Before Jázmin Pellegrini was found dead in an Oceanview driveway last year, she’d been through the ringer of dozens of hospitalizations, discharges, and drug regimens at for-profit health facilities that made a litany of highly questionable decisions.

The whole Bay Area was shocked last April when Bay Point 15-year-old Jázmin Pellegrini was found dead in an Oceanview driveway in SF, three days after running away from home. The SF Medical Examiner’s Office determined that she’d overdosed on a mixture of cocaine, fentanyl, and methamphetamine. But a GoFundMe from Pellegrini’s family raised pointed questions about finding the “perpetrators who committed acts of rape, sex trafficking, and provided drugs to Jazmin,” and hoped to identify “gaps in the system including service providers, hospitals, psych wards, [and] law enforcement.”

Today’s Chronicle has an extremely deep investigation into Jázmin’s fractured and tumultuous journey through teen psychiatric facilities across Northern California, and it certainly identifies several of those gaps in the system. The Chron found that these facilities are largely run by out-of-state-based firms Signature Healthcare Services, Universal Health Services, and Acadia Healthcare, many of whom are funded generously through Gavin Newsom’s $6.4 billion mental health bond — though often produce dubious outcomes like Jázmin’s.

These firms handle a significant share of California teens’ “5150” holds, that is, mental health emergencies where the patient is deemed to pose a potential harm to themselves or others. The Chron found that two-thirds of these teen patients are girls.

And in these facilities, the Chronicle also reports that “hundreds of patients have reported being physically and sexually abused in recent years,” and that “at times, they have seriously injured themselves, or died, when no one was watching.”

The Chronicle tracks Jázmin’s ordeal through some 40 hospitalizations at ten different facilities in seven different NorCal counties over a two-year period. Over this time, she was given a staggering number of different drugs with serious side effects, and subjected to erratic and inconsistent treatment plans.

We knew from previous reporting that Jázmin was sexually abused by her grandfather before immigrating here from Hungary when she was 10 years old. The trauma from the abuse manifested in 2022 when she was 13, when she engaged in self-harm acts like cutting herself.  She was shipped to a Universal Health Services facility in Sacramento.

But at that facility, she was reportedly assigned a roommate who was perpetually banging her head against the wall, which exacerbated Jázmin’s condition. She engaged in cutting herself more, and experts to whom the Chronicle spoke said there should not have had sharp objects available in that room.

She was eventually released, but the following year, at age 14, Jázmin attempted to overdose on antihistamines. She was admitted to a Signature Healthcare Services facility in Santa Rosa, a facility which the Chronicle reports had a track record of riots and sexual assaults. And sure enough, Jázmin was left unmonitored and had sex with another patient twice in two days. Her mother learned of this when staff called her and asked if they could administer a morning after pill.

A California Department of Public Health investigation found that facility was not properly staffed, and one of its employees would be fired for falsifying records.

At that same facility, Jázmin experienced such severe nightmares that she wanted caffeine to stay up all night, and banged her head against the wall so much she needed emergency room care. Yet she was cleared for release eight days later.

She was 5150’d again not long after that release, and sent back to the same Santa Rosa facility over her mother’s objections. In 5150 cases involving minors, the parents have no say in what faculty the teen will be treated. Though Jázmin bounced to several facilities over the next two months.

“My child is slipping further and further away into her despair with each hospital stay,” her mother Márta wrote in a December 2023 letter to county authorities. “In these hospital settings, she is not receiving adequate treatment to address her mental illness.”

Jázmin was released again, ran away from home in February 2024, and was sent to an Acadia Healthcare facility in San Jose. After an incident where she hit another patient, she was prescribed Thorazine, on which she got hooked and would misbehave so she could get more. She would also swipe other patients’ medications in attempts to either get high or take her own life, which represents a pretty serious safety lapse in a mental health care facility.

That Acadia Healthcare facility was oddly simultaneously pushing for Jázmin to get full-time residential care, while also advocating for her release. The release plan won out in the end, with the tragic result we now know.

Jázmin left her Bay Point house the night of that release, not even wearing shoes, on April 17, 2024. Surveillance video shows she did approach a Contra Costa Sheriff's Department vehicle, and was briefly monitored, before slipping away.

The next that we know of Jázmin was that she was found dead three days later. Authorities have determined that she took BART from Bay Point to San Francisco, but they still don’t know how she got the drugs.

Chronicle reporters describe this piece as "PART 1 of an investigation" into safety violations at these state-funded, for-profit health facilities. And Governor Gavin Newsom’s office seems to realize there may be more damaging information forthcoming.

“The Chronicle’s investigation raises serious concern about the quality of care received by these individuals,” Newsom’s spokesperson Elana Ross told the Chronicle. “We take each incident seriously and will be reviewing the care standards for psychiatric hospitals.”

Related: East Bay Family Seeks Answers In Mysterious Death of Teen Girl Found Dead In SF Driveway [SFist]

Image via GoFundMe