LAKE COUNTY, Fla. — Two state agencies believe a group home failed an autistic man who died in their care, including the morning he stopped breathing the day before Thanksgiving in November of 2020.
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Caleb Walker’s mother was preparing to visit him when she got the call.
“I replay that conversation. He told me that there was a behavior and that they were doing the best they could, something happened, and then he said, ‘I’m so sorry,’ and when he said that, I knew what he meant,” Saralyn Walker told investigative reporter Daralene Jones, while recounting the worst day of her life during an interview in her living room. It’s the home where she and her husband, Thomas, raised their four children. Caleb was the youngest.
9 Investigates has been trying to get more details about what led to the death of Caleb Walker, since we first reported about the wrongful death lawsuit his parents filed in January of 2022 against the Oconee Group Home and its operators, Crystal Lake Supportive Environments, doing business as ATTAIN.
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Caleb Walker required intense behavioral therapy to control aggressive behavior, which is why his parents made the difficult decision to put him in a group home in 2013. Five years later, he had been placed in the Oconee home in Eustis, Florida. The Wednesday before Thanksgiving, Lake County Sheriff’s office reports show that he acted aggressively toward a worker, who used a restraint technique to control him. There are cameras, everywhere around the home, except the bedroom where the incident occurred. Caleb was days shy of his 28th birthday when his parents got the call.
“‘I’m so sorry’ — no one wants to hear that because you know what that means,” Walker said.
According to the lawsuit filed against ATTAIN, the two workers on duty that morning used what’s known as a BARR restraint, usually requiring at least two to three people, according to Caleb’s behavior plan. The family’s attorneys allege in the lawsuit that the worker likely slammed Caleb onto a mat so hard while applying pressure to his neck, that it caused several injuries. Caleb was held down for about 20 minutes, according to various law enforcement reports, and according to testimony from the two workers on duty.
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The lawsuit alleges the second worker wasn’t initially helping to restrain Caleb. Surveillance video the family attorneys provided 9 Investigates shows he was wandering around the small home into the kitchen, during the initial minutes of the restraint.
“The problem is for one person to do it, it requires significant pressure, in this case, on the resident’s back. So, the normal result of that is pressure on the chest and inability to breathe,” Attorney Aaron Karger told Jones. Karger is part of a large legal team representing the family, which includes Matt Dietz, Natalie Jackson and well-known civil rights attorney Ben Crump.
Surveillance video shows the panic that ensued, as one of the workers called 911. Caleb was dead by the time paramedics arrived, shortly after 5:30 a.m. Caleb’s parents told us that they don’t what buy what the workers portrayed during the re-enactment, during which they say the second worker almost immediately rushed in to help restrain Caleb, and they demonstrated for detectives step-by-step how they worked to keep Caleb restrained as his aggressions continued.
“No, no, how can you know what actually happened in that room and there’s no cameras?” Thomas Walker said.
The Executive Director of ATTAIN, Dr. Craig Cook, was in Tallahassee for legislative meetings when Jones spoke with him over the phone, and eventually in a video-recorded interview. Cook denied his employees did anything wrong, and said the facility followed all protocols and procedures.
“All of the understanding we have, and investigation we’ve done is that the staff acted properly,” Cook told Jones. “We as an agency can only implement approved procedures the state approved, which was the case in this situation. We try to do what we can to minimize their use but when they are necessary there are inherent risk which could include injury and death,” stated Cook.
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9 Investigates has since obtained a 15-page complaint filed against the Oconee House Group Home and its operator, with more details about the incident. We received it as part of a public records request, requesting all past and pending complaints filed by the Agency for Persons with Disabilities, which oversees the state-funded group homes.
APD initially would only confirm for 9 Investigates that ATTAIN had a pending complaint filed in September of 2021, but declined to provide details. In a follow-up email the next day, the state agency provided a link to a long list of PDF files associated with that complaint, which could result in a fine, license suspension or revocation.
It turns out that APD filed the complaint against ATTAIN and its parent company, Crystal Lake Supportive Environments LLC, because of the findings of a DCF investigation into the death of a resident only referred to as C.W. (who Channel 9 confirmed is Caleb Walker) and another incident a month before his death in 2020.
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Caleb was required to be in a group home that could provide enhanced intensive behavior services.
The Oconee group home in Eustis agreed to do it, and received an enhanced pay rate to provide care according to the state records, which required 24/7 one-to-one supervision, because he was known to intentionally eat non-food items and harm himself.
“We had behavioral support, we had people in our home since he was 5 years old,” Saralyn Walker said.
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A month before Caleb’s death the APD complaint and a DCF investigation found that Caleb was left unsupervised three times for six to seven minutes, and intentionally swallowed two batteries he pulled from a remote control.
“The Respondent elected to serve clients with the most intense behavioral presentations. Despite knowing this and receiving enhanced pay rates to care for these clients, on October 2, 2020, Respondent’s staff left C.W. alone for approximately six minutes and thus allowed C.W. to engage in known pica behavior by swallowing batteries,” the APD General Counsel, Trevor Suter, wrote in the agency complaint.
DCF determined as part of its probe that Caleb was neglected, but APD raised concerns that the worker only received a written warning and retraining from management.
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“Respondent only issued a written warning to the employee. No discipline was issued after such negligence and resultant serious harm. The Agency is not aware of any other incentives, like higher wage, special shift compensation, special recruitment, or more thorough training that Respondent attempted following the October 2, 2020 incident,” Suter continued.
A month later, Caleb died, while being restrained by two employees on duty, who re-enacted their version of events for investigators. According to the complaint one of them had been previously cited in another DCF investigation where a resident escaped from a facility and was injured while the worker was asleep on the job.
“[The worker] had previous DCF verified findings against him for the abuse, neglect, or exploitation of a vulnerable adult … had been verified for abuse neglect or exploitation for falling asleep during an overnight shift, leaving residents unsupervised. An unsupervised resident then walked past the sleeping [worker], escaped the facility, and was hurt, Suter wrote.
That employee is the same person captured on surveillance video provided by the family attorney seen wandering around Caleb’s group home during the initial moments Caleb was restrained.
The complaint explains that one of the workers on duty that night participating in the restraint told investigators that the restraint continued while Caleb was coughing up blood. “He never verbally stated he could not breathe,” the employee told a Lake County deputy.
The DCF investigation found the two employees were responsible for the inadequate supervision, physical injury, asphyxiation and death of Caleb Walker, and alleges the operators of the home failed him, which is how his parents feel.
“Seems kind of like, these folks are placed in the group homes and then that’s kind of it. Yeah, I don’t think there’s enough oversight,” Thomas Walker told Jones.
Attain Incorporated operates this small residential group home in Eustis and has a license to run 21 others in Lake, Orange, and Seminole counties. Two of the group homes it has a license to operate are currently empty, although it’s unclear why. APD told 9 Investigates that ATTAIN’s funding increased from $11.1 million in 2019 to $13.8 million in 2020, and it’s currently funded for about $13.5 million this year.
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A newly retained spokesperson for the company issued the following statement:
“While we have great compassion for the Walker family’s sorrow, Florida’s Department of Children and Families has disregarded the official State of Florida autopsy report, the evidence gathered by law enforcement, and the state attorney’s official report, and instead relied on a fatally flawed report paid for by the Walker family. None of these reports conclude any failure in ATTAIN’s care, but DCF’s decision to disregard official findings in favor of findings supplied by the family has triggered a chain of events that lack any foundation in the evidence.”
The attorneys for the family told us that the only document they provided to DCF was a private autopsy report. While they were aware that DCF investigated Caleb’s death, they were unaware of the findings, or that that APD had filed a complaint against the company because of it until we told them. “ATTAIN is now attacking the very state agency responsible for holding them accountable,” attorney Matt Dietz told Jones. APD is scheduled to hold a virtual hearing the week of Feb. 7, expected to last four days, to determine if ATTAIN and its parent company Crystal Lake Supportive Environments will face any consequences. APD issued the following statement to 9 Investigates:
“The Agency for Persons with Disabilities is deeply saddened by the death of a group home resident in Lake County and our hearts go out to the family and friends of the individual. APD conducted wellness checks on the other group home residents immediately following the incident to ensure their health and safety in an abundance of caution. APD has zero tolerance for any forms of abuse or neglect of individuals with disabilities, and we hold our providers to the highest level of accountability. All employees of group homes pass a Level 2 background screening before they begin working with our clients.”
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