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On November 4, 2020, at I :04 a.m., c.o. Valenzuela logged a welfare check of Floor 3 Modules C and D via computer <br />and reported no issues with any of the inmates. SAPD Detention Facility video surveillance system recordings showed, <br />however, that c.o. Valenzuela remained at the module's officer podium for the entire period of time she covered for C.0. <br />Fernandez, which lasted until 1 :14 a.m. c,o.. Valenzuela subsequently declined to give a statement to investigators to <br />explain the discrepancy between her computer log entry and the surveillance video recording. <br />At approximatelyl:04 a.m., c.o. Fernandez returned from her lunch break and can be seen on surveillance conversing <br />with c.o. Valenzuela for a few minutes before c.o. Valenzuela left. At 1:IO a.m., 1:15 a.m. and "1:16 a.m., video <br />surveilfance recorded moving freely near the front entrance door of his cell. Due to the angle and distance of the <br />surveillance camera, it cannot be determined what was specifically doing inside his cell. <br />At approximately 1:30 a.m., c.o. Fernandez began her first set of welfare checks after returning from her break. At <br />approximately "1:35 a.m., surveillance shows c.o. Fernandez approach cell, immediately reach for her handheld <br />radio, request emergency assistance, and attempt to enter the cell. When interviewed by investigators, c.o. Fernandez <br />stated that it was at this time that she saw unresponsive and hanging by a bedsheet from the top bunk inside his <br />cell. Specifically, she stated that was in a seated position between the bunk and toilet with bedding wrapped around <br />his neck, and his head was slumped downward and his arms were hanging at his sides. <br />Immediately upon entering the cell, c.o. Fernandez tried to free neck from the bedding. Her initial efforts were <br />unsuccessful, and she yelled for responding personnel to bring scissors. Within seconds, Correctional Officer James <br />Elizondo (c.o. Elizondo) and an LVN anived to assist. c.o. Fernandez and the LVN were able to lift body while <br />c.o. Elizondo loosened all three knots in the bedding. Together, they were able to free <br />At approximately 1:36 a.m., a Registered Nurse (RN) arrived on scene to also provide aid. In a subsequent interview with <br />investigators, the RN stated that immediately upon her arrival, was unresponsive to verbal and tactile stimuli; his <br />face and hands were mild-moderately cyanotic; and his skin was warm and dry, but pallid in color. At approximately 1 :37 <br />a.m., personnel moved to a common area outside his cell where medical staff determined had no pulse or <br />respirations. A pulse oximeter reading indicated had a b(ood oxygen level of 48%, consistent with a deceased <br />person. <br />Medical staff began cardiopulmonary resuscitation (CPR), and a bag-valve mask was utilized to provide oxygen to <br />At approximately 1 :44 a.m., an LVN administered one dose of Narcan to At approximately "l :46 a.m., personnel <br />removed shirt, and an Automatic External Defibrillator (AED) was attached to his upper torso. After analyzing his <br />condition, the AED audibly stated, "No treatment advised." CPR and oxygen delivery continued, although medical staff <br />still did not detect any pulse, any measurable blood pressure, or any pupillary response. <br />At approximately 1:47 a.m., a second pulse oximeter reading indicated had a blood oxygen level of 50%. At <br />approximately 1:48 a.m., Orange County Fire Authority (OCFA) personnel from Engine #71 arrived and took over patient <br />care. They examined and confirmed that he had no pulse, was not breathing, and had no blood pressure. <br />Glasgow Coma Scale score was measured as a three, the lowest score possible and also consistent with a deceased <br />person. <br />At 1:50 a.m., was intubated, an intraosseous infusion line was established in his lower right leg, and a Lucas Chest <br />Compression System was attached to his chest. At I :58 a.m., was administered 1 mg of epinephrine. At <br />approximately 1:59 a.m., was transported Code-3 (lights and siren) via ambulance to OCGMC. During his <br />transportation to the hospital, received another dose of epinephrine. The ambulance arrived at the hospital at <br />approximately 2:09 a.m., and OCFA relinquished responsibility of care to OCGMC Emergency Room staff. <br />Following arrival at the emergency room, was observed to have an asystolic heart rhythm (having no e(ectrical <br />cardiac activity), his skin was cyanotic, and his pupils were fixed and dilated. Emergency room staff continued advanced <br />life-saving measures, including administering medications and providing mechanical ventilation. These efforts did not <br />3