A Granada Hills group home for adults with developmental disabilities contributed to the brutal stabbing death of a resident by failing to provide adequate care and supervision, state licensing regulators have found.
As a result of its nine-month investigation, the California Department of Social Services Community Care Licensing Division has cited the Aacres facility on Bircher Street for several deficiencies that are a direct threat to the health and safety of residents and levied a civil penalty of $15,000 for the death, according to the state agency.
“The death of any resident is extremely tragic,” said Michael Weston, a spokesman for the state Department of Social Services in an email. “In this case, the maximum civil penalty allowed by law was assessed.”
REPORT: Aacres facility evaluation report
Dawn Marie Ritz, 61, was fatally stabbed in her bed on the morning of May 14 allegedly by another resident who had obtained a kitchen knife from the facility, Los Angeles police have said.
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Robert Efford, chief executive officer of Embassy Management, the parent company of Aacres California, said their entire team is “profoundly saddened” by Ritz’s death.
“The health and safety of our residents is always paramount, and while this report is only now being released, all noted observations and responses were immediately addressed once they came to our attention,” Efford said in an emailed statement Tuesday.
The state’s investigation revealed that the suspect, identified by authorities as 18-year-old Ravneet Kaur, had access to a 4-inch knife by unlocking the cabinet that stored sharp objects.
She also had “a history of physical aggressive acts toward others,” the investigation found.
“Staff interviews confirmed that the keys for the locked cabinet were kept in an unlocked drawer,” the report stated.
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Kaur, the suspect, pleaded not guilty to one count of murder in May and faces life in prison if convicted.
The investigation also found that there was only one direct support professional scheduled for the night shift at the time the stabbing occurred. The facility was required to have two awake professionals on duty and one overnight staff member on call, according to the report.
Kaur’s individual program plan required that she have one-on-one staffing while Ritz required that she be checked every 15 minutes while sleeping. However, staff members said they were not aware of this component of Ritz’s plan.
Since the stabbing, the group home requires staff members to keep keys on them and hand them off to oncoming staff, according to the state agency’s report. The facility has also agreed to submit a copy of the new policy for keys.
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In addition, the process of admitting residents now includes review by a clinical team member with recommendations for support and supervision.
Staff are also now trained on the client’s individual plan prior to admission and home staff meetings are conducted at least twice monthly to review individual client’s needs, according to the report. Changes were also made to ensure the level of staffing meets their clients’ needs.
If a facility fails to follow a plan of correction outlined for the offending facility, the Department can take additional action, Weston noted.
Embassy Management will make a decision shortly about whether they will appeal the state’s findings, Efford said.
Family members of Ritz, a former Special Olympics athlete, filed a civil lawsuit against Aacres, Embassy Management and the home’s administrator in November alleging that her killing was preventable.
“The (state) report proves that this was not an accident; this was not an act of simple negligence where someone had a momentary lapse of judgement or a fleeting lack of attention,” said attorney Gregory L. Johnson, who is representing the family in the civil lawsuit.
“This was a systemic failure to follow the rules that are meant to keep people safe in these facilities.”