A searing internal review of Sacramento County's Child Protective Services has concluded that judgment errors and bias among agency workers were factors in the 2008 death of a 4 1/2-year-old foster child.
For the first time since Amariana Crenshaw died in January 2008, top agency officials acknowledged a series of mistakes leading up to the girl's death and outlined how they plan to fix them.
"For all our good intentions, we were really not on track," said CPS Director Laura Coulthard, who became tearful at times discussing the case.
"As painful as it is, it's also just a great call to all of us that we can't work in silos, we've got to come together, we've got to be accountable."
Coulthard said the agency's internal review was in direct response to a Bee series published in January about Amariana's death while in foster care. The Bee's investigation raised numerous questions about the quality of care the little girl received in the crowded and tumultuous foster home of Tracy Dossman, who has since been decertified for foster care by the state.
CPS continued to place children in Dossman's care for more than two years after Amariana's body was pulled from a burning rental home owned by the foster provider. The case remains unsolved by Sacramento police, who are investigating the child's death as a homicide after at least one Molotov cocktail ignited in the room where Amariana reportedly was sleeping.
The report and an accompanying letter released Thursday detail a "troubling combination of organizational, practice and communication issues" involving both front-line social workers and supervisors.
For instance, Amariana during just 30 months in foster care was seen by seven different CPS social workers as well as numerous social workers for the private foster family agencies that monitored the home.
Coulthard's boss, Ann Edwards-Buckley, told The Bee that CPS is "absolutely committed" to making changes, despite deep budget cuts. By month's end, the agency will have cut 34 percent of its staff in the last two years including some 142 social worker positions.
"The kind of change we are implementing is a culture change," said Edwards-Buckley, director of the county's Department of Health and Human Services. "That kind of change takes time to kind of imbed and infuse deeply into the organization."
Coulthard and Edwards-Buckley also said some disciplinary action has been taken as a result of Amariana's case but would not elaborate. Both said that aspect remains under review.
Mother's concerns ignored
A recurring theme throughout the review is that CPS workers trusted Dossman and took her word "at face value," failing to adequately investigate numerous allegations of abuse and neglect in the foster home. One of the CPS supervisors overseeing the foster home was a close friend of Dossman, and was buying the rental property from her at the time of the fire.
Dossman repeatedly has declined to talk with The Bee.
Compounding the problem within CPS, the report found, was a "bias" against Amariana's biological mother, Anisha Hill, who frequently complained to CPS about injuries her daughter was suffering in foster care. Workers dismissed Hill's claims about her daughter because she and Dossman, who are loosely related, had been feuding, the investigator found.
It was only when the county reopened the case this spring that it confirmed what The Bee reported in January that Amariana had been seen by medical providers 17 times in a two-year span while living with Dossman. Only half of those medical visits were reported to officials by the foster parent, in violation of state licensing regulations.
And, the county learned that Dossman had failed to follow through on mental health treatment for Amariana, who exhibited such behaviors as hoarding food, gorging and vomiting, and banging her head.
She received only four visits with a counselor before Dossman began missing appointments.
"The foster parent gave just a list of excuses," said Coulthard.
The investigation also found that seven referrals alleging "specific maltreatment" of Amariana while in Dossman's care were "not investigated according to (CPS) standards."
Most of the investigations relied on Dossman's explanations for the girl's injuries, or on a "visual observation" of the girl.
Foster mom adopted sister
Amariana's biological father, Curtis Crenshaw, also raised concerns about his daughter's frequent black eyes and split lips while in foster care, according to internal records from CPS and the Juvenile Court.
Crenshaw expressed sadness Thursday over the CPS internal review, saying it will not bring back his daughter.
"She (Dossman) had too much help from CPS," Crenshaw said.
Amariana's mother, Hill, could not be reached Thursday for comment, as she was recently arrested on a federal probation violation related to drug use. But Hill had previously expressed deep concerns about the welfare of another daughter, now 10, who was adopted by Dossman after the fire.
Coulthard and Edwards-Buckley said they could not publicly comment on that aspect of the case, because the child was legally adopted.
Heed 'smaller factors,' too
A letter e-mailed Thursday to child advocates and agencies, signed by Coulthard, expressed regret over Amariana's "tragic death" and a commitment to addressing the "larger systemic issues" that were uncovered.
But Coulthard also stressed a need to focus on the "smaller factors" that can significantly affect a child's safety.
"As the Sacramento Bee noted in its 2008 series on CPS, 'the tipping point for kids' safety often comes down to seemingly small things: an unanswered knock at the door, a miscue between agencies, a lack of follow-through, an incomplete background check ' "
The agency's public acknowledgment of errors and the scope of its internal review were applauded by one child advocate who has been among the agency's toughest critics.
Robert Wilson, executive director of the nonprofit Sacramento Child Advocates, said he believes CPS leadership is committed to change.
"I can't recall ever seeing a government agency take this kind of ownership," said Wilson, whose team of attorneys represents children in Dependency Court.
Coulthard and Edwards-Buckley said the internal review of Amariana's journey through the system already has prompted changes.
For instance, all investigations of suspected abuse and neglect will be centralized in the Emergency Response program, where social workers have the most experience with such inquiries.
"This will also protect against possible bias by the case-carrying social worker," who tends to have a more personal relationship with the foster provider, the investigation concluded.
Among other changes:
CPS and the state's Community Care Licensing Division are developing a process for joint review when a foster home has had two or more complaints.
CPS social workers will begin contacting the medical providers for foster children every six months, ensuring that records are up to date and identifying any necessary follow-up.
All deaths or near-deaths of children with CPS histories will be scrutinized at the top levels. Amariana's case was given only a cursory review after the fire because it was not believed to be the result of abuse or neglect.
Plans are under way to create an in-house panel charged with evaluating all alleged conflicts of interest by CPS staff.