154 facilities found
Napa State Hospital
Deaths
6
Primary service
Psychiatric
County
Napa
Psychiatric beds
1255
Facility details
Address
2100 Napa-Vallejo Highway, Napa 94558
Ownership
State
Parent Company
California Department of State Hospitals
Violations and incidents:
47 found
Year
2011
Detail
A patient who told staff he wanted to hurt himself jumped off a second-story balcony and died, according to state records. The facility failed to adequately monitor a patient with suicidal tendencies, according to a state inspection report.
Year
2009
Detail
A 30-year-old man died in the facility after hanging himself from a light fixture, according to a county coroner's report.
Year
2009
Detail
A 47-year-old patient died after he hanged himself from an air conditioning unit on hospital grounds, according to coroner's reports.
Year
2012
Detail
A patient died after hospital security officers whom he had allegedly assaulted placed him face down in handcuffs, what federal attorneys called part of “a pattern of incidents of death and serious harm over a recent 16-month period” resulting from poor use of restraints, according to coroner's reports and Times reporting.
Year
2011
Detail
Staff's poor use of restraints contributed to a patient's death, according to court documents reported on by The Times.
Year
2014
Detail
A 55-year-old patient stopped breathing and died while he was being restrained by eight staff members, according to coroner's reports.
Year
2010
Detail
A psychiatric technician who worked at the hospital was killed by a patient. The patient pleaded no contest to murder, according to Times reporting.
Year
2010
Detail
A patient attempted suicide twice in two weeks while admitted to the facility, according to state records. Staff failed to protect her from harm, investigators found.
Year
2012
Detail
A staff member punched and kicked a patient repeatedly, causing bruising on the patient's stomach, arm and penis, according to state records.
Year
2013
Detail
A staff member coerced patients into giving her money, telling them she would not offer them certain privileges unless they gave her money or gifts, according to a state investigation. When they received packages, she asked for the things inside them. She made patients buy coffee from her. Another staff member saw her sell two bags of coffee for $10 each, according to a state inspection report.
Year
2010
Detail
A longtime staff member broke his skull and several bones in his face after he was attacked by a patient, according to state records. The worker had gone on a nature walk with the patient, but never returned to the facility, the records show. In the week before the attack, the patient had assaulted another patient and another staff member, according to the records.
Year
2011
Detail
State inspectors determined that the facility's psychiatrist failed to assess a patient with a recent increase in sexually inappropriate behavior, which resulted in a sexual assault. Two female staff members entered a patient's room to check his blood pressure. The patient grabbed one of the staffers from behind and began groping her. The patient pulled down the staff member's pants as the other staff member tried to pull him off of her. The patient did not let go until numerous staffers arrived to contain him, investigators found.
Year
2010
Detail
After a patient took a swing at a staff member, the staff member put the patient in a chokehold, according to state records. A supervisor noticed the staff member was pressing his knuckles into the patient's neck and feared he would harm or kill the patient, the supervisor told state investigators. He told the staff member to stop three times, but he didn't, according to state records.
Year
2013
Detail
A staff member recorded mentally ill patients and posted videos on the internet, violating their privacy, according to state records. In one video, the staff member wakes up a patient by popping an inflated glove above his head, in what the staff member's supervisor deemed psychological abuse. The videos remained online for 32 months, during which time anyone could have viewed or copied them, according to a state investigation.
Year
2012
Detail
A patient entered another patient's room while she was sleeping and tried to choke her to death, according to state records.
Year
2013
Detail
State regulators determined that the hospital failed to establish and implement policies and procedures to ensure patients were protected from mental and physical abuse when a patient who was known to have a violent history engaged in multiple assaultive behaviors on other patients and staff without provocation.
Year
2012
Detail
A staff member and a patient had a sexual relationship, which is not allowed, according to state records.
Year
2011
Detail
Two patients got into a physical fight, with one fracturing his nose, according to state records.
Year
2009
Detail
When a patient was sexually assaulted by another patient, staff failed to report the incident to state officials, as required by law. "The client stated that she told her psychiatrist, but they never called the doctor and no one checked her. Patient 1 was visibly upset and stated she was scared to go anywhere because she might run into him," reads the state investigation. Investigators noted that the patient told them: "It was terrifying, shocking, I kept telling him no. They never told me how they would protect me."
Year
2013
Detail
A staff member hit a patient on the head with a clipboard, according to state records.
Year
2010
Detail
Two patients and a staff member were assaulted by another patient, according to state records.
Year
2010
Detail
A patient assaulted two other patients, according to state records. Staff failed to develop a behavioral plan that would limit the assaults, state investigators found.
Year
2014
Detail
The facility failed to ensure that a patient had the right to be free from sexual abuse when his roommate, who had a history of sexual assault, climbed into his bed in the middle of the night, state investigators found. The patient awoke to his roommate performing oral sex on him, according to a state report.
Year
2013
Detail
When a patient was assaulted by his roommate, staff failed to report the incident to the state as required by law, according to state investigators. Doctors who examined the patient noted that the victim's ear was bleeding and that his eardrum had possibly been ruptured, state records show.
Year
2010
Detail
A patient was struck in the head by another patient with the arm of a broken chair, according to state records. The victim's forehead was cut and he needed two stitches, records show.
Year
2011
Detail
A patient sitting in his room on his bed was attacked by another patient, according to state records. The victim was left with bruises and scrapes, records show.
Year
2011
Detail
Staff did not properly prepare two patients for becoming roommates, state investigators found. One of the roommates assaulted the other, cutting his cheek. Then the victim struck back, fracturing the other patient's nose, according to state records.
Year
2011
Detail
A patient put another patient in a choke hold and punched him several times in the face, according to state records.
Year
2013
Detail
A male patient groped a female patient, according to state records. The hospital failed to protect the female patient from harm by the male patient, who had a history of sexually aggressive behavior, state investigators found.
Year
2011
Detail
A patient repeatedly sexually harassed and assaulted another patient, according to a state investigator. The aggressor groped the victim multiple times and threatened to rape him. The victim said that the perpetrator "sat at the table in the cafeteria and verbally described plans to rape [him], discussing the bloody rectum expected as a result. [The victim] stated he found this 'very disturbing' and that he was 'terrified ... every day,'" according to a state inspection report.
Year
2012
Detail
A patient was sitting listening to music on his headphones when another patient approached him and began punching him in the face, according to state records. When the patient fell over from the blows, the aggressor started kicking him in the head. The victim required three stitches above his left eye. Four days later, the aggressor approached another patient, who was sitting on the floor. He kicked that patient several times in the face, breaking his nose, according to a state investigation of the incidents.
Year
2011
Detail
In 2011, the facility was faulted for not reporting assaults at the hospital to the state. According to facility reports, there were 580 recorded physical acts of aggression by patients toward others — mostly against other patients — in the first four months of 2011. Only 35 incidents were reported to the state Public Health Department.
Year
2013
Detail
State inspectors faulted the hospital for not ending repeated patterns of abuse, after a few patients repeatedly assaulted others. At least seven patients were attacked.
Year
2013
Detail
Staff failed to report to the state recurrent cases of lice at the facility, according to state records.
Year
2010
Detail
A patient went missing from the facility and was found and returned by law enforcement, according to state records. Staff failed to report the incident to the state health department as required. State officials found out via a TV news report.
Year
2013
Detail
A patient was sitting on her bed when she was physically assaulted by another patient, according to state records. When staff came to stop the attack, they found the victim trying to protect her head, while the aggressor held fistfuls of her hair. The victim said she had been hit 20 times, and was found with scratches on her face and a bruise on her eyelid, records show.
Year
2009
Detail
Four staff members failed to report when a female staff member had sex with a patient, which is not allowed and considered abuse, according to a state investigation.
Year
2015
Detail
While a patient was watching television, another patient began punching him in the face until he fell on the floor, according to state records. The aggressor then began kicking him in the face. The victim's jaw was broken.
Year
2011
Detail
Two patients entered another patient's room, striking him in the face with clenched fists. The victim required stitches to his eyelid.
Year
2010
Detail
The facility failed to ensure that two patients were protected from harm when two peers physically assaulted them, leaving them in need of medical treatment.
Year
2011
Detail
A staff member fell asleep while watching a patient with violent tendencies, including a history of murder, according to a state investigation.
Year
2013
Detail
The facility failed to protect five patients and potentially more by allowing patients who had assaulted others to continue to exhibit violent behavior, a state investigation found.
Year
2012
Detail
When a patient assaulted another patient and threatened to kill all of his roommates, hospital staff failed to report the incident to the state health department, as required by law, according to a state investigation.
Year
2010
Detail
The hospital failed to provide a patient with prompt medical care, according to state inspectors. A patient with eye cancer visited a doctor who told him he needed surgery as soon as possible, but staff did not schedule the surgery for four months, records show.
Year
2010
Detail
Staff did not properly monitor a patient who had been showing increasingly aggressive behavior, state investigators found. The patient then attacked another patient, causing a serious eye injury as well as rib fractures.
Year
2016
Detail
One patient struck another patient in the face, according to state investigators.
Year
2016
Detail
A patient beat up another patient, according to a state investigation.
*This facility does not accept voluntary admissions and primarily treats patients in the criminal justice system, such as those deemed incompetent to stand trial or found not guilty by reason of insanity.
Patton State Hospital
Deaths
6
Primary service
Psychiatric
County
San Bernardino
Psychiatric beds
1527
Facility details
Address
3102 E. Highland Avenue, Patton 92369
Ownership
Public
Parent Company
California Department of State Hospitals
Violations and incidents:
22 found
Year
2017
Detail
A patient was found dead in the hospital, hanging from a piece of a bedsheet, according to state records. A state investigation into the incident found that staff did not conduct rounds every 30 minutes as required, records show.
Year
2009
Detail
Staff did not properly supervise a suicidal patient, who hanged himself, according to a state investigation into the death. State investigators issued an immediate jeopardy citation, the most serious violation a hospital can receive, indicating the hospital's actions put a patient at risk of death.
Year
2011
Detail
A patient drowned in a trash can full of water when safety rounds were not conducted every 15 minutes as they were supposed to be, according to state records. Staff found the patient had filled a trash can with water and immersed his head covered with a laundry bag in the can, killing him, records show.
Year
2010
Detail
A 54-year-old patient hanged himself in his bedroom, according to Times reporting.
Year
2010
Detail
A patient with depression attempted to hang herself with her shirt and was found by staff, not breathing, according to state records. Facility staff did not monitor her properly, state investigators found.
Year
2013
Detail
A 65-year-old patient died after he was shanked, beaten and kicked by another patient, according to state records. The facility failed to keep him free from abuse, state investigators found.
Year
2012
Detail
A 55-year-old man with schizophrenia hanged himself in his bathroom, according to state records. The hospital failed to protect the patient from harm, allowing him to commit suicide, according to a state investigation.
Year
2016
Detail
Staff failed to properly supervise a patient, allowing him to escape from the facility twice in one day, according to state records. The second escape was 45 minutes after he had returned from the first.
Year
2014
Detail
When staff put a patient in restraints, they covered the patient's face with a sheet, which "had the potential for Patient A to cease breathing and for possible death," according to a state investigation into the incident.
Year
2014
Detail
A staff member pulled a pink slipper away from a patient and smacked her on the head with it twice, according to state records.
Year
2009
Detail
When a patient asked a staff member for a piece of the staff's food, the staff member said no, and the patient, who had dementia, reached out to grab the food, state records show. The staff member then forcefully shoved the patient in the chest, and, using profanity, said, "Don't touch my ... food," state records show.
Year
2010
Detail
A patient on close watch for self-harming behaviors was able to ingest two batteries from a television remote control, according to state records. State investigators determined that the facility failed to properly monitor the patient, who had to undergo a surgical procedure to remove the batteries from her stomach, records show.
Year
2011
Detail
A patient with a history of self-harming behavior who was supposed to be on 1:1 observation, meaning a staff member was supposed to be within an arm's reach of him at all times, inserted a pen into his penis twice.
Year
2009
Detail
A patient swallowed two batteries, according to state records.
Year
2011
Detail
A patient with a history of self-harming behavior who was supposed to be on 1:1 observation, meaning a staff member was supposed to be within an arm's reach of her at all times, swallowed a pen and a key.
Year
2012
Detail
A staff member smiled while watching a patient be put into five-point restraints and then flicked the patient on the nose, according to state records. State investigators determined the hospital failed to protect the patient's dignity, according to state records.
Year
2012
Detail
A patient said she overheard staff members saying she was hurting herself because she was just seeking attention, according to state records. Afterward, she cut her arm and was found bleeding in the bathroom stall, the records show.
Year
2010
Detail
A staff member was assigned to continuously monitor a patient who had hurt his head by banging it against a wall, yet the facility failed to stop him from injuring his head further, according to state records.
Year
2012
Detail
While a patient was on 1:1 supervision, meaning someone was supposed to be watching her at all times, she took a paper cup out of her locker, ripped off a piece of it and used it to cut the inner part of her arm, according to state records. She required three stitches to close the gash.
Year
2012
Detail
Two patients were injured when another patient attacked them, according to state records.
Year
2013
Detail
A patient was able to use a plastic knife to cut herself, according to state records.
Year
2011
Detail
A patient filled a sock with four batteries and repeatedly hit another patient with it, according to state records. The physical altercation between the two patients left both of them injured in several places, records show.
*This facility does not accept voluntary admissions and primarily treats patients in the criminal justice system, such as those deemed incompetent to stand trial or found not guilty by reason of insanity.
Metropolitan State Hospital
Deaths
4
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
826
Facility details
Address
11401 Bloomfield Avenue, Norwalk 90650
Ownership
Public
Parent Company
California Department of State Hospitals
Violations and incidents:
37 found
Year
2012
Detail
A patient, a former kindergarten teacher, died after she broke her neck in the hospital while she was supposed to be constantly monitored, according to L.A. Times reporting. The patient fell off her bed and seriously injured herself, yet the hospital delayed treatment for several hours, records show.
Year
2015
Detail
A 28-year-old woman died by suicide while at the hospital, according to coroner's records.
Year
2014
Detail
A 45-year-old patient with a history of bipolar disorder died of a drug overdose, according to coroner's records.
Year
2010
Detail
Hospital staff reported to the state that a patient had died by suicide or attempted suicide, according to state records. State investigators could not find evidence of hospital wrongdoing, according to the records.
Year
2010
Detail
Hospital staff reported to the state that a patient had died by suicide or attempted suicide, according to state records. State investigators did not find that the hospital was at fault, records show.
Year
2012
Detail
An 18-year-old patient was in her room reading when a male staff member entered the room and raped her, according to state records. State investigators determined the facility had not protected her from harm.
Year
2009 through 2018
Detail
On at least 41 occasions, patients injured themselves while at the facility, in what state investigators deemed the facility's fault.
Year
2009 through 2018
Detail
At least 12 patients escaped the facility in what state investigators deemed a lack of oversight.
Year
2009 through 2018
Detail
On at least 50 occasions, patients swallowed objects, such as glass and pens, that could have harmed them, according to state records. State investigators found the facility failed to protect patients from harm.
Year
2016
Detail
A patient was abused by a staff member, according to state records. State investigators found the facility had failed to protect the patient from the abuse.
Year
2016
Detail
A staff member punched a patient in the face, knocking out two of his teeth, according to state records.
Year
2017
Detail
A physician took photos of a patient's breasts and groin on his personal cellphone during a medical exam, according to state records.
Year
2009
Detail
A patient raped another patient, according to state records. State investigators determined that the facility had failed to protect the victim from harm.
Year
2013
Detail
A staff member punched a patient in the head twice, according to state records.
Year
2012
Detail
A patient assaulted another patient, damaging his face and eye and giving him a concussion, according to state records. State investigators determined the facility failed to protect the victim from harm.
Year
2011
Detail
A patient was attacked by a group of patients while defenseless and in five-point restraints, according to state records. His jaw was broken. State investigators determined the facility did not properly protect the victim.
Year
2011
Detail
A patient was attacked by another patient, requiring 16 stitches to reattach his ear, according to state records. State investigators found the facility did not properly protect patients from harm.
Year
2013
Detail
A male patient sexually assaulted a female patient, after the male patient had been asking staff to be moved to an all-male area because he was having urges to touch women, according to state records. State investigators determined the facility did not handle the situation properly.
Year
2010
Detail
A patient was struck three times in the face within five weeks, breaking his nose in multiple places. State investigators determined the facility failed to ensure that the patient was free from harm.
Year
2013
Detail
A 61-year-old patient was repeatedly assaulted and on one occasion, broke her nose and had to go to the hospital for treatment, according to state records. State investigators found the facility failed to protect her from harm.
Year
2009
Detail
A patient said she was raped by another patient, according to state records. State investigators said the facility did not properly monitor patients.
Year
2012
Detail
A patient said she was raped by another patient, according to state records. State investigators said the facility did not properly monitor patients.
Year
2013
Detail
One patient assaulted several others, requiring them to go to the hospital for head trauma, according to state records. The facility failed to protect its patients, according to state investigators.
Year
2009
Detail
A patient inserted a staple into his wrist, and three months later, an appointment still had not been made for a doctor to remove it, according to state records.
Year
2011
Detail
A patient cut herself with broken glass and required 43 stiches, according to state records. The facility did not properly monitor her, according to state investigators.
Year
2014
Detail
A patient hit another patient, requiring 16 stitches near his eye, according to state records. The facility failed to protect the patient from harm, according to state investigators.
Year
2012
Detail
One patient assaulted another, breaking his nose, according to state records. State investigators determined that the facility did not properly protect him from harm.
Year
2010
Detail
A patient assaulted another, knocking him unconscious, according to state records. State investigators determined that the facility did not properly protect him from harm.
Year
2011
Detail
A patient was assaulted by another patient, according to state records. State investigators deemed that the facility failed in its duties.
Year
2010
Detail
A patient attacked three other patients, according to state records.
Year
2011
Detail
A patient attacked another patient, breaking his ankle, according to state records.
Year
2013
Detail
The hospital's dishwasher broke, but staff continued to use it and served meals on contaminated dishes. State investigators issued an immediate jeopardy citation, the most severe violation a hospital can receive, indicating the facility's actions put patients at risk of serious harm or death.
Year
2010
Detail
A patient had a swollen eye after another patient hit him, according to state records.
Year
2011
Detail
A patient punched and kicked another patient, requiring stitches to his nose, according to state records.
Year
2013
Detail
A patient was beaten by another patient, breaking his eye socket, nose and upper jaw, according to state records.
Year
2014
Detail
A female patient was raped by another patient, according to state records.
Year
2019
Detail
Staff failed to follow protocol when taking a patient to a scheduled court hearing, allowing the patient to escape, according to state records.
*This facility does not accept voluntary admissions and primarily treats patients in the criminal justice system, such as those deemed incompetent to stand trial or found not guilty by reason of insanity.
College Hospital
Deaths
3
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
187
Facility details
Address
10802 College Place, Cerritos 90703
Ownership
Private
Parent Company
College Health Enterprises
Violations and incidents:
11 found
Year
2012
Detail
A 17-year-old admitted to the facility because she was suicidal hanged herself with a shower hose after staff left her unattended. State investigators determined the facility failed to protect the patient and invoked an immediate jeopardy citation, the most serious violation a hospital can receive. The hospital was fined $50,000.
Year
2012
Detail
A patient who was suicidal and ordered to be checked on every five minutes was left alone and hanged himself in the shower, according to state records. The patient survived, but state investigators determined that the facility had failed to protect him from harm and issued an immediate jeopardy citation, the most serious violation a hospital can receive. The hospital was fined $75,000.
Year
2015
Detail
Hospital staff reported to the state that a patient had died by suicide or attempted suicide. State investigators determined the facility was not at fault, according to state records.
Year
2018
Detail
A patient died after he smuggled in a rope and used it to hang himself, according to state records.
Year
2012
Detail
A 51-year-old man died of a fentanyl overdose 10 days after being admitted to the facility, according to county coroner records.
Year
2016
Detail
Hospital staff did not properly document that a patient was experiencing heart problems when the patient was admitted to the facility from an emergency room, a failure that ended with the patient being sent again to the emergency room in cardiac arrest, according to state records.
Year
2015
Detail
An employee punched a patient in the chest, according to state records. State investigators determined that the hospital failed to protect the patient from harm.
Year
2013
Detail
Patients who alleged sexual assault were sent to the hospital, where doctors found scratches and injuries on their bodies indicating sexual assault, according to state records. Yet the facility failed to investigate these incidents, potentially harming other patients, state investigators found. The state issued the hospital an immediate jeopardy citation, the most serious violation a hospital can receive.
Year
2016
Detail
A patient was sexually assaulted by another patient in an incident that state investigators determined resulted from the facility's failure to protect the victim, according to state records.
Year
2018
Detail
Staff did not properly cool and store leftover rice, possibly spreading foodborne illness to patients, according to state records. State investigators issued an immediate jeopardy citation because the hospital had put patients at risk of serious harm or death, according to the records.
Year
2019
Detail
A patient was punched in the abdomen by a staff member, whom the hospital then fired, according to state records.
Del Amo Hospital
Deaths
3
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
166
Facility details
Address
23700 Camino Del Sol, Torrance 90505
Ownership
Private
Parent Company
Universal Health Services
Violations and incidents:
5 found
Year
2009
Detail
The day after a 49-year-old man was admitted to the hospital for suicide attempts, he hanged himself with a sheet, according to coroner's records.
Year
2014
Detail
Hospital staff did not gather a medical history for a patient, allowing the patient to die of a seizure, according to a state investigation. State investigators issued an immediate jeopardy citation, the most serious violation a hospital can receive, indicating the hospital had put a patient at risk of serious harm or death.
Year
2018
Detail
An employee skipped a patient's 15-minute check, and the patient died. The facility fired the employee, according to state records.
Year
2017
Detail
The facility failed to report and investigate when a patient, who was a child, said he was sexually assaulted by another patient, according to state records.
Year
2019
Detail
A suicidal patient was able to escape the facility when a staff member left an exit door unlocked, according to a state report.
Telecare Riverside County Psychiatric Health Facility
Deaths
3
Primary service
Psychiatric
County
Riverside
Psychiatric beds
16
Facility details
Address
47-915 Oasis Street, Indio 92201
Ownership
Private
Parent Company
Telecare
Violations and incidents:
3 found
Year
2019
Detail
A patient admitted to the facility died. State investigators found that the facility had not complied with all regulations, according to state records.
Year
2018
Detail
A patient admitted to the facility died. State inspectors investigating the death found that the facility had failed to follow all regulations, according to state records.
Year
2016
Detail
A patient admitted to the facility died. State inspectors investigating the death found that the facility had failed to follow all regulations, according to state records.
Aurora Las Encinas Hospital
Deaths
2
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
118
Facility details
Address
2900 East Del Mar Boulevard, Pasadena 91107
Ownership
Private
Parent Company
Signature Healthcare Services, LLC
Violations and incidents:
17 found
Year
2013
Detail
Staff did not properly monitor a patient who was on a 15-minute watch and the patient hanged himself, according to state records. Staff had left him unmonitored from 6:30 p.m. to 7:35 p.m., when they found him dead, according to a state investigation into the incident. State investigators issued an immediate jeopardy citation, which is given to hospitals that have seriously threatened the safety of patients. It is the most serious violation a hospital can receive.
Year
2018
Detail
A patient died after staff restrained him and pushed him to the ground, stopping his breathing, according to state records. Staff had not been trained in how to hold a patient on the ground, according to state records.
Year
2009
Detail
A patient tried to hang herself by using the strings on a hospital gown. Staff had given the patient the gown in error, according to state records.
Year
2013
Detail
Hospital staff reported to the state that a patient had died by suicide or attempted suicide. State investigators did not find the facility at fault, according to state records.
Year
2009
Detail
The hospital failed to protect a patient and she was found in the bathroom cutting her forearm with a piece of broken metal, according to a state investigation into the incident. "The patient required the structure of the hospital setting in order to ensure her safety," but the facility failed to ensure her safety, the investigators determined.
Year
2018
Detail
A patient wrongly discharged from the facility early went home and attacked a family member and was shot and killed by the police, according to state records.
Year
2011
Detail
A staff member sent sexually explicit text messages to a patient, including graphic photos and an offer to perform oral sex, according to state records. The facility failed to protect the patient from abuse, according to state investigators.
Year
2019
Detail
Hospital staff did not administer a patient's seizure medication correctly, resulting in the patient having two seizures, according to state investigators.
Year
2018
Detail
A patient alleged that he was injured by staff when they restrained him on the floor and that they kicked him and broke a blood vessel in his eye, according to state records. The facility never reported the abuse, violating the law, according to state investigators.
Year
2018
Detail
A staff member dated a patient, though relationships between staff and patients are considered abuse, according to a state investigation. Another patient admitted at the same time reported to the state health department that "it was not a secret that they fooled around on facility grounds," according to a state report.
Year
2018
Detail
A patient reported to her therapist that she was sleeping with a staff member, according to state records. The facility failed to protect patients from such relationships, which are considered abuse, according to a state investigation.
Year
2016
Detail
A transgender female patient asked to be treated and body-searched by a female mental health worker, but her request was denied, according to state records. The facility did not ensure the patient was free from discrimination, state investigators determined.
Year
2018
Detail
A patient was kept 10 hours after her involuntarily hold had expired, according to state records.
Year
2012
Detail
A male patient with a history of violence walked up to a fellow patient who was eating lunch and hit him in the face, resulting in the victim having to get stitches, according to state records. The now-defunct Department of Mental Health determined that the hospital didn’t provide adequate supervision. It wasn’t until the next day, when he punched a social worker, that the hospital provided one-on-one supervision, according to state records.
Year
2010
Detail
Two patients got into a fight, with one patient suffering a cut on his cheek and fracturing his eye socket, according to state records. The facility failed to report the incident to the state in a timely manner, according to state investigators.
Year
2009
Detail
A patient on suicide watch swallowed batteries and glass and had to go to the emergency room, according to state records.
Year
2019
Detail
A mental health worker pushed a patient against a wall, kicked her and pulled her hair, according to state records.
Aurora San Diego
Deaths
2
Primary service
Psychiatric
County
San Diego
Psychiatric beds
80
Facility details
Address
11878 Avenue Of Industry, San Diego 92128
Ownership
Private
Parent Company
Signature Healthcare Services, LLC
Violations and incidents:
3 found
Year
2010
Detail
Staff did not properly monitor a 27-year-old patient, who left the facility and then died, according to a state investigation. The patient was hit by a car when she ran into the road, according to state records. State investigators issued an immediate jeopardy citation, the most serious penalty that can be issued to a hospital, and fined the hospital.
Year
2012
Detail
A 13-year-old mental health patient hanged herself using a bed sheet, according to state records. A state investigation into the incident found that staff had been required to check on the girl every 15 minutes, but did not. After 40 minutes of not monitoring her, staff found her dead, records show. State investigators issued an immediate jeopardy citation to the hospital and fined it $75,000.
Year
2014
Detail
A patient alleged that another patient sexually assaulted her, but staff did not report the incident as required by law, according to state records.
Community Behavioral Health Center
Deaths
2
Primary service
Psychiatric
County
Fresno
Psychiatric beds
61
Facility details
Address
7171 North Cedar Avenue, Fresno 93720
Ownership
Non-Profit Corporation
Parent Company
Fresno Community Hospital and Medical Center
Violations and incidents:
2 found
Year
2014
Detail
A woman admitted to the facility for suicidal thoughts hanged herself in the bathroom, dying one day after admission, according to a lawsuit filed against the hospital by the family.
Year
2013
Detail
A 67-year-old patient was attacked by a male patient, who grabbed her by the neck, punched her and kicked her in the back. The patient broke her back and died less than two weeks later, according to court documents. A state investigation found the hospital failed to protect the woman from harm. The patient's family sued the facility and settled with them, according to court records.
Community Hospital Of San Bernardino
Deaths
2
Primary service
General Medical
County
San Bernardino
Psychiatric beds
74
Facility details
Address
1805 Medical Center Drive, San Bernardino 92411
Ownership
Non-Profit Corporation
Parent Company
Dignity Health
Violations and incidents:
2 found
Year
2017
Detail
A mental health patient died after he hanged himself with a bedsheet at the facility, according to state records. A state investigation into the incident determined that a mental health worker did not check on him as often as staff were supposed to. Plus, though the patient had tried to slice his wrists with a toothpaste cap a few days earlier, the psychiatrist failed to recommend continuous observation for the patient, according to state investigators. "This failure resulted in the cause of death," for the patient, reads the state investigation report.
Year
2014
Detail
Staff did not check on a suicidal patient who was supposed to be checked on every 15 minutes and the patient died, according to state records. An investigation into the incident found that staff falsified records showing they had checked on the patient every 15 minutes, records show. Video surveillance showed that staff had not entered the patient's room for nearly five hours. State investigators issued an immediate jeopardy citation, the most serious violation a hospital can receive, indicating that the hospital's actions caused serious harm or death of a patient.
La Casa Psychiatric Health Facility
Deaths
2
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
206
Facility details
Address
6060 Paramount Blvd., Long Beach 90805
Ownership
Private
Parent Company
Telecare
Violations and incidents:
3 found
Year
2012
Detail
A 22-year-old admitted to the facility for suicidal thoughts hanged himself with a scarf, according to coroner's records.
Year
2014
Detail
A 24-year-old died after he suffocated himself with a plastic bag, according to coroner's records. Staff tried to resuscitate him, but failed, records show.
Year
2013
Detail
A patient died while admitted to the facility, according to records from the California Department of Social Services. A state investigation found that the facility had properly handled the patient's care, records show.
Loma Linda University Behavioral Medicine Center
Deaths
2
Primary service
Psychiatric
County
San Bernardino
Psychiatric beds
89
Facility details
Address
1710 Barton Road, Redlands 92373
Ownership
Non-Profit Corporation
Parent Company
Loma Linda University Behavioral Medicine Center
Violations and incidents:
3 found
Year
2011
Detail
A mental health patient died after hospital staff failed to do proper checks on the patient, according to a state investigation into the death.
Year
2017
Detail
A patient died after hospital staff failed to do required 15-minute checks, according to a state investigation into the death.
Year
2010
Detail
A staff member hit a patient on the side of the face, according to state records.
Mission Hospital Laguna Beach
Deaths
2
Primary service
General Medical
County
Orange
Psychiatric beds
36
Facility details
Address
31872 Coast Highway, Laguna Beach 92651
Ownership
Non-Profit Corporation
Parent Company
MISSION HOSPITAL REGIONAL MEDICAL CENTER
Violations and incidents:
4 found
Year
2018
Detail
A 23-year-old man who arrived at the hospital and was diagnosed with a mental illness hanged himself with a sheet, according to coroner's records.
Year
2009
Detail
A 51-year-old man brought to the hospital as a psychiatric patient hanged himself in his room in the emergency ward, according to coroner's records.
Year
2018
Detail
A patient in the hospital's behavioral health unit who said he wanted to kill himself was found trying to hang himself in the hospital bathroom, after hospital staff failed to properly monitor him, according to a state investigation into the incident. The patient had been admitted to the hospital two days prior because he was a danger to himself, records show.
Year
2018
Detail
A patient who doctors agreed needed to be admitted to the inpatient psychiatry unit was kept in the emergency room for 10 days despite psychiatric beds being available, according to state records. Hospital administrators told state investigators that the hospital could not admit the patient because it did not accept Medi-Cal, but the hospital did accept Medi-Cal patients, according to a state investigation into the incident.
Northridge Hospital Medical Center
Deaths
2
Primary service
General Medical
County
Los Angeles
Psychiatric beds
40
Facility details
Address
18300 Roscoe Boulevard, Northridge 91325
Ownership
Non-Profit Corporation
Parent Company
Dignity Health
Violations and incidents:
2 found
Year
2010
Detail
A patient who arrived in the hospital's emergency room and said she was thinking of killing herself was assigned a staff member to observe her at all times, according to state records. However, the patient managed to escape and jumped off a parking structure and died, according to state records.
Year
2018
Detail
State inspectors found that when a patient became unstable, staff in the psychiatric unit did not respond quickly enough. Resuscitation efforts failed and the patient died.
Palomar Medical Center -- Downtown Escondido
Deaths
2
Primary service
Physical Rehabilitation
County
San Diego
Psychiatric beds
25
Facility details
Address
555 E. Valley Parkway, Escondido 92025
Ownership
Public
Parent Company
Palomar Health
Violations and incidents:
2 found
Year
2017
Detail
A 31-year-old patient hanged himself in the psychiatric unit of the hospital, according to coroner's records.
Year
2012
Detail
A patient with a history of suicide attempts admitted to the facility hanged herself in the bathroom using her hospital gown, according to state records. A state investigation found that hospital staff were supposed to monitor her every 15 minutes, but those check-ins were not shown in the hospital logs, according to state records.
Santa Barbara Psychiatric Health Facility
Deaths
2
Primary service
Psychiatric
County
Santa Barbara
Psychiatric beds
16
Facility details
Address
315 Camino Del Remedio, Santa Barbara 93110
Ownership
Public
Parent Company
Santa Barbara County
Violations and incidents:
4 found
Year
2010
Detail
A patient died after being placed in five-point leather restraints without justification, according to a state investigation into the death.
Year
2016
Detail
A mental health patient died while admitted to the facility. State inspectors who investigated the incident found that the facility did not have a proper protocol for monitoring and evaluating patient care.
Year
2012
Detail
State investigators determined that the facility failed to protect two patients when they had sex while admitted to the facility, which could be considered a form of abuse. "The fact of their involuntary admission to the facility on such grounds would argue against their action being considered to be consensual. Such impaired individuals could lack proper judgment for their actions and their involvement in sexual activities after being committed to a locked psychiatric facility while mentally unstable could be viewed as abuse," reads a state report.
Year
2011
Detail
State investigators issued an immediate jeopardy citation, the most serious violation a hospital can receive, after they discovered the hospital had no record of testing its fire alarm system.
Sharp Mesa Vista Hospital
Deaths
2
Primary service
Psychiatric
County
San Diego
Psychiatric beds
159
Facility details
Address
7850 Vista Hill Avenue, San Diego 92123
Ownership
Non-Profit Corporation
Parent Company
Sharp HealthCare
Violations and incidents:
5 found
Year
2015
Detail
A 15-year-old admitted for depression and attempts to harm himself hanged himself with a bed sheet and a pillowcase, according to coroner's reports.
Year
2009
Detail
A 21-year-old woman admitted for depression and an overdose attempt hanged herself with a bed sheet 12 hours after being admitted to the facility, according to coroner's records.
Year
2014
Detail
An employee was convicted of sexual assault for abusing a 20-year-old mental health patient who was admitted to the facility because she was a danger to herself, according to state records.
Year
2011
Detail
A paramedic reported that he saw a staff member grab a patient by the neck so his legs were dangling above the ground, and then slammed him to the floor, state records show.
Year
2015
Detail
In a 2015 survey, federal inspectors noted that despite the hospital identifying several bathroom faucets as locations where patients could hang themselves, the hospital had not yet replaced the faucets. "As a result, patients admitted with suicidal tendencies were potentially at risk for a serious suicide attempt," reads the report.
L.A. Downtown Medical Center
Deaths
2
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
147
Facility details
Address
1711 West Temple Street / 7500 East Hellman
Avenue, Los Angeles / Rosemead 90026 / 91770
Ownership
Private
Parent Company
SUCCESS HEALTHCARE 1 LLC
Violations and incidents:
6 found
Year
2012
Detail
A 25-year-old man who had been involuntarily admitted to the hospital because he was having suicidal thoughts hanged himself in his room, according to coroner's records. Staff were supposed to check on him every 15 minutes, records show.
Year
2009
Detail
A patient admitted to the hospital for psychiatric illness was not closely monitored, allowing him to pull one of his eyeballs out of its socket, according to state records. While the patient remained at the hospital for medical care, staff failed to protect him from further self-injurious behavior, according to state investigators. The state issued an immediate jeopardy citation, the most serious violation issued to hospitals, indicating the facility had put the patient at risk of death or serious harm.
Year
2011
Detail
Staff did not properly supervise patients, allowing a male patient to sexually assault a female patient, state investigators found. Staff found the man on top of the woman, touching her breasts and placing his penis on her face, according to state records. After the incident, the patient remained anxious, nervous and depressed, and felt traumatized. The state issued an immediate jeopardy citation, the most serious deficiency that can be issued to a hospital, and fined the hospital $50,000.
Year
2010
Detail
Staff did not properly respond when a patient complained of chest pain and did not call a doctor, according to a state investigation. The patient died.
Year
2018
Detail
The Los Angeles city attorney ordered that the hospital pay $550,000 for dumping mentally ill homeless patients at train stations and on the street.
Year
2018
Detail
The hospital fired a nurse after he acted inappropriately with patients, according to state records. The nurse slapped one patient, held his hands down and elbowed him in the face. The nurse slapped another patient on the side of the head and told her to shut up.
Telecare Placer County Psychiatric Health Facility
Deaths
2
Primary service
Psychiatric
County
Placer
Psychiatric beds
16
Facility details
Address
101 Cirby Hills Drive, Roseville 95678
Ownership
Private
Parent Company
Telecare
Violations and incidents:
2 found
Year
2014
Detail
A patient admitted to the facility died while there and state inspectors determined the facility had failed to protect the patient from harm, according to state records.
Year
2013
Detail
A 56-year-old woman admitted to the facility after overdosing in a suicide attempt died shortly after arriving there, according to coroner's records.
Uc San Diego Medical Center -- Hillcrest
Deaths
2
Primary service
General Medical
County
San Diego
Psychiatric beds
32
Facility details
Address
200 West Arbor Drive, San Diego 92103
Ownership
University Of California
Parent Company
The Regents of the University of California
Violations and incidents:
4 found
Year
2011
Detail
An elderly woman admitted to the emergency room because of a suicide attempt was neither assessed nor monitored properly by staff and hanged herself, according to a state investigation into the death.
Year
2012
Detail
A patient with a history of schizophrenia and depression who came to the hospital due to an apparent overdose attempt was able to escape staff watch and consume a bottle of hand sanitizer that he found in the hospital, according to state records. He was discovered in a hospital bathroom and died shortly after, records show.
Year
2013
Detail
A security guard punched two patients in the face who were having psychiatric problems, according to state records. The incident was not reported to hospital leadership and the security guard continued to work there, potentially endangering other patients, state investigators found.
Year
2014
Detail
A patient admitted to the hospital for a suicide attempt went missing because staff did not properly watch him, according to state records.
Adventist Health Glendale
Deaths
1
Primary service
General Medical
County
Los Angeles
Psychiatric beds
60
Facility details
Address
1509 Wilson Terrace, Glendale 91206
Ownership
Non-Profit Corporation
Parent Company
Adventist Health
Violations and incidents:
1 found
Year
2012
Detail
A 57-year-old man who checked himself into the hospital for suicidal thoughts escaped from his room, jumped off the hospital's roof and died, according to coroner's records.
Adventist Health St. Helena
Deaths
1
Primary service
General Medical
County
Napa
Psychiatric beds
37
Facility details
Address
10 Woodland Road, St. Helena 94574
Ownership
Non-Profit Corporation
Parent Company
Adventist Health
Violations and incidents:
2 found
Year
2019
Detail
A psychiatric patient admitted to the hospital because he was a danger to himself hanged himself in his bathroom. State investigators determined staff did not check on the patient frequently enough or take away materials that the patient had told them he wanted to use to kill himself. State officials issued an immediate jeopardy citation, the most severe violation that can be issued to a hospital.
Year
2012
Detail
A suicidal patient was allowed to escape from the psychiatric unit and jumped from a height onto a concrete patio in a suicide attempt, sustaining very severe injuries, according to a state report. State investigators found that hospital staff had not been trained in how to properly secure the mental health unit and issued an immediate jeopardy citation, the most serious penalty a hospital an receive, and fined the hospital $50,000.
Adventist Health Vallejo
Deaths
1
Primary service
Psychiatric
County
Solano
Psychiatric beds
61
Facility details
Address
525 Oregon Street, Vallejo 94590
Ownership
Non-Profit Corporation
Parent Company
Adventist Health
Violations and incidents:
4 found
Year
2009
Detail
A psychiatric patient escaped from the facility, was hit by a bus and severely injured, ending up in a coma, according to state records. State investigators determined that the facility did not properly supervise the patient.
Year
2013
Detail
A staff member punched an elderly patient admitted for a psychiatric illness, resulting in the patient vomiting, losing bowel and bladder control, getting a cut on his forehead as well as some bruising, according to state records.
Year
2018
Detail
After a patient became aggressive toward staff, a mental health technician pushed the patient to the floor, causing the patient to fracture several ribs, according to state records.
Year
2010
Detail
The hospital did not have a proper procedure in place for making sure patients were not administered medicines to which they were allergic, according to state records. State investigators issued an immediate jeopardy citation, the most serious violation a hospital can receive.
Alvarado Parkway Institute
Deaths
1
Primary service
Psychiatric
County
San Diego
Psychiatric beds
66
Facility details
Address
7050 Parkway Drive, La Mesa 91942
Ownership
Private
Parent Company
BH-SD OPCo, LLC
Violations and incidents:
4 found
Year
2018
Detail
A 53-year-old patient admitted to the facility after threatening to kill himself hanged himself, according to county coroner's records.
Year
2011
Detail
The facility reported to the state that a patient had disappeared for at least four hours and the disappearance had led to either serious disability or death, according to state records. State investigators did not find the facilty was at fault, according to state records.
Year
2017
Detail
A patient admitted because she was a danger to herself managed to leave the hospital without staff noticing and did not return for three days, according to state records. State investigators determined that the facility failed to properly monitor the patient, records show.
Year
2017
Detail
Staff did not properly monitor a psychiatric patient, allowing him to remove a fire extinguisher, spray the guards with it and endanger other patients, state records show.
Arrowhead Regional Medical Center
Deaths
1
Primary service
General Medical
County
San Bernardino
Psychiatric beds
90
Facility details
Address
400 N. Pepper Avenue, Colton 92324
Ownership
Public
Parent Company
County of San Bernardino
Violations and incidents:
6 found
Year
2015
Detail
A patient who came into the emergency room because he had been hearing voices was admitted to the inpatient psychiatric unit, but was not checked on for seven hours and died, according to state records. "This failure created the potential to have contributed to the death of a patient," reads a report by state investigators, who issued an immediate jeopardy citation, the most serious penalty a hospital can receive for misconduct.
Year
2018
Detail
A staff member made sexual advances toward a patient in the psychiatric ward, asking the patient to show him his body while in the bathroom, according to state records. In an interview with state investigators, the patient said that he and the staff member proceeded to kiss, records show. Inspectors reviewed a video that showed the staff member caressing the patient's body, records show. The patient chose to not press charges against the staff member. State investigators found that the facility failed to protect the patient from abuse.
Year
2009
Detail
A staff member threw a cup of water in a patient's face, according to a state report. Another staff member heard the staffer say, "Now how do you like it?" according to a state report.
Year
2010
Detail
Facility staff failed to investigate or report to the proper authorities when a psychiatric patient had extensive bruising all over her body, a state report found. "These failure had the potential to cause the patient to suffer abuse, other physical and emotional trauma, including death," the report reads.
Year
2009
Detail
A nurse slapped a 15-year-old patient admitted for bipolar disorder, according to state records.
Year
2011
Detail
A patient was able to attempt suicide while admitted to the facility despite the fact that she was supposed to be continuously watched by staff, according to a state report. The patient had been admitted to the facility for trying to kill herself by taking a large number of pills, and, while admitted, ingested a large number of pills again, records show.
Atascadero State Hospital
Deaths
1
Primary service
Psychiatric
County
San Luis Obispo
Psychiatric beds
1184
Facility details
Address
10333 El Camino Real, Atascadero 93422
Ownership
Public
Parent Company
California Department of State Hospitals
Violations and incidents:
12 found
Year
2014
Detail
A 53-year-old patient died after his roommate strangled him, according to coroner's records. The killer was convicted of first-degree murder.
Year
2014
Detail
A patient had multiple seizures and fell, fracturing his hip. But he did not get X-rays for days, delaying a necessary surgery to fix his hip, according to a state investigation. While his hip was broken, he developed a dangerous medical condition that could have killed him.
Year
2011
Detail
A violent patient attacked another patient after staff failed to develop a proper care plan for the patient with violent tendencies, according to a state investigation into the attack. The victim's hip and several ribs were broken, state records show.
Year
2009
Detail
A patient was hit by another patient, splitting open his lip, according to state records. The staff failed to develop a care plan to attend to the patient's injuries, state investigators found.
Year
2010
Detail
A patient broke another patient's ankle, according to state records. The facility failed to ensure the victim was free from harm, state investigators found.
Year
2010
Detail
Hospital staff did not take proper precautions to deal with a violent patient and the patient assaulted another, breaking his hip and ribs, according to a state investigation.
Year
2014
Detail
A 51-year-old man was severely injured when another patient violently attacked him, stomping on and kicking him, according to state records. The victim fractured his shoulder blade, ankle and leg, records show.
Year
2010
Detail
The facility's failure to properly monitor patients resulted in one of them being attacked by another, according to state investigators. The victim was kicked in the head.
Year
2010
Detail
A patient rolled his wheelchair into the dayroom and struck another patient in the face, creating a big cut near his eye that required nine stitches to close, according to state records.
Year
2010
Detail
Staff did not follow the policy barring patients from entering each other's rooms, which led to a patient assaulting another, according to state records.
Year
2010
Detail
The facility failed to protect two patients from harm when they ended up in a physical altercation, injuring one patient's nose and mouth and the other's hand, according to a state investigation.
Year
2014
Detail
A patient assaulted another patient in the dinner line, fracturing his left ankle and shoulder and requiring surgery, according to state records. State investigators found the facility failed to protect the victim from abuse.
*This all-male facility does not accept voluntary admissions and primarily treats patients in the criminal justice system, such as those deemed incompetent to stand trial or found not guilty by reason of insanity.
Aurora Charter Oak
Deaths
1
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
134
Facility details
Address
1161 East Covina Boulevard, Covina 91724
Ownership
Private
Parent Company
Signature Healthcare Services, LLC
Violations and incidents:
1 found
Year
2018
Detail
A 26-year-old patient escaped the facility and jumped off a five-story parking structure and died, according to state records. State investigators determined that the facility failed to provide a safe environment for the patient.
Aurora Vista Del Mar Hospital
Deaths
1
Primary service
Psychiatric
County
Ventura
Psychiatric beds
87
Facility details
Address
801 Seneca Street, Ventura 93001
Ownership
Private
Parent Company
Signature Healthcare Services, LLC
Violations and incidents:
10 found
Year
2015
Detail
A 17-year-old patient at risk for suicide killed herself because the hospital did not take away equipment that could be used for self-harm and also did not monitor her enough, according to state investigators. The state issued an immediate jeopardy citation, the most serious violation a hospital can receive, and fined the hospital $75,000.
Year
2013
Detail
A mental health worker sexually abused three patients admitted to the facility, according to court records. He was sentenced to six years in jail. In 2019, a jury ordered that the hospital and its parent company pay $13 million to the three women.
Year
2017
Detail
Staff unnecessarily restrained a patient who was sitting calmly and drinking coffee, according to state records. The facility failed in its responsibilities to the patient, state investigators found, writing that "this failure resulted in the physical injury" of the patient.
Year
2016
Detail
Staff failed to monitor a patient who was supposed to be constantly supervised, allowing the patient to walk outside, scale a fence and jump off a roof, injuring his foot, according to state records.
Year
2019
Detail
A patient jumped onto a nearby roof and ran away, according to state records. State inspectors determined the hospital had failed to keep patients safe, according to the records.
Year
2014
Detail
A mental health worker slapped a patient across the face, according to a state investigation. The facility failed to protect the patient from abuse, investigators determined.
Year
2011
Detail
The facility broke protocol when it did not report that a patient alleged that she had been raped while she was admitted to the hospital, according to state investigators.
Year
2009
Detail
The hospital failed to ensure that a door was locked, allowing a patient to escape, according to state records. A patient had exited through the same door a year prior, according to state investigators.
Year
2012
Detail
Staff restrained a patient incorrectly and bruised the patient's torso and arms, injuries that were later reported by doctors to law enforcement, according to a state investigation.
Year
2016
Detail
A patient physically assaulted another patient, who then had to go the hospital for treatment of his injuries, according to state records.
Butte County Mental Health Services
Deaths
1
Primary service
Psychiatric
County
Butte
Psychiatric beds
16
Facility details
Address
592 Rio Lindo Avenue, Chico 95926
Ownership
Public
Parent Company
Butte County
Violations and incidents:
1 found
Year
2013
Detail
A 31-year-old patient died after three staff members restrained him and his heart stopped beating, according to county coroner's records. Someone tried to use a defibrillator to restart his heart, but it did not work, records show.
California Pacific Medical Center -- Pacific Campus
Deaths
1
Primary service
General Medical
County
San Francisco
Psychiatric beds
16
Facility details
Address
2333 Buch, Street, San Francisco 94115
Ownership
Non-Profit Corporation
Parent Company
Sutter Bay Hospitals
Violations and incidents:
1 found
Year
2016
Detail
A patient died by suicide when staff who had been advised to check on the patient every 15 minutes did not follow orders, according to a state investigation into the death.
Coalinga State Hospital
Deaths
1
Primary service
Psychiatric
County
Fresno
Psychiatric beds
1286
Facility details
Address
24511 West Jayne Avenue, Coalinga 93210
Ownership
Public
Parent Company
California Department of State Hospitals
Violations and incidents:
4 found
Year
2018
Detail
A 64-year-old man living at the hospital died of a methamphetamine overdose, according to county coroner's records.
Year
2010
Detail
Staff did not properly monitor a suicidal patient, allowing him to wrap a cord around his neck in a suicide attempt, according to state records. The patient had attempted suicide earlier that morning and was supposed to be constantly monitored by staff, records show.
Year
2014
Detail
A staff member did not knock before opening bathroom doors, exposing patients who were half naked, according to a state report. The staff member was giving a tour to inspectors, who pointed out he should knock before opening the doors to respect patient privacy, the report shows.
Year
2009
Detail
The hospital failed to investigate when a staff member said he saw another staff member violently push a patient multiple times, according to a state report.
*This facility does not accept voluntary admissions and mostly treats sexually violent predators.
College Hospital Costa Mesa
Deaths
1
Primary service
Psychiatric
County
Orange
Psychiatric beds
99
Facility details
Address
301 Victoria Street, Costa Mesa 92627
Ownership
Private
Parent Company
College Health Enterprises
Violations and incidents:
9 found
Year
2013
Detail
A 36-year-old patient admitted to the hospital hanged himself with a T-shirt, according to coroner's records.
Year
2009
Detail
A patient who was supposed to be monitored at all times hanged herself using a sheet, according to state records. The hospital failed to prevent her from harming herself, according to state investigators.
Year
2018
Detail
The facility failed to monitor a patient who was supposed to be checked on every five minutes, allowing him to strike another patient in the head several times, according to state records. The victim had to be sent to the hospital, records show.
Year
2014
Detail
When a patient alleged that another patient sexually assaulted her, hospital staff did not report the allegation to a supervisor for investigation, according to state records.
Year
2012
Detail
State investigators determined that staff failed to monitor a patient as he was able to escape from the facility by jumping over a fence in the patio, according to records.
Year
2009
Detail
When a patient was taken to a courthouse for a court date, a staff member did not monitor him and he escaped, according to state records. State investigators determined that the facility had not properly trained its staff.
Year
2013
Detail
The hospital failed to closely monitor a patient, who was assaulted by another patient when staff were distracted, state investigators found.
Year
2009
Detail
The hospital dumped more than 150 mentally ill patients on downtown L.A.'s skid row in 2007 and 2008, according to the Los Angeles city attorney's office. The hospital was required to pay $1.6 million in penalties and charitable contributions to a host of psychiatric and social service agencies.
Year
2019
Detail
Hospital staff did not properly investigate when a female patient said a male patient had sexually abused her, according to state records.
Crestwood Psychiatric Health Facility -- Bakersfield
Deaths
1
Primary service
Psychiatric
County
Kern
Psychiatric beds
71
Facility details
Address
6700 Eucalyptus Drive, Ste C, Bakersfield 93306
Ownership
Private
Parent Company
Crestwood Behavioral Health
Violations and incidents:
1 found
Year
2018
Detail
A patient admitted to the facility died after being transferred to a nearby hospital and state investigators found at least some fault on the part of the facility, according to state records.
Fremont Hospital
Deaths
1
Primary service
Psychiatric
County
Alameda
Psychiatric beds
148
Facility details
Address
39001 Sundale Drive, Fremont 94538
Ownership
Investor - Corporation
Parent Company
Universal Health Services
Violations and incidents:
3 found
Year
2016
Detail
When a patient became severely dehydrated and stopped breathing, facility staff failed to notice and respond, leading to the patient's death, according to state inspectors. The state called the situation an immediate jeopardy, the most serious violation a hospital can commit. The hospital was fined $75,000.
Year
2018
Detail
A patient told staff she was sexually assaulted and staff took too long to report the assault to police, possibly losing evidence, according to a state investigation.
Year
2016
Detail
One patient attacked two others, giving one of them a concussion. The facility failed to report the incident to the state as required by law, according to state investigators.
Harbor-Ucla Medical Center
Deaths
1
Primary service
General Medical
County
Los Angeles
Psychiatric beds
38
Facility details
Address
1000 West Carson Street, Torrance 90502
Ownership
Public
Parent Company
Los Angeles County
Violations and incidents:
2 found
Year
2011
Detail
The hospital admitted a patient to its psychiatric ward, but failed to make sure he was consuming food or water, according to state records. The patient died of dehydration, according to state records. State investigators issued an immediate jeopardy citation, the most serious violation a hospital can commit, and fined the facility $75,000 for the error.
Year
2009
Detail
A patient admitted to the hospital for psychiatric illness was not closely monitored, allowing him to pull one of his eyeballs out of its socket, according to state records. While the patient remained at the hospital for medical care, staff failed to protect him from further self-injurious behavior, according to state investigators.
Henry Mayo Newhall Hospital
Deaths
1
Primary service
General Medical
County
Los Angeles
Psychiatric beds
23
Facility details
Address
23845 Mcbean Parkway, Valencia 91355
Ownership
Non-Profit Corporation
Parent Company
HENRY MAYO NEWHALL HOSPITAL
Violations and incidents:
1 found
Year
2018
Detail
A 54-year-old man admitted to the hospital's psychiatric ward after a suicide attempt hanged himself in his room, according to county coroner records. The man had a history of depression and PTSD, according to coroner's reports.
John George Psychiatric Hospital
Deaths
1
Primary service
General Medical
County
Alameda
Psychiatric beds
80
Facility details
Address
2060 Fairmont Drive, San Leandro 94602
Ownership
Public
Parent Company
Alameda Health System
Violations and incidents:
6 found
Year
2009
Detail
Hospital staff did not regularly monitor a suicidal patient, allowing him to kill himself with a plastic bag and string, according to a state inspection. The state issued an immediate jeopardy citation for putting patients at risk of harm or death, the most serious violation a hospital can commit, and fined the hospital $50,000.
Year
2018
Detail
Two patients were sexually assaulted by two other patients, according to state investigators. The investigation found the facility did not properly protect the patients from harm or report the incidents as required by law, according to the state report.
Year
2015
Detail
The hospital did not respond properly when a patient inappropriately touched another patient, according to a state inspection report.
Year
2018
Detail
State inspectors found that the facility was not properly secured, allowing a patient who was under criminal arrest to escape.
Year
2018
Detail
Nursing staff did not follow hospital protocol when they put a patient in restraints, potentially harming the patient, according to state inspectors.
Year
2018
Detail
Hospital staff failed to communicate to each other that a patient was on an involuntarily hold and should not be allowed to leave the facility. The patient left the facility, potentially putting himself in danger, according to a state investigation.
John Muir Behavioral Health Center
Deaths
1
Primary service
Psychiatric
County
Contra Costa
Psychiatric beds
73
Facility details
Address
2740 Grant Street, Concord 94520
Ownership
Non-Profit Corporation
Parent Company
John Muir Health
Violations and incidents:
2 found
Year
2010
Detail
A 17-year-old admitted for suicide attempts hanged himself four days after being admitted to the facility. State investigators found the facility did not properly monitor the boy and put him at risk of harm or death. The state issued an immediate jeopardy citation, the most serious violation that can be issued to a hospital, and fined the hospital $30,000.
Year
2009
Detail
Staff did not properly search patients' belongings when they entered the facility, allowing a patient to use an electric razor to break off a sprinkler head in a room and flood five rooms in the facility, potentially endangering other patients, according to state records.
Joyce Eisenberg Keefer Medical Center
Deaths
1
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
10
Facility details
Address
7150 Tampa Avenue, Reseda 91335
Ownership
Non-Profit Corporation
Parent Company
Grancell Village of the Los Angeles Jewish Home for the Aging
Violations and incidents:
1 found
Year
2014
Detail
A patient was improperly cared for by staff and died, according to state records.
Kaiser Permanente Mental Health Center
Deaths
1
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
68
Facility details
Address
765 College Street, Los Angeles 90012
Ownership
Non-Profit Corporation
Parent Company
Kaiser Foundation Hospital
Violations and incidents:
1 found
Year
2012
Detail
A patient hanged himself after staff who were supposed to check on him every 15 minutes didn't check on him for nearly 30 minutes, according to a state investigation into the death. State regulators issued an immediate jeopardy citation to the hospital, the most severe violation a hospital can receive, and fined the hospital.
Kedren Community Mental Health Center
Deaths
1
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
72
Facility details
Address
4211 Avalon Boulevard, Los Angeles 90011
Ownership
Non-Profit Corporation
Parent Company
KEDREN COMMUNITY MENTAL HEALTH CENTER
Violations and incidents:
3 found
Year
2017
Detail
A 30-year-old patient was strangled to death by his roommate, according to coroner's records. An investigation by state officials found the hospital should have been monitoring the killer more carefully and that its failure to do so, as well as other errors, "presented an imminent danger to the patient and were a direct cause of the death of the patient," according to a state report.
Year
2017
Detail
A patient attacked another patient who was asleep, injuring his eye, according to state records. The facility failed to protect the injured patient from harm, state investigators found.
Year
2018
Detail
Hospital staff were not trained how to handle food properly and stored frozen food in the fridge. State investigators issued an immediate jeopardy citation, the most serious violation a hospital can receive, indicating that the facility's actions put patients at risk of serious harm or death.
Los Angeles Community Hospital At Bellflower
Deaths
1
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
32
Facility details
Address
9542 Artesia Boulevard, Bellflower 90706
Ownership
Private
Parent Company
Prospect Medical Holdings, Inc.
Violations and incidents:
1 found
Year
2010
Detail
A schizophrenic patient admitted to the psychiatric ward after a suicide attempt hanged himself, according to coroner's records.
Mission Community Hospital - Panorama Campus
Deaths
1
Primary service
General Medical
County
Los Angeles
Psychiatric beds
60
Facility details
Address
14850 Roscoe Boulevard, Panorama City 91402
Ownership
Private
Parent Company
Deanco Healthcare, LLC
Violations and incidents:
2 found
Year
2014
Detail
When a patient exhibited aggressive behavior, a nursing assistant restrained the patient by placing her face down on a bed for 10 minutes. While in this position, the patient stopped breathing and suffered extreme brain damage, according to state records. The patient eventually became brain-dead, state records show. State investigators issued an immediate jeopardy citation, the most severe penalty that can be given to a hospital, and fined the hospital $50,000, according to state records.
Year
2015
Detail
Staff did not properly transport a mentally ill patient to a board-and-care facility, allowing the patient to go missing for two days, according to state records.
Natividad Medical Center
Deaths
1
Primary service
General Medical
County
Monterey
Psychiatric beds
22
Facility details
Address
1441 Constitution Boulevard, Salinas 93906
Ownership
Public
Parent Company
County of Monterey
Violations and incidents:
1 found
Year
2010
Detail
A teenager died after he hanged himself in the facility while on suicide watch, according to lawsuits filed by his family.
Pacifica Hospital Of The Valley
Deaths
1
Primary service
General Medical
County
Los Angeles
Psychiatric beds
38
Facility details
Address
9449 San Fe,do Road, Sun Valley 91352
Ownership
Private
Parent Company
Pacifica of the Valley Corporation
Violations and incidents:
3 found
Year
2011
Detail
A patient stabbed his roommate to death, according to court records. When the victim's family sued, a jury found that the hospital and its staff acted recklessly in assigning the two men to the same room, despite knowing that the aggressor had a violent past, a criminal background and was known to attack others without provocation, according to court documents.
Year
2016
Detail
The hospital failed to properly discharge a schizophrenic patient, instead sending her to a skilled nursing facility by taxi. The patient went missing and was not found for three days, according to state inspectors.
Year
2016
Detail
During a state inspection in August 2016, at least eight patients were put in restraints or seclusion and were not seen by a doctor or a nurse within an hour to evaluate whether such drastic measures were still needed.
Resnick Neuropsychiatric Hospital At Ucla
Deaths
1
Primary service
Psychiatric
County
Los Angeles
Psychiatric beds
74
Facility details
Address
150 Medical Plaza, Los Angeles 90095
Ownership
Public
Parent Company
University of California
Violations and incidents:
4 found
Year
2018
Detail
A 31-year-old man diagnosed with schizophrenia and admitted to the hospital for a suicide attempt swallowed an object that killed him by blocking his airway and preventing oxygen from reaching his brain, according to coroner's records.
Year
2014
Detail
Hospital staff reported to the state that a patient had died by suicide or attempted suicide, according to state records. State investigators did not find any fault on the part of the hospital, records show.
Year
2016
Detail
An employee took a picture of a hospital computer screen using his personal cellphone showing the name of a high-profile patient and posted it on Instagram. Another employee's daughter posted on Twitter that her dad worked at the hospital and that the high-profile patient was being treated there. "My Dad confirmed, Patient 1 had a mental break down and is psychotic rn lol," said one tweet. Both employees were placed on leave.
Year
2018
Detail
Staff failed to report when a minor admitted to the facility broke his arm, according to state records. A doctor who treated the injury said she thought his arm had been broken by "someone grabbing him," records show.
Restpadd Psychiatric Health Facility
Deaths
1
Primary service
Psychiatric
County
Shasta
Psychiatric beds
16
Facility details
Address
2750 Eureka Way, Redding 96001
Ownership
Private
Parent Company
Restpadd Health Corp
Violations and incidents:
1 found
Year
2017
Detail
A patient died while admitted to the facility and state investigators found at least some fault on the part of the facility, according to state records.
Restpadd Red Bluff Psychiatric Health Facility
Deaths
1
Primary service
Psychiatric
County
Tehama
Psychiatric beds
16
Facility details
Address
925 Walnut Street, Red Bluff 96080
Ownership
Private
Parent Company
Restpadd Health Corp
Violations and incidents:
1 found
Year
2017
Detail
A patient died while admitted to the facility and state investigators who looked into the death found several errors on the part of the facility, according to state records.
Royale Therapeutic Residential Center
Deaths
1
Primary service
General Medical
County
Orange
Psychiatric beds
40
Facility details
Address
1030 West Warner Avenue, Santa Ana 92707
Ownership
Private
Parent Company
Royale Health Care Center
Violations and incidents:
1 found
Year
2012
Detail
A 63-year-old patient admitted to the hospital's psychiatric ward died after hanging himself with a bedsheet, according to county coroner's records.
San Diego County Psychiatric Hospital
Deaths
1
Primary service
Psychiatric
County
San Diego
Psychiatric beds
109
Facility details
Address
3853 Rosecrans Street, San Diego 92110
Ownership
Public
Parent Company
San Diego County
Violations and incidents:
4 found
Year
2012
Detail
A 53-year-old patient with a history of schizophrenia died while admitted to the facility after another patient attacked him and caused severe head injuries, according to coroner's records. The killer was sentenced to 15 years in prison for manslaughter, according to news reports.
Year
2015
Detail
When a patient became agitated, two staff members grabbed her and broke her arm, according to state records. The patient required surgery for the fracture. "The restraint was unnecessary, excessive, and not used in accordance with hospital policy and procedure," reads a state investigation into the incident. The state issued an immediate jeopardy citation, the most serious violation a hospital can receive, and fined the facility $50,000 for the violation.
Year
2018
Detail
A patient admitted to the facility after being diagnosed with a psychiatric disorder escaped from the hospital, according to state records. Staff admitted that the door the patient left through should have been locked, records show.
Year
2015
Detail
A patient escaped the facility when staff failed to follow their own policy for escorting patients to doctor's appointments, according to state records.
San Luis Obispo County Psychiatric Health Facility
Deaths
1
Primary service
Psychiatric
County
San Luis Obispo
Psychiatric beds
16
Facility details
Address
2178 Johnson Ave, San Luis Obispo 93401
Ownership
Public
Parent Company
San Luis Obispo County
Violations and incidents:
1 found
Year
2017
Detail
A mental health patient died while admitted to the facility. State investigators found that the facility was at least partly to blame.
Santa Barbara Cottage Hospital
Deaths
1
Primary service
General Medical
County
Santa Barbara
Psychiatric beds
20
Facility details
Address
400 W. Pueblo Street, Santa Barbara 93105
Ownership
Non-Profit Corporation
Parent Company
Cottage Health System
Violations and incidents:
1 found
Year
2015
Detail
A 93-year-old patient killed himself after staff did not properly monitor him, though he had stated his suicide plan to them, according to state records. The state issued an immediate jeopardy citation, the most severe violation a hospital can receive, and fined the hospital $100,000 for the mistake.
Scripps Mercy Hospital
Deaths
1
Primary service
General Medical
County
San Diego
Psychiatric beds
36
Facility details
Address
4077 Fifth Avenue, San Diego 92103
Ownership
Non-Profit Corporation
Parent Company
Scripps Health
Violations and incidents:
2 found
Year
2014
Detail
A 25-year-old man admitted to the psychiatric ward of the hospital after a suicide attempt stood up on his bed and jumped through the hospital room window, falling 60 feet to his death. State investigators issued an immediate jeopardy citation, the most serious violation a hospital can receive, and fined the hospital $100,000.
Year
2011
Detail
A 31-year-old woman admitted to the psychiatric ward was sexually assaulted by her roommate, according to a state investigation into the incident. It took the clinical staff 10 hours to move the perpetrator to a new unit, state records show. The victim "stated that she just came to the hospital to get help for stress, anxiety and depression, but she was 'molested by a lesbian rapist.' [She] felt that the clinical staff minimized what was going on. She did not feel that the staff were protecting her. The administrator of the behavioral health unit was present during the interview with [the patient]. At the end of the interview, the administrator stated 'This can't happen again to anybody,'" according to the investigation report.
Sherman Oaks Hospital
Deaths
1
Primary service
General Medical
County
Los Angeles
Psychiatric beds
19
Facility details
Address
4929 Van Nuys Boulevard, Sherman Oaks 91403
Ownership
Non-Profit Corporation
Parent Company
Prime Healthcare
Violations and incidents:
1 found
Year
2015
Detail
A 51-year-old man brought to the hospital as a psychiatric patient because he was a danger to himself died after he hanged himself in his bathroom, according to coroner's records.
Sierra Vista Hospital
Deaths
1
Primary service
Psychiatric
County
Sacramento
Psychiatric beds
171
Facility details
Address
8001 Bruceville Road, Sacramento 95823
Ownership
Private
Parent Company
Universal Health Services
Violations and incidents:
3 found
Year
2013
Detail
State investigators determined that facility staff may not have administered medicines and CPR properly to a patient, contributing to his death, according to state records.
Year
2016
Detail
A patient said a staff member shoved him, slamming his back against a windowsill, according to state records. An examination found a red bruise on the patient's back as well as a lump on his head, records show.
Year
2016
Detail
When a patient was punched in the face twice by another patient, the facility failed to report the incident as required by law, according to state records.