In March 2006, a Long Beach hospital put state licensing authorities on notice: Two patients had accused a nurse of molesting them on a single night. One said that he massaged her breasts, the other that he groped her under her hospital gown, according to hospital and court records.
By year's end, licensed vocational nurse Carlito Paar Manabat Jr. had pleaded no contest to two counts of sexual battery. He went on to serve six months in jail and register as a sex offender.
Last February, he renewed his license, checking "yes" on the application when asked if he'd been convicted of a crime.
It wasn't until July, more than two years after first being alerted to the problem, that the California Bureau of Vocational Nursing and Psychiatric Technicians took the first formal steps to revoke or restrict Manabat's license.
Today, with the case pending, Manabat is still free to practice -- though he says he doesn't, on the advice of his probation officer.
A review of the vocational nursing bureau by The Times and ProPublica, a nonprofit investigative newsroom, found many cases similar to Manabat's in which regulators acted belatedly or not at all, even when explicitly told that nurses had committed serious crimes. Some were handed renewals after reporting their own felonies to the bureau.
"Obviously the public isn't protected," said John M. Brion, an assistant clinical professor at the Duke University School of Nursing and former executive director of the Ohio Board of Nursing. "If you have a person who's already been convicted and served their time and they haven't even been charged by the board . . . I would really question what's wrong with their system."
In an interview, Manabat denied molesting his patients, saying they must have been hallucinating. He didn't fight the charges, he said, fearing a lengthy prison sentence.
The findings expand upon a Times report last month that examined the bureau's sister agency, the Board of Registered Nursing, and cited dozens of examples in which RNs retained their licenses for years despite serious or repeated criminal convictions.
Problems with the two agencies, both overseen by the state Department of Consumer Affairs, may signal a broader breakdown in the regulation of health professions. The department presides over more than 30 professional boards and bureaus, with varying and sometimes inconsistent approaches to screening for criminal offenses.
"The fear is that there's any vulnerability in the consumer protection we're offering," said Carrie Lopez, the department's director.
In general, Lopez said, she does not believe it is acceptable to take two years for regulators to file a formal complaint against a convicted sex offender. "We want to see action taken as soon as possible," she said.
The best way to do that, Lopez said, is to require all applicants for professional licenses to provide their fingerprints, allowing law enforcement to notify regulators of any arrests. The vocational nursing bureau has usable fingerprints from fewer than half of its 79,000 licensees because fingerprinting has been an on-again-off-again requirement since 1952.
The Times previously reported that more than 40% of the state's 344,000 registered nurses had no fingerprints on record because they were not required before 1990. After the story ran, the Board of Registered Nursing voted to require fingerprinting for all its licensees.
Registered and vocational nurses account for the bulk of bedside care in hospitals, nursing homes and other health facilities. Registered nurses have more training and assume primary responsibility for fulfilling doctors' orders and monitoring patients' conditions. Vocational nurses perform more basic tasks such as administering medications and taking vital signs.
In examining the vocational nursing bureau, reporters reviewed 162 disciplinary decisions made in 2007 against licensed vocational nurses. The documents were obtained through a Public Records Act request because the bureau historically has not made them available on its website.
Twenty-seven nurses racked up three or more criminal convictions before regulators filed complaints against them. Three had accumulated nine or more. In some cases the bureau took so long to act that judges said revoking the nurse's license was no longer necessary to protect the public.
That was the case for Donna Redcross of Mountain View. From 1990 to 2001, she was convicted three times for petty theft, three times for driving without a license and once each for possession of methamphetamine, disturbing the peace and drunk driving, bureau records show.
But the bureau made no move to restrict her license until February 2007. An administrative law judge, citing that delay, put her on three years of administrative probation. Through her lawyer, Redcross declined to comment.
In several other cases, convicted felons were described as having "clear" records on the bureau's public website. Among them: a Corona nurse convicted in December 2005 of bludgeoning her boyfriend to death and a Colton nurse convicted this year of using a patient's identifying information as part of a real estate scheme.
In February 2007, nurse Cynthia Knott was arrested after allegedly selling drugs to undercover investigators that had been stolen from her job at the Fresno County Jail. Investigators found hundreds of pills from the jail in her home, records show. She pleaded no contest to felony grand theft and possessing Vicodin for sale, was featured on the local TV news and was sentenced to a year in jail.
This September she was caught with methamphetamine and arrested again.
In Knott's court file are three letters from the vocational nursing bureau in 2007 asking the court to provide records for its review. Notes on the letters indicate that the court complied.
But as of last week, Knott was a nurse in good standing with the bureau, according to its website.
Knott's mother, Becky Owens, said that her daughter's arrest was a misunderstanding and that prosecutors scared Knott into pleading no contest. "They found medicine that she had taken home by mistake," Owens said.
Not every crime is directly related to nursing. But in many cases the potential for patient harm is obvious: Stolen drugs may not go to the patients for whom they are intended. An addicted nurse may make mistakes while under the influence. A sex offender may go on to commit similar offenses.
Several healthcare executives said they were troubled by the bureau's slow pace and by the dearth of information it disclosed about pending discipline. Hospitals and clinics rely on that information to vet job candidates.
Until recently, the vocational nursing bureau's website indicated that nurses had clear licenses even if they were in the midst of proceedings to restrict or revoke their licenses.
After reporters began inquiring in recent weeks, Lopez, the Consumer Affairs Department director, ordered the bureau to post documents online outlining pending accusations, starting immediately.
The bureau itself has recognized its increasing workload and received approval last year to hire at least eight more staffers for enforcement. But some weaknesses go beyond staffing.
As a backup to its inconsistent fingerprinting system, the bureau asks all nurses renewing their licenses if they have been convicted of any crimes since their last renewal, usually a span of two years. The method essentially relies on the integrity of criminals.
With no fingerprints on record, Inette Schwam Linstead checked "no" when asked in November 2002 if she'd been convicted of a crime, according to bureau documents. In fact, she had been convicted months earlier of driving under the influence and of forging a prescription. In 2003, with her license freshly renewed, she was convicted twice of possessing controlled substances, the bureau documents state.
The bureau did not seek to revoke or restrict her license until 2006. The next year, an administrative law judge gave her five years' probation.
In an interview, Linstead acknowledged that while in the throes of her addiction, she went to work under the influence of methamphetamine. But she said she does not believe she harmed patients. Now five years sober, she admits having lied to the bureau but says she feels she deserved a second chance."When you're fearful of losing something, people tend to be dishonest because they don't have a higher power in their life," she said.
Even when licensees are truthful about criminal convictions, the process can be nonsensical.
In April 2002, David Leland Lowe revealed to the bureau that he had been convicted of lewd and lascivious acts with a 14-year-old, according to nursing bureau documents. Lowe had sex with the teenager in 1995 when he was 31, the records state.
The bureau renewed his license anyway.
In 2004, Lowe again disclosed his conviction, in writing, to the vocational nursing bureau.
It wasn't until more than two years later, in November 2006, that the bureau took the first step against his license, leaving unexplained why Lowe's crime suddenly merited attention.
An administrative law judge allowed Lowe to keep his license but placed him on five years' probation, noting that Lowe's employer, a nursing registry, described him as the best it had.
Lowe did not return calls for comment, but his former attorney, Michael Coffino, said in an e-mail that his client is "a perfect example of why all convicts should not be treated with the same degree of trepidation, even when it comes to having them as nurses."
San Bernardino nurse David Roberge agrees -- but he never thought the bureau would accept that argument.
He said he served nearly 2 1/2 years in prison for manufacturing methamphetamine in the presence of children.
When Roberge asked about renewing his license after his release, bureau officials told him to send a letter explaining his circumstances. He did so and soon received a new license with no restrictions, he said.
For 1 1/2 years, Roberge was a nurse in good standing. Then, in 2006, the bureau decided to act. He's now on administrative probation and must submit to a host of requirements.
Still, he is grateful. "I'm not proud of what I've done, but I'm proud of where I've come since then."I didn't think I would ever get my license back," he said.
Weber and Ornstein are senior reporters for ProPublica.