Seven years before the March 2018 shooting at the Yountville Veterans Home of California, a security consultant expressed serious safety concerns about the building where the shooting took place.

Los Angeles-based Legacy Protection Services was hired by the Tug McGraw Foundation — a nonprofit that’s based at the Veterans Home and serves people with brain conditions such as post-traumatic stress disorder — in late 2010 to assess security risks at Madison Hall. The foundation moved to a different campus building years later, but at the time it shared the building with The Pathway Home, a residential treatment program for combat veterans suffering from PTSD.

Legacy Protection Services was so troubled by the potential for a problem involving trauma-scarred Pathway Home clients that it recommended the foundation move to a building with controlled access and without residential services for patients.

Fred Gusman, who was Pathway Home’s executive director at the time, told Legacy Protection Services that some patients are expelled before completion and others relapse after graduation, according to the report.

“To ignore these risk factors would be irresponsible to the (Tug McGraw Foundation) and (Pathway Home) staff, patients and visitors,” Legacy Protection Services wrote in its report.

This report was unveiled in an updated legal complaint filed last month in Napa County Superior Court by attorneys representing the family of Pathway Home Clinical Director Jennifer Golick, 42, who was one of three women killed in the shooting.

The Golick family has sued the Napa County Sheriff’s Office, Napa County and the California Department of Veterans Affairs — which operates Veterans Homes across the state and is known commonly as CalVet — and Sheriff’s Deputy Steve Lombardi, who first responded to the active shooter call.

Pathway Home Executive Director Christine Loeber, 48, and psychologist Jennifer Gonzales Shushereba, who was 32 years old and six months pregnant, were also killed by an ex-patient who had previously “joked” about wanting to kill staff, according to California Highway Patrol investigatory records recently released by the Napa County Sheriff’s Office.

The gunman was an Afghanistan war veteran who came to Madison Hall armed with three guns and dressed in combat gear. He took the women hostage before killing them and himself.

Family members of Loeber and Gonzales Shushereba have also filed lawsuits in connection with the shooting.

The lawsuit alleges that CalVet knew about Legacy Protection Services’s report. The report was presented to CalVet during contract negotiations around December 2010, according to the lawsuit.

“This is really … an avoidable tragedy,” said Ronald Foreman, attorney for the Golick family. “It’s really a shame that there are probably so many steps that CalVet could have taken.”

CalVet and the Napa County Sheriff’s Office declined to comment, citing pending litigation.

Staff were vulnerable, security consultant found

PTSD carries risks of flashbacks, sudden anger and irritability, drinking and drug dependency, relationship problems and violence — all of which can pose threats to staff, according to the Legacy Protection Services report.

Legacy Protection Services evaluators met a patient who made many references to his girlfriend and his plans with her after leaving the Pathway Home, according to the report. They later learned that he had been chatting with that woman for a week online and had never met her in person.

Pathway Home and Tug McGraw Foundation staff told Legacy Protection Services that “poor relationship choices” were among the most common issues that patients faced, according to the report.

Evaluators noted that patients had unrestricted access to Tug McGraw Foundation staff.

This created “an open and caring atmosphere for patients,” but also presented serious security risks to staff.

Legacy Protection Services recommended that the foundation move to another building, but acknowledged that moving to another part of Madison Hall might be a more feasible option.

Still, without armed security, moving to another part of Madison Hall would only “temporarily delay someone determined and prepared to act out violently upon a specific target,” evaluators wrote in the report.

Golicks make new claims

The complaint filed June 27 includes many new details that were not in the Golick family’s original complaint, which was filed in March. Attorneys for the family have sought dozens of records in connection with the lawsuit, Foreman said.

The complaint references a meeting held in November 2016, after the Pathway Home ran out of funding and shut down in September 2015. The meeting was held to discuss how to keep the program running, in spite of aggressive behavior of Pathway veterans, according to the complaint. Pathway reopened in September 2016.

The Napa County Sheriff’s Office completed a site assessment of the campus a year or two before the shooting, according to the complaint. The assessment found a lack of security checkpoints, surveillance cameras and staff, and recommended that CalVet install a security checkpoint, front gate, fencing, working locks and intercoms, according to the complaint.

Attorneys argued that CalVet’s safety officers lacked adequate training, equipment and authority. They wrote that Deputy Lombardi acted recklessly by firing at gunman Albert Wong through a closed door, after Lombardi heard the sound of a rifle racking and a woman screaming.

“By doing this, Lombardi inserted himself into the situation and caused a desperate Wong to react more violently,” attorneys wrote in the complaint.

Since the attack, Lombardi has been honored by U.S. Rep. Mike Thompson, of Napa, as a Napa County Public Safety Hero of 2018.

Attorneys on both sides of the lawsuit will next meet in court on Aug. 7 before Napa County Superior Court Judge Victoria Wood, court records show.

This story has been changed since the original posting to eliminate incorrect information regarding CalVet's security obligations in the lease of a building to the Pathway program. The Pathway program was responsible for its own building security, state officials said.

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Public Safety Reporter

Courtney Teague is the Napa Valley Register public safety reporter. She can be reached at 707-256-2221. You can follow her reporting on Twitter and Facebook, or send her anonymous tip at: tinyurl.com/anonymous-tipbox-courtney.