Unanswered questions about elderly woman’s death at homeless shelter show why people are choosing tents over beds

Vivan Nishi was best known for her daily bike rides across Richmond, where she made frequent stops to visit with her son and friends. Then suddenly one day in September, the 73-year-old died of a heart attack in Brookside Homeless Shelter.

Because her face bore a shallow cut from her cheek to her mouth and bruising around both eyes, Nishi’s son and daughter wanted to know more about what happened before she died. Her children paid for a private autopsy to see if it might reveal some clues. The report concluded that she died of natural causes but did not explain the bruises and marks on her face.

But her oldest son, Pat Nishi, who lives in a homeless encampment in Richmond, believes his mother’s facial injuries could have been the result of an assault in the shelter before the fatal heart attack. More than four months later, he still doesn’t have any additional answers.

“Enter at your own risk,” he said to describe Brookside Homeless Shelter, which sits next to the railroad tracks in North Richmond and where he frequently visited his mom.

The unanswered questions about the hours before the death of Nishi, who was a professional figure skater in her teens and later worked as a telephone operator, underscores the fears many homeless people express about living in shelters across the state. They are often viewed by the homeless as being uncomfortable, mismanaged and unsafe.

These concerns help explain why homeless people are leaving shelters to live in tents, and homeless encampments are spreading across California. Seventy percent of the nearly 135,000 homeless people in the state were unsheltered last year, according to the U.S. Department of Housing and Urban Development. Nearly 70 percent of the more than 2,200 homeless people in Contra Costa County live outside, according to the county’s 2018 point in time count.

Contra Costa County partners with Heluna Health, a nonprofit organization providing program services and sponsorships to health initiatives, to run the emergency shelter where Vivian Nishi lived in her final months. That shelter, Brookside, houses up to 88 single adults and offers support services including counseling and case management to help residents find jobs and permanent housing. Residents can stay at the shelter for up to 120 days. A separate shelter for homeless youth is located next door.

The first call indicating Nishi was in distress was apparently made to the Richmond Fire Department, the Richmond Police Department said. The fire department could not comment on Nishi’s death due to the Health Insurance Portability and Accountability Act, a spokesman said.

The police were called next. The detailed report of the police call states that an 87 year-old woman was having trouble breathing, inaccurately describing Nishi as fourteen years older than her actual age. The call was labeled a “1054,” or possible dead body, on the report.

Pat Nishi received a call from his mother’s cellphone on the morning of September 2nd. When he heard a Brookside staff member’s voice on the other end, he said, he knew something was wrong. He was told his mother had passed away and that he needed to come and pick up her belongings.

Nishi and his girlfriend, who doesn’t want to reveal her name because of safety concerns, said they rushed to the shelter to pick up his mom’s belongings before heading to Kaiser Permanente Richmond Medical Center to identify her body. They were worried that her belongings would be thrown away by the shelter’s staff.

When they got to Brookside, Nishi and his girlfriend said, they felt rushed and disrespected by the shelter staff.

“They just wanted to throw her stuff in a plastic bag and get us the hell out of there,” his girlfriend said.

When the couple walked into the room that Vivian Nishi shared with a few other women, they said, they found that some of her belongings were broken on the ground and water was all over the floor. When they asked the shelter’s staff what happened, they said, they were not given answers.

“Nobody would tell us anything,” Pat Nishi’s girlfriend said. “They snapped at me like I was garbage off the street.”

When asked to respond to the couple’s allegations of what they saw and how they were treated at Brookside, Lavonna Martin, the director of health, housing and homeless services for Contra Costa county, said she could not discuss the circumstances surrounding Nishi’s death due to privacy concerns.

There is one mention of a 911 call on September 2^nd, the day of Nishi’s death, in a log book that the shelter staff uses to chronicle daily activity. But no time was specified and no details about events leading up to Nishi’s death were documented.

The Contra Costa coroner’s office reported that four people have died at Brookside in the last five years. The coroner’s office said it was notified of these deaths but conducted no autopsy reports.

When Vivian Nishi died, she had been living at Brookside for three months. She had been collecting things for the future apartment she hoped she would move to soon. She was on a waitlist for government subsidized apartments in Richmond and San Rafael, and in anticipation, had gathered tchotchkes and dish sets and stashed them in her room.

The disarray of her room did not alarm police officers because other rooms at the shelter were also not clean, according to a police department spokesperson. No police report was written.

Pat Nishi said that when he arrived at Kaiser hospital shortly after gathering his mother’s belongings, he was shocked to see the small cut and bruises on his mother’s face.

He said he had visited with his mother the previous day and she had had none of the injuries.

“It wasn’t there the day before,” he said, and so he thought, “I have to take pictures of this.”  

In the late 1980s, Nishi was “forced into early retirement” when she was diagnosed with bipolar disorder, said her daughter, Tori Nishi. Her mother had been working as a phone operator at the time, her daughter said.

In the ensuing years, as Vivian Nishi struggled with the effects of the disorder, she lost her home to foreclosure and moved around to different apartment rentals. She headed to Richmond a year ago to be closer to her son. Since then, she has bounced between Brookside and the Bay Area Rescue Mission, a non-profit shelter in Richmond.

Nishi’s mental illness was not managed with medication, her daughter said. She said her mom refused to drink alcohol and take drugs, including prescription drugs to treat her mental health diagnoses, which made it difficult for her to manage her money and pay her bills on time.

In recent years, Nishi also suffered from diabetes. She had to start injecting insulin to help manage her condition a few months before she died. She also started to feel pain in her arms and legs that made it hard for her to walk and ride her bike, her son’s girlfriend said.

Pat Nishi and his girlfriend said they visited his mother at the shelter frequently, and during those times, they witnessed mismanagement by the staff and fights among the residents.

Several other homeless people in Richmond said they have also faced challenges while living at Brookside.  

Margaret Mcnair, 57, has lived at Brookside for the past four months. Because she recently underwent open heart surgery, her stay at the shelter was extended past the 120-day limit to allow time for her to recover indoors. But because she doesn’t feel safe at Brookside, Mcnair said, she is choosing to leave the shelter and move into a homeless encampment where her son lives.

“I feel safer on the streets,” Mcnair said.

Mcnair knows that she should live inside while she recovers from the surgery, but she said there are too many people living in the shelter with too little staff, especially at night.

There are at least five staff members at the shelter during the day. But at 10 p.m., once the lights go out for bed, only two staff members remain onsite overnight. Mcnair said a handful of staff members are helpful and go above and beyond the call of duty, but some do not assist the homeless residents.

In addition, she said, “There is no security here,” and staff is slow to respond to serious problems the homeless guests face.

“I have told staff that somebody had fallen in the bathroom and somebody needs help and they just act like I’m bothering them,” she said.

Mcnair said she leaves the shelter early in the morning and returns in the evening. She said she has found Brookside to be infested with rodents and bugs during her stay.

“I’ve seen mice, bed bugs, lice. I don’t want to know what’s next. I am not going to be here to see it,” Mcnair said.

“I’ve seen mice, bed bugs, lice. I don’t want to know what’s next. I am not going to be here to see it.”– Margaret McNair, 57.

Martin, the director of homeless services for the county, said in an email that, “occurrences of lice and bedbugs are an unfortunate reality for many individuals experiencing homelessness who are living outside, under bridges, and other areas not meant for human habitation.” She said Brookside followed strict protocols to refer patients with lice to health services and adhered to pest management control. Brookside has never had an outbreak of bedbugs, she said.

Mcnair said other shelter residents told her there are frequently fights at the shelter and that older people are frequent targets of violence. Because she doesn’t spend very much time at the shelter during the day, she said, she couldn’t confirm that there were fights.

“I’ve heard about all of it. People putting their hands on other elderly,” Mcnair said. “It’s just a mess.”

Terry Lee Walker Jr. said he lived at Brookside until three months ago, when he was kicked out for getting into a fight with another resident. He said he was only acting in self-defense.

“They don’t have real security,” Walker said. “The staff just sits behind the desk. They don’t really know who is coming in or out.”

Walker said his elderly godmother currently lives at Brookside, and because he did not feel safe during his stay at the shelter, he walks the perimeter of the property every couple of days to make sure she is okay and moving around. He believes the security at Brookside is inadequate and the management is unfair.

“If she’s outside, I know she’s okay,” Walker said.

As for himself, he said: “I’d rather stay on the street than go back in there.”

“I’d rather stay on the street than go back in there.”– Terry Lee Walker Jr.

Martin said she could not respond to direct complaints by former residents due to privacy concerns but asserted that Brookside had, “clear operational policies around maintaining a safe shelter.” These policies ranged from, “non-violent crisis intervention, appropriate staff to client ratio, indoor and outdoor lighting to regular fire and sprinkler inspections,” she said.

Martin said there are no written complaints on file regarding mismanagement by staff but emphasized the county’s commitment to accountability.

“We most certainly would want to know about any experience, whether it is a resident or a community person, that’s had a difficult interaction with staff,” Martin said.

Martin acknowledged that violence can arise between residents, and said the shelter works closely with law enforcement and trains staff in, “non-violent crisis intervention” to mitigate altercations. There are no trained security guards at Brookside, she said.

The complaints about Brookside’s safety, security and management are not unique to Contra Costa County and reflect the grey area nationally about who is responsible for ensuring the safety and security of residents at emergency shelters.

According to an investigation by Southern California Public Radio into why homeless people are choosing not to stay at shelters in Los Angeles, no single public entity is in charge of making sure that shelters are clean and safe. This is in contrast to international organizations serving refugees that have far more specific standards, experts said.

“The world health organization, for example, has international standards for refugee camps, in terms of water and sanitation,” said Eve Gallow, a homelessness policy analyst and advocate at the American Civil Liberties Union.

“And some of our shelters even fail to rise to that level.”

Gallow believes that these standards need to include staff training in order to create a safe and secure environment for residents. Some counties in California, like Alameda and Los Angeles, have created their own set of standards for emergency shelters.

“Sometimes there are problems with the staff and security guards,” Gallow said. “If they themselves become abusive, then who are people staying in shelters supposed to turn to?”

There is also a lack of uniformity among shelters in the state on the question of who is supposed to attend to medical needs—both emergency and chronic—of the residents who are arguably the most fragile population.

While some emergency shelters may provide basic services, like food, laundry and counseling, most shelters in the state are not licensed to provide on-site medical care.

Fifteen shelters in California do offer respite care to homeless people. These shelters provide medical care for people who are too fragile to be in emergency shelters but not ill enough to be in the hospital, according to the 2018 medical respite care directory.

The nearest respite facility for Richmond’s homeless population is Phillip Dorn Respite Center for the Homeless in Concord, 22 miles away. The shelter provides housing and services to 26 people for an average of four to six weeks.

Mcnair has stayed in Concord’s respite shelter before to access round-the-clock medical services, but she said she chose to reside in Brookside this time because it is in Richmond, where her adult children and grandchildren live.

Sixty-five percent of the homeless population in Contra Costa County have a disability, including behavioral and primary health issues, according to the county’s 2018 point in time count. The county’s data also shows an 88 percent spike in homeless seniors last year.

Brookside, like many other shelters in the state, addresses residents’ chronic medical needs by partnering with a mobile clinic to offer a weekly, and sometimes biweekly, checkups for residents.

The remaining six days each week that the medical team is not on-site, the shelter relies on 911 for emergency medical assistance.

Medical emergencies, “may be the most common emergency occurring in the shelter,” according to Brookside’s 2018 policy and procedure manual. The city’s fire department responded to 196 emergency calls from Brookside last year, although some of these calls may have been made by the county’s youth shelter next door.

Mcnair said she used the mobile clinic if she had a medical concern at the time that the clinic was on site, and added that, “they are great.”

But Mcnair said that when she sits at a park near the shelter during the day, she sees ambulances drive by in the direction of the shelter.

“I will be sitting out in the park, reading my book, and as soon as I see an ambulance, I say, ‘they are going to Brookside,’” Mcnair said.

Gallow, the ACLU homelessness analyst and advocate, said the health of homeless people shouldn’t be treated primarily with emergency medicine.

“We shouldn’t be allowing the health of these vulnerable people to deteriorate to the point when it becomes a medical emergency,” Gallow said.

“We shouldn’t be allowing the health of these vulnerable people to deteriorate to the point when it becomes a medical emergency.”– Eve Gallow.

“I think making access to health and mental healthcare as easy and simple as possible is really an important thing to consider while people have to live in shelters,” she said.

Whether a shelter has adequate services, safety and security can largely depend on how much funding it receives. Emergency shelters rely on competitive grants from state and federal organizations, including U.S. Department of Housing and Urban Development and California Department of Housing and Community Development. The amount of money an emergency shelter is allocated can change year to year based on the shelter’s needs, the number of applicants and the available funds.

“It’s a variety of mostly federal funding that support the shelters and a lot of grant writing,” Martin said. There remained “very little” county funding to assist in paying the operating costs of shelters like Brookside, she said.

Some federal funding programs, including the emergency solutions funds that have helped Brookside and the youth shelter next door, set minimum standards. But these standards outlined in the grant are broad and provide no specifics about safety and security protocols.

The “space and security” requirement under the grant requires that an emergency shelter provide each resident, “with an acceptable place to sleep and adequate space and security for themselves and their belongings.” But exactly what constitutes adequate space and security are not specified.

Improving security may come at a high cost. Some shelters have installed video cameras and hired security guards. Others, like Brookside, rely on staff de-escalation tactics and calling the police when violence or disruption occurs. The Richmond police reported receiving 57 calls for service from Brookside over the last year, an average of about one call per week. Over one quarter of these calls were for help with unwanted individuals at the shelter and another quarter of the calls involved the mental health of a client. The other calls last year addressed issues including domestic assault, battery, theft and fights. The 911 call for Nishi was the only call from Brookside regarding a possible dead body last year, according to the police department’s records.

The lack of uniform standards and consistent funding can present challenges for the nonprofits, cities and counties running emergency shelters.

“I can think of many things from an idealistic perspective that shelters should be responsible for,” said Suzanne Wenzel, an expert in homelessness and professor at the University of Southern California.

“And yet, I know some shelter providers and understand the challenges they are faced with, sometimes a very short staff and a shoestring budget to provide for so many people in need,” she said.

Brookside recently received a federal public facilities grant to buy a monitoring device with video surveillance and remote entry, in order to enhance security and allow staff to more closely monitor who enters and exits the shelter at night.

Martin emphasized the important role that shelters play in helping homeless people get off the streets. Despite funding challenges, she said, keeping the doors of the shelter open is a major victory.

“All of our shelters, our family shelters, our youth shelters, all play a critical role as one of the first steps in helping people out of homelessness,” Martin said.

Pat Nishi, like many other homeless people in Richmond, chooses to live in an encampment because he believes it is safer and more comfortable than a shelter. Looking back, he said, he wondered if his mother would still be alive if she had lived in the encampment with him. He said he might have been able to keep a better eye on her and make sure she was safe and healthy.

“That’s where I blame myself now,” Nishi said. “I guess I’m weighing the trade off now.”