AJC investigation: State actions inadequate to halt group home’s long slide into anarchy
By Alan Judd, email@example.com
The Atlanta Journal–Constitution
4:24 a.m. Monday, April 19, 2010
Even before the riot, state regulators found plenty wrong at the Downing Clark Center.
They said the group home for foster children had detained a resident in a filthy isolation room as long as 24 hours at a time. They cited the facility because employees had been too distracted to notice suicide attempts, had stood by as one resident attacked another, and had propositioned teenagers placed there for protection.
By Jan. 4, residents had gone days without the medicines that helped control their behavior: antidepressant and antipsychotic drugs that had not been dispensed after the home’s nurse quit.
That night, residents roamed free through Downing Clark’s dormitories. They ripped fixtures from the walls. They smashed television screens. They beat others who were younger and smaller. It took three hours, more than two dozen sheriff’s deputies and state troopers and 20 arrests to quell the disturbance.
Capt. T.M. Goswick of the Gordon County sheriff’s office later gave this third–person account: “During this event, Captain Goswick, after serving numerous years in the military and in law enforcement, had never seen or heard as much foul language used and abusive actions taken by anyone, much less young females.”
The descent into anarchy at Downing Clark, a residential treatment facility near Calhoun for teenage girls with psychological and behavioral disorders, is detailed in state inspection records and police reports. It mirrors the disarray that pervades Georgia’s system of publicly funded but privately operated foster care, an investigation by The Atlanta Journal–Constitution shows.
Children who are removed from their families for protection often are subjected to additional abuse and neglect in foster care, according to the Journal–Constitution’s investigation, based on interviews and examination of more than 1,500 state reports. But state regulators seldom punish private foster agencies where maltreatment occurs, the newspaper found.
Authorities inspected Downing Clark 38 times from January 2008 to January 2010. Sixteen times, they cited the facility for a total of more than 80 rules violations. Six citations resulted in penalties, but in two of those cases, state officials reduced the original punishment.
The state may impose fines or, in cases where a rules violation causes a child’s death or physical or emotional harm, may revoke a foster care agency’s license. But shutting down any facility further stresses a system already short of space and money.
“There’s a big balancing act,” said Karen Worthington, director of the Barton Child Law and Policy Center at Emory University. “Do you close down a facility, or do you try to work it out and hope the worst doesn’t happen?”
Officials took the latter approach at Downing Clark, interviews, inspection reports and other public documents suggest. In doing so, they failed to take advantage of numerous chances to intervene before the facility finally imploded.
“All I can assume,” said Melissa Carter, the state child advocate, “is it wasn’t being watched closely enough.”
“At Downing Clark Center, priority #1 is always keeping the GIRLS safe and secure!”
On the facility’s Web site, “girls” is printed in alternating orange and blue capital letters.
Downing Clark opened five years ago on 23 acres in rural Gordon County, established by two sisters experienced in the foster care industry: Cindy Downing and Kelli Clark. Their goal, the women say on the Web, was to provide girls 6 to 17 with a “colorful kid friendly home–like treatment setting.”
The facility’s grounds, 60 miles north of Atlanta, feature a swimming pool, a horse barn and unobstructed views of North Georgia’s verdant mountains. But the tranquility, officials say, is deceptive.
From 2008 to 2010, Gordon County’s 911 center received 199 calls for service at Downing Clark – an emergency every three to four days. Assaults, escapes, fights: the list of calls runs five pages, single-spaced.
In interviews, Clark and Downing said police reports and state investigations portray their facility in a bad light. Regulators, Clark said, operate with “a witch-hunt mentality,” and minor deficiencies may lead to sanctions.
“It’s very, very frustrating to me, where it’s really not about the kids any more,” Clark said. “It’s more about the politics.”
Her sister added: “We put our heart and soul into this facility. This is our life’s work.”
Tension between Downing Clark and state regulators escalated in March 2008 after a resident reported that a staff member choked her.
A state inspector confirmed that allegation – and more.
Another resident had been strip-searched by staff members looking for contraband. When she resisted, one staff member held the girl’s shoulders while another yanked off her underpants. They found no contraband.
Other residents complained about a filthy isolation room for girls who misbehaved. Girls had urinated and defecated and smeared blood around the room, which residents said was rarely cleaned. They told an inspector of being forced to enter the room barefoot, and some said they were kept there at least 24 hours. State rules forbid seclusions lasting more than one hour.
The state cited Downing Clark for 11 rules violations.
Two weeks later, after another complaint, a state inspector returned to Downing Clark. This time, the facility was cited for failing to protect the children in its care, among other violations.
A resident reported she had been beaten by another girl while two staff members watched without intervening. The resident was bleeding from her ear and had swelling in her right temple; an emergency room doctor said she had minor head trauma.
The two March investigations led state regulators to take the rarest of disciplinary actions: They said they were revoking the facility’s license.
The state quickly abandoned that plan.
In a settlement agreement, Downing Clark kept its license by pledging “substantial compliance” with rules governing group homes. That meant no new violations that endangered the girls and no repeat violations of less serious rules.
Two months later, the state again cited Downing Clark for not protecting its residents.
From May to August 2008, according to state reports, the facility’s employees allowed one girl’s dangerous behavior to escalate: In May, she tied a string around her neck in a suicide attempt. In June, she cut her arms with broken pieces of hard plastic. In August, while a staff member was distracted, she drank a mixture of apple juice and bleach in another suicide attempt. Later, she shattered a light bulb and chewed on the pieces.
The state imposed no penalty, an inspector wrote, because Downing Clark already was “in the midst of implementing” a plan to correct the deficiencies cited earlier.
Violations continued into 2009, however.
In February, another girl attempted suicide despite being on what the facility described as “tight one-to-one supervision” because of her self-destructive tendencies. She was in a common area, supposedly watched by a staff member across the room, but went alone into a telephone booth and broke a light bulb. No one searched her for any of the shattered pieces. Unsupervised, she went into a bathroom and used the broken bulb to slash deep cuts into her right arm. A doctor closed the girl’s wounds with six staples.
The facility’s failure to protect the girl, a state inspector wrote, “may result in an adverse action.”
Several weeks later, the state said it would fine Downing Clark $500 over the episode. But after “supervisory review,” records show, officials reduced the penalty to $300 and downgraded the severity of the citation – even though Downing Clark had been cited for three other serious violations while this case was under review.
In one instance, a staff member sat by while a girl kicked loose a steel rod from the door of an isolation room, broke a light fixture and cut her wrist. In another, a male staff member fondled and propositioned one girl and engaged in sexual foreplay with another. In the third case, the facility failed to promptly get medical attention for a girl whose nose was broken in an assault by another resident.
“We tried to use a nudge versus the big stick,” said Keith Bostick, director of the state Office of Residential Child Care, which enforces foster care rules. “They continued to have issues.”
By the end of 2009, conditions at Downing Clark had deteriorated. The staff nurse had quit, state records say, and no one else administered the residents’ prescriptions. Residents may have gone as long as eight days without drugs to control diabetes, seizures and high blood pressure. Downing said staff members may have failed to document medicines they dispensed.
Many girls also went without antidepressant and antipsychotic drugs. One of the drugs, Risperdal, is used to prevent such behavioral aberrations as sudden mood changes, self-injury and aggression.
‘Out of Control’
Downing Clark housed 43 girls on Jan. 4, with eight staff members on duty by late evening. One of those would walk off the job before midnight.
About 8 p.m., according to state reports, several girls got into a fight – the first of at least four altercations that evening. Three to four staff members had to break up each fight, leaving other girls unattended.
“The residents,” an employee later told a state inspector, “were out of control.”
At one point, a fire alarm sounded. Girls attacked staff members – pulling hair, throwing punches – and fought among themselves. Some residents roamed the halls, attacking other girls in their rooms or in common areas.
About 10:30, two sheriff’s deputies arrived amid what a police report would later describe as “total chaos.”
“Staff members had no control over the situation,” the report said, “and were struck several times by juveniles.”
Capt. Goswick, the sheriff’s chief of detectives, got to Downing Clark about an hour later. He wrote that he saw a group of girls running outside, and he followed.
“Captain Goswick attempted to stop the group of females, and was immediately accosted by at least two. … Other females in the group, and the two that accosted Captain Goswick, were continuously using very, very vulgar language, and making threatening comments to Captain Goswick.”
Other officers joined him and tried to calm the girls.
“This proved to be futile,” Goswick wrote, “as the females began accosting these officers.”
Two detectives fought with the girls; one officer was bitten on the hand.
The disturbance quieted sometime after 11:30. The police arrested 20 girls on charges that included rioting, obstructing police officers and damaging property. Because they were 17, five girls face charges as adults and could be sentenced to a year in jail.
Worthington, of the Barton child law center at Emory, said the outcome was not surprising, considering the residents apparently had been off their medications.
“Adults responsible for the children’s care should have taken measures to prevent an outcome like this,” Worthington said. She characterized the situation as “medical neglect” that may have contributed to the girls’ criminal charges.
Clark and Downing both refer to the episode as “the incident.” Clark depicted the evening as a pajama party gone bad – all, she said, because of one girl’s “prank 911 phone call” that brought the police.
“The girls who were arrested were not rioting with each other or with the staff,” Clark said. “They were walking around in their pajamas.”
The women claim deputies incited the girls’ behavior.
“That stinks,” Clark said. “We as a system should have done a lot better job protecting those kids from, unfortunately, our own law enforcement department.”
The riot – or incident – prompted the state to again move to revoke Downing Clark’s license. Officials have moved all of the facility’s residents, starting with the 20 who were arrested.
“We worked a long time with them trying to help them right the ship,” said Bostick, the chief state regulator. “They didn’t get it.”
Now, dorms sit empty. The facility’s horses and other animals have been taken to other farms. The facility has laid off most of its 80 employees.
“We’ve had our share of faux pas and missteps,” Downing said last week. “We just never thought we had done anything to jeopardize our license.”
Downing Clark is appealing the revocation. The state has not offered to negotiate a settlement, so far.
Twenty foster children went to jail after a disturbance at their North Georgia group home. Before the riot, regulators did little to intervene.
Sisters Cindy Downing and Kelli Clark thought such amenities as a pool and a horse barn (above) would create a therapeutic setting for emotionally disturbed foster children. But a five-page, single-spaced list of 911 calls from the Downing Clark Center since 2008 (left) suggests a more chaotic environment.
How we got the story
For this series of articles exploring Georgia’s increasing reliance on private agencies to operate the state’s child welfare system, The Atlanta Journal–Constitution examined more than 1,500 state reports and other public documents and interviewed foster care providers, state officials and children’s advocates. Today’s article is based on state inspection and investigation reports of the Downing Clark Center, on police reports and records from Gordon County’s 911 center and on interviews with law enforcement authorities, children’s advocates, and the facility’s owners.
In the series:
Substandard conditions in privately operated foster care settings seldom incur penalties.
A riot at a North Georgia group home for foster children was the culmination of a long slide into chaos and of the state’s failure to intervene.
Breakdowns in multi-state adoptions arranged by a private agency from Georgia largely escape the attention of state regulators.
Private adoption and foster care agencies are supposed to be not-for-profit organizations. That doesn’t stop some agency officials from turning child welfare into a lucrative enterprise.
Find this article at: http://www.ajc.com/news/riot-at-downing-clark-473183.html