Claims of abuse of adults in group homes
Video taken at L.A. facility ‘is violent and horrible to watch.’ Mothers of autistic residents want justice.
The two caregivers edged toward the staff bathroom as the sounds of slaps and screams ricocheted across the ranch-style home.
The evening of Aug. 25, 2023, had already been an exceptionally trying one for staff at Elwyn-Mayall, a fourperson home in Northridge for adults with developmental disabilities.
Jude Cabanete, a resident with autism, had spread feces across his mattress and vomited on the floor, according to staff reports from that night. The caregivers had hosed down the sheets. Cabanete seemed to want to get clean too.
“Shower, shower,” said Cabanete, 31.
Adekunle Fabunmi, who was assigned to watch him that evening, said no, a co-worker would later tell an internal investigator. Cabanete ran for the staff bathroom, where he emptied a container of disinfectant wipes and began to chug water out of it, according to an incident report reviewed by The Times. Fabunmi followed.
By the time two other caregivers got to the bathroom, Fabunmi was striking Cabanete in the head — a scene captured on cellphone video taken by one of the caregivers. The 13-second video, viewed by The Times, captures four slaps to the face and one punch to the left ear. One more slap can be heard off-camera.
“No,” Cabanete groaned after each hit, cowering by the bathroom window, arms pinned to his side. “No. No. No.”
Fabunmi, a 53-year-old employee known as “Pastor,” would continue to torment Cabanete throughout the home, additional footage showed. In the living room, he threw Cabanete, naked from the waist down, from the couch to the ground as he screamed. In the adjacent room, he ordered Cabanete, still wearing only a bright-red Tshirt, to do 400 jumping jacks as he cried out to stop.
The videos do not show either of Fabunmi’s colleagues intervening.
Fabunmi declined to discuss the case in a brief phone call and referred a reporter to his attorney. Christian Oronsaye, the attorney who represented him in a state investigation into the incident, provided The Times with a letter sent to the state saying he believed the accusations of abuse at the Northridge facility were false after interviewing Fabunmi but declined to comment further.
As California looks to move people with developmental disabilities from institution-style facilities into smaller, more intimate homes, Elwyn has become a lifeline for the state, where such homes are in critically short supply, officials say.
The 170-year-old nonprofit, which describes itself as a “premier, internationally recognized” provider for people with developmental disabilities, operates nearly 50 licensed homes in California for adults who can’t live alone. That’s more than nearly any other organization, state data show.
The violence captured on video at the Northridge home has raised questions about Elwyn’s prominent role as caregiver for some of the most vulnerable Californians — and whether oversight bodies are prepared to keep troubled homes in check amid a severe shortage in beds.
On Aug. 25, the night Fabunmi hit and punched Cabanete, he forced another resident of the home, 30year-old Gregorio Topete, to sit on the living room floor for three hours, a co-worker later told police. Fabunmi stood over Topete “in an intimidating manner” when he tried to move, slapping him twice on the head, according to a Los Angeles police detective’s case log. Topete stayed on the floor until 2 a.m.
Fabunmi would deny to his bosses hitting anyone that night. Within a week, he no longer worked for Elwyn, according to the nonprofit.
The LAPD in late October submitted the case for the Los Angeles city attorney’s office to consider misdemeanor battery charges. The case is pending.
Elwyn said in a statement that the health and safety of those it serves are of “paramount importance.”
“For over 20 years, Elwyn has supported this mission in California very effectively and with a high level of satisfaction from both supported persons and their loved ones,” Elwyn said, adding that the nonprofit’s track record was “exemplary.”
“The allegations ... are isolated to a particular set of circumstances, and do not represent Elwyn’s longstanding activities in California.”
Fabunmi’s colleagues had accused him of assaulting a man he was paid to protect once before.
In the spring of 2019, Fabunmi was working as a caregiver for both Elwyn and People Creating Success, a company that serves people with developmental disabilities.
That June, a manager at People Creating Success called the LAPD after a staffer said she saw Fabunmi slap a nonverbal man who had cerebral palsy at a group home in West Hills, according to a police report. The staffer told police Fabunmi had grown frustrated trying to put a shirt on the trembling 55year-old, telling her he was “the most difficult to work with.” People Creating Success terminated Fabunmi within two weeks of the incident, according to the report.
Fabunmi would later sue the company, arguing that staff “made up” the accusation to get rid of him. The attorney who represented the company said the case was resolved through a confidential settlement.
After investigating, the LAPD referred a case of misdemeanor battery to the city attorney’s office. Frank Mateljan, an official with the office, said the matter was “resolved outside of court” through a city attorney hearing, a way to settle lowlevel crimes without a criminal prosecution.
Typically in these hearings, the perpetrator is provided “guidance as to how to avoid violating” the law, he said. No criminal charges were filed.
People Creating Success reported the alleged abuse to the California Department of Social Services, which licenses the home, according to a state report. After an internal investigation, the company banned Fabunmi from going near the home. The state agency told The Times it investigated the claim but did not find enough evidence to warrant banning him from other licensed homes.
This meant he could keep working at a cluster of Elwyn homes just a few miles from where he was fired. Elwyn said it was never notified about the investigation or the criminal case by the Department of Social Services, which had received a report on the alleged abuse.
Advocates say the incident has exposed failure at every level in a system built to hold abusers accountable.
“When a licensing authority lets someone who is credibly accused of abusing a vulnerable person have a chance to go back and do that again rather than stripping their license, it’s absolutely a system failure,” said Larkin Taylor-Parker, legal director of the Autistic Self Advocacy Network, a national public policy nonprofit run by autistic people.
On Aug. 27, the employee who took video of the incident two days earlier sent the footage to a colleague who worked at a group home in Agua Dulce. The employee would later tell an Elwyn investigator that she “did not feel safe” reporting the assault to her direct boss.
“All the males in the home, when they get close to residents, the residents flinched,” she told him. “Jude flinched.”
By Aug. 30, staff at the North Los Angeles County Regional Center had seen the video footage. The government-funded nonprofit, which provides services for people with developmental disabilities in the northern part of the county, contracts with Elwyn for eight homes, including the Northridge location. One more is under development in the Antelope
Valley.
“It is violent and horrible to watch,” Ari Stark, a quality assurance specialist at the regional center, wrote to two colleagues, according to a transcript of instant messages reviewed by The Times.
Stark, who was responsible for monitoring ElwynMayall, wrote in emails to colleagues that he was concerned about “a lack of oversight from ‘management’ ” at Elwyn, which “has obviously lead to this situation where someone physically assaults a client and staff sit by.”
“I am super concerned with Elwyn’s ability to provide a safe and appropriate environment to any of their consumers,” Stark wrote in an email to a supervisor. “If it were up to me, I would terminate their contract once we found a better provider.
“I don’t believe their clients are safe with them,” he wrote. “Just needed to share that opinion with you.”
On Jan. 9, Elwyn reported that Cabanete had again been a victim of suspected psychological abuse.
According to a report from an Elwyn specialist inspecting the Northridge home that afternoon, a staffer had again ordered Cabanete, who is about 5 feet 10 and 240 pounds, to do 100 jumping jacks — twice.
When staff approached, Cabanete would still flinch.
Cabanete was about 12 when his mother realized he was no longer safe at home. He would get frustrated when he couldn’t communicate, banging his head until it swelled up.
As a teenager, Cabanete moved to the Fairview Developmental Center, a state facility in Orange County for people with developmental disabilities, many of whom required round-the-clock care. He stayed there until 2016, when officials finalized a plan to shutter Fairview, concerned that developmental centers isolated people with disabilities from their communities. He spent six years at a home near Culver City before arriving at Elwyn-Mayall in April 2022.
His mother said the home seemed “family friendly,” located on Mayall Street in the northwest San Fernando Valley. She could drive there every afternoon from her home in North Hills and drop off his favorite meals: KFC, El Pollo Loco and homemade chop suey. Caregivers would take him on excursions to the Santa Monica Pier.
“It was sold beautifully,” agreed Laura Topete, whose son Gregorio moved there nine years ago.
The home had a good sales pitch for desperate parents: a stay with no end date, an on-site nurse 24/7, caregivers never out of their sons’ sight.
Elwyn would get paid extra for this.
Since landmark legislation passed nearly half a century ago, California is required to ensure that all residents with developmental disabilities get the services they need. To that end, hundreds of millions of dollars flow each year from the California Department of Developmental Services to the state’s 21 nonprofit regional centers.
The centers pay more to providers that house people with more intensive needs, such as Cabanete and Topete. Whereas the North Los Angeles County Regional Center would pay about $1,400 per month for a person at the lowest-level home, Elwyn got roughly $20,000 a month for Cabanete last year, according to regional center records provided by his mother.
But Mary Cabanete and Laura Topete say the heftier price tag never translated to better care. Both mothers said they found staff illequipped for the most fundamental part of the job: keeping their sons safe.
The mothers said they would find bruises the staff couldn’t explain — even though the home was required to have a caregiver, sometimes two, near the men at all times. Twice, the home called police after Topete hurt himself, his mother said. Cabanete once escaped into a busy intersection after “terrible explosive behavior,” according to an incident report.
The tensions between the mothers and the staff had been building. In early September, about two weeks after Fabunmi slapped and punched her son, Mary got a call from Elwyn as she was dropping off lunch at the home, she said. She was told the home was “investigating an allegation of abuse.”
It was another week before she got the details.
“It was torture,” said Mary, who read Elwyn’s report detailing the abuse but has not watched the videos.
Both women, represented by personal injury attorney Craig Charles, have sued Fabunmi and Elwyn, as well as the North Los Angeles County Regional Center. The mothers allege their sons were “assaulted and battered” by Fabunmi while the other two staffers, both required by law to report abuse, failed to intervene.
Elwyn said in a statement that it is not able to comment on pending lawsuits but that mistreatment of residents “is not tolerated.”
“I’m actually really grateful that somebody recorded it — because both of our sons are not good historians,” Laura Topete said. “They would have gotten away with it.”
Linda Carter, 65, found herself in a similar position five years ago: convinced her autistic son had been abused at an Elwyn facility. But she didn’t have video.
With Fairview closing, her son, Brandon Newman, was moved in October 2017 to an Elwyn home in West Covina. Carter said it became clear the workers there were not prepared to be a 24/7 caregiver for her son, an attention-loving 40-year-old who lives for rides in the back seat of his mother’s car.
She said his leg swelled with cellulitis. She took photos of a hematoma on his eye that went untreated for so long his socket bulged to the size of a golf ball. Once, she said, she found him lying in sheets soaked in urine.
Carter began to suspect the injuries weren’t just from neglect.
In October 2018, the West Covina Police Department got a call from a woman at a pay phone at an Arco gas station alleging that Elwyn employees were abusing a man matching Newman’s description: a Black man with a disability. A few months later, someone sent an anonymous letter to Elwyn’s leaders alleging that three staff members, referred to as “monsters,” would grab Newman by the testicles and “sock” him in the head.
“I pray to Jesus that one day the abuse don’t go to far and kill a client,” the person wrote.
The physical abuse was never proved. Staff members insisted the bruises were self-injuries, Newman’s mother said. Newman, whose speech is limited to two- or three-word sentences, couldn’t say either way.
“Brandon is helpless. They’re going to hurt him and say he did it?” Carter said. “No, they messed with the wrong child.”
In June 2019, she sued Elwyn and the San Gabriel Pomona Regional Center, which had placed him in the home, calling it a “last resort” to stop the abuse of her son. The lawsuit was settled for $75,000, according to court records.
Elwyn said in a statement that there was “no determination of liability” against the organization and called the allegations “speculative and uncorroborated.”
Carter later quit her job at a military base to care for Newman full time.
In California, an alphabet soup of bureaucracies is tasked with making sure people with developmental disabilities are not abused — and if they are, making sure those responsible are held accountable.
But advocates say the oversight system has broken down, allowing problem homes to stay in business and abusers to circulate through them.
The California Department of Social Services, which licenses group homes, often takes the lead on big investigations and can permanently bar employees from all homes if it finds enough evidence that abuse occurred. But advocates say complaints of abuse are rarely proved, making it easy for problematic staff to drift from one home to another.
“The state doesn’t have enough investigators to do the sort of due diligence that’s required to understand what really happened,” said Jody Moore, a lawyer who represented Carter and specializes in cases of abuse in nursing and group homes.
The department said in a statement that staff investigate all complaints that suggest a threat to residents in licensed homes and take “appropriate disciplinary action, in accordance with state law.”
Experts say allegations of abuse of autistic people who require significant support can be particularly difficult to prove. Some victims harm themselves, making it easy for an abuser to brush off injuries as self-inflicted, or struggle to communicate what happened. For example, Cabanete twice told investigators he was not hit, despite it being clearly captured on video.
In the last five years, the state has investigated 25 complaints alleging that adults in Elwyn homes were injured or physically mishandled, according to publicly available investigation reports from the state’s licensing division. All but three complaints were not substantiated.
The regional centers, meanwhile, have the power to impose sanctions on problem homes, including pulling their contract. But advocates say they rarely do, instead encouraging families to move the loved one out of the home — a “sanction” that families say is useless when there’s nowhere to go. On Nov. 2, the North Los Angeles County Regional Center sent Elwyn-Mayall a letter that cited state regulations, saying it would recommend relocation and “discuss the consequences of refusing to relocate” with families immediately. Nobody moved.
Former and current staff at regional centers say there’s little appetite for cracking down on providers when there’s a shortage of beds, particularly for those who need the most intensive support. This leaves staff with an essential question: How bad does the care have to be before it is worse than nothing?
“I’ve heard of vendor programs where the [inspectors] went in, and the place is infested with bedbugs, the sheets haven’t clearly been changed in months, and they really are faced with a tough choice,” said a former regional center staffer who spoke on the condition of anonymity to discuss her past employer. “They know there’s no open beds. So what do they do?”
Cristina Preuss, head of the North Los Angeles County Regional Center, said in an email to The Times that it was “inaccurate and incorrect” to say the shortage of beds makes regional centers reluctant to shutter homes.
State regulations allow residents to stay in a facility as improvements are made, she said, as long as they’re not in “immediate danger,” to avoid upending their lives.
“The residents may have close relationships with their housemates and not be able to live with them ever again if the home closes. The
Caregivers,