Dr. Cohen Grand Jury Testimony

SUPERIOR COURT - STATE OF CALIFORNIA
COUNTY OF RIVERSIDE
PEOPLE OF THE STATE OF CALIFORNIA,

Plaintiff,
vs.
KRISTOFER MICHAEL MCCAUSLAND, JAMES
ANDREW FENT, MIGNON HERNANDEZ DEAN,
JERROD NATHAN MENZ, TAMI DAWN
SCARCELLA, ABTTC, INC., dba A
BETTER TOMORROW TREATMENT CENTERS,
FORTERUS, INC., and FORTERUS HEALTH
CARE SYSTEMS, INC.,
Defendants.
)
)
)
)
) CASE NO. SWF1501351
)
)
) Volume 7 of 9
) Pages 1118-1336
)
)
S-E-A-L-E-D
)
)
)
)
)
REPORTER'S TRANSCRIPT OF CRIMINAL GRAND JURY PROCEEDINGS

JULY 15, 2015
APPEARANCES:
FOR THE PLAINTIFF:
DEPARTMENT OF JUSTICE
OFFICE OF THE ATTORNEY GENERAL
DIVISION OF CRIMINAL LAW
BUREAU OF MEDI-CAL FRAUD & ELDER ABUSE
BY: JOEL SAMUELS
1425 River Park Drive #300
Sacramento, California 95815
REPORTED BY:
SONJA A. HUDSON, CSR NO. 13150
Sonja A. Hudson, CSR
1
2
3
RIVERSIDE, CALIFORNIA; JULY 15, 2015.

GRAND JURY FOREPERSON:
Good morning, everyone.
The
grand jury will now come to order.
Will the secretary please take roll.
GRAND JURY SECRETARY:
GRAND JUROR NO. 1:
GRAND JUROR NO. 2:
Juror No. 1.
Here.
Juror No. 2.
Here.
10
GRAND JUROR NO. 3:
11
12
Juror No. 5.
13
GRAND JUROR NO. 5:
14
15
GRAND JUROR NO. 6:
16
17
GRAND JUROR NO. 7:
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19
GRAND JUROR NO. 8:
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21
GRAND JUROR NO. 9:
22
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GRAND JUROR NO. 10:
24
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GRAND JUROR NO. 11:
26
27
GRAND JUROR NO. 12:
28
Juror No. 3.
Here.
Juror No. 4.
Here.
Juror No. 6.
Here.
Juror No. 7.
Here.
Juror No. 8.
Here.
Juror No. 9.
Here.
Juror No. 10.
Here.
Juror No. 11.
Oh, here.
Juror No. 12.
Here.
Juror No. 13.

1118
GRAND JUROR NO. 13:
Here.
GRAND JUROR NO. 14:
GRAND JUROR NO. 16:
GRAND JUROR NO. 17:
Juror No. 14.

Here.
Juror No. 15.
Juror No. 16.

Here.
Juror No. 17.
Here.
10
11
Juror No. 19.
12
GRAND JUROR NO. 19:
13
14
Juror No. 18.
Here.
Counsel, you may begin.
16
MR. SAMUELS:
17
THE GRAND JURY:
18
MR. SAMUELS:
20
21
22
The record will reflect all
17 jurors are present.
15
19
Here.
Thank you.
Good morning.
Good morning.
It's my memory we were finished with
Sergeant Gomez last night, so I will bring another witness in.

Please remain standing and
raise your right hand.

You do solemnly swear that the evidence you shall
23
give in this investigation now pending before the grand jury
24
shall be the truth, the whole truth, and nothing but the
25
truth, so help you God?
26
THE WITNESS:
Yes.
27
28
I have a statement acknowledging a secrecy order that
Please be seated.

1119
I would like you to read, sign and print your name at the
bottom.
(Pause in proceedings.)
Please state and spell your full name for the record.
THE WITNESS:
Larry Steve Albert, Jr.
First is
L-a-r-r-y, middle S-t-e-v-e, last A-l-b-e-r-t, and last of
Jr., J-u- -- I'm sorry.
Go ahead.
10
MR. SAMUELS:
Thank you.
Thank you.
11
LARRY STEVE ALBERT, JR.,
12
called as a witness by the People, was sworn and testified as
13
follows:
14
15
DIRECT EXAMINATION
BY MR. SAMUELS:
16
Q.
Good morning.
17
A.
Good morning.
18
Q.
How are you employed?
19
A.
I am employed with the Riverside Sheriff's Department
20
as a sergeant with the coroner's bureau.
21
Q.
So are you sworn law enforcement?
22
A.
Yes, sir.
23
Q.
And how long have you had the position with law
24
enforcement?
25
A.
I have been law enforcement since 2005.
26
Q.
And do you know what POST training is?
27
A.
Yes.
28
Q.
P-O-S-T?

1120
A.
Yes, sir.
Q.
What is it?
A.
It's Police Officers Standards Training, which is
something that is required by the State of California for all
of its sworn peace officers to meet certain requirements.
6
7
Q.
As part of your POST-certified training, did you take
a class on writing reports?
A.
Yes, sir.
Q.
Did you pass that class?
10
A.
Yes, sir.
11
Q.
Were you on duty as a Riverside sheriff's coroner in
12
July of 2010, the 26th of July, to be specific?
13
A.
Yes, sir.
14
Q.
And do you remember getting a call for service?
15
A.
Yes, I do.
16
Q.
Do you remember where you went?
17
A.
I went to the -- to an Iron Gate address in the City
18
19
20
21
22
23
24
25
26
27
28
of Murrieta regarding an unattended death.

Q.
And do you remember who summoned you there by any
chance?
A.
It was Murrieta PD.
I'd have to refresh my memory as
to the officer's name.

Q.
Okay.
this address?
A.
So do you know what time you got there, to

Do you remember the address by any chance?
Not offhand.
I do remember it was on Iron Gate, but
I don't remember the exact address.

Q.
All right.
Do you remember what time you arrived at
the house you were summoned to or the address you were

1121
1
2
3
4
5
summoned to?
A.
I would have to look at my report to refresh my
memory.
Q.
Would it refresh your recollection to look at your
report?
A.
Yes, sir.
Q.
Is that a copy of your report in front of you?
A.
Yes, sir.
Q.
And it's been sitting there facedown?
10
A.
Yes, sir.
11
Q.
I see some other documents here.
I'm going to put
12
those to the side and ask you not to review them during your
13
testimony.
14
A.
Yes, sir, it is.
15
Q.
Okay.
Is this your report?
You may refresh your recollection, which means
16
if reading your report or looking at it brings it back into
17
your present memory, you may testify as to what you remember
18
in your own mind.
19
20
A.
About approximately 0935 hours, I arrived at the
address.
21
Q.
So 0935, is that morning or evening?
22
A.
That's military time for morning.
23
Q.
Okay.
24
A.
9:35 in the morning.
25
Q.
And I'm going to show you some portions of an
Thank you.
26
exhibit, Exhibit 43.
27
ask you if you recognize a page marked 000154.
28
A.
It's got multiple pages.
I'm going to
Yes, I do.

1122
Q.
And what is it?
A.
It's my photographs from the scene.
Q.
You took this photograph?
photograph?
A.
Yeah, I believe I did.
Q.
Okay.
You believe you took this
And what's that in the upper portion of this
page that I'm showing you from this exhibit?
A.
A sober living residence.
Q.
Well, what kind of -- what kind of building are we
10
looking at?
11
A.
It's a single-family home.
12
Q.
And is it related to what you've testified to?
13
A.
Yes, sir.
14
Q.
How?
15
A.
It is a single-family home that is used by a
16
company --
17
Q.
No, no.
18
A.
I'm sorry.
19
20
21
Q.
Okay.
Yes.
23
Q.
Okay.
MR. SAMUELS:
25
control in here.
26
secretary.
28
Thank you.
And is that number there -- did
you take that picture of the address plate?

A.
27
This is the address that I responded to
for an unattended death.
22
24
What you've already testified to.
I have a question about the climate
I'm going to go ask the grand jury
If I may be excused to do that?
Thank you, sir.
(Brief recess.)

1123
1
2
Q.
BY MR. SAMUELS:
Okay.
Now, did you go in this house
on Iron Gate?
A.
Yes, sir.
Q.
And do you recall where in the house you did any
investigation there?
6
7
A.
I conducted some interviews which occurred in the
kitchen area.
Q.
Okay.
A.
And I also conducted my investigation in a bedroom,
10
which, if I remember correctly, was located in the northeast
11
corner of the residence.
12
Q.
All right.
Do you remember -- I'm going to show you
13
a portion of this exhibit that has a Bates stamp of 000161 on
14
it.
Do you recognize that?
15
A.
Yes.
That's the decedent's bedroom right here.
16
Q.
And I'm going to show you what's been Bates stamped
17
as 000162.
18
A.
Yes, sir.
19
Q.
So I'm projecting up here for the grand jury's view,

Still the decedent's bedroom.
20
page 000161.
There are two pictures on it; one on the upper
21
half, one on the lower half.
22
being depicted.
We're looking at the lower half
Is that a view that you recall?
23
A.
Yes.
24
Q.
What is it?
25
A.
The decedent's bedroom.
26
Q.
And the area that I'm pointing toward, this, do you
27
28
remember that?
A.
Yes.

1124
Q.
What is it?
A.
That's the -- where the decedent slept.
Q.
Okay.
And this darker area here that's under my pen
hovering over the picture, can you tell us what that object
is?
A.
Comforter.
Q.
A comforter.
Okay.
you were holding onto?
picture of top and bottom.
And may I have the next one that
This is -- excuse me.
This is a
The bottom picture has now been
10
turned 90 degrees so it's oriented properly in terms of its
11
spacial orientation.
12
A.
What's that?
The picture on the right, a bedside table with a
13
number of personal items on it, decedent on the floor, and
14
then the -- near the decedent's head, an 02 tank and a
15
traveling pouch.
16
Q.
Okay.
So it's not just a tank, it's in what again?
17
A.
I don't know what they refer to them as, but it's
18
usually used as a little traveling pouch they can -- it has a
19
strap so they can carry the 02 around with them.
20
Q.
What's 02?
21
A.
I'm sorry.
Oxygen, an oxygen tank.
22
Q.
All right.
And are you -- are you -- I'm going to
23
give you a laser pointer and let you point out what you're
24
referring to.
25
and point it at the wall, it should display.
There's a red dot on this.
26
A.
There we go.
27
Q.
Okay.
28
A.
Right here, the 02 tank.
If you push that
We often see individuals

1125
that have very small 02 tanks and they have a little zip-up
container that usually has a strap that allows them to carry
the 02 container around with him as they travel through their
day.
cigarettes, watch, clock.
was in this.
delivery system.
deliver a drug as a mist, and it's almost like an oxygen mask
that one wears and it delivers that over time.
10
11
12
13
14
And right up here you see a few personal items,
Q.
This is -- I don't remember what
Right back here is a nebulizer, which is a drug

A nebulizer is basically used as -- to
Do you know if the nebulizer delivers oxygen or are
you just referring to the mask?

A.
Just to the -- it's like -- it's like an oxygen mask.
It does not, as far as I know, deliver oxygen.

Q.
Did you see anything -- talking about the oxygen
15
tank, the 02 tank that you said was in the black pouch there
16
by the decedent's head, was there anything hooked up to that?
17
A.
If I remember correctly, a nasal cannula.
18
Q.
All right.
19
A.
Which is basically when you have a person that is
20
taking oxygen, it can be delivered a couple of different ways,
21
just with a mask that's placed over the face, and something
22
else that's called a nasal cannula, which is little tubing
23
that fits over the nose right in here, which you've often, I'm
24
sure, seen in medical shows.
25
26
Q.
Do you remember if there was a regulator of any type
on that tank?
27
A.
No, I don't.
28
Q.
Okay.
I'm going to show you another picture here.

1126
This is the one that's marked Bates stamped 000164, ask you to
identify it, and then I'll project it.
3
4
A.
This is still the decedent's bedroom, the floor of
the decedent's bedroom.
Q.
Okay.
Let me project that and we can discuss it.
A.
Sure.
Q.
We're looking first -- this is a page with two
pictures.
We're looking first at the upper picture.
Now, is
this the condition that you observed when you arrived?
10
A.
Yes.
11
Q.
So what do you see on the wall there?
12
A.
A plug right here.
13
Q.
Is that also called an electrical outlet?
14
A.
Yes.
15
Q.
Is there anything attached to that electrical outlet?
16
A.
No.
17
Q.
And I see some things on the floor there.
18
19
Can you
describe them?
A.
This right here would be the cable that runs up to
20
the nebulizer.
It's unplugged and on the floor.
This tubing
21
right here is tubing that's commonly used for oxygen and may
22
or may not be attached with a nasal cannula.
23
Q.
So is it attached to anything at either end?
24
A.
I don't recollect at this point if he had the nasal
25
cannula on him but, no, on this end, as far as I can tell, no,
26
it is not.
27
Q.
28
So it's not attached to either the nebulizer or the
oxygen bottle?

1127
A.
Correct.
Q.
Okay.
And here this is the other picture on 000164.
I'm turning the page so that it orients correctly.
this picture depict?
What's
A.
This is a nebulizer.
Q.
And how do you know that?
A.
I don't recognize this particular model, but I
recognize it as a nebulizer, as a delivery system for
delivering drugs.
10
Q.
11
nebulizers?
12
A.
13
Do you have training and experience with regard to
For visualizing in numerous cases and being out on
numerous unattendeds.
14
Q.
Okay.
15
A.
Yes, sir.
16
Q.
I'm handing you what's Bates stamped as 000166.
17
In your job?
you recognize that?
18
A.
Yes.
19
Q.
Okay.
20
A.
Okay.
21
Q.
There are two pictures here.
This is the -Let me project it so you can discuss it.
22
I'm referring to as the top one.
23
lower right-hand corner.
24
see there?
25
A.
This is the top one.
What do you
This is the gentleman's luggage and that is an 02
mask.
27
photo, but it is the 02 tubing, if I -Q.
I'm going to show what
The Bates stamp is in the
26
28
Do
And this right here, I believe, falls into the second
All right.
I'm showing you the lower tubing now.

1128
1
2
A.
I can see the mask here.
And then the container
right here, this packet, I believe, contains 02 tubing.
Q.
All right.
And when you say 02, you mean oxygen?
A.
I'm sorry.
Yes, oxygen.
Q.
It's just an abbreviation or --
A.
Yeah, it's an abbreviation.
Q.
And these photos, you said they were taken of items
8
9
in his luggage.
A.
Can you explain what you mean by that?
When I come in and I do my investigation, what I do
10
is I come into, for example, an area where I'm doing my
11
investigation in this particular room, and I will do overalls.
12
Everything should be as was.
13
will not move anything when I walk into the room.
14
overall photos and then I will shoot photos of anything of
15
particular interest.
16
17
18
19
This gentleman required 02.
And I
I'll shoot
So when I opened up his
luggage, I took photographs of what was in his luggage.

Q.
Okay.
I'm going to show you the picture that's got a
Bates stamp of 167.
20
A.
Yes, I do.
21
Q.
Okay.
22
A.
I'm sorry.
23
Q.
Sure.
24
Nothing should be moved.
on 167.
Just tell me if you recognize it.

This is the decedent's bedroom and --
I keep reading on.
I'm going to show you the lower picture first
What's that depict?
25
A.
The decedent in the bedroom where he was found.
26
Q.
Now, to your knowledge, has he been moved to this
27
point?
28
A.
No, he had not.

1129
Q.
And do you see an object by -- I'll turn it to make
it a little clearer.
when you entered?
Is this how the decedent was oriented
A.
Yes.
Q.
What's that immediately to his left?
him is a better way of saying it.
Now, immediately behind him.
Well, behind
Behind him, I'm sorry.
A.
Behind him?
Q.
By his seat.
10
A.
I'm not sure where you're referring to.
11
Q.
I'm referring to here on the left side.
12
A.
Oh, I'm sorry, the bed.
13
on the floor.
By his bottom.
I was looking for something
I apologize.
14
Q.
Okay.
15
A.
That is a water bottle.
16
Q.
And so was he touching the bed?
17
A.
Yes, he was.
18
Q.
And his foot in this photo, it may appear to be under
19
What's that on the floor?
the bed, but did you check to see if it was under the bed?
20
A.
It's very slightly under the bed.
21
Q.
All right.
22
And is this picture a proper depiction of
what you saw at that time?
23
A.
Yes, sir.
24
Q.
And did you make a closer inspection of the decedent?
25
A.
Yes, sir.
26
Q.
And is this a photo of that inspection -- from that
27
inspection?
28
A.
Yes.

1130
Q.
Why did you take this?
A.
Every single body exam we do, again we shoot overalls
of the room, but when we come to the body, we -- basically we
cone in and we move closer to photos of the body just as it
is, and then I will move the body after that and do my body
exam, shoot overalls of the individual front and back.
Q.
Okay.
Looking at these two photos together, is there
anything remarkable about the condition of the decedent's
body?
10
A.
Yes.
11
Q.
What's that?
12
A.
The lividity present, which you can see right away.
13
Q.
All right.
14
15
Let me stop you.
What does your training
and experience tell you lividity means?

A.
Lividity is the -- when someone passes away, your
16
heart stops pumping.
The easiest way to explain it is that
17
your body settles to the lowest point.
18
your back, the blood is going to settle to your back.
19
this gentleman right here, he was almost kneeling and it looks
20
like he's slumped forward, so everything settles in the chest
21
area and in the dependent areas.
So if you're laying on
And
22
Q.
Okay.
23
A.
You can see the very dark red that is right in the
24
And how do we see that in these picture?
areas around here.
25
Q.
And it goes higher or lower in his body?
26
A.
Lower.
27
his skin.
28
things like that.
He also had a couple of things going on with
He had some injuries from -- from his dogs and

1131
Q.
Well, how would you know they were from his dogs?
A.
The gentleman at the facility told me when I had
asked him.
Q.
So it wasn't based on your inspection that you knew?
You just saw injuries?
A.
I saw injuries and I asked about them because I
wanted to make sure.
what they were from.
Q.
Okay.
They were healing.
But I wanted to know
But from your own inspection, your own eyes,
10
your own training and experience, you saw injuries.
11
describe those injuries?
12
does that mean?
13
A.
You said they were healing.
Can you
What
You can -- you know, you can often see -- when
14
somebody gets a cut, you see that fresh kind of redness to it.
15
You can see when it's starting to heal over, just like when
16
you get a cut, you see that scab kind of healing over it so
17
you get a kind of general idea of how well-healed something
18
is.
19
healing that were apparently from his dogs.
This gentleman had quite a few injuries that were all
20
Q.
21
knowledge?
22
A.
No.
23
Q.
Okay.
24
000168.
Okay.
But you don't know about that from personal
I'm handing you what's been Bates stamped as
25
A.
Yes, sir, I do.
26
Q.
Okay.
All right.
This is the decedent.

And I'm going to display this.
27
It's again two pictures on one page.
This time what I will
28
refer to as the bottom picture, the one closer to the Bates

1132
stamp number, what's this?
A.
This is the decedent in his found position.
Q.
And this picture, which I've reoriented to place the
4
5
decedent's head at the top of the picture.

A.
This is what you'll note is the plastic right under
here, it's plastic that I had my transport guys put down.
was moved onto the plastic from his found position so I could
do a body exam.
9
10
Q.
He
Now, is his position, once he's been moved onto the
plastic, suggestive of anything?
11
A.
Oh, yes.
Rigor mortis --
12
Q.
Okay.
13
A.
Rigor mortis is the stiffening of limbs.
Let me stop you.
What is rigor mortis?

When you
14
pass away, what happens is the -- your -- whatever position
15
you're in, your limbs start to stiffen and the body starts to
16
stiffen, and it will become more and more prominent over time.
17
And it actually will eventually leave.
18
going away.
19
Q.
So is this progressive?
You will -- it starts
The body becomes stiffer.
20
If I'm understanding you, you said more and more over time.
21
Does that mean it's progressively stiffer until it goes away?
22
A.
Yes.
Progressively stiffer until it goes away.
And
23
there are some varying factors which are very complicated and
24
beyond me.
25
high temperature, you'll see this occur very quickly
26
sometimes.
27
occur.
28
person has been dead.
When somebody is febrile, when they have a very
But there's other factors that may cause it to
But it gives us a general sense as to how long a

1133
1
2
Q.
Okay.
Are you familiar with the concept of different
stages of rigor mortis?
A.
Yes.
Q.
What does that mean?
A.
The different stages of rigor mortis, if you're
referring to just general over time, what we refer to in the
simplest terms is that when someone passes away and the rigor
is present but easily breakable, that kind of gives us a
general time frame as to how long they have been dead.
If
10
they are very stiff in this manner and rigor mortis -- if I
11
have to literally take their arm and push it down and it
12
really won't go all the way down, that tells me that rigor
13
mortis has set and it's probably on the very outside of the
14
window of how long this person has been deed.
15
Q.
What do you mean on the outside of the window?
16
A.
Probably close to the stages where rigor mortis is
17
going to start leaving the body.
Within probably several
18
hours, it will probably start leaving the body.
19
Q.
And are there numeric values for these stages?
20
A.
General numeric values, yes.
21
mortis sometimes occur very quickly.
22
occur incredibly quick.
I mean, we see rigor

I mean, I've seen it
But we've felt --
23
Q.
Let me stop you.
24
A.
Sure.
25
Q.
Do you say it's stage 1, stage 17, stage 105 rigor
26
mortis?
That's what I'm referring -- the numeric values that
27
you use to say to associate with whatever stage rigor mortis
28
is in.

1134
A.
Yeah.
And generally what we refer to is we do --
yes, there are.
breakable and things like that.
usually starts occurring in approximately two hours.
hours, it reaches -- probably reaches about this point.
Q.
Okay.
We refer to the stages as just being easily
I'm sorry.
We see that rigor mortis

In eight
So when it's easily breakable, do
you call that stage 1 or stage 2 or stage 3 or something, or
do you just call it easily breakable?
A.
We call it easily breakable in our notes for simple
10
terms, yes.
11
Q.
12
Okay.
That's what I was getting at.
So you don't
use numbers?
13
A.
No.
14
Q.
All right.
15
A.
No, no, no.
Sorry.
Anything else you need to add?
It's out there, but we just -- we
16
generally don't use it.
17
write our reports or things like that, what we're looking for
18
is to communicate to the public in simpler terms.
19
our notes when we write it in house, we don't use those.
20
Nobody really does in house.
21
22
23
Q.
Okay.
I mean, it's something that when we
And even in
So you use the terms easily breakable and what
else?
A.
Easily -- the beginning stages of rigor mortis were
24
present, and rigor mortis present and easily breakable with
25
gentle pressure, with moderate pressure, with heavy pressure.
26
27
28
Q.
How would you characterize the rigor mortis that you
found in this subject on that day?

A.
I would have described it as rigor mortis being set

1135
and breakable with heavy pressure.
Q.
All right.
Now, I want you to look at this picture
that's projected and I want you to tell us about the
coloration of the decedent.
A.
That's the -- that's the extreme for lividity.
That
is set.
first starts, you see those areas -- like if my hand were down
like this and the blood were settling right here, if you could
see a little bit of redness, you know -- if I press down and
10
you see white, what we call blanching, if you see that white
11
on there, then you know that it hasn't been there that long.
12
And then you can press down and you can see that it may not
13
hold as much white and may be a lot more red.
14
completely red.
15
would just be, again, the pressure of when you push down, it
16
will go white.
17
it.
18
19
20
Q.
Now, what happens with lividity is that when it very
There's no blanching.
This is just
What we call blanching
So if you push down on your arm, you'll see
What about this area here near the decedent's knee
where I'm showing you with the pen?

A.
Those are called pressure marks.
And what happens is
21
is that lividity is setting but what happens is that was the
22
heaviest pressure areas where his body was resting, so you
23
won't see the lividity in those areas.
24
Q.
All right.
25
A.
Excuse me.
26
Q.
Are you familiar with the term cyanosis?
27
A.
No.
28
Q.
Okay.
So I'm going to show you what's been Bates

1136
stamped 000170.
A.
Yes.
Q.
And 000169.
A.
Yes.
Q.
First, the one that's 169, upper portion.
Now, the
mark on his arm here, is that consistent with the mark that
was on his knee --
A.
Yes.
Q.
-- that you just described?
10
11
And that's due to, once
again, could you describe -- tell me?

A.
That's going to be where you're seeing the heaviest
12
parts of the body pressing down where all that pressure is and
13
we call this pressure marks.
14
Q.
Okay.
And his arm was pressing down where, if you
15
can associate it with a part of his body with a part of the
16
room?
Do you need to go back?
17
A.
If I remember correctly, the floor.
18
Q.
Okay.
19
And I'm going to put up -- first, the lower
portion of 000170, what do you see in this picture?
20
A.
The pressure marks on the -- near the knee.
21
Q.
And I'm going to point out a portion of this picture
22
with the tip of my pen here.
Do you see where I'm indicating?
23
A.
Yes, that's --
24
Q.
What is that?
25
A.
That would be -- if you're pointing to exactly this
26
right here?
27
Q.
I am.
28
A.
Okay.
If I remember correctly, that's one of the

1137
1
2
3
injuries from his -- from his dog.

Q.
Well, I'm asking you what you saw at that time.
didn't see any dogs, did you?
A.
Right.
Q.
Okay.
A.
It's a well-healed injury.
Q.
Well-healed injury.
A.
Correct.
Q.
And one last picture.
10
11
You
It's an injury.
This picture, can you describe
what that shows us?

A.
After moving him onto the plastic, and as you saw him
12
as he was, I broke rigor and was able to get his legs down and
13
his arms down.
14
15
Q.
Okay.
Now, do you create a report based on your
investigation?
16
A.
Yes, sir.
17
Q.
And you actually -- do you do investigation beyond
18
what you showed us with regard to the decedent's body?
19
A.
Yes.
20
Q.
In this case, did you do any investigation beyond
21
Depending on the case, yes.
what is described in handling the deceased's body?
22
A.
Yes.
23
Q.
What did you do?
24
A.
Interviews with the staff.
I attempted to interview
25
the other guests of the detoxification house.
26
speaking to the wife to confirm social and medical history.
27
28
Q.
Okay.
And then
Do you remember any of the staff you
interviewed?

1138
A.
Yes.
Q.
Can you give me any names?
A.
Mr. McCausland, if I'm pronouncing that correctly.
Q.
And do you remember a first name for Mr. McCausland?
A.
Not offhand, I do not.
Q.
I'm going to show you what has been marked as
Exhibit 11.
It's a one-page photo.
look at it.
Do you recognize that person?
A.
That looks like Mr. McCausland.
10
Q.
All right.
11
A.
Yes, sir.
13
Q.
Okay.
15
Is that the individual
projected on the wall to your left?
12
14
Thank you.
You can turn it over and
Thank you.
And what did Mr. McCausland have
to tell you that you recall?

A.
The gentleman that passed away flew into San Diego
16
airport, was picked up by a staff member of the detoxification
17
house at the San Diego airport.
18
detoxification house, arriving approximately 1730 hours, which
19
is 5:30 in the afternoon.
20
intake process.
21
which they were going to dispense to him over time.
22
doctor.
They brought him back to the
At that time, they began their
They took all of his prescribed medications,
Hold on.
He saw a
23
Q.
Okay.
Let me stop you occasionally.
24
A.
Sure.
25
Q.
They took all of his prescribed medications.
Did
26
Kris McCausland tell you what those prescribed medications
27
were?
28
A.
Yes.
I'd have to look at my report to refresh my

1139
1
2
3
memory exactly to what all of them were.

Q.
Okay.
If it will refresh your memory, you may look
at your report.
Is that your report on the table facedown?
A.
Yes, sir.
Q.
Okay.
Turn it over, read it to yourself.
If it
refreshes your recollection, if you'd indicate it to me.
A.
Sure.
Q.
Okay.
A.
Okay.
10
Q.
So do you remember the meds they took into their
11
possession?
12
A.
Theophylline, Chantix, hydrocodone, Digoxin,
13
Levaquin.
I'm missing a couple.
14
could look again?
If you don't mind, if I
15
Q.
Would it refresh your recollection?
16
A.
Yes, sir, it would.
17
Q.
You may.
18
You've turned your report upside down.
What do you remember now?
19
A.
Cardizem and prednisone.
20
Q.
Now, when you looked in his room in his luggage, did
21
I think I covered them all.
you find any -- are you fam- -- well, let me go back.
22
Do you know what an inhaler is?
23
A.
Yes.
24
Q.
Describe it for me.
25
A.
Inhalers generally have different drugs or they do
26
have different drugs and it's just a little canister that's
27
placed inside a little plastic inhaler.
28
on it, it sends out a puff of the medication and the
When you press down

1140
1
2
3
4
individual just breathes the medication in.

Q.
All right.
You held your hand out with your
forefinger and thumb in the shape of a C.

A.
Just about the size.
What did that mean?
They're pretty small.
I mean,
they're not very large at all.
They're generally kind of in a
very small L-shape with the -- with the delivery down right
down here.
plastic delivery system.
and it sends a little puff of the medication out and you
So the canister is just placed inside in the

And again, you just press down on it
10
inhale it.
11
Q.
Through your nose or your mouth?
12
A.
Through your mouth.
13
Q.
Did you see any inhalers when you did an inventory of
14
the personal possessions in Gary Benefield's room?
15
A.
No.
16
Q.
Okay.
I don't remember any inhalers in there.

And did you actually see the drugs or the
17
prescription medications that had been taken by Kris
18
McCausland from Gary Benefield?
19
20
21
A.
No.
If I remember correctly, they had them locked
and they couldn't get the key for it.

Q.
And did -- you didn't mention these, but do you
22
recall whether or not Kris McCausland told you they had taken
23
prescribed medications including a Spiriva HandiHaler?
24
A.
Yes.
25
Q.
You do recall that now?
26
A.
Yes.
27
28
That was -- I'm sorry, I thought I mentioned
that one when I went through all of those.

Q.
Okay.
Do you know what a Spiriva HandiHaler is?

1141
A.
The -- he had a couple or different medications,
heart medications and medications for -- he had chronic -- he
had chronic obstructive pulmonary disease.
Q.
How do you know that?
A.
That was given to us by the -- or given to me by the
staff as part of his medical history.
confirmed that with his wife.
disease is something that is basically a lung issue.
have somebody that smokes a lot, they have trouble
10
Additionally, I
Chronic obstructive pulmonary
breathing --
11
Q.
Okay.
12
A.
-- and you'll see -- I'm sorry.
13
Q.
Let me stop you.
14
There's no question about chronic
obstructive pulmonary disease.
15
16
When you
My question is, I think I asked you if you know what

a Spiriva HandiHaler is.
17
A.
Yes.
18
Q.
Okay.
19
A.
It's for his chronic -- his -- for his COPD, for his
Go ahead.
20
chronic obstructive pulmonary disease.
21
medications that would help him breathe easier.
22
Q.
Okay.
Thank you.
It's a -- one of the
Now, did Mr. McCausland tell you
23
about any tests he did on Gary Benefield when Gary Benefield
24
arrived at the house on Iron Gate?
25
26
27
28
A.
Yes.
They did a breathalyzer and they did a drug
test.
Q.
And what did the breathalyzer show?
What did
McCausland tell you it showed?

1142
1
2
A.
It was .059, if I remember correctly, for the
breathalyzer.
Q.
And what does that measure to you?
A.
That's a fairly --
Q.
What it measures, not what the --
A.
Oh, I'm sorry.
Q.
-- not what the numbers are.
A.
Okay.
Q.
What does it measure?
10
A.
Alcohol.
11
Q.
Alcohol and what, if anything?
12
A.
In the -- when you exhale, it measures the alcohol
13
molecules and gives you a number as to how much a person has
14
been drinking.
15
Q.
Okay.
16
A.
They did a drug test.
17
Q.
And did Mr. McCausland tell you if it was indicative
18
And did he say anything about any other tests?
of anything?
19
A.
It was positive for marijuana.
20
Q.
Okay.
Now, I think I interrupted you to talk about
21
the medications just when you said that Mr. McCausland told
22
you something about Mr. Benefield and the doctor.
23
24
A.
Yes.
As part of their intake process, he said that
Mr. Benefield had seen a doctor upon intake, which was --
25
Q.
Go ahead.
26
A.
-- Dr. Noreen Bumby.
27
Q.
Now, had you ever heard of Dr. Noreen Bumby up until
28
that time?

1143
A.
No.
Q.
So would you have any reason to know that name other
3
4
than Mr. McCausland telling it to you?

A.
No.
And I asked him several times about it, because
I wanted to make sure.
mean, I didn't think it was too unusual.
know, this doc saw him so quickly upon arrival, and I would
have thought that the doctor would have seen him the next day
or something like that.
10
11
Q.
All right.
Because when they had the doctor -- I

But I thought, you
Did he say if he, Mr. McCausland, did
anything with regard to the deceased and medication?
12
A.
Yeah.
13
Q.
And did he say what they were?
14
A.
I would have to refresh my memory from my report, but
15
16
He dispensed out two medications to him.
they were part of the detoxification process.

Q.
So you believe that the names of the medications are
17
in your report but you can't remember them specifically or
18
you'd have to refer to your report to --
19
20
21
22
A.
I would have to refer to my report to remember them
specifically.
Q.
Okay.
I'm just asking if you know that they are
listed in there.
23
A.
Yes, they are.
24
Q.
Okay.
25
They are listed in there.
Would you look at your report and let me know
if it refreshes your recollection.
26
A.
27
Serax.
28
Q.
Those two medications were trazodone and Serax or
Do you know how to spell that now that you've looked

1144
at it?
A.
3
4
It's S-e-r-a-x.
And to be honest with you, it's not
a medication I'm familiar with.

Q.
Okay.
Did Mr. McCausland tell you about any
interactions he had with Gary Benefield after he -- I think
you said he did intake, he gave him some detox medications.
Any interactions after that?
8
9
A.
The only interaction that he told me about after that
was that he saw Mr. Benefield leave his bedroom to go to the
10
bathroom.
11
from the bathroom, Mr. McCausland said that he, Mr. Benefield,
12
did not have a shirt on, and because of their policies, he
13
told him that he needed to put a shirt when he was leaving his
14
room.
15
0030 hours, which is 12 -- 30 minutes after midnight.
16
Q.
Mr. Benefield went to the bathroom.
Upon returning
And that was approximately -- he said it was about
Did he say -- did Kris -- did Mr. McCausland tell you
17
anything about going into Gary Benefield's room with another
18
worker named Andrea Powell and finding Gary Benefield seated
19
on the floor next to his bed?
20
A.
I don't remember him saying that he went in with
21
Andrea Powell, but he did give a wake-up call, I believe it
22
was about 0800 to zero --
23
24
Q.
Okay.
Nope.
I'm just asking about whether he said
anything to you about going in with Andrea Powell.
25
A.
No, not that I remember.
26
Q.
Would that be something you would have noted in your
27
28
report?
A.
Yes.

1145
1
2
3
Q.
Would it have been an important piece of information
for you as an investigator?

A.
Oh, yeah, because it would have been between the last
time that he was seen alive and the time that he -- I was told
that he was found dead.
there, then that narrows -- that's very significant for me
because it narrows the time of death now.
8
9
10
11
Q.
If there was something in between
What about if it was before the last time he was
seen, would it still -- but after he was given the

medications, would it still be significant?
A.
If it was -- if it was after he was given the
12
medications and before Mr. McCausland told him to put a shirt
13
on, it wouldn't have been very significant to me.
14
something that I would have wanted to know and would have
15
noted in my report, and depending on what their reason was for
16
going into the bedroom together.
17
18
Q.
Well, if they found him on the floor and needing
assistance to be placed back --
19
A.
That's very significant to me.
20
Q.
Okay.
21
A.
I'm sorry.
22
Q.
Okay.
23
It would be
And so let me finish --
I think you answered it anyway.
So it's very
significant to you why?
24
A.
Well, the gentleman would have been in distress at
25
that time.
26
help him?
27
mean, what did you -- what did you do to help him and why
28
didn't you?
And my questions would have been, why didn't you

What time was that?
What occurred after that?

1146
Q.
Okay.
Now, did Mr. McCausland tell you the next time
he saw Gary Benefield after he saw him with no shirt on and
told you it was 12:30, in other words, 30 minutes past
midnight?
A.
Approximately 8:00 in the morning is when he said
that he was making rounds to do wake-up calls, as they often
do in these homes.
knock on the door and make sure they get up.
9
10
11
12
Q.
And they go to each individual's door and
And what did he say he noticed when he went to the
door?
A.
There was no answer at the door, so he went in and he
found Mr. Benefield on the floor.
13
Q.
I'm sorry.
14
A.
I'd have to refresh my memory to the exact time.
15
16
17
18
19
Did you say what time he said that was?
was 0800 -- I'm sorry, 8:00 in the morning.

Q.
So that's from your memory.
I apologize.
You didn't look at
your -A.
That's from my memory.
I can look at my report and
give you the exact time he told me.
20
Q.
Did you check to see what time 911 was called?
21
A.
I believe I did.
22
Q.
Well, I guess I'm getting ahead of myself.
23
It
Do you
know whether or not 911 was called?
24
A.
Yes.
25
Q.
How do you know that?
26
A.
Well, because law enforcement was there and they
27
reported the death to me and they came out and pronounced the
28
gentleman prior to my arrival.

1147
Q.
What does pronounce the gentleman mean?
A.
That means that when either law enforcement comes out
or, let's say, paramedics or the fire department and they
either monitor the person through an EKG or there's obvious
signs of death, what they'll do is they pronounce the death.
That means that that's the time that they're actually
pronounced.
died.
9
10
Q.
It doesn't mean that that's the time that they
Okay.
So would it refresh your recollection as to
the time Mr. McCausland told you that the police were called?
11
A.
Yes.
12
Q.
What time did Kris -- I'm sorry, Mr. McCausland --
13
14
15
16
17
18
19
20
21
tell you that he had gone to the door of Gary Benefield?

A.
Approximately 800 -- 0800 hours.
Again, about

Q.
Now, did you speak with any person who identified
himself as having pronounced him?

A.
I don't remember if I spoke to the individual that
actually pronounced or not.

Q.
Okay.
Are you familiar with the terms within the
context of your work of foam, froth, blood, and purge?
22
A.
Uh-huh.
23
Q.
What do those terms mean?
24
A.
It's a -- every single case that we do, whether it's
25
a case that's being reported to us over the phone and we may
26
not respond out to it or if we respond out, it's a common
27
question that we always ask, foam, froth, blood, and purge.
28
Foam is something that we may see in an overdose case

1148
and will set off alarm bells that the officers that are -- or
deputy that's reporting to us says that they see what we call
a foam cone.
4
5
Froth is probably -- it's just a different way of

asking the same question.
6
7
Blood, it -- you know, we're looking for any possible

trauma or anything like that.
8
9
12
13
Do you see any blood?
Purge, any vomit or anything like that, significant

amounts.
10
11
It's repeated in there twice.
Each one of these, for different reasons, kind of set

off alarm bells for us.
Q.
So do you -- in a typical death investigation, do you
look for signs of foam, froth, blood, or purge?
14
A.
Every single one.
15
Q.
And in this particular one, do you recall what you
16
saw in regards to foam, froth, blood, and purge?
17
A.
I don't remember seeing anything.
18
Q.
I'm sorry, could you --
19
A.
I don't remember seeing anything, any foam, froth,
20
21
blood or purge.
Q.
All right.
And did you interview anyone else at the
22
residence who was associated with the services that were
23
provided there?
24
A.
Mr. Ortega, which was the --
25
Q.
Hold on.
26
A.
I would need to refresh my memory.
27
Q.
Okay.
28
A.
Is that okay?
Hold on.
Are you sure it was Ortega?

1149
Q.
You may.
A.
No, I do not.
Q.
Okay.
A.
I don't remember his exact name.
Q.
All right.
6
7
In other words, you don't remember?
Mr. Ochoa.
What do you remember, if anything, about
your interaction with Mr. Ochoa?

A.
Specifically, my interaction was a little difficult
with him because he didn't want to give me the intake
paperwork and his medical records, which they had, which
10
included the dispensing of the medications.
11
Q.
Okay.
His medical records, who's "his"?
12
A.
The decedent, Mr. Benefield.
13
Q.
Okay.
So he didn't want to give you the intake
14
records and the medication records; is that what you're
15
saying?
16
A.
Correct.
17
Q.
Did you eventually get them or did you not get them?
18
A.
I eventually got them.
Actually, he -- I had to
19
explain to him that as the coroner's office, we're exempt from
20
all of that, from HIPAA, that he had to give them to me, he
21
was going to give them to me.
22
make my copies.
23
already given the officer that was on scene, the Murrieta PD,
24
copies of these documents.
25
was kind enough to make copies for me at their station and I
26
got those from him.
27
28
Q.
Okay.
He went back to his office to
He was taking so long.
He had apparently
And the officer from Murrieta PD
And did you speak to anyone else associated
with the facility itself?

1150
A.
Ms. Powell.
Q.
And did you do a formal interview with her?
A.
Yes.
The interview process was not broken up into
individuals.
the kitchen, was gathering of information from the
individuals.
Mr. McCausland.
8
9
Q.
The interview process that was conducted was in
And my primary interaction was with
Okay.
Was Ms. Powell standing there when you spoke
to Mr. McCausland?
10
A.
Yes.
11
Q.
Did she make any additions or corrections or go
12
beyond Mr. McCausland's statement?
13
A.
Not that I remember.
14
Q.
Did you make any calls to anyone associated with the
15
16
No, none at all.
facility?
A.
Yes.
I spoke to a gentleman from their corporate
17
offices and he had told me that he had called Ms. Benefield
18
and notified her of the death, which I was upset about because
19
that's something that we do as the coroner's office, our
20
responsibility.
21
give her the news and be able to get all the information that
22
I needed.
23
24
25
Q.
But I -- you know, I wanted to be able to
Now, is that just territoriality?
Is that important?
Why did it upset you?

A.
Well, it's not territoriality and it's not something
26
that is broken down in the law that says that we have to do it
27
or anything like that.
28
difficult for us because what happens is is that maybe the
It can often make the process more

1151
individual is notified and then they quit taking phone calls.
They will -- they will -- a lot of times they'll go to
family's house, a friend's house.
sometimes for days.
to gather the necessary information that we need, which is,
for our medical investigation, medical history, social
history, and, of course, also the story of what was going on
with this gentleman.
9
10
Q.
All right.
We can't reach them and
And it's very important for us to be able
So it can make it difficult to do that.

Now, do you know if any samples were
taken from the body for analysis?
11
A.
Yes.
12
Q.
What do you know about that?
13
A.
Every single body that comes in to the coroner's
14
office is processed in the same way.
And part of that process
15
that's done by our forensic techs is that they take a blood
16
sample upon intake and that blood sample is labeled and then
17
stored with the body on the table.
18
the body goes in for autopsy or an external examination, the
19
doctors will notate that the blood sample is on the table.
And then after the -- when
20
They'll take a look at the label, verify that it is
21
the correct label, the correct person, and then they will --
22
the coroner technicians will take it from the table, after
23
everything is done, and all the other -- all the other samples
24
that are gathered also, because the doctor will gather blood,
25
bile, urine, other samples from the body.
26
refrigerator and, of course, every one of those being labeled
27
with the gentleman's name.
28
Those go into a
And then after that, they are eventually sent to

1152
Bio-Tox, which is our contract company, which is a laboratory
that we use to process all of our samples.
come out and they will pick up everything and then those
samples are logged by our coroner technicians and then placed
in a lockbox for Bio-Tox.
their laboratory for processing.
Q.
thoroughly?
A.
10
Okay.
Once a week they
And then Bio-Tox will take it to
And how do you know this process so
I was a coroner technician prior to being a deputy
and so I'm very familiar with the process.
11
Q.
And when were you last a coroner technician?
12
A.
Back in 2003 to 2005.
13
Q.
And, to your knowledge, your personal knowledge, had
14
that process that you just described for us, the handling of
15
the samples, changed at all by 2010?
16
17
A.
I'm a sergeant now with the coroner's office and
most definitely not.
18
19
No.
MR. SAMUELS:
That's part of our policy and procedure.

Okay.
So at this time, I'll ask if any
members of the grand jury have any questions for this witness?
20
A question from Grand Juror No. 17.
I'm afraid that
21
this question, while it may be appropriate later in the
22
testimony of other witnesses, it is beyond the scope of this
23
witness' expertise, so I'm not going to ask him.
24
Q.
BY MR. SAMUELS:
This is a question from Grand Juror
25
No. 15.
And the question is, in your opinion, based on your
26
training and experience, was there anything significant
27
regarding the position -- the position you found the decedent
28
in?

1153
A.
Significant in that what his position suggested is
that the gentleman was very likely on the edge of the bed and
had collapsed down to the floor forward, slumping forward.
was a -- significant in that there was a very prominent
presentation of lividity and then eventually -- and also rigor
mortis.
7
8
Q.
It
They were extremely prominent.

All right.
And do you know who moved the comforter
that was pictured in some of the photos?
A.
No, I do not.
10
Q.
Would you have moved it?
11
A.
Definitely not.
12
Q.
Well, do you move objects that are around a deceased
13
14
in order to take pictures of the deceased's body?

A.
Not when I -- what -- what you saw as a progression
15
is literally when I walk in that room.
My first photo, that's
16
when I'm first stepping in the room to do my overall photos.
17
That's when I start and I shoot my photos from there.
18
Q.
Okay.
19
A.
So prior to -- prior to -- and that is a very big no
20
no with us, that we get very upset with law enforcement or
21
even individuals, hospice nurses, anyone tampering with the
22
scene, moving anything or moving the body.
23
have done any -- anything to change the scene, move the body,
24
move anything in there without doing my overalls first.
25
then eventually when I did do my overalls, then, yes, I would
26
have definitely started moving things around to start my
27
investigation.
28
Q.
Okay.
And I would not
And
So going through those photos, were they

1154
progressive as you did your investigation?
A.
Yes.
Q.
So as you did your investigation, would someone, with
your permission, have moved the comforter?
A.
With my permission?
Q.
Yes.
A.
As I move through, yes.
If I had a reason for them
to move it from my transport or something along those lines,
yeah.
I don't -- I don't remember removing the comforter.
10
Oh, you're talking about the comforter as to from when I first
11
came in and to -- to later, or are you speaking of prior from
12
my first photos prior to that comforter being moved?
13
Q.
Well, let me clarify.
14
A.
Because I may be answering the question wrong.
15
Q.
Well, let me clarify the question.
16
You're not
answering it wrong, I'm asking it wrong.
17
If you recall -- and I can show you again if it helps
18
you recall -- when you entered the room, there was a bed and
19
the decedent's body.
20
the bed and I heard you say it was.
21
in those early photos that we see.
I asked you if his bottom was up against

And there was a comforter
22
A.
Okay.
23
Q.
And then in the later photos, the comforter was not
24
in the photos.
25
whether that comforter was moved by -- with your knowledge and
26
at your direction.
27
28
A.
Okay.
So I believe the thrust of the question was
So that's two questions.
So I answered the question incorrectly.
thought you were referring prior to my arrival and taking my

1155
overall photos.
I started shooting the photos and the comforter would have
been moved by myself.
the gentleman's position.
the way, that way I could do a better exam of him.
6
7
Q.
Okay.
Most definitely when I walked in the room and
That way I could get a clearer shot of

And also to move everything out of
And did you see any fresh injuries on the body
of the deceased?
A.
No.
Q.
Do you remember what the room temperature was when
10
you entered?
11
12
A.
Cool.
It was air conditioned, but I could not tell
you what the exact temperature was.
13
Q.
Can you tell me what you mean by cool?
14
A.
Comfortable.
Somewhere within the range of easily
15
within 70, 78 degrees, somewhere in there, what you would set
16
a normal home at.
17
Q.
So 70 to 78?
18
A.
Yeah, somewhere in there.
19
Q.
And I -- there's another question, but I believe it
20
is another way of asking the question that I asked you about
21
position so I'm going to leave it at that.
22
MR. SAMUELS:
23
24
MR. SAMUELS:
25
Q.
Are there any further questions?
Thank you.
BY MR. SAMUELS:
26
3.
27
enforcement personnel?
28
Yes, Counsel.
It's a question from Grand Juror No.
Do you ever delegate the taking of photos to other law
A.
Most definitely not.

1156
Q.
So do you believe you took these particular photos?
A.
Definitely.
MR. SAMUELS:
All right.
Grand Juror No. 7 has a
question that is going to be covered in subsequent testimony
and so it's outside the scope of this witness' personal
knowledge.
I'm going to defer that question until later.
Juror No. 2 has a question.
It's also dependent upon
the testimony of a later witness and not subject to this
witness' personal knowledge.
10
So I'm going to ask Grand Juror No. 2 and the
11
previous question of Grand Juror No. 7 to bear their questions
12
in mind.
13
again at a later time.
If they are not satisfied, to raise them with me
14
Are there any further questions?
15
16
MR. SAMUELS:
17
All right.
No more, Counsel.
May this witness be
excused?
18
Yes.
19
Before you leave, I have an admonition to read to
20
you.
21
of this jury room, the questions that have been asked of you
22
in regard to this matter or your answers until authorized by
23
this grand jury or the Court, or until such time as these
24
grand jury proceedings become a matter of public record.
25
will understand that a violation of these instructions on your
26
part may be the basis for a charge against you of contempt of
27
court.
28
You are admonished not to discuss, at any time outside
You
This admonition, of course, does not preclude you

1157
from discussing your legal rights with any legally employed
attorney representing you, should you feel that your personal
rights are in any way in jeopardy.
Do you understand, sir?
THE WITNESS:
THE WITNESS:
Yes, sir, I do.
The grand jury will take a
ten-minute break, so we should be back by 9:15.

(Brief recess.)
11
The grand jury will now come
to order.
13
MR. SAMUELS:
14
15
I'll get the next witness.

Yes, Counsel.
16
17
You are excused.
Thank you.
10
12
Thank you.
raise your right hand, please.
18
19
give in this investigation now pending before this grand jury
20
21
22
THE WITNESS:
23
24
25
I would like you to read, then sign and print your name at the
26
bottom.
27
28
I do.
Please be seated.
Please state and spell your

1158
full name for the record.
THE WITNESS:
Anne Patton, A-n-n-e, P-a-t-t-o-n.
Thank you.
ANNE PATTON,
follows:
8
9
DIRECT EXAMINATION
BY MR. SAMUELS:
10
Q.
Good morning, Ms. Patton.
11
A.
Good morning.
12
Q.
Could you please make sure that when you answer
13
questions, you speak right up so everyone all the way in the
14
back of the room can hear you.
15
A.
Okay.
16
Q.
All right.
17
Do you remember in July of 2010 seeking
any treatment in Murrieta, California?
18
A.
Yes.
19
Q.
What was that treatment for?
20
A.
For alcohol.
21
Q.
And do you remember where you were treated in
22
Murrieta, California?
23
A.
I think it was called Stone Gate.
24
Q.
Do you remember what it was, what kind of building or
25
hospital or --
26
A.
It was called A Better Tomorrow.
27
Q.
All right.
28
Now, there's a young lady here taking
down all of the things we ask and your responses, but we can't

1159
talk at the same time.
question before you begin to answer.
All right?
Have you ever been a witness before?
A.
No.
Q.
Okay.
So please wait for me to finish a
And are you sure that the facility you were in
was called Stone Gate?
A.
Yes, the place I was placed at.
Q.
All right.
Iron Gate?
Have you ever heard of a place called
10
A.
Maybe that was it.
11
Q.
Is your answer then you don't remember the exact
12
name?
13
A.
Not exactly.
14
Q.
Okay.
15
Tomorrow; is that what you said?
16
A.
Yes.
17
Q.
Okay.
18
But you're sure that the company was A Better
Now, do you remember what part of the month of
July 2010 you were in a facility run by A Better Tomorrow?
19
A.
No.
20
Q.
Do you remember the day separately?
21
A.
All I know was I was sent there for five days by my
Q.
Okay.
22
23
24
son.
Do you remember whether or not you saw a
doctor on the very first day?
25
A.
A counselor.
26
Q.
All right.
27
A.
The next day.
28
Q.
Okay.
Wait.
Is a counselor a doctor, an M.D. to you?
My question was, was that counselor a

1160
doctor to you?
A.
No.
Q.
All right.
in words.
You shook your head.
You have to answer
And you said no; is that right?
A.
No.
Q.
And then you said the next day.
A.
Yes.
Q.
So the first day you saw a counselor who was not an
Correct.
M.D., and the next day you saw a doctor --
10
A.
Correct.
11
Q.
Let me finish.
12
A.
Oh.
13
Q.
Okay.
Now, do you remember on that first day whether
14
you were given any medications that you had not brought to the
15
facility?
16
A.
Yes.
17
Q.
What do you remember in that regard?
18
A.
They had given me a -- something to help me sleep and
19
something for my anxiety.
I don't know what it was called.
20
Q.
Were those different things?
21
A.
Yeah, two different medications.
22
Q.
All right.
23
there.
24
house where you were treated named Gary Benefield?
Now, you say you had a five-day stay
Do you remember a patient who was also there at the
25
A.
Yes.
26
Q.
And do you remember when you met Gary Benefield?
27
A.
I don't remember if it was the second day or the
28
third day I was there, but he arrived in the evening.

1161
Q.
Do you remember what time he arrived?
A.
I think -- I believe it was around 7:30, 8:00 because
3
4
5
6
7
8
9
it was still daylight out.

Q.
Now, when you say "arrived," would you necessarily
see someone the first moment they came in the door?

A.
Yeah.
We were sitting in the living room and he came
in the front door.

Q.
Okay.
And did you have any interaction with him the
night he arrived, the evening he arrived?
10
A.
Yes.
11
Q.
What kind of interaction?
12
A.
He sat on the couch and I asked him where he was
13
from.
And he had mentioned that the altitude was different
14
here.
And I asked him why, and he said he was from Arizona.
15
Q.
What else did he say about the altitude there?
16
A.
The altitude?
17
Q.
Yeah.
18
A.
He just said he just couldn't breathe, the altitude
19
was different here.
And I said, "Well, where are you from?"
20
He said, "Arizona."
And I said, "Well, that's not much
21
different."
22
Q.
Let me break it down.
23
A.
That's what he said.
24
Q.
Okay.
25
That's what he said.
So did he introduce himself?
26
A.
Yes, when he sat on the couch.
27
Q.
All right.
28
couch?
Was he doing anything while he sat on the

1162
A.
No.
Q.
Was there a TV on?
A.
We -- me and somebody else -- yeah, the TV was on.
Q.
Okay.
Now, I want you to listen carefully to the
question and answer it as best you can from your memory.
did he say about altitude?
A.
He was sitting there -- he had just came in, he sat
down by another girl and I that were -- we were playing
Monopoly.
And he was having a hard time breathing.
10
"Are you okay?"
11
here."
12
"Arizona."
13
Q.
Okay.
14
A.
Okay.
15
Q.
Okay.
16
What
I said,
And he said, "Well, the altitude is different
I said, "Why?
Where are you from?"
He said,
I said, "Well, it's not that much different."

Let me stop you right there.
During your answer, you said he was having a
hard time breathing.
Why do you say that?
17
A.
Because he was (untranslatable sound), like wheezing.
18
Q.
And how deeply was he breathing?
19
A.
Just like he couldn't catch his breath.
20
Q.
I'm sorry, I'm writing some notes as we go so that's
21
why -- I'm not ignoring you.
I'm just writing myself a note.
22
A.
Okay.
23
Q.
And what else did you notice about his breathing, if
24
25
26
anything?
A.
Just that his face was red and that he didn't know
why he was there.
27
Q.
Did he say that?
28
A.
Yes.

1163
Q.
Did you ask him what he meant by that?
A.
I said -- no, I didn't ask him what he meant by that.
Q.
All right.
Now, going back to the altitude.
If I
understand your testimony, was he talking about the
altitude -- well, let me ask you because I'm unclear.
talking about the altitude there at the house where you were
sitting on the couch?
Was he
A.
Yes.
Q.
In Murrieta, California?
10
A.
Yes, correct.
11
Q.
And do you have any personal knowledge of where he
12
lives in Arizona?
13
A.
No, I don't.
14
Q.
So when you say the altitude is similar between
15
16
Murrieta and Arizona.

A.
No.
Do you know that for sure?
I was just -- that was just being demographic.
17
When he had said that to me, he goes, "Well, the altitude is
18
different here."
I'm going, "Well, Arizona is not that far."
19
Q.
Okay.
20
A.
Yeah.
21
Q.
Did you notice if he was hooked up to any tubes?
22
A.
No.
23
Q.
Have you ever seen people using supplemental oxygen?
24
Just conversation?
He had nothing, no tubes.
You never have?
25
A.
Never.
26
Q.
You're shaking your head.
27
A.
No.
28
Q.
Okay.
Did you see any tubes around his face?

1164
A.
No.
Q.
Anything covering his mouth?
A.
No.
Q.
Now, you said that the first day you were there,
someone gave you two medications, one to help you sleep and
one for your anxiety.
A.
Correct.
Q.
Do you remember who gave you those?
A.
A black lady.
10
11
12
That's all I know.
I can't remember
her name.
Q.
Uh-huh.
And was there anybody else there at the --
who was running the house while you were there?
13
A.
A gentleman named Kris.
14
Q.
Did he ever give you any medications that weren't
15
prescribed to you?
16
A.
Just those two.
17
Q.
Well, who -- okay.
I'm sorry, maybe I was unclear.
18
You said the people who were there were a black lady and a
19
gentleman named Kris.
20
before you had seen a doctor, someone gave you medications; is
21
that what you testified to?
On the night you were first there,
22
A.
Yes.
23
Q.
Which of -- was it one of these two people?
24
A.
Yes.
25
Q.
Okay.
26
A.
Yes.
27
Q.
Okay.
28
It was the lady.

African-American?
Do you remember how many clients were at the
house when you were there during those five days, "clients"

1165
being people like yourself there for treatment?
A.
I believe there were five.
Q.
And on the morning of the 26th of July, do you
remember anything -- from 2010, anything occurring on the 26th
of July, which would have been a Monday?
6
7
8
9
A.
I don't even know how many days I was in there, so I
don't know the days I was there.

Q.
Okay.
You said five.
Can you reconcile that with
what you just told me?
10
A.
11
he arrived.
12
Q.
Okay.
13
A.
I'm sure it was either the third or the fourth night.
14
Q.
And what do you remember about the evening he arrived
15
16
Well, the fourth day I remember.
That was the night
Are you sure about that?
through the next morning?

A.
The evening when he arrived, when he came in, like I
17
said, he came in and he said the altitude was different here
18
and that he couldn't breathe.
19
arms and I asked him why he had sores on his arms and he said
20
because he had some kind of a dog rescue that he runs in
21
Arizona.
22
wanted to play Monopoly with me and Erin, the other girl that
23
was there.
24
cigarette out in the back.
25
26
27
28
Q.
And then he had sores on his
And I went, "Oh, okay."
He said, "No."
And then I asked him if he
We went out and we smoked a
Now, when you went out with Gary Benefield to smoke a
cigarette, did his breathing change?

A.
No.
He just said he was have a hard time breathing
and he didn't even want to smoke the cigarette because he

1166
couldn't breathe.
Q.
But he did?
A.
But he finished it anyway.
Q.
Okay.
A.
Excuse me?
Q.
Where did you go to smoke a cigarette?
A.
Right out in the back of the backyard.
Q.
Okay.
A.
They put -- we came back in and sat down and they had
And that was where again?
And did you go to bed that night?
10
changed rooms around so he could have his own room that would
11
be across from Kris, the night manager, or the night guy.
12
Q.
All right.
13
A.
So they put him in there.
They -- before that, when
14
we were sitting on the couch, he had all these medications,
15
like three or four different kinds of bottles of medication,
16
and they noticed -- they said, "Well, we don't know how much
17
you're supposed to take."
18
Q.
Who is "they"?
19
A.
The -- Kris, the night manager that stayed there, and
20
the black lady.
21
Q.
Uh-huh.
22
A.
They said, "Well, we don't know what your dose is.
23
You haven't told us, so we don't know what to give you.
24
we're just going to go ahead and give you what we think you
25
should have tonight and monitor you in the room by yourself."
26
Q.
Do you remember that specifically?
27
A.
Yeah.
28
So
I was sitting there right next to him when
they said that.

1167
Q.
What bottles were --
A.
I --
Q.
Well, are you familiar with the bottles that
prescription drugs come in?
and filled a prescription?
Have you ever gone to a pharmacy
A.
(Inaudible response.)
Q.
Never?
A.
No.
Q.
Never.
10
Okay.
Well, has a doctor ever given you
drugs to take?
11
A.
Excuse me?
12
Q.
Has a doctor, a licensed doctor, ever given you drugs
13
to take?
14
A.
Ibuprofen.
15
Q.
Okay.
16
A.
17
Q.
All right.
18
19
Nothing else?
These bottles that you saw on the table,
can you describe them?

A.
They were in the -- Kris' hand.

They each had a white cap on them.
There was three of
20
them.
One of them had a
21
little orange tab on the side.
22
shaking them.
23
amount in this one and I don't know how many you've taken out
24
of this one, so we're just going to just go when it's your
25
medication time," which I don't know what time that was
26
because we had to be in bed at 10:00, "And I'll give you your
27
medications and I'll put you in the room right across from me
28
so I can monitor you."
And then I remember him
And he goes, "Well, there's not the right

1168
Q.
And you heard this?
A.
Yes, I heard that.
Q.
Okay.
A.
Q.
This is the first time you've told --
A.
Yes.
Q.
-- what you saw and heard?
A.
Yes.
Q.
And you said they put you to bed at 10:00.
10
Have you ever told anyone about this before?
Is
that --
11
A.
Yes.
12
Q.
When you saw "our," what do you mean?
13
A.
All the girls that are in that group.
14
Q.
What about the boys?
15
A.
The boys had their side over there.
17
Q.
So their curfew was?
18
A.
10:00.
19
Q.
Okay.
20
A.
Yes.
21
Q.
Now, these bottles -- I want to go back to that for a
16
That's our curfew.
They had to go
too.
They closed it down.

You mean the whole house?
22
moment.
You said they had white caps.
And at one time you
23
said four and one time you said three.
Do you remember how
24
many there were?
25
A.
I know for sure there were three.
26
Q.
Okay.
And they were in Kris' hand; is that what you
Yeah.
Kris had them in his hand.
27
28
said?
A.

1169
1
2
Q.
Could you see whether there was any labeling on the
bottles?
A.
I don't know what kind of labels they were.
Q.
Well, my question wasn't what kind of labels.
there labels?
A.
They were white labels.
Q.
Okay.
Were
Could you see if there was printing on the
labels?
A.
No.
10
Q.
It's been five years, so are you sure about that,
11
that there was white labels on these bottles?
12
A.
Yes.
13
Q.
You said there was a wing for girls and a wing for
14
15
16
boys.
A.
What do you mean by that?

Well, it was just a regular house and it had one
bedroom over here that had four beds in it.
17
Q.
Okay.
And which direction?
18
A.
For the girls.
19
Q.
Okay.
And you're motioning with which hand to show
20
where the girls were.
21
hands.
22
A.
23
You were motioning.
You're making a motion with one of your
I'm just asking you -Left side over here was for girls.
They had four --
four beds in there.
24
Q.
Uh-huh.
25
A.
And then on the right side of the house there was
26
one, two -- there was four bedrooms on that side.
Two of them
27
belonged to the house managers and then the other two were for
28
the other guys that stayed in there.

1170
Q.
Benefield?
A.
bathroom.
And was -- which bedroom did you associate with Gary
Gary was right across from the manager and the

They put him in his own room by himself.
Q.
Did you see him go in there?
A.
Seen him go in there.
Q.
Okay.
A.
Yep.
Q.
So did you see that these rooms were oriented in a
10
11
Did you ever see Kris go into his room?
certain way to each other?

A.
Yes.
There was one bedroom here for the -- four beds
12
in there for the gentleman; there was a desk right here; there
13
was a bathroom right here; there was Kris' room.
14
right up against that wall was the black lady's room.
15
then here is where Gary was staying in this room, right
16
across.
And then
And
17
Q.
Right across from Gary's room?
18
A.
Yes.
19
Q.
You made a bunch of motions with your hand there
20
which can't be taken down by this young lady.
21
able to draw a little diagram of this if I gave you a blank
22
piece of paper and a writing utensil?
23
A.
Okay.
I can try.
24
Q.
Okay.
Well, let's try then.
25
Would you be
I'm giving you a single
sheet of yellow lined paper.
26
A.
Okay.
27
Q.
Are you an artist?
28
A.
No.

1171
Q.
Are you a draftsman?
A.
No.
Q.
So are you just going to try your best?
A.
I'm just going to --
Q.
Okay.
A.
Okay.
Q.
I'll give you an opportunity to do that.
Well, you draw.
8
9
Q.
BY MR. SAMUELS:
Are you finished?
10
have this marked as the next exhibit in line.
11
and I met before?
I am going to
Now, have you
12
A.
No, sir.
13
Q.
Didn't we meet in the lobby of this building earlier
14
today?
15
A.
Yes, sir.
16
Q.
And did you discuss the content of your testimony?
17
A.
Yes, sir.
18
Q.
In what way?
19
A.
Just to be honest and tell them -- tell the truth.
20
Q.
Right.
21
A.
No.
22
Q.
-- meaning what you said here today?
23
A.
No.
24
Q.
Do you remember being interviewed by the Department
Did we discuss the content --
25
of Justice agents about this series of events you've been
26
telling me about?
27
A.
Yes.
28
Q.
Do you remember when that was?

1172
1
2
A.
No.
Just when I had talked to another gentleman
regarding this case before I came here.
Q.
All right.
A.
Months back.
Q.
Months back you said?
A.
Well, yeah, almost a year ago.
Q.
Could it have been in August of 2013?
A.
Could be, yes.
Q.
All right.
Now, I'm just waiting for this projector
10
to warm up a little bit so we can look at what you've drawn
11
for us.
12
A.
Okay.
13
Q.
Okay.
14
A.
My fancy work.
15
Q.
Well, we'll see.
16
Now, on the desk there in the corner --
17
A.
Yes.
18
Q.
The desk you're sitting at, there's a thing that
19
looks like a TV clicker over here in front of you and there's
20
a red dot on it.
21
red dot, you'll see that it shoots out a laser.
22
See that red dot on the wall?
23
A.
Oh.
24
Q.
Okay.
25
If you point that at the wall and press the
So I'm going to ask you to describe what
you've drawn and show us what you're talking about.
26
What's that?
27
Okay.
28
There you go.
Thank you.
Now, is what's being projected on the wall to
your left the drawing you just made?
Ma'am, could you answer

1173
with a word or two?
A.
Yes, sir.
Q.
Okay.
Is this the drawing you just drew?
I want to orient it so that we can figure out
where the front door is.
where the front door is?
Can you tell me -- can you point out
A.
Way back over here.
Q.
Okay.
A.
No.
Q.
All right.
10
A.
The front door is way back here.
11
Q.
Okay.
12
So this isn't the entire house, is it?
What are we seeing here?
Tell me about what
you've drawn.
13
A.
Okay.
You walk in the front door right here.
14
Q.
Okay.
And so that's to the very --
15
A.
Yeah.
16
Q.
-- bottom of the photo where I've got the pen now.
17
A.
Right.
18
Q.
Okay.
19
A.
So you walk into a little area that's right here.
Go ahead.
20
That's where they have a desk and chairs where they do your
21
intake.
22
Q.
Uh-huh.
23
A.
And then, like I said, right there's a kitchen.
24
Girls' room is back over here.
25
Q.
How many beds in that girls' room?
26
A.
There was one, two, three, four bedrooms.
27
Q.
Four bedrooms or four beds?
28
A.
Excuse me?

1174
Q.
Four bedrooms or four beds?
A.
Four bedrooms.
Q.
Okay.
A.
And there were four beds in this room right here.
Q.
All right.
A.
And then the kitchen was right here.
Thank you.
Keep going, please.

We weren't
allowed to cook anything in the kitchen; they had to cook for
us.
hallway.
The living room is here where we watched TV, and the

You could see right here where this bedroom was and
10
then a little table like this sitting there, the bathroom,
11
Kris' room, and then that lady's room.
12
Q.
So where was the room Gary Benefield was in?
13
A.
Right here.
14
Q.
Okay.
15
A.
No.
16
Q.
Okay.
17
A.
But that's where his room was because it was right
18
Now, you haven't drawn anything there.
across from the bathroom.
19
Q.
So is that right across from Kris' room or --
20
A.
It would be -- it would have been -- actually, this
21
is how bad my drawing is.
22
Q.
That's okay.
It's your drawing.
23
A.
So, yeah, it's the hallway.
Kris' room would have
24
been right here because this lady -- the black lady's room was
25
right at the end of the hallway direct.
26
Q.
Straight back.
27
A.
Yeah.
28
Q.
So is this, what I'm drawing my pen on --

1175
A.
That's the hallway.
Q.
That says "hallway"?
A.
Yeah.
Q.
Okay.
So would it have been more correct for this
square that says "black lady," for that to be right at the end
of the hallway where my pen is now?
A.
Yeah.
Q.
And would Kris' room have been back toward where it
says "bathroom"?
10
A.
Yes.
11
Q.
Okay.
12
I'm asking.
I'm just trying to understand.
And so where it says "living room," were there
bedrooms on that side of the hallway?
13
A.
No.
There was a -- just a laundry room.
14
Q.
So where was Gary's bedroom?
I'm unclear on that.
15
Okay.
You're making a square with the laser pointer at the
16
bottom of the area, the bottom right corner of the area where
17
it says "living room."
18
A.
Right.
19
Q.
Okay.
20
If I give this back to you, can you draw in
Gary's bedroom?
21
A.
Yeah.
I can do it a little bit better.
22
Q.
Well, I want you to --
23
A.
Draw his room?
24
Q.
Yeah, because we've been talking about this, I'd like
Okay.
25
you to try to make modifications if that matches your memory
26
to this drawing, not to make a new drawing.
27
A.
Right.
28
Q.
Okay.

1176
A.
Okay.
Q.
Let me turn on the light for you.
3
4
5
Q.
BY MR. SAMUELS:
Have you ever been back in this
house since July of 2010?
A.
No.
It shut down.
Q.
Okay.
A.
Oh, no.
Q.
I'm just asking if you've been back.
10
A.
Okay.
11
Q.
Okay.
I'm not asking about that.
So you have the laser pointer.
You've made
12
some changes in the drawing that is marked as Exhibit 86.
13
you describe the changes you've made, point them out to the
14
members of the jury.
15
A.
Yeah.
Can
I moved Gary's room right across from Kris'
16
room, put the bathroom back down here a little way where it's
17
supposed to be --
18
Q.
Okay.
19
A.
-- because the bathroom, it was here, it's down here.
20
He was right across from Kris.
21
Q.
All right.
22
A.
And then that lady is still right there.
23
Q.
Okay.
24
page?
And --
And what's that on the far left side of the
You seem to have made an addition.
25
A.
That was the front door that I put in to make sure.
26
Q.
Okay.
27
A.
And that was the first bedroom where there was four
28
beds in there.

1177
Q.
Was that on the men's or the women's side?
A.
Men's.
Q.
Okay.
4
5
6
7
And where was that little desk where they did
intake?
A.
That was in between the bathroom and Kris' room.
It
was just like a little desk with cabinets.

Q.
I thought you said there was a -- if I may, next to
the front door, didn't you describe an open area where there
was a desk where intake was?
10
A.
Yeah.
That's way over here.
11
Q.
Okay.
Now, let me ask you to clarify, was intake
12
down in this area where there's a rectangular area near where
13
it says "front door," or in this area next to the bathroom?
14
Which one of these, because I think you've said it was done in
15
both.
Was it done in one or the other or both?
16
A.
Both.
17
Q.
Okay.
18
place?
19
A.
So did you -- where did your intake take
Right here at the front door, then I had to go over
20
here to the bathroom where they give me a little urine test so
21
I could do a urinalysis.
22
23
24
25
Q.
All right.
if anywhere?
A.
Where did you sit down and do paperwork,
Describe where that is, please.
There was just a desk with six -- I mean, a table
with six chairs and that black lady with her paperwork.
26
Q.
Right.
27
A.
And that was all.
28
Q.
Where is that in relation to the front door?
I want

1178
you to describe it in relation to what you've drawn for us
here so there's a record.
can't take down where the laser pointer is.
tell us in words where you did your paperwork.
A.
This lady takes down words but she

So I want you to
I did my paperwork right as I entered the front door
and sat down at the desk -- at the table and chairs that she
had sitting there.
8
9
Q.
Okay.
Thank you.
Now, after 10:00, the curfew for
everybody in the house, did you see Gary Benefield again that
10
night?
11
A.
No.
12
Q.
What's the next thing that you found out or saw --
13
what's the next thing you saw happen at that house in
14
Murrieta?
15
A.
We were woken up at 6:30 in the morning by the house
16
manager and we looked out -- we came out all to the living
17
room and there was a fire truck, ambulance there.
18
asked what happened, and they said that Gary had passed away
19
and that we had to all go get in a bus and go to the office
20
and stay there and get Starbucks while they handled this --
21
his death.
22
Q.
23
Okay.
And we all
How do you know it was 6:00 in the morning
when you were awakened?
24
A.
Because there's an alarm clock right there.
25
Q.
All right.
26
27
28
And when you went to -- did you go --
when you got up, what was the first thing you did?
A.
They told us to get dressed and get ready and lined
up because we were going to the office.

1179
Q.
So where did you go after you got dressed?
A.
We went and lined up by the front door for the bus to
3
4
5
get there to take us back to the office.

Q.
And did you see any emergency personnel there when
you were still at the house?
A.
Yes.
Q.
Do you remember what kinds of emergency personnel?
A.
There was a fire truck, there was an ambulance, and
they were in the house.
10
Q.
Did you see any law enforcement personnel?
11
A.
Yes.
12
Q.
Do you remember how many?
13
A.
No, not right offhand.
14
Q.
When I say "law enforcement personnel," what's that
15
mean to you?
16
A.
A police officer.
17
Q.
All right.
18
And how do you recognize a police officer
when they'd come to the house?
19
A.
He's got his uniform on.
20
Q.
Okay.
21
And did you ever go back to that house after
you left on the bus?
22
A.
We went back later on that afternoon.
23
Q.
How long did you stay when you went back later on
24
that afternoon?
25
A.
We were at the office for, I think, five hours.
26
Q.
Uh-huh.
27
28
Did anyone at the office ask you about your
interactions with Gary Benefield?

A.
No.

1180
Q.
What did you do at the office for those five hours?
A.
Sat outside in the little waiting area and they
gave -- got us Starbucks coffee.
Q.
Did you get any therapy or --
A.
No.
Q.
While you were still at the house, the treatment
We just --
house, did you ever see Gary Benefield's body?
A.
Yes.
Q.
How did that happen?
10
A.
The morning of the incident, they -- we all was
11
curious and wanted to know what was going on, right, and they
12
wouldn't tell us, so the managers let us go see him.
13
was in between a little nightstand and the bed stiff.
14
Q.
Okay.
15
A.
And it was his birthday.
16
Q.
Okay.
17
asked.
18
19
He was --
Please just stick with the question you're
Okay?
When you went to see him, did you enter the room he
was in?
20
A.
No.
21
Q.
So where did you see him from?
22
A.
Just peeked around the corner.
23
Q.
Of what?
24
A.
Of the hallway.
25
Q.
Okay.
26
And he
hallway.
So you peeked around the corner of the
Was he in his own room still?
27
A.
Yes.
28
Q.
So when you say the corner of the hallway, what do

1181
you mean?
2
3
A.
I just peeked like I was at a hallway and I would
just -- I just peeked in.
Q.
Through the doorway or --
A.
Yeah, through the doorway.
Q.
Okay.
A.
Because the door was open.
Q.
You said he was between the bed and a --
A.
-- nightstand.
10
Q.
All right.
Do you remember if he was oriented in any
11
way?
12
back, on his side, or on his face, like, you know, curled up?
13
What did you notice about him, if anything?
14
15
What I mean by that, was he sprawled out?
A.
He was on his side and it looked like he was pinned
in between the nightstand and the bed.
16
Q.
How long did you look at him in there?
17
A.
Just for a glance, a quick second.
18
Q.
Okay.
19
Was he on his
Now, because I'm not you, I don't know what
you mean by a quick second.
20
A.
Just a look and then --
21
Q.
So less than a count of 1,001?
22
A.
1,001.
23
Q.
Okay.
24
A.
No.
25
Q.
And you didn't enter the room?
26
A.
No.
27
Q.
When you say you didn't enter, does that mean you did
28
not enter?
Did you ever look again?

1182
A.
Did not enter.
Q.
Now, when you were at this house, do you remember if
you were there for -- you said you were there for alcohol but
you didn't say whether you were there for -- what kind of
services you were there for.
services you were receiving at the house were called?
Do you remember what the
A.
No.
Q.
Are you familiar with the term rehabilitation?
A.
Yes.
10
Q.
Are you familiar with the term detoxification?
11
A.
Yes.
12
Q.
Are you familiar with the term sober living?
13
A.
Yes.
14
Q.
Was it any of those?
15
A.
Nope.
16
Q.
Okay.
So you don't have any independent recollection
17
of the services -- of the term for the services you were
18
receiving at that house?
19
A.
No.
20
Q.
Okay.
When you were there, during all of the nights
21
you were there, did anyone ever come check on you during the
22
night?
23
A.
No.
24
Q.
When you first entered, do you know what getting your
25
blood pressure checked is?
26
A.
Yes.
27
Q.
Do you remember if anyone checked your blood
28
pressure?

1183
A.
Yes.
Q.
So you remember or they did?
A.
They did.
Q.
And did they ever do that again?
A.
No.
Q.
So one time?
A.
One time.
Q.
Now, you said you got sent there by your son.
don't mean to pry.
I'm not trying to embarrass you in any
10
way, but can you describe what your situation was with regard
11
to alcohol at that time?
12
A.
Yeah.
I was living in Northern California and I came
13
down to visit my son and my grandkids and I had got up at
14
15
didn't like that because I had two beers at 11:00.
16
oldest son was in this rehab already, A Better Tomorrow, doing
17
a sober living.
18
your grandkids again, you're going to go to this place."
19
said, "I'll go.
20
want."
21
Q.
22
By 11:00, I had a beer.
Well, he
So my
And so he said, "Mom, if you ever want to see

I
I'll go for five days if that's what you
So I checked in for five days.

All right.
And when you checked in, did you say --
did you say what you were there for?
23
A.
Yeah.
I said, "My son says that I'm alcoholic."
24
Q.
Okay.
And so what did they say they were going to do
25
for you, if you recall?
26
A.
They wanted to send me to a 28-day program.
27
Q.
Okay.
28
So were the five days that you were there for
at the house you were in part of the 28-day program?

1184
A.
It was -- they wanted it to be.
Q.
Okay.
A.
But I left.
Q.
Right.
So here's my question.
your understanding, they were part of the 28-day program?
A.
After the five-day detox.
Q.
Okay.
A.
Where I was at.
Q.
All right.
10
11
12
13
14
What's the five-day detox?
Were you going to -- were you supposed to
do more days beyond that, to your understanding?

A.
No.
After the five-day detox, I was supposed to do a
28-day program.
Q.
Okay.
Thanks.
I don't mean to frustrate you, I'm
just trying to understand.
15
A.
No, that's --
16
Q.
Okay.
17
Those five days, to
So if I'm understanding you -- and correct me
if I'm wrong -- you were at that house to do a five-day detox?
18
A.
Correct.
19
Q.
Okay.
So let me ask you this:
It's been five years
20
since these events occurred.
Was your memory of these events
21
clearer closer to the time they occurred or is it clearer
22
today?
23
A.
Not as clear today.
24
Q.
So when you spoke with agents from the Department of
25
Justice maybe in August of 2013 or maybe a year ago, somewhere
26
in there, was your memory better or worse than it is today?
27
A.
Probably better then.
28
Q.
All right.
Did you tell them about everything that

1185
you've told us about today?
A.
Yes.
Q.
But you told us that you had never told anybody about
the prescription drug bottles, I believe it was, that Kris
McCausland had in his hand that had the white caps that you
could see.
A.
I might have.
Q.
Okay.
A.
Yes.
10
Q.
And I asked you if you had ever told anybody before.
11
A.
And I can't remember.
12
13
14
Do you remember saying that?

I can't remember.
I mean, you remember saying that here today?
I might have.
and I'm not going to -Q.
Okay.
All right.
All I'm asking you now is
everything you've said to us here today clear in your memory?
15
A.
Today, yes.
16
Q.
Does your memory vary from day to day?
17
A.
Yeah.
18
19
I can't be sure
I'm getting old.
I think I'm getting
Alzheimer's.
Q.
Okay.
Well, that's -- the important thing I'm trying
20
to get to, ma'am, is whether or not you have an independent
21
recollection of everything you've spoken about.
22
A.
Pretty much so, yes.
23
Q.
All right.
You say, "Pretty much so, yes."
What
24
parts, if any -- and I'm not in your head, I can't tell, so I
25
have to ask you, what are you not clear about you've testified
26
to today?
27
A.
At what time that he arrived and -- his arrival time.
28
Q.
Anything else?

1186
A.
No.
Q.
Okay.
3
4
5
All right.
MR. SAMUELS:
Just one moment.
I'm going to ask the grand jurors if
they have questions for this witness.

Q.
BY MR. SAMUELS:
Question from Grand Juror No. 15.
During the time you were with Gary Benefield in that house,
did you ever see him, Gary Benefield, without a shirt on?
A.
No.
Q.
When you were in that house, did you notice and do
10
you remember -- well, let me ask it this way.
11
over.
12
13
I'll start
Do you remember if you could hear sounds in that

house from other rooms?
14
A.
No.
15
Q.
Does that mean you couldn't hear sounds or you don't
16
remember?
17
A.
I don't remember.
18
Q.
Have you ever been to the A Better Tomorrow's office
19
for group sessions?
20
A.
No.
21
Q.
Did you have any group sessions that you remember?
22
A.
That I remember?
23
Q.
Did you have any individual counseling?
24
A.
No.
25
Q.
Well, didn't you say --
26
A.
I was only there for five days just for detox, so I
No, I had none.
27
didn't -- there was no counseling, there was no going to
28
classes.

1187
Q.
I'm sorry?
A.
There was no counseling, there was no going to
3
4
5
classes because I was in the detox.

Q.
Okay.
This question is what time were you woken up
on the day of Gary's death?
A.
6:30, quarter to 7:00.
Q.
Do you remember who woke you?
A.
It was the black lady.
Q.
Why did you leave the detox program at A Better
10
I can't remember her name.
Tomorrow?
11
A.
Because I felt I didn't even need to be there.
12
Q.
Did the fact that anyone -- that someone had died in
13
the house where you were have anything to do with it?
14
A.
No.
15
Q.
This is a question from Grand Juror No. 3.
Did you
16
have any thoughts about the fact that you were given drugs to
17
help you sleep and drugs for your anxiety without a
18
prescription on the first day?
19
A.
Yeah.
20
Q.
Why?
21
A.
Because I don't take drugs and I didn't think I
22
I didn't like that.
needed anything for anxiety or to help me sleep.
23
Q.
Did you take those pills?
24
A.
Yes, I did.
25
Q.
Okay.
How were they offered to you?
Were they --
26
I'm just going to ask you were they in someone's hand?
27
they in a bottle?
28
they were offered to you?
Were they on a plate?
Were
Do you remember how

1188
A.
A little cup.
Q.
Paper or plastic?
A.
It was a little plastic cup.
Q.
Did it have a lid?
A.
Excuse me?
Q.
Did it have a lid?
A.
No lid.
Q.
Did you take any prescription drugs with you when you
were admitted to this facility?
10
A.
No.
11
Q.
Did you see where the pills you were given -- well,
12
how many pills were you given?
Do you recall?
13
A.
Two.
Two a night.
14
Q.
Okay.
15
A.
Yes.
16
Q.
Now, is that two of each medication or two total?
17
A.
Two total.
18
Q.
And did you see where they came from?
Two a night?
19
got them in a cup.
20
what I'm asking.
Did you see how they got into the cup is
21
A.
No, I really didn't.
22
Q.
Okay.
23
I mean, you
Now, did this cup have your name on it or
anything?
24
A.
No.
25
Q.
Can you describe the cup?
26
A.
It was just a little clear little white cup.
27
Q.
Okay.
28
A.
Just a little clear cup like that.
So is it clear or is it white?

1189
Q.
All right.
A.
It was only like this big.
Q.
All right.
How far apart are your fingers when you
say this big?
A.
About an inch.
Q.
All right.
circular --
A.
And then you indicated, I think, a
Just a circular like a Vicks bottle of medicine or
something you would take.
10
Q.
Okay.
11
A.
Or, yeah, a little Nyquil or something, that size
12
So if you take Vicks --
bottle.
13
Q.
Okay.
Bottle or cup?
14
A.
Well, cup.
15
Q.
Okay.
16
A.
Cup.
17
Q.
Let me clarify, if I may.
18
A.
Okay.
19
Q.
So if I took over-the-counter Vicks medication and I
Sorry.
20
used the cup that came with the Vicks medication, are you
21
saying that that's the size cup it was?
22
A.
Yes.
23
Q.
Okay.
24
Thank you.
And was that the size you were
indicating with your hands?
25
A.
Yes.
26
Q.
Okay.
This question is from Grand Juror No. 6.
The
27
morning of Gary Benefield's death, before you left the house
28
where you were to go to the corporate A Better Tomorrow

1190
office, were you interviewed by any law enforcement personnel?
A.
No.
Q.
Were you interviewed by any law enforcement personnel
that day that you recall?
A.
No.
Q.
You don't recall or you weren't interviewed?
A.
I was never interviewed by anybody in that facility.
Q.
From that facility or in that facility?
A.
From that office or anything.
10
Q.
Okay.
11
We're not talking about people from the
office, we're talking about law enforcement personnel.
12
A.
No.
13
Q.
Okay.
So that includes people who were in plain
14
clothes who show you a badge as well as people who are in
15
uniforms.
16
A.
Correct.
17
Q.
All right.
18
A.
No.
19
Q.
During the time that you were in Gary Benefield's
No law enforcement --
20
presence, you were together on the couch and you were together
21
in the back and wherever else you were, did you see Gary
22
Benefield with an inhaler?
23
A.
No.
24
Q.
Do you know what an inhaler is?
25
A.
Yes.
26
Q.
Can you describe an inhaler for us?
27
A.
It's a little gadget that you inhale.
28
Q.
Okay.
And you were holding your hand up in front of

1191
your face with your thumb --
A.
Yeah, like because it's got a little press on it --
Q.
Okay.
A.
-- an inhaler.
Q.
So you're closing your hand --
A.
Yes (untranslatable sound).
Q.
-- and you made a sound of inhaling?
A.
Correct.
Q.
Okay.
Did you form the belief that you had to take
10
the medication that you were getting in the evenings, the two
11
pills that you described to be participating in the detox
12
program?
13
A.
Yes.
14
Q.
How did you get that impression?
15
A.
Because that's what they did when they came in and
16
said, "We're going to give you something for your anxiety."
17
said, "I didn't know I had anxiety."
"And to help you sleep."
18
Q.
Okay.
19
A.
And they said, "We're going to give you these."
20
Q.
Did they say you had to take them?
22
A.
They said it was part of the program.
23
Q.
Okay.
25
26
27
28
went --
21
24
And that's not quite the same thing, though.
Did you ever say I don't want to take them?

A.
No, I didn't, because they were authority and I
figured they know what they were doing.

Q.
days.
You said that you left A Better Tomorrow after five

Do you remember that?

1192
A.
Excuse me?
Q.
You said you left the A Better Tomorrow house after
five days.
A.
Correct.
Q.
Did you have any trouble getting your personal
belongings and taking them with you when you left?
A.
No.
Q.
Had you handed in any personal belongings when you
went to this house?
10
A.
To the office.
11
Q.
So you went to the office?
12
A.
The office first had my phone, had all my money, had
13
all my belongings.
14
I stayed was my clothes and suitcase.
15
16
17
18
Q.
The only thing that was at the house that
All right.
So when you left, how did you get your
phone and other belongings?

A.
I had to walk from that house all the way to the
office.
19
Q.
Why is that?
20
A.
Because they would not furnish me a ride.
21
Q.
Who did you ask for a ride?
22
A.
The house managers.
23
Q.
Is that Kris and --
24
A.
Kris and that other lady, yes.
25
Q.
And what happened when you got to the office?
26
A.
I told them that I wanted my stuff, that I was
27
leaving.
And they made me sign a piece of paper saying I got
28
my stuff and I left.

1193
Q.
Do you remember who you spoke with at the office?
A.
No.
Q.
Man or woman?
A.
Both.
Q.
I'm sorry, I asked my question poorly.
There was all kinds of people in there that day.

You can't recall?
There was both men and women in there working.
remember who you spoke with?
A.
It was a male.
Q.
Tall, short?
A.
Probably about your size.
10
Q.
Okay.
11
A.
Well, you're kind of like short.
12
Q.
Okay.
13
Anything you remember about him?
Am I tall or short?
So you spoke to a short man in the office.
A.
No.
15
Q.
Do you remember if he was Caucasian or
African-American or Hispanic or anything like that?
17
A.
Might have been Asian.
18
Q.
All right.
19
20
Do
you remember his hair at all?
14
16
Do you
And did you have to -- how long was your
conversation with this man to get your personal belongings?

A.
It was a total of maybe ten minutes from the time I
21
went in there and asked them that I'm checking out and I need
22
my things.
23
Q.
Did you tell them about having to walk?
24
A.
Yes.
25
Q.
What did he say about that?
26
A.
He didn't care.
27
Q.
Okay.
28
That wasn't his problem.
What did you do after you got your phone and
your other personal belongings?

1194
A.
I got my phone and I called the taxi and I went to
the airport and I went back home to Northern California where
I live.
4
5
Q.
Do you remember how many days after the day Gary
Benefield was found dead this was?
A.
The next day.
Q.
All right.
So if I tell you it was a Monday when he
was found dead, this would have been Tuesday?
A.
The next day I left.
10
Q.
Okay.
Okay.
This next question is from Grand Juror
11
No. 17, and it's almost exactly the same subject matter that
12
was covered in the last question.
13
14
MR. SAMUELS:
Are there any other questions, ladies
and gentlemen?
15
16
MR. SAMUELS:
17
May this witness be excused,
Mr. Foreman?
18
19
No more questions, Counsel.
Before you leave, Ms. Patton,
I have an admonition to read to you.
20
You are admonished not to discuss, at any time
21
outside of this jury room, the questions that have been asked
22
of you in regard to this matter, or your answers, until
23
authorized by this grand jury or the Court, or until such time
24
as these grand jury proceedings become a matter of public
25
record.
26
instructions on your part may be the basis for a charge
27
against you of contempt of court.
28
You will understand that a violation of these

1195
Do you understand that?
THE WITNESS:
Yes.
THE WITNESS:
Thank you.
MR. SAMUELS:
That means you can get up.
THE WITNESS:
Oh.
MR. SAMUELS:
Please.
10
THE WITNESS:
Thank you.
11
MR. SAMUELS:
You are subject to recall.
12
subpoena lasts until the 24th.
13
THE WITNESS:
Okay.
14
MR. SAMUELS:
If you get called back.
15
THE WITNESS:
All right.
16
MR. SAMUELS:
Mr. Foreman, if you remember, I asked
Thank you.
You're excused.
That's all?
That's all.
Your
Thank you so much.
17
yesterday if the grand jurors could take their break at 11:30
18
today, because we had the witness coming promptly at 1:00
19
because of travel arrangements.
20
ready right now, but I just wanted to remind folks that it's
21
10:15-ish now.
22
as close to 11:30 as we can to maximum your time.
23
a break, I suggest that you take it right now rather than
24
count on one between now and 11:30.
25
26
27
28
So there's a witness who's
So if -- I'd like to take this witness and go
GRAND JUROR NO. 7:
Juror No. 7.
If you need
May I talk to you,
Mr. Foreman?
MR. SAMUELS:
If you're going to have discussions,
then I should leave the room.

1196
GRAND JUROR NO. 7:
(Grand jurors have discussion off the record.)
3
4
Okay.

break.
MR. SAMUELS:
All right.
What time for return?

We return at 10:35.
Thank
you.
(Brief recess.)
9
10
Counsel, we need a ten-minute
to order.
11
Counsel, we have some questions for you, or requests.
12
MR. SAMUELS:
13
Yes.
Number one is one of the
14
jurors has a question to Detective Gomez or to law
15
enforcement.
16
enforcement.
17
18
19
And again I have some questions from the law
MR. SAMUELS:
We can have Detective Gomez summoned to
reappear.
Okay.
The second one is a
20
juror suggests that the maximum time in the afternoon is only
21
until 4:30 due to other obligations, especially at home.
22
23
MR. SAMUELS:
That's up to you.
Yesterday I did
ask -- it's my recollection I asked and got your consent.
24
25
MR. SAMUELS:
Okay.
I don't mean to impose and I don't mean
26
to rush this grand jury.
So if at any time you think you need
27
more time with a witness, you need to inform me and I will
28
make arrangements for that.

1197
1
2

today.
MR. SAMUELS:
It was only made aware to me
Okay.
Today we are good until
11:45 a.m. and be back by 1:00 p.m.
MR. SAMUELS:
Okay.
Very good.
And for next week, we have
one of the jurors requesting July 21 -- that's a Tuesday --
that we recess early at 4:00 p.m. so she would be able to pick
10
11
12
up family arriving at the airport.

MR. SAMUELS:
Okay.
I would prefer to put off
deciding that until Monday.
13
14
MR. SAMUELS:
Okay.
And I don't see any problem with it.
15
I'm not saying no, I'm just saying it might be helpful to see
16
where we are.
17
18
Is that all right?
Are we satisfied?
Just nod
your head.
19
We're good, Counsel.
20
MR. SAMUELS:
We're good, Counsel.
I just want to stress again, the grand
21
jury has its independent authority with regard to the things
22
that the judge told you you could have and have been
23
instructed.
24
hearing full testimony, you should inform me so the witness
25
can be returned to your presence, all right?
And if you feel that you are being kept from
26
27
MR. SAMUELS:
28
Thank you, Counsel.
Can I get the next witness?

Yes, please.

1198
2
3
raise your right hand, please.
THE WITNESS:
I do.
Please be seated.
10
11
I would like you to read, then sign and print your name at the
12
bottom.
13
14
15

16
17
THE WITNESS:
Janelle Ito-Orille, J-a-n-e-l-l-e, last
name I-t-o, hyphen, O-r-i-l-l-e.
18
19
Counsel, please proceed.
20
MR. SAMUELS:
Thank you.
Thank you.
21
JANELLE ITO-ORILLE,
22
23
follows:
24
25
DIRECT EXAMINATION
BY MR. SAMUELS:
26
Q.
If I get your name wrong and say Orille-Ito, please
27
excuse me.
28
A.
But it's Ito-Orille?
Yes.

1199
1
2
Q.
You're somewhat soft-spoken, so please be sure to
speak up loudly so the folks in the back can hear you.
A.
Okay.
Q.
All right.
A.
Currently I'm employed with the Department of Health
How are you employed?
Care Services.
Q.
What's your job with them?
A.
Staff Services Manager II.
Q.
And is that a department of the State of California?
10
A.
Yes.
11
Q.
And how long have you held this position?
12
A.
I've been in this current position for about
13
14 months.
14
Q.
Before that what did do you?
15
A.
I was a Staff Services Manager I.
16
Q.
Okay.
17
And was that with the California Department of
Health Care Services?
18
A.
Yes.
19
Q.
All right.
20
21
And Department of Alcohol and Drug Programs.

Did you change departments?
How did --
what does that mean?

A.
Our Department of Alcohol and Drug Programs was
22
merged with Department of Health Care Services in July of
23
2013.
24
25
Q.
So before that, was it a stand-alone program, the
Department of Alcohol and Drug Programs?
26
A.
Yes.
27
Q.
And did you work for them?
28
A.
Yes.

1200
Q.
When did you start with them?
A.
In 2008.
Q.
And can we call it ADP for short?
A.
Yes.
Q.
What did you do for ADP when you started there in
2008?
A.
I was hired as a complaint analyst.
Q.
What did you do as a complaint analyst?
A.
Investigated complaints in regards to facilities that
10
are licensed and/or certified by the department, as well as
11
investigate complaints against counselors who are registered
12
or certified.
13
Q.
All right.
Now, you used the terms certified and
14
licensed with regard to what -- who gets certified and
15
licensed?
16
A.
Who or what gets certified?

A licensed program would be a facility that provides
17
24-hour residential, nonmedical drug and alcohol treatment
18
services.
19
Q.
24-hour --
20
A.
Residential, nonmedical substance use or alcohol and
21
drug treatment services.
22
Q.
Would that cover a detoxification facility?
23
A.
Yes.
24
Q.
As long as it had 24-hour and residential?
25
A.
Yes.
26
Q.
Would that cover a rehab facility?
27
A.
Yes.
28
Q.
So what's the difference?
You said certified as

1201
well.
A.
What's that mean?

A certified program would be a program --
predominantly they are outpatient programs, so they are
nonresidential programs.
that do groups and one-on-ones.
for services and then leave.
carry a certification as well.
programs can opt in and decide if they want to carry the
certification.
10
California.
11
Q.
A lot of times they are programs

They -- the clients will come
But a licensed program can also

Certification is voluntary, so
However, a license is required by the State of
So if I want -- I or my buddy wants to run a 24-hour
12
residential, nonmedical detox facility, do they need to be
13
certified?
14
A.
Licensed.
15
Q.
Okay.
16
certified unless they voluntarily decide to be there?
17
A.
Yes.
18
Q.
Okay.
19
A.
That services cannot be provided without first
obtaining a license.
22
23
And is that -- what's your understanding of --
when you say a license is mandatory, what does that mean?
20
21
So you're saying they don't need to be
Q.
All right.
And you said you were a complaint analyst
from 2008 on.
24
A.
25
Manager I.
26
Q.
All right.
A.
I supervised still within the complaints unit, so I
27
28
Until 2010, and then I became a Staff Services
And what does a staff services manager
do?

1202
supervised four to five staff at the time, four to five
complaint analysts.
Q.
Okay.
So now you're a supervisor?
A.
Yes.
Q.
Do you know what a custodian of records is?
A.
Yes.
Q.
And are you a custodian of records for the records of
alcohol and drug -- the Department of Alcohol and Drug
Programs that was in existence before and after its merger
10
with the Department of Health Care Services?
11
A.
Yes.
12
Q.
And are you familiar with the way records are
13
generated both during that time when it was the Department of
14
Alcohol and Drug Programs and under DHCS or Department of
15
Health Care Services?
16
A.
Yes.
17
Q.
And are records generated by you as the supervisor or
18
19
by investigators?
A.
It could be both.
It depends on who actually
20
conducts the investigation.
21
the complaint analyst; however, if as a supervisor you go out
22
and conduct investigation, you might be the one generating the
23
record.
24
25
Q.
So predominantly it's going to be
And when are those records created by the
investigator or the supervisor, whoever is doing the work?
26
A.
I'm sorry, could you repeat the question?
27
Q.
When are those records generated?
28
A.
Generally, they're created very timely after the

1203
investigation.
investigation, but it depends on the amount of documentation
that needs to be reviewed and analyzed.
the reports done very timely after our site visits to get the
investigation concluded.
6
7
Q.
Okay.
I would say within a few months of the
But we work to get
Are you trained to take notes about the things
you do while you're doing an investigation?
A.
Yes.
Q.
And do you know whether or not those notes are used
10
to create these reports?
11
A.
Yes.
12
Q.
Do you know what -- you know.
13
notes used?
14
A.
So what -- how are the
A lot of times the notes will be used so that you can
15
write your report.
16
to be able to document everything quickly, but then when you
17
return to the office, you'll put all of your notes into the
18
report.
19
20
Q.
Okay.
You might take notes during an interview
So the notes are done at the time and then
reduced to a report later?
21
A.
Yes.
22
Q.
Are these writings required of the investigators as
23
24
part of the business of being in ADP or DHCS?

A.
They're not required.
Some analysts actually might
25
use video -- or not video, recording.
They might record
26
interviews, but they're not required, I would say, but it's
27
very difficult to remember everything accurately without
28
writing things down.

1204
Q.
Okay.
A.
Reports are, yes.
Q.
And are the investigators trained that these reports
Are the reports required as part of what you
do?
need to be trustworthy, in other words, accurate and timely?
A.
Yes.
Q.
Is that important?
A.
Yes.
Q.
And so it's a -- is it a -- let me ask you, is it a
10
priority?
11
A.
Yes.
12
Q.
And as a custodian of records, are you familiar with
13
the records of a detoxification and rehabilitation service
14
that was doing business under the name of A Better Tomorrow?
15
A.
Yes.
16
Q.
And did you personally have any dealings with A
17
Better Tomorrow?
18
A.
Yes.
19
Q.
Can you describe your personal dealings with A Better
20
Tomorrow prior to July of 2010, if any?
21
A.
Prior to July of 2010, I had no involvement.
22
Q.
All right.
23
A.
Was when -- in July when I was informed of a death
24
25
26
27
28
So your first involvement was when?
that had occurred at one of their facilities.

Q.
Okay.
Now, you say you were informed.
Were you
called directly by someone reporting the death?

A.
I don't exactly recall, but I believe I was informed
by a supervisor that a death had occurred and that I needed to

1205
1
2
3
investigate it.
Q.
All right.
And do you remember when that was with
any -- you know, give or take, when was that?
A.
I would guess that it was around the end of July.
Q.
2010?
A.
2010.
Q.
All right.
A.
Prior to going out on the site visit investigation, I
And what did you do to investigate?
made contact with the Murrieta Police Department and detective
10
by the name of Phil Gomez and obtained some information from
11
him, made arrangements with him to meet with him because he
12
was going to accompany me on my site visit to the location.
13
Q.
Why was that?
14
A.
We were going -- we were working in collaboration in
15
regards to the investigation, so I believe the Murrieta Police
16
Department was also looking into the death at the facility.
17
18
Q.
Is it normal to have law enforcement accompany you on
an investigation?
19
A.
Not normally, no.
20
Q.
Okay.
21
A.
Site visit would be when we actually physically go to
What's a site visit?
22
the location of our facility and generally we will do a
23
walkthrough, investigate -- you know, observe the facility,
24
talk with clients, talk with staff, conduct interviews.
25
26
27
28
Q.
Okay.
And so after you spoke with Murrieta Police
Department Detective Gomez, what did you do next?

A.
We then went to the facility located on Iron Gate
Lane.

1206
Q.
Do you remember what date that was?
A.
I believe it was August 9th, 2010.
Q.
And what was your understanding of when the death had
occurred?
A.
It was -- I believe it was on July 25th of 2010.
Q.
Okay.
7
8
9
And so when you went to Iron Gate on
August 9th, 2010, what did you find, if anything?

A.
That the facility had -- was shut down.
no clients, no people in the facility.
There were
We were able to kind
10
of peer in the windows and we could see that there were no
11
people in there, the furniture looked -- it looked pretty
12
cleaned out when we looked in from the front.
13
to the back of the house because the side gate was open and
14
there was a sliding glass door and there were no curtains and
15
so we were able to get a pretty good view of the full living
16
room and kitchen.
17
18
19
20
Q.
And the facility appeared empty.
Did it appear empty or was the part you could see
empty or did it have things in it?

A.
There was, I believe, a few furniture pieces but it
definitely appeared that there was no one living there.
21
Q.
Okay.
22
A.
But the doors were locked.
23
24
We went around
We did try to open the
doors just to check and we weren't able to get in.

Q.
Now, did you -- as part of your investigation, did
25
you review the files that ADP -- it would have been ADP in
26
July of 2010?
27
A.
Yes.
28
Q.
Did you review the files that ADP had on the facility

1207
1
2
at Iron Gate?
A.
I don't recall all of the documents.
I looked at
some general licensing documents for the Iron Gate, but I
don't remember if I reviewed the whole file.
MR. SAMUELS:
Thank you.
Q.
Okay.
BY MR. SAMUELS:
Can I have this marked, please.
I'm handing you what has been marked
as Exhibit 87.
It's a one-page document.
at that and tell me if you recognize it.
Would you just look
10
A.
Yes.
11
Q.
What do you recognize it as?
12
A.
This is a copy of the licenses that we issue to
13
14
15
programs that are generally hung in the facilities.

Q.
Do you know if it's required that a license be hung
in a licensed facility?
16
A.
It is required by regulations.
17
Q.
Okay.
Now, did you ever see this -- you said you
18
never entered Iron Gate, so did you ever see this particular
19
document at Iron Gate?
20
A.
I did not.
21
Q.
Did you ever see this particular document or a copy
22
of it in the file?
23
A.
I don't recall.
24
Q.
I don't mean to be snippy, but why do you say you
25
26
27
28
recognize it?
A.
Because it's very -- all of our licenses for any
program looks -- is in this format.

Q.
Okay.

1208
1
2
A.
With the seal on the bottom.
The original will have
a gold sticker seal on it.
Q.
Okay.
Now, on the table, there is a laser pointer.
It has a red button.
Could you show where the seal is on this
document, please, using the laser pointer?
the laser -- is that the seal?
Okay.
So is that
A.
Yes.
Q.
And on the original it's what?
A.
This would be like a gold foil sticker and I believe
10
this said ADP on it.
11
Q.
Okay.
It has like embossing of ADP.
Now, is this license -- the information that
12
is in print on this copy of this license consistent with what
13
you learned about the facility on Iron Gate you were
14
investigating?
15
A.
Yes.
16
Q.
So who was -- who's the licensee per this particular
17
document?
18
19
20
21
22
A.
So the licensee would be A Better Tomorrow, ABTTC,
Q.
All right.
Inc.
And what other information are we looking
at here?
A.
So this would be the name of the facility and the
23
address, the location of the facility.
24
the legal entity or corporation.
This ABTTC, Inc. is
25
Q.
What's the name of the facility though?
26
A.
A Better Tomorrow.
27
Q.
And the address?
28
A.
42368 Iron Gate Lane, Murrieta, California 92562.

1209
Q.
projector.
the projector and I can return it to you.
section refer to?
A.
It looks good to me.
We've had trouble with the
I'll ask you to confirm that when we take this off

What's the next
So the next section, which states, "individual
sessions, recovery, or treatment planning, detoxification
group sessions, and educational sessions."
of the services that could be provided at the program.
9
10
11
Q.
This is a summary
Now, does that indicate whether it's a residential
facility or not?
A.
This information does not indicate that it's a
12
residential; however, what is indicative that it is a
13
residential program is the fact that it is a license.
14
15
16
Q.
Okay.
Below that paragraph you just read, what's the
next portion describe?

A.
So then the next portion right here is the
17
limitations or conditions, and it's the treatment recovery
18
capacity, which states six, and the total occupancy is eight.
19
What that indicates is treatment recovery capacity is the
20
amount of clients that the program can serve, which is six
21
clients.
22
means that generally the people above the treatment capacity
23
are going to be staff, which in most cases it is, which we
24
would say that the eight in the house would be two people
25
would be house managers or live-in staff.
The total occupancy for the location is eight, which
26
Q.
Okay.
27
A.
Males and females, which is indicating that it's a
28
And just below that, what does it say?
co-ed facility.

1210
Q.
And below that?
A.
The license numbers.
So all of our programs that are
licensed or certified have a number and it's a high number.
Q.
Could you read that number?
A.
330071CP.
Q.
Is that as in Charles Paul?
A.
Correct.
Q.
And over to the right, just kind of below and to the
9
10
right of that number you read?

A.
Effective date.
So the effective date is the day
11
that this license was issued.
12
license is effective as of that date.
13
date, which is when the license will expire.
14
Q.
And its effect- -- their

And then the expiration
Now, that effective date, is that the original
15
issuing date or could it be a reissue date or a reissue date
16
after a reissue after a reissue?
17
A.
It could be a reissue date.
So this -- that
18
effective date is just what is effective for this licensing
19
period.
20
they're required to renew.
21
22
Q.
Our licenses are effective for two years and then
Okay.
And do you recognize the signature on this
form?
23
A.
Yes.
24
Q.
Who's that?
25
A.
Her name is Ann McDowell and she was the supervisor
26
in the licensing and certification branch.
27
Q.
Was she personally known to you?
28
A.
I had brief dealings with her.

1211
Q.
Okay.
A.
Yes.
Q.
Do you recognize this as her signature?
A.
Yes.
Q.
All right.
Did you see her signature?
I'm going to return this to you just so
you can make sure that you read the zip code correctly.
A.
Yes, 92562.
Q.
All right.
Hold on to that for a moment.
Now, you
said you were a custodian of records for this facility, but
10
you also said that you didn't start until 2008 with ADP; is
11
that right?
12
A.
Correct.
13
Q.
Okay.
This is the next exhibit.
It is a paper
14
clipped document with eight pages.
15
to staple it so they don't get moved around.
16
And the secretary is going
Now, in your job as the investigator, if you found
17
things that weren't consistent with the rules of alcohol and
18
drug programs, did you notify the folks that ran the facility?
19
A.
Yes.
20
Q.
And was there a formal process for this?
21
A.
Yes.
22
Q.
Can you describe that?
23
A.
So once we do an investigation and determine there
24
have been deficiencies in the program, any regulation
25
violations, then we will do our report and the report is given
26
to the program and they're made aware of the deficiencies.
27
Q.
Okay.
28
Exhibit 88.
I'm handing you what has been marked as
Would you tell me if -- look at all the pages of

1212
it and tell me if you recognize what that is.
A.
Yes.
Q.
What is it?
A.
It is the program investigative report or what we
call the PIR.
Q.
And what entity or facility is it for?
A.
For ABTTC/A Better Tomorrow.
Q.
And is there a license number on that?
A.
Yes.
10
Q.
Could you read that into the record, please.
11
A.
330071AP.
12
Q.
So that's Adam Paul at the end?
13
A.
Yes.
14
Q.
Now, those two letters at the end of the number that
15
you read, what do they mean, if you know?
16
A.
So generally the first letter --
17
Q.
Uh-huh.
18
A.
-- will indicate if a program has the -- so if an
19
entity might have, say, three facilities.
20
Q.
Uh-huh.
21
A.
So the first facility that we receive a license for,
22
the first one that the department might license will be given
23
the letter A and then the next facility will be given the B
24
and so on and so forth, so it will go down the alphabet that
25
way.
26
So other programs that are nonprofit will end -- will have an
27
N there.
28
The P stand for profit and that's what that indicates.
Q.
Okay.
Now, the designation for a particular address,

1213
will that change over time like if they get re-licensed or
recertified if I -- can I re- -- you know, reorder the
facilities?
A.
Generally, I -- no, I don't believe so.
So if a
facility changes location, they would take that number with
them.
7
8
Q.
All right.
So can you tell from that exhibit what
facility was under investigation in this report?
A.
A Better Tomorrow.
10
Q.
And does it have an address for the A Better Tomorrow
11
facility that was the focus of this investigation?
12
A.
Yes.
40465 Erica Avenue.
13
Q.
All right.
14
A.
No.
15
Q.
But it has A Better Tomorrow?
16
A.
Correct.
17
Q.
All right.
So this was not Iron Gate?
Now, I want to look at a page.
In the
18
exhibit in the lower right-hand corner of the pages are some
19
number indicators.
20
page says page 6 of 8.
21
that's described in an area that's got a 3 next to it.
22
see what I'm indicating?
This one says page 5 of 8 and the next

And I'm talking about a deficiency
Do you
23
A.
Yes.
24
Q.
And can you tell me what deficiency that was reviewed
25
26
27
28
and describe them?

A.
The program's website advertises that they provide
medically managed detoxification at this facility.

Q.
All right.
And what program was that again?

1214
A.
A Better Tomorrow.
Q.
And is that page initialled by someone at the bottom
or was there a signature of any kind?
A.
There are initials.
Q.
And do you know how initials -- is this a form you're
familiar with?
A.
Yes.
Q.
And did you ever use this kind of form?
A.
Yes.
10
Q.
And did you have people fill in initials -- were
11
there initials on this page on other forms that you generated?
12
A.
Yes.
13
Q.
And so what's the purpose of those -- that initial
14
15
space being there?

A.
The purpose of having someone initial this is that
16
it's indicating that they have read and understand the above
17
information and it needs -- the initials need to be by a
18
program or facility representative.
19
20
Q.
Okay.
So they are not filled in by you or another
investigator, they're filled in by a program representative?
21
A.
Correct.
22
Q.
Or a facility representative?
23
A.
Correct.
24
Q.
All right.
25
A.
I did not.
26
Q.
All right.
27
28
Did you do this investigation?
But is it part of the A Better Tomorrow
file?
A.
Yes.

1215
Q.
There was -- the report, was it performed per the
directions that we described earlier that the person write it
in a certain way, things like that?
A.
Yes.
Q.
Do you recognize who did this investigation?
A.
Yes.
Q.
Who was that?
A.
Cindy Jamison.
Q.
Did you personally know Cindy Jamison?
10
A.
Yes.
11
Q.
And do you know where she worked in 2008?
12
A.
She was working with Alcohol and Drug Programs, ADP.
13
Q.
Do you know what her position was?
14
A.
Complaint analyst.
15
Q.
Same as you?
16
A.
Yes.
17
Q.
Okay.
18
A.
July 15th, 2008.
19
Q.
Okay.
And what's the date on this report?
Now, it says that -- I believe you read that
20
this is a deficiency sighting because there was computer
21
advertising that said there was medical treatment at this
22
facility; is that a fair kind of summary?
23
A.
Yes.
24
Q.
Why is this a deficiency, to your understanding?
25
A.
Because our facilities -- when I say "our," I mean
26
the Department of Alcohol and Drug Program.
The facilities
27
are nonmedical and it would be a deficiency to advertise or
28
provide services, medical services.

1216
Q.
Okay.
So the facilities that Alcohol and Drug
Programs supervised and licensed could not be medical
facilities?
A.
Correct.
Q.
Can you describe for the members of the jury what you
as an investigator were told and trained were medical services
in that context?
8
9
A.
So how we were trained would be that medical services
are really services that need to be performed or within a
10
hospital setting, hospital-type setting.
So they could also
11
be if services -- if a program -- you know, sorry.
12
back up a little bit, slow down.
Let me
13
Q.
It's okay.
Go ahead.
14
A.
I guess I would just summarize it that we've been
15
trained that if they need to -- if a client, or any type of
16
services that need to be performed in a hospital setting, they
17
cannot be performed in our programs.
18
Q.
Okay.
So in a hospital setting.
19
like just seeing a doctor?
20
programs?
21
A.
What about things
Could they be done in your
They could be seen -- they could see a doctor in our
22
programs as long as it was at the choice of the client.
23
client has the right to choose to see a doctor and which
24
doctor they would want to see.
25
Q.
Okay.
The
What if they were just assigned a doctor?
26
Would that be consistent with your understanding of what was
27
allowed under the medical services that ADP licensed?
28
A.
If the program were to assign them a doctor, it would

1217
still have to be a client's choice, and it has to be an
agreement that the client makes directly with the doctor.
Q.
All right.
Now, were ADP -- so what -- if they were
nonmedical services, how would you characterize the services
that ADP licensed facilities were allowed to provide?
there a term for it?
7
8
9
10
A.
Yes.
Is
It was -- we, the department, follows a social
model recovery program.

Q.
Social model recovery program.
Does this cover
detoxification as well?
11
A.
Yes.
12
Q.
Now, what about something like taking a blood
13
pressure?
Is that something that can happen in a social model
14
detoxification program?
15
A.
Yes.
16
Q.
So it's not the level of medical services that are of
17
concern?
18
A.
No.
19
Q.
Is that no, it's not the level or --
20
A.
No, it's not a concern.
21
Q.
I'm sorry, I asked the question poorly.
22
That's why I
didn't understand your answer, so my fault.
23
If a -- if a person had a medical condition and
24
wanted to enter a detoxification program, were there steps
25
that the department wanted licensed detoxification programs to
26
undertake to make sure whether the person was medically
27
appropriate for the detoxification program?
28
A.
Yes.
They should -- the program should have the

1218
client go through some form of medical assessment by a
doctor -- by a licensed doctor, and clear them for treatment
in a program that is not -- that doesn't provide medical
services.
they should go to an appropriate facility.
So if a client is in need of medical treatment,
Q.
Okay.
And when should that occur?
A.
It should occur prior to entry.
And if not prior to
entry, immediately upon entering, physically entering the
program.
10
Q.
So that's an assessment by a doctor?
11
A.
Yes.
Per our regulations, it is the program -- the
12
programs are accountable for the health and safety of their
13
clients.
14
clients is to have clients go through and get a medical
15
clearance.
16
Q.
17
And one way to ensure the health and safety of the
Okay.
Now, would it be appropriate for a client to
offer medical services in the licensed program?
18
A.
I'm sorry.
Could you restate the question?
19
Q.
Would it be appropriate for the programs to offer
20
medical services like the services of a doctor during the
21
licensed program's provision of detox services?
22
A.
No, because that would make them a medical facility.
23
Q.
Okay.
24
25
26
27
28
Because they'd have a doctor there, is that
what you're saying?

A.
Yes.
And that would be a part of the treatment is
the treatment would be inclusive of medical care.

Q.
All right.
What if a program had a house where detox
took place and another house where they had a doctor who would

1219
1
2
see patients?
A.
Would that be okay because it was off site?
It still couldn't be inclusive of the treatment, so
it would really have to be that the client chooses to go to
this doctor and they have -- the client has their own
agreement with the doctor for treatment.
Q.
Okay.
What if it was for assessment?
A.
The same.
Q.
They'd have to choose the doctor?
A.
Yes.
10
Q.
You said assessment was supposed to take place prior
11
to or immediately upon entry.
12
last upon entry, 24 hours?
13
A.
So how long does immediately
There's -- it's not specific in our regulations;
14
however, it needs to be very timely.
15
arrival, so --
I would say within their
16
Q.
So it's not specific?
17
A.
It's not specific.
18
Q.
And you can't put a time on it?
19
A.
No.
20
Q.
Can you say when -- can you -- well, does it
21
immediately expire at some point?
22
A.
Yes.
23
Q.
Okay.
24
Is that a you know when you see it kind of
thing, or is there an exact number of hours or days, or what?
25
A.
I would say it's more you know it when you see it.
26
Q.
Okay.
27
A.
Right.
28
Q.
So would it be fair to say that these regulations are
So it's nonspecific?

1220
a bit unclear?
A.
Yes.
Q.
Okay.
Now, you said you went out to interview or to
do an investigation at the address on Iron Gate where a person
had died.
there was nobody there and the place looked like it had been
vacated.
8
9
10
A.
I believe you put the date as July 25th, 2010.
And
What did you do to further your investigation?

So after that, I went over to the outpatient facility
that is certified by the department and that is located on

Corning Place.
11
Q.
Uh-huh.
12
A.
I pulled some personnel files, client files, and the
13
What did you do there?
next day, I conducted interviews with some staff.
14
Q.
Okay.
15
A.
Yes.
16
Q.
Were any of them other than face to face?
17
A.
I conducted one telephone interview.
18
Q.
Okay.
19
20
Were these face-to-face interviews?
How did you know you had reached the right
person when you did a telephone interview?

A.
I was informed that the staff member had moved and
21
was working at a different facility.
22
asked for the person by name.
23
Q.
Uh-huh.
And when I called, I
And when you called, did they answer in a
24
way that indicated you had reached the proper facility or
25
anything like that?
26
A.
I don't recall.
27
Q.
All right.
28
So do you recall the people you
interviewed?

1221
A.
Yes.
I interviewed Andrea Powell.
Q.
Uh-huh.
A.
And I interviewed her actually at a different
location.
I interviewed her at the facility located on
Winchester Drive, I believe.
Q.
Okay.
A.
She was working there --
Q.
Uh-huh.
A.
-- at the time.
10
Q.
Go ahead.
11
A.
And that was A Better Tomorrow location as well.
And
12
then I interviewed Josie Gann and Jim Fent, and I interviewed
13
both of them at the outpatient facility on Corning.
14
Q.
Now, you say "outpatient facility."
So you said a
15
residential place.
16
residential -- 24-hour residential facility and an outpatient
17
facility?
18
A.
What's the difference between a
So a 24-hour residential would be someplace where
19
people live and sleep at, and an outpatient operates more on
20
business hours.
21
groups and one-on-ones and then leave.
22
23
Q.
Okay.
People will come between 8:00 to 5:00 and do
And was the Corning Place -- Corning Avenue
residence an outpatient facility?
24
A.
Yes.
25
Q.
Who ran it there?
26
Who's the entity that ran that
outpatient facility?
27
A.
A Better Tomorrow.
28
Q.
And was it the same A Better Tomorrow that operated

1222
Iron Gate?
A.
Yes.
Q.
Is this considered all part of one entity?
A.
I believe they had three different legal entities at
the time, but I would say they were all under the same
umbrella.
Q.
A.
So they had three different legal entity corporations
involved with them, but they all worked in conjunction.
So
10
even if one house was licensed under ABTTC, Inc., and another
11
house was licensed under Forterus Health Care or just
12
Forterus, they all funneled in and worked through the Corning
13
Place, where services were provided, so all clients came
14
together.
15
Q.
At Corning?
16
A.
Yeah -- yes.
17
Q.
And you said ABTTC, Inc., and Forterus, and Forterus
18
what?
19
A.
Health Care, Inc.
20
Q.
And did the same people answer questions, if you had
21
questions about these different facilities, for the different
22
corporate entities?
23
these three that you mentioned, ABTTC, Inc., Forterus, and
24
Forterus Health Care, would you go to the same people to get
25
the answers?
Like if you had a question for any of
26
A.
Yes.
27
Q.
And they were the people at Corning?
28
A.
Yes.

1223
Q.
Who were those people, if you recall?
A.
Jim Fent, Josie Gann, and Jerrod Menz.
Q.
All right.
Now, are you trained in how to do
interviews with people about these incidents that you're
investigating?
A.
Yes.
Q.
And just describe that training for us.
A.
So we go through a training program and then we are
also trained by other staff, such as staff that have been --
10
when you initially come on, you are trained by veteran staff
11
in different interviewing techniques.
12
13
Q.
Okay.
Are you trained on how to write reports after
you've done an interview?
14
A.
Yes.
15
Q.
What's included in that training?
16
A.
So it would be similar.
17
18
19
course and then also train by veteran staff.

Q.
Okay.
And the report writing course, what does it
stress, if you recall, if anything?
20
A.
Accuracy.
21
Q.
Okay.
22
We do take a report writing
And was this your first death investigation,
this one in July of 2010?
23
A.
I don't recall if it --
24
Q.
Could it have been?
25
A.
It could be, but I might have done one other one
26
27
28
before that.
Q.
All right.
So did anyone assist you in this
investigation?

1224
A.
Not -- no, not while I was out in the field, no.
Q.
Okay.
A.
Yes, back at the office.
Q.
All right.
5
6
Did you have a supervisor?
So was it an individual or a
collaborative process?
A.
I would say collaborative.
So I would write the
reports and then discuss the information with my supervisor,
and my supervisor reviews all our reports prior to signing
them and sending them out.
10
Q.
Okay.
And these reports are held by, at that time,
11
the Department of Alcohol and Drug Programs.
12
now, who would it be through?
If you did one
13
A.
Department of Health Care Services.
14
Q.
So these aren't reports that just get thrown away or
15
anything, are they?
16
A.
No.
17
Q.
How are they maintained?
18
A.
They are maintained in a locked file -- in a locked
19
20
room in a file cabinet.

Q.
Okay.
So you did an investigation and you spoke to
21
Kris McCausland, Andrea Powell, Josie Gann, and Jim Fent.
22
did you become aware of Jerrod Menz?
23
A.
How
I believe I was made aware of who Jerrod Menz was
24
when talking with Jim Fent, and he had informed me that Jerrod
25
Menz was the CEO of the program.
26
27
28
Q.
Did you ever ask him questions about A Better
Tomorrow?
A.
Jerrod?

1225
Q.
Yes.
In this investigation.
A.
I don't recall.
Q.
Have you ever spoken with Jerrod Menz?
A.
I have.
Q.
Was it with regard to this circumstance?
A.
I don't recall.
Q.
Okay.
Now, I want to go through your interviews to
the extent you recall them.
McCausland.
I want to start with Kris
All right?
10
A.
Okay.
11
Q.
You don't have any paperwork open on the desk and I'd
12
ask you to keep it that way.
13
me what you remember as best you can from your investigation.
14
I'll ask questions and you tell
Now, was Kris McCausland a face-to-face interview?
15
A.
No.
16
Q.
And is that the only contact you had with him?
17
A.
Yes.
18
Q.
Did you ever meet him face to face?
19
A.
No.
20
Q.
Okay.
21
22
That was over the phone.
And did you take any steps to identify him,
with particularity, ask him anything that he would know?

A.
I interviewed him about the death and he -- just
23
himself and Andrea were the only ones present in the facility,
24
so the questions were very specific to the incidents that
25
night.
26
Q.
So I believe that was indicative of who it was.

Okay.
When you say they were the only ones in the
27
facility, Andrea and Kris, were there any other people there,
28
to your knowledge?

1226
A.
staff.
Q.
beginning.
Mr. McCausland, what he told you regarding that night?
A.
I'm sorry.
Okay.
For clarification, they were the only two
Thank you.
All right.
So starting from the
What do you remember that stands out about
What really stood out was the fact that a detox
protocol was initiated on this client and the client had not
met with a doctor yet, so they did not have medications
prescribed to him.
Mr. McCausland explained that the detox
10
protocol is there and there were medications available in the
11
house.
12
with the doctor and there was a specific drug that they were
13
detoxing from, he would follow the protocol and just give the
14
medications to the client.
15
16
Q.
Okay.
You said quite a bit there.
Did Kris McCausland tell you when Gary Benefield

arrived at the house?
19
A.
I don't remember the specific time.
20
Q.
Okay.
21
And did he tell you -- what did he tell you
about whether or not Gary Benefield had seen a doctor?
22
A.
23
doctor yet.
24
Q.
25
I'd like to roll
that back and go through it.
17
18
And if a client came in and they were unable to meet
I believe he had confirmed that he had not seen a
And did he tell you anything about Gary Benefield's
condition, in his opinion, when he arrived?
26
A.
I remember that he indicated that he had his oxygen
27
tank and --
28
Q.
He who?

1227
A.
Mr. Benefield.
Q.
Okay.
A.
And that he was smoking and that he had Chantix with
him, but he had informed him he can't have both -- "You can't
have both Chantix and the cigarettes."
Q.
Okay.
A.
Mr. McCausland informed Mr. Benefield, "You can't
have both."
Q.
Now, what do you know about Chantix?
10
A.
I'm not real familiar except basic knowledge that
11
12
13
Who informed who?
it's a nicotine substitute.

Q.
All right.
Do you know whether or not it's a
prescription medication?
14
A.
I believe it is.
15
Q.
Did it cause you any concern that Kris McCausland was
16
telling Gary Benefield he couldn't have a medication that had
17
been prescribed to him?
18
A.
The concern is just that the clients have rights to
19
choose or deny any medication that is prescribed to them.
20
That is their medication, so they have their own rights to
21
their medication.
22
Q.
All right.
What about the house managers?
23
have any rights with regard to medication, by your
24
understanding?
25
A.
To my understanding, no.
26
Q.
All right.
Did they
So you mentioned that Kris McCausland
27
told you that Gary Benefield had an 02 tank or else you said
28
oxygen.
Did he tell you anything particularly about this

1228
1
2
3
4
5
6
tank, Kristofer McCausland?

A.
From what I recall, he indicated that it was empty.
It wasn't full.
Q.
All right.
Did Mr. McCausland indicate any knowledge
of why there was an 02 tank?

A.
I believe Mr. Benefield had informed him that he had
some health issues and one of them being COPD.
remember the name of it right now, but -- and that was why he
needed the oxygen.
10
Q.
Did McCausland indicate when he became aware that
11
Gary Benefield had COPD and needed oxygen?
12
Benefield's arrival, prior to that time?
13
that?
14
A.
I can't
I believe it was at arrival.
Was it upon Gary

Did he tell you
And when he was doing
15
the intake paperwork for him, he was -- is when Mr. Benefield
16
indicated some of his health history.
17
Q.
Now, do you remember Mr. McCausland telling you
18
anything about how Gary presented to him -- Gary Benefield
19
presented to him?
20
A.
I remember that he indicated that he had seen him
21
smoking, walking around.
And then when -- in the evening,
22
late evening, I want to say like around 11:30, 11:45 that
23
evening, he saw him walking in the hallway, I believe to the
24
restroom, and he had just boxers -- boxer shorts on --
25
Q.
Uh-huh.
26
A.
-- and Mr. McCausland informed him that he needed to
27
put clothes on and that he couldn't walk around like that
28
because it was a co-ed facility.

1229
Q.
All right.
Do you remember Kris McCausland tell you
that during his interaction with Gary Benefield, Gary
Benefield seemed fine?
A.
Yes.
And I remember that Mr. McCausland had stated
that when he told him that, he made kind of a comment back to
him, which he indicated it was a smart aleck comment, in those
words, what he stated to me.
that he thought he was fine.
So that's what indicated to him
Q.
This is when he saw him without a shirt?
10
A.
Yes.
11
Q.
What about earlier?
12
Did he say anything about how
Gary Benefield seemed earlier upon intake?
13
A.
I don't remember when he --
14
Q.
Would it refresh your recollection to refer to your
15
report?
16
A.
Yes.
17
Q.
Do you have a copy of your report there?
18
A.
I do.
19
Q.
May I see it?
20
A.
Yes.
21
MR. SAMUELS:
Is this your entire report?
I'm going to -- I think it might be too
22
thick to have it stapled, but if I could have it paper clipped
23
and have this marked.
24
Q.
BY MR. SAMUELS:
Now, what I'm going to ask you to do
25
is to refer to your report and see if it refreshes your
26
recollection.
27
present memory in your own mind of the events we're inquiring
28
about.
Refreshing your recollection is when you have a
Please don't read from your report.
Just see if you

1230
bring back a memory by referring to it.
and if it brings back a memory, you can look up at me and let
me know whether or not it does.
So look at the report
THE WITNESS:
Can you repeat your question?
MR. SAMUELS:
May I have the reporter read back the
last question.
Yes, Counsel.
(Record read by the court reporter.)
10
THE WITNESS:
To my knowledge, in what I'm
11
remembering is just that he had indicated initially that he
12
seemed fine.
13
Q.
BY MR. SAMUELS:
Okay.
All right.
Can you close that report and
14
turn it over, please.
So you said that -- if I'm
15
remembering correctly, you said that Gary Benefield was
16
supplied with drugs that were on the premises without seeing a
17
doctor?
18
A.
Yes.
19
Q.
Did you ask about that?
20
A.
Yes.
21
Q.
And what was -- what did Kris McCausland tell you in
22
23
that regard?
A.
What told me was that there were always medications
24
onsite at the facility, what we call sample medications or
25
bulk medications, because they are not directly prescribed to
26
a client.
27
They could have belonged to a client who left and the
28
medication -- they left their medications.
So they're just medications that are available.
We don't know, but

1231
the department -- we call them sample or bulk medications.
So
Mr. McCausland had indicated that there were always -- always
sample medications at the facility.
got there.
arrived, just that there were always medications available.
He didn't know how they
He had never been present when medications
Q.
Did he say how they were stored at the facility?
A.
I believe he stated that they were stored in the same
room where all the other medications are and that was
generally in the bedroom closet of one of the house managers
10
and at that time it was Andrea Powell.
11
Q.
All right.
Did he say how they were packaged?
12
A.
He had indicated that they were in what we call
13
bubble packets, so each pill is in its own bubble and you pop
14
them -- we say pop them out, you press each one out.
15
16
Q.
Okay.
Did he say anything about any meds being
stored in bottles?
17
A.
I don't recall.
18
Q.
You mean you don't recall if he said that or you
19
don't recall in general?
20
A.
I don't recall in general.
21
Q.
Would it refresh your recollection if you referred to
22
your report?
23
A.
Yes.
24
Q.
Then please do so.
25
Yes, ma'am?
26
A.
I don't recall him indicating bottles.
27
Q.
Okay.
28
Flip your report back over so it's not face
up.

1232
A.
Oh, sure.
Q.
Did you discuss Gary Benefield's oxygen tank with
Kris McCausland in any detail?
A.
Yes.
Q.
What was that discussion like?
A.
I asked him in regards to the oxygen being empty or
full, he indicated it was empty and any attempts to get it
filled for him.
Q.
What do you mean by "any attempts to get it filled"?
10
A.
Were the staff making any attempts to get his oxygen
11
tank filled for him.
12
Q.
And what was said in that regard?
13
A.
I believe Mr. McCausland indicated that it wasn't
14
urgent because the client had indicated that he didn't need it
15
because he had his inhaler.
16
17
Q.
Okay.
So that's what Kris McCausland told that you
Gary Benefield told him?
18
A.
Yes.
19
Q.
Did you ask McCausland if he had ever had any
20
patients with oxygen before?
21
A.
I don't recall if I asked him that.
22
Q.
Would it refresh your recollection if you referred to
23
your report?
24
A.
Yes.
25
Q.
You may do so.
26
27
28
Do you remember now?

A.
Yes.
So I remember he had indicated that it was the
first client that he had worked with that required oxygen.

1233
Q.
Okay.
Now, are there any best practices or
guidelines regarding monitoring in a residential detox
facility?
A.
I don't understand your question.
Q.
Well, you said that there are certain things that
differentiated a social detox facility from a medical model.
And so I'm asking, I guess, is there any kind of guidelines or
programs at ADP, the Alcohol and Drug Programs, you would give
folks about, you know, you're a social model, you're supposed
10
to monitor; you're a medical model, you're supposed to hook
11
them up to machines that monitor.
12
or directions you know about in that regard?
13
14
15
16
17
Any sort of best practices
Well, let me just step back.
What does monitoring a
detox patient mean to you?

A.
So in our programs, that monitoring would be visual
checks of the clients to ensure that they're okay.

Q.
Okay.
And do you know -- understand that there are
18
any guidelines or directions on how often a client in a detox
19
facility was supposed to be visually checked?
20
A.
In a licensed facility, there are no regulatory
21
requirements for time frame, so what the department will
22
follow and hold a program accountable for is their own
23
policies and procedures.
24
Q.
So did you review policies and procedures for A
25
Better Tomorrow regarding visual checks on clients to make
26
sure they were okay?
27
A.
Yes.
28
Q.
And your review of A Better Tomorrow's policies and

1234
1
2
procedures, do you remember what it told you about monitoring?

A.
Yes.
From what I recall, there were -- it was a
little confusing because there were some indicators that it
was every four hours that clients need to be checked on, and
then I also found other indicators that their policy was to do
two-hour checks on clients.
7
8
Q.
Okay.
And were those policies all for A Better
Tomorrow?
A.
Yes.
10
Q.
Did you talk with Kris McCausland about monitoring in
11
general?
12
A.
Yes.
13
Q.
Do you remember what he told you?
14
A.
He indicated that he is -- was supposed to do regular
15
checks for any detoxing clients, and specifically
16
Mr. Benefield, he was supposed to do, I believe, four-hour
17
checks on him.
18
19
Q.
And did he say anything about whether or not he had
done a four-hour check?
20
A.
He indicated he had not.
21
Q.
And so did he give you a time -- the last time he saw
22
Gary Benefield alive?
23
A.
I believe it was around 12:15 a.m.
24
Q.
And when did he see him the next time he saw him?
25
A.
At 8:00 a.m. when he had found him deceased.
26
Q.
But that's not a rule of the State or anything,
27
28
that's the policies and procedure of A Better Tomorrow?

A.
The checks?

1235
Q.
Yes.
A.
Correct.
Q.
Okay.
I want to go back to the oxygen for just a
moment.
Did Kris McCausland tell you that Gary Benefield made
any requests to him about oxygen?
A.
I don't recall.
Q.
Would you -- okay.
I'll leave it at that for a
moment.
If you wrote in your report that Kris McCausland told
10
that you Gary Benefield never made any requests for oxygen,
11
would that be -- and you had never in quotes, why would never
12
be in quotes?
13
A.
If it is in quotes, then that would be -- I would
14
have put it in quotes because that's the exact word that
15
Mr. McCausland used while I was interviewing.
16
Q.
Okay.
Would you look at your report on page -- I'm
17
sorry, I had it.
18
paragraph, and I'm going to show you where I'm referring to.
19
I want you to say whether those are the words McCausland told
20
you, so start right here.
21
A.
Yes.
22
Q.
Okay.
23
On page 9 of 24, there's a big middle
So -Would you read that sentence starting from
where I pointed out.
It says, "That" --
24
A.
"That it was okay and could be filled the next day."
25
Q.
And read the next sentence, please.
26
A.
"Mr. McCausland stated that Client 1 never asked for
27
his oxygen tank to be filled.
And from what he was told,
28
Client 1 was already asked and if he needed it to be filled

1236
1
2
3
and he declined to them as well."

Q.
All right.
And some portions of that are in quotes,
are they not?
A.
Yes.
Q.
And so that would have been because it's exactly what
Kris McCausland told you?
A.
Yes.
Q.
All right.
Now, it's my understanding we're going to
break at a quarter 'til.
So I want you to turn back to the
10
very first page of your report.
And if I may, I'm going to
11
project this up on the screen.
12
pointer from you?
13
our projection equipment, you may not be able to read this on
14
the screen, but I'll give you the form back, if necessary.
15
Remember on the other program investigative report or PIR you
16
read the number up here?
And may I get the laser
And because we have had difficulties with
17
A.
Yes.
18
Q.
Okay.
19
A.
330071CP.
20
Q.
Is that the same number and alphabetic designations
21
Can you read that number?
in the other report?
22
A.
No.
23
Q.
What's different?
24
A.
The A and the C.
25
Q.
Indicating what?
26
A.
That it's a different location.
27
Q.
And this location is?
28
A.
The Iron Gate Lane.

1237
Q.
Okay.
And in the middle of the top of the -- oops,
wrong button.
The middle of the top of the PIR right here
where I'm circling, what's that?
A.
That is the name of the facility.
Q.
And what's it say on this?
A.
Forterus Health Care, Inc.
Q.
Did you fill in this form yourself?
A.
Yes.
Q.
Where would you have gotten that information?
10
A.
From a licensing document.
11
Q.
All right.
12
A.
In the licensing file or in our database.
13
Housed where?
licensing database.
14
Q.
Okay.
15
A.
That is the name of the legal entity, the
16
We had a
And here I'm circling.
What's that?
corporation.
17
Q.
And what's it say?
18
A.
A Better Tomorrow, ABTTC, Inc.
19
Q.
So tell me what's the relationship between the
20
program facility name and the program facility legal name, if
21
you can?
22
A.
So the legal entity is generally the corporation that
23
owns the company and the facility name, the Forterus, is the
24
name of the actual facility.
25
26
Q.
Okay.
So Forterus was the name of the actual
facility at 42368 Iron Gate when you did this report?
27
A.
Yes.
28
Q.
Okay.
Let me just get a date of when you did this

1238
report.
Is it -- is the report dated there?
A.
Yes.
Q.
Where?
A.
At the bottom.
Q.
Okay.
I'm going to give you back the laser pointer.
Please show us where it's dated.
Right there.
What's it say?
A.
That is March 8th, 2011.
Q.
And there's a signature to the left of that.
Whose
signature is that, if you recognize it?
10
A.
Mine.
11
Q.
Janelle Ito-Orille?
12
A.
Yes.
13
Q.
So did your investigation take from August, I believe
14
you said you started, until March of 2011 to complete?
15
A.
Yes.
16
Q.
And do you know whether or not during that time the
17
18
19
20
program facility name was changed in any way?

A.
down.
Q.
The only knowledge I have is that the program closed

That was the change.
All right.
Did you talk to people who represented
21
that they were in charge of the facility during the time the
22
death occurred there?
23
A.
Yes.
24
Q.
And they're the people you've discussed in your
25
testimony earlier?
26
A.
Yes.
27
Q.
Okay.
28
And so if I'm understanding, their corporation
was known as A Better Tomorrow, ABTTC, Inc., and the facility

1239
at Iron Gate had a formal name in your database as Forterus
Health Care?
A.
Yes.
Q.
Okay.
Thank you.
Now, it is a little past a quarter
'til.
MR. SAMUELS:
Mr. Foreman, what I would ask is this
witness be excused to remain present in the -- at our beck and
call, so to speak, and that the witness who has a limited time
to testify be called at 1:00 so his testimony can be included,
10
and then Ms. Ito-Orille's testimony can be completed and/or
11
concluded.
Is that appropriate?
12
13
MR. SAMUELS:
14
Yes, Counsel.
And I intend to finish at or before
4:30 today.
15
Okay.
Ms. Ito, you are
16
admonished not to reveal to any person, except as directed to
17
the Court, what questions were asked or what responses were
18
given, or any other matters concerning the nature or the
19
subject of the grand jury, unless and until such time as the
20
transcript of this grand jury proceeding is made public.
21
Violation of this admonition is punishable as contempt of
22
court.
23
THE WITNESS:
24
25
MR. SAMUELS:
26
27
28
Okay.
You are excused.
The jury will take a recess and should
promptly be back by 1:00 p.m.
Thank you.
(Lunch recess.)

1240
to order.
Will the secretary please take roll again.
GRAND JUROR NO. 1:
GRAND JUROR NO. 2:
GRAND JUROR NO. 3:
Juror No. 1.
Here.
Juror No. 2.
Here.
Juror No. 3.
Here.
10
Juror No. 5.
11
GRAND JUROR NO. 5:
12
13
GRAND JUROR NO. 6:
14
15
GRAND JUROR NO. 7:
16
17
GRAND JUROR NO. 8:
18
19
GRAND JUROR NO. 9:
20
21
GRAND JUROR NO. 10:
22
23
GRAND JUROR NO. 11:
24
25
Juror No. 13.
26
GRAND JUROR NO. 13:
27
28
GRAND JUROR NO. 14:
Juror No. 4.
Here.
Juror No. 6.
Here.
Juror No. 7.
Here.
Juror No. 8.
Here.
Juror No. 9.
Here.
Juror No. 10.
Here.
Juror No. 11.
Right here.
Juror No. 12, here.
Here.
Juror No. 14.
Here.

1241
GRAND JUROR NO. 16:
GRAND JUROR NO. 17:
And Juror No. 19.
GRAND JUROR NO. 19:
10
11
Juror No. 15.

Here.
Juror No. 16.
Here.
Juror No. 17.
Here.
Juror No. 18.
Here.
The record will reflect all
17 jurors are present.
12
Counsel, good afternoon.
13
MR. SAMUELS:
Good afternoon.
In preparation for
14
this witness' testimony, could I have the photos from the
15
house?
16
Are we ready for the witness?
17
18
Reminder to everyone, please turn off your electronic
19
devices or silence them.
20
Yes.
Thank you.
Please remain standing and raise your right hand,
21
please.
22
23
24
25
THE WITNESS:
I do.
26
27
THE WITNESS:
28
Please be seated.
Thank you.
I have a statement

1242
acknowledging a secrecy order that I would like you to read.
THE WITNESS:
Okay.
the bottom.
THE WITNESS:
THE WITNESS:
Sign and print your name at
Okay.
Great.
Thank you.
Would you like me to read out loud or
to myself?
To yourself.
10
MR. SAMUELS:
To yourself.
11
THE WITNESS:
Okay.
12
13
14
15
THE WITNESS:
Sure.
My name is Joseph I. Cohen,
16
first name is J-o-s-e-p-h, middle initial I., last name
17
C-o-h-e-n.
18
19
THE WITNESS:
20
21
MR. SAMUELS:
22
Thank you.
You're welcome.
Counsel, you may proceed.
Thank you.
JOSEPH I. COHEN,
23
24
follows:
25
26
DIRECT EXAMINATION
BY MR. SAMUELS:
27
Q.
Good morning -- good afternoon, excuse me.
28
A.
Good afternoon.

1243
Q.
And how are you employed, if at all?
A.
I am a forensic pathologist, a full-time practicing
forensic pathologist in Northern California through my
company, United Forensic Services.
Q.
Now, is a pathologist a particular profession?
A.
Yes.
Q.
What's that?
A.
Well, a forensic pathologist is a very specialized
type of physician that generally deals with coroner cases or
10
medical examiner cases.
11
by law, reportable to the coroner or medical examiner.
12
that would include homicides, suicides, accidents, any
13
unnatural death, any sudden unexpected death, unattended
14
deaths of children, deaths involving law enforcement, deaths
15
that may be a public health issue, such as an outbreak of
16
disease, and so forth.
17
what a forensic pathologist does, this is a physician who
18
generally performs autopsies for the purpose of determining
19
the cause of death, that is, why the person died, as well as
20
the manner of death, which is just a box that's checked on the
21
death certificate, whether the death is a natural death,
22
accident, suicide, homicide, or undetermined.
23
24
Q.
All right.
These are deaths that occur and are,
These would be all reportable.
for identification as Exhibit 90.

A.
Okay.
26
Q.
Do you recognize this document?
28
And so
And I'm handing you what's been marked
25
27
So
It's a multipage
paper-clipped document.
A.
Yes.

1244
Q.
What is it?
A.
This is my curriculum vitae, my CV.
Q.
Is that like a resum for lay people?
A.
Yes.
Q.
And briefly could you describe your educational
background?
A.
Sure.
Well, I was raised in Arizona.
I attended
high school there and college.
Science in Biology at the University of Arizona in Tucson.
10
I received my Bachelor of
I went on to medical school in Milwaukee, Wisconsin,
11
Marquette University Medical School, which is now known as the
12
Medical College of Wisconsin.
13
training and my medical degree from there.
14
So I received my medical
After that, I returned to my hometown of Phoenix,
15
Arizona, and I spent one year of training in general surgery.
16
That was my internship the year following medical school.
17
After that, I switched to pathology, general
18
pathology, and I spent four years training at UC Irvine,
19
University of California, Irvine program, based in Orange --
20
Orange, California.
21
which includes both anatomic and clinical pathology, mostly
22
hospital-based pathology with only maybe one month of forensic
23
training in those four years.
24
This was my general pathology training,
After that, I relocated to New York City to Manhattan
25
and I spent one year training in forensic pathology.
This was
26
my first exposure to performing autopsies in a medical
27
examiner setting on a regular basis.
28
forensic autopsies in that year, 1994, '95, in Manhattan at
So I performed about 300

1245
the Office of Chief Medical Examiner under the supervision of
my boss, Dr. Charles Hirsch.
Following that year, I remained on the staff as a
full-time medical examiner in New York City performing
autopsies on a day-to-day basis.
for five years almost to the day.
So I was in New York City
For the last four years of that, I was stationed
primarily in the Bronx but also performed autopsies in
Manhattan and Brooklyn.
10
Following -- that takes us to June and July of 1999
11
where I was offered the position of Chief Forensic Pathologist
12
for the county we're in today, Riverside County.
13
accepted that position at a time that the lay coroner was
14
being transitioned to a sheriff coroner system.
15
hired by the Board of Supervisors under the administrative
16
guidance of the Sheriff, where I spent 11 years, again almost
17
to the day, as the Chief Forensic Pathologist for Riverside
18
County.
And I
So I was
19
Q.
Let me stop you there.
20
A.
Yep.
21
Q.
Chief Forensic Pathologist, that means you were the
22
boss, the head of the forensic pathology department for the
23
County?
24
A.
Yes.
Yes.
I would manage five or six other full-
25
and part-time forensic pathologists that performed autopsies
26
in Riverside County between our two offices, one in Perris and
27
the other in Indio.
28
Indio in the Indio facility.
About a third of our cases were done in

But I would supervise those

1246
other doctors from 1999 to 2010, ones that were either already
performing autopsies when I arrived, plus the ones that I
hired, which were several.
4
5
Q.
So were you the boss of Riverside County Sheriff's
Forensic Pathology Department in July of 2010?
A.
That was my last month.
Q.
Okay.
A.
I believe my last day was July 26th of 2010.
Q.
All right.
10
A.
Maybe August 5th.
11
Q.
Okay.
12
And are you still -I stand corrected.
Are you still working as a forensic
pathologist?
13
A.
Yes.
14
Q.
And have you been continuously licensed since you
15
16
17
18
first got your license back in 1986, was it?

A.
Yes.
In three states, California, Arizona, and
New York.
Q.
And there's, unfortunately, pages -- the copy I have
19
of your CV, the pages are not numbered, but can you tell us
20
after the second page what's contained on your CV, what kinds
21
of entries, just a general characterization.
22
A.
Well, the resum basically has some identifying data,
23
some biographical information, where I'm from, my experience
24
that I've discussed already, short of my current position,
25
which is the Chief Forensic Pathologist of Marin County and
26
Napa County, both in Northern California, through my company.
27
So I incorporated in 2010 at or about the time that I took
28
early retirement from Riverside County.

1247
The resum has a list of numerous lectures and
presentations and other activities, professional activities
that I was involved with, agencies and organizations that I
was either a member or a participant.
of the various topics that I provided training for many
different agencies.
locally and for the State, for defense attorneys and numerous
other agencies, Child Protective Services, and others.
Q.
Okay.
Most of this is a list
That would include district attorneys,
Now, were you presented with materials
10
regarding a death that occurred in Riverside County in
11
Murrieta in July of 2010?
12
A.
Yes, I was.
13
Q.
Could you tell us what materials you were provided to
14
15
review?
A.
Yes.
Well, I received, I believe on -- as multiple
16
PDF files, I think that I received them through the Dropbox
17
process over the Internet.
18
different files.
19
pertinent to my involvement would be the autopsy report of
20
Gary Benefield, which is listed under File No. 2010-05812.
21
And that's an autopsy report that is authored by one of my
22
pathologists at the time, Dr. Marc Fajardo.
And there were some 30 or 35
The -- I think the ones that are most
23
Q.
When you say "at the time," what do you mean?
24
A.
Well, the autopsy was performed on July 27th of 2010.
25
My departure was August 5th, so it was just about a week after
26
that.
27
Dr. Fajardo until September 20th, 2010, which was already
28
quite some time after I had departed.
However, the case was not certified and signed by

1248
1
2
3
Q.
Okay.
We'll get back to what certified and signed
means, but let's stick to what materials you reviewed.

A.
Sure.
So the autopsy report, which lists the cause
of death and other significant conditions, drug testing
reports by Bio-Tox Laboratories, Bio-Tox, B-i-o, dash, T-o-x.
They're based in Riverside.
from the coroner division of the Riverside County Sheriff's.
The coroner investigator's report
Q.
And do you know who authored that?
A.
That was Steve Albert, I believe.
10
Yes, Deputy
Coroner Steve Albert.
11
Q.
Go on, please.
12
A.
And then the rest were numerous medical records,
13
doctors' visits, hospital stays pertaining to Mr. Benefield
14
dating back to, I think, 2006 or '7.
15
16
17
Q.
Galhotra?
A.
Did those records include records from Dr. Simranjit

Do you recall?
I could check.
I don't recall the name.
18
depends on -- I'm not sure.
19
the name.
20
21
22
Q.
All right.
It's possible.
And it
I don't recall
What's the easiest way for you to recall
which records you reviewed?

A.
Well, the easiest way is, you know, this is the --
23
these are the PDFs.
So I have a single page, which doesn't
24
really say much.
25
some 35 or so, approximately, PDF files.
26
fairly short, in the five- to seven-page range.
27
longer, such as the autopsy report and the coroner
28
investigator's report and the Murrieta Police Department
These are labeled by numbers.
So there are
Most of these are

Several are

1249
report, which I believe was 35 pages.
reviewed that.
So that was there and I
The other records were -- pertain to doctor visits
and at least one recent hospital stay that was, I believe,
July 13th through the 17th or 18th.
question on the -- on the date of discharge, but that was
about a week before the death of Mr. Benefield.
about a one week hospital stay where he was admitted with
pneumonia.
There's a little bit of
10
Q.
Do you remember where that was?
11
A.
That was -- let's see, that was at --
12
There was
it was White
Mountain Regional Medical Center in Springerville, Arizona.
13
Q.
Okay.
14
A.
Yeah.
15
Q.
-- including the police report that you've already
16
All right.
So you reviewed those materials --
indicated regarding the death of Gary Benefield?
17
A.
I did, yes.
18
Q.
And you reviewed Dr. Fajardo's autopsy?
19
A.
I did, yes.
20
Q.
And did you obtain and review pictures of the
21
decedent as he was found?
22
A.
I sure did, yes.
23
Q.
And did you get any records regarding any medications
24
or prescription drugs the decedent was provided on July 25th,
25
this evening -- his last evening?
26
A.
Yes.
27
Q.
All right.
28
Now, what did -- in your examination of
this patient, was there anything about him physically that was

1250
remarkable in your opinion?
2
3
A.
By way of the clinical history or by way of the
autopsy findings?
Q.
I want to talk about his clinical history.
A.
Yes.
Q.
If you were to see this patient's medical records --
A.
Yes.
Q.
-- and not know he was dead, was there anything in
9
10
11
those medical records that you would have said that stands
out?
A.
Absolutely, yes.
He was quite ill.
Even though he
12
was not that advanced in age, I think 52 or 53 years of age,
13
he had a long-standing history of severe emphysema, chronic
14
obstructive pulmonary disease, and he was requiring 24/7
15
oxygen to supplement to keep him alive.
16
of congestive heart failure and some atrial arrhythmias, such
17
as atrial fibrillation and atrial flutter, I believe.
18
heart was not in great shape from hypertension, from high
19
blood pressure over time.
He also had a history
So his
20
He also had pneumonia, which I mentioned earlier.
21
That's all directly related to heart and lung disease, the
22
development of pneumonia, including up to a week before his
23
death.
24
Q.
What about bad habits, if any?
25
A.
Yeah, he did.
26
aside.
27
drinker of alcohol.
28
problem for him as well.
What else?
And I was going to mention that as an
He was a smoker of many, many years and he was a

So he was an alcoholic and that was a big

1251
Q.
All right.
Now, do you know -- you said he was
required to have oxygen at all times as a supplement to keep
him alive.
A.
Do you know how much oxygen he was using?
It was many liters per minute by the nasal prongs or
nasal cannula.
than ten liters per minute.
7
8
Q.
So I don't know if was eight to ten or more
All right.
Do you have an impression that it was
less than that on a regular basis?
A.
No.
10
Q.
This is two pages out of an exhibit that's been
11
labeled as Exhibit 40, which were the records of Eileen
12
Furman, a family nurse practitioner who treated Gary Benefield
13
in July of 2010.
14
It's a two-page document.
And this is her record of July 20th, 2010.
15
A.
Okay.
Thank you.
16
Q.
Could I offer it for your quick review?
17
18
19
THE WITNESS:
Q.
Okay.
BY MR. SAMUELS:
Now, that record from Nurse
20
Practitioner Furman, did it note, from your reading and
21
review, how much supplemental oxygen Gary Benefield was
22
receiving on July 20th?
23
A.
Yes.
24
Q.
How much?
25
A.
It was 4 liters by nasal cannula, and then it says 2
26
liters at 86 percent.
27
oxygen saturation.
28
Q.
So that was insufficient to maintain
Why is 86 percent

1252
insufficient?
A.
means.
100 percent.
that's a measurement of the amount of oxygen that's being
bound to the red blood cells in your body.
blood cells are only 86 percent saturated, then about
14 percent of the oxygen that you should have being
distributed to the tissues, 14 percent less is actually making
10
11
If that's what that means.
I think that's what that
The normal oxygen saturation should be close to

It should be 97, 98 percent, in that area.
And
So if the red
it to the brain and to the heart and vital organs.

Q.
Including that record and all the other records you
12
reviewed, can you characterize your conclusions about to what
13
degree Gary Benefield was dependent on supplemental oxygen?
14
A.
Very, very high degree.
I would say -- I mean, how
15
do you express that in words?
16
being very little dependency and 10 being that oxygen -- your
17
life depends on your oxygen supplementation, I mean, it's got
18
to be at least an 8 to a 10, in my opinion.
19
I mean, if on a 1 to 10, 1
This is a gentleman that had severe emphysema that is
20
well-documented back to 2007, at least that far back.
21
it's -- he was dependent upon oxygen, no question about that,
22
very much so.
23
Q.
When you say dependent on oxygen.
24
A.
We are.
So
Aren't we all?
Unfortunately, his lungs were damaged to an
25
extent that they themselves were unable to exchange oxygen and
26
carbon dioxide with the environment sufficiently.
27
Q.
You mean "they," his lungs?
28
A.
His lungs, yes.

1253
Q.
Okay.
Now, did you review -- did the records you
reviewed include any medications that were provided to Gary
Benefield on July 25th, 2010?
A.
Yes.
Q.
And what did you learn about the medications?
A.
Well, the two that he was provided with on that day
were trazodone and Serax.
Serax is also known as oxazepam and
that's an antianxiety agent and also used for -- to treat
alcohol withdrawal.
And trazodone, the other drug, is an
10
antidepressant but also used as a sleep aid, and some other
11
things as well.
12
13
Q.
Now, do you know if these drugs fall in any class of
prescription drugs?
14
A.
Yes, they do.
15
Q.
And what's that?
16
A.
Serax falls under the class of benzodiazepines,
17
B-e-n-z-o-d-i-a-z-e-p-i-n-i-s or e-s, I guess.
I'm glad it's
18
not a spelling bee today.
19
which is the general antianxiety class.
20
antidepressant.
21
inhibitor, along with some other mechanisms, but it's an
22
antidepressant.
So oxazepam is a benzodiazepine,
And trazodone is an
I believe it's a serotonin reuptake
23
Q.
And, to your knowledge, are these prescription drugs?
24
A.
Absolutely, yes.
25
Q.
And you're a physician; right?
26
A.
Yes.
27
Q.
So what can you tell me about prescription drugs that
28
are available out there?

1254
A.
Well, unfortunately, they are too available many
times, you know, through my experience.
You know, drugs are
actually categorized as being highly addictive or not so much.
And so the rules and regulations for each of the drugs are
different depending on the type of drug in terms of who can
prescribe and what for and so forth.
a pathologist, so I don't regularly prescribe, you know,
prescription medication.
for family and friends when they need antibiotics.
So in my experience, I'm
On occasion I do, but I generally do

I would
10
never prescribe an opiate drug like methadone even for family
11
members.
12
think that's crossing a line.
13
be prescribed by physicians who are seasoned at and
14
experienced at using them and prescribing them.
15
16
Q.
And I know that, you know, some doctors do and I
All right.
But these are drugs that should
So these are drugs that should be
prescribed by a physician?
17
A.
Absolutely.
18
Q.
Would it be inappropriate for these drugs to be
19
handed out by a nonphysician?
20
A.
Absolutely.
21
Q.
All right.
Now, if Gary Benefield were deprived of
22
his supplemental oxygen, what would this effect on him be, in
23
your medical opinion?
24
A.
Well, the effect of not having his supplement in the
25
way of oxygen is that he is going to feel air hunger.
He's
26
going to feel like he's just not getting enough air.
27
is a noxious stimulus, meaning it's -- if anybody has, you
28
know, had the experience of either inhaling something that's a
And that

1255
noxious gas or, you know, a near drowning accident or
something like that, the feeling of not having adequate oxygen
supply is quite scary.
shortness of breath.
faster to get more air and oxygen in to compensate for that.
His heart rate would increase to try to get the blood to the
tissues and what -- what oxygen remains to the tissues in the
absence of his supplemental oxygen.
So he would experience air hunger,

His body would naturally try to breathe
So there are bodily physiological functions that take
10
effect, either consciously or subconsciously, in the presence
11
of low oxygen saturation in the blood.
12
effect on his body would be.
So that's what the
13
Q.
Now, do these things occur all at once?
14
A.
They occur together in time fairly much.
I mean, I
15
think that, you know, the increase in breathing rate and the
16
increase in heart rate would occur at or about the same time.
17
I'm not an exercised physiologist, but I can say that, for
18
example, both of those functions would increase to try and get
19
more oxygen to the brain and the heart.
20
Q.
Okay.
21
A.
Okay.
22
Q.
And in the records you reviewed, did you notice a
23
Well, let's turn to your area of expertise.
time when death was pronounced on Gary Benefield --
24
A.
Yes.
25
Q.
-- by a qualified person?
26
A.
It was 8:09 in the morning on the 26th of July, 2010.
27
Q.
And did you see any indication of when there was a
28
last sighting of Gary Benefield by anybody when he was alive?

1256
1
2
3
A.
It was some eight hours earlier, maybe just after
midnight, 12:30, I think.

Q.
Now, were you able to determine from your review of
the records what time Gary Benefield stopped using
supplemental oxygen on the 25th?
A.
Approximately, yes.
Q.
Can you give me that approximate time?
A.
On the 25th, that would have been his trip from
Phoenix to San Diego arriving at -- well, he had the oxygen
10
tank at the airport in Phoenix.
Reportedly that tank was
11
emptied at the airport.
12
I know he checked in at about 5:30 p.m.
So whatever time he departed Phoenix,
13
Q.
Checked in where?
14
A.
Checked into A Better Tomorrow.
15
Q.
All right.
So let's work back from 5:30 and I'm
16
going to ask you to take some things as facts because I
17
believe there's been testimony to these timelines.
18
A.
Okay.
19
Q.
If he checked in and did intake at A Better Tomorrow
20
at 5:30, and he was driven there and it took 45 minutes to an
21
hour from another facility, and he had gone to that facility
22
from the airport where it took awhile to find him and get him
23
to the facility, about 45 minutes, I believe, so we're back an
24
hour and a half.
25
Phoenix, so we're about an hour and a half, plus another hour
26
from 5:30, now we're back to about 3:00.
And the flight took about an hour from
27
A.
Correct.
28
Q.
So let's say between the hour of 2:00 and 3:00, just

1257
for the sake of putting a bracket around it, Gary Benefield
stopped using supplemental oxygen.
A.
Okay.
Q.
And I want you to further presume that at around
4:30, Gary Benefield was provided with two 15 milligrams pills
of Serax.
A.
Okay.
Q.
And that at about 2100 hours or 9:00 on the evening
of 25th, he was given two more 15 milligrams Serax, as well as
10
three 50 milligram trazodone, as well as two number 3, if that
11
has a meaning to you, Tylenol with codeine?
12
A.
Yes.
13
Q.
Now --
14
A.
At 9:00?
15
Q.
Yes.
16
A.
Okay.
17
Q.
You have all of those written down --
18
A.
Yeah.
19
Q.
-- or in your mind?
20
A.
Yes.
21
Q.
Now, before you go to that, in general, what would
22
the effect of Serax be?
23
was an antianxiety drug.
24
25
A.
Yes.
You said it was benzodiazepine that
It's a central nervous system depressant, so it
will slow the breathing.
26
Q.
What about trazodone?
You said it's a sleep aid.
27
A.
Same thing.
28
Q.
And what about Tylenol with codeine?

1258
1
2
A.
Definitely codeine, same thing, depresses
respiration.
Q.
And what class is codeine?
A.
Codeine is an opioid or opiate drug.
5
6
It's a narcotic
drug.
Q.
Okay.
Now, in a patient or person who has
compromised lungs because of COPD, to the extent that you've
seen in your review of the medical records -- you've seen
Dr. -- I'm sorry, Nurse Practitioner Furman's notes from just
10
a few days before -- do you have an impression of what effect
11
these drugs and the lack of oxygen would do to Gary Benefield?
12
13
A.
They -- they would do no good.
This would -- would
put him over the edge potentially, and did.
14
Q.
And what do you mean by "put him over the edge"?
15
A.
Well, I mean that he's already in pretty bad shape
16
even with the oxygen.
17
Without his oxygen, especially for that long, if it was from
18
3:00 in the afternoon until -- let's just assume for the
19
purpose of discussion that he died shortly after he was last
20
seen, say, at 12:30 or 1:00 in the morning, if that was the
21
case, it would be still at least about ten hours of being, you
22
know, without his oxygen.
23
8:09 in the morning, then that adds that many more hours to
24
it, although the autopsy evidence does not -- or the scene
25
photographs and the scene investigation does not point to the
26
death occurring closer to 8:00, it points at death occurring
27
in the early morning hours.
28
Q.
Without it, it's a ticking time bomb.
And if he had expired closer to
So you've reviewed your report from the deputy

1259
coroner on the scene, Travis -- I'm sorry, not Travis -- what
was his name, please?
Steve Albert.
A.
Yes.
Q.
And did you review the pictures?
A.
I sure did, yes.
Q.
Okay.
I've got Exhibit 43, which has a number of
pictures that Deputy Albert testified to earlier today.
A.
Okay.
Q.
And I'm going to show them to you for your comment
10
regarding what you just said about what they indicate as to
11
the possible time of death.
12
A.
Okay.
13
Q.
So this is out of the exhibit.
This is page marked
14
000167 that shows where Gary Benefield was when the deputy
15
coroner observed him.
16
picture, Doctor?
17
A.
Now, what can you say about this
Well, this picture, it's -- the resolution, at least
18
on the screen, is not the best, but it does tell us quite a
19
bit of information.
20
Q.
There was a laser pointer.
21
A.
I think this may be it here.
22
Q.
Okay.
23
A.
Make sure I hit the right button and not something
24
25
26
27
28
Great.
Red button.
that's going to set off anything.

Q.
Right up in the top in the middle there's a red
button.
A.
There we go.
Okay.
So Mr. Benefield is in a
facedown sort of a crouched position.
To me -- well, I mean,

1260
the first thing that stands out is the appearance here is that
of a sudden -- fairly sudden collapse.
comfortable, you know, sleeping position.
just collapsed and died right here.
He's not laying in a

It looks like he
The next thing that stands out is this deep red
purply discoloration that you can see on the upper back,
shoulders, and all extremities.
color, and that's livor mortis or livor mortis.
pooling of blood after death in the dependent portions of the
It's very deep, purply red

That's
10
body closest to gravity.
So the blood pools and, hence, the
11
areas that are closest to the ground become red.
12
And this is very, very vivid.
And you can see that
13
the back doesn't have any down by the buttocks, the lower
14
back, and the midback, so that's because that's the upper part
15
away from gravity and the blood is pooling downward.
16
This is a very intense livor mortis.
This does not
17
happen in seconds or minutes.
Something like this takes hours
18
to develop like this.
19
mortis patterns you'll see.
20
many hours?
21
taken, going backwards, I mean, it could be 6 or 12 hours, I
22
mean, if I didn't know anything else about the case.
23
quite prominent.
This is one of the most intense livor

So this puts -- one may ask how
I would say that from the time this picture was
It's
24
Q.
Okay.
25
A.
It could be longer, I mean, with -- depending on
26
27
28
Now, I'm going to show you another --
environmental factors.
Q.
Okay.
I'm going to tell you that there's testimony
that the room was cool, somewhere between 70 and 78 degrees.

1261
A.
Okay.
Q.
This is page 000168 from this exhibit and this is the
decedent, Gary Benefield.
from that last photo?
A.
It does.
Now, does this add to your analysis
It does add another attribute.
This -- not
only can we see the livor mortis more easily since it's --
we're facing it, but the appearance here is that the joints
are stiff, that the knees are -- the legs are flexed, and the
upper extremities are flexed.
This is rigor mortis, or the
10
stiffening of the muscles after death that occurs.
And this
11
doesn't occur in seconds to minutes, this would take several
12
hours or longer depending on the environmental conditions.
13
Now, if it's cool in the room, it takes longer to
14
develop these processes.
15
takes longer to develop these livor and rigor mortis patterns.
16
So that adds a little bit more time, relatively speaking, if
17
it was a cool environment.
18
time was that these photographs were taken, we can estimate
19
backwards the approximate time of death.
20
So a cooler environment means it
So depending on what exactly the
Now, I want to point out very clearly that unlike
21
some of the television shows that, you know, putting a time of
22
death based on any postmortem change, whether it's the gastric
23
digestion process, livor mortis, rigor mortis, it's very
24
dangerous and very difficult because there's so many factors,
25
body weight, the type of flooring, the humidity, air currents,
26
if there's a lot of clothing, a lot of factors.
27
generally speaking, the fact that it takes a number of hours
28
doesn't change my opinion here.
So -- but,

1262
1
2
Q.
All right.
Now, rigor mortis, what you just
discussed, the stiffening of the joints --
A.
Yes.
Q.
-- does it get -- is it progressive?
A.
It is progressive.
dissipates.
rigor mortis.
very tense rigor mortis, where it takes a lot of work to even
break the rigor mortis, and then it dissipates over time.
It then peaks and then it
In other words, when a person dies, they have no

In 24 hours or 36 hours, it may peak to be the
10
That continuum can come and go as quickly as six hours in a
11
hot environment in the desert or it can take many days to a
12
couple of weeks or longer in a cold environment.
13
14
Q.
All right.
You've used the terms hot and cool and
cold --
15
A.
Yes.
16
Q.
-- can you put any temperature ranges on those?
17
A.
Yes.
18
Q.
Is that hot or cool or cold?
19
A.
It's in the middle.
20
Q.
Okay.
21
mouth.
22
A.
Comfortable.
23
Q.
Comfortable.
24
A.
Baseline.
25
Q.
All right.
I put 70 to 75 degrees Fahrenheit as average.
Cool/hot?
I don't want to put words into your
Thank you.
So it's neither hot nor cold, so it would
26
be kind of the average progression of rigor mortis in the
27
average dead person.
28
A.
For temperature --

1263
Q.
Okay.
A.
-- yes.
Q.
Okay.
A.
Not average if you're considering my parents because
5
6
they're on completely opposite ends of the spectrum.

Q.
Okay.
We'll leave them out of this.
Now, in your review, did you review -- you said, I
believe, that you reviewed toxicology results from Bio-Tox
Labs.
10
A.
I did, yes.
11
Q.
Did they include a benzodiazepine confirmation panel?
12
A.
They did, yes.
13
Q.
And did they include a confirmation panel for
14
trazodone?
15
A.
Yes.
16
Q.
Okay.
What can you tell us about any findings of
17
trazodone or any findings of trazodone or benzodiazepine in
18
the toxicology of Gary Benefield?
19
A.
Okay.
Both were present in a blood sample.
20
Trazodone was present in the concentration of 0.89 milligrams
21
per liter; and oxazepam, which is Serax, S-e-r-a-x, is the
22
tradename, returned 0.12 milligrams per liter.
23
24
Q.
All right.
Are you familiar with the term
therapeutic dose?
25
A.
Yes.
26
Q.
And how would you relate that to what you see in
27
28
these toxicology results?

A.
I would say that the trazodone is pretty close to the

1264
middle of steady state therapeutic; and oxazepam is not very
high, it's fairly low.
3
4
5
Q.
Okay.
It may be subtherapeutic.
Now, for a layperson, can you give us a lay
definition of therapeutic?
A.
Yes.
So a therapeutic level of a drug would be
the -- well, a therapeutic dose would be the amount of drug a
person needs to take to achieve blood levels that are going to
treat the problem without having adverse side effects.
Q.
Okay.
So when you say without having adverse side
10
effects, is that in a normal stable person or does that
11
account for every person with every medical condition on the
12
face of the earth?
13
A.
Everybody's different.
14
Q.
Everybody is different.
15
A.
Everybody is different.
So a person with severe
16
heart and lung disease would achieve -- generally speaking,
17
with certain drugs, would achieve toxicity adverse effects
18
more easily even with therapeutic concentrations perhaps.
19
There's a lot of variability.
20
Q.
All right.
So, in other words, it's really difficult
21
to say what therapeutic is without knowing what the underlying
22
physical and health conditions are of the individual patient.
23
A.
That's fair.
24
Q.
That's fair?
25
A.
Yes.
26
Q.
Okay.
27
28
All right.
So I want to talk about your
practice as a forensic pathologist.

A.
Okay.

1265
1
2
Q.
When you are asked to reach some sort of medical
opinion about the cause of death --
A.
Right.
Q.
-- for a patient, what kinds of things are important
for you to know as specifically as possible to reach a good
conclusion?
A.
what we do.
investigation is certifying the death fairly and accurately,
That -- the answer to that is really the basis of

And so to -- the essence of forensic death
10
and that requires -- it's fairly simple as long as a
11
systematic approach is taken.
12
a technically adequate autopsy examination, document the
13
findings, review the medical history, any health history, the
14
scene, and the circumstances of the death and then put it all
15
together.
16
determine whether there's any injury that contributed to the
17
death, the injury -- physical injury or drug or poison that
18
caused or contributed to the death either by their presence or
19
by their absence.
20
21
Q.
And that approach is to perform
Part of this involves the autopsy, which is to
Let me stop you.
Just in case anyone is not aware of
what an autopsy is, can you define what an autopsy is?
22
A.
Yes.
An autopsy is an examination of a body after
23
death.
24
surfaces and documenting tattoos and scars, body height and
25
weight, and other identifying features, and then we make
26
incisions on the body to remove and examine the organs one by
27
one all for the purpose of determining the extent of natural
28
disease, the presence of any physical injury, and then through
We do an external examination, looking at the body

1266
drug testing, whether there are any contributing factors from
drugs or alcohol.
Q.
Now, when you were the chief of the Riverside County
forensic pathology department, did you have any policy that
you personally implemented to achieve this kind of
put-it-all-together approach to an examination of someone's
death?
A.
I sure did, yes.
Q.
Can you describe those policies?
10
A.
Yeah.
I remember them vividly.
I arrived in July of
11
1999.
12
and procedures in place, not to embarrass the Sheriff, and to
13
provide fair and accurate death certification for the citizens
14
of the County.
15
I mean -- and people weren't happy about that, including my
16
doctors sometimes.
17
know if it's still in use.
18
still uses it.
19
Worksheet and Inventory Form.
20
form that you can check what specimens were retained from the
21
autopsy, what, if any, records were reviewed for the case,
22
what samples were taken, any evidence that was taken.
23
very straightforward and fairly complete, nice form that one
24
just needs to make some checks and fill in some blanks and
25
then it's there for the record.
26
Q.
I was -- I was requested by the Sheriff to put policies
And so I did that through numerous forms and,
But I actually had a form that -- I don't

I still use it and New York City
That's where I got it.
And it's called a
And that is just a single-page
It's a
Now, was it a policy that you implemented during your
27
time as a chief pathologist that the pathologist in your
28
employee -- in the employ of the Riverside County Forensic

1267
Pathology Department used such a checklist?
A.
They were supposed to use that checklist, yes.
Q.
They were supposed to?
A.
Absolutely.
Q.
And would it be a document that would be attached to
6
7
8
9
10
11
a copy of an autopsy?
A.
It wouldn't be part of the text portion of the
autopsy, but it would be available to attorneys on subpoena.

Q.
All right.
And did you receive the entire autopsy
file in the materials you reviewed for this case?

A.
I did.
I received what's called the packet.
The
12
packet is three things.
13
autopsy report, and the coroner investigator's report, that
14
triad or that packet, those three things.

Okay.
It's the toxicology testing, the
15
Q.
I'm handing you what's been marked as
16
Exhibit 91.
17
review that and tell me if you recognize it?
It's a multiple-page stapled document.
Could you
18
A.
Yes.
19
Q.
What is it?
20
A.
This is an autopsy report pertaining to Gary
21
Yes, I do.
Benefield authored by Dr. Marc Fajardo.
22
Q.
Do you know Dr. Fajardo?
23
A.
I sure do, yes.
24
Q.
And how long have you known him?
25
A.
I've known him since August of 1999, I believe,
26
August or September.
27
in Riverside County.
28
Q.
It would have been right after I arrived
And what -- in what context did you know him?

1268
A.
I hired him.
Q.
As?
A.
As a full-time forensic pathologist.
Q.
Did you do any of his training?
A.
Not formal training.
He was trained elsewhere, but I
was his supervisor.
Q.
For how long were you his supervisor?
A.
I was his supervisor for the entire time that I was
9
10
here through my departure of August 6th or August 5th of 2010,

11 years.
11
Q.
So in July of 2010, you were Mark Fajardo's
12
supervisor?
13
A.
Yes.
14
Q.
And have you seen this autopsy protocol before?
15
A.
I sure have, yes.
16
Q.
And have you reviewed it as part of your review of
17
this case?
18
A.
I sure have.
19
Q.
Is there anything that you see in here -- well, first
20
of all, let me just start out this way.
21
death assigned by this autopsy protocol?
Is there a cause of
22
A.
There is, yes.
23
Q.
And what is it?
24
A.
The cause of death is hypertensive cardiovascular
25
disease.
26
Q.
And is there another significant condition specified?
27
A.
Yes.
28
Q.
What's that?

1269
A.
Chronic obstructive pulmonary disease.
Q.
Now, just to start with, you mentioned that an
autopsy includes an external and internal examination.
they reflected in this report?
Are
A.
They are, yes.
Q.
And what other things are reflected in this report?
A.
In this report?
Well, this report has again a
description of the external examination of Mr. Benefield as
well as the description of the organs one by one.
10
Q.
Okay.
11
A.
Sure does, yes.
12
Q.
Does it include the lungs?
13
A.
Sure does, yes.
14
Q.
Now, on the very last page of the report, do you see
15
Does that include the heart?
a signature?
16
A.
Yes.
17
Q.
And do you recognize that signature?
18
A.
Yes.
19
Q.
Whose is it?
20
A.
Marc Fajardo, M.D.
21
Q.
And just above that, are there a couple of lines of
22
entries?
23
A.
Yes.
24
Q.
Do you see one that's labeled specimens for
25
toxicology?
26
A.
Yes.
27
Q.
And do you see what's written there?
28
A.
I do, yes.

1270
Q.
What are those?
A.
Those are the specimens that were recovered from
Mr. Benefield's body at -- during the autopsy examination,
peripheral blood, which a blood sample, vitreous,
v-i-t-r-e-o-u-s, is the fluid from the eye that we typically
draw on most or every case, gastric contents, liver tissue,
bile from the gall bladder, and urine.
8
9
Q.
And do you associate, in your medical knowledge, any
of these specimens with the toxicology reports you reviewed?
10
A.
Yes.
11
Q.
Which one?
12
A.
Peripheral blood.
13
Q.
Okay.
14
15
Now, I want to turn to -- first, were you
present for this autopsy protocol?

A.
I don't have an independent recollection.
Typically,
16
we would specify in the beginning of the report who was
17
present, and I don't see that mentioned here.
18
an independent recollection of being present for this case.
19
can't exclude it, but I don't remember.
20
21
Q.
Okay.
placed somewhere on the first page.

A.
It should have been, yes.
23
Q.
Okay.
So is there a section that is entitled
cardiovascular system?
25
A.
Yes.
26
Q.
Are all these sections, are they boilerplate?
27
28
But if you were present, it should have been
22
24
So I don't have
Do you
review all these sections in every autopsy that comes in?

A.
Pretty much.
They are boilerplate but we add or

1271
subtract as appropriate.
Q.
And what makes something appropriate?
A.
Well, if there's disease, we specify what the disease
is.
we would add that.
6
7
If something is not normal, as is in the template, then
Q.
Okay.
Now, you see Dr. Fajardo's review of the
cardiovascular system.
A.
Yes.
Q.
What's included there?
10
A.
The heart weight, 550 grams, the fact that it's
What kind of information?
11
enlarged, the description of the heart muscle, the measurement
12
of the thickness of the left and right ventricles, the pumping
13
chambers of the heart, left ventricle being 1.6 centimeters,
14
the right being 1.3 centimeters, and then the rest is fairly
15
template.
16
The coronary arteries of the heart, these are the
17
arteries that supply blood to the heart, the ones that are
18
bypassed by surgeons if they get blocked.
19
slight to moderate blockages, so up to 50 percent narrowing of
20
the three major coronary arteries of the heart.
21
disease there.
22
Q.
They did show
So there was
And those were the significant findings.
Let me ask you this.
Have you done autopsy protocols
23
yourself where someone died to a traumatic condition of the
24
heart?
25
A.
A traumatic?
26
Q.
Such as a vessel blowing out.
27
A.
Oh, many times, yeah.
28
Q.
Okay.
Last week.
And this description of the heart, is there

1272
1
2
any evidence of a vessel blowing out?

A.
There is no -- we would call that a Class 1 finding.
A Class 1 finding is something that we see that clearly
explains the death and without it, the death would not have
occurred.
6
7
Q.
Is there any Class 1 finding with regard to the heart
in this autopsy --
A.
No.
Q.
-- protocol?
10
A.
No.
11
Q.
Now, are you familiar with an important blood vessel
12
such as an artery getting clogged with plaque or some material
13
causing injury to the heart?
14
A.
Yes.
15
Q.
Was there any evidence of that in this autopsy
16
protocol?
17
A.
That's a thrombus.
On top of a plaque, no.
18
Q.
Was there any evidence that the heart stopped for a
19
dramatic reason related to any of the veinous structures or
20
arterial structures?
21
A.
Not related to those structure, definitely not.
22
Q.
Okay.
So what in the examination of the heart is
23
related to the diagnosis of cardiovas- -- what was it,
24
hypertensive cardiovascular disease?
25
A.
Correct.
26
Q.
Can you explain that?
27
A.
Yes.
28
400 grams.
A normal heart weighs between 300 and
Mr. Benefield's heart weighed 550 grams, so it's

1273
about one and one half times normal size.
longstanding high blood pressure that your heart has to pump
over -- pump blood through high pressures and so it
hypertrophies.
500 grams or bigger, we consider that pretty severely
enlarged.
or more.
zone even if he were to have nothing else going on in his
body.
10
It gets bigger.
That occurs through
And once a person reaches
Now, they get up to 1,000 grams on rare occasions

But this is a heart that is clearly in the danger
So it's a significantly enlarged heart.
And we call
that hypertensive heart disease.
11
So hypertensive cardiovascular disease includes the
12
damage that high blood pressure does to the vasculature or
13
blood vessels, which is seen in the kidneys.
14
discussed that, but there's some changes in the kidneys that
15
are consistent with high blood pressure over time.
16
We haven't
So I agree with the conclusion, but I would add -- on
17
top of hypertensive cardiovascular disease, I would add
18
atherosclerotic -- I can spell that.
19
but I think I can do it -- a-t-h-e-r-o-s-c-l-e-r-o-t-i-c.
20
that's just hardening of the arteries.
21
heart and blood vessels, his disease would be best classified
22
as hypertensive and atherosclerotic cardiovascular disease.
23
So that's it for the heart.
It will be challenging,
And
So with respect to his
24
Q.
Okay.
25
A.
The other -- the other findings, excuse me, is the
26
thickness of the ventricles.
So the normal thickness of the
27
left ventricle should be less than 1.5 centimeters.
28
was -- Gary Benefield was 1.6 on the left, a little bit big.
His

1274
That's because again it's hypertrophied from working over time
extra hard.
And on top of that, the right ventricle is
1.3 centimeters, very hypertrophied for the right ventricle.
Normal should be 0.5 or 0.7 maybe at the most.
this is because of the lung disease.
is pumping blood into the lungs and when the resistance to
flow increases because of lung disease, then the heart suffers
from that.
So there was 1.3 centimeters on the right
10
ventricle.
And we call that left and right ventricular
11
hypertrophy.
12
13
Q.
Okay.
The reason for
So the right ventricle
Now, is there a section for respiratory
systems?
14
A.
Yes.
15
Q.
What was written there that's of note?
16
A.
It's fairly easy.
It's a short paragraph, but it is
17
actually, in my opinion, is the biggest problem that
18
Mr. Benefield had was his lung disease, even worse than his
19
heart disease, which was pretty bad.
20
So it lists the weights.
The right lung is
21
660 grams, the left lung is 570 grams.
22
of the lungs.
23
Dr. Fajardo describes as anthracotic mottling.
24
a-n-t-h-r-a-c-o-t-i-c, anthracotic mottling, m-o-t-t-l-i-n-g.
25
That's just smoker's pigment, the black spots that are
26
deposited over time in the lungs.
27
28
There's a description
There's some pigment accumulation which

It's
In addition, Dr. Fajardo describes the lung tissue as

being spongy and hyper crepitant, h-y-p-e-r,

1275
c-r-e-p-i-t-a-n-t.
being like a sponge, well, an abnormal lung with emphysema
would be a sponge with the holes.
So there's more -- they're more airy because of the damage to
the walls to the tissue from smoking over time.
called hyper crepitant.
emphysema.
8
9
That means if you picture a normal lung
The spaces are much bigger.
So that's
That's a very specific description of
He does describe the emphysematous change or the

changes of emphysema to be moderate, which is his subjective
10
opinion.
11
given this state of his clinical condition with his breathing.
12
Q.
I find it interesting that it wasn't more severe,
So what do you mean by that, that everything else you
13
read in your review would indicate a different state of his
14
lungs?
15
A.
I mean, everything that I've read through medical
16
records and hospital stays and his breathing tests that were
17
done in the past dating back to 2007, the description of him
18
having severe emphysema, I would have expected severe and not
19
moderate.
20
okay.
So that becomes subjective and, you know, that's
I mean, we have that disparity sometimes.
21
Q.
Subjective means an individual opinion?
22
A.
Correct.
23
Q.
Now, would you expect to see anything -- any
24
25
condition in his lungs related to his recent pneumonia?

A.
You could.
And so the answer to that is we sometimes
26
look at tissues microscopically.
We take samples and so we
27
can evaluate the status of the lungs more carefully through
28
microscopic examination.
That was not done here, but that

1276
would pick that up.
like pneumonia that's been there for three days versus three
weeks versus three months and say it looks like it's recent,
it looks like it's older, it looks like it's very old.
wasn't done here.
In other words, we can look at disease
The other way we can assess for pneumonia is just by
the appearance and the texture of the lungs.
lungs are very heavy and solidified, very solid and not
spongy, we think then there's something going on, either
10
11
That
So when the
pneumonia, congestion, or edema, or a combination.

Q.
So is there anything at all in this autopsy protocol
12
that indicate that Dr. Fajardo was aware of Gary Benefield's
13
recent hospitalization for pneumonia?
14
A.
No.
15
Q.
All right.
16
Is there anything else under the
respiratory system that's of note?
17
A.
That covers it.
18
Q.
Before I forget, I wanted to ask you about an entry
19
that's on page -- I guess it's the first page, where it says
20
"Final Diagnosis."
21
A.
Okay.
22
Q.
There appears to be four points there.
23
24
Could you
just read through them each and identify them?

A.
"Final Diagnoses, I, decedent status post apparent
25
sudden death event while at a drug rehabilitation center,
26
recently positive for THC."
That's marijuana.
27
Q.
All right.
28
A.
"II, please refer to formal toxicology report."

1277
That's what's stated for II.
"III, hypertensive cardiovascular disease.
that is A, cardiomegaly" -- that's an enlarged heart -- "with
concomitant left ventricular hypertrophy."
thickening of the left ventricular wall.
6
7
That's increased
Then under III as well is "B, nephrosclerosis," and

that's kidney damage from high blood pressure.
8
9
Under
"IV is chronic obstructive pulmonary disease with

moderate emphysematous change."
10
Q.
Okay.
Let's go to III B, the nephrosclerosis.
11
A.
Okay.
12
Q.
What is that about?
13
A.
That simply means that over time a person with high
14
blood pressure tends to get a granularity to the surface of
15
the kidneys or we call it pitting, p-i-t-t-i-n-g.
16
scarring on the surface of the kidney due to high blood
17
pressure.
18
kidneys.
And that's
That's the effect of high blood pressure on the
19
Q.
All right.
So if you were Dr. Fajardo --
20
A.
Okay.
21
Q.
-- I don't mean -- I'm not asking you to criticize
22
Dr. Fajardo necessarily.
I want you to put an unknown
23
pathologist in this position.
24
A.
Okay.
25
Q.
He's presented with a decedent who has this much
26
information.
27
A.
Okay.
28
Q.
Let's assume that this autopsy protocol was done

1278
appropriately and you knew nothing else.
A.
Okay.
Q.
Just what's on the page.
You knew nothing about his
prior medical condition other than decedent's status post
apparent sudden death while at a drug rehabilitation center
recently positive for THC and the rest of it.
would you be able to reach with these findings that are
incapsulated in this report?
What conclusion
A.
Without any clinical history?
10
Q.
Right.
11
A.
Okay.
12
Q.
Yes.
13
A.
And manner of death?
14
Q.
Yes.
15
A.
Well, with the prime- -- I would place the lung
And opinions with respect to cause of death?
16
disease at the top under the cause of death.
Now, seeing what
17
I see in Dr. Fajardo's report, maybe not.
18
saying moderate lung disease and the heart is 550 grams, I
19
don't think I can argue with the way he did it here, but
20
that's not including the clinical history of being on oxygen
21
and having severe emphysema dating back to 2007.
22
known heart issues, but not to the extent that his lung was
23
failing.
I mean, if he's
And he had
24
Q.
All right.
25
A.
So I would have probably kept it somewhat similar to
26
27
28
what Dr. Fajardo says.

Another way to do it would be to specifically say a
fatal cardiac arrhythmia due to hypertensive and

1279
atherosclerotic cardiovascular disease because it looks like a
sudden collapse.
sudden death.
mentioned in Dr. Fajardo's final diagnosis.
the cause of death would be fatal cardiac arrhythmia, which
would occur over seconds due to hypertensive and
atherosclerotic cardiovascular disease which occurred over
years.
would put chronic obstructive pulmonary disease.
12
I would add in the atherosclerotic that was not

So I would say
And then as another significant contributing factor, I
10
11
The heart is big enough to explain the
Now, knowing what I know about the clinical history,

that's not how I would have done it.
Q.
Okay.
So do you believe, as a forensic pathologist
13
and someone who ran a department of forensic pathologists,
14
that in order to have an accurate analysis and reach an
15
accurate and scientifically valid cause of death, that you
16
need to review more than just what's done in the autopsy
17
protocol?
18
A.
Absolutely.
I mean, this is a big problem in our
19
business that, you know, people drop dead on a day-to-day
20
basis and there are families that want answers and there's a
21
lot that rides on these cases.
22
at times, there's a lot of money involved.
23
There's a lot of emotion and
And in -- and they did a great job, I've got to say,
24
in Riverside County when I was here in getting records for us.
25
But whether they were reviewed routinely to the extent that
26
they should have been on some cases, it's hard to say.
27
28
Currently, I'm the only guy in my shop in Marin

County and Napa County.
So I play by my own rules pretty

1280
much, and I've trained the Sheriff's Department to get me
medical records on every case.
basis, hundreds of pages, so I can review them and include
that in my assessment.
Q.
All right.
And I get PDF files on a daily
While you were the chief of the forensic
pathology department here in Riverside County, did you
encourage or direct -- well, did you direct the pathologists
that worked under your control and direction to obtain these
records?
10
A.
The records were obtained.
And, yes, I did direct
11
the pathologists to review records to the extent that is
12
necessary.
13
drops dead there, the medical records don't usually make a lot
14
of difference.
15
surgery from a complication of surgery or something that was
16
placed in the body, it becomes very important.
17
Yes, they were directed.
18
Q.
If somebody is shot dead, shot in the head and
Okay.
But if somebody dies three weeks after having
So it depends.
Is there anything you saw in the packet -- you
19
called it the packet -- that you received regarding the
20
autopsy of Gary Benefield that was done by Mark Fajardo and
21
signed by Mark Fajardo, and includes the toxicology and the
22
report of Steve Albert.
23
Benefield's records, his clinical history?
Did you see anything about Gary
24
A.
I don't recall seeing anything.
25
Q.
All right.
26
Now, I want to show you some sworn
statements that Dr. Fajardo made.
27
A.
Okay.
28
Q.
And we'll go through them and I'd like you to comment

1281
on whether you reached the same conclusions.
These are
statements in two exhibits, one marked 92 and one marked 93.
The first one runs marked pages 15 through 27.
marks -- covers some of the same pages and it's 20 through 23.
The second one
A.
Okay.
Q.
So I'll direct you to certain portions of this.
Okay.
On page 15, Dr. Fajardo was asked if his
conclusion, his determination as to the cause of Gary
Benefield's death was hypertensive cardiovascular disease and
10
he said correct.
Do you see where I'm referring?
11
A.
Yes.
12
Q.
Now, as you stand -- sit here today, excuse me, do
13
you agree with that conclusion?
14
A.
No.
15
Q.
All right.
16
17
What do you believe the cause of Gary
Benefield's death was?

A.
So I -- my opinion is that this is a collapse due to
18
acute respiratory failure due to chronic obstructive pulmonary
19
disease with the heart disease mentioned as a contributing
20
factor, not the primary factor.
21
22
Q.
Is that your opinion to a medical certainty based on
your training and experience?
23
A.
Sure is, yes.
24
Q.
Okay.
25
A.
Okay.
26
Q.
And I'm looking at -- the page has lines on the left
27
side of it.
28
A.
Now, I would like you to turn to page 18.
Do you see those?
Yes.

1282
Q.
Lines 18 through 22.
A.
Okay.
Q.
I'm going to read them out loud and ask you if agree
with this --
A.
Okay.
Q.
-- okay?
"Question:
Okay.
Now, is this hypertensive
cardiovascular disease, is this something
that occurs over many, many years or --
10
"Answer:
11
years to develop."
12
Do you agree with that?
13
A.
Yes.
14
Q.
All right.
15
Yes, absolutely.
It takes a number of
Does that change your opinion in any way
about the cause of death?
16
A.
No.
17
Q.
Turning to page 19, looking at lines 19 through 25 on
18
that page --
19
A.
Okay.
20
Q.
-- and going down the entire next page and the entire
21
next one, two, three, three and a half pages.
22
break it up into sections.
So I'm going to
23
A.
Okay.
24
Q.
The first section at page 19 -- and just as an aside,
25
this has been marked as an exhibit.
26
"Was the autopsy protocol, was that drafted
27
before you sent these specimens off to toxicology?
28
I guess what I'm asking you is when you wrote the

1283
autopsy report, did you have the results of the
toxicology?
"At the time of the autopsy, we get our notes
my notes are in the back of the protocol, and
from these notes we have a dictated report that is
made on that day before we walk out the door
"So clearly you didn't have the toxicology report,
the results at that time?
"Exactly."
10
11
12
13
14
Is that normal procedure?

A.
I want to make sure before I answer that I'm -- I'm
not missing something outside of these excerpts.

Q.
I believe this is talking about the blood sample that
was sent for toxicology.
15
A.
Yeah, this is -- this is correct.
16
Q.
Okay.
And it goes on and talks about when the
17
autopsy report was signed.
18
Dr. Fajardo was asked:
And then at the bottom of page 20,
19
"Walk me through what this means and the
20
significance of the findings in reference
21
to the toxicology report."
22
Dr. Fajardo responded:
23
"He, Gary Benefield, has a multitude of medicines,
24
prescription medications in his system.
25
codeine, a very common cough suppressant that's
26
used in cough syrup but is also given as a
27
painkiller, he has low in the therapeutic range.
28
He has a very, very small amount of morphine.
He has
It's

1284
possible and it's probable that that represents
biotransformation, a byproduct of the codeine
itself, and he wasn't given morphine directly."
A.
Yes.
Q.
"He also has hydrocodone.
Again, it's possible
that it's directly a metabolite of codeine, but
actually that's a little unlikely.
likely it's not he was given hydrocodone by
More than
10
itself" --
11
I'm sorry.
12
"More likely than not, he was given hydrocodone
13
by itself -- Vicodin is its common name -- also in
14
the therapeutic range."
15
16
A.
Yes.
17
Q.
"He's got Tylenol, again therapeutic.
18
He has trazodone, another pain medication in the
19
therapeutic range.
20
cannabinoids, which is marijuana?"
21
He does have the presence of
22
A.
Yes.
23
Q.
Do you agree with the statement that trazodone is
24
another pain medication?
25
A.
I -- no, that's not correct.
26
Q.
Okay.
And then, finally:
27
"He has a class of drugs known as benzodiazepines.
28
Valium would be the most common recognizable

1285
medication.
He has what's called oxazepam,
similar to Valium, in a very small amount in
his bloodstream?"
A.
Yes.
Q.
A.
Yes.
Q.
And did you discuss that in your comments about the
toxicology report?
A.
Yes.
10
Q.
And then the next thing Dr. Fajardo says is:
11
"So everything in the therapeutic range or
12
subtherapeutic?"
13
14
A.
Yes.
15
Q.
Then he's asked:
"What does that mean when you say
16
everything is in the therapeutic range?
17
the significance of that?
18
"Answer:
19
We're concerned about overdoses obviously.
20
very common cause of death and that's one of the
21
things we do when you look at the toxicology
22
results, is to exclude that possibility.
23
case, all of his levels are in keeping and
24
would not contribute to his cause of death."
25
Do you agree with that statement?
26
A.
What is
It has nothing to do with his death.

It's a
In this
I stand corrected on my last answer, I'm thinking
27
about still.
I apologize.
28
before this one.
The last question, I think I erred

1286
Q.
What was that question, to your memory?
A.
I know what it is.
It's the -- whether the --
everything is in a therapeutic or subtherapeutic range.
of the drugs -- hydrocodone, which I don't think we've talked
about before, is getting up in concentration.
very, very low end of potential toxicity or overdose according
to some reports.
8
9
10
11
Q.
Okay.
It's on the
And hydrocodone, you may have mentioned it,
but in case you didn't, how would that affect -- how would
that relate to his COPD and his breathing difficulties?
A.
It's a central nervous system depressant.
12
or depresses respiration.
13
COPD.
14
One
Q.
It slows
It is not helpful to a person with
And are these drugs, you know, additive or do they
15
interact to form even bigger bang for the buck?
We're talking
16
about the drugs hydrocodone, Serax, and trazodone.
17
A.
They're additive or what we call synergistic.
18
Q.
So can you explain what you mean by that?
19
A.
Yes.
It means that the combination of two or three
20
drugs may be even more active than each of the drugs alone.
21
If you were to take the three individually, add them up, when
22
you -- you think that you'll get a certain effect but, in
23
effect, what happens is you get an increased effect.
24
called synergism.
That's
25
Q.
Okay.
26
A.
It's another way of saying it more generically, yes.
27
Q.
So you believe that the hydrocodone was at the high
28
Is it sometimes called a drug interaction?
level, maybe the low level of bad, the high level of

1287
therapeutic; is that what you're saying?
A.
It was very, very low level of toxicity in some case.
Q.
And what's the word toxicity mean to you?
A.
Toxicity is getting into a concentration where the
5
6
effects are not good.

Q.
Okay.
They're -- they're -- they're harmful.
Now, the question that I believe was posed to
you, back to that question, was regarding his, Dr. Fajardo's,
statement.
9
10
I'll just sum it up with his last sentence.
"In this case, all of his levels are in keeping and

would not contribute to his cause of death?"
11
12
A.
No.
13
Q.
And why not?
14
A.
Well, I mean, it's pretty clear to me that
15
Dr. Fajardo is not considering this to be a drug toxicity
16
case.
17
toxicity, while not the primary issue, may very well be a
18
contributing factor to his death.
19
20
21
Q.
And I would say that I am very concerned that drug
All right.
When you say "a contributing factor,"
what does that mean?

A.
Well, it means that if I have to list what I think is
22
the most important factor in causing Mr. Benefield's death,
23
one, two, three, four, five, I would put lung disease, number
24
1, heart disease, and then I would consider drug toxicity.
25
I'm also not sure, because he was taking some other
26
drugs to help his COPD, other drugs that open up the airways.
27
And I'm not sure -- we haven't even discussed that, nor do I
28
even really know if those were given to help him in that way.

1288
Q.
Uh-huh.
A.
So it's not always the effect of drugs being present
but sometimes the absence of giving a drug that's needed can
be harmful.
certainty level is, you know, based on, you know, a high
degree of medical certainty.
toxicity which did not help him and would have contributed to
the physiologic derangement, the problems that ultimately made
his heart stop.
10
So I have -- I do have concerns.
And again, my
There's some issues with drug
The lung is the primary culprit in causing the heart
11
to stop, but I can't sit here and say the drug toxicity didn't
12
contribute to the breathing problem that led to his collapse
13
and the heart stopping.
14
Q.
Okay.
You said what you can't say.
But, in essence,
15
what you are saying is that drug toxicity, to a high degree of
16
medical certainty, is a contributing factor?
17
A.
It's a contributing factor.
18
Q.
Okay.
19
A.
Albeit small to medium.
It's hard to argue that
20
these respiratory depressant drugs, several of them, is not
21
going to place a stress on his already difficult breathing
22
situation from not having oxygen.
23
Q.
All right.
24
absence of drugs.
25
oxygen?
Now, you talked about the presence or
What about the absence of supplemental
26
A.
That's the biggest.
27
Q.
And is there anything in this autopsy protocol that
28
That's the biggest factor here.
indicates that Dr. Fajardo was aware of Gary Benefield's use

1289
of supplemental oxygen?
A.
I didn't see anything, no.
Q.
And is there anything that indicates Dr. Fajardo was
aware of the degree to which Gary Benefield was dependent on
supplemental oxygen?
A.
Definitely not.
Q.
All right.
I want to return to this sworn statement.
Dr. Fajardo was asked:
"Are you familiar with that drug Serax?
10
"Answer:
I am not.
11
Do you see that?
I don't know what Serax is."
12
A.
I do see that.
13
Q.
Do you think that that's -- what do you think about
14
that in terms of reaching full evaluation about the cause of
15
Gary Benefield's death?
16
A.
Well, I mean, I think it's a bit short-sided in that
17
I -- it's obvious to me he knows what Serax is, he just didn't
18
know that Serax was oxazepam.
19
through this very quickly just, again, is minimizing the
20
potential effect of these respiratory depressant drugs.
21
22
Q.
All right.
And I think that brushing
And then he's asked at the bottom of
page 23:
23
"But it's your conclusion that the presence of
24
trazodone was not a -- did not cause or contribute
25
to his death; is that correct?"
26
And the answer is, "Correct."
27
Now, would you, in your analysis, break things up
28
that way and consider each drug singly?

1290
A.
You know, that's one way to do it, but really the
body doesn't look at it that way.
The body looks at it as,
you know, what do I have in my body that's causing my
breathing to become impaired.
Q.
Okay.
A.
And that's really what it comes down to is not
breaking things down one by one necessarily, but saying, you
know, three or four drugs have this similar effect of slowing
breathing.
10
11
That is not good in a person that is already
vulnerable from a breathing standpoint.

Q.
Now, on page 27, Dr. Fajardo was asked:
12
"Okay.
13
training and your expertise, would you -- was
14
it your conclusion that Mr. Gary Benefield died
15
of natural causes?
16
"Answer:
17
18
A.
Based upon your medical experience and
Absolutely."
Well, that -- unfortunately, I hate to say this but
19
there's -- this is the big question and it's one that I can
20
summarize in one or two minutes.
21
quick.
22
a natural death.
23
to determine what the manner of death is.
The manner of death
24
we also call the classification of death.
That's just a box
25
we check.
26
undetermined.
27
manner of death.
28
death.
I promise it will be fairly
But what this -- so Dr. Fajardo is saying that this is

And you recall earlier, one of our jobs is
It's natural, accident, suicide, homicide, or

It's on the death certificate.
That's the
And so Dr. Fajardo would call it a natural
The coroner's office would call it a natural death.

1291
And I suspect the death certificate says natural death on it
as well.
Q.
Did you review the death certificate?
A.
I don't remember.
Q.
Okay.
A.
I don't have it today and I don't -- I'm not even
sure if I received it.
Q.
Okay.
A.
However, now the difference between a natural and
10
unnatural death is that for a death to be natural, there can
11
be no contribution, however small -- even if it's a five or
12
ten percent contribution -- cannot be a contribution by
13
physical injury or drug or alcohol toxicity.
14
there's any alcohol or drug toxicity or any physical injury
15
that is contributory to the death, it takes it out of the
16
natural category, and so we have to choose either accident,
17
suicide, or homicide.
18
Okay.
So if
So then it becomes an issue because if there's
19
neglect, we have the option of calling it a homicide if the
20
death occurred not from like an act of commission but say
21
medical neglect, we have the option of ruling those homicides.
22
Now, so what's the difference?
Well, there is no
23
difference in why the person died, but there is a difference
24
in how a grand jury or a judge or a jury is going to perceive
25
it.
26
it, which may be inappropriate, maybe not.
If we call it a homicide, it has a little extra fluff to
27
So without giving examples of those -- I could, but
28
the bottom line here is that the simplistic approach to this

1292
is that it's a natural death.
But looking at this case in more detail, that we're
dealing with a person that is under the care of an operation
that is supposed to do their best to make him better, the
question becomes is there some element of neglect, whether
it's conscious or subconscious.
on our ruling.
8
9
So that is an option for us
And we can call these undetermined and let the

layperson, let the public decide, but the fact of the matter
10
is, what we call it doesn't change what happened.
11
happened to Mr. Benefield is that he -- he collapsed, probably
12
due to a respiratory arrest, inability to breathe, collapsed
13
and his heart stopped after, and that was due to the extent of
14
his lung disease, number one, his heart disease, number two,
15
the potential contribution by drug toxicity next, and the fact
16
that there is no supplemental oxygen being given in somebody
17
whose wife the day before clearly made it -- informed staff --
18
and it's all over the records -- that he has this oxygen 24/7
19
to carry him along.
20
30 minutes or 60 minutes is deleterious, it's problematic to
21
me, let alone just letting it go.
22
doing anything, that, to me, is harmful.
23
Q.
Okay.
And what
So to not have that oxygen for even
Checking him in and not
So given the entire scope of the records you
24
reviewed, including the police report, including the medical
25
records, including the autopsy protocol, including the
26
toxicology, including the first responder's note -- the first
27
responder coroner's -- deputy coroner's note, what do you say,
28
in your professional opinion, given your training and

1293
experience, was the major cause of Gary Benefield's death on
or about July 26th, 2010?
A.
Okay.
So the cause of death would be acute
respiratory arrest or acute respiratory failure.
He's
basically having a respiratory arrest due to chronic
obstructive pulmonary disease or emphysema.
primarily cause of death.
be hypertensive and atherosclerotic cardiovascular disease.
It would also include the respiratory depressant effects of
That is the
The contributing conditions would
10
medications.
And I would also -- I mean, really to make this
11
right, I would include interruption or cessation in
12
supplemental oxygen administration.
13
Q.
And where would you put that?
14
A.
You could put it right -- tack it in anyplace you
15
want.
16
Everything other than the lung disease would come under that,
17
would come as a contributing factor.
18
Q.
We have the luxury of writing it where we want.
So it would be acute respiratory failure due to COPD,
19
interruption of supplemental oxygen, and then the hypertensive
20
atherosclerotic issues?
21
22
A.
Negative.
It's going to go like this.
We have two
lines for the cause of death --
23
Q.
Uh-huh.
24
A.
-- the primary cause of death and then other
25
significant contributing factors.
26
Q.
Okay.
27
A.
So everything has to go under those two categories
28
for cause of death.
The primary cause of death is acute

1294
respiratory failure due to chronic obstructive pulmonary
disease.
atherosclerotic cardiovascular disease, the respiratory
depressant effects of medication -- medications plural, and
cessation or interruption of oxygen supplementation, something
to that effect.
The contributing factors are hypertensive and
Q.
Okay.
A.
Now, the other option -- in all fairness, now there's
9
10
11
a lot of freedom because it's the pathologist that has the

freedom to write what they want.
Now, the other option is, you know, to not be as
12
wordy on the death certificate but still include the clinical
13
information on the final diagnosis.
14
definitely, instead of having those four Roman numerals under
15
final diagnosis, I would add several others.
16
include the fact that he wasn't getting his oxygen, it would
17
include the drug toxicity probability, and whatever else.
18
I would make sure it's highlighted on the report and I may
19
also include it on the death certificate.
20
So I would have included
That would
So
But keep in mind, to place that kind of wording on
21
the death certificate, then we've got to start thinking about,
22
you know, is this going to take it out of a natural death into
23
an accidental or a homicide.
24
So, you know, there are different variations and
25
different levels of homicide.
26
homicides and there are accidents that are bordering on
27
medical malpractice.
28
There's, you know, weak
So the perception is important.
But don't let the

1295
words and the forms and the death certificate throw you
because what really counts is physiologically what's happening
in the body, why this person ceased to exist.
factors and what is the priority?
Q.
Okay.
What were the
Now, when you were the chief of pathology,
forensic pathology, did you train your pathologists as to a
particular meaning for homicide?
8
9
A.
That -- that was a discussion that came up regularly
not just amongst the pathologists, but amongst the sheriff's
10
officials and others.
11
explain to juries and to judges.
12
It was something we always had to
So the answer is yes, but it's -- that is not
13
something that is my decision.
14
decision in a medical examiner setting like New York City,
15
Chicago, LA, San Diego, but in a Sheriff Coroner, like San
16
Bernardino now, Riverside, Orange County, Marin County, Napa
17
County, most counties in California, nearly 50 out of 58
18
counties, are Sheriff Coroner systems.
19
her designee controls the manner of death solely.
20
It -- it is -- it would be my
The Sheriff or his or
Now, since they're cops and don't really know usually
21
much about death certification, who do they come running to
22
for help?
23
that in mind.
24
pathologist controls the whole death certificate.
25
Sheriff Coroner situation -- the pathologist is not called a
26
medical examiner, he's call a forensic pathologist -- controls
27
the cause of death but not the manner of death on the death
28
certificate.
They come running to the pathologists.
So keep
In a medical examiner setting, the forensic

In a

1296
So that -- that -- what that means is that, to answer
your question, this made for a lot of not only discussion but
debate.
and police confrontations, whether deaths are accidents,
naturals, or homicides, as can you imagine.
after many months, thanks to the Sheriff and thanks to the
understanding on the part of the District Attorney and thanks
to the pathologists coming together and having an
understanding, we did develop a -- an approach to this so we
It was specifically in relation to police shootings
So we finally,
10
weren't going to be arbitrary and capricious from case to
11
case.
12
Even if there are differences in opinion, they should be
13
consistent within their county.
14
Q.
And that's the same way that every county should do it.
Okay.
So you spoke about a death certificate.
15
showing you a two-page exhibit marked as Exhibit 94.
16
recognize that?
I'm
Do you
17
A.
Yeah.
18
Q.
And what is it, if you recognize it?
19
A.
Well, there are two death certificates with Gary
20
Benefield's name on both.
21
that was generated that says pending.
22
initially, pending for drug testing and whatnot.
23
that was certified on July 28th, which was one -- it was the
24
next day after the autopsy or two days after death.
25
pending goes out right away.
26
And the first one is the first one

So it was pending
That was --
So
And then on September 28th, 2010, which is just after
27
Dr. Fajardo provided his autopsy report, the Sheriff Coroner
28
then amended the death certificate to read natural, what I

1297
mentioned from Dr. Fajardo's report, hypertensive
cardiovascular disease as the primary and chronic obstructive
pulmonary disease as the contributing.
Q.
Okay.
Now, if you had done this case -- and I'm
asking this hypothetically and I'm going to give you the facts
I want you to pay attention to.
A.
Okay.
Q.
If you had been the examining forensic pathologist
and you knew that Gary Benefield had a history of severe
10
oxygen dependency going back to 2007, and you knew that he had
11
been hospitalized for pneumonia from the 13th to the 17th of
12
July, 2010, and you knew that he and his wife had said that it
13
was essential that he have oxygen 24/7, and then he flew on
14
July 26th, and because of airline regulations, he had to
15
disable his portable supplemental oxygen --
16
A.
He flew on the 25th, no?
17
Q.
Yes.
18
A.
Okay.
19
Q.
I appreciate that.
Thank you.
20
And he was given two Serax around 4:00,
21
30 milligrams, and then around -- I'm sorry, around 4:30,
22
let's say.
23
30 milligrams total, three trazodone, and I don't have the
24
toxicology in front of me, but as we've discussed earlier, and
25
the Tylenol with codeine as we discussed earlier, and then was
26
last seen alive at 12:30, and was found dead and pronounced
27
dead at 8:09 the next morning, and had the physical
28
characteristics that you've seen in the pictures that were
And around 9:00, he was given two more Serax,

1298
taken at or around 9:30 that morning of the 26th, and you'd
had to prepare -- and autopsy results consistent with those
noted by Dr. Fajardo, the physical characteristics --
A.
Okay.
Q.
-- are consistent, what conclusion would you have
reached when you had to do that check the box to be the cause
of death, the nature of his death?
A.
The manner of death.
Q.
The manner of death.
10
A.
Yeah, I was afraid you were going to ask me that.
11
was expecting it.
12
important.
13
And that's okay.
It's good because that's
And I -- you know, I would have ruled it either -- I
14
mean, I could articulate natural, accident, or homicide either
15
of the ways.
16
would do what I think is the most fair approach and one that I
17
think that I could explain to a court, but it would depend on
18
the law enforcement investigation, on Murrieta Police
19
Department's investigation.
20
I could, in other words.
So what would I do?
And so with that investigation, which clearly points
21
to, you know, doctors not being available, you know,
22
medications being given without prescription, not being
23
monitored properly or at all during certain times, you know, I
24
mean, I could explain a homicide.
25
do that, the Sheriff may, before he certifies the amended
26
death certificate, he may not buy in on it.
27
is not my call.
28
would come to me for a roundtable to have a discussion.
I just -- now, if I were to
So, again, this
But in a case like this, the Sheriff will --

1299
I would -- if there was frank neglect, if it's -- if
it is a conscious -- in other words, a care facility that
consciously neglected a patient, I would call that a homicide.
If it was a facility or one or more individuals that forgot or
didn't understand or they're ignorant or don't care, you could
call it either a homicide or an accident.
Now, what makes it an accident is the fact that the
drugs play in drug toxicity.
What makes it a homicide is not
monitoring, not -- not -- giving, you know, inappropriate
10
medications, not giving the oxygen -- getting the oxygen in
11
that first hour to take care of that patient who needs it
12
24/7.
13
what happened in terms of what box we check.
It could be a homicide.
But again, it doesn't change
14
If it is -- just to give you an example, which I
15
think is one that I recall in this County that we ruled a
16
homicide, was a 16-year-old diabetic --
17
Q.
I want to stop you.
18
A.
-- that didn't get her insulin.
19
Q.
Yeah, I don't want to go there --
20
A.
Yeah.
21
Q.
-- because I don't want --
22
A.
So they're different gradations or different levels
23
of homicide.
24
Q.
All right.
25
A.
There's, you know, voluntary, involuntarily, and
26
whatnot, which --
27
Q.
Let's not discuss other cases --
28
A.
Okay.

1300
Q.
-- or legal characterizations.
What I do want to clarify, though, is the
determination by the pathologist and the Sheriff that it's a
homicide or a natural death, that's a characterization; is
that a fair way to put it?
A.
Yes.
Q.
It doesn't change what medically -- the medical
opinions that contribute to that characterization, does it?
A.
That is exactly the point, that's correct.
10
Q.
All right.
11
12
13
14
15
So I'm asking you as a doctor of
30 years, 29 years?
A.
Yeah.
It's getting up there.
It's somewhere in that
area.
Q.
All right.
And you've been a pathologist, I believe
you said, since '96?
16
A.
Correct.
17
Q.
So we're going on 20 years there too.
18
A.
Since '94, so --
19
Q.
'94, so more than 20 years ago.
So given your
20
training and experience as a forensic pathologist, putting
21
aside the check the box, is it your -- you said -- you've
22
described what you believe the cause of death was.
23
A.
Yes.
24
Q.
And you said that that was -- I want to use the
25
correct term of art -- to a high degree of medical certainty.
26
A.
Yes.
27
Q.
And the absence of oxygen, the failure to supply
28
oxygen, is that also a cause of death in the same high degree

1301
of medical certainty?
A.
Yes.
Q.
Greater or lower than the supplying the drugs?
A.
Greater.
Definitely greater.
And I would place
that -- I would prioritize that.
on that second line, I would put it at the beginning.
that it makes a difference, but I would highlight it.
Q.
Okay.
A.
Yes, in my report.
10
Q.
Okay.
Instead of putting it last

Not
In your autopsy.
And as you sit here today, do you agree or
11
disagree with the conclusions of Dr. Fajardo's autopsy or is
12
there more nuance response you want to make?
13
A.
Well, based on what he -- what I believe Dr. Fajardo
14
knew at the time that he certified it, I can't argue with it.
15
But based on what really the totality of the information that
16
we have, I disagree with it.
17
18
19
Q.
And do you believe that he fell short in some fashion
in not getting more information to base his opinion?

A.
I do.
I feel he fell short.
And he's a very, very
20
smart pathologist, but I do feel that he fell short on this.
21
And in the transcripts that you've provided, I feel that not
22
having reviewed the medical history and the clinical
23
information, he fell short on that.
24
Q.
25
Okay.
Just one moment, please.
Now, do you believe that Gary Benefield, that he --
26
that it was just his time, you know, he just died as a matter
27
of his ongoing medical condition that night?
28
A.
No.

1302
Q.
Do you believe that the things we've discussed had
the contrib- -- that they were such strong contributing
factors that it's fair to say that they are integrally related
to the timing of his death?
A.
Yes.
Q.
You said in a sworn statement, "Mr. Benefield died of
acute respiratory failure primarily due to his COPD, and to a
strong degree of medical certainty, he would not have died
when he did if he had received external oxygen support as
10
promised by ABT and as prescribed."
11
A.
Correct.
12
Q.
Do you agree with that statement still?
13
A.
Yes.
14
Q.
Thank you.
15
16
MR. SAMUELS:
have any questions for you.
17
18
19
I'm going to ask if the grand jurors

Q.
BY MR. SAMUELS:
Yes, Counsel.
I'll try to clarify this but it may be a little difficult.
20
Given Gary's entire medical history, can you clarify
21
if the Serax or trazodone was within therapeutic levels and if
22
his medical condition would affect those therapeutic levels?
23
And can you tell how long ago the Serax and trazodone would
24
have been given to him by their levels?
25
A.
I wish I was a toxicologist, to answer that question.
26
And I can answer part of the question.
The levels were within
27
therapeutic.
28
having received them at the time noted earlier in the
I believe their levels are consistent with

1303
testimony, but I can't be certain because I -- I'm not able to
break down these drugs like a toxicologist with respect to
their half lives and the timing of metabolism and the effects
of heart and lung disease on those levels.
Q.
All right.
This is a question from Juror No. 10.
your opinion, would Gary Benefield be alive if he had had
constant supplemental oxygen?
A.
Absolutely.
Q.
This is a question from Juror No. 3.
And I'm going
10
to decline to ask it as being outside the scope of his
11
testimony for this witness.
12
A.
Okay.
13
Q.
So another question from Juror No. 3.
In
In your
14
professional opinion, would you, as a practitioner, as a
15
doctor, ever prescribe Serax, trazodone, Tylenol with codeine
16
and it says hydrocodone for one person to take in these
17
amounts?
18
A.
I don't think so, but I don't know because, again, I
19
haven't prescribed any of these types of medications since
20
1987 when I was in my general surgery.
21
doctor, I'm a pathologist.
22
is my concern here, and the presence of those drugs in
23
combination definitely had a physiologic effect on
24
respiration.
25
26
Q.
So I'm not a clinical
So it sounds like a lot and that
Would a different -- a doctor who had a different
specialty practice be able to comment on that kind of issue?
27
A.
Yes.
28
Q.
What specialty?

1304
A.
It would be a toxicologist or a pharmacologist,
perhaps an intensive care doctor or an internal medicine
doctor.
Q.
What about a pulmonologist?
A.
Sure.
Any practicing physician with experience with
those types of medications --
Q.
And --
A.
-- should be able to address that --
Q.
Would it --
10
A.
-- question.
11
Q.
I'm sorry, I didn't mean to interrupt.
12
A.
That's okay.
13
Q.
Would it be important for the physician who gave that
14
opinion to know the severity of Gary Benefield's underlying
15
condition?
16
A.
Absolutely.
17
Q.
The question from Grand Juror No. 2, was a time of
18
19
death determined by your review of the records?

A.
Well, the time of death is -- officially on the death
20
certificate is when the death was pronounced, it's not when
21
the death occurred.
22
certificate is definitely different than the actual time of
23
death.
24
So the time of death on the death
The actual time of death -- and we touched on this
25
earlier -- is closer to 12:30 or 1:00 in the morning than it
26
is closer to 7:00 or 8:00 in the morning for sure.
27
it was 1:00 or 2:30, I don't know.
28
in the morning, it could have been 2:00 or 2:30 or 1:30, but
So whether
It could have been 12:35

1305
not 4:00, 5:00, 6:00, or 7:00 most likely, definitely not on
the closer to the 8:00 side.
3
4
5
Q.
You said 2:30 and you said not 4:00.
What about
between 2:30 and 4:00?

A.
You're pressing me.
I'm not that good.
And that's
the point is that to place a specific time on it is, in my
opinion, unless there's a witness to the death, is
inappropriate when a body is found in this condition.
tell you that it is a very high probability it was between --
I can
10
if it's accurate that 12:30 was the last time that Gary was
11
seen and he was found -- and found at, what, 8:00 -- I think
12
there was a mixup in the times on one of the reports, but I
13
think 8:09 he was pronounced, so a little bit before that,
14
they called 911.
15
The other factor is when were the photographs taken?
16
So if the photographs were taken at 8:15 as opposed to 3:00 in
17
the afternoon, that makes a difference.
18
uncertain as to when they were taken.
19
within a couple hours of the death.
20
were the case, I would pin it on the early morning hours, not
21
6:00 or 7:00 or 8:00.
22
23
Q.
So I'm a little
Usually they're taken
But still, even if that
When you say the early morning hours, you mean a.m.
hours, not --
24
A.
Early a.m. between 12:30 and 2:00 or 3:00.
25
Q.
And just to round things out, have you ever seen
26
television programs or movies where a forensic pathologist is
27
able to determine within a very tight window, such as a half
28
hour, when a death occurred according to that program or

1306
movie?
A.
Mr. Samuels, that is not a problem seen only on TV,
that is a problem we see in real practice.
and it's -- it's not the way it is in real life.
are pathologists that will come in and try to pin it down to a
specific half hour.
7
8
9
Q.
12
13
14
15
16
But there
I know they're out there.
In your experience, is that something you believe
that a pathologist can do to a medical certainty?

A.
10
11
And I've seen that
Only give a range.

MR. SAMUELS:
Okay.
Are there any more questions for
this witness?
Q.
coming.
A.
BY MR. SAMUELS:
Just one moment, Doctor.
I see one
The question from Grand Juror No. 7.

I know which one Grand Juror No. 7 is.
I didn't know
who the other ones were, but I know who this one is.
Q.
Would alcohol have played a role in Gary Benefield's
17
death if alcohol were found to have been in his body at the
18
time all these events took place?
19
A.
Yes.
Alcohol is also a respiratory depressant and so
20
it would act in additive way or synergistic way with the other
21
ones.
22
Q.
If at 5:30, when he checked into the house, he had an
23
alcohol -- a blood alcohol level read by a breath device at
24
.059 percent, would that be remarkable to you?
25
A.
Only so much that it tells us he was drinking
26
recently and probably earlier that day.
With respect to his
27
death, probably not.
28
about two or three drinks -- about three drinks, plus or
Because a .059 is the equivalent of

1307
minus, in the body at the time of the test.
at what time?
Q.
5:30.
A.
5:30 p.m.?
And if that was
Then all of that alcohol, assuming he
didn't take any more, that he didn't imbibe in any more
alcohol, all of that .059 would be gone within several hours.
Q.
Would it be gone by 12:30 at night?
A.
Yes.
Q.
I appreciate this question.
10
but --
11
A.
Do I have to answer it?
12
Q.
I'm going to decline to ask it because I believe it
Before then.
13
was meant in good spirits --
14
GRAND JUROR NO. 11:
15
Q.
BY MR. SAMUELS:
GRAND JUROR NO. 11:
17
THE WITNESS:
19
Q.
Yes.
-- but it's not relevant.
16
18
It's from Juror No. 11,
Okay.
I don't mind.
BY MR. SAMUELS:
The question is do you have a high
tech machine like in the movies?
20
A.
Oh, a high tech machine.
21
Q.
And I'm going to strike that question.
22
A.
Okay.
23
Q.
I'm going to not ask you.
24
25
that in terms of the technical nature.

A.
I was going to say asked and answered, but I guess
26
that wouldn't be right either.
27
MR. SAMUELS:
28
I'll ask you to disregard
All right.
Are there any more
questions for this witness?

1308
May he be excused?
Doctor, before you leave, I
have an admonition to read to you.
THE WITNESS:
Yes.
I figured that.
You're admonished not to
discuss, at any time outside of this jury room, the questions
that have been asked of you in regard to this matter, or your
answers, until authorized by this grand jury or the Court, or
until such time as these grand jury proceedings become a
10
matter of public record.
11
of this instructions on your part may be the basis for a
12
charge against you of contempt of court.
13
You will understand that a violation
14
15
16
17
Do you understand, Doctor?
18
THE WITNESS:
19
20
THE WITNESS:
Thank you so much.
21
MR. SAMUELS:
Would the grand jury like to take a
22
You're excused.
The grand jury will take a
ten-minute break and return at 3:20.
25
Thank you, Counsel.
26
(Brief recess.)
27
28
Thank you.
break at this time?
23
24
I do, yes.
to order.

1309
MR. SAMUELS:
Mr. Foreman, a couple things before I
summon the next witness.
In this envelope that I'd like to
have marked as an exhibit, are what are known as returns on
subpoenas issued under the authority of this grand jury.
subpoena is a lawful order for a person to attend court or
this grand jury or to provide documents or materials to this
grand jury.
that this -- you know, on the person who's summoned.
are a record that goes with this grand jury, although they
And the returns indicate the manner of service

And they
10
don't necessarily come back to this grand jury other than in
11
this fashion.
12
marked for the record and your inspection, if necessary.
13
that is Exhibit No. --
And they'll be in an envelope together and
14
15
16
GRAND JUROR NO. 8:
17
18
MR. SAMUELS:
19
And
94.
Exhibit 94.
I already have a 94.

No, Exhibit 95.
Sorry.
You may find names of people who are
subpoenaed who you don't hear testimony from.
20
21
MR. SAMUELS:
Uh-huh.
And that shouldn't lead you to
22
speculate about what these people may or may not have had to
23
add to the record.
24
subpoena but were not required to testify.
25
It just means that they were served with a
The other thing is I just want to make it clear, it's
26
all right in a long proceeding such as this to have a laugh
27
and I'm not discouraging that.
28
to strike something and not consider it in your deliberations,
I do -- when I say -- ask you

1310
I think it was clear that that last question was meant to be
frivolous and fun and wasn't serious, and so I hope you don't
take any offense when I ask you to exclude it.
maintain a serious demeanor and attitude towards serious
issues.
All right?
But you should
That's all I'm saying on the record.

MR. SAMUELS:
All right.
This is a question from
Juror No. 2, and I believe it has been answered now.
was a cause of death determined?
It is
And it was to be directed
10
toward the deputy coroner this morning who did not determine
11
the cause of death.
12
evidence that came in through Dr. Cohen does address that
13
issue, so I'm going to return that question to you as
14
answered.
15
Did the coroner's office -- this is a question from
16
Grand Juror No. 7.
17
Gary Benefield?
18
as well.
19
But I believe the testimony and the
Did the coroner's office do an autopsy on
I believe that question has now been answered
It was
20
toward Dr. Cohen and I don't know why.
21
that I said I would decline to answer because it's involving
22
patients other than Gary Benefield.
23
subject of Dr. Cohen's testimony, and for that reason, I
24
declined to ask it.
25
Oh, this is the one
And that wasn't the
This is from Grand Juror No. 11, and it's a question
26
about -- it's a question I'm still going to decline to answer,
27
but I believe will be an issue that becomes clear as the
28
testimony develops.
And I would like the foreman to hold onto

1311
it.
MR. SAMUELS:
MR. SAMUELS:
MR. SAMUELS:
Okay.
All right?
Yes.
Thank you.
May I get the witness now?

Yes, please.
Now, this clock says it's 3:27.
And I
think this witness is likely to take less than a full hour but
probably not -- somewhat less.
I won't estimate.
If we end
10
early, it's not looking like we can fit another witness in, I
11
will leave it up to you whether you want to start another
12
witness and go right to 4:30 or whether you'd like to end
13
earlier today and start each witness fresh.
14
that to your --
15
16
MR. SAMUELS:
17
And I'll leave
Thank you.
-- discretion.
Good afternoon, Janelle.
18
may resume the stand.
19
same oath as previously given, okay?
You
I would admonish you you are under the
20
21
MR. SAMUELS:
Thank you.
Thank you.
22
JANELLE ITO-ORILLE,
23
having been previously sworn, resumed the stand and testified
24
further as follows:
25
26
27
28
DIRECT EXAMINATION RESUMED

BY MR. SAMUELS:
Q.
Just to reset the stage since we've had another
witness in between, we were talking about your investigation

1312
of a death at the A Better Tomorrow facility on Iron Gate in
Murrieta, California, in July of 2010.
investigation, you interviewed certain employees who were
associated with the A Better Tomorrow facility.
remember that?
A.
Yes.
Q.
Okay.
And in your
Do you
And I believe when we -- when we stopped for
our break, you were talking about your interview with Kris
McCausland.
10
A.
Yes.
11
Q.
Okay.
And if I ask you a question that you believe
12
was asked prior to the break and you answered it already,
13
please let me know, all right, if you can.
14
cover ground we've covered again.
I don't want to
All right?
15
A.
Okay.
16
Q.
Did you ask -- or in your conversation with Kris
17
McCausland, did Kris McCausland tell you whether he had any
18
medical training or not?
19
A.
I don't recall him telling me that.
20
Q.
You don't recall the subject coming up or you don't
21
recall him telling you?
22
A.
I don't recall him telling me that.
23
Q.
Okay.
Did he talk about anything with regard to what
24
he believed was the cause of Gary Benefield's death?
25
talk about what he believed the cause of death to be?
26
27
28
Did he
A.
He did not talk about what he believed the cause to
Q.
Did he talk about things he did not believe caused
be.

1313
1
2
3
4
5
6
Gary Benefield's death?

A.
He did state to me that he did not believe the
medications were the cause of his death.

Q.
And did he tell you the basis for his opinion, Kris
McCausland's opinion?
A.
He was of the opinion that if the medications were to
have had an adverse effect on him, then it would have happened
sooner than the last time he saw them, which was 12:30 a.m.
9
10
Q.
And did he tell you -- did he describe his training
and experience on which he based that opinion?
11
A.
No, not of what he based that opinion on, no.
12
Q.
Do you remember if you asked him any questions about
13
how he reached that conclusion?
14
A.
I don't recall asking him questions about that.
15
Q.
Okay.
Now, were there -- did you, in your analysis
16
of the death of Gary Benefield, find any -- anything in what
17
was described to you by Mr. McCausland that you believed was
18
at odds with regulations as you understood them for the social
19
model detox facility?
20
A.
What was of concern or a violation of our regulations
21
was the administration of the medications to Mr. Benefield
22
without a prescription.
23
24
Q.
Okay.
What about the fact that they had the
medications at the house?
Was that a concern?
25
A.
Yes.
26
Q.
Why?
27
A.
Because our facility -- per regulations, our
28
facilities don't allow medications that are not prescribed to

1314
1
2
a person.
Q.
Okay.
And if he hadn't seen a doctor before these
medications arrived, what conclusion did you reach?
sorry, I misphrased that.
I'm
If I recall your testimony, Kris McCausland told you
that Gary Benefield had not seen a doctor and that they gave
him medication that was in the house meds.
concern?
Was that a
A.
Yes.
10
Q.
Why?
11
A.
Because they're administering medications that
12
they're unaware if the client can take those medications based
13
off of their health history.
14
prescription medications are just being given to a client
15
without any type of medical assessment --
So it's a concern that
16
Q.
All right.
17
A.
-- or being prescribed by an appropriate person.
18
Q.
Such as?
19
A.
A doctor.
20
Q.
Okay.
21
And is this one of the things you focus on in
your investigation, these kinds of concerns?
22
A.
Yes.
23
Q.
All right.
But you don't decide yourself whether
24
there's been a violation of a regulation or law, do you?
25
yourself.
26
27
28
A.
By
I will take the information and analyze it and
determine if there is a violation of our regulations.

Q.
All right.
But you do that in a vacuum by yourself?

1315
1
2
3
A.
No.
All of -- I will make a determination or an
assessment and then a supervisor will review.

Q.
All right.
And so there's a process beyond what you
think before someone suffers any penalty or anything like
that.
A.
That's all I'm getting at.

Yes.
Is that what you believe?
And if there's anything that is an action that
we feel is severe enough, it will also go through our legal
counsel as well.
Q.
Okay.
So what I want you to limit yourself to in
10
your testimony is just things that you believe presented a
11
concern for an investigator such as yourself.
All right?
12
A.
Okay.
13
Q.
And have we been successful in limiting your
14
testimony in that way up to this point?
15
A.
Yes.
16
Q.
Okay.
So who else did you speak with again?
17
believe you said you spoke to Kris McCausland, Jim Fent, and
18
Andrea Powell.
19
A.
And Josie Gann.
20
Q.
Okay.
21
A.
Okay.
22
Q.
Do you remember where you spoke with him?
23
A.
In his office at Corning Place.
24
Q.
And do you remember when this was in relationship to
25
I want to turn to Jim Fent.
your going to the facility at Iron Gate and finding it empty?
26
A.
The next day.
27
Q.
And do you remember the date?
28
A.
August 10th, 2010.

1316
Q.
Okay.
A.
No.
Q.
And do you remember what you talked about with
4
5
Anybody accompany you?
Mr. Fent very well?

A.
Yes.
I had spoke with him about the policies and
procedures of A Better Tomorrow and then I spoke with him
specifically about the client.
8
9
10
11
12
13
Q.
All right.
And did he tell you when he -- when he
first became aware of Gary Benefield?

A.
He stated that he was made aware of the client the
evening that he came into the program.

Q.
All right.
So would that have been -- what date
would that have been, if you recall?
14
A.
I believe that was July 25th, 2010.
15
Q.
All right.
16
17
18
But did he say how he became aware of it
that evening?
A.
Ms. Powell, who was on duty at the time, called him
and asked for some direction in regards to medications.
19
Q.
And did he explain to you what the question was
20
about?
21
A.
I believe that Ms. Powell stated that Mr. --
22
Q.
No, I'm asking what Mr. Fent told you, not what
23
Ms. Powell told you.
24
straight, but just what Mr. Fent told you at the time.
25
A.
I know that may be hard to keep
What Mr. Fent told me was that Ms. Powell had
26
contacted him and stated that Mr. Benefield was also detoxing
27
from opiates and was inquiring about what medications to give
28
the client.

1317
Q.
And did he tell you what he told Ms. Powell?
A.
He stated that to continue -- for Mr. Benefield to
continue taking the medications that he arrived at the
facility with.
5
6
7
Q.
Did Mr. Fent say anything about the detox protocol
that Kris McCausland told you about?

A.
He had informed me that the protocols were
Dr. Bumby's orders and that they were not policies of A Better
Tomorrow.
10
Q.
Okay.
I'm sorry, I misphrased the question.
What
11
I'm asking for is did Jim Fent tell you about the protocol
12
drugs in that phone call that he got from Andrea Powell?
13
A.
I'm not sure I understand your question.
14
Q.
All right.
I'll try to make it clearer.
15
You said you talked to Jim Fent and he was made aware
16
of Gary Benefield on the evening of July 25th, 2010, by a call
17
from Andrea Powell.
18
about the medications Gary Benefield could take given that he
19
was detoxing, and you said detoxing from opiates in your
20
testimony.
21
told you that he told Powell that he could take the drugs he
22
had come with.
23
And in that call, Andrea Powell asked him
So did Mr. Fent mention -- and you said Mr. Fent
But my question is, did he say anything about detox
24
drugs?
25
drugs he came with and the detox drugs, the detox drugs and
26
some of the drug he came with?
27
detox drugs at all?
28
A.
Did he tell Powell that Gary Benefield could have the
Did he say anything about the
I don't recall him saying anything about them.

1318
1
2
Q.
Okay.
But was Kris McCausland clear that he gave the
detox drugs?
A.
Yes.
Q.
And that they were per protocol?
A.
Yes.
Q.
Even though a doctor had not been seen by this
client?
A.
Yes.
Q.
And did you speak separately with Andrea Powell about
10
the detox drugs?
11
A.
Yes.
12
Q.
What did she say in regard to that?
13
A.
I don't recall.
14
15
16
MR. SAMUELS:
Do you have the marked exhibit of the
report?
Q.
BY MR. SAMUELS:
Just a moment, please.
Okay.
I'm
17
going to give you Exhibit 89, and I'm going to direct you to
18
page 4 and 5 of the 24 page -- 24 pages of the report
19
contained in the exhibit.
20
those and see if they refresh your recollection, as you sit
21
here today, about your interview with Ms. Powell.
I'm going to ask you to look at
22
A.
Okay.
23
Q.
So take your time.
All right?
And what I'm asking for, in case
24
you don't remember, a refreshed recollection is your
25
independent memory sitting here today because something in
26
that report jogs your memory, not because you're reading from
27
the report.
28
A.
Please don't read from the report.
Okay.

1319
1
2
Q.
All right.
You're looking up at me.
Is your
recollection refreshed?
A.
Yes.
Q.
Do you remember it now as you sit here?
A.
Can you rephrase the question?
6
7
MR. SAMUELS:
Let me ask the court reporter, if I
may, to read back the last question.
(Record read by the court reporter.)
Q.
BY MR. SAMUELS:
10
A.
Yes.
11
Q.
Okay.
12
Okay.
Do you remember now?
I'm going to ask you just to flip the report
over --
13
A.
Yes.
14
Q.
-- and tell me what you remember about what Andrea
15
16
Powell told you.

A.
So Andrea Powell confirmed to me that they do have
17
what is called an alcohol detox protocol, and in that protocol
18
they administer the medications Serax and trazodone.
19
20
21
22
23
24
Q.
Did she say if they had those at the house on Iron
Gate?
A.
Yes.
She stated that there was an extra supply of
medications at the house.

Q.
Did she describe how they came to have an extra
supply of these medications at the house?
25
A.
No.
26
Q.
And did she say whether they were provided these
27
medications, the medications for the alcohol detox protocol,
28
whether they were provided to Gary Benefield?

1320
A.
Yes.
She stated that the house manager,
Mr. McCausland, had started providing the medications to
Mr. Benefield.
Q.
Did she talk about a phone call with Jim Fent?
A.
No.
6
7
8
I'm sorry, not that I recall.
I would need to
refresh if she mentioned that.

Q.
Okay.
Would it refresh your recollection if you
referred to your report?
A.
Yes.
10
Q.
All right.
11
Please do so.
12
Q.
BY MR. SAMUELS:
So do you remember the question?
13
A.
Yes.
14
Q.
And what's your answer?
15
A.
No, she did not mention that she talked to Mr. Fent.
16
Q.
Now, do you remember, sitting here today, whether you
17
spoke to Andrea Powell first or Jim Fent first or do you
18
remember the order in which you spoke to these folks?
19
A.
I interviewed them in order.
So Andrea Powell first
20
and then Josie Gann and Jim Fent and then Mr. McCausland via
21
telephone a few days later.
22
23
Q.
Okay.
But the first three, Powell, Fent, and Gann
were in person?
24
A.
Yes.
25
Q.
Now, did you ask Fent about the medications in the
26
home, the alcohol detox protocol medications?
27
A.
Yes.
28
Q.
Did you ask him what he knew about them?

1321
A.
Yes.
Q.
Do you remember what he told you that he knew about
3
4
5
them, what the scope of his knowledge was?

A.
He stated that the protocols, the detox protocols
were Dr. Bumby's orders --
Q.
Uh-huh.
A.
-- and that they weren't the policy of A Better
8
9
10
11
12
Tomorrow.
Q.
Now, did Mr. Fent tell you whether or not he believed
Gary Benefield had seen Dr. Bumby?

A.
Mr. Fent said he had reviewed his chart and confirmed
that he had not met with Dr. Bumby.
13
Q.
He being Gary Benefield?
14
A.
Yes.
15
Q.
So did he have any knowledge of where -- did he tell
16
you about any knowledge that he had about where these drugs
17
were coming from?
18
A.
No.
19
Q.
Did he express any concern on this issue?
20
A.
He stated that the night of the death, he had seen
21
He was not sure where the medications came from.
some medication concerns and addressed it with staff.
22
Q.
Did he describe how he addressed it with staff?
23
A.
No, he didn't go into the specifics.
24
Q.
Okay.
Now, did Mr. Fent tell you anything about his
25
knowledge of Gary Benefield's health condition when he arrived
26
at A Better Tomorrow?
27
28
A.
He stated that he wasn't aware that Mr. Benefield was
in need of an oxygen tank.

1322
1
2
Q.
Did he tell you when he became aware of Gary
Benefield's need for an oxygen -- supplemental oxygen?
A.
After his death.
Q.
When you spoke to Ms. Gann, did she have any personal
knowledge about Gary Benefield's coming to A Better Tomorrow,
his arrival at A Better Tomorrow before his death?
asking is before his death, did Ms. Gann -- did Ms. Gann tell
you that she knew about Gary Benefield before she was informed
of his death?
What I'm
10
A.
I don't --
11
Q.
Did that make sense?
12
A.
It did, and I would have to look at my report.
13
Q.
Okay.
14
A.
Yes.
15
Q.
All right.
I'm sorry.
Would it refresh your recollection?
16
You may do so.

17
Q.
BY MR. SAMUELS:
Yes.
I'm sorry, what's your answer?
18
A.
She was not made aware of the death of Mr. Benefield
19
until after he had -- or the condition of Mr. Benefield until
20
after he passed.
21
Q.
Okay.
What about Kris McCausland?
Did he say he had
22
any prior knowledge about Gary Benefield's medical condition
23
before Gary Benefield arrived at the Iron Gate facility?
24
A.
No, he did not have any prior knowledge.
25
Q.
You said he said he did not have any prior knowledge?
26
A.
Correct.
27
Q.
What about Andrea Powell?
28
Did she say she had any
prior knowledge about Gary Benefield's medical condition?

1323
A.
I don't recall asking her that question.
Q.
Okay.
So did you ask Jim Fent about the intake
process for new clients?
A.
Yes.
Q.
Do you remember what Mr. Fent told you in that
6
7
regard?
A.
He had informed me that there are some initial phone
screenings that are done with clients and that when they
arrive, they should have a medical assessment done.
10
Q.
Did he say when those medical assessments were done?
11
A.
I don't recall if he gave a specific time.
12
Q.
Okay.
13
Do you recall if he spoke about the assessment
process?
14
A.
I would have to look at my report.
15
Q.
All right.
I'm going to direct you to page 7.
16
believe there may be something there to refresh your
17
recollection.
18
19
Q.
BY MR. SAMUELS:
Let me ask it you this way.
Did you
20
prepare this report shortly after you had this interview with
21
Mr. Fent?
22
A.
Yes.
23
Q.
And what did you base your report on?
24
A.
Based off of my notes that I took while doing my
25
interviews.
26
Q.
27
28
And how long would you say lapsed between the time
you spoke to Jim Fent and the time you wrote this report?
A.
Maybe a month.

1324
Q.
All right.
So in that amount of time, do you believe
that your memory and your notes allowed you to create an
accurate and a full report of what occurred in your
conversations with Jim Fent?
A.
Yes.
Q.
And was that way of preparing this report consistent
with your -- with the Department of Alcohol and Drug Programs'
policy for creating investigative reports?
A.
Yes.
10
Q.
And was this report prepared in the course and scope
11
of your duties as an investigator?
12
A.
Yes.
13
Q.
All right.
I'm going to ask you to read two
14
sentences or three sentences from your report and I'll
15
indicate which ones to you.
16
going down through the word "process" there.
17
I'm indicating?
Starting here, "Mr. Fent," and

Do you see where
18
A.
Right here.
19
Q.
Okay.
20
A.
"Mr. Fent stated that a phone call is used initially
Would you read that?
21
to screen potential new clients and will bring the clients in
22
for a full assessment and discuss any concerns.
23
stated that if there is a medical concern, then the clients
24
will be taken to the urgent care.
25
from 8:00 a.m. to 5:00 p.m. Monday through Saturday.
26
intakes are done at the individual residential homes by the
27
house managers on the days and times that the office isn't
28
open.
Mr. Fent
The intake office is open

The
Mr. Fent stated that Dr. Bumby has a standing order for

1325
1
2
3
clients that are going through the detox process."

Q.
Now, there was a time for when the office was open on
there; right?
A.
Yes.
Q.
And there was a mention of urgent care.
A.
Yes.
Q.
Did Mr. Fent tell you what happened with patients who
came in for A Better Tomorrow services and it wasn't during
the office hours and if they, for whatever reason, were not
10
taken to urgent care?
Did he address that?
I'm not asking
11
you to look at your report, I'm asking you if you remember
12
that.
13
A.
I don't recall.
14
Q.
And did you ever hear anyone admit that a patient or
15
a client was supposed to see a doctor before any detox
16
protocol was started?
17
A.
I recall Mr. McCausland stating to me that if a
18
client had any medical issues, they were to be taken to urgent
19
care immediately.
20
from the airport where he would pick them up to an urgent care
21
before bringing them to the facility.
22
23
Q.
And generally he would take them straight
All right.
And did he say whether or not Gary
Benefield was taken to urgent care?
24
A.
He stated he was not.
25
Q.
Did he say whether or not Gary Benefield was taken to
26
a doctor?
27
A.
He confirmed that he was not.
28
Q.
And did he say whether or not he believed Gary

1326
Benefield had a medical condition that required him to see a
doctor, him, Gary Benefield?
A.
I don't believe he stated that.
Q.
Did he state anything in that regard?
A.
Mr. McCausland stated that he didn't feel that the
6
7
client shouldn't be at the program.

Q.
All right.
be at the program.
for him to be there.
Didn't feel that Mr. Benefield shouldn't

In other words, he felt that it was okay
10
A.
Yes.
11
Q.
What about Andrea Powell?
Did she say anything in
12
that regard about whether or not Gary Benefield was physically
13
able, healthy enough to be at the program?
14
15
A.
Ms. Powell did not feel the client should be at the
program.
16
Q.
Really.
17
A.
She felt that he needed a higher level of medical
18
19
care.
Q.
20
21
Okay.
Thank you.
MR. SAMUELS:
Are there any questions from the
members of the grand jury for this witness?
22
23
What did she say in that regard?

Q.
BY MR. SAMUELS:
Yes, Counsel.
This is a question from Grand Juror
24
No. 11.
25
set in such a way as to ensure that a detox business is run
26
with the protection of clients' rights in mind?
27
understand that question?
28
A.
Are the standards of your application for licensing
Do you
Can you repeat it one more time?

1327
Q.
The licensing process and the application for
licensing that's part of that process, is part of the goal to
ensure that the clients at the detox facilities, that their
rights, the rights of these clients are protected?
A.
Yes, that's the purpose of our regulations there.
There is a section in our regulations that fall -- or are
called personal rights, and that is to ensure the health and
safety of our clients.
Q.
This is a question from Grand Juror No. 15, who asks,
10
Can you please explain your report, which I believe is in
11
front of you, signed on March 8th, '11 -- 2011, but the report
12
date itself is January 24th, 2011?
13
A.
So the report date that states January 24th, that
14
would be the date that I initially submitted it to -- for --
15
to my supervisor for -- at that point when I would consider it
16
to be completed, but then there might be some revisions that
17
go back and forth, which would then be the discrepancy and
18
have a March 8th signature date.
19
the day that it actually will leave the department and be sent
20
out to the licensee.
The March 8th date indicates
21
Q.
Okay.
So it's kind of a review process?
22
A.
Yes.
23
Q.
I'm going to adopt some different language to this
24
other question on this form.
25
investigator of Alcohol and Drug Programs, any concern about
26
when a client in a social model detox facility arrives with an
27
oxygen tank?
28
A.
Yes.
Does it cause you, as an
That would be a concern that we -- that we

1328
would feel that that client needs a higher level of medical
care.
Q.
All right.
A.
And maybe needs to be in a medically managed detox
5
6
7
program.
Q.
All right.
A.
No.
Q.
Okay.
11
12
13
So it
wouldn't lead you to a conclusion by itself, would it?
10
You said a concern and maybe.
So meaning no, it would not lead you to a
conclusion, the fact that someone had an oxygen tank?

A.
Not alone, as we would want to assess and analyze the
whole situation.
Q.
All right.
In a licensed outpatient facility, would
14
it be appropriate for a doctor to have an office in the same
15
building as the licensed outpatient facility?
16
A.
I'm sorry, could you repeat that question?
17
Q.
Sure.
This a question from Grand Juror No. 3.
In an
18
outpatient -- in a licensed outpatient facility, would it be
19
appropriate for a doctor to have their office in the same
20
building as the licensed outpatient facility?
21
same building, I mean in the same offices as the licensed
22
outpatient facility.
23
A.
I would say that it's -- yes.
24
Q.
Yes.
25
When I say the
Yes.
Okay.
It's a question from Grand Juror No. 11.
26
A.
Can I just clarify?
27
acceptable.
28
Q.
I would say that it's
I don't know about appropriate.
Okay.
Acceptable though?

1329
A.
Yes.
Q.
Within guidelines?
A.
Yes.
That would not be a violation.
And just for
clarification --
Q.
All right.
A.
-- an outpatient program that's certified, not
7
8
9
10
licensed.
Q.
Thank you.
I appreciate that.
Do you do spot checks
without notice to licensed facilities?

A.
When we receive -- all complaint investigations are
11
done unannounced and then licensing will do biannual reviews
12
for renewal for a licensure renewal, but that is a scheduled
13
visit.
14
Q.
15
16
17
18
Any there any unscheduled visits when there's no
active investigation?
A.
There could be.
Licensing may go out and do a
compliance review.
Q.
Well, if licensing goes out to do a compliance
19
review, do they do an assessment of a facility or business's
20
infrastructure in terms of how that business is complying with
21
regulations and providing for the safety of their clients?
22
A.
Yes.
23
Q.
24
believe it's been asked.
25
has been asked.
26
And I
It has to do with spot checks and it
I've got a question.
This question is from Grand
27
Juror No. 11.
After a license has been granted, someone
28
applies for a license and it's granted, to your knowledge,

1330
does the licensing -- did the licensing authorities of ADP
ever go out to do spot checks to make sure that what has been
stated in the license application is consistent with the
actual practice at the facility?
5
6
7
A.
Not to my knowledge were any spot checks done after
the initial licensure.

Q.
There's another question I'm going to decline to ask
because it requests your personal opinion rather than factual
material.
10
11
staff member in a licensed house be required or be trained in
12
reporting any concerns they might have at their facility to
13
ADP, reporting their concerns to ADP?
14
A.
Did the question ask trained and/or required?
15
Q.
Yeah, I guess that's two questions.
Would a
So I would say
16
was there a requirement that staff members be trained about
17
reporting their concerns?
18
A.
No, there are no requirements for them to be trained.
19
Q.
Do you know if there were any requirements that a
20
21
staff member report concerns to ADP directly?

A.
There are regulatory requirements that for staff --
22
for the licensee to report any deaths, any injuries to clients
23
if they need to go to the hospital, there's other admin
24
requirements, if there's a change in organizational structure,
25
things like that.
26
reported to the department.
27
28
Q.
Those are all regulatory requirements to be
So such as the death report you got regarding
Mr. Benefield?

1331
A.
Correct.
Q.
I'm
going to decline to ask the first part because that's an issue
for the grand jurors themselves, as well as the second part.
Given your familiarity with A Better Tomorrow and its
other corporate entities, do you know if after the Iron Gate
facility was closed, if the corporate -- if the corporation
opened any other detoxification houses?
A.
Yes.
10
Q.
Do you know how many or can you approximate -- well,
11
12
13
let me put it this way, do you know how many?

A.
I believe they currently are operating with seven
homes and the Corning Place outpatient is still operating.
14
Q.
All right.
Do you know if those -- you said
15
currently.
16
and Forterus Health Care Services.
17
for a moment.
But I'm asking about A Better Tomorrow, Forterus,

Let's restrict it to that
18
A.
I believe that the current homes are under Forterus.
19
Q.
Okay.
And I'm going to decline to ask the last
20
portion of this question as not relevant to the grand jury's
21
inquiry.
22
If the Department of Alcohol and Drug Programs
23
received an anonymous report that a facility -- a licensed
24
facility were violating regulations, how would that be handled
25
and would it -- well, how would it be handled, first of all?
26
A.
We would open up a complaint.
27
Q.
And did you inspect the files regarding the Iron Gate
28
facility of A Better Tomorrow?

1332
A.
The licensing files?
Q.
Yes.
A.
No.
Q.
What about in complying with any subpoena from the
grand jury?
A.
No.
Q.
All right.
In preparation for your testimony here today.
So in your work with the investigation
you performed with A Better Tomorrow, did you come across any
other investigations that were opened up because of anonymous
10
11
12
13
reports to Alcohol and Drug Programs?

A.
I don't recall them being anonymous or reviewing
anything that was an anonymous complaint.

Q.
Okay.
Now, are you sure that every anonymous
14
complaint would have a file opened?
15
always given that kind of weight where an investigation file
16
would be opened?
17
A.
Yes.
Were anonymous complaints
So any complaint that comes into our
18
department, regardless if it's anonymous or by staff or a
19
family member, we open up a complaint on it.
20
jurisdiction over the allegation, we would open up a
21
complaint.
22
Q.
So any complaint you say?
23
A.
That is within the department's jurisdiction.
24
Q.
All right.
If we have
Without
25
specifically speaking about A Better Tomorrow or the facility
26
at Iron Gate -- that's strictly in a generic sense without any
27
connection to any known facility -- if a facility was found to
28
have deficiencies, what kinds of repercussions could it face?

1333
A.
Depending on severity of the deficiencies, the
department could revoke a license, suspend a license, and/or
issue a temporary suspension.
Q.
If a client were
sent to a hospital from a detox facility, would that
necessarily trigger an investigation by your department?
A.
No.
Q.
Why not?
A.
If during the course of a client coming in and
10
needing medical attention and the program appropriately takes
11
the client, then it doesn't necessarily or automatically
12
trigger a complaint.
13
Q.
And, in fact, even though you're informed of deaths
14
at detox facilities, is there anything necessarily wrong about
15
a death at a detox facility?
16
A.
Not always.
17
Q.
Do people just happen to die in detox facilities
18
sometimes?
19
A.
Sometimes.
20
Q.
And have you had investigations where that was your
21
opinion after the investigation?
22
A.
Yes.
23
Q.
And I'm
24
pausing because it's a difficult legal issue for me to ask
25
this question as written now.
26
a moment, so if you'll give me a moment.
27
28
I need to think it through for
Because I believe this question is not likely to

result in what is called material evidence to this inquiry,

1334
I'm going to decline to ask it because it's also potentially
more prejudicial than it is what we call probative, meaning
it's not going to reveal information about this inquest.
likely it will reveal information about other things that are
outside the scope of this inquiry.
6
7
MR. SAMUELS:
It's
Are there any other questions for this
witness?
MR. SAMUELS:
No more questions, Counsel.
All right.
May she be excused?
10
11
Before you leave, I have an admonition to read to
12
Yes.
you.
13
You are admonished not to discuss, at any time
14
outside of this jury room, the questions that have been asked
15
of you in this regard to this matter, or your answers, until
16
authorized by this grand jury or the Court, or until such time
17
as these grand jury proceedings become a matter of public
18
record.
19
instructions on your part may be the basis for a charge
20
against you of contempt of court.
21
You will understand that a violation of these
22
23
24
25
Do you understand, ma'am?
26
THE WITNESS:
27
28
MR. SAMUELS:
Yes.
Thank you.
You are excused.
Mr. Foreman, it is now 14 after 4:00.

1335
I don't have another witness who would fit into the 16 minutes
remaining, so I'll leave it up to you whether you want to hear
very short, partial testimony or whether you'd like to break
at this time.
5
6
recess and return tomorrow at 8:00 a.m.
MR. SAMUELS:
The grand jury will be in
Thank you, sir.

Thank you, Counsel.
(Proceedings adjourned.)
10
11
12
13
14
15
16
17
18
19
20
21
22
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25
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28

1336

Dr. Cohen Grand Jury Testimony

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Dr. Cohen Grand Jury Testimony

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SUPERIOR COURT - STATE OF CALIFORNIA

PEOPLE OF THE STATE OF CALIFORNIA,

REPORTER'S TRANSCRIPT OF CRIMINAL GRAND JURY PROCEEDINGS

SONJA A. HUDSON, CSR NO. 13150

Sonja A. Hudson, CSR

RIVERSIDE, CALIFORNIA; JULY 15, 2015.

Good morning, everyone.

grand jury will now come to order.

Will the secretary please take roll.

GRAND JURY SECRETARY:

GRAND JUROR NO. 1:

GRAND JURY SECRETARY:

GRAND JUROR NO. 2:

GRAND JURY SECRETARY:

GRAND JUROR NO. 3:

GRAND JURY SECRETARY:

GRAND JUROR NO. 5:

GRAND JURY SECRETARY:

GRAND JUROR NO. 6:

GRAND JURY SECRETARY:

GRAND JUROR NO. 7:

GRAND JURY SECRETARY:

GRAND JUROR NO. 8:

GRAND JURY SECRETARY:

GRAND JUROR NO. 9:

GRAND JURY SECRETARY:

GRAND JUROR NO. 10:

GRAND JURY SECRETARY:

GRAND JUROR NO. 11:

GRAND JURY SECRETARY:

GRAND JUROR NO. 12:

GRAND JURY SECRETARY:

Sonja A. Hudson, CSR

GRAND JUROR NO. 13:

GRAND JURY SECRETARY:

GRAND JUROR NO. 14:

GRAND JURY SECRETARY:

GRAND JURY FOREPERSON:

GRAND JURY SECRETARY:

GRAND JUROR NO. 16:

GRAND JURY SECRETARY:

GRAND JUROR NO. 17:

Juror No. 14.

Juror No. 16.

GRAND JURY SECRETARY:

Juror No. 19.

GRAND JUROR NO. 19:

GRAND JURY FOREPERSON:

Juror No. 18.

Counsel, you may begin.

THE GRAND JURY:

The record will reflect all

17 jurors are present.

It's my memory we were finished with

Sergeant Gomez last night, so I will bring another witness in.

Please remain standing and

raise your right hand.

give in this investigation now pending before the grand jury

truth, so help you God?

GRAND JURY FOREPERSON:

I have a statement acknowledging a secrecy order that

Sonja A. Hudson, CSR

Larry Steve Albert, Jr.