This story includes descriptions of physical and sexual violence. Please be advised. The name of one of the main subjects (Elle) has been anonymized as her mental health remains tenuous. 

It was just after midnight on Jan. 16, 2024, when a young woman ran into the hallway of San Francisco’s Crestwood Healing Center screaming, blood seeping from deep wounds on her right cheek. 

The clinic’s skeleton staff rushed the patient into an office to provide care. 

The woman’s assailant, her roommate, Elle, followed her into the hallway, waltzing through the locked fifth-floor facility in Saint Mary’s Hospital. In Elle’s hand was a shard from a broken CD, dripping with blood.

Elle bent and scooped up blood from the floor. As panicked patients and staff moved around her, Elle put her fingers in her mouth and said she liked the taste. 

Police arrived at the acute mental health facility just off Golden Gate Park, where roughly 50 patients live, and arrested Elle. She was charged with aggravated mayhem and assault with a deadly weapon. The victim was taken to the hospital and received 30 stitches, according to court documents.  

What brought Elle to that hallway, and why no one stopped her, reflects broader issues at San Francisco’s most important mental health facility. The chaos inside its walls speaks to problems across the state’s archipelago of mental health care.

This report is the latest in a series of investigations by The Standard into the Crestwood Healing Center. The facility said in a statement that it takes all violence seriously and complies with state licensing requirements. Our reporting has previously revealed repeated alleged sexual assaults by one resident and exposed how a facility designed to house potentially dangerous patients has a track record of repeatedly allowing them to go AWOL.

“I would say that Crestwood was potentially the most dangerous place I‘ve ever worked,” said Brad Barnes, who was a case manager and recovery coach from 2023 to 2025. “Really, it’s an asylum for the criminally insane.”

Elle’s path to that night had been years in the making. In 2021, she was arrested and charged with several felonies: assault, elder abuse, carrying a knife, and using tear gas as a weapon. A judge found her incompetent to stand trial, and she was placed into an involuntary conservatorship, the legal mechanism California uses to compel treatment for people too mentally ill to navigate the courts. Napa State Hospital, a state-run psychiatric facility, had two years to restore her to competency. It couldn’t.

When that window closed, Elle entered the revolving door that connects California’s courts, jails, and locked psychiatric facilities. In December 2023, she was sent to Crestwood. Former staff say she began threatening people almost immediately after arriving.

Less than two months later, she was standing in that hallway with the blood-soaked CD shard.

After her arrest, a San Francisco court again found her incompetent to stand trial. She was sent back to the Napa hospital, which again failed to restore her to competency. On Oct. 29, 2025, she was returned to the county jail, awaiting a locked facility willing to take her. In March, a judge dismissed the stabbing case “for the sake of justice” — a term that, in practice, means the system has given up on the idea that Elle will ever be well enough to face trial.

Elle’s case reflects a system under strain. At any given time, roughly 700 people in San Francisco are under involuntary conservatorship — a number that has grown as state laws expanded the grounds for nonvoluntary treatment for conditions like drug addiction. When they can get a bed, many of these people are sent to facilities like Crestwood. But state law requires the eventual release of stable patients back into the community, where many deteriorate and cycle back into the criminal justice system. 

Roughly 50% of all people put into conservatorships in San Francisco fall back into crisis, a recent state report noted (opens in new tab).

The events of  Jan. 16, 2024 were recounted to The Standard by a former Crestwood employee who was a witness; three others corroborated the account. The Standard’s reporting drew on interviews with 10 former workers, state reviews (opens in new tab), internal documents, and contemporaneous text messages.

That night’s violence had been simmering for weeks. Several days before the attack, Elle was telling others her roommate was a snitch. Elle wrote a song, “A Delightful Dirge,” with violent lyrics, on a notebook page seen by The Standard; it included scenes of carnage and aggression in neat but exaggerated script.  

“I cut up all my bitches with butcher knives. I can’t find a woman who’s not scared of me, when I smell their fear I go in for the kill, the Devil makes me act against my will,” she wrote.

At least three former staffers said they told Crestwood management about Elle’s troubling behavior, but nothing was done. 

Management often responded to issues raised by staff by reminding everyone that punishment was not part of Crestwood’s values, according to five former workers and internal documents. On any given shift, just six staff members worked the floor to oversee 50 patients.

One incident in October 2023 involved a patient who attempted to strike staff and used a pen as a weapon. Once restrained, she expressed remorse. Management’s report that day called for a revised care plan and staff education around healthy coping strategies.

Days later, MacKenzie Williams, who was a case manager at Crestwood from 2023 to 2024, reported to management an incident where a patient spat on another worker and said he would “kill you, bitch.” When she asked for guidance, she said, managers responded by telling her not to punish clients.

“All people respond better to positive reinforcement for changed behavior, and punishment does not actually result in change,” one senior manager wrote to Williams in a report reviewed by The Standard. “Being told to punish or be punitive … is against Crestwood values.”

In the aftermath of the CD attack by Elle, staffers traded horrified text messages, held hushed conversations in the hallways, and spoke at length about what had happened. Case workers tried to reassure patients who were terrified they would be killed in their sleep.

“Wait, I’m still not over this. I’m hella scared to go back to work knowing she prob got something that can kill me,” one worker texted the day after the event. A colleague told The Standard: “That event did shake me to my core.”

Former staffers say the attack was the most striking example of the chaos, violence, and mismanagement inside Crestwood. 

Opened in 2018 as a solution to one of the city’s most vexing problems — where to put severely mentally ill people with nowhere to go — the facility occupies the fifth floor of what is now Stanyan Hospital, just off Golden Gate Park. Its 50 beds make it the city’s largest locked mental health treatment facility. San Francisco spends $35 million a year for the services provided by Crestwood, the private company that runs it, which operates 32 facilities across California. 

The facilities run by Crestwood have been at the center of complaints. A Los Angeles Times statewide database (opens in new tab) of assaults and deaths in such facilities did not list Crestwood’s San Francisco facility but noted that a death occurred at Crestwood in San Jose. No fault was found related to that incident. 

Almost all of the former staffers interviewed by The Standard said they left because of conditions at Crestwood and management’s failure to address them. One said he was fired following The Standard’s first story about the facility. Collectively, they worked at the facility from 2022 to late 2025.

The accounts by Crestwood staff are echoed by employee reviews on Glassdoor (opens in new tab) and Indeed (opens in new tab). The reviews describe organizational and leadership problems affecting patient care and staff morale, and scheduling and operations are described as chaotic. One Indeed reviewer wrote, “Clients suffer due to overworked staff and not enough staff on the shift. Safety concerns are heard without providing solutions. Management passes blame onto staff, without providing support for positive change.” 

But the reviews are not uniformly negative. A thread of positive feedback runs through both platforms, with staff frequently praising the dedication of their colleagues and the rewarding nature of working with clients. “The floor staff help each other and are typically good people,” wrote one Glassdoor reviewer. Another described coworkers as “fun and supportive.” 

At an all-hands meeting after the incident with Elle, senior managers pointed the finger at staff. “Well, treatment team, why didn’t she get sent out?” a former employee recalled a manager saying. “Like it was somehow our fault that she didn’t listen to the fact that we were screaming at her.”

The state requires several steps after any violence or threats of violence, including a risk assessment, more supervision, safety protocols, and safety interventions. 

Independent hospital monitor Elizabeth Jones, who was the director of St. Elizabeths Hospital (opens in new tab) in Washington, D.C., and the receiver for Augusta Mental Health Institute (opens in new tab) in Maine, said such violence is not normal or acceptable and should have been taken seriously by leadership. 

A “culture of violence is never acceptable. It doesn’t matter what the characteristics of the people who are confined to the hospital. A hospital is for recovery,” she said. “If they aren’t looking at what causes violence and what would remedy it, they are not exercising leadership. That is absolutely irresponsible, and there’s an absence of management.”

Before she began working in San Francisco, Williams was at a facility similar to Crestwood in Kingsburg (opens in new tab). She said the contrast was stark: At Kingsburg, there was no violence, responsive management, clear protocols — and none of the chaos or indifferent leadership she perceived in San Francisco. There were also safety protocols such as a contraband closet (one was eventually created at Crestwood) to ensure patients had limited access to items that could be used as weapons.

While patients have a right to possess pens and pencils, and the state does not require a contraband closet, Williams chalks the difference up to leadership. 

Meanwhile, according to nearly all the former staffers interviewed and a group text after the CD attack, leaders resisted taking steps workers believed could better ensure safety in dealing with dangerous patients. Management had few protocols to track potential weapons like pens and continued to invoke a no-punishment culture even as violence and sexual assaults continued, according to staffers. 

Former employees paint a picture of a last-resort psychiatric facility that was traumatizing the very patients it was meant to save — in the case of Elle and other incidents — before releasing them back onto San Francisco streets. The facility’s issues could be undermining an already shaky system.

Crestwood officials say the facility is run according to national standards, has layers of local and state oversight, and has high employee and patient satisfaction.

“Crestwood Behavioral Health, Inc. takes seriously all concerns regarding the safety and well-being of the people we serve and our staff,” company spokesperson Larry Kamer said. The company’s facilities, he noted, are accredited by the Commission on Accreditation of Rehabilitation Facilities, “reflecting adherence to the highest nationally recognized standards.”

Kamer pointed to last year’s client satisfaction rate of 86% and staff surveys showing strong confidence in the workplace. Staffers follow strict protocols and training, including de-escalation and safety practices, he said.

“Our focus is unambiguous: treatment, healing, compassion, kindness, and the dignity of every individual in our care,” Kamer said.

Crestwood declined to address specific allegations of violence and specific incidents of patient mistreatment.

The San Francisco Department of Public Health said in a statement that Crestwood is “invaluable” and has a number of levels of oversight, including city monitoring and reviews of programs, as well as site visits. The department did not address past incidents inside the facility. 

The state Department of Healthcare Services cited its oversight actions and the facility’s safety and reporting requirements, but also declined to comment on any specific incident. 

Despite those reassurances from officials, many interviewed by The Standard said the solution is a root-and-branch overhaul of policies, practices, and the people who lead them.  

Hannah Liddell, head of the investigations unit of the nonprofit advocacy group Disability Rights California (opens in new tab), said such reform would require a broad approach. 

“It appears that no single approach would be sufficient; instead, meaningful reform would likely require coordination across agencies, both governmental and nonprofit, to effect real change,” she said. 

For instance, the city could threaten to remove its contracts with Crestwood unless staffing and conditions change, she said. In addition to government action, nonprofit watchdog agencies could report issues to the Department of Justice under the Civil Rights of Institutionalized Persons Act. Outside groups could sue to force Crestwood to change its practices. 

The former workers say the incidents they witnessed were not an abstract problem of institutional oversight or responsibility. For them, the issue was all too real.

When Karianna Grigsby was training to work at Crestwood as a service coordinator, she was warned that assisting patients with a range of mental illnesses could put her in unsafe situations. 

But when she started at the facility in July 2022, she found she was ill-prepared for what she described as the near disregard of her bosses in the aftermath of those situations. 

 One attack took place when she was responding to a patient with schizophrenia who was destroying property and hitting walls. She tried to calm him down, and he struck her in the face. She had to go to the emergency room. 

“I was attacked, and nothing was done,” said Grigsby, adding that she reported the incident. “They don’t give a fuck about their staff.” She left in late 2023 because she did not feel supported by her bosses. According to state documents, Crestwood failed to report to state licensing officials a previous incident, in 2018 (opens in new tab), that resulted in a hospital visit by a staffer.

Crestwood said it takes the safety of its staff seriously but did not comment on specific cases. 

Employees were spat on, attacked, groped, and sworn at, according to a staff grievance document (opens in new tab) obtained by The Standard. Nearly every incident had to be documented internally and reviewed by management.

Barnes, the former recovery coach, said he saw almost every kind of mayhem inside of Crestwood. “It was a wild, dangerous place,” he said. “There was drug abuse, and there was violence.” 

Not all former staffers said the level of violence was abnormal, or that leaders were unresponsive. One who was a case worker for four years said there will always be incidents of violence with such patients.

“At the end of the day, you can have the most training in the world, and things are gonna happen,” he said. “I think we prepared them to the best of our ability.” He left Crestwood to work in another field, he said. 

Five former staffers said leaders rarely reacted appropriately in the aftermath of violence or abuse directed at staff, which would have involved getting at the root of what caused an incident so it does not happen again. 

Jones said the issues at Crestwood are troubling and should be dealt with by leaders, who must ensure there are consequences for patients who act out and put in place protocols, such as potential isolation and removal, to make sure threats of violence are dealt with before incidents occur.

“The task is to understand what those causes are and why they are happening and then to develop a strategy to undo those factors,” she said.

State officials said such actions are required, and all facilities must report their progress.

As a case manager, Williams found that the facility’s one-size-fits-all approach made some troublesome patients worse. Misbehavior sometimes led to rewards instead of discipline. For instance, employees who took well-behaved patients on chaperoned trips to Golden Gate Park were instructed not to physically stop patients who wandered away. 

Williams was part of a failed unionization drive born from the issues staff relayed to The Standard. 

From 2023 to 2025, at least 20 patients were reported missing by staff, according to 911 dispatch records. Some never returned. State reviews noted a number of instances around how AWOL patients were dealt with but cited the facility only once, in 2019 (opens in new tab), for failing to monitor a client’s whereabouts.

Barnes said when he first saw a fight between two patients, he was told to observe. A nurse walked away, leaving him alone to deal with the violence. He ended up taking no action because policy dictated that to intervene, there must be two staff members present. 

Crestwood did not respond to The Standard’s questions about this policy.

According to former employees, the same management philosophy that allowed violence against staff created a second, equally serious problem: an environment that allowed sexual assault to occur.

Early last summer, Gilberto Lopez-Duarte, a patient who had been in and out of the criminal justice system for years, was kicked out of Crestwood twice for two alleged sexual assaults. 

According to police and court records, he had been allowed back into Crestwood after promising he would refrain from any sexual activity. But he allegedly reoffended and was kicked out of the facility permanently. After his release, he was sent to transitional housing, where he allegedly attacked a woman and was arrested. 

Seven staffers say his case illustrated a broader pattern: a loose environment around sex at Crestwood that may have enabled assault.

Crestwood did not respond to an inquiry regarding its policy on sex among patients, but Barnes said it was allowed, and staffers tried to educate patients to use contraception. 

Jones said sex among patients is generally frowned upon in such settings, although there may be exceptions, if both patients are consenting and in no danger.

Crestwood’s layout, while not unusual for such facilities, may hinder efforts to keep sex between patients at a minimum. All residents live in unlocked rooms. Most are single rooms, but some are shared. There is a day room and cafeteria on the same floor. 

A former employee said she had an HIV-positive client who asked for a pregnancy test. When the worker asked why she was having sex with other patients without protection, the client tried to punch her in the face. The staff grievance document (opens in new tab) also mentioned sexually transmitted diseases being spread through patients having unprotected sex.

In at least one case, a janitor was fired for coercing a client into having sex, according to two staffers. 

One of those workers said she searched the room of the female sexual assault victim and found a meth pipe and other drugs. When she asked how the patient had received them, “The client said that ‘I hit his weed pen. In order for me to hit his weed pen I had to have sex with him,’” the worker said. The staff grievance did not explicitly mention the incident but said two staffers were hired without background checks for misconduct. 

The janitor was later fired. Crestwood did not respond to The Standard’s question about this incident. 

A 2024 state review of Crestwood noted that it had failed to do background checks on some employees prior to hiring them. This is in violation of state regulations requiring pre-employment background checks.

One former janitor who worked at Crestwood for four months in 2024 disclosed during the interview process that he had a nearly 30-year-old nonviolent conviction — and was hired anyway. He was fired once his background check came back.

The state agency that licenses the facility, the California Department of Health Care Services, found deficiencies at Crestwood in its 2024 review, but the annual review did not list many of the most serious issues around violence that staff reported.

Ann Carroll, a spokesperson for the agency, said all licensed facilities are required to report and investigate violence, injuries, or threats and must ensure that safety protocols are in place before and after any violence or harm.

Licensed facilities like Crestwood “must take immediate steps to protect clients and staff when threats or harm occur,” Carroll said in a statement. “This includes assessing risk, increasing supervision, implementing safety interventions, and notifying law enforcement, when needed.”

In 2024, state reviewers cited Crestwood for a cascade of failures: missing proof of mandatory training for six of 22 new hires, unverified employee credentials, inadequate nurse staffing, improper linen handling, and missing patient health plans and follow-ups. Similar issues were found in the three previous year’s reviews. 

Four former employees say the reviews barely touched the surface of what was happening at Crestwood. The state said it conducts announced and surprise inspections of the facility but would not comment on the efficacy of the reviews. 

One former worker wondered how state officials had not found out about what was happening. “I am surprised it’s not been shut down yet.”