Child Protective Services
Investigation Report
Child Welfare Agency

Many names of staff members and ABR residents were deleted by CPS before the document was released to The Arizona Republic.

AGENCY NAME: Arizona Boys Ranch

DATE OF REPORT: March 6, 1998

DATE ASSIGNED: March 13, 1998

CHILD VICTIM (DOB): Nicholaus Contreraz l/15/82 (16.2 years)

ALLEGATION:

Nicholaus Contreraz was placed at Arizona Boys Ranch on 1/5/98 by the Sacramento Juvenile Probation Department. On 3/2/98, at 8:30 PM Nicholaus died following an incident at the Arizona Boys Ranch in which staff, and _. "put him in a control position". The restraint was performed when Nicholaus was uncooperative with staff. He stopped breathing and staff called 9-1-1. Nicholaus was air-evacuated to Northwest Hospital in Tucson.

ACTIONS TAKEN:

SITE VISITS

Field visits were made to the Arizona Boys Ranch (ABR). Oracle facility on the following dates:
3/16/98
3/19/98
3/27/98
4/16/98
5/6/98
5/8/98
5/18/98
5/20/98

INTERVIEWS CONDUCTED BY CHILD PROTECTIVE SERVICES

3/16/98 Dorothy Porter and Steve Madrid, Paramedics - Rural Metro, San Manuel Substation
3/16/98 Kaja Jezycki,ABR attorney - Telephone call
3/16/98 ABR resident - Oracle Facility
3/16/98 ABR resident - Oracle Facility
3/16/98 ABR resident - Oracle Faciliy
3/l6/98 Billy Craig, Paramedic volunteer - San Manuel Health Care Center
3/18/98 Don Berg, Sacramento County Probation Officer - Telephone call
3/19/98 Sgt. Ron Pugliese, Pinal County Sheriff's Department - telephone call
3/19/98 ABR resident - Oracle Facility
3/26/98 ABR resident - Oracle Facility
4/8/98 John Wejmer, Don Berg, Pamela hIoore, Sacramento County Probation Department
4/8/98 Detective Ed Schweitzer, Michael Do~ning, Brenda Alston and Sgt. Ron Pugliese, Pinal County Sheriff's Department
4/16/98 ABR resident - Oracle facility
4/16/98 ABR resident- Oracle faciliry
4/16/98 ABR resident - Oracle faciliry
4/16/98 ABR resident - Oracle facility
4/16198 ABR resident - Oracle facility
4/16198 victim's mother - Telephone call
4/20/98 Don Berg and John Wejmer, SacrameMo County Probation Department
4/20/98 Judge Kenneth Peterson, Juvenile Court Judge, Sacramento, California
4/20/98 (victim's maternal grandmother) and Robert Buccola _ - Sacramento, California
4/21/98 ex-ABR resident - Los Padrinos Detention Center, Los Angeles, California
4/21/98 ex-ABR resident - home residence, Los Angeles, California
4/30/98 ex-ABR employee - Pima County Sheriff's Offce, Tucson
5/1/98 ex-ABR employee - Pinal County Sheriff's Off~ce, Oracle Substation
5/6/98 ABR staff - Oracle facility
5/6/98 ABR staff - Oracle facility
5/6/98 ABR sraff - Oracle facility
5/8/98 ABR staff - Oracle facility
5/8/98 ABR Staff - Oracle facility
5/8/98 ABR s~aff - Oracle facility
5/8/98 ABR staff - Oracle facility
5/18/98 ABR staff - Oracle facility
5/18/98 ABR staff - Oracle facility
5/18/98 ABR staff - Oracle facility
5/20/98 ABR staff - Oracle facility
5/20/98 ABR staff - Oracle facility
5/20/98 ABR staff - Oracle facility
5/20/98 ABR staff - Oracle facility
5/20/98 ABR staff - Oracle facility
5/20/98 ABR staff - Oracle facility
5/20/98 ABR staff - Oracle facility
6/10/98 Bruce Parks, forensic pathologist - Pima County Medical Examiner's Office
7/1/98 Mary Dudley, Forensic Pathologist - Consultant
7/16/98 Mary Dudley, Forensic Pathologist - Consultant
7/21/98 ABR resident, Oracle facility
7/22/98 Mary Dudley, Forensic Pathologist - Consultant
7/22/98
7/27/98
7/27/98 ABR resident

DOCUMENTATION REVIEWED

Pima County Medical Examiner's report

Transcribed reports of interviews conducted by the Pinal County Sheriff's Deparment

Records obtained from ABR on Nicholaus Contreraz

Sacramento County Juvenile Court medical records of Nicholaus Contreraz

Written statements from two ex-ABR residents

Forensic Pathologist Consultant report

Chronology repon provided by _

Information collected by Sacramento County Juvenile Probation Depanment

California Depanment of Social Services Oversight Committee Repon

CHRONOLOGY OF EVENTS

The following is a chronology of significant events culminating in the death of Nicholaus Contreraz.

Monday, 1/5/98

The victim was placed at ABR by the Sacramento Juvenile Probation Department.

Wednesday, 1/7/98

The victim was seen by the nurse and doctor for a routine medical exam at admission. The history noted the victim had asthma and was using two inhalers, Ventolin and Beclovent.

10:45 AM - An incident repon was written by . The report had "Negative" as the behavior. The incident occurred in the chapel. The report stated the victim was cursing and he was isolated from the group to have a discussion about his negative behaviors. The report indicated no consequence was given. The "Treatment Direction noted in the report was "Hold Mr. Contreraz highly accountable of his actions.

Thursday, 1/8/98

According to chronology, the victim was seen by _. His asthma medication doses were adjusted. (Attachment 1)

Tuesday, 1/13/98

1:50 PM - The victim was seen by the nurse,_, for a swollen right heel. The victim told the nurse he had an asthma anack the prior night. He was given protection to back heel.

Thursday, 1/15/98

10:05 AM - The victim was seen by a nursing assistant, for a swollen tendon on his right foot and blisters on his left foot. He was given Band Aids.

Monday, 1/19/98

9:15 AM - The victim was seen by the nurse . The victim complained his back on the left side was sore and he had pain while breathing. The documentation stated the victim "shll has difficulty with asthma". The victim reported he had been hit two days before. The documentation stated the victim was to see on 11/21/98.

Thursday, 1/22/98

7:00 AM - The victim was seen by_who documented the victim's lungs were clear and he demonstrated correct use of inhalers. The victim had a cough. The victim was given Drixoral, for drainage and cough.

9:20 AM - The victim was seen by~for a swollen tendon on his right foot and a blister on his left foot. A cushion and Band Aid were applied

Sunday, 2/8/98

7:40 AM - An incident report was completed by - _ The report had "Negative" checked as the behavior. The incident involved the clean up in Barracks 31 and the victim failing to follow orders. The victim carried a bottle of cleaner to the window he was cleaning. The residents were required to spray the solution on rags and leave the bottles in one location. The victim was informed he was not utilizing teamwork and time management skills by removing the cleaning from his peers' access.

Monday, 2/9/98

9:30 AM - The victim was seen by_ The victim complained of pain on the right side of his rib cage. He was diagnosed as ~lled muscle and was given Ibuprofen. The documentation noted a dentist appointment was needed.

Monday, 2/16/98

10:52 AM - The victim was seen by _. The victim complained of a headache, sinus pain, drainage and cough. It was noted the victim had been using cough syrup. The victim was given Drixoral.

Thursday, 2/19/98 (10 days before Nicholaus Contreraz's death)

12:15 AM - An incident report was written by_. The report had "Negative" checked as the behavior. The incident took place in the dining hall. The report stated the following: "Upon arrival to ABR, all residents are informed that they will display honesty at all times. Residents are asked by staff to go outside and clean their shoes off if they were involved in the morning activity. Mr. Contreraz did not move and gave another peer a disrespectful look his peer protected his environment. He was isolated from his peers and a discussion took place about his inappropriate actions. He remained appropriate and respectful and was then returned to group. "

Saturday, 2/21/98 (9 days~re Nicholaus Contreraz's death)

The victim was seen by . The victim reported difficulty breathing during exercises and stated his inhaler did not work. He was instructed to use his inhaler 3O minutes prior to exercising. A chronology from the nurse states staff were informed the victim required the use of his inhaler 30 minutes prior to exercising.

8:00 - An incident report was completed . The report does not indicate if the incident occurred in the morning or night. The report had "Informative" checked as the behavior. The report indicated a hygiene inspection was conducted and residents had conditions for the nurse to evaluate. For the victim, the note stated: "Contreraz, Nicholaus - coldflu symptoms - fever, chills-. Thc incident report does not contain any infor nation on follow up taken. Based on interviews, this incident occurred in the evening.

Sunday, 2/22/98 (8 days before Nicholaus Contreraz's death)

The nurse's chronology states she was called at home. The victim had a temperature of 103 degrees. She instructed staff to put the victim to bed, increase fluids, apply cold compresses and take his temperature again in two hours. The chronology does not name the staff who called her at home. In an interview, recalled writing an entry into the log of Barracks 22 that the victim had a temperature of 103.8 degrees. (A copy of the complete log was not provided to CPS.)

Monday, 2/23/98 (7 days before Nicholaus Contreraz's death)

11:15 AM - The victim was seen by someone for a medical exam. The documentation was not signed. The victim complained of nausea, cough and fever for three days. His temperature was taken and noted at 99.8 degrees. There is no documentation of treatment. According to the nurse's chronology, _ saw the victim and gave him Tylenol.

1:00 PM - The victim was seen by a dentist. The dentist gave the victim amoxicillin and aspirin with codeine. The dentist's office noted the victim had a temperature of 103 degrees.

Tuesday, 2/24/98 (6 days before Nicholaus Contreraz's death) The nurse's chronology states saw the victim while he was sitting outside on a block wall during the camp's Olympics. She stated the victim was cool to the touch and he reporred his tooth hurt. _ stated the victim was upset because she would not allow him to join the "games". The victim was observed vomiting and coughing by staff and residents during this day.

Wednesday, 2/25/98 (5 days before Nicholaus Contreraz's death)

11:00 - An incident repon was completed by_ The repon does not indicate if the incident was in the morning or night. It is believed it occurred in the morning. The repon had "Informative" checked as the behavior. The incident occurred at the chapel. The victim had informed staff the nurse had placed him on restriction and he was not to do any physical activity. The nurse was contacted and she indicated the victim was not restricted from physical activity. The report stated the nurse had seen the victim the prior day and advised him that he needed to do more physical activity. The victim was isolated as a result of this incident. The repon stated the victim responded "appropriately to the discussion and ~vas skortb returned to the group with a calm, yet downtrodden demeanor. The report stated the following under Treatment Direction ": "Continue to hold him accountable. He uses the nurse as a scapegoat, so communication with her is essential.

The nurse's chronology states _ saw the victim with a work crew. She asked the victim how he felt and he stated he was 'okay". The nurse reported the victim felt cool to her touch. Also, the victim was ~able to keep breakfast down, no nausea. ~ The chronology states staff reported the victim would occasionally hyperventilate. does not report in either her interviews or chronology the incident report recorded on this day which indicated she was contacted by staff. Sometime during this night the victim was placed on yellow shirt status.

Thursday, 2/26/98 (4 days before Nicholaus Contreraz's death)

10:00 AM - According to the nurse's chronology, saw the victim at this time. The victim complained he hurt all over. The chronology states the victim's lungs sounded clear and there was no wheezing. Staff reported the victim would occasionally hyperventilate.

1:15 PM - An incident repon was completed by_. The report had "Informative" checked as the behavior. The incident occurred at the basketball count The summary stated the following: "On the above date and time staff observed a yellowish wet spot on the back of Mr. Contreraz' pants. StaJf asked Mr. Contreraz whar the spot was and he stated that he defecated. Staff took Mr. Contreraz immediately to Barracks 31. He was given a shower and clean clothing. " In the section noted "Follow-up Goals. the following was noted: "1. Inform staff of hygiene needs. 2; Ask staff for pennission to use proper facilities. Staff informed Mr. Contreraz that he needs to tell staff of his restroom needs so as staff can take him to the proper facilities. He was receprive to staff 's feedback and placed back with the group. In the section "Treatment Direction the following was noted: Teach proper hygiene.

2:35 PM - An incident report was completed by _. The report had "Informative " checked as the behavior. The incident occurred in the "PT Field". The report stated the victim defecated while performing physical activities. The victim was taken to Barracks 31 to clean up. _ took the victim to the nurse. He was given lmmodium. The victim had trouble breathing. The nurse gave him a paper bag to use to control his breathing. The victim was cleared by the nurse to return to a work crew. That afternoon the victim moved rocks and did physical training in the barracks. (It should be noted CPS was not provided with any nursing notes on this incideM nor does the nurse's chronology state _ or _ saw the victim at this time.)

3:15 PM - An incident report was completed by . The report had "Physical Assistance" checked as the behavior. The incident occurred at the volleyball court. The report described the victim "putting out no effort" while doing physical activities. The report stated staff "corrected and encouraged him to put forth effort". The report stated "Mr. Contreraz was unresponsive to the continuous feedback from staff. At this point staff had to physically assist Mr. Contreraz through all of the activines given by staff. Mr. Contreraz was consistently nonresponsive and still put forth no effort. After further correction Mr. Contreraz responded appropriately and finished the activities. Follow up began there after. The report noted the victim was given three days of extra duty as a consequence. The "Treatment Direction noted the following: "Hold young man highly accountable for his lack of efforts.

In the incident noted above, and _ were present and involved. The incident report noted _ was a witness.

6:00 PM - An incident report was completed by . The report had "Physical Assistance checked as the behavior. The incident occurred at the volleyball court. The incident was witnessed by _ and _. The incident described the victim not doing physical activity correctly. The report stated the victim did not respond when given feedback. It described the victim as frustrated because staff would physically assist the victim. The report stated the victim attempted to hit his head on the ground and staff held him to prevent him from hitting himself. Staff told the victim if he could perform exercises for fifteen minutes he would be allowed to continue with his day. The victim responded by performing the exercises and he was placed back with the group.

The "Follow-up & Goals" stated:

1. Improve physical activities by not giving up on yourself.

2. Develop ways to handle frustrations in a more appropriate manner. The "Treatment Direction n noted the following: Challenge young man to improve his ability to meet physical challenging activities. noticed a scrape on the victim's chin sometime during this day. The victim was given his inhaler at least 4 to 5 times during the day. The victim slept on a mattress on the floor.

Friday, 2/27/98 (3 days before Nicholaus Conbreraz's death)

10:00 AM - The victim was seen by _. He complained of hurting all over and stated he wanted to die. The nurse stated she checked his lungs which sounded clear. She noticed no difficulty in breathing. The nursing notes stated "`Vo visible signs of edema, bruising or laceranons. Abrasions 1 x 2 on sternum, clean and dry.

10:00 AM - An incident report was completed _. The report had "Informative" checked as the behavior. The incident occurred at the nurse's office. The incident report stated that while the victim was being seen by the nurse, the victim stated he wanted to kill himself. The victim stated he could not take it anymore and he wanted to be with his father. The victim was told staff would not allow him to harm himself and he needed to meet expectations rather than harm himself.

The "Follow-up & Goals n stated: "1. Begin to meet basic expectations. 2. Not harm himself in any way. Mr. Contreraz is very emotional and as such will be placed on yellow shirt/high visibility status for a further 72 hours for close observation. n The victim was returned to a work crew.

11:00 AM - An incident report was completed _. The report had "Informative " checked as the behavior. The incideM occurred at "social services -. The report stated a conference call was conducted between the victim, his mother and d_. The report stated: that Nick needed to follow instrucdons, stop defecating on himself and accept responsibility for his actions. The victim told his mother he wanted to die and his mother began "giving him feedback on his poor choices and informed him to 'Be a man!'

Staff informed the victim had defecated on himself three times to avoid group activities to which _ stated, "Nick, aren't you embarrassed of yourself?"

Lunch - _ took the victim to finish his lunch outside sitting on rocks by the Port-A-John. The victim vomited after eating. ._ stated he thought this was because the victim stuffed his lunch into his mouth to force himself to vomit.

8:00 PM - An incident report was completed by -. The report had "Physical Assistance" checked as the behavior. The incident occurred at Barracks 31. The report stated that during "structured physical training" in the barracks the victim was not performing the exercises the rest of the group was doing. He was separated from the group and given "corrective feedback". The victim told staff he felt like vomiting. He was physically assisted in the exercises. The victim defecated on himself and the victim was given the opportuniy to shower and clean up and physical training resumed ". One of the follow up items noted was the victim was to "perform all exercises that you are instructed to do with quality and detail.

In an interview, _ reported this incident involved four residents, including the victim, who had not met weekly goals and were required to do physical training. The victim was unable to perform the required physical activities and was assisted by_, and _. reported it was at this time gave the victim a bucket to use for vomiting, although stated he gave the bucket to the victim the following day.

Regardless of the date, stated his intention was to remind the victim to appropriately request permission to use the restroom.

Saturday, 2/28/98 (2 days before Nicholaus Contreraz's death)

8:00 AM - The victim was at the volleyball court doing physical training. He was assisted by _ in doing "up/down".

8:00 AM - 11:00 AM - Sometime after breakfast residents were cleaning Barracks 31. The victim was cleaning the crates where residents store personal items. -, the cook, observed the victim moving too slow and not doing his task correctly. He instructed the victim to do push ups. He moved a yellow bucket close to the victim when the victim stated he felt nauseous. - observed - with the victim. He heard the victim say he was going to vomit. - observed place a yellow trash can next to victim to use for vomiting.

Dinner - The victim was in the dining facility with other residents. He was eating alone by the microwave oven. The victim defecated on himself. He was moved to sit on the back pantry toilet and instructed to sit with his pants down while eating his meal.

Another resident _ had also defected on himself because he was not allowed to go to the bathroom. This resident was made to sit on a crate next to the victim. The resident observed the victim sitting on the toilet eating his meal.

In an interview, - reported he observed the victim eating his lunch while sitting on a toilet. However, he could not recall the specific day but recalled there was another resident present at the same time. After the residents finished eating they were moved outside. - observed the victim eating his dinner slowly. He took the victim outside by some rocks to finish his meal. The victim vomited while he was eating. walked the victim to Barracks 31. The victim stated he was tired and needed to stop to rest. - told the victim he could rest when he reached the barracks. A resident,-, observed - with the victim. He observed the victim vomit. He heard - tell the victim he was a baby. The victim slept on a mattress on the floor that night.

Sunday, 311/98 (1 day before Nicholaus Contreraz's death)

7:45 AM - The victim was unable to eat breakfast.

9:00 AM - The victim was taken to the volleyball court to do physical training. He was observed carrying a yellow trash can.

10:45 AM - The victim was instructed to run up and down a hill. He was unable to do so and collapsed.

1:00 PM - While on their way to the chapel, the victim was marching with the other residents and he was unable to walk and fainted. _ and _ assisted the victim up a hill by carrying him under his arms. - stated they stopped the assist because the victim was dragging his feet and they did not want the victim to scrape his knees.

- and - had a resident get a wheelbarrow and placed the victim in the wheelbarrow. - and - had - push the wheelbarrow up the hill to the chapel. -heard the victim say, - Lord help me, I need help, I need help. Another resident, _ observed the victim in a wheelbarrow being pushed by -.

At the chapel the victim was assisted in doing push-ups. The victim was instructed to take a four square position (laying face down with arms and legs extended and holding his body above the ground and maintaining this for a prescribed time). The victim vomited during physical training Staff made the victim clean up the vomit and the victim was taken outside. The victim returned shortly and he was crying.

4:30 PM - The victim was seen -. The victim complained of "hurting all over". The nursing notes stated the following: Numerous abrasions to chest, upper arms and scapula 24 - 35 hours old. Scabbed over. C/O tingling infingers and toes from hyperventilation). No further signs of edema, bruising, lacerations and/or abrasions noted. The comment section stated the following: "breathing/equipped with paper bag, 12 hours sleep tonight.

According to - the nurse told the victim, "your breathing problems are in your head.

7:00 PM - The victim slept on a matress on the floor.

There was an incident report on this day. The time and type of report was not noted. The report was completed by -. The report noted the victim had been involved in over 14 hours of groups since admission. It noted the victim has always been a willing and enthusiastic participant asking questions and seeking new knowledge. This report appears to be a treatment progress report. Monday, 3/2/98 (the day Nicholaus Contreraz died)

6:00 - 6:30 AM - The victim was awake before the other residents. A resident - heard him brushing his teeth and staff yelling at him because he was too slow.

7:45 AM - The victim was unable to eat breakfast.

Before lunch - The victim was unable to run. Staff attempted to have the victim run by dragging him while holding him under his arms. He was seen carrying the yellow bucket. He was being marched, was sweaty and his pants kept falling.

- a resident, observed the victim with and -. They were telling the victim to march down the hill and the victim kept falling. He observed the victim in front of the supervisor's office, his eyes were half closed and he had tears in his eyes.

Lunch - _ instructed - a resident working in the pantry, to serve the victim the bare minimum of food. - crunched the victim's potato chips and laughed at the victim. The victim was observed eating alone by the microwave oven.

In an interview, _ claimed she ate lunch with him this day but no one observed her with him during lunch.

12:30 PM - An incident report was completed by _. The repon had "Informative" checked as the behavior. _ called the victim's probation of ficer (Don Berg) in Sacramento. The victim talked with his probation officer. According to the incident repon, the probation officer told the victim his continuous effons to get terminated from the program were not going to be effective and he was going to stay with the program until he graduated. The victim asked to speak with another probation officer and was told by Mr. Berg that person had been transferred.

Following this contact, the victim was returned to the chapel to eat his lunch. The reponse stated "His demeanor was lethargic and withdrawn. "

2:10 PM - An incident repon was completed by The repon had "Informative " checked as the behavior. The incident occurred at Barracks 8. The repon stated _ and _ spoke with the victim concerning his failure to meet expectations. lhe issue was the victim's failure to exercise as required.

- and _had the victim run the steps at the parking area outside of Barracks 16. The victim told them he could not run and - expressed to him that he wasn't eyen making an attempt. After being forced to run the steps, the victim told and - that he wanted to die and was going to stab himself with a knife. The "Treatment Direction" was as follows: "Work witk the resident on his self esteem through physical activity and positive reinforcement."

2:30 PM - The victim was taken by _ to join a work crew. He was instructed by - to pick up leaves, which the victim refused to do. The victim was instructed by _ to pick up cinder blocks. and - noticed the victim was laying on the ground. The victim was ordered by - and to get up. The victim was unable to get up. The victim was picked up by _ and -. They carried the victim with the victim's feet dragging on the ground. When - and _ tired of carrying the victim, - used a "fireman's carry" to carry the victim.

2:45 PM - - completed an incident report which stated the following, "On the above date on the walk way in front of the supervisor's of fice I observed Mr. Contreraz being supporred by and -. When I asked Mr. Contreraz what was wrong, he responded by saying 'I can't walk any more. ' I reiterated he needed to slow down his breathing. Breathing was 22/min shallow. When I asked if he was in pain, he stated he 'hurled all over'. He slowed his breathing when he was being carried back to the group via the fireman's carry by _. Mr. Contreraz was alert and oriented to person, place and time. He appeared to be in no distress while being carried..

- arried the victim to the volleyball court where the orientation group was putting away tools. While they waited, - and - instructed the victim to do push-ups. The victim was unable to complete the task so he was physically assisted by

The victim then went into formation with the orientation group, which started marching to the chapel. The group stopped because the victim collapsed on the ground. The victim was taken to the chapel and ordered to do push-ups. The victim was unable to do them. He was assisted by and - observed - and _ picking the victim up bv the shirt, pants and belt loops. They lifted the victim up and down from the floor. - instructed nd to remove the victim from the chapel in order not to disrupt the residents. They took the victim to Barracks 8.

At Barracks 8, - and - instructed the victim to do push-ups. The victim was unable to do push-ups. - and - attempted to get the victim in the push-up position and - was supporting his weight.

_was watching staff assist the victim when he reported the victim grabbed the leg of a metal bed frame and hit his head and _ then placed the victim in a control position for approximately three minutes.

4:00 PM - An incident report was completed by _ The report had "Negative, Control Position and Physical Assistance checked as the behaviors noted. The location of the incident was Barracks 8. The report states that while performing "structured physical training the victim was observed to be "putting forth minimal efforts ". He was isolated following this and a discussion took place in which the victim was informed if he did not perform the exercises he would be physically assisted. The victim was instructed to perform pushups and he failed to do so. According to the report, the victim grabbed onto a leg of a bed and hit his head. He was placed into a control position during which he struggled "violently" and stated staff had hit him. The victim then bit one of the staff on the thigh. The report stated that following this incident the victim just lay on the floor.

4:17 PM - An incident report was completed by _ The report had "Negative and Physical Assistance. checked as the behaviors. The incident report stated the victim defecated on himself. The victim was instructed to stand up and get on the road. The victim told staff "if you touch me I'll hit you. The victim was assisted to stand and the report stated the victim would not stand on his own. Staff picked up the victim to carry him to Barracks 31. The report then stated, "Mr. Contreraz attempted to break free. Staff tried to reach around to better situate the resident, when he leaned over and bit staff in the shoulder and chest. There is no documentation on follow up that may have occurred.

During interviews with staff it was determined the victim defecated while in the control position.

While the incident report does not indicate this, several staff report the victim stated he wanted to die while he was being carried to Barracks 31.

At Barracks 31 the victim was unable to undress himself. - and - undressed the victim and placed him in the shower. According to staff, the victim hit himself on the left side of the head against the shower wall. Following the shower, the victim dried himself off, then attempted to dress himself and collapsed. He was unable to continue dressing. Staff dressed the victim.

The victim was ordered by - to place his soiled clothes in a plastic bag and carry the bag to a dumpster by the pantry. The victim collapsed on the way to the dumpster. During the victim's attempt to walk to the dumpster, __ told the victim he deserved an "academy award" for moving so slowly to throw away his clorhes.

4:30 _ observed - and the victim placing the plastic bag in the dumpster.

The victim walked slowly from the dumpster to the volleyball court. He was instructed repearedly by - and - to do barrel rolls. When the victim refused to do the barrel rolls, he was assisted by staff who rolled the victim on the ground.

According to - the victim asked for water. The victim did not have his canteen. According to _ he went and got a pitcher of water and some cups, but the victim refused to drink the water. _ "encouraged" the victim to drink some water by pouring water into the victim's mouth. The victim was standing up with his head tilted back while _ poured the water. The victim would spit the water out but according to staff he eventually drank approximately 16 ounces of water.

Residents were passing by on their way to dinner and the volley ball court was visible to them. A resident - observed the victim standing, while staff had his head tilted back and they poured water into his mouth, forcing him to drink. was grilling dinner for residents. He was outside and observed _ and _pick the victim up when the victim fell to the ground. He heard _ state, "We're doing everything by the book. "

While the victim was being given water, - went to get pack-out dinners because he knew the victim would not be eating with the other residents.

5:15 PM - ~was on his way to take residents to eat dinner. He observed the victim at the volleyball court. _ called _ to assist them. and - carried the victim to the amphitheater. They stated they did not want to humiliate the victim by having the other residents observe the victim. _was on his way to dinner and observed the victim with - and - at the volleyball court. They are moving the victim out of the volleyball court as residents were in the area. (An incident report of the physical assistance at the volleyball court was not provided to CPS.) Based on interviews with staff and residents, the victim was being carried in a "fireman 's carry " by - and - observed that while being carried the victim was not holding up his head, his chin was on his chest and his toes were dragging on the ground. The victim was instructed to do pushups on the steps at the amphitheater. He was unable to do them. The victim was ordered by - to do modi)fied push-ups. The victim was ordered to maintain the pushup position by strerching his arTns out, while he was on his knees. The victim stated he could not do the pushups.

- assisted the victim in completing pushups. The victim was held by the waist of his pants and his shoulder while being pushed down and pulled up to perform the push-ups. He was forced to complete five modified push-ups. A resident - observed staff assisting the victim with push-ups. He observed them lifting the victim and dropping him on the ground.

While the victim was being assisted with the pmh ups, _ and - joined the group. - stated that while he was with the victim at the amphitheater he noticed the victim's eyes were closed most of the time. _ and __walked and carried the victim against a wall in the amphitheater. - The purpose was to "address ~ the victim for failing to "put forth the effort n completing physical activities.

The victim was pushed against the wall. _ slapped the wall next to the victim's head and began to "address" the victim. and _ were present but stated they "disengaged" according to policy. This meant they did not look at the situation. They heard - and - yelling at the victim. (An incident report of the addressing and physical assistance at the amphitheater was not provided to CPS.)

In Barracks 22 an employee _ was sleeping in preparation of a late shift. He was awakened by the noise of banging on the wall. Barracks 22 is approximately 60 to 75 feet from the amphitheater wall. Following the "addressing" at the wall, the victim was instructed to get back down in the push-up position. The victim lay down on his side in the sand. According to he victim requested water. The victim was instructed to stand up. The victim said, "No". and - arried the victim to the outside of Barracks 22. They carried the victim by his wrists and ankles. The victim was laid on the ground. got water in a canteen. He returned with the water and noticed the victim was "unresponsive". - poured water on the victim's face, to clean the dirt from the victim's mouth. Water was also poured on the victim's chest in an attempt to obtain a response. - hecked the victim's pulse on the neck. - checked the victim's pulse on his arm and wrist. No pulse was detected by either - or - so - began CPR. - went to obtain assistance and returned to assist with the CPR. _ noticed the victim regurgitated bile "and things" during the CPR.

5:59 PM - 911 call was received.

6:00 PM - _received a radio call to respond to the amphitheater. On his way he met - who directed him to Barracks 22.

6:29 PM - airevac arrived at ABR

6:55 PM - airevac left ABR

7:30 PM - Nicholaus Contreraz was pronounced dead.

10:33 PM - The DES licensing unit received a call from _ who reported the victim had died during a recreational acdvity. (Attachment 2)

Tuesday, 3/3/98

9:00 AM - DES licensing staff spoke with _ described the incident as one in which the victim had been uncooperative and during exercise the victim collapsed. _ was asked if the vicdm had been placed in a control position to which he stated there had been no hands on the victim by staff. - stated the victim had possible had a heart attack because his mother has a history of heart problems. (Attachment 3)

Later that same day the licensing staff spoke with Kaya Jezycki, ABR's attorney. Ms. Jezycki stated their internal investigation had found no wrong doing on the part of staff. -- (Attachrnent 3)

3:14 PM - A faxed incident report was received from~. The incident report describes the activities of March 2, 1998. The information provided differs from the voice mail and verbal report given by -. The report describes a different situation from that determined during the course of this investigation. "Attachment 4)

- instructed _ , a resident, to search a dumpster to find a yellow shirt. _ found a yellow shirt, tan pants and underwear with defecation on them. The clothing was in a black plastic bag. He gave the bag, to _. In an interview, - reported he was called into a conference room in which staff were meeting to put together a chronology of events. He was directed to find the bag of clothing. He had a resident search for the bag of clothing and once located, he resumed to the conference room. He reported he was directed to leave the bag in the room and leave. He stated he did not know what happened to the bag of clothing. He also stated he did not recall who was in the conference room and who directed him to locate the clothing. He stated he recalled - and - were in the meeting but was uncertain if - and Kaja-Anne Jezycki, the ABR attorney, were present in the room. CPS was unable to detemmine what happened to the bag of clothing.

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