The state of Colorado allowed a dental clinic to stay open for months even after former employees complained an unlicensed woman was performing dental procedures with improperly sterilized equipment.
Contact7 Investigates obtained records detailing the state's handling of the case during a months-long investigation into unlicensed health care practice in Colorado. The results of that investigation prompted Gov. John Hickenlooper to order numerous changes to the way the state handles complaints of unlicensed individuals working in health care professions posing as the real thing.
The timeline in the case of Maria Alvarez appears to be a perfect case study into why those changes were necessary. Internal records show at one point a state investigator complained staff in the office was "overwhelmed."
Former employees complain of "illegal, unethical and unprofessional practices"
State records show three former employees submitted a complaint to the Colorado Dental Board in September of 2015 alleging Maria Alvarez was presenting herself as a dentist to patients, wearing a white lab coat, identifying herself as "Dr. Maria" and advertising on Spanish-speaking radio.
The complaint said Alvarez was regularly treating patients by drilling on teeth, giving anesthetic shots and extracting teeth, and was doing so with equipment that was not always properly sterilized.
"We started noticing the instruments were getting rusted," Noemi Hernandez, one of the former employees told Contact7 Investigates.
Records show the dental board referred the case to the Office of Investigations within the Department of Regulatory Agencies (DORA) within days of receiving the complaint, requesting a surprise inspection of the business and interviews with the former employees who complained.
But the case file indicates DORA investigators did not take action on the troubling complaint for five months, when they made a surprise visit to the U Smile Dental office at 2025 West Evans Avenue. Public records show Alvarez owns the property and was the registered agent for the business.
During that visit, an inspection found inadequate sterilization procedures and monitoring.
Alvarez told the state investigator who dropped in she did not present herself as a dentist or perform any unauthorized procedures. Alvarez also showed a certificate showing she was trained as an extended duties dental assistant and said she worked as a dentist in Mexico.
A licensed dentist working in the practice also told investigators Alvarez did not perform the duties of a dentist.
An attorney representing Alvarez later sent a detailed letter denying the allegations in the complaint and criticizing the job performance of the former employees who wrote it.
When the board responded with a detailed list of 18 follow-up questions, the attorney responded about one month later saying because the office had voluntarily shut down, the board's questions became "moot" and she would no longer be representing Alvarez.
Records show U Smile remained open until May 9, 2016 – about eight months after its former employees filed their complaint about the office.
After the office closed, DORA investigators spoke with Dr. Benjamin Menlove, a dentist with an office nearby who said he found himself treating many of Alvarez's former patients and trying to fix her mistakes.
"She would do extractions and the roots were broken off in the bone, which is actually ten times worse, and it's a lot more difficult to treat the patient," Menlove told Contact7 Investigates. "A lot of these patients weren't really aware of what was happening, what should happen, and that's completely unfair."
Menlove had hired the former U Smile employees and helped them write their complaint about Alvarez.
DORA investigators also interviewed former patients of U Smile. One patient told the state she was "devastated" with the treatment she said she received from Alvarez and one of the dentists in the practice.
She said she learned she had been wearing a temporary partial denture for more than a year believing it was permanent, and that Medicaid was refusing to pay for her treatments. The patient said she remembered receiving numbing shots from Alvarez, although Alvarez's attorney had denied she ever gave injections to patients.
It would take until October of 2016 for the state to officially issue a cease and desist order to Alvarez. The dental board also sent a letter of admonition to retired dentist John Lee Weber, saying he "aided and abetted the unlicensed practice of Maria Alvarez." That all happened more than a year after the employees filed their complaint.
This year, DORA officials said such delays were unacceptable in cases where public safety may be jeopardized.
"Thanks to media stories like yours, we really take those matters seriously," Ronnie Hines, Director of Professions and Occupations at DORA told Contact7 Investigates in an interview. "And I find them really concerning."
Although unlicensed practice of certain professions is a crime under Colorado law, DORA said it had no record of referring Alvarez's case to law enforcement. A DORA spokesman added that it did not always document such referrals and "because of staff turnover, we are unable to confirm either way."
After Contact7's initial investigations aired, DORA began requiring referrals to law enforcement for certain cases of unlicensed practice and said it added investigative staff to try to speed up the agency's response to such complaints.
Contact7 Investigates made repeated attempts to contact Maria Alvarez without success.
The former dental office now bears signs for Alcamar Skin Care, with signs advertising "free cleanings" and "medical consultations."
Records show Maria D. Alcazar registered the business with the Colorado Secretary of State in March of 2017 under the name Doncella Skin Care, LLC.
When Contact7 Investigates visited the property in June of 2018 it appeared to be closed, with fixtures piled in front and lock boxes on the front door and fence.