Carlton Palms Educational Center in Mount Dora is a gorgeous place. The isolated facility — the only one in the state that's licensed to care for intellectually disabled Floridians with severe behavioral challenges — is wedged between farmland and serene lakes; long, graceful strands of Spanish moss dangle from the branches of nearby oak trees.
It's also the place where 26-year-old William James Lamson died last week after beating his head against objects in his bedroom, police say.
Five years before that, it was where a non-verbal Broward girl succumbed to dehydration days after her arrival at her new home. In 1997, it was where Jon Henley, 14, was found dead in his bed with low levels of anti-seizure medicine in his system. Most recently, it was where a man was beaten up by his caregivers.
"I did not observe any blood in (Lamson's) bedroom," said a Lake County deputy in a March 1 police report. "It was explained that the deceased was a self-harmer, and was constantly banging his head."
How Lamson was able to slam his head against a hard surface so long without being stopped by staff remains a mystery.
As of Wednesday, the cause of death had not yet been determined by the medical examiner's office pending toxicology tests.
The young man's death — currently being investigated by the state Agency for Persons with Disabilities, the Lake County Sheriff's Office and the Department of Children and Families — came days before a federally funded advocacy group released a 33-page report detailing "abuse or neglect" at the long-troubled complex for disabled people with complex behavioral problems.
The investigation by Disability Rights Florida shed more light on the happenings in the complex, which for years has had state administrators scrambling to shut it down amid numerous abuse reports, and settlement agreements between the state and Carlton Palms. The agreements ultimately mandated improved video surveillance and random inspections.
In the report released Monday, the advocacy group, which combed through 28 allegations of abuse or neglect that happened in the first nine months of 2016, says surveillance footage shows a resident being slapped by a staffer and residents being strapped into makeshift restraint chairs inappropriately.
The report also details how staffers failed to explain why a resident suffered a black eye and described the staff's "outright avoidance" to file accurate and timely resident injury reports.
In the case of the black eye, two different reports about the injury were made by the same person after the resident changed his story about being punched by a caregiver. The incident was reported to state officials almost a week later instead of within one business day, as per APD policy.
In another case, a resident was restrained almost four hours despite being "calm the entire time." Florida law prohibits the use of restraints as punishment.
"It looks like a medieval restraint. It's not a straitjacket, but it's the modern form of one," said Matthew Dietz, the attorney for Arnaldo Rios Soto.
In 2016, Soto, a then-26-year-old with autism, schizophrenia and an intellectual disability, was swept up in a national spectacle when a North Miami police sniper shot his African American caregiver in the leg as the man lay prone in an intersection. All the while, Rios played with a toy truck.
"They are raised chairs; almost like on a pedestal in the middle of the community room. When a person is restrained, they would put them in the restraint chair while all the residents watch," Dietz added.
The report describes them as "low-back chairs with restraints that appeared to be constructed 'in-house' with bolts in the legs and eyelets in the arms used for restraint. The chairs lacked proper head and neck support, arm padding, and sound engineering."
Because there were no group homes near his family in Miami capable of handling his very challenging behavior, Rios was bused to Mount Dora. He has since been relocated.
"While APD's administrative complaints could not be resolved fast enough due to subsequent findings of abuse and neglect for Carlton Palms' residents, there were and are few options for individuals that require the kind of intensive and focused behavioral interventions as the residents at Carlton Palms," the report said. "When options are lacking, tolerance becomes an acceptable or necessary trait."
In a response to Disability Rights' investigation, APD didn't dispute the group's findings. Spokeswoman Melanie Etters told the Miami Herald Tuesday the agency hopes to shut down the 100-plus-person complex by March 2019 and that to date "44 people have transitioned into new community group homes."
There were two attempts by the Legislature to eliminate funding for the facility, which would have ultimately resulted in shutting it down. But the language that would have accomplished that mysteriously vanished from the two bills, according to Tony DePalma of Disability Rights Florida.
Because Carlton Palms is the only center of its kind in the state, shutting it down would have dire consequences for the residents, many of whom are incapable of living in a less-supervised setting. As yet, APD has been unable to develop suitable alternatives.
Bellwether Behavioral Health, which owns Carlton Palms, did not respond to phone calls by the Miami Herald regarding the most recent death.
Meanwhile, Lamson, who in his obituary was described to have loved Swiss cake rolls, Pop-Tarts, and Reese's Peanut Butter Cups, was to be cremated in Leesburg.
His family called him "Buddy."
Miami Herald staff writer Carol Marbin Miller contributed to this report. Contact Monique O. Madan: at (305) 376-2108 or firstname.lastname@example.org. Follow @MoniqueOMadan