Arthur Capper Senior Apartments Fire Lawsuit
Arthur Capper Senior Apartments Fire Lawsuit
Arthur Capper Senior Apartments Fire Lawsuit
Plaintiff Raymond Holton, by counsel and thru his attorneys-in-fact appointed by Hattie
White with a Durable Power of Attorney, brings this tort action for negligence and punitive
1. This court has jurisdiction over this action pursuant to 28 U.S.C. § 1332 because
there is complete diversity of citizenship between the parties and the amount in controversy
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2. Venue lies in this judicial district pursuant to 28 U.S.C. § 1391(b)(2), the District
of Columbia being the district in which a substantial part of the events or omissions giving rise to
PARTIES
incorporated and with its principal place of business in Maryland, located at 9711 Washingtonian
6. At all relevant times herein mentioned, Defendant Edgewood was the managing
company responsible for managing, operating, maintaining, and/or controlling the Arthur Capper
Senior Homes located at 900 5th Street SE, Washington, DC, 20003 (hereinafter the
“Residence”).
7. At all relevant times herein mentioned and specifically around the time of the fire
event at the Residence, Defendant Edgewood was acting by and through its agents, servants,
and/or employees, who were acting within the scope of their employment with Defendant
Edgewood.
8. On or about September 19, 2018 at 3:00 PM, a fire began at the Residence.
9. On or about the aforesaid date and time Plaintiff Holton was inside his apartment
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Defendant Edgewood Neglected and Intentionally Disabled the Residence’s Fire Alarm
System.
10. Neither the Residence’s smoke detectors nor its fire alarms functioned properly or
11. Neighbors from across the street saw the flames and began evacuating residents.
12. Plaintiff Holton was one of the residents who did not receive notice of the fire
Firearms (ATF) confirmed that the fire alarms were not functioning. According to one witness
account, he “ran into the building alerting residents of the fire” and “also pulled all of the fire
14. According to the Report, another witness “did not hear the fire alarm alert at any
time.”
15. Plaintiff Holton himself did not hear any fire alarm.
16. In fact, no fire alarm sounded after the fire event began.
17. Plaintiff Holton’s door was swollen shut as a result of the heat from the fire, so he
18. Plaintiff Holton was abandoned and alone at the Residence in his unit without
19. According to the ATF investigative report dated January 16, 2019 (henceforth
“Report”), a staff member stated that “he has pushed the silence button on the fire alarm system
several time [sic] in the past, the last time on Tuesday September 18th, the day before the fire
event.”
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20. The fire alarm system was intentionally disabled by Defendant Edgewood’s
employees.
21. Defendant Edgewood had knowledge of the alarm system’s deficiencies in the
22. The ATF detected no evidence whatever that the fire alarms functioned properly
23. According to the Report, “The fire alarm system for the building was an Edward
Systems Technology Model EST-2 that was installed in 2006 when this structure was built. The
system was manufactured in 2000. This system’s most recent inspection also occurred on
December 29, 2017 and was conducted by Castle Sprinkler and Alarm, Inc. Documents from the
inspection revealed the system to consist of 17 manual pull stations, 22 Smoke Detectors, 89
Horn/Strobes, and 7 strobes. The inspection revealed the system to have a number of deficiencies
and listed the following: ‘(1) Five (5) Strobes flashes but horns don’t work on 4th Floor. (2)
Three (3) Strobes flashes but horns don’t work on 3rd Floor. (3) One (1) Strobe flashes but horn
does not work basement. (4) Display Screen on operating panel inoperable. (5) Recommendation
to have the system monitored offsite.’ . . . [T]here is no evidence that this system was being
monitored at the time of this fire event. There is also no evidence that an alarm sounded or a
strobe illuminated during this event despite the investigators confirming that multiple pull station
24. At the orders of Fire Chief Gregory Dean and the District of Columbia Fire
Department, the EST-2 fire alarm panel was not removed in a timely manner after the fire event
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Defendant Edgewood Failed to Secure the Residence against Trespassers and Vagrants.
25. Defendant Edgewood’s and its employees were aware that there was a persistent
problem with vagrants, trespassers, and squatters entering and remaining on the premises of the
Residence, including its roof and the area around which the fire began.
26. According to the ATF investigative report, “[Witness] stated she would hear
people on the roof at all times of the day and night. [Witness] stated she had contacted the
building management to complain about people on the roof and was informed it was
maintenance staff. [Witness] stated that she would often hear people overnight on the roof and
was quite sure it was not maintenance staff. [Witness] would also smell smoke coming from the
roof through the ventilation fan for her apartment. [Witness] stated it did not smell like cigarettes
and was more like a narcotic.” Elsewhere in the report, investigators noted that “[t]he area
[Witness] heard these footsteps and the area from which [Witness] smelled this smoke is in close
were on the premises of the Residence without permission at various times before the fire event.
28. At various times before the fire event, Defendant Edgewood’s management staff
received complaints from residents about the presence of non-residents and their use of drugs on
29. At various times before the fire event, Defendant Edgewood’s management staff
received complaints from residents that non-residents were on the roof of the Residence doing
drugs or smoking.
30. Residents alerted Defendant Edgewood and its employees that trespassers and
vagrants were regularly occupying the areas of the premises around which the fire began and
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Defendant Edgewood either knowingly falsely represented to them that they were in fact its
maintenance employees, or else failed to check to see who these people were.
31. Defendant Edgewood did not check to see if anyone was squatting on its premises
32. According to the ATF report, “there had been issues in the past with outside
individuals gaining access into the building and ‘squatting’ in different areas of the building.
Maintenance staff have also revealed that although five or six individuals had key access to the
roof, access could also be obtained with the use of simple tools such as a flat head screwdriver.
The cockloft of the building could be accessed through panels from the flat section of the roof. A
simple ¼ turn of screws on these access panels could open them up. Maintenance reported that
33. Defendant Edgewood’s staff knew that outsiders could easily gain access to the
34. Defendant Edgewood’s staff did nothing to correct this problem to prevent
35. Defendant Edgewood did not have building security between roughly 9 AM and 5
36. No security guards were present at the Residence around the time of the fire event
37. According to the report, “[t]he surveillance equipment for the building was not
operable at the time of this event. Investigators located no working cameras that would have
assisted in identifying who was coming and going from the building. Maintenance staff and
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residents also told investigators that there was minimal security at the front door of the building
during the day, with people gaining access to the building whether they lived there or not.”
38. The Residence’s surveillance equipment, including its security cameras, were not
working on or before the date of the fire event. No recording was taken as a result.
39. Defendant Edgewood did not increase security during the day time despite
knowledge that trespassers regularly entered the premises of the Residence during daytime,
40. The fire was caused by trespassers during daytime who gained access to the roof.
41. According to the ATF report, “investigators also located a garden hose used by
maintenance to clean the air conditioning units on the roof. This garden hose was running and
pulled as close to the area of origin [of the fire] as it would reach. This is clear evidence that
there was some attempt by an unknown individual to fight the fire in its early stages.”
43. On the basis of all of the evidence herein mentioned and additional evidence, the
ATF concluded that “the most likely cause of this fire was some form of human activity in the
44. Accordingly, the actions of vagrants and trespassers sparked the fire at the
Residence.
45. Defendant Edgewood and its employees had knowledge of all of these problems.
46. For example, some months prior to the fire, Defendant Edgewood and its
employees knew that a man was stabbed in the Residence at approximately 2 AM. Both the
victim and perpetrator did not live in the Residence and lived elsewhere.
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47. Trespassers and vagrants regularly walked by security guards through the
Residence’s front door without any resistance from the Residence’s security guards, or through a
back door that was left unlocked and with a disabled alarm.
48. When security guards were present, they were often asleep or distracted, allowing
49. Defendant Edgewood received complaints from residents of the Residence about
Defendant Edgewood Falsely Represents to the Government that All Residents Were Safe;
Plaintiff Holton is Left Trapped for Five Days.
50. After the fire commenced at the Residence, representatives of the District of
51. To make the determination that all residents were evacuated safely, government
officials used a list of residents of the Residence provided by the Residence’s management
52. The report by government officials that all residents were safely evacuated was
false. Plaintiff Holton, a 74-year-old man, was trapped in his apartment in part because his front
door swelled shut as a result of the fire. Plaintiff Holton was trapped for approximately five days
53. After the fire event began, Defendant Edgewood, by and through its employees,
reported to District of Columbia officials that everyone at the Residence was safe and accounted
for.
54. This report by Defendant Edgewood to officials was false: not everyone at the
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55. District of Columbia officials relied on this false representation when they took
the decision to end rescue efforts. Officials believed that the Residence was empty of residents
because Defendant Edgewood reported to them that all residents were safe and accounted for.
56. Defendant Edgewood reported to officials that Plaintiff Holton was accounted for
despite the fact that he had not been evacuated from the Residence.
57. After the fire event and before his rescue, Defendant Edgewood never checked to
58. Such a determination would have been easy for Defendant Edgewood to make.
Defendant Edgewood was in the best position to confirm whether Plaintiff Holton had been
accounted for.
59. On the basis of the false representation by Defendant Edgewood that nobody was
left in the Residence, officials concluded that checking the Residence further would
unnecessarily risk the lives of firefighters and stopped all rescue and evacuation efforts.
of lying to the government about the status of its residents during and after the fire event.
62. According to news reports, Defendant Edgewood publicly admitted to giving the
government false information about whether all residents had been evacuated from the
Residence.
Plaintiff Holton’s Entrapment Caused Him Severe and Permanent Physical, Mental, and
Emotional Injury.
63. In the five days during which Plaintiff Holton was trapped, the sprinklers
activated in his apartment, leaving virtually everything in his apartment wet, including the couch
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on which he slept. Plaintiff Holton at one point attempted to sleep on a cabinet because
64. Plaintiff Holton’s toilet stopped functioning properly and could no longer flush.
66. The electricity in the Residence stopped working while Plaintiff Holton was
trapped.
67. Plaintiff Holton’s phone did not work, leaving him with no way to communicate
with anyone.
68. Because there was no electricity in the Residence, Plaintiff Holton’s apartment
69. Plaintiff Holton’s refrigerator stopped working, as a result of which what little
70. Plaintiff Holton ran out of food, causing him to starve for days.
71. Plaintiff Holton began eating his medication in the form of pills to quench his
72. Plaintiff Holton was sleep-deprived for the five days of his entrapment. He
suffered from nightmares throughout this period and prayed to God constantly for rescue, fearing
74. Plaintiff Holton lacked running water. He could not bathe in or drink water.
75. Plaintiff Holton was in a state of mental and emotional misery during his
entrapment.
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76. At some point during his entrapment, Plaintiff Holton fell, causing injuries to his
77. Plaintiff Holton can no longer walk without the assistance of others. Plaintiff
Holton was able to walk with the assistance of canes before his entrapment.
78. At some point during his entrapment, Plaintiff Holton lost almost all of his teeth.
79. On or about September 24, 2018, approximately five days after the fire began at
Residence’s owner pried open Plaintiff Holton’s door after they heard him screaming for his life.
80. Plaintiff Holton was discovered sitting on his soaked couch, covered in his own
feces and urine. Plaintiff Holton’s clothes were soaked in urine. The unit’s smell was repulsive.
pain.
82. Plaintiff Holton was taken to the hospital by ambulance. He was presented with a
83. Plaintiff Holton was not able to adequately respond to hospital officials and could
84. Medical history assists doctors and nurses to treat patients adequately.
85. Because of his altered mental state and injuries, Plaintiff Holton was not able to
adequately describe his medical history to hospital nurses and doctors, making treatment more
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88. Medical examination confirmed that Plaintiff Holton had suffered from starvation
89. Medical examination confirmed that Plaintiff Holton had significantly elevated
levels of his thyroid medication in his system because he had been consuming his medication for
90. Medical examination confirmed that Plaintiff Holton suffered from back,
91. Plaintiff Holton suffered from significant emotional distress during his
93. Plaintiff Holton will never be able to walk again without assistance as well as he
94. Plaintiff Holton can now no longer live independently as he had done before the
95. Plaintiff Holton has suffered permanent loss of cognitive and mental functioning.
96. Plaintiff hereby incorporates by reference all allegations in all paragraphs of the
97. At all relevant times immediately before, during, and while Plaintiff Holton was
trapped in his unit at the Residence, Defendant Edgewood managed the Residence, a multi-unit
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100. Defendant Edgewood owed a duty of care to Plaintiff Holton, who was a senior
common areas of the Residence, a duty requiring it to maintain those areas in a safe and
reasonable condition.
102. Apartment managers are legally obliged to reasonably maintain and ensure the
103. Defendant Edgewood’s employees were acting within the scope of their
employment at all times in their roles managing a home for senior citizens. Defendant Edgewood
104. Defendant Edgewood’s and its employees’ negligent acts and omissions, and their
breaches of the duties of care it owed to Plaintiff Holton, include but are not limited to the
following:
a. Defendant Edgewood did not properly maintain the fire alarm system in the
Residence, as a result of which Plaintiff Holton had no warning of the fire and
his door swelled shut and the electricity turned off. The fire alarms did not
sound during the fire. Defendant Edgewood knew of deficiencies with the
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c. Defendant Edgewood did not properly maintain its smoke detectors in the
without checking to make sure that all residents, including Plaintiff Holton,
officials stopped rescue efforts that would have discovered Plaintiff Holton.
e. Defendant Edgewood and its employees did not properly secure and maintain
or other contraband, or arson, that caused the fire. Defendant Edgewood did
not take reasonable steps to prevent these problems despite many complaints
from residents.
f. Defendant Edgewood did not adequately secure from trespassers access to the
roof and place around which the fire began despite the knowledge of its
employees that trespassers were able to gain access to the roof without
needing keys.
which would have helped to identify trespassers and prevent future trespasses.
h. Defendant Edgewood did not employ competent security guards, who allowed
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105. That trespassers, vagrants, and/or squatters would access the roof on the day of
the fire and that a fire would start on the roof of the Residence was highly foreseeable in the light
of Defendant Edgewood’s knowledge before the fire event that trespassers, vagrants, and/or
squatters would regularly engage in drug- and smoking-related activity there. Defendant
Edgewood’s knowledge that trespassers, vagrants, and squatters would regularly engage in
serious illegal and hazardous activity legally required it to adequately guard against these threats.
Notwithstanding the knowledge of these serious risks, Defendant Edgewood took no adequate
compliance with District of Columbia law, see, e.g., D.C. Mun. Regs. tit. 12, § PM-704G; D.C.
Code Ann. § 7-2807(c) (West), despite knowledge that they were deficient, and its decision to
intentionally shut off the system; its decision to falsely represent to government officials that all
residents, including Plaintiff Holton, were safe and accounted for in the knowledge that it had
not accounted for residents and did not check to see if they were safe; and its intentional and
knowing failure to secure the Residence from trespassers and vagrants despite complaints from
residents and past dangerous incidents and conditions, constitute both ordinary and gross
negligence. These actions were so wanton and reckless in nature as to constitute an intentional
outrageous and reckless disregard for residents of the Residence, Plaintiff Holton suffered all the
injuries herein mentioned, including but not limited to permanent physical incapacitation and
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inability to walk without assistance; inability ever to live on his own again; severe emotional
distress and mental anguish; the loss of his teeth; physical injury to his body; permanent loss of
cognitive and mental functioning; and will continue to suffer severe emotional distress,
108. At all times herein mentioned, Plaintiff Holton exercised the ordinary care of a
reasonably prudent person in his condition and circumstances as an elderly, disabled, and trapped
person, and the negligent acts and omissions that caused all injuries to Plaintiff Holton herein
mentioned were due to the sole negligence of Defendant Edgewood and its employees, without
109. WHEREFORE, for the premises considered, Plaintiff Holton demands judgement
against Defendant Edgewood in the fair and just amount of $3,000,000.00 in compensatory
damages for all of the injuries herein mentioned, including but not limited to his severe
emotional and mental distress; pain and suffering; and the permanent loss of his teeth and the
110. Plaintiff hereby incorporates by reference all allegations in all paragraphs of the
111. Neither the fire alarms nor the smoke detectors in the Residence functioned on the
day of the fire and both failed to alert residents, including Plaintiff Holton, of the fire.
112. Plaintiff Holton could not escape his room because the door was swelled shut as a
result of the fire. If Plaintiff Holton had heard the fire alarm, he could have called for help before
the electricity shut down or attempted to leave through his door before it swelled shut.
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113. Defendant Edgewood’s employees were acting within the scope of their
employment at all times in their roles managing a home for senior citizens. Defendant Edgewood
114. Defendant Edgewood and its employees failed to comply with applicable District
of Columbia law regulating the proper maintenance of fire prevention systems, such as fire alarm
systems and smoke detectors. Relevant District of Columbia regulations include but are not
directed by the code official.” D.C. Mun. Regs. tit. 12, § PM-704G.
b. “704.5.1 Manual fire alarm boxes. All manual fire alarm boxes shall be
installed and maintained in Groups R-2, R-3, and R-4, and dwellings not
area in the immediate vicinity of bedrooms. 2. In each room used for sleeping
cellars but not including crawl spaces and uninhabitable attics. In dwellings or
dwelling units with split levels and without an intervening door between the
adjacent levels, a smoke alarm installed on the upper level shall suffice for the
adjacent lower level provided that the lower level is less than one full story
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installed and maintained in other groups in accordance with the Fire Code.”
Id.
d. “Alarm users shall be responsible for seeing that alarm systems are
maintained in good working order and that defects which could cause false
115. The aforementioned regulations and statutes promote safety (by warning people
of danger from fire); are intended to protect people and residents/tenants in Plaintiff Holton’s
position; and together with its contractual obligations with the owner of the Residence impose a
legal duty on Defendant Edgewood as manager of the Residence to act in accordance with them,
116. Apartment managers are legally obliged to reasonably maintain and ensure the
safety of common areas in the Residence. This obligation extends to the maintenance of fire
alarm boxes in common areas and the fire alarm system generally.
a. The fire alarms in the Residence were not maintained properly and did not
function on the day of the fire. Manual fire alarm boxes were inoperable.
system at the Residence and failed to correct them before the fire.
c. Defendant Edgewood, by and through its employees acting within the scope
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compliance with District of Columbia law despite knowledge that they were deficient, and its
decision to intentionally shut off the system, constitute gross negligence. These actions were so
wanton and reckless in nature as to constitute an intentional disregard for the welfare and safety
outrageous and reckless intentional failure to comply with District of Columbia regulations,
Plaintiff Holton could not escape his room and became trapped for five days, and suffered all of
the injuries mentioned above, including but not limited to permanent physical incapacitation and
inability to walk without assistance; inability ever to live on his own again; severe emotional
distress and mental anguish; the loss of his teeth; physical injury to his body; permanent loss of
cognitive and mental functioning; and will continue to suffer severe emotional distress,
120. At all times herein mentioned, Plaintiff Holton exercised the ordinary care of a
reasonably prudent person in his condition and circumstances as an elderly, disabled, and trapped
person, and the negligent acts and omissions that caused all injuries to Plaintiff Holton herein
mentioned were due to the sole negligence of Defendant Edgewood and its employees, without
121. WHEREFORE, for the premises considered, Plaintiff Holton demands judgement
against Defendant Edgewood in the fair and just amount of $3,000,000.00 in compensatory
damages for all of the injuries herein mentioned, including but not limited to his severe
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emotional and mental distress; pain and suffering; and the permanent loss of his teeth and the
122. Plaintiff hereby incorporates by reference all allegations in all paragraphs of the
123. Both the fire at the Residence and Plaintiff Holton’s entrapment and solitary
confinement for five days in his unit at the Residence without adequate provisions created a zone
of danger and caused Plaintiff Holton to be in significant danger of physical and psychological
injury.
124. Both the fire at the Residence and Plaintiff Holton’s entrapment for five days in
his unit at the Residence were factually and proximately caused by Defendant Edgewood’s or its
a. Defendant Edgewood did not properly maintain the fire alarm system in the
Residence, as a result of which Plaintiff Holton had no warning of the fire and
no opportunity to attempt an early escape, before his door swelled shut. The
fire alarms did not sound during the fire. Defendant Edgewood knew of
b. Defendant Edgewood intentionally disabled the fire alarm system before the
fire.
c. Defendant Edgewood did not properly maintain its smoke detectors in the
Residence. As a result, the smoke detectors did not sound during the fire.
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without checking to make sure that all residents, including Plaintiff Holton,
officials stopped rescue efforts that would have discovered Plaintiff Holton.
e. Defendant Edgewood and its employees did not properly secure and maintain
f. Defendant Edgewood did not adequately secure access to the roof and place
which would have helped to identify trespassers and prevent future trespasses.
h. Defendant Edgewood did not employ competent security guards, who allowed
address them.
residence for the care of senior citizens and Plaintiff Holton as a senior citizen resident, a
relationship that involves obligations to Plaintiff Holton to take care that his well-being is
preserved and to take care that the Residence is managed reasonably, safely, and in accord with
District of Columbia and federal law, and the applicable standards of care for managers of
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apartment buildings. Defendant Edgewood was in part responsible for Plaintiff Holton’s physical
126. It is highly likely and reasonably foreseeable that a significant fire and physical
entrapment and solitary confinement in a small unit for five days as a result of Defendant
Edgewood’s intentional and negligent acts and omissions would cause Plaintiff Holton serious
Holton suffered all the injuries herein mentioned, including but not limited to permanent physical
incapacitation and inability to walk without assistance; inability ever to live on his own again;
the loss of his teeth; physical injury to his body; permanent loss of cognitive and mental
functioning; severe emotional distress and mental anguish, both because of these physical and
mental injuries, but also because of the severe distress and substantial fear of death and injury he
suffered during his solitary confinement for five days; and will continue to suffer severe
emotional distress, psychological harm, and mental anguish as a result of the fire and his
entrapment.
128. At all times herein mentioned, Plaintiff Holton exercised the ordinary care of a
reasonably prudent person in his condition and circumstances as an elderly, disabled, and trapped
person, and the negligent acts and omissions that caused all injuries to Plaintiff Holton herein
mentioned were due to the sole negligence of Defendant Edgewood and its employees, without
129. WHEREFORE, for the premises considered, Plaintiff Holton demands judgement
against Defendant Edgewood in the fair and just amount of $3,000,000.00 in compensatory
damages for all of the injuries herein mentioned, including but not limited to his severe
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emotional and mental distress; pain and suffering; and the permanent loss of his teeth and the
130. Plaintiff hereby incorporates by reference all other allegations in all paragraphs of
the Complaint as if fully set forth herein and further alleges as follows:
131. The damages and injuries from which Plaintiff Holton has suffered are the direct
and proximate result of Defendant Edgewood’s grossly negligent and willful and reckless
conduct. This conduct was so reckless and wanton in nature as to rise to the level of an
intentional disregard for the welfare and safety of the residents under its care, including Plaintiff
Holton.
outrageous and reckless disregard for residents of the Residence, Plaintiff Holton suffered all the
injuries herein mentioned, including but not limited to permanent physical incapacitation and
inability to walk without assistance; inability ever to live on his own again; severe emotional
distress and mental anguish; the loss of his teeth; physical injury to his body; permanent loss of
cognitive and mental functioning; and will continue to suffer severe emotional distress,
grossly negligent, and so wanton and reckless in nature as to constitute an intentional disregard
for the residents in the Residence, Plaintiff Holton demands judgement for PUNITIVE
DAMAGES against Defendant Edgewood in an amount that considers its net worth, the nature
of the wrong committed, its state of mind, and other factors that are recognized as relevant to
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determining an amount sufficient to punish it and serve as an example to prevent others similarly
Respectfully submitted,
/s/William P. Lightfoot
William P. Lightfoot #313593
2001 Pennsylvania Avenue NW, Suite 450
Washington, D.C. 20006
(202) 659-5500
(202)-785-3719 Facsimile
[email protected]
Counsel for Plaintiffs
_/s/William P. Lightfoot_________
William P. Lightfoot
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__________ District
District of __________
of Columbia
Within 21 days after service of this summons on you (not counting the day you received it) — or 60 days if you
are the United States or a United States agency, or an officer or employee of the United States described in Fed. R. Civ.
P. 12 (a)(2) or (3) — you must serve on the plaintiff an answer to the attached complaint or a motion under Rule 12 of
the Federal Rules of Civil Procedure. The answer or motion must be served on the plaintiff or plaintiff’s attorney,
whose name and address are: William P. Lightfoot, Esq.
Koonz, McKenney, Johnson, DePaolis & Lightfoot, LLP
2001 Pennsylvania Avenue, NW, Suite 450
Washington, DC 20006
202-659-5500
If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint.
You also must file your answer or motion with the court.
Date:
Signature of Clerk or Deputy Clerk
Case 1:19-cv-02508 Document 1-2 Filed 08/20/19 Page 2 of 2
PROOF OF SERVICE
(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))
’ I left the summons at the individual’s residence or usual place of abode with (name)
, a person of suitable age and discretion who resides there,
on (date) , and mailed a copy to the individual’s last known address; or
’ Other (specify):
.
My fees are $ for travel and $ for services, for a total of $ 0.00 .
Date:
Server’s signature
Server’s address