Pearl Inferrera had $70 to her name when she arrived at Providence St. Joseph Medical Center. At 83, she had fallen in her apartment and broken her wrist. Doctors diagnosed her with dementia and chronic anemia.
Inferrera's meager circumstances and failing health made her the archetypal client for the Public Guardian's Office, Los Angeles County's conservator of last resort.
But Inferrera's treatment over four years as a county ward shows the agency's painful decline.
The public guardian once embodied a commitment to protect elderly men and women no longer able to care for themselves. It now represents something quite different: a broken promise to these fragile adults.
Until September, when the Board of Supervisors allotted $1.1 million to expand the agency's staff, the nation's largest county had not spent a penny of its own money on its program for the elderly since 1990.
It was the only such program in Southern California -- and one of the few in the state -- abandoned in this manner by elected officials.
The agency now rejects more than four of five aged citizens referred for help. Months or even years have passed before it acts -- at least 660 seniors have died since 1998 waiting for the public guardian to decide whether to assist them.
For the comparatively few whose cases are accepted, the office's swamped staff has trouble meeting their basic needs. Seniors have had to do without eyeglasses, hearing aids and dentures. One elderly woman lost much of her small estate when the agency allowed her house to slip into foreclosure.
Three years ago, the public guardian had a waiting list of more than 300 senior citizens, each one in or near a crisis.
It is down to 15 now -- but not because more people are being served.
After The Times requested information about the backlog, the agency adopted a new policy: It started rejecting people faster.
"Can we meet the need?" said Deputy Director Christopher Fierro, the office's top administrator. "No."
Inferrera was a divorcee who lived alone in a small Burbank apartment complex before she was hospitalized.
The public guardian asked a Los Angeles County Probate Court for authority over her affairs in August 1998, saying alcoholism and increasing confusion had left her unable to return to independent living.
As Inferrera's conservator, the agency was responsible for managing her money and seeing to her daily needs.
Its performance fell short.
Although a doctor concluded that she did not need to live in a locked nursing home, court records show, the public guardian obtained court authority to put her in one anyway. The agency then moved her to a Pasadena facility where many of the patients had serious mental illnesses.
One attacked Inferrera, battering her head with a cane.
Her injuries were minor, but the incident left her traumatized, said Lorraine Woodburn, her grand-niece.
"She was like a whimpering puppy," Woodburn said. "Very sad, very frightened and very alone."
Woodburn helped Inferrera find a board-and-care home she preferred, but a year later, her new landlord sued to evict her: The public guardian hadn't paid her rent.
Fierro said the agency had done its best for Inferrera and that her unpaid rent stemmed from a holdup involving her Social Security benefits, not inattention.
But attorney Trikkia Keel, Inferrera's court-appointed lawyer, told a judge the agency had neglected her client.
"She begins to sob each time she talks about what she has been undergoing," Keel wrote.
Faced with Keel's opposition, the public guardian resigned from Inferrera's case in June 2002, replaced by a nonprofit group until her death in April.
Woodburn's eyes still well up when she recalls what her great-aunt went through.
"I wouldn't want to do that to anyone," she said, "and I wouldn't want it done to me."
A More Urgent Mission
Los Angeles County created the Public Guardian's Office in 1945 to step in when adults had no one else to care for them. Its services were to be provided free, courtesy of county taxpayers.
The agency's mission has become more urgent as the county's elderly population has expanded. Yet today, the public guardian has about 500 wards, compared with 1,200 in 1979.
Between 1998 and 2003, the agency sifted through more than 4,000 requests to take over the affairs of physically or mentally disabled adults. It accepted just 16% of them.
The public guardian's inability to meet the demand has helped fuel the rise of for-profit conservators, some of whom got their start at the agency.
Private conservators typically take on wards with sizable estates. The public guardian is often the only source of help for elderly people with little or no money.
The agency's 24-member probate staff occupies threadbare offices in the county Hall of Records, partly in a windowless, bunker-like space called "the stacks."
Until the mid-1980s, the public guardian and public administrator, the agency that manages estates of the dead, received more than $1 million a year from Los Angeles County.
The county broke them apart in 1987 to save money, folding the public guardian into the Department of Mental Health.
The probate program for the elderly and incapacitated, allocated just $200,000, dangled by a thread.
A 1988 county audit said the program desperately needed more staff, but the county's chief administrative officer, Richard Dixon, blocked the proposal, citing "severe budgetary constraints." Officials discussed killing it or having it refuse the indigent.
The county eliminated funding for the program in 1990.
Since then, agency officials have kept it alive by squeezing revenue from an array of other sources, public and private.
They also have cut costs, shedding clerical employees as well as a part-time doctor and two nurses who helped assess clients' medical needs.
Fierro, 60, who started at the agency in 1975 as an entry-level caseworker, talked about the erosion with a weary acceptance.
"I've always thought that any service is better than no service," he said.
He paused for a moment, then allowed as how, more recently, "I have questioned that."
Attorney Michael Harrison had much the same thought after a court appointed him to represent 83-year-old Tamara Arutunian.
She had been hospitalized after police found her, confused and disoriented, in a McDonald's restaurant in Santa Monica. After diagnosing her with dementia, hypertension and heart problems, the hospital transferred her to a locked nursing home.
The public guardian became her conservator in September 2003.
Arutunian had lived for decades in a rent-stabilized apartment across the street from St. Monica Church, where she had worked as a cook in the rectory.
Eager to go back home, she instructed Harrison to call her bank and make sure her rent was paid. After several conversations with her, Harrison came to believe she was well enough to live on her own. In mid-October, he asked the court to end the conservatorship.
By that time, however, a deputy public guardian had told Arutunian's apartment manager that she would not be returning.
The deputy abandoned all but a few of her belongings, deciding they were not worth the expense of storing. Her furniture, housewares and religious artwork were set out for other tenants to take, or to be hauled away.
Arutunian was crushed when she found out, said Evelyn Tummolo, who knew the elderly woman for years through the church. Arutunian had attended Mass there daily, always dressed neatly and wearing white gloves.
"When she heard that her apartment was gone, she kind of gave up," Tummolo said.
Harrison tried to get Arutunian out of the public guardian's care. Before a hearing on her case, Arutunian suffered a stroke that left her paralyzed and unable to speak. She died in March 2004.
$18 for a $5.79 Bill
The public guardian's thirst for revenue has come to shape every aspect of what it does, from which cases it takes to how it manages clients' care and finances.
The agency collects some income directly from its wards -- the comparatively few who have enough assets to pay fees.
The public guardian charges more than $70 an hour, a rate comparable to those of for-profit private conservators. In one case, the office billed a blind 86-year-old $18 to write a check for a $5.79 phone bill.
Wards are charged for the theoretical cost of taking out bonds to insure their assets, even though the agency does not actually buy such bonds -- a charge allowed by law.
The public guardian also keeps the difference between the interest rate it receives on clients' cash and the lower rate the law allows it to pass back to them.
Charles Donelon, 91, had an estate of nearly $300,000 when the public guardian took his case in 2003. In almost two years, Donelon has made less in interest ($2,309.52) than his expenses eat up in a single month ($5,708).
Unlike Donelon, most county wards have estates worth less than $2,000. The agency has had to look elsewhere to subsidize their care.
It draws fees from the state Medi-Cal program for visiting impoverished wards living in board-and-care homes. The payments came to more than $462,000 last year.
Though less than 20% of the agency's wards live in board-and-cares, they now get more than 40% of the visits.
Fierro said that the agency checks on those clients more frequently in part because their facilities provide less supervision than hospitals or nursing homes.
But he acknowledged that employees have gone out to see the same wards over and over to pack in the maximum number of visits covered by Medi-Cal. Meanwhile, some wards not eligible for the program went six months or more without visits, records show.
In 1993, at the urging of county Supervisor Mike Antonovich, the public guardian struck a deal with a network of about 25 private hospitals. The hospitals needed a way to transfer patients who were ready for discharge but could not manage on their own. The public guardian agreed to give those cases top priority in return for a fee, currently $977 per case.
Last year, the agency took two of three cases referred by private hospitals that pay fees, looking into them within a few days.
It rejected nine out of 10 cases from community senior-service groups and nursing homes, sometimes after months of delay.
Living in Squalor
The public guardian does not follow up on the elderly people it turns away. They sometimes end up living in squalid conditions, unable to clean their homes, buy food, go to the doctor or pay their bills, social workers with the county and area senior centers said.
"People say, 'Oh, well, they're old, they're going to die anyway,' " said Oleeta Igar, a former county caseworker who chairs an advisory committee of the Area Agency on Aging. "But the things we're talking about are not just part of the aging process. It's not OK for elderly people to live in filth."
In early 2004, social workers told the public guardian that Mid-City resident Easter Moon needed a conservatorship. They said the 68-year-old was unkempt and emaciated, with almost no food in her refrigerator. Her memory was impaired from alcohol abuse.
As it had twice before, the public guardian declined to take her case, records show. Asked why, Fierro said: "We did not believe the criteria for conservatorship were met." He declined to elaborate, citing privacy restrictions.
Months later, social workers found Moon sleeping on a mattress in the living room of her house, too weak to go upstairs. She had no phone service or power, they said. She was placed in a nursing home, the social workers said, speaking on condition of anonymity. Moon died in January.
A nursing home referred 80-year-old Koichi Tagami to the public guardian in April 2000, saying dementia had left him unable to manage his retirement benefits or make healthcare decisions. Months passed. The public guardian never responded, the nursing home said.
In a statement, agency officials said they did not intervene, because "Mr. Tagami's needs were apparently being met."
Tagami's nursing home later transferred him to another home where staff members could help handle his finances. But state and federal inspectors had repeatedly cited that facility for unclean conditions and substandard care.
Three months later, Tagami died of a massive infection after contracting gangrene that required doctors to amputate his right leg.
He had a circulatory ailment, peripheral arterial disease, which can lead to gangrene. Proper care usually prevents it. Because the public guardian takes so few indigent clients who do not come from fee-paying hospitals, a perception has arisen that an elderly person must have at least $100,000 in assets to get in the door.
"Quite frankly, the difference between having money and not having it matters a lot," said Elizabeth Wilson, a longtime geriatric care manager in West Los Angeles. "When there isn't any, those are the people who are really up a creek."
For years, social workers asked the public guardian to assist Betty Lubin.
A secretary at the Department of Veterans Affairs, Lubin worked for years in Washington, D.C., before transferring to the VA's Westwood office in the 1980s to live closer to her brother and his family.
By the time Lubin's health began to falter, however, most of her California relatives had died. So reclusive and tightfisted that she chose not to have a phone, she fell out of touch with the last of them, Renee Morley, a niece.
In 2000, the county's Adult Protective Services program responded to a report that Lubin, then 89, seemed confused and had lost her medical insurance after falling behind on the premiums. The agency referred her case to the public guardian.
An investigator visited Lubin and concluded that she could still feed and groom herself and was up to date on her bills.
Two years later, the public guardian received new reports that Lubin was deteriorating.
When a caseworker from a senior-care group visited her, Lubin greeted her at the door naked from the waist up. Asked to finish dressing, Lubin wandered into her bedroom, then returned in the same state. Her apartment was filthy and her vision was failing, another social worker told the public guardian.
Again, the agency did not act.
In October 2002, Lubin had hip surgery at County-USC Medical Center. The hospital asked the public guardian to assist her, concerned that she could not manage on her own.
The public guardian rarely offers assistance to people referred by county hospitals, which do not pay fees for each referral. It did not in this instance, closing Lubin's case when she agreed to move into a nursing home.
Three months later, Lubin was referred yet again. This time, she had suffered a near-fatal series of seizures. And this time, paramedics rushed her to Northridge Hospital Medical Center -- part of the fee-paying network.
The public guardian took the case. "I'm grateful they stepped in," Morley said. "I just wish she'd had someone to care for her sooner."
Visiting the Wards
When Lubin was entrusted to the public guardian, she become part of a "file" -- one of up to 90 wards overseen by a single case administrator.
Los Angeles County's administrators have long juggled the heaviest caseloads in the state.There have been persistent complaints that the crush of cases has led to lapses in both day-to-day care and financial management.
The agency has been consistently late in filing court reports showing how it has handled wards' money, often missing deadlines by a year or more. As of August, reports were overdue in 192 cases.
The agency's goal is to see clients roughly every three months, a crucial element in ensuring their well-being. In a recent performance audit, consultants said many wait far longer. At least one had not been visited in a year.
Deputy Public Guardian Anne Bell tries to make visits one day a week, leaving her house at 7:30 a.m. and packing in seven or eight stops in quick succession.
One day in September, Bell visited 83-year-old William Carpenter at a Burbank care home. Observing that his clothes were faded and worn, she helped him order more through a catalog. She checked with the nursing supervisor, who said Carpenter had been given a "lap buddy" to prevent falls from his wheelchair.
"Is there anything you need?" Bell asked Carpenter.
"Not especially," he said.
Next up was Owen Chalmers, 94, who lives at a Santa Monica nursing facility. Bell has arranged for him to have a supply of birdseed so he won't use his food to feed the birds. Sitting in a sun-washed courtyard, Chalmers complained that he can no longer walk and needed an aide to lift him from his bed.
"Do you think you might be slowing down a little bit because of your age?" Bell asked gently. "I know there are things you wish you could do, but I still think you're doing good."
Bell handles the smallest caseload among the L.A. deputies, 75 clients with larger estates. Still, one week out of four, she estimated, she gets stuck in the office and can't make visits at all.
Beyond looking after her file, she rotates regularly onto the duty desk, picking up urgent calls for other deputies who are out.
This fall, the staff struggled to care for about 200 wards left without case managers when one deputy took time off to recuperate from knee surgery and another retired without giving notice. The workload has eaten away at morale, current and former employees said. One deputy went on vacation and never returned.
Fierro said his staff often goes above and beyond for wards. When one turned 100, Bell brought her an ice cream cake and balloons, at her own expense.
At times, however, simple tasks fall through the cracks.
A B-movie actress and model in the 1940s, Phyllis Planchard always loved to dress in stylish clothes. A poetry lover, she collected the works of Robert Frost and Shelley. She cherished a 1920s maple bedroom set that once belonged to her parents.
Planchard, then 77, was placed in the public guardian's hands in May 2000 after exhibiting signs of confusion and mental decline. She owned a house in North Hollywood, but police found her living in her car. She was taken to a Burbank hospital, then discharged to a nursing home in Glendale.
After becoming her conservator, the public guardian moved her possessions to a county warehouse in Pico Rivera.
Attorney Lisa MacCarley, appointed to represent Planchard, said in court filings that she had asked that at least a few personal items, particularly clothes, be brought to the nursing home.
On photos from her acting days, Planchard wrote across the bottom: "A beautiful Phyllis loves clothes!"
But for seven months, Planchard lived in an almost bare room.
She wore used clothing -- even underwear -- donated by her care home, mostly from patients who had died.
"It's about human dignity. She was aware she had clothing and it wasn't brought to her," MacCarley said.
Planchard's nursing home complained about her treatment to professional conservator Dan Stubbs, who asked a probate court to remove the public guardian from the case.
Agency officials said an employee eventually brought Planchard some belongings and ordered her new clothes. Nonetheless, in 2001 a judge decided Planchard was better off out of the public guardian's hands. The court named Stubbs as her caretaker.
Making Do With Less
Frustration with the public guardian reached a boil in 2003.
Senior-service agencies that usually routed referrals to the office began sending them to private attorneys and conservators instead.
County officials formed a task force to air out grievances and propose ways that the agency could clarify how it chose cases.
After months of meetings, many of its members came away convinced that the probate program's inadequacies would get even worse as baby boomers moved into old age. The county's population age 60 and older is expected to double between 2000 and 2010, from 800,000 to 1.6 million.
"We have to look at what we have looming," said Yvette Townsend, the task force's co-chairwoman and a former top official at the Department of Mental Health. "If we're having problems now, imagine 10 years from now."
Driven by similar concerns, Antonovich brought a board motion last year to commission a more comprehensive examination of the program.
An audit he requested, issued in April by Blue Consulting, was grim: The public guardian's program for the elderly could not perform its basic function, it said.
Auditors blamed not only scant resources, but a lethargic culture and a top-heavy structure in which each manager supervised an average of just three employees.
Fierro took exception, saying that managers handle a lot of casework because of the thin staffing.
The $1.1 million approved by county supervisors last month will pay for 16 new employees, including eight deputies.
But county officials have offered no guarantee that the positions will be paid for beyond this fiscal year. If funding is not renewed, the public guardian could have to lay off all of those it hired come July, Fierro said.
Still, the board's action is "an acknowledgment that if we're going to take care of what is a growing part of the population, more resources will be necessary," said Marvin Southard, head of the Department of Mental Health, the public guardian's parent agency.
It came too late for Leslie Joseph Smith.
Smith, 61, was referred to the Public Guardian's Office in March 1999. A drug user who was often homeless, he had inherited his aunt's house in Watts and, with it, the prospect of a better life.
Attorney Juanita Miller, who represented Smith's cousins in the probate of his aunt's estate, said she called the guardian's office hoping it could find Smith and take care of the home.
Over the next six months, the agency tried just twice to contact Smith after finding his last known address through the Social Security Administration.
In April 1999, an investigator went to see him at the Wilshire Vista Board and Care, but left after 15 minutes when told that Smith had gone for a walk, records show. Three months later, a staff member checked back by phone, but was told Smith had moved out.
Still, that September, the agency decided to extend Smith the services it denies so many others: It went to court and asked to become his conservator, saying he was a missing person with an estate that needed protecting.
In fact, Smith was dead. He had been found face-down in an alley near skid row two weeks earlier. His body lay in the county morgue, waiting to be claimed.
Two years passed before the public guardian, making a routine inquiry at the behest of its lawyer, the county counsel, discovered that Smith had died.
"That's a little tough to swallow," Miller said. "Two Christmases had gone by. Two Easters."
In the meantime, the agency had sold the house Smith inherited and paid itself and its lawyer almost $11,000 for work done on his behalf.
Even after discovering Smith had died, the agency did not notify his relatives, Miller said.
His unclaimed remains had been burned at the county crematory, which waited for someone to collect his ashes.
No one did.
After four years, the crematory placed them in a common grave for indigents.
The gravestone is marked "2000," the year of his cremation.
Researcher Maloy Moore contributed to this report.
(BEGIN TEXT OF INFOBOX)
Little room for the needy
The Los Angeles Public Guardian's Office is the county's conservator of last resort. Once a national model, it is now the only such agency in Southern California that has received no support from county taxpayers.
Deputy public guardians in Los Angeles juggle the heaviest caseloads in the state.
Open cases: 502
Average caseload per deputy: 84
The agency rejects more than four of five aged citizens referred for help.
Cases rejected: 675
Of the cases rejected, 110 died while waiting
Cases accepted: 103
The office takes the highest percentage of its cases from an "access network" of hospitals that pay a fee for each referral.
Access network: 69% appointed
Adult Protective Services: 35%
Nursing homes/community: 10%
L.A. County-USC Hospital: 7%
Sources: Times reporting, Los Angeles County Public Guardian, Blue Consulting Report