Gov. Gavin Newsom is moving to impose minimum staffing requirements in California’s psychiatric hospitals in response to a Chronicle investigative series that spotlighted rampant abuse and neglect tied to understaffing in many of the locked facilities.
Finalist: Cynthia Dizikes and Joaquin Palomino of the San Francisco Chronicle
For their meticulous and heart-wrenching reporting on California’s psychiatric hospitals that put profits over patients and endangered some of the state’s most vulnerable citizens.
Nominated Work
February 26, 2025
By Joaquin Palomino and Cynthia Dizikes
The sun had burned through the fog on a Saturday morning last April when residents of a hilltop neighborhood on the outskirts of San Francisco noticed a girl face down in a driveway. Her arms lay above her head. A black jacket hung off her body.
At first, neighbors on the steep street of worn, pastel row homes thought she might be homeless and sleeping. But when they turned her over, she didn’t move. Her skin was pale, her arms marked by scars. She had braces on her teeth.
Police soon identified the girl by her fingerprints as Jázmin Pellegrini, a 15-year-old from the East Bay suburbs who had gone missing days earlier.
“They said, ‘Jázmin is dead,’ and the whole world went black,” her mother, Márta Bárány, told the Chronicle. “I just couldn’t believe it. I heard their words, but I did not believe it.”
The death of an adolescent girl in the Oceanview neighborhood was a mystery that shocked the city. But even before local authorities examined her body, Jázmin’s mother knew the underlying cause. Severe mental illness had ravaged Jázmin for the last two years of her life.
Depression and trauma from early childhood sexual abuse drove Jázmin to self-medicate, run away and intentionally hurt herself. She was repeatedly detained in locked psychiatric hospitals operated by for-profit companies. These facilities are intended to stabilize children and adults in mental health crises while keeping them safe.
But rather than help, they subjected Jázmin to chaotic conditions and deficient care, according to a Chronicle investigation based on Jázmin’s medical records, state health department documents, input from four experts in adolescent mental health and extensive interviews with Jázmin’s family.
Then, despite desperate efforts by her mother and other mental health care providers to secure passage to a long-term residential treatment program, the hospitals repeatedly sent Jázmin home, even when people closest to her said she still posed a grave risk to herself. This propelled a dizzying cycle of admissions and discharges leading up to her death.
Jázmin’s first hospitalization in a for-profit facility came in 2022, when she was 13. She received limited treatment, then cut herself after staff members at a Sacramento hospital run by the behavioral health care giant Universal Health Services appeared to dismiss concerns about her emotional state.
The following year, Jázmin’s mental health deteriorated after employees failed to properly monitor her and she had sex with another patient at a Santa Rosa facility run by Signature Healthcare Services, the fastest growing operator of psychiatric hospitals in California. She later told a hospital caregiver that the incidents “hurt me emotionally since (they) reminded me of the past.”
Then last March, one month before she died, staff members at a San Jose hospital run by the national chain Acadia Healthcare regularly injected Jázmin with sedatives to calm her down, despite evidence in her medical record that the teenager had developed a dependency on the drugs and would act out in order to receive them. Jázmin also managed to grab and swallow other patients’ medications twice in attempts to take her own life — safety lapses that, according to state regulations, never should have occurred.
“Mom, they’re taking me to the emergency room,” Jázmin said in a voicemail she left for Márta, using the hospital’s phone, after her first overdose attempt in the facility. “I love you. I love you.”
The Chronicle investigated Jázmin’s case as part of a broader examination of for-profit psychiatric hospitals, which are a central piece of Gov. Gavin Newsom’s sweeping behavioral health care reforms. Reporters found that these facilities have grown in recent years to become the backbone of the state’s emergency mental health care system, treating an expanding share of children in crisis despite racking up an outsized share of serious safety violations.
Psychiatric hospitals, in general, serve an inherently challenging population — people who are being detained because they actively pose a threat to themselves or others. Even the best-run facilities can struggle to provide effective treatment during stays that last just over one week on average.
But across California’s for-profit psychiatric hospitals, nearly all of which are run by Signature, Universal and Acadia, hundreds of patients have reported being physically and sexually abused in recent years, police and state health records show. They have received little to no therapy in some facilities because there was not enough staff to provide it. And, at times, they have seriously injured themselves, or died, when no one was watching.
Together, Signature and Universal have cornered the market on adolescent acute psychiatric care in California, with Acadia expanding its presence in the state. In 2022, the most recent year with available state data, these companies operated a majority of the 775 beds for children and teenagers in hospitals approved to forcibly treat patients on “5150” holds, a reference to the state law that allows authorities to detain people to protect them from harming themselves or others.
Girls have been disproportionately affected by this profit-driven system. More than two-thirds of the 17,600 adolescents discharged from for-profit psychiatric hospitals in 2022 identified as female, according to a Chronicle analysis of state data.
Jázmin’s death speaks to what is at stake under Newsom’s mental health care reforms, which are positioned to expand who can be forced into these facilities on 5150 holds, without reckoning with the conditions behind their locked doors.
The governor’s office declined to comment on Jázmin’s case, but his administration said in a statement that the state’s public health agency would investigate the care she received in for-profit psychiatric hospitals to see if there had been any violations of state law or regulations.
“The Chronicle’s investigation raises serious concern about the quality of care received by these individuals,” said Newsom spokesperson Elana Ross, referring to the broader safety violations in for-profit psychiatric hospitals. “We take each incident seriously and will be reviewing the care standards for psychiatric hospitals.”
Ross added that the Newsom administration is working to address California’s shortage of adolescent residential treatment programs — the type of facilities that experts said could have offered Jázmin longer-term care and potentially broken her cycle of hospitalizations. Through a $6.4 billion bond measure, Ross said, the governor is “taking dramatic steps to increase access to a variety of behavioral health services, including building new residential facilities.”
Signature, Universal and Acadia did not respond to specific questions about Jázmin’s care, citing patient privacy laws, even though reporters offered to send signed HIPAA waivers from Jázmin’s mother giving them permission to talk about her case.
The companies all disputed the Chronicle’s broader findings about understaffing, violence and neglect in their psychiatric hospitals, saying the vast majority of people treated in their facilities receive effective care in a safe environment and have positive experiences.
For this investigation, Jázmin’s family shared an expansive — though not complete — set of medical records with the Chronicle. The documents indicate that Jázmin was hospitalized roughly 40 times between March 2022 and April 2024 in nearly a dozen different locked for-profit and nonprofit psychiatric hospitals, psychiatric units in general hospitals and emergency departments.
Two years, seven counties, 10 facilities — and one patient
This scattershot hospital care appeared to leave Jázmin without a coordinated treatment plan, particularly with medication. Over those two years, doctors started and stopped more than a dozen different antidepressants, mood stabilizers, antihistamines and other pharmaceuticals. Experts said such a complex combination of drugs in adolescents has unknown side effects.
In the brief periods when Jázmin was at home she received therapy and other services from community-based providers. But given how frequently she was hospitalized — and the inability of multiple agencies to connect her to residential care — the locked facilities became her primary mental health support.
With Márta’s permission, the Chronicle had four experts in adolescent mental health review portions of Jázmin’s records to evaluate the treatment she received in for-profit psychiatric hospitals.
All said that, at times, the erratic care and lack of supervision in these facilities appeared to worsen Jázmin’s mental health. Even when critically ill, children facing profound emotional struggles are often able to begin rebuilding their lives if given proper therapy and medication in a safe and supportive environment, the experts said.
“These inpatient units failed this girl,” said Dr. Christopher Bellonci, a psychiatrist and assistant professor of adolescent psychiatry at Harvard Medical School, after reviewing Jázmin’s hospital records. “It is tragic that she died, because this was treatable.”
Márta, who immigrated with her family from Hungary, said she tried her best to navigate California’s convoluted behavioral health care system while raising her five other children and adjusting to life in a different country.
In interviews conducted with the assistance of a Hungarian interpreter over several months, Márta said she would see flickers of the happy child Jázmin had once been.
She would skateboard with friends, play with her siblings in the family’s pool and laugh while braiding her mother’s long black hair. At night, Jázmin would often stay up late with her older sister, Dorina, practicing English and talking about what they might be when they grew up.
Márta trusted this version of Jázmin would return. Instead, Jázmin died on April 20 from a fentanyl overdose, her body discovered on the slanted street in San Francisco overlooking the city’s skyline.
Jázmin was 10 when her family moved to California from Budapest in the summer of 2019. In their new country, Márta remembers, her daughter felt free.
Jázmin settled with her mother, stepfather and siblings in Bay Point, a working-class suburb in Contra Costa County, joining a network of relatives who had lived in the Bay Area for years. Jázmin explored the wetlands along Suisun Bay, climbed trees in the East Bay and swam past the wave break in Santa Cruz, which reminded her of towns she had visited on the Adriatic Sea.
In a painting of her family that Márta commissioned, she had the artist depict each of her children in their most natural state. Jázmin balanced atop a picket fence, grinning and holding a paintbrush, with her arms outstretched toward a passing butterfly.
“Jázmin was a miraculous creature,” Márta said.
But in the summer of 2021, when Jázmin was 12, she told her mother that for years before moving to the United States, she had been molested by her grandfather, who was still in Hungary. As local police launched a criminal investigation, Jázmin began reliving the abuse. The family said they were unable to travel back to Hungary to testify and the inquiry was ultimately closed without criminal charges.
Jázmin struggled to manage her pain, becoming withdrawn and unpredictable. In March 2022, she attempted to cut herself and was admitted to the psychiatric unit of a medical hospital on the Peninsula. Around this time, she was diagnosed with major depressive disorder and post-traumatic stress disorder and prescribed two psychiatric medications.
Back at home, she complained about dizziness and fainting episodes. Both are possible side effects of the medications, and she decided to stop taking them.
About two months later, on May 24, 2022, Jázmin told her family that she had “thoughts of killing herself.” Sheriff’s deputies placed her on a 5150 hold. Once detained, neither patients nor their relatives have final say on where they go for treatment. The decision typically comes down to which facility has an open bed and is willing to accept a patient and their insurance.
In Jázmin’s case, that meant a 70-mile ride in the back of an ambulance to Sierra Vista Hospital, in Sacramento.
Sierra Vista is run by Universal Health Services, a multibillion-dollar company based in Pennsylvania that operates about a quarter of the state’s acute adolescent psychiatric beds allowed to treat people on involuntary holds. Numerous patients have reported being physically and sexually abused at Universal’s California facilities in recent years, resulting in lawsuits, calls to police and citations by state health officials. The company has denied that its hospitals are unsafe.
On May 27, Jázmin’s first full day at Sierra Vista, other patients began “engaging in conflict,” causing staff to order everyone to stay in their rooms. Patients were "triggered by the event” and needed nurses and mental health workers to help calm them down, according to Jázmin’s medical records.
Beyond medications, records indicate treatment at Sierra Vista was mostly group activities, such as art, stretching and discussing coping skills. Jázmin had limited interactions with doctors, and nurses documented that she was making “minimal progress.” She lay in bed, facing the wall, and described her mood as “bad, every single day.”
On June 4, Jázmin told nurses that her roommate was crying and self-harming by picking at scars. The roommate’s distress was deepening Jázmin’s own feelings of hopelessness. But Sierra Vista staff members appeared not to separate the two struggling patients, or check on Jázmin more often, according to her medical records. Instead, they had put Jázmin on the hospital’s least-restrictive monitoring, observing her once every 15 minutes.
Three days later, Jázmin’s roommate banged her head against the wall, causing Jázmin to become so “upset and anxious” that she cut herself — the very harm Sierra Vista was supposed to protect her from.
“Putting two kids in a room like this, and then not listening when it is making one of the patients worse, can absolutely make it a horrible situation for that patient and increase the likelihood that they would harm themselves in the hospital,” said Jonathan Singer, a licensed clinical social worker, professor at Loyola University Chicago and expert in suicide prevention.
Jázmin cried as she told a nurse she regretted what she had done. Medical records do not explain how Jázmin cut herself inside a locked facility that is required to keep sharp objects far out of reach, nor do they provide the extent of her injuries.
In response to the Chronicle’s detailed summary of Jázmin’s hospital stay at Sierra Vista, Universal spokesperson Jane Crawford said “the narrative as presented is incomplete,” emphasizing that Jázmin was discharged more than a year before she died.
Crawford added that Universal facilities prioritize “high quality, evidence-based patient care,” and that in patient surveys last year, 93% of the respondents at the company’s California psychiatric hospitals said they felt better after receiving treatment. “While even one incident of harm is one too many, the rates of such occurrences are extremely rare,” Crawford said.
At Sierra Vista, Jázmin tested positive for COVID-19 on June 8, 2022, and spent her last seven days in the hospital isolated and sick in her room. The group therapy she had been receiving appeared to have stopped, records show.
At home, Márta prepared for Jázmin’s return, locking away sharp objects and medications, and installing cameras to more closely monitor her. Jázmin had been gone for three weeks and Márta was eager for their family to be together again.
As the hospital planned for her discharge, staff asked Jázmin to list the places and people that could help when she felt overwhelmed. Going to the beach, she said, and talking to her aunt and cousins.
When asked to name one thing that was important and worth living for, Jázmin responded: “My family.”
Jázmin tried to resume a normal life. In the summer of 2022, she and her family took their usual trip to her great-uncle’s Sierra cabin near Calaveras Big Trees State Park, spending the days swimming and walking the family dog, Benicia, through the towering redwoods and pines.
The family later adopted a second dog they named Rigo, which refers to a small bird in Hungarian. Márta hoped he might provide emotional support to her daughter.
Jázmin said she had plans of going to college and getting tattoos to cover the scars on her arms. But the abuse during early childhood made the depression in her adolescence unbearable, driving a frantic search for relief.
Jázmin sought reprieve through self-harm, hospital-administered sedatives and, several times, through illicit substances she obtained on the streets by men who sexually abused her, further deepening her trauma.
“Every touch is a burn, it hurts, it destroys me,” she wrote during a hospitalization toward the end of her life.
Between July 2022 and July 2023, Jázmin was hospitalized at least 19 times. She spent days or weeks in six different facilities, including a local emergency department, as well as for-profit and nonprofit psychiatric hospitals, after hurting herself or threatening suicide.
During this time, Jázmin said she wanted “to get better,” but seemed “genuinely at a loss” about how to do that, according to records.
Still, people who crossed paths with Jázmin in the hospitals told the Chronicle she would try to help others, comforting teenagers who were scared, holding their hands when they cried and sometimes sneaking cookies from the staff members for struggling friends.
“She had the most beautiful soul,” a teenager who was hospitalized with Jázmin in 2023 at Universal’s Fremont Hospital texted to Márta. “Even in the horrible situation we were put in.”
After being discharged from the facility, the teen also wrote a letter to Jázmin expressing hope for her future. “You are so funny, kind hearted, smart, and fun to be around,” she wrote. “Your life will eventually turn around and this will be a part of your life that you will look back on.”
But the inconsistent treatment that Jázmin received in the facilities, and ever-shifting mix of medications, only seemed to destabilize her more, Márta said.
In just eight months, Jázmin was intermittently prescribed three mood stabilizers and three antihistamines for anxiety in addition to the antidepressant and antihypertensive for PTSD that she was already taking. There is little to no evidence, experts told the Chronicle, that using such a mix of drugs is effective in adolescents.
“The more medications you are on, the more side effects you are going to have,” said Lisa Cosgrove, a clinical psychologist and professor at the University of Massachusetts Boston. “It can have the unintended effect of making people guinea pigs because we don't know what this combination of drugs does.”
Márta said her daughter was rapidly gaining weight and increasingly disoriented, sometimes returning to a hospital days to weeks after her last discharge.
Then, on Oct. 31, 2023, as the family was getting ready to go trick-or-treating, Jázmin tried to overdose on her antihistamine medication. She was sent to Santa Rosa Behavioral Healthcare Hospital run by Signature, a Southern California-based company that has a particularly troubling track record of safety violations.
State health records show Santa Rosa Behavioral was critically understaffed at multiple points that year, contributing to a spate of serious patient safety incidents.
A riot in the adolescent unit prompted police to enter the hospital with loaded guns. Patients were beaten and sexually assaulted by their peers. And a man, who had previously tried to hang himself in the facility, was able to attempt suicide again when staff did not properly monitor him. The company has denied there are widespread problems in its facilities.
Jázmin had been in Santa Rosa Behavioral just a day when she was able to have sexual intercourse with another patient. The following afternoon, they were able to have sex again. The boy reported that he felt pressured into the interactions, state health records show, while Jázmin said she had been retraumatized by what had occurred.
The hospital called Márta asking permission to give Jázmin the morning-after pill. Márta said she felt that the staff member’s tone was distant when they spoke, and they offered no suggestions for how the family could help Jázmin process what had occurred.
State health records presented the incidents as consensual. But Márta questioned how that was possible when Jázmin and many of the other patients in the facility had been deemed unable to take care of themselves or make safe decisions.
Susan Matorin, a senior lecturer of social work in psychiatry and a family therapist at Weill Cornell Medicine, called the incidents an “egregious breach of security,” particularly given Jázmin’s documented history of being sexually abused. “That is one of the worst things that can happen in a unit,” Matorin told the Chronicle. “This is very bad, tragic care.”
Santa Rosa Behavioral’s own policies ban sexual contact between patients “regardless of age or perceived consent” because of the potential to “negatively impact progress towards treatment goals and / or cause harm to both the patient and others.”
A subsequent investigation by the California Department of Public Health found that the hospital was not properly staffed at the time of the incidents and employees had failed to adequately monitor Jázmin and the other teen. One of the workers was later fired for “multiple disciplinary issues,” including falsifying patient observation records.
“How is it even possible that children who are under psychiatric care, and cannot control themselves, are not being kept safe?” Márta told the Chronicle.
For the next three weeks, Jázmin complained of nightmares and of seeing “shadows” when she was awake. A former Santa Rosa Behavioral employee, who requested anonymity due to concerns of professional repercussions, recalled that Jázmin’s nightmares were so bad she asked for caffeine to keep her awake and begged the worker to stay by her side through the night.
On Nov. 24, 2023, Jázmin said she hallucinated that she was being sexually assaulted and banged her head against a wall, leaving such a large welt on her forehead that she was sent to a local emergency department for treatment, according to medical records.
Eight days later, Santa Rosa Behavioral cleared her for discharge.
In a statement, a Signature spokesperson said the company is “dedicated to providing the best and safest care for all patients” and called the Chronicle’s broader findings about deficient care in their hospitals “alarmingly misleading.” Signature did not respond to a request for further details.
“No health care provider achieves 100% positive patient outcomes, regardless of the health care specialty,” the spokesperson said. “Oftentimes, patients come to our hospitals with serious intent to harm themselves or others. The hospitals utilize evidence-based treatment protocols to mitigate these risks, but they cannot guarantee an outcome — no hospital can.”
Márta said she was barely able to speak to Jázmin during the monthlong hospital stay at Santa Rosa Behavioral. Whenever she called, staff members told her Jázmin was asleep or unavailable. Unaware of her precarious condition, Márta prepared her daughter’s favorite meal: a beef soup with broth that cooked for several days, along with mochi ice cream for dessert.
“I was always so excited when she was coming home,” Márta said.
But when Jázmin walked through the door, Márta could see that her daughter was shattered.
“My body is still here,” Jázmin told her mother. “But my soul is dead.”
March 5, 2025
By Cynthia Dizikes and Joaquin Palomino
Soon after taking office in 2019, Gov. Gavin Newsom vowed to finally fix a crisis that had come to define California. Emergency rooms were overflowing with people routed by depression, drug addiction and psychosis, many with unstable housing and nowhere to go except the streets.
“This is California’s original sin,” Newsom would say, pointing to decades of government mistakes and neglect that had left the state with a severe shortage of psychiatric treatment beds and narrow restrictions on who could be forced into them. “This is the manifestation of our failure.”
For the first time in a generation, California would pour billions of dollars into mental health facilities while making it easier to lock people in some of them. Those who had long been overlooked, Newsom pledged, would receive stabilizing medication and therapy to help them return to their communities, families, schools and careers.
Yet a Chronicle investigation has found that the institutions Newsom’s administration is increasingly relying on are themselves a public health catastrophe.
Psychiatric hospitals operated by for-profit companies are now the fastest-growing destination for tens of thousands of Californians experiencing mental health emergencies.
But instead of offering a healing respite, reporters found that these companies have capitalized on lax state regulations to strip their workforces bare, generating massive earnings for investors and owners while exposing patients to erratic care, violence and deadly neglect.
The fallout over the past six years has been statewide and devastating. Hundreds of patients have reported being beaten and sexually assaulted, leaving them bloodied, bruised and begging to go home. They have struggled to breathe under dangerous and improper restraints. And some have died, unnoticed in their bedrooms and bathrooms, after these facilities failed at their most basic job: to watch them.
The California Department of Public Health, which licenses and oversees psychiatric hospitals, has long known of these dangers. Yet Newsom’s administration has allowed many of the state’s for-profit facilities to provide woefully inadequate care, largely without consequence, while rewarding some with lucrative state contracts and new licenses to intervene in more frayed lives.
“I would literally run away from anyone who tried to put me back there — it felt like a prison,” said Miriam Revesz of her involuntary admissions in 2019 to two for-profit psychiatric facilities.
Miriam said she needed help for severe anxiety and depression, but was physically attacked and sexually assaulted by a roommate at a for-profit in the Los Angeles area when staff members weren’t monitoring them.
“I just remember losing myself completely,” she said, “to where I wanted to die.”
Newsom declined to be interviewed for this article, but in response to a detailed summary of the Chronicle’s findings, his administration said that it would review its oversight of psychiatric hospitals, including how the state’s health agency investigates complaints, as well as staffing requirements for these facilities.
“The Chronicle’s investigation raises serious concern about the quality of care received by these individuals,” Newsom spokesperson Elana Ross said. “We take each incident seriously and will be reviewing the care standards for psychiatric hospitals.”
A spokesperson for the California Department of Public Health (CDPH) said the agency will also investigate incidents spotlighted by the Chronicle “to further examine the issues and take potential action.”
“This includes, but is not limited to, potentially opening complaints on our own end against one or all locations to further look into any potential missteps on the part of the facilities,” department spokesperson Mark Smith said.
For this investigation, the Chronicle interviewed more than 100 people, including patients and their families, frontline hospital employees, therapists and county behavioral health directors. Reporters obtained hundreds of deficiency reports issued by CDPH, 911 call summaries, autopsy reports and hospital financial documents.
The Chronicle then built unique datasets to measure staffing, patient spending and quality of care in hospitals that are approved in California to treat people on “5150” holds, a reference to the state law that allows authorities to detain people against their will for 72 hours if they’re a danger to themselves or others or are “gravely disabled.”
Reporters compared three different types of facilities: for-profit psychiatric hospitals, nonprofit psychiatric hospitals and locked psychiatric units in general hospitals.
All offer a similar service, providing short-term treatment to stabilize patients. The Chronicle’s analysis found they operate very differently, though. Nonprofits and psychiatric units employ more, and better paid, frontline workers and nurses, while for-profits thrive on a straightforward business strategy: bring in ever more patients and spend far less on their care.
Four companies — Signature Healthcare Services, Universal Health Services, Acadia Healthcare and College Health Enterprises — own 20 of California’s 21 for-profits. Together, they have added more than 600 acute psychiatric treatment beds across the state since 2019, a roughly 33% increase, while the number of beds available in nonprofits and psychiatric units has remained stagnant amid sputtering finances.
State regulations mandate that general hospitals have a minimum number of licensed staff per patient in their psychiatric units to ensure adequate care. Under state law, the health department was supposed to create similar standards in psychiatric hospitals decades ago — but it never did.
With looser regulations, the Chronicle found that for-profits spend less than half as much on direct care per-patient than their counterparts, contributing to roughly $440 million in profits from their California facilities between 2019 and 2022, the most recent years with state data available.
Overwhelmed, inexperienced and at times abusive employees at these facilities routinely neglected and harmed people in their care. The Chronicle’s database of hospital deficiency reports since 2019 revealed 300 serious patient care incidents in for-profits, including physical and sexual assaults, dangerous restraints, and potentially preventable deaths that public health inspectors connected to violations of state or federal regulations. Officials documented hundreds of additional cases of potential abuse that facilities failed to investigate or report to the state.
At Acadia’s Pacific Grove Hospital in Riverside, a patient said a staff member kneeled on his neck, blocking his airway. A social worker pleaded with employees to stop carrying a patient face down by his arms and legs “because they were going to break his spine.” And an agitated patient on an understaffed unit suffered a broken rib as two employees struggled to restrain him and a third worker hid nearby.
At Universal’s Del Amo Behavioral Health System in Torrance (Los Angeles County), two patients beat an adolescent boy unconscious in the cafeteria and broke his shoulder while an employee, who was watching twice as many patients as she should have been, tried to shield him with her body. The assault was one of several serious incidents the facility failed to report to CDPH as required, with a hospital official explaining that “kids fight all the time.”
And at Signature hospitals, at least 11 people have died after receiving substandard care, representing about two-thirds of the patient deaths that CDPH cited at for-profits during this time. In one case, a 20-year-old woman overdosed on medication the facility prescribed. In another, a 15-year-old boy asphyxiated himself as an unlicensed employee — who had been fired after not monitoring another critically ill child, then rehired — failed to watch him.
The companies all disputed the Chronicle’s broader findings about understaffing and the prevalence of violence and neglect in their psychiatric hospitals. Spokespeople for the companies said that their hospitals employ adequate numbers of frontline workers and that the vast majority of people they treat receive effective care in a safe environment.
The spokespeople said the facilities provide a crucial service to a challenging population of patients who pose a serious risk to themselves or others. They said assaults, injuries and other safety violations are rare. When incidents do occur, they said, the hospitals promptly investigate, and any resulting deficiencies cited by CDPH are quickly corrected.
However, the level of dysfunction the Chronicle documented in for-profit facilities is not intrinsic to high-need mental health care. Reporters found there were three times as many serious safety violations per patient at for-profits than in the more robustly staffed general hospital psychiatric units in 2022, the most recent year with complete records available. There were no serious safety violations in the state’s nonprofits that year.
“People are there because they need help, and early intervention, but nothing was being done for them,” said Alexandra Del Cima, who worked as a mental health technician from 2017 to 2019 at Universal’s Heritage Oaks Hospital, but left after raising concerns about understaffing. “It was awful.”
The violence CDPH has detailed in for-profits also represents just a fraction of the harm that patients and their families have reported unfolding behind locked doors.
The Chronicle requested police dispatch records for all of the for-profits and obtained reports for five facilities from a recent 2½-year period. The records detailed more than 160 reported assaults involving patients — 16 times greater than the number CDPH documented in deficiency records, which include only incidents reported to the agency that inspectors substantiated and linked to regulatory violations. Some of the calls to police were so serious that patients had to be treated in emergency departments or suspects were detained for alleged crimes.
In the coming years, California is poised to rely on for-profit psychiatric hospitals even more as the state prepares to add thousands of treatment beds in both locked and unlocked facilities, while making it easier to place people on 5150 holds.
Newsom has presented these sweeping reforms as proof that he is filling a vacuum created by former California Gov. Ronald Reagan, who signed a landmark law in 1967 that emptied state-run psychiatric hospitals by restricting who could be treated in them against their will, while building out few alternatives.
But amid this shift, little has been said, or done, to address the perils that remain, leaving the people forced to receive treatment within profit-driven institutions bearing the greatest cost.
“Our nephew was making a noose, banging his head against a wall, in complete turmoil, and not one person paid attention to him,” said Alix Nolin, whose 22-year-old nephew, Tyler Thatcher Cox, died by suicide at Signature’s San Diego facility in July 2022 after caregivers didn’t check on him for two hours.
“The number of beds and buildings is not the issue,” Nolin said. “It’s the staffing that is the difference between life and death.”
It's not easy to improve the lives of people beset by severe mental illness. But California is uniquely positioned to confront the staffing problems in its for-profit psychiatric hospitals because of actions government leaders took 25 years ago.
At the time, overwhelmed nurses in California recognized a dire need for more licensed workers. Unsupervised psychiatric patients had been able to wrap cords around their necks or cut themselves. Staff members had been punched, kicked and bitten, sometimes missing work for months to recover from injuries suffered while caring for people in emotional crisis. Patients experiencing psychosis had been ignored and neglected, causing their conditions to worsen, according to archived regulatory files reviewed by reporters.
“At times, I fear for my life and the life of my patients,” a psychiatric nurse in Los Angeles wrote to state officials.
Hospitals had understaffed their facilities, leaving everyone at risk, according to thousands of health care workers who lobbied lawmakers to make California the first state in the nation to establish minimum nurse-to-patient ratios.
In 1999, the Legislature and then-Gov. Gray Davis complied, enacting a law that required the state’s health department to set ratios to “ensure patient safety.”
For psychiatric units within general hospitals, that meant at least one nurse or licensed technician for every six patients. Officials promised to create similar standards for stand-alone psychiatric hospitals next.
But in November 2003, Davis was replaced through a recall election by Arnold Schwarzenegger. Amid the upheaval, and with little notice, state leaders abandoned the promised staffing minimums for psychiatric hospitals — even though state law specified that the health agency “shall adopt” them.
Because of this 25-year oversight, current public health department regulations hold psychiatric hospitals to a looser standard, giving them leeway to decide the minimum number of licensed workers that are needed based on the severity of patient conditions.
California’s dozen nonprofit-run psychiatric hospitals fall under these weaker staffing rules. However, the Chronicle found that they have chosen to staff more similarly to general hospital psychiatric units, sometimes due to nurses’ unions.
If Newsom wants to fix these disparities, he could direct his health agency to finish the process the state began decades ago, said Vicki Bermudez, a former nurse who worked on the state’s original staffing bill and is now a consultant for the California Nurses Association.
“If there is the political will,” Bermudez said. “It can be done.”
In the absence of state-imposed nursing ratios, the Chronicle found staggering differences between the workforces at for-profit psychiatric hospitals, nonprofit psychiatric hospitals and psychiatric units within general hospitals.
The Chronicle analyzed financial data that all hospitals must submit to the California Department of Health Care Access and Information. These records contain detailed information on how many people are treated each year, the number and type of patient care staff assigned, and how much the hospital is spending on direct care in each unit.
In 2022, the most recent year of data audited by the state, for-profits employed about 35% fewer nurses, mental health workers and other frontline employees per patient than general hospital psychiatric units, and 41% fewer than nonprofits.
The patient care staff that for-profits hired were also lower-paid and less qualified, according to the Chronicle’s analysis. While general hospital psychiatric units and nonprofits primarily employed higher-paid registered nurses, for-profits relied on aides, orderlies, “technical” workers and “specialists” to provide the bulk of direct care.
These workers are often not licensed, and do not need prior health care experience. Some had recently graduated high school, or had only worked in retail or food service, according to a review of more than 100 professional résumés that current and former employees of for-profit psychiatric hospitals uploaded to the employment website Indeed.
As a result, on average, for-profits spent about $390 each day per patient on direct care in 2022, while psychiatric units in general hospitals spent roughly $930 and nonprofits $1,000, the Chronicle analysis found. These figures primarily cover salaries and benefits for nurses and other frontline workers, and do not include administrative or overhead costs.
Some of the companies challenged the Chronicle’s findings. In a statement, a Signature spokesperson said they “dispute much of the information you have laid out and assert it to be alarmingly misleading,” but did not respond to a request for further details.
College Health Enterprises general counsel Patti Koch said the spending figures exclude some members of the health care team who are involved in patient treatment plans. Further, she asserted that employing fewer licensed staff members does not reduce patient safety.
“We strongly disagree that patient safety incidents are linked to the number of licensed staff members,” said Koch. “All College staff members perform a valuable role in the patient’s care and none of them should be diminished based upon their licensed status or role.”
Universal spokesperson Jane Crawford said “staffing budgets are secondary to patient care and safety.” She said the direct patient care costs were “grossly misrepresented” as they did not “include additional costs associated with facility operations,” such as dietary services, social services and nursing administration. However, when the Chronicle factored in this additional spending, the disparities were similar between facility types.
The state financial data does not detail the specific nurse-to-patient ratios in each hospital. But, in addition to unlicensed patient care staff, some for-profits have internal policies requiring at least one nurse or licensed technician for up to 10 patients — nearly double the 1-to-6 standard in general hospitals.
When staffing is short, workloads can quickly multiply, according to state records and interviews with more than a dozen former employees.
In 2023, CDPH found that Universal’s Del Amo had repeatedly saddled a single nurse with nearly 40 patients, as an employee warned that persistent staffing shortages were “affecting patient safety."
That year, at Signature’s Bakersfield Behavioral Healthcare Hospital, staff members reported there were so few workers that they canceled therapy sessions and outdoor time on the patio, confining patients inside with nothing more to keep them occupied than word-search games. Without an outlet, an employee told state health inspectors, patients were getting worse, not better.
It felt “like a prison,” one patient said, adding that it was “hard dealing with your mind when you are stuck inside.”
Yelicse Velez said she was taking psychology classes at a junior college in 2019 when she was hired as a mental health worker at Signature’s Santa Rosa Behavioral Healthcare Hospital, which she described as understaffed, chaotic and dangerous.
In that environment, Velez said, one or two unlicensed workers would often have to monitor up to 19 patients. Assaults and self-harm incidents were inevitable with so few caregivers present. Facing an impossible workload, she said, employees would sign off on 15-minute patient checks they didn’t actually perform.
“I realized the priority wasn’t the safety of our clients,” said Velez, who’d been inspired to enter the field due to a family member’s mental health challenges, but later left.
“Nobody was safe,” she said, “not the staff, not the patients.”
On the afternoon of June 27, 2022, Tyler Thatcher Cox sat on his bed at Aurora Behavioral Healthcare San Diego Hospital, twisting his bedsheet into a noose, when staff members walked in. Tyler had spent six days inside, his condition worsening.
What happened after the discovery is emblematic of the problems festering in for-profit psychiatric hospitals.
Family members said years of trauma had brought Tyler, then 22, to Aurora San Diego. The facility is owned by Signature, the fastest-growing operator of psychiatric hospitals in California, which also accounts for an outsize share of serious safety violations across the state.
Tyler was a teenager when his mother, Doreen, was diagnosed with metastatic breast cancer. For years, he helped take care of her through rounds of radiation and chemotherapy, wrapping his arms around her in July 2020 as she died in a hospice bed in their living room. Soon after, a motorcycle accident killed one of his close friends. Tyler became increasingly withdrawn and depressed.
“It was crushing as time went on,” Alix Nolin, his aunt, recalled.
On June 19, 2022, Tyler attempted to end his life by poisoning himself with carbon monoxide in his car. Police responded to the scene, and Tyler was placed on a 5150 hold and taken to an emergency department in San Diego.
Hospital staff members medically screened him, then began working to find a locked facility that could treat him. Aurora San Diego agreed to take Tyler, but officials there delayed his admission for a day because the facility was “currently understaffed,” according to medical records that Tyler’s family members shared with the Chronicle.
State data show that during the year Tyler was admitted, Aurora had far lower patient spending and staffing levels than most other psychiatric hospitals or general hospital psychiatric units in the county. After reading negative online reviews, Debbie Thatcher, another of Tyler’s aunts, said she asked the medical team to send him anywhere else.
But when a person is placed on an involuntary hold, they often don’t get to decide where they go for treatment, and neither does their family. The decision frequently comes down to which hospital has space and is willing to accept the patient.
Soon after arriving at Aurora San Diego on June 21, 2022, Tyler called Thatcher, sounding desperate and afraid. “He was scared that the nurses and doctor didn’t seem to be paying attention to him and they were threatening him with long-term treatment,” Thatcher said. “He said, ‘I’m never going to leave here.’”
Signature declined to comment on the care provided to specific patients, including Tyler, citing privacy laws. Overall, a spokesperson said, “all Signature hospitals provide an excellent standard of care for all patients.”
After staff members found Tyler making the noose, a doctor placed him on “line-of-sight monitoring,” meaning an employee was required to keep him in view at all times, even accompanying him to the bathroom.
In the days that followed, a facility doctor documented that Tyler continued to think about suicide and was fixated on being discharged. The doctor increased his medication dosage. Tyler’s anxiety only grew.
During phone calls with Thatcher and his grandmother, Silvena, Tyler sounded despondent and drugged, his speech jumbled and slow. He begged them to take him out of the locked facility. Thatcher tried to explain she was powerless: “I can’t even get through the front doors.”
On July 3, Tyler’s panic appeared to peak. A doctor documented that he was having chest pain, and he was sent to an emergency room to be examined. When Tyler returned to the facility later that day, a behavioral health specialist noted that he remained “very anxious” and wanted to leave.
Staff had moved Tyler into the “Quiet Room” to keep him safer. Located beside a nurses’ station, the room had two attached bedrooms, a separate bathroom and surveillance cameras that employees could monitor.
Regardless, an employee was supposed to keep Tyler in sight at all times.
The Chronicle reviewed 2½ hours of camera footage of Tyler during his time at Aurora San Diego. Around 3:30 p.m. on July 4, the footage shows that Tyler intermittently paced the Quiet Room, banged his head against one of the walls and repeatedly twisted his sheets into a rope, in view of the hospital cameras.
A little past 4 p.m., Tyler stepped into the bathroom, just feet from the nurses’ station. Over the next minute, he tried to attach the sheet to the door before finally securing the fabric, shutting the door, and hanging himself.
For the next two hours, no one checked on Tyler.
In the patient observation logs, employees documented that Tyler received his regular 15-minute checks between 4:15 and 6 p.m. In depositions taken as part of the family’s subsequent lawsuit, two staff members said they had mistaken Tyler for another patient.
One of the employees said no one had told him he needed to watch Tyler nonstop. He said that when he started his shift, the other workers on the unit “abandoned” him, forcing him to take care of all the patients by himself.
Thatcher called the hospital shortly after 6 p.m. and asked to talk to her nephew. The nurse who answered put her on hold.
Several minutes later, camera footage shows a nurse entering the Quiet Room. The bathroom door was closed and she struggled to open it. She peered through the small observation window into the dark bathroom, then quickly left. When the nurse returned to the phone, she told Thatcher there was an emergency involving Tyler and hung up.
San Diego police and paramedics responded to Aurora San Diego, body camera recordings reviewed by the Chronicle show. As one of the officers entered the hospital, he looked at an employee and said, “This place is a place you come to be safe from stuff like that.”
At 6:53 p.m., Tyler was pronounced dead.
Little more than a year later, Newsom stood in the lobby of a Los Angeles hospital, behind a lectern bearing the words “Treatment Not Tents.” The governor was there to promote and sign multiple bills that would secure his historic transformation of the state’s behavioral health care system.
Two of the bills paved the way for Proposition 1, a $6.4 billion bond measure that will create thousands of beds in supportive housing and behavioral health treatment facilities. Although the cash influx was initially intended only for voluntary mental health programs, Newsom later allowed the funds to also be spent on locked facilities. At the time, a spokesperson told reporters that local officials and family members of people with mental illness wanted the money to go toward “the full spectrum of behavioral health treatment.”
For-profit psychiatric hospital operators, including Acadia and College, already have applied for nearly $250 million of these funds, with awarded amounts set to be announced in May.
The third piece of legislation, Senate Bill 43, expands who can be involuntarily held in hospitals on 5150 holds to include people who are deemed “gravely disabled” due to a severe substance use disorder and those who can’t take care of their urgent medical needs as a result of mental illness. Several local behavioral health directors have estimated that the number of people who qualify for involuntary treatment will substantially increase under the law, which has not been fully implemented.
“I think it’s a big day for, not only the state, but I think this is a model for the nation as well,” the governor told reporters in Los Angeles after signing the Prop 1 bills on Oct. 12, 2023.
Yet even as Newsom spoke, many of the institutions serving as a safety net for tens of thousands of state residents every year were in disarray.
That same day in Riverside, state health inspectors were descending on Acadia’s Pacific Grove Hospital after a male patient — who was supposed to be watched at all times, but due to understaffing was not — choked and attempted to rape a female patient as she screamed for help.
Also that day, in Sacramento, health inspectors were opening their second investigation in seven weeks into reports that staff members had assaulted and injured patients in their care at Universal’s Heritage Oaks Hospital.
And in Ventura that week, local officials were taking action against Signature’s Vista del Mar Hospital. Five patients had died in less than two years as staff members at the persistently understaffed facility failed to monitor some and unsafely discharged others.
In total, the Chronicle’s database of state citations revealed 300 serious safety violations in for-profit psychiatric hospitals since 2019, including 128 physical or sexual assaults on patients, 77 improper restraints or seclusion incidents, and 17 deaths linked to deficient care.
But the incidents detailed in state deficiency records represent a vast undercount of the harm patients are experiencing in these facilities.
California regulations require hospitals to report to the state health department any “adverse event” or “unusual occurrence which threatens the welfare, safety, or health of patients, personnel, or visitors.” In 2022, CDPH clarified that this includes any allegation of sexual assault as well as any physical assault that causes “physical pain.” Most adverse events must be reported to the state within five days and sexual assaults within 24 hours.
But that frequently does not happen.
Police dispatch records obtained by reporters related to five for-profit psychiatric hospitals run by Signature and Universal revealed at least 160 reported assaults involving patients between January 2021 and June 2023 — far more than the 10 incidents documented in publicly available deficiency reports in those facilities during that time.
In some cases, the facilities appeared to not report the violence to CDPH. In others, hospitals may have reported the incident, but health inspectors were not able to determine that abuse occurred or that it violated state laws or regulations.
At Universal’s Fremont Hospital, for example, there were roughly two dozen 911 calls alleging physical or sexual abuse in an 18-month period.
A mother told police in May 2022 that her teenage daughter had been sexually assaulted inside the hospital, and that staff members kept “putting off the investigation.” The following month, two adolescent patients reportedly attacked a 12-year-old boy, sending him to the emergency department to be assessed for a head injury and a separated shoulder. In 2023, a parent told police they planned to sue the hospital after their daughter was kicked and had her hair ripped out by another patient.
The health department has issued no citations to Fremont Hospital since at least 2021.
Crawford, Universal’s spokesperson, said that none of the 911 calls “resulted in law enforcement action,” but did not answer specific questions about why some of the alleged incidents were seemingly not reported to state health officials. In the case of the alleged sexual assault, she said, law enforcement conducted interviews and took no action. Although the boy who was assaulted was sent to an emergency room, she said that records indicate he did not sustain a head injury or a separated shoulder.
“Although there have been rare and isolated incidents,” Crawford said, “each incident is immediately investigated, and mitigating actions are taken.”
A Signature spokesperson said that the company’s hospitals follow state and federal regulations for reporting incidents and that calls to police often come from patients in ongoing psychiatric crises who may be “unable to distinguish between reality and their delusions.” Many of the calls in the Chronicle’s dataset, however, reference specific injuries that apparently resulted from the alleged assaults, such as blurred vision, a bloody lip, or needing to go to an emergency department for stitches. In many cases, staff members also reported witnessing the incidents and appeared to take action to separate the patients involved.
CDPH spokesperson Mark Smith said the agency would investigate the possible underreporting. “If we determine that a violation has occurred, CDPH may issue deficiencies and administer administrative penalties for violations,” Smith said.
Hospital leaders have acknowledged reporting failures when CDPH catches them. During a 2021 investigation, health inspectors discovered Bakersfield Behavioral staff hadn’t reviewed more than 200 instances of potential abuse, self-harm and other safety issues that had occurred over a 3½-month period. A nurse manager admitted that “incidents were never reported” to the state.
At Signature’s Aurora Charter Oak Hospital in Covina east of Los Angeles, Miriam Revesz told the Chronicle that staff members discouraged her from calling police in May 2019 after her roommate punched her in the face and head, then held her down and sexually assaulted her.
A doctor at a UCLA clinic later documented bruises on Miriam’s face and arm, according to a copy of her medical record, which Miriam shared with the Chronicle. There is no record in CDPH’s incident data that Charter Oak reported an alleged assault during the month that Miriam was being treated there.
Signature declined to comment about the incident.
“They brushed it under the rug, like stuff like that happened all the time,” said Miriam, who later sued and settled a lawsuit against Signature for an undisclosed amount, with the company not admitting fault. “These places are supposed to help you mentally, but they destroy you.”
December 29, 2025
By Cynthia Dizikes and Joaquin Palomino
Late one day in April 2022, an ambulance delivered a teenage boy to a psychiatric hospital on a palm tree-dotted hillside overlooking the Pacific Ocean.
“Mom, I need help,” Raymond Jimenez had confided to his mother as he struggled with suicidal urges and repeatedly cut himself. “I’m really scared about my thoughts.”
Raymond’s parents had found a psychiatrist and therapist for the 15-year-old, and had tried to reconnect him to things that once brought him joy: skateboarding with friends, playing the keyboard and training his pet songbirds. At night, his mother would watch over him while he slept.
But it hadn’t lifted the younger of their two children from his depression. This was Raymond’s second admission in two months to the locked facility in Ventura, run by California’s largest psychiatric hospital operator, Signature Healthcare Services.
Employees at Vista del Mar Hospital assured Elsy and Lionel Jimenez they would watch over their son. “He can’t hurt himself because there is going to be someone there,” Elsy Jimenez recalled a staff member saying. “Your son is going to be safe.”
Five days after he entered the hospital, Raymond asphyxiated himself with a bedsheet. Employees in the understaffed hospital had failed to properly monitor him, state health inspectors found, even though he had recently attempted suicide there in a similar way.
But Raymond’s death — and the state’s conclusion that it stemmed from deficient care — were not isolated occurrences within Signature’s facilities. Patients have suffered inordinate harm in recent years, as the company has rapidly expanded through financial maneuvers that have imposed enormous strain on its own hospitals, a Chronicle investigation found.
Signature’s California facilities, which have received increasing public funding, now rank among the most dangerous psychiatric hospitals in the state, accounting for an outsized number of deaths, reported assaults and serious regulatory actions connected to deficient care, according to county records and a Chronicle-compiled database of citations issued by the California Department of Public Health (CDPH).
Between 2019 and 2024, 12 of the 18 deaths that CDPH tied to deficient care at for-profit psychiatric hospitals involved Signature facilities, even though the company accounted for a third of discharges. About a quarter of the reported physical and sexual assaults happened at just two of the company’s hospitals.
During this time, local health agencies also significantly reduced admissions to two psychiatric hospitals in the state due to unsafe conditions; Signature operates both.
“We acknowledge the concerns raised regarding this provider and its facilities,” CDPH spokesperson Mark Smith said in a statement about Signature. “Our regulatory oversight has documented multiple deficiencies at these hospitals, including those related to staffing, patient safety, and failure to implement required policies.”
“We recognize that repeated violations are unacceptable and are evaluating additional strategies to strengthen our oversight and enforcement,” Smith said.
Signature spokesperson Nathan Miller said in a statement that incidents are appropriately addressed and exceedingly rare compared to the hundreds of thousands of patients Signature hospitals have treated. “Signature is proud of its extraordinarily strong track record,” Miller said.
He declined to discuss specific cases, citing privacy laws, and said that “any patient death is a tragedy.”
As profit-driven companies and private-equity investors have flocked to the behavioral health care industry, no psychiatric hospital chain has grown faster in California than Signature.
In the last six years, Gov. Gavin Newsom’s administration has signed more than $230 million in contracts with Signature facilities, while approving licenses for the company to open new hospitals and expand existing ones — increasing Signature’s number of hospital beds in the state by 60%.
The company, which is headquartered in Corona (Riverside County), operates nine facilities across California, representing more than a quarter of the state’s psychiatric hospitals, and another nine in Arizona, Massachusetts, Nevada and Texas.
These facilities treat tens of thousands of people a year who are in severe emotional distress and are often admitted involuntarily for short-term stays after being deemed a danger to themselves or others.
“We are dealing with the most serious patients,” Signature’s owner and CEO, Dr. Soon Kim, said in an October 2024 deposition when asked about patient deaths and abuse at one of his Los Angeles County hospitals. “So certain incidents happen. It’s regrettable, but sometimes, it’s a really inevitable situation, too.”
Kim, a retired psychiatrist, declined an interview request from the Chronicle.
The Chronicle examined Signature’s rise in California as part of an ongoing investigation into the state’s psychiatric hospitals. In March, the newspaper reported that California’s 21 for-profit psychiatric hospitals hired fewer frontline workers and paid them less than similar nonprofit facilities, leading to serious lapses in patient care.
Unlike other major psychiatric hospital chains in California, Signature is privately held, and thus public details about the company are limited.
The Chronicle, however, obtained information about Signature’s hospitals through state and federal financial data, municipal bond disclosures and county property records. Reporters interviewed dozens of current and former hospital employees and former patients and their family members. They also obtained internal documents, as well as thousands of pages of sworn testimony from company executives and hospital leaders that have not previously been reported.
Signature is part of a dizzyingly complex network of related limited liability companies that include separate entities for the hospitals’ operations, real estate and management services. Many of the companies are owned by Kim, according to litigation documents and property records.
Since 2011, records show that Signature’s hospitals have reported being charged hundreds of millions of dollars by these companies for an array of services. The companies have also executed large real estate transactions involving the properties where Signature hospitals operate.
The most consequential deal was in 2017, when Kim sold the land and buildings at six facilities, including Vista del Mar and two others in California, to an outside investment firm for $380 million.
In exchange for the money, Signature agreed to lease the properties back from the new owner at drastically higher rates than the hospitals had previously been paying, leaving them with long-term debt.
The infusion of cash from the “sale-leaseback” helped fund Signature’s recent opening of three California hospitals, Miller said.
But in the years that followed, a Chronicle analysis found that the new lease agreements caused reported rents to double. The California sale-leaseback facilities now report directing a higher proportion of expenses toward rent than any other psychiatric hospital in the state.
Health finance experts who spoke to the Chronicle said it can be difficult to gauge whether a hospital system’s business tactics contribute to any one patient incident, or circumstances inside a facility. However, these experts said that sale-leaseback deals, and the rents they impose, can financially destabilize hospitals, impacting staffing and patient services.
“It’s outrageous,” Rosemary Batt, a professor at Cornell University and nationally recognized authority on for-profit interests in health care, said of sale-leasebacks. “It is purely a financial logic, not a healthcare logic.”
As Signature embarked on its expansion, the system also grappled with unforeseen costs, including from COVID and a fire at Vista del Mar, according to litigation records and Miller’s statements to the Chronicle.
In October 2022, Rob Tyler, Signature’s chief financial officer, was called to testify in a lawsuit and provided a rare glimpse into the private company’s finances.
Tyler said that Signature had recorded net operating losses between 2018 and 2021. Cash flow was “extremely tight,” he said, as some checks to vendors bounced and other bills were pushed out “as far as we can.” Physicians had threatened to “no longer see patients” until they were paid.
The company had taken out loans around 2021 and 2022 to pay rent at the sale-leaseback facilities and to settle overdue bills for medication, food service and housekeeping, Tyler said. Federal data indicate financial struggles continued through at least last year.
During this time, state and local health departments documented deficient staffing and other dysfunction within Signature’s hospitals. At the company’s now-closed Chicago Lakeshore Hospital, health inspectors found in 2018 that malfunctioning surveillance cameras had prevented the facility from thoroughly investigating allegations of sexual abuse involving children as young as 10.
At Signature’s Santa Rosa Behavioral Healthcare Hospital, CDPH cited the facility in 2023 for failing to remediate outdated and hazardous toilets after a patient used them to attempt suicide multiple times. The following year, state inspectors returned to the facility and found that persistent understaffing had contributed to repeated assaults and a lack of basic care.
“There were no activities or therapists in the unit interacting with patients,” health inspectors wrote in March 2024. “Patients were in their darkened rooms, covered by sheets or blankets. There was no music. The walls had multiple areas of unpainted plaster patches that were in various states of repair.”
Dan Shearn was director of nursing at the hospital from 2022 until he resigned in 2024 after the CDPH inspection.
“I can’t believe people like this are allowed to own hospitals,” Shearn told the Chronicle in an interview. “It was so morally bankrupt.”
Patients have also died following problematic care cited by CDPH at Signature’s hospitals, including five people treated at Vista del Mar during a recent two-year period.
Employees there failed to properly watch some patients and unsafely discharged others, health inspectors determined. A sixth patient was released over the objections of his family and personal psychiatrist; three days later, he was arrested and charged with killing and dismembering his mother.
By the time Elsy and Lionel Jimenez arrived at Vista del Mar seeking help for Raymond, records show the hospital had fallen into chaos.
“His death certificate says suicide,” Elsy Jimenez told the Chronicle. “But to me, this business killed my son.”
Kim founded Signature in 2000 amid controversy over his earlier business operations in the Detroit area.
Kim had purchased two local hospitals out of bankruptcy in the mid-1990s and had established a structure in which the facilities paid separate companies he controlled for rent, management and other services, according to litigation records and news reports.
When the facilities ultimately closed, Kim blamed steep Medicaid funding cuts and difficulties getting the county to fully cover bills for care. But board members at one of the hospitals said the money paid to Kim’s other businesses added to the financial pressure.
“There was no doubt about the fact that monies for improving the hospital and keeping staff up to the required ratios were frustrated by all the capital going to Dr. Kim,” former board member George Gaines said in a 2017 sworn statement from a lawsuit about sexual abuse at Vista del Mar that resulted in a jury verdict against Signature. “You couldn't have that amount of money going to an entity and still have a well-run hospital.”
Kim and other board members denied the allegations in Michigan, saying at the time that his companies had provided services at below-market rates and that the hospital board had approved the contracts.
Still, in 2004, the U.S. Department of Justice sued Kim and other defendants for submitting “false and fraudulent” claims to the government, alleging they concealed that the hospital was doing business with his other companies to reap inflated reimbursements.
“Fraud against the Medicare and Medicaid programs reached nearly $1 million,” the U.S. Attorney’s Office for the Eastern District of Michigan alleged in a summary of the case in its 2005 annual report, which was obtained by the Chronicle.
In 2007, Michigan’s attorney general and state health department filed a separate lawsuit against Kim and other defendants for improperly disposing of medical records from the other shuttered hospital. Investigators discovered that one of Kim’s employees had been burning X-rays and other sensitive patient information in large piles on Kim’s farm outside Detroit, with authorities calling the situation “a shameful and blatant disregard of the public trust.”
In Signature’s statement to the Chronicle, Miller said that “the employee made an incorrect decision to dispose of the records in a manner not ordered or approved by Dr. Kim or the company.” He attributed the DOJ lawsuit to “an unintentional oversight” and described it as “strictly an accounting dispute.”
These cases never went to trial. Kim and other defendants settled the federal lawsuit for about $1.7 million and the state case for $350,000 with no assignment of fault.
By then, Signature was already becoming a major provider of emergency mental health care in California, where Kim had bought three psychiatric facilities in Los Angeles County and San Diego, as well as Vista del Mar’s pale stucco complex on the coast.
Over the next decade, the company expanded its reach, including through a $1 billion-plus joint venture with a Santa Monica-based investment firm, Watch Hill Capital, to acquire or construct additional hospitals in the Western U.S.
As in Michigan, Kim and his business partners formed companies that sold services to the hospitals and became their landlords, according to a review of contracts, lease agreements and data that the hospitals submit to the Centers for Medicare and Medicaid Services (CMS) and the California Department of Health Care Access and Information (HCAI).
Hospitals in California are required to report detailed financial information to HCAI and CMS, which administers the country's largest insurance programs and establishes payment rates.
As part of these disclosures, hospitals must document how much they were “charged” for services and rent by “organizations related to the provider by common ownership or control,” representatives with CMS and HCAI told the Chronicle. Those that knowingly submit false CMS information can face penalties.
Since 2011, Signature’s California hospitals have reported being charged more than $200 million by Kim’s companies, CMS and HCAI data show.
The hospitals paid their parent company for management services, including “daily operational direction.” They paid a firm previously overseen by Kim’s son, Eric Kim, for IT support.
They also paid rent, in some cases through unique lease agreements with companies owned by Soon Kim and his business partners.
At Signature’s Las Vegas hospital, for example, rent was set at 95% of the facility’s net income each year, rather than a fixed amount, according to financial records. Federal data show a similar pattern at other properties jointly owned by Kim and Watch Hill, which account for at least a third of Signature’s portfolio.
Under such arrangements, “the hospital operations are effectively being treated like an ATM machine,” said Dr. Vikas Saini, president of the nonprofit Lown Institute, a Massachusetts-based think tank that advocates for safe and affordable health care and conducts research into the financial behavior of hospital systems.
A Watch Hill representative declined to answer questions from the Chronicle, saying the firm “is just a minority real estate partner and we absolutely have nothing to do with day-to-day operations.”
Miller said Kim’s companies provide Signature hospitals with quality services at below-market rates, that rental payments are used to cover mortgages and that the hospital data reported to CMS and HCAI do not indicate improper or inflated charges.
Kim capitalized further on his hospital real estate in 2017.
That April, he sold the land and buildings at six of his facilities, including Vista del Mar, Aurora Behavioral Healthcare San Diego Hospital and Aurora Charter Oak Hospital in Los Angeles County, for $380 million to SABRA Health Care REIT.
The sale was worth far more than the property values alone because Signature agreed to lease the properties back from SABRA at significantly higher prices for at least a decade, though potentially far longer, according to county property records and filings with the U.S. Securities and Exchange Commission. The hospitals would also have to cover additional expenses like property taxes, insurance and repairs.
Sale-leasebacks are a common way for companies to turn their real estate into cash that can be distributed to owners and investors, used to pay off debt and spent on expansion, health finance experts told the Chronicle. Increased revenues from that growth can offset the lease price hikes.
Yet such financial deals have been disastrous for some struggling hospital systems, experts said, with the high rental costs reducing funds needed for supplies and staff.
Atul Gupta, an assistant professor of health care management at the University of Pennsylvania’s Wharton School of Business, who has studied private equity ownership of nursing homes, including sale-leasebacks, said the deals give owners and investors “instant cash,” but pull money out of operations.
“I personally believe sale-leasebacks should not be allowed in health care,” Gupta said, “especially for facilities where lives are at stake.”
March 19, 2025
By Joaquin Palomino and Cynthia Dizikes
Five police officers barged into Santa Rosa Behavioral Healthcare Hospital with their guns at the ready.
Inside the psychiatric hospital’s adolescent unit on that Wednesday night in May 2023, patients were kicking, scratching and spitting on employees as staff members struggled to pin them down and quell the riot. A girl ripped a block of Sheetrock from the wall and hurled it at workers.
The on-call hospital administrator was nowhere to be found. There were too few employees to keep watch, let alone care for the 18 children suffering from depression, addiction and suicidal urges who were supposed to be receiving therapy and mental health treatment.
“It was very chaotic and there appeared to be no one in charge,” one of the Santa Rosa police officers, who responded to the hospital’s 911 call that night, recounted to health regulators. “The staff was not prepared for this kind of situation.”
The riot was not the first time — nor would it be the last — that the for-profit facility run by Signature Healthcare Services was overrun by dysfunction due to neglect by both its operator and the state agency overseeing psychiatric hospitals.
For nearly a decade, Santa Rosa Behavioral employees and patients have pleaded for the California Department of Public Health to better protect the thousands of people treated inside the facility each year.
The agency, which licenses hospitals and responds to patient and worker complaints, has documented dozens of violations at Santa Rosa Behavioral since it opened, many of them tied to understaffing. The failures have contributed to a litany of assaults, sexual abuses and potentially preventable deaths.
But a Chronicle investigation found that CDPH has chosen not to meaningfully intervene, even as Santa Rosa Behavioral has again and again broken promises to reform itself — a pattern emblematic of the agency’s hands-off approach to regulating for-profit psychiatric hospitals across the state.
The health department answers to the governor, but otherwise has broad discretion to determine how — or if — it will hold dangerous facilities accountable. The agency can issue fines up to $125,000 for violations of state or federal regulations, and it can stop hospitals from accepting patients until serious safety concerns are addressed. These penalties, though, are not mandatory.
As a result, even as CDPH has cited California’s 21 for-profit psychiatric hospitals for hundreds of safety lapses since 2019, it has chosen to collect only $94,200 from three facilities — none of which were Santa Rosa Behavioral. Not once during this period has the agency halted admissions anywhere in the state.
Instead, the Chronicle found, CDPH requires hospital administrators to submit “plans of correction” that outline how they will address deficiencies and prevent future violations. The department approves the plans, but the reforms are often short-lived — or never fully realized, state records show — allowing problems to fester.
“The system is broken,” said Charlene Harrington, a former top regulator at CDPH and professor emeritus of social behavioral sciences at UCSF, who reviewed the Chronicle’s findings. “If they are not giving fines and penalties or placing holds on admissions, they aren't going to be successful because there are no teeth. It’s just a game.”
The health department did not respond to specific questions about why the agency hasn’t taken stronger actions against for-profit psychiatric hospitals, including Santa Rosa Behavioral. In a statement, spokesperson Mark Smith said the department regularly investigates psychiatric hospitals to ensure they are providing safe care. If violations are discovered, officials review them on a “case-by-case basis” to determine whether to issue fines or revoke a hospital’s license.
“Ensuring hospitals at all levels are adequately staffed, and that proper care is provided to patients, is a crucial part of our mission to protect the quality and safety of health care for all Californians,” Smith said.
Signature also did not respond to specific questions about Santa Rosa Behavioral. A spokesperson said the company’s psychiatric hospitals are staffed based on “the specialized needs” of patients by employing nurses, mental health technicians, therapists and psychiatrists.
“Each hospital takes all incidents and negative outcomes seriously, investigating and adjusting protocols or retraining staff to prevent recurrence,” the spokesperson said.
The Chronicle examined CDPH’s oversight of for-profit psychiatric hospitals through the history of Santa Rosa Behavioral, as Gov. Gavin Newsom embarks on foundational changes to the state’s behavioral health care system that are poised to push more people into these locked facilities.
In an earlier part of this series, reporters detailed how for-profit psychiatric hospital operators have taken advantage of lax state staffing regulations to generate hundreds of millions of dollars in earnings. Although California law requires CDPH to set minimum nurse-to-patient ratios in psychiatric hospitals, the agency has failed to do so, contributing to understaffing, violence and deadly neglect.
For this investigation, reporters reviewed nearly 10 years of deficiency reports, corrective action plans and litigation records to assess the effectiveness of the department’s near-exclusive reliance on plans of correction to police for-profit psychiatric hospitals. They also interviewed dozens of current and former employees, local and state regulators, and other health care experts.
Psychiatric hospitals serve a critical role in the community, offering short-term treatment to people placed on involuntary “5150” holds — a reference to the state law that allows authorities to detain people who are a danger to themselves or others, or are unable to take care of their basic needs due to mental illness.
But the Chronicle found that CDPH’s weak oversight has enabled some for-profit psychiatric facilities to repeatedly harm patients as they violate the same rules with near impunity. Santa Rosa Behavioral, in particular, shows the cost of this failure.
In plans of correction since 2016, administrators at the Sonoma County hospital have pledged to create systems to promptly inform health officials, child protective services or law enforcement about instances of abuse at least five times. But as recently as last year, the facility was still not doing that.
Hospital leaders have promised to better staff units or monitor vulnerable patients at least eight times, only to have health inspectors return to the facility to cite them for not meeting those bare minimum standards.
And violence and abuse recently exploded inside the hospital, despite numerous reforms specifically intended to prevent it. Employees told CDPH last March that there were so few staff members that assaults had become a daily occurrence and patients received no treatment while being warehoused in their rooms like “caged animals.”
“There is so much pressure to get more patients, ‘heads in beds,’” the hospital’s director of nursing told state health inspectors last spring, adding that patients were admitted “without considering if we had enough staff to safely care for them.”
The nursing director resigned after speaking to inspectors.
After years of alerting the state to dire safety violations, former Santa Rosa Behavioral employees told the Chronicle it was hard to believe conditions had become even worse.
“I am surprised that their doors are still open,” said Lily Akers, a former Santa Rosa Behavioral nurse. “If the state isn’t looking out for these patients, who is?”
Officials in the North Bay celebrated when Santa Rosa Behavioral opened in 2013 in a residential corner of the city, where suburban homes give way to vineyards.
Financial pressures had pushed a pair of psychiatric units in Sonoma County to shutter, forcing residents in crisis to travel far from home. Signature, a fast-growing, privately held company based in Southern California, purchased one of the defunct hospitals and rebranded it.
The revived facility would treat patients seeking voluntary care, as well as those placed on involuntary holds lasting 72 hours or longer. This kindled hope that top-notch mental health care would be available locally.
“We’re really delighted,” the county’s then-director of health services said at the time. “Having it here means that our clients will be recovering in the community.”
But those expectations were short-lived.
In October 2016, Santa Rosa Behavioral’s chief nursing officer alerted CDPH to a series of problems. Hospital staff were badly overstretched, she told state health inspectors, and administrators kept bringing in more patients. Caregivers couldn’t keep up with the demand, nor maintain full control of the facility, causing “negative patient events” and employee injuries.
In this environment, state health records show, a teenage girl said she was sexually abused by another patient. The facility did not promptly investigate the allegation or report it to police, child protective services and CDPH, as required by regulations. Instead, staff members kept the two children in the same unit for another four days and provided the victim no additional protections.
Shortly afterwards, CDPH uncovered a slew of additional violations so severe that inspectors concluded they were likely to cause “serious injury, harm, impairment or death.”
Children said they “didn’t feel safe” due to violence inside the hospital. Staff members left patients who were experiencing suicidal urges and needed constant supervision unmonitored for long stretches. And management assigned a file clerk from the business office to watch patients, even though the employee had no training for that role.
The results were as troubling as they were predictable. The day before the chief nursing officer filed her complaint, an adolescent patient wrapped a pillowcase and sheet around their neck before staff members noticed.
Afterward, a doctor ordered an employee to be within arm’s reach of the patient at all times, but due to understaffing, that didn’t happen. The patient who attempted suicide was then sexually assaulted by a peer who was also not being properly monitored. Health inspectors found that workers had fabricated their observation logs by documenting that they were watching the patients when they weren’t.
Santa Rosa Behavioral “had no formal system for preventing, identifying and investigating suspected abuse,” CDPH concluded. On top of that, the chief nursing officer said the facility simply “did not have enough staff” to keep some of its most vulnerable patients safe.
“When you are lacking staff, what that really comes down to is people are not getting their needs met, and that is when bad things happen,” said Jessica Thomas-Langdon, a nurse who used to work at the Santa Rosa hospital and is now part of a class-action employment lawsuit against the facility. Signature has denied violating labor laws.
“If I am in the back charting, and trying to shove a sandwich down my throat, I am not watching my kids,” Thomas-Langdon said.
Some former employees told the Chronicle that even with full staffing, serious incidents can still occur given a challenging and at times unpredictable patient population. In general, Signature said “no health care provider achieves 100% positive patient outcomes” and to suggest otherwise “misleads the public and sews further barriers for those suffering mental illness from seeking help.”
CDPH, however, recognized the severity of Santa Rosa Behavioral’s staffing problems at the time, and its impacts on patient safety. But, the agency still chose not to issue any fines, state data shows, and instead asked only for two plans of correction.
The hospital pledged to prevent future assaults and to ensure that all serious incidents would be reported to state officials. Additional employees were hired, including hallway monitors in the adolescent units, to better keep track of patients.
Lily Akers had just graduated from nursing school and was preparing to take her licensing exams in 2019 when Santa Rosa Behavioral hired her as an unlicensed mental health worker, an entry-level position that provides much of the direct care to patients in psychiatric hospitals.
Although she had been excited to start her career, Akers told the Chronicle that she was almost immediately confronted with staffing shortages that placed workers in danger, particularly at the outset of the COVID-19 pandemic. She and her colleagues raised concerns with supervisors and hospital leaders, Akers said, but they did nothing about it.
So in April 2020, she put in her resignation notice, then called CDPH to report the hospital’s unsafe conditions. “Both staff and patients deserved better — better treatment, better communication, better safety,” Akers said. “It would have been a disservice to the patients and the people who worked there to not speak up.”
Her complaint was one of several made to CDPH about Santa Rosa Behavioral that year, sparking another round of investigations and citations.
The public health department had already issued a deficiency report in February 2020 after inspectors found that the hospital had again failed to protect adolescent patients, resulting in separate instances of sexual abuse.
In the first case, a preteen boy was allegedly able to have oral sex with his roommate when the facility did not put him in his own room, despite the boy being considered at high risk of “sexually acting out.” An employee said “a push to fill empty beds” had kept the hospital from properly screening patients at admission, leading to such mistakes.
In the second case, a teenage girl said that she was pressured into sex acts by her roommate, and that staff members said it was her fault.
Around the same time, a 12-year-old girl reported that a male nurse had placed her hand on his genitals. Staff members did not properly investigate the incident and allowed the accused nurse, who had denied the allegation, to write the hospital’s internal incident report, state health records show.
Santa Rosa Behavioral staff members did not notify police, CPS or CDPH, with an employee later telling state health insectors that “adolescent patients made accusations of sexual abuse all the time.”
Akers said she worked with the victim during a subsequent admission and recalled her breaking down in tears as she recounted being molested. “I was heartbroken,” Akers said. “Nobody was listening to this patient, and that was so disheartening.”
The male nurse continued working at the hospital for at least two months, until a second female patient made a nearly identical claim, records show. Hospital administrators concluded that both assaults “appeared to have happened,” with a facility director admitting that it was “not a good idea to have the perpetrator complete an incident report against himself.”
In response, CDPH asked administrators to write additional plans of correction. Yet even as those fixes were supposed to be implemented, CDPH uncovered another string of violations.
Nurses fresh out of school were forced to care for up to 19 patients each, twice as many as Signature’s own policies allowed. “It became very overwhelming,” a caregiver told CDPH. “It became more about tasks than providing the care patients needed.”
Critical jobs were skipped. In August 2020, the hospital turned away a 21-year-old woman seeking treatment for insomnia and auditory hallucinations because it didn’t have space, but failed to screen her or coordinate her transfer to another emergency facility. She died by suicide less than 24 hours later.
The following month, a hospital employee took a patient at risk of suicide to a local emergency department and didn’t keep track of her. The patient ended her life in an ER bathroom.
CDPH found that there was no evidence Santa Rosa Behavioral had maintained promised reforms. Administrators had not trained employees to directly report safety issues to the health department and they were still inadequately staffing their units, leaving workers and patients in potentially unsafe situations.
Yet even after issuing seven more deficiency reports in 2020 and 2021, state officials again chose not to fine Santa Rosa Behavioral. Instead, the hospital submitted seven new plans of correction.
Amid this regulatory back and forth, a 17-year-old boy arrived at Santa Rosa Behavioral in the middle of the night after being placed on an involuntary psychiatric hold for worsening depression and suicidal thoughts.
His mother, a nurse, told the Chronicle that she and her husband felt lucky there was an open bed, even if it was far from their South Bay home. “I trusted my peers, I trusted my profession, that my child would be taken care of,” she said.
But two days after being admitted in April 2021, the boy was sexually assaulted by his roommate. His parents sped through San Francisco and up Highway 101 to get their child.
According to a state deficiency report completed in January 2022, the boy told police officers that his roommate forced him into oral sex after he tried to push him away and told him to stop. During the assault, the boy said he “‘froze and didn’t know what to do,’ and felt like he could not leave the room because he was ‘really scared,’” health inspectors wrote.
It was at least the fifth reported sexual assault inside the hospital that health inspectors had linked to deficient care.
Again, Santa Rosa Behavioral did not report the incident to police or child protective services, and waited to notify CDPH for about a month, until after the boy’s family had filed their own complaint.
A hospital director told health inspectors that she initially did not know she needed to contact authorities. Internal policies “revealed no procedure for reporting incidents” to the health department, even though the facility had previously been cited for similar problems and had agreed to correct them.
The South Bay family — which the Chronicle is not identifying in accordance with the newspaper’s policies on naming minors who have been sexually assaulted — is now suing Signature for negligence and fraud. The family alleges in court filings that the company jeopardized the teen’s health and safety and misled the public about the specialized care it was providing by understaffing its facility to maximize profits. Signature has denied the allegations.
“To me, if children are being sexually assaulted by other children at a facility, that is not a fine situation, that is a ‘shutting down the facility and figuring out what is happening there’ situation,” the boy’s mother said.
As part of the resulting plan of correction, hospital leaders said they would reeducate employees on their legal duty to report suspected child abuse and on how to identify patients at risk of “sexually acting out.” Staff would also check on patients more frequently — the hospital’s third time making a similar promise.
Despite Santa Rosa Behavioral’s persistent patient safety violations, in 2022, CDPH approved the hospital’s request to add 49 new beds. Local officials said the expansion was critical to meet the growing need for mental health services in the region.
As before, more patients led to more problems.
The riot that brought police officers on May 10, 2023, was among a cascade of violations that would overwhelm the hospital over the next year and a half.
A few days before the uproar on the adolescent unit, workers found a male patient unresponsive, but still breathing, with his shirt wrapped around his neck. The patient had already tried to hang himself in the hospital multiple times, but the staff member who was supposed to watch him had been assigned a workload that was impossible to manage, the state found.
CDPH inspectors discovered Santa Rosa Behavioral had stopped employing hallway monitors, despite agreeing to staff those extra workers in prior plans of correction, and had canceled a contract with its security company after guards were injured and quit.
Between March and December of last year, state health inspectors completed four additional investigations.
Chronic understaffing had again saddled some nurses with caseloads double those prescribed by hospital policy, allowing problems to escalate into crises, state health records show.
A man who had been in the hospital for years was confined to his room for so long that his muscles atrophied. A second patient had to be rushed to a local emergency department after attempting suicide when staff members did not monitor her, then fabricated their observation logs to make it appear they had.
And a woman with a pacemaker to treat heart problems died of a heart attack after employees did not check on her for about eight hours overnight. The patient was left alone for so long that by the time mental health workers discovered her, she had developed rigor mortis.
“The state’s obligation is to keep the public safe, and in my opinion, they are failing to do that,” the woman’s daughter told the Chronicle in an interview. She only learned that health officials had cited the hospital when reporters contacted her.
CDPH also documented nearly two dozen physical or sexual assaults involving patients, all of them connected to deficient care. “Everyday at the morning daily meeting I hear about patient-to-patient assaults,” the hospital’s director of nursing told inspectors.
Despite years of promises, the state concluded that the hospital’s abuse prevention strategy “was mostly done by word of mouth.” The director of nursing said workforce training was “basically non-existent.” And staffing guidelines that had been refined through numerous state interventions were ignored.
CDPH did not issue any fines. Nor did the agency halt admissions to protect future patients. Instead, state health authorities leaned on a familiar tool.
They asked for a plan of correction.
Credits
Reporting by Joaquin Palomino and Cynthia Dizikes. Visuals by Gabrielle Lurie, Brontë Wittpenn and Sandy Huffaker. Illustrations by Huanhuan Wang. Editing by Ryan Gabrielson, Demian Bulwa and Lisa Gartner. Visuals editing by Nicole Frugé. Data editing by Dan Kopf. Design by Sophie D’Amato. Design and development by Stephanie Zhu. Design and development editing by Alex K. Fong. Graphics, illustrations, design and development editing, and art direction by Alex Tatusian. Audience by Jess Marmor Shaw. Copy editing by Linda Houser/Tafur.
April 29, 2025
By Cynthia Dizikes
By deploying the state’s emergency regulations process, the Newsom administration intends to establish nurse-to-patient ratios within these hospitals, which treat tens of thousands of people experiencing mental health crises every year, according to the California Health and Human Services Agency.
The move would close a regulatory loophole detailed by the Chronicle that for decades has left psychiatric hospitals without mandated staffing minimums, despite a 1999 law requiring the state to set them.
“We are ensuring better behavioral health care for all Californians by modernizing our behavioral health system to provide services to help anybody, anywhere, at any time,” CalHHS Secretary Kim Johnson said in a statement provided to the Chronicle. “As part of this broader commitment, the California Department of Public Health plans to issue emergency regulations aimed at increasing transparency and accountability within acute psychiatric hospitals.”
The California Hospital Association did not immediately respond to a request for comment. Unions representing nurses and other hospital workers in California lauded the news Monday, emphasizing that such standards are particularly needed in psychiatric hospitals operated by for-profit companies. The Chronicle found these for-profit facilities have exposed patients to violence and deadly neglect by relying on bare-bones workforces that generate massive earnings for owners and investors.
“It’s a good start,” said Sandy Reding, a president with the California Nurses Association, which spearheaded the original minimum staffing legislation 25 years ago. “But they need to include the input of frontline nurses and ensure that when they are setting standards, they are setting minimum nurse-to-patient ratios with acuity, meaning how sick the patients are.”
Sophia Mendoza, president of the National Union of Healthcare Workers, which represents nurses and other caregivers at multiple psychiatric hospitals, including a for-profit facility in Sacramento, said the emergency regulations are “a desperately needed first step toward compelling for-profit psychiatric hospitals to provide the staffing necessary to protect patients and workers in their facilities.”
On top of nurse staffing requirements, Mendoza said, “it’s critical that these hospitals are also required to adequately staff unlicensed caregivers who provide much of the day-to-day direct care that patients receive.”
Since Newsom took office in 2019, and embarked on unprecedented changes to the state’s behavioral health care system aimed at increasing access to care, psychiatric hospitals operated by for-profit companies have become the fastest-growing destination for people in California experiencing severe mental health emergencies, the Chronicle’s investigation found.
California’s 21 for-profit psychiatric hospitals now treat a growing share of adults in emotional crisis and a majority of children. The hospitals are approved to admit patients on involuntary “5150” holds, a reference to the state law that allows authorities to detain people for at least 72 hours to protect them from harming themselves or others by providing stabilizing medication and therapy.
Yet the Chronicle found that instead of receiving help, hundreds of patients in these profit-driven facilities have reported being physically and sexually abused in recent years, often due to deficient staffing. At the same time, state health officials have cited the hospitals for at least 17 deaths connected to violations of state or federal regulations, while documenting scores of additional potential abuse cases that the facilities failed to investigate or report to the state.
The dysfunction within facilities can derail recovery for adults and children who are often struggling with depression, drug addiction or psychosis. In the case of Jázmin Pellegrini, the Chronicle detailed how the 15-year-old girl from the East Bay died after being repeatedly exposed to unsafe and traumatizing conditions in several for-profit psychiatric hospitals.
The Chronicle found that serious patient safety incidents were far more likely to occur in for-profits than in nonprofit psychiatric hospitals and psychiatric units within general hospitals, which are also approved to admit patients on 5150 holds and provide similar services.
Under the 1999 staffing law, psychiatric units in general hospitals are required to employ at least one nurse or licensed technician for every six patients. But the state never established these standards for psychiatric hospitals, giving them wide discretion over caregiver staffing.
The Chronicle found that those operated by nonprofits still staff more similarly to psychiatric units. Yet for-profit companies, which operate a vast majority of psychiatric hospitals in California, employ far fewer frontline workers and spend far less on direct patient care than their counterparts, contributing to widespread safety problems.
In order to fix this regulatory breakdown, the California Department of Public Health, which licenses hospitals and operates under CalHHS, will activate the state’s so-called “emergency rulemaking process.” The agency will first issue a letter to all facilities to begin discussions with various stakeholders, including hospitals and employee groups, on staffing and other issues related to the new regulations.
“We recognize that systemic change requires collaboration,” said Johnson with the health and human services agency. “Together, we can build a more equitable and compassionate mental health system that truly serves the needs of all our communities.”
In a letter sent this month to Newsom, the California Nurses Association proposed minimum ratios for different types of units within psychiatric hospitals, including at least one registered nurse for every six patients in adult acute units, and at least one registered nurse for every four patients in adolescent acute units.
California’s regular rulemaking process can stretch for months and includes official notice of the proposed regulations and a public comment period of at least 45 days. Emergency rulemaking, however, generally requires agencies to file notice with the California Office of Administrative Law explaining how a situation “calls for immediate action to avoid serious harm to the public peace, health, safety, or general welfare” or pointing to state law documenting the same urgency.
That office would have 10 calendar days to review and make a decision. If approved, the emergency regulations would remain in effect for 360 days at most. During this time, agencies can move to make these measures permanent.
CalHHS did not respond to questions on the exact route it would pursue to enact the rules. Last month, state Sen. Caroline Menjivar, D-Los Angeles, amended a bill that, if passed and signed by Newsom, would give the state department of public health the statutory authority to quickly move forward with staffing standards. At the time, Menjivar said “the gravity of this is so severe that we need emergency regulations.”
As part of the Chronicle’s series, reporters also found that the health department almost exclusively relies on plans of correction to police for-profit psychiatric hospitals instead of levying fines, or pausing admissions to force lasting change, even after repeated assaults and patient deaths linked to deficient care. And as of January, more than 380 health department investigations into California’s psychiatric hospitals were older than six months and considered “backlogged.”
CDPH is still investigating some of the incidents that were detailed in the Chronicle’s reporting. As part of the planned actions, the Newsom administration said state health officials will issue an additional letter to hospitals reminding them of the reporting requirements and will increase staff training on psychiatric hospitals “to strengthen enforcement efforts, including use of penalties and additional approaches.”
Former patients in California’s for-profit psychiatric hospitals, and their families, told the Chronicle on Monday that they were heartened by the governor’s actions. But they also want to see where the state lands with specific ratios as well as other potential improvements.
“We need a lot more workers, professionals who are trained for this,” Jázmin’s mother, Márta Bárány, said. “What I would personally add is that I consider it very important, especially in cases involving children, for hospital staff to listen to the parents, as no one knows their child and their problems better than they do.”
December 29, 2025
By Cynthia Dizikes, Joaquin Palomino
Gov. Gavin Newsom’s administration has unveiled proposed staffing requirements for psychiatric hospitals, spurred by a Chronicle investigation that exposed systemic abuse, dysfunction and understaffing in the locked facilities.
The draft regulations by the California Department of Public Health seek to bring psychiatric hospitals in line with other facilities in the state that provide emergency mental health care, closing a decades-old loophole uncovered by the Chronicle. The rules, posted online last week, would also give the state the authority to increase staffing above the minimums when necessary.
“CDPH is taking a very important step forward to protect the health and safety of psychiatric patients,” Charlene Harrington, a former top regulator at the state health department and professor emeritus of social behavioral sciences at UCSF, told the Chronicle. “I hope that CDPH can be vigilant in their enforcement of their rules.”
The regulations are set to go into effect on Jan. 31, under the state’s emergency rulemaking process, which Newsom set in motion after the Chronicle’s “Failed to Death” investigative series began publishing earlier this year. The state may still amend the proposal, however, before officially implementing the emergency regulations.
CDPH will then have 1½ years to finalize the standards with additional input from front-line employees and hospital operators.
At the first public meeting to discuss the proposal on Monday, organizations representing various stakeholders — including the hospitals, nurses, and other licensed and unlicensed caregivers — raised various concerns and recommended adjustments, including requests by multiple hospital leaders to allow facilities to ramp up their staffing over a longer period of time.
“It is impossible for the facilities to meet these requirements with this short notice,” Peggy Minnick, the CEO of Universal Health Services’ BHC Alhambra Hospital, said at the meeting. “What will happen is we will have to close psychiatric beds, which unfortunately will then have a negative impact on not only the provision of psychiatric care to people who need it, but it will cause emergency rooms to be inundated with psychiatric patients.”
The proposed emergency regulations for psychiatric hospitals include the following requirements:
Minimum nurse-to-patient ratios: 1 nurse for every 6 adult patients. 1 nurse for every 5 adolescent patients (under 18 years old).
Expertise mandates: Registered nurses, among the most skilled and well-paid nursing professionals in psychiatric hospitals, must make up at least 50% of the nurses counted toward these ratios. Licensed vocational nurses and psychiatric technicians are allowed to make up the rest. Further, any nurse counted toward the ratio must be “awake and on duty in the hospital.”
Oversight of patient care: A registered nurse, separate from those counted in the ratios, must be available to assess patients, with a limit that they not evaluate more than 24 patients in a 12-hour shift, or 16 patients in an 8-hour shift.
Staffing above minimums: The ratios represent baseline staffing. Hospitals are explicitly required to consider patient suicide risk and risk of violence when determining whether patient care requires staffing above the minimums.
Staffing governance: Hospitals must establish a staffing committee, with nurses making up at least half of its members, to maintain staffing policies and ensure they are effective.
Documentation and record retention: Hospitals must keep staffing documentation for at least three years, including plans, actual time worked and unit assignments for licensed nurses and certain unlicensed staff.
Increased CDPH authority over staffing: If CDPH determines that additional personnel are necessary to meet patient needs or ensure the safety of patients or workers, the agency can require a hospital to add personnel.
Since Newsom took office in 2019, he has led a transformation of California’s mental health system that has increased access to care while making it easier to force people into treatment.
In this environment, the Chronicle’s investigation found that hospitals operated by for-profit companies have become the fastest-growing destination for people in California experiencing severe mental health emergencies, particularly children.
The companies operate the majority of beds for adolescents in California hospitals approved to forcibly treat patients on “5150” holds, a reference to the state law that allows authorities to detain people to protect them from harming themselves or others.
Yet, the Chronicle found that instead of receiving help, hundreds of patients in these profit-driven facilities have reported being physically and sexually abused, while many more were exposed to substandard and hazardous care, often due to poor staffing.
Serious patient safety incidents were far more likely to occur in for-profit psychiatric hospitals than in nonprofit psychiatric hospitals and psychiatric units within general hospitals, the other main facilities approved to admit patients on 5150 holds.
A state law enacted in 1999 required the health department to “establish minimum, specific, and numerical licensed nurse-to-patient ratios” in both general hospitals and freestanding psychiatric hospitals. However, the Chronicle’s investigation found that the state set these only for general hospitals at the time, requiring their psychiatric units to staff one nurse, or licensed psychiatric technician, for every six patients.
Due to this long-standing state oversight, the Chronicle found that 21 psychiatric hospitals, run by a handful of for-profit chains, employed far fewer and lower-paid front-line workers than their counterparts, and spent less than half as much on direct patient care. That disparity contributed to nearly a half billion dollars in reported profits for owners and investors in recent years.
Much of the direct patient care in these facilities is provided by unlicensed mental health workers who are often not required to have previous health care experience. The Chronicle found that some of these workers had recently graduated high school, or had worked only in retail or food service before being hired to monitor critically ill patients.
On Monday, representatives of the California Nurses Association said the regulations did not go far enough to protect patients when compared to the nursing regulations for general hospitals.
Under those regulations, nurses working in “pediatric service units” can be assigned a maximum of four patients, as opposed to five. General hospital regulations also specify that ratios cannot be met by “averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time.”
“CNA strongly urges CDPH to require that an assigned registered nurse have no more than four children or adolescent patients in the acute psychiatric hospital,” said Brandy Welch, a CNA board member and pediatric registered nurse. “Our young patients, whether they receive care in the general acute care hospital, or an acute psychiatric hospital, deserve to have the same safe staffing standards.”
Representatives of the California Association of Psychiatric Technicians supported the move toward staffing requirements but said licensed psychiatric technicians should play a larger role given their expertise.
Like psychiatric units in general hospitals, the psychiatric hospital regulations will allow the ratios to be filled with licensed vocational nurses and psychiatric technicians, as long as those employees do not exceed 50% of the workers making up the ratio.
Eric Soto, state president for CAPT, said that psychiatric technicians are specifically trained to treat patients in psychiatric hospitals and that the proposed regulations would diminish their presence “in a setting that is tailor made for them.”
“I believe the more nursing staff on a unit, the safer the environment will be, absolutely,” Soto told the Chronicle in an interview. “But in this type of setting, psychiatric techs need to play a larger role.”
Sal Rosselli, president emeritus of the National Union of Healthcare Workers, which represents 19,000 caregivers across various types of facilities in the state, called the proposed regulations “a step forward” in a statement, but said they were “not nearly sufficient to provide safe, effective care at psychiatric hospitals.” The union had asked for additional ratios for unlicensed mental health workers, who make up much of the front-line workforce in psychiatric hospitals, as well as mental health worker representation on the staffing committee.
“It’s disappointing that there is no proposed staffing ratio for non-nurse patient care support staff and that these workers who interact closely with patients would have no guaranteed voice in how patient care is provided,” Rosselli said.
David Simon, a spokesperson for the California Hospital Association, said in a statement that the proposed regulations “have inherent flaws” and fail to recognize the interdisciplinary treatment approach in psychiatric hospitals, which includes not only nurses, but unlicensed mental health workers, counselors, social workers and others.
“At a time when almost a quarter of adults with a mental illness in California cannot receive the treatment they need, the proposed regulations … fail to account for an acute and growing nationwide behavioral health and nursing workforce shortage that will make compliance challenging,” Simon said.
Simon added that the state should provide psychiatric hospitals at least a year to implement the new regulations, “as it has done with health provider staffing ratio requirements in the past.”
Following the Chronicle’s reporting, Newsom declared the lack of staffing requirements in psychiatric hospitals to be an emergency and said minimum nurse-to-patient ratios were “necessary for the immediate preservation of the public peace, health, safety or general welfare.”
The emergency declaration allowed the agency to adopt the new regulations on a shorter timeline, and then work through the normal rulemaking process to set permanent regulations by July 31, 2027.
Tony Chicotel, a senior attorney for California Advocates for Nursing Home Reform, described required minimum staffing as a “positive step.” However, based on his experience with separate state-mandated staffing rules in nursing homes, Chicotel said the impact of such regulations will largely depend on whether and how the state ultimately holds facilities accountable.
“Regulatory standards are nice,” Chicotel said. “But it’s really going to be enforcement and costs of violating the standards that determines whether the new rules will mean anything.”
December 31, 2025
By Joaquin Palomino, Cynthia Dizikes
California health officials have moved to strengthen oversight of for-profit psychiatric hospitals in response to a Chronicle investigation into patient abuses at the facilities, issuing new sanctions and more than a million dollars in fines related to the newspaper’s reporting.
Gov. Gavin Newsom has made mental health care a centerpiece of his administration, saying the state should intervene in more people’s lives. But reporters found that California has increasingly turned to profit-driven companies that make money by relying on lean staffing, while exposing thousands of patients to substandard and dangerous care.
Since the Chronicle began publishing its “Failed to Death” investigative series in February, the California Department of Public Health has levied nearly $1.8 million in penalties to four for-profit psychiatric hospitals — about six times more than the agency had issued to all of the state’s for-profit facilities in the previous six years combined.
Fremont Hospital received $1.6 million of these fines, mostly for widespread underreporting of patient abuse allegations first revealed in the Chronicle’s series. The state launched investigations into the problem in the spring.
CDPH also declared multiple “immediate jeopardies,” among the most serious actions health officials can take to force improvements, after finding that deficient care “caused, or is likely to cause, serious injury or death to the patient.”
More broadly, California has sought to bolster inspections of psychiatric hospitals, including the 22 freestanding facilities operated by for-profit companies. CDPH requested and received about $1 million per year to employ additional inspectors to respond to increasing complaints about the hospitals and to “identify, and hold facilities accountable for any deficient practices.”
CDPH spokesperson Mark Smith said the agency, which oversees most health care providers in the state, is prioritizing its investigations into psychiatric hospitals “to ensure patients receive safe and appropriate care that meets all regulatory requirements.”
Biography
Cynthia Dizikes is an investigative reporter at the San Francisco Chronicle. Her reporting has focused on wrongdoing, negligence and fraud in health care organizations, public agencies and the cleanup of contaminated land. Her work has led to new laws and regulations, leadership overhauls, improved practices, and millions of dollars in funding for vulnerable populations.
Joaquin Palomino is an investigative reporter at the San Francisco Chronicle. Since joining the newsroom, he has covered a wide range of topics, including dangerous conditions inside aging supportive housing hotels, abuse and understaffing in for-profit psychiatric hospitals and increasingly empty and expensive juvenile detention centers. His work has prompted local and state politicians to enact new laws, regulations and other critical reforms to protect people throughout California.
Winners
Prize Winner in Investigative Reporting in 2026:
Staff of The New York Times
For deeply reported stories that exposed how President Trump has shattered constraints on conflicts of interest and exploited the moneymaking opportunities that come with power, enriching his family and allies.
Investigative Reporting
Finalists
Nominated as finalists in Investigative Reporting in 2026:
Debbie Cenziper, Megan Rose and Brandon Roberts of ProPublica
For exposing how the Food and Drug Administration allowed the import of generic drugs from foreign factories that violated safety standards – with potentially lethal consequences for unsuspecting Americans.
The Jury
The Jury
Brody Mullins(Chair)
Journalist and Author, Washington, D.C.
Andrew Metz
Managing Editor, FRONTLINE
Zachary R. Mider*
Reporter, Investigations Team, Bloomberg News
Manuel Torres
Senior Editor, The Marshall Project
Patricia Wen
Staff Writer, The Boston Globe
Trish Wilson Belli
Former Investigations Editor, Miami Herald
Bernice Yeung
Managing Editor, Investigative Reporting Program, University of California, Berkeley
Winners in Investigative Reporting
Staff of Reuters
For a boldly reported exposé of lax regulation in the U.S. and abroad that makes fentanyl, one of the world’s deadliest drugs, inexpensive and widely available to users in the United States.
Hannah Dreier of The New York Times
For a deeply reported series of stories revealing the stunning reach of migrant child labor across the United States—and the corporate and governmental failures that perpetuate it.
Staff of The Wall Street Journal
For sharp accountability reporting on financial conflicts of interest among officials at 50 federal agencies, revealing those who bought and sold stocks they regulated and other ethical violations by individuals charged with safeguarding the public’s interest.
Corey G. Johnson, Rebecca Woolington and Eli Murray of the Tampa Bay Times
For a compelling exposé of highly toxic hazards inside Florida’s only battery recycling plant that forced the implementation of safety measures to adequately protect workers and nearby residents.
2026 Prize Winners
Saher Alghorra, contributor, The New York Times
For his haunting, sensitive series showing the devastation and starvation in Gaza resulting from the war with Israel.
Jahi Chikwendiu of The Washington Post
For a heart-wrenching and achingly beautiful photo essay on a young family welcoming the birth of their first child as the father is slowly dying from cancer.
Dake Kang, Garance Burke, Byron Tau, Aniruddha Ghosal and Yael Grauer, contributor, of Associated Press
For an astonishing global investigation into state-of-the-art tools of mass surveillance, created in Silicon Valley, advanced in China and spreading worldwide before returning to America for secret new uses by the U.S. Border Patrol.
M. Gessen of The New York Times
For an illuminating collection of reported essays on rising authoritarian regimes that draw on history and personal experience to probe timely themes of oppression, belonging and exile.