Gennaco was also critical of the department's failure to give Gavira prescribed medications for alcohol withdrawal and diabetes.
Since Gavira's death, the report said, sheriff's officials have implemented reforms to improve both the delivery of medications and the quality of investigations of incidents in which inmates are hurt or killed. "The review of Mr. Gavira's case demonstrates the lessons that can be learned from a critical event such as this," Gennaco wrote.
Gennaco declined to be interviewed about the report, saying he considered the document confidential.
Antonio Rodriguez, one of the Gavira family's attorneys, said the settlement helped "achieve some closure."
"But no matter what the amount of money is, nothing replaces the loss of a loved one," he said. "The Sheriff's Department, and the jail in general, still rot with elements of cruelty, torture and inhumane treatment of inmates. Mr. Gavira deserved some compassion and care, but he got the opposite."