We're still trying to understand the unconscionable ineptitude at the state Department of Social Services that left a janitor and a cook looking after elderly and mentally ill patients in a Castro Valley care facility.

It's been three weeks since the state agency suspended the license of Valley Springs Manor without bothering to ensure its residents were moved elsewhere. It's long past time for agency Director Will Lightbourne, and his boss, Gov. Jerry Brown, to explain what went wrong.

Through a spokesman, we've been told the department is conducting an investigation and that "it is clear procedures were not followed and that is unacceptable." That's an understatement.

Alameda County Sheriff’s Department tape is seen in front of he Valley Springs Manor care home on Apricot Way in Castro Valley, Calif., on Sunday,
Alameda County Sheriff's Department tape is seen in front of he Valley Springs Manor care home on Apricot Way in Castro Valley, Calif., on Sunday, Oct. 27, 2013. Residents of the home were evacuated on Saturday afternoon after the facility was shut down and their license was suspended by the California Department of Social Services on Thursday. Only several staff members, including a cook, assistant cook and a housekeeper, remained at the facility until Saturday. (Jane Tyska//Bay Area News Group)

We're also told the department is reviewing internal procedures to prevent future incidents of this kind. But from the paper record available so far, it appears this wasn't a breakdown in procedure; this was a failure to use common sense.

Inspectors had been carefully watching the Castro Valley facility for a year or more. Effective Oct. 24, the department suspended the licenses for three facilities, including Valley Springs Manor, run by Hilda N. Manuel.

The accompanying 34-page accusation detailed findings of substandard conditions, including insufficient and inadequately trained staff, hiring workers who lacked criminal background clearances, improper medication distribution, residents locked inside the facility, rodent droppings in the food pantry, moldy and rotten produce and no administrator on site.


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The conditions were so bad that the department was not only suspending the facility licenses, it was seeking to bar Manuel and her daughter Mary, who was assistant general manager at Valley Springs, from ever working in licensed care facilities again.

But despite those concerns, the agency leaders didn't bother to consider what would happen to the residents. Indeed, the day after the suspension, licensing evaluator Maria Galang went back to the facility and found residents still there, an insufficient food supply and the person in charge of the medications unable to find them.

Galang issued a notice the facility was operating in violation of the law, with a civil penalty of $3,800, and gave a copy of the findings to the cook. But there's no indication she or her supervisor, Mary Segura, took steps to secure new homes for the residents. When reached, Galang and Segura declined to comment.

The next day, with 12 remaining residents and one missing, the two workers left at the care home called for medical help, prompting the sheriff's department to step in.

It should have never come to that. The public deserves an explanation of what went wrong and who's to blame. There must be accountability.