A death in March triggers more scrutiny of Veterans Village

A little more than a year ago, from deep inside the downtown federal jail, Jeffrey Scott Connors Jr. picked up a pencil and two sheets of paper and in slanting block print, wrote a letter to U.S. District Court Judge John Houston.

The judge had sentenced Connors to 33 months in prison in 2020 for human smuggling and assaulting a federal officer. Released in early 2022, the 46-year-old with a history of drug use he could never quite shake had numerous setbacks, court records show. 

He had been kicked out of a residential recovery center in Brawley after getting into a confrontation with another resident. He had been arrested for driving with a suspended license in Orange County, failed drug tests, no-showed for meetings with his federal probation officer. The final straw: When he did arrive for a meeting with his probation officer, security found four knives on him.

Now facing another stint in custody, Connors asked Houston to instead allow him to go to a halfway house in Flagstaff, Arizona, where he had family and would be away from California.

“If I can’t go to Arizona, can I go to Veterans Village or some other program for the next six months, the remainder of my time plus probation please sir,” he wrote.

Connors never made it to Arizona. But he did get a spot at Veterans Village of San Diego, the nationally renowned program on Pacific Highway that provides treatment and housing for service members and people referred by the county through the state’s Drug Medi-Cal program. 

Admitted in January, Connors lasted a month before being kicked out for a rules violation — but was encouraged to reapply. He did, getting readmitted on Feb. 21, court records show.

But on the evening of March 18, Connors took fentanyl along with another resident. That resident survived but Connors did not, expiring on the ground of the village just after 9:30 p.m.

Connors was the sixth person known to have died at Veterans Village since the start of 2022, following a string of five fatalities documented in inewsource stories that year.

Since then, Veterans Village has continued to service hundreds of clients dealing with substance abuse, mental health and other challenges. But it also has been subject to ongoing scrutiny from state and local agencies and, most recently, complaints from veterans about conditions there.

In March 2023, the state Department of Health Care Services placed VVSD’s license on probation, after an investigation prompted by the deaths and other complaints turned up more than two dozen violations of state standards. 

The agency also fined the organization $35,000, according to a settlement agreement that inewsource obtained through the state Public Records Act. 

Then in May, after Connors’ death, San Diego County issued a Corrective Action Notice — a notice of noncompliance with one or more terms of a contract — listing four “critical areas of concern” that needed improvement.

The county contracts with VVSD to provide residential treatment for substance abuse. The notice was issued following an inspection of the program after Connors died — a routine event when a death occurs at such a facility, according to a county official.

The violations included patients not attending group and individual therapy sessions, patients being discharged “without proper connection to necessary, ongoing services,” and some participants “not receiving prescribed medications.”

And just recently, a group of veterans who are residents there have organized to demand changes. Their complaints run a spectrum, from poor quality food to drug use, lax security and dirty conditions. 

On July 11, Zach Wildey, a former U.S. Navy hull technician, and Jeffrey Flannigan, a Navy SEAL and Vietnam combat vet, delivered a letter to the San Diego office of the Department of Veterans Affairs detailing their complaints.

The letter also contains an ultimatum for Veterans Village: Either President and CEO Akilah Templeton should resign and be replaced with a new leader who is a veteran, or the organization should remove the word “veterans” from its name.

“We want the name veterans taken off that place,” Wildey said. “They’re not deserving of that name.”

Templeton declined to speak with inewsource. The organization did not respond to written questions about the license probation, the county’s latest action and other issues.

In the past, VVSD has vigorously disputed the inewsource reporting, contending it was biased, sensationalized, and inaccurate, and ignored the work the group does helping thousands of veterans and non-veterans through its various programs.

inewsource has stood behind its reporting and no corrections or retractions have been made.

Veterans Village has provided substance abuse and mental health treatment since 1981, and in recent years expanded its services to non-veterans. The organization provides counseling, housing and employment for residents.

It contracts with San Diego County to provide a maximum of 101 beds for treatment under the Drug Medi-Cal program. Since 2017, the organization has received more than $30.6 million in county funding, with about 20% of that being collected last fiscal year.

In 1988 the organization launched Stand Down, a much-lauded event that connects homeless vets with public services and community support. The program has been copied in cities across the country since it began.

But in recent years, stories of overdose deaths, poor conditions, staff turnover and other issues have cast a shadow over the organization. After the inewsource investigation, the county halted referring people there, though it later lifted that ban and resumed referrals — which it continues to this day.

Also, the state Department of Health Care Services investigated several complaints and the reported deaths in 2022. A sheaf of department investigation records that inewsource obtained were heavily redacted, but show more than a dozen “Class A deficiencies” were found.

Those are the most significant findings, defined by the state as posing “imminent danger to residents,” and must be addressed immediately. The records indicate some of the violations were flagged following the facility’s report of a 2022 death, though the state withheld details. 

Other violations detailed in other reports include providing an incomplete staff file when requested by the state, and not ensuring the proper disposal of medication, among other findings.

A total of 15 lesser deficiencies were also identified, the records show.

All those findings were the basis of the settlement agreement that led to the license being put on an 18-month probation set to end in September. In the agreement, VVSD said it disputes the department’s findings and “does not admit to any fault or wrongdoing by entering into this agreement.”

Since the license was put on probationary status, the state has conducted seven inspections at VVSD and found no further deficiencies, an agency spokesperson said. The state has taken no further actions against the license. It’s still investigating Connors’ death.

A county visit

A team of workers from the county conducted an inspection of VVSD in the wake of Connors’ death, said Charity White-Voth, deputy director of programs and services for Behavioral Health Services, part of the Health and Humans Services Agency.

That is done whenever a program the county contracts with has a serious injury, death or other incident. The county reviewed numerous files to determine if the organization is following policies and procedures correctly, she said.

The county had done the same thing with VVSD in 2022, and in June of that year issued a notice detailing deficiencies in various areas of record keeping and documentation, she said. By last November, VVSD had corrected the deficiencies and the matter was formally closed, records show.

Yet the inspection conducted after Connors’ death revealed additional problems, such as inconsistent record keeping when it came to patients getting medications they were prescribed. File reviews showed that some clients — “a handful,” White-Voth said — were discharged, but their records did not reflect they had been given referrals or counseled about continuing care, she said. 

“You could say they’re paperwork violations, but they do represent clinical care,” she said of the deficiencies that were found. “So it’s not just missing a billing code, and putting a four instead of a three. These are clinical standards that are areas that need improvement.

“Are they so egregious that we need to go in and remove all clients? No. But there are areas that need to be improved just for overall standards of care.”

VVSD has submitted a plan to correct each deficiency as required. The county notice says all deficiencies must be corrected by Aug. 15.

‘They don’t do enough to stop’ drug use

Wildey arrived at the village in September. In a June interview with inewsource, he said he was the designated spokesman for a group of veterans fed up with conditions at the site. 

He said the quality of the food was “basically jail food,” and shared photographs of several recent meals. A scoop of beans, some rice, a piece of bread one evening. Lunch on another day was a hot dog in a bun, beans, some macaroni salad.

Wildey said not all aspects of VVSD are poor. He said the therapists there are “wonderful,” and was grateful that staff members helped him get a drivers license for the first time in years. Other vets get help with issues like child support payments.

Still, there are problems. In the letter delivered to the VA, the group said the site was dirty with bed bugs, that veterans felt unsafe, and there was open drug and alcohol use that went unpunished. 

“I think a total refresh start is necessary here Judge Houston. It would be much easier to start somewhere fresh than in my known pile of old trouble here.”

— Jeffrey Connors Jr. in his 2023 letter

“I’ve seen people doing drugs here on the property,” Wildey said. “Now, they say, don’t do drugs, you’re gonna get kicked out of here. But they don’t do it. They don’t do enough to stop it.”

Jeffrey Connors Sr. acknowledged his son had many problems, but thought this time he would be able to put those behind him. The younger Connors seemed to think so, too, when he wrote to Houston. 

“I think a total refresh start is necessary here Judge Houston,” Connors said in his 2023 letter. “It would be much easier to start somewhere fresh than in my known pile of old trouble here.”

His father said his son had worked as a teamster, and he was planning to get his license back to operate a forklift. His son, he said, was a “very giving individual” despite his problems. 

Connors Sr. said he was hopeful that Veterans Village would help his son. 

“You know, I got the false impression just thinking, oh, this is run by the Veterans Village. It’s gonna, you know, they got a tight grip on a place, this is gonna be great,” he said. “But, it unfortunately wasn’t.”