Someone using a stun gun like a cattle prod assaulted a dozen patients at the Sonoma Developmental Center last fall, inflicting painful thermal burns on their buttocks, arms, legs and backs.
The center's in-house police force, the Office of Protective Services, had a suspect from the start. An anonymous whistle-blower called a tip line in September 2011 and accused Archie Millora, a caregiver at the Sonoma center, of abusing several profoundly disabled men with high-voltage probes.
Detectives found burn injuries on the patients, according to internal records obtained by California Watch. The following morning, they discovered a Taser and a loaded handgun in Millora's car at the Sonoma center.
The facility is one of five state-run board-and-care institutions that serve roughly 1,700 residents with cerebral palsy, mental retardation and severe autism -- disabilities that make communication difficult, if not impossible.
The one victim who is able to speak named Millora and used the word "stun" when interviewed by a detective at the center, according to a state licensing record.
As part of an ongoing investigation, California Watch has detailed how the institutions' internal police force, created by the state to protect the vulnerable residents at these state homes, often fails to conduct basic police work when patients are abused and harmed.
In case after case, detectives and officers have delayed interviews with witnesses or suspects -- if they have conducted interviews at all. The force also has waited too long to collect evidence or secure crime scenes and has been accused of going easy on co-workers who care for the disabled.
Those shortfalls again were on display in the Taser case, records show.
After the assaults were discovered, the Office of Protective Services made no arrest, deciding instead to handle it as an administrative matter. Also, at least nine days after the revelations, records show, detectives still had not interviewed Millora, whose personal Facebook page includes wall photos of assault weapons and handguns.
"There's absolutely no excuse for allowing that to happen like that without any ramifications," Assemblywoman Connie Conway, the Republican leader from Tulare, said of the stun gun assaults.
After California Watch published its initial investigation about the police force, a former state worker alerted reporters to the Taser incidents. Other whistle-blowers turned over records to the news organization, allowing the story to be told for the first time. The state Department of Developmental Services, which operates the developmental centers and in-house police force, has not responded to requests for additional documentation.
The Sonoma County district attorney's office announced this week it would review the stun gun cases, after examining state Department of Public Health records. "We're continuing to review the entire case; we haven't closed the door on our investigation," said Spencer Brady, chief deputy district attorney.
In a written statement, Terri Delgadillo, director of the state Department of Developmental Services, said the center's investigation "included interviews of over 100 individuals, including the suspect who was interviewed on three separate occasions and terminated from employment." She said that the department took the matter seriously and is continuing to investigate, nearly a year after the abuse occurred.
Millora -- who started working as a caregiver at the center in 1998, according to the Department of Developmental Services -- was fired in November, state controller records show. He did not respond to multiple interview requests made by phone and in person at his home.
Jim Rogers, the Sonoma center's executive director, also was fired, according to Delgadillo's statement. Rogers did not return phone calls seeking comment.
Leslie Morrison, head of investigations for Disability Rights California, said she was surprised that the Office of Protective Services kept control of these abuse cases.
Police at the Sonoma center "should have immediately picked up the phone and called outside law enforcement," Morrison said. "We've got a serial abuser here."
At the same time, the police force took steps to thwart a criminal investigation by local authorities, records show.
The stun gun allegation arrived on an answering machine in the executive director's office sometime on Sept. 26, the Sonoma center records show.
A male voice said Millora had used the stun gun on patients, according to records. When Millora returned to work, police found the stun gun and loaded handgun in his car.
On Oct. 5, the Sonoma center's top administrators met with an inspector from the state Department of Public Health investigating the injuries, according to an internal memo. The inspector, Ann Fitzgerald, asked whether the attacks were a criminal case.
"It could be," said the center's police commander, Bob Lewis, according to the memo.
But police at the center took steps that might have discouraged the Sonoma County Sheriff's Office from opening its own investigation. Lewis downplayed the series of attacks against patients, telling the sheriff's office there was an abuse allegation, not a dozen confirmed cases, the internal correspondence shows.
In the Office of Protective Services' call to the sheriff's office, center police disclosed they found two weapons, said Sonoma County Lt. Dennis O'Leary. Regarding the assaults against patients, O'Leary said Lewis informed them "just that there was some suspicion that there may have been some abuse to the patients." At the time, however, the in-house police detectives at the state center still had not questioned Millora, records indicate.
Delgadillo said in her statement that the sheriff's office decided "not to intercede and take over the investigation."
The sheriff's office had a different take.
"We offered to assist in their investigation, but we were told that they didn't need our help," said Sonoma County Assistant Sheriff Lorenzo Dueñas.
The Office of Protective Services did refer a criminal charge against Millora for carrying a concealed firearm, a misdemeanor, according to Sonoma County Superior Court records. He pleaded no contest to the charge in April and received 20 days of electronic monitoring, plus three years' probation and a $190 fine.
Charges of assault against a dozen patients could have meant decades in prison.
Sonoma center officials accepted responsibility for the stun gun abuses in June, when the state Department of Public Health issued the facility a "Class A" citation. The penalty included a $10,000 fine for violations that put patients at serious risk of harm or death.
The citation said 11 patients had stun gun injuries. Internal records from the Sonoma center list a dozen victims.
The precise burn marks on the victims' bodies indicate the Taser was used at close range to the victims -- almost like a cattle prod.
The burn marks came in pairs, roughly a half-inch apart, the citation said, and "represented non-accidental trauma." Some of the injuries were healing into scars, suggesting the attacker had abused the patients over the course of several days, if not weeks.
Based on the doctor's findings, the state inspector concluded the patient injuries were "abrasions consistent with the use of an electrical thermal device (Taser Gun)," the citation said.
All of the patients were treated at the center's own acute care clinic.
ABC 7 reporter Vic Lee contributed to this report. This story was edited by Mark Katches and copy edited by Nikki Frick and Christine Lee.