This story is heartbreaking and is a prime example of the Child Protective Services corruption that is occurring nationwide. There are two stories on this post, with links to more that have occurred in this same area. I suggest you visit the site and view the pdf documents and read some of these other news reports. When are people going to open their eyes and see what is occurring in this system, honestly how many children have to die, be they foster children, children in state custody, or abused children left at home, before everyone realizes this system is not working?
http://www.sacbee.com/cps/story/1511666
.html
Boy’s CPS record altered after death to reflect likely abuse
Published: Friday, Jan. 02, 2009 | Page 10A
Jahmaurae Allen was pronounced dead at 11:10 p.m. July 21 of head injuries. Seven fractured ribs were healing. His body – from scalp to tongue to chest to foot – was bruised.
He was 4 years old.
Three days later, at 9:10 a.m., a somber e-mail discussion began in the highest ranks of Sacramento County’s Child Protective Services.
CPS Director Laura Coulthard triggered the exchange by sending her top three lieutenants a draft of her “CALL TO ACTION” – a proposed memo to CPS staff regarding the death.
“An inadequate or incomplete investigation leaves children in danger,” she wrote in her draft memo.
Then Coulthard and her division managers – Melinda Lake, Kim Pearson and Jose Villa – began discussing how they should deal with the electronic record on the troubled case, according to the e-mails, excerpted here.
10:28 a.m. Villa responds to Coulthard and the others that a “totally inadequate investigation” followed a doctor’s initial abuse allegation to CPS on June 17.
10:43 a.m. Lake strongly recommends that the original investigative finding of an unfounded abuse allegation be “changed to substantiated. I believe the referral is still open … so I’ll have it changed there,” she writes.
10:53 a.m. Coulthard concurs, saying: “Changed with notation of why,” meaning the record should reflect that an alteration has been made.
11 a.m. Lake says the record “needs to be amended to substantiated based on the doctor’s statement if nothing else.”
11:12 a.m. Pearson responds that she is “at loss here.” With “this shoddy investigation,” could the agency legally support changing the finding of the June referral? But, she concludes, “I will change to whatever directive is …”
By 1:49 p.m., there is apparent agreement that the conclusion contained in the electronic case file should reflect that the boy’s abuse was “substantiated,” meaning likely to be true.
The boy, after all, was dead. A suspect was in custody. If a social worker should open the file again on a subsequent referral, Coulthard explained later, this conclusion would accurately reflect what had occurred.
The file was changed, with the conclusion now reading “effective 7/21/08, a review of this case has deemed the conclusion to be substantiated.”
“This is routine,” Coulthard told The Bee in an interview. “I wasn’t thinking this is altering. This is just what we do.”
But somewhere along the line, the altering went further, and passages of the social worker’s narrative also were deleted and changed.
Coulthard’s boss, Lynn Frank, recently acknowledged that the workers who altered those portions of Jahmaurae Allen’s case records had done so improperly, and she said they were disciplined.
- Marjie Lundstrom and Sam Stanton
http://www.sacbee.com/ourregion/story/1511633.html
Sacramento County child protection woes extend into management, critics say
mlundstrom@sacbee.com
Published Friday, Jan. 02, 2009
Within days of 4-year-old Jahmaurae Allen’s beating death last summer, the leadership of Sacramento County’s Child Protective Services laid the blame for the troubled investigation on a single social worker who operated “in isolation.”
Her work was described by top CPS management as “shoddy” and “totally inadequate,” according to internal e-mails obtained by The Bee.
But those documents and recent interviews reveal a broader failure of the county’s child protection system that reached into CPS management ranks – before and after the boy’s July 21 death.
CPS officials, responding to questions from The Bee, recently acknowledged that a supervisor of social worker Adriane Miles did not scrutinize Miles’ work in June as required, even though the original abuse complaint involving the boy was classified as an emergency.
The supervisor did not review any case documentation until the boy was dead – five weeks after the emergency referral.
And, at least two CPS supervisors went into the boy’s case file after his death and altered the records before they were publicly released, a violation of the government code and Child Protective Services’ written policy.
The CPS investigation into Jahmaurae’s household was so cursory that the agency’s top four managers debated by e-mail three days after the child’s death how to massage the case file to more closely reflect reality.
Those e-mails, initially withheld from The Bee in August as “confidential,” were released last month after the newspaper independently obtained them from a source.
“It sounds as though CPS – instead of taking top-level responsibility for the systemic, stubborn and ongoing failures of its supervisors and leadership – has adopted a policy of trying to throw individual social workers under a bus,” said Ed Howard, senior counsel for the Children’s Advocacy Institute.
A worker’s inexperience also was blamed in 2006 death
The death of Jahmaurae – along with other children who died despite the agency’s intervention – graphically illustrates why the agency needs massive internal changes, said Howard and Robert Wilson, executive director of Sacramento Child Advocates.
The two said they are especially upset by the string of child-abuse deaths that followed the July 2006 death of 12-year-old Daelynn Foreman of Orangevale, who withered to 23 pounds and allegedly starved to death under CPS’ watch. The agency, which received six referrals about the child with cerebral palsy, blamed the fiasco on an inexperienced social worker.
“The Board of Supervisors needs to take an active role and do the job they were elected to do,” said Wilson, whose attorneys represent Sacramento children in dependency court. “They need to hold those in (CPS) leadership accountable for a pattern of mismanagement and unfortunate deaths.”
CPS Director Laura Coulthard told The Bee earlier this year – before the newspaper published an investigation in June about weaknesses and lack of accountability within the agency – that CPS had a rigorous “checks-and-balances” system of oversight.
A cornerstone of that oversight, Coulthard said, was careful case review by supervisors.
That didn’t happen for Jahmaurae Allen, whose mother’s boyfriend, Jonathan Perry, was arrested and charged with murder and child endangerment in his death. The mother, Tiffany Lacy, also was arrested in November on felony child endangerment charges related to the boy’s death.
“We didn’t do what we should have done for this child,” said Lynn Frank, director of the county’s Department of Health and Human Services, which oversees CPS. “And that child died.”
Unidentified supervisor got ‘verbal update only’ on case
Through interviews and internal documents, The Bee pieced together a disturbing picture of how the agency responded in the 34 days between the first report of suspected abuse June 17 and Jahmaurae’s death July 21.
As previously reported, emergency response worker Miles made a series of missteps – from a six-day delay in meeting the family to her failure to consult with a doctor who had first phoned CPS on June 17 with suspicions about a bruise the size of an adult fist on the boy’s chest.
Miles classified the doctor’s allegation as “unfounded,” meaning she believed the abuse report was false.
But CPS acknowledged for the first time last month that Miles’ supervisor did not review any case documentation before Jahmaurae’s death. Health and Human Services spokeswoman Laura McCasland said the supervisor was given a “verbal update only” about the case.
CPS policy states that supervisors must review a worker’s case for accuracy, completeness and other standards before the case is closed. If the work is inadequate, the supervisor is supposed to return the case to the worker and discuss problems, set a time frame for fixing them and identify any needed training.
CPS also requires that social workers enter information and follow-up investigations into the file within five days of an abuse report. But only “minimal information” was entered into the agency’s files before Jahmaurae’s death, according to McCasland.
Social worker Miles, a 10-year employee of the agency, was placed on paid leave shortly after the boy’s death. She has declined to speak to The Bee.
The agency would not disclose the supervisor’s name or whether that manager was disciplined.
The CPS Oversight Committee, a citizens group created after the 1996 death of 3-year-old Adrian Conway, has raised concerns about “inadequate training and supervision” since its first report – and has repeatedly told the Board of Supervisors, as recently as this fall.
In cases of abuse-related deaths in which the children received CPS services, the committee recently found that inadequate supervision had contributed “to a potential risk of harm going undetected or potentially being exacerbated.”
Agency officials adjusted boy’s case file after death
The full role that CPS managers played in the Jahmaurae Allen case is unknown. However, it is clear that agency officials realized within days of the boy’s death that the case had been mishandled.
On July 24, three days after Jahmaurae’s death, the top four CPS managers bemoaned the “totally inadequate” casework by the social worker in a string of e-mails obtained by The Bee. CPS Director Coulthard and her top three lieutenants – division managers Melinda Lake, Kim Pearson and Luis Villa – debated in those e-mails how to adjust the agency’s conclusion in the boy’s case file.
Ultimately, the managers agreed to call allegations that the boy had been abused “substantiated.” After the boy’s death, a second worker already had changed the original finding from “unfounded” to “inconclusive.”
Coulthard told The Bee that such changes are important for accuracy because new social workers rely on those assessments, should a case be reopened on the family in the future. Additionally, findings of “inconclusive” or “substantiated” automatically place alleged abusers on the state’s Child Abuse Central Index, used by police, prosecutors and agencies screening applicants for jobs involving children.
Coulthard and other county officials insisted in recent interviews that management’s decision to change the conclusion in the case, as outlined by the e-mails, was appropriate.
But deleting and rewriting the social worker’s case narrative, as also happened, was not, they acknowledged.
“We can consult and discuss and come up with a different conclusion than the worker, and then it’s not supposed to be deleted,” Coulthard said. “It should show the history here on the computer.”
Coulthard’s boss, Lynn Frank, conceded that other portions of Jahmaurae’s files had been altered or deleted after the boy’s death and that “disciplinary action” had been taken against the workers found to be at fault.
One of the supervisors who sources said changed the records was an agency veteran, with more than 20 years’ experience at CPS.
Official: ‘No criminal intent’ found in probe of file changes
Coulthard was warned of the alterations Aug. 7 by a CPS social worker who noticed the differences between the internal CPS file and the one released to The Bee and posted on sacbee.com.
“I need a detailed response to this asap,” Coulthard said in an e-mail to two CPS managers at 1:02 p.m. the following day.
She and others subsequently ordered an investigation by officials from outside CPS into the file altering.
“I requested through county counsel that they bring them in because this is just way too hot,” Frank said. “And I said I need to understand what happened because it’s beyond me why someone would think it’s OK to delete something in a case file.”
The result of the probe, Frank said, was that there was “absolutely no criminal intent.”
Asked this week to respond to additional questions about its handling of the Jahmaurae Allen case, the agency released a statement saying, in part: “Child Protective Services’ mission is to protect children. While child tragedies result in great despair, CPS workers will continue to work hard to protect all children within the county and take action to prevent tragedies in the future.”
Call The Bee’s Marjie Lundstrom, (916) 321-1055.
Bee researcher Pete Basofin contributed to this report.
http://www.sacbee.com/cps/story/1465230.html
Girl told CPS of abuse 2 years before stepdad’s rampage, documents show
mlundstrom@sacbee.com
Published Thursday, Dec. 11, 2008
The 14-year-old girl who survived the slaying of her mother and siblings by her stepfather Dec. 1 had reported him to authorities two years earlier for allegedly beating her with a stick, forcing her to go without food, shaving her head and making her sleep in the garage without blankets, documents from Sacramento County’s Child Protective Services show.
CPS briefly took the children out of the home in September 2006. Yet it determined that the then-12-year-old’s claims were “unfounded” and returned the children to the south Sacramento home of her stepfather, Ying “Chris” Moua, and her mother, Bouavanh “Kim” Moua, internal documents released to The Bee Wednesday indicate.
Sacramento sheriff’s officials say Ying Moua, 33, went on a rampage Dec. 1 and killed his wife and the couple’s 2-year-old twins, and seriously injured their 3-year-old daughter, before he shot himself.
The 14-year-old was not harmed because CPS had placed her in protective custody on Nov. 21, after a teacher at her school discovered a journal she had kept for more than a year that described her stepfather’s abuse of her. Another sibling, an 8-year-old boy, also escaped harm because he had been living in a different home at the time.
The deaths raise new questions about CPS’ decision to leave the three siblings in the home after the teenager reported her abuse allegations last month, and for its failure to even go to the home to investigate. Instead, the agency asked sheriff’s deputies to inspect the home on Nov. 22, and no further action was taken.
“I don’t know how many more little coffins the people of Sacramento County have to see before the Board of Supervisors, who run this program, start taking personal responsibility for the number and nature of these crimes,” said Ed Howard of Sacramento, senior counsel for the Children’s Advocacy Institute.
“The accumulated weight of these deaths indicates a deeply rooted, systemic problem” that transcends individual social workers, Howard said.
A CPS spokeswoman reiterated Wednesday that the agency cannot comment beyond the required release of the documents because of confidentiality laws.
With a few exceptions, the Board of Supervisors has been largely silent about the string of deaths. In August, they signed off on a $100,000 review of CPS’ policies and procedures. That audit is under way.
Supervisor Roger Dickinson said the board has been, and continues to be, deeply involved in CPS issues. “I don’t think there’s been any lack of attention or concern,” he said.
CPS has been under scrutiny for much of this year following a series of deaths of children whose families were known to the agency. A Bee investigation published in June found that the agency still was troubled, despite large funding increases that followed the 1996 death of 3-year-old Adrian Conway.
The agency also is the subject of a county grand jury investigation that was sparked by The Bee’s revelation that documents in the death of one child this year had been altered. But recalcitrance inside the agency apparently was so great the grand jury took the unusual step of warning all CPS workers and management in October that they must cooperate with the probe, which is ongoing.
The documents released Wednesday indicate that CPS was told about three weeks ago about violence in the home, as detailed by the 14-year-old in new abuse claims. Portions of the documents were redacted, but it is clear the girl reported one member of the family “has been thrown onto a wall” by the stepfather.
That document, an emergency response sheet that indicates it was compiled the afternoon the girl lodged her allegations, also states that “mom is being hit by the stepfather” and “the stepfather is reported to have anger issues.”
It notes that “(m)om knows about the abuse and has not interceded,” and lists allegations against the stepfather as including “emotional abuse, general neglect, physical abuse.” The document also indicates that CPS was aware of the September 2006 abuse report but states those earlier accusations were “unfounded.”
A determination of “unfounded” means that CPS deemed the report to be false or unlikely to constitute child abuse.
This summer, another child on CPS’ watch was killed four weeks after a social worker determined that a doctor’s suspicion of abuse was unfounded. Jahmaurae Allen, 4, was beaten to death in July after the worker visited the apartment in June and determined that no abuse had occurred, despite the doctor’s call to CPS.
When those records later were released to The Bee, the social worker’s original findings had been altered.
In the more recent Moua case, the 2006 CPS documents show that the girl made her first report in September of that year. The girl stated that – besides the beatings and shaved head – her stepfather “curses at them and calls them names.” She said he twice made her go without food “to see what hunger felt like.”
“(She) is very soft spoken and crying,” according to the emergency response referral form. “She is afraid to go home.”
The CPS screener wrote that the mother “witnesses this abuse and does not intervene. Three younger kids are not abused.”
At the time, the girl’s siblings reportedly were taken into protective custody but were quickly returned home, according to one source familiar with the case.
Ultimately, in the 2006 case, the agency determined that the children’s risk of neglect was “moderate” and risk of abuse was “low,” according to the newly released documents. A safety assessment determined that there were “no children likely to be in immediate danger of serious harm.”
Two years later, two of those children would be fatally shot and a third seriously injured.
The agency has been criticized in recent years for how it assesses risk to children. The CPS oversight committee, formed in the aftermath of Adrian Conway’s brutal death in 1996, has repeatedly told the Board of Supervisors that CPS workers and supervisors are failing to properly use the tools that help assess a child’s current safety and future risk of harm.
Workers in several CPS programs, including emergency response and family maintenance, are required to use what’s known as SDM, or Structured Decision Making. The written, check-off system provides structure to social workers by making them note present circumstances and history such as prior CPS contact, excessive discipline, drug abuse or domestic violence.
SDM has been widely praised in California for increasing consistency and accuracy, and leading to better outcomes for kids.
But the oversight committee – once again – reported this fall that it “continues to have concerns” with the agency’s use of the SDM tool. In years past, when examining child deaths, the committee has found poor risk assessment was a precursor to tragedies.
In the Moua case, the documents were released to The Bee Wednesday in response to a Public Records Act request. After the Nov. 21 reports, there is no indication that any further reports were compiled on the family until Dec. 1 – the day Moua killed his two children, his wife and himself.
That document, written after the killings had been discovered, indicates that the 14-year-old’s allegations of general neglect and one form of abuse had been “substantiated” by CPS. Claims of emotional and physical abuse were deemed to be unfounded.
A finding of “substantiated” means the agency has credible information to believe child abuse or neglect did occur.
Call The Bee’s Marjie Lundstrom, (916) 321-1055.
http://www.sacbee.com/cps/
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