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Hepatitis C falling in San Diego, but eliminating disease will take more work

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Hepatitis C falling in San Diego, but eliminating disease will take more work


Modern medicine can cure a hepatitis C infection with three doctor’s appointments and two prescription refills. For most, it is not a big ask to rid oneself of a deadly disease.

But for those without homes, keeping up with the required 12-week treatment regimen can be an overwhelming commitment.

Sitting on a metal folding chair at the edge of an empty parking lot in Balboa Park on a recent morning, Holly, a resident of San Diego’s nearby O Lot safe sleeping site, explained that visiting a doctor’s office miles away comes with significant risk.

A tent can never be fully secured, so leaving one’s possessions inside to go to the doctor’s office all but guarantees returning to find possessions missing.

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“There is nobody that holds themselves accountable for your stuff, so it’s just hard for me to leave, knowing that,” she said. “Everything I have left in the world is in that campsite, and it’s easy for people to just walk right in.”

And yet Holly just completed her full hepatitis C treatment, not missing a dose over three straight months after a screening test detected her infection. Her friend, Chris, just started his second week. Like his companion, he said that because his infection had not yet progressed far enough in damaging his liver to start causing symptoms, there is pretty much no way he would have traveled to the clinic for treatment.

“You know, you just sort of put it on the back burner if it’s not causing any signs,” he said.

Finding and keeping housing trumps following up on test results. And that is the particular problem with hepatitis C, which may take decades to cause its first symptom. Often, by the time signs and signals such as easy bruising, fatigue, yellowing of the skin and weight loss appear, a person’s liver is significantly damaged, making life-altering consequences such as liver cancer much more likely.

In recognition of the disease’s slow and deadly burn, the county health department, several local medical providers and the Liver Coalition of San Diego County launched a hepatitis C elimination plan in 2021 with the goal of preventing new cases while simultaneously working to discover and treat so-called “chronic” cases that have gone undetected.

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Though recent results are skewed slightly due to a change in how hepatitis C cases are counted, the overall case trend has been downward since 2019 when 4,249 chronic cases were confirmed or suspected compared with 2,298 in 2023.

A big part of driving that number down, said Dr. Christian Ramers, medical director for research and special populations at Family Health Centers of San Diego, has been more aggressive outreach to those at increased risk of hepatitis C infection. Because the virus transmits in human blood, injection drug users are at an increased risk as are those with HIV.

The crusade to eliminate hepatitis C started with increasing screening to detect chronic cases and with the region’s first needle exchange programs, helping drug users avoid re-using and sharing needles. Many have recently begun to realize that those techniques, while effective, are not enough.

Chris and Holly’s recent experience in a Balboa Park parking lot involved a physician assistant with Family Health Centers whose job is to take many services, including the checkups and medication delivery necessary to cure the disease, out of doctor’s offices and into the places where people with reduced mobility live.

“Really, the only way is to bring the care to this population,” Ramers said. “They’re not going to come in and meet us at the clinic, so we have to find a way to go to them.”

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And, simply showing up in tent encampments for checkups and to fill prescriptions is not enough. Family Health Centers workers have learned that the usual practice of delivering one month’s worth of medication at a time does not work. Such a large supply is likely to be stolen before it can be consumed.

Instead, workers deliver seven pills at a time, making weekly visits and using those encounters to discuss other health matters that a person might also be experiencing.

But eliminating the disease will not be accomplished only by embracing street medicine for those experiencing homelessness. Scott Suckow, executive director of the Liver Coalition of San Diego County, said recent modeling by researchers at UC San Diego found that reaching intravenous drug users in many different types of venues will be key to winning this fight.

More work could be done, he said, in organizations that treat substance use disorder, often combined with mental health care, to screen for hepatitis C and to make sure that those who test positive are referred to medical providers for treatment.

The state, through the ongoing reform of its Medi-Cal health insurance system for needy residents, has recently approved paying substance use treatment and behavioral health providers for “enhanced care management” when treating patients with substance use disorder. This additional benefit allows for a more holistic set of services that can go beyond drug and alcohol treatment.

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Driving hepatitis C infections lower, getting more people screened and treated, Suckow said, is likely to see a significant benefit from the enhanced care management benefit if the disease is included in the host of additional health problems that doctors look for when care management is engaged.

“The position we’re taking is that it’s the behavioral health and substance use disorder treatment community’s responsibility if they’re providing whole-person care, to make these linkages, especially if they know that a client has hepatitis C or they’re at risk for it,” Suckow said.

Why couldn’t this simply be a mandate of the county health department, which spends millions per year contracting with substance use treatment programs serving patients whose care is covered by Medi-Cal? Why couldn’t a mandate to test all substance use treatment patients for hepatitis C infection just be written into county contracts?

Dr. Nicole Esposito, chief population health officer for the county’s behavioral health department, said that contracting is not seen as the right solution for promoting better coordination between different types of medical providers serving Medi-Cal beneficiaries.

Better coordination of care is not, she noted, about only one disease.

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“The goal of care coordination is to really assess all of the needs of the whole person, rather than programmatically calling out specific diseases in contracts,” Esposito said. “Then it becomes like a patchwork where we have the hepatitis C expectations and the HIV expectations and we have some that get missed.

“I think the goal is to put the person at the center and work across all of the various factors, whether it’s all of the illnesses they might have or housing needs or social needs or school needs, rather than trying to do it with line item contract language.”

Medi-Cal changes, she added, will make it easier for different types of providers to securely share patient information electronically, making it easier for referrals to be made across organizations that are engaged in different missions.

“I think the big hope for significant progress lies in the fact that, in the future, we’re going to have a lot more data sharing so that there will be more visibility of whether tests were done, what were the results, was treatment started, was treatment completed,” Esposito said.

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Morning Report: Newsom Pumps the Brakes on Homelessness Funding

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Morning Report: Newsom Pumps the Brakes on Homelessness Funding


During Gov. Gavin Newsom’s final annual address to the Legislature this week, he announced that the state’s principal homelessness program will get $500 million. 

That’s half the $1 billion that has been allocated for the program annually since 2019, reports our Nadia Lathan, except for this year when it was gutted completely. 

Service providers were disappointed by the news. Newsom previously suggested he needs to see more results before committing more dollars. 

But Mayor Todd Gloria is pushing hard to get that cash. He was in Sacramento last week rallying lawmakers to support restoring the funding, Lathan writes. 

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Read more in the Sacramento Report here. 

Gloria is giving his State of the City address this week. We’ll have more deets and a summary for you later this week. 

Last year, he gave his speech from City Hall and declared that this was the “era of austerity” as city leaders faced a $350 million budget deficit. Our Mariana Martínez Barba looked out how the mayor’s plans to “right-size” the ship turned out in 2025. 

Read more here. 

VOSD Podcast: How About Them Parking Fees?

Our podcast crew is back for the new year, and boy has it been a busy controversial week for parking. The city of San Diego rolled out its parking program in Balboa Park last week and backlash from the public and City Council was swift. 

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While some councilmembers wanted the mayor to suspend the fees, he said that wasn’t an option. It all went down in a memo war. The crew digs explains what this means for the city’s budget. 

Also on the podcast, the latest on the legal debacle between the city and people living in their RVs in Mission Bay. The city opened a safe parking lot, H Barracks, in May that would allow police to start ticketing vehicle dwellers in the area. But some people say H Barracks isn’t a viable option for everyone.

Listen to the Podcast here.

In Other News

  • Fundraising for San Diego City Council races is kicking into high gear, with seats up for grabs in Districts 2 and 8. The possible entry of former Coronado Mayor Richard Bailey could shake things up in District 2. (Union-Tribune)
  • Medicaid, the Supplemental Nutrition Program, and other homelessness programs are facing big cuts this year. San Diegans who rely on food assistance, and immigrants who can no longer qualify for the state’s low-cost insurance could be some of the hardest hit. (inewsource)
  • Unemployment across the region went down in November after holiday retail hiring brought the unemployment rate down from 4.9 percent to 4.6 percent. (Union-Tribune)

The Morning Report was written by Mariana Martínez Barba. It was edited by Andrea Sanchez-Villafaña. 



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Tom Krasovic: Josh Allen wows with his arms, legs and head in Bills’ playoff win

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Tom Krasovic: Josh Allen wows with his arms, legs and head in Bills’ playoff win


Josh Allen came into this Super Bowl tournament as the most capable quarterback in the 14-team field.He showed it Sunday.

Allen made top-tier plays as a passer, rusher and thinker — none better than on a late-game touchdown drive for the lead, and the Bills held for a 27-24 win against the Jaguars in Jacksonville.

The NFL is flexing its theatrical muscles in this wild-card round.

Saturday, league MVP candidate Matthew Stafford drove the Rams to a 34-31 road win after the Panthers, 10 1/2-point underdogs, took their second fourth-quarter lead. Hours later as the Bears and Packers reprised their century-plus rivalry, QB Caleb Williams’ playmaking fueled a 25-point fourth quarter in Chicago’s 31-27 homefield win.

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Allen’s performance stood as the best, though, and made it six straight years Buffalo (13-5) has won a playoff game.

Start with his rushing prowess.

At 6-foot-5, 237 pounds, bullish, quick and agile, the 29-year-old stands as the NFL’s all-time leader in rushing TDs by a quarterback.

He can’t be stopped short on most sneaks. Pass-rushers detest him, knowing he can break their tackles or get off passes in a blink.

Keep this in mind: if they charge at him too fast, he’ll sidestep them.

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Allen’s rushing and rushing threat bled out the Jaguars.

Where the North Florida team couldn’t stop him from bulling for two 1-yard touchdowns and several other other successful sneaks, Bills defenders stopped quarterback Trevor Lawrence’s fourth-and-2 rush at their 8.

The Jags (13-5) found Allen too adept as a passer, too. He went 28 for 35 for 273 yards without a turnover. He hit former University of San Diego tight end Dalton Kincaid for a 15-yard touchdown — one of four TDs in the game’s fourth quarter.

The decisive 66-yard drive Allen that capped with his second rushing TD, putting the Bills ahead by four points with 64 seconds left, featured one of his best career throws, a 36-yard completion to Brandin Cooks.

A San Diego County product had a good look at Allen on that first-down play.

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Though he got a free run as a blitzer, Chula Vista’s Devin Lloyd had to respect Allen’s evasivenes. The Otay Ranch High School alum raised his arms without jumping, nor could he approach at max speed.

Though Cooks hadn’t run past the man covering him, Allen chose to throw the ball downfield ahead of him. The QB was able to flick it some 45 yards, despite stepping back from Lloyd and lacking leverage.

Cooks ran under it and gathered it.

Nixing the Jaguars’ comeback bid on the first snap, Bills cornerback Tre’Davious White broke up Lawrence’s accurate pass and safety Cole Bishop caught the deflection.

It was Allen’s seventh win in 13 playoff games.

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For many reasons, he hasn’t reached a Super Bowl. He was frenetic in his first playoff game, a loss at Houston five years ago. He was sensational a year later, only for the Bills to collapse on defense — the infamous “13 seconds” loss to the Chiefs.

The great Patrick Mahomes and the Chiefs have dealt him four playoff losses, and Joe Burrow and the Bengals got him en route to the Super Bowl.

With Mahomes and Burrow absent from this postseason, it’s tempting to say the door has opened wider for Allen — but that’s too simplistic. Allen outplayed Mahomes in one playoff loss. The Bengals ran for 172 yards at snowy Buffalo.

Though this Bills’ defense remains suspect against the run and lost a good safety Sunday in Jordan Poyer, Allen looks close to peak form, notwithstanding medical checks Sunday to his throwing hand, head and a knee.

49ers fallout

By beating the Eagles 23-19 on Sunday, the 49ers may have helped their top rivals.

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The Seahawks will face a 49ers team hit hard by injury instead of drawing the healthier Rams.

Two weeks ago, the Seahawks smothered the Niners in Santa Clara, 13-3. George Kittle will sit out the rematch. An Achilles’ tendon injury has ended the All-Pro tight end’s postseason.

The Niners get an A+ for winning. Coordinator Robert Saleh’s defense allowed no second-half touchdowns.

Playcaller Kyle Shanahan’s gadget play went for a 29-yard, go-ahead TD to open the fourth quarter. Receiver Jauan Jennings threw to Christian McCaffrey after the fake suckered Reed Blankenship, a veteran safety.

The Eagles, my preseason pick to win the Super Bowl, got two interceptions from Quinyon Mitchell. But they scored just 19 points off 72 plays, a fitting end to the offense’s ugly season.

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Eagles All-Pro right tackle Lane Johnson didn’t play. Defensive star Jordan Davis went down late. But the defending champs couldn’t match the Niners’ resourcefulness. A shakeup within Philly’s offensive staff seems likely.

Patriots-Chargers

Jesse Minter’s defense looked well-prepared early against a Pats team that averaged 28.8 points per game, second-best in the NFL.

Several Chargers players had traction problems on New England’s synthetic field.

A late first-half non-call on a Patriots blow to Justin Herbert’s head was mystifying. The Chargers stood to break a 3-3 tie with those 15 yards.

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Santana High shooter ruling follows evolving approach to juvenile offenders

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Santana High shooter ruling follows evolving approach to juvenile offenders


For many, it was a surprise when a San Diego judge issued a ruling last week that could see the region’s most notorious school shooter freed from prison at age 39.

But a series of laws and court rulings favoring rehabilitation for youth offenders for more than a decade have paved the way for the possible release of Santana High School shooter Charles “Andy” Williams, who killed two classmates and wounded 11 more students and two adults in March 2001.

No longer can anyone under age 16 be charged as an adult in California courts. Parole is now available to youth offenders after serving 25 years of their sentence. And lawmakers have created a path for youths previously sentenced to life without the possibility parole to seek relief.

Then there are those like Williams, who, at 15 years old, was sentenced to 50 years to life in prison. Recently, courts have been grappling with the question: When does such a lengthy sentence become a de facto sentence of life without parole?

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Last week, San Diego Superior Court Judge Lisa Rodriguez found that such a lengthy sentence is essentially life without parole. She recalled — or essentially, erased — Williams’ sentence and set him to be resentenced in Juvenile Court. There, he will get the benefits of today’s laws governing juvenile offenders, and that likely translates into a release from custody. The District Attorney’s Office is appealing.

The main entrance to the Juvenile Court in San Diego, where Charles “Andy” Williams’ case is likely headed next for resentencing. (Nelvin C. Cepeda / The San Diego Union-Tribune)

On Tuesday, as survivors of the Santana High rampage listened in, the judge explained her decision, saying she was following the guidance set by the San Diego-based 4th District Court of Appeal, Division 1, which she said “has made its position on this issue clear.”

It is the same appellate court — although not necessarily the same panel of judges — that will review the district attorney’s appeal of the Williams decision.

Victims of and witnesses to the rampage expressed disappointment and concern following the ruling, with at least one questioning whether the decision was moral or just. Many pointed to the deaths of students Bryan Zuckor, 14, and Randy Gordon, 17.

In a statement issued last week, District Attorney Summer Stephan said Williams had “carried out a calculated, cold-blooded attack” and that his “cruel actions in this case continue to warrant the 50-years-to-life sentence that was imposed.”

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“At some point our laws must balance the rights of defendants, the rights of victims, and the rights of the community to be safe,” Stephan said.

Community members along with students from Santana High come to the entrance of the school to place flowers and pray for those injured and fatally shot. (Nelvin C. Cepeda / U-T file)
Community members along with students from Santana High come to the entrance of the school to place flowers and pray for those injured and fatally shot. (Nelvin C. Cepeda / U-T file)

Had the Santana attack happened today, a 15-year-old shooter — even if convicted of multiple murders — would be tried as a juvenile and generally could not be held in custody longer than age 25, with maybe an additional two years in transitional housing.

State Assemblymember Carl DeMaio, whose district includes Santee, said last week he is developing legislation that would exclude those who commit school shootings and similar mass-casualty crimes from resentencing laws offering relief to juvenile offenders.

“School shootings are not impulsive mistakes — they are acts of terror,” DeMaio said in a statement. “California’s laws should draw a bright line: if you commit mass violence in a school, you should never be eligible for resentencing designed for lesser offenses.”

People who work with juvenile offenders note that the courts and lawmakers have come to understand that teens are different from adults and should be given the chance at rehabilitation and release. They point to scientific research on the lack of adolescent brain development and the ability for juvenile offenders to be rehabilitated.

“I think that the question we ought to be answering is, ‘Do we want to throw away people who do something terrible at age 15?’” said law professor Christopher Hawthorne, director of the Juvenile Innocence and Fair Sentencing Clinic at Loyola Marymount University, which takes on post-conviction cases for juvenile defenders.

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Hawthorne said lawmakers “woke up” in 2012 and began giving juvenile offenders a path for release.

San Diego defense attorney Danni Iredale, who represents clients in federal and state court, including juveniles, said that while she understands some may believe that juvenile offenders should be given harsher sentences — especially in “outlier” cases such as the Santana shooting — she believes strongly in the research on brain development and rehabilitation.

“There’s always going to be an outlier case that pushes us to the bounds of what we can tolerate, but … juveniles are different, and I think the Supreme Court has recognized that time and time and time again,” she said.

An evolving approach

Juvenile sentencing laws have evolved since Williams was initially sentenced in 2002. While not all of the changes directly impacted Williams, they had a cascading effect that ultimately led to this past week’s ruling.

The first big decision came in 2005 when the U.S. Supreme Court banned the death penalty for juvenile offenders, ruling that it violated the Eighth Amendment restriction against cruel and unusual punishment. The Supreme Court also issued rulings in 2010 and 2012 that limited the ability of states to sentence juveniles to life in prison without parole.

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The main visitors entrance to the East Mesa Juvenile Detention Facility in San Diego. (Nelvin C. Cepeda / The San Diego Union-Tribune)
The main visitors entrance to the East Mesa Juvenile Detention Facility in San Diego. The facility does not house anyone over 25. (Nelvin C. Cepeda / The San Diego Union-Tribune)

Those laws laid out a more nuanced viewpoint of the distinctions between adults and juveniles who commit the worst crimes and the unconstitutionality of punishing them equally.

As a California appeals court wrote in 2022: “These decisions arose in large part from advances in research on adolescent brain development, and the related, growing recognition that juveniles ‘have diminished culpability and greater prospects for reform’ and are therefore ‘constitutionally different from adults for purposes of sentencing.’”

The Supreme Court rulings prompted legislative changes in some states, including California. Those changes, plus subsequent court rulings, did eventually have a direct impact on Williams.

California Senate Bill 9, which took effect in 2013, allowed juvenile offenders serving life without parole to petition to have their sentences recalled and to be resentenced. Since Williams was not sentenced to life without parole, the law did not initially affect him. But that changed in 2022 in a decision arising from another case involving a juvenile offender from San Diego.

In 2005, when Frank Heard was 15 years old, he and other members of his San Diego street gang wounded two people in a drive-by shooting targeting rival gang members. Six months later, shortly after Heard turned 16, he fatally shot a person on a street corner who he believed was selling drugs in his gang’s territory.

Heard was charged as an adult and convicted of attempted murder and manslaughter charges. A judge sentenced him to what essentially amounted to 103 years to life in prison.

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Heard filed an appeal in 2021, citing the 2013 law, arguing that he should be eligible for resentencing “because his sentence was a de facto life without parole sentence.” A San Diego Superior Court judge denied the appeal, ruling the law only applied to juvenile offenders explicitly sentenced to life without parole. Heard appealed that ruling, arguing that his sentence was the “functional equivalent” of life without parole.

In 2022, California’s Fourth Appellate District agreed with the San Diego judge that the 2013 statute only applied to juvenile offenders explicitly sentenced to life without parole. But Heard had also argued that if the law did not apply to him and others with sentences functionally equivalent to life without parole, it would violate his rights to equal protection of the laws under the 14th Amendment and the California Constitution.

“On this, we agree,” the appellate court wrote.

The ruling allowed similarly situated juvenile offenders such as Williams to petition for a resentencing — if, like Heard, they could successfully argue that their lengthy prison terms were the functional equivalent of life without parole.

A flood of petitions for resentencing followed. Williams’ attorney said last week that her client initially declined to petition because he wanted to have a parole hearing first, in order to give his victims a chance to confront him. And even that parole hearing was possible under reforms that now offer parole hearings for youth offenders who have served 25 years of their sentence.

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At that parole hearing in September 2024, Williams was found unsuitable for release. One commissioner told Williams it was “unclear if you understand why you committed this horrendous act of violence.”

Williams then filed a petition to have his sentence recalled. But then, in the last year, differing appeals courts in California handed down opinions contrary to the Heard finding.

Charles
Charles “Andy” Williams, shown on a video monitor, weeps during a court hearing at the San Diego Central Courthouse downtown on Tuesday. (Sandy Huffaker / For The San Diego Union-Tribune)

What exactly constitutes the functional equivalent of life without parole is still up for debate. With now competing decisions in trial and appellate courts, the California Supreme Court agreed last year to take up the question, but that action is still in its infancy. It is not clear if the prosecutors in Stephan’s office will ask the Juvenile Court to pause Williams’ case until the high court rules.

As for case law, Rodriguez, the judge in Williams’ matter, said one case that stood out was a 2018 California Supreme Court ruling that 50 to life was equal to life without parole. That ruling arose from a San Diego case in which two 16-year-olds came across two teen girls in a Rancho Peñasquitos park in 2011, kidnapped and raped them. In that case, the state’s high court said it agreed with the San Diego appellate court finding that the lengthy sentences tended to reflect a judgment that the two defendants were “irretrievably incorrigible” and fell short of a realistic chance for release. 

Fewer teens can be tried as adults

The venue for Williams’ resentencing is also the result of state laws that have changed in recent years.

In 2016, California voters approved Proposition 57, a measure that required prosecutors to seek a hearing if they wished to charge 14- and 15-year-old offenders as adults. A few years later, in 2018, state legislators passed a law that banned offenders 15 years old and younger from being charged as adults in any circumstances.

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There was another big change geared toward placement of youth offenders in 2021, when the Legislature agreed to do away with the Department of Juvenile Justice, which ran prisons for juvenile offenders. Since mid-2023, housing those youth offenders now falls to the individual counties, which keeps them closer to their families. In San Diego, that meant creating a wing in the East Mesa Juvenile Facility to house that population.

Williams, 39, would not be sent to such a facility, which doesn’t house people older than age 25. His attorney has said he hopes to move to Northern California.



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