The Sacramento County grand jury's anger over years of failed promises to fix Child Protective Services was evident from the title page of its new report released Wednesday.
"Nothing Ever Changes – Ever," was the name of the 29-page document, which rips the county's child welfare system for "persistent, recurring and systemic problems resulting in child abuse related deaths."
"The Grand Jury has reported on the shortcomings of CPS since 1996," says a cover letter from grand jury foreman Donald W. Prange Sr. "Findings and recommendations have fallen on deaf ears."
The panel launched its probe of the agency after a series of revelations by The Bee about CPS missteps in the case of 4-year-old Jahmaurae Allen, who was beaten to death last summer, allegedly by his mother's live-in boyfriend.
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It was the seventh grand jury probe of CPS since 1996, though its tone was by far the harshest. The panel reported that CPS had repeatedly ignored past investigations and suggestions on how to improve performance.
"When are the citizens going to demand that something be done with CPS?" Prange's letter asks. "We heard promises that CPS is studying and working on problems.
"How many years does it take to do 'something or anything?' "
Three members of the county Board of Supervisors contacted Wednesday said they want to make sure something happens this time.
Board Chairwoman Susan Peters said that the title of the grand jury report "really stands out," making clear that "there is a history of (CPS) not implementing the recommended changes.
"We need to managerially figure out how to make these things stick and not just pay lip service," Peters said.
Report follows resignation
The grand jury report's release came one day after the top county official overseeing CPS, Health and Human Services Director Lynn Frank, stepped down from her post, saying she will retire from county service at year's end.
It also closely followed an audit presented to the Board of Supervisors on March 31 by an independent consultant, MGT of America Inc., which concluded that CPS had "missed opportunities" to save children.
The findings renewed calls by children's advocates and others for permanent, meaningful changes to be made at the troubled agency.
"The grand jury report is the equivalent of an angry shout to the board saying, 'Please, for the love of God and for the sake of these children, will you finally do something?' " said Ed Howard of Sacramento, senior counsel of the San Diego-based Children's Advocacy Institute.
Supervisor Don Nottoli vowed that this time supervisors would follow through, including requiring regular public reports on progress.
"We need to keep this front and center, because there's too much risk to the children of our community," Nottoli said.
What Supervisor Roberta MacGlashan found "especially troubling," she said, was the foreman's account that some CPS staff was not forthcoming during the investigation and didn't take responsibility for problems.
Supervisor Roger Dickinson said he had not "really read" the report and so had no reaction to it. Supervisor Jimmie Yee did not return a call for comment.
While acknowledging that changes are necessary within CPS, one of the county's top child welfare officials said he disagreed with the grand jury's blunt assessment that "nothing ever changes."
Jim Hunt, acting administrator for the Countywide Services Agency, said the Birth and Beyond program developed in the late 1990s was a prime example of positive change resulting from a report from the Child Death Review Team, one of the groups that routinely reviews CPS cases. That program provides home visitation and other services to new and struggling parents as part of an effort to prevent child abuse.
"Things do change," Hunt said.
Report critical of leadership
The grand jury was especially harsh toward CPS' leadership, stating that senior management at both CPS and the county Department of Health and Human Services lacked a "positive vision and have a persistent unwillingness to accept responsibility for the outcome of their actions.
"CPS management acknowledged that they failed to follow and enforce their own policies, procedures and rules," the report continues. "Their disturbingly repetitive response was 'we're working on this.' "
Secrecy and confidentiality barriers apparently stymied the 19-member grand jury panel throughout its work, and the final report notes that the "shield of privacy and secrecy that surrounds much of the operations of CPS is unwarranted."
The grand jury, which issued more than 40 subpoenas, renewed its claim that CPS management had tried to stonewall its investigation – a charge it made in October when it issued a letter to CPS workers telling them to cooperate.
"There are many people who care about the work they do at CPS," the foreman's cover letter says. "Apparently, some top CPS management does not share the same view.
"Management made misrepresentations to the Grand Jury. We need the help of the community to put pressure on our county administrators to act quickly and take responsibility to see that changes are made."
Panel: Children left in danger
The grand jury's findings, which are available online at www.sacgrandjury.org, mirror many of the revelations that have come in the past year as The Bee investigated a series of CPS-related child deaths.
Persistent issues include sloppy record-keeping and case management, as well as a records system that allowed more than 100 people to access the computerized case file on Jahmaurae's death, many of them simply out of curiosity.
Among the most hazardous failings for those children on CPS' watch is the agency's continued misuse – or lack of use – of a screening tool to help social workers evaluate children's safety and risk of future harm, the grand jury found.
The panel said the tool, known as Structured Decision Making (SDM), has been misused over the years, leaving children in dangerous settings – an observation also made by the independent consultant and the CPS oversight committee.
Hunt noted that CPS recently made "dramatic improvement" in timely decision-making assessments.
"We obviously need to have significant improvement, but we are making changes and moving in the right direction," said Hunt, stressing that he has full confidence in CPS Director Laura Coulthard.
High turnover rate at agency
The grand jury panel found low morale, high turnover rates and poor leadership from both CPS managers and their superiors at the county's Health and Human Services Department.
The agency experienced a 22 percent turnover rate among social workers between July 2007 and June 2008 – nearly a quarter of the agency's professional staff – the grand jury noted. It says that while CPS supervisors and managers acknowledged the burden of high turnover, "no one testified to any detailed knowledge of the root causes."
A cumbersome policy manual was singled out for the third time in recent weeks as a serious impediment to workers. MGT, the independent consultant, criticized the agency for its voluminous 1,300-page manual, rife with inconsistencies and outdated policies. The grand jury called the manual "an exercise in redundancy" that "fails in its purpose to provide concise and usable direction."
Supervisor Peters, the board chairwoman, said earlier this week that fixing the manual – also criticized by District Attorney Jan Scully in recent comments before the board – should be a high priority.
Hunt agreed that the agency needs to "slim that down," and a senior manager has already been assigned the task.
"We're hitting that hard," said Hunt, adding that other action plans also are under way.
Scully was joined earlier this month by Sheriff John McGinness in calling for changes at the agency. McGinness said Wednesday that this latest report had "identified a very sensitive, critical deficiency."
"Anybody who's in a position to make things better for these most vulnerable citizens has an absolute obligation to step up and be a part of it," the sheriff said.
Scully said Wednesday she believes that, moving forward, there is "going to be a different system of checks and balances and accountability." In the past, she speculated that supervisors might have assumed that recommendations from previous critical reviews of CPS were being followed.
"Obviously they have learned that that has not happened – in spades," she said.
The grand jury issued 49 recommendations in its new report, to which the Board of Supervisors must respond by July 14. They include:
Allowing the next grand jury to revisit the issue in six months to see what progress has been made toward improving CPS.
Requiring a report to the public within six months on any improvements.
Having the Board of Supervisors "conduct a thorough assessment of the performance of (county health and human services) and CPS management."
The panel also noted that CPS workers are rarely given performance evaluations and that one longtime worker concurred, telling The Bee that she has not received a job evaluation in a decade.
That failing, the grand jury report states, delays discipline when problems arise. On average, a worker now is out on paid leave for a year while disciplinary matters are resolved, the report found, which "contributes to the caseload of other employees, and decreases staff morale."
District Attorney Scully, who recently urged supervisors to act, said study after study has made the case for change at CPS.
"Now it's a choir," she said. "Now is the time to act."