5 Residents Die at Unlicensed Care Home That County Tried to Close

At least five mentally ill residents of an unlicensed boarding house in Rosemead died this year, two of them after Los Angeles County authorities found “deplorable living conditions” at the home in March and attempted to shut it. The county coroner determined that three of the residents died of morphine overdose, although other medications played a role in two of the deaths. The fourth patient died of bleeding in the brain, and the fifth from still-undetermined causes. All were living at the house on Tegner Street, which billed itself as a sober-living facility.

The county Sheriff’s Department is investigating the deaths but prosecutors have filed no criminal charges against the owner or operator of the San Gabriel Valley home, which went by various names including Sober R Us and San Gabriel House of Independence. It is illegal for a boarding house to provide medical care or supervision without a license.

The home’s owner is Yu-Chen “Tony” Wang of Chino Hills and the manager is Kevin Slavin of Los Angeles, according to a sworn declaration filed by a county sheriff’s deputy. Neither man could be reached for comment.

Earlier this month, the county Department of Mental Health took rare disciplinary action against two psychiatric hospitals that had referred patients to the Rosemead home.

Mental health department officials contended that City of Angels Medical Center-Ingleside and Hollywood Community Hospital of Van Nuys improperly discharged to the Rosemead facility three of the patients who later died. In letters sent in July to both hospitals and filed in court, one top official described the boarding home as “unclean, unsafe, unsanitary and in very poor condition.”

The county subsequently stripped City of Angels and Hollywood Community of their authority to detain mentally ill patients and treat them against their will. Both hospitals filed lawsuits in Los Angeles Superior Court, asking that the county’s disciplinary action be overturned.

The hospitals contended that the county has unfairly blamed them. Hospitals can recommend places for discharged patients to stay, but “the patient’s ultimate right is to live where they choose,” said City of Angels chief executive John Fenton.

The patients who died were: Gary Michael Reddish, 33; Rudolfo Fuentes, 32; Charles Edward Stiel, 27; Ryan Powell, 19; and Matthew Lee Janssen, 42. Their hometowns were not immediately available.

The deaths highlight the difficulty of monitoring vulnerable residents at unlicensed boarding houses, which do not fall clearly within the jurisdiction of any regulatory agency.

In fact, public officials this week said they were virtually powerless even to put such facilities out of operation. Authorities often don’t find out about problems at unlicensed homes until a resident is harmed.

Task Force Formed

Earlier this year, a constituent brought concerns about the Rosemead home to the attention of county Supervisor Gloria Molina, and a multi-agency task force was formed to investigate.

During a March 27 inspection, the team found more than 30 people living in four bedrooms, including 20 who needed care for mental disorders or substance abuse, according to mental health department correspondence filed in court.

The facility stored residents’ prescription medications in open cabinets, which allowed all residents to have access to each others’ prescriptions, the documents said.

It was not clear from court records or mental health department correspondence where the patients who overdosed obtained morphine.

Task-force investigators also found that the Rosemead facility lacked telephone service and first aid supplies, according to the documents. In fact, residents--not staff members--performed first aid and CPR on two of the residents who died, the county alleged in the court filings and letters to the psychiatric hospitals.

In one case, a resident had to walk to a pay phone on a nearby corner to summon 911 for a patient who had died, the documents stated.

Several residents of the Rosemead home told investigators that they had been moved there by Slavin after another boarding house he managed, known as Priscilla’s Place, was shut down, according to an affidavit by a county mental health department employee. State and local agencies closed the home after citing it for being unlicensed, according to court documents filed by the county.

Similarly, after the March 27 inspection of the Rosemead home, authorities moved most of the residents to other licensed facilities. But the owner of the Rosemead home allowed other people to move in, keeping the number of occupants less than six. The small number of residents meant that the facility was just like any home under the law, and even zoning inspectors could not take action against the operator, county officials said.

“There was nothing that anybody could in fact do to shut them down or board up their operation,” said Roberta Fesler, senior assistant county counsel. County officials from various agencies did, however, visit the home regularly, she said, to ensure that no more than six people lived there and that no one needed care or supervision.

Still, one resident died in April and another died in July. Within days of the final death, the home was abandoned, and it was subsequently boarded up by county workers.

County officials said the residents were being misled by the home’s owner and operator. They were “duped out of their Social Security benefits under the false pretense that they will be receiving adequate licensed care while living at the facility,” Sheriff’s Deputy Stephen Opferman wrote in a July declaration filed in court.

Opferman wrote that the owner and operator of the Rosemead facility “willfully and knowingly engaged in the theft of benefits from dependent adults and are subjecting them to conditions likely to cause great bodily injury or death.”

Unlicensed board-and-care centers have been a problem for years in Los Angeles County.

Six years ago, home operators picked up destitute and disabled people from skid row, took their Social Security checks and placed them in decaying houses, according to an investigation by The Times.

In this case, the only punishment meted out so far has been directed at psychiatric hospitals that allegedly sent patients to unlicensed homes.

“Given the level of what has happened here and the fact that several people have died, we feel it is our responsibility to take vigorous action,” said David Meyer, chief deputy director of the Department of Mental Health.

Officials at City of Angels said they were taken aback by the county’s action.

Of the two City of Angels patients who died, one was discharged to a different home 13 days before his death, hospital officials said.

He moved to Rosemead after that without the hospital’s knowledge, they said.

The second patient insisted on being discharged to the Rosemead facility against doctor’s advice, hospital officials said.

He died 17 or 18 days later, after entering and being discharged again from another psychiatric hospital, City of Angels officials contended.

Fenton disputed the county’s claim that his staff should have known about problems at the Rosemead home. “We had no knowledge,” Fenton said. “We had no right to inspect the facility. We are not the policing body. We are the caregiver.”

Hollywood Community lawyers and officials did not respond to multiple requests for comment.

In court papers, they argued that they could not legitimately be held responsible for where a patient chooses to live after hospitalization.