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State Auditor Finds the Department of Public Health is Placing Nursing Home Residents at Risk


On October 30, 2014, the California State Auditor released a report condemning the Department of Public Health’s systemic mismanagement of nursing home complaint investigations. Assembly Member Mariko Yamada and the Joint Legislative Audit Committee sought the investigation by the State Auditor earlier this year after embarrassing public reports that DPH often took years to complete investigations of severe abuse and neglect in nursing homes. CANHR called for the state audit in testimony at a legislative oversight committee on January 21, 2014.

The central finding of the report – California Department of Public Health: It Has Not Effectively Managed Investigations of Complaints Related to Long-Term Health Care Facilities – is that, as of April 2014, DPH had more than 11,000 open complaints, many of which had high priorities and had remained open for an average of nearly a year. When nursing home residents die from neglect or suffer from abuse, DPH is usually nowhere to be found.

Other key findings include:

  • DPH does not provide adequate oversight of complaint processing by its district offices and the Professional Certification Branch.
  • DPH is slowest to act on the most serious complaints involving immediate jeopardy to residents, some of which had been open for more than three years.
  • Some district offices close out almost all reports by facilities of suspected abuse and neglect without investigation. For example, in 2012 and 2013, the Los Angeles County North District office did not conduct an onsite investigation for 90 percent of the 1,103 reports it received from facilities.
  • In 2009, DPH eliminated its policy calling for complaint investigations to be completed within 40 days and now has no specific time frames for completing investigations.
  • DPH has no idea what levels of staffing are needed at its district offices to complete complaint investigations and other assignments in a timely manner.
  • None of the district offices visited by the auditor consistently collected corrective action plans from facilities in a timely manner or verified that facilities had implemented corrective actions when required.
  • Caregivers who have abused residents continue to work in nursing homes because of long delays in conducting appeals. One appeal was not heard for nearly 1,200 days.

The State Auditor made numerous recommendations for improvement, including a call to establish a specific time frame for completing complaint investigations. The defiant DPH response, signed by Kathleen Billingsely for DPH Director Dr. Ron Chapman, rejects this recommendation without explanation. Elaine Howle, the State Auditor, ends the report by criticizing DPH for its lack of accountability. She states: “We believe that Public Health’s lack of accountability has contributed to its district offices’ failure to complete investigations within reasonable time periods.”

DPH leaders appear immune to accountability. The new report by the State Auditor is the third report she has issued since 2007 that raises serious concerns about DPH’s oversight of nursing homes.

Full Report, California Department of Public Health: It Has Not Effectively Managed Investigations of Complaints Related to Long-Term Health Care Facilities, Report 2014-111, October 2014

Summary Report by California State Auditor

October 30, 2014 Fact Sheet by the California State Auditor on the DPH audit

October 30, 2014 Sacramento Bee article, Audit: California nursing home oversight haphazard

October 31, 2014 Kaiser Health News Article: California Audit Finds Backlog of 11,000 Nursing Home Investigations

Prior Audits of the DPH Licensing and Certification Division by the California State Auditor

June 17, 2010: Department of Public Health: It Reported Inaccurate Financial Information and Can Likely Increase Revenues for the State and Federal Health Facilities Citation Penalties Accounts

April 12, 2007: Department of Health Services: Its Licensing and Certification Division Is Struggling to Meet State and Federal Oversight Requirements for Skilled Nursing Facilities, Report # 2006-106