SAN GABRIEL VALLEY / COVER STORY : Bleak Dahlia : Board-and-Care Home Had History of Citations

At the end, they left in haste.

Last week, the mentally ill residents of Dahlia Gar dens Guest Home packed up their belongings in big garbage bags as relatives and social workers hustled them off to new surroundings.

The El Monte board-and-care home had been given two days to shut its doors under a rare license suspension issued by the state. By the time Joe Chavez got there, his brother already had been moved.

Chavez was upset, partly because he didn’t know where social workers had taken his 48-year-old brother, a diagnosed schizophrenic who had lived in the home for more than a year. Partly because no one had told him about the closure; he had read about it in that morning’s newspaper. But mostly because he was suddenly learning that Dahlia Gardens was a troubled place that had racked up 78 violations of state regulations within the past year.

“I didn’t know anything about that,” said Chavez, a La Puente resident. “I would have been here a long time ago and gotten him out of here.”

Chavez’s dilemma underscores a common worry for the families of the mentally ill. Their unmanageable relatives often are referred by social workers to homes that might provide secure, healthy surroundings--or might not; the social workers are too busy to know the home’s record intimately and few members of the public know how to find out themselves. Even families who do know how to look up a home’s file with the state Department of Social Services may find some of the paperwork removed for confidentiality reasons. The public sees the bare-bones citations, which include a list of violations and dates.

In the case of Dahlia Gardens, the citations alone were formidable. Lack of adequate staff. Poorly trained personnel. Staff doing housework instead of supervising residents. Residents substituting for staff, with access to keys and client records. Failure to dispense medication. Dirty linens. Cockroaches.

But someone reading the home’s extensive file--nearly 150 violations since it opened in 1987--would not find a clue that a woman, left unsupervised three years ago, got into the home’s medicine cabinet and took a lethal overdose of drugs.

Nor would they see that a man had been slain there Feb. 8, allegedly by a fellow resident.

These and other earmarks of potential danger were revealed last week in the state’s suspension order as among the reasons why the state did not wait to go through a formal hearing process before ordering the home closed.

Dahlia Gardens owner Karl Hoffman has declined comment since the state decided to seek revocation of his license. His attorney, Doug Otto, could not be reached for comment.

But in a previous interview with The Times, Hoffman said the home had only minor violations, all of which had been corrected. Hoffman said any problems he had with the state were the result of misunderstandings on his part.

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

According to the state suspension order, Hoffman “engaged in a pattern and practice of failing or refusing to employ sufficient qualified staff to ensure the provision of adequate care and supervision to clients . . . in spite of numerous warnings and directions.”

The suspect in the beating death had been evicted from a previous home for violence, according to the state’s temporary suspension order. The order said he also had killed another person, although it gave no details about that death, and that he had spent time in a psychiatric ward during the two months before the killing after complaining of hearing voices that told him to kill. Dahlia Gardens admitted him even though “they knew or should have known that (he) presented a danger to others,” the order said.

But all the public file shows about the beating death is a citation issued Feb. 10 for lack of supervision involving “the incident on 2-8-95.”

The public records do not include “incident reports,” which homes must file in the event of an unusual occurrence, said Martha Lopez, a deputy director for the Department of Social Services. Incident reports are withheld from public files because they include confidential information, such as a client’s name and mental capacity, she said. It would take too much staff time to peruse all reports and black out confidential information, she said.

If someone requested an incident report, however, or even asked to see all of a home’s incident reports, “surely, we would honor that,” Lopez said.

But an advocate for the mentally ill criticized the state procedures, saying it should routinely make all important information available to the public.

“That’s ridiculous,” said Tilda De Wolfe, president of the San Gabriel Valley Alliance for the Mentally Ill. “No matter how hard you try, you are not going to be coming up with all the information you need. We should probably push for some cleaning up for the regulations.”

Information in the public file is adequate for family members to get a feel for a home’s record, Lopez said. But reading the public file is no substitute for visiting the home, more than once and at different times of the day, she said.

“There is quite a bit of information in there to give them clues,” she said. “The most important thing is for them to talk to the staff of the facility and to talk to residents themselves.”

Family members often get referrals on institutions from county and private social workers. But county social workers rely on the state’s judgment, said Ambrose Rodriguez, assistant director of adult services for the county Department of Mental Health. If a home is licensed, social workers figure that the state has done its homework and will place clients there, Rodriguez said.

But De Wolfe said families assume that a social worker who makes a referral thinks the home is well run--not just that it has managed to hang on to its license.

“I think it’s a shame if (social workers) don’t have more selectivity,” she said.

“When a family gets a recommendation from a social worker . . . (the social workers) are supposed to know,” said Jean Sanchez, a volunteer with the Alliance for the Mentally Ill. “I know sometimes social workers recommend places to families that they have not been to. I know that. Who is the family supposed to rely on?”

Rodriguez said that keeping tabs on board-and-care homes isn’t the social workers’ responsibility. “It’s clearly (the state’s) responsibility,” he said. “They have the statutory authority to oversee (homes). . . . It’s their responsibility to license the facility and make sure those facilities meet state standards. As long as they meet state standards . . . we are operating on the assumption that it’s OK to have patients there.”

It is possible, Rodriguez conceded, for the state to make a mistake in allowing a home to operate despite chronic problems.

“Now, what are the options for us?” he said. “One thing we probably need to do is to come back and re-examine how frequently we go to see our patients. We have to weigh that in terms of resources we have and what the demand would be.”

The county mental health department’s 60 case managers oversee 1,450 clients at 90 facilities, Rodriguez said.

With such a heavy caseload, social workers can’t read all state licensing reports, said one county social worker, who would not give his name.

He tries to visit homes regularly or get references from colleagues before advising a family. Still, it’s hard to keep up with clients once they are placed.

“You place somebody two years ago, you may not even remember placing them,” he said. “There’s no way to go in . . . and look at (state) violations. . . . There’s very little we can do on a regular basis.”

Sanchez agreed. “It’s not the social worker” who’s letting patients and families down, she said. “It’s the whole system that needs help.”

County Department of Mental Health social workers visited Dahlia Gardens weekly to check up on their seven clients, said Phyllis Key, an administrator in the department’s Arcadia office. Other social workers, for hospitals and private clinics, also check on board-and-care homes from time to time.

County social workers regularly checked Dahlia Garden’s state record but, because of time constraints, weren’t up on all of the violations, she said. Each social worker at the Arcadia office juggles 30 to 50 clients, doing everything from helping clients obtain prescriptions to making appointments for them at clinics.

“I wouldn’t say we didn’t see problems,” Key said. “We did see problems, but we were trying to work with Mr. Hoffman. We knew there were very difficult patients there.”

She declined to say if social workers will do anything differently as a result of the situation at Dahlia Gardens.

Even relatives who suspect problems hesitate to act. For instance, Hank Kroker wasn’t sure his son, Steve, a diagnosed schizophrenic, had proper supervision at Dahlia Gardens. But his 39-year-old son seemed happy.

“Sure, I worried,” said Kroker, a 77-year-old Monrovia resident whose son is now at a board-and-care home in La Puente. “But the only reason I didn’t (move him) was because he seemed to like it all right. I wouldn’t live in a place like that.”

Board-and-care homes are meant to fill a gap for mentally ill people who do not need hospital care but who cannot function independently, or whose families would be overwhelmed by the burden of responsibility.

The state does not require a specific staff-to-client ratio but says that staff must be adequate. Owners of the homes must screen potential clients and decide whether they have adequate staff to meet each resident’s needs. One of the continuing criticisms of Dahlia Gardens in state reports was that it accepted clients it was not prepared to handle.

In the past three years, three Dahlia Gardens’ residents have suffered untimely deaths. According to the suspension order, lack of care and inadequate supervision contributed to the death of two of the three residents:

* In the Feb. 8 incident, LaRay King, 34, a diagnosed schizophrenic, allegedly killed his ex-roommate, 34-year-old Leonard Sutton Jr., by sneaking up on him in the recreation room and beating him with a large rock. At the time, a housekeeper--the lone staff member on duty in charge of supervising 73 residents--was washing dishes in another building. Murder charges have been filed against King.

* On March 6, 1992, while unsupervised, 41-year-old Cynthia Sue Shepardson took a lethal amount of drugs and died. The coroner’s office ruled that Shepardson’s death was a suicide and attributed it to a combination of alcohol and drugs. The home was cited for inadequate supervision in the incident.

* In a third death, for which Dahlia Gardens was not cited, 47-year-old Jack Lansing Moore was killed on Nov. 4, 1994, when he tried to cross Durfee Avenue to buy cigarettes, police said. Moore, a diagnosed schizophrenic, was pronounced dead at the scene after being hit by three cars. No charges were filed in the incident.

Other problems cited in the state’s order:

* Violence. Eleven incidents are cited in which inadequately supervised residents assaulted other residents or staff members, destroyed property or hurt themselves. In one incident last year, a resident struck the home’s assistant manager; in another, one resident attacked another, resulting in medical treatment for both.

* Shoddy medication practices. In dozens of instances this year and last, Dahlia Gardens owners Karl and Pearl Hoffman failed to administer medication to clients and failed to prevent a client from drinking alcohol while taking his medication.

* Unsafe conditions, including a failure to provide an adequate food supply. On June 8, 1994, for instance, a licensing evaluator observed more than 30 maintenance code violations.

Last week, a Los Angeles Superior Court judge denied Hoffman’s request for a temporary restraining order halting the suspension of his license.

Meanwhile, family members with loved ones at other board-and-care homes are talking about the Dahlia Gardens case and wondering if similar situations are happening elsewhere, said De Wolfe.

“You just think, what if?” said De Wolfe, who has had a relative in board and care. “Naturally, things can happen anywhere, but when you find the one staff member (at Dahlia Gardens during the beating death) was washing dishes in another building, it just sounds very unprofessional.”

Most family members don’t know how to make the right choice, she said.

“Most people will just check it out if there’s an opening or the social worker said it was good, or (say), ‘I went there, and I guess it was all right,’ ” De Wolfe said.

Recently, during a discussion on the Dahlia Gardens case, even a board member for the alliance admitted that she didn’t know how to look up state licensing reports, De Wolfe said.

Neither did alliance volunteer Delores Encinas, the mother of twin sons who are paranoid schizophrenic and now live in federally subsidized housing.

“I know when we went to board-and-care homes years ago, we didn’t see anything suitable,” she said. “But sometimes, people don’t have many choices.”