Description

This report chronicles the effects of the absence of proper monitoring by agencies which sponsor and certify individuals who undertake to serve mentally disabled persons. The agencies failed to detect an illegal and overcrowded family care home, as well as inappropriate discharges from state psychiatric centers to a home certified only for individuals with mental retardation, and failed to ensure the safety and well-being of residents at the home, where the deceased died under possibly abusive conditions, following earlier allegations of abuse.