San Francisco pays Crestwood Healing Center $35 million a year to treat its most vulnerable residents. A Standard investigation found the facility has become one of the most dangerous places in the city.

Our most recent story reveals how chaos and violence inside a facility designed to house the severely mentally ill end up traumatizing and abusing the people it is meant to help.  

It’s the third in a series of Standard articles about the facility. Previous investigations revealed how potentially dangerous patients were allowed to go AWOL and how one patient who had been kicked out in connection with a sexual assault was allowed to return, only to allegedly reoffend. 

The reporting reveals how lax procedures and management have created conditions for physical and sexual violence inside the clinic. The Standard investigation drew on interviews with 10 former workers, state reviews (opens in new tab), internal documents, and contemporaneous text messages.

“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 told the Standard. The company’s facilities, he noted, are accredited by the Commission on Accreditation of Rehabilitation Facilities, “reflecting adherence to the highest nationally recognized standards.”

When Crestwood was opened in 2018, the idea was to create a locked facility with specialized mental healthcare that would stabilize patients before transferring them into less secure settings or releasing them to the public. Instead, it has become yet another way station in the archipelago of courts, jails, and locked psychiatric facilities that make up the state’s overburdened mental health system.

Here are four takeaways from our reporting:

A violent stabbing traumatized patients and staff

On Jan. 16, 2024, a patient attacked her roommate with a broken CD shard, causing deep wounds to the cheek. 

Following the attack, the suspect was arrested and 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. 

In the aftermath of the attack, staffers traded horrified text messages and spoke at length about what had happened. Case workers tried to reassure patients terrified they would be killed in their sleep.

The suspect had initially been found incompetent to stand trial after being arrested in 2021 and charged with several felonies, including assault, elder abuse, and carrying a knife. The team at Napa State Hospital failed to restore her to mental competency before she was sent to Crestwood. 

In the stabbing case, the court again found her incompetent to stand trial. In March, a judge dismissed the case “for the sake of justice” — essentially meaning the system has given up on the idea that the assailant will ever be well enough to face trial. Her next likely stop is another center like Crestwood.

Staffers said management regularly ignored warning signs of regular violence

Several days before the attack, the suspect told people her roommate was a snitch. She wrote a song, “A Delightful Dirge,” with violent lyrics, on a notebook page seen by The Standard.

“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 the suspected assailant’s troubling behavior, but nothing was done. 

State officials require several steps after any violence or threats of violence, including a risk assessment, more supervision, safety protocols, and safety interventions. 

In the aftermath of violence, management allegedly blamed staff, provided few resources

At an all-hands meeting after the CD attack, 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.”

For workers traumatized by the event, Crestwood offered what amounted to a group therapy session. “They sent out some dude to make sticker books with us,” said a former worker. 

Leaders resisted taking steps that staffers believed could better ensure safety in dealing with dangerous patients, workers said. 

Employees were spat on, attacked, groped, and sworn at, according to a staff grievance document (opens in new tab) obtained by The Standard.

Staffers claim a loose environment around sex may have enabled assault

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 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. 

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

Several people interviewed said there’s a surprisingly permissive approach to sex at a facility where many residents have been deemed unable to care for themselves and placed under conservatorship. Crestwood did not respond to an inquiry regarding its policy on sex among patients. Staffers tried to educate patients to use contraception. 

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) mentioned sexually transmitted diseases being spread through patients having unprotected sex.

Read the full investigation here.