The Noah Cuatro Report: Another whitewash by the Los Angeles Office of Child Protection

On July 5, the parents of four-year-old Noah Cuatro called 911, saying their son had drowned in the pool at their apartment complex. But Noah did not look like a drowning victim, and the sheriff is investigating his death. Noah’s family had been under the supervision of the Department of Children and Family Services (DCFS). The eagerly awaited report on the Noah Cuatro investigation has appeared after a long delay, and OCP in the person of Judge Michael Nash (Ret.) has exonerated DCFS from responsibility for Noah’s death. This is not surprising given the similar results of OCP’s Anthony Avalos investigation, which Child Welfare Monitor addressed in our last post.

The flaws in this latest report are so glaring that they are evident even to readers without access to Noah’s case file. The report describes a child who may have been wrongly sent back to his parents, and an agency that failed to protect him after he was sent home. But Nash limited the scope of the investigation to DCFS’s failure to carry out an order to remove Noah from his parents. “Given what is currently known, the primary issue in this case from a systemic perspective focuses on the removal order,” Nash states. He defines three questions, all of which involve the removal order. Was it appropriate? Should it have been issued? Should it have been executed? Nash concludes that the order was inappropriate, the judge was correct (nevertheless in issuing it), and the decision not to execute it was correct. End of story.

But the decision to confine his conclusions to the removal order disregards a much larger issue. Here is a family that was under DCFS supervision since the reunification of Noah and his parents in November 2018.  A child under supervision by DCFS died in unexplained circumstances in the Antelope Valley of Los Angeles County. Sound familiar? Think of Gabriel Fernandez in 2013. Think of Anthony Avalos, who had been under court supervision for years but was left unprotected for over a year until he died in 2018.  Had there been no removal order at all, this case would have raised serious questions.

A Story of a Troubled Family

Let us step back and look at the history, as summarized by Nash. In August 2014, shortly after Noah’s birth, he and his sister were placed in foster care with their maternal great-grandmother as a result of DCFS finding that their mother had fractured the skull of her own infant sibling, and that their father was abusing marijuana. They were returned to their parents in May 2015 based on dismissal of the allegations in the original petition for removal.

Noah and his sister were removed again in November 2016 (although his sister was returned over the objections of DCFS) due to DCFS finding that Noah had been diagnosed with “failure to thrive,” developmental delay, and congenital hypertonia, and that he was medically neglected by his parents, who failed to take him to eight scheduled appointments. Noah was originally placed in an unrelated foster home and was then placed with his maternal great grandparents in August 2017.

In November 2018, the court ordered Noah returned home to his parents over the objections of DCFS. As is common practice in Los Angeles and around the country, Noah was placed under court supervision after being reunified with his parents.  The court ordered DCFS to make unannounced visits and set up a visitation schedule for Noah’s maternal great-grandparents and also ordered that Noah and his parents participate in Parent Child Interaction Therapy (PCIT) to help improve their bond. The next judicial review was scheduled for May 9.

Between Noah’s return to his parents in November 2018 and his death in July 2019 the following occurred:

• The parents did not enroll in PCIT or put Noah in preschool–which would have been another set of eyes on the child. Noah had only one visit with his maternal grandmother.
• On her February 28 visit the caseworker supervising the family’s case (referred to as a “CS-CSW” without clarification by Nash) described Noah as lethargic and advised his parents to take him to the doctor. They did not follow his advice, waiting for Noah’s well-child visit on March 7, where Noah was diagnosed with an ear infection and prescribed medication.
• On April 17, 2019, the hotline received a call (almost certainly from Noah’s maternal great-grandmother) stating that he appeared “thinner, intimidated, and scared.” The caller alleged that Noah suffered from night terrors and said his “butt hurt” and that his father hits and curses at him. The family’s caseworker was informed of the report and went to see Noah. She noted a bruise on his back and a scab on his forearm. He denied all the allegations and agreed with his mother that he had fallen off a bunkbed. The caseworker suspected he had been coached.
• On April 18, the caseworker made a report to the hotline and an investigative worker met with the family. She took Noah for a forensic exam on April 19. Noah denied any abuse and the examiner concluded that the injury could have occurred as Noah and his mother reported. On May 9, the investigator met with the family’s prior caseworker. The latter said she “always had concerns for Noah, was opposed to his return home, and felt that the parents are habitual liars who present well.” She also expressed doubts about the bonding between Noah and his parents and concerns that he was targeted by them for abuse among their other children. Nevertheless, the referral was closed on May 9 or shortly thereafter with a finding of “inconclusive.”
• On May 13, the investigative worker advised the current caseworker that the allegations could not be verified, but the caseworker indicated that she was working on a petition to the court for permission to remove Noah due to concerns about the compliance and honesty of the parents. On May 15, the caseworker submitted the removal petition to the court and it was signed the same day.
• On May 15, the maternal grandmother called the hotline alleging that Noah’s maternal aunt reported his father beat his mother in front of the children and sometimes threw them in the street. She also reported that Noah spent the night at an aunt’s home and woke up screaming in the middle of the night. He also told the maternal uncle that his “butt hurt” and the uncle told the aunt that Noah was being sexually abused. This referral was assigned to the same investigative worker. When the investigator saw the family on May 20, the parents and Noah denied all the allegations and Noah even denied staying over with his aunt. The mother also denied being pregnant–a fact that becomes significant later.
• On May 22, a case conference including the Assistant Regional Administrator agreed not to execute the removal order while the investigation was underway. They agreed to facilitate a meeting with the family. “Unsuccessful attempts were made through July 5” to schedule this meeting, according to Nash.
• On June 6, the mother, who had denied pregnancy on May 20, gave birth. At the hospital she initially denied the baby was hers, claimed she was artificially inseminated as a surrogate, but that she did not know she was pregnant. Hospital staff reported that the mother had no prenatal care and they were concerned about her mental health. Nevertheless the baby was discharged with her parents.
• On June 13, the investigator, in consultation with her supervisor, decided to add Noah’s three siblings to the family’s case because of “concerns for Mother’s mental health and her ability to comply with court orders.”
• On June 18, according to redacted documents that have since disappeared from the internet, an automated assessment found the risk to Noah to be “very high” and the caseworker noted “current concerns for the mother’s mental health,” as cited by the Chronicle of Social Change.
• On June 19, the investigation begun on May 15 was closed. The allegation of general neglect by the mother was substantiated and the allegation of abuse by the father was found inconclusive.
• On June 28 the investigative worker saw all the children and reported Noah to be in good spirits. (Note: It is unusual for an investigative worker to visit 9 days after an investigation is closed. Perhaps this is an error and the visit was by the caseworker).
• On July 5, Noah was hospitalized after his parents said they found him in the pool at their apartment complex. The county sheriff stated that Noah had signs of trauma that were not consistent with drowning, and an investigation is ongoing.  Noah died on July 6.

Critical Questions

This history raises serious questions aside from the question of why the removal order was not implemented, which is all that Nash addressed. This family was under supervision by the the court, with DCFS responsible for monitoring the family. The family’s caseworker was concerned enough about Noah’s safety to file a 26-page request for a removal order from court. If the agency later decided to shelve the order, what was done to ensure Noah’s safety?  Between the decision not to carry out the court order on May 22 and Noah’s hospitalization on July 5, Nash does not list any visits to Noah by the caseworker who was supposed to be supervising the case. Unusually, the investigative worker was recorded as visiting them one more time on June 28, after the investigation was closed. If that was the only visit to Noah in six weeks, this is evidence of serious negligence, especially in light of the fact that the family’s caseworker thought his situation was bad enough to require a removal. Moreover, the investigator had added the other children to the case on June 13 due to concerns about the mother. Other than gross negligence, the only possible explanation for the lack of visits noted is that there were visits but Nash was not given access to the notes. That possibility is concerning; also concerning is the fact that Nash apparently did not notice the gap and ask for any missing notes.

More questions abound. Information from the hospital after the birth of the new baby was very concerning as to the mother’s lack of veracity and her mental health. Yet, this did not seem to change the outcome of the still-open investigation or result in more intensive supervision of the family. Why not? Why is there no report on the court hearing that was supposed to take place on May 9? Moreover, how could an agency make “unsuccessful attempts” to schedule a family meeting for six weeks without raising the stakes? The agency had recently had a removal order for Noah. Did they try to involve the court? Why is the family’s former caseworker now a “Human Services Aide,” which appears to be a demotion?

Perhaps Nash is right in his narrow conclusion that a removal was not warranted on May 15 when the order was granted. But it is impossible to assess this conclusion without seeing the text of the removal petition or the judge’s order. Note that DCFS was against returning Noah to his parents in the first place and was overruled by the judge in the case. Nash’s report does not provide any of the reasons why DCFS opposed the reunification. (It would be interesting to see these reasons and also learn whether they were restated in the petition requesting the removal order.) One would think that if the same team was in place when new concerns were raised, they would have been very happy to implement the removal order when they finally received it. We need to know if the team was the same and if so, why it changed.

We will have to wait for the release of the full case file to know the answers to these questions. It is not clear why Judge Nash authored such a faulty report. Perhaps it was a deliberate attempt to whitewash DCFS; perhaps DCFS administrators provided incomplete or misleading information; or maybe Judge Nash simply failed to appreciate the questions raised by the information he received. It is ironic that OCP exonerated the agency for Anthony Avilas‘s death because unlike the family of Gabriel Fernandez, Anthony’s family was not under agency supervision at the time of his death. But in addressing Noah Cuatro’s death while under agency supervision and in light of numerous red flags, OCP has exonerated DCFS, giving the agency a free pass for losing a child it was supposed to protect. It seems that the agency cannot go wrong in the eyes of Judge Nash.