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Beverlyn Lee, left, takes her son, Virgil Hamilton, on an outing at Sycamore Grove Park in Livermore, Calif., on Wednesday, Aug. 20, 2014. Virgil has severe brain trauma after nearly drowning 31 years ago. Lee said she has concerns about the quality of care he is receiving at a facility on Chablis Way in Livermore since several caregivers were recently fired. (Jim Stevens/Bay Area News Group)

LIVERMORE -- Until last summer, Beverlyn Lee had been content with the care her paraplegic son received at his residential care facility in Livermore. Then Elwyn Northern California took over management.

In May, a female resident died at the home. In July, 12 staffers were dismissed. Since the death, the state has slapped Elwyn's Chablis facility with five citations for practices that immediately affected the health, safety or personal rights of clients.

Lee, former employees and state regulators are deeply worried about the quality of the care at the facility, which houses the most severely disabled, those who require intensive, around-the-clock care. But Elwyn says it has moved to bolster the facility since taking over last year, dismissing poorly performing staff and bringing in physicians and consultants to address the problems and get the home on track.

"My main concern is for the health and safety of the patients there," Lee said. "We want this to be done right. We don't want to lose another life."

A near-drowning at the age of 6 left Lee's son, Virgil Hamilton, a wheelchair-bound paraplegic, only able to communicate through eye blinks and needing a feeding tube to stay alive. Now 37, he requires constant care from nurses and therapists at the state-licensed residential facility for the seriously developmentally disabled on Chablis Way in Livermore. He has lived there since transferring from the Agnews Developmental Center in San Jose, which closed in 2009.

Elwyn Northern California has 13 similar 24-hour facilities in the Bay Area, including San Jose, Santa Clara, Fremont, Morgan Hill and Union City. Each home serves up to five people.


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The nonprofit company took over operation of the Livermore home from California MENTOR, another nonprofit residential agency, in August 2013. It houses four severely disabled adults; the cost for the service is about $20,000 per month for each resident, paid by the state.¿

The five Class A violations received by the facility since Elwyn took over are very serious, said Michael Weston, spokesman for the California Department of Social Services.

"Obviously, if we continue to see repeat violations in the same areas, something needs to change," Weston said. "Any time the agency is using civil penalties, we take that very seriously."

The group home is one of 23 specialized health care facilities opened in the Bay Area to provide 24-hour care for former patients of Agnews. The state oversees the facilities through its Community Care Licensing division.

Class A violations, which according to the California Department of Public Health's website, are issued when there is "imminent danger of death or serious harm to patients, or a substantial probability of death or serious physical harm to patients."

Three of Elwyn's violations stemmed from complaints over the "questionable death" of a female client at the home, whose name has not been released. The state's investigation concluded that medication was administered against prescribed directions (staff members gave the patient a scopolamine patch at twice the dosage prescribed); that staff willfully administered the wrong dosage despite being aware it was wrong; and that the facility failed to report the medication error.

State investigators concluded the evidence neither refuted, nor substantiated the allegation that the high dose of scopolamine given the patient contributed to her death, making a finding of "inconclusive."

Instead of retraining staff on dispersing medication as recommended by the state, nurses said, Elwyn cleaned house by dismissing 12 nurses and therapists -- nearly a third of the staff. Some had been at Chablis since it opened, and at Agnews before that.

Elwyn NC Executive Director Michael Kottke said the provider conducted a "thorough investigation of the medicinal errors," and either terminated the employees who were found culpable or allowed them to resign.

"I don't know what precipitated the errors ... It's an indication that the checks and balances we have weren't being followed," Kottke said. If the nurses involved had participated in the protocol, there wouldn't have been a problem."

A nurse who was terminated but did not want her name used, said she was not involved in the care of the client who died. She said she worked at Agnews for 20 years before coming to the home. Whenever there had been problems at other places she'd worked at, the staff would be retrained, but in this case, "They didn't give us any training. They just gave us our termination notices."

Another nurse who still works at the Chablis home and spoke under condition of anonymity for fear of retaliation, said the staffers were "shocked" by the dismissals. They've been working six days a week, sometimes 12-hour days to fill the gap, and are concerned about "burnout," she said.

"The clients are at risk," she said. "We are working overtime; half of our staff is gone. We have to divide the work among the rest of us."

A state evaluation from June 2013 -- before Elwyn took over -- noted some items in need of maintenance and repair. A follow-up visit in June 2014, spurred by the client's death and staff complaints, found that the maintenance issues had been resolved, and patients appeared to be adequately cared for. However, during an unannounced visit on Aug. 8, state investigators found that Elwyn staff did not properly document Lee's son's medication the previous month, which indicated the staff couldn't tell whether or not he had received his medication. The facility was fined and cited for a Class A violation, its fourth. The fifth Class A violation was issued because the home's administrator was not licensed to work at that facility.

The Regional Center of the East Bay, a private, nonprofit agency, provides support and case management for disabled residents and funding for the homes. Lisa Kleinbub, the nonprofit's director of health and behavioral services, said Elwyn has proved to be a successful provider in the past, but they have upped the number of unannounced visits to the Livermore home to several times a week since the recent incident. She said her agency would work with Elwyn to bring in trained nurses and help the clients through a "difficult time."We take this very seriously," Kleinbub said. "Right now, our primary concern is the significant staff loss and the health and safety of individuals. They need experienced staff." Kottke said the home has adequate nurses to handle the current load of clients.

"We're having no problem maintaining staff ratios," Kottke said. "Certainly, we have enough staff to cover all shifts, and we're working carefully to ensure employees aren't overworked or overburdened ... The level of care in the home isn't going to be affected."

Kottke added that Elwyn has retrained all existing staff on administering medications and has brought in outside physicians and consultants to address the concerns and ensure the problems are behind them.

Kathleen Miller is president of the Parent Hospital Association, an advocacy group at the Sonoma Development Center, one of several operated by the California Department of Developmental Services. The woman who died was a longtime client there before moving to Elwyn's Chablis home.

"I find it disturbing because it doesn't bode well for our clients going into these ... homes," Miller said. "We're being told they're great. We sent somebody to one of these homes, and she dies. Not only does she die, but it's under these very cloudy circumstances."

In the meantime, Lee is advocating for a new administration and for Elwyn to rehire the nurses who had nothing to do with the woman's death, until a full investigation is completed.

"Everything has been a disaster," Lee said. "There's a lot of issues, and it has to do with a lack of qualified management. They've made irrational, reckless decisions and created a hostile environment."

Contact Jeremy Thomas at 925-847-2184. Follow him at Twitter.com/jet_bang.