A disproportionately high number of foster children in Sacramento are shuffled in assembly-line fashion through numerous placements, too many social workers and a disjointed medical system that even insiders don't understand, the Sacramento County grand jury has found.
As a result, the 19-member panel concluded the safety and well-being of Sacramento's most vulnerable children remain in jeopardy.
County Child Protective Services "has been structured for the convenience of the organization, not in a way that works best for the children," according to the latest grand jury report, released Thursday. "For CPS to succeed in its mission, it must change. It must focus on children."
The report marks the second time in two years that the grand jury has drilled into the inner-workings of the county's child protection agency, the subject of an ongoing Bee investigation that began in 2007.
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Yet unlike last year's scathing report, titled "Nothing Ever Changes – Ever," the new report indicates the agency is beginning to move in the right direction.
Agency leadership "is attempting to implement systems that will make it more effective and efficient," the panel concluded, in spite of deep budget cuts and layoffs. Among the improvements cited is a reorganization to allow a single social worker to follow a child throughout the CPS system.
However, "while CPS has made changes in the last year to improve its operations, it has a substantial way to go," the grand jury cautioned.
Following up on a Bee investigation of the deaths of children whose families had prior involvement with CPS, the previous grand jury focused on the agency's procedures in deciding when to remove a child from a potentially dangerous home.
The current grand jury turned its attention to what happens once a child has been removed.
Earlier this year, The Bee examined the case of 4 1/2-year-old Amariana Crenshaw, whose mysterious death in foster care raised questions about the quality of her care and how well it was monitored. Amariana's story was among the materials examined by the grand jury.
Among the concerns highlighted in "The State of Foster Care in Sacramento County":
Sacramento has ranked at the bottom of California's 20 largest counties in placement stability for foster children. A November 2009 CPS report showed that more than 30 percent of the county's foster children were in at least their fourth placement – and many had been moved six or more times.
Foster children are being passed among too many social workers, making it "extremely difficult" for them to even know their workers, let alone establish a "trusting relationship."
The agency's monitoring of medical care for foster children is "disjointed and ineffective for recognizing potential problems; few in the organization understand it, and even fewer can explain it," the grand jury found.
The private foster family agencies that collect money to oversee the care of many Sacramento children have a vested interest in preserving their placements. "This does not always serve the best interest of the child if a home is not working well," the grand jury said.
In a prepared statement, CPS Director Laura Coulthard said the agency agrees "with many of the grand jury's observations about how the foster care system should improve and (its) recommended solutions," noting that many already are "in place or in progress."
"We share the grand jury's concerns that lack of resources will make continuing improvements a challenge," Coulthard added.
Grand jury forewoman Rosemary Kelley declined to comment, saying, "The report speaks for itself."
In her cover letter to the report, Kelley, a local attorney, wrote, "CPS is trying to change, but it needs the cooperation of the entire agency and the necessary financial resources."
The grand jury's concerns mirror many of the conditions that existed for Amariana Crenshaw before her Jan. 11, 2008, death. Amariana's foster mother, Tracy Dossman, was affiliated with a series of private foster family agencies.
While Amariana lived in only one foster home, her care was monitored by numerous social workers and supervisors with the county and private agencies. Medical records reveal she was injured at least 17 times before her death, yet no one seemed to question whether that signaled a pattern.
The grand jury also noted that CPS has no way of tracking whether a child on its watch is growing properly, a basic indicator of well-being. In one of the most stunning revelations in Amariana's case, The Bee pieced together medical records to determine that she grew 3 inches yet gained only one pound in her last three years of life, most of which she spent in foster care.
After Amariana's charred body was removed from a burning rental home owned by Dossman, her foster family agency described Dossman as a "model foster parent." She continued to provide foster care until early this year, when the state ordered that agency to decertify her.
County officials have conducted an internal investigation into CPS' handling of Amariana's case and are expected to make their findings public later this month.