NOVATO, Calif. (KGO) -- This should have been the best time of Teddy Russell's life. He had just finished his freshman year at UC Santa Barbara and was home for the summer in Novato.
But instead, he was coping with an addiction to painkillers. So bad, he checked himself into rehab: Mountain Vista Farm in Glen Ellen.
Eight hours later, Teddy died. He was found unconscious in his room by a counselor.
The state fined Mountain Vista Farm $700 for Teddy's death, but the family is outraged. Teddy's parents are now suing the Sonoma County rehab facility for negligence -- and calling for a state-wide change in rehab centers.
"We thought they were going to care for him and they didn't," Teddy's mother, Anne Russell, said through tears. "I think there's good people trying to help other people, but my son wasn't helped at all. He died in their hands and it's just awful."
According to a state death investigative report provided to ABC7 by the family's attorney, Teddy checked into Mountain Vista Farm at 3 p.m. on June 16th, 2018.
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"He was sending his friends messages on the car ride up saying I'll see you in 30 days, and everybody was saying, 'We're proud of you. Go for it,'" Anne Russell recalled.
But at 10:15 p.m., he was found in his room by a counselor unresponsive. His roommate tried doing CPR, a counselor called 911-- but it was too late.
His parents learned of Teddy's death from a 3 a.m. knock on the door by police.
"They said, 'Your son is at the morgue,' and I was like in complete shock," Anne Russell said, "Like, he's at the treatment facility, how can he be at the morgue?"
The family's attorney, Gary Gwilliam, said Teddy did have drugs in his system. One report indicated fentanyl. But, he said, that's not what matters.
What does matter to the family is understanding how this happened. They have now filed suit against Mountain Vista Farm for negligence.
According to the California Department of Health Care Services, licensed rehab facilities are required to provide face-to-face checks with patients every 30 minutes in the first 72 hours following admission. The state investigative report shows that didn't happen to Teddy. Only three of 12 check-ins were face-to-face.
"All they did was poke their head in the room and look at him," Gwilliam said. "The family is suing for what they call a wrongful death action in order to have accountability for Mountain Vista Farm for what we consider extremely serious misconduct in not properly caring for their son."
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Mountain Vista Farm bills itself on its website as the "premier addiction treatment facility in Northern California." In an email, the facility's CEO Crag McMahon responded to requests for comment from ABC7.
"All of us at Mountain Vista Farm are saddened by this event and the family's loss," McMahon wrote. "However, because of the pending lawsuit and pending litigation, as well as to protect the privacy and confidentiality concerns of all involved, we are unable to make any comments."
The death investigative report shows that the state did cite Mountain Vista Farm for failing to conduct those face-to-face checks on Teddy, and for not allowing its own detoxification policies and procedures, which say the facility will also take vitals of patients during those checks. Mountain Vista Farm was fined $700 - and the investigation is now closed.
The California Department of Health Care Services says that in the past five years there have been more than 100 deaths at licensed rehab facilities in the state. There were 32 alone in the last fiscal year.
That's something Teddy's family is now hoping to change.
"I want to shed light on change needing to happen and how we treat people," Anne Russell said.
Teddy's younger sister, Lucie, also wants more regulations.
"He was my only brother and now I don't have that anymore," Lucie said. "Something needs to change. That shouldn't have happened, and it shouldn't happen to anyone else."
'He died in their hands': Marin family suing Sonoma County rehab center over son's death speaks exclusively with ABC7