Slaying Raises Questions About Mental Facility : Health care: State officials are to meet with the owner of Dahlia Gardens, which has been cited numerous times for violations.

When one schizophrenic man killed another at an El Monte board-and-care home this month, the lone staff member on duty was washing dishes instead of supervising residents--yet another violation of state code among nearly 150 issued to the home since it opened in 1987.

More than half of the violations at Dahlia Gardens Guest Home for the mentally ill, and almost all of the serious ones, were in the last year, state records show. And staffing problems were a repeated note in inspectors’ records: too few staff, untrained staff, staff who failed to dispense medication properly, and the use of mentally ill residents to substitute for staff, state Department of Social Services records show.

State officials have scheduled an informal conference today with Dahlia Gardens owner Karl Hoffman--the third such meeting since June--to discuss chronic violations at the home, which have also included cockroach infestation and improper food handling, state licensing records show.

Informal conferences are considered serious measures, often the final step before a home’s license is suspended or revoked, social services officials said, but the meetings before the killing led to no such discipline.

Nor did the November death of another resident who was killed by a car while he was crossing the street.

“We are taking a look at the whole history of this facility,” said Martha Lopez, a deputy director for the state agency. “I want to move very quickly on this one.”

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The state does not track the average number of citations or fines issued to group homes, but there is no doubt that Dahlia Gardens is a troubled, problematic place, Lopez said. Although it has a long list of citations, the home only recently has drawn attention because of major violations such as the staffing problems, she said. Of the home’s 148 citations, 78 were issued last year, state licensing records show.

Last week, Hoffman told The Times he had not violated any state codes and had no citations. But Tuesday, when confronted with a list of citations, he backtracked, saying the violations were minor or that the major ones had been corrected. Hoffman, who has operated the home for eight years, said any problems he had with the state were the result of misunderstandings on his part.

“I didn’t understand what was required,” said Hoffman, who says he is over 60. “I run an excellent home for the people. They know I care for them.”

The recent killing at the home occurred Feb. 8. A 34-year-old ex-Marine was watching TV in the recreation room when another resident sneaked up and beat him to death with a large rock, according to police reports. At the time, the one employee, a housekeeper, was in another building, leaving all 73 residents with no direct supervision, according to Department of Social Services records.

In the wake of the killing, the home was cited for violating the state code that required the night employee to directly supervise clients and perform no other duties.

Social services officials said an investigation of the death and other incidents, including the November traffic death, is under way.

Hoffman dismissed the possibility of negligence in either death. State regulations do not allow residents at adult care homes to be locked up. Residents, who, until January, have included a convicted child molester and a rapist, come and go at will, he said.

“How can they blame the board-and-care home?” Hoffman asked. “We have a very nice place here.”

He added that he hired another staff member last week to help him follow state requirements. The new administrator, Maury Hoche, said he has never had a job working with mentally ill adults, although he has done volunteer work with them.

Neighbors, meanwhile, complain about the home, saying disheveled clients sometimes wander onto their property and, in at least one case, into a house. Some clients also lie down in the middle of the street, neighbors said. Throughout the day, they said, the home’s loudspeakers blare, alerting its residents to medication and mealtimes. At times, they said, the loudspeakers warn residents that if they fail to show up for their medication, they won’t get any.

Neighbor Maria Perez said she keeps her gate locked because the home’s residents sometimes wander onto her property.

El Monte police and fire officials say patients often make 911 calls from the home’s two pay phones. Fire officials respond to the home up to 10 times a month, mostly on bogus calls, said Capt. James Rock.

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Board-and-care homes fill the gap for mentally ill people who are not so badly off that they need a hospital, but who cannot function independently. Many residents are referred to specific homes by hospitals or social workers. Most Dahlia Gardens residents are diagnosed as schizophrenics, Hoffman said. Men and women live at the home.

Rent at board-and-care homes is state-regulated; most Dahlia Gardens boarders pay $671 a month.

State regulations do not specify a staff-to-client ratio, requiring only that supervision is adequate, based on the clients’ needs. In a Feb. 10 report, two days after the killing, social services inspector Leslie Word-Mendoza said at least six residents of Dahlia Gardens had not been properly assessed to determine what level of supervision they needed. Word-Mendoza also questioned whether Hoffman had the “knowledge of the requirements for providing the care and supervision needed by the clients at this facility.”

“Mr. Hoffman, by inappropriately admitting clients whose needs (neither) he nor the facility can meet, is placing all clients in danger,” the report said.

A state inspection report last year warned that Dahlia Gardens was woefully short-staffed.

“This is a very strong concern for this (inspector) that the licensee has not hired enough staff to complete the required duties of this facility,” said the April inspection report. “Clients are very dirty . . . clothing very soiled.”

In June, a state inspector noted that according to the home’s records, 44 of 62 clients had refused daily medication for one week in May. Staff failed to document why the medication was refused and did not notify the clients’ doctors, as required by state code, according to the inspector’s report.

The home was cited three times last year for using residents to perform staff duties. The resident who took on bookkeeping duties had complete access to client files, the state inspector noted, while the resident handling maintenance had staff keys.

Hoffman said his 14-member staff is adequate. He blamed himself for not understanding state requirements for documents on giving medication, and said residents did staff work only when social workers suggested that the duty might be good for them.

The beating death, he said, was unfortunate but could not have been prevented, no matter how many staff people he had.

“Nobody is going to interfere with a fight,” he said. “I’m not a prizefighter. My safety is first.”

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On Feb. 14, the Los Angeles County district attorney’s office filed murder charges against 34-year-old LaRay Anthony King in the death of his former roommate, Leonard Sutton. Sutton, who had lived at the home for two years, died at Greater El Monte Hospital an hour after the beating. King, diagnosed as schizophrenic, is being held in lieu of $1-million bail at Men’s Central Jail in Los Angeles.

Sutton’s family said they did not learn of his death until two days afterward, when a detective called. Hoffman said he tried to call the family but had gotten no answer.

Leonard Sutton Sr. said his son, who had been in and out of institutions for more than a decade, should have been more closely supervised. His son had been in the the psychiatric ward of St. Francis Hospital in Lynwood, which referred him to Dahlia Gardens, the father said.

“The whole thing should be investigated,” said Sutton, 66, a Riverside resident. “If he was under their care, they should have taken care of him. He had too much liberty for a schizophrenic.”

On Nov. 4, Jack Lansing Moore, 47, was killed when he tried to cross Durfee Avenue to buy cigarettes, police said. Moore, also a diagnosed schizophrenic, was pronounced dead at the scene. No charges were filed in the incident.

His mother, Johanna Moore, said her son had been in group homes and hospitals most of his life. She was unsure how he had ended up at Dahlia Gardens, but said the day her son died, she had taken him new clothes and money.

“I can’t say it was the best of care,” said Moore, 78, an Azusa resident. “I would take clothes over there for Jack, and they would always disappear. . . . I don’t think they have enough help there.”

Staff officials use no exact formula to determine when to suspend or revoke a license, and have no guidelines on the number of warning conferences that are scheduled before any such action, Lopez said. In 1994, officials revoked or suspended operations at 121 of the state’s 4,497 adult care homes, or nearly 3%.

Renee Tawa is a Times staff writer. Lisa O’Neill is a community correspondent.