"What I found was, uh, I mean, Just nothing like I had ever seen at any home that I have ever worked at, any program I've ever worked at."Ileya Silva
It’s January, 2023. I’m meeting a woman named Ileya Silva. We meet up at a library in Vacaville, about halfway between my home in the San Francisco Bay Area and hers in Sacramento. Ileya has dark hair and a serious demeanor. She’s understandably wary about talking with me because what she’s about to share could jeopardize her job and her entire career.
She tells me that even though she’d worked in group homes for 20 years, she still wasn’t prepared for what she experienced at the Illinois Home.
“What I found,” Ileya says, “was, I mean, just nothing like I had ever seen at any home that I have ever worked at, any program I've ever worked at.”
Seven months prior, in March, 2022, Ileya had started a new job as an administrator at a group home in Sacramento. The job had been promising. It was with a company called Sevita Health, a large national operator of group homes and care facilities throughout the country. At the time, the company already operated over twenty five facilities in California, and had recently obtained contracts to operate several new ones.
Ileya works with people who have severe intellectual and developmental disabilities — conditions like autism, cerebral palsy, and Down Syndrome. She’d built a reputation in her field as someone who excelled at working with the most challenging clients — first as a caregiver, then as administrator. She’d found that she just had the right temperament.
“I didn't take their behaviors personally,” Ileya says, “which is a vital skill in this field. I found my niche and I said this is where I want to be, and where I want to develop my career.”
In early 2022, before Ileya came on board, Sevita Health had a problem. Things weren’t going well with the new homes. One home in particular — called “The Illinois Home” because it sits on Illinois avenue — had gotten in trouble with some of the local oversight agencies. “Regional Center had put them on notice,” says Ileya. “And let them know they needed an administrator now.”
Ileya seemed like the perfect fit. She says the hiring process was a blur. She says that even though she didn’t know exactly what had gone wrong at The Illinois Home, she felt confident that she’d be up to the task.
Ileya says that what followed was a harrowing eight months, which left her mentally and physically burnt out, and suspended from her job. She says the role required her to compromise her ethics and claims that she was targeted by management for speaking out.
She says the role required her to compromise her ethics and claims that she was targeted by management for speaking out.
Sevita declined my request for an interview. In a written statement, the company said they wouldn’t comment on specifics.
“Mini Institutions”
Before I met Ileya in early 2023, I’d already been investigating the Illinois home for eight months.
The family of a resident named Katrina Turner had reached out to me. They suspected Katrina was being abused by staff, and that the company was covering it up. Katrina has autism and is non-verbal. She wasn’t able to accuse her alleged abusers directly. But, her family found Katrina with bruises and a black eye after a concerned staff member contacted them from a personal email account.
The Illinois Home, where Katrina lives, is a special kind of group home. The full name is Enhanced Behavioral Support Home, or EBSH. They’re designed to house a maximum of four people at a time, and they’re designed to support people who need constant care and supervision.
“They're really developed and conceptualized as part of the state and nationwide trend… to no longer just warehouse people in large segregated institutions,” says Will Leiner, a managing attorney at Disability Rights California.
He’s referring to those big, state-run facilities with hundreds, or thousands of residents. Many of these facilities had reputations for being hotbeds of abuse.
In 2012, California made the decision to close down almost all of its remaining institutions over the following decade. But, Will says, there were big questions at the time: “Where will people be served if there are no longer developmental centers?”
So, the Department of Developmental Services made a plan to create a safety net. After some back and forth, it was finally approved in 2017. These Enhanced Behavioral Support Homes were central to this plan.
“The growth has been pretty staggering,” says Will. In just a few years, around 65 licensed EBSHs have opened, with dozens more in development.
On paper, these homes look pretty good. “The homes are new, the rates are good,” explains Will. “The staffing is funded at a level based on the needs of the people living there.”
However, Will says his department has begun to notice warning signs. “We're also concerned that in practice, some of these homes are at risk of turning into the very types of institutional placements they've been designed to prevent just on a smaller scale.”
“We're also concerned that in practice, some of these homes are at risk of turning into the very types of institutional placements they've been designed to prevent just on a smaller scale.”
Another advocate I spoke with called them “mini-institutions.”
That brings us back to Sevita home administrator Ileya Silva. She says that Sevita took over The Illinois Home in July, 2021. “It appeared to me that from July, pretty much until I was hired, there was absolutely no oversight.”
Ileya was hired in February 2022, so that’s eight months during which, according to Ileya, it appeared that Sevita was not doing the typical things that are required to operate a home like this. That includes internal audits, check ins, and inspections, basically, making sure that staff members are following the rules.
By law, employees are required to go through dozens of hours of training before they’re even allowed to work, but Ileya says staff were not trained on even the most basic things. She found herself spending much of her time on the floor training staff just to try and get them up to speed.
“They didn't know how to process anything,” Ileya tells me. “They didn't know how to check a med out if they had to go on an outing. And, ‘how do we take it with us?’ Just the most basic things.”
Ileya says it’s management’s job to make sure this training happens, and it just wasn’t happening. I obtained a facility report from one of the oversight agencies, called Alta Regional Center. It shows that multiple staff members at all different levels were behind on training, missing certifications, and some didn’t have the experience required to even work in an EBSH.
In addition, Ileya says that staff members were stretched thin. The home was chronically under-staffed and employees worked long hours — sometimes 16 or even 24 hour shifts, according to Ileya and another employee I spoke with.
Ileya says the Illinois Home isn’t an isolated case, either. Sevita was operating two other group homes in the nearby area, as well as dozens of other homes throughout California.
“It was very systemic,” Ileya says. “Like all of the facilities, they would send staff from other facilities and they were at the same deficit. They didn't have the understanding, they didn't know the regs.”
Medication Mismanagement
The clearest example of just how bad things were at the Illinois Home was how staff had handled — or mishandled — medications.
For most roles in a healthcare field, medication management is one of the most tightly controlled, carefully documented aspects of the job. “Every medication you have in your home you need to account for,” says Ileya. EBSHs are no exception.
“We have controlled medications in the home that are abused,” she explains. “In this field, staff do steal medications. It is a reality and it is why there are so many checks and balances.”
Ileya tells me that standard protocol is to destroy unused medications at the end of each month. but, she says that at the Illinois home, “they had a year's worth of backed up meds that had not been destroyed. I have photos of a giant, like, gallon freezer bag that had maybe 150 pills in it. Didn't state what the medications were, didn't state who the medications belonged to.”
“they had a year's worth of backed up meds that had not been destroyed. I have photos of a giant, like, gallon freezer bag that had maybe 150 pills in it."
Ileya shared these photos with me, and she’s actually underselling it here. There are also boxes and a filing cabinet full of leftover meds.
I ask what her reaction to finding that was, given her understanding of how things were supposed to be. She thinks for a moment, and then shakes her head and gives a laugh. “Internal panic.”
Ileya says she also noticed that all of the residents seemed to be on multiple heavy duty medications at extremely high dosages. “It's not very often that you're gonna see all of the meds, and so many of them, prescribed at the maxed out level,” she says.
Katrina herself was on anti-psychotics, sedatives, and other powerful meds. Ileya says that it was similar with the other residents.
When medications are used to sedate a resident to make them more compliant, that’s actually a form of restraint.
“It's not openly described as this, but it's medical restraint,” says Ileya.
It’s also known as chemical restraint. Ileya says she had serious concerns that all the residents in the home were being chemically restrained. This concern was shared by Katrina’s family — Katrina’s father Pat Turner, who is also her conservator, and Elaine Sheffer, her stepmother.
“She's walking hunched over and she walks like a little old lady,” says Elaine. “And her mouth is open and she's drooling. And we're like, this is not Katrina.”
“She's walking hunched over and she walks like a little old lady,” says Elaine. “And her mouth is open and she's drooling. And we're like, this is not Katrina.”
Ileya began building a relationship with Elaine and Pat. The couple are very involved in Katrina’s care, constantly asking staff questions and often demanding changes. It’s a quality they say has not endeared them to leadership at Sevita Health or Alta regional center.
But, Ileya says she understood where they were coming from. “My focus was what can I do? How do we get us back on track?”
The Garage Files
At one point the couple sent Ileya a request for Katrina’s health history. She says she searched throughout the house but couldn’t find the records. Since EBSHs are just converted single family homes, there was also an attached garage that the staff used for storage. She figured what she was looking for must be out there. With the help of some staff, she began searching for Katrina’s health records, sifting through the thousands of files.
“That's when I slowly started to catch things in the notes and the documents that were very alarming,” recalls Ileya. “Things I will honestly tell you, I have never seen in any of the homes that I've ever worked in.”
She tells me about a resident with a neurological disorder who uses a wheelchair. “There were shift notes documenting staff leaving him on the toilet for three to four hours on multiple occasions.”
I was able to confirm this, and many other stories, from copies of shift notes Ileya shared.
One note shows that staff discovered a leaking faucet and mold in the kitchen in February 2022. A complaint investigation report shows that the mold is still an issue eight months later in October.
Ileya says that a lot of the incidents she discovered involved Katrina. One shocking report about Katrina’s behavior suggested to Ileya that she wasn’t getting the water she needed, and that she was forced to find it wherever she could.
“I mean with what they wrote about Katrina,” she recounts. “You know, ‘we caught her drinking out of the toilet again. We've caught her drinking from the sprinklers again, and she's been vomiting because she got a bunch of mud and dirt in her mouth.’ How much was this happening?”
“You know, ‘we caught her drinking out of the toilet again'...How much was this happening?”
Remember, Katrina is supposed to be monitored 24/7. Ileya says that to her, it all suggested serious neglect. She decided to send all of the reports to Pat and Elaine.
She says that reading the reports made her physically sick, and it was heartbreaking to send it to them.
She says that report after report indicated that Katrina was being mistreated. “There was a bunch that I found that I sent them, where it was like unexplained bruises, unexplained marks.” The shift notes seemed to attempt to explain those injuries away. “‘Oh, she fell. Oh, she fell. Oh, this happened,’” Ileya recalls.
I reviewed these shift notes as well. “March 5th, 2022. [Katrina] fell in her room at 11:30pm.” “February 24, 2022, 4:45am. She fell gracefully to the floor.”
Ileya remembers reading this shift note. “She gracefully fell backwards. I mean, when I read that, I'm like, ‘are you kidding me?’”
Another note reads “September 7th, 2021. [Katrina] fell in her room and broke one of her front teeth.”
Ileya says it just didn’t add up. She’d never seen Katrina fall like that. “I always joke that she's kind of like a cat,” Ileya says. “Because when I've seen her trip, slip, because she doesn't put her sock on all the way… she will catch herself. She will twist and turn.”
Ileya found a trail of reports leading up to a black eye and concussion Katrina had suffered in February 2022. She says all the evidence pointed to one person as Katrina’s abuser. The shift notes I reviewed had the names of staff redacted, so I couldn’t verify this. But, I could verify that most of the injuries Katrina suffered during this time happened during the night shift. And, if you were to go just based on the night worker’s shift notes, you’d think nothing was happening.
“And [the night worker’s shift notes] said over and over again that no bruises, uh, no bruises,” says Ileya. “But other staff in the AM were noting that she had marks on her.”
Once the AM staff began their shifts and took over, they kept finding these large holes in Katrina’s walls. To Ileya, it seemed likely that they were caused by Katrina banging her head against the walls repeatedly.
“So for me to see all the damage to her walls,” she says. “It didn't sit right with me because I've never seen her do that. And to me it just said that something was happening on these shifts. That possibly she wasn't being allowed out of the room.”
It’s the only thing Ileya could imagine to explain all of this: certain staff were locking Katrina in her room against her will, all night. And, due to her history of self-harm and trauma, Katrina was hitting her head against the wall repeatedly. It’s a claim echoed by other staff members I’ve spoken with.
“Something was happening to her, pretty brutally,” Ileya says.
“Something was happening to her, pretty brutally,”
Eventually, after another employee turned whistleblower, the licensing agency got involved and the staff member in question was terminated. But, by that time, Ileya says the incidents had already been allowed to continue for months.
She tells me that what’s especially infuriating to her is that management at Sevita Health, the company that owns and operates the home, had been aware that this was happening.
“A staff disclosed to me that they had disclosed to [Sevita’s internal investigator] back in June about this staff, and it was never investigated,” Ileya says. “It’s things like this where something is thrown out there, they really don't investigate it.”
"They really don't investigate it.”
I reached out to that investigator, who referred me back to Sevita.
Some of these allegations are difficult to prove, since we can’t hear from the one person who was affected most: Katrina. But, many of the complaints against the Illinois Home were substantiated by investigators at regulating agencies. As a result, the home was fined twice, as well as sanctioned — essentially it was put on a blacklist and prevented from receiving any new residents.
Sevita declined my interview request, so I sent the company detailed allegations and a list of questions. They declined to comment on specifics, citing the privacy of their residents. They did send me a general statement, which read in part, “Sevita promotes ethical practices at all levels of the organization and we remain committed to our core values of integrity, respect, inclusion, and growth.”
To read the full statement from Sevita Health, click HERE.
In the statement, Sevita also points to staffing challenges across the industry, and says they’ve made “significant investments to attract and retain a dedicated and compassionate workforce.”
And it is true that the caregiving industry is one that faces serious issues. Workers are leaving the field in droves, at the same time that the need is ballooning.
But, as we’ll see in a bit, the story isn’t so simple.
Ileya says that outside of some specific individuals, most of the staff at the Illinois Home were doing their best. Most were undertrained, overworked, and burnt out. And, these were almost all low wage positions with high rates of turnover. She says it was Sevita Health and its management that didn’t follow regulations, failed to follow up on complaints, and fostered a culture of negligence.
Again, Sevita would not respond to Ileya's specific allegations.
A Track Record of Abuse
I wanted to understand more about this company: Sevita Health. How was it possible that this large company with decades of experience running group homes had failed to meet the basic standards of care in this way? And, was this a pattern or a one-off? One of the first things I began to understand is how central the role of money is.
Though some group homes are nonprofits, California allows for-profit companies to operate them as well. A facility like The Illinois Home can bring in a lot of revenue, considering the residents’ high need for services and support. I asked the Department of Developmental Services exactly how much the state paid Sevita Health to house the four residents at The Illinois Home, including Katrina. Their answer? Just over $1.5 million this past fiscal year. It makes sense why the company would want to expand aggressively into the field.
As you keep digging, however, the story gets more complex. Sevita Health is actually owned by two private equity firms: Centerbridge Partners and The Vistria Group. Here’s the rundown on private equity: these are companies that use money from investors to try and make big profits on buying and selling private companies, or companies that are not publicly traded on a stock exchange. Specifically, they try to buy (or invest in) a company at a low price. Then, they attempt to increase its profitability, often by cutting costs. Ultimately, the goal of private equity is to sell the purchased company for much more than they paid for it.
This video on Sevita’s website paints a much more altruistic picture. Over lilting piano music, a heartfelt narrator tells us, “for over 50 years, we've been right here. Here with the individuals we serve. Right here to help them grow as a vital part of their community. We meet them where they are.”
Here’s where it gets strange, though. The video tells us that Sevita has been around for 50 years, but if you check online records, Sevita has only been in existence since 2021. That’s the year the company did a rebrand. Sevita Health used to go by a different name — The Mentor Network. And, it turns out the Mentor Network had quite a reputation.
“It has had a host of allegations of abuse, neglect, mistreatment of people under Mentor Network's care,” says Eileen O’Grady. She’s a lead researcher at the Private Equity Stakeholder Project, a nonprofit that researches private equity’s impact on communities and industries, including group homes. In 2022, she authored a report that digs into the allegations that have swirled around the company.
“[Sevita Health] has been investigated by a Senate committee,” Eileen says. “It's been investigated multiple times by state regulatory agencies for abuse.”
One of Sevita/Mentor’s major lines of business is running youth foster homes. The Senate investigation Eileen is referring to found that, over a decade, at least 86 children died at homes run by the company, or 42% higher than the national average. And, the committee found that the company only conducted internal investigations in 13 of those deaths.
At least 86 children died at homes run by the company, or 42% higher than the national average.
That Senate investigation was prompted in part by a sweeping 2015 investigation by Buzzfeed News. In one article, Buzzfeed “identified deaths, sex abuse, and blunders in screening, training, and overseeing foster parents at the nation’s largest for-profit foster care company.”
More recently, the US Senate investigated Sevita/Mentor subsidiaries in Oregon and Iowa that ran homes for disabled adults. It found residents were subjected to abuse, including sexual abuse, substandard care, lack of training, and extreme neglect. In one 2017 case in Oregon, a resident’s bed sores became so severe after months of neglect, they had to be relocated to a hospital over 200 miles away for treatment.
In 2018, a Sevita/Mentor program supervisor in Iowa groomed a developmentally disabled resident for months before sexually abusing them. The supervisor was eventually arrested and pleaded guilty.
Through the same time period, Sevita/Mentor has been intensely profitable. Remember those two private equity firms that own the company? Eileen O’Grady says they’ve been making a lot of money.
“The last two private equity firms that bought it in March, 2019, CenterBridge Partners in the Vistria Group,” Eileen says. “Have piled debt onto The Mentor Network and used the proceeds of that debt to pay themselves hundreds of millions of dollars. It's unconscionable that they should be making profits hand over fist just to the private equity firms while the company is continuing to mistreat the people under its care.”
"It's unconscionable that they should be making profits hand over fist...while the company is continuing to mistreat the people under its care.”
Again, Sevita declined to comment on this.
A Dysfunctional Cycle
In late 2022, Ileya, the Sevita administrator at The Illinois Home, was sharing any and all incident reports with Katrina's parents, Pat and Elaine. And, as Ileya pushed for more transparency and accountability within the company, she says it strained her relationships with her superiors.
“Where the tides started turning for me,” says Ileya. “Was because I was seen as a problem, because I wasn't moving in the manner of ‘we're protecting company over all else.’”
"I was seen as a problem, because I wasn't moving in the manner of ‘we're protecting company over all else.’”
She says that one day she was talking to another administrator who told her that one of her managers had made a comment: “‘We're trying to get rid of Ileya. She hasn't done anything yet for us to get her out of here. So we just have to wait until she does something.’”
At the time of our interview, in January 2023, Ileya had been suspended from her job.
As we near the end of our interview, I can feel the gravity of what she’s telling me. I ask her why she decided to come forward, knowing the risks to herself and her career.
“I don't want this to be the situation where I turn on the news one day and one of the clients has died,” she replies. “And I just can't have that on my conscience… that I didn't say something, I didn't do something.”
I connect with Ileya a few months later. She’s in her car at a parking lot, talking to me over Zoom from her phone. She says that in the time that she was out on suspension, the home had been cited several more times. Sevita Health actually brought her back to The Illinois Home to help, but she became overworked and burnt out. She began having dangerously high blood pressure.
I was having heart palpitations,” Ileya tells me. “I had had a really, like progressively bad headache, but then I was also getting back pain.”
In March, 2023, Ileya went on medical leave. When she thinks about the situation at the home, and with Sevita Health, she says she felt stuck in a dysfunctional cycle.
She says she felt stuck in a dysfunctional cycle.
As for Katrina and her family, as of June 30, 2023 — that’s over a year and a half after Katrina got the black eye and concussion – Sevita Health is no longer running the Illinois Home. According to the Department of Developmental Services, Sevita Health no longer operates any EBSHs in California. However, it still runs more than 20 residential facilities, and a number of day programs for adults with developmental disabilities in California.
This series was produced as a part of the USC Annenberg Center for Health Journalism’s 2022 Data Journalism Fellowship.
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