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Fatal overdoses raise new questions about city-funded drug rehab nonprofit

Sydnee Hollenback looks at the fish tank at his girlfriend’s home on Tuesday, Jan 17, 2023, in San Francisco, Calif. The Baker Places co-op resident says he often stays there because he feels his home is unsafe. | Michaela Vatcheva for The Standard

Clients say a San Francisco nonprofit that receives millions in public funds to rehabilitate people suffering from mental illness and drug addiction has left them without caregivers for months at a time as they struggle with relapses, violence and thoughts of suicide.  

The absence of care has resulted in at least four fatal overdoses and one suicide in programs run by Baker Places, a nonprofit that fell under the microscope last year after asking the city for two emergency bailouts to keep it solvent. 

The Department of Public Health refused to release data on the total number of overdoses and suicides within programs managed by Baker Places, but The Standard independently verified the string of deaths across four of the nonprofit’s facilities in the past two years.

“I was able to sell dope out of this house,” Baker Places resident Sydnee Hollenbeck told The Standard. “I could’ve easily overdosed, and nobody would’ve cared.”

Baker Places, which is set to receive about $59 million in payments from the city this fiscal year, is supposed to help clients with serious addiction and mental health issues graduate into independent living. 

But clients who spoke to The Standard described a culture of carelessness and impunity where concerns about violence and drug dealing and use inside its facilities, coupled with too few case managers, left them struggling to escape the cycle of addiction. 

Public records point to long-standing warning signs at the nonprofit, ranging from allegations of “warehousing” clients without proper care to a pattern of financial mismanagement that culminated in a demand for a $4.2 million bailout from the city in October 2022. Just months earlier, the city had forked over $2.2 million in emergency funds to Baker Places, which is managed by another nonprofit called Positive Resource Center (PRC).

Meanwhile, The Standard uncovered an arrangement in which a top official at the Department of Public Health was taking a $123,000 “on-call” salary from Baker Places—working for the charity while on city time—as the organization begged the city for two successive bailouts.

The Department of Public Health denied that Baker Places has issues with its clinical services and said that the services offered are desperately needed in San Francisco for people with behavioral health needs.

“While Baker Places has struggled financially, there have not been issues with clinical operations,” the statement read. “All programs have varying degrees of independent living and case management.”

In a statement, PRC declined to address specific accusations made by Baker Places clients, citing HIPAA guidelines, but said that its staff uses a harm-reduction approach to deliver counseling and case management services. 

Regarding the lives lost at the organization, PRC said that cause of death determinations are not released to it. The organization listed group therapy, individual counseling and a 24/7 emergency phone line as resources available to its clients.

“PRC cares very deeply about the mental and physical well-being of our clients,” the statement read. “We take program complaints seriously and aim to constantly improve services to better meet client needs.”

‘Nobody Really Gives a Shit’

Baker Places’ Assisted Independent Living Program, which serves between 80 and 100 clients with histories of drug addiction and mental illness, is meant to be a temporary rehabilitation program that eventually assimilates people into independent living. But clients said that people often get stuck there for years, rarely graduating to make space for new clients. 

Hollenbeck, who’s been in Baker Places’ detox and treatment programs since 2019, said it's been months since he’s seen his case manager. In the meantime, he described rampant drug dealing and abuse that leaves him fearful of his fellow housemates. 

“There’s a guy upstairs who’s tweaking really hard,” Hollenbeck said. “It’s just allowed, and nobody really gives a shit about us.” 

Hollenbeck said he’s only witnessed one of his housemates, who had lived in the facility for 15 years, successfully matriculate into independent living.  

Sydnee Hollenback poses for a portrait at his girlfriend’s home on Tuesday, Jan 17, 2023, in San Francisco, Calif. Hollenback said the Baker Places co-op where he lives offers no safety measures or interventions when violence between house mates breaks out. | Michaela Vatcheva for The Standard

Using addresses and names provided by clients and employees along with data from the Medical Examiner’s Office, The Standard verified four fatal overdoses within Baker Places’ facilities since January 2021.  

A client who spoke on the condition of anonymity said that they are among those still using drugs while in the program.

“It’s just me and God here,” the client said. “Don’t nobody else care.” 

One of the people who fatally overdosed in Baker Places’ Assisted Independent Living Program was a well-known San Francisco homeless advocate named Brian Edwards.

Edwards was 41 years old when he died from fentanyl and methamphetamine use in a Baker Places’ program on Nov. 21, 2021. 

Edwards’ friends remember him for his relentless compassion and his ability to bring opposing sides together on tough issues. Formerly homeless himself, Edwards put his health on the line during the pandemic to perform outreach and provide resources for people living on the streets. 

His friends suspect that the stress of his advocacy coupled with risky conditions at Baker Places led him to relapse.  

“We told [staff] what was going on with him,” Hollenbeck said. “It made me sick to my stomach.” 

Kelley Cutler, a good friend of Edwards’ who worked closely with him on homeless advocacy, said that the program repeatedly failed to address his concerns that he felt unsafe in the facility. 

“I cut case managers slack because they’re trying to do what they can without the appropriate support,” Cutler said. “But some of the things that Brian was encountering and dealing with in the house were crossing that line.” 

Mary Kate Johnson, another friend of Edwards’ and the director of Regional Homelessness Prevention at the nonprofit All Home, didn’t speak specifically about Baker Places but said that a lack of case management widely impacts social service nonprofits. 

“If the salaries don't attract people, then the positions sit vacant, and there's high levels of turnover,” Johnson said. “We're advocating for more money for [case managers] across the system.”

Brian Edwards was 41 years old when he fatally overdosed on fentanyl and methamphetamine in Baker Places’ Assisted Independent Living Program on Nov. 21, 2021. | Courtesy Edwards family

Warning Signs

Emails unearthed through a public records request show that Baker Places has been the subject of complaints for years.  

Barbara Garcia, former director of the Department of Public Health, personally fielded complaints in 2016 that Baker Places’ programs were unsafe, and that the organization was misusing funds and abusing clients. 

A former Baker Places employee named Erland Torrico, who was hired to help optimize services offered by the charity, said he was fired by the nonprofit in 2018 after presenting findings to Baker Places’ Chief Clinical Officer John Fostel showing that the organization was failing to rehabilitate clients, according to a lawsuit.  

Torrico said in a wrongful termination suit that he repeatedly warned Baker Places’ management that the company was merely warehousing clients by not providing an appropriate level of care. 

Patients weren’t graduating from the program, he said, meaning that the charity was out of compliance with a state reimbursement policy that requires the organization to rehabilitate patients or have them re-diagnosed yearly.

The organization reportedly argued that moving patients through the program could cause them to become homeless, according to the lawsuit

PRC told The Standard that it can’t comment on any current or past legal matters with employees.  

Torrico said he was fired the same day that the health department published an audit based on his findings that required Baker Places to pay back $342,000 in illegitimately acquired funds from the state. The lawsuit alleged that for up to 15 years, Baker Places billed Medi-Cal for services that it did not offer. 

Those allegations echo a record of mismanagement that landed Baker Places and PRC on a “red flag” list maintained by the Controller’s Office. That status is reserved for agencies facing “imminent risk of being unable to perform services” because of financial or organizational turmoil. 

Financial statements show Baker Places with a recurring deficit since it attempted a merger with PRC in 2016. In 2017, just a year after receiving a $15 million contract extension, the organization logged a $1.9 million deficit. And one month before city officials awarded the nonprofit an emergency grant in June, the city had granted Baker Places a $65 million, five-year contract extension.

An independent audit of the two related nonprofits conducted in 2021 found that the organizations were failing to properly keep track of employee time cards due to a high employee turnover rate. The audit determined that the continued lapses may have resulted in “unauthorized transactions that went undetected.” 

The city has placed two of Baker Places’ programs under the supervision of the nonprofit HealthRight360, while the future of the other two programs remains unclear. 

Despite the department’s promise to rehouse every client, many worry about what’s next for the residential living program. Kerrington Osborne, a client of Baker Places, said that he is refusing to pay rent until the charity ensures that his housing is secure. 

“Over the past couple years, I know of four people who have died,” Osborne said. “Why isn’t the city stepping in?”

Traumatized Neighbors

The problems at Baker Places have spilled over into the community as well. In November, a group of 50 neighbors signed a petition asking the city to permanently close a Baker Places program called Grove Street House that had temporarily shuttered for renovations two years ago.

Olga Tikhonova, a mother of two who lives next to the facility in the Panhandle, said that ambulances visit the program regularly when it’s operating. Neighbors complain that they could see clients masturbating from their windows, that construction on the building swept asbestos onto their property and that stray cigarette ashes have started fires. 

The constant annoyances turned traumatic in February 2021, when Tikhonova’s 14-year-old daughter said she saw a client who had committed suicide from the program’s backyard balcony.  

The backyard area of the Severinova family home, where two years ago, Vera Severinova, along with staff from the San Francisco nonprofit organization, Baker Places, saw a Baker Places client who had died in the backyard of one of the program's facilities. | Michaela Vatcheva for The Standard

“My daughter was calling me crying,” Tikhonova said. “I don’t know what we can possibly do. Sell the house?”

In January 2020, the Mayor’s Office of Housing and Community Development gave Baker Places $3.9 million–or $437,778 per bed–to purchase and renovate the Grove Street building after the nonprofit rented the property for over 40 years. 

In a statement, the mayor’s housing department said that it’s awaiting guidance from the Controller’s Office to ensure that the city’s nonprofit partners are in good standing, referring questions about oversight to the health department.

The health department said that Baker Places is in the process of fulfilling a corrective action plan at Grove Street that includes window replacements, removal of asbestos and de-escalation of clients in crisis.

Neighbors say that the program abruptly closed for renovations in March 2021, leaving mail on the doorstep and old furniture on the front sidewalk. But its reopening appears imminent as they reported seeing workers from Comcast servicing the house on Monday. 

Vera Severinova (left) and her mother, Olga Tikhonova, pose for a portrait in their living room in San Francisco on Thursday, Jan. 12, 2023. Roughly two years earlier, Vera, along with staff from the San Francisco nonprofit organization, Baker Places, discovered a Baker Places client who had died in the backyard of one of the program's facilities. | Michaela Vatcheva for The Standard

The neighbors are urging city officials to keep Baker Places from reopening the facility in light of the nonprofit’s recently publicized fiscal mismanagement.

Tikhonova said that apart from a visit from the program’s manager a few months ago, she’s unsure how the nonprofit will recoup the community’s trust. 

“How is it going to be any different than what we experienced two years ago?” Tikhonova said.

David Sjostedt can be reached at david@sfstandard.com