Probation officers at a dangerously understaffed Los Angeles County juvenile detention facility in Sylmar lacked the training and equipment to deal with overdoses and failed to make timely safety checks in the hours leading up to the fentanyl-related death of a teenager three years ago, according to a new report.
The county, in a recently published assessment of the incident, found there was “inadequate supervision due to critical staffing issues” and disclosed that officers were subsequently disciplined in the aftermath for failing to follow department policy.
This month, in light of the findings, the Los Angeles County Claims Board recommended the Board of Supervisors pay out a $2.5 million settlement to Marlen Medina, the mother of 18-year-old Bryan Diaz, to resolve a federal wrongful death lawsuit. Attorneys for the two sides submitted a notice of settlement to the court back in January 2025, but the case has stalled since then due to the county’s lengthy review process, according to court filings.
A county spokesperson declined to say when the settlement will go to the supervisors for final approval. Attorneys for the county indicated in an April 15 status report to the judge that they would use their “best efforts” to ensure the settlement is presented “at the earliest available opportunity.”
Death called an accident
Diaz, who died in May 2023, was facing an attempted murder charge and had been inside the Barry J. Nidorf Secure Youth Treatment Facility for less than two months. The Los Angeles County Medical Examiner classified his death as an accident caused by the effects of fentanyl.
Medina’s lawsuit alleges that officers did not perform any safety checks on Diaz from 9 p.m. May 8, 2023, when he was last seen alive, to 8 a.m. May 9, when he was found unresponsive. State law requires safety checks every 15 minutes.
The window of Diaz’s cell had been covered and staff could not see inside, according to the lawsuit. Staff members are supposed to immediately remove, or instruct detainees to remove, any obstruction.
The department declined to provide additional information about the disciplinary actions taken against the officers.
Drugs allegedly supplied by staff
The lawsuit further alleges a probation officer, Michael Solis, and a teacher, Alejandro Lopez, supplied the drugs that killed the teen. The county’s assessment makes no mention of that allegation and Vicky Waters, the spokesperson for the Probation Department, declined to comment on it due to the pending litigation.
David McLane, the attorney for Medina, also declined to discuss the case as the settlement has yet to be approved.
Two deputy probation officers, who claimed they were placed on leave for investigating Solis, similarly alleged Solis and Avila were the sources for fentanyl in the facility, according to a October 2023 letter from their attorney to Probation Chief Guillermo Viera Rosa.
The Los Angeles County District Attorney’s Office did charge Solis and Lopez, separately, in June and July 2025 — roughly a year after the allegations were made in the lawsuit — for allegedly smuggling Xanax into the county’s juvenile facilities. However, none of the charges related directly to Diaz and the crimes alleged in their respective criminal complaints occurred after his death.
Both men have pleaded not guilty and their cases have yet to progress beyond the initial arraignment.
Investigations into Diaz’s death by the Los Angeles Police Department and the L.A. County Probation Department led investigators to Solis and Avila, according to the lawsuit.
Warning signs
Advocates, a county watchdog and even a judge had warned for months before Diaz’s death that rampant drug use inside the county’s juvenile facilities would lead to disaster if the county did not make changes. At least six youths in custody were hospitalized for suspected drug use in the months after Diaz’s death.
An investigation by the Office of the Inspector General found that lax security, driven by a dire staffing crisis, had allowed drugs to proliferate at several L.A. County juvenile facilities. Drug runners threw contraband over the walls, dropped packages with drones and even walked through security — posing as fake food delivery drivers — without ever being searched, the OIG’s report found.
Emails obtained through a public records request described a “state of emergency” inside the SYTF, in particular, with one credible messenger warning probation’s leadership that “someone will die unless you take immediate and extreme action” just two months before Diaz’s overdose.
‘State of emergency’
Filmmaker Scott Budnick, founder of the Anti-Recidivism Coalition and a member of the Board of State and Community Corrections, wrote in a March 2023 email to then-Probation Chief Karen Fletcher that he witnessed a group of youth “smoking and playing video games 5 deep in one room — away from cameras” and another six smoking marijuana in a circle in the bathroom. He described “the amount of pills and marijuana and phones in the unit” as astounding.
“Unit X is in a state of emergency, and no one is present or doing anything about it,” he warned. “Someone will die soon.”
Just days after Diaz’s death, the BSCC, with Budnick recusing himself, ordered the shuttering of Barry J. Nidorf Juvenile Hall — which shares the building with the SYTF — and Central Juvenile Hall due to the deteriorating conditions inside those facilities.
Budnick explained after the vote that he mentored Diaz and the teen was on a “real path of change.”
He blamed the death on the county’s poor management and said the short staffing had left youth with nothing to do all day. Juveniles told him that drugs helped make monotonous days feel less long, he said at the time.
“There’s hundreds of emails that said someone is going to die in Unit X and nothing happened,” he said. “I would walk into that unit and, every week, it would be the exact same thing. They’re not getting recreation, they’re not going to school.”
Los Angeles County Superior Court Judge Miguel Espinoza expressed similar concerns after learning about two nonfatal overdoses at the same facility during a March 2023 court hearing. He called it a “stroke of luck that the individuals who came across those two youths were trained in the use of Narcan and actually had it accessible,” according to Medina’s lawsuit.
“If the youth had been in a different unit, or it had been at a time when there was an untrained staff member, it appears highly likely that one or both of the youths would have passed away,” he said at the time.
Lack of Narcan training
In its assessment, Los Angeles County listed “a lack of training on use of Narcan” and the insufficient number of staff issued Narcan, a nasal spray that can reverse opioid overdoses, as one of the root causes behind the lawsuit over Diaz’s death.
Diaz was found by probation officers at about 8 a.m., but the report indicates nursing staff responded and administered Narcan, unsuccessfully, to him, suggesting the officers were unable to do so.
Probation began training officers on the use of Narcan in December 2022 and the training remained ongoing at the time of Diaz’s death. Since then, all deputized staff have been taught to administer the nasal spray and received two doses to carry on their person, according to the summary of the county’s corrective action plan.
The county Probation Department has stepped up security significantly in the years since Diaz’s death. Employees now must bring in belongings and lunches inside clear bags. Airport-style baggage and body scanners have been installed at facility entrances and the county has increased the frequency of searches and the use of drug-sniffing canines.