Internal problems at Sacramento's Child Protective Services are so deep and severe that at least four children died of abuse and neglect after CPS bungled their cases and missed "clear opportunities" to remove them from danger, a draft of an independent report has concluded.
The report, funded by the county last year after a Bee series documented chronic failings within CPS, is harshly critical of the large agency – especially its senior management, according to two draft copies obtained by The Bee. It recommends an outside manager be brought in to ensure needed changes are made.
"Our review of CPS revealed systematic organizational, policy, procedural, and staffing problems throughout the division," according to the report by MGT, a Florida-based firm paid $100,000 by the county to investigate the agency.
Many of the findings in the audit by MGT of America Inc. underscore those reported over the past 13 years by CPS oversight groups and grand jury investigations.
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Linus Li, partner in MGT's Sacramento office, would not elaborate Tuesday on the upcoming report.
"Our policy is, we don't discuss it until we present it to the board," he said.
The final audit will be posted on the county's Web site on Friday in advance of next week's Board of Supervisors meeting. The county is expected to have a detailed response, but it is unclear when that will be made public.
Draft versions of the MGT report obtained by The Bee show auditors found widespread deficiencies inside the agency, including:
A failure to respond quickly to reports of child abuse or neglect.
Low morale, high turnover and high absenteeism, as well as a lack of discipline "even in extreme cases, such as when employees have been caught lying, stealing supplies meant for families or children, or falsifying case documents."
Repeated failures to adopt new policies or update old ones, even after CPS has told investigative agencies it agrees the changes need to be made.
Struggles by social workers and supervisors to cope with a system that "places a higher emphasis on documentation and deskwork than on children and fieldwork."
Caseload increases that are not being properly addressed by management.
The auditors, who began studying CPS in September, met with both county and CPS executive managers in December and January to discuss their findings and recommendations, according to the MGT report. They requested additional records based on CPS' responses and made some changes. However, the report said, the agency provided four binders filled with 2,100 pages of documents, most of which MGT noted "were not germane to our review."
The county's formal response was not available to The Bee on Tuesday. Spokeswoman Laura McCasland said that the head of the Department of Health and Human Services, which oversees CPS, had not seen the final version of the report and would not comment. County supervisors said they had not seen the report and declined to comment.
Sweeping changes sought
The draft findings are the latest in a series of stinging reports on how the agency conducts its business – from hiring policies to disciplinary practices to policy lapses.
This week, a two-part Bee series disclosed that 7 percent of Sacramento CPS workers have criminal records – some for the same offenses that drew troubled families into the agency's radar. The Bee identified at least 68 CPS workers with criminal histories, including convictions for such crimes as possession of heroin for sale, theft, embezzlement, spousal abuse, obstructing an officer, prostitution and identity theft.
County Supervisor Don Nottoli said he was "concerned" by The Bee's report, and Supervisor Roberta MacGlashan, who was out of town Tuesday, said she would open an inquiry into the issues it raised.
"Sacramento County should have (the) best personnel practices in CPS that put the safety and well being of children first," she said in an e-mailed statement. "I will be asking County Counsel to review the policies of other counties in California when the CPS audit comes to the Board of Supervisors next Tuesday."
Both of the drafts reviewed by The Bee indicate MGT will recommend sweeping changes in the agency and suggest that the Board of Supervisors might need to become heavily involved in seeing that those changes occur.
Rise in deaths key concern
In its review, MGT was particularly alarmed by the rising number of child abuse and neglect deaths.
From September 2007 to December 2008, 10 children were killed in a 15-month span even though they or their families were known to CPS. Those 10 deaths represented "a substantial increase in the occurrence of these tragic events."
MGT noted that between 1997 and 2007, a citizens' oversight panel had reviewed a dozen deaths and one near-death of children known to CPS.
Since the brutal beating death of 3-year-old Adrian Conway in 1996, the county's CPS oversight committee has issued eight reports with 281 recommended changes, the audits found. Six grand jury reports highly critical of CPS were conducted over the same period, and a seventh is expected to be completed soon.
The same problems continued to be reported year after year, and CPS management agreed to solve many of them but did not follow through, the draft audits found.
The most serious findings involve the seven children who died between September 2007 and July 2008, whose cases were examined by MGT. In all seven, the auditors found, there were "serious deficiencies and questionable decisions made by social workers."
In four of those cases, the deficiencies were such that "had the social workers and supervisors been diligent about complying with requirements, the child may have had a better chance," the report stated.
That conclusion came after auditors went to Juvenile Court and won permission to obtain the files involving the children. CPS had not allowed the auditors to access its case files, citing confidentiality.
A review of the files uncovered repeated lapses by social workers. One marked "no" on a reporting form asking whether a parent used drugs or alcohol, even though the parent had admitted to drug use. One failed to follow up on why a caretaker had a black eye and accepted as fact a claim that a child's broken arm came from falling out of bed.
The report did not name any of the children, but The Bee's earlier reporting on the death of 3-year-old Valeeya Brazile revealed that CPS had documented a broken arm and a healing burn on the girl's hand two months before the court closed her case and kept her in her home. The Fair Oaks girl died six months later.
The social worker in that case has since been placed on paid leave.
The auditors also confirmed earlier reports in The Bee that files in one case were altered after the child died. The Bee uncovered the alteration last year in the file of 4-year-old Jahmaurae Allen, beaten to death July 21, a month after a CPS social worker had closed his case for being "unfounded," or untrue. That assessment later was changed to say "inconclusive" and changed again to say "substantiated."
At the time of Jahmaurae's death, CPS blamed errors in the case on a "lack of work of one long-time poor performing" social worker.
The auditors also found that one social worker was involved in two child death cases and "had past problems with complying with policies and investigating referrals properly." The audit did not identify that social worker or the cases.
Absenteeism, turnover high
As part of the study, the auditors surveyed CPS' 981 workers (about 29 percent of the staff responded) and found the agency suffers from high turnover, low morale and a lack of leadership.
Social workers were absent from work 12 percent of the time during a three-month period studied. In the emergency response program, the absenteeism rate was 18 percent.
"Staff and supervisors reported that they do not feel supported by CPS management," the audit found. Workers said they felt thrown "under the bus" by management whenever controversy arose.
The auditors also found workers believe there is "a large problem" in how the agency handles problem employees and that the disciplinary process is "cumbersome."
Some workers, they wrote, went for "several years" without a performance evaluation, a complaint workers also have made to The Bee.
"We are concerned that CPS has had a number of years to correct problem areas identified internally or by external agencies, but has consistently failed to fully address these recurring issues in ways that result in meaningful and substantive changes," the audit stated.
Auditors suggested that an outside manager be brought in to report directly to the Board of Supervisors each month until CPS has shown "measurable improvement."
"The county must hold CPS responsible for developing and implementing a comprehensive change management plan," the auditors wrote, "to allow it to correct identified deficiencies and to improve outcomes for children and families in the Sacramento area."