hold \/an down and itwould be very difficultfor that to happen. Tortes stated he never told L. lngraham that Van's injuries occurred at Hoag Hospital. Tortes did tell L. lngraham that he didn't know why the hospital staff didn't x-ray \/an immediately instead of waiting so long. Tortes said he didn't recali blaming Hoag Hospital for \/an's injuries. Tortes said he did hear that L. lngraham alleged Tortes said that the staff at Hoag Hospital hurt Van. Tortes heard that the Hoag Hospital staff removed the backboard and the neck brace. Then an > According to Tortes, -is a verbal and a smart client. State of Califomia - Health Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 53 of 109 os 214 Rev zrzuos 4.0ASE NUMBER OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. Felony msrremeanor- rnrracrrorr 5_ OORREOTEO REPORT I $1 ops OPS PS07-06-372 . CMPD Tortes -stated that L. Ingraham averaged a visit to Van approximately once or twice a year. L. Ingraham was very realistic about Van's condition. L. Ingraham also had a fund for all the clients on the Residence. Interview with William 'Jergy' Arnold, Technician on Residence 41 On 06-19-07 at 0949 hours, I interviewed Arnold in the Conference Room at OPS at FDC. Arnold stated he has been employed at FDC for approximately 30 years. Amold said he has been working on Residence 41 for the majority of his service at FDC. Investigator Mastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: Arnold stated he worked the AM shift on 06-06-07. Arnold said he was not on Residence 41 between the hours of 24-00 hours and 0630 hours on 06-06-07. Arnold said upon arriving. to the Residence, he went into the ofhce and signed in and read the reports. As Arnold started his rounds, Montes, AmoId's Group 1 co-leader, asked him to come down to Van's bedroom. When Arnold entered the room, Van was lying supine on his bed wearing "powder blue" . colored pants, no shirt and no shoes. Van was awake but not moving his arms or legs. The staff were concerned with what was wrong with Van. Sotingco, Limbong and Montes were also present in Van's room at that time. Dr. Reddy had been notihed, but had not arrived on the Residence at that time. Arnold stated Limbong told him _that the staff found Van on the floor and the staff had to assist him up. According to Amold, the staff said they didn't know the reason for Van's change in condition. Previously, Van had exhibited a decrease in his normal activity level following sedation, but Van did not receive any sedation prior to this incident. Arnold stated that L. Ingraham alleged that Sotingco tried to keep Van in bed by pushing Van back in bed or putting some type of hold on Van and resulted in the injury to Van. At the . time that Arnold entered the room, there were no sheets on the bed and Arnold didn't notice any urine on the floor when he went into Van's room at 0630 hours. Arnold said maybe the sheets had been stripped off the bed- because _Van had been incontinent. Arnold said that Van was following the staff with his eyes. Arnold said Dr. Reddy arrived and while she assessed Van, Arnold started to care for the other clients that were wakingup. Arnold said he learned that the Paramedics had been called. Arnold recollected that Dr. Reddy had seen some swelling to Van's neck and was concerned about a possible neck injury. Van . also had a slight discoloration (light purple) over the left and no swelling was noted. Dr. Reddy ordered a stiff neck support a_nd Tan went to get the neck support, but Tan returned with a soft neck support. State of California -- Health and Human Senrices Agency Department of Developmental Services REPORT Page 54 orios A os 214 (asv zlzocsj mince OF PROTECTIVE TYPE OF REPORT Special investigations Unit 1. crurviinat ci Felony in misdemeanor mrraciion eii_e . - ros. o- Arnold stated he was present when the Paramedics arrived. Arnold said he was in Group 1 and the Paramedics were with Van. Arnold said the Paramedics applied a rigid neck support to Van's neck. Arnold said he didn't know if Van had a backboard or not, Arnold stated he didn't know anything about how the injury occurred to Van. Arnold said when he learned how severe the neck injury was, it was hard to think how the injury occurred. L. Ingraham was so certain that it was Sotingco, but Arnold found it hard to believe that someone would do that to Van. The staff were all very shocked and all very sad about Van's death. Van was a very big part of the Residence, like the "heartbeat" of the Residence. Arnold stated he did not recall seeing-. or-, in Van's room the morning of 06-06-07. Arnold said it seemed that Van got along well with his roommates. Van liked to sleep with the light on. Arnold said that- and - go to bed late due to their behaviors that keep them up at night, Usually, -is under the covers in his bed in the morning. Arnold said - is usually in his own bed in the morning.- has aggressive behaviors toward staff and clients because he flips tables and throws objects. All the beds in Van's room are bolted to the floor because - has flipped beds in the past. Arnold said he has not known to flip a bed or a mattress when a client has been on the bed or mattress. Arnold said that . flipped-, a client, in his wheelchair within the past month. The staff did not think that- targeted -, but flipped - because he was the closest to . is very strong when he is upset. I has also grabbed at staff members glasses and clothing. Arnold stated that when he has seen Van be touched or aggressed on by a peer, Van would just stand there. Van would start yelling or he exhibited ?self--injurious behavior following this type of incident. Arnold said he has observed some physical altercations between Van and --, a client in Group 2. Arnold said- is pretty strong and pretty smart. \/an has been the victim in these altercations, but Arnold did not recall any significant injuries. Arnold stated Van had chronic infections in his left foot. Van had a high tolerance to pain and would continue to ambulate even when his foot was infected. Arnold described Van as having been in very good physical condition, often acted on instantaneous gratification, and had one to two staff that he particularly attached himself to. Van's preferred staff was Montes. \/an had a social development class at Daily Training Activity Center (DTAC), where he did a variety of activities. Van vvasn't interested in many activities, unless he had reinforcers such as food, sodas and attention from Montes. Arnold said Van had episodes of incontinence at night. During the day, Van would use the toilet unless he was frustrated or upset and then he would urinate in the hallway. \/an's usual gait was normal. He wore special shoes and would occasionally stumble, but for the most part his gait was good and he could run. Van used to be able to climb over fences, and he was very agile. Van would climb over half walls in between some of the rooms and he climbed up on furniture. Arnold State of California - Health ane . .aman Services Agency ir Department of Developmental Services INCIDENT REPORT Page ss or 102 DS YRGV iw,. r,r, E, i, . A 4.CASE NUMBER --, csc?-oc-F-081-F 3 OFFIGE OF SERVICES TYPE OE REPORT t; (-M4) 9576077 3, [1 INFORMATION ONLY OPS so E, MP @222231 said Van had difficulty undressing himself because he couldn't remove his clothing over his special shoes. At times Van would come out of his room with his pants down around his ankles after a period ofincontinence. Van was able to dress himself with some minimal assistance and he preferred not to wear a shirt. Van usually kept his pants on unless they were wet and then he would try to pull them off. Arnold stated Van always seemed to be up, except for when he took naps, Van would nap for approximately 30 minutes to 90 minutes. Van had behaviors of yelling and banging on hard surfaces when he was upset. Van also had a seIf--in]urious behavior of slapping himself on the right side of his head with an open -- hand. Van would on occasion also tip over a chair, not violently, when he was very upset. Van would get upset if he saw others with food and he was hungry, when he had to have a hands on treatment that required touching or ifpreferred staff left the Residence. Van preferred not to be touched or held. Van required restraints and sedation for invasive types of procedures. Van liked to have doors open and the lights on. Arnold stated that he has known Tan, Limbong, and Sotingco for approximately one to two years. Arnold said he has only worked with Tan on occasion, but he has never worked with Limbong or Sotingco, Arnold said Limbong always seems to be in a good mood. Arnold said he didn't know how Limbong worked with the clients. Arnold said Limbong is always very nice and friendly and he has never heard any complaints about her. Limbong always seems to have the clients best interests in mind. Arnold said Tan is a very hard worker and he is able to do a lot of different tasks, Arnold said Tan is "an employee of the month kind of guy." Arnold said Sotingco is quiet and he has never heard any complaints about Sotingco. Arnold said there are no "red-fIags" in his mind about any of these three staff members. Arnold stated he is not aware of any staff that study or practice martial arts or self-defense. Arnold said there are some clients that go in and out of other cIients' rooms. Arnold said -- and-. would wander into others' rooms. -will go through others' lockers to find clothing and -would lie in others' beds. -. also displayed aggressive behaviors of hitting others in the hallway or in the group rooms. - can be very opportunistic, but Arnold didn't recall seeing- up the morning of 06-06-07. Arnold said another client that was aggressive was Arnold said -focused on Van and - would call Van names. Van didn't react to name-calling. Also, Van liked to open the door to the Group 2 group room and that bothered ln the mornings,- was usually in bed. Arnold said -. would run ou in the hallway and hit others using an overhand slap. Arnold said - is approximately 5'l and he can hit hard. - doesn't seem to single out anyone. Arnold said- would hit from the back or from the front. - has been known to climb over the half wall between the bedrooms and attack a client in another room. Arnold said- room is three to four rooms down from Van's A room on the same side. State of California - Health and Human Services Agency . 4 Department of Developmental Services INCIDENT REPORT page ss of109 D5 . mw . f. N, ETNMBER I 2 I OFFICE OF RRQTECTIVE SERVICES WRE OF REPORT I gg? I Um 957'5'm ops psu?-os-372 I M, - -. -. MM 361 Arnold stated he didn't know how the injury to Van occurred. Arnold said he initially thought that Van might have slipped and fell because sometimes there was urine on the floor in his room. Arnold said he didn't know what happened based on the severity of the injury and information that he received from L. Ingraham, indicating that the Hoag Hospital physicians said the injury could not have resulted from a slip and fall. I Interview with Fernando Casillas, Technician on Residence 41 On 06-19-07 at 1326 hours, I interviewed Fernando Casillas in the Conference Room at OPS at FDC. Casillas stated he has been employed at FDC for approximately two years. Investigator Mastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence item No, 1). The following is a summary of the information obtainedt Casillas stated he was not on the Residence between 2400 hours and 0630 hours on 06-06- it 07. Casillas denied any knowledge of martial arts. Casillas stated he worked during the AM shift on 06-05-07 and he saw Van walking around the hallway and closing doors, as was his usual routine. Van was not wearing a shirt and he was active. Casillas said \/an liked to play with balls and walk a lot. Van had a behavior of pulling down his pants and urinating in the hallway. Van also liked to close doors, and he enjoyed eating well. Van was not an aggressive client and he got along with people. Van had a good relationship with the staff. Casillas stated he was assigned to sit with Van at Hoag Hospital on the morning of 06-07-07. Casillas said he was shocked and sad to see Van in the condition he was in, Van was awake and making his usual noises (moaning). The I-loag Hospital respiratory team came over prior to 0900 hours and informed L. lngraham that Van may need to be intubated because Van's vital signs were up and down. L. Ingraham was Van's conservator. L. Ingraham indicated that he didn't want Van to be intubated. At that time, Van's lips were cyanotic (bluish color). Van was able to move his right arm and a wrist restraint had been applied to Van's right arm. Additionally, Casillas said that Van moved his legs two to three times, but it appeared to be a reflexive action. Casillas stated he didn't know how Van sustained his injuries. The staff were not talking about the incident. Casillas thought it was possible that \/an had a tall. Casillas stated a client on Residence 41, hits others and hits him everyday. - has a behavior of slapping staff. - targets staff. Casillas had never seen - hit his peers. -uses an open hand over the head downward slap. Casillas said that- had muscles and was aggressive toward his peers at times. Stale of California - Health Senrices Agency a Department of Developmental Services CRIME INCIDENT REPORT Page 57 0f1D9 os 214 is (Rev zrzurm TT i omci; or Paorecrivs seavices OR RERORT Special Investigations Unit 1. ci cRiiviiNAl. I3 Felony ij misdemeanor I3 infraction GRT rr?rr 4 Fairview Developmental Center GPS lm`) 9576077 0Ps PS07-06-372 iw . . Casillas stated he didn't know much about Limbong or Sotingco. Casillas said Tan was a hard worker. Interview with Alan Maliwat, Technician on Residence 41 On 06-19-07 at 1405 hours, interviewed Alan l\/laliwat, a Technician, in the Conference Room at OPS at FDC. I\/Ialiwat stated he has been employed at FDC for approximately seven years. Investigator ll/lastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary ofthe information obtained: Il/laliwat stated he worked the AIVI shift on Residence 41 on 06-06-07 in Group 3. Upon entering the Residence on 06-6-07, I\/laliwat saw Van in the hallway and he heard people coming on the Residence. l\/laliwat asked what happened and was told that \/an had an injury. Later that afternoon, Nlaliwat was told that Van was taken to Hoag Hospital due to an injury. Il/laliwat stated Van was usually in the hallway when he arrived to work. Van had a behavior of checking doors to be sure they were opened or closed. I\/laliwat said Van was a nice guy that didn't hurt anyone. Maliwat stated that., one of Van's roommates, had a history of flipping beds and furniture, but ir had been a iehg time since- exhibited that behavior. iviaiiwai said that- hit eo le overhead with an open hand or a fist. -did not target anyone specifically. ihits hard and has broken a staff mernber's finger. Maliwat stated that Tan was a good worker and had a good rapport with the clients. l\/laliwat said that Limbong is a good worker and she is compassionate with the clients. I\/laliwat said Sotingco is calm and nice with the clients. Sotingco helps the clients. Maliwat stated thathe was taught that if a client is on the ground, the staff should assess the client but not touch the client. The staff are supposed to call for assistance. Interview with Carissa Pruett, Technician Assistant on Residence 41 On 06-19-07 at 1452 hours, interviewed Carissa Pruett, a Technician Assistant, in the Conference Room at OPS at FDC. Pruett stated she has been employed at FDC for approximately two years. Investigator lvlastrosimone was present during the intenriew. The rl interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary ofthe information obtained; State of California -- Health and Human Services Agency 7 Department of Developmental Services CRIME I INCIDENT REPORT Page sa or ros os zu is (Rev zrzuuai 777 7 777777 777777 7 77 7 777 77 77`` 7 77`77RROTECTIVE OF REPORT . A Special ll'lV95tlQ3ttOl`lS Unit 1. CRIMINAL Felony 1] Misdemeanor infraction gl CO RT I Fairview Developmental Center 2- REPORT OPS (714} 9576077 3. INFORMATION ONLY OPS PSO7--O6-372 i e.Pruett stated she was not on the Residence between 2400 hours and 0630 hours on 06--06--07. Pruett said she was sent home from Employee Occupational Health during her `shift on 06-05-07, due to an injury. Pruett denied any knowledge of martial arts. Pruett stated that she reported to work by telephone on O6--0l3--07, and at that time she was informed that Van was paralyzed Pruett asked what happened, but no one knew. Pruett stated Van was a very active guy. Van liked running up and down the hallway Van made sounds like, 'You. You.' Van was very physically fit. Van was very gentle and not an aggressive client. Van liked to play with balls. Pruett stated-was mad at Van. pushed Van and scratched him one time. According to Pruett, Van ignored Pruett said that- had aggressive behaviors of hitting others. was aggressive with everyone - hit people with an overhand downward swing usually with a fist, and he hit hard. - gets up at night and will go into others' rooms. - will make sneak attacks on others. Pruett stated that Tan is a soft--spoken and easy-going staff member who does his job well. Tan is calm and has a good rapport with the clients. The clients listen to Tan. Pruett said that she has worked with Limbong a few times. Limbong is calm, relaxed and not easily 7 flustered. Limbong is detail oriented. Pruett said that Sotingco is good at his job and he is reliable. Sotingco is easy going and does not get mad. Sotingco is very efficient and has a great rapport with the clients. Pruett had no concerns that any of these staff wereinvolved with Van's injuries. Pruett stated that the nurses and emergency personnel did not like the clients to be moved prior to their assessment. According to Pruett, she understood that an injured client should not be moved. Pruett wasn't sure if this information was based on a policy or training. lnterview with Michelle Taylor, Registered Nurse on Residence 41 On O6--20--O7 at 0919 hours, interviewed Michelle Taylor, a Registered Nurse, in the Conference Room at OPS at FDC. Taylor stated she has been employed at FDC for approximately 10 years. Investigator Mastrosimone was present during the intenriew. administered the Beheler Admonishment to Taylor. Taylor elected to provide a statement for the criminal investigation. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary ofthe information obtalnedi I - Taylor stated she arrived to work late on 06--06--07. Taylor arrived to work at 0730 hours, and noticed there was a fire truck and ambulance parked outside of Residence 41. Taylor said that once on the Residence she to the nursing office. Taylor said she .. . State of`CaIifomia - Health and`Y?lGnan Services Agency Department of Developmental Services CRIME 1 INCIDENT REPORT . page ss 0f109 os 214 Rev mm 4.CASE NUMBER 5 . Dsov-06-F-081-F Special Investigations Unit - 1. carmlum. cr Fermy misdemeanor mrracnan 5_ CCNNECTEC REPORT I D8v&l0pmGl'll3l CGDIBF 2- ADMINISTRATIVE REPORT OPS pS07_06_357 CMPD 07-9361 could not remember who gave her report, but she did receive a report about Van. Taylor- said she was told that Van was found in the early morning hours on the floor and he could not bear weight and was acting very_strangely. The physician was notihed and decided to call a "222" because Van's injuries were so severe. Van left the Residence right after Taylor arrived and he had a neck brace applied and was on a backboard. Taylor stated she did not speak to Dr. Reddy. The Transfer Summary Report was on the counter after Van was transferred. Taylor saw some pertinent information in the report including the physician's plan to rule out trauma to the head and neck, and Taylor asked a - staff member to take the report to the Clinical Liaison at FDC to fax to Hoag Hospital. Taylor stated it was a very busy `day. All the staff wondered what happened to Van. Taylor said she suspected some kind of spinal injury because it really concerned her that Van was not able to bear weight. Taylor said she received several phone calls from Bruch with updates about Van. Taylor said Bruch told her that a CT Scan was done and was normal and blood work was also normal. Bruch reported that the ER staff were taking Van off the - backboard and Taylor said she was very concerned and asked Bruch to ask the staff to take an x-ray. Bruch called backapproximately 30 minutes later and said the physician ordered an x--ray. Bruch called back to Taylor several hours later and said that the x-ray was done . and that it revealed a fracture of the C4 and C5. Bruch told Taylor that after the fracture was found a halo traction device was applied to Van. Bruch informed Taylor that the staff at Hoag Hospital ER indicated there was a possibility that Van might need surgery and wanted someone available to sign the consents. Taylor stated she knew that L. Ingraham was out of town because she had attempted to contact him the previous day to obtain consent for sedation for a treatment that Van required. The sedation was for an appointment scheduled during the day on ~06-06-07; therefore, Van never received any sedatio_n on 06-06-07 at FDC. According to Taylor, Kastelz had spoken to L. Ingraham and arrangements had been made to fax the consent to L. Ingraham. Taylor informed Bruch not to sign any forms and to have them contact the FDC Clinical Liaison for any consents. Taylor said she spoke to one of the Hoag Hospital ER nurses over the phone and was informed that Van was going to have an MRI. The MRI was - done and revealed there was not a fracture but a subluxation ofthe vertebra where one of - the vertebrae is on top of another vertebrae. Taylor said she didn't remember when L. Ingraham arrived at the hospital. Taylor said she heard from Bruch that L. Ingraham had arrived at the hospital and was completing do not resuscitate (DNR) paperwork. Taylor stated she spoke to Limbong about the incident. Limbong told her that Van had been up for most of the night. Taylor said Limbong told her that during 0530 or 0545 hour rounds, Sotingco found Van on the floor and attempted to get Van back into bed. Van was not able to bear weight so Sotingco called Tan forassistance. Van was placed back in bed. Limbong State of California - Health and Human Services Agency Department of Developmental Services I INCIDENT REPORT Page so ?r tos DS 2148 (Fggv 2/2003) . 7*77* nig") i i wV__m if i NUMBER . DS07--06-9081-F OF PROTECTIVE SERVICES TYPE OF REPORT i I emean rerun or salssiasfsii I OPS PSOY-06-372 . - i j_ i iw CM 0 361 was notified and called the physician. The staff obtained vital signs from Van and according to Taylor that was very unusual because usually Van was resistive to having his vital signs . taken. Taylor said she thought that Van's blood pressure was low upon transfer Hoag . Hospital. Taylor stated that all the staff were in shock and wondering how Van's injury occurred. Taylor said she heard that the NOC shift staff had gone into Van's room, found him wet and changed him, then put him back to bed. The next time the staff checked on \/an was when they found Van on the floor and Van was not able to bear weight. A Taylor stated that Van had two roommates- and Taylor said -is not aggressive toward others. -does exhibit a self-injurious behavior of banging his head. -likes to flip items over, and he has flipped objects when clients are involved. For example,. has flipped a wheelchair with a client seated in it. . is opportunistic. Taylor said she didn't know what clients were up on the morning of 0606-07. Taylor said some al clients that are early in the morning are-., -, and Van. Taylor w, i and -have aggressive behaviors toward others. Taylor said has a very unsteady gait and he usually exhibits self-injurious behaviors in his own room. -wanders into other cIients' rooms and he slaps himself and hits others with an open hand. - is pretty strong but Taylor did not recall that- had in`ured anyone. Taylor said - usually only goes into his room and the day room. i hits with an open hand and he hits very hard. - aggresses on others almost daily. - will continue to aggress on a client. -brings his hands down over his head and hits others. - is strong and he has injured many staff. -has aggressed on Van because Van is always in the hallway. - will come out of his room and aggress on the first person he sees. Taylor was not sure if Van had sustained injury from- Taylor stated she did not know how Van's injury occurred. Taylor said in her opinion, based on the conversations she had with Bruch, she felt that Van should not have been taken olf the backboard because Van possibly sustained more spinal damage as a result of that action. Bruch told her that the Hoag Hospital staff were moving Van around and sat him in a chair to obtain a blood pressure. Taylor said she proposed a situation to the physician, that if a client was moved with a subluxation, then the spinal cord could have sustained more damage. Taylor said that L. Ingraham said that once Van was placed in traction the subluxation straightened out, but there was severe spinal cord injury. Taylor said she believed that the Hoag Hospital staff exacerbated Van's by taking Van off the backboard and moving him around. Taylor stated that if the staff suspected a client had a neck injurythen the client should not be moved. Taylor said in Van's case, if Van wasnt getting up on his own, then she would have thought Van should not have been moved. Taylor said she couldn't speak for the NOC State of California Health andHurnan Services Agency Department of Developmental Services --. NUMBER i Ds07--0o-float-F OF Paorecrive OPE OF REPORT Special Investigations Unit 1. in cnuviinai. ci Felony ivnsoemeanorm inrraettcn g_ NNECTED REPORT CM ops psrim-357 OPS Ps07>>0s-372 . .--.-- .--.-- . ,,tt tete . eette . eeteetle teet W- QNP shift staff. Taylor said the NOC shift staff might have thought that Van was groggy and wet and in need of assistance. Taylor said there is some basic first aid training, but the staff also need to take into account the speoinc client and that client's abilities Taylor said it could have gone either way, Van may have been just groggy and wet or there was possibly something more significant happening. Once someone can't bear weight and they usually can, then injury should be suspected and the client should be assessed. Taylor said that the training indicated that if a client had a suspected neck injury then the client should not be moved. Taylor said all the staff should be aware where the Nursing Procedure Manual was located, but in each situation, a staff member is expected to not only follow the procedures but to also use their best judgment. Taylor said the NOC shift staff indicated to her that they thoughtVan was just groggy and needed help back into bed. Taylor stated that Van had a behavior of pulling his pants down around his ankles and then running. Taylor-said Van's gait was fairly stable, even when he had a foot infection. Taylor said Van had chronic cellulitis. Taylor said that \/an was very resistive to treatments and cx medication. Van would run up and down the halls. Van never wore a shirt. Van was by frustrating, but he was a fixture. Taylor said that Van was not aggressive. Van had a behavior of urinating in the hallway. Taylor said it was very difficult to get Van to clinics. Taylor stated that she has worked with Limbong, Tan and Sotingco. They are all very sweet, mild-mannered staff. Limbong and Tan are very attentive and kind to the clients. Taylor said Tan and Limbong probably get pushed around more by the clients. Taylor said she feels the same way about Sotingco, but she hasn't worked with Sotingco often. Taylor said Sotingco is veiy mild with the clients. Taylor said she has seen Tan in a stressful situation with clients and he is very calm and patient in those situations. Taylor has not seen Sotingco or Limbong in a stressful situation. Taylor did not suspect any of the NOC shift staff of causing the injury to Van. Taylor stated she was not aware of any staff that practice martial arts or self defense. Taylor said-thinks he is Superman and he can do anything. Taylor stated she spoke to L. Ingraham when he came to the Residence one day while Van was still alive at Hoag Hospital. L. Ingraham told Taylor that the Hoag Hospital physicians told him that the injury to Van could not have resulted from a fall. Taylor stated she heard that L. Ingraham was left alone in the nursing office on the shift. Taylor said she heard that after that time, the Journal of Falls and the NOC shift schedule was missing. Taylor said she has since heard that the original NOC shift schedule was found, but she didn't know what happened to the original Journal of Falls. State of California - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page ez of 109 lR*= A W, -.-. ..--.-L LL- L- NUMBER DS07-06-F-081-F I OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT I I Special Investigations Unit 1. i:i ceiivunnt Felony 1:1 misdemeanor El inrraelion 5_ Fairview Developmental Center gi 5 OPS ops Psa?-os-272 L. -- . . . . -..-.L.- D. *3?i 979363 Interview with Lorelei Carigma, Technician Assistant on Residence 41 On 06-20-07 at 1034 hours, I interviewed Lorelei Carigma, a Technician, in the Conference Room at OPS at FDC. Carigma stated she has been employed at FDC for over one year. Amanda Oliver, a representative with the California Association of Technicians (CAPT), was present during the interview. Investigator l\/Iastrosimone was also present during the interview. The intenziew was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained; Carigma stated she signed in for her shift on 06-06-07 at 0625 hours. Carigma said she didn't see Van prior to his transfer. Carigma saw Sotingco writing an Incident Report. Carigma said she heard that Van was found on the floor by the NOC shift staff. Carigma said she didn't hear any additional information about Van's injury that day. Carigma later heard that Van was comatose, paralyzed and that he had traction applied. On 06-11-07, Carigma was informed that Van had died. Carigma said she heard Van's brother made an allegation that one of the staff hurt Van. Carigma denied knowledge of martial arts. Carigma stated she saw Van on 06-05-07, and he was running in the hallway as usual. Van had behaviors of urinating in the hallway. Van also liked to open and close the doors. Van was not aggressive. Van was independent with arnbulation and required assistance with dressing. Carigma stated that-would hold Van's arm. Another client, hits others with a downward striking motion, but Carigma had not seen any contact between Van and Carigma stated that she never worked with Sotingco or Limbong. Carigma said she worked with Tan for one week and he was very hard working. Communication with Lawrence Ingraham' Ingraham, Brother of Van Ingraham On or about 06-20-07 at 1130 hours, I had a telephone conversation with L. Ingraham. The . following is a summary of the information obtained: I placed a telephone call to L. Ingraham. L. Ingraham said that he had letters from two physicians at Hoag Hospital (Dr. Hong and Dr. Dohkin) indicating that Van's injuries were not the result of a fall. L. Ingraham also mentioned that he had requested a full examination of Van's body by Dr. Krutzik. L. Ingraham stated that he ended up with the Journal of Falls Log from the Residence and he gave a copy to Kastelz. i State of Califomia -- Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page ss or 109 . os 214 Rev zrzooa 4.0ASE NUMBER OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. r=?r?rry 1:1 rwsuemeamr 5_ CCNNECT-EC REPORT - Fairview Developmental Center gz OPS pS07_06_357 (mi - ops Psome-372 CMPD 07-9361 Letter from William Ross Dobkin, M.D. -- 06-1-2-07 . On or about 06-20-07, I received a copy ofthe Letter dated 06-12-07, written by William Ross Dobkin, M.D., via e--maiI from L. Ingraham (Attachment No. 35). The following is a summary of the information obtained; - Dr. Dobkin wrote that Van was admitted to Hoag Hospital with a severe bilateral facet dislocation at the C5--C6 level causing quadriplegia. Van underwent closed reduction of his deformity but unfortunately was left quadriplegic. Due to aspiration, he developed pulmonary problems. Given his overallpicture, it was not likely that Van was going to survive. Dr. Dobkin continued that these types of injuries generally take "quite a bit of force to occur." These injuriesare often seen in body surfing accidents where the body has been thrown against the ground or in motor vehicle accidents. "lt's unlikely that minimal force would cause this and, as such, it's difficult to come to any type of conclusion what circumstances injured Mr. Ingraham. Certainly a fall from his bed where he was found would not have sufficient impact to cause any type ofinjury like this." Letter from Derrick Hong, M.D. 06-13-07 On or about 06-20-07, received a copy of the Letter dated 06-13-07, written by Derrick Hong,_ M.D.,.via e-mail from L. Ingraham (Attachment No. 36). The following is a summary of the information obtained: Dr. Hong wrote that he was Van's lnternest at Hoag Hospital between the dates of 06-06-07 and 06-11-07. Paramedics transported Van to Hoag Hospital from Fairview Developmental Center on 06-06-07, after he was found down on the floor by caregivers. The . circumstances leading to this situation are not known. His caregivers stated that he had a mechanical fall while ambulating, although this was not witnessed. Mulitiple imaging studies were performed in the ER which showed the Van had a C5-C6 bilateral facet dislocation injury complicated by spinal cord compression. "Such injuries usually result from extreme flexion of the head and neck." Despiteprompt closed reduction of his cervical dislocation by the neurosurgeon, Van developed complete paralysis. His clinical status would deteriorate after aspirating. According to his brother and durable power of health care, L. Ingraham, Van had a very good quality of life despite being autistic. He loved to ambulate and run around the confines of Fairview Developmental Center and he also loved to eat. Because he would no longer be able to do these things, heroic measures were not pursued and the patient was placed on palliative care. He passed away early in the morning on 06-12-07. State of California - Health and an Services Agency L: Department of Developmental Services CRIME I INCIDENT REPORT Page 64 or 109 os 214 a new zrzocs 5 4.CASE NUMBER I OFFICE OF PROTECTIVE SERVICES- TYPE OP REPORT 323;:321;:33;:; Special Investigations Unit CRIMINAL Felony EI wsuemeamr 13 Inrracuon 5_ CONNECTEO REPORT Fairview Developmental Center ig- OPS - ops PS07-06-372 CMPD 07-9361 Journal of Falls Pro ram 4 Residence 41 - June 2007 `On or about 06-20-07, I received a copy of the Journal of Falls for Residence 41 at FDC for the month of June 2007, via e-mail from L. Ingraham (Attachment No. 37). The following is a summary of the information obtained: - The only entry was Van at 06-06-07 unseen. The Joumal of Falls Log stated the fall was a "sIip out of bed." The cause of the injury was not observed by staff. Injury was noted. An IDN was completed. The physician was notified. 24-Hour Report follow--up was required. Interview with Veronica Cuevas, Technician on Residence 41 I On 06-20-07 at 1318 hours, I interviewed Veronica Cuevas, a Technician, in the Conference Room at OPS at FDC. Cuevas stated she has been employed at FDC for . approximately seven years. Investigator Mastrosimone was present during the interview. . The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: Cuevas stated she was not o_n the Residence between the hours of 2400 hours and 0630 hours on 06-06-07. Cuevas denied any knowledge of martial arts. . Cuevas stated she heard that Van had a spinal cord injury. Cuevas heard from other staff on the Residence that L. Ingraham, was very vocal that Van's injury was not the result of a fall. Van's brother was intent that the person who caused Van's injury was Sotingco. Cuevas said she was shocked to hear that Sotingco was being accused of causing the injury. Cuevas said she visited Van in the hospital on 06-07-07. Van was lying in bed and Van- I hated to be lying down. Van had traction to stabilize his neck. Cuevas said Van's eyes were not pleasant. Cuevas said that Van was able to move his right arm, but it was very weak. Van had reflexes when his feet were touched. Van did not like obstructions and he seemed to be trying to tight his oxygen mask. Van was able to swallow some Coke when Cuevas was with him. While present with Van. at Hoag Hospital, Cuevas saw L. Ingraham along with some other family members. Cuevas said the family found out that Van would never walk again. Cuevas said later she asked Limbong what happened. Limbong told Cuevas that the staff found Van on the floor. Van had tears in his eyes and he wasn'.t moving. Van was trying.to reach up to the staff and the staff helped him up. Cuevas said Limbong told her that something was wrong with Van, and they notified the physicianand the Health Services Stale of California Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 4.CASE NUMBER i ir Ds07~0e~F~0s1?F SERVMS ?anu as I Fairview osvernpmaltax came I (714) 9576077 3. Cl INFORMATION ONLY OPS I CMPD 07-9361 Specialist. \/an was placed on a gurney with a backboard behind him. According to Cuevas, Limbong told her that \/an had been up around 0400 hours or 0430 hours. Cuevas stated Bruch told her that the hospital staff at Hoag Hospital attempted to sit Van up after the CT Scan and the blood was drawn. No x--ray had been taken when they sat \/an up. Bruch informed Taylor via a telephone regarding Van's status and Taylor said to request an The Hoag Hospital staff were moving Van and did not seem to be aware that he had a spinal injury. Cuevas stated Van was not an aggressive client. Van was always in the hallway. Van did not like to take his medication and he preferred male staff. Van had cellulitis to his feet that required treatment. Van had a good rapport with the staff. Van loved to drink Coke and he liked rewards. Van exhibited self-injurious behaviors when he was upset and he would also bang the Plexiglas windows. Van did not like loud noises. \/an was non--verbaI and he was A able to make his needs known. Van was strong. He was able to ambulate with a steady gait, had a history of falls, and he was incontinent of urine. Van often pulled his pants down I around his knees or ankles after he had an episode of incontinence and he attempted to walk or run. Van required some assistance with dressing and he preferred not to wear a shirt. According to Cuevas, Van could be a trying client, but the staffjust let him be and Van was compliant. Van was part of Group 1. Van usually urinated in the hallway between Group 2 and Group 3. Van also liked to open and close doors. Cuevas stated that- was upset with Van because Van was naked or he urinated on the floor. - is authoritarian and he had a history of attacking Van. Van never attacked back.- was up at night to go to the bathroom and he had insomnia. - was not very strong according to Cuevas. Cuevas stated-. had behaviors of slapping others on the arms and hitting others. mould put his hands over his head and strike in a downward motion. -did no go into other clients rooms. I Cuevas stated that during the night shift a staff member sits in the hallway at one end between the two group rooms. Van required 30--minute checks during the night. Cuevas stated that she did not socialize with any of the NOC shift staff working with \/an the morning of his injury. Cuevas said Lirnbong is a hard worker and a good NOC shift lead. Limbong goes over and above her duty. Limbong completes all the paperwork and she assists on the floor. Cuevas said that she has worked with Sotingco and he is a hard worker who is dedicated. Cuevas said Sotingco does not raise his voice to the clients. Cuevas said that Tan is a quiet hard worker. Tan doesn't look like he gels stressed. State of California -?Health and Human Services Agency Department of Developmental Services REPORT Page as urine DS 214 (Rev 2/2003) li I A 7'"r 7 r`'r iww VT Numara I DS07-06-F-081-F OFFICE OF PROTECTIVE SERVICES ORE OR Special investigations Unit 1] E1 CRIMINAL EI Felony Mtsdemeanor I3 lnfractron 5_ CO I Cm' ops Pew-06-257 3 OPS PS07-06-372 . - N-, I Interview with Gricelda Gomez, Technician Assistant on Residence 41 On 06-20-07 at 1415 hours, I interviewed Gricelda Gomez, a Technician Assistant, in the Conference Room at OPS at FDC. Gomez stated she has been employed at FDC for approximately three years. Investigator Mastrosimone was present during the intewiew. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: Gomez stated she was not on the Residence between 2400 hours and 0630 hours on 06-06-07. Gomez denied any knowledge of martial arts. Gomez stated she worked the PM shift on 06-06-07. Upon arrival to work, Gomez was informed that Van was found on the floor in his room at FDC by Sotingco. Van sustained a fractured neck. Gomez said she was assigned to sit with \/an at the hospital on Friday 06-08-07, during the PM shift. Gomez said she was shocked at Van's condition in the hospital. Van had on halo traction for his neck, he was lying down and he only moved his I mouth, his eyes and his right hand a little. Gomez said she never saw any of Van's family while she was at his bedside for two shifts. A Gomez stated that she didn't know Van well, but she had seen him in the hallway on the Residence. Van was very active and he would run in the hallway. Van did not like others to invade his personal space. Van was not bothersome to others. Van was a nice guy and he was harmless. Van was not aggressive toward others. Van had behaviors of screaming and urinating on the floor in the hallway. l/an was assigned to Group 1. Gomez stated that there were aggressive clients living on Residence 41. had aggressive behaviors of hitting staff and clients. -would.tap the head and back of staff and his peers. -was not known to enter into other clients' rooms. - had a history of injuring staff. - had aggressive behaviors of slapping, punching, but Gomez was not aware of any altercations between- and Van. Gomez stated that Tan, Sotingco and Limbong worked the NOC shift on 06-05-07. Gomez said that Sotingco is a responsible guy who is very nice. Sotingco does not harm the clients. The clients have a good rapport with Sotingco and they listen to him. Tan is a quiet, nice guy. Limbong is very responsible and goes by the book. Limbong is very nice. Gomez stated that when a client is found injured, the staff are to_ check the client's vital Vi signs, check for fracture, and check the client's position. The staff should get help based on the assessment and not move the client if there is any doubt about the client's condition. State of California Health and Human Services Agency Department of Developmental Services - CRIME INCIDENT REPORT Page or or 109 DS 2148 2/200 A my r_'r_r rr_> TT TT 4.CASE NUMBER I OFFICE OF PROTECTIVE SERVICES qq/PE Op REPORT ia"? i I I (mi 957'5C,rr_ Communication with Ernesto Collazo, Coroner Investigator with Orange County Sheriff-Coroner Office On or about 06-21-07 at 0635 hours, I placed a telephone call to Ernesto Collazo, Coroner Investigator with the Orange County Sheriffs Office. The following is a summary of the information obtained: I requested any updated information regarding Van's death from Investigator Collazo. Investigator Collazo said that there was no information available for release at the time of the call. The autopsy was still pending the microbiology, toxicity, and neuropathology testing. Interview with Maria Juanita Pulido, Technician on Residence 41 On 06-21-07 at 0940 hours, I interviewed I\/laria Juanita Pulido, a Technician, in the Conference Room at OPS at FDC. Pulido stated she has been employed at FDC for Ty approximately seven years. Investigator ll/Iastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summanr of the information obtained: Pulido stated she was not on the Residence between 2400 hours and 0630 hours on 06-06-07. Pulido denied any knowledge of martial arts. Pulido stated she arrived to work for the PIVI shift on 06-06-07 and was told that Van had been transferred to Hoag Hospital. Van had been found on the floor in his room during the early morning hours. Pulido didn't know what position Van was in when he was found. Pulido heard that Sotingco found Van. Pulido said she worked with Sotingco the following day, but neither of them discussed the incident. Pulido heard that Van sustained a possible neck injury. Pulido stated that there are aggressive clients on the Residence. Pulido said that had an aggressive behavior of putting his hands over his head and using an overhand motion to slap others with his open hand. -is strong and has injured staff as a result gressive behavior. Pulido said she heard there was an altercation between and Van, but she didn't witness the incident. Pulido said there are other aggressive clients including--., and but she wasn`t aware of any altercations between Van and these clients. I Pulido stated she was aware that Limbong, Tan, and Sotingco were the staff assigned to the NOC shift on the day Van was found with his injury. Pulido said Van required checks every 30 minutes during the night shift. Pulido said Sotingco was a very hard working staff member. Sotingco helps the clients and his care is good. Sotingco is cheerful with the I . I State of Califomia - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page zrzooar 5 4.CASE NUMBER OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. cr cr Fsrorry cr Mrsuemeamr CONNECTEO REPORT Fairview Developmental Center 2- REPORT Ops pS0y_06_357 (714) 3. INFORMATION ONLY OPS PSO7-06-372 CIVIPO 07-9361 clients. Pulido said she did not believe that Sotingco caused the injury to Van. Pulido said Limbong is a good worker. Pulido said she has never seen Limbong get upset or angry, she is very professional. Limbong is nice and never inappropriate. Pulido said Tan is fairly new, . but she hasnoticed he is helpful. Pulido has never seen Tan frustrated. Pulido said she did not have any reason to believe that any of the staff working the NOC shift had anything to do with Van's injury. Pulido stated that if a client is found on the floor, the staff are responsible to call for help, evaluate the client, and call for the physician as needed. The staff are to assess the client for fractures, bruises and cuts prior to moving the client. There is a possibility of broken - bones and therefore the client should`n't be moved. Pulido provided a hand drawn diagram of Residence 41 (Attachment No. Interview with Michaelina 'Mickey' William-Mensah, Senior Technician on 5 Residence 41 On 06-21-07 at 1037 hours, interviewed Michaelina 'Mickey' William-Mensah, a Senior Technician, in the Conference Room at OPS at FDC. V\Iilliam--Mensah stated - she has been employed at FDC for approximately six years and has been working the PM shift on Residence 41 for approximately one year. Investigator Mastrosimone was`present during the interview. provided a statement for the criminal investigation. The interview was audio recorded for note taking purposes and for the record. The following . is a summary of the information obtained: V\Iilliam-Mensah stated she worked the PM shift on Residence 41 on 06-06-07 and the NOC - shift on 06-06-07. William-Mensah said she heard in the shift change report that Van was found in his room by his bed, he was injured and sent to Hoag Hospital, William-Mensah said she didn't know any details about Van's condition at the time he was found. William- Mensah leamed in report that the NOC shift staff found Van and Sotingco was the staff person that completed the Interdisciplinary Note (IDN). Limbong was the person giving report. William-Mensah said she never spoke to Sotingco about the incident. . William-Mensah said she sat with Van at Hoag Hospitallduring the NOC shift on 06-06-07. V\Hlliam-Mensah met L. Ingraham at Hoag Hospital. L. Ingraham wanted to know Van's condition and he told how wonderful FDC had been for the 42 years that Van lived there. Van was able to lift up his hand and move both legs. William-Mensah said when she arrived, Van recognized her. William-Mensah described Van. Van didn't like to wear a shirt, ran in the hallway everyday, tried to get into the office, liked to bang on the walls, opened and shut the door, and said, Stale otCaliiornia -- Health and Human Services Agency Department of Developmental Services REPORT Page as urros . . . ., . . E. All OFFICE OF PROTECTIVE SERVICES WPE OF REPORT 5 Special Investigations Unit r. cr cnirvirivat Felonylj wrisuemeanmm inrraciicrr Fairview Developmental Center gi gl OPS I ops PS07-06-372 I L. .. ee- es)_ . .- as 07 'yogi, yogi, yogi} Van liked tennis balls. Van was a very energetic, vibrant and a happy man. said she had a very good rapport with Van, Van had a good rapport with the staff. Van was not an aggressive client. stated that no other clients targeted Van. was not aware of any other clients that have aggressed on Van. said is an aggressive client, but she had never seen- act aggressively. William-Mensah has seen. flip a wheelchair with a client in it. According to she was not aware of any problems between Van and Other clients that exhibit aggressive behaviors include -, and -hit and kicked others. - hit people in the hallway repeatedly and he hits "pretty hard." -wiII hit others without provocation. said -did not go Into other cIients' rooms. - thinks he is Superman, he wants to hit and punch. - thinks he is strong. All the clients and staff have access to the clients' rooms on Residence 41, except for clients and who lock their rooms. All the Residence 41 staff have keys to the Residence as well as the Program 4 program staff, medical and nursing staff. The NOC shift staff would most likely be aware if any other staff were on the Residence during the night shift. denied being on Residence 41 on between the hours of 2400 hours and 0630 hours. stated she has worked with Tan and Limbong previously, but she has never worked with Sotingco. WilIiam--lt/lensah said Limbong is a nice lady and she is fair. Limbong is very simple, she is a religious lady and she is a "peace--maker." said she doesn't see Limbong bringing in stress from home to work and she is able to handle stressful situations at work. has never seen Limbong act inappropriately with a client. stated Tan is a "nice guy." Tan is a very good worker, he is very calm and he is very gentle with the clients. said she is happy to be working with.Tan. According to the clients liked Tan. William--lVlensah stated Sotingco is very nice and he is very soft spoken. didn't have any other information about Sotingco because she has never worked with him directly. stated she was not concerned that any of these three staff members i harmed Van. William-Mensah said she told L. Ingraham that the person that he was fl accusing (Sotingco) was a very nice guy, State of California - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT page 70 gr ics .. . . ,,OFFICE OF PROTECTIVE SERVICES TYPE OE REPORT Special Investigations Unit mn cRiIviiMAi.? Falcnyumisuemeanoru infraction fggmi center gig l. ,,William-Mensah stated she was not aware that any staff members took any martial arts or self-defense classes. William-Mensah said the only client that thinks he is Superman was William-Mensah stated that the staff that knew Van the best were his Group 1 group leaders. Arnold and Montes were Van's AM shift group leaders and Colin and BI_anton were Van's PM shift group leaders. Kastelz also knew Van very well. stated she saw L. In raham on the Residence. According to William- Mensah, she was going to take iout for a cigarette break and she met L. Ingraham at the door to Residence 41. L. Ingraham told William-Mensah that he wanted to leave a note for Kastelz. William-Mensah explained that she could let L. Ingraham into the visitor's room to wait, and as they were talking they saw Montes in the hallway. L. Ingraham wanted to talk to Montes and William-Mensah left with Upon returning to the Residence, William- Mensah said L. Ingraham was in the office and no staff were present and L. Ingraham was writing a note. William-Mensah stated she later heard that the NOC shift schedule for 08-05-07 and the Journal of Falls was missing. William-Mensah said she had sent the entire schedule to the Program Office that afternoon and another thought was that perhaps L. Ingraham had taken the documents, but William-Mensah wasn't sure about that because L. Ingraham said he was a police officer. WilIiam--Mensah stated she was assigned to sit with Van on the night of 06-11-07, but by the time she arrived Van had already passed away. The Coroner had arrived at Hoag Hospital and was in Van's room along with L. Ingraham, so William-Mensah and Kastelz went for a break. Upon returning to Van's room at the hospital, Kastelz went into Van's room and William-Mensah stayed at the Nurses' Station. William-Mensah said when Kastelz came out of Van's room, Kastelz told her that while in Van's room, she saw the original Journal of Falls document in L. |ngraham's folder. William-Mensah said when L. Ingraham came out of Van's room, Kastelz told him she saw the Journal of Falls in his possession and requested a copy. Kastelz then asked L. Ingraham how he got the Journal of Falls document. L. Ingraham replied that he wasn't going to say how he got the document. According to William-Mensah, L. Ingraham said some people are very unhappy with what happened to my brother. William-Mensah said L. Ingraham denied having the NOC Shift Schedule. William- Mensah denied that she provided L. Ingraham with any documentationfrom Residence 41. William-Mensah stated that L. Ingraham told her that the Hoag Hospital physicians confirmed I that Van could not have sustained his injury as the result of a fall. L. Ingraham told William- Mensah that he thought someone caused Van's injury. State of Califomia - Health an`d*Human Services Agency I Department of Developmental Services CRIME I INCIDENT REPORT page rr or 109 os me zrzoos - .- OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations Unit 1. r=a6?y? msuememr ci mrmum 5_ OONREOTEO REPORT Fairview Developmental Center . 7- OPS tm) 1 -oI=?s PS07--06-372 CMPD 07-9361 \/Wiliam-Mensah did not have any idea how the injury occurred. V\Hlliam--Mensah said she heard the Hoag Hospital staff moved Van around a lot prior to the time that Van had an x--ray. William-Mensah stated when a client is found on the floor, the actions of the staff depend on the client's condition'. _William-Mensah said if she came across a client on the floor with some limitiations in movement but responsive, she would call a physician, then position the client in a wheelchair and complete an assessment. interview with Kidrat Shoakzode, Hospital Worker on Residence 41 I On 06-21-07 at 1138 hours, Iinterviewed Kidrat Shoakzode, a Hospital Worker, in the -- Conference Room at OPS at FDC. Shoakzode-stated he has been employed at FDC for approximately 28 years. Investigator Mastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence Item TD No. 1). The following is a summary of the information obtained: - U- Shoakzode stated he arrived to work on Residence 41 at 0630 hours on 06-06-07. . Shoakzode said he was making beds. Shoakzode said that he was in Van's room making beds, but there were no clients in the room. Shoakzodesaid he didn't see Vanphysicians and nurses in the hallway. Shoakzode stated he heard that Van urinated on the floor in the hallway. No one told Shoakzode what happened to Van. Shoakzode said that Van was a nice guy and he was not aggressive to others. Van liked to walk around in the hallway. Shoakzode did not have any additional pertinent information for the investigation. Interview with Dr. Sailaia Reddy, Physician and Surgeon at FDC - On 06-22-07 at 0719 hours, I interviewed Dr. Reddy in the Conference Room at OPS at . FDC. Dr. Reddy stated she has been employed at FDC for approximately 10 years. Dr. Reddy stated she is Board Certified in lntemal Medicine. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: I Dr. Reddy stated she was called to Residence 41 on 06-06-07 at 0615 hours. Upon arrival, Dr. Reddy received a history from Limbong that at approximately 0545 hours, Van was found down on the floor by the bed in his room. Van's pants were down around his knees and he was wet with urine. Limbong was concerned that Van had tripped and fell. Van was refusing to bear weight and the staff helped him back to bed. .2 I I State of Califomia - Health and H-uman Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 72of109 DS 214 ev 2/2003 . 4.CASE NUMBER OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT Special Investigations Unit r;1 cr Felony Misdemeanor rnrracrrurr 5_ CONNECTED REPORT DGV6l0plT\8l'\t8l ops Psor-os-372 . CMPD 07-9361 Dr. Reddy arrived on the Residence approximately 30 minutes later and when she assessed Van, he was lying in a supine position on a gurney. Upon Dr. Reddy's arrival, Van had already been moved. Van was not wearing any shoes during Dr. Reddy's evaluation. Van was awake and alert. Van had tears on his face and he seemed to be in pain. Van was not moving his legs and he did not want to move. Van had an abnormal to his left eye. Dr. Reddy was concerned regarding Van's neck because he had some slight swelling to the neck. Dr. Reddy was concerned that Van might have suffered trauma to his neck, even though he didn't have any obvious extemal bruising to the neck. Dr- Reddy decided to transfer Van to an outside acute hospital and he was accepted for transfer at Coastal - Communities Hospital. Dr. Reddy wanted Van to have a cervical collar, but there wasn't one available on Residence 41. Dr. Reddy decided to call a Code 222 for the Paramedics. The Paramedics arrived and placed Van on a backboard and placed a cervical collar on his neck, I then transferred Van to Hoag Hospital. . Dr. Reddy stated that based on her experience at FDC,-the staff usually moved the clients and it varied whether this was before or after a nursing assessment. Dr. Reddy stated that - she didn't see the Health Services Specialist and she could not recall who the Nurse-on-Duty was that morning. Dr. Reddy said it was unusual that Van was on a gurney when she arrived to assess him. Dr. Reddy said that Van's primary diagnosis was cervical subluxation, which usually results from an impact with accelerated force. Dr. Reddy stated that the staff would determine whether to move or not move a patient, based on the evaluation that was done. Usually this training is included in CPR training. Interview with David Meyers, Medical Doctor at Hoag Hospital On 06-28-07 at 1430 hours, interviewed David Meyers, a Medical Doctor, in the Conference Room of the Administration Offices at Hoag Hospital in Newport Beach, California. - Investigator Mastrosimone was present for the interview. Lisa Bynum, RN, JD and Director of Risk Management Services at Hoag Hospital was present during the interview. Dr. Meyers stated he is employed as an ER Physician at Hoag Hospital. Dr. Meyers declined to have the interview audio recorded. The following is a summary of the information obtained: - . Dr. Meyers stated he was the ER physician at Hoag Hospital when Van arrived at Hoag Hospital. The Paramedics had immobilized Van with a backboard andthe application of a cervicalcollar prior to his arrival at the hospital. The history that Dr. Meyers received was that Van had an unwitnessed fall and he was found lying down on the floor. Van was admitted with altered level of consciousness (LOC), lethargy, sepsis, possible post-ictal seizure activity, metabolic abnormalities (electrolytes/chemistry), and rule out lithium toxicity. Laboratory value_s were obtained and a CT scan was ordered. These tests did not reveal the cause of Van's condition. Van was admitted and additional testing was done including a State of California - Health and tluman Services Agency lk Department of Developmental Services CRIME INCIDENT REPORT Page 73 or 109 DS 214 (Rev 2/2003ILCASE NUMBER . DS07-06-F-081-F I I OFFICE OF PROTECTIVE SERVICES TYPE OE REPORT . ll 1 on is emma cion I 5. I (714) 3. INFORMATION ONLY OPS EE- N. wid, - E, .. -- . cervical spine x-ray. The cervical spine x-ray revealed Van had a fracture and dislocation of C5 and C6 in the upper spine/neck. Dr. initial assessment of Van revealed he had movement to his right leg and he was responsive to pain. Dr. Meyers did not observe any movement to Van's arms. Or. Meyers said the only sign of trauma was a slight discoloration to Van's left eyebrow. Dr. Meyers stated that in his opinion Van's injuries were consistent with classic mechanical injuries resulting from hyperflexion and rotation of theneck. Dr. Meyers explained that these types of injuries are often seen as the result of great force with acceleration such as a push or speed. Or. Meyers said he had not seen this type of injury result from a fall out of bed, but that was a possibility because Van was a large man. Dr. Meyers stated that Van had deep bleeding, but no external injuries to his recollection. Van had total paralysis. Van had leg contractures, but he did have reflexes to touch in his legs. Interview with Oliver Maglagui, Technician Assistant on Residence 41 On 07-05-07 at 1327 hours, I interviewed Oliver Maglaqui, a Technician Assistant, in the Conference Room at OPS at FDC. Maglaqui stated he has been employed at FDC for approximately 20 months Investigator Mastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: Maglaqui stated he was not on the Residence between 2400 hours and 0630 hours on 06-06-07. Maglaqui denied any knowledge of martial arts. Maglaqui stated he heard that Van fell down and that was the reason for his transfer to Hoag Hospital. Maglaqui said he heard that Van had a bad fall and it messed up Van's vertebrae and caused Van's death. - Maglaqui stated that Van frequently urinated on the floor. Van preferred not to wear a shirt. Van was obsessive compulsive about closing doors that were opened. Van liked to be in the A hallway and he would run in the hallway. Van was faster than many other clients and his gait was steady. Occasionally, Van slipped in urine on the floor. Van did not exhibit any aggressive behaviors toward others. Van was playful with the staff and he liked playing with balls. Van was able to verbalize comments such as 'You. You} Otherwise, Van was not verbal. Van liked sodas and cookies. Maglaqui stated that other clients were sometimes frustrated with Van's behaviors. Maglaqui said that is smaller than Van, but- was frustrated with According to Maglagui, - previously caused an injury to Van with a door. Maglaqui said that- State ottlalitornia -- Health and Human Services Agency Department of Developmental Services CRIME INCIDENT REPORT . Page 74 ot109 . -. . in - -.. rj 4.CASE NUMBER OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT Special Investigations Unit 1. in cniivumti. in Felonyll Misaemeamro lnrraeueri 5 CONNECTED i Fairview Developmental Center 5 OPS i (714) 957-5077 Ops Ps07--06?372 . 2.2. - 2.. -.. ?Z:936i_. will retaliate, but it would be at the moment. l\/laglaqui also mentioned- has a behavior of slapping others and he can be forceful. -hits by bringing his hand down on others from above his headl - has caused injuries to the staff. Maglaqui said that -, a roommate of Van, has behaviors of flipping furniture and he once flipped a client while the clientwas in his wheelchair l\/laglaqui stated that he knew Sotingco. Nlaglaqui described Sotingco as a quiet guy and a good worker. Solingco is good with the clients and he acts professional with the clients. tviaglaqui said he doesn't work with Sotingco often, but he has no concerns about Sotingco. Maglaqui stated that he has never seen Lirnbong work with the clients, but he has no concerns with her care of the clients. l\/laglaqui also said he has no concerns about Tan. Interview with Guillermo Andrade, Technician Training Candidate on Residence 41 K1 On 07-05-07 at 1428 hours, I interviewed Guillermo Andrade, a Technician Training Candidate, in the Conference Room at OPS at FDC. Andrade stated he has been employed at FDC for approximately two months. Investigator I\/lastrosimone was present during the interview. John Canto, Special Investigator with OPS at FDC was also present during the interview to assist with translation services. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained; Andrade said he was not on the Residence between 2400 hours and 0630 hours on Andrade denied knowledge of martial arts. Andrade stated he worked with Group 2 during the PIVI shift on 00-05-07. Andrade said he heard Van was in the hospital, but he didn`t know what happened because staff didn't want to comment on the incident. Andrade stated Van liked to walk and run in the hallway. Van had a behavior of urinating on the floor. Van did not like to wear his shirt. Van was not aggressive toward others and others were not aggressive toward Van. Andrade said that- slapped others on the forearm, but he didn`t slap hard. Andrade said that-was not aggressive toward others. Andrade stated that he had no concerns about Tan or Limbong. Andrade said he had never worked with Sotingco. Interview with Rick Delrosario, Technician Trainee on Residence 41 I On 07--06--07 at 1059 hours, I interviewed Rick Delrosario, a Technician Trainee, in the Conference Room at OPS at FDC. Delrosario stated he has been employed at FDC for approximately two years. Investigator li/lastrosimone was present during the interview. State of Catilomia - Health and lelurnan Services Agency if Department of Developmental Services REPORT page vs arms - we4.CASE NUMBER 1 OFFICE OF PROTECTIVE SERVICES WRE OF REPORT I ii Ba"? (714) 9576077 3. INFORMATION ONLY OPS . --7 Y- as . use PP 93?1 The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtainedi Delrosario stated that he was not on the Residence between the hours of 2400 hours and 0630 hours on 06--06--07. Delrosario denied knowledge of martial arts. Delrosario stated that he heard Van was in the hospital, but none of the staff were talking about what happened. Van was very active and spent a lot of time running in the hallway. Van liked to play with balls. \/an was not aggressive toward others. Delrosario said he wasn't aware of any issues between Van and other clients. Delrosario stated that there were a couple of aggressive clients on Residence 41. Delrosario said- slapped others hard. _didn't target anyone in particular, hejust slapped people randomly. Delrosario was not aware if- ever went into other clients' rooms. -is approximately the same size as Van. According to Delrosario, was not strong enough to take another client to the ground. Delrosario also said one of 7 Van's roommates, had a behavior of flipping unoccupied beds, but-was not aggressive toward other clients. Delrosario said he was not aware of any problems between Van and Delrosario was not aware of any missing documents from the Residence. Interview with Jason Deats, Senior Technician on Residence 41 On 07-05-07 at 1153 hours, interviewed Jason Deats, a Senior Technician, in the Conference Room at OPS at FDC. Deats stated he has been employed at FDC for approximately 11 years. Investigator I\/lastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary ofthe information obtained; Deats denied being on the Residence between the hours of 2400 hours and 0630 hours on` 06-06-07. Deats denied knowledge of martial arts. Deats stated he heard that Van tripped and fell. Van was found with his pants around his ankles. Deats didn't know if Van had urinated or not. Deats stated that Bruch told him that while he was sitting with Van at Hoag Hospital the day of his admission, the Hoag staff were moving Van around and had taken Van off the backboard and the cervical collar. Bruch said he requested that the staff do an x--ray. I Around noon, an x?ray was done and revealed Van had a broken neck. State of California Health and Human Services Agency Department of Developmental Sen/ices CRIME I REPORT Page 76 or1o9 DS 214 B__(_Rgy 2/2003) 4_cA`sE NUMBER i OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT 3 Special investigations Unit Cl cnlii/|iNAL Cl in fn time inf rr" "rw 1 Fairview Developmental Center ea ra za. inroniwxrion oNi_Y (7147 9575077 ops Psoms-372 eE,e .Edd do be W. - .Y OOEE . . -EEA MP0 Deats stated he did not have a group assignment on the Residence. Deats said \/an was in Group Deats described Van as loud and frequently in the hallway where he would bang on windows, doors and walls. Deats said Van was a deep sleeper, Van didn't like clothes and he would pull his pants down around his ankles and run around. Van was fast and had a shuffling gait. Van had a behavior of constantly urinating on the floor. Van had the ability to be continent of urine, but chose to urinate on the floor. Deats stated the staff were good with Van, and added that everyone liked ive toward others. Deats stated that other clients on the Residence had aggressive behaviors. Deats said was not specihcally a problem with Van. Deats had never seen- harm Van. However, Deats said that he had knowledge that-. had scratched Van's face; and that- had hit Van. Deats added that-is (legally) blind. Deats stated that', one of Van's roommates, had impulse control issues. - is very strong and has a behavior of flipping tables and beds. Deats stated that is youn and bigger and stronger than randomly attacks others and has no control. has a behavior of hitting others in downward motion with his open hand. -will enter other clients` rooms. hits hard. 2 has caused injuries to the staff and clients on the Residence, Recently restraints were ordered for: Deats stated that Sotingco is a family guy. He is very nice and soft spoken. Sotingco is not easily frustrated. Deats stated Limbong is caring, rational and mellow. Deats had no concerns about the care that Limbong provided to the clients. Deats stated that Tan was quiet and relaxed. Tan was very laid back. Deats stated that when a client is found on the floor it is important to assess the client to determine if the client can safelybe moved. The assessment would be a visual assessment. Deats stated that he had heard something about some missing documentation on the Residence. The missing documents included the NOC shift schedule, a staff phone list, and the Journal of Falls Log. Deats heard that William-Mensah let L. lngraham in the office on the Residence and left him there alone for a brief period of time. Deats said that it was unusual to leave a visitor alone in the office on the Residence. Deats said he did not speak to about the incident. Deats told me that he heard that L. lngraham admitted to Kastelz that he had one of the documents. State of California - Health and Human Services Agency Department of Developmental Services CRIME WCIDENT REPORT Page 77 of 109 an in it sometime in the past. another client on Residence 41, recently exhibited seizures and he attacks himself and others. -will grab and pull down on others and he will also bite himself, wears a helmet due to self-injurious behavior. He also will bring his hands over his head and strike other clients and staff in a downward motion with an open hand or a fist. State of California - Health and Human Services Agency if Department of Developmental Services CRIME I REPORT Page vs or me DS 214 (Rev 2/2003OFFICE OF SERVICES TYPE OF REPORT gi it (714>es7>>sur7 ops PS07-06-372 . EE EE . .El - is-bigger than Van and is very strong. - is capable of hitting someone hard enough to knock him/her down. Blanton stated he knew all the staff working the NOC that Van's injury was discovered. Blanton didn't have any concerns regarding the staff on duty that night. Blanton said that Tan is quiet; Limbong is very thorough; and Sotingco is very nice and good to work with. Blanton stated he heard that there were some documents missing from Residence 41 2 including the NOC Shift Schedule and the Journal of Falls Log. Blanton stated the documents were either recovered or regenerated. Blanton heard that L. Ingraham had I possibly taken the documents. Interview with Phalla Sam, Technician Trainee on Residence 41 g_ On 07-06-07 at 1402 hours, I interviewed Phalla Sam, a Technician Trainee, in the Conference Room at OPS at FDC. Sam stated she has been employed at FDC for approximately four months. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary ofthe information obtained: Sam stated she was not on the Residence between 2400 hours and 0630 hours on 06-06-07. Sam denied knowledge about how Van sustained his injuries. Sam denied that she knew martial arts. Sam said she knew that Van was in the hospital as a result of his injuries following a fall. Sam was assigned to care for Van at Hoag Hospital on three occasions. Sam stated that when she saw Van at the hospital he was able to move his extremities, but she didn't know if the movement was just reflex or not. Van loved to walk, but he was not able to ambulate at the hospital. Van's right upper arm was restrained while he was at Hoag Hospital. While at Hoag Hospital, Sam had an opportunity to meet L. Ingraham, who told Sam that he didn't believe Van's injuries were accidental. According to Sam, L. Ingraham was angry and mad about the incident and he blamed Sotirigco because Sotingco found Van on the floor. Sam stated Van liked to take off his clothes. Van would frequently pull his pants down around his ankles. Van liked to. play with balls and he would place a ball on a cabinet then he would try to jump on the cabinets to get the ball. Van was not aggressive, but he would touch the staff and his peers if they invaded his space. Van didn't sleep a lot at night. Sam stated- a client and roommate of Van, had a behavior of flipping beds. Sam wasn't aware if he ever tried to flip Van in his bed. State of California - Health and Human Services Agency CRIME INCIDENT REPORT Department of Developments! Services Page 79 of 109 DS 214B Rev 212003VEIV I My Dso7~06~F~osi-F orifice or Paorecrive seavices TYPE OF REPORT NPoR|viAr|oN on OPS P597 O5 35 (714) 957-5077 LY ops Pso7-os~372 I gWgg_ gg* gg iiWY i Sam stated that .wore a helmet and had injured her finger previously. According to Sam, was very strong and he was able to knock people down due to his strength. Sam said usually hit people in the hallway. Sam never saw aggress on Van. Sam stated she knew the three staff members that worked the NOC shift with \/an on the day he was found with the injury. Sam described Tan as a good worker and gentle with the clients. Tan is patient with the clients and the clients love him. Sam said she had no concerns about Limbong. Limbong treats the clients well and she is nice. Limbong does not get frustrated easily. According to Sam, Sotingco is a cool guy. Sotingco is not aggressive and he is nice and calm with the clients. Sam said she was shocked to hear the injuries occurred during a shift when these three staff members were working. Interview with Norberto Colin, Technician Assistant on Residence 41 On 07-06-07 at 1459 hours, interviewed Colin in the Conference Room at OPS at FDC. Colin stated he has been employed at FDC for approximately 15 years. investigator l\/lastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence ltem No. 1). The following is a summary of the information obtained: Colin stated he did not work the morning of O6-06-07. Colin denied being on the Residence between the hours of 2400 hours and 0630 hours on 06-06-07. Colin said he didn't know how Van's injuries occurred Colin worked the afternoon shift on 06a05-07, and he saw \/an that afternoon. \/an didn't have any changes when he saw him on 06~05a07. Colin described Van as not aggressive. Van urinated on the floor, but he didn't have any other behaviors. Van liked to run in the hallway and sometimes he would run around with his pants pulled down around his ankles. Colin said he never saw Van fall. Everyone liked Colin stated there were other clients on the Residence that had aggressive behaviors. had a history of scratching, but he had not exhibited that behavior for a long time. 'had a behavior of flipping beds. He also flipped mattresses. 'was usualiy compliant. -would slap others in the hallway, but he usually wasn't forceful. Colin stated he was not aware of any missing documents. Colin stated he knew the three staff members that worked the NOC shift that Van was found with his injuries. Colin said Tan was very professional and shy. According to Colin, Limbong was very busy with paperwork and didn't spend much time with the clients. Colin said he did not know very well, but he seemed professional and did not seem to get upset. Colin described Sotingco as "cool." Slate of California Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page ao or 109 US 214 Rev 2/2003) i I _miivii i W) 4_cAsE NUMBER OFFICE OF PROTECTIVE SERVICES 1-Ypg OF REPORT if (714) 9576077 3, inroaiwxrioii omv OPS PS07-O6-372 Interview with Kathy Kastelz, Unit Supervisor on Residence 211 On 07-12-07 at 0857 hours, I inter\/iewed Kathy Kastelz, the Unit Supervisor, in the Conference Room at OPS at FDC. Kastelz stated she has been employed at FDC for approximately 18 years. Investigator I\/lastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence Item No. 1). The following is a summary ofthe information obtained; 'Kastelz stated that she had information from- regarding circumstances surrounding \/an's injuries. Kastelz said that on or about 06-27-07 at 0910 hours! reported to her that on the morning that \/an was sent to the hospital the following events occurred. was using the bathroom by Van's bedroom at approximately 0400 hours. exited \/an's bedroom and said, 'Don't say anythingf Kastelz stated that- is (Iega ind and she asked him how he knew it was told Kastelz that he knew-_ denied hearing any noises from Van's bedroom. Kastelz stated that- has identified behaviors of throwing objects, he likes to boss his peers around, and that he and Van had issues in the past and had struck Van in the past (months prior to Van's injury). According to Kastelz, is somewhat smaller than Van was, but -is very strong and even likes to act like a "superhero" Kastelz said it was possible that might follow another client into his bedroom. is capable of verbalizing and he is hard of hearing. Kastelz stated that \/an was very easy to get along with. Van had behaviors of urinating in the hallway and banging on the windows. Van would gently guide clients out of his space, but he was not aggressive toward others. \/an was loud at times. Kastelz stated that she had a conversation with L. lngraham following Van's death on 06-11~07. Kastelz stated that during the evening she noticed that Ingraham had an original document, the Journal of Falls, from Residence 41 at FDC in his possession. Kastelz told me she requested a copy of the document because the Residence had been trying to locate the missing document. Kastelz mentioned that other documents were missing from the Residence including the NOC Shift Staffing Sheet for the NOC shift on the day of Van's injury, a staff Rolodex, and a call back list that included staff names and phone numbers. Kastelz said that Gomez found the Rolodex and the staff callback sheet in the parking lot in front of Residence 41 sometime later. Kastelzsaid that a NOC Shift Staff Sheet was recreated. Kastelz stated that Tories told her that on 06-O7-07, lngraham was on Residence 41. Tortes told Kastelz that Williams-Mensah let Ingraham in the office on the Residence and lngraham was left alone in the office for an unspecified amount of time. Slate of California - Health and Human Services Agency Department ol' Developmental Services CRIME REPORT Page 82 of109 >>n_cAsE NUMBER DS 1 -F I OFFICE OF PROTECTIVE SERVICES WPE OF REPORT Special Investigations Unit ii El CRIMINAL FelonyD demeanor E11 fra I Fairview Developmental Center . (714) 9575077 OPS PSO7-O6-372 two D. . W. DW purposes and for the record (Evidence Item No. 1). The following is a summary ofthe information obtained; stated that at approximately 0400 hours, on the day Van went to the hospital, he was using the Group 2 bathroom on Residence 41. said the Group 2 bathroom is next to Van's old bedroom. said that exite an's bedroom and said, 'Don't say anything) According to seemed afraid because he was stuttering and doesn't usually stutter, told me that he thought that- had something to do with Van's death. said that he is very familiar with Residence 41 and he knew he was by Van's bedroom because he used to live in a bedroom near Van's_ told me that he knew the person that exited Van's bedroom was- because he recognized -'s voice. stated he was telling the truth. said that he knew the difference between telling the truth and a lie_ said that telling a lie was "against God." Meeting with Orange County Sheriff Coroner's Office On or about 10-18~07 at 1300 hours, I met with members ofthe Costa Mesa Police Department and with the Orange County Sheriff-Coroner Department at the Orange County Coronefs Office in Santa Ana, California. Also present representing the Ofnce of Protective Services at FDC were Don Ackermann, Commander; Investigator Mastrosimone; and Christine McAnIis, Senior Special Investigator. Members ofthe Costa Mesa Police Department included Tom Curtis; Lieutenant, Detective Bureau; Kevin Condon, Sergeant; and Robert Phillips, Detective Sergeant Members of the Orange County Sheritf~Coroner Department included Ernesto Collazo, Coroner Investigator; Rod Thomas, Manager of Investigations; Dr. Fukumoto, Forensic Pathologist; and Bruce Lyle, Assistant Chief Deputy, The following is a summary of the information obtained: The case details and ali leads from the investigation conducted by OPS were shared with all members present at the meeting. A discussion regarding possible causes of Van`s injury ensued. Additional follow-up was discussed and an agreement was made between all represented agencies to continue to communicate any new information relative to the case. Follow-UQ Interview with Johannes Sotingco, Technician on Residence 41 On 10-26-07 at 1108 hours, I interviewed Sotingco in Room 59 on Residence 41 at FDC. Senior Special Investigator McAnlis was present during the interview. Paul Alizaga, a Union Representative with California Association of Technicians (CAPT) was also present during the interview. I administered the Beheler Admonishment Sotingco declined State of California Health and Human Services Agency Department of Developmental Services REPORT Page 81 06109 US 2'5? .WN Hs .--, - 4.CASE NUMBER I - I OFFICE OF PROTECTIVE SERVICES OF REPORT Special Investigations Unil 11 Cl CRIMINAL El Felony 13 MisdemeanorD infraction REP I Fairview Developmental Center 2- ADMINISTRATIVE REPORT GPS I (714) 9575077 3,13 INFORMATION ONLY I OPS I WM Wg po Dl;936'i Follow-ug Interview with Kathy Kastelz, Unit Supervisor on Residence 211 On at 0808 hours, I interviewed Kathy Kastelz, the Unit Supervisor, in the Conference Room at OPS at FDC. Investigator Mastrosimone was present during the interview. The interview was audio recorded for note taking purposes and for the record (Evidence ltem No. 1). The following is a summary of the information obtained: Kastelz stated that she had a conversation with L. lngraham late on the evening of 07-1 1-07 and early on the morning of O7-12-07 at Hoag Hospital. During the conversation, lngraham informed Kastelz that he had spoken with three physicians at Hoag Hospital including Dr. David Meyers, Dr. Michael Krutzik, and Dr. Derrick Hong, a Neurosurgeon. According to L. lngraham, the opinion of the three physicians was that Van's injuries were intentional and that the physicians had completed reports based on their opinion During the same conversation, L. lngraham alleged that Sotingco caused the injury to \/an and that Sotingcowas a 'liar.' Kastelz provided a copy of her notes written shortly after her conversation with L. lngraham (Attachment No. 39). Kastelz also provided La type-written document of her hand written notes (Attachment No. 40), Interview with Michael Krulzik, Medical Doctor at Hoag Hospital On 07-18-07 at 1320 hours, interviewed Michael Krutzik, a Medical Doctor, in the Cafeteria at Hoag Hospital in Newport Beach, California, Lisa Bynum, RN, JD and Director of Risk Management Services at Hoag Hospital was present during the interview. Dr. Krutzik stated he is employed as an Intensive Care Unit Physician at Hoag Hospital. Dr. Krutzik declined to have the interview audio recorded. The following is a summary of the information obtained: Dr. Krutzik stated that he was the ICU physician that cared for Van during his hospitalization at Hoag Hospital, Dr. Krutzik said he recalled that L. lngraham, requested that he perform a complete head-to-toe physical of Van. According to Dr. Krutzik, he compieted a head-to-toe physical on Van on O6-07-07. Dr. Krutzik recalled that Van had a small bump to the back of his head. Van had been admitted to the Neurological ICU with Halo traction, hypoxemia, and on antibiotic therapy for cellulitis. Dr. Krutzik said he never indicated to Van's family that Van's condition was not accidental. Dr. Krutzik informed me that he dictated the findings ofthe head-to-toe physical examination of Van (Attachment No, 41). Interview with Client on Residence 41 On 09-27-O7 at 0830 hours, i interviewed a Client on Residence 41, in front of Residence 41 at FDC. Investigator Mastrosimone was present during the interview. Carolina Rodriguez, a Technician, was also present during the interview. The interview was audio recorded with the knowledge of all parties present for note taking State of California - Health and Human Services Agency Department of Developmental Services CRIMEIINCIDENT REPORT Page ss mics - - -.. I i i II eon is emeanor nra ion provide a statement for the criminal investigation. I administered the Administrative Admonishment. An Administrative interview was conducted. The interview was audio recorded with the knowledge of all parties present for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the in-formation obtained: Measurements were obtained for the area between the footboard of Van's bed and the footboard of the bed directly across from Van's bed. There was 98 inches between the two footboards. The measurement between Van's bed and the bed adjacent to Van's bed was 34 inches. The measurement of Van's bed from the wall to the footboard was 85 inches. A Resusci-Annie (a mannequin head and torso usually used for CPR purposes) was made available for Solingco to place in the location where he found Van on the morning of 06-06-07. Sotingco placed the mannequin in the center ofthe room between the two footboards between Van's bed and the footboard of the bed across _from Van's bed. The mannequin was supine and the head of the mannequin was toward the footboard of the bed opposite of Van's bed. The measurement from the footboard opposite Van's bed and the placement of Van's head was approximately one to two feet. Sotingco said Van's head was visible in the center of the room. Van's feet and head were in the center of the room. Sotingco stated that Van's bed was wet on the morning that Van was found on the floor. Sotingco said that Van was in his own bed when Sotingco made his rounds. Sotingco said that the majority of the urine remained in the bed and there was some urine on the floor and \/an's pants were wet with urine. Sotingco said one of Van's legs was bent up in the air and the other leg was bent on the ground. Sotingco said he straightened Van's legs to change his pants. Sotingco stated that he was changing Van at \/an's feet. Van's feet were approximately two feet away from the footboard of his bed. Tan had enough room to walk around Van's head to get to the bed to change the linens. Sotingco stated that when he entered the room, Van turned his head toward Sotingco and \/an moaned. Sotingco said he told Van, "Get up Van. Get up." Van didn't move so Sotingco approached Van and pulled his left arm and- pulled him partially up using both of his hands. Sotingco was only able tolift Van's torso to a sitting position. Van was not able to get to his feet. Van didn't get up so Sotingco lowered Van back to the ground. Sotingco said it is his habit to leave the linen cart propped in the doorway of the room that he -, is making the rounds. Sotingco went to the doorway and called Tan for assistance. Sotingco said he went to change \/an while he waited for Tan to arrive for help- State of California - Health and Human Services Agency it Department of Developmental Services CRll\/lE/ INCIDENT REPORT Page B4 ?r1o9 DS 214_ll@eii A 1/ 4.CA5E NUMBER 3 DSO7--06-F-0B1--F OFFICE OF PROTEOTNE SERVICES WRE OF Ea"?f Gi 9576077 Ii. El ONLY nes E. aces E. . - Sotingco stated that he noticed a red mark that looked like a line down \/an's face extending from his left eye. Sotingco said he didn't see the reddened area to Van's face when he saw Van at the hospital later that morning. Sotingco thought that \/an had injured himself. Sotingco said that he was concerned that he might have caused Van's injury to be worse because he pulled on Van's arm to sit him up. Sotingco stated that he and Tan assisted Van to his feet, each staff member had a hold of Van under one of Van's arms Van was not able to bear weight, but Van could move his feet. Sotingco said he and Tan did not drag Van's feet to get Van to the bed. Van was placed on his bed by Sotingco and Tan. Sotingco assessed Van while back in the bed. Sotingco said that he even removed Van's shoes to check Van's feet. Sotingco stated that-was up on the morning of 06-06-07, because-had smeared and needed to be changed. was also up and in and out of his room that morning, and-. were also up. Sotingco said Tan was by Group 1 and Sotingco was seated in a chair on rollers near the East and West hallway and near Van's bedroom door. Sotingco stated there was a previous incident, one to two months previous, involving Van. Van was found by Sotingco with one leg, on the bed and one leg off the bed and Van's head was toward the floor. \/an was half on and half off the bed. Van was wet with urine. Van was like he was asleep, but he was moving The shift staff complained that Van was not able to bear weight when they tried to get Van up out of bed. Sotingco said he was thinking about that incident and thought he should complete an lncident Report on the morning of 06-06-07. Six photographs were obtained of the placement of the mannequin by Sotingco (Attachment No. 42). Follow-Ug interview with Alvin Tan, Technician on Residence 41 Onr10--26-07 at 1154 hours, interyiewed Tan in Room 59 on Residence 41 at FDC. Investigator li/lcAnlis was present during the interview. Alizaga was also present during the interview. The interview was audio recorded with the knowledge of all parties present for note taking purposes and for the record (Evidence Item No. 1). administered the Beheler Admonishment. Tan declined to provide a statement for the criminal investigation. administered the Administrative Adrnonishment. An Administrative interview was conducted, The following is a summary of the information obtained: Tan stated when he came into Van's room, he saw Sotingco changing Van's pants. Sotingco was positioned toward Van's feet. Van was supine. Tan went to change \/an's .bed. \/an was lying in the center of the room, with his head toward the footboard of the bed 1 State of California - Health and Human Services Agency Department of Developmental Services INCIDENT REPORT Page NUMBER I D307-O6-F-O81-F OFFICE OF PROTECTIVE SERVICES OF REPORT i Special Investigations Unit r. EI CRIMINAL Felony El Misdemeanor aclon 5 Fairview Developmental Center 2- ADMINISTRATIVE REPURT (714) 9575077 3. lj INFORNLATION ONLY OPS PSO706372 019361 opposite of \/an's bed. Tan said he walked around Van's head to get to Van's bed to change the linens. Tan placed the Resusci-Annie (mannequin) in a supine between the footboard of Van's bed and the footboard of the bed opposite of \/an's beds The mannequins head was placed approximately 2 feet out toward the center of the room from the footboard ot the bed opposite Van's bed. Tan stated that he walked around to the far side of Van's bed tochange the linens. Sotingco asked for help to put Van back to bed. Tan lifted Van's right arm by placing his arm under Van's arm and Sotingco assisted Van on the left side. Tan said he and Sotingco got Van to his feet. Tan said Van was kind of weak or tired, Tan said Van was helping when they got him up because he was moving his feet in a stepping, shuffling motion. \/an was very weak. Tan stated that once Van got back into bed, Van was moving his arm and legs. Tan said he thought that Van might have moved his head a little bit when he was placed back in bed. Tan stated that he saw the clients up on the morning of O6-O6-07. Tan saw the following clients up on the morning of O6-06437: --, -, -and Ten photographs were obtained ofthe placement of the mannequin by Tan (Attachment No. 43). Follow-Up Interview with Johannes Sotingco, Technician on Residence 41 On 11-O1-O7 at 0907 hours, I interviewed Sotingco in Conference Room 128 at OPS at FDC. Investigator ll/lastrosimone was present during the interview. Alizaga was present during the interview. administered the Criminal Admonishment referred to as Beheler. Sotingco declined to provide a statement forthe criminal investigation. I administered the Administrative Admonishment. An Administrative interview was conducted. The interview was audio recorded with the knowledge of all parties present for note taking purposes and for the record. The following is a summary of the information obtained; Sotingco stated he started his shift at 2245 hours on Sotingco made rounds and then put away the laundry, made toileting rounds for the clients, set up the cart with extra linens and clothing, gathered the clients that were awake into a specified area. Limbong was in charge, Tan was working overtime, and he was the usual NOC shift floor staff that shift. Tan was familiar with the clients and had previously worked overtime on the NOC shift. During that particular night, Tan and Sotingco worked at the medication cart in the hallway to separate the clients' medications, Limbong was busy with assignments and papen/vork in the Nurses' Station and then in the medication room to determine the medications and State of California - Health and Human Services Agency Department of Developmental Services CRIME I INCIDENT REPORT Page 87 oft09 D5 2145 (REV ,a 4 NUMBER OFFICE OF PROTECTIVE SERVICES Wag OF Special Investigations Unit 1. lo misuemeamfmi i' rr rr 1" ri Fairview Developmental Center 2- REPORT Vac mn I (714) 9575077 an |NFofs head rolled forward, it was very loose when they lifted Van. Sotingco again said Ir__Vr - - '**o-dar-..-. -.-II-?-??-Vrh i - -- . - vnI.-. - --1-.- - E-VFVV4.m;rjk?*` ag" Vg :2 V. *jjq5512 VV QV--V 3* V- VIE*>>oyi5.Fir. -- .. A - sf Vi: np: ueu-"-'Znw ELg}! =i a e- rjinyigIll'I=?WT-I.-- - -1-.-- VV wi JV . 1 Vi WTEQZ-fel . Il-Jillf TTI TQit-?r??i .. =V-.-. fgikq-few fl - ,.Vj Vii IleVai--I-_p 4V VV V- Ji, if-; ., it {mswV;VV?Vj? 'sfVV-I-IHV-VVwzau?=iTr_ . I V1 q'V-1W"Vj- gr; VE - Irvoo'iid.; . o" I II 'TEmu =t_V VZV . - giI.-Ny.; 1 ..rV Vu_Vo_ - VLEV IIIQII . gvLg}, . gy ..-.State of California - Health and Human Services Agency Department of Developmental Services INCIDENT REPORT Page 88 of109 DS 214 (Rev 2/4.CASE NUMBER . I SERVICES TYPE OF i ecra nves iga ions nit IUCRIMINA Fgirview Developmentai Center 2- V3 (714) 9575077 3. ci ONLY OPS PSO7-O6-372 . WW .. WW PQQI3 193 Van appeared "drunk" and "tired" based on \/an's actions. Sotingco and Tan placed Van back in his bed positioned with Van's feet on the bed. Sotingco stated that after \/an was placed back in bed, he completed his rounds and returned the barrels and carts. Sotingco said that it took him at the most five minutes, Sotingco didn`t know where Tan went after \/an was placed back in bed. Sotingco again said he remembered a previous incident when the AM shift questioned what happened to Van because Van was very weak. The AM shift staff made a big deal about that incident. Sotingco thought the HSS was called for that previous incident. Sotingco rechecked Van and Van appeared different than when he was placed back in bed. Sotingco said \/an wasn't moving and he had tears in his eyes. Sotingco called Limbong to assess Van. Sotingco said he assessed Van's neck when he called Limbong. Sotingco said Van was able to grasp with his right hand at that time, because Van gripped Sotingco's hand. Sotingco stated at that time, a laboratory technician arrived on the Residence to obtain some blood from some of the clients. Sotingco left Van with Limbong and went to assist the laboratory technician. When Sotingco went back after the laboratory technician left, he saw Limbong taking Van's vital signs. Limbong even got a soda to see if Van would reachfor the soda, because Van loved soda. According to Sotingco, Van wasn't able to reach for the soda and he thought, "This isn't good." Sotingco even removed Van's shoes and socks to assess him, but did not see any problems with his feet. Sotingco stated he thought that Limbong called the MOD. Sotingco said it was after 0600 hours, and the AM shift staff were arriving. The NOC shift staff asked the shift staff to help assess Van. Sotingco said he and an Al\/l shift staff attempted to get Van up, but Van was not able to stand. Arnold and Montes assisted with standing Van at the bedside, \/an was not able to bear weight. \/an laid back down sideways on the bed with his feet dangling over the side. Sotingco said Van was not moving as normal and his activity level was decreasing. Sotingco stated that after~the incident occurred, he thought that maybe \/an hurt himself because of the red mark on Van's face. Sotingco did not think that the mark on Van's face was related to the self-injurious behavior that Van exhibited during the night shift on 06-O6-07. Sotingco stated was lying in his bed under the covers or between the rubber lining and the mattress. was ing in his bed under the covers when Sotingco entered the room, but Sotingco didn't know if was awake or asleep at that time. Investigator l\/lastrosimone told Sotingco that Tortes informed him that when he entered Van's room, he saw Van lying on his bed and Van's feet were dangling over the footboard of State of California - Health and Human Services Agency Department of Developmental Services REPORT Page NUMBER orrice or Paorecrive seavices OF REPORT . s; (714) 9575077 3, WFORMATION ONLY 6' OPS PSO7-O6-372 .. . NH e,ve< .WEE . -E E.-- .CM Sotingco stated \/an was transported to Hoag Hospital via ambulance. Bruch rode with \/an in the ambulance and Sotingco followed behind in his personal vehicle a little later because only one staff member was allowed to ride in the ambulance with Tortes was the Acting Unit Supervisor at that time, and Tortes wanted two staff members to escort \/an because he was concerned that Van might be hard to handle when he felt better.- Sotingco stated that he arrived at Hoag Hospital after Van and therefore he didn't provide the initial information to the ER staff. the time Sotingco arrived to the hospital ER, Van was already in a bed in the ER. Sotingco stayed with \/an in the ER and completed his interdisciplinary Note. Sotingco said when he was in the ER with Van, the physician ordered for Van to have his blood pressure taken lying down, sitting up and standing up. The ER staff removed Van's brace. Sotingco said he and Tan assisted the hospital staff to attempt to stand Van, but again Van's head rolled forward and Van could not bear weight. The ER staff nurse said to put \/an back in the bed and Sotingco did not see the ER staff replace Van's neck brace. Sotingco said that Bruch called Tortes to give him an update and Tortes told Bruch to request an >t do. Some time ago a client on Residence 41 sustained a broken arm and- admitted to causing the injury State ct California - Health and Human Services Agency Department of Developmental Services INCIDENT REPORT Page ss of ros DS 214 Rev 2i2003) _f __ii wwiir rr'' inmri if nf i ''Arr 4_cAs 5R OFFICE OF PROTECTIVE SERVICES TYPE QF I Special investigations Uni! r. EI CRIMINAL CI Felony ll/lrsdemeanor El infraction 5_ I Fairview Developmental Center is OPS I (714) 957'5?" ops eso?-oe-272 i Wifi 4V M, iVi__ _i_f gg irr huh A 5 the bed. Investigator l\/Iastrosimone asked Sotingco it he knew how Van came to be in that position on the bed. Sotingco responded that he did not position someone on the bed with his or her legs hanging off the bed. Sotingco said he didn't remain with Van in his room until the time that Tortes entered Van's room. Sotingco said he was busy completing the Incident Report and making phone calls, Sotingco overheard the Physician order a brace and someone ran to get one, The Physician then asked Sotingco to check Van's blood sugar. Sotingco went to obtain the blood sugar and saw Van lying on a gurney in the Group 1 group room. Sotingco stated he had seen Van like that (appearing "tired" or "drunk") previously. Sotingco said prior to this incident, Sotingco and another co-worker had seen Van lying with his feet hanging off ot his bed and he wasn't able to get up on his own. Van was wet and the staff changed him. The person in charge was notified and assisted to position Van correctly on the bed. According to Sotingco, this previous incident occurred a couple months prior to 06-06-07. Sotin co stated that clients that were awake during morning rounds on 06-06-07 included -- and-- Svtinoco said he saw- up before he found Van during morning rounds. Sotingco said . has a behavior of flipping mattresses, but Sotingco added that he didn't hear any noise from Van's room during the night on 06-06-07. Sotingco stated he did not see- in the hallway in the morning on 06-06-07. Sotingco said - likes to hang out in the Group 2 group room when he gets up in the morning. Sotingco said he doesn't know how the relationship was between - and -- Sotingco said he saw some clients hit Van, but Van would not hit . will hit anyone in the hallway and often Van is in the hallway. Previously has hit Van in the back ofthe head and Van hunched over and stood still, sort of cowering in the hallway. - has also hit Van. Sotingco said the staff intervene to prevent injury. Sotingco said he has seen - grab Van around the neck with his arm (a movement similar to a head lock). - is aggressive with certain clients, like Van. During the ni ht shift, the staff leave the Group 2 group room door open, Van likes to shut the door, buthdidnt like it because he liked the Group 2 group room door to remain open. Sotingco said he has seen- go into other clients' rooms. Sotingco said - also went into other clients' rooms to take belongings. - thinks that he is Superman. - is able to verbalize his wants and needs, but he does have a speech impediment. Sotingco said he didn't see any clients enter Van's bedroom during the night shift on 06-06-07. Sotingco said- can be aggressive, but he has never seen - go into any other clients rooms. - is the biggest client on the Residence and he is very strong. State of California - Health and Human Services Agency Department of Developmental Services CRIME I REPORT Page 91 of 109 DS 214 (Rev 2/2003) WN MM FT Ti ifsenumaen or eaorecrivs seavices OF RERORT 5 Special Investigations Unit 1. ci CRIMINAL Felony Misuemeanm- Cl infraction DNN i Fairview Developmental Center gi OPS (ml 95*5077 ops Psp?-os-372 i ea - Rret D- RR.R D. We mw. . e_eet .9MPE Dr. l\/lerlino stated thatis hard of hearing, but he can read lips. -does have a communication barrier. functions at the level of a hyperactive 5--year--old. Dr. |\/lerlino stated- has behaviors of hitting others and using objects as weapons. - is very strong physically and likes to show it. Follow-Up interview with Alvin Tan, Technician on Residence 41 On 11-02-07 at 1004 hours, interviewed Tan in Conference Room 128 at OPS at FDC. Investigator lvlcAnlis was present during the interview. Alizaga was present during the inten/iew. Tan stated he has been employed at FDC for approximately five years and he has been working on Residence 41 for approximately two years. administered the Beheler Admonishment. Tan declined to be interviewed for the criminal investigation. administered the Administrative Admonishment. An Administrative interview was conducted. The A interview was audio recorded with the knowledge of all parties present for note taking . 5 purposes and for the record (Evidence ltem No. 1). The following is a summary of the information obtained: Tan stated he started his shift at 2245 hours on 06-05-07. Tan received report from the previous shift. During report, no one mentioned Van. Following report, Tan made rounds, but he didn't check Van. Tan thought that Sotingco or Limbong made rounds on Van. Tan finished his rounds at approximately 2315 hours. After rounds, Tan started folding clothes and then he began separating medications from larger packets into smaller doses. Tan and Sotingco were separating medications outside of the Nurses' Station. Tan said he was working on the medications for approximately one hour. Tan stated he first saw Van when he was separating the medications. Van was coming toward him in the hallway and he was wet. Tan said he knew Van was wet because Van had his pants pulled down and was walking toward him. Tan said Van had a behavior of walking with his pants down, particularly when he was wet. Van was ambulating without problems. Tan did not notice anything unusual aboutVan at that time. Tan said he and Sotingco changed Van in the hallway and Limbong also did a treatment at that time to Van's feet. Tan said he continued separating the medications. Tan stated he continued to separate medications then he went to Group 1 to watch the clients that were awake. The clients in the Group 1 room were and- Tan didn't recall any other clients in the Group 1 room. Tan added that might have gone to sleep in a bed across the room from Van's during the early morning hours of 06-06-07. Tan stated he sat in a chair in the doorway to the Group 1 room, positioned so that he could visualize the hallway and the Group 1 room. Tan said that Sotingco was the staff member State of California Health and Human Services Agency Department of Developmental Services REPORT Page sz erios .. DS (Bei;/2003?fuum en I i OFHOE OF PROTECTIVE SERvlcEs WPE OF REPORT Special Investigations Unit t. r;i cniminms ii: Felony i;i Misdemeanor in animation OR, zi?i?tinttii? li. r_clM ., r,_i . fs be DR 1 responsible for rounds while Tan remained with the clients that were awake in the Group 1 room. Tan stated that at some point during the early morning hours, he saw Van running toward him with his pants down and then he changed Van in the Group room. After \/an was changed, he went back into the hallway. Tan clarified that he just pulled up Van's pants because Van wasn't wet. Tan said Van did not have to have his pants changed at that time. Tan told me that after a while, he was going to start rounds, but-was wet so he took- to the toilet. Tan had to get a change of clothing for- and then he changed After Tan changed Tan heard Sotingco calling to him to help with Van. Tan stated that prior to Sotingco calling for help, he had changed a client on Residence 41, because- smeared. Tan said he helped Limbong change- Tan was not sure if Sotingco also helped change Tan said -vvas changed in his room. Tan wasn't sure if Sotingco called for help before or after Tan changed Tan stated that Sotingco called him from Van's bedroom doonrvay. Sotingco called, 'Alvin.' Tan said he went to Van's room and saw that Van's bed was wet. Tan said he grabbed some linen and changed the bed right away. Sotingco was already changing Van. After Van was changed, Tan assisted Sotingco to get Van back to bed. Tan said Vaniwas feeling "sleepy, tired." Tan said Van required assistance to bed when "he is weak." Tan said Van's condition was different from earlier during the shift. Tan said Sotingco asked him for help to get Van up and that was unusual. Tan said that he thought Sotingco tried to get Van up but was unsuccessful and therefore requested assistance from Tan. Tan said he either used his left or right arm and held underneath Van's right arm to lift Van and assist him to get up. According to Tan, Van was not able to bear his own weight. Tan said Sotingco was on Van's left side. Tan and Sotingco held Van under the arms and Van made stepping motions on the way to Van's bed, but Van was weak. Tan denied carrying or dragging Van to the bed. Tan did not recall the position of Van's head when they stood him up. Tan stated that he checked the back of Van's head for injuries, but found no injuries. Tan said he visually looked at the back of Van's head. There were no bruises or lumps. Van did not have a shirt on when he was found on the floor. Tan said Van was wearing pants and shoes while on the floor. Tan stated he and Sotingco placed Van back on his bed and Van's feet were positioned and jj resting on the mattress. Tan said \/an was moving while in bed. Vari was jerking around and moving his shoulders from side to side and he was reaching out with his right hand after he was placed in bed; Tan said Van did not appear to be in distress when placed back in State of California - Health and Human Senzices Agency Department of Developmental Services REPORT Page as orios REURV 2'2 W. WW .. WW. 4.CASE NUMBER I . OFFICE OF PROTECTIVE SERVICES WEE OE REPORT $3 I (-M4) 3. CI ONLY OPS WW . bed. Van wasn't crying or moaning. Tan said he thought that Van seemed tired and really sleepy. Tan stated that after he got Van back to bed, he went to the Group 1 group room to stay with -and Tan said he had to restrain - According to Tan, - has a behavior of hitting. - was exhibiting a behavior of hitting himself and staff on the morning of 06-06-07, for which he required restraints. -was placed in wrist-to- waist restraints. Tan initially said he wasn't sure if-was up that morning, because usually he gets up and asks for underwear as he usually wets himself. Tan did recall that -was up on the morning of 06-06-07. Tan thought he saw-drinking from the drinking fountain by the Nurses' Station before he changed Van. Tan said it vvasn't unusual for- to drink out of the drinking fountain by the Nurses Station. Tan said he wasn't sure if he saw -- Tan added that sometimes -gets up to use the bathroom during the night, -will use the middle bathroom (by the Nurses' Station and close to Van's bedroom) or he will use the Group 2 bathroom. Tan said -- got up to use the toilet close to Group 1. Tan denied observing any clients or staff entering Van's bedroom. Tan said that- was in Van's room on the morning of 06-06-07. Tan was not sure if-was in Van's room on the morning of 06-06-07. Tan stated that Sotingco never mentioned that he (Sotingco) did-anything to cause Van's injury. Tan said he didn't suspect Sotingco of causing Van's injury. Tan said Van made a lot of noise if someone tried to do something to him. Tan said there was no noise from Van's room that morning. Tan denied any contact with Van that could have resulted in injury to Van on the morning of 06-06-07, Tan stated that-doesn't like to be bothered by noise and he will try to attack and hit other clients. Tan said- didn't like Van. - doesn't like that Van tried to repeatedly open and close the Group 2 room door and -doesn't like that. Tan told me that he has seen -attempt to hit Van in the past, but Tan intervened to prevent a physical altercation. Tan has seen - attempt to hit Van with a closed fist. Van reacted by running away or pounding on the door and making a lot of noise. Tan said he has never seen -- - - or any other clients aggress on Van. Tan said that would get upset when Van made noise and -would say, 'Stop doing that.' According to Tan, Van was at times annoying to the other clients because he would bang on the doors and open and close the doors. Tan said Van was not an aggressive client to others. Tan said that of all the clients that were awake during the morning hours on 06- 06-07, - and - were the only two clients that would enter into another client's room. Tan stated that after he helped Sotingco get Van back into bed, he went to the Group 1 group room and then he stayed with-because-was in restraints. Tan heard that the HSS and the MOD were called to assess Van. Tan said Van was usually up early in . . - iu.? . 7 State of Califomia Health and Human Services Agency Department .of Developmental Services CRIME I INCIDENT REPORT Page 94 of109 bs z14s - I I OFFICE OF PROTECTIVE SERVICES NRE OF REPORT Special Investigations Unit i. cn1Mmru.? Felony Nisdemeanor mrmuon 5_ . I ops OPS PS07-06-372 . CMPD 07-9361 the morning, but Van never came out of his room after he was placed back to bed. Tan said I he wasn't really concerned because he thought Van was sleepy or tired. Tan told me he spoke to one of the HSSs and was told that the MOD was called. After the physician arrived, Tan said someone asked him to get a cervical collar. Tan said that a cervical collar is used to stabilize the head and neck. Prior to getting the cervical collar, Tan did not have any thought that Van had injured his head or neck. Previously when Van has experienced pain, he will make a lot of noise. Tan stated that his training indicates the if he Ends a client on the fIoor.with a significant . change, not moving, pupils dilated, exhibiting signs of pain, then the client should not be moved.- Tan was responsible for notifying the charge nurse, the HSS, and obtaining vital signs. Tan did not immediately notify Limbong of Van's change of condition. Tan stated that he finds a_client in another cIient's room approximately once or twice a month. Tan said Van wouldn't react to another client in his room. Tan said he would be able to hear a loud noise from Van's room even if the door was closed because it is quiet at night on the Residence. Tan stated that Van does not wear a diaper. Van wore underwear and pants. Van willfollow commands to lift his hips toassist with changing when on the floor. Tan did not know if Van's legs were bent or straight when being changed. Tan said he didn't know if Van lifted his hips when Sotingco changed him on the morning. of 06-06-07. Tan said Sotingco pulled up Van's underwear and pants while Van was still on the floor. Tan said that he did hear that Van had a similar experience where he was very unsteady and weak "kind of sedated" a few months prior to 06-06-07. Tan stated he started the morning rounds around 0500 or 0530 hours. Tan did not recall the time that Sotingco called him into Van's bedroom. Tan said Van had a red mark on his face when he saw Van on the gurney. Tan said the Paramedics transferred Van to the gurney. Tan told me he wasn't aware if anyone else tried to get him up out of bed. Tan stated he was assigned as the one--to-one with Van at Hoag Hospital a few days after Van was transferred. Tan said he stayed with Van during the AM shift. Tan said Van's brother, L. Ingraham, was present at the time. Tan said he told L. Ingraham that he worked the morning 'of 06-06-07, and that his co--worker found Van, called him and he assisted Sotingco to put Van back to bed. L. Ingraham asked Tan if Sotingco seemed nervous around the time that Van was found and Tan replied that Sotingco did not appear nervous. L. Ingraham then told Tan that he had a good friend who was a Iavvyer and he wanted to - press charges against Sotingco. Tan said L. Ingraham told him that one ofthe physicians at Hoag Hospital said that Van's injuries did not result from a fall. Tan said L. Ingraham told . him that this physician said Van's injuries were similar to those of a surling type injury. Tan State of California - Health and Human Services Agency CRll\/lE INCIDENT REPORT of Developmental Services 109 Department Page 95 of DS 214 Rev 2/2003 Awiw 'Tic/iss nuns 5 OFFICE OF PROTECTIVE SERVICES TYPE OF REPORT 2 Special Investigations Unit 1_ Cl CRIMINAL Ci Feim-ry misdemeanor I3 lrilracli OPS so .C sc, I, said he first heard that Van had a fractured neck on O6-O6-07, after Van was transferred to Hoag Hospital. Tan stated he did not see any clients going in or out of Van's bedroom on O6-O6-07, Tan said he only saw Sotingco enter Van's bedroom, but he didn't suspect that Sotingco caused \/an's injury because Van would make noise if someone attacked him and Tan didn't hear \/an making any noise. Tan said is a calm person and he has never seen Sotingco hurt or act inappropriately with any ofthe clients. Tan said he was trying to figure out how Van got injured, but the only thing he suspected was that Van felt Tan stated that there was urine on the bed, but he didn't check the floor by \/an's bed for urine Tan said there was a lot of urine on the bed and the urine appeared tc be fresh. Tan said that he heard \/an had falls in the past. Tan didn't know the circumstances surrounding Van's falls. Tan stated that Van did not annoy him and he never had any problems with Van. Tan said Van could be annoying to some of the staff_ Tan said that-, and had injured staff or clients in the past. Tan said is very strong and shorter than Van. Tan said that he wasn't aware of any clients making allegations of abuse, Tan said -is very intelligent and he has a very good memoiy Tan said was manipulative with staff regarding his request for cigarettes. Meeting with the Orange County District Attorneys Office On or about 11-O6-O7 at 1030 hours, I met with Steve Howe, Investigator with the Orange County District Attorney's Office and Barrie Pink, Deputy District Attorney with the Orange County District Attorney's Ofhce at the Orange County District Attorneys Office located in Santa Ana, California. Also present from the Office of Protective Services at FDC were Commander Ackermann, and Investigator I\/lastrosimone The following is a summary ofthe information obtained: The case details and all leads from the investigation conducted by OPS at FDC were shared with everyone present at the meeting. A discussion regarding the case ensued. Additional folIow>>up was discussed and an agreement was made between the represented agencies to continue to communicate any new information relative to the case. Meeting with Johannes Sotingco, Technician at FDC On or about it-16-O7 at 0930 hours, I met with Sotingco outside the Laundry at FDC. Also present was Investigator l\/lcAnlis_ The following is a summary cf the information obtained: I IU I- I. State of Califomia - Health and Fluiinan Services Agency In Department of Developmental Services CRIME I INCIDENT REPORT Page 96 of 109 os 214 Rev zrzoosr 5 7 OFFICE OF PROTECTIVE SERVICES CRE OF REPORT . 'Special Investigations Unit 1. Cl carmimr. Felony CJ Misoemeanoru infraction CONNECTED RERCRT FSINIBW DGVBIOPTTIBFIIBI CBTIIGT 2- ADMINISTRATIVE REPORT 3. Cl INFORMATION ONLY OPS PS07-06-372 CMPD 07-9361 met with Sotingco and informed him of the opportunity to participate in a Certified Voice Stress Analysis (CVSA) test, which would be made available through the Costa Mesa Police Department. I explained that the Voice Stress Analysis test was voluntary and encouraged Sotingco to participate in this test. Meeting with Alvin Tan, Technician at FDC On or about 11-16-07 at 0945_hours, met with Tan outside Residence 41 at Also present was Investigator McAnlis. The following is a summary of the information obtained: met with Tan and informed him of the opportunity to participate in a CVSA test, which would be made available through the Costa Mesa Police Department. I explained that the Voice Stress Analysis test was voluntary and encouraged Tan to participate in this test. Communication with Deb Williams, Program Director for Program about 11-16-07 at 1030 hours, conducted a telephone call with Deb the Program Director for Program 4 at FDC. The following is a summary of the information obtained: - I informed Williams that wanted to offer Limbong the opportunity to participate in a CVSA . test, which would be made available through the Costa Mesa Police Department. I explained that the test was voluntary and requested that Limbong contact me to discuss this further. Williams said she would contact Limbong with the above--mentioned information; Meeting with Costa Mesa Police Department On or about 11-21-07 at 1400 hours, met with Dana Potts, Detective with the Costa Mesa Police Department. Also present were Don Ackermann, Commander of OPS at FDC and Investigator Mastrosimone with the Office of Protective Services at FDC. The following is a summary of the information obtained: I Detective Potts explained the process for the CVSA testing. Detective Potts indicated that he would be willing to make up' a series of questions based on the investigation of Van's death, and administer the test to any FDC employees that would volunteer for the test. - . Detective Potts said he would be willing to go over the questions with the test volunteers prior to them taking the test. Detective Potts added that any of the volunteers could call him or speak to him inperson regarding any concerns about the testing process. Iwkk . - 1 State of Califomia Health and Hirinan Services Agency Department of Developmental Services INCIDENT REPORT Page zrzooar . -- I OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations 1. CRMINAL Felony lHff'8dlOh 5 REPORT A F3il'Vl6W 2- REPORT 07-9361 Additionally, Detective Potts stated that he would attempt to use the taped interview for Sotingco to obtain CVSA results, if Sotingco refused the test. (Sotingco agreed to provide a statement for the criminal investigation during his interview on 06-11-07.) . Interview with Derrick Hong M.D., lnternist at Hoag Hospital On 12-10-07 at 1146 hours, I interviewed Dr. Hong at Hoag Hospital in a Medical Staff Room. Investigator Mastrosimone was present during the interview. The interview was audio recorded with the knowledge of all parties present for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: Dr. Hong stated he has been a medical doctor, board certified in intemal medicine, at Hoag Hospital since 2003. Dr. Hong reviewed the letter he had written dated 06-12-07. Dr. Hong - stated he wrote the letter after Van had expired. Dr. Hong explained that Van sustained the injury at the cervical vertebrae C5 and C6. A dislocation is a disruption in the normal alignment of the vertebrae. The facet is the anterior portion of the cervical spine. Dr. Hong .- clarifiedthat the injury was a misalignment of the cervical spine with many ligaments being broken. Dr. Hong did not remember any external bruising to Van"s head or neck. Dr. Hong said it is not unusual in this type of injury to see external bruising. Dr.-Hong added that it is possible that swelling could be present with this type ofinjury, but often the swelling is intemal. - Dr. Hong stated that Van received x-rays in the ER, but he did not personally review the x- rays. Dr. Hong received notification from the ER physician and then he initiated a stat call to the neurosurgeon. Dr. Hong did not recall if Van sustained a fracture. Dr. Hong stated that Van had limited movement to his upper and lower extremities upon admission to Hoag Hospital. Dr. Hong said it is not uncommon from his experience to see a progressive decline in movement following this type of injury. Dr. Hong stated that possible causes for the type of injury that Van sustained would be the - result of extreme flexion of the neck, seen frequently with- bodyboarders or surfers. Dr. Hong said this type of injury requires a lot of force. Dr. Hong said it is certainly possible that the injury could have been the result of gravitational forces due to a fall, but he has never seen this type of injury as a result of a fall. Dr. Hong said he didn't know if this type of injury could be the result of placing a patient in a headlock, some other type of wrestling maneuver, or martial arts technique. Dr. Hong said he has never seen this type of injury caused by any of those techniques. Dr. Hong stated that he could not detemrine if any movement of Van following the initial injury would have exacerbated or affected the initial injury in any way. Dr. Hong suggested - I ,r 5 State of California - Health and Human Services Agency Iv Department of Developmental Services CRIME I INCIDENT REPORT Page Rev zrzoos I I OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT Special Investigations _Unit 1. r;1 Feruny msugmeamr cr rnrmerrorr 5_ CONNECTED REPORT Fainriew Developmental Center gc OPS ops Psoms-372 - CMPD 07-9361 that possibly a trauma surgeon or a neurosurgeon would best be able to make that determination. Dr. Hong stated he was not able to answer whether a pull on a patient's arm following a neck injury would have affected the neck injury. .- Dr. Hong stated he has thought of all the different possibilities that might have caused this injury to Va_n, but he did not want to speculate.- Dr. _Hong said he had no definitive indication whether Van's injury was due to an accident, neglect or if it was intentional. Dr Hong said that he never discussed whether Van's injury was the result of an accident, neglect or if it was intentional with L. Ingraham. `Dr: Hong said he never told L. Ingraham that Van's injury was not accidental and he.never told L. Ingraham that Van's injury could not have been the result of a fall from bed. However, Dr. Hong stated that he did discuss possible causes of Van's injury with L. Ingraham. Dr. Hong stated he has not discussed the case with anyone from the media. I - Interview with William Ross Dobkin, Neurosurgeon at Hoag Hospital . On 12-11-07 at 1117 hours, I interviewed Dr. Dobkin in his office located in Newport Beach, Califomia. Investigator Mastrosimone was present during the interview. The interview was audio recorded with the knowledge of all parties present for note taking purposes and for the record (Evidence Item No. 1). The following is a summary of the information obtained: Dr. Dobkin stated he was a neurosurgeon at Hoag Hospital and he has been in practice for approximately 22 years. Dr. Dobkin stated that he wrote the letter_dated 06-13-07. The -- spine is connected in the front by the discs and in the back by joints and they are all pretty strong structures by themselves. 'When you have a fracture dislocation inthe spine it usually causes the joints in the back to move forward and ride over one another. We see that a lot in very severe injuries where people break their necks in the waves or in a motor vehicle accident where there is a lot of force. To disrupt those things it takes a lot of force, unless there is the presence of some congenital forces or osteoporosis, which was not the case for Van. The family asked me what I thought. I guess there was some concern that_the client had fallen out of bed. They asked me if the injury could have occurred from falling out of bed. I replied not typically, it takes too much force to cause an injury like that. had no idea what happened to him. Dr. Dobkin stated he didn't know if this Injury was due to an accident, neglect or if it was intentional. Dr. Dobkin said he never told L. Ingraham that this injury to Van was not accidental. . Dr. Dobkin stated fracture dislocations are usually caused when the head is bent forward and the back is compressed. Those kinds of things usually occur when someone is hit in the State of California Health and Human Services Agency Department of Developmental Services - CRIME I INCIDENT REPORT page ss or ros os 214 a new zrzoosr 5 4.cAse OFFICE OF PROTECTIVE SERVICES WPE OF REPORT Special Investigations Unit r. cr Ferony uvrrsuemsanor CCNNECTEC REPORT FBINIGW CBDIGF 2- lm ADMINISTRATIVE REPORT OPS CMPD 07-9361 back or struck by a wave and forces the head downward. Dr. Dobkin said it could result from falling from a -10--foot height. Dr. Dobkin said it was possible that the injury could have resulted from an accelerated run followed by a slip and fall, but usually people fall forward. Dr. Dobkin said he has never seen this type of injury result from a martial arts type of strike or a headlock, but it is possible. Dr. Dobkin said he is sure there are areas that clients can climb up on things and jump off of. Dr. Dobkin said it is possible that if Van fell back and hit his head, causing it to flex forward, the injury could have occurred that way. - asked Dr. Dobkin if movement of the client following the initial injurywould have affected or exacerbated the client's initial injury. Dr. Dobkin said it is possible, butwhen there is a dislocation injury like Van's it is very stable, but in a bad position. Dr. Dobkin added that it - takes approximately 60 pounds of traction to reduce this type of injury. Dr. Dobkin stated that following this type of injury, there would immediately be a significant change in the patient's mobility. Dr. Dobkin said progressive loss of movement would . depend on the size of the spinal canal. Dr. Dobkin explained that when a dislocation occurs - the spinal canal narrows, there could be more distortion with increased swelling placing pressure on the spinal cord, causing additional reduction in movement. - Dr. Dobkin stated that it is the typical policy to visualize the entire spine before mobilization of the neck and spine occurs. Dr. Dobkin stated that his documentation reflected that there was some bruising to the back of the patient's head. Dr. Dobkin said he didn't recall any swelling to the neck area. . Dr. Dobkin stated -he initially saw Van in the ER and Van had been there for quite sometime. X-rays of the cervical spine were obtained in the ER, and reading the cervical spine x-rays can be difficult. Dr. Dobkins said that he didn't think initially the staff had "appreciated the fact that he had fractured his neck." Shortly thereafter, a CT Scan was done and revealed the fracture dislocation of the spine. . Dr. Dobkin stated he was contacted to the media and he did speak to a" member of the _media. Dr. Dobkin said he told the media the same thing that he stated during this interview. Costa Mesa Police Department Supplemental Report (DR No. 07-9361) On or about 12-18-07, I received a Supplemental Narrative Report (DR No. 07-9361) written by Sergeant Condon with the Costa Mesa Police Department and dated 12-18-07 -- (Attachment No. 44). The interview was audio recorded by the Costa Mesa Police Department. The interview was also audio recorded (Evidence lte?m No. 1) and digitally video recorded (DVD/Evidence Item No. 6) by the OPS at FDC. The following is a summary of the information obtained: State of California - Health and Human Services Agency Department of Developmental Services INCIDENT REPORT Page 100 of109 PS 21** -- K, - - 4.CASE NUMBER I 1 OFFICE OF PROTECTIVE SERVICES TYPE OP REPORT 1 Special Investigations Unit 1. cmiviimit 1:1 Felony K1 Misuemeancrm infraction i Fairview Developmental Center OPS i (mt g57'5?77 ops i?s07-0e-372 -9 -I Sergeant Condon wrote that on 12-17-07 at 1345 hours, he conducted an inten/iew of-. Also present were Sergeant Detective Phillips with Costa Mesa Police Department and Deb Williams, Director for Program 4, - was able to state his last name, but did not state his date of birth when asked. - said he recognized Van from a picture presented to him during the interview. When asked if he wasin Van's room on the morning of the incident of Van's injury, - replied, "Yeah," Sergeant Condon asked - if he did anything that would have hurt Van, and his head side to side in the negative, Sergeant Condon asked -if he had seen at the drinking fountain the morning of Van's injury and - indicated that he had seen However, - did not answer whether or not he had said anything to- that morning. Sergeant Condon again asked -what happened in Van's room on the morning of 06-06-07. - replied, "He timed me out." -did not explain what he meant by that statement. Sergeant Condon asked- if he had ever wrestled with Van and - indicated that he had. When asked if he wrestled with Van the morning that \/an got hurt, - shrugged his shoulders. - did not provide any additional information relevant to the events of the incident involving Van on the morning of 06-06-07 on Residence 41 at FDC. Follow-ug Meeting with Orange County Sheriff Cor0ner's Office On or about 12-18-07 at 1300 hours, I met with members of the Costa Mesa Police Department and with the Orange_ County Sheriff-Coroner's OfEce at the Orange County Coroner's Oflice in Santa Ana, California. Also present representing the Office of Protective Services at FDC were Nancy Irving, Interim Chief of OPS, Commander Ackermann and Investigator Mastrosimone. Members of the Costa Mesa Police Department included Kevin Condon, Sergeant; and Detective Sergeant Phillips. Members of the Orange County Sheriff- Coroner Department included Investigator Collazo; Rod Thomas, Manager of Investigations; Dr. Singhania; Jackque Burndt, Chief Coroner and Dr. Thay I-ee, The following is a summary of the information obtained: . An update was presented regarding the case details and all leads from the investigation conducted by OPS. All new leads and findings were shared with all members present at the meeting. A discussion regarding possible causes of Van's injury ensued. Dr. Lee presented his findings relative to a biomechanical assessment of Van's injury. Dr. I-ee stated he would provide a. copy of his presentation and findings to the OPS at FDC. The manner of death provided by the Coroner's Office was "undetermined." tr. State of California - Health Services Agency Department of Developmental Services I INCIDENT REPORT page 101 or 109 os 2148 --E zrzuos 4.CASE NUMBER 5 OFFICE OF PROTECTIVE SERVICES WE. Special Investigations Unit 1. Felony Misdemeanor rnrracrion 5 CONNECTED REPORT Fainriew DEVSIOPITIBUYBI CGl'li6I' 2- NADWNISTRATNE REPORT (714) es?-sow ruroruwmcn only OPS CMPD 07-9361 Meeting with the Special Investigations Unit Staff at Metropolitan State Hospital On or about 12-20-07 at 0945 hours, I met with Barry Hudson, Senior Special Investigator at Metropolitan State Hospital for the Department of Mental Health. Also present was Investigator Mastrosimone. The following is a summary ofthe information obtained: Investigator Hudson stated that Sotingco had been an employee at Metropolitan State Hospital. During his course of employment at Metropolitan State Hospital, Sotingco was named as the subject of four separate investigations that occurred around or about 1993; All of the allegations against Sotingco were unsubstantiated. Additionally, Senior Special Investigator Hudson made a_ telephone call to Angie Rodriguez, an Office Technician in the Human Resources Department and asked it Sotingco had any adverse actions while employed at Metropolitan State Hospital. Rodriguez informed Investigator Hudson that Sotingco did not have any adverse actions against him while . employed at Metropolitan _State Hospital. - . I Reguest for information from Anaheim Police Department On or about 12-20-07 at 1130 hours, I requested that the Anaheim Police Department provide information pertaining to any complaints of violence at Sotingco's Residence in _Anaheim, California. Also present was Investigator Mastrosimone. The following is a. summary of the infonnation provided: There were no recorded or documented complaints of violence involving the Residence - A identified as Sotingco's. Interview with-Rene Montes, Technician Assistant on Residence 41 On 01-25-08 at 1359 hours, I interviewed Montes in Conference Room 128 at OPS at FDC. Montes stated he has been employed at FDC for approximately 16 years and he has been worI