Summary

April 2014 Child Welfare Services The County Child Welfare Services Agencies We Reviewed Must Provide Better Protection for Abused and Neglected Children Report 2013-110 COMMITMENT INTEGRITY LEADERSHIP The first five copies of each California State Auditor report are free. Additional copies are $3 each, payable by check or money order. You can obtain reports by contacting the California State Auditor’s Office at the following address: California State Auditor 621 Capitol Mall, Suite 1200 Sacramento, California 95814 916.445.0255 or TTY 916.445.0033 OR This report is also available on our Web site at www.auditor.ca.gov. The California State Auditor is pleased to announce the availability of an online subscription service. For information on how to subscribe, visit our Web site at www.auditor.ca.gov. Alternate format reports available upon request. Permission is granted to reproduce reports. For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Affairs, at 916.445.0255. For complaints of state employee misconduct, contact the California State Auditor’s Whistleblower Hotline: 1.800.952.5665. Elaine M. Howle State Auditor Doug Cordiner Chief Deputy April 8, 2014 2013-110 The Governor of California President pro Tempore of the Senate Speaker of the Assembly State Capitol Sacramento, California 95814 Dear Governor and Legislative Leaders: As requested by the Joint Legislative Audit Committee, the California State Auditor presents this audit report concerning the policies and procedures the child welfare services (CWS) agencies of Butte, Orange, and San Francisco counties follow when considering whether to remove children from their homes. This report concludes that these agencies must provide better protection for abused and neglected children. Specifically, although all three agencies require the use of standardized safety and risk assessments, the agencies’ social workers frequently did not prepare these assessments in a timely manner or at all, and the information used in these assessments was often inaccurate. This led to flawed evaluations of safety, risk, and needed services and, at times, led to poor decisions related to child safety. Additionally, when their initial attempts to make in-person contact with children to investigate reports of child maltreatment were unsuccessful, social workers did not consistently follow up in a reasonable time frame—sometimes waiting weeks before attempting to see the child again. Further, when social workers decided to leave a child in a home that presented a safety threat, they often did not establish a credible safety plan to mitigate that threat. In addition, social workers at times allowed the child to be placed or remain in a temporary living situation without performing any history check on the temporary caregivers and, in a few instances, these individuals were later found to be unfit to supervise the child. When the county CWS agencies we visited did formally remove a child, they did not always perform required background checks before a subsequent placement. State laws and regulations provide county CWS agencies with broad discretion in determining when to involve law enforcement in investigations and in removing children from their homes. As such, we noted that the three CWS agencies we visited have adopted divergent approaches to coordinating with law enforcement. Although each county’s practices reflect the flexibility given to CWS agencies, we found instances where coordination and communication between local law enforcement and the county CWS agencies could have been better. To varying degrees, each of the three county CWS agencies we visited needs to improve its practices. Even so, for most of the items we reviewed, the Orange County CWS agency appeared to perform better than the other two CWS agencies, and had better management processes. Given the relationship we observed between the strength of management processes and county CWS agencies’ performance, we believe the California Department of Social Services—as the state agency responsible for overseeing the CWS system—should encourage and monitor the establishment of the key management processes of policy development and quality assurance at all 58 counties. Respectfully submitted, ELAINE M. HOWLE, CPA State Auditor 621 Capitol Mall, Suite 1200 Sacramento, CA 95814 916.445.0255 916.327.0019 fax www.auditor.ca.gov Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 v April 2014 Contents Summary 1 Introduction 5 Chapter 1 Inconsistent and Inaccurate Investigative Assessments at Times Led to Poor Decisions Related to Child Safety 17 Recommendations 42 Chapter 2 The County Child Welfare Services Agencies We Visited Could Improve Their Coordination With Local Law Enforcement and Their Implementation of Quality Control Processes 45 Recommendations 62 Appendix Child Welfare Services Expenditures for Butte, Orange, and San Francisco Child Welfare Services Agencies 65 Responses to the Audit California Department of Social Services 71 California State Auditor’s Comment on the Response From the California Department of Social Services 75 Butte County Department of Employment and Social Services 77 California State Auditor’s Comment on the Response From the Butte County Department of Employment and Social Services 83 Orange County Social Services Agency 85 California State Auditor’s Comment on the Response From the Orange County Social Services Agency 93 City and County of San Francisco Human Services Agency 95 vi California State Auditor Report 2013-110 April 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 1 April 2014 Summary Results in Brief Audit Highlights . . . The three county child welfare services (CWS) agencies that we Our audit of child welfare services visited are not adequately ensuring that their decisions to remove (CWS) agencies in Butte, Orange, and or not remove children from homes are appropriate. Although the San Francisco counties highlighted California Department of Social Services (Social Services) provides the following: oversight of the CWS system, county CWS agencies administer the » Information contained in the initial programs that are designed to protect children from ongoing abuse intake documents prepared when reports and neglect. When necessary for the protection of a child, county of child maltreatment are received, was CWS agencies may remove a child from the home and place the often inaccurate or incomplete. child with relatives or in foster care. Before a CWS agency takes this step, state law and regulations require that it make efforts to keep » Assessments that analyze safety and risk the family together when services and other support make it safe to factors were sometimes not prepared in do so. a timely manner or were not prepared at all. When a report of child maltreatment (referral) is received, » The county CWS agencies did not county CWS agencies must determine how to respond. We consistently follow up, in a reasonable visited the CWS agencies in Butte, Orange, and San Francisco time frame, on unsuccessful attempts to counties and found that information contained in the initial intake make in-person contact with children— documents was often inaccurate or incomplete. Although most sometimes waiting weeks before of these errors ultimately proved inconsequential, a few ended attempting to make contact. up affecting decisions regarding the appropriate response to a referral. The three county CWS agencies have each adopted the » When social workers decided to leave a use of standardized assessments that analyze safety and risk factors child in a home that presented a safety of families for which the agencies have received a referral, and the threat, they often did not establish agencies also examine what services a family may need to allow a credible safety plan to mitigate the child to safely remain in or return to the home. Although these that threat. assessments are the principal mechanism by which these agencies document critical decisions regarding the child’s safety, we found » Social workers at times allowed the that some assessments were not prepared in a timely manner or child to be placed or remain in a were not prepared at all. We also found that the information used in temporary living situation and often did these assessments was often incomplete and inconsistent. At times, not perform any history check on the this led to flawed evaluations of safety, risk, and needed services. temporary caregivers. Although we found a few instances where safety threats identified » Required assessments used to determine in assessments had no documented basis, most of the errors we the strengths and needs of a family, and found involved social workers leaving out key safety threats from to develop the corresponding case plan, assessments, which can lead to leaving children in unsafe situations. were not always completed. When their initial attempts to make in‑person contact with » For each item we reviewed, we noted children and parents to investigate allegations of child maltreatment a frequent lack of documented were unsuccessful, the county CWS agencies we visited did not supervisory review. consistently follow up in a reasonable time frame—sometimes waiting weeks before attempting to see the child again. Further, when social workers decided to leave a child in a home that presented a safety threat, they often did not establish a credible safety plan to mitigate that threat. In addition, social workers at times allowed the child to be placed or remain in a temporary 2 California State Auditor Report 2013-110 April 2014 living situation until safety concerns could be alleviated. In these instances, they often did not perform any history check on the temporary caregivers and, in a few instances, these individuals were later found to be unfit to supervise the child. When the county CWS agencies we visited did formally remove a child, they did not consistently perform required background checks before a subsequent placement. We also found that required assessments used to determine the strengths and needs of a family, and to develop the corresponding case plan, were not always completed. In addition, assessments used to determine whether a child could be reunited with his or her family were frequently not performed in a timely manner and were sometimes not performed at all. Failing to complete this assessment could lead to social workers improperly assessing the potential danger of a child returning to the home, while late assessments indicate a child could be spending longer in out‑of‑home placement than necessary. For each item we reviewed, we noted a frequent lack of documented supervisory review. For those instances when reviews were documented, it appeared at times that supervisory review occurred so late that it had little or no effect on the safety or risk decision. For instance, we found that approximately one‑fourth of all safety and risk assessments received no supervisory review within 30 days of the completion of the assessment. State laws and regulations provide county CWS agencies with broad discretion in determining when to involve law enforcement in investigations and in removing children from their homes. Their policies and practices regarding involvement of law enforcement in CWS efforts reflect this flexibility. Even so, we found instances where coordination and communication between local law enforcement and the county CWS agencies we visited could have been better. To varying degrees, each of the three county CWS agencies we visited needs to improve its practices, as any deficiency in these practices increases the likelihood that a child will suffer further abuse and neglect. Even so, for most of the items we reviewed, the Orange County CWS agency, which was one of the earliest adopters of standardized assessments, appeared to perform better than the other two CWS agencies. Although all three aspire to models considered to encompass best practices in California, the Orange County CWS agency appears to have better developed its management processes designed to ensure compliance with requirements. In particular, for a number of years it has maintained designated policy development and quality assurance units that help provide clear communication to staff and ongoing feedback California State Auditor Report 2013-110 3 April 2014 to management. The Butte County CWS agency recently developed a one‑person quality assurance function, but neither this agency nor the San Francisco County CWS agency has personnel designated to update policies and procedures. Given the relationship we observed between the strength of management processes and county CWS agencies’ performance, we believe Social Services—as the state agency responsible for overseeing the CWS system— should encourage and monitor, for a time, the establishment of the key management processes of policy development and quality assurance at all 58 counties. Recommendations To ensure that all required assessments are completed, the CWS agencies of Butte and San Francisco counties should develop and implement clear guidance regarding which assessments are required in different situations. To improve the timeliness and accuracy of all required assessments, the CWS agencies of Butte, Orange, and San Francisco counties should ensure that their supervisors are reviewing assessments in a timely manner. The CWS agencies of Butte, Orange, and San Francisco counties should ensure that social workers are making reasonable and timely efforts to make in‑person contact with children who are allegedly being maltreated. To help strengthen safety plans to effectively mitigate safety threats, the CWS agencies of Butte, Orange, and San Francisco counties should ensure that supervisors are reviewing and approving all safety plans. To improve the timeliness of their supervisors’ reviews: • The CWS agencies of Butte and San Francisco counties should develop time frames for supervisors’ review and approval of assessments, and monitor supervisors’ compliance with those time frames. • The CWS agency of Orange County should more closely monitor supervisors’ compliance with its existing policy setting a 30‑day time frame for review and approval of assessments. 4 California State Auditor Report 2013-110 April 2014 To ensure that required safety plans are created, the CWS agencies of Butte, Orange, and San Francisco counties should have supervisors promptly review all safety assessments and verify that a written safety plan the responsible parties have signed accompanies any assessments designating the need for such a safety plan. As part of their responsibility to help children remain safe at all points during the investigation of a referral, the CWS agencies of Butte, Orange, and San Francisco counties should do the following: • Vet temporary living situations and caregivers to the extent allowable under the law, including a review of information contained within the statewide CWS database. • Perform statutorily required background checks and inspections before allowing children to be placed in a home. To ensure that they provide clear, up‑to‑date guidance to their social workers, the CWS agencies of Butte and San Francisco counties should designate specific personnel to stay informed of relevant practice changes and to ensure that corresponding updates are made to their policies and procedures. To promote continued improvement in the CWS system, Social Services should encourage each county CWS agency to designate personnel to regularly update policies and procedures and perform quality assurance reviews. Further, Social Services should monitor the status of each county CWS agency’s efforts. Agency Comments Social Services and the three county CWS agencies we reviewed agreed with our findings and recommendations. Each outlined actions it plans to take in response to the recommendations. California State Auditor Report 2013-110 5 April 2014 Introduction Background California has a system of laws and agencies designed to prevent and respond to child abuse and neglect. This system—often called child protective services—is part of a larger set of programs commonly referred to as child welfare services (CWS). Generally, the CWS system investigates reports of child abuse and neglect, provides family preservation services, removes children from unsafe homes, provides for the temporary placement of these children with relatives or into foster or group homes, and facilitates legal guardianship or the adoption of these children into permanent families when appropriate. While state law requires the California Department of Social Services (Social Services) to provide system oversight, county CWS agencies carry out the required activities. California CWS agencies received 482,000 allegations of maltreatment of children in 2013. They substantiated 81,000 of these allegations through their investigative efforts and removed more than 31,000 children from their homes as a result of the investigations.1 According to Social Services’ estimates, California’s systemwide child welfare budget from federal, state, and county funding sources was approximately $5.4 billion in fiscal year 2012–13. Roles of Entities Involved in CWS California’s Welfare and Institutions Code requires that the State, through Social Services and county welfare departments, establish and support a CWS system. California uses a state‑supervised, county‑administered model of CWS governance. Under this model, each of California’s 58 counties establishes and maintains its own program, and Social Services monitors and provides support to counties through oversight, administrative services, and development of program policies and regulations. State law requires both county CWS agencies and local law enforcement (which may share information) to receive and investigate allegations of child abuse or neglect and make immediate decisions about whether a child is safe to remain in the home or must be temporarily removed. When CWS removes a child from the home, the CWS agency must file a petition within 48 hours with the county juvenile court 1 The source of this information is unaudited data from CWS reports retrieved from the University of California at Berkeley, Center for Social Services Research Web site. Of the allegations that were not substantiated, 193,000 were unfounded, 89,000 were inconclusive, 104,000 received an initial assessment but did not warrant an investigation, and 15,000 had not yet been determined as of December 2013. 6 California State Auditor Report 2013-110 April 2014 detailing facts regarding the child. The juvenile court subsequently hears the facts surrounding the removal and decides on the best course of action for the child. The Role of Social Services Social Services—through its Children and Family Services Division—is responsible for providing oversight of the State’s CWS system. Social Services also receives and distributes federal and state funding that provides support for county CWS agencies and ensures that counties provide matching funds at specified levels. Additionally, Social Services oversees operation of the statewide automated Child Welfare Services/Case Management System, which agencies use to manage and document their case management activities. Further, Social Services monitors county CWS programs through an outcome‑based quality assurance system called the California Child and Family Services Review. This review uses a continuous five‑year cycle of peer reviews, self‑assessments, and improvement plans to assess, monitor, and track county CWS agency performance. Finally, Social Services’ Community Care Licensing Division provides oversight and regulatory enforcement for licensed community care facilities statewide, including licensing foster and group homes that house children removed from unsafe homes. The Role of County CWS Agencies Under Social Services’ oversight and the governance of their respective board of supervisors, each of California’s 58 counties administers its own CWS program. Because the counties differ widely in population, economic base, and demographics, each has some flexibility in determining how best to meet the needs of the children and families it serves. Although they have flexibility, under state law each county must provide four key services: • Emergency response: In‑person, 24‑hour response to reports of child abuse, neglect, and exploitation, with the purpose of maintaining the child safely in the home or protecting the child’s safety through emergency removal and foster care placement. • Family maintenance: Time‑limited services designed to prevent or remedy neglect, abuse, and exploitation in an attempt to avoid separating children from their families. • Family reunification: Time‑limited services designed to reunite children with their families subsequent to their removal for safety reasons. California State Auditor Report 2013-110 7 April 2014 • Permanent placement: Services designed to ensure that children who have been removed from their families find new safe, stable, and permanent homes. In the short term, county CWS agencies have the responsibility to make decisions regarding the type and duration of services provided to an individual child or family, but juvenile dependency courts ultimately make decisions regarding the long‑term needs of dependent children in the CWS system. State law generally requires county CWS agencies to leave children in their homes whenever it is safe to do so. To this end, state regulations require county CWS agencies, when initially investigating allegations of child maltreatment, to determine whether safety or other risks exist for a child in his or her home. When a CWS agency identifies safety risks, it attempts to mitigate those risks with interventions developed with the family and documented in a safety plan. Safety plans contain interventions such as connecting families with community services, obtaining restraining orders, or having a nonoffending parent move with the child to a safe location, such as a domestic violence shelter or relative’s home. These efforts are intended to keep the child with his or her family when possible and appropriate. The Role of the Courts The juvenile court is a division of the superior court that handles child abuse and neglect cases. When a child has suffered, or is at risk of suffering, abuse or neglect from the parent or guardian, the juvenile court may place the child under a program of supervision and Mandated Reporters order that services be provided or it may declare the child a dependent of the court (dependent child) California law requires various individuals to report known as discussed in more detail in the next section. The or suspected child abuse. Mandated reporters include county CWS agencies act as the administrative arm the following: of the court, providing regular updates and carrying • County welfare workers out the court’s decisions regarding the child. • Police and probation officers • Clinical social workers The CWS Process • Clergy, except in certain instances Although variations exist, the typical CWS process • School teachers and counselors begins when a mandated reporter (see the text box) • Employees of day care facilities or a concerned individual calls in a report of child • Nurses and physicians maltreatment (referral) to a county child abuse hotline. A social worker screens the call, assesses the • Commercial film and photographic print and risk to the child, and decides whether the referral image processors should be evaluated out (no further action is taken) Source: California Penal Code, sections 11165.7 and 11166. or whether an in‑person investigation must be conducted immediately or within a 10‑day period. 8 California State Auditor Report 2013-110 April 2014 Referrals from law enforcement must be investigated in person and cannot be evaluated out unless law enforcement has already investigated and determined that there is no indication of abuse or neglect. State law requires an immediate in‑person investigation in all situations in which a child is in imminent danger of physical pain, injury, disability, severe emotional harm, or death. Although county policies for response times vary, when a referral requires an immediate in‑person investigation, it typically must occur within two to 24 hours. State law requires an in‑person investigation within 10 days when a child is not in imminent danger (for example, when the child is in a safe place, such as a hospital or a relative’s home where the perpetrator no longer has access to the child). If a CWS agency determines through its investigation that an allegation of abuse or neglect is unfounded, or if the evidence is inconclusive, it may close the referral. As indicated in Figure 1, once a referral is substantiated, the child may either remain at home while voluntary services are provided or be removed temporarily from the home by the social worker or law enforcement officer and placed in a safe environment. Within 30 calendar days of the initial removal of the child, of the in‑person investigation, or of the date of a juvenile court hearing, whichever comes first, the CWS agency must determine whether continued services are necessary and, if so, begin a corresponding case plan. When a social worker or law enforcement officer removes a child from the care of a parent or guardian, placing the child in temporary custody, and the social worker believes continued detention is necessary for the child’s protection, the county CWS agency files a petition for detention and jurisdiction over the child with the juvenile court, and a hearing is scheduled. After hearing the evidence, the court can either dismiss the petition or declare the child a dependent of the court. During the hearing process, the parent or guardian and the child have the right to be represented by an attorney. The court will appoint an attorney for a parent or guardian who cannot afford one. When a court declares a child a dependent child, it may allow the child to remain at home, ordering family maintenance services and potentially limiting the control the child’s parent or guardian exercises. Alternatively, the court may order that a dependent child be removed from the custody of the parent or guardian, in which case state law requires the court to first consider placing the child with a parent who did not have custody when the abuse or neglect occurred. If a noncustodial parent is not an option, the court will order that the child’s care, custody, control, and conduct be under the supervision of the county CWS agency. A social worker may California State Auditor Report 2013-110 9 April 2014 Figure 1 Major Components and Processes of the Child Welfare System Report of child maltreatment (referral) called into county hotline >> CALL SCREENED Referral evaluated out: Allegations do not meet definition of child abuse or neglect, lack critical details, orX relate to an open or previously unsubstantiated case. In-person investigation Referral closed: Allegation unfounded or X evidence is inconclusive. Referral substantiated: Likely that abuse or neglect occurred. Child removed from home temporarily and placed in a safe environment. Referral closed: Voluntary services provided: Services succeed in X Child can remain at home and family creating a safe receives services for set time periods.* environment for the child. Voluntary services fail Petition dismissed: Child returns or remains with his or her family. X Dependency petition filed with court Family reunification: Family maintenance: Court orders removal of child Court returns or leaves child Child becomes a dependent of the court from home and services at home and orders family designed to reunite family. services to be provided. Dependency terminated: Family Court finds that safety maintenance fails: Permanency planning: Family reunified: concerns have A petition for removal of Court decides child Family successfully completes been alleviated. child from home is filed cannot return home and service plan and child is with dependency court. orders another returned home. Court can permanent placement order family maintenance plan to be selected services to keep family (for example, adoption or successfully reunified. legal guardianship). Sources: California Welfare and Institutions Code; California Department of Social Services’ Child Welfare Services Manual; Administrative Office of the Courts’ Web site; and dependency flow charts. * If a voluntary placement agreement occurs, state law allows a county welfare department to place the child outside the home within a specified time frame while the family receives voluntary services. 10 California State Auditor Report 2013-110 April 2014 place that dependent child, in order of priority, with relatives or in a foster home or other suitable community care facility such as a group home. In both of these situations, the social worker and the family jointly develop a case plan to meet the needs of the family and address the safety concerns about the home environment. The CWS agency must provide permanent placement services for children who cannot safely live with their parents and who are not likely to return home. The court may also dismiss a petition at any point if the issues that brought the family into court have been remedied and the child is no longer at risk. Reunification of children with their families is a priority until the court decides that it is not in the children’s best interest, which then allows them to be adopted by parents that Social Services or the county CWS agency has recruited. State Efforts to Identify and Implement Best Practices for the Protection of Children In 2000, Assembly Bill 1740 (Chapter 52, Statutes of 2000) authorized the establishment of an advisory group of CWS stakeholders, eventually comprising more than 60 members, to review the State’s CWS system and make recommendations for improvement. In 2003 the stakeholders group published its final report, referred to as the Child Welfare Services Redesign. That same year, Social Services launched an 11‑county pilot project, based largely on the system improvements that the stakeholders group recommended. In March 2010 Social Services published a report evaluating the pilot project. The report indicated that child welfare workers and community partners found the following strategies to be best practices: • Standardized Safety Assessment: A set of tools that assist social workers in gathering and evaluating information, deciding how to respond, and determining whether children are safe in their current living situation or whether an alternative living arrangement is appropriate. • Differential Response: A strategy that allows social workers to respond in a flexible manner to reports of child abuse or neglect by, for example, providing services and support to families whose levels of risk and safety would traditionally not have required a CWS intervention. • Permanency and Youth Transition: A strategy that involves parents, children, and others, such as extended family members, foster families, and other interested parties, in making decisions California State Auditor Report 2013-110 11 April 2014 regarding the safety of the child. This includes attempts to find members of the child’s family with whom the abused or neglected child might be placed. Standardized Safety Assessments Standardized Safety Assessments are now a part of all the critical decisions California county CWS agencies must make regarding the safety and well‑being of children. They consist of a comprehensive set of tools and assessments that assist social workers in making decisions throughout child maltreatment cases, including whether children are safe in their current living situation and whether factors exist that place the children at risk of being abused or neglected. Social Services encourages county CWS agencies to use one of two available Standardized Safety Assessment methodologies: Structured Decision Making (SDM) or the Comprehensive Assessment Tool (CAT). 2 The policies of each of the counties we visited require the use of SDM. According to Social Services, SDM promotes a consistent practice of assessing children’s safety; helps ensure consistency in service delivery throughout the State; and provides specific, written documentation of the review, evaluation, and decisions made in a case. In Chapter 1 we provide a detailed review of how consistently and accurately the three county CWS agencies adhered to the tenets of SDM. The components of SDM, including when each tool or assessment should be used, are listed in Table 1 on the following page. Funding for CWS Funding for CWS is a combination of federal, state, and county resources. As indicated in Figure 2 on page 13, systemwide funding has generally remained steady for the last several fiscal years. The figure depicts the primary funding sources for the State’s child welfare system, including allocations for the four key services discussed earlier as well as foster care and adoption programs. 2 Social Services indicated that 54 counties use SDM, while four counties use CAT. 12 California State Auditor Report 2013-110 April 2014 Table 1 Description of Structured Decision Making Tools and Assessments STRUCTURED DECISION MAKING TOOL WHEN IS IT USED IN THE BY WHEN IS CWS REQUIRED OR ASSESSMENT CHILD WELFARE SERVICES (CWS) PROCESS? WHICH CWS DECISIONS DOES IT INFORM? TO COMPLETE IT? Hotline tool When a CWS agency receives a report Whether an in‑person response Immediately upon receipt of of child maltreatment (referral). is necessary and, if so, whether a referral. CWS should respond immediately or within 10 days. Safety assessment When a CWS worker is conducting an Whether the child may safely During the investigation, before in‑person investigation of a referral, remain in the home with or leaving a child in the home; the before leaving a child in the home. without safety interventions, form itself should be completed or whether the child must be within two working days of the removed from the home. first CWS contact. Risk assessment After a CWS worker conducts an Whether the risk of future No later than 30 days from the in‑person investigation, but before the maltreatment is enough to warrant first face‑to‑face contact with referral is closed or is opened as a case. opening a case and preparing a the child. case plan. Family strengths and When planning service interventions Which family needs should be Before creating a case plan. needs assessment for CWS case plans. addressed in the case plan. Reunification assessment At the start of a review of a CWS Whether to return a child to a home, Within six months of the case involving children in placement maintain out‑of‑home placement, county providing reunification with a goal of being reunified with and/or terminate reunification services, and at least once every their families. services and implement a six months thereafter. permanency alternative. Source: Children’s Research Center, The Structured Decision Making System: Policy and Procedures Manual. Historically, the State’s share of CWS funding has been paid primarily out of the State’s General Fund. However, as shown in the figure, as part of a new law called the 2011 Realignment (realignment), beginning in fiscal year 2011–12, a portion of state sales and use tax revenues and vehicle license fee revenues are now designated for the counties and deposited into a separate account within the State’s Local Revenue Fund 2011 to support various CWS activities. The Legislative Analyst’s Office reported that realignment did not change major functions of the CWS system. Rather, it transferred most nonfederal funding responsibility for child welfare programs to the counties. Before realignment, when CWS caseloads increased, the State and counties would share in these increased costs. Counties now bear the primary financial California State Auditor Report 2013-110 13 April 2014 responsibility for increased caseloads, thereby placing greater financial pressure on the counties to contain child welfare system costs. In the Appendix we provide specific expenditure information for the three county CWS agencies we reviewed during the audit: Butte County, Orange County, and San Francisco County. Figure 2 Child Welfare Services Budget Fiscal Years 2005–06 Through 2012–13 County share State share Federal share snoilliB nI $6 5 4 3 * * 2 1 0 6 7 8 9 0 1 2 3 0 0 0 0 1 1 1 1 – – – – – – – – 5 6 7 8 9 0 1 2 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 Fiscal Year Sources: Appropriation tables from the California Department of Social Services (Social Services). Note: Budgeted amounts reflect unaudited estimates from Social Services. The federal, state, and county shares are based on approved funding ratios and do not reflect the effects of any additional money budgeted by counties. * As a result of a new law called the 2011 Realignment, most of the funds previously designated as state share are now included in the county share shown in the figure. Scope and Methodology The Joint Legislative Audit Committee (audit committee) directed the California State Auditor to examine the practices of three selected county CWS agencies related to the removal of children from their homes. The analysis the audit committee approved contained seven separate objectives. Table 2 beginning on the following page lists the audit committee’s objectives and the methods we used to address those objectives. 14 California State Auditor Report 2013-110 April 2014 Table 2 Audit Objectives and the Methods Used to Address Them AUDIT OBJECTIVE METHOD 1 Review and evaluate the laws, rules, We reviewed relevant laws, rules, regulations, and other background materials. and regulations significant to the audit objectives. 2 Determine and assess the policies, • We reviewed the policies and procedures of the three county CWS agencies we visited. procedures, and processes county • We used a data extract of the Child Welfare Services/Case Management System child welfare services (CWS) agencies (statewide case management system) provided to us by the California Department follow for removing a child, including of Social Services (Social Services) to randomly select 120 total referrals (40 at each the following: of the three agencies) to determine whether social workers followed state laws and a. Handling of complaints regulations and local policies and procedures. Of the 40 referrals at each county, and investigations. 20 were selected because they resulted in a child’s removal, while the remaining 20 all had a subsequent substantiated referral within six months. • Because we used the statewide case management system only for sample selection, we determined that a data reliability assessment was not required. Rather, we determined that it was necessary to perform data‑set verification procedures and to verify the completeness of the population from which we selected referrals in Butte County, Orange County, and San Francisco County that were received from April 1, 2010, through March 31, 2013.* For the purposes of this audit, we found the data from which we extracted our sample to be complete for each reviewed county. b. Evidentiary requirements. We reviewed relevant state laws and regulations regarding the level of evidence necessary to remove a child from his or her home and substantiate an allegation of child abuse or neglect. In instances when a referral resulted in court hearings, we reviewed the associated court findings document to see whether the county CWS agencies met the evidentiary requirements. c. Oversight structure and • We verified what type of assessments the county CWS agencies perform before decision‑making authority. removing a child from the home. • Because each of the three county CWS agencies has implemented an assessment model called Structured Decision Making (SDM), we examined the requirements of this model. • We examined 120 total referrals to determine the level of supervisory oversight exercised over SDM assessments and other components of the investigatory and decision‑making processes, such as investigative narratives and case notes. d. Process for returning children to For 120 total referrals, we examined the extent to which the three county CWS agencies their parents. performed strengths and needs assessments, created and implemented case plans, and completed reunification assessments. 3 Determine how county CWS agencies • As indicated in item 2c, each of the three county CWS agencies we visited uses SDM to determine the severity of risk to the determine the risk to a child and to guide subsequent actions. child and, once determined, what • For a total of 120 referrals, we examined the extent to which these three agencies used actions the agencies are required SDM tools appropriately. In particular, we examined whether the information used in to take. these assessments accurately reflected information known to the agency at the time of the assessment. 4 To the extent possible, determine • To determine county CWS agencies’ expenditures of state and federal funds, we county CWS agencies’ and law obtained expenditure information from Social Services and matched those figures to enforcement’s expenditure of state expenditure records from county expense claims we received from the three counties. and federal funds for various actions, CWS agencies do not separately track the cost of removing children from their homes. including removing children from These costs are included within the emergency response category. their homes. • To determine law enforcement’s expenditures of state and federal funds, we contacted representatives from the largest law enforcement agencies in the respective counties. In all three counties, we were informed that law enforcement agencies do not track expenditures of state and federal funds for the related actions, including the removal of children. Therefore, we were unable to obtain law enforcement’s expenditure information. California State Auditor Report 2013-110 15 April 2014 AUDIT OBJECTIVE METHOD 5 Identify whether best practices • To identify best practices, we researched recent improvement plans related to exist for determining the protection California’s CWS system. We also interviewed key staff at Social Services and at each of of children and coordinating with the three CWS agencies we visited. law enforcement. • To identify whether best practices exist for coordinating with law enforcement, we interviewed key staff at Social Services and at each of the three CWS agencies we visited. We also reviewed county CWS agencies’ policies and procedures for involving law enforcement, and reviewed any applicable cooperative agreements with local law enforcement at the three counties we visited. 6 Ascertain the protocols county • We reviewed state laws and regulations, and CWS agency policies and practices CWS agencies follow for determining regarding the involvement of law enforcement. when to use law enforcement, • We evaluated the extent of law enforcement involvement in a total of 120 CWS including the removal of children investigations (40 at each of the three agencies). from their homes, and identify any • We also identified whether the CWS agencies had formalized cooperative agreements procedures CWS agencies use in with local law enforcement. coordinating with law enforcement when making in‑person visits. 7 Review and assess any other issues • For each county CWS agency we visited, we identified internal controls used to ensure that are significant to CWS agencies’ that the agency’s objectives were met, including the implementation of policies and processes for removing children from procedures related to receiving and investigating allegations of child maltreatment, their homes. assessing the immediate safety and ongoing risks to children, and making decisions to either remove children from their homes or allow them to remain with their families. • We also examined how management within these agencies monitored how well their personnel carry out policies and procedures. Sources: California State Auditor’s analysis of Joint Legislative Audit Committee audit request 2013–110, and information and documentation identified in the table column titled Method. * To test the completeness of each county’s referrals, we haphazardly selected 29 referrals and traced them from hard copy files back to the electronic database. 16 California State Auditor Report 2013-110 April 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 17 April 2014 Chapter 1 INCONSISTENT AND INACCURATE INVESTIGATIVE ASSESSMENTS AT TIMES LED TO POOR DECISIONS RELATED TO CHILD SAFETY Chapter Summary When receiving allegations of child maltreatment, the child welfare services (CWS) agencies at the three counties we reviewed completed intake tools that often omitted key details or contained contradictory information, contributing to social workers’ flawed decisions about how quickly the agency should respond. In responding to the maltreatment allegations, the social workers generally attempted to contact the alleged victims in accordance with state laws and regulations, but they were not always successful in making initial contact and did not always follow up on unsuccessful contacts in a timely manner. Further, assessments social workers made during their investigations frequently contained inaccurate information that in some instances led to incorrect conclusions. When social workers decided to leave children in a home that presented safety threats, they often did not establish a credible safety plan to mitigate those threats. Additionally, agencies may be allowing children to be placed or to remain in risky living situations outside of their homes by not vetting alternative caregivers (suggested by the parents) and by not performing background checks before formal placements with relatives or family friends. Finally, the agencies sometimes did not appropriately use assessments designed to guide them in determining what services a family needed and whether parents were ready to reunite with their children, risking that reunification could place children at future risk. Table 3 on the following page summarizes our assessment of the completion, timeliness, and accuracy of the Structured Decision Making (SDM) tools and assessments the three county CWS agencies used at different points in the child welfare process, from the initial allegation through the investigation and—when applicable—removal and reunification. As indicated in the table, although the Orange County CWS agency was more consistent in completing these tools and assessments than the other two agencies, each county CWS agency we reviewed—including Orange County—needs at least some improvement in aspects of their use. The remainder of this chapter details these results and describes their impact on child safety. 18 California State Auditor Report 2013-110 April 2014 Table 3 Summary of the Use of Structured Decision Making Tools and Assessments by the Three County Child Welfare Services Agencies COUNTY CHILD WELFARE SERVICES (CWS) AGENCY STRUCTURED RESULTS OF OUR REVIEW OF DECISION MAKING (SDM) BUTTE ORANGE SAN FRANCISCO SELECTION OF 40 REFERRALS DOCUMENT Hotline tool Completed 88% 95% 100% Timely (same day as referral reported) 80 100 90 Substantially accurate 90 93 98 Safety assessment Completed 85% 100% 90% Timely (within two days of initial contact) 59 75 92 Substantially accurate 91 95 78 Supervisor oversight (within one month) 62 78 75 Safety plan* Completed 31% 86% 40% Credibly mitigates safety risks 100 74 75 Supervisor oversight (within one month) 25 37 25 Risk assessment Completed 74% 100% 88% Timely (within 30 days of initial contact) 92 93 83 Substantially accurate 77 68 43 Supervisor oversight (within one month) 73 73 73 Family strengths and Completed 53% 97% 97% needs assessment Timely (prior to initial case plan) 70 72 68 Substantially accurate 90 86 76 Reunification assessment Completed 83% 95% 92% Timely (within six months of the disposition 70 81 64 hearing and every six months thereafter) Source: California State Auditor’s review of 40 referrals each at the CWS agencies for Butte, Orange, and San Francisco counties. * A safety plan is not a specific form or tool within the SDM model but is required when a safety assessment identifies safety concerns that must be mitigated.  96 to 100 percent  90 to 95 percent  80 to 89 percent  70 to 79 percent  0 to 69 percent Incomplete and Inconsistent Information in Initial Intake Documents May Impede Emergency Response Actions At the three county CWS agencies, information contained in initial intake documents prepared when a report of child maltreatment (referral) is received was sometimes inaccurate or incomplete. While many of these errors were ultimately inconsequential, some ended up affecting either decisions on the appropriate response to a referral or the CWS histories contained within the State’s California State Auditor Report 2013-110 19 April 2014 Child Welfare Services/Case Management System (statewide case management system). State regulations require county CWS agencies to consider certain factors when determining their responses to referrals, such as the nature of the alleged incident; the child’s history of maltreatment; and the caregiver’s history of substance abuse, mental health problems, and criminal behavior. We examined the accuracy of information included in the agencies’ initial intake documents, which include a screener narrative that generally summarizes the allegation,3 the parties involved, and, in some counties, the household’s CWS history; an emergency response referral information form (referral form) that provides details on information that was obtained from and entered into the statewide case management system; and a SDM hotline tool (described in the Introduction). In our review of 40 referrals at each of the three counties, we found that 10 Orange County intake files were inaccurate in some manner, as were seven intake files in both Butte County and San Francisco County. However, many of these inaccuracies did not result in a change to the priority placed on the referral. Typical errors included not identifying all potential victims (such as all siblings) and perpetrators (such as both parents), not consistently identifying the main abuse categories, and not incorporating all relevant information into the response timing decision. As indicated in Table 4, a total of eight of these 24 errors affected the decision of how quickly to respond to a referral. Table 4 Factual Consistency of the Initial Intake Documents COUNTY CHILD WELFARE SERVICES (CWS) AGENCY LEVEL OF CONSISTENCY BUTTE ORANGE SAN FRANCISCO TOTAL Factually consistent 33 30 33 96 Not factually consistent: did not affect response decision 3 7 6 16 Not factually consistent: affected response decision 4 3 1 8 Total referrals reviewed 40 40 40 120 Source: California State Auditor’s review of 40 referrals each at the CWS agencies for Butte, Orange, and San Francisco counties. With regard to the higher number of inaccuracies we observed in the intake files of the Orange County CWS agency, we noted that this agency included more detailed information in its initial intake documents, which in our view were better prepared but 3 Butte County does not typically use the screener narrative form. Instead, it includes an allegation summary with this information in the alerts section of the referral form. 20 California State Auditor Report 2013-110 April 2014 ultimately provided more opportunity for small errors to occur. Although Orange County had a higher number of total inaccuracies than the other two CWS agencies, the number of instances in which the inaccuracies affected the response priority assigned to its referrals was lower than that for Butte County. The hotline tool is an SDM form used to determine whether an in‑person response to a referral is necessary and, if so, how quickly the agency must respond—either immediately or within 10 days. The hotline tool is made up of two sections. The first section identifies the type of abuse or neglect noted in the referral and determines whether an in‑person response is necessary. The second section employs one or more decision trees based on the type of abuse or neglect reported to establish the appropriate response time. Although our review of Butte, Orange, and San Francisco counties revealed that the hotline tool was generally used once a referral was received, we found eight instances in which inaccuracies among the initial intake documents caused the county CWS agency to establish a later response time than was appropriate. For example, in Butte County we found an instance in which a file’s hotline tool indicated a necessary response time of 10 days for a referral alleging sexual abuse and general neglect. Because the screener narrative describing the allegation indicated that the alleged perpetrator had access to the child within the next 10 days, the referral would have required a 24‑hour response priority if the social worker had used the hotline tool appropriately. Similarly, in San Francisco, a screener narrative included allegations of physical abuse, but the referral form and hotline tool indicated emotional abuse. Had the physical When CWS agencies make abuse allegation been included in the hotline tool, the physical inappropriate decisions regarding abuse decision tree would have recommended a 24‑hour response referral response times, children instead of the 10‑day response assigned. When CWS agencies make may be exposed to additional abuse inappropriate decisions regarding referral response times, children or neglect. may be exposed to additional abuse or neglect. In addition, errors recorded in the referral form, which contains the information entered into the statewide case management system, sometimes indicated that the intake social worker had entered incomplete or inaccurate information into the system. Such errors were typically related to either incomplete documentation of all involved individuals (that is, victims or perpetrators) or an incorrect category of alleged child maltreatment. Categories of maltreatment include severe and general neglect as well as physical, sexual, and emotional abuse. Overall, we found that referral forms for a total of 12 of the referrals we reviewed across the three counties contained errors that remained in the statewide case management system at the time of our review. Of these, six referrals (three each in Orange and San Francisco counties) did not accurately document the individuals involved. For example, one of the San Francisco California State Auditor Report 2013-110 21 April 2014 referrals we reviewed described a situation in which police arrested a man for illegal drug possession while his wife and children were in the car. However, the referral form does not list him as a perpetrator; instead, it identifies only his wife as a perpetrator of general neglect against the children. We also found six referrals (three in San Francisco County, two in Orange County, and one in Butte County) in which errors regarding the category of alleged maltreatment led to inaccurate and incomplete information in the statewide case management system. In Butte County, for example, a referral form was missing an allegation of physical abuse, despite the fact that, according to the allegation summary, the allegation involved a sibling’s father, who was residing in the home and reportedly punching the child in the head. Such discrepancies can lead to certain referrals or allegations not being included in the victims’ and perpetrators’ history in the statewide case management system; thus, subsequent investigators receive inaccurate and incomplete information. State regulations require supervisors to approve referral intake response decisions, but they do not require supervisors to review the hotline tool. Likewise, the SDM manual—which all three county CWS agencies follow—contains no requirement for supervisor oversight of the hotline tool. Orange County’s CWS agency policies require supervisory oversight of the intake process, including both the response decision and the hotline tool—a policy we believe to be a best practice. Neither Butte County nor San Francisco County CWS agencies have equivalent policies. Supervisors in Orange and Butte counties provided oversight of the intake process in 39 and 34 of the 40 referrals we reviewed at each county, respectively. Supervisors in San Francisco County provided oversight in only Supervisors in San Francisco County 18 of 40 referrals.4 San Francisco’s deputy director of Family and provided oversight of the intake Children Services (deputy director) stated that it is not currently process in only 18 of 40 referrals. clear exactly what proportion of response decisions receive supervisory oversight, but that it is likely more common than the instances we found in our review. We agree it is possible that insufficient documentation of oversight contributed to what we found. However, given the inconsistencies we identified in the referral intake documents during our review, we believe requiring documented supervisory oversight in Butte and San Francisco counties would greatly reduce inaccuracies and better ensure that social workers make appropriate decisions. The fact that inaccuracies persisted in Orange County despite that agency’s aforementioned policy indicates that agency management should take steps to ensure that all supervisors understand the hotline tool and regularly review their staff’s use of the tool. 4 Unlike the two other county CWS agencies, the San Francisco County CWS agency frequently did not use a field in the statewide case management system that indicates supervisory approval of referral response decisions. 22 California State Auditor Report 2013-110 April 2014 Although the Counties We Visited Generally Attempted Timely In‑Person Investigations, They Were Not Always Successful in Establishing Contact With Alleged Victims The county CWS agencies we visited generally attempted to contact the victims of alleged maltreatment in accordance with state laws and guidelines, but the agencies were not always successful in making contact in a timely manner and did not always follow up on unsuccessful contacts within a reasonable time frame. State laws and regulations and county policies dictate the time frame within which social workers must make in‑person responses to allegations. As discussed previously, a social worker screens each call to the child abuse hotline and uses a hotline tool to determine the appropriate response. Depending on the severity of the allegation, the social worker must respond in person either immediately, in cases of imminent danger to the child, or within 10 calendar days. To fulfill this requirement, state regulations require social workers to have in‑person contact with all alleged child victims. State laws and regulations do not define immediately, but county policies generally require such responses to take place in 24 hours or less. If an initial attempt to visit a child is unsuccessful (for example, if the family is not at home), CWS workers would need to perform follow‑up visits to ensure that the child is safe. Although state laws and regulations do not address requirements for follow‑up attempts, Orange County policy directs workers to make additional attempts at contact as soon as possible, and no less than once every five business days, until contact is made. We applied this five‑business‑day standard to review the follow‑up efforts of Orange County social workers as well as the efforts of social workers in Butte and San Francisco counties, whose policies are silent on this issue. The CWS agencies we visited generally attempted to make in‑person contact with the alleged victim of abuse or neglect within the required 24‑hour or 10‑day time frame. Our review confirmed that Orange County successfully completed or attempted to complete in‑person contacts for all 40 referrals we reviewed by the assigned deadline. In Butte and San Francisco counties, this was true for 39 and 36 of 40 referrals, respectively. Although they generally made We noted that although they generally made timely initial attempts timely initial attempts at contact, at contact, the three counties were often not successful in making the three counties were often not in‑person contact with alleged victims within the required time successful in making in-person frames. For example, as Table 5 shows, Butte County made contact contact with alleged victims within with the alleged victims by the response deadline in only 29 of the required time frames. the 40 referrals we reviewed. Of the remaining 11 referrals, Butte County made timely follow‑up attempts for three of the initially unsuccessful attempts. However, the county social workers California State Auditor Report 2013-110 23 April 2014 failed to follow up on the remaining eight referrals soon after the unsuccessful initial attempt. As indicated in Table 5, the other two county CWS agencies had similar failure rates. Table 5 In‑Person Investigation Completion Rates by County COUNTY CHILD WELFARE SERVICES (CWS) AGENCY RESULTS OF OUR REVIEW BUTTE ORANGE SAN FRANCISCO TOTAL Completed on time* 29 27 28 84 Not completed on time: timely follow‑up efforts† 3 6 7 16 Not completed on time: untimely follow‑up efforts† 8 7 5 20 Total referrals reviewed 40 40 40 120 Source: California State Auditor’s review of 40 referrals each at the CWS agencies for Butte, Orange, and San Francisco counties. * These results do not include attempted visits where the social worker failed to make a successful in‑person contact with the alleged victim. † We measured timely follow‑up using the Orange County CWS agency’s policy of follow‑up needing to occur within five business days. Despite being the only county CWS agency we visited with a policy governing efforts to contact alleged victims after an initially unsuccessful attempt, Orange County social workers did not attempt to make another contact with a child within five business days, as required in its policy, in seven referrals. We noted five instances among these seven in which the Orange County social worker did not make a follow‑up attempt for at least two weeks. Similarly, when initial attempts were unsuccessful, social workers in San Francisco and Butte counties did not always follow up within five business days. For example, in one instance a Butte County social worker did not try to contact an alleged victim until more than three weeks after the worker’s initial unsuccessful attempt. By that time, the home at the family’s address on record was vacant. In San Francisco County, the longest such delay between attempts was 15 days. Further, we noted a total of four instances, three in Butte County and one in San Francisco, in which the county CWS agencies— after successive failed attempts at making in‑person contact— closed the referral. In one of the instances in Butte County, the agency received a report alleging that a woman was using drugs in her child’s presence and not providing adequate care. The social worker made one unsuccessful attempt at contact at the woman’s home. Soon after, another individual called in a similar report regarding the same woman and indicated where the woman would be staying for the next two weeks. Despite receiving this report, the social worker waited 20 days before making a subsequent unsuccessful attempt to locate the woman at her original address instead of at the reported updated location. A Butte County Department of Employment and Social Services 24 California State Auditor Report 2013-110 April 2014 program manager (program manager) stated that social workers must have a reasonable expectation of a child’s specific location in order to attempt contact. Based on the case notes, it appears that the county did have a reasonable expectation based on this information. After several additional unsuccessful attempts to contact the mother by phone and mail, the social worker closed the referral. There was no indication that the social worker ever attempted to visit the other reported location or to contact the reporters, both of whom were relatives of the child, to gather further information regarding the mother’s whereabouts. The program manager cited the agency’s lack of a written policy that In one instance, less than four specifies the number and frequency of follow‑up attempts and the months after the Butte County CWS method social workers should pursue when making these attempts agency closed the initial referral, as the reason for the social worker’s inadequate investigation. Less the same child was the victim of than four months after the initial referral was closed, the same child substantiated neglect. was the victim of substantiated neglect. In the one instance we identified in San Francisco County, a social worker attempted contact nine times between early July and mid‑August before finally deciding to close the referral as a result of the failed attempts. However, our review noted that the worker handled the first eight of those attempts in exactly the same manner—by leaving his business card at the residence on record for the family. The worker did not attempt an alternate means of contact, such as visiting the children’s schools, until more than eight weeks after the initial referral. A San Francisco County Family and Children Services manager (department manager) stated that the individual making the referral did not state which schools the children attended and that the worker followed current county protocol. However, the department manager did not clarify why it took the worker more than six weeks to identify the schools, and we found no written protocol describing how to conduct follow‑up attempts or when to close referrals when attempts at contact are unsuccessful. Three months after it closed the first referral, the San Francisco CWS agency received another referral—substantiated neglect against the mother—and removed the children from her care. As discussed previously, San Francisco and Butte County CWS agencies lack policies regarding the frequency of social workers’ follow‑up attempts at contacting alleged victims. This may contribute to lengthy delays in some cases in achieving contact with the alleged victims. Further, these two counties do not have formal policies dictating how workers make follow‑up attempts or when a referral should be closed because of failed contact attempts.5 When the safety of the child is in doubt, the lack of specific 5 The Orange County CWS agency has a policy describing the diverse follow‑up efforts their social workers must perform before closing a referral because the family cannot be located. California State Auditor Report 2013-110 25 April 2014 guidelines means counties cannot be confident that social workers are making reasonable efforts to reach the child and prevent future maltreatment. Both county CWS agencies agreed that providing clear guidance to social workers regarding what is expected for follow‑up attempts—in terms of both frequency and method— would be good practice. The Assessments County Social Workers Completed During Their Investigations Contained Inaccurate Information, Sometimes Leading to Questionable Decisions In addition to the inaccurate information we identified in the initial intake documents, as discussed previously, our review discovered that social workers did not always prepare the required standardized assessments during the course of their investigations and, when they did, the assessments frequently contained inaccurate information. As a result of these inaccuracies, subsequent decisions about the related cases—including conclusions about the allegations in question and determinations regarding whether to remove children—may have been predicated on faulty information and therefore may not have been appropriate. Further, supervisors did not always review these assessments in a timely manner, potentially contributing to the inaccuracies we found. Inaccurate Safety Assessments Undermined Workers’ Conclusions About Children’s Safety While investigating maltreatment allegations, social workers at the three county CWS agencies we visited did not always complete the required safety assessment in a manner substantially consistent with the case history and the facts of the allegations. Further, in Butte and San Francisco counties, social workers sometimes did not In Butte and San Francisco counties, complete the assessment at all. This assessment is an element of the social workers sometimes did SDM tools described in the Introduction; it is designed to help the not complete the required safety social worker determine whether it is safe for the child to remain assessment at all. in the home and, if so, whether additional intervention is required to ensure that safety. As indicated in Table 6 on the following page, the Butte and San Francisco County CWS agencies had the most difficulty in preparing accurate safety assessments. In our review of 40 referrals in Butte County, we determined that six assessments were not completed and three were not substantially consistent with information available to the social worker at the time the assessment was completed. San Francisco had even more problems with accuracy: eight safety assessments were not substantially consistent with available information; in addition, four were not completed. Typical inaccuracies included a social worker failing to note a caregiver’s substance abuse or domestic violence issues. 26 California State Auditor Report 2013-110 April 2014 Table 6 Factual Consistency of the Safety Assessments COUNTY CHILD WELFARE SERVICES (CWS) AGENCY ACCURACY OF SAFETY ASSESSMENTS BUTTE ORANGE SAN FRANCISCO TOTAL Substantially consistent 31 38 28 97 Not substantially consistent 3 2 8 13 Not performed 6 0 4 10 Total referrals reviewed 40 40 40 120 Source: California State Auditor’s review of 40 referrals each at the CWS agencies for Butte, Orange, and San Francisco counties. Because this assessment is the main tool used to determine whether a child faces immediate safety threats, failure to complete or accurately complete the assessment means that social workers could reach an improper conclusion in deciding whether to remove the child. In one example in Butte County, a parent refused to allow a social worker access to her home and children during an investigation of alleged child neglect because of the parent’s alleged substance abuse. The parent stated that the child who was the focus of the referral refused to speak with the social worker and expressed anger that the social worker had interviewed the child’s younger sibling at school. The social worker apologized for performing this required action and agreed not to interview the child. All observations related to the home were made based on what could be seen from the home’s porch. The safety assessment associated with this investigation indicated no for the safety threat of “The family refuses access to the child . . .”, indicated no for substance abuse, and indicated yes, among eight other protective capacities, for “the caregiver was willing to accept temporary interventions offered by the worker . . . including cooperation with continuing investigation/assessment.” Finally, the worker concluded on the safety assessment that no intervention was needed and that the child was safe. Three weeks later, the child was the subject of another allegation, this time for abuse as well as neglect. The child was willing to speak with the assigned social worker, and the allegation of neglect was substantiated. For most of the inaccuracies we found, such as the example just discussed, the social worker completing the safety assessment left out key safety threats, which sometimes led to children remaining in unsafe situations. However, in two instances in San Francisco, the social worker based the decision to remove a child at least in part on safety threats that information in the case file did not support. In the first instance, the county court ultimately agreed with the social worker’s decision to remove the child. In the second instance, the child was not removed because the mother fled with the child California State Auditor Report 2013-110 27 April 2014 and could not be located. We did not find any instances in Butte We did not find any instances in or Orange counties in which assessments contained safety threats Butte or Orange counties in which that available information did not support. assessments contained safety threats that available information The SDM manual states that the safety assessment “guides the did not support. decision about whether the child may remain in the home,” but the assessment does not include a clear decision‑making mechanism. Therefore, we were not always able to conclude that inaccurate assessments led social workers to improper safety decisions. However, given the purpose of the assessment, any substantial inaccuracy or inconsistency in its completion could lead to a decision that jeopardizes a child’s safety or contributes to a child’s improper removal. County Social Workers at Times Relied Upon Inaccurate Information in Deciding Whether to Open CWS Cases In their completion of the second standardized investigation tool—the risk assessment—the counties were even less accurate than for the safety assessments. Risk assessments represent a social worker’s judgment of the likelihood of future maltreatment. When completed, they provide the social worker with direction as to whether to close a referral or to elevate the referral to an open CWS case. A child with an open CWS case receives regular follow‑up visits from a social worker, who continues to monitor the care the child is receiving. Therefore, inaccurate risk assessments can lead to inappropriate decisions regarding whether a child should receive these ongoing services. As shown in Table 7 on the following page, our review of 40 referrals in San Francisco County found only 13 in which the risk assessment was substantially consistent with the information available at the time. For 15 referrals, the inaccuracies in the risk assessment did not change the decision the social worker ultimately made about the referral. In two instances, however, the inaccuracies led to a decision to open a case that a correctly prepared risk assessment would not have recommended.6 Additionally, four required assessments were not performed at all. The table displays similar issues with the risk assessments in Butte and Orange counties. 6 In one of these instances, the San Francisco County CWS agency closed the case within a month; in the other instance, the agency closed the case after 10 months of family maintenance services. 28 California State Auditor Report 2013-110 April 2014 Table 7 Factual Consistency of the Risk Assessments COUNTY CHILD WELFARE SERVICES (CWS) AGENCY ACCURACY OF RISK ASSESSMENTS AND EFFECT ON DECISION AS TO WHETHER TO OPEN A CASE BUTTE ORANGE SAN FRANCISCO TOTAL Substantially consistent with case information 20 27 13 60 Inaccuracies exist, but had no effect on decision 6 10 15 31 Inaccuracies exist and led to an incorrect decision 0 3 2 5 Assessment required but not performed 9 0 4 13 Assessment not required* 5 0† 6 11 Total referrals reviewed 40 40 40 120 Source: California State Auditor’s review of 40 referrals each at the CWS agencies for Butte, Orange, and San Francisco counties. * The Structured Decision Making System: Policy and Procedures Manual requires social workers to complete risk assessments only for substantiated and inconclusive referrals. The manual recommends the completion of risk assessments for referrals determined to be unfounded. † Orange County’s policy is to require risk assessments for all investigated referrals, including those that social workers determine to be unfounded. Once completed by the social worker, the risk assessment provides the social worker with a separate numerical score for neglect risk and abuse risk. As Figure 3 illustrates, these scores in turn correspond to one of four risk levels. The SDM manual instructs the user to select the higher of the neglect and abuse risk levels. If the ultimate risk level is “high” or “very high,” the default decision is to open a case as a result of the referral. If the ultimate level is “low” or “moderate,” the default decision is to close the referral. As such, among the inaccurate assessments we identified, some inaccuracies resulted in no change in the risk level and others resulted in an incorrect risk level but not an incorrect decision. Figure 3 Risk Assessment Scoring and Recommended Decision Recommended Neglect Score Abuse Score Decision Low -1 – 1 -1 – 0 Referral Moderate 2 – 5 1 – 3 Scored Risk Level High 6 – 8 4 – 6 A Case Very High 9 + 7 + Source: Children’s Research Center, The Structured Decision Making System: Policy and Procedures Manual. California State Auditor Report 2013-110 29 April 2014 As discussed, in some instances the inaccuracies social workers made in completing risk assessments led them to an incorrect default decision. This occurred three times at the Orange County CWS agency and twice at the San Francisco County CWS agency. In one example at Orange County, the social worker failed to indicate the caregiver’s prior substantiated neglect, mental health concerns, and alcohol abuse on the risk assessment, although all three issues were present in other case documents compiled before the assessment was prepared. A supervisor for Orange County’s quality support team confirmed that the social worker failed to capture these issues. As a result, the assessment indicated a low risk score when the score should have been high, resulting in a default decision to close the referral rather than the correct default decision to open a CWS case. In Butte County we found six inaccurate risk assessments, but In Butte County social workers none affected the ultimate decision as to whether to open a CWS made risk level determinations case.7 The more frequent problem in Butte County was social without actually completing workers not performing required risk assessments. Although the required assessments. In they did not formally complete nine required risk assessments (of four of seven instances, these the 40 referrals we reviewed), Butte County social workers still determinations did not match what offered a risk‑level determination in their investigative narratives a correctly prepared assessment for seven of these referrals. To assess these determinations, we would have determined. completed a risk assessment tool based on the available information and compared the risk level derived from our completed assessment with the risk level the social worker determined without using the tool. In four instances, the social worker’s risk‑level determination did not match what a correctly prepared risk assessment would have determined; however, only two of these risk‑level inaccuracies would have affected the decision to open a case. In the first instance, an accurate risk assessment would not have recommended that the referral be opened as a case, but the social worker opened a CWS case (the social worker obtained an agreement from the parent to participate in services, returned the child to the home four days later, and closed the case within three months). In the second instance, the social worker concluded, without filling out the risk assessment, that the risk of future neglect was low and closed the referral, despite numerous factors indicating that the neglect risk was high. Less than two months later, the Butte County CWS agency received another referral for this family, alleging the same neglectful conditions. This time the agency determined the neglect risk to be very high but did not open the case because the family moved and the agency did not have a new address for them. According to a Butte County program manager, 7 In one of these six instances, the inaccuracies in the assessment caused the risk level and default decision to be incorrect, but the social worker overrode the incorrect default decision, making the errors essentially moot. 30 California State Auditor Report 2013-110 April 2014 there was no requirement to complete the initial risk assessment because the home was determined to be conditionally safe.8 However, the SDM manual expressly requires a risk assessment be completed for all substantiated referrals, as was the case in this situation. Had a risk assessment been correctly completed, the social worker could have opened a case and provided services to the family before losing contact. Inadequate Oversight of Investigative Assessments Exacerbates Issues With the Assessments’ Accuracy Our review indicated that supervisors do not always review social workers’ risk and safety assessments in a timely manner, possibly contributing to the problems we found with those assessments. No state law or regulation dictates requirements for supervisory review of these assessment tools. All three of the county CWS agencies have policies requiring supervisory review; however, only Orange County has a policy specifying a time frame for this review: within 30 days of being submitted for approval.9 At all three counties, however, we noted that it was not uncommon for such approval to take more than a month. As Table 8 indicates, supervisors at these counties approved between 62 percent and 78 percent of safety assessments within one month of their completion. For approval of risk assessments within one month, the rate was 73 percent at all three counties. Table 8 Percentage of Supervisory Reviews of Investigative Assessments and Decisions Completed Within 30 Days COUNTY CHILD WELFARE SERVICES (CWS) AGENCY COMPONENT OF INVESTIGATION BUTTE ORANGE SAN FRANCISCO Safety assessment 62% 78% 75% Risk assessment 73 73 73 Source: California State Auditor’s review of 40 referrals each at the CWS agencies for Butte, Orange, and San Francisco counties. 8 The term conditionally safe refers to a safety assessment determination that a child can remain at home under a safety plan to mitigate safety risks. 9 Because a number of safety and risk assessments were formally submitted to supervisors long after the social workers completed them, we used 30 days from assessment completion as our standard for evaluating timely supervisory review. Although this does not align perfectly with Orange County’s policy, using this benchmark appeared to be a more reasonable assessment of the timeliness of supervisory review, given that supervisors should be making sure that assessments are submitted on time. California State Auditor Report 2013-110 31 April 2014 The lack of timely supervisory review of risk assessments is problematic in light of the three CWS agencies’ accuracy problems described earlier. An example from San Francisco County illustrates the importance of supervisory review in preventing inappropriate action. In this instance, errors on the risk assessment resulted in a decision to close the referral; however, our review determined that the risk level for this referral warranted opening a case. If a supervisor had not overruled the suggested action and opened the case anyway, ultimately resulting in the removal of an endangered infant, the referral would likely have been closed. When social workers’ assessments do not receive this level of timely supervisory oversight, county CWS agencies may allow preventable errors that put children’s well‑being at risk. Documentation of Investigative Results Varied in Quality Among the Three Counties We found substantial variation in the quality of the investigative We found substantial variation narratives county social workers prepared to document the in the quality of the investigative results of their investigations. Although there are no standardized narratives county social workers requirements for investigative narratives, each of the three counties prepared to document the results of requires its social workers to complete them. However, the their investigations. templates social workers use to complete these narratives differ substantially at each of the three counties. Orange County social workers use a template that includes standard sections for discussing key investigative elements, such as the family’s history of CWS involvement, all investigative contacts, pertinent medical information, and any applicable court or police involvement in the referral. Consequently, the narratives we reviewed from the Orange County CWS agency were generally much more comprehensive and detailed than those from either the Butte or San Francisco County CWS agencies. We found eight instances in San Francisco County in which the social worker did not prepare an investigative narrative at all. According to the deputy director, San Francisco began requiring investigative narratives for all referrals only about two years ago, but the deputy director could not provide the exact date that this change occurred. Because of that, we could not determine whether all of the missing narratives constituted violations of county policy. In five other instances in San Francisco County, the investigative narrative contained no substantive information or merely reprinted information verbatim from the initial intake documents. In these instances, we reviewed the case files for any additional documents containing narratives, but we also found inconsistent levels of detail there. For Butte County, the investigative narratives tend to be quite brief. According to its CWS assistant director, the investigative narrative is not intended to detail the social worker’s investigation. 32 California State Auditor Report 2013-110 April 2014 Rather, its purpose is to provide summary information. However, in three instances, the investigative narratives did not adequately provide even a summary of the information the social worker gathered during the investigation. Because the standardized risk assessments discussed earlier draw on investigative findings, it is possible that the variation in the three counties’ investigative narratives contributed to the Although we found inaccuracies in problem of inaccurate assessments. Indeed, although we found the safety and risk assessments for inaccuracies in the safety and risk assessments for all three counties, all three counties, Orange County Orange County was generally more accurate in its completion of was generally more accurate in its both assessments. Further, incomplete or imprecise investigative completion of both assessments. narratives are of little use to subsequent county workers who may be examining the circumstances of a past investigation while investigating a new referral or handling the resulting ongoing case. San Francisco’s deputy director agreed that expanding the narrative’s template to include some key indicators found in the SDM assessments might help ensure that social workers are contemplating these issues as they investigate referrals. The deputy director also concurred that more complete narratives would help future social workers access information about a previous referral, even if that referral did not result in a formal case. County CWS Agencies’ Inadequate Safety Plans and Questionable Placement Decisions May Have Put Children at Risk Our review of the three county CWS agencies’ decisions regarding the removal of children identified instances in which insufficient county intervention may have placed children at risk. When social workers determined that safety plans were necessary to allow children to remain in their homes, the workers often failed to complete such a plan or produced plans unlikely to mitigate the identified safety risks. Additionally, agencies allowed children to be informally placed or to remain in risky living situations outside of their homes rather than formally removing them from the custody of their parents. Finally, when the agencies formally removed children and placed them with relatives or family friends, social workers did not always perform background checks before making those placements. Inadequate Safety Plans Increased the Risk of Recurring Child Maltreatment At the three agencies we visited, we found that required safety plans were not being developed, that social workers were creating some plans that did not address all identified safety threats, and that social workers were instituting plans that were unlikely to California State Auditor Report 2013-110 33 April 2014 be effective given the family’s history. As discussed earlier, social workers at all three of the county CWS agencies are required to use standardized safety assessments to determine initially whether a child must be removed from the home to ensure his or her safety. When a social worker determines that one or more safety When a social worker determines threats to a child exist but immediate removal is not necessary, the that one or more safety threats SDM policies the three counties follow require the social worker to a child exist but immediate to develop a safety plan designed to mitigate the identified safety removal is not necessary, the social threats so that the child can remain in the home. The safety plan worker must develop a safety describes specific and sufficient interventions that the parents agree plan designed to mitigate those to implement. safety threats. The frequency with which social workers concluded that a safety plan could mitigate safety risks varied among the three counties as did the extent to which the plans those workers developed could reasonably be expected to mitigate the risks in question. Orange County social workers most frequently determined that safety plans would mitigate the need for removal. However, of 22 referrals for which Orange County social workers determined such plans were needed, the social worker did not complete a plan for three of them. Our review found mention of one of these missing plans elsewhere in the files, but as the SDM manual requires a form on which caregivers agree to and sign all pertinent safety plans, a mere description is not enough to document a plan’s existence. Further, we determined that five of the 19 safety plans that were included in the county’s files were inadequate to mitigate the safety threats to the child, based on information in the current allegations and case history.10 These safety plans were inadequate because they were dependent on the following: • The credibility and suitability of a nonrelative caregiver for whom the social worker did not conduct any history checks (and who ultimately proved to be a felon who had lost custody of her own children). • The protective capacity of a mother who had expressed doubt about her daughter’s sexual abuse allegations against the stepfather and who had previously failed to intervene when the daughter described the stepfather’s behavior. • The ability of a known drug user simply not to use drugs. 10 We noted three other instances in Orange County where social workers failed to follow agency policy on information to be included in its safety plans (each child involved, person to monitor intervention, and time frame for intervention); however, we concluded that these three plans were otherwise adequate. 34 California State Auditor Report 2013-110 April 2014 • A safety plan that did not obtain agreement from the parents to take steps to end the domestic violence that sparked the original referral but rather to call law enforcement should domestic violence occur again. • A safety plan that required the parents to not neglect their child’s needs. Within the context of the referral, this vague requirement likely meant that the parents needed to fill the child’s prescriptions, ensure the child took vital medications, and take the child to medical appointments. However, the safety plan did not specify this and, as documented in a subsequent substantiated referral, the parents did not complete these activities. In these five instances, social workers predicated their decisions to leave children in the home on the existence of safety plans that could not reasonably have been expected to succeed, thereby putting those children at further safety risk. Social workers in San Francisco and Butte counties were less likely than those in Orange County to employ safety plans. However, we determined that San Francisco County social workers completed a safety plan for only four of 10 referrals for which the worker had indicated that a plan was required to keep the child safe. Further, one of the four plans was unlikely to mitigate the safety threats in question. In that instance, a social worker instituted a safety plan to mitigate a domestic violence threat that required the mother to keep her abusive boyfriend out of the home. However, the worker was aware that a restraining order was already in effect against the boyfriend and that neither the mother nor the boyfriend had been observing that order. Days later, the boyfriend once again returned home and became violent, resulting in the removal of the child. Of the 13 referrals we reviewed for Butte County that indicated the need for safety plans, we found only four had completed plans, all of which appeared to be adequate. The frequency with which social The frequency with which social workers failed to complete safety workers failed to complete safety plans that they themselves determined were necessary to protect plans that they themselves children points to a major disconnect in agencies’ effective use determined were necessary to of the standardized SDM system, especially as it relates to early protect children points to a major decisions about the child’s safety. Further, the fact that the plans disconnect in agencies’ effective use social workers did create were often inadequate to address the of the standardized SDM system, safety threats they identified, suggests a limitation in the methods especially as it relates to early agencies employ to create these plans. The lack of evidence of decisions about the child’s safety. supervisory review of many of these plans underscores this concern. Three of the four plans we reviewed in Butte County lacked evidence of such oversight, as did three of four plans in San Francisco County. The rate of reviews in Orange County was slightly better, with seven of 18 safety plans showing evidence of California State Auditor Report 2013-110 35 April 2014 supervisory review. According to the director of the Butte County Department of Employment and Social Services, the agency needs to improve its documentation of supervisory review of safety plans, stating that supervisors review all safety plans before a referral is closed. However, social workers may take up to 30 days or longer to close a referral. Consequently, we believe it would be more appropriate for the supervisor to review the safety plans soon after they are implemented, to better ensure the plan’s ability to mitigate the safety threats in the home. CWS Agencies Sometimes Allowed Potentially Risky Living Arrangements Rather Than Formally Removing Children Our review identified instances in each of the three counties in which a social worker left a child with family or others as temporary living arrangements, but the social worker did not take additional steps to ensure that these caregivers were appropriate. One way this When social workers allow children type of arrangement arises is when the social worker allows a child to stay with alternate caregivers to stay with an alternate caregiver with the consent of a parent or while they conclude investigations guardian while the social worker concludes the investigation into into the allegations, the social the allegations. Because these children are not being detained by the workers are not required to perform CWS agencies, social workers are not required to perform critical critical criminal background criminal background or CWS history checks on the temporary or CWS history checks on the caregivers. Of the 40 referrals we reviewed in San Francisco, we temporary caregivers. identified eight instances of these arrangements in which the social worker did not perform any checks on the temporary caregiver. We also identified one such instance in Orange County and one in Butte County. The inherent risks associated with these arrangements could have been prevented with basic inquiries into the caregivers’ histories. For example, during an investigation into neglect of a medically vulnerable infant, a neighbor of the alleged perpetrator declared herself to an Orange County social worker as “the principal caregiver” for the infant because the mother was a transient. The social worker met with the neighbor and encouraged her to obtain the mother’s authorization to access medical care for the child—because of the child’s special needs—but made no further inquiries into this person’s background at the time. Two weeks later, after hospital staff reported to the social worker that the infant was not being brought in for its vital medical appointments, the social worker made a formal inquiry into the caregiver’s background and discovered not only a 10‑year history of violent crime and drug‑related arrests but also a significant history of CWS intervention—including losing custody of her own children. A supervisor for Orange County CWS agency’s quality support team 36 California State Auditor Report 2013-110 April 2014 confirmed that the agency did not perform any check until 10 days after learning this individual was caring for the child and stated that ideally a history check would have been run more promptly. In an example from San Francisco County, the social worker allowed a child to remain in a grandparent’s home for a week leading up to a court hearing while the alleged perpetrator was in and out of that home. The social worker appears to have done so without making any inquiries into the grandparent’s history, despite observing during the investigation that the grandparent appeared to be under the influence of drugs. At the court hearing, the agency subsequently recommended that the grandparent not be considered for official placement, in part because of the grandparent’s extensive CWS history. However, the social worker also had access to this CWS history and could have checked it before leaving the child with the grandparent. A San Francisco County department manager stated that it is unknown why the child remained in the home of the grandparent for the period leading up to the hearing with no history checks. In this case, the unsuitability of the temporary living arrangement with the grandparent would likely have come to light from even a cursory initial inquiry by the social worker. Failure to properly vet these types of Failure to properly vet these types of arrangements, temporary arrangements, temporary though though they may be, creates situations in which children remain at they may be, creates situations risk because they are in the care of someone with unknown history in which children remain at risk and in homes of unverified safety. Orange County’s CWS agency because they are in the care of asserted that in these situations, they do not have the right to someone with unknown history and perform criminal background checks and our legal counsel agrees. in homes of unverified safety. However, our legal counsel believes that agencies are not restricted from looking up prospective caregivers within the CWS database as well as reviewing public criminal sites for this purpose, or simply asking a prospective temporary caregiver about his or her past. These two examples indicate that cursory research such as this would have revealed risks to the children in question sooner and could have prevented inappropriate living situations. County CWS Agencies Did Not Always Perform Even Basic Background Checks When Formally Placing Children With Caregivers When county CSW agencies formally remove children from the home, state law requires that the agencies ensure a safe placement for the child. To that end, when they place children in locations other than licensed facilities, such as the homes of relatives or nonrelative extended family members, state law requires the agencies to complete criminal background and CWS history checks on the proposed caregivers before placing the child in that setting. California State Auditor Report 2013-110 37 April 2014 Nevertheless, at the three agencies we reviewed, we found instances At the three agencies we reviewed, in which they did not perform the required background checks we found instances in which they before placing the child in a relative’s home.11 did not perform the required background checks before placing In Orange County, of 18 such placements, we identified the child in a relative’s home. two instances in which the background checks were completed after the child was placed in the home. This was true for one of four such placements in Butte County and for four of 18 placements in San Francisco. In one example from San Francisco, the social worker officially placed the child with a friend of the offending parent before obtaining the background check results for this new caregiver. As a result, the social worker did not discover until weeks later that the friend was a convicted felon who had met the parent at a substance abuse facility where they were both patients and that the friend had failed to complete the treatment program. After learning this, the agency ended the placement and returned the child to the parent, who had again started substance abuse treatment. A San Francisco department manager stated that the agency considered the mother a more appropriate placement at that point and noted that she was receiving treatment under the court’s supervision. Although no harm came to the child in this instance and reunification happened relatively quickly, better placement practices may have prevented what was an inappropriate setting and the additional sudden removal for the child. Failure to complete these checks in a timely manner risks subjecting children who have already suffered maltreatment to further danger. Substantiation Rates of Allegations Varied Significantly Across the Counties We Visited The county CWS agencies we visited varied significantly in the frequency with which they substantiated that child maltreatment had occurred. Although related to the previously discussed safety and risk assessments, whether to substantiate an allegation of abuse and neglect is a separate decision that can have lasting impacts, such as a person’s inclusion on the Department of Justice Child Abuse Index. For child abuse or neglect to be substantiated, state law requires that a county CWS agency find “evidence that makes it more likely than not that child abuse or neglect, as defined, occurred.” As Figure 4 on the following page demonstrates, social workers must exercise judgment in two important ways when determining whether an allegation is substantiated, inconclusive, unfounded, 11 In instances where the background checks and the child’s placement occurred on the same day, we gave the counties credit for timely completion. 38 California State Auditor Report 2013-110 April 2014 or not investigated at all. Beginning with the initial intake of an allegation, social workers determine whether the alleged abuse, if true, would constitute abuse or neglect. If not, the referral will typically be evaluated out, which means it will not be further investigated. The second determination, which is typically made after an in‑person investigation, is whether the abuse or neglect likely occurred. In many instances, the answer to one or both of these questions might not be clear‑cut and the ultimate determination is inconclusive. Unlike the safety and risk assessments, this decision does not appear to be made using a structured model or other instructions. Figure 4 Potential Outcomes for Child Welfare Services Allegations Source: California State Auditor’s analysis of applicable state laws and regulations. The statewide average for allegation substantiation in 2012 was 17.4 percent. Among all of the allegations San Francisco County received, only 11.5 percent were substantiated, compared to a substantiation rate of 23.7 percent in Orange County. California State Auditor Report 2013-110 39 April 2014 The substantiation rate in Butte County, at 16.3 percent, was closer to the statewide average. Although we cannot conclude that any one of these percentages is the “correct” proportion of allegations to substantiate, the previously discussed lack of policies at Butte and San Francisco counties concerning social workers’ follow‑up attempts at contact may be contributing to these two counties’ lower substantiation rates. We found a total of four instances between Butte and San Francisco counties in which social workers closed the referrals without ever making contact with the alleged victims. In these instances, the social workers determined the allegations to be either unfounded or inconclusive, due not to the results of investigative work but rather as a result of not making contact with the victims. Variation in the accuracy of investigative narratives and risk Variation in the accuracy of assessments raise further concerns that San Francisco may not investigative narratives and risk be substantiating all allegations that warrant such action. In fact, assessments raise further concerns in five of 40 referral cases in San Francisco, we found that the that San Francisco may not be information in the county’s case file at the time of the determination substantiating all allegations that did not support the social worker’s conclusion that the allegations warrant such action. were unfounded. For example, one case file suggests that the agency concluded that an allegation was unfounded because the mother agreed to subsequent drug testing. The willingness of the mother to engage in services should not be the determining factor in deciding whether past maltreatment meets the definition of abuse or neglect and is likely to have occurred. After the county issued the finding of “unfounded,” the mother ceased her participation in drug testing. Because the county had not substantiated the referral, it was unable to take additional steps to persuade the mother to participate and instead closed the referral. A department manager confirmed that no state or county policy indicates that such a consideration is appropriate in making an allegation determination. County CWS Agencies Did Not Always Appropriately Complete the Required Assessments Before Reunification The county CWS agencies we reviewed did not consistently and accurately complete family strengths and needs assessments (family assessments) and reunification assessments. Consequently, corresponding case plans outlining needed services, as well as decisions to reunify children with their parents, were less informed. After a child is removed from the home, the county CWS agency is responsible to work with the family to determine if reunification is an appropriate goal and to make corresponding recommendations to the dependency court. To assist in making these determinations, the policies of the three county 40 California State Auditor Report 2013-110 April 2014 CWS agencies require social workers to use SDM’s family and reunification assessments. Figure 5 outlines how these assessments are used in deciding whether to return a child to the home. Figure 5 Steps to Reunification Sources: California Department of Social Services Child Welfare Services Manual of Policies and Procedures and Children’s Research Center, The Structured Decision Making System: Policy and Procedures Manual. The purpose of the family assessment is to evaluate the strengths and identify critical family needs for every family involved in a referral that is opened as a case. Possible strengths include strong parenting skills or a strong social support system, while needs can range from moderate mental health issues to severe domestic violence or destructive parenting. This assessment helps ensure that families receive appropriate services and allows social workers to assess any changes in family functioning. For cases that required a family assessment, Orange County completed 97 percent of the assessments, San Francisco completed 97 percent, and Butte County completed 53 percent. According to the director of Butte County’s Department of Employment and Social Services, the agency’s social workers have struggled with the consistent use of the SDM assessment tools such as the family assessment. She further stated that the county is aware of this issue and has previously and will continue to provide training to address this concern. When we compared the needs described in the family assessments with the files’ case history, we found that they were not always consistent with issues identified during the investigation process. Of the 10 family assessments we reviewed in Butte County, one contained inconsistencies. Of the 29 and 34 family assessments we reviewed in Orange and California State Auditor Report 2013-110 41 April 2014 San Francisco counties, four and eight, respectively, were not consistent with issues identified during the investigation process. For example, a San Francisco family assessment failed to identify frequent domestic violence as a need to be resolved in the home, although such issues were mentioned in the detention report. Similarly, a Butte County family assessment made no mention of substance abuse, although the parent’s use of drugs was the impetus for the referral. If critical family needs are missing from the family assessment, social workers risk omitting necessary services when creating the family’s case plan. After completing the family assessment, social workers collaborate with the parents or guardians to create a case plan. Based on the needs identified in the family assessment, the case plan identifies a case plan goal, which considers maintaining the child in the home with services, reunifying the child with the family, or placing the child permanently in out‑of‑home care. It also includes objectives, planned family services, and case management activities. We compared the needs identified in the family assessments with the case plans to determine whether the case plans, if followed, could effectively address the family’s weaknesses. We found that agencies were generally consistent in addressing the needs identified in the family assessment in the subsequent case plan. However, when a family assessment is not prepared before the case plan is created or is not consistent with the case history, the subsequent case plan may not identify needed services. As a result, the social worker risks returning a child to a home where a threat of abuse or neglect still exists. To help determine whether a child and his or her parents are ready for reunification, social workers are required to complete a reunification assessment tool. This tool allows social workers to reassess periodically the family’s progress in achieving its case plan goal and to determine whether to return a child to the home, maintain out‑of‑home placement, or terminate reunification services and implement a permanent alternative such as adoption. The SDM manual requires social workers to complete the assessment only for cases in which the child has a reunification goal. For those cases, the assessment must be completed if six months have passed since the county began providing services to reunify the family and every six months thereafter. We found that Orange and San Francisco counties almost We found that Orange and always completed the required reunification assessments, while San Francisco counties almost Butte County did not. Of the 40 cases we reviewed at each of the always completed the required counties, Orange County was required to complete 22 reunification reunification assessments, while reassessments, under the guidelines described in the SDM Butte County did not. manual, and both Butte and San Francisco counties were required to complete 12. Orange County completed 95 percent of the required reassessments. The completion rates for San Francisco 42 California State Auditor Report 2013-110 April 2014 and Butte counties were 92 percent and 83 percent, respectively. According to the director of Butte County’s Department of Employment and Social Services, the county is working to improve its usage of SDM tools such as the reunification reassessment through employee and supervisor trainings. The counties varied more notably in the timeliness with which they completed the required assessments, with Orange County completing 81 percent of its reassessments by the six‑month deadline and at least once every six months thereafter. Butte County completed 70 percent of the required reassessments within the required time frame, and San Francisco did so at a rate of 64 percent. San Francisco’s deputy director stated that there has been inconsistency in how the agency’s social workers prioritize the timely completion of these reassessments and that improving performance in this area is a priority to the agency. Failing to complete the reunification reassessment could lead social workers to assess improperly the potential danger of a child returning to the home, while late reassessments mean a child could spend longer in an out‑of‑home placement than necessary. Recommendations To ensure that referral response decisions are accurate: • Butte and San Francisco County CWS agencies should develop policies requiring a supervisory review of the hotline tool and a monitoring system to ensure that supervisory reviews are completed. • The Orange County CWS agency should ensure that all intake supervisors are trained on the use of the hotline tool and that they are regularly reviewing their staff’s use of this tool. To ensure that the statewide case management system contains accurate and complete information for each referral, Butte, Orange, and San Francisco County CWS agencies should update their policies or otherwise provide clear guidance to social workers about the importance of ensuring that all alleged perpetrators, victims, and types of maltreatment are accurately recorded upon intake. To ensure that social workers are making reasonable and timely efforts to make in‑person contact with children who are allegedly being maltreated, the CWS agencies in Butte and San Francisco counties should do the following: • Develop clear policies for how frequently social workers must follow up with alleged victims in the event that initial attempts at contact are unsuccessful. California State Auditor Report 2013-110 43 April 2014 • Develop clear policies about the method and duration of social workers’ attempts at making contact with hard‑to‑reach families, and clearly state under what circumstances a referral may be closed for lack of contact. To ensure that its social workers are following its policy regarding timely follow‑up visits, the Orange County CWS agency should provide training or other clarification of its policy and have its supervisors regularly review whether their staff are complying with this requirement. To ensure that all required SDM assessments are completed, the CWS agencies of Butte and San Francisco counties should develop and implement clear guidance regarding which assessments are required in different situations. To improve the timeliness and accuracy of SDM assessments, the CWS agencies of Butte, Orange, and San Francisco counties should ensure that their supervisors are promptly reviewing assessments. To improve the timeliness of their supervisors’ reviews: • The CWS agencies of Butte and San Francisco counties should develop time frames for supervisors’ review and approval of assessments and monitor supervisors’ compliance with those time frames. • The CWS agency of Orange County should more closely monitor supervisors’ compliance with its existing policy setting a 30‑day time frame for review and approval of assessments. To improve the quality of the investigative information available to social workers, the CWS agencies of Butte and San Francisco counties should expand on their investigative narrative templates to include fields such as relevant criminal history, substance abuse, or mental health concerns. To ensure that required safety plans are created, the CWS agencies of Butte, Orange, and San Francisco counties should have supervisors review all safety assessments in a timely manner and verify that a written safety plan signed by the responsible parties accompanies any assessments designating the need for a safety plan. To help strengthen safety plans to effectively mitigate safety threats, the CWS agencies of Butte, Orange, and San Francisco counties should ensure that supervisors are reviewing and approving all safety plans. 44 California State Auditor Report 2013-110 April 2014 As part of their responsibility to help children remain safe at all points during the investigation of a referral, the CWS agencies of Butte, Orange, and San Francisco counties should do the following: • Vet temporary living situations and caregivers to the extent allowable under the law, including a review of information contained within the statewide CWS database. • Perform statutorily required background checks and inspections before allowing children to be placed in a home. California State Auditor Report 2013-110 45 April 2014 Chapter 2 THE COUNTY CHILD WELFARE SERVICES AGENCIES WE VISITED COULD IMPROVE THEIR COORDINATION WITH LOCAL LAW ENFORCEMENT AND THEIR IMPLEMENTATION OF QUALITY CONTROL PROCESSES Chapter Summary Under the broad discretion state law and regulations afford, the child welfare services (CWS) agencies in the three counties we visited have adopted divergent approaches to coordinating with law enforcement in their investigations of reports of child maltreatment (referrals). Two of these agencies have cooperative agreements with local law enforcement and tend to collaborate with local law enforcement in their investigations and in removal of children from unsafe homes. Because of local preferences, the CWS agency in San Francisco does not have a similar agreement and tends not to involve local law enforcement in its efforts. This permittable preference notwithstanding, we found some instances in which communication between the CWS agency and local law enforcement in San Francisco could be improved. We also found that all three of these agencies aspire to safety models considered best practices, but each agency could improve— to varying degrees—their use of fundamental management processes. In particular, management of the CWS agencies in Butte and San Francisco counties needs to communicate expectations better by developing clear, up‑to‑date policies and procedures. In addition, while the San Francisco CWS agency needs to develop a process for monitoring and improving the quality of its social work, both the Butte and Orange County CWS agencies could improve the practices or resources of their existing quality assurance units. County CWS Agencies Have Discretion in Coordinating Their Efforts With Law Enforcement, and County Policies and Practices Vary Accordingly State laws and regulations provide county CWS agencies with broad discretion in determining when to involve law enforcement in investigations and in removing children from their homes. Their policies and practices regarding involvement of law enforcement in CWS efforts reflect this flexibility. Even so, we found instances where coordination and communication between local law enforcement and the county CWS agencies we visited could have been better. 46 California State Auditor Report 2013-110 April 2014 State Laws and Regulations Give County CWS Agencies Broad Discretion in Determining When to Request Law Enforcement Assistance State laws and regulations provide county CWS agencies with broad discretion in determining when to involve law enforcement in child maltreatment investigations (investigations) and in removing children from their homes (removals). State regulations require CWS agencies to request law enforcement assistance when (1) the physical safety of family members or agency staff is endangered or (2) when a child must be placed in temporary custody and the social worker is not legally authorized to do so. Beyond these requirements, state laws and regulations provide no further guidance regarding when social workers should or should not request law enforcement assistance. Although some agencies have specified situations in Legal Authority to Remove a Child From the which they want their social workers to call in law Home Without a Court Order enforcement (such as when the presence of illegal If a child has an immediate need for medical care, drugs is identified), determining when physical or if the child is in immediate danger of physical or safety is endangered is generally a subjective sexual abuse: decision that is dependent on a social worker’s judgment and the information available to him or Social workers may place a child into temporary custody her. Similarly, because many situations in which (remove him or her from the home) when: a child has suffered physical harm can be traced • The child has suffered, or is at risk of suffering, to a caretaker’s failure to supervise or protect a physical harm due to a caretaker’s failure or inability child, and because the removal authority of social to adequately supervise or protect the child. workers includes the particular phrase “or is at • The child has been left without any provision for risk of suffering physical harm,” most allegations support (for example, no caretaker is present). that may result in removal could fall under both law enforcement’s and social workers’ statutory Law enforcement officers may place a child into temporary custody under the abovementioned circumstances as well authority.12 Consequently, deciding whether to as in situations involving: bring law enforcement to an investigative visit that may result in a removal is a subjective judgment • Physical, emotional, or sexual abuse. that, at least at the time of receiving the referral, is • The death of another child caused by the caretaker’s based on limited information. abuse or neglect. • The child being freed for adoption by the caretaker. We are not aware of any requirement that a CWS agency document why it did or did not involve • The child being subjected to acts of cruelty due to a law enforcement in its investigations or removals. caretaker’s failure to protect. The case management system that all county CWS • The child being at risk where a sibling has been agencies use has a field that specifies who removed abused or neglected. the child—CWS or law enforcement; however, Source: California Welfare and Institutions Code, sections 300, we found this field to be frequently inaccurate. 305, and 306. Although we noted these administrative errors, we are not aware of any impact that they have. 12 As noted in the text box, both social workers and law enforcement must have reasonable cause to believe that a child’s immediate health or well‑being is in danger before removing the child from the home without a court order. California State Auditor Report 2013-110 47 April 2014 Further, the level of discretion provided to county CWS agencies The level of discretion provided in including law enforcement in their efforts appears to be the type to county CWS agencies in of flexibility envisioned by the county‑administered model used including law enforcement in their in California. efforts appears to be the type of flexibility envisioned by the county-administered model used Variations in Levels of Law Enforcement Involvement in CWS in California. Investigations Reflect Allowable Differences in County Policies and Philosophies The extent of law enforcement involvement in CWS investigations varies by county and generally reflects differences in county policies and philosophies related to requesting law enforcement assistance. We evaluated the extent of law enforcement involvement in a total of 120 county CWS agency investigations (40 at each of the three counties we visited). For each case, we determined whether the CWS agency had requested law enforcement assistance and whether this request appeared to be required by state regulations or was at least warranted given the circumstances of a referral. We determined that CWS requesting law enforcement assistance was warranted when the referral included potentially criminal allegations (such as sexual or physical abuse) or when doing so aligned with county policies, which we discuss later. In instances when law enforcement did not assist CWS, we examined whether information known to the social worker at the time would have required CWS to request law enforcement assistance under state regulations. Although we did not find any such instances in our review, we did find, as we describe later, an instance in which we believe a county CWS agency should have involved law enforcement in attempting to find an at‑risk child. Of the 40 referrals we reviewed in each county, law enforcement was involved in 19, 15, and six of the Butte, Orange, and San Francisco County CWS agencies’ investigations, respectively. The high level of law enforcement involvement in Butte County CWS investigations includes two potentially related factors: the CWS agency in Butte County frequently requests law enforcement assistance and, more so than in the other counties we visited, law enforcement in Butte County often requests CWS assistance. Nearly half of the CWS investigations in which law enforcement was involved in Butte County stemmed from law enforcement requesting in‑person CWS assistance. In contrast, only one CWS investigation each in San Francisco and Orange counties involved law enforcement making a similar request. As indicated in Table 9 on the following page, the CWS agencies in Butte and Orange counties regularly involve law enforcement in their investigations, while the San Francisco CWS agency appears to rarely request law enforcement assistance. In addition, all of the 48 California State Auditor Report 2013-110 April 2014 referrals in which county CWS agencies involved law enforcement either were clearly required by state regulations or were warranted by the conditions described in the county CWS case files. Table 9 Summary of Law Enforcement Assistance in Child Welfare Services Investigations COUNTY CHILD WELFARE SERVICES (CWS) AGENCY LEVEL OF AND REASON FOR INVOLVEMENT BUTTE ORANGE SAN FRANCISCO TOTAL No law enforcement involved in the CWS investigation 21 25 34 80 Total with law enforcement involvement in CWS investigation 19 15 6 40 Law enforcement requested CWS immediate assistance 9 1 1 11 Law enforcement involvement required by state regulations 1 3 1 5 Law enforcement involvement may not have been required by 9 11 4 24 state regulations but appeared to be warranted* Source: California State Auditor’s review of 40 referrals each at the CWS agencies for Butte, Orange, and San Francisco counties. * We deemed law enforcement involvement warranted when their involvement was in accordance with established county policy or when referrals involved allegations of potentially criminal acts of abuse. The differences we observed reflect variations in county policies and in expressed philosophies related to requesting law enforcement assistance. For example, a county protocol requires both CWS and law enforcement in Butte County to investigate whenever child maltreatment may be related to the use or manufacture of illegal drugs. Although these investigations can be performed separately, we observed a number of joint visits when drugs were involved. Also, while it is not required to do so, the Butte County CWS agency generally requests law enforcement assistance if a child is likely to be removed and encourages social workers to consider requesting law enforcement assistance when serving a court order to bring a child into protective custody. Similarly, the policies of the Orange County CWS agency require social workers to request law enforcement assistance in investigations that may result in a child removal or a police report, and when serving a warrant to gain entry to a home. In contrast, the policies of the San Francisco County CWS agency require social workers to request law enforcement assistance only in situations involving allegations of sexual or severe physical abuse and suggest that law enforcement may conceivably be involved when serving a court‑issued entry order. Officials with the San Francisco CWS agency stated that they prefer to avoid involving law enforcement, if possible, because doing so can impair their ability to engage some families in future services. California State Auditor Report 2013-110 49 April 2014 Although this preference may be permissible, we noted several instances in our review that may indicate a breakdown in communication between San Francisco local law enforcement and the CWS agency. In particular, we found five referrals for which law enforcement was aware of critical information, including allegations of child maltreatment, but did not share this information in a timely manner with the agency. Two of these incidents related to arrests made by law enforcement. In the first incident, which took place more than four months before the CWS referral report, a teenager was arrested by law enforcement because of a physical altercation We found five referrals for which with his caretaker. In another incident, a child witnessed domestic the San Francisco local law violence between the child’s adult siblings that resulted in an arrest. enforcement was aware of critical We did not find any indication that law enforcement had reported information, including allegations either of these incidents to the county CWS, and the agency did of child maltreatment, but did not not become aware of the incidents until someone else called in share this information in a timely a referral. manner with the CWS agency. In a third referral, which was reported 11 days after the corresponding incident, a teenager called law enforcement while being physically abused by her mother. Police did not arrest the mother but suggested that the girl leave the house and go for a walk to calm down. The child left and spent a couple of days with a former foster parent. The CWS agency became aware of the incident only after the mother later attempted suicide and a therapist submitted a required report to the agency. The lack of communication between CWS and law enforcement in this instance is particularly disconcerting because the child could easily have returned home later that night and been at risk of further physical abuse. In a fourth referral, a 14‑year‑old allegedly stole firearms from his mother. The San Francisco County CWS agency called law enforcement before the in‑person investigation requesting information regarding the firearms and law enforcement’s investigation. However, in this case law enforcement did not respond until 11 days later after CWS had conducted an in‑person investigation. This delay could have placed the social worker or family members in harm’s way. In a final example, the person making the report stated that law enforcement responded to an incident that took place between a mother and an 11‑year‑old a week before the current referral. According to the person making the report, law enforcement determined that the children residing in the home were well cared for but expressed concern about them not attending school. We did not find any indication that law enforcement reported the original incident to CWS or that the investigating social worker attempted to contact law enforcement despite being aware of its prior involvement. Although the San Francisco County CWS agency indicated that it has a positive relationship with local law enforcement, the abovementioned instances indicate that it may not be getting 50 California State Auditor Report 2013-110 April 2014 the information it needs from law enforcement, State Law Regarding Cooperative Agreements which could result in placing children With Local Law Enforcement unnecessarily at risk. Unlike the Butte and Orange County CWS agencies, the San Francisco “The Legislature intends that in each county the law County CWS agency does not have a enforcement agencies and the county welfare or probation formalized cooperative agreement with its local department shall develop and implement cooperative law enforcement. Therefore, as encouraged by arrangements in order to coordinate existing duties in state law (see the text box), a cooperative connection with the investigation of suspected child abuse or neglect cases.” agreement with local law enforcement that formalizes expectations and coordination Source: California Penal Code, Section 11166.3 (a). appears warranted. We also assessed whether the county CWS agency should have requested law enforcement assistance in situations where law enforcement was not otherwise involved. We found only one instance in which we believe the agency should have involved law enforcement in its investigation but did not. The Butte County CWS agency received a report alleging that an adult male was providing drugs and sexually abusing a 13‑year‑old girl who had an extensive CWS history and no active caretaker. The CWS agency assigned this referral a 10‑day response, preparing no hotline tool to justify this delay. Despite being given two potential locations to search for the girl, the agency visited only the child’s school (to which she was truant) and a prior caretaker who did not know the exact address of her whereabouts but provided a reasonable description of an additional place to search. The agency made a required report to law enforcement upon receiving the allegation but made no other effort to involve law enforcement in its investigation. After further unexplained delays in the CWS agency response and an arguably minimal effort to locate the child, the referral was closed. Justification for closure of the referral was that social workers were not able to find the girl and that the girl had previously refused CWS services. The Butte County CWS agency admitted that a Structured Decision Making (SDM) hotline tool was required for this referral but was not completed and that additional efforts to locate the child should have occurred up to and including the possible involvement of law enforcement. Variations in Levels of Law Enforcement Involvement in Child Removals Reflect Acceptable Differences in County Policies Similar to the varying county policies regarding CWS investigations, county policies regarding the extent of law enforcement involvement when removing children from the home also vary. We examined the prevalence of law enforcement involvement in 20 removals reviewed from each county by identifying who was present. In keeping with its propensity to conduct joint investigations with law enforcement, the California State Auditor Report 2013-110 51 April 2014 Butte County CWS agency had the highest occurrence of removals with both CWS and law enforcement personnel present, as indicated in Table 10. However, more than half of these removals were a result of law enforcement requesting immediate assistance from CWS. The Orange County CWS agency had a much higher number of removals that occurred at a court hearing after CWS investigated a referral, decided to leave the children in the home, and requested a court hearing. This agency rarely removed a child on its own, and when it did, it contacted law enforcement and obtained their concurrence, in accordance with its policy. The other two county CWS agencies do not have a similar policy. Table 10 Summary of Who Was Present During Child Removals COUNTY CHILD WELFARE SERVICES (CWS) AGENCY CIRCUMSTANCES OF REMOVAL BUTTE ORANGE SAN FRANCISCO TOTAL Removed with both CWS and law 12 6 5 23 enforcement present Removed by CWS alone 7 4 10 21 Removed by law enforcement alone 1 1 3 5 Removed at a court hearing 0 9 2 11 Total removals reviewed 20 20 20 60 Source: California State Auditor’s review of 20 removals each at the CWS agencies for Butte, Orange, and San Francisco counties. The San Francisco CWS agency had the highest occurrence of removals in which CWS removed a child without law enforcement involvement, and it also had the highest number of instances in which law enforcement removed a child without consulting CWS. As discussed earlier, these results reflect differences in county policies and philosophies that appear to reflect the flexibility afforded to county administration of CWS programs. The Butte and San Francisco County CWS Agencies Did Not Always Comply With Requirements to Report Child Abuse and Neglect to Law Enforcement We found a few instances in which county CWS agencies did not comply with state laws that require them to report suspected child maltreatment to law enforcement (cross‑report). State law requires that CWS provide a written report to local law enforcement within 36 hours for every known or suspected instance of child abuse or neglect, except in cases of general neglect or where the 52 California State Auditor Report 2013-110 April 2014 risk to a child is solely related to a caretaker’s incapacity from substance abuse. In our review of 40 referrals at each county, we found that the Orange County CWS agency reported all referrals as required. The San Francisco County CWS agency did not cross‑report one referral to law enforcement that we determined was required. For this referral, the agency noted that the intake worker forgot to send the initial cross‑report but indicated that law enforcement would not have wanted a subsequent report since the agency later ruled the referral was unfounded. The Butte County CWS agency did not cross‑report two referrals to law enforcement as required. One of these referrals alleged physical abuse of a child. At the time of the referral, the child was staying at a hospital in another county. Rather than file a report within 36 hours as required, the agency reported the incident to law enforcement five days later, after completing its investigation. In the second referral, the person making the report alleged severe neglect of a child. The Butte County CWS agency did not initially cross‑report the referral to law enforcement as required, and it eventually determined this referral was unfounded and consequently made no subsequent report to law enforcement. Although we noted these errors and brought them to the attention of Butte and San Francisco County CWS agency management, these few instances do not appear to point to a systemic problem in need of further recommendation or follow‑up. To Varying Degrees, Each County CWS Agency We Visited Could Improve Its Internal Controls For each county CWS agency we visited, we identified management processes, which we refer to as internal controls, that the agency should improve; and we also identified best practices that other county CWS agencies may want to emulate. Internal controls are used to ensure that an agency meets its objectives, and they include the implementation of policies and procedures designed to provide reasonable assurance that the agency conducts a program in accordance with applicable laws and regulations. For the three agencies we visited, we examined their policies and procedures that related to receiving and investigating allegations of child maltreatment, assessing the immediate safety and ongoing risks to children, and making decisions to either remove children from their homes or allow them to remain with their families. We also examined how management within these agencies monitors how well CWS personnel carry out the policies and procedures of their respective agency. California State Auditor Report 2013-110 53 April 2014 The Butte and San Francisco County CWS Agencies Need to Improve Their Policies and Procedures Pattern for Policies and Procedures of the Child Welfare Services Agency in Orange County The process of the Orange County CWS agency for developing clear policies and procedures would Each major section of the operations manual contains benefit other county CWS agencies, including both descriptions of the following: the Butte and San Francisco County CWS agencies. • Date of the policy and dates of all subsequent The Orange County CWS agency maintains policies policy revisions and procedures in an operations manual and • Purpose of the policy updates them frequently. The agency has a designated unit charged with monitoring applicable • Approval date and approving officer statutory and regulatory changes and with having • A description of the most recent policy revision ongoing communications with management on what policies and procedures should be revised. • Relevant background This unit takes the lead in gathering relevant input, • Links to the legal basis for the policy drafting the policy, obtaining feedback and • Definitions of terms management approval for revisions, and then disseminating these changes to agency personnel. • The policy itself (visually delineated with titles and Based on our review, we found that the policies and boldface descriptors in the margins) procedures of the agency appear robust and clear. • References to related policies and required forms They systematically detail each of the agency’s Source: Orange County Social Services Agency, Children and major functions and, as indicated in the text box, Family Services Operations Manual. generally follow a consistent pattern that communicates all necessary information well. Unlike the Orange County CWS agency, the Butte and San Francisco County CWS agencies do not have designated personnel responsible for updating policies and procedures. We analyzed the policies and procedures of the Butte County CWS agency and found that they lack clear policy statements in some areas and generally lack a systematic description of the requirements for each functional area (for example, intake of allegations, investigation of referrals, removal of children from unsafe homes, and placement of children in new homes). In San Francisco, CWS managers and staff were frequently unable to locate specific policies or documentation regarding their operations, including the handling of referrals. With inadequate communication of requirements, these agencies are at higher risk of having inconsistent practices among staff and limiting their ability to hold staff and managers accountable for completion of required activities. Management from both these CWS agencies acknowledged that their policies and procedures could be improved and agreed that they need to designate a person or unit to develop and maintain policies and procedures. The deputy director of the San Francisco County CWS agency indicated that the agency has already begun an overhaul of its policies and procedures using the policies and procedures of the Orange County CWS agency as a template with its permission. 54 California State Auditor Report 2013-110 April 2014 The San Francisco CWS Agency Has No Quality Assurance Program, and the Butte and Orange County CWS Agencies Could Make Improvements to Their Quality Assurance Efforts Both the Butte and Orange County CWS agencies have designated units that monitor the quality of investigative and ongoing casework within their agencies. However, a comparison of the resources and practices of these two units shows that both agencies could improve their quality assurance units. The San Francisco CWS agency has not established a quality assurance unit responsible for monitoring whether agency personnel are effectively carrying out required activities. Consequently, its management does not receive the same level of detailed feedback that the management of the other two county CWS agencies receives and uses to continuously improve their respective agency’s practices. All county CWS agencies participate in the California Child and Family Review system (outcome review), a review process the California Department of Social Services (Social Services) uses to monitor the activities of county CWS agencies. The outcome review is a five‑year cycle of regular activities focused on improving the safety and well‑being of children and their families. These measurements use aggregate data, which can provide insight into the quality of social work in a county CWS agency but cannot necessarily detect all types of noncompliance or ineffective practices. Social Services supplements its outcome reviews with an online review of a sample of cases, but it does not conduct these reviews on a regular schedule, and the statewide sample size is too small to act as an adequate substitute for ongoing monitoring that the management of county CWS agencies should be doing. Further, although each county CWS agency we visited requires supervisors to review key documents and decisions of the social workers they oversee, management still needs a mechanism to know if these We expected to find, at least at supervisory reviews are being performed appropriately. Thus, we some level, ongoing monitoring of expected to find, at least at some level, ongoing monitoring of the the quality of casework. quality of casework. In Butte County, the county CWS agency recently established a one‑person quality assurance unit that has developed, in collaboration with management and social workers, a robust set of tools to review the quality of referral intake and ongoing case management. According to the director who oversees the agency, it assigned a senior social worker to be a quality assurance specialist in January 2013 because, after receiving the results of an earlier consultant study, “it was evident that more focused energy needed to be dedicated to regularly evaluating cases.” In addition to developing the review tools, this specialist reported that she had completed approximately five referral intake reviews per month and a total of five more comprehensive case reviews as California State Auditor Report 2013-110 55 April 2014 of December 2013. The specialist indicated that she still needs to develop review tools for investigation and placement practices, and she acknowledged that the quality assurance unit may eventually require more staff. The director stated that they would like to review more referrals and cases to improve practice within the agency. The agency has plans in its proposed 2014–15 budget to request additional personnel for the quality assurance unit. In contrast, the county CWS agency in Orange County has a six‑member quality assurance unit, which, in addition to performing random case reviews, serves a number of other roles, including completing child death reviews, investigating community complaints, and coordinating federal and state audits. As indicated in the Appendix, the Orange County CWS agency had over seven times the budget of the Butte County CWS agency and six times the caseload in fiscal year 2012–13. Consequently, the quality assurance unit in Orange County, which was formed in 1997, is more robust than what might be found in a smaller county such as Butte County. In fact, in December 2012, Orange County moved supervision of its quality assurance unit from its CWS agency to a quality support team that the county’s social services agency oversees. Despite this level of organizational development, the quality assurance unit in Orange County does not yet use referral and case review tools like those in Butte County. The manager of the quality support team stated that they have had a goal to develop review tools for program supervisors and managers to monitor their casework and also for the quality assurance unit to use on a quarterly or semiannual basis. In November 2013 the quality assurance unit completed development of a draft tool for reviewing certain types of ongoing cases; however, the unit still needs to vet this tool with program staff. By spring 2014 the unit plans to complete development of at least two review tools—one for intake and investigations and one for ongoing cases. Developing and then using these tools consistently will allow Orange County’s quality assurance unit to regularly report to agency management on whether the quality of social work in the agency is improving or needs attention. Despite higher per‑case funding than the other two agencies we San Francisco does not currently reviewed (as described in the Appendix), San Francisco does not have a quality assurance unit currently have a quality assurance unit responsible for evaluating responsible for evaluating and and monitoring organizational compliance with or the overall monitoring organizational effectiveness of its policies. The deputy director of the CWS compliance with or the overall agency in San Francisco explained that at one time the agency effectiveness of its policies. had a quality assurance unit but that it was dissolved, apparently as a result of budget cuts. The deputy director also stated that she and other CWS officials are currently attending trainings on 56 California State Auditor Report 2013-110 April 2014 continuous quality improvement sponsored by Social Services. These trainings and her own observations have convinced her that the San Francisco CWS agency could benefit from having a unit that conducts case reviews and provides feedback on how well policies are being implemented. As a result, the deputy director stated that the agency is developing a quality assurance unit with the help of a program manager who was part of the former quality assurance unit. The County CWS Agencies We Visited Are in Different Stages of Implementing Best Practices for the Protection of Children The three CWS agencies we visited have identified and begun implementing best practices for the protection of children in their counties. As discussed in the Introduction, child welfare workers and community partners have deemed the then‑pilot strategies of Standardized Safety Assessments, Differential Response, and Permanency and Youth Transition to be best practices that improved their ability to achieve positive outcomes.13 According to the pilot project report, these three pilot strategies were selected in part because they were research‑based or already‑proven practices that had been implemented in other states and, in some cases, certain counties in California. The report cited research that these approaches were likely to achieve positive improvement in children’s safety, permanency, and well‑being. Officials at Social Services and the three county CWS agencies we visited agreed that these strategies, in addition to a more recent safety model, were best practices. The annual number of children removed from their homes and placed within California’s CWS system decreased over the last decade from roughly 35,000 to 31,000. Social Services cited studies that found that children left in their homes do better than comparably maltreated children placed in foster care. The chief of Social Services’ Child Protection and Family Support Branch stated that the “research is clear that the removal of a child from his or her home is a traumatic event, and that CWS’s focus is trying to work with children and families, providing services to California county CWS agencies attempt to resolve the issues that put children at risk of abuse and have been implementing new neglect.” Consequently, California county CWS agencies have been strategies to deal with child implementing new strategies to deal with child maltreatment, maltreatment, including the best including the best practices identified in the 2003 pilot project practices identified in the 2003 pilot report. Combined with efforts to help children exit the CWS project report. system to permanent homes (via reunification and adoption), 13 Permanency and Youth Transition encompasses a number of reform efforts, including Team Decision Making and parent mentors, which are discussed in more detail in this chapter. California State Auditor Report 2013-110 57 April 2014 the decrease in entries into the CWS system has dramatically reduced the number of children in CWS placements, as indicated in Figure 6. Figure 6 Number of Children in Child Welfare Services Placements 2000 Through 2013 120,000 100,000 80,000 60,000 40,000 20,000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 )71 – 0 egA( nerdlihC fo rebmuN Point in Time (January 1) Source: Unaudited data from child welfare services reports retrieved from the University of California at Berkeley, Center for Social Services Research Web site. Structured Decision Making As shown in Table 11 on page 59, all three CWS agencies have been using Structured Decision Making (SDM) for their safety assessments for a number of years. The 2003 pilot project report cited a study conducted in another state that found that locations using SDM were significantly more likely to effectively screen out referrals, identify safety‑related issues, and develop corresponding safety plans, and they were significantly less likely to see a valid repeat referral. In its most recent Annual Progress and Services Report, Social Services stated that the tools that make up SDM promote a uniform practice of intake assessments by increasing consistency and accuracy in emergency response among child welfare staff within and across the State. Even so, as we discuss in Chapter 1, all of the county CWS agencies we visited could improve the consistency and accuracy with which they use these tools. 58 California State Auditor Report 2013-110 April 2014 Team Decision Making Meetings In 2003 and 2004 the three county CWS agencies implemented another best practice, Team Decision Making meetings. In the pilot project report, Team Decision Making was identified as a best practice under the Permanency and Youth Transition category. According to the report, social workers found that these meetings, which involve families and other support system members participating in a dialogue about a child’s needs, result in greater cooperation from families and more viable placement options for children. Social workers also reported that Team Decision Making meetings stabilized troubled placements when the meeting process facilitated communication and conflict resolution. The primary goal of Team Decision Making is to make the best possible decision with families about their children’s placement. In these meetings, child welfare staff, family, family supports, service providers, and community members work together to assess a family’s strengths and needs, Decision Points Addressed by make critical placement decisions, and develop Team Decision Making Meetings specific safety plans for children at risk. Although • Possible removal of a child from the home. the goal of these meetings is to reach consensus regarding whether a child is to be moved, the • Possible placement change. agency maintains responsibility for final decision • Implementation of a permanency plan (reunification, making while inviting and welcoming input from adoption, guardianship). family and community partners. As shown in the text box, Team Decision Making meetings Source: Annie E. Casey Foundation, Four Approaches to Family Team Meetings. can be used at different decision‑making points in the CWS process. In its most recent Annual Progress and Services Report, Social Services states that Team Decision Making is an effective and common method for improving placement stability. The report further states that Team Decision Making meetings help ensure that community and family support systems are in place at the inception of a CWS case and that safety plans are in place for the family. Moreover, Social Services reports that completing these meetings at placement changes ensures that children are placed in the least restrictive and most appropriate setting, reduces unnecessary placement moves for children, and assists families with the needed support to reunify successfully. As a possible result of the implementation of these meetings, placement stability (measured as the number of children who have experienced two or fewer placements while in CWS care) increased statewide from 60 percent in 2004 to a high of 70 percent in 2012.14 14 These percentages combine three separate groups that Social Services reports on separately. Following Social Services’ methodology, this calculation excludes children who were in a CWS placement for fewer than eight days. California State Auditor Report 2013-110 59 April 2014 Table 11 Summary of Best Practices Implemented by Butte, Orange, and San Francisco County Child Welfare Services Agencies BEST PRACTICES AND YEAR IMPLEMENTED STRUCTURED TEAM DIFFERENTIAL PARENT MENTORING/ SAFETY ORGANIZED COUNTY DECISION MAKING DECISION MAKING RESPONSE PEER PARENTS PRACTICE (SOP) MODEL Butte 2005 2004 2014* 2011 2010 Orange 1999 2004 2007 2007 2013† San Francisco 2007 2003 2009 2005 2011 Sources: Interviews with and documentation obtained from the child welfare services agencies for Butte, Orange, and San Francisco counties. * Butte County had a Differential Response program from 2005 through 2007. The program formally ended in 2008 because of reduced overall funding in child welfare services in Butte County. However, Butte County officials indicated that new funding has been identified and the program is being implemented in 2014. † Although Orange County has no formalized plan to implement SOP agencywide, in October 2013, Orange County began monthly SOP training for 60 supervisors and social workers who work directly with its client families. This is a 12‑month module that is scheduled to be completed in October 2014. Differential Response All three county CWS agencies are now using Differential Response, a strategy that allows a CWS agency to respond more flexibly to reports of child abuse or neglect. Differential Response has three referral paths, which are assigned by the social worker based on information taken from the initial report: • Path 1—Community response: This response is selected when a family is referred to CWS for child maltreatment but the initial assessment indicates that although the family is experiencing problems, the allegations do not meet statutory definitions of abuse or neglect. Families designated for this response path are linked to voluntary services such as counseling, parenting classes, or other supportive options to strengthen the family. • Path 2—CWS and agency partners response: This response may be selected when allegations meet statutory definitions of abuse and neglect at the low to moderate risk level. Assessments indicate that with targeted services a family is likely to make needed progress to improve child safety and mitigate risk. This path emphasizes teamwork among CWS and interagency or community partners to provide a multidisciplinary approach in working with families. • Path 3—CWS response: This response is chosen when the initial assessment indicates that the child is not safe. With the family’s agreement whenever possible, actions must be taken to protect the child. Court orders and law enforcement may be involved. This path is most similar to the traditional CWS response to child maltreatment. 60 California State Auditor Report 2013-110 April 2014 The pilot project report cites research that families receiving Differential Response services were more likely to be receptive to and engaged in services and had lower recidivism rates and fewer subsequent allegations of child abuse and neglect; in addition when subsequent reports were made, the reports were less severe. In its most recent Annual Progress and Services Report, Social Services stated that Differential Response has contributed to reducing the recurrence of maltreatment by providing earlier and more comprehensive intervention services by both CWS agencies and community‑based partners. Parent Mentoring and Peer Parents All three CWS agencies identified using parent mentors as a best practice. The pilot project report also identified parent mentors as an additional approach in the Permanency and Youth Transition Each of the CWS agencies has category. Each of the CWS agencies has parent mentors who have parent mentors who have successfully reunified with their children and who subsequently successfully reunified with their work one on one with parents currently involved in the CWS children and who subsequently system. The San Francisco CWS agency began using parent work one on one with parents mentors in 2005, the Orange County CWS agency in 2007, and currently involved in the the Butte County CWS agency in 2011. The agencies indicate that CWS system. parent mentors have had firsthand experience with CWS and have exhibited exceptional qualities in their own efforts to reunify successfully with their children. San Francisco’s CWS agency has parent mentors that it refers to as peer parent advocates. These individuals advocate for parents currently involved in the CWS system and attend court hearings and Team Decision Making meetings. In addition, the parent mentors provide information about community resources to the parents with whom they are working. In the Butte County CWS agency, parent mentors work directly with parents in Family Treatment Court who may have challenges in understanding or successfully navigating the requirements of the CWS system and learning to parent while in recovery from drug addiction. The Orange County CWS agency’s most recent Annual System Improvement Plan Progress Report identified the use of parent mentors as a means of improving its reunification efforts. Safety Organized Practice One of the more recent efforts to reform child welfare work is the Safety Organized Practice model. Social Services reported that California has recently begun to work with this new approach to family engagement, which has been adopted by numerous CWS agencies throughout the country. Social Services indicated that California State Auditor Report 2013-110 61 April 2014 California’s regional training academies are conducting training and facilitating the implementation of Safety Organized Practice. The Safety Organized Practice model consists of different strategies to improve child safety by involving the children, their families, social workers, and other parties in decision making. Safety Organized Practice objectives include: • Engagement: To create a shared focus to help families, social workers, and others work together to create safety for children. • Critical thinking: To help everyone involved in a family’s life consider the complicated and confusing information and sort it in a way that makes sense to all involved in the case. • Enhancing safety: To provide a path for families, social workers, and others to create a careful, thoughtful, and lasting plan to ensure that children remain safe over time. Social Services believes county CSW agencies receive two primary benefits from implementing the Safety Organized Practice model. The first is a common understanding among child welfare workers, families, and the extended community as to what the dangers and risks are that should bring CWS agencies into contact with families, as well as the protective capacities, family strengths, and natural supports that can create safety As of August 2013, 42 of California’s for children in the home. The second is training, coaching, and 58 counties had implemented technical assistance in the application of research‑based tools Safety Organized Practice and to enhance the consistency, validity, and equity of key CWS seven counties had begun decisions. Social Services reported that as of August 2013, 42 of implementing this model, which California’s 58 counties had implemented Safety Organized Practice consists of different strategies to and seven counties had begun implementing it; the remaining improve child safety by involving nine counties had not yet begun implementation. several parties in decision making. The Butte County CWS agency began using the Safety Organized Practice model in 2010, and the San Francisco CWS agency began using it in 2011. The Orange County CWS agency began Safety Organized Practice training for some of its supervisors and social workers in October 2013 and is scheduled to complete it in October 2014. At the Butte County CWS agency, its facilitators use Safety Organized Practice as a framework for Team Decision Making meetings. In addition, according to an administrative analyst in that agency, its goal is to use Safety Organized Practice tools to gather the information to be included in SDM assessments. When asked if there was any monitoring mechanism to determine positive outcomes attributable to this model, she stated that monitoring outcomes is challenging because many aspects of this model are used throughout the life of the case. She further stated that some aspects of Safety Organized Practice usage are monitored 62 California State Auditor Report 2013-110 April 2014 by supervisor case conferences, SDM usage statistics, and Team Decision Making meeting records, but it is difficult to pinpoint the exact effect of using the Safety Organized Practice model. As county CWS agencies adopt this new model and continue to use strategies that were part of previous trends within the CWS system, the results of our review indicate that they should not neglect the fundamental management processes of developing clear policies and procedures, having supervisors perform ongoing reviews of staff work, and establishing mechanisms to monitor the quality of staff and supervisor performance. These key practices will not only help county CWS agencies comply with applicable requirements but will help them manage the organizational change that occurs when adopting new methods and models. Recommendations To improve its coordination and communication with local law enforcement, the San Francisco County CWS agency should consider entering into a memorandum of understanding with the applicable law enforcement agency that delineates how the two agencies will share information and assist each other in responding to child maltreatment. To ensure that they provide clear, up‑to‑date guidance to their social workers, the CWS agencies of Butte and San Francisco counties should designate specific personnel to stay informed of relevant statutory, regulatory, and needed practice changes and to ensure that corresponding updates are made to their policies and procedures. To ensure that its social workers and supervisors are performing required activities in a timely and effective manner, the San Francisco County CWS agency should follow through on its plans to develop a quality assurance unit. The unit should regularly review and report to management on the degree of compliance with, and effectiveness of, the agency’s policies and procedures. To promote the consistent application of agency policies and procedures, and to provide a consistent framework for its reviews, the quality assurance unit that monitors the Orange County CWS agency should complete its plans to develop and regularly use tools for examining the quality of investigative and ongoing casework. To be able to review regularly more referrals and cases, the Butte County CWS agency should consider adding additional staff to its quality assurance function. California State Auditor Report 2013-110 63 April 2014 To promote continued improvement in the CWS system, Social Services should encourage each county CWS agency to designate personnel to update regularly their policies and procedures, to include a detailed description of the need for ongoing supervisory reviews of key aspects of their respective service processes and incorporate that description into their policies and procedures, and to designate personnel to perform regular quality assurance reviews. Social Services should ask each county CWS agency to report to Social Services on the status of these efforts within 60 days, six months, and one year from the publication of this audit report. We conducted this audit under the authority vested in the California State Auditor by Section 8543 et seq. of the California Government Code and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives specified in the scope section of the report. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Respectfully submitted, ELAINE M. HOWLE, CPA State Auditor Date: April 8, 2014 Staff: Benjamin M. Belnap, CIA, Audit Principal Sharon Best David J. Edwards, MPPA Brett D. Noble, MPA Scott R. Osborne, MBA Scilla M. Outcault, MBA Mark Reinardy, MPP Erin Satterwhite, MBA Legal Counsel: Scott A. Baxter, JD Richard B. Weisberg, JD For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Affairs, at (916) 445‑0255. 64 California State Auditor Report 2013-110 April 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 65 April 2014 Appendix CHILD WELFARE SERVICES EXPENDITURES FOR BUTTE, ORANGE, AND SAN FRANCISCO CHILD WELFARE SERVICES AGENCIES Tables A.1 through A.3 on the following pages display fiscal year 2010–11 through 2012–13 expenditures on child welfare services (CWS) administered by the county CWS agencies we visited: Butte County, Orange County, and San Francisco County. As identified in the Introduction to this report, the key services CWS agencies provide include emergency response, family maintenance, family reunification, and permanent placement. Each of these categories, as well as staff development, is included in tables A.1 through A.3. We also separately account for expenditures related to guardianship, which includes children who have exited the juvenile court dependency system and have entered into a legal guardianship. Because our audit focuses on activities that occur before children are placed into foster care or made available for adoption, the expenditures shown in the tables do not include direct payments made to out‑of‑home providers (for example, foster family agencies, foster family homes, and group homes). Additionally, as discussed in the Introduction, in fiscal year 2011–12, there was a change to the funding method for some local government services, including CWS. This change, referred to as the 2011 Realignment (realignment), resulted in a shift in funding from the State’s General Fund to the counties through the State’s Local Revenue Fund 2011 starting in fiscal year 2011–12. We note this change in funding in the tables. As indicated in Table A.1, Butte County’s total expenditures decreased from a high of $11.45 million in fiscal year 2010–11 to a low of $9.6 million in fiscal year 2012–13, representing a 16 percent decrease. However, over this same time period, Butte County also experienced a 26 percent decrease in its caseload. 66 California State Auditor Report 2013-110 April 2014 Table A.1 Butte County Child Welfare Services Expenditures FEDERAL STATE COUNTY TOTAL CASELOAD Fiscal Year 2010–11 Emergency response $1,618,638 $792,998 $409,094 $2,820,729 231 Family maintenance 722,206 565,804 189,197 1,477,207 156 Family reunification 1,293,853 854,711 324,591 2,473,155 249 Permanent placement 2,248,367 1,464,115 556,022 4,268,503 426 Staff development 250,105 94,787 41,742 386,634 Guardianship 1,459 22,606 0 24,065 Other 0 0 0 0 Totals $6,134,628 $3,795,020 $1,520,646 $11,450,294 1,062 2011 FEDERAL REALIGNMENT* COUNTY TOTAL CASELOAD Fiscal Year 2011–12 Emergency response $1,541,831 $757,093 $390,045 $2,688,969 211 Family maintenance 754,614 562,461 191,162 1,508,237 149 Family reunification 1,234,952 789,587 307,312 2,331,851 222 Permanent placement 2,004,664 1,262,418 491,341 3,758,423 354 Staff development 423,132 121,252 51,901 596,285 Guardianship 5,932 19,119 0 25,051 Other 0 0 0 0 Totals $5,965,126 $3,511,930 $1,431,761 $10,908,817 936 2011 FEDERAL REALIGNMENT* COUNTY TOTAL CASELOAD Fiscal Year 2012–13 Emergency response $1,397,128 $636,588 $341,666 $2,375,381 180 Family maintenance 547,470 412,949 131,478 1,091,897 102 Family reunification 1,112,939 688,059 269,219 2,070,218 193 Permanent placement 1,831,566 1,109,629 434,168 3,375,363 311 Staff development 404,883 115,446 49,514 569,843 Guardianship 17,874 71,979 47,663 137,516 Other 0 0 0 0 Totals $5,311,861 $3,034,649 $1,273,708 $9,620,218 786 Source: California Department of Social Services and audited county expense claims. Note: It was not possible to determine law enforcement’s expenditure of state and federal funds for various actions, including the removal of children. * Assembly Bill 118 (Chapter 40, Statutes of 2011) realigned the funding for child welfare services and established the Local Revenue Fund 2011, which is used to reimburse the counties for activities previously reimbursed by the State. California State Auditor Report 2013-110 67 April 2014 Orange County As Table A.2 shows, similar to Butte County, Orange County’s overall expenditures decreased from a high of $80.6 million in fiscal year 2010–11 to $75.2 million in fiscal year 2012–13, a 6.8 percent decrease over the period. Orange County’s caseload experienced a 12 percent decline over that same period. Table A.2 Orange County Child Welfare Services Expenditures FEDERAL STATE COUNTY TOTAL CASELOAD Fiscal Year 2010–11 Emergency response $24,619,785 $7,591,110 $5,525,614 $37,736,508 2,039 Family maintenance 5,505,146 3,963,719 1,239,922 10,708,787 882 Family reunification 6,323,919 4,318,468 1,676,747 12,319,135 1,048 Permanent placement 9,432,353 6,167,523 2,394,687 17,994,563 1,496 Staff development 1,172,241 308,903 127,547 1,608,691 Guardianship 8,760 222,240 1,295 232,295 Other 0 0 0 0 Totals $47,062,204 $22,571,963 $10,965,812 $80,599,979 5,464 2011 FEDERAL REALIGNMENT* COUNTY TOTAL CASELOAD Fiscal Year 2011–12 Emergency response $24,297,228 $7,155,507 $5,374,005 $36,826,740 1,894 Family maintenance 5,545,529 4,074,879 1,233,510 10,853,918 908 Family reunification 6,232,005 4,105,020 1,569,495 11,906,520 1,024 Permanent placement 8,545,498 5,365,546 2,051,438 15,962,483 1,338 Staff development 1,248,808 327,260 131,451 1,707,519 Guardianship 134,110 299,686 18,199 451,995 Other 0 0 455 455 Totals $46,003,179 $21,327,898 $10,378,553 $77,709,630 5,163 2011 FEDERAL REALIGNMENT* COUNTY TOTAL CASELOAD Fiscal Year 2012–13 Emergency response $23,270,337 $6,735,048 $5,118,647 $35,124,032 1,762 Family maintenance 4,978,294 3,566,987 1,092,338 9,637,619 792 Family reunification 5,974,406 3,928,978 1,490,686 11,394,071 960 Permanent placement 8,675,594 5,613,522 2,147,852 16,436,969 1,269 Staff development 1,697,989 433,170 176,632 2,307,791 Guardianship 9,123 167,114 74,490 250,727 Other 0 0 578 578 Totals $44,605,744 $20,444,819 $10,101,223 $75,151,786 4,783 Source: California Department of Social Services and audited county expense claims. Note: It was not possible to determine law enforcement’s expenditure of state and federal funds for various actions, including the removal of children. * Assembly Bill 118 (Chapter 40, Statutes of 2011) realigned the funding for child welfare services and established the Local Revenue Fund 2011, which is used to reimburse the counties for activities previously reimbursed by the State. 68 California State Auditor Report 2013-110 April 2014 San Francisco County Unlike the other counties we visited, San Francisco County’s overall expenditures increased by $8.5 million during fiscal years 2010–11 through 2012–13, an 18 percent increase. This increase occurred despite a 16 percent reduction in caseload. According to the finance director of San Francisco’s Human Services Agency, there are several reasons for the increase in expenditures. First, agencywide, there was a 6 percent reduction in the total workforce from fiscal years 2009–10 to 2010–11, the first year of our calculation. This reduction was followed by a corresponding 6 percent increase in total workforce over the two‑year period from fiscal years 2011–12 to 2012–13. He explained that approximately $2 million (23 percent) of the nearly $8.5 million increase in expenditures was attributable to this increase in staffing levels. Further, he reported that approximately $3.7 million (42 percent) was attributable to cost‑of‑living adjustments for staff, and $2.3 million (26 percent) was attributable to increased agency overhead costs. The agency was able to sustain this expenditure increase because it increased the percentage of children eligible for federal funding from a low of 70 percent in September 2010 to a high of 80 percent in June 2013 and because it made efforts to use a new state program that provides state funding for young adults age 18 to 21 that are still in the CWS system.15 With this additional revenue, the San Francisco CWS agency had expenditure increases while its caseloads were declining. In fact, by fiscal year 2012–13, its expenditure per CWS case was $32,399, more than double Orange County’s $15,712 expenditure per CWS case, and more than two‑and‑a‑half times Butte County’s $12,246 expenditure per CWS case. With this level of funding, we believe the San Francisco CWS agency should be able to implement the organizational improvements we recommend in chapters 1 and 2. 15 The Extended Foster Care Program was implemented in January 2012 and provided the San Francisco County CWS agency nearly $1 million in fiscal year 2011–12 and $2.3 million in fiscal year 2012–13. California State Auditor Report 2013-110 69 April 2014 Table A.3 San Francisco County Child Welfare Services Expenditures FEDERAL STATE COUNTY TOTAL CASELOAD Fiscal Year 2010–11 Emergency response $6,820,022 $2,164,906 $1,490,841 $10,475,769 374 Family maintenance 5,666,150 2,512,992 795,892 8,975,033 388 Family reunification 2,931,826 2,052,582 664,098 5,648,506 293 Permanent placement 10,022,815 6,943,431 2,246,498 19,212,744 992 Staff development 1,619,166 432,195 172,278 2,223,639 Guardianship 0 421,543 15,244 436,787 Other 0 0 0 0 Totals $27,059,978 $14,527,649 $5,384,851 $46,972,478 2,047 2011 FEDERAL REALIGNMENT* COUNTY TOTAL CASELOAD Fiscal Year 2011–12 Emergency response $8,148,068 $2,199,199 $1,734,733 $12,082,001 353 Family maintenance 5,019,735 3,282,855 905,936 9,208,525 404 Family reunification 3,204,826 2,085,848 712,258 6,002,932 280 Permanent placement 10,037,084 6,523,736 2,242,404 18,803,225 835 Staff development 2,149,807 545,714 236,901 2,932,422 Guardianship 163,436 205,112 11,304 379,852 Other 0 0 0 0 Totals $28,722,957 $14,842,464 $5,843,536 $49,408,957 1,872 2011 FEDERAL REALIGNMENT* COUNTY TOTAL CASELOAD Fiscal Year 2012–13 Emergency response $10,201,485 $2,671,859 $2,177,528 $15,050,872 364 Family maintenance 6,579,055 2,899,557 1,108,582 10,587,194 405 Family reunification 3,758,765 2,460,372 873,726 7,092,864 281 Permanent placement 9,940,219 6,586,315 2,360,014 18,886,548 662 Staff development 2,481,616 630,415 271,707 3,383,738 Guardianship 195,400 245,665 24,967 466,032 Other 0 0 0 0 Totals $33,156,541 $15,494,184 $6,816,524 $55,467,249 1,712 Source: California Department of Social Services and audited county expense claims. Note: It was not possible to determine law enforcement’s expenditure of state and federal funds for various actions, including the removal of children. * Assembly Bill 118 (Chapter 40, Statutes of 2011) realigned the funding for child welfare services and established the Local Revenue Fund 2011, which is used to reimburse the counties for activities previously reimbursed by the State. 70 California State Auditor Report 2013-110 April 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 71 April 2014 * * California State Auditor’s comment appears on page 75. 72 California State Auditor Report 2013-110 April 2014 1 California State Auditor Report 2013-110 73 April 2014 74 California State Auditor Report 2013-110 April 2014 BBllaannkk ppaaggee iinnsseerrtteedd ffoorr rreepprroodduuccttiioonn ppuurrppoosseess oonnllyy.. California State Auditor Report 2013-110 75 April 2014 Comment CALIFORNIA STATE AUDITOR’S COMMENT ON THE RESPONSE FROM THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES To provide clarity and perspective, we are commenting on the California Department of Social Services’ (Social Services) response to our audit. The number below corresponds to the number we have placed in the margin of Social Services’ response. 1 While our report does not explicitly refer to any instances of “abuse of power by child welfare agencies,” we do describe on page 25 that social workers did not always complete the required safety assessment and when they did, the safety assessment was not always substantially consistent with the case history and the facts of the allegations. Specifically, as noted on page 26, we found two instances where the social worker based the decision to remove a child at least in part on safety threats that information in the case file did not support. Because the safety assessment is the main tool used to determine whether a child can safely remain in the home, failure to complete or accurately complete the assessment means that social workers could reach an improper conclusion in deciding whether to remove the child. 76 California State Auditor Report 2013-110 April 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 77 April 2014 COUNTY OF BUTTE DEPARTMENT OF EMPLOYMENT AND SOCIAL SERVICES CATHI GRAMS Director and Public Guardian/Public Administrator P.O. Box 1649, Oroville, CA 95965 PHONE: (530) 538-7572 FAX: (530) 534-5745 County of Butte Department of Employment and Social Services 202 Mira Loma Oroville, CA 95965 March 27, 2014 Ms. Elaine Howle, State Auditor* Bureau of State Audits 555 Capitol Mall, Suite 300 Sacramento, CA 95814 Dear Ms. Howle: Thank you for your review and recommendations to improve the safety and protection of children in Butte County. The Child Welfare Services: The County Child Welfare Services Agencies We Reviewed Must Provide Better Protection for Abused and Neglected Children (Audit 2013-110) audit report takes a constructive look at the practices related to the removal of children from their home utilizing seven separate objectives. The Department of Employment and Social Services (DESS) is proud to be a partner in the service of its children and families with our State oversight agency, the California Department of Social Services (CDSS), our County oversight body, the Butte County Board of Supervisors, and the Bureau of State Audits (BSA). DESS prides itself on being a responsive, innovative and forward-thinking agency in its efforts to strengthen families and protect children from abuse and neglect. We strive to provide the highest caliber of services along with other County departments and community partners. DESS generally agrees with the findings and recommendations of the BSA audit report. Our comments on specific items are enclosed. We appreciate the collaborative manner in which your staff conducted the work leading to this report. We welcome the opportunity to examine our practices and will work to implement positive changes, both those prescribed by the BSA and other efforts that are currently in the implementation or planning phase. If you have any additional questions, I can be reached at (530) 538-7891. Sincerely, (Original signed by: Cathi Grams) Cathi Grams Director Enclosure * California State Auditor’s comment appears on page 83. 78 California State Auditor Report 2013-110 April 2014 COUNTY OF BUTTE DEPARTMENT OF EMPLOYMENT AND SOCIAL SERVICES CATHI GRAMS Director and Public Guardian/Public Administrator P.O. Box 1649, Oroville, CA 95965 PHONE: (530) 538-7572 FAX: (530) 534-5745 Butte County Response Audit No. 2013 -110 Chapter 1 Although the Counties We Visited Generally Attempted Timely In-Person Investigations, They Were Not Always Successful in Establishing Contact with Alleged Victims. If an initial attempt to visit a child is unsuccessful, (for example if the family is not at home), social workers would need to perform follow up visits to ensure that the children are safe. As stated in the report, “State laws and regulations do not address requirements for follow up attempts”. The BSA applied a five business day standard (adopted from another county) to review the follow up efforts of social workers in Butte County. Butte DESS concurs with the recommendation that it develop a clear policy for how frequently social workers must follow up with alleged victims in the event that initial attempts at contact are not successful. We do not 1 concur with the BSA’s methodology of measuring our performance based on another county’s policy where no clear definition exists in State law and regulation. RECOMMENDATIONS To ensure that referral response decisions are accurate, the Butte County CWS agency should develop policies requiring a supervisory review of the hotline tool and a monitoring system to ensure the supervisory reviews are completed. Butte County Department of Social Services (DESS) agrees with this recommendation. The DESS has already begun the process of updating and revising existing policies to enhance the supervisory review process. To ensure that the statewide case management system contains accurate and complete information for each referral, the Butte County CWS agency should update its policies or otherwise provide clear guidance to social workers about the importance of ensuring that all alleged perpetrators, victims, and types of maltreatment are accurately recorded upon intake. Butte County DESS agrees with this recommendation. Butte County Response 1 Audit No. 2013-110 California State Auditor Report 2013-110 79 April 2014 To ensure that social workers are making reasonable and timely efforts to make in- person contact with children who are allegedly being maltreated, the Butte County CWS agency should do the following: • Develop clear policies for how frequently social workers must follow up with alleged victims in the event that initial attempts at contact are unsuccessful. Butte County DESS agrees with this recommendation. • Develop clear policies about the method and durations of social workers’ attempts at making contact with hard-to-reach families, and clearly state under what circumstances a referral may be closed for lack of contact. Butte County DESS agrees with this recommendation. To ensure that all required SDM assessments are completed, the Butte County CWS agency should develop and implement clear guidance regarding which assessments are required in different situations. Butte County DESS agrees with this recommendation. To improve the timeliness and accuracy of SDM assessments, the Butte County CWS agency should ensure that their supervisors are reviewing assessments in a timely manner. Butte County DESS agrees with this recommendation. The DESS will enhance the existing policy regarding SDM assessments to ensure that they are completed and reviewed in a timely manner. To improve the timeliness of their supervisors’ reviews, the Butte County CWS agency should develop time frames for supervisors’ review and approval of assessments and monitor supervisors’ compliance with those time frames. Butte County DESS agrees with this recommendation. Time frames for supervisory oversight will be added to the existing SDM policy. To improve the quality of the investigative information available to social workers, the Butte County CWS agency should expand on their investigative narrative templates to include fields such as relevant criminal history, substance abuse, or mental health concerns. Butte County Response 2 Audit No. 2013-110 80 California State Auditor Report 2013-110 April 2014 Butte County DESS agrees with this recommendation. During the period of April 2011 to March 2013 examined during the course of this audit, the investigative narrative was revised multiple times. The current investigative narrative template includes relevant criminal history, substance abuse and mental health concerns. DESS currently has a team of social workers, supervisors and management that are revising the investigative narrative template to better incorporate safety organized practice and investigation outcome information. To ensure that required safety plans are created, the Butte County CWS agency should have supervisors review all safety assessments in a timely manner and verify that any assessments designating the need for a safety plan are accompanied by a written safety plan signed by the responsible parties. Butte County DESS agrees with this recommendation. Revision of the current policy will occur to include more clearly defined time frames for supervisory approval. To help strengthen safety plans to effectively mitigate safety threats, the Butte County CWS agency should ensure that supervisors are reviewing and approving all safety plans. Butte County DESS agrees with this recommendation. The existing policy will be updated to include specific expectations regarding supervisory review and approval of all safety plans. As part of their responsibility to help children be safe at all points during the investigation of a referral, the Butte County CWS agency should do the following: • Vet temporary living situations and caregivers to the extent allowable under the law, including a review of information contained within the statewide CWS database. Butte County DESS agrees with this recommendation. • Perform statutorily-required background checks and inspections before allowing children to be placed in a home. Butte County DESS agrees with this recommendation. In April 2012, DESS developed a policy regarding Emergency Relative and Non-Related Extended Family Member Placements. This policy gives clear guidance to social workers regarding the statutorily-required background checks and inspections before allowing a child to be placed in a home during the course of a child being brought into protective custody. Additional training to social workers and supervisors will occur reiterating the policy. Butte County Response 3 Audit No. 2013-110 California State Auditor Report 2013-110 81 April 2014 Chapter 2 RECOMMENDATIONS To ensure that they provide clear, up-to-date guidance to their social workers, the Butte County CWS agency should designate specific personnel to stay informed of relevant statutory, regulatory, and needed practice changes and to ensure that corresponding updates are made to their policies and procedures. Butte County DESS agrees with this recommendation. DESS is seeking to add additional personnel to meet the need for increased policy/procedure management, legislative oversight and law changes as they relate to child welfare practice. If the requested positions are approved with the FY 2014/2015 budget, it is anticipated that the new positions will be filled in September 2014. With the addition of these positions, a designee will be appointed for all regulatory oversight as it relates to child welfare in Butte County. This designee will report to the management team. To be able to regularly review more referrals and cases, the Butte County CWS Agency should consider adding additional staff to its quality assurance function. Butte County DESS agrees with this recommendation. DESS agrees that additional staff to its Quality Assurance Unit is necessary and is evaluating the best way to accomplish this goal. Butte County Response 4 Audit No. 2013-110 82 California State Auditor Report 2013-110 April 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 83 April 2014 Comment CALIFORNIA STATE AUDITOR’S COMMENT ON THE RESPONSE FROM THE BUTTE COUNTY DEPARTMENT OF EMPLOYMENT AND SOCIAL SERVICES To provide clarity and perspective, we are commenting on the Butte County child welfare services (CWS) agency’s response to our audit. The number below corresponds to the number we have placed in the margin of Butte County CWS agency’s response. 1 We appreciate that Butte County CWS agency agrees with our recommendation to develop clear policies for how frequently social workers must follow up with alleged victims in the event that initial attempts at contact are unsuccessful. If the agency had such a policy, we would have used its policy when evaluating its social workers. Because it did not, as stated on page 22, we evaluated follow‑up efforts of Butte County social workers using a five‑business‑day standard. 84 California State Auditor Report 2013-110 April 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 85 April 2014 * * California State Auditor’s comment appears on page 93. 86 California State Auditor Report 2013-110 April 2014 California State Auditor Report 2013-110 87 April 2014 88 California State Auditor Report 2013-110 April 2014 California State Auditor Report 2013-110 89 April 2014 90 California State Auditor Report 2013-110 April 2014 1 California State Auditor Report 2013-110 91 April 2014 92 California State Auditor Report 2013-110 April 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 93 April 2014 Comment CALIFORNIA STATE AUDITOR’S COMMENT ON THE RESPONSE FROM THE ORANGE COUNTY SOCIAL SERVICES AGENCY To provide clarity and perspective, we are commenting on the Orange County child welfare services (CWS) agency’s response to our audit. The number below corresponds to the number we have placed in the margin of Orange County CWS agency’s response. 1 As described on page 36, our report refers to social workers performing statutorily required background checks before allowing children to be placed in locations other than licensed facilities, such as the homes of relatives or nonrelative extended family members. As a result, we conclude that the Orange County CWS agency agrees with our recommendation. 94 California State Auditor Report 2013-110 April 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-110 95 April 2014 City and County of San Francisco Human Services Agency Department of Human Services Family & Children’sServices Edwin M. Lee, Mayor Trent Rhorer, Executive Director Sylvia Deporto, FCS Deputy Director March 28, 2014 Ms. Howle Lead State Auditor 621 Capitol Mall, Suite 1200 Sacramento, CA 95814 Dear Ms. Howle, We appreciate the time and effort that was put forward by you and your staff in conducting this audit. We have reviewed the comments and recommendations contained in the draft report provided by your office. Enclosed please find Table 1A, San Francisco County’s response to the report findings which incorporate the specific tasks that will be implemented to address the recommendations. As discussed, we concur with the audit findings and have begun to put structures in place in order to improve the provision of services to the families and children we serve. Last fall, the Family and Children’s Services Division (FCS) of the San Francisco Human Services Agency (HSA), conducted an examination of its policies and procedures and concluded that an overhaul was needed to provide clear expectations and guidance to FCS staff. After examining the policies and procedures manuals of several counties we identified Orange County’s manual as the one which would best fit San Francisco. Orange County graciously provided us with the template for their policies and procedures to use in the development of our county’s manual. We are currently in the processof establishing a Policy and a Quality Assurance Unit (Q.A.). Specifically we have submitted a supplemental budget request to the Mayor’s Office to create a Policy Unit which will be responsible for developing and maintaining up-to-date policies and procedures for FCS. Additionally, they will be required to stay informed of relevant statutory, regulatory, and needed practice changes and to ensure that corresponding updates are made to all FCS policies and procedures. The Policy unit will also develop clear practice guidelines which will address the recommendations of this report. Prior to 2009, FCS had a Q.A. unit responsible for ongoing monitoring and reviewing of staff compliance with Federal, State and Local policies and laws. Due to the severity of the local budget crisis, the unit was cut. We are currently in the process of re-establishing a new Q.A. unit which will be responsible for monitoring quality, accuracy and timeliness of assessments, visits, CWS/CMS input, supervisory oversight, and overall program improvement. Q.A. will develop monitoring tools and will provide ongoing compliance reports and findings to the management team. P.O. Box 7988, San Francisco, CA 94120-7988 (415) 557-5000www.sfgov.org/dhs 96 California State Auditor Report 2013-110 April 2014 The Policy and Q.A. units will report to one manager who will provide oversight to both units thus ensuring that new policies and procedures are incorporated into practice and monitored for timely and accurate compliance. Accountability for all aforementioned practice changes and requirements will be addressed through the inclusion of expectations in annual performance appraisals for child welfare program directors, supervisors and staff. Performance standards will be integrated into the day-to-day supervision of staff in order to ensure ongoing practice improvement. If you have any questions regarding our response, please feel free to contact me at (415) 558-2660. Sincerely, (Original signed by: Sylvia Deporto) Sylvia Deporto Deputy Director Family & Children’s Services Division Human Services Agency Cc: Trent Rhorer, Executive Director Christiane Medina, FCS Program Manager California State Auditor Report 2013-110 97 April 2014 snoitadnemmoceR tiduA etatS ot esnopseR s’ocsicnarF naS A1 ELBAT esnopseR ytnuoC noitadnemmoceR etatS aerA tnemevorpmI .sgnidnif htiw srucnoc ytnuoC gniriuqer seicilop poleved dluohs ytnuoC ehT snoisiced esnopser larrefer taht erusnE a dna loot eniltoh eht fo weiver yrosivrepus a .etarucca era evisnetxe gniogrednu si rosivrepus eniltoh tnerruc ehT eht taht erusne ot metsys gnirotinom edoc CIW ,sedoc laneP etairporppa ni gniniart-er .detelpmoc era sweiver yrosivrepus rosivrepus ,stnemucod eniltoh SMC/SWC ,snoitces .sloot dna ycilop eniltoh MDS ,ytilanoitcnuf eht fo thgisrevo tnemeganam eht degnahc yltnecer eW eht htiW .snoitcnuf esnopseR ycnegremE dna eniltoH evorpmi lliw ew ,ecalp ni rotceriD margorP wen .saera margorp eseht fo thgisrevo dna seicilop ,dehsilbatse si tinu ycilop eht ecnO yrosivrepus gniriuqer depoleved eb lliw serudecorp .slarrefer eniltoh lla fo weiver a dehsilbatse si tinu ecnarussA ytilauQ eht ecnO erusne ot ecalp ni tup eb lliw metsys gnirotinom yrosivrepus eriuqer taht seicilop wen htiw ecnailpmoc lla rof yletarucca dna ylemit detelpmoc eb ot sweiver .slarrefer eniltoh .sgnidnif htiw srucnoc ytnuoC ro seicilop sti etadpu dluohs ytnuoC ehT sniatnoc SMC/SWC eht taht erusnE laicos ot ecnadiug raelc edivorp esiwrehto rof noitamrofni etelpmoc dna etarucca ,sedoC laneP ni gniniart deviecer yltnecer ffats eniltoH taht gnirusne fo ecnatropmi eht tuoba srekrow larrefer hcae dna egdelwonk rieht evorpmi ot sedoc CIW fo sepyt dna ,smitciv ,srotarteprep degella lla .snoitagella fo gnidnatsrednu nopu dedrocer yletarucca era tnemtaertlam dna seicilop gnitsixe etadpu lliw tinU yciloP ehT .ekatni .esu ffats rof sediug kciuQ tnaveler poleved SCF eht htiw krow lliw .A.Q revo reganam ehT ni gniniart yrotadnam tcudnoc ot rotanidrooC gniniarT .snoitatcepxe ecitcarp dna ycilop wen eht rof sloot dna metsys gnirotinom a poleved lliw .A.Q .gnirotinom ecnailpmoc gniogno 1 98 California State Auditor Report 2013-110 April 2014 esnopseR ytnuoC noitadnemmoceR etatS aerA tnemevorpmI .sgnidnif htiw srucnoc ytnuoC :gniwollof eht od dluohs ycnega ytnuoC ehT era srekrow laicos taht erusne oT stroffe ylemit dna elbanosaer gnikam raelc tnemelpmi dna poleved lliw tinU yciloP ehT  yltneuqerf woh rof seicilop raelc poleveD  htiw tcatnoc nosrep-ni ekam ot snoitatcepxe ycnega gnidrager serudecorp dna seicilop htiw pu wollof tsum srekrow laicos gnieb yldegella era ohw nerdlihc nosrep-ni rof stroffe ylemit dna elbanosaer rof laitini taht tneve eht ni smitciv degella detaertlam nerdlihc htiw stcatnoc .lufsseccusnu era stcatnoc ta stpmetta cificeps edulcni lliw dna depoleved eb lliw senilediuG -ni fo ytilauq dna ,dohtem ,ycneuqerf rof snoitatcepxe dohtem eht tuoba seicilop raelc poleveD  ta stpmetta laitini taht tneve eht ni stcatnoc nosrep stpmetta ’srekrow laicos fo noitarud dna .lufsseccusnu era stcatnoc hcaer–ot-drah htiw tcatnoc gnikam ta eht gniyficeps depoleved eb osla lliw senilediuG  tahw rednu etats ylraelc dna ,seilimaf rof desolc eb yam larrefer a secnatsmucric desolc eb yam larrefer a hcihw rednu secnatsmucric .tcatnoc fo kcal .tcatnoc fo kcal rof ot rotanidrooC gniniarT SCF eht htiw krow lliw .A.Q dna ycilop wen eht ni gniniart yrotadnam tcudnoc ylretrauq tcudnoc lliw .A.Q .snoitatcepxe ecitcarp .seicilop wen eht htiw ecnerehda erusne ot sweiver .sgnidnif htiw srucnoc ytnuoC tnemelpmi dna poleved dluohs ytnuoC ehT MDS deriuqer lla taht erusnE stnemssessa hcihw gnidrager ecnadiug raelc detelpmoc era stnemssessa dna seicilop tnemelpmi dna poleved lliw tinU yciloP ehT .snoitautis tnereffid ni deriuqer era ot woh dna nehw no snoitatcepxe gniyfiralc serudecorp .MDS esu retneC hcraeseR s’nerdlihC eht htiw krow lliw ytnuoc ehT gniniart edivorp ot ,ymedacA gniniarT aerA yaB eht dna esu tnetsisnoc erusne ot ,dedeen sa ,gnihcaoc laitini dna .loot MDS eht fo noitelpmoc dna gniogno rof sloot dna metsys weiver a poleved lliw .A.Q .gnirotinom ecnailpmoc 2 California State Auditor Report 2013-110 99 April 2014 esnopseR ytnuoC noitadnemmoceR etatS aerA tnemevorpmI .sgnidnif htiw srucnoc ytnuoC rieht taht erusne dluohs ytnuoC ehT ycarucca dna ssenilemit eht evorpmI a ni stnemssessa gniweiver era srosivrepus stnemssessa MDS fo srosivrepus rof gniniart dna senilediug ,seicilop poleveD .rennam ylemit .MDS fo weiver dna esu ylemit dna etarucca eht no yrosivrepus rof semarfemit no secilop raelc hsilbatsE .stnemssessa fo weiver erusne ot sloot dna metsys gnirotinom a poleved lliw .A.Q rennam ylemit a ni stnemssessa gniweiver era srosivrepus .etarucca era stnemssessa eht taht dna .sgnidnif htiw srucnoc ytnuoC rof semarf emit poleved dluohs ytnuoC ehT sti fo ssenilemit eht evorpmI fo lavorppa dna weiver ’srosivrepus sweiver ’srosivrepus eht rof senilediug dna seicilop gnipoleved ot noitidda nI ’srosivrepus rotinom dna stnemssessa poleved lliw ytnuoc eht ,MDS fo weiver dna esu etarucca .semarf emit esoht htiw ecnailpmoc rof semarfemit deriuqer gnitaeniled sloot yrosivrepus .stnemssessa MDS fo lavorppa dna weiver taht erusne ot metsys gnirotinom a poleved lliw .A.Q stnemssessa gnivorppa dna gniweiver era srosivrepus .semarfemit deriuqer eht nihtiw .sgnidnif htiw srucnoc ytnuoC rieht no dnapxe dluohs ytnuoC ehT eht fo ytilauq eht evorpmI edulcni ot setalpmet evitarran evitagitsevni ot elbaliavanoitamrofni evitagitsevni evitagitsevni tnerruc eht esiver ot snalp ytnuoc ehT ,yrotsih lanimirc tnaveler sa hcus sdleif srekrow laicos dna hguoroht erom rof wolla ot etalpmet evitarran .snrecnoc htlaeh latnem ro ,esuba ecnatsbus wen ehT .stnemssessa fo noitatnemucod etelpmoc .sdleif dednemmocer eht edulcni lliw evitarran eht ni ffats rof gniniart edivorp lliw ew ,detelpmoc ecnO osla lliw eW .evitarran eht fo noitelpmoc dna esu reporp .esu sti rof snoitatcepxe dna seicilop raelc hsilbatse ytilauq taht erusne ot sweiver cidoirep tcudnoc lliw .A.Q .detelpmoc gnieb era sevitarran 3 100 California State Auditor Report 2013-110 April 2014 esnopseR ytnuoC noitadnemmoceR etatS aerA tnemevorpmI .sgnidnif htiw srucnoc ytnuoC srosivrepus evah dluohs ytnuoC ehT snalp ytefas deriuqer taht erusnE ylemit a ni stnemssessa ytefas lla weiver detaerc era serudecorp dna seicilop raelc poleved lliw tinU yciloP ehT stnemssessa yna taht yfirev dna rennam lliw tI .snalp dna stnemssessa ytefas fo esu eht gnidrager era nalp ytefas a rof deen eht gnitangised fo weiver ylemit eht rof snoitatcepxe yrosivrepus edulcni nalp ytefas nettirw a yb deinapmocca ytefas deriuqer taht gniyfirev ni elor rieht dna ,stnemssessa .seitrap elbisnopser eht yb dengis .seitrap elbisnopser lla yb dengis dna detelpmoc era snalp .sgnidnif htiw srucnoc ytnuoC srosivrepus taht erusne dluohsytnuoC ehT ot snalp ytefas nehtgnertS ytefas lla gnivorppa dna gniweiver era staerht ytefas etagitim ylevitceffe eht rof serudecorp dna seicilop raelc gnipoleved ot noitidda nI .snalp modnar tcudnoc lliw .A.Q ,snalp dna stnemssessa ytefas fo esu hguoroht gnidivorp era srosivrepus taht erusne ot stidua eht rotinom ot sloot poleved lliw .A.Q ,yllanoitiddA .sweiver ylevitceffe ni snalp ytefas fo ssenetairporppa dna ytilauq .staerht ytefas gnitagitim .sgnidnif htiw srucnoc ytnuoC :gniwollof eht od dluohs ytnuoC ehT lla ta efas era nerdlihc erusnE a fo noitagitsevni eht fo stniop dna seicilop tnerruc esiver dna weiver lliw ytnuoC  dna snoitautis gnivil yraropmet teV  .larrefer ytefas dlihc gnirusne rof stnemeriuqer gnidrager serudecorp rednu elbawolla tnetxe eht ot srevigerac .stnemegnarra gnivil yraropmet gnikam nehw fo weiver a gnidulcni ,wal eht snoitatcepxe rekrow dna yrosivrepus yfiralc lliw ytnuoC eht nihtiw deniatnoc noitamrofni taht erusne ot sweiver esac ylretrauq etutitsni dna .esabatad SWC ediwetats .wal eht htiw ecnadrocca ni enod era stnemegnarra ezisahpme ot seicilop tnerruc esiver dna weiver lliw ytnuoC  deriuqer-ylirotutats mrofreP  snoitcepsni dna skcehc dnuorgkcab ot roirp snoitcepsni dna skcehc dnuorgkcab deriuqer eht ni decalp eb ot nerdlihc gniwolla erofeb dednetxe detaler non ro evitaler a htiw dlihc a gnicalp .emoh a .rebmem ylimaf gnisneciL eht htiw gnola ffats dna srosivrepus eraflew dlihC ot troppus dna gniniart lanoitidda htiw dedivorp eb lliw tinU .ecnailpmoc erusne sweiver ylretrauq modnar mrofrep lliw .A.Q ,yllanoitiddA eht ot gnirehda era srosivrepus dna ffats taht niatrec ekam ot .seicilop 4 California State Auditor Report 2013-110 101 April 2014 esnopseR ytnuoC noitadnemmoceR etatS aerA tnemevorpmI .sgnidnif htiw srucnoc ytnuoC a otni gniretne redisnoc dluohs ytnuoC ehT dna noitanidrooc sti evorpmI eht htiw gnidnatsrednu fo mudnaromem wal lacol htiw noitacinummoc eht woh gnitaeniled DPFS htiw UOM na poleved lliw SCF taht ycnega tnemecrofne wal elbacilppa tnemecrofne ni rehto hcae tsissa dna noitamrofni erahs lliw seicnega owt erahs lliw seicnega owt eht woh setaeniled .snoitagitsevni esuba dlihc ot gnidnopser ni rehto hcae tsissa dna noitamrofni dna sessecorp ,serudecorp cificeps eht yficeps lliw UOM ehT .tnemtaertlam dlihc ot gnidnopser ot dnopser ot etaroballoc lliw ew woh no yrassecen smrof .snoitagitsevni esuba dlihc a poleved lliw tnemecrofne wal htiw noitcnujnoc ni ASH erusne dna UOM eht rof nalp noitatnemelpmi dna gniniart sreciffo tnemecrofne wal dna srekrow eraflew dlihc lla taht .deniart era .sgnidnif htiw srucnoc ytnuoC cificeps etangised dluohsytnuoC ehT si ffats eraflew dlihc taht erusnE tnaveler fo demrofni yats ot lennosrep etad-ot-pu ,raelc htiw dedivorp dna weiver ot eb lliw tinu yciloP eht fo noitcnuf wen A ecitcarp dedeen dna ,yrotaluger ,yrotutats ecnadiug ecitcarp dna swal yrotaluger dna ,yrotutats ,tnaveler ezylana gnidnopserroc taht erusne ot dna segnahc ytnuoC llA fo mrof eht ni SSDC yb deussi era taht segnahc dna seicilop rieht ot edam era setadpu ytnuoC llA dna secitoN noitamrofnI ytnuoC llA ,sretteL .serudecorp .sretteL lacsiF poleved dna seicilop gnitsixe etadpu lliw tinU yciloP ehT .ffats rof senilediug tnaveler ot rotanidrooC gniniarT SCF eht htiw krow lliw yciloP ecitcarp dna ycilop wen eht no gniniart yrotadnam tcudnoc .snoitatcepxe gniogno rof sloot dna metsys weiver a poleved lliw .A.Q .gnirotinom ecnailpmoc 5 102 California State Auditor Report 2013-110 April 2014 esnopseR ytnuoC noitadnemmoceR etatS aerA tnemevorpmI .sgnidnif htiw srucnoc ytnuoC sti no hguorht wollof dluohs ytnuoC ehT srekrow laicos ytnuoC taht erusnE .tinu ecnarussa ytilauq a poleved ot snalp gnimrofrep era srosivrepus dna tcudnoc lliw .A.Q ,ffats erih ot lavorppa eviecer ew ecnO troper dna weiver ylraluger dluohs tinu ehT dna ylemit a ni seitivitca deriuqer ffats eraflew dlihc rotinom lliw dna sweiver ylretrauq modnar fo eerged eht no tnemeganam ot rennam evitceffe fo ssenilemit dna ycarucca ,ytilauq rof srosivrepus dna eht ,fo ssenevitceffe dna ,htiw ecnailpmoc thgisrevo yrosivrepus ,tupni SMC/SWC ,stisiv ,stnemssessa .serudecorp dna seicilop s’ycnega htiw ecnadrocca ni yreviled ecivres fo saera yek rehto dna .serudecorp dna seicilop SCF maet tnemeganam eht ot stroper gniogno edivorp lliw .A.Q dna seicilop htiw ecnailpmoc ffats fo eerged gnisserdda rof snoitadnemmocer edivorp osla lliw .A.Q .serudecorp .tnemevorpmi gniogno 6