Molly Simones, appalled at what she had seen, picked up the phone and knocked over a domino. Six months later, the dominos keep falling.
Simones is certain that there is homelessness in La Crosse, Wis., the college town of 51,000 people where she grew up. But it's nothing like what she has come to know at Loaves & Fishes, the homeless shelter at the far north end of downtown Sacramento.
"I wouldn't have guessed it was possible," Simones said. "How can you envision Friendship Park?"
Simones, 25, graduated three years ago from one of her hometown's three colleges, Viterbo, a Franciscan university with 3,000 students. Her degree was in biochemistry, but she decided to live her faith by joining the Jesuit Volunteer Corps.
Loaves & Fishes, among the charities that draw from the organization, offered her a job. She arrived in town not knowing a soul and started working first as a volunteer and now as a staff member helping to oversee Friendship Park.
A thousand "guests" arrive each day, day after day, seeking hot coffee, showers, lunch, counseling and a safe place. Many of them spend their days on the park's shaded benches. Simones smiles and greets many by name.
A gray-haired man limped up to her, showed her his swollen leg and asked for directions to a hospital. A heavyset guy asked if she could get him a jacket that is extra-extra-extra large. She promised to look.
"Some of them are so tortured. I think what could have possibly happened to them to produce that sort of misery," she said.
In February, she took the time to listen to a guest named James Flavy Coy Brown, and took notes. Mental health care workers at Rawson-Neal Psychiatric Hospital in Las Vegas had given him a one-way Greyhound ticket to Sacramento, three bottles of Ensure, a three-day supply of antipsychotic medication and told him to find his way to an emergency room when he arrived.
"I thought it was unbelievable that a mental health worker would be OK with sending him here," she said. "He was so vulnerable."
Seeing that Brown was incapable of navigating the Sacramento County system of clinics, Simones took it upon herself to call the county for advice. A worker told her to send him to the UC Davis Medical Center emergency room, where someone would be expecting him. It was, she thought, something of a miracle that he would get care so quickly.
She already had done more than most people would do. But she felt a need to do more. My colleague Cynthia Hubert had spoken to Simones earlier for a story about homeless people who succumb to the elements.
After thinking about it for a week, Simones left a message for Hubert. Hubert called back, and on March 1, told Brown's story, at least the beginnings of it, based on the documentation provided by Simones.
Ever since, Hubert and Phillip Reese have been detailing Nevada's broken mental health care system, and documenting how Nevada officials who were supposed to care for mentally ill people instead bused 1,500 of them to every state in the continental United States.
All the while, dominoes have been tipping over. Earlier this month, an agency that accredits hospitals took the extraordinary step of stripping Rawson-Neal of its accreditation. A week ago, the Centers for Medicare and Medicaid Services announced it may cut off federal funds for Rawson-Neal unless deficiencies are corrected immediately, a step that would cost Nevada millions a year.
Gov. Brian Sandoval, a Republican with national aspirations, has tried to put the matter behind him by increasing mental health care spending by $27.4 million. A Nevada state board last week requested an additional $3 million to reopen a shuttered 58-bed psychiatric hospital in Las Vegas.
Since that first story in March, the Las Vegas Sun and Las Vegas Review-Journal have produced no fewer than 109 articles mentioning Rawson-Neal, more than double the number of stories that mentioned the hospital since its opening in 2006.
Most importantly, the state ended the inhumane and reckless practice of busing mentally ill people unescorted to all corners of the country.
None of it would have happened if Molly Simones had not picked up the phone.
She is sorry that people got fired at Rawson-Neal. She is concerned that the feds might take away money. But she should not feel too bad.
Top state officials who set policy remain on the job. Money that Nevada promises to spend on mental health care in the next two years doesn't equal the money that lawmakers cut from the system during the previous six years.
"She did exactly what none of us would have done," said her boss, Garren Bratcher. "We get so busy. It is never-ending. She treats everybody as if they're the most important person in her life that day."
On an afternoon last week, dozens of people were hanging out in Friendship Park. Some were napping, others were talking to one another or to themselves, and a bearded man with torn clothes was ranting incoherently about the CIA.
Earlier that day, as happens often, a man arrived in a paper jumpsuit, the garb given to inmates by the Sacramento County jail upon their release if they have no clothes. She helped get him clothes. A man trying to fix his baby's stroller asked where he might find a cap for one of the wheels.
We walked to the memorial where the names of Loaves & Fishes guests who have died are inscribed on a granite wall. For many of them, Simones said, the wall is the only recognition that they had lived.
"The first stall in the bathroom, looks like it's clogged," a woman told her.
Simones smiled, as she does often. "I'm incredibly good with the plunger," she said. As it happens, she's also good at tipping over dominoes.