Audit Highlights . . .
Our review of the health and safety of children in the care of the department revealed the following:
- » The department has risked the health and safety of children in its care because it has not consistently completed child abuse and neglect investigations, and related safety and risk assessments, on time or accurately.
- Social workers completed only 72 percent of safety assessments and 76 percent of risk assessments on time during fiscal year 2017–18.
- Social workers did not always accurately identify safety threats present in children’s homes and several assessments were prepared without actually visiting the child’s home.
- » The department does not have specific time frames for when supervisors must complete reviews of safety and risk assessments.
- Supervisors could have corrected many risk and safety issues, but often completed their reviews long after the social worker made decisions affecting children.
- » The department did not consistently perform required home inspections and criminal background checks before it placed children with relatives.
- » Once children were in its care, the department did not always meet requirements for evaluating the well‑being of those children.
- » Although the department reviews the circumstances surrounding child deaths, it has not ensured that it consistently implements recommendations resulting from these reviews.
Results in Brief
The Los Angeles County Department of Children and Family Services (department) is tasked with responding to child abuse and neglect in Los Angeles County. When the department receives an allegation of child abuse or neglect (referral), it routes it to one of its 19 regional offices for in‑person investigation and case management, if warranted. However, the department has unnecessarily risked the health and safety of children in its care because it has not consistently completed investigations and required safety and risk assessments on time or accurately. As a result, the department has left children in unsafe and abusive situations for months longer than necessary. Further, despite budget increases that allowed it to hire more social workers and reduce caseloads, it has not improved its compliance with several state‑required child welfare practices.
After the department receives an allegation of abuse or neglect and decides to pursue an in‑person response, state law requires that it begin the investigation within 24 hours or 10 days, depending on the severity or circumstances of the referral. However, the department complied with the applicable requirement for only 19 of the 30 investigations we reviewed. For one referral, the social worker made one unsuccessful attempt to contact the family within 24 hours but did not make subsequent attempts. Once the department sought and found the family—151 days after the referral—it removed the children from an unsafe home situation.
The department also struggled to complete investigations within the allotted time frames. Although state law allows up to 30 days from the initial in‑person response to complete an investigation of child abuse or neglect in most situations, the department adhered to these required time frames for only nine of the 30 referrals we reviewed. In fact, six of these investigations lasted more than 90 days, and one exceeded 400 days.
The department’s social workers were also often late in completing safety and risk assessments, which are standardized tools the department uses to document critical decisions regarding children’s safety. Social workers must complete safety assessments and enter them into a database within 48 hours of meeting children in person for the first time, and they must complete risk assessments within 30 days of starting investigations that analyze the likelihood that families will have subsequent referrals. However, departmentwide data show that social workers completed only 72 percent of safety assessments and 76 percent of risk assessments on time during fiscal year 2017–18. In that same year, the department failed to complete 10 percent of safety assessments and 8 percent of risk assessments. The department agreed that these late and incomplete assessments are inappropriate and told us that it is developing new policies and processes that it believes will help address this issue.
We also determined that the department’s safety and risk assessments were frequently inaccurate. For five of the 30 safety assessments we reviewed, social workers did not accurately identify or attempt to address safety threats present in the homes. In two instances, the social workers erroneously performed the safety assessments for homes and caregivers who were not the subjects of the referrals. In three other instances, social workers filled out safety assessments without actually visiting the children’s homes; nonetheless, they asserted that the homes were safe and without hazards. Similarly, of the 30 risk assessments we reviewed, 12 were inaccurate, largely because social workers failed to consider important risk factors, such as past domestic violence in the homes or results of previous department investigations. The social workers had this information available to them when performing the assessments but did not include it.
Although supervisors could have identified and corrected many of these issues upon review of the assessments, they did not do so. Further, the supervisors often completed their reviews long after the social workers had made decisions regarding the children’s safety. In fact, the department does not have policies requiring supervisors to approve assessments within specified time periods; rather, the department’s policy is that supervisors review and approve safety and risk assessments before the department closes referral investigations. Although we do not agree that this policy is sufficient, we examined whether department supervisors had complied it and found that they had not. Of the 30 safety and 30 risk assessments we reviewed, supervisors approved 12 risk assessments and five safety assessments after closing investigations. They never approved two of the assessments.
The department also did not consistently perform required home inspections and criminal background checks before it placed children with relatives. The department conducted initial in‑home inspections before placement for only 16 of the 22 relative placements we reviewed, and in one case, a social worker did not visit the home until nearly a month after the placement occurred. The department documented required background checks of such relatives for only five of the 22 placements we reviewed. In fact, the department did not complete the required background check for the relatives of one child until we raised the issue in December 2018—nearly 800 days after the placement. Although the department ultimately confirmed that the adults living in the home passed the background check, it unnecessarily risked this child’s safety by not conducting a proper review before placement.
The department also failed to consistently perform other critical steps required for relative placements. In addition to the initial in‑home assessment and criminal background check, state law requires the department to conduct a more thorough home environment assessment within five business days of a relative placement. However, the department did not conduct home environment assessments within this time frame for 16 of the 22 relative placements we reviewed, and in four of those cases, it did not complete the assessments until more than a month after it placed the children with the relatives. The law in effect during most of our audit period required the department to complete a fingerprint criminal clearance (live scan) for all adults living in the home within 10 days of the initial background check.1 Nonetheless, the department did not complete the live scans within 10 days for all adults living in the homes for 10 of the 22 relative placements we reviewed.
Moreover, once children were in its care, the department did not consistently meet requirements for evaluating the well‑being of those children. State law requires the department to conduct monthly in‑home visits of children in its care. Social workers use those visits to verify children’s locations, monitor their safety, and assess the effectiveness of the services provided. Before 2015 the law required the department to complete at least 90 percent of these monthly visits; since 2015 the required amount of visits has increased to 95 percent. The law also requires that the majority of each child’s visits occur in that child’s home. The department complied with the previous 90 percent threshold and the requirement that the majority of the visits take place in children’s homes, but it did not meet the 95 percent requirement in fiscal year 2017–18. In fact, although the social workers’ caseloads decreased, the department’s percentage of completed monthly visits declined from 95 percent in fiscal year 2016–17 to 93 percent in fiscal year 2017–18. Further, when we reviewed 30 cases, we found that two social workers repeatedly used nearly identical narratives to document ongoing visits for multiple months, casting doubt on whether the visits actually occurred. The department confirmed that it will take appropriate action for any falsification of contact documentation.
We identified several underlying causes for the deficiencies we describe above. As we state earlier, the department has not developed time frames for the completion of most supervisory reviews. As a result, the department may not discover for many months—if at all—errors in judgment by social workers that affect the safety of children. In addition, although the department provides new social workers with training on the use of assessments, it does not provide any other regular training on this subject. The department also performs reviews of a limited number of cases, but these reviews do not include an analysis of the quality of supervisors’ reviews. Further, only one type of review looks at the accuracy of assessments.
The department has not ensured that its reviews of the deaths of children in the county improve the services it provides. Although the department conducts robust reviews of the circumstances surrounding the deaths of children, it does not have a mechanism to ensure that it consistently implements recommendations resulting from these reviews. Further, the documentation related to children’s deaths rarely focuses on the performance of the supervisors involved. Half of the 10 cases we reviewed did not have findings of fault or recommendations for supervisors’ improvement, even though the related documentation identified numerous errors that social workers—whose work the supervisors should have reviewed—had made.
Finally, although the department has generally decreased its social workers’ caseloads, its ratio of social workers to supervisors increased from 5.5 in August 2017 to 6.3 in October 2018. If any of its supervisors oversee more than six social workers, a provision in the supervisor’s union contract limits the department’s ability to discipline them for poor performance. The department confirmed that a smaller ratio of supervisors to staff would improve the quality of the supervisors’ review of cases. To address these concerns, we offer the recommendations below.
To ensure that it protects children by completing investigations, assessments, home inspections, and background checks in a timely manner, the department should do the following by November 2019:
- Require staff and supervisors to use tracking reports that identify investigations and assessments that are not completed on time.
- Establish thresholds for the number of outstanding days that will trigger follow up from the department’s various levels of management.
- Implement a tracking mechanism to monitor and follow up on uncompleted or undocumented initial home inspections and background checks.
- Implement a tracking mechanism to monitor live scan criminal record checks and home environment assessments to ensure that these assessments are completed on time.
To ensure that its staff appropriately use assessments to identify safety threats and risks, the department should revise its policies and procedures by July 2019 and provide mandatory annual training for applicable staff, supervisors, and other members of management by May 2020.
To ensure that supervisors review investigations, assessments, and other documentation on time, the department should, by November 2019, specify time frames by which each type of document should be reviewed.
To improve the accuracy of its assessments, the department should require its supervisors to regularly review and evaluate assessments against available evidence and observations. It should implement this process by July 2019.
To improve the quality of supervisors’ reviews and to allow it to hold supervisors accountable, the department should, by May 2020, reduce the number of social workers assigned to each supervisor to at least the ratio specified in its union contract.
To strengthen and improve its quality control processes, the department should do the following by November 2019:
- Enhance the focus of its case reviews to not only include a review of particular case outcomes, but to also determine whether critical assessments are accurate and thorough.
- Broaden its case reviews to include an evaluation of the quality of supervisor reviews.
- Implement a tracking system to monitor the implementation and results of recommendations resulting from child‑death reviews.
The department agreed with the findings and recommendations in our report and indicated that it is initiating corrective actions to address our concerns.
1 Beginning January 1, 2018, the Legislature amended state law to require the department to conduct the live scan within five business days of the relative placement or 10 days of the initial background check, whichever comes first. This change impacted only two of the 22 relative placements we reviewed. Go back to text