Description

This report is on the investigation of an unlicensed adult home where two residents with mental illness died and residents lived under filthy and unsafe conditions, while the Department of Social Services failed repeatedly over several years to take effective enforcement action to protect residents and close the home. One resident died of hypothermia after the home lacked adequate heat and neglect by the home's operator of another resident's medical needs resulted in his death from tuberculosis. Mental health clinic case mangers responsible for residents' needs and services also did not maintain regular contact or respond to resident complaints about their treatment and obvious problems at the home.