Child Protective Services
Investigation Report 
Child Welfare Agency

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

AGENCY NAME: Arizona Boys Ranch 

DATE OF REPORT: March 6, 1998 

DATE ASSIGNED: March 13, 1998 

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

ALLEGATION: 

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

ACTIONS TAKEN: 

SITE VISITS 

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

INTERVIEWS CONDUCTED BY CHILD PROTECTIVE
SERVICES 

3/16/98 Dorothy Porter and Steve Madrid, Paramedics - Rural
Metro, San Manuel Substation 
3/16/98 Kaja Jezycki, ABR attorney - Telephone call 
3/16/98 ABR resident - Oracle Facility 
3/16/98 ABR resident - Oracle Facility 
3/16/98 ABR resident - Oracle Facility 
3/l6/98 Billy Craig, Paramedic volunteer - San Manuel Health Care
Center 
3/18/98 Don Berg, Sacramento County Probation Officer -
Telephone call 
3/19/98 Sgt. Ron Pugliese, Pinal County Sheriff's Department -
telephone call 
3/19/98 ABR resident - Oracle Facility 
3/26/98 ABR resident - Oracle Facility 
4/8/98 John Wejmer, Don Berg, Pamela Moore, Sacramento
County Probation Department 
4/8/98 Detective Ed Schweitzer, Michael Downing, Brenda Alston
and Sgt. Ron Pugliese, Pinal County Sheriff's Department 
4/16/98 ABR resident - Oracle facility 
4/16/98 ABR resident- Oracle facility 
4/16/98 ABR resident - Oracle facility 
4/16/98 ABR resident - Oracle facility 
4/16198 ABR resident - Oracle facility 
4/16198 victim's mother - Telephone call 
4/20/98 Don Berg and John Wejmer, Sacramento County
Probation Department 
4/20/98 Judge Kenneth Peterson, Juvenile Court Judge,
Sacramento, California 
4/20/98 (victim's maternal grandmother) and Robert Buccola _ -
Sacramento, California 
4/21/98 ex-ABR resident - Los Padrinos Detention Center, Los
Angeles, California 
4/21/98 ex-ABR resident - home residence, Los Angeles,
California 
4/30/98 ex-ABR employee - Pima County Sheriff's Office, Tucson

5/1/98 ex-ABR employee - Pinal County Sheriff's Office, Oracle
Substation 
5/6/98 ABR staff - Oracle facility 
5/6/98 ABR staff - Oracle facility 
5/6/98 ABR staff - Oracle facility 
5/8/98 ABR staff - Oracle facility 
5/8/98 ABR Staff - Oracle facility 
5/8/98 ABR staff - Oracle facility 
5/8/98 ABR staff - Oracle facility 
5/18/98 ABR staff - Oracle facility 
5/18/98 ABR staff - Oracle facility 
5/18/98 ABR staff - Oracle facility 
5/20/98 ABR staff - Oracle facility 
5/20/98 ABR staff - Oracle facility 
5/20/98 ABR staff - Oracle facility 
5/20/98 ABR staff - Oracle facility 
5/20/98 ABR staff - Oracle facility 
5/20/98 ABR staff - Oracle facility 
5/20/98 ABR staff - Oracle facility 
6/10/98 Bruce Parks, forensic pathologist - Pima County Medical
Examiner's Office 
7/1/98 Mary Dudley, Forensic Pathologist - Consultant 
7/16/98 Mary Dudley, Forensic Pathologist - Consultant 
7/21/98 ABR resident, Oracle facility 
7/22/98 Mary Dudley, Forensic Pathologist - Consultant 
7/22/98 
7/27/98 
7/27/98 ABR resident 

DOCUMENTATION REVIEWED 

Pima County Medical Examiner's report 

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

Records obtained from ABR on Nicholaus Contreraz 

Sacramento County Juvenile Court medical records of Nicholaus
Contreraz 

Written statements from two ex-ABR residents 

Forensic Pathologist Consultant report 

Chronology report provided by _ 

Information collected by Sacramento County Juvenile Probation
Department 

California Department of Social Services Oversight Committee
Report 

CHRONOLOGY OF EVENTS 

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

Monday, 1/5/98 

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

Wednesday, 1/7/98 

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

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

Thursday, 1/8/98 

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

Tuesday, 1/13/98 

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

Thursday, 1/15/98 

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

Monday, 1/19/98 

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

Thursday, 1/22/98 

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

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

Sunday, 2/8/98 

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

Monday, 2/9/98 

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

Monday, 2/16/98 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The "Follow-up & Goals" stated: 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

5:59 PM - 911 call was received. 

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

6:29 PM - airevac arrived at ABR 

6:55 PM - airevac left ABR 

7:30 PM - Nicholaus Contreraz was pronounced dead. 

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

Tuesday, 3/3/98 

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

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

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

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

FINDINGS 

The information obtained is from interviews conducted by the Pinal
County Sheriff's Office (PCSO) and Child Protective Services
(CPS). Summaries of these interviews, of interviews conducted
only by PCSO and of interviews conducted by the Sacramento
Juvenile Probation Department are an attachment to this report and
identified as attachments 1 through 59. 

ALLEGATION 1 

Pl - 24 

Propose to substantiate 

Child death due to alleged abuse or neglect or suspicious death. 

PERPETRATORS 

_ ABR staff 
_ABR staff 
_ABR staff 
_ABR staff 
_ABR staff 
_ABR staff 
_ABR staff 
_ABR staff 
_ABR staff 
_ABR staff 
_ABR staff 
_ABR staff 

SUPPORTING EVIDENCE 

_ - _ ABR Oracle facility (Attachment 5) 

Records provided by ABR indicate she examined the victim on
the following dates: 1/7/98, 1/13/98, 1/15/98, 1/19/98, 1/22/98,
2/2/98, 2/9/98, 2/16/98, 2/23/98, 2/27/98, 3/1/98 and 3/2/98. 

On 1/7/98 the victim was seen for his admission medical exam.
The documentation indicates the nurse took a medical history. The
notes indicate the victim had asthma and was on two inhalant
medications, Beclovent, a steroid, and Ventolin, a bronchial dilator.
The nursing notes indicate the victim weighed 141 pounds. 

On 1/13/98 at 1:50 PM the victim was seen by the nurse for a
swollen right heel. The heel had been rubbing against the shoe. The
victim told the nurse he had an asthma attack the prior night and
used two extra puffs of Ventolin. 

On 1/15/98 at 10:05 AM the victim was seen by Ginger Tarin, a
nursing assistant, for a swollen tendon of his right foot. 

On 1/19/98 at 9:15 AM the victim was seen by the nurse. The
documentation indicates the victim's back ribs were sore, he had
been hit two days before. There is no documentation of the details
of how the victim had been hit. The notes state there was no
swelling or bruising. The victim reported pain when breathing and
still having difficulty with asthma. The notes indicate the victim was
to see Dr. Rutz on 1/21/98. 

On 1/22/98 at 7:00 AM the victim was seen by _ The
documentation states as follows, "Lungs clear, cough, and
demonstrated correct use of inhalers. Drixoral 1 tab twice daily x 5
days for drainage and cough." 

On 2/2/98 at 9:20 AM the victim was seen b _. The victim was
seen for a swollen tendon on his right foot. 

On 2/9/98 at 9:30 AM the victim was seen by _ . The victim
was complaining of rib cage pain on his right side. He was given
400 mg of Ibuprofen for what was diagnosed as a pulled muscle. 

On 2/16/98 at 10:52 AM the victim was seen by _. The victim
complained of headaches, drainage, sinus pain, and coughing. It
was noted the victim had been using cough medicine. He was given
Drixoral and sent back to the barracks. 

On 2/23/98 at 11:15 AM the victim was seen by someone, the
note is not signed. The victim complained of nausea, cough, and
fevers for three days. According to the note, his temperature was
noted as 99.8 degrees and throat and lungs were clear. 

On 2/27/98 at 10:00 AM the victim was seen by the nurse for
two physical assistance incidents that occurred on 2/26/98. The
documentation stated there are "no visible signs of edema, bruising
or lacerations. Abrasion 1"x2" on sternum clean and dry." 

On 3/1/98 at 4:30 PM the victim was seen by the nurse for a
physical assistance incident. The nursing notes stated the following:
"c/o hurting all over. Numerous abrasions to chest, upper arms,
over r / I scapula 24-36 hrs old. Scabbed over. C/o tingling in
fingers and toes (from hyperventilation). No further signs of edema,
bruising, lacerations and/or abrasions noted." In the comments
section the notes state: "& breathing / equipped c/ paper bag 12
(degrees) sleep tonight". The note was supposedly signed by the
victim, however, the signature appears significantly different from
other documents. 

On 3/2/98 the nurse completed an incident report. It
documented an incident at 2:45 PM. The note states the following:
"On the above date on the walkway in front of the supervisor's
office I observed Mr. Contreraz being supported by _ and _.
When I asked Mr. Contreraz what was wrong, he responded by
saying 'I can't walk any more.' I reiterated he needed to slow down
his breathing. Breathing was 22/min shallow. When I asked if he
was in pain, he stated he 'hurted all over'. He slowed his breathing
when he was being carried back to the group via the fireman's
carry by _. _ was alert and oriented to person, place and time. He
appeared to be in no distress while being carried." 

_ stated during an interview with CPS on 7/27/98 that on 3/2/98
she worked on a chronology of her contacts with the victim. She
stated she turned it over to ABR staff. She gave CPS a copy of the
chronology (Attachment 56). 

During the interview, _stated that prior to the victim's death, she
did not have concerns that items from the victim's chart were being
removed. However, since leaving ABR, she now has concerns her
chart was altered. She could not state exactly how it was altered. 

The chronology indicated the victim was seen more often than
the documentation provided by ABR. The chronology provides
very detailed information of _ contact with the victim. Of particular
significance is _ states in her chronology that on 3/1/98 she
examined the victim and he weighed 141 1/4 pounds. (The autopsy
performed on 3/4/98 states the victim weighed 132 pounds.) 

The nurse's chronology lists the following additional contacts by
_ with Nicholaus Contreraz. 

1/8/98 The victim was seen by _. The asthma medication doses
were adjusted. 

1/21/98 The victim was seen by _. The victim reported difficulty
breathing and stated the inhalers do not work. He was prescribed
the use of his inhaler 30 minutes prior to any exercise. The
chronology states this information was provided to staff. 

2/22/98 The nurse was called at home. The victim has a
temperature of 103 degrees. The victim vomited his lunch. He was
given Tylenol. The nurse instructs staff to put the victim to bed,
increase his fluid intake, apply cold compresses and check his
temperature in two hours. Staff were to call the nurse if the victim's
temperature remained high. During interviews with staff, no one
reported contacting the nurse at home to report the high
temperature. 

2/24/98 At 9:00 AM were the camp Olympics. The nurse
observed the victim sitting on a block wall with other restricted
residents. The victim reported his tooth hurt. At 11:00 AM she
again saw the victim sitting on the block wall and he was cool to
her touch. She stated the victim was upset because she would not
allow him to join in the "games". During interviews with other staff,
this contact was observed. 

2/25/98 The nurse observed the victim with a work crew. The
victim reported he was okay and he felt cool to her touch.
According to the chronology staff reported the victim would
occasionally hyperventilate. (It needs to be noted that in the
numerous interviews conducted with ABR staff and residents, no
one reported observing this contact with the nurse while the victim
was with a work crew.) 

2/26/98 At 10:00 AM the victim was seen by the nurse. The victim
complained he hurt all over. Staff stated the victim would
hyperventilate occasionally. The victim denied having a headache.
The nurse noted his lungs sounded clear. 

_ stated her job at ABR consisted of evaluating residents to
determine if residents needed to see a doctor or dentist, needed to
go to the emergency room, or triaged on site for illness. 

_ stated the victim arrived at ABR without medical records. She
received medical reports after she requested them on 1/7/98. They
arrived approximately one week after she called to make the
request for the information. 

_ stated she did not realize the seriousness of the victim's asthma
until after the victim died. She stated the victim did not inform her of
the asthma problems he had in Sacramento. (Although it should be
noted nursing notes on 1/7/98 state the child was on medication
routinely used to treat asthma. One of those medications, the
steroid, is used to treat more serious forms of asthma.) 

_ stated she was not aware of the victim's allergy to dairy
products until informed by the CPS investigator during the
interview. She stated that had she been aware of the many
problems the victim had, he would not have been admitted to ABR.

_ stated that when she examined the victim on 3/1/98 regarding
the numerous abrasions on his body, she did not ask the victim or
anyone else how the abrasions were caused. 

She reported that on 3/2/98 she checked on the victim as a
follow up. She stated she had lunch with him at noon. The CPS
interviewer informed her that no one could recall seeing her with the
victim at lunch. However, there were several reports that the victim
was with _ during lunch on this day. 

She stated she last saw the victim at approximately 2:45 PM in
front of the supervisor's office. The victim looked at her while he
was down on his knees and staff were holding him. She walked
over to him and talked to him. The victim told her he could not
walk. She stated she checked his pupils and pulse and both were
normal. She released him to staff to continue with physical activity. 

_- shift _ ABR Oracle facility (Attachment 6) 

He observed the victim cough up phlegm. 

He stated he believed there was something wrong with the
victim. He noticed the victim was lethargic and had lost significant
weight. He saw the victim's behavior decline in a short period of
time but did not know why. 

_- night shift staff, ABR Oracle facility (Attachment 7) 

Prior to 2/22/98 he recalled writing an entry into the log of
Barracks 31 indicating the victim had a fever of 103.8 degrees. On
2/22/98 he woke the victim up at night to check his temperature. 

According to _, on 2/23/98 the victim was written into the log
for having a fever. (It should be noted this log was not included in
the documentation provided by ABR to CPS.) 

On 3/1/98 the victim was ordered to have 12 hours of bed rest.
The victim got up in the middle of the night to urinate and he asked
the victim how he was feeling. The victim was coughing a lot and
had been coughing for several nights. The victim would cough
continuously in his sleep. _ recalls telling _ about the coughing. He
does not recall if he wrote the information in the barracks log. 

He observed the victim cough up bright yellow mucous on more
than one occasion. 

He made contradicting statements about whether he reported
the coughing to anyone. In one interview with PCSO he stated he
did not. In an interview with CPS he stated he reported the
coughing to _. 

He told PCSO that on 3/1/98 he did not note his observations in
the barracks log because it was not a function of his job to do so. 

He has an emergency medical technician license. 

_- work specialist, ABR Oracle facility (Attachment 8) 

He stated the victim appeared "weak, wobbly and exhausted". 

For the last couple of weeks he observed the victim fall to the
ground on several occasions. He also noticed the victim's difficulty
with breathing and panting while breathing. 

He observed the victim unable to perform physical activities. 

He thought the victim just wanted out of ABR. 

_ - shift supervisor, ABR Oracle facility (Attachment 9) 

He knew the victim was vomiting and defecating on himself
repeatedly. He believed the victim was "faking". 

He observed the victim being carried in a wheelbarrow by _.
The victim could not walk. 

_ told him the victim had defecated on himself and was not
feeling well. 

_ - work specialist, Oracle facility (Attachment 10) 

He does not recall the day, but he observed the victim sitting on
the toilet eating his food. There was another resident present at the
time. He stated he was not the staff person who directed the victim
to eat his food while sitting on the toilet. 

He stated he did not recall giving instructions to another resident
to serve the victim the minimum amount of food and then crunch up
his potato chips. 

He stated the victim would "dehydrate himself and defecate in
his pants". 

He admits to carrying the victim in a wheelbarrow on 3/1/98
because the victim would not walk. 

He stated it was possible he saw the victim carry a yellow
bucket which contained his soiled clothes and vomit. 

On 3/2/98 he instructed the victim to throw his soiled clothes in
the dumpster. _ told PCSO that he, _, told the victim he deserved
an "academy award" for the way he was moving slowly to throw
his soiled clothes into the dumpster. On this same day, while he
carried the victim on his shoulders, the victim bit him. 

_ - work specialist, ABR Oracle facility (Attachment 11) 

On 3/2/98 at 5:15 PM he was taking residents to eat dinner. He
saw the victim on the volleyball court with staff. _ called_ to assist
them. They were in view of the other residents so they decided to
move the victim to the amphitheater so the victim would not be
ridiculed or embarrassed. 

The victim refused to walk so he and _ carried him by the ankles
and wrists. 

At the amphitheater they instructed the victim to do pushups.
They told the victim he owed them 10 to 15 push-ups. The victim
refused to do the push-ups. _ modified the push-ups and the victim
was able to do a couple. They again modified the push-ups and the






Child Pro
completing the push-ups. He stated he grabbed the victim by the
belt and shoulder and raised him up and down. 

On 3/2/98 at the amphitheater he noticed the victim's eyes were
closed most of the time. 

He and _ walked and carried the victim and stood him against a
wall. He does not recall anyone hitting the wall. The victim refused
to talk to staff so they told him to get back down in a push-up
position. The victim obeyed the instruction. 

The victim stated he was thirsty. They instructed him to stand up
and walk to the water. The victim refused so he and _ carried the
victim by his ankles and wrists to Barracks 22. _ poured water on
the victim's mouth and there was no reaction. They checked his
pulse and determined he was no longer breathing. They began
administering CPR. 

_- work specialist, ABR Oracle facility (Attachment 12) 

On 2/26/98 he was walking down the main street where staff
were leading physical exercise and he observed the victim had
defecated on himself. He took the victim to Barracks 31 to clean
him up. The victim again defecated on himself fifteen minutes later.
He took the victim to the nurse who gave the victim some
anti-diarrhea medicine. The victim began to breathe heavily while in
the nurse's office and the nurse tried to calm him. The nurse gave
the victim a paper bag to use for the hyperventilation. 

After the visit to the nurse the victim was returned to a work
crew. The victim was instructed to move rocks from the top of the
hil1 to the bottom. He and _ tried to encourage the victim to
complete this task. He stated they assisted the victim by placing
some rocks in the wheelbarrow. He stated they would not have put
a big rock in the wheelbarrow to make the victim feel worse. 

After dinner he observed the victim at the volleyball court with _
doing physical training. He later saw _ with them. He stated the
victim was making no effort to comply and was non-responsive.
The staff were giving him continual feedback and physically
assisting him throughout the activity. Because he would not
cooperate he was given the consequence of three days of extra
duty. 

On 3/2/98, at the volleyball court he saw the victim with _ and
_. He joined them and they encouraged the victim to drink water.
At first the victim refused. _ then poured water into his mouth. The
victim would spit it out but he did finally drink about two cups of
water. 

On 3/2/98 at the amphitheater, he observed the victim was
"wobbly" and tired. He noticed his breathing was short and he was
panting with his mouth open, breathing heavily. He attributed the
breathing difficulties to hyperventilation and instructed the victim to
breathe correctly. 

_ - cook, ABR Oracle facility (Attachment 13) 

On 2/28/98, during clean up of Barracks 31, he moved a yellow
bucket closer to the victim when the victim stated he was feeling
nauseous. He then instructed the victim to complete pushups. 

On 3/1/98 he observed the victim sitting in the pantry on the
toilet during mealtime. 

On 3/2/98 sometime in late afternoon while he was outside
grilling dinner for residents, he observed _ and _ pick the victim up
when the victim fell to the ground. He heard _ state, "We're doing
everything by the book." Later he saw the ambulance lights and
helicopter. 

_ - shift leader, ABR Oracle facility (Attachment 14) 

Two weeks prior to the victim's death, he noticed the victim had
symptoms of a cold or flu. The victim was taking over the counter
cold tablets. He stated he was sure these symptoms were
communicated to the nurse, although he did not do so personally. 

He observed the victim had a change in weight but felt it was
normal. 

On 3/1/98 he told the victim the nurse had cleared him for
assigned activities. He checked with his supervisor, __, who told
him the victim was cleared for all activities. However, he noticed
the victim continued to have problems with defecating and difficulty
breathing. He contacted _ because the victim seemed lethargic and
thought he needed to double check with his supervisor. 

On 3/1/98, in the evening, _ contacted the nurse to ask her to
come to the facility to check the victim. 

On 3/2/98 he was in the chapel and observed _ and __ assisting
the victim with modified push-ups. He instructed _ to take the
victim out of the chapel so the other residents would not be
disturbed. About five minutes later he went to check on the victim
and found they had taken the victim to Barracks 8. He entered the
barracks and found staff instructing the victim to do push-ups. He
states the-victim hit himself on the head against the leg of the bed
frame. _ attempted to have the victim release his grasp on the bed
frame leg and then placed him in a control position. They then
helped the victim out of Barracks 8 trying to calm him. The victim
had defecated while in Barracks 8 and staff were trying to calm him
down so they could take him to shower and clean up. While he
was outside _ placed the victim on his side in case the victim might
need to vomit. The victim was making gurgling sounds. At this point
it was 2:00 PM. 

He was aware the victim was vomiting, had difficulty breathing
and breathed deeply through his mouth. 

He observed the breathing difficulties during physical activities
and physical training. 

He observed the victim appeared to breath well when sleeping. 

He knew the victim was cleared for physical activity, yet he
noticed no improvement in the victim's breathing. 

The victim told him he had chest pains while breathing and he
gave the victim an inhaler to use. 

_ - work specialist, ABR Oracle facility (Attachment 15) 

On 2/28/98 he observed the victim vomiting while __ was with
him. 

He heard the victim complain of being tired and sick. 

He observed the victim had lost weight the last couple of weeks
before his death. 

He stated he did not think the victim acted aggressively towards
staff but would just go limp. 

On 2/28/98 he gave the victim a trash can to use for vomiting
and to place his soiled clothes. He stated the reason he gave the
victim a bucket to carry his soiled clothes was to remind him to
appropriately request permission to use the restroom. His intention
was for the victim to carry the trash can with him on 2/28/98 and
3/1/98. 

_ - work specialist, Oracle facility (Attachment 16) 

On 2/26/98 he observed the victim sleeping on a mattress on the
floor. 

On 2/26/98 he gave the victim his inhaler once when the victim
asked for it. 

On 2/27/98 the victim complained of breathing difficulties. He
gave the victim his inhaler possibly twice on that day. 

On 2/27/98, after the other residents finished their lunch, he
took the resident with him to sit on some rocks to finish his lunch.
The victim vomited after eating. He thought this was because the
victim stuffed his lunch into his mouth to make himself vomit. 

On 2/27/98 after the other residents were going to sleep, he and
made the victim do make-up physical training in the center bay
because the victim had not done physical training with the group.
The victim was required to do jumping jacks. He and _ assisted the
victim, who resisted the assistance by trying to break away. He
observed _ correcting the victim for not putting forth effort or doing
the physical training correctly. He heard the victim say he could not
do the pushups. He and _ assisted the victim by grabbing the
victim's upper arms and taking him up and down and jog in place.
The victim defecated on himself. After the victim was cleaned up,
he vomited. _ gave the victim a bucket to use to vomit. 

On either 2/26/98 or 2/27/98 he observed _ take the victim to
the nurse. Following the visit to the nurse, the victim was returned
to the work crew. _ told him the victim had been cleared to resume
regular activities. 

On 2/28/98 he observed the victim spit up brownish phlegm into
the bucket while marching to the pantry. He did not tell the nurse
about this. 

On 2/27/98 and 2/28/98 he heard the victim coughing a dry,
non-wheezing cough. 

On 2/28/98 he gave the victim his inhaler once when the victim
asked for it. 

On 2/28/98 in the morning, he observed the victim doing
push-ups with _ present. While doing push-ups, the victim kept
saying he was going to throw up. He observed _ put a yellow trash
can next to the victim and told the victim to use the trash can if he
needed to throw up. 

On 2/28/98 the victim ate his dinner slowly. He made sure the
victim finished his meal outside on a rock. The victim vomited while
eating his meal. He was not concerned that the victim had vomited
While walking back to the barracks the victim said he was tired
and needed to stop and rest. He told the victim he could rest when
he reached the barracks. He did not check the victim's
temperature, despite throwing up, because he thought the victim did
not look feverish. The victim slept on a mattress on the floor that
night. 

The following interviews provide further evidence which supports
the finding. 

_ - work specialist, ABR Oracle facility (Attachment 22) 

He stated he was not involved in the fireman's carry of the
victim. The only contact he had with the victim was on 3/2/98. He
thought the victim looked sad and down on life. 

On 3/2/98 _ asked him to come to the chapel to talk to the
victim. The victim spoke in a low, emotionless tone. He told the
victim he looked "pretty crappy and sad". _ had the victim do
physical training, including climbing stairs. The victim climbed to the
top and back. The victim asked how many more stair runs he had
to do and told him it depended on the victim's effort. The victim
told _ he wanted to kill himself. 

On 3/2/98, on his way to dinner, he observed _, _, and _, at
approximately 5:00 PM to 5:30 PM with the victim on the
volleyball court. Staff wanted to get him out of the area because
residents were coming out of the pantry. Either _ or _ was carrying
the victim in the "fireman's carry". The victim was not holding his
head up, his chin was on his chest and his toes were dragging. The
victim was leaning forward with his arms back and staff were
holding him under the arms carrying him toward the supervisor's
office. 

_ - work specialist, ABR Oracle facility (Attachment 23) 

He thought the victim looked sickly, like he had a cold or flu.
The victim looked sad, with blackened eyes and pale skin. 

During the past couple of weeks prior to the victim's death, he
observed the victim's breathing problems. 

He thought in part the victim was "faking" but then did appear
sick. 

He stated that on 3/1/98 he brought to _ attention the victim's
condition. He thought _ agreed that the victim should be sent to
Tucson for a physical. 

_ - work specialist, ABR Oracle facility (Attachment 20) 

On 2/28/98 _ took the victim to the nurse. The nurse taught the
victim to breath. 

On 3/1/98 he and _ took the victim to the nurse. He heard the
nurse tell the victim they had spoken about this before and his
breathing problems were in his head. 

On 3/2/98 he and _ observed the victim with _ and_ at the
amphitheater. The victim was in a pushup position but was not
doing pushups. The victim was then stood up against the wall. _
and _ did this by putting a hand under the victim's arms. _ then
talked to the victim with a raised voice and hit the wall loud enough
to get the victim's attention. He spoke with _ about the loud noise
and believes it was only a way _ used to get the victim's attention. 

He stated he did not document what he saw as normally the
witness or the lead would document any incident and he was not a
lead or witness. He did not think it was his place to write the
documentation. 

_ - shift supervisor, ABR Oracle facility (Attachment 24) 

Two weeks prior to the victim's death, he informed _ the victim
had been coughing and may have pneumonia. _ told him that
according to the nurse there was nothing wrong with the victim. 

Sometime within the two weeks prior to the victim's death, the
victim had a temperature of 103. He was told by his supervisor, _,
to give the victim Tylenol, a shower and put him back to bed. _
told him the victim was faking the fever. 

He had been giving the victim cough medicine because he was
coughing badly. 

He was instructed a week prior to the victim's death to stop
taking the victim's temperature as the victim was faking the 103
degree temperature. 

_ - work specialist, ABR Oracle facility (Attachment 19) 

On 2/26/98 the victim's food intake was monitored. The victim
was on suicide watch and did not eat everything and was given a
"packout" (boxed meal). He stated the victim did not vomit at this
time, nor did he play dead, lose consciousness and fall to the
ground. 

On 2/26/98 he observed the victim roll his head back and
stumble, falling out of formation but not actually fall on the ground. 

Staff perceived the victim as manipulating as each time he had
physical activity the victim would urinate on himself. He believed
the victim was faking his physical symptoms and being defiant as a
way of getting out of physical activity. 

He did not work on 3/1/98 or 3/2/98 but he heard from _ that
the victim had stumbled out of formation and had been unable to
walk up a hill. 

He thought the victim's problems gradually increased over the
two weeks prior to the victim's death. He believed the victim
looked sad, emotional and frustrated. He also thought the victim
had lost fat and gained muscle. 

_ - work specialist, ABR Oracle facility (Attachment 18) 

On 2/28/98 he saw the victim eating a "packout" (boxed meal)
by the portajohns. He saw the victim eat a little then vomit, then he
would continue to eat more on his own. 

On 3/2/98 in the afternoon he observed the victim with _ and _ .
They were with a work crew picking up leaves. The victim refused
to walk. _, _ and _ had the victim do push-ups and they assisted
the victim in the push-ups when the victim refused to do them. He
stated the victim got tired of having staff assist him so he stood up
and walked on his own to join the group. They marched to the
chapel and half way there, in front of the supervisor's office, he saw
the victim on the ground. _ and other staff were with the victim.
This was the last contact he had with the victim. 

_ - work specialist, ABR Oracle facility (Attachment 25) 

He saw the victim on his third day of working orientation. He
observed the victim marching up the hill toward the chapel. The
victim seemed out of breath and would stop to catch his breath. He
sat down at one point and saw someone put his arm around the
victim. He did not see if the victim went into a wheelbarrow by
himself or if someone put him into the wheelbarrow. It was the first
time he had seen a resident in a wheelbarrow. 

_ - shift supervisor, ABR Oracle facility (Attachment 26) 

He had a few contacts with the victim when he ate with the
victim. He knew the victim had not been eating for some time. His
understanding was the victim did not feel like eating, sat with food
sitting in front of him and said nothing and did not eat his food. 

He never saw the victim vomiting but he heard about the victim
vomiting. 

_ - activities coordinator, ABR Oracle facility (Attachment 27) 

On 3/2/98, at a management meeting at the main ranch facility,
the victim was discussed. They stated the victim was on yellow shirt
status for high visibility because the victim did not want to be at
ABR. He read incident reports about the victim. 

He stated he should have known, but did not know, that the
victim was not participating in the program. He did not have first
hand knowledge of the problems the victim had in meeting basic
expectations. 

On 3/2/98 he had his first contact with the victim when he
arrived at the southwest corner of Barracks 22, near the
amphitheater and staff were doing CPR on the victim. 

_ - resident, ABR Oracle facility (Attachment 30) 

On 3/1/98 he overheard _ say the victim was cleared for
physical training. 

He observed the victim doing physical training in the barracks,
and overheard the victim tell staff that his chest hurt and he was
sick, then he observed staff knock his hands off his chest. 

_ - resident, ABR Oracle facility (Attachment 31) 

The victim would spit up brownish yellow stuff when he would
cough. The victim was coughing a lot, ate less each day, was losing
weight, would fall down while walking, had difficulty breathing and
would wheeze, and was hot to the touch. 

On either 2/28/98 or 3/1/98 the victim had been going up the hill
when he collapsed. _ and other staff made _ get a wheelbarrow
and the victim was placed into the wheelbarrow. He was told to
push the wheelbarrow and staff followed behind. The victim said,
"Lord help me. I need help! I need help!" Staff told him to shut up. 

Staff would tease the victim saying the victim would do anything
to get out of physical training. 

He noticed the victim had a foul odor on his body and breath,
even if he showered and brushed his teeth. 

_ - resident, ABR Oracle facility (Attachment 32) 

On 3/2/98 he saw the victim with _ and _. Staff were telling the
victim to march down the hill. The victim kept falling. _ was
laughing at the victim saying he was faking it. 

On 3/2/98 he saw staff yelling at the victim while in front of the
supervisor's office. He saw tears coming out of the victim's eyes.
The victim was "just out of it..." Staff were holding the victim up,
and his eyes were half closed. All of the residents of Barracks 16
also observed this incident. 

On 3/2/98, at noon, he served the victim lunch. _ was with the
victim. _ instructed him to give the victim the bare minimum in food.
_ crunched up the potato chips on the victim's plate into little
pieces. _ laughed while he crunched up the chips. 

On 3/2/98 he heard _ say to the victim, "Hey! You defecated on
yourself!" and placed the victim on the toilet to eat his lunch.
Another resident was sitting on a crate next to the victim. The other
staff member present was _. 

On 3/3/98, _ asked him to go digging in a dumpster to find a
yellow shirt. He found the yellow shirt, tan pants and underwear
with defecation on them, all of which were in a black plastic bag.
He gave them to _. He knew it was the victim's clothes in the bag,
because the victim had been on yellow shirt status, and there was
no other reason to take these clothes out of the garbage. 

_ - resident, ABR Oracle facility (Attachment 33) 

One night, he heard the victim tell staff he needed to defecate
while he was doing jumping jacks. Staff told him he could not. The
victim then told staff he had defecated on himself. The staff had him
continue jumping jacks. 

He believes it was at this point the victim was made to carry a
trash can around with him. He observed staff making the victim
place his face into a trash can while in the push-up position. 

_ - resident, ABR Oracle facility (Attachment 34) 

He observed the victim carry around a trash can with his soiled
clothes and vomit. He states he saw this on 2/27/98, 2/28/98 and
3/1/98. He stated the trash can stank but they could not say
anything about it because staff would give them feedback. He
observed the victim vomiting after meals. 

He observed and heard staff saying, "Ready, set, fire...," when
the victim would begin to vomit. The victim would vomit on the
word "fire." 

On 3/2/98 in the morning, he heard staff yelling at the victim for
not brushing his teeth quickly. 

He believed the victim received more feedback than the usual
resident because he would move slowly. 

The victim told him he could not try harder because his stomach
hurt, he did not have energy and did not feel well. 

_ - resident, ABR Oracle facility (Attachment 35) 

He observed the victim eating outside and then throwing up.
Staff did not do anything about the victim vomiting. He heard _ tell
the victim he was a baby. 

_ - resident, ABR Oracle facility (Attachment 36) 

In the last two weeks, the victim had a deep cough, a runny
nose and trouble breathing. 

Staff took the victim to the nurse. Staff would say there was
nothing wrong with the victim and he had been cleared by the nurse
for physical training. On one occasion he observed a maintenance
man stop to offer the victim a ride. _ yelled out the victim would not
be allowed to manipulate. 

He observed _ dragging the victim down a hill. He then saw _
stick the victim's head in a bucket telling him to stay. This happened
when the victim was on yellow shirt status. 

He observed the victim carrying a bucket with his soiled clothes
after he had defecated on himself. Staff made him stick his head
into the bucket. The victim was on yellow shirt status during this
time. 

He observed _ yelling in the victim's ear at the top of his lungs. 

On the day the victim was in a wheelbarrow being pushed by _
they went to the chapel. He observed the victim in a four square
position (laying face down with arms and legs extended and holding
his body above the ground and maintaining for a prescribed time). 

_ - resident, ABR Oracle facility (Attachment 37) 

He would hear _ call the victim, 'Oh Contrer Ass'. 

Staff would make fun of the victim. 

He observed _ make the victim carry defecation and vomit in a
trash can. _ and _ called it motivational physical training. 

He believed _ and _ had the most contact with the victim
toward the end of his life. 

He observed _ making the victim exercise all day. 

He observed _ not letting the victim use the bathroom when
requested, causing the victim to defecate in his pants. 

_ resident, ABR Oracle facility (Attachment 38) On 2/28/98,
during physical training, he saw the victim become tired and unable
to walk. A staff member picked him up by one arm, with the other
arm around his waist, to see if he could walk. The victim's eyes
were rolled back inside his head, his head was leaning, and his
mouth was partially open. 

He stated that before dinner on 2/28/98 he, -, had to use the
bathroom. Staff refused to allow him and he defecated on himself.
He was not allowed to change and was made to sit on a crate in
the back. He saw the victim was also in the back sitting on the
toilet, with his pants down, eating his dinner. 

On 2/28/98 after dinner he saw the victim on the rocks,
throwing up. Staff were laughing and clapping. 

On 3/2/98 he saw a staff member holding the victim in a
fireman's carry. The victim was breathing in deep gasps. He did not
know who the staff person was. This occurred right before they
went to the chapel. 

- resident, ABR Oracle facility (Attachment 39) 

On 3/1/98 he heard staff kidding around saying if they had to
give the victim mouth to mouth they would rather let him die. 

He stated that since the victim arrived at ABR he was "all sick".
Staff did not believe him and made him exercise more. He was
aware the victim was vomiting and staff would make him eat, saying
"You're going to eat or we're going to help you." 

He stated the victim got to the point he would collapse while
walking. Staff got a wheelbarrow and made another resident push
the wheelbarrow up the hill. When the victim collapsed, staff made
fun of the victim, saying "Oh, poor little baby." 

On one occasion he observed the victim vomit in the chapel.
The victim was made to clean it up. 

He observed the victim being made to do push-ups when he
could not complete even one. 

He recalled seeing a bruise on the victim's right arm. 

He recalled seeing the victim carrying a yellow bucket. 

- resident, ABR Oracle facility (Attachment 40) 

He stated three weeks after the victim arrived at ABR the victim
began having problems and telling staff he could not do physical
training because his chest hurt. 

He believed once the victim was a "yellow shirt" the victim was
singled out by _ and made to do more physical training than other
yellow shirts. 

The victim would defecate on himself. The victim was made to
sleep on a mattress in the bathroom. 

A week before his death, the victim was forced to carry a
bucket containing his soiled clothes. - made the victim put his nose
into the bucket. 

The victim would ask to go to the nurse. Staff would take him to
the nurse. After the third time, __ put the victim in front of the
group and told the group the nurse said there was nothing wrong
with the victim. 

- resident, ABR Oracle facility (Attachment 41) 

He observed the victim carrying a trash can. 

He heard staff state the victim was faking his illness. Staff would
make fun of the victim. 

On 3/2/98 residents were running. The victim said he could not
run. Staff grabbed his arm and dragged him. The victim would fall
to the ground and say he could not run. He observed another
resident pushing a wheelbarrow in which the victim had been
placed. The victim was instructed by staff to pick up leaves. When
the victim was unable to do so, he was taken by staff to a building
for physical training. He heard the victim yelling that he could not
do the physical training, that he was going to faint. He saw the
victim taken to the volleyball court for push-ups. When the victim
was unable to do this, he observed staff pick up and drop the
victim several times. At this point he left with the other residents for
lunch. 

- resident, ABR Oracle Facility (Attachment 42j 

He was aware the victim was hyperventilating but he was made
to exercise. 

On 2/28/98 he observed the victim fainting. Staff picked him up
and said the victim was faking. Staff placed the victim in a
wheelbarrow. 

He was working in the pantry and observed the victim was
unable to eat. He observed the victim would vomit after eating. He
heard staff making fun of the victim, stating "You better eat your
food Mr. Contreraz, you're going to have long day." 

On 3/2/98 he observed staff dragging the victim around. The
victim was coughing and gagging. 

- resident, ABR Oracle facility (Attachment 43) About two weeks
before the victim died he heard the victim cry and vomit in his
"rack" (bed). 

Staff would laugh at the victim. 

He observed the victim carrying a bucket. 

He was in the nurse's office one day with the victim and he did
not see the nurse use a stethoscope on the victim. 

- resident, ABR Oracle facility (Attachment 44) 

About one and one half weeks before the victim died he
overheard staff talking about the nurse, _, giving him chicken soup
because he had a fever. He said staff still made him do physical
training despite the fever. 

He said he was present when the victim would ask staff if he
could go to the bathroom, but was told to wait, so he would
defecate on himself. _ and _ made the victim carry his dirty clothes
in a trash can, then staff would force him to do physical training
while smelling his own defecation. 

On 3/2/98 he heard the victim talk about getting better and
feeling a little better. 

- resident, ABR Oracle facility (Attachment 45) 

He heard the victim tell staff his chest was hurting, he was sore,
could not catch his breath and could not walk. Then he heard _ say
the victim should be pushed in a wheelbarrow, - told the victim to
make ambulance-sounding noises. 

On one night, about 30 to 45 minutes after the other residents
went to bed, he heard the victim, while doing physical training, tell
staff that he had to go to the bathroom. He heard staff yell at the
victim and they told him to go on himself. When the victim
defecated on himself staff made him sleep on a mattress on the
floor and did not allow him to clean himself up until the next day. 

He said staff messed with the victim more than other yellow shirt
residents. They called him bad names and made him exercise for
hours. 

- resident, ABR Oracle facility (Attachment 46) 

The victim told him that he felt sick, his head and his stomach
hurt. He told staff but they said the victim was manipulating. He
heard say there was nothing wrong with the victim so he could do
the exercises. 

On 3/1/98 he saw - and _ forcing the victim to do physical
training, "hard exercises." 

- resident, ABR Oracle facility (Attachment 47) 

On 3/2/98 he observed the victim at around noon at the
volleyball courts. He was doing a lot of running and jogging. He
stopped and vomited. Staff that were present just stood back. 

Later on 3/2/98 while outside the pantry area he saw the victim.
The victim looked real sick and pale. - and - were trying to carry
the victim, with his feet hanging down. He heard staff tell the victim
to hurry up. About 20 to 30 minutes later he saw the helicopters,
ambulances and police cars. 

- resident, ABR Oracle facility (Attachment 48) 

He observed the victim vomiting after eating. 

He observed the victim defecating on himself. 

During the week prior to the victim's death, he observed the
victim run up and down a hill and pass Out. Staff dragged the
victim down the hill. When the victim was revived, staff made him
run again. He recalled one time when after the victim passed out
after a run on the hill, one staff person,- , put a bucket on the
victim's head. 

- resident, ABR Oracle facility (Attachment 49) 

He heard the victim tell _ he was sick. - responded by saying
there was nothing wrong with the victim. 

He observed the victim request the use of his inhaler and staff
refusing to give it to him saying the victim did not need the inhaler. 

He thought the victim was made to do extra things while on
yellow shirt status. The victim could not do push-ups and was put
into a four square position but the victim kept falling down. The
staff placed sticks under the victim's knees. 

About a week prior to his death, he heard the victim state he
needed to defecate. Staff told the victim to urinate and defecate on
himself. The victim defecated and he was not allowed to shower
and had to sleep in his soiled clothes on a mattress on the floor.
The next day they made the victim carry his soiled clothes
everywhere he went in a yellow trash can. Residents did not want
to be around the victim because he smelled bad. 

One time he observed the victim running up and down the hill.
He asked for his inhaler and staff would give it to him. He passed
Out when he got to the top of the hill. He observed - drag the
victim down the hill, put him in a comer and put a bucket on the
victim's head. The bucket contained feces, urine and vomit. 

One day in the barracks he observed the victim vomit into his
canteen because staff made the victim drink the whole canteen of
water. After this they would not allow the victim to carry a canteen
and instead staff would get a pitcher of water and pour drops of
water on the victim's tongue. 

He observed the victim eat and vomit. 

He once observed the victim in the volleyball court doing barrel
rolls. Staff would pick up the victim and slam him back down on
the ground. The victim asked staff why they did not leave him
alone, that he did not do anything. Staff told the victim to shut up. 

He stated that after about two weeks of vomiting the victim was
wearing a red band (restricted duties) for about four or five days.
While wearing the red band, the victim would sit while the group
exercised but staff would make him be in the four square position
for an extra 30 minutes after the other residents were in bed. 

After the victim was taken off the red band, the victim was still
sick, coughing and vomiting. When residents were watching a
movie the victim would be vomiting while doing exercises, such as
push-ups and the four square position. He observed the victim
vomit in the chapel and the victim being made to clean it up and
then taken outside. 

- resident, ABR Oracle facility (Attachment 50) 

On 3/1/98 he observed staff making the victim do push-ups
while residents were in the chapel. The victim told them he could
not do them because his arm hurt. Staff told the victim it was too
bad and they had given him a chance. The victim then defecated on
himself. Staff told him it was too bad. The victim then vomited.
Staff made him clean it up and they took the victim to change. 

He thought the victim was sick because he looked skinnier and
vomited a lot. He observed the victim vomiting when eating. 

He saw the victim carrying a yellow trash can for a couple of
days. 

- resident, ABR Oracle facility (Attachment 59) 

He was at the Oracle facility until the victim's birthday,
11/23/98. He recalls this as the victim gave all of them a piece of
his birthday cake. He was also in the same barracks as the victim. 

Sometime after the victim's birthday, possibly the following day,
he was sent to another ABR facility. 

On 3/2/98 he was sent to the Oracle facility to get his teeth
filled. He observed the victim carrying a trash can containing his
soiled clothes. He was carrying the trash can above his head. 

He saw the victim in the sand pit (volleyball court) with - and -.
They were carrying him by the hands and feet. He heard say
"Watch this little punk clown. He bites." He noticed the victim was
pale. 

- resident, ABR Oracle facility (Attachment 53) 

He states he was on yellow shirt status at the same as the victim.

He observed the victim unable to perform the physical activities
that were required of him while on yellow shirt status. 

He recalls seeing _ carrying the victim on his shoulders. This was
following an incident in which the victim fainted. The victim was
pale. The victim was laid on the ground. _ was walking by at the
time and he was instructed to "Lock it in", but he glanced at the
victim as he walking past the victim. He then saw them try to make
the victim push a wheelbarrow. The victim was unable, so staff put
the victim into the wheelbarrow and _ pushed the wheelbarrow. -
told the victim, "Boy, you need to get yourself off this yellow shirt
so you can move on in your program." 

On 3/1/98 he told - that he believed the victim was sick. He was
told to be quiet. He described the victim as having red eyes, pale
faced, tongue sticking out and "stuff" coming from his mouth. 

On 3/2/98 he observed the victim being forced to run up and
down the hill. The victim told the staff he could not run. Staff made
him get down and do push-ups. He observed staff pushing the
victim's face into a bucket containing the victim's soiled clothes. The
clothes contained feces and vomit from the victim. He heard staff
say, "Boy, get your face down there! Throw up down there! Yea,
you see what you did?" He stated the staff with the victim were -
and - 

- Forensic Pathologist, Pima County Medical Examiner's Office
(Attachment 55) 

Dr. Parks was interviewed by CPS on 6/10/98. 

On 3/4/98 he performed the postmortem examination of the
victim. (Attachment 56) 

A 3/27/98 press release notes the following: "Nicholaus
Contreraz died of complications of an empyema of the left chest.
An empyema is a collection of pus between the lung and the inside
lining of the chest cavity. Approximately 21/2 quarts of pus were
present and there was collapse of much of the left lung because of
space taken up by the fluid The appearance of the lining of the left
lung and chest cavity indicates that the infection had been present
for at least weeks prior to his death. (Attachment 57) 

In his twelve years of experience he had never seen a collection
of pus between the lung and chest cavity to the magnitude the
victim had. 

He stated it was an infection which caused the collection of pus.
He identified the infection as a staphylococcus organism. 

He stated people generally know when an infection is present
because of generalized symptoms. The symptoms include fever,
sweats, chills, pain, nausea and an inability to keep food down. 

He stated if lung capacity was diminished, such as the presence
of pus in the chest, a person becomes easily winded and
hyperventilates. 

He believes a person with infection and diminished lung capacity
could exhibit a short amount of energy for a short period of time,
and then become fatigued or exhausted as opposed to having no
energy. He also thought fainting might occur. 

Mary Dudley, MD - Forensic Pathologist, Consultant (Attachment
58) 

Dr. Dudley is employed as a Forensic Pathologist in the
Maricopa County Medical Examiner's Office. 

She was asked, in her capacity as a private consultant, to
provide CPS with a medical consult on the death of Nicholaus
Contreraz. 

Dr. Dudley was interviewed by CPS on 7/1/98, 7/16/98 and
7/22/98 

Dr. Dudley was provided a copy of pertinent documents on the
victim, including documentation provided to CPS by ABR and the
autopsy report provided by the Pima County Medical Examiner's
Office of the autopsy conducted by Bruce Parks, MD. 

She stated the records showed the victim was very ill. 

The autopsy by Dr. Parks showed he had streptococcus
pneumonia and pleural fluid in the chest cavity that equaled 5
pounds which was pushing on the left lung. 

She noted the victim was bitten, while in California, by a brown
recluse spider. The bite became infected and may have continued in
his system. 

The documentation of the victim's physical exam in January
1998 showed he weighed 141 pounds. At the time of death the
victim's weight, minus the fluid, was 127 pounds, a loss of 14
pounds in two months. 

Dr. Dudley reviewed the medical records provided to CPS from
ABR. There is no documentation of the victim's temperature,
weight, symptoms or a physical assessment of the lungs. There is
no record of his nutrition history, fluid intake and loss, of stool
samples sent for culture or of chest x-rays being taken.
Additionally, there is no documentation of the victim's level or
duration of exercise and his response to the exercise. There is no
documentation on observations by staff of the victim's tolerance to
exercise. 

ARB had documentation of the victim's past history of asthma,
but there is no documentation of follow-up regarding how often the
victim used his inhaler, use of a peak flow meter to check lung
capacity or documentation of how he responded under physical
exertion. 

The higher elevation of the Oracle ABR facility could have been
a factor in the victim's asthma problems. 

The only intervention noted for the victim were instructions on
how to breathe and the use of a paper bag to treat breathing
problems. He was repeatedly released to staff to resume physical
activities. 

The nurse did not document scrapes and bruises, which should
have been photographed, measured and reported appropriately. 

The victim's symptoms of nausea and diarrhea should have
resulted in a changed diet and observations of fluid intake and loss.
The victim apparently was treated by a dentist on 2/23/98 and
given codeine which can cause bronchial spasms in someone with
asthma. This may have exacerbated his symptoms. 

It appeared many individuals caring for the victim at ABR
observed his symptoms, but they did not take them seriously and
the victim was forced to increase his physical activities. 

The staff appeared to think the victim's symptoms were faked
for manipulation. However, many of the symptoms documented
cannot be faked, including sweating, fever, chills, rapid respiration
and pulse, nausea, vomiting, diarrhea, cyanosis and flushing of the
skin, trembling and muscle fatigue with exercise, cough, left chest
pain, dry heaves, difficulty breathing, wheezing, "moldy" body odor
and weight loss. 

It appears the victim was exhausted and had very rapid
breathing, to the point he was exhaling so much carbon dioxide his
fingers were getting tingly. 

One of the residents interviewed stated he noticed a "moldy
odor" which could be present with an empyema. 

The victim did communicate his concerns by saying he "couldn't"
do what was expected. He was noticed to walk with difficulty, at
times falling or fainting. Many times he had to stop and rest while
walking, an indicator he was unable to perform required activities. 

The need for assistance with physical activities was an indicator
the victim's muscles were really fatigued to the point of failure. 

The majority of staff interviewed reported observing symptoms
of some sort. 

The fact the victim was forced to carry his vomit and soiled
clothing in a bucket also created a health risk for the other
residents. As the victim's illness was not diagnosed, risks were
taken exposing the other residents to an unknown potential
contagious disease. 

Dr. Dudley states in her report "Untreated pneumonia is a
life-threatening medical condition that can progress to
complications (empyema in this case) and led to death. This is a
natural manner of death. If the diagnosis of pneumonia and
empyema had been made sooner through a thorough physical
examination and chest x-ray and proper early treatment, it is most
likely that Nicholaus would have responded to antibiotics, drainage
of fluid, bed rest, etc. and his health would have improved.
Therefore, neglect in recognizing and reporting Nicholaus' medical
problems and physical symptoms most probably contributed to his
death. (Attachment 59) 

Based on information obtained, ABR staff observed physical
symptoms indicating Nicholaus Contreraz was seriously ill. ABR
staff failed to obtain appropriate medical treatment for the child.
Their failure to do so was based on their belief the child was
"faking" symptoms, including a fever, to avoid physical training. 

Nicholaus Contreraz was examined by on several occasions.
_failed to conduct appropriate medical assessments of the child's
physical symptoms. She instead chose to believe these symptoms
were being "faked" by the child. _ considered the child's difficulties
with breathing as episodes of hyperventilation. _ failed to recognize
the serious physical symptoms indicative of Nicholaus Contreraz's
grave illness. She failed to refer the child to a medical doctor for
assessment and treatment. 

Residents reported some prevalent incidents and information.
Several heard Nicholaus Contreraz report to staff he did not feel
well. Several residents observed Nicholaus Contreraz's physical
symptoms indicating he was ill. The residents report ABR staff
would disregard the child's complaints of not feeling well and would
instead make fun of him, accuse him of faking symptoms, and force
him to continue with physical activities. 

Several residents reported seeing Nicholaus Contreraz being
forced to carry a bucket with his vomit or feces covered clothing.
Residents observed Nicholaus Contreraz being carried in a
wheelbarrow because he was unable to walk. Residents observed
the child being carried in a "fireman's carry" by his ankles and
wrists, or underneath his shoulders. Residents observed staff yelling
at the child because he was slow in performing tasks. 

Many residents reported Nicholaus Contreraz was made to
continue physical training after informing staff he needed to
defecate. Staff would force him to continue physical activities,
sometimes by physically assisting him, causing him to defecate on
himself. Residents reported staff would, at times, continue to
require Nicholaus Contreraz to perform physical training without
changing his clothing or showering. They also forced him to sleep
on a mattress on the floor, partially inside the bathroom, with feces
or vomit still on him. 

The Pima County Medical Examiner's report indicates Nicholaus
Contreraz died as result of complications of empyema of the left
chest, a collection of pus between the lung and the inside lining of
the chest cavity. The medical examiner's office press release states
"All of these conditions combined to reduce the body's inability to
take in oxygen. Additional stress was placed on the body through
physical activity Nicholaus was required to perform. Ultimately, the
inability to properly oxygenate the organs in the body probably led
to strain on the heart and the development of an irregular rhythm
and cardiac arrest. 

A medical review of available medical documentation was
conducted by Mary Dudley, MD. Dr. Dudley states in her report
that Nicholaus Contreraz displayed classical symptoms of
pneumonia and empyema. These symptoms include fever, weight
loss, chills, cough, anorexia, nausea, vomiting, diarrhea, exercise
intolerance and fatigue. She noted the failure of the nurse, _, to
conduct an appropriate physical assessment, a procedure - would
have known to conduct due to her training as a registered nurse
who had experience in intensive critical care. Dr. Dudley also noted
the repeated failure of staff to respond appropriately to the clear
physical symptoms the child displayed during the course of his
illness. She noted staff made the decision to ignore the symptoms
and instead to consider them "faked" and continued the forced
physical activities. 

Despite clear physical symptoms indicating this child's health was
quickly deteriorating, ABR staff chose to believe the symptoms
were being "faked". As a result, they increased the frequency of
physical activity this child was required to perform. They failed to
consider other possibilities for the child's inability to perform
physical activities. Therefore this constituted neglect by Arizona
Boys Ranch staff responsible for the care and safety of this child
and was a significant contributing factor in the death of Nicholaus
Contreraz. 

ALLEGATION 2 Pl - 33 Propose to substantiate 

Untreated medical condition which is life threatening 

PERPETRATORS 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 

SUPPORTING EVIDENCE 

-, registered nurse, ABR Oracle facility (Attachment 5) 

Approximately a week prior to the victim's death she instructed_
to use a paper bag to treat the victim's hyperventilation. 

She stated that on 2/27/98 while the victim was in her office he
spoke with his grandmother. She heard the victim tell his
grandmother he wanted to join his father, who is dead. 

On 3/1198 while examining the victim, -, heard - tell the victim
they had discussed his breathing problems before and the
"breathing problem is in your head". 

Note the prior information listed in Allegation 1. The same
information supports the finding in this allegation. 

_ failed to make an appropriate assessment of the victim's
precarious health. She failed to properly assess his statements of
wanting to die. She failed to provide the victim with adequate
medical care or to refer him for appropriate medical care. 

- work specialist. ABR Oracle Facility (Attachment 1S) 

On 2/28/98 and 3/1/98, when the victim had been vomiting, he
had the victim carry a trash can. 

He did not refer the victim to inappropriate medical staff for
assessment and treatment. 

-, work specialist, ABR Oracle facility (Attachment 10) 

On 3/2/98 he observed the victim defecate on himself. The
victim coughed and he placed the victim on his side believing the
victim was going to vomit. 

On several occasions he assisted in carrying the victim when the
victim was unable to walk. 

He did not refer the victim to appropriate medical staff for
assessment and treatment. 

_ shift supervisor, ABR Oracle facility (Attachment 6) 

On one occasion he observed the victim cough up phlegm. 

He did not inform the nurse about his opinion the victim did not
look well or the specific symptoms he observed. 

He did not refer the victim to appropriate medical staff for
further evaluation. 

-, night shift staff, ABR Oracle facility (Attachment 7) 

He has experience as an emergency medical technician. 

He heard the victim cough for several nights. The type of
coughing led him to suspect the victim had a viral infection. 

He made contradicting statements about whether he reported
the coughing to anyone. In one interview with law enforcement he
stated he did not. In an interview with CPS he stated he reported
the coughing to others but he could not recall to whom. He then
stated he informed -. 

He told law enforcement that on 3/1/98 he did not note his
observations in the barracks log because it was not a function of his
job to do so. 

He did not refer the victim to appropriate medical staff for
further evaluation. 

- cook, ABR Oracle facility (Attachment 13) 

On 2/28/98 he provided the victim with a yellow bucket to use
for vomiting. 

He did not refer the victim to appropriate medical staff for
assessment and treatment. 

-, work specialist, ABR Oracle facility (Attachment 17) 

On 2/21/98 he completed an incident report. The report stated,
"On the above date a hygiene inspection was conducted and the
following residents had the listed conditions for the nurse to
evaluate." The victim's name is then listed with the conditions noted
"cold, flu symptoms - fever, chills". The documents provided to
CPS do not contain nursing notes for 2/21/98 or 2/22/98 indicating
whether the victim was seen or treated for the conditions
described. 

He knew the victim had been vomiting and thought he might be
dehydrated. He saw the victim vomiting on a few occasions during
or right after meals. It was his opinion the victim was forcing,
himself to vomit. 

He did not refer the victim to appropriate medical staff for
assessment and treatment. 

The following interviews provide further evidence which
supports the finding. 

-, work specialist, ABR Oracle facility (Attachment 8) 

On 3/2/98 while in Barracks 8 the victim told him he wanted to
kill himself. 

- work specialist, ABR Oracle facility (Attachment 12) 

On 3/2/98, at the amphitheater, he observed the victim to be
wobbly and tired. He noticed his breathing was short and he was
panting with his mouth open. He attributed the breathing difficulties
to hyperventilation and instructed the victim to breath correctly. 

- work specialist, ABR Oracle facility (Attachment 22) 

On 3/2/98 the victim told him he was going to kill himself by
stabbing himself with a knife from the pantry. This occurred while
the victim was being made to run up 30 steps in Barracks 9 and
was stating he could not complete the run. 

-, work specialist, ABR Oracle facility (Attachment 19) 

On 2/27/98 he took the victim to the nurse regarding the two
physical assists the staff had done the previous day. He stated the
victim was able to walk and breathe normally. 

He observed _ examine the victim. She had the victim squeeze
her hand and checked his pulse and blood pressure. 

The victim told the nurse he was tired and wanted to kill himself.

-, family coordinator, ABR (Attachment 28) 

He conducted the initial case review and case plan upon
admission of the victim. He is required to write quarterly progress
reports on residents. 

He received a packet of information on the victim from the
community services worker. He did not receive any medical
information on the victim. He stated he was not sure where the
information was directed but it was not to him. 

Mary Dudley, MD - Forensic Pathologist, Consultant (Attachment
58) 

Dr. Dudley's report states: 

"According to the records from Arizona Boy's Ranch, Nicholaus
had flu like symptoms in February 1998 and was removed from the
exercise program for two weeks. Following the initial flu symptoms,
he seemed to have progressive decline in health status with
symptoms noticed by staff and teen residents, including fatigue,
weight loss, vomiting, diarrhea, and resvictim still would not do
frequently sent to the nurse for these symptoms and repeatedly
returned for increased exercise. He was unable to perform the
exercise alone and was placed in "assisted exercises", or forced
exercise, resulting in further decline in his physical health. Nicholaus
died in March 1998 following a month of declining health and daily
assisted exercise. " (Attachment 59) 

Dr. Dudley noted in her report that other residents were well
aware of the victim's declining health, exhaustion and his inability to
keep up with the demanding physical regime. 

Dr. Dudley noted that while staff seemed to think the victim was
faking symptoms, the symptoms displayed by the victim could not
have been faked. 

Dr. Dudley notes the poor documentation ABR maintained to
determine the ability of the victim to perform the activities that were
required. She also noted the lack of written documentation
between the nurse and staff regarding the victim's medical history,
his physical condition and his response to exercise. 

There were numerous observations by ABR staff of physical
symptoms indicating Nicholaus Contreraz was ill. There were also
numerous occasions in which the child stated he wanted to kill
himself and he was not referred for appropriate assessment. ABR
staff failed to make adequate efforts to provide the child with
appropriate medical and psychological assessment and treatment. 

_the nurse, made claims of having seen Nicholaus Contreraz on
many more occasions than what was provided by ABR to CPS as
complete official information on the child's medical records. Her
chronology contains very detailed information of the examination
she conducted of the child in each of her contacts. They all indicate
a child in perfect health, including a child who had gained 6 pound
since his admission to ABR. This information is completely contrary
to information reported by many others regarding the symptom and
appearance of Nicholaus in the last weeks of his life. 

_ failed to seriously consider the physical symptoms as indicators
requiring medical treatment, she instead cleared him for physical
activities and gave the child a paper bag to self treat his breathing
difficulties. 

ALLEGATION 3 P2 - 45 Propose to substantiate

Injuries that may require medical treatment which may include: 
multiple injuries or multiple plane injuries 
injuries to torso or extremities 

PERPETRATORS 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 
-, ABR staff 

SUPPORTING EVIDENCE 

_ - work specialist, ABR Oracle facility (Attachment 8) 

On 3/2/98 the victim was forced to perform "barrel rolls" at the
volleyball court. When the victim was unable to do the "barrel rolls"
he was assisted by _. The assistance rendered was to physically
roll the victim. The volleyball court has a sand floor. (The medical
examiner's report notes the victim had abrasions and sand around
his waist and buttock area.) 

On 3/2/98 he and other staff used a "fireman's carry" on two
occasions when the victim would not walk. (The medical
examiner's report noted the victim had, bruising on his wrists and
ankles.) 

On 3/2/98 at the amphitheater he observed _ and _ "address"
the victim against the wall. Following policy, he "disengaged" when
they began "addressing" the victim. He recalled _ and _ pushing the
victim against the wall and begin yelling at the victim. He believes
one of the staff slapped the wall while yelling at the victim but did
not recall if it was _ or _ . (The medical examiner's report notes the
victim had bruises and abrasions to the back and side of the head.) 

He later went to _, his shift supervisor, and talked to him about
the results of the autopsy and his opinion the bruising to the back of
the victim's head could have been caused by the victim being
pushed against the wall by _ and _ . (The medical examiner's report
notes the victim had abrasions and bruising to the back of his
head.) 

On 3/2/98, while at the volleyball court at approximately 4:00
PM, _ stated the victim asked for water. The victim did not have
his canteen. _ stated he went for water which he carried back in a
pitcher. He stated the victim refused to drink the water so staff
tilted his head back and they poured water into the victim's mouth.
The victim allegedly drank about 16 ounces of water. 

_ work specialist, ABR Oracle facility (Attachment 12) 

On 3/2/98, he stated during an interview with the Pinal County
Sheriff's Office, that while at the amphitheater he grabbed the victim
by the shoulders and walked him to the wall yelling at him to pick it
up and that the victim could do it. It was at that time that he
slapped the wall, and possibly hit the victim against the wall, as he
was slapping the wall and holding him against the wall. _ assisted
him in addressing the victim. (The medical examiner's report notes
the victim had bruises and abrasions to the back and side of the
head.) 

He stated he slapped the wall three to five times with his hands
and the victim's body possibly hit the wall causing a loud noise. He
stated it was possible the noise was loud enough to awaken
someone sleeping in Barracks 22, which is the closest building to
the amphitheater, approximately 60 to 75 feet. 

_ work specialist, ABR Oracle facility (Attachment 10) 

On 3/1/98 he and another staff, _ assisted the victim up a hill
with their hands under the victim's arms. He admitted to carrying
the victim by the armpits. He saw redness on the victim's armpits.
(The medical examiner's report notes redness and abrasions on the
victim's armpits.) 

On 3/2/98 he was present when the victim was assisted with
"barrel rolls" on the volleyball court. 

On 3/2/98 at the volleyball court he assisted the victim with
push-ups when the victim was unable to do these on his own. The
volleyball court has a sand floor. (The medical examiner's report
notes the victim had abrasions and sand on his back, abdomen and
tip of his shoulder. He also had linear bruising along his hips and an
abrasion on his penis.) 

_, work specialist, ABR Oracle facility (Attachment 11) 

On 3/2/98 he and _ carried the victim from the volleyball court
to the amphitheater using the "fireman's carry". (The medical
examiner's report notes the victim had bruises to the wrists and
ankles.) 

On 3/2/98 he assisted the victim with pushups by grabbing him
by the waistband and shoulder and lifted and lowered him. He
admitted his assistance could have left the marks noted in the
medical examiner's report. (The medical examiner's report notes
the victim had abrasions and sand around his waist and buttock
area.) 

_ , work specialist, ABR Oracle facility (Attachment 18) 

On 3/1/98 he was with the victim while running on the hill for
physical training. He claims staff told the victim he could not run
because he was on restriction from running. The victim was told he
could walk and stay with the rest of the group. However, he claims
the victim refused to walk and he collapsed on the ground stating
he could not do it. He and _ told the victim if he could do this, they
would assist him. They had the victim sit by the side of the road out
of the way of the other residents who were running. They assisted
the victim by holding him by the arms, under the shoulders. He
states the victim started walking then stopped and was dragging his
feet. They stopped carrying him because they did not want the
victim to scrape his knees. (The medical examiner's report notes
the victim had redness and abrasions under his arms and armpits
and abrasions on his knees.) 

On 3/2/98 he and assisted the victim to walk. He noticed the
victim's feet were dragging and he had no body control. He
interpreted this to be defiance. (The medical examiner's report
notes the victim's left great toe had a discoloration which could
have been a contusion.) 

_ work specialist, ABR Oracle facility (Attachment 15) 

On 2/28/98 he assisted the victim with "ups/downs" and jumping
jacks. 

When the victim would hit the ground, he would not get back
up. 

He grabbed the victim by the forearms to stand him. (The
medical examiner's report notes the victim had bruising to the upper
arms.) 

_ , work specialist, ABR Oracle facility (Attachment 16) 

On 2/28/98 he and _ assisted the victim two to three times in
performing bends and thrusts by grabbing him by the upper arm,
taking him down, he would be dropped (in a push up position with
his legs extended), then the victim would come up and commence
jogging in place. (The medical examiner's report notes the victim
had bruising to the upper arms.) 

_ , shift supervisor, ABR Oracle facility (Attachment 6) 

On 2/26/98 at night, in the barracks, he and _ assisted the victim
in doing physical activities because the victim did not want to do
them. 

He and _ took the victim "away from the group" to the volleyball
court. _ instructed the victim to do 15 minutes worth of any
exercise and, according to _ the victim did them. However, _
stated the victim had been unable to do them. 

_ did not report any further information on this situation.
However, _ provided a detailed account. His statements are noted
in the following section. 

_, work specialist, ABR Oracle facility (Attachment 19) 

On 2/26/98, after dinner ,the victim was taken to the volleyball
pit to make up physical training he had missed. He stated _ , _ and
he had to encourage the victim through feedback but the victim
wouldn't make an effort. The victim did a slow jog twice on his
own. 

He and _ assisted the victim holding him under the armpits and
running alongside the victim at a fast jog. They did this for a minute
then would stop and ask the victim if he was ready to run on his
own. (The medical examiner's report notes the victim had redness
and abrasions on the armpits.) 

The victim was not steady and could not run, so staff had him do
jumping jacks right after the running exercise. The victim did two
jumping jacks after which _ stood behind the victim, held him by
the wrists and assisted him in doing jumping jacks. (The medical
examiner's report notes the victim had bruises on his wrists.) 

Staff then had the victim do regular push-ups. The victim was
able to do a few on his own. 

_ assisted the victim in push-ups. He held the victim by the waist
of his pants. He stated at this point the victim banged his head
violently a few times on the ground. He thought the victim might
have received a small scrape on his forehead. (The medical
examiner's report notes the victim had abrasions and bruises on his
head.) He took water from a canteen and poured it on the victim's
face to wipe off the sand. The victim was able to drink water on his
own. 

He cradled the victim's head while _ assisted the victim with
push-ups. He did this to prevent the victim from banging his head. 

The victim was unable to stand on his own so he held the victim
against his chest. He told the victim if the victim was unable to do
the physical training, then staff would not help him and they would
isolate him. 

He told _ the victim had to do 15 minutes of physical training on
his own. The victim was unable to do the and __ and he talked to
the victim while the victim was in a push-up position. They told the
victim to put forth effort, stop getting frustrated and stop crying.
(The medical examiner's report notes bruises and scrapes to the
hips, back and buttocks, upper arms, under the arms, head and
chest.) 

The following interviews provide further evidence which
supports the findings. 

_ , work specialist, ABR Oracle facility (Attachment 14) 

On 3/2/98 he observed _ and _ participate in carrying the victim
to the chapel using a "fireman's carry". He observed _ and _ assist
the victim with stomach crunches and push-ups. He heard banging
during the physical activity. He stated he did not think it was
unusual for staff to hit residents to the ground when assisting in
push-ups. (The medical examiner's report notes the victim had
bruises on the ankles, wrists, and abrasions and sand on his hips,
back and buttocks.) 

_ , work specialist on night shift, ABR Oracle facility (Attachment
29) 

On 3/2/98 he was awakened between 4:30 PM and 5:00 PM
by loud banging outside Barracks 22. The banging continued for 3
to 5 minutes. He left the barracks sometime between 5:00 PM to
6:00 PM and saw the victim on the floor with staff administering
CPR. He was told by staff to watch what he said because he could
get fired. 

_ , activities coordinator, ABR Oracle facility (Attachment 27) 

Stated his brother, _ is honest and if he said he heard loud
banging, then he did hear loud banging. 

Staff were discouraged from gossiping about the incident. He
denied anyone made a reference about being fired. He admits
telling his brother if the victim was killed by staff then all their jobs
would be in jeopardy. 

_, shift supervisor, ABR Oracle facility (Attachment 24) On 3/2/98
he arrived to work at 8:00 PM. He was met by _ who appeared
badly shaken and who told him something happened "really bad
and they told me I can't tell you anything or I'd get fired." 

On 3/2/98 _ told him he heard them "banging the kid against the
wall by the amphitheater". _ stated the noise woke him up. He sat
up in bed and heard staff saying "c'mon kid, breath." He reported it
was not unusual for youth to be taken to the amphitheater and get
banged against the wall. He stated he had witnessed this in the past.

_, resident, ABR Oracle facility (Attachment 30) 

On 3/2/98 at approximately 5:00 PM he heard staff assisting
Nicholaus Contreraz with push ups. He did not see it because
residents are not allowed to look at those situations. (The medical
examiner's report notes the victim had abrasions and sand around
his waist and buttock area.) 

_, resident. ABR Oracle facility (Attachment 31) 

On approximately 2/23/98 the victim could not run. Staff
physically assisted the victim by holding him up by the arms and
shirt and dragging him. (The medical examiner's report notes the
victim had abrasions and redness on the armpits and bruising on the
upper arms.) 

On 2/26/98 the victim was placed into yellow shirt status. On
that day he observed staff drag the victim and hit him because the
victim would not do physical training. 

On 3/l/98 he observed _ smack the victim hard on the back. 

On 3/2/98, while the resident were on their way to the chapel,
he observed _ and _ pick up the victim and throw him down. 

_, - resident, ABR Oracle facility (Attachment 32) 

On 3/2/98 at approximately 4:00 to 5:00 PM, while he was
working in the pantry, he observed _ and _ telling the victim to
march down a hill and the victim kept falling. He observed _ and _
drag the victim when he was unable to march down the hill. The
victim's lower legs were dragging on the ground. (The medical
examiner's report notes the victim had abrasions on his knees.) 

_ , resident, ABR Oracle facility (Attachment 34) 

On either 2/28/98 or 3/l/98 he observed _ and _ pick the victim
up and throw him down. They would laugh at the victim when he
would hold up his hands. He observed _ and _ watch Nicholaus
Contreraz attempt to catch himself while falling. 

On 3/2/98 he observed _ and another staff grab the victim by
the shoulders and force him to his knees to pick up leaves. The
victim said he could not do it. 

_ , resident, ABR Oracle facility (Attachment 35) 

He observed the victim in the barracks in the center bay, in a
four square position. A bucket was under the victim. _ was present
during this incident. 

On 3/1/98 the residents were marching to the chapel. A staff
member carried the victim on his shoulders because the victim
could not walk. Then the staff person dragged the victim on the
floor. He observed staff assisting the victim with push-ups. Staff
held the victim's shirt and pushed him up and down. 

_ , resident, ABR Oracle facility (Attachment 36) 

He observed staff dragging the victim across the grounds. He
saw _ holding the victim and dragging him down the hill. He saw
bruises on the victim. This happened while the victim was on yellow
shirt status. 

On one occasion in the chapel he observed _ pick up and shake
the victim and then had the victim sit next to him so he could watch
the victim. 

_, resident, ABR Oracle facility (Attachment 38) 

On one occasion he heard the victim thrown on the ground. He
heard the victim ask why they were hurting him. The victim would
try to get up and staff would keep throwing the victim to the
ground. He observed this from the corner of his eye. 

He observed marks, such as bruises and scuffs, on the victim's
legs. 

_ , resident, ABR Oracle facility (Attachment 41) 

He stated that on 3/2/98 in the morning residents were running.
The victim said he could not run. Staff grabbed the victim by the
arms and dragged him. The victim would fall to the ground saying
he could not do it. 

On 3/2/98 before lunch he observed the victim at the volleyball
court doing push-ups. When the victim was unable to do push-ups,
staff picked him up and dropped him down several times. 

- , resident, ABR Oracle facility (Attachment 43) 

He heard staff slamming the victim in the hall. 

He saw staff throwing the victim, picking him up by his shirt and
sometimes the victim's head would hit the wall. 

_ resident, ABR Oracle facility (Attachment 44) 

On 3/1/98 he heard the victim slammed to the ground and
forced to do physical training, ups/downs and jumping jacks. The
victim told staff his arms hurt. Staff forced the victim to continue
physical activity. 

He observed staff yelling at the victim and dragging him up and
down the hill. He stated staff were always shouting and "putting
hands" on the victim. 

The last time he saw the victim was on 3/2/98. It was
approximately 5:45 PM and he was coming out of the pantry from
dinner. He observed the victim in the pit (volleyball court) with _
and _ . The victim was standing, _ had the victim's head tilted back
and another staff was forcing water down the victim's mouth. Staff
were using a pitcher to pour the water. 

_ , resident, ABR Oracle facility (Attachment 45) 

He observed staff do hands on training with the victim, pushing
him, and dragging him by his shirt. 

While in the chapel, he observed staff make the victim do push
ups in the aisles. The victim told staff he could not do them and staff
picked the victim up and threw him down. The victim asked staff
why they were hurting him. The victim then threw up on the floor.
The staff made him clean it up and took him outside. The victim
was later returned and was crying. 

_ , resident, ABR Oracle facility (Attachment 46) 

He stated that a few weeks before his death, the victim
defecated on himself while doing a four square position. The victim
stated he was weak and unable to do the exercise. Staff yanked the
victim up by his pants, threw him against the wall and told him he
had to do the exercises. The victim asked staff to stop because he
was defecating on himself. Staff had the victim place the feces in a
bucket, walk around campus and smell the feces. 

_ , resident, ABR Oracle facility (Attachment 51) 

He stated the victim had problems doing physical training. He
heard the victim tell staff about five times that they could either help
him or hurt him. 

He observed the victim with his jacket ripped. 

He observed the victim fall down. Staff would instruct the victim
to get up. The victim would tell staff he was unable to get up as he
hurt. The victim would cry, staff would pick him up and force him
up. 

He observed staff drag the victim face up down a hill. 

_ , resident, ABR Oracle facility (Attachment 53) 

On 3/1/98 he observed the victim at the volleyball pit being
forced to do push-ups. The victim kept saying he could not do
push-ups. The victim was crying and had dirt on his face and
mouth. He observed _ and _ assisting the victim to complete the
push-ups. The victim was assisted by _ and _ who would lift the
victim by the back of his shirt then drop him on the ground. He
stated the victim would lock his arms while in the up position and _
would place his knee on the victim's back and force the victim
down. The victim vomited during the assisted exercise. 

On 3/1/98, while at the volleyball pit, he observed _ and _
pushing the victim's face into the dirt. He stated _ was not hurting
the victim too much. 

He stated that approximately one or two days before the victim
died, he observed the victim at the basketball court doing
push-ups. The victim was being pushed up and down by _ and _. 

_ , resident, ABR Oracle facility (Attachment 54) 

The victim told him he was being tortured at Arizona Boys
Ranch. 

Bruce O. Parks, MD - Forensic Pathologist, Pima County Medical
Examiner's Office (Attachment 55) 

The autopsy report documented 71 separate injuries on the
victim. The injuries were abrasions and contusions in various sizes
and stages of healing. (Attachment 56) 

Stated the bruises and abrasions to the victim's chest area were
too many to have been only the result of resuscitation efforts. 

He noted that some of the injuries to the victim could have been
the result of assisting the victim in physical activities. 

He stated if the victim had been wearing a shirt it would have
been harder to explain the broad scrapes on the chest as being
caused by contact with a surface such as sand. 

Mary Dudley, MD - Forensic Pathologist, Consultant (Attachment
58) 

Dr. Dudley's report states the following: 

"There are numerous bruises and scrapes on his body, consistent
with forced exercise as reported. Nicholaus suffered, apparently at
the hands of the staff (direct, or indirectly), recent injuries on his
chest and abdomen, back, shoulder, chin, knees, arm and head
from reported 'assisted exercise', including decline push-ups, and
barrel rolls. Iron stains of the microscopic skin slides were negative
on sections from the left arm, left hand, left side of the chest, and
right arm, indicating recent injury (less than three days old). There
were positive iron staining on sections from the left forearm, left
axilla, right side of the head, left side of the neck, mid chest, right
forearm, and right iliac, indicating injury more than three days old.
The injuries consist of approximately 70 blunt force injuries
according to the autopsy, including abrasions and contusions.
Although numerous, the injuries appeared to be superficial and
minor. There were no underlying fractures or injury to internal
organs. The external injuries were not life threatening and did not
contribute to the cause of death. However, the pattern of external
injuries are consistent with the history of forced exercise or impact
against blunt objects. The forced exercise may have contributed to
his death in lieu of his debilitated physical state and medical
condition." (Attachment 59) 

Several residents stated they witnessed Nicholaus Contreraz
collapse and unable to respond to commands. ABR staff would
pick him up, throw him down, or let him fall, then laugh at him for
falling, often calling him names and deriding him. Residents stated
they witnessed Nicholaus Contreraz cut his chin while assisted with
push ups, and they described staff throwing Nicholaus Contreraz to
the ground with enough force to cause physical injury. 

Residents witnessed staff physically assist the victim, carrying the
victim under his arms with his feet dragging on the ground. Several
residents indicated Nicholaus Contreraz was forced by staff to do
much more than the usual yellow shirt resident, including more
hands on physical assistance. They believed this occurred more
often due to his weakened condition and staff perception the victim
was manipulating. Some residents saw scrapes, bruises and cuts on
Nicholaus Contreraz, which they said came from the handling of
staff who were physically assisting him with physical training. 

Nicholaus Contreraz had numerous abrasions and bruising on his
chest, back, shoulders, arms, hands, elbows, knees, legs, feet,
stomach, hip, pelvic area, head and face. Although no one
responsible for the care of Nicholaus Contreraz in last few weeks
of his life has admitted to inflicting any of the injuries, they are too
numerous and in areas of the body to be consistent with accidental
injuries. It is clear at minimum the "assistance" rendered to the child
in the course of forcing him to complete physical activity resulted in
injuries to the child. 

ALLEGATION 4 P3 - 67 Propose to substantiate 

Parent, guardian or custodian is not protecting children a person
who does not live in the home and who abused the child. 

PERPETRATORS 

_ , ABR staff 
_ , ABR staff 
_ , ABR staff 
_ , ABR Camp Director 

SUPPORTING EVIDENCE 

_ , ABR Oracle facility (Attachment 5) 

On 1/19/98 she examined the victim who complained his back
on the left side was sore and he had pain while breathing. The
victim reported he had been hit two days before. She did not ask
the victim who hit him. 

On 2/27/98 she noticed a bruise on the victim. The victim
complained of hurting all over. 

On 3/1/98 she documented numerous abrasions and marks on
the victim. They were on his chest, upper arms and back. She did
not ask how the injuries were inflicted and did not report them to
the proper authorities. She did not think it was unusual to see
residents with bruises and marks. 

_ , work specialist, ABR Oracle facility (Attachment 20) 

He and _ asked to see the abrasions around the chest of the
victim for documentation purposes. 

Based on information provided by _ , he questioned _ regarding
the "addressing" at the amphitheater and accepted his explanation
and took no further action. 

__ , ABR Oracle facility (Attachment 9) 

On 3/1/98 he observed various marks and abrasions on the
victim. The victim told him they had been received from staff during
a physical assistance incident on 2/28/98. He did not ask the victim
which staff. He did not report these injuries to the proper
authorities. 

He states in the 3/10/98 interview that he believed the marks
under the victim's arms were caused by staff picking him up. He did
not report his suspicions to the proper authorities. 

_ , ABR Oracle facility 

The _ , as the person assigned with the responsibility of
overseeing the __ , knew or should have known: 

1. Staff continually violated standards for providing for the safety
and care of a child placed in their physical custody. 

2. The agency's policy of "addressing", "physical training" and
"assisting" in exercise resulted in the victim being physically abused. 

3. The medical care available on site was insufficient and
inadequate. The victim did not receive adequate medical care. 

4. A safe environment was not provided for the victim. The neglect
and abuse cannot be attributed to an individual because many staff
were involved in actions, or lack of actions, which led to the abuse
of the victim and the neglect which led to the death of the victim. 

The interviews with staff and residents depict a situation in which
there were several incidents in which staff should have written
incident reports and failed to do so. These incidents involved every
injury the victim received while in their care. 

The following interviews provide further evidence which supports
the finding. 

Bob Thomas - Executive Director, ABR (Attachment 21) 

During an interview with CPS on 7/22/98, Bob Thomas stated
the victim should have been terminated from the program as his
behaviors were malingering. He stated he believes staff thought the
victim was malingering and they were trying to encourage the
victim. 

He declared ABR had conducted an internal investigation. He
only had a verbal report. He stated they had been unable to make a
finding because ABR did not have any more information than the
CPS investigators. He agreed to provide a written report if his
attorney approved providing CPS with a written report. 

He maintained all information ABR has on the incident has been
turned over to law enforcement. 

He stated ABR staff did not follow policy and mistakes were
made in dealing with the victim. 

He stated ABR made a "misdiagnosis" of the victim's situation at
ABR. 

He stated there were mismanagement mistakes, particularly in
the Orientation program. 

He stated a staff person used poor judgment when the victim
was made to carry around a bucket. 

He stated ABR staff had made some mistakes and failed in the
supervision of the victim. He felt supervision should have protected
the victim from the bucket incident, specifically, staff members _ , _
and any others involved. 

He admitted several ABR staff had needed guidance, because
on their own they made choices contrary to ABR policy. 

He stated staff used improper discipline and broke ABR
discipline policies. 

He stated the _ made errors in assessing the victim's medical
condition. 

He stated the three-tier management system led to a breakdown
of communication and reporting among staff. He stated newer staff
members needed more training and they should have been
monitored more closely by ABR administration. 

He stated it was obvious there was a communication problem
among staff members. 

He stated if the _ was told by a resident he was being physically
hurt, she would report it to the shift leader and the information
would have worked its way to _ . He said _ would have checked
out the allegation and a written report should have been done and
sent to the county authorities and CPS. 

The _ was required to report any medical concerns to the _ .
The _ had the final say regarding residents. Since both the _ and _
are no longer employees, he did not talk to them to see if there had
been communication between them regarding the victim's medical
condition. 

James A. Hart, DES Assistant Director, contacted Bob Thomas
to inquire what action ABR had taken regarding _ . Mr. Thomas
informed Mr. Hart they had removed _ from her duties. He stated
that for the past couple of weeks, prior to the victim's death, they
had been concerned about her work. The Executive Director, as
the person assigned with the responsibility of overseeing the
Arizona's Boys Ranch, knew the medical care available on site was
insufficient and inadequate. 

He stated _ was involved in many administrative things and was
not aware of how serious the victim's problems were at ABR. He
thought _ might have delegated the issue of the victim to other staff
such as _ and others. 

He stated that perhaps _ and the medical staff should have
known something about the victim's situation. 

He did not believe there was a failure to protect the victim and,
in fact, the facility was safe for youth. 

He stated the incident with the victim was an aberration and not
the norm. 

He could not answer if excessive force had been used on the
victim. He stated that perhaps the bruises and marks resulted from
the CPR administered and from the sand in the area. 

He stated it was up to him, as well as the __ to be aware of
what was going on with the victim. 

When asked if there had been a failure to protect Nicholaus
Contreraz and would he still be alive today if ABR staff and
management had been aware of the victim's situation, Mr. Thomas
stated the failure to protect and responsibility should go back to
Sacramento, the victim's mother and Don Berg, the probation
officer. He stated there was enough fault to go around for
everybody. 

_ reported that following the death of Nicholaus Contreraz, on
3/2/98, she began working on a chronology of her contacts with
Nicholaus. She stated this chronology was not part of the child's file
kept at ABR. She stated that prior to the death of Nicholaus, she
had no concerns about records being altered at ABR. However,
since Nicholaus' death, the medical chart was removed from her
office and then given to her. She noticed there were missing items.
She was unable to provide specifics regarding what items were
missing. 

Several individuals employed by Arizona Boys Ranch failed to
intervene to protect Nicholaus Contreraz from neglect and abuse
he suffered while placed at Arizona Boys Ranch. While the abuse
was not life threatening, several ABR staff saw incidents and noted
injuries on the child and failed to report those incidents. 

Those responsible for the operations of the agency should have
known the practices of staff were inappropriate and could lead to
injuries. They also should have known the quality of medical care at
the facility was inadequate and posed a risk to residents. 

It is clear staff failed to follow policies and procedures in that
incident reports are not available regarding many of the incidents
that were reported by staff and residents. It is also clear staff failed
to make child abuse reports to law enforcement or CPS. 

REPORT DISPOSITION: 

Allegation 1 - Proposed substantiation referred to the Protective
Services Review Team and appeals process pursuant to A.R.S.§
8-546.12. 

Allegation 2 - Proposed substantiation referred to the Protective
Services Review Team and appeals process pursuant to A.R.S.§
8-546.12. 

Allegation 3 - Proposed substantiation referred to the Protective
Services Review Team and appeals process pursuant to A.R.S.§
8-546.12. 

Allegation 4 Proposed substantiation referred to the Protective
Services Review Team and appeals process pursuant to A.R.S.§
8-546.12. 

SUBMITTED BY: 

Lillian Sanchez, CPS Unit Supervisor, Lead Investigator 

Alice Davis, CPS Program Specialist, Group Care CPS
Investigator 

Mark Grover, specialist III, CPS Investigator / 

APPROVED BY: 

Flora Sotomayor, ACYF Field Operations Manager