The Veterans Village of San Diego campus is shown on June 3, 2022. (Zoë Meyers/inewsource)

For the fifth time this year, a client at Veterans Village of San Diego’s campus has died.

Marcus Mondragon, a 40-year-old resident at the nonprofit’s drug treatment center, was pronounced dead at Scripps Mercy Hospital in Chula Vista on Oct. 1. The cause of his death is under investigation by the Medical Examiner’s Office.

Despite a requirement to report all client deaths to a California oversight agency, Veterans Village hasn’t notified the Department of Health Care Services of any deaths that have occurred this month.

Why this matters

Veterans Village of San Diego receives more than $17 million a year in funding from county, state and federal government agencies, which supports rehabilitation, employment, housing and other services.

The department “will inquire with VVSD and immediately open an investigation,” spokesperson Anthony Cava said.

The health care agency was already investigating seven complaints against Veterans Village, Cava said. And on Monday, officials sent the nonprofit a list of noncompliance issues that must be corrected.

“Each of the reports require a response from VVSD identifying how VVSD will remedy all deficiencies,” Cava said. “Due to imminent danger to residents, any Class A deficiencies cited must be abated or eliminated immediately upon receipt of the notice of the deficiency.”

Veterans Village has come under heavy scrutiny this year following numerous reports of unsafe living conditions at its facilities near Mission Hills. An inewsource investigation in June revealed widespread drug use, multiple overdoses, a litany of health hazards and a severe staffing shortage were plaguing the institution and posing risks to clients.

In January, two deaths occurred at the nonprofit’s central campus — one in the transitional housing program, due to natural causes, and the other in the rehab center, which is still under review by the medical examiner.

Explore the project

Read more from the investigation into Veterans Village here.

Two more deaths came in April and July, both catching the interest of the Drug Enforcement Administration. Brandon Caldera and Tyrone Mimms were each found unresponsive in their rooms at Veterans Village’s rehab center. The DEA has been investigating the cases as suspected fentanyl overdoses and looking for information on possible drug suppliers.

In addition, a woman living at a separate Veterans Village transitional housing facility near Valencia Park was killed earlier this year, allegedly by another resident. The victim had expressed concerns about her personal safety in the program to staff and to inewsource in interviews prior to her death.

Jennelle Self, a resident at Veterans Village of San Diego who was killed, is shown in this undated photo. (Courtesy of Tina O’Connor)

The week inewsource’s investigation into Veterans Village published, county officials issued a Corrective Action Plan to the nonprofit. Then, after Mimms died at the treatment center in July, the county froze admissions “to ensure the safety, support and clinical wellbeing of those with behavioral health needs.”

The admissions hold is still in place, said county spokesperson Michael Workman. He did not elaborate on when it may be lifted or the status of the Corrective Action Plan.

San Diego County oversees all residents coming into the facility through the state’s Drug MediCal program, a funding source for substance use treatment centers. Last fiscal year, the program brought in $6 million to Veterans Village, amounting to more than a quarter of the organization’s revenue.

On Monday, the county said it received notification from Veterans Village that a resident recently died — but the state could not find a record of the incident.

“DHCS was not notified of the death of a VVSD client to date in October 2022,” a state spokesperson said.

According to government manuals, serious events, including the deaths of rehab center clients on or off campus, need to be shared with the state health care services department within 24 hours.

The department, which licenses drug treatment centers, said there is no typical number of deaths for facilities it oversees, adding that Veterans Village operates a larger program than most other institutions.

The state would not elaborate any further on recent deaths at the San Diego rehab center because they are part of ongoing investigations.

The department’s most recent available data shows that 63 deaths occurred across 1,727 rehab centers in the 2021 fiscal year. Like most treatment programs that year, Veterans Village reported zero fatalities.

Death counts have climbed across the industry since then due to the growing opioid crisis, which has devastated communities across the U.S. In June, the county declared fentanyl, a potent synthetic opioid, a public health emergency.

Akilah Templeton, the chief executive officer of Veterans Village, did not respond to requests for comment. In an interview in May, she stated that her institution prioritizes the health and wellbeing of its residents and is committed to providing quality care for clients struggling with severe conditions amid the opioid epidemic.

Update: Oct. 6, 2022. This story has been updated to include additional information about reporting requirements for serious incidents at substance use treatment programs.

Type of Content

News: Based on facts, either observed and verified directly by the reporter, or reported and verified from knowledgeable sources.

Jill Castellano is an investigative data coordinator for inewsource. When she's not deep in a spreadsheet or holed up reporting and writing her next story, she's probably hiking, running or rock climbing. She also loves playing board games and discussing the latest chapters with her book club. Jill...