Review of The Sacramento County Child Protective Services Division MGT (Mar 2009)

ReviewoftheSacramentoCounty y ChildProtectiveServicesDivision
Final Report
PRESENTEDTO: Ms.AnnEdwards Buckley Ms. Ann EdwardsBuckley DeputyAgencyAdministrator SacramentoCountywideServicesAgency SacramentoCounty 700HStreet,Room7650 Sacramento,California,95814 , ,
SUBMITTEDBY: MGTofAmerica,Inc. 455CapitolMall,Suite600 Sacramento,California95814 9164433411 916 443 3411 LinusLi,CPA,CMA,CFM,CIA,Principal CelinaM.Knippling,CPA,SeniorConsultant March23,2009
Table of Contents
Executive Summary ...................................................................................................................... 1 Project Background....................................................................................................................... 9 Description of Child Protective Services Processes ................................................................... 15 Findings and Recommendations ................................................................................................ 25 Appendix A Process Maps ....................................................................................................... 84 Appendix B Survey Results ..................................................................................................... 86
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Appreciations
MGT of America, Inc. could not have completed this review without the assistance of the dedicated staff at the Sacramento Childrens Coalition, the Sacramento Child Protective Systems Oversight Committee, and Sacramento County. We wish to thank Sara Fung and Nancy Bui of the Sacramento Childrens Coalition who helped to facilitate interviews and document requests. We also wish to thank Ann Edwards-Buckley, Deputy Administrator of the Sacramento Countywide Services Agency, who oversaw our progress and provided valuable feedback on our periodic updates and status reports. We also wish to thank all the members of the Child Protective Systems Oversight Committee, and especially Alyson Collier, for participating in the review and providing our team with feedback and perspective. Finally, we wish to thank all members of the Sacramento County Child Protective Services division who participated in this review. We appreciate the staffs willingness to participate in time-consuming focus groups and interviews, and for responding quickly to our requests to provide data and documents, and to clarify our understanding of issues.
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Executive Summary
This report presents a review of Sacramento County (County) Child Protective Services division (CPS or division) and its management and operations over specific services.
Background
The review was requested as a result of a long history of incidents and investigations pertaining to CPS. In 1996, following the hospitalization and subsequent death of Adrian Conway, a young child whose family had been previously investigated by CPS, the Sacramento County Board of Supervisors (Board) convened a panel of independent experts to examine what went wrong in the case. The Critical Case Investigation Committee (Committee) was formed to examine this specific case and to determine whether any systemic problems existed with the child protective system. The Committee issued its report in May 1996, concluding that CPS had leaned too strongly towards keeping troubled families together, leaving children at risk. The Committees findings mirrored those of the Sacramento County Grand Jury (Grand Jury) report issued in June 1996. In July 1996, the Board approved policy changes recommended by the Committee and Grand Jury to amend the way CPS monitored and investigated abuse cases. In 1997, the Board issued additional policies mandating that CPS staff become more aggressive in removing children from homes with known drug abuse, stemming from another child fatality in which CPS had closed the case as moderate-to-low risk. The Board also added 58 CPS staff positions to deal with the demands of removing children from drug-abusing homes. Concurrent with the process changes, and following the final report of the Committee, the Board took the step of authorizing the creation of a Child Protective Systems Oversight Committee (CPS Oversight Committee). The Board charged the CPS Oversight Committee with the responsibility for providing community oversight of child protective systems, including preparing annual reports to the Board on the outcomes and effectiveness of the system, and any recommendations for policy and program changes. The CPS Oversight Committee investigated 13 critical incidents and one near fatality between 1997 and 2007 related to families or children who were known to CPS either through referrals or cases. During these years, the CPS Oversight Committee issued eight reports with 281 recommendations for improvement to CPS services. Despite the efforts of the CPS Oversight Committee, however, CPS continued to attract negative public attention between 1996 and 2008 and experienced criticism from other review organizations. For instance, the Child Death Review Team (CDRT) issued a number of findings and recommendations directed at the County and CPS. CPS was also the subject of six Grand Jury reports between fiscal years 1996-97 and 2007-08. Additionally, the media continued to report on cases involving children known to CPS who were subsequently killed by their parents or guardians. Beginning in late 2007 and continuing through the end of calendar year 2008, the number of fatalities relating to children or families who were known to CPS through referrals or cases began to rise sharply, increasing the negative public attention to CPS. From September 2007 to July 2008, seven children who were known or whose families were known to CPS were killed, and an additional three children who were known or whose families were known to CPS were killed between August 2008 and December 2008.
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Sacramento County Child Protective Services Review
Executive Summary
CPS was also subject to negative criticism from the media. The local newspaper published a series of articles investigating CPS operations and found that CPS had continued to fail to protect the most vulnerable children at the most basic level. The newspaper reported instances in which CPS had an active or recently closed referral or case that involved a child fatality. Subsequent articles described significant deficiencies with CPS operations, including failures by supervisors and managers related to case oversight, case files altered by staff after a childs death, and missing or incomplete case files and information. Although, CPS initially downplayed some of the newspapers articles, reports of another childs death involving a CPS case triggered the County to authorize a review of CPS activities.
Scope and Methodology

The County awarded a contract to MGT to perform a review of CPS services. This review began in September 2008 and continued through February 2009. The scope of work focused on evaluating CPS to determine whether it was adequately and sufficiently providing services to families and children to allow it to meet its mission. The review targeted areas that may have been involved in cases or referrals pertaining to child fatalities and did not include analyses of some programs within CPS, such as adoptions, licensing, and permanent placement. The MGT team reviewed the divisions organizational structure and work-flow processes in four areas: Intake and Emergency Services; Family Maintenance and Informal Supervision; Court Services and Dependent Intake; and Family Reunification. Our work included conducting interviews and focus groups of CPS staff throughout the organization. In addition, we conducted an on-line, confidential survey of all CPS staff to obtain input regarding various resources and activities within the division. We tabulated the survey results and interview comments and used this information, along with our observations, review of documentation, and analysis of processes to identify possible findings and recommendations for inclusion in our report. For those items that seemed to indicate weaknesses or obstacles for the division, we substantiated those concerns through our focus group discussions with supervisors, review of CPS data and statewide child welfare statistical data, review of child fatality cases, and review of the divisions policies and procedures. We also interviewed staff who provided us with their direct contact information and who were willing to participate in follow-up discussions to obtain perspective on selected issues. Because these staff self-identified and volunteered for interviews, we note that the interviewees do not represent a random or statistical sample of all CPS staff. We compared the policies and procedures for the County with those used by a sample of other, comparable, counties in California. Our review of the policies and procedures focused on addressing various issues, including the extent to which CPS policies and procedures were current, comprehendible, reliable, effective, and optimal. In addition, we conducted data comparisons for the County against the selected counties and the state, using information related to death rates and outcomes, caseload ratios and funding, and use of technology. We identified any strategies needed for implementation of recommendations, including any necessary changes in staffing levels and funding to enact the recommendations and future planning for expected population growth. We also reviewed best practices and benchmarks of measurements in comparable agencies and California counties and recommended a strategy to employ them in Sacramento County. We obtained and analyzed caseload levels to determine what, if any, impact the levels have had on work quality and performance. Within existing caseload levels, our team identified, to the extent possible, what realistically can be achieved by line workers within established policies and procedures. We used this analysis in our evaluation of the divisions allocation of resources Page2
Executive Summary
to identify where, if any, staffing deficiencies or surpluses exist and to develop recommendations on how to correct them. We conducted a detailed review of seven cases involving child fatalities. To the extent possible, we created a general profile of the children or families, and the employees involved in each critical incident in order to determine if there were any trends. However, due to concerns from the County over identifying specific case workers given the limited number of cases in the sample, we did not present data related to specific social workers in the report. We followed up on problem areas by identifying concerns with the training and level of supervision provided to each employee, including an analysis of the adequacy of training and supervisory support. We also reviewed, but at the Countys request did not report on, demographics related to the employees associated with the child fatality cases, as well as any performance issues noted for the employees on prior cases. The identification of performance issues came solely from our review of case files and quality assurance reports since we were not granted access to employee files. Based on our analysis, we developed recommendations on the timeliness and quality of service provided, and whether or not adequate resources are made available to staff to best provide this service. These findings and recommendations are summarized in the following sections and described in detail throughout the report.
Overall Findings and Recommendations

Our review found that children and families in the Sacramento child welfare system are underserved and CPS is missing opportunities for improvements to protect children from abuse and neglect and to ensure that children have permanency and stability in their lives. In analyzing outcomes related to safety and permanency for children served by CPS, our team found that Sacramento has seen decreases in many key performance areas in recent years. We note that Sacramento is not the only county in California that has had decreased performance in outcome measures related to childrens safety and permanency. However, the scope of our review was not to determine deficiencies in operations for all countiesrather, our focus was solely on Sacramentos performance and the results of its efforts to make improvements to its services for children and families in the region. The Countys performance across outcome measures, coupled with internal performance measures, leads us to conclude that CPS may not be adequately or sufficiently providing services to families and children to allow it to meet its mission, that its policies and procedures are not working when followed, and that actions taken to ameliorate findings have failed to result in measurable improvements to CPS operations. Our review of statistics created internally by CPS staff or published through the use of the Safe Measures data system by the County found that on many levels, the County is failing to provide timely services to the children and families it serves. Social workers are not using the SDM risk and safety assessment tools for all referrals for which these tools are required. Furthermore, the social workers often complete the tools late in those instances in which they are being used. Research has found that counties implementing SDM had significant improvements in children and family outcomes. By accurately classifying families according to the level of risk, an organization can also more selectively focus its resources. Our discussions with supervisors and social workers found that morale levels are low and frustration levels are high within the division. The current structure and requirements contained within this system are such that social workers cannot fulfill all required functions. Staff at all levels lack access to comprehensive formal guidelines. Social workers and supervisors struggle to work in a system that is overly dependent on paper-based and manual systems rather than making better use of the technology and data systems CPS currently has. Social workers and Page3
Executive Summary
staff we talked to demonstrated a great deal of dedication and commitment to helping families and children. Many social workers and supervisors work far more than the expected 40 hours per week in an effort to provide as many services and to help as many families as they can. Unfortunately, their efforts are often hampered by a system that places a higher emphasis on documentation and deskwork than on children and fieldwork. In our review, we did not find that CPS is failing to help all or the majority of children and families that it serves. CPS investigates a large number of referrals and provides services to a large number of children and families in the region. However, the current CPS requirements and operating structure hamper its ability to provide child welfare services effectively and efficiently. Moreover, inconsistent procedures and failure to follow best practices have resulted in negative outcomes for some children in the Countys child welfare system. Utilizing poor practices has also resulted in families and children not receiving the best services to meet their needs. Consequently, the issues within these families that brought them into the child welfare system in the first place may continue to be unaddressed, leaving children at risk. Improving CPS operations and processes is imperative if the County is to address these issues and optimize its service delivery to families and children in the future. The number of critical incidentsfatalities or near fatalities of children who were known to CPS through cases or referrals that were open or closed within six months of the incidenthas increased dramatically in the most recent year. Between 1997 and mid-2007, the CPS Oversight Committee investigated 13 critical incidents (12 fatalities and one near-fatality) of children who were known to CPS at the time of the incident. However, between September 2007 and July 2008, there were seven critical incidents, along with an additional three incidents that occurred between August 2008 and December 2008. This brings the total in a 15-month period to ten critical incidentsa substantial increase in the occurrence of these tragic events over the prior ten years. Our review of seven fatality cases that had open or recently opened CPS cases or referrals found procedural deficiencies in all cases. In all seven cases, social workers failed to comply with one or more of the divisions requirements related to referral investigation and/or case management. These failures include inadequate or inappropriate use of the Structured Decision Making (SDM) tool for risk or safety assessments, failure to complete the SDM tool, inadequate case documentation, inadequate follow-up or attempts to corroborate statements made by parents or children, and delays in transferring or handing off cases between bureaus. In four of the cases, the process deficiencies resulted in CPS missing clear opportunities to offer services to the family and/or possibly remove the child from the unsafe situations that led to the childs death. CPS has seen increases in higher risk referrals and program caseloads in selected programs. Caseloads are increasing to the point that in many instances, it is not possible for social workers to carry out all required activities for the children assigned to them. We found that management did not appropriately address increases in caseloads. CPS needs to perform contingency planning to allow it to proactively address workload shifts, rather than managing case spikes reactively. Having a contingency plan would also set expectations for staff and also ensure that the division is prepared to handle large influxes of cases or referrals. Increases in caseloads are exacerbated by CPS high absentee and vacancy rate for its social worker classifications. These vacancies and absences result in a shift of caseload onto other social workers or programs, impacting the divisions ability to deliver quality services. During a three month period we reviewed, social worker absentee rates division-wide averaged over 12
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Executive Summary
percent, and two programsEmergency Response and Team Decision Makingaveraged more than 18 percent absenteeism during these months. Moreover, CPS vacancy rates have increased in recent years. Combining vacancy and absentee rates, we found that most program areas within CPS averaged more than a 25 percent rate of missed work. Consequently, staff in these units who were available and working had to take on an increasing number of cases flowing into the system, as well as make up for the hours that were not worked by others. Further adding to the problem is Sacramentos high turnover rates. Average statewide turnover rates in a 2006 study by the Child Welfare Directors Association (CWDA) ranged between 10.6 and 18.4 percent depending on the social workers classification (entry level, journey level, or professional level). Turnover rates within the Sacramento CPS exceeded the reported amounts. In the most recent fiscal year (2007-08), CPS average turnover rate for all programs was 22 percent, with some units, such as Family Reunification, as high as 30 percent. The County incurs significant fiscal costs related to CPS social worker turnover. Estimates by the CWDA reported that the cost of turnover is approximately $9,500 per employee who leaves. Reducing turnover and increasing retention is thus a key strategy to realize fiscal savings for the County; especially critical given the Countys current economic situation. We benchmarked CPS caseloads against ratios in the funding levels by the state and found that some Sacramento workers are carrying case loads that are more than double the recommended and funded levels of children. The trend over the past year has been for casecarrying social workers to have a larger number of cases. Carrying a high number of cases can effectively result in social workers being set up for failure, by not having the ability or time to manage all assigned cases. In part, low staff morale and high frustration levels may be due to CPS failure to provide adequate resources and guidance to support staff in their work. Staff at all levels lack access to comprehensive formal guidelines. Further, social workers and supervisors struggle to work in a system that is overly dependent on paper-based and manual systems rather than making better use of the technology and data systems CPS currently has. CPS documents its policies and procedures in a series of guideline documents. Our team found numerous deficiencies in reviewing these guidelines. The division guidelines contain a mix of policies and procedures without clearly defining or differentiating between the two. CPS has a large number and quantity of pages in its documented guidelines compared to some other counties. Many of these guidelines are outdated and duplicated other guideline documents. The Countys guidelines for its social workers contain 167 policies spanning more than 1,300 pages. Over 60 percent of these guidelines were last created or updated more than five years ago. CPSs existing guidelines include a mix of outdated or conflicting guidance, caused, for example, when the division created a new guideline without revoking or amending a prior guideline document related to the same procedure. CPSs guideline documents also include redundant or duplicate steps in some instances and fail to document key steps or requirements in other instances. CPS lacks a systematic process to periodically review and update policies and procedures for changes to legislation, regulations, or best practices. It appears that in many cases, as it has identified the need for changes to existing guidelines, CPS simply issued new guidelines or program information notices without rescinding or modifying prior documents. Our review of procedures actually used by CPS staff found a high number of handoffs and a large dependence on paper documentation, which hamper the expedient movement of cases and referrals through the system. Lacking clear guidance, staff and supervisors decide which of
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Executive Summary
the required activities they will perform. Furthermore, inconsistent written guidelines that are often contradictory, duplicative, or outdated hampered our ability to determine whether policies and procedures work when followed, because the department lacks a consistent set of policies and procedures. Having multiple handoffs means that the division has a built-in learning curve time required for each social worker to familiarize herself or himself with the case and prior activities. This could be ameliorated with adequate communication between the past and current social workers. However, given increasing caseloads and documentation requirements, in many instances there is minimal contact or discussion between social workers in different bureaus related to case handoff. This has resulted in tension between the programs, which hampers the ability of CPS staff to work together to offer the best services possible to children and families. This tension has only increased in recent months as formerly mandatory meetings (hand-to-hand meetings) between the prior and new social workers for case transfers have been suspended. CPS has multiple paper documents required for case management. These documents may or may not ultimately appear in the Child Welfare Services Case Management System (CWS/CMS). Therefore, social workers who are not the primary workers on the case or who are waiting for the hard-copy case file to be transported to them do not have full access to all information related to the case. As a result, they may either duplicate procedures already being performed or fail to perform action steps required for the family. Additionally, most of the paper documents require an approval by a supervisor, and in some instances by a program manager. Because the division lacks a process for transmitting and tracking these documents electronically, there are hundreds of paper documents at any given time circulating throughout the division with no formal tracking process. Staff and supervisors reported a great deal of frustration when documents are lost, delayed, or returned to the wrong person. CPS has processes that are not adding value or that require a great deal of manual or duplicative steps. These problem areas include the staff meeting process, which requires a large amount of paperwork and documentation, much of which could be documented in the electronic data system. Additionally, we found that Team Decision Making (TDM) meetings are not resulting in significant value to the division and have resulted in the division under-utilizing some social workers. Taken as a whole, the divisions processes result in it placing more emphasis and focus on documentation and desk-work activities than it does on meeting with children and families and performing out-of-office fieldwork. This focus does not result in the best services for children and families and does not ensure social workers can give the support to families that is needed to reunify or end CPS involvement safely and promptly. In looking at prior external reviews, we found that CPS has failed to adequately address ongoing and recurring issues and recommendations by the CPS Oversight Committee, the primary external reviewer of CPS for the past several years. Since 1996, the CPS Oversight Committee has issued eight reports and 281 recommendations. Although CPS has reported implementing many action items, the majority of the issues identified by the CPS Oversight Committee have continued to be reported from year to year, and continue to persist within the divisions current practices. Moreover, many of the CPS Oversight Committees recommendations have been mirrored in the six Sacramento County Grand Jury reports issued between fiscal years 1996-97 and 2007-08.
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Executive Summary
CPS management has not disagreed with the findings in the CPS Oversight Committee reports, and in many instances has acknowledged that the problems exist and that it intends to find solutions. In fact, CPS management has implemented a large number of action steps to attempt to resolve deficiencies and findings. However, these actions have failed to result in substantive changes and improvements to service delivery. In general, it appears that most of managements solutions are short-term in nature or involve creating, but not necessarily implementing, new policies or procedures. In other cases, these solutions are quickly overridden by staffs actions, especially when the new requirements add to already high workloads. CPS does not appear to be effectively tracking the implementation status of its action plan items. CPS action items do not contain timelines, responsible staff, start and end dates, or steps to measure the results of its actions. Therefore, not only does CPS lack data on the effectiveness of its actions, it also lacks a means to determine which recommendations staff have actually implemented. In part, CPS problems with addressing issues stems from executive management (division managers and the deputy director) not functioning as strategic leaders within the division. Issues related to child fatalities in recent years have resulted in executive managers spending a large portion of their time reviewing cases and unit metricstasks better suited for program managers or supervisors. Communication issues and staff resistance have also played a role in CPS failure to implement recommendations and make substantive changes within the organization. CPS executive managers will need to address and remedy communication gaps at all levels if they are to successfully implement fixes to the system and improve outcomes for children and families. It appears that given the number of cases and children served by CPS compared to expectations established by the state in funding child welfare services, CPS may need additional staff. However, determining the number of staff required by CPS and for which programs is difficult to estimate. This is because the inefficiencies in the current system contribute greatly to the amount of work social workers must perform. Bringing in more social workers without addressing process deficiencies and lack of clear guidelines could result in CPS paying for a larger number of staff who are not providing timely or compliant services to children and families. These actions could also result in increase costs to the County as social workers become frustrated with working in a broken system and subsequently leave the division. The County therefore needs to combine exploring ways to address issues with CPS lacking sufficient staff in conjunction with making system improvements to better retain existing staff. CPS also has a continuing problem with obtaining sufficient technology and resources for staff to effectively and efficiently perform their jobs. The division needs technology that allows social workers to document case notes and findings and perform risk assessments while in the field. CPS manual process that must be used to obtain vehicles is frustrating for social workers. Social workers also expressed concern with the quality of the vehicles available to them. Given the large geographic area and number of children served, cars are experiencing a high degree of wear and tear, resulting in shorter than expected life spans. Social workers reported feeling unsafe in cars and experiencing frequent breakdowns while in County vehicles. Given the high usage and large geographic area, it may be beneficial for CPS to consider contracting with the County for additional vehicles, using lower paid staff as runners to obtain vehicles for social workers at their field offices, and reviewing replacement policies related to vehicles to determine if the policy should be modified. Finally, CPS has opportunities to improve its coordination with other governmental agencies and not-for-profit organizations. Building on and strengthening partnerships with other organizations
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Executive Summary
would allow CPS to foster the strengths of these groups and leverage their resources to help families and children in the community. Given the nature and extent of the issues, we found that CPS needs to take significant efforts to address the findings. It will need to undertake a comprehensive plan of action to restructure its policies and procedures, reallocate staff based on identified needs and caseloads, train staff on the proper use of available resources and tools, and analyze technology and resource needs to ensure staff have the resources available to do their jobs. We are concerned that CPS has had a number of years to correct problem areas identified internally and by external agencies, but has consistently failed to fully address these recurring issues in ways that result in meaningful and substantive changes. The County needs to strongly consider bringing in external assistance to lead the change development efforts and to ensure that the action steps taken have clear, measurable goals. These steps will help the County oversee the efforts made by CPS to remedy the areas of concern. Although the County is experiencing a large budget deficit, we believe that CPS has opportunities to achieve cost reductions by implementing the recommendations.
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Project Background
Introduction
This chapter describes the project background, including the scope and methodology used by our team to evaluate the Sacramento County (County) Child Protective Services division (CPS or division).
Project Background
A number of issues led to the request by the County to review CPS activities. In this section, we present the issues leading up to the Countys request for a comprehensive review of CPS and its services. CPS began its time in the public spotlight in 1996 following the hospitalization of a young child, Adrian Conway. Adrian Conways family had previously been investigated by CPS. However, the division had closed the case in 1995 after determining the childs risk to be moderate. Responding to the negative public attention generated after a newspaper investigation described the childs death and CPS involvement, the Sacramento County Board of Supervisors (Board) called for a full investigation and announced plans to convene a panel of independent experts to examine what went wrong in the case. The primary charge of this Critical Case Investigation Committee (Committee) was to examine this specific case and to determine whether any systemic problems existed with the child protective system. Adrian Conway subsequently died from his injuries during the time the County was forming the Committee. In May 1996, the Committee issued its report, concluding that CPS had leaned too strongly towards keeping troubled families together, leaving children at risk. The Committee issued 43 findings and 35 recommendations. In June 1996, the Grand Jury (Grand Jury) also issued a report of its investigation of CPS activities. In this report, the Grand Jury noted that CPS had improperly evaluated the Adrian Conway referral and that supervisors had failed to catch the social workers error. The Grand Jury noted that the explanation for the failure appeared to be case overload as well as a misguided emphasis on trying to unify a totally dysfunctional family. In July 1996, the Board approved policy changes recommended by the Committee and Grand Jury to amend the way CPS monitored and investigated abuse cases. In 1997, after another child fatality in which CPS had closed the case as moderate-to-low risk, the Board issued additional policies mandating that CPS staff become more aggressive in removing children from homes with known drug abuse. The Board also added 58 CPS staff positions to deal with the demands of removing children from drug-abusing homes. Implementing these changes led to the Countys foster care population increasing from approximately 5,500 children in 1998 to almost 6,000 children in 2000. In 2001, given the increase in children in foster care, the Sacramento County Grand Jury asked the County to assess whether its new policy emphasizing child safety was working, or if officials needed to return to the practice of helping troubled families stay together. After studying the matter, the Board decided to make no policy changes, wanting to continue to emphasize child safety over family reunification. Concurrently with the process changes, and following the final report of the Committee, the Board took the step of authorizing the creation of a Child Protective Systems Oversight Committee (the CPS Oversight Committee). The Board charged the CPS Oversight Committee
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Project Background
with the responsibility for providing community oversight of child protective systems, including preparing annual reports to the Board on the outcomes and effectiveness of the system, and any recommendations for policy and program changes. The CPS Oversight Committee investigates critical incidents (fatalities involving families or children who were known to CPS either through referrals or cases), and issues reports to the Board. The reports contain findings related to the critical incidents and a series of recommendations for improvement to CPS activities. Between 1996 and 2008, the CPS Oversight Committee issued eight reports and made 281 recommendations. Despite the efforts of the CPS Oversight Committee, CPS continued to attract negative public attention between 1996 and 2008. CPS experienced criticism from other review organizations, such as the Child Death Review Team (CDRT)a collaborative inter-agency team that investigates, analyzes, and documents the circumstances that led to all child deaths in Sacramento County. The CDRT issued a number of findings and recommendations directed at the County and CPS. CPS was also the subject of six Grand Jury reports between fiscal years 1996-97 and 2007-08. Additionally, the media continued to report on cases involving children known to CPS who were subsequently killed by their parents or guardians. Excluding the Adrian Conway case, between 1997 and 2007, the CPS Oversight Committee investigated 13 critical incidents and one near fatality related to families or children who were known to CPS either through referrals or cases. Beginning in late 2007 through the end of calendar year 2008, the number of fatalities relating to children or families who were known to CPS through referrals or cases began to rise sharply, bringing a great deal of negative public attention to CPS. Between September 2007 and July 2008, seven children who were known or whose families were known to CPS were killed, and an additional three children who were known or whose families were known to CPS were killed between August 2008 and December 2008. In June 2008, the Sacramento Bee published a series of articles entitled Unprotected concerning CPS operations. The investigation found that more than a decade after the Adrian Conway murder and investigation, CPS had continued to fail to protect the most vulnerable children at the most basic level. Over the course of several weeks, the newspaper reported additional instances in which CPS had an active or recently closed referral or case that involved a child fatality. In subsequent articles, the Sacramento Bee also described significant deficiencies with CPS operations, including failures by supervisors and managers related to case oversight; case files altered by staff after a childs death; and missing or incomplete case files and information. Initially, CPS downplayed some of the series findings, stating it was unfair to compare Sacramentos results with those of other large counties. However, after another death occurred involving a CPS case, the County authorized a review of CPS activities, including policies and procedures.
Scope and Methodology

In August 2008, MGT responded to the Countys request to conduct a review of CPS services. The County awarded a contract to MGT to perform these services. This review began in September 2008 and continued through January 2009. Our scope of work for this project was to evaluate CPS to determine whether it was adequately and sufficiently providing services to families and children to allow it to meet its mission. Because the primary focus was on identifying issues that may have contributed to child fatalities, we excluded from our review several programs within CPS, including adoptions, licensing, and permanent placement.
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Project Background
Our team conducted a variety of tests and procedures in conducting the review and gathering data to support our findings and recommendations. First, our team held a number of interviews with staff and stakeholders to identify key issues, trends, goals, expectations, objectives, procedures, and service delivery goals relevant to CPS operations. We interviewed, among others, members of the CPS Oversight Committee and its Critical Incident Review Committee; representatives on the CDRT; CPS supervisors; CPS staff; CPS executive managers; and union representatives. We performed a detailed case review of seven cases in Sacramento County from fiscal year 2007-08 involving child fatalities and for which either an open CPS referral or case existed, or had recently been closed prior to the childs death. Due to the confidential nature of CPS case and referral files, CPS and the County declined to provide us with access to the Child Welfare Services/Case Management System (CWS/CMS) to allow us to identify the cases for review. Therefore, we relied on CPS to identify the fatality cases for our review. Once CPS had identified the group of cases, the Sacramento County Office of the County Counsel (County Counsel) filed petitions with the Sacramento County Juvenile Court to request access to the case files. The County Counsel also provided required notifications to the parents or guardians of the children for whom we were requesting case files. After the Juvenile Court approved the petitions, CPS prepared redacted copies of the requested case files for our review. Our team reviewed demographics associated with the children and families for each case as well as the demographics of the social workers assigned to the referrals or cases. We also reviewed the cases in conjunction with reviewing CPS policies and procedures to determine if CPS workers had complied with best practices and required policies of the division. In cases where we had questions related to social workers activities, we followed-up with the appropriate CPS executive managers or administrative staff. Initially, we planned on interviewing the social workers and supervisors involved with these cases. However, the Sacramento County Department of Health and Human Services (DHHS) and County Counsel raised concerns that interviewing these staff may not be appropriate as the interviews could conflict with ongoing personnel actions and cause concerns with the unions representing the employees. Therefore, at the Countys direction, we did not interview the staff or supervisors directly about these cases. Next, we reviewed reports from the CPS Oversight Committee and the CDRT related to child abuse and neglect fatalities over the past eight fiscal years. We used these reports to identify ongoing and recurring issues and recommendations, and followed-up with division staff on any items that have continued to be problems for several years. We also reviewed the quality assurance (QA) reports created by CPS related to each of the child fatality cases that we reviewed. Our team reviewed the divisions organizational structure and work-flow processes through a variety of tasks. To diagram the work flows, we conducted a series of focus groups with CPS supervisors in four areas: Intake and Emergency Services; Family Maintenance and Informal Supervision; Court Services and Dependent Intake; and Family Reunification. During the focus groups, MGT mapped out the case and referral work flows and identified issues of concern or items that prevent cases or referrals from moving as smoothly as possible. MGT identified in its maps critical decision-making points in the processes and any service gaps. After developing the maps and initial issues list, MGT met with the supervisors to vet the maps and issues lists and to verify that our understanding was correct.
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Project Background
Due to the limited amount of time available to conduct the review, we did not interview all CPS staff. However, we did initiate an on-line, confidential survey of all CPS staff to obtain input regarding various resources and activities within the division. We relied on CPS executive management to notify CPS staff of the on-line survey. Ultimately, we received 288 responses to the surveya response rate of 29.4 percent of CPS 981 employees. We tabulated the survey results and used the resulting tables and graphs, as well as employee comments to identify possible findings and recommendations for inclusion in our report. For those items that seemed to indicate weaknesses or obstacles for the division, we verified the survey results through our focus group discussions with supervisors, our review of CPS and University of California Berkeley-provided data, our review of child fatality cases, and our review of the divisions policies and procedures. We also interviewed staff who provided us with their direct contact information and who were willing to participate in follow-up discussions to obtain perspective on selected issues. Because these staff self-identified and volunteered for interviews, we note that the interviewees do not represent a random or statistical sample of all CPS staff. We reviewed the hiring, training, and supervision practices within the division by examining division policies and procedures, employee minimum qualifications by job type, and training requirements. We also followed-up on any problem areas with executive managers, supervisors, and CPS staff. Our team performed a thorough review of policies and procedures in place at CPS, as well as the Corrective Action Plans resulting from critical incidents. The review included the following activities: Analyzing the practical application of each policy in child fatalities during fiscal year 2007-08, with specific attention to those policies that staff did follow, as well as failed to follow, and any patterns regarding these cases. Identifying barriers to the successful application of policies. Reporting on the status and implementation of activities called for in the Corrective Action Plans for critical incidents, as well as any barriers to the successful implementation of any recommended corrective actions. We compared the policies and procedures for the County with those used by a sample of other, comparable, counties in California. These comparison counties were selected based on the size and demographics of the counties, as well as the identification of counties leading in best practices related to child welfare services. The counties selected for comparison with Sacramento County were San Joaquin, Fresno, Santa Clara, and San Diego counties. Our review of the policies and procedures was developed to allow us to answer the following questions: Does the division have policies and procedures that are reliable? Is there an adequate management control system for measuring, reporting, and monitoring a programs policies and procedures? Is there duplication of effort by employees and procedures that serve little or no purpose? Are effective operating procedures in place? Are the division policies and procedures objective and understandable?
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Project Background
Is there consistency in interpretation and application of the policies and procedures? Are the policies and procedures in need of revision? Are policies and procedures working when followed? Is the division using the optimum amount of resources (staff, equipment, and facilities) in producing or delivering the appropriate quantity and quality of services in a timely manner? Based on a review of the divisions approach to new and proposed legislation impacting the business of the division, is there a proactive approach and adequate advocacy in the legislative process, and is there adequate planning and preparation for the changes enacted by the legislature? We conducted data comparisons for the County against selected counties and the state, using information related to death rates and outcomes (such as permanency); caseload ratios and funding; and use of technology. We identified any strategies needed for implementation of recommendations, including any necessary changes in staffing levels and funding to enact the recommendations and future planning for expected population growth. We also reviewed best practices and benchmarks of measurements in comparable agencies and California counties and recommended a strategy to employ them in Sacramento County. We obtained and analyzed caseload levels to determine what, if any, impact the levels have had on work quality and performance. Within existing caseload levels, our team identified, to the extent possible, what realistically can be achieved by line workers within established policies and procedures. We used this analysis in our evaluation of the divisions allocation of resources to identify where, if any, staffing deficiencies or surpluses exist and to develop recommendations on how to correct them. We considered staffing levels, staff deployment, and the use of temporary employees and consultants, workload, shifting priorities, demands for service, response time, job descriptions, division organization, and management. We also reviewed vacancy reports and staff-leave statistics as part of this review. To the extent possible, we created a general profile of the employees involved in each critical incident in order to determine if there are any trends. However, due to concerns from the County over identifying specific case workers given the limited number of cases in the sample, we did not present data related to specific social workers in the report. We did follow-up on problem areas by identifying concerns with the training and level of supervision provided to each employee, including an analysis of the adequacy of training and supervisory support. We also reviewed, but at the Countys request did not report on, demographics related to the employees associated with the child fatality cases, as well as any performance issues noted for the employees on prior cases. The identification of performance issues came solely from our review of case files and QA reports since we were not granted access to employee files. Finally, based on the work described above, we developed recommendations on the timeliness and quality of service provided, and whether or not adequate resources are made available to staff to best provide this service. We documented all study findings, conclusions, and recommendations in a formal written report. In December 2008, as we neared the end of our fieldwork, we met with both the County and CPS executive managers in separate meetings to discuss our draft findings. We also met again with the County and CPS executive managers in January 2009, holding separate meetings to discuss the findings and recommendations in our draft report. At the conclusion of the meetings Page13
Project Background
with CPS, we requested additional data and documents based on CPS executive managers response to our draft findings. CPS provided these in early January 2009. To solicit input from the CPS executive managers, we provided the deputy director and her division managers with a copy of the draft report and gave them 27 calendar days to review and comment on the report. At the end of this review period, CPS provided its response in the form of four binders containing over 2,100 pages of material. The majority of the documents provided by CPS were not germane to our review and did not provide any additional information that changed the context of our findings and recommendations. For example, we reported on CPS difficulties in forming and building on partnerships and linkages with community-based organizations and other governmental entities serving much of its population. Our report addresses problems in CPS relationship with agencies such as the County Department of Mental Health or the Department of Health Services. However, in its response, CPS provided more than 1,800 pages of copies of agreements with foster family agencies and vendors that were unrelated to the types of partnerships referenced in our finding. After reviewing CPS response, we provided the County and CPS with a revised report and a summary table that addressed each of the comments and identified any edits we made to the report then requested the County and CPS to provide a formal written response to address the findings and recommendations in the report. We met with the County and CPS in a joint meeting in mid-March 2009. The County and CPS provided verbal comments at this meeting that we considered in drafting the final report. At the end of the comment period, neither the County nor CPS provided additional written comments or changes. Therefore, at the conclusion of this process, we prepared and presented the final report to the County.
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Description of the Child Protective Services Processes

Introduction
To appreciate the significance of the findings and recommendations, one must understand the separate processes carried out by staff within CPS. This chapter describes the main processes at a high level. For a detailed description of each process, please see Appendix A, which is a pictorial representation of some of the Countys child welfare processes.
Child Welfare System in California and Sacramento County

In California, almost a half a million children come to the attention of child welfare officials via reports of suspected abuse or neglect each year. On any given day, more than 100,000 children are active in the child welfare system. That is, one or more counties in California are maintaining an active case or referral and/or providing Child Welfare Services services to these children and their families.
Participants
Child welfare services are provided by a variety of agencies and organizations. Federal, state, and county governmental organizations, Juvenile Courts, and private social service agencies all play a part in administering and overseeing child welfare services. The basic philosophical tenets of child welfare services in California are as follows: A safe and permanent home and family is the best place for a child to grow up. Child welfare services activities are most likely to succeed when clients are involved and actively participating in the process. When parents cannot, or will not, fulfill their responsibilities to protect their children, the state has the right and obligation to intervene directly on the childs behalf.
Federal: The U.S. Department of Health and Human Services Administration of Children, Youth, and Families provides oversight of state child welfare services and foster care programs. State: The CDSS supervises county administration of child welfare system and foster care programs through statute, regulation, policy, and compliance reviews. County: Social services agencies comply with federal and state requirements and provide child welfare services and foster care programs. Each countys Juvenile Court system determines if the child needs protection, and, if so, removes responsibility for care from the parents and assigns custody and care responsibilities to the social services department.
California has a state-supervised and county-administered child welfare system. The California Department of Social Services (CDSS) is responsible for designing and overseeing an array of programs and services for Californias at-risk families and children. Among other services, CDSS provides education and outreach related to child abuse prevention; helps to develop family strengthening approaches to childrens services, such as wraparound services, family unity models, and best practices guidelines; and develops and monitors county performance metrics related to child welfare services. Individual counties are responsible for administering the child welfare services within their geographic boundaries. As shown in Exhibit I-1 on the following page, there are a number of County organizations that oversee, administer, or provide input into the child welfare services process in the County. CPS is a division in the Countys DHHS, which is in turn a department of the Sacramento Countywide
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Services Agency. The Sacramento County Board of Supervisors (Board) oversees the County Executive and the public services agencies, including DHHS and CPS. Exhibit I-1Sacramento County Organizations Involved in Providing or Overseeing Child Welfare Services
Reports annually to the County on child fatalities that had CPS involvement.
SACRAMENTO COUNTY BOARD OF SUPERVISORS
Reports annually to the county on all child fatalities, including those with CPS involvement.
SUPERIOR COURT OF CALIFORNIA SACRAMENTO COUNTY
Sacramento Child Protective Systems Oversight Committee
COUNTY EXECUTIVE COUNTYWIDE SERVICES AGENCY
Child Abuse Prevention Council of Sacramento Child Death Review Team
Sacramento County Juvenile Court
Sacramento County Department of Health and Human Services
Annually reviews child fatalities with CPS involvement.
Sacramento County Division of Child Protective Services (CPS)
Juvenile Court has authority over dependent children. CPS carries out court orders and reports on family progress with case plans.
CPS is responsible for carrying out state and federal initiatives, and overseeing child welfare in the County. Among other tasks, CPS is responsible for investigating allegations of child abuse and neglect, and for providing a variety of services to keep children safe and to strengthen families. CPS also recruits and trains foster parents, acts as an adoption agency, and licenses family day-care homes. The mission of CPS is to achieve the well being of children in the community by protecting children, strengthening families, providing permanent homes, and building community partnerships. In addition to CPS, the Juvenile Court also plays a role in protecting children. The Juvenile Court system has ultimate authority over outcomes for children and families. The court serves as an independent judge of fact; its role is to protect the rights of all interested parties and to ensure that each child has a permanent home. The Juvenile Court decides if children will remain in foster care, and whether (and when) they will return to their parents. Several other agencies assist in monitoring and reporting on CPS activities in Sacramento. First, the state Welfare and Institutions Code authorizes counties to establish review teams to receive information related to child abuse or relevant to the prevention, identification, or treatment of child abuse. In November 1988, the Board directed the Child Abuse Prevention Council of Sacramento, Inc. to develop and coordinate an interagency team to investigate child abuse and neglect fatalities. After a year of planning, the CDRT was initiated in November 1989. The CDRT meets monthly to review deaths of all children under the age of 18 in the County. The team identifies the deaths from the Vital Records Unit of DHHS. Members of the team
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include representatives from the Sacramento County Coroners Office, the Sacramento County Sheriffs Department, the Sacramento City Police and Fire Departments, DHHS, the Sacramento County District Attorneys Office, and local hospitals. The CDRT issues an annual report to the Board related to each childs death, with an assessment of what contributing factors existed and what recommendations, if any, exist to prevent similar deaths in the future. To the extent that the team identifies issues with service delivery provided by any of the Countys agencies, departments, or divisions, it presents recommendations for improvements related to these findings. Between 2000 and 2005, the majority of the CDRTs findings and recommendations related to County activities as a whole and tangentially to CPS. However, in its 2006 report, the CDRT issued six recommendations directly related to CPS. Additionally, as discussed earlier in the project background section of this report, in February 1996, the Sacramento County Executive convened a Critical Case Investigation Committee in response to the child abuse and neglect death of Adrian Conway. The primary charge of this Committee was to examine this specific case and to determine whether any systemic problems existed with the child protective systems. Following the final report of this committee in May 1996, the Board authorized the creation of the CPS Oversight Committee. The Board charged the CPS Oversight Committee with the responsibility for providing community oversight of child protective systems, including preparation of an annual report to the Board on the outcomes and effectiveness of the system, and any recommendations for policy and program changes. The CPS Oversight Committee consists of members from the Sacramento area who are employed in a variety of occupations and who possess a wide range of expertise related to childrens issues. Members include representatives from the Sacramento County Childrens Coalition, Sacramento County DHHS, law enforcement, education, District Attorneys office, medical profession, and mental health, as well as foster parents. Annually, the CPS Oversight Committee investigates critical incidents (fatalities involving families or children who were known to CPS either through referrals or cases), and issues a report to the Board. The reports contain findings related to the critical incidents and a series of recommendations for improvement to CPS activities. Since 1996, the CPS Oversight Committee has issued eight reports and made 281 recommendations.
Description of the Child Protective Services Process

Intake and Emergency Response The Countys involvement in childrens lives typically begins with a phone call or letter sent to the CPS hotline (Intake) unit. Intake workers process referrals from the general public as well as from mandated reporters, and determine whether the allegation of abuse or neglect meets the divisions standards for acceptance of the referral.1 Intake workers determine whether there is sufficient information for them to process allegations as referrals. Intake social workers try to determine the answers to key questions, such as the following: Is the child in imminent danger?
Mandated reporters are those people who have a special relationship or contact with children or the home such as teachers, counselors, or law enforcement and who are legally required to report reasonable suspicions of child abuse or neglect.
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What is the risk of maltreatment? Does the suspected child abuse meet the legal definition of abuse or neglect? Is an in-person response required and, if so, how quickly? Intake staff report allegations as information only if insufficient information exists to conduct an investigation, or refer the allegation out to another County organization or entity if it does not fall within CPS parameters. If the Intake workers determine that an in-person investigation is appropriate, they assign a response time based on state and local criteria. This requires them to determine that either an immediate response is called for (an in-person contact with the family within 24 hours, although Sacramento attempts to make contact within two hours), or a ten-day response is appropriate (an in-person contact with the family within ten calendar days of the referral). After the referral is accepted and assigned to an Emergency Response social worker, the Emergency Response staff begin investigating the referral and attempting to make contact with the child and family members. Social workers gather information from their interviews as well as from collateral contacts (discussions with doctors, teachers, witnesses, neighbors, and relatives, among others). The social worker also uses the Structured Decision Making (SDM) assessment tools to weigh the safety and risk to the child. The social worker can designate referrals as low, moderate, high, or very high-risk depending on the investigation and the results of the SDM assessments. Using the information gathered, the social worker makes one of three determinations for the referral: Unfounded: The report is determined to be false, inherently improbable, to involve accidental injury, or not constitute child abuse as defined in the law. Substantiated: The report is based on credible evidence and constitutes child abuse and/or neglect. Inconclusive: The findings are inconclusive and there is insufficient evidence to determine whether child abuse and/or neglect have occurred. If the social worker deems the report of child maltreatment to be unfounded or finds that there is insufficient evidence to determine whether the maltreatment occurred, he or she closes the case. Based on the conclusion and the severity of the abuse or neglect, the social worker will determine an appropriate response for families for which it has substantiated abuse or neglect. If the social worker finds that the parents do not pose an immediate and high risk of maltreating their child the social worker can decide to leave the child at home and offer caregivers up to 30 days of emergency response services or up to six months of voluntary family maintenance services. At the end of these periods, the case is either closed or referred to juvenile dependency court if there is a new report of suspected child abuse or the social worker determines that the voluntary services have failed. If the parents refuse to voluntarily accept services, the social worker may leave the child at home and petition the court for an order to provide court-ordered family maintenance services. If the social worker determines that the child cannot remain safely in the home, he or she must take immediate steps to remove and place the child in a safe environment. Social workers, with the assistance of law enforcement, can place children into protective custody (PC) for up to 48 hours if exigent circumstances exist. The term exigent circumstances encompasses a group of Page18
related exceptions to probable cause and search warrant requirements. Government officials are required to obtain prior judicial authorization before intruding on a parents custody of his or her child unless they believe that exigent circumstances exist. Exigent circumstances are those circumstances that support a reasonable belief that there is an imminent and substantial threat to the childs life or health. The determination of exigent circumstances is made on a case-bycase basis by the social worker and/or his or her supervisor. For children removed from the home under exigent circumstances, the social worker must file a Section 300 petition to the court within 48 hours of the child being taken into custody if the social worker feels that the intervention of the juvenile court is required. If exigent circumstances do not exist, but the social worker has concerns about the childs longterm health or safety in the home, the social worker can seek a protective custody warrant. Social workers first consult with their supervisors about the case to determine whether a protective custody warrant petition is required for the child. If the social worker and supervisor agree that they would like to seek a protective custody warrant, they consult with County Counsel to discuss the case and the support for the petition. If the County Counsel, social worker, and supervisor feel that adequate support exists, the social worker prepares a petition to the juvenile dependency court to request that the court grant a protective custody warrant. The Juvenile Court generally elects to approve the petition if it finds circumstances that cause harm or pose a serious risk of causing harm to a child exist. These circumstances are outlined in Section 300 of the California Welfare and Institutions Code, and include, but are not limited to, the following circumstances: There is substantial danger to the child. A person residing in the home has sexually molested the child. The child is left without provision for his or her support. The parent or caretaker is unwilling to have physical custody of the child. When the court approves the protective custody warrant it gives the social worker the authority to remove the child from the home. To declare dependency and formally place the child under the courts jurisdiction, the court subsequently holds one or more of a series of hearings outlined in the Juvenile Court Process section. In doing so, the court determines the appropriate actions to take related to the child and his or her family. The Emergency Response activities typically end when the referral is closed as unsubstantiated or inconclusive, when the case is accepted and transferred to a voluntary services unit (such as Informal Supervision), or when the child is placed into custody and the case is transferred to the Dependent Intake and Court Services unit. Dependent Intake and Court Services Dependent Intake social workers, who are part of the CPS Court Services program, process children who have been placed into protective custody, either by the courts or by social workers and law enforcement. Children are initially brought to one of two locations depending on their age and needs. At the intake facilities, the Dependent Intake social workers conduct a body check, assess the childs need for urgent care, process children who meet the criteria to the University of California at Davis, Child and Adolescent Abuse, Resource, Evaluation (UCD CAARE) center for a medical exam as needed, and interview children on the circumstances
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related to their removal. The Dependent Intake worker then places the child into his or her first temporary placement. After processing a child into custody, the Dependent Intake worker provides case file and contact information to the Court Services unit. Court Services social workers are responsible for filing petitions with the court (if not already done so), and for investigating situations where other social workers have filed petitions with the Juvenile Court. During the course of their investigation, Court Services staff gathers information about the parents, the family, the child, siblings, and the home. Based on the investigation results, the Court Services social worker prepares a report for the court. The report includes recommendations about child placement during the time the child is a dependent of the court. Additionally, the social worker assists the family in developing a case plan to be presented to the court. The case plan is a plan of action to improve the situation that led up to the courts involvement in the childs life. The case plan can include parenting classes, individual counseling, family counseling, alcohol or drug treatment, visitation requirements, or other programs and classes as needed. The court can choose to adopt the case plan in part or in total and can also elect to add requirements to the plan. The social worker then assists the family in obtaining the services that the court has determined to be necessary. Juvenile Court Process The Juvenile Court has the ultimate responsibility for outcomes for children and families. The court process involves a series of hearings and case reviews within specified time frames. Judges or court-appointed referees rely on assessments and information from social workers, service providers, and others to reach their decisions. They may appoint special child advocates and attorneys to represent the child, parent, and placement agency. The legal process is ultimately intended to protect children through the use of the Courts authority. The court process begins when the social worker or law enforcement removes a child from his or her parents or when the social worker determines that court intervention is required. The social worker files a petition with the Juvenile Court to request that the Juvenile Court take the child under its jurisdiction and declare the child a dependent of the Court. Through a series of hearings, and depending on the safety needs of the child, the Court can leave the child in the care of the parents and order family maintenance services for the parents to address concerns. The Court can also place the child in out-of-home care as a necessary step to keep the child safe and order the family reunification services be provided to the parents to help them regain custody of the child. Following the filing of the WIC 300 petition and the detention or initial hearing, the Juvenile Court conducts additional hearings to determine whether the allegations are true, and, if true, whether Court jurisdiction is necessary. The Juvenile Court relies on the social worker to provide case management for the family, to prepare service plans aimed at family reunification or alternative permanent placement, and find appropriate out-of-home placement that meets the childs needs, among other services. The court obtains periodic updates from social workers via court reports and periodic hearings in compliance with statutory timeframes and requirements. Types of hearings and statutory timeframes are described belowit should be noted that not every child will need all of these hearings.
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Initial (Detention) Hearing: The hearing to determine whether there are sufficient grounds to support the petition to seek court intervention. Due within 48 hours if the child has been removed from the home. Jurisdiction Hearing: The hearing to determine whether or not neglect and/or abuse have occurred and whether court intervention is warranted under Section 300 of the California Welfare and Institutions Code. Due within 20 days of the detention hearing if the child is in custody or within 30 days if the child is not in foster care. Disposition Hearing: The hearing to determine the childs placement and to establish the plan for services. Generally the court orders family maintenance if the child is living at home or family reunification services if the child is in foster care. Due within ten days after the jurisdiction hearing if the child is in custody or within 30 days if the child is not in foster care. Review Hearing: The hearing to review service efforts and to determine if a child in outof-home care can be reunified with parents or guardians or whether a child in courtordered family maintenance can remain at home. Due at six-month intervals. Permanency Planning Hearing: The hearing to determine if a child can be reunified, or to identify the long-term plan when reunification will not occur. Due within 12 months (six months for children under the age of 3), but can be extended to within 18 months. Selection and Implementation Hearing: The hearing to select and implement the appropriate permanent placement for the child. The court can terminate parental rights and order adoption or another option (such as long-term foster care or guardianship) as a permanent plan. Due within 120 days after reunification services end. Post-Permanency Planning Hearing: The hearing to monitor the progress of the longterm plan. Due every six months until the case is closed. The Court may dismiss a case at any point if the problems that brought the family into Court have been remedied and the child is no longer at risk in the care of his or her parent(s). The Court may also dismiss a case if the child emancipates while in foster care (generally, when the child reaches the age of 18, but could be extended depending on the childs circumstances). Family Maintenance and Informal Supervision Family maintenance programs offer time-limited protective services to families in crisis to prevent or remedy abuse or neglect. These services allow the social workers to work with the family while keeping the child in the home. Services include counseling, emergency shelter care, respite care, emergency in-home caretakers, substance abuse treatment, domestic violence intervention, victim services, and parenting education. Family maintenance programs are designed to maintain the child in his or her home for a set period of time, while addressing the issues that led to the familys involvement with CPS. Sacramento offers both Voluntary Family Maintenance and Informal Supervision services to families and children. Both programs provide services that are designed to reduce risk to children and to promote and strengthen the family unit. Parents referred to these programs are offered services to encourage them to make healthy choices and positive changes in their lives and the lives of their children. For the first three months of the program the Family Maintenance social worker meets with the family once every 15 days. At each meeting, the social worker assesses the risk to the children of abuse or neglect. If the social worker determines that the
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childs health or safety is in jeopardy, he or she may place the child in protective custody or seek a protective custody warrant from Juvenile Court. Informal Supervision is supervision made in accordance with provisions in the California Welfare and Institutions Code, Section 301. CPS uses these intensive services in lieu of filing a petition with the dependency court, or subsequent to the dismissal of the petition. CPS enters into a contract with the parents or guardians. The contract outlines the goals of protecting the child who has been neglected or abused and the plan for ameliorating the conditions. If the family refuses to cooperate with the services in the case plan, a social worker can elect to file a petition under California Welfare and Institutions Code, Section 300 to request court-ordered Family Maintenance services. Voluntary Family Maintenance offers essentially the same level of services as Informal Supervision. However, Voluntary Family Maintenance services rely on the familys voluntary cooperation with CPS and compliance with the agreed-upon service plan. The County generally provides Family Maintenance and Informal Supervision services to families for up to six months, although some cases can continue longer if CPS can demonstrate that the family should be able to reach the objectives of the service plan in the extended time period. Family Maintenance and Informal Supervision activities cease when the social worker closes the case, when the child is taken into protective custody and declared a dependent of the Juvenile Court (transfers to Court Services), or when the child emancipates. Family Reunification Family Reunification services provide time-limited intervention and support services to parents and to children, generally for those who have been removed from the home to make the family environment safe for the child to return home. Family Reunification services can also provide intensive services to children who remain in their home for court-ordered Family Maintenance services. Family Reunification services are designed to safely reunite the child with his or her family as soon as possible, or, if the child is in the home, to provide intensive services designed to ameliorate the conditions that led to the Countys involvement with the family. With Family Reunification services, the social worker provides a variety of services and support to the children, their families, and their foster parents, or other services providers in accordance with the reunification plan or case plan. These services aim to help each child and family to achieve and maintain, at any given time, their optimal level of reconnection from full re-entry of the child into the family system to other forms of contact, such as visiting, that affirm the child's membership in the family. Social workers are required by law to provide concurrent planning services at the same time they provide family reunification services. Concurrent planning requires social workers to provide family reunification services while, at the same time, working to develop an alternative permanent living arrangement should reunification not be achieved. The County provides Family Reunification services to children and families after children have been declared dependents of the Juvenile Court. CPS provides these services for a period that ranges from six- to 18-months, depending on the age of the child and case circumstances. Social workers meet regularly with families and children and ensure that the case plan and court-ordered activities are occurring as required. Family Reunification social workers make periodic reports to the court related to the familys progress and determine whether to
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recommend reunification of the child with the family or whether to recommend permanent placement outside the home. Family Reunification services terminate when the court ends dependency of the child and reunifies the child with his or her parents or guardians, when the case is transferred to the Permanency Placement division if children cannot be reunified safely, of when the child emancipates. Other Services CPS provides many additional services that were not included in the focus of our review. The teams review focused on areas where critical incidents had occurred. Typically, in prior years, critical incidents (fatalities or near-fatalities) of children have occurred when children are coming into the system or are in, or have recently left, Emergency Response, Family Maintenance, Informal Supervision, or Family Reunification Services. Other services provided by CPS, but not included in this report are Permanency Placement services (services to identify a permanent home for children who cannot safely return home or who are unlikely to ever return home); Adoption Services (services to identify potential adoptive families and to bring these families together with children who have had parental rights terminated and who are ready for adoption); and Foster Home Licensing (licensing and review of foster homes in the Sacramento area).
Description of the Child Protective Services Staff

CPS employs a wide variety of staff serving at various levels to carry out child welfare services activities. Exhibit I-2 below shows the divisions current organizational structure. Exhibit I-2Sacramento County Child Protective Services Organizational Structure
DEPUTY DIRECTOR, CHILD PROTECTIVE SERVICES (CPS) DIVISION Administrative Services Officer Administration
Division Manager
Division Manager
Division Manager
Administrative Services Officer Budgets
Program Managers (4) Permanency Services Adoptions Kinship Licensing
Program Managers (4) Family Reunification Court Services
Program Managers (5) Emergency Response Family Maintenance Birth and Beyond Team Decision Making
Program Manager Quality Assurance Program Administration CWS/CMS
Communications and Media Officer Media Relations
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CPS employs a total of 980.9 full-time equivalent staff in various classifications. The largest job classification group within the division is the Social Worker group, as shown in Exhibit I-3 on the following page. Core child welfare activities, including case management, referral investigation, and intake evaluation are performed by Human Services Social Workers (HSSW), and Human Services Social WorkersMaster degree (HSSWM) staff, and overseen by Human Services program and division managers. In general, both HSSW and HSSWM staff are required to carry out the same duties. These include providing access to community services to their clients; assessing client needs and making appropriate referrals; and counseling clients regarding interpersonal relationships. However, social workers with a masters degree are expected to act more independently and to take on a higher level of cases due to the increased knowledge and abilities gained through their graduate degree program. The HSSW workers cannot move into the HSSWM category without a masters degree from an accredited college or university. Exhibit I-3: Breakout of Sacramento County Child Protective Services Staff by Job Classification and Number of Full-Time Equivalent Staff as of June 2008
Administrative Staff, 24.0 Management Staff, 37.0
Clerical and Transcription Staff, 249.8 Social Worker Staff, 469.5
CWS/CMS Support Staff, 4.0
Family Services, Child Development, Public Health Nurses and Vocational Assessment Staff, 93.8
Social Worker and Family Services Supervisors, 102.8
CPS also employs a large number of clerical and transcription staff. Many of these staff perform administrative functions for the various bureaus and programs within the division. Additionally, some of these staff are responsible for assisting social workers in transcribing dictated reports and formatting the reports for Juvenile Court.
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Findings and Recommendations

Introduction
This chapter identifies MGTs findings and recommendations resulting from our review of CPS. Children and families in the Sacramento child welfare system are under-served and CPS is missing opportunities for improvements to protect children from abuse and neglect and to ensure that children have permanency and stability in their lives. Our review of CPS revealed systematic organizational, policy, procedural, and staffing problems throughout the division. CPS has implemented a number of action plans and changes in recent years to try to address problems it has self-identified as well as findings from external review entities. However, despite the divisions actions, its state outcome measures related to child safety and permanency performance have declined from baseline measures in many instances. Additionally, internal measures used by CPS indicate that it is failing to make improvements in its services for families and children. Our review of child fatality cases also found numerous problems and examples of poor practices. Our discussions with supervisors and social workers found that morale levels are low and frustration levels are high within the division. The current structure and requirements contained within this system are such that social workers cannot fulfill all required functions. Staff at all levels lack access to comprehensive formal guidelines. Social workers and supervisors struggle to work in a system that is overly dependent on paper-based and manual systems rather than making better use of the technology and data systems CPS currently has. Social workers and staff we talked to demonstrated a great deal of dedication and commitment to helping families and children. Many social workers and supervisors work far more than the expected 40 hours per week in an effort to provide as many services and to help as many families as they can. Unfortunately, their efforts are often hampered by a system that places a higher emphasis on documentation and deskwork than on children and fieldwork. In each of the following sections, we start with one or more of the primary questions posed to our team by the County related to CPS operations and then provide detail to support our findings.
Analysis of Sacramento Countys Provision of Child Welfare Services

Questions: Is CPS adequately and sufficiently providing services to families and children to allow it to meet its mission?
Answer: CPS may not be adequately and sufficiently providing services to families and children. Specifically, CPS has seen a decrease in its performance for several outcome measures related to safety and permanency for children served by CPS. CPS internal measures also indicate that its actions are not resulting in improved performance.
In analyzing outcomes related to safety and permanency for children served by CPS, our team found that Sacramento has seen decreases in many key performance areas in recent years.
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The Countys performance across these measures, coupled with internal performance measures, leads us to conclude that CPS may not be adequately or sufficiently providing services to families and children to allow it to meet its mission, that its policies and procedures are not working when followed, and that actions taken to ameliorate findings have failed to result in measurable improvements to CPS operations. In making this conclusion, we are not saying that CPS is failing to help all or the majority of children and families that it serves. CPS investigates a large number of referrals and provides services to a large number of children and families in the region. However, performance issues are hampering the Countys ability to provide these child welfare services effectively and efficiently. Additionally, inconsistent procedures and failure to follow best practices have resulted in negative outcomes for some children in the Countys child welfare system. Utilizing poor practices has also resulted in families and children not receiving the best services to meet their needs. Consequently, the issues within these families that brought them into the child welfare system in the first place may continue to be unaddressed, leaving children at risk. Improving CPS operations and processes is imperative if the County is to address these issues and optimize its service delivery to families and children in the future. State Outcome Measures The California Department of Social Services (CDSS) measures state and county performance using a set of outcome measures. Since 2002, the CDSS and the University of California at Berkeley have published quarterly updates to the outcome measures that show each countys performance compared to state performance, national performance goals (if established), and prior performance by each County. The outcome measures generally measure performance related to one of three main categories: Safety: Children are first and foremost to be protected from abuse and neglect. Also, children should be safely maintained in their homes whenever possible and appropriate. Permanency: Children have permanency and stability in their living situations and the continuity of family relationships and connections is preserved for children. Well Being: Children receive adequate services to meet their physical, emotional, educational, and mental health needs. In the initial years of the outcome measure rollout, the County made improvements in a wide variety of measures related to safety, permanency, and well-being. However, in recent years, Sacramentos performance has begun to slip. In many instances, the County is now performing worse than it did when the state first began publishing these measures. In this section, we discuss the Countys performance for two types of measuressafety and permanency. As shown in Exhibit 1, out of five safety outcome measures, the County has declined in performance for three of the measures, and is failing to meet the national standard for one of the only two measures with an established goal.
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Exhibit 1Sacramento Child Protective Services Performance Decreased from Baseline Measures on Three Out of Five Safety Measures
Most Recent Performance Quarter 1, 2008 Extract County Improved from Baseline? County is Meeting National Standard or Goal?
Measure
No recurrence of maltreatment
Effect of Countys Performance

97 out of 1,908 children who were victims of maltreatment (abuse or neglect) had another substantiated maltreatment episode during the most recent six-months. 26 out of 5,753 children were maltreated while in foster care during the most recent year. CPS attempted to respond or responded more than 24 hours after receiving a report of abuse or neglect for 232 out of 1,292 referrals coded for immediate response in the most recent quarter. CPS attempted to respond or responded more than 10 days after receiving a report of abuse or neglect for 379 out of 2,099 referrals coded for ten-day response in the most recent quarter. CPS failed to have at least one face-to-face contact with 622 out of 5,856 children during the most recent month.
94.90 No maltreatment in foster care Child abuse and/or neglect referrals with a timely response (IMMEDIATE) 82.00 Child abuse and/or neglect referrals with a timely response (TEN DAY) 81.90 Timely social worker visits with children
Yes
Yes
99.55
No
No
No
N/A no goal established
No
N/A no goal established N/A no goal established
89.40
Yes
Source: University of California at Berkeley, Child Welfare Dynamic Report System, Quarter 1, 2008.
Additionally, as shown in Exhibit 2, of 15 permanency and stability measures, the County has declined in performance on ten of the measures and is failing to meet established national goals or performance standards for 11 of the measures. Exhibit 2Child Protective Services Performance Decreased from Baseline Measures on Ten Out of Fifteen Permanency Measures
Most Recent Performance Quarter 1, 2008 Extract
67.6
Measure
Children reunified within 12 months of removal.
County Improved from Baseline?

No
County is Meeting National Standard or Goal?

No

378 out of 1,166 children removed from the home in the most recent year were not reunified within 12 months of removal from the home. Children who reunified within 12 months of removal spent an average of 7.7 months in foster care. 354 out of 693 children removed from the home for the first time in the most recent year were not reunified within 12 months of removal from the home. 267 out of 1,692 children reunified reentered foster care within 12 months of reunification. 187 out of 456 children in care less than 24 months were adopted.
Median time to reunification. Children with a first entry to foster care who reunified within 12 months of removal. Children who re-entered foster care within 12 months of reunification. Children adopted within 24 months of removal.
7.7 months
No
No
48.9
No
Yes
15.8 41.0
Yes No
No Yes
Continued
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Sacramento County Child Protective Services Review County is Meeting National Standard or Goal?
Yes
Measure
Median time to adoption. Children adopted who had been in foster care 17 months or longer. Children who became legally free for adoption and who had been in foster care 17 months or longer. Children adopted within 12 months of becoming legally free Children who exited to a permanent home who had been in care 24 months or longer Children who exited to a permanent home and who were legally free for adoption. Children in care between one and two years and with two or fewer placement changes. Children in care more than 24 months with two or fewer placement changes.
Most Recent Performance Quarter 1, 2008 Extract

27.2 months
County Improved from Baseline?

Yes

Children who were adopted spent an average of 27.2 months in foster care prior to adoption. 299 out of 1,694 children in care more than 17 months were adopted. 51 out of 1,694 children in care more than 17 months and who were not legally free became legally free for adoption. 300 out of 488 children were adopted within 12 months of becoming legally free for adoption. 1,152 out of 1,474 children in care 24 months or longer did not find a permanent home. 463 out of 483 children who were legally free for adoption exited to a permanent home. 763 out of 1,345 children in care between one and two years had more than two placement changes. 1,539 out of 2,105 children in care more than 24 months had more than two placement changes.
17.7
Yes
No
4.1
No
No
61.5
No
Yes
21.8
Yes
No
95.9
No
No
43.3
No
No
29.1
No
No
Source: University of California at Berkeley, Child Welfare Dynamic Report System, Quarter 1, 2008.
As seen in Exhibits 1 and 2, small percentages in the Countys performance measures can still have a significant negative effect on a large number of childrens lives. CPS is working to protect children who have often been subjected to horrific acts of abuse or neglect. Therefore, the division must hold itself and social workers up to a high performance standard. Declining performance related to childrens safety and permanency is unacceptable. The divisions declining performance also indicates that its attempts to make improvements in its provision of services have been largely unsuccessful. The fiscal and human costs to the County due to low performance in safety and permanency outcomes can be considerable. The Countys budget for child protective services for fiscal year 2007-08 was more than $127 million. Although a large portion of the budgeted expenses are funded through federal and state funds, the County had to contribute $11.2 million in local funds. The declining performance in safety and permanency measures is resulting in increasing costs to the County. For example, maintenance payments to foster care homes for children range between $425 and $597 per month. Sacramentos average stay in foster care has increased from a baseline average of 4.5 months per child, to 7.7 months per child. The additional 3.2 months therefore equates to between $1,360 and $1,910 to the County per child. Given Sacramentos more than 3,900 children in out-of-home care as of July 2008, these additional months in care can equate to large costs for the state and for the County. Additionally, a study by the Pew Commission on Children in Foster Care found that children who experience multiple placement changes while in foster care pay the cost through ruptured relationships, interrupted schooling, delayed medical care, poor social connections to adults and communities, and delayed child development. Ultimately, this results in the County and State
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bearing additional costs for medical care, future foster care if children grow up to become abusers in turn, and possibly jail or court costs. This is particularly relevant given that our review of Sacramentos stability rates for children in out-of-home care found that the Countys performance has decreased significantly from baseline measures. This means that an increasing number of children go from placement to placement, disrupting their lives and sense of stability and decreasing their trust in the systems ability to protect them. In comparing CPS performance against the performance of similar counties,2 we found that Sacramento is performing worse than other counties for several outcomes. As shown in Exhibit 3, Sacramento performed better than the state average and other counties for one measure (no recurrence of maltreatment) using Quarter 1, 2008 data. However, it performed worse than the state and all comparison counties on the other Safety Measure (no maltreatment while in foster care). In permanency composite measures, Sacramento performed strongly on the Adoption Composite relative to the state and other counties. However, for other composites, especially the placement stability composite, Sacramento performed worse than both the state and one or of the more comparison counties. Although the percentage differences were small, as discussed earlier in this section, even small percentages translate to large numbers of children who are affected. Exhibit 3Sacramento County Had Weaker Performance Relative to State and Comparison Counties for Several Outcome Measures
Sacramento Countys Performance Relative to the Performance of: Measure State Average Fresno Santa Clara San Diego San Joaquin Riverside Safety Measure 1 Better Better Better Better Better Better Safety Measure 2 Worse Worse Worse Worse Worse Worse Reunification Composite Worse Better Worse Better Better Worse Adoption Composite Better Better Better Better Worse Worse Long-Term Care Composite Worse Better Worse Better Better Worse Placement Stability Composite Worse Worse Better Worse Worse Worse Source: University of California at Berkeley, Child Welfare Dynamic Report System, Quarter 1, 2008.
We note that in making these comparisons, and as shown in the preceding table, it is clear that Sacramento is not alone in the state when it comes to performance issues. However, our review focused on examining how Sacramento is serving children and families in its own region, rather than looking at all counties statewide. In comparing Sacramento against other counties, we also reviewed the rate of referrals and foster care entries for the County compared to state averages and other counties. As shown in Exhibits 4 and 5 on the following pages, on average between calendar years 1998 and 2007, Sacramento County had a larger percentage of children with one or more referrals as a percentage of the total child population, compared to statewide averages and other counties. Additionally, Sacramento had a higher percentage of children with substantiated referrals as a percentage of all referrals than did most other counties or the state as a whole. This means that poor performance in its outcome measures can translate to a relatively higher number of children impacted by the poor performance within the County. Thus, it is imperative that Sacramento identify and address problem areas timely.
2
Counties were selected based on their similarity to Sacramento Countys population, geographic size, resident demographics, or a combination of all three.
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Exhibit 4
Source: University of California at Berkeley, Child Welfare Dynamic Report System.
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Exhibit 5
Source: University of California at Berkeley, Child Welfare Dynamic Report System.
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Internal Measures In addition to looking at outcome measures produced by the state, our team also examined statistics created internally by CPS staff or published through the use of the Safe Measures data system by the County for its internal use. Our review found that on many levels, the County is failing to provide timely services to the children and families it serves. For example, as part of referral investigation, social workers are required to use the SDM assessment tools. The SDM is a research-based risk assessment tool that assists social workers in classifying child protective services cases according to the likelihood of future maltreatment. Studies performed by the Childrens Research Center found that counties implementing SDM had 27 percent fewer new referrals, 54 percent fewer new substantiated allegations, 40 percent fewer children removed to foster care, and 42 percent fewer child injuries that required medical assistance than did non-SDM counties. These results indicate that when an organization is able to accurately classify families according to the level of risk, it is also able to more selectively focus its resources, resulting in better outcomes for children and families. The SDM tool has several components, including a response priority tree (to assist social workers in determining the appropriate response time), a safety assessment (an assessment of any immediate, pressing conditions that threaten the safety of the child) and a risk assessment (an assessment of potential risk factors related to the likelihood of subsequent maltreatment of a child). Given the decline in multiple safety and performance outcomes for Sacramento County as described earlier, it appears critical that all social workers are fully and appropriately using the SDM tools. However, the divisions own reports show that many staff members are not using the tool as designed. In addition, managers and supervisors are not requiring the timely use of the tool. In our discussions with staff and supervisors, and through comments received via an on-line survey, many CPS employees agreed that the SDM tool is a valid and valuable tool to assist social workers in assessing risk factors. However, many staff also expressed the viewpoint that the tool should not be mandatory for all staff since experienced social workers know the risks associated with cases and can make the determination without the tool. Our team does not believe this to be accurate given the research showing that counties using the tool appropriately have recognized significant improvements to childrens safety and well-being. Furthermore, CPS own internal quality reviews contradict its staffs beliefa September 2007 review by CPS Quality Assurance (QA) unit found 10 out of 45 referrals they reviewed (22 percent) had incorrect risk assessments. In all instances, Emergency Response workers had assessed the risk at too low a level. In analyzing the departments use of the SDM tools shown in the data in the following pages, we used reports from the Safe Measures system for the months of December 2007 through December 2008. The Safe Measures reports pull data from the Child Welfare Services/Case Management System (CWS/CMS)the States information management for all child welfare services. CPS staff who are responsible for Intake (taking referrals over the phone or via mail) are required to complete the SDM response priority tool (hotline tool) immediately while they are taking referrals. However, as shown in Exhibit 6 below, although CPS staff use it on the majority of referrals (94.1 percent), they are not using it on all referrals. Between December 2007 and December 2008, staff failed to use the assessment tool for 1,182 referrals. The hotline
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assessment is a vital tool to assist staff in determining proper response times and risk related to incoming allegations of abuse or neglect. Failing to use it could result in staff incorrectly assessing the risk associated with referrals, meaning that children could be left in unsafe situations longer than necessary. Exhibit 6CPS Staff Did Not Always Use the Structured Decision Making Hotline Tool
NotCompleted, Incomplete,0.1% 5.8%
Completed,94.1%
Source: The Child Welfare Services/Case Management System (CWS/CMS) Safe Measures Data System, SDM Hotline Usage Reports, December 2007 through December 2008.
Similarly, social workers are failing to use SDM safety and risk assessment tools in many instances and are often not completing these tools timely. Social workers are required to complete the SDM safety tool within two business days of the social workers first contact with a child and/or family. However, as shown in Exhibit 7 below, CPS staff completed the SDM safety assessment completely in only 84.5 percent of all referrals for which the SDM safety tool was required. This means that staff did not complete the safety assessment on 2,026 referrals for which they should have done so.
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Exhibit 7CPS Social Workers Did Not Complete the SDM Safety Assessment Tool for All Required Referrals during December 2007 through December 2008
Incomplete Assessment, 0.2% Completed Without Contact, 1.0%
Missing Assessment, 14.3%
Completed, 84.5%
Source: The CWS/CMS Safe Measures Data System.
The exhibit above does not include referrals for which CPS determined that the tool was not required, such as for secondary referrals, referrals evaluated out, referrals for which the social worker determined the allegation to be unfounded prior to completing the SDM safety assessment, referrals where the alleged perpetrator was an out-of-home caregiver, or referrals where CPS did not conduct an investigation due to lack of contact with the children or lack of a child victim. Additionally, as shown in Exhibit 8, when CPS staff did utilize the tool completely, they generally did not meet the required time frames in doing so. Staff completed the SDM safety assessment tool late (more than two business days after initial contact with the child and family) for 8,962 referrals (75.5 percent of all cases) during 2008. For children in high or very high-risk situations, CPS delay in completing the tool may leave children exposed to dangerous living situations for longer periods.
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Exhibit 8CPS Social Workers Completed the SDM Safety Assessment Late for Most Referrals during December 2007 through December 2008
Completed Without Contact, 1.1% Completed Timely(Within 2Business Daysof Contact), 23.3%
Completed Late,75.5%
In reviewing the report, CPS executive management commented that, while they accept the accuracy of the exhibits, they believe that a number of factors could result in a late SDM. For example, they stated that social workers may be completing a hard copy of the tool first, and then completing the computer form later. They also stated that the social workers could be completing the tool late because they are having difficulty in locating all family members. We acknowledge that there is a possibility that these may contribute to the divisions poor compliance rates. However, based on survey results and discussions with staff and supervisors, it is equally likely that they are completing these late because staff do not have sufficient time or resources. Similar findings exist for CPS staffs usage of the SDM risk assessment tool. As shown in Exhibit 9 below, CPS staff used the SDM risk assessment tool completely in only 84.3 percent of all referrals for which an assessment was required. This means that CPS did not use the risk assessment tool for 2,022 referrals for which they should have done so.
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Exhibit 9CPS Staff Did Not Complete the SDM Risk Assessment Tool for All Required Referrals during December 2007 through December 2008
Incomplete Assessment, 0.4% Completed Without Contact,0.8%
Missing Assessment, 14.6%
Completed, 84.3%
Again, similar to Exhibit 7, the exhibit shown above does not include referrals for which CPS determined that the tool was not required, such as for secondary referrals, referrals evaluated out, referrals for which the social worker determined the allegation to be unfounded prior to completing the SDM risk assessment, referrals where the alleged perpetrator was an out-ofhome caregiver, or referrals where CPS did not conduct an investigation due to lack of contact with the children or lack of a child victim. Additionally, as shown in Exhibit 10, for those instances where staff did complete the SDM risk assessment tool, the staff completed the tool timely in only 77.9 percent of all cases. This is especially significant given that staff have 30 business days from initial contact to complete this tool. Therefore, the staff took more than 30 business days from the first contact to conduct the risk assessment for more than 2,400 referrals during December 2007 through December 2008. Additionally, on average, for those cases where staff did complete the risk assessment timely, the average time to completion was 16.8 days. Again, this delay can result in leaving children in potentially risky situations for longer periods.
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Exhibit 10CPS Staff Completed the Risk Assessment Tool Late More Than 20 Percent of the Time during December 2007 through December 2008
Completed WithoutContact, 0.9%
CompletedLate, 21.2%
Completed Timely(Within 30Daysof Contact),77.9%
Failure to use the SDM tool has been a continuous finding by the CPS Oversight Committee in its reports, and has also appeared as a problem area in CPS internal QA reviews. For example, the QA unit conducted a review in May 2007 that found that Emergency Response staff had made conclusion errors in 7 out of 26 (27 percent) referrals reviewed by the QA team. Additionally, a June 2007 follow-up review by the QA unit identified conclusion errors in 7 out of 30 referrals reviewed, three of which resulted in the childs risk being assessed by the social worker at too low of a level. These errors may have been reduced with the use of the SDM tool. Moreover, as will be discussed in the child fatality review section, five of the seven child fatalities we reviewed had missing, incomplete, or inaccurate uses of the SDM risk and safety assessment tool. Emergency Response supervisors reported that there is a lag time between the time a referral is entered into CWS/CMS and the time it is available in the SDM electronic tool. Therefore, if it is an immediate response case, the Emergency Response worker has to wait to complete the SDM until it appears in the system. Our discussions with managers found that the delay is seldom more than one day, however, and staff has two business days from contact to enter the information (thus, negating the argument that staff cannot enter the information timely). Emergency Response supervisors also reported that staff is pressed for time to do full investigations and to complete all required documentation. Staff and supervisors stated that part of the reason they do not complete SDM assessments timely is because they do not have the resources to do the SDMs while in the field. Staff can only complete the SDM assessments while in the office since most do not have remote access. Staff rely on laminated cards as SDM reminders while they are in the fieldthe card has a list of questions that they need to ask or consider. However, these cards do not allow for the weighting of risk factors, nor do they comply with best practices.
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In addition to failing to perform critical assessments timely, we also found that CPS has often not assigned referrals to social workers for investigation until after critical deadlines have elapsed. As will be discussed later in the policy and procedure section, this delay is mainly attributable to the large number of handoffs and decision points in the intake and investigation process. State law requires that counties attempt contact with children or families for referrals within 24 hours for referrals designated as needing an Immediate Response. CPS policy is more stringent, requiring social workers to attempt contact within two hours. However, in many instances, CPS did not assign cases to social workers until after the two-hour window had elapsed. As shown in Exhibit 11, referrals designated an Immediate Response were, on average, assigned the same day in only 48.6 percent of all cases. Next day referrals were 40.8 percent, with the remainder assigned more than two days from receipt of the referral. These are the highest risk referrals and are most in need of immediate intervention. Delaying assignment may result in children remaining in risky living situations longer. Exhibit 11CPS Assigned Immediate Response Referrals to Social Workers for Investigation Timely Less than 50 Percent of the Time
Assignedwithin 2to5Days, 9.2% Assignedin Morethan6 Days,0.3% Contact Not Recorded, 1.1%
AssignedNext Day,40.8%
AssignedSame Day,48.6%
Surprisingly, referrals designated for ten-day response had same or next day assignments in 48.8 percent of all cases as shown in Exhibit 12. Although this data does not provide the basis for delaying assignment of ten-day investigation referrals, it appears that the division has opportunities to improve its referral process to ensure it is placing a higher emphasis on assigning out immediate responses prior to assigning ten-day response cases.
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Exhibit 12CPS Assigned Referrals Designated for Ten-Day Response in Fewer than Five Days for the Majority of Referrals
AssignedinMore Assignedwithin6 than10days, 1.3% 10days,8.1% ContactNot Recorded,2.7%
AssignedSameor NextDay,48.8% Assignedwithin2 to5Days, 39.1%
The data we present in Exhibits 11 and 12 agrees with the Countys performance in two of the States safety outcome measures related to response rates. As shown earlier in Exhibit 1, the County has seen decreased performance related to its timely responses for immediate and tenday referrals. Its most recent performance indicted a compliance rate of approximately 82 percent for both categories. This means that during a three month period, CPS attempted to respond or responded late more than 24 hours after referral assignmentfor 232 referrals coded for immediate response and responded or attempted to respond latemore than 10 days after referral assignmentfor 622 referrals coded for a ten day response. Question: For child fatality cases reviewed, did CPS workers comply with best practices and required policies of the division? Answer: The teams review of seven fatality cases that had open or recently opened CPS cases or referrals found procedural deficiencies in all cases. Before reviewing critical incidents we first examined past incidents reviewed and reported on by outside entities such as the CPS Oversight Committee. We noted with concern that it appears that critical incidents have increased dramatically in the most recent year. Between 1997 and mid-2007, the CPS Oversight Committee investigated 13 critical incidents (12 fatalities and one near-fatality) of children who were known to CPS at the time of the incident. However, between September 2007 and July 2008, there were seven critical incidents and an additional three occurred between August 2008 and December 2008. This brings the total in a 15-month period
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to ten critical incidentsa substantial increase in the occurrence of these tragic events over the prior ten years. We reviewed the seven cases that occurred between September 2007 and July 2008 in detail. These cases all involved child fatalities and either an open CPS case or referral, or a recently closed (within six months of the childs death) case or referral. In reviewing these cases, we considered the processes used by social workers and evaluated whether these complied with both the Countys internal guidelines, as well as state and federal requirements and best practices. The general demographics associated with these cases are as follows: Six of the children died while in the custody of their parents and one died while in outofhome care (foster home). Six of the children were under the age of 5 at the time of death. All were under the age of 10. Five children were African American, one was Hispanic, and one was Caucasian. All children and/or families appear to have been English speaking. Five of the children were female and two were male. All children were known to at least one other system at the time of their death, such as Mental Health, Public Health, law enforcement, MediCal, Food Stamp programs, or California Work Opportunity and Responsibility to KidsCalWorks. Two cases involved caretakers with serious mental health issues. All cases had prior referrals to child welfare and many had multiple referrals. All cases involved multiple social workers and reviews. In reviewing the cases, we noted that in all seven cases, social workers failed to comply with one or more of the divisions requirements related to referral investigation and/or case management. These failures include inadequate or inappropriate use of the SDM tool for risk or safety assessments, failure to complete the SDM tool, inadequate case documentation, inadequate follow-up or attempts to corroborate statements made by parents or children, and delays in transferring or handing off cases between bureaus. Specific examples of poor case management practices noted in our review include the following: Social worker incorrectly filled out the SDM assessment tool (marked no for drug or alcohol abuse when the parent admitted to drug use; assessed the case as needing a ten-day response when it really needed an immediate response). Social worker failed to follow-up on caretaker statements (accepted the caretakers word that a black eye was due to a fight with a stranger and not due to domestic violence; accepted that a childs broken arm was due to a fall out of the bed in another instance). Case was lost in transit between two CPS programs and case file did not include information on whether social workers in either program made contact or provided services to the family for an 83-day period.
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The supervisor did not review a case that a social worker closed as unfounded. After the childs death, the supervisor reviewed the case and approved the social worker altering the assessment disposition from unfounded to substantiated. For several cases, social workers did not completely document all services provided. In one case, the division moved the child into a different placement home, but there was no note of the date or rationale for the move. In four of the seven cases we reviewed, the process deficiencies were of such a nature that, in our opinion, had the social workers and supervisors been diligent about complying with requirements, the child may have had a better chance of having an improved outcome. This is not to say that CPS could have prevented the childs death in every one of these four instances. However, it is clear that CPS missed clear opportunities to offer services to the family and/or possibly remove the child from the unsafe situations that led to the childs death. Additionally, in two of the child fatality cases, the team notes that the same social worker was responsible for poor casework related to the families. In internal reviews, CPS noted that this social worker had a history of poor performance and failed to comply with required policies and procedures. However, prior to being placed on administrative leave following the two incidents, CPS had allowed this individual to volunteer for extra (overtime) work, despite a history of poor performance. This social worker was carrying a high case load65 open casesseveral weeks after the critical incident. Finally, the team notes that for one of the cases where the childs death was directly related to a parents actions, another agency may bear some responsibility for failing to provide services. In this case, the parent had significant mental health problems, and CPS had referred the family to the Department of Mental Health for services. At the time of the childs death, the child was living with a grandparent and was not receiving CPS services since it appeared the child was in a stable living situation. There are no indications that the Department of Mental Health had opened a case or continued services beyond an initial consultation (although our team was unable to confirm this due to our lack of access to Department of Mental Health files related to this case). Despite what the other agency did or did not do, however, we do note that CPS staff did not follow division guidelines related to investigation of referrals received about this child. For example, the social workers did not perform an SDM risk or safety assessment for any of the referrals they received on this child. Question: What are the key trends related to CPS operations? Answer: CPS has seen increases in higher risk referrals and program caseloads in selected programs.
In this section, we discuss recent trends in referral and caseload levels and how these impact the various CPS program units ability to handle cases. After several years of declines, referrals designated as needing immediate response of abuse and neglect (highest risk referrals) coming into CPS in Sacramento County have begun to rise, especially over the past 12 months. It is unknown whether the increase in referrals is a result of the declining economy in the Sacramento region, the recent press attention focused on CPS, or a combination of these and other factors.
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As shown in Exhibit 13, referrals designated for a ten-day response have fluctuated. Our analysis of the trends with these referrals showed a slight decrease in these referrals over time. Referrals designated for immediate response (high-risk referrals), however, have shown a sharp increase. Note that the straight lines indicate the trend lines for each type of referral response category. Exhibit 13Referrals Designated for Immediate Response Have Increased between July 2007 and September 2008
Additionally, as shown on Exhibit 14, for those referrals that CPS has investigated, substantiated and inconclusive referral dispositions are trending upward, while unfounded referrals are remaining fairly steady. Again, the straight lines indicate trends over time for each type of referral.
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Exhibit 14CPS Has Had an Increased Number of Substantiated and Inconclusive Referrals between July 2007 and September 2008
CPS social workers are also filing petitions for a larger number of families. On average, in fiscal year 2006-07, of the families with children placed in protective custody during the year, CPS filed petitions with the Juvenile Court for 62.1 percent of these families. In fiscal year 2007-08, this increased to 74.2 percent, and in the first quarter of fiscal year 2008-09, CPS filed petitions on 89.6 percent of the families who had children placed in protective custody. CPS has also had an increase in the number of petitions it files due to its implementation of the protective custody warrant process in fiscal year 2007-08. Court involvement in these cases increases the amount of time and resources that CPS must dedicate to working on these cases, since social workers must prepare court reports and related documents in addition to providing services to the families. This can also have a ripple effect throughout the division, increasing caseloads for all programs as children move through the system and programs. In our discussions with supervisors and managers, we did not find that CPS has done adequate contingency planning to address possible workload increases nor have they identified what steps they should or can take to handle both short- and long-term increases to specific program workloads. Many of the actions taken appear to be reactionary only and generally are implemented after programs reach crisis levels. When managers have had to move staff temporarily to back-fill and assist in managing cases in programs, staff have generally not
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proven receptive to these moves. Having a contingency plan would set expectations for staff and also ensure that the division is prepared to handle large influxes of cases or referrals. Questions: How do staffing levels, vacancies, or absences impact workloads? What impact, if any, do caseloads have on the work quality and performance? Answer: CPS has a high absentee and vacancy rate for its social worker classifications. These vacancies and absences result in a shift of caseload onto other social workers or programs, impacting the divisions ability to deliver quality services.
Exhibit 15 depicts an analysis of caseload activity for three programs. Looking at average caseloads by program, using the definition of total cases divided by filled full-time equivalent social worker positions, caseload shows a slight decline for Family Reunification, a slight increase for Emergency Response, Screening, Investigations, and Court Services, and a large increase in Informal Supervision and Family Maintenance cases. Exhibit 15CPS has Seen Increased Caseloads in Two Programs between July 2007 and September 2008
However, this analysis does not take into account the effect that social worker absences and vacancies have had on workloads. During the three month period from July to September 2008, the absentee rate for social workers averaged over 12 percent. As shown in Exhibit 16, two programs (Emergency Response and Team Decision Making) averaged more than 18 percent absenteeism during these months. This means that of the total hours available to work in these
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months, social workers missed work due to paid leave, sick leave, leaves of absences, family medical leave, or administrative leave, over 18 percent of the time for those divisions. This has a ripple effect throughout the programs as other staff that are present have to take an increasingly larger amount of cases from their coworkers. Exhibit 16CPS Programs Had Average Absentee Rates for Filled Positions Greater than 12 Percent between July 2008 and September 2008
20.0% 18.2% 18.0% 16.0% 14.1% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% CourtServices EmergencyResponse Family Maintenance/Informal Supervision FamilyReunification TeamDecisionMaking 13.1% 12.2% 18.5%
Source: Sacramento County CPS Human Resources Data.
Absentee rates must also be reviewed alongside vacancy rates within programs. Average vacancy rates for all programs have increased in recent years. For all social workers throughout the division, fiscal years 2002-03 and 2003-04 had vacancy rates of 4.3 percent and 4.5 percent respectively; the vacancy rate for 2006-07 was 8.2 percent, and for 2007-08 was 9.2 percent. These rates represent the averagesome units had higher rates. Combining vacancy and absentee rates, we found that most program areas within CPS averaged more than a 25 percent rate of missed work. This means that staff in these units who were available and working had to take on an increasing number of cases flowing into the system, as well as make up for the hours that were not worked by others. Sacramento has 469.5 approved full-time equivalent (FTE) social worker positions distributed across various programs within the division. As caseloads have increased for specific programs, managers have tried to implement various solutions to keep up with the demands on program staff. For example, management has reassigned some staff in the team decision-making unit to the Court Services program to work on a backlog of cases in this program. This is a temporary solution, however, and does not address long-term program needs. Additionally, the division may find it harder to reallocate limited resources while continuing to provide quality services to families and children if cases continue to rise. Management has not implemented effective actions to slow the influx of cases, such as putting more resources into
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community support and outreach or in diverting lower risk cases to the extent possible to Family Maintenance or Informal Supervision. Furthermore, although all social workers within the division have similar classifications (HSSW or HSSWM), the union contracts contain provisions allocating staff by program. Thus, management does not have the flexibility to annually review and reallocate social workers based on actual and forecasted needs within programs. Sacramento is not the only county experiencing problems with vacancies, but it does have higher rates than many counties. A 2005 study by University of California at Berkeley Social Work Education Center (CalSWEC) found an average vacancy rate of 7.5 percent throughout the state (excluding Los Angeles) for county social worker positions. The study found that most counties noted low or noncompetitive salaries or budget restrictions as the reasons vacancies remained open. Further compounding Sacramentos problems are its high turnover rate for social worker staff. Average statewide turnover rates reported in the most recent CalSWEC study, using fiscal year 2002-03 data, found that the average turnover was 9.5 percent for child welfare workers and 8.6 percent for child welfare supervisors. Another study by the Child Welfare Directors Association (CWDA) issued in 2006 that studied County social worker turnover rates from 2001 to 2005 reported that turnover rates in California for social workers ranged between 10.6 and 18.4 percent depending on the social workers classification (entry level, journey level, or professional level). Turnover rates within the Sacramento CPS exceeded the reported amounts. In the most recent fiscal year (2007-08), CPS average turnover rate for all programs was 22 percent (with some units, such as Family Reunification as high as 30 percent). Given the high rate of turnover and large number of cases flowing into the system, new employees generally have a limited time to overcome the learning curve associated with entering a bureau and taking on caseloads. More senior staff must also shoulder the burden of taking on higher case loads while CPS trains and orients the new staff. This is especially concerning given the high fiscal costs to the County that result from turnover. Estimates by the CWDA reported that the cost of turnover is approximately $9,500 per employee who leaves. Reducing turnover and increasing retention is thus a key strategy to realize fiscal savings for the County, especially critical given the Countys current economic situation. The CWDAs 2006 study listed several factors important for retention of social worker staff. These include personal and organizational factorsfactors such as good supervision, an agency with a mission or purpose that makes workers feel that their jobs are important, and manageable workloads. They also include recommendations for agency actions, such as reduced caseloads, workloads, or supervisory ratios. In the following section, we discuss our analysis of CPS average caseloads caseloads that have increased in the past year and that exceed expected benchmark levels. Furthermore, as will be discussed later in this report, our online survey of CPS employees found that 42 percent of respondents disagreed or strongly disagreed with the statement: Employees feel supported by management. These factors may have a strong correlation with CPS excessive turnover rates. Analysis of Average Case Loads To analyze the CPS caseloads, we conducted research to identify benchmarks for comparisons. In 2000, the state contracted with the American Humane Association (AHA) to conduct a workload study required by Senate Bill 2030 (SB 2030) (Chapter 785, Statutes of 1998). The AHAs report contained recommended case levels for counties by program type. The SB 2030
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standard has never been implemented in Sacramento County or in any county in the state. CPS executive managers reported that they have been unable to implement this standard due to lack of state funding. Division supervisors also were dubious about the Countys ability to implement these caseload levels given additional requirements added to social worker casework since the AHA study was completed. These additional requirements include Assembly Bill (AB) 636 outcomes, Team Decision Making, AB 490, and other initiatives. Nonetheless, the SB 2030 report issued in April 2000 recommended the following minimum and optimum caseload levels by program, listed in Exhibit 17. Exhibit 17Senate Bill 2030 Caseload Recommendations
Program Minimum Caseload per Worker 116.10 Optimum Caseload per Worker 68.70
Screening, Hotline, Intake Emergency Response 13.03 9.88 Family Maintenance 14.18 10.15 Family Reunification 15.58 11.94 Permanent Placement 23.69 16.42 Source: The American Humane Association SB 2030 Report, April 2000.
Because the state and counties have been unable to adopt these standards, we selected an alternative benchmark comparison for reviewfunding provided by the state. The state provides funding to counties through a combination of federal, state, and local sources. Funding by the state during fiscal year 2007-08 provided for program funding using workload measures shown in Exhibit 18. Exhibit 18Fiscal Year 2007-08 State Funding Mechanism for Child Welfare Services
Program One FTE Per:
Screening, Hotline, Intake Emergency Response Family Maintenance Family Reunification Permanent Placement
320 assessments 15.8 children 35 children 27 children 54 children
Source: Fiscal year 2007-08 General Fund allocations.
Some Sacramento workers are carrying case loads that are more than double the recommended and funded levels of children, however. Over the past year, looking at three points in time (the last day of December 2007, June 2008, and December 2008), the trend has been for case-carrying social workers to have a larger number of cases. For two programs (Family Maintenance and Family Reunification), the exhibits show, for those social workers who were carrying cases at the point-in time, the number of social workers and average cases carried broken out into ranges. As seen in Exhibit 19, Family Maintenance cases shifted to having a larger portion of workers carrying 31 or more cases when viewed over the three time periods.
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Exhibit 19Family Maintenance and Informal Supervision Point-in-Time by Range of Cases Carried
December 31, 2007 June 30, 2008 Number Number and Percent and Percent of Caseof CaseRange of Carrying Carrying Cases Carried SWs, this Average SWs, this Average (Point in Time) Range Case Load Range Case Load 1 4 0 to 5 2.1% 3.0 8.5% 3.3 5 4 6 to 10 8.4% 8.4 8.5% 8.0 17 14 11 to 20 36.2% 15.0 29.8% 15.8 9 9 21 to 30 19.1% 24.1 19.1% 25.0 8 5 31 to 40 17.0% 36.5 10.6% 34.8 7 11 41 or more 14.9% 48.7 23.4% 51.6 Totals 47 24.5 47 26.2 Source: The CWS/CMS Safe Measures Data System. December 31, 2008 Number and Percent of CaseCarrying SWs, this Average Range Case Load 1 2.0% 3.0 7 13.7% 8.6 19 37.3% 15.8 6 11.8% 26.5 8 15.7% 37.1 10 19.6% 48.6 51 25.6
Family Reunification social workers, as shown in Exhibit 20 below, have also seen a shift in the number of cases over time. Exhibit 20Family Reunification Cases, Point-in-Time by Range of Cases Carried
December 31, 2007 June 30, 2008 Number Number and percent and percent of Caseof CaseRange of Carrying Carrying Cases Carried SWs, this Average SWs, this Average (Point in Time) Range Case Load Range Case Load 1 2 0 to 5 1.7% 3 2.9% 4 1 5 6 to 10 1.7% 7 7.4% 8.4 6 7 11 to 20 10.2% 18.2 10.3% 14.7 14 30 21 to 30 23.7% 27.9 44.1% 27.1 37 24 31 to 40 62.7% 34.4 35.3% 32.0 0 0 41 or more 0% 0 0% 0 Totals 59 30.2 68 25.5 Source: The CWS/CMS Safe Measures Data System. December 31, 2008 Number and percent of CaseCarrying SWs, this Average Range Case Load 0 0.0% 0 1 1.6% 10 1 1.6% 16 3 4.9% 27 43 70.5% 36.5 13 21.3% 41.3 61 36.3
Moreover, the numbers shown in these exhibits may underreport the extent of the problem. The number of cases in the previous exhibits indicate that some social workers are carrying far more cases than would be expected given state funding. However, we note that since they represent
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cases, rather than number of children, these can understate the social workers workload, because social workers often provide services to multiple children on a given case. CPS executive managers, in reviewing these tables, noted that case levels can also be a reflection of staff who have performance challenges and who are working with supervisors to close cases. Nevertheless, we remain concerned that the trend for social workers in these program areas has trended upward over time. Moreover, carrying a high number of cases in Family Reunification and Family Maintenance programs often results in social workers being essentially set up for failure (i.e. having no functional way to manage all cases). For example, Family Maintenance social workers are expected to meet with children and family members at least twice in every 30 day period for the first three months. Because children are not placed in the home with their parents, this often means separate meetings with the parent(s) and children. Carrying 40 cases and estimating one hour per visit can thus equate to the social worker being required to spend 160 hours per month on face-to-face contacts with the child and parents alone. This does not include additional time if the case has multiple children in different placements. This also does not include time needed to drive to various meeting locations, document contacts, fill out required paperwork, create court reports if needed, and investigate subsequent referrals. It also does not include additional contacts social workers must also make with teachers, doctors, siblings, and relatives. Since the average work month contains 168 hours, it is readily apparent that social workers carrying a heavy caseload have no chance to successfully accomplish all required activities. This is evidenced further by CPS most recent performance on a safety performance measure. As shown earlier in Exhibit 1, for the most recent reporting period, CPS staff failed to have at least one monthly contact with 622 children. Question: What barriers, issues, or items of concern exist that prevent the successful application of policies and that prevent cases or referrals from moving as smoothly as possible?
Answer: CPS has a variety of problems, including inconsistent and outdated guidelines, lack of consistent Human Resources practices, and a lack of resources that prevent the successful application of policies and prevent cases or referrals from moving as smoothly as possible.
In the next sections, we examine some of the reasons why the division has failed to provide adequate and sufficient services and why caseload levels may have been increasing. We also answer the question Are the policies and procedures working when followed? Because the divisions policies and procedures are so dysfunctional, it is difficult to assert that they provide children and families with optimal or improved outcomes when used.
Policies and Procedures Evaluation

As part of our scope of work, our team was tasked with reviewing the divisions policies and proceduresthat is, the underlying guidance available to social workers, supervisors, and managers throughout CPS to be used in providing child welfare services to Sacramento residents. Included in the following section are the questions and answers related to our review of the Countys guidelines.
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Questions: Does CPS have policies and procedures that are reliable? Are effective operating procedures in place? Are CPS policies and procedures objective and understandable? Are the policies and procedures in need of revision?
Answer: Many of CPS guidelines are not reliable, effective, objective, and/or understandable. CPS needs to completely review and revise its written guidelines for social workers.
CPS documents its policies and procedures in a series of guideline documents. Our team found numerous deficiencies in reviewing these guidelines. First, the division guidelines contain a mix of policies and procedures without clearly defining or differentiating between the two. Policies are the formal guidance given to staff to focus attention and resources on high-priority issues and provide the operational framework within which the entity functions. Policies define what that an organization should be doing. Procedures are the operational processes required to implement the policy. Procedures define how the organization should carry out the policy. Policies, as the operational framework, should be changed less frequently than procedures, and should align with federal, state, and local laws or regulations. Procedures should be reviewed periodically (at least annually) and amended to account for any staffing or technology changes implemented since the last review. Although some of CPS guidelines do identify the policy apart from the actual steps (procedures) needed to carry out the policy, the majority of division guidelines do not differentiate between the two. Often, the guidelines switch confusingly back and forth between policy and procedure or a mixture of both. We also found that CPS has a large number and quantity of pages in its documented guidelines compared to other counties. The Countys guidelines for its social workers contain 167 policies spanning more than 1,300 pages. Some of the documents appear to be holdovers from previous documented requirements. For example, guideline document 315-4.2 is numbered CPS Section 68 on the title page. Additionally, CPS uses inconsistent means of documenting requirements. Although most required activities are documented via the written guidelines, the division has elected to use more informal Program Information Notices (PINs) to staff to communicate other requirements. For example, supervisors are required to enter all referrals with an Immediate response designation into the Immediate Response Information System (IRIS). The use of this system is not, however, included in the written guideline documents. Instead, the division communicated the requirements via a PIN it issued in July 2007 and updated in October 2008. Since this PIN is not cross-referenced within the formal guideline documents available to staff, we are unsure how new employees would know of this requirement without reviewing all PINs to identify requirements not contained in the formal guidelines. CPSs existing guidelines include a mix of outdated or conflicting guidancecaused, for example, when the division created a new guideline without revoking or amending a prior guideline document related to the same procedure. CPSs guideline documents also include redundant or duplicate steps in some instances and fail to document key steps or requirements in other instances. Based on the above issues and taken as a whole, the CPS formal guidance is weak and fragmented. To provide context and to illustrate this, we created a table of the requirements Page50
related to one of the divisions central activities performed by staff in many divisionsthe investigation of initial or subsequent allegations of abuse or neglect. Although the primary charge for investigating allegations falls on staff within the Emergency Response unit, staff serving in other programs (Family Maintenance, Informal Supervision, Court Services, Family Reunification, etc.), and who are the primary social worker on a given case, will be called upon to conduct subsequent investigations related to abuse or neglect allegations for children on that case. Given the nature of this activity, and the wide variety of staff that may be called upon to perform investigations, clear guidance outlining requirements for investigating allegations of abuse and neglect is critical. Our review of other counties policies and procedures found that many counties recognize the critical need for guidance for this function, typically collecting and organizing investigation guidelines into one or more documents grouped together by subject. For example, San Joaquin County provides social workers with a comprehensive Intake and Assessment Handbook, which contains flowcharts, required steps, references to state or local laws and regulations, and if-then decision trees. However, Sacramento does not provide a unified set of procedures for social workers to use in conducting investigations and assessments. Our review found that staff seeking guidance on investigating allegations of abuse or neglect would need to sift through at least 18 guideline documents, most of which are not cross-referenced to each other, and which are contained in a variety of sections in the divisions guidelines. Additionally, the guidelines themselves often are not consistent with best practices or changes in laws and regulations, and are often duplicative or contradictory, as described in Exhibit 21 on the following pages. Exhibit 21CPS Social Workers Conducting Investigations Must Comply with 18 Guidelines, Many of Which are Duplicative or Outdated
Policy Number and Creation/Last Revision Effective Date
Title and Purpose Emergency Response Social Worker Standards: Establishes requirement Emergency Response social workers and for the use of SDM tools.
Meets best practices standards?
5-2 04/16/2001
Yesrequires documentation in CWS/CMS and the use of the SDM response priority trees and assessment tools.
Conflicts with or duplicates other policies or guidelines? Yes. The guideline, rather than defining social worker expectations (training, education, etc.), repeats expectations for intake and referral investigation that are already included in subsequent guidelines (Sections 105 and 110 et al., for example). It is unclear what value this guidance provides given that expectations are already covered in other documents.
20-2 10/03/2000
Procedures for Referrals from Family Law Court or Probate Court for Dependency Investigation: Describes process for investigating referrals from family law or probate courts.
UnclearGuidance describes how Family Law Court staff can refer cases to CPS for investigation. It is unclear why CPS would issue guidelines for another organization.
Yes. Requires court staff to contact and provide documents to specific CPS social workers who are no longer with the division.
Continued
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Title and Purpose Emergency Response Protocol: Requires social workers to initiate and complete the Emergency Response Protocol process to determine if an inperson response is required. Process and Criteria for Assessing CPS Reports and Determining Agency Response Time: Provides guidance to staff processing reports of abuse or neglect on how to determine if the allegation meets the criteria for in-person response and (if so), what level of response is appropriate. Emergency Response Prior History Check: Requires staff investigating allegations to review Child Welfare Services prior history in determining the appropriate response to allegations of abuse or neglect
Meets best practices standards? Noguideline does not require the social worker to assess the allegation and determine the response time using the SDM response priority decision tree, even though Sacramento was one of the early adopters of the SDM assessment tool in 1998.
105 No date
Conflicts with or duplicates other policies or guidelines? Yes. Duplicates steps in guideline 105-1, but adds some new criteria on how to determine whether an in-person investigation is necessary (such as consideration of the divisions ability to locate the child or family or identification of any previously investigated unsubstantiated or unfounded reports from the same reporter).
105-1 02/26/1999
Noguideline does not require the social worker to assess the allegation and determine the response time using the SDM response priority decision tree, even though Sacramento was one of the early adopters of the SDM assessment tool in 1998.
Yes. Duplicates guideline 105, and a large amount of steps in Section 110 to 110-5 (although 105 contains some required steps not included in this document).
105-2 03/01/1999
Yes
105-3 09/12/2000
Criminal Record Checks on Emergency Response Cases: Documents procedures for obtaining criminal history information and how to complete a criminal record check
Yes
Yes. Even though this is a required step in determining referrals and response times, this requirement is not referenced in Guideline 105-1 (primary guidance for intake of referrals). Also, guideline states that workers should not make a determination of Information Only versus Ten Day response until after clerical staff process history checks. This is not given as criteria in the Guideline 105-1. Yes. Even though this is a required step in determining acceptance of referrals and response time, this requirement is not referenced in Guideline 105-1 (primary guidance for intake of referrals). Also, guideline states that Emergency Response workers must comply with this document, but doesnt reference other social workers or units. Continued
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Title and Purpose
Meets best practices standards? Yesrequires the on-call social worker to perform Emergency Response functions, including completing the SDM Emergency Response Priority Response Tool and CPS Emergency Response Protocol. No. Requires the social worker to make their determination on the Emergency Response Protocol (Section 105-1). This section does not require the use of SDM.
105-4 08/22/2000
On-Call Policies and Procedures: Defines requirements of CPS Emergency Response on-call social worker
Conflicts with or duplicates other policies or guidelines? Yes. Duplicates guidelines already defined in Sections 105 to 105-3. Makes reference to social workers needing to complete the SDM Emergency Response Priority Response Tool and CPS Emergency Response Protocol, which is not previously referenced in prior guidance. Yes. Duplicates several other guidelines, including 110-1, 110-2, and 105-1. No. Builds on requirements in Guideline 125-1 (referral documentation). However, this policy is not cross-referenced in Guideline 125-1, so social workers would have to know to look for this policy elsewhere. Yes. Duplicates information in Section 105-1 and 110. However, Guidelines 105-1 and 110-3, which were issued after this policy, provide additional steps not included in this document. Yes. Duplicates information in Section 105-1. However, provides additional guidance on how to prepare for the investigation not included in prior guidelines. No. However, some requirements are superseded by a program information notice that has not been incorporated into division guidelines.
110 No Date
In-Person Investigation Summary: Provides guidance on in-person immediate and ten-day investigation requirements Body Checks: Provides guidance on how to conduct body checks of all children in child welfare programs. Immediate Response Referral Procedures: Provides guidance on how to conduct an immediate response investigation. Requirements of the Emergency Response Investigation: Provides guidance on how to conduct an Emergency Response investigation. Request for Evidentiary or other Medical Exams: Provides guidelines for scheduling and authorizing evidentiary medical exams. Pregnant or Parenting Minors Guidelines: Provides guidance for completing investigations on minor parents.
110-1 05/17/2004
Yes
110-2 07/01/1998
NoDoes not require the use of the SDM tools.
110-3 05/05/2003
Yes
110-4 08/05/2002
Yes, except that it is not updated for recent changes issued through a PIN in 2008 related to medically fragile children. No. References state laws or programs no longer in effect (Aid to Families with Dependent Children [AFDC]) and does not require the use of SDM tools.
110-5 05/01/1997
Yes. Duplicates prior investigation guidelines.
Continued
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Title and Purpose Investigation Requirements: Establishes expectations for investigations.
Meets best practices standards? No. Requires the social worker to make their determination on the Emergency Response Protocol (Section 105-1). This section, however, does not require the use of SDM.
Conflicts with or duplicates other policies or guidelines?
125 No Date
Yes. Duplicates several other guidelines, including 110-1, 110-2, and 105-1.
125-1 12/18/2007
Referral Documentation: Provides guidance on how programs are to document assessments of abuse or neglect allegations.
In partthe document addresses multiple issues that social workers should (or must) consider in conducting investigations. However, staff provided documents showing that the division has added sections that social workers must fill out within a template that is not incorporated into this guidance document.
Yes. Documents what should be included in the referral assessment when carrying out tasks defined in Sections 105 and 110. Some, but not all, of the documentation requirements are also provided in these earlier sections. Staff would need to use all documents together to obtain a full understanding of all documentation needs. Yes. Requires the use of outdated Emergency Response disposition forms. Also, contains steps overridden by subsequent policies (but not amended in this policy). Yes. Documents guidelines on how social workers can identify appropriate interventions, service levels, and resources. However, this requirement should be included in the investigation requirements in earlier guidelines rather than in a separate policy that is not cross-referenced in those documents. Yes. Guideline is confusing and has multiple criteria staff must consider to determine whether or not they should take a subsequent allegation.
125-2 04/30/1998
Feedback to Mandated Reporters: Details requirements for providing feedback to mandated reporters.
125-3 08/01/2006
Safety and Risk Based Intervention Process: Describes requirements related to SDM tool usage.
In part. Guidelines were issued in 1998. There have been several legislative changes related to mandated reporters since that year that are not incorporated into this guideline. Yes. However, it is telling that the division did not issue guidance for both safety and risk-based SDM assessments until 2006 (eight years after initiating the use of the tool). The team does note that the division had prior guidance on SDM issued in July 2000, but this guidance covered the risk-based intervention process.
Guidelines for Subsequent Allegations 125-4 on Open Referrals 12/03/2001 Cases: Establishes guidelines for subsequent referrals. Source: MGT review of CPS Guidelines.
Yes
The division does not have a systematic process to periodically review and update policies and procedures for changes to legislation, regulations, or best practices. It appears that in many cases, as it has identified the need for changes to existing guidelines, CPS simply issued new guidelines or program information notices without rescinding or modifying prior documents. Moreover, many of the divisions guidelines are outdated and have not been reviewed or
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modified for subsequent changes to laws or regulations. Our review found that the majority of the divisions guidelines101 guidelines or 60.5 percent of all guideline documentsas shown in Exhibit 22 below, were last created or updated more than five years ago. Some of the outdated policies are related to topics that have had significant changes in state and federal requirements since the policies were last issued or updated. For example, the oldest guideline document, last updated in 1991, relates to placements for children at risk of HIV or AIDS. The team notes that there have been significant discoveries and research done since 1991 related to treatment of and care for HIV-exposed children or children with AIDS, but the lack of an updated policy leads us to conclude that the guidelines have not factored in this modern knowledge. Exhibit 22Most of the Child Protective Services Guidelines Have Not Been Updated for More than Five Years
Policies Either Created or Last Updated this Date Range Date Range 1 Pre-1995 (0.6%) January 1, 1995 through 16 December 31, 1999 (9.6%) January 1, 2000 through 37 December 31, 2001 (22.2%) January 1, 2002 through 47 December 31, 2003 (28.1%) January 1, 2004 through 20 December 31, 2005 (12.0%) January 1, 2006 through 8 December 31, 2007 (4.8%) 1 January 1, 2008 onward (0.6%) 37 Not Dated or Unknown (22.2%) Totals 167 Source: The MGT review of CPS policies and procedures documents.
Our analysis leads us to conclude that there is a significant need for CPS to revise its guideline documents. Many of the staff, supervisors, and managers we spoke with stated that there was insufficient guidance for social workers and CPS staff. However, many also stated that they believed that social workers were complying with required activities and making decisions using a risk-based approach even if the SDM tools were not used. However, we believe the state outcome measures, the departments internal reports, and the results of our review of case files and QA review reports all indicate otherwise. As will be discussed in the next section, lack of sufficient guidance has resulted in staff freedom to decide which required activities they will perform, leading to inconsistent provision of services for children in the child welfare system and to decreased outcomes for children and families in the region.
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Evaluation of Current Procedures Used by CPS

Questions: Are the policies and procedures working when followed? What issues or items of concern exist that prevent cases or referrals from moving as smoothly as possible? Is there consistency in interpretation and application of CPS policies and procedures?
Answer: Some of CPS guidelines have the potential to work, but may not always be successful given conflicts in existing guidelines that has resulted in inconsistent application and provision of services. Given the Countys poor performance on several outcome measures, it cannot support that policies and procedures are working to optimize services and outcomes. The current processes used by staff, coupled with excessive hard-copy paper documentation requirements and multiple handoffs impede case and referral progress. There is a great deal of inconsistency in how staff interpret and apply CPS policies and procedures (guidelines).
Our review of procedures used by CPS staff found a high number of handoffs and a large dependence on paper documentation, which hamper the expedient movement of cases and referrals through the system. Lacking clear guidance, staff and supervisors decide which of the required activities they will perform. Furthermore, inconsistent written guidelines that are often contradictory, duplicative, or outdated hamper our ability to answer whether policies and procedures work when followed, because the department lacks a consistent set of policies and procedures. To determine if the CPS policies and procedures are working when followed, we found it difficult to answer this question. As discussed in our review of child welfare outcomes and internal measures, CPS is failing to provide timely services and to improve outcomes to children on many measures. Exhibit 21 in the prior section presents, in part, why this situation is occurring. Given the conflicting requirements that, in some cases require the use of the SDM tool in some cases but not in others, it is difficult to prove that the policies and procedures work (improve outcomes) if followed because there are so many contradictions and missing pieces of information in the policies and procedures. However, given that the CPS is performing poorly on many safety and permanency outcome measures, we do not believe that the divisions guidelines are working. The state requires that counties ensure that all case information is documented in the CWS/CMS information system. However, Sacramento tends to rely on a large number of paper documents, many of which staff do not enter fully or at all into CWS/CMS. For example, we noted that paper documents were used in various programs for the following: To document staffing decisions (rationale for transferring cases from one program to another). To inventory and track childrens possessions when taken into custody. To assign referrals to the medical neglect response team.
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To determine whether a referral meets the ten-day or Immediate Response criteria or should be evaluated out. To document action plans resulting from TDMs. To document supervisor reviews of case files. To document planned visits and activities each day. In most cases, when CPS requires paper documents, social workers are required to obtain the review and approval of the forms from their supervisors and/or program managers. There is no electronic routing or tracking mechanism in place for transferring these forms around the division. Staff and supervisors reported that many forms are misplaced or misrouted, leading to delays in providing services or transferring cases between programs. Additionally, for almost all paper documents CPS currently uses, the CWS/CMS system has the capacity to track the information electronically through data fields and tables. Some staff reported that CWS/CMS can be cumbersome to use, which is why they believe that the division has created so much paperwork over the years. However, if CPS were to create step-by-step procedures and train staff on using CWS/CMS rather than paper documents, it would be able to eliminate many of these paper documents from the divisions processes. Furthermore, in the absence of consistent guidance, staff and supervisors determine which requirements they will follow, especially when the CPS guidelines and PINs are unclear or contain steps that appear to serve little or no purpose. For example, in the PIN that details case handoffs between Emergency Response and Family Maintenance or Informal Supervision staff the following requirements are outlined: If the Emergency Response social worker (working on the case to be transferred) cannot participate in the (hand-to-hand) meeting, the Emergency Response supervisor must notify the Family Maintenance social worker and Family Maintenance supervisor by telephone. The Emergency Response supervisor then designates another Emergency Response social worker to participate in the meeting. This essentially states, that if an Emergency Response social worker who has been working on a case to be transferred to Family Maintenance cannot attend the meeting, the Emergency Response supervisor will choose another worker with no previous knowledge of the case to sit in on the meeting. We found this to be a nonsensical procedure in that there would be little value added in having a meeting between two social workers, both of whom lacked any previous knowledge of or information on the family and the case. Supervisors stated that they do not follow this requirement and will simply wait until both social workers are free to meet together. Based on our review of guideline documents, if staff were to follow all policies and procedures as currently documented, it appears that staff would perform a large amount of duplicated or nonvalue-added activities. However, cannot, and do not, follow all policies and procedures in the divisions written guidelines. Moreover, as part of our review, we mapped out processes with supervisors in several programs to identify how cases and referrals move through the system (see Appendix A for the detailed maps). In general, we found that CPS has multiple handoff points for referrals and cases as these move through the system. This means that at each handoff point, a new social worker and supervisor will begin working on a referral or case and with the family and children. In some cases, it means that multiple social workers and supervisors are working with families.
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This leads to confusion and frustrations for families who may not be sure who their primary social worker is. Additionally, having multiple handoffs means that the division has a built-in learning curve time required for each social worker to familiarize herself or himself with the case and prior activities. This could be ameliorated with adequate communication between the past and current social workers. However, given increasing caseloads and documentation requirements, in many instances there is minimal contact or discussion between social workers in different bureaus related to case handoff. This has resulted in tension between the programs, which hampers the ability of CPS staff to work together to offer the best services possible to children and families. This tension has only increased in recent months as formerly mandatory meetings (hand-tohand meetings) between the prior and new social workers for case transfers have been suspended. In our survey of CPS employees, many employees reported that case handoffs contribute to problems with moving cases and referrals efficiently through the system. When asked to rate the effectiveness of the case handoff process, many employees reported that case handoffs were ineffective or very ineffective, as shown in Exhibit 23. Exhibit 23Response to Survey Question What is the effectiveness of case handoffs?
VeryEffectiveandEffective 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0%
EmergencyResponse FamilyMaintenanceand FamilyReunification InformalSupervision Intake AllRespondents 23.8% 39.3% 36.7% 32.1% 46.9% 43.2% 40.5% 38.1% 32.7% 32.3%
VeryIneffectiveandIneffective
Source: The MGT survey of CPS employees, November/December 2008. Note that responses do not add up to 100 percent since some staff responded not applicable to this question.
As discussed earlier, CPS has multiple paper documents required for case management. These documents may or may not ultimately appear in CWS/CMS. Therefore, social workers who are not the primary workers on the case or who are waiting for the hard-copy case file to be transported to them do not have full access to all information related to the case. Therefore, they may either duplicate procedures already being performed or fail to perform action steps required for the family. Additionally, most of the paper documents require an approval by a supervisor, and in some instances by a program manager. Because the division lacks a process for transmitting and tracking these documents electronically, at any given time, there are hundreds of paper documents circulating throughout the division with no formal tracking
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process. Staff and supervisors reported a great deal of frustration when documents are lost, delayed, or returned to the wrong person. The teams review of procedures used by other counties found that it is not uncommon for counties to split service delivery by program component (emergency response, family maintenance, family reunification, permanency placement, etc.). However, counties with best practices ensure that there is sufficient communication during the handoff process and that action items are documented electronically as well as in the hard-copy case file. We also found that other counties do not appear to be relying on paper documentation to the extent that CPS does. The CWS/CMS has many fields, tables, and templates available that CPS social workers could use and therefore eliminate or reduce CPS dependency on paper documentation. Question: Is there duplication of effort by employees or work that serves little or no purpose?
Answer: Our review found that there does appear to be processes that are non-value adding.
Our team found that there is a great deal of inconsistency in interpretation and application of CPS the policies and procedures. Lacking clear guidance (policies and procedures) on required actions leaves staff struggling to comply with all division, county, state, and federal requirements. Staff has access to supervisors and managers to obtain additional information related to case work and referral investigations. However, managers and supervisors themselves are often at a loss for how to address a particular situation, and in many cases provide staff with conflicting interpretations of how to carry out a policy. In the absence of clear guidelines, staff and supervisors may carry out procedures that do not comply with best practices and/or that do not add value. In response to our teams on-line survey questions, Exhibit 24 shows that almost 60 percent of staff responding reported that they felt the division has too many policies. Additionally, more than 40 percent of the staff felt that they were not kept well-informed by management, as shown in Exhibit 25. In follow-up discussions, staff clarified that managers and supervisors often provide conflicting and confusing directions to staff on how to carry out required activities. These responses appear consistent with reviews conducted by the divisions QA team. For example, the QA staff reported in a January 2007 review of Emergency Response cases that supervisors were not reviewing cases using the QA review form and were therefore missing opportunities to provide guidance to staff to correct mistakes staff were making in their assessments. However, they also noted that workers and supervisors had failed to demonstrate an understanding of the difference between a safety plan and a support plan. Therefore, it was possible that, even with a case review by supervisors, the supervisors would have been unable to identify instances of noncompliance. Another QA review in March 2007 found that social workers were apparently not familiar with requirements contained in several guidelines related to investigations of referrals. The review found that social workers were failing to completely address discrepant information, assess or inquire about pertinent information, or interview caretakers. As a result, the QA team found that it could not determine whether investigations were concluded correctly for half of the reviewed referrals. Again, having supervisors familiar with the requirements who were providing guidance to staff would help to address these issues.
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Exhibit 24Response to Survey Question Do you agree or disagree that the Department has too many policies?
80.0% 70.0% 60.0%
52.38% 69.39% 64.29% 64.86%
StronglyAgreeandAgree StronglyDisagreeandDisagree
59.62%
50.0% 40.0%
30.61% 35.71% 35.14%
47.62% 40.38%
30.0% 20.0% 10.0% 0.0%

EmergencyResponse FamilyMaintenanceand FamilyReunification InformalSupervision Intake AllRespondents
Source: The MGT survey of CPS employees, November/December 2008.
Exhibit 25Response to Survey Question Do you agree or disagree that management keeps employees well-informed?
StronglyAgreeandAgree 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
EmergencyResponse FamilyMaintenanceand FamilyReunification InformalSupervision Intake AllRespondents
StronglyDisagreeandDisagree
67.9% 59.5% 53.1% 46.9% 40.5% 32.1% 19.1%
81.0%
59.2%
40.8%
The lack of formal guidance from the division means that staff, supervisors, and managers are left to carry out required activities using their best judgment. Additionally, supervisors and managers are under pressure to keep up with increased caseloads while knowing that staff have no way to possibly carry out all of the (often conflicting and duplicative) activities listed in
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the current guideline documents. Therefore, supervisors and managers end up deciding which policies and procedures they will follow. This, however, does not result in optimal outcomes for children and families, nor does it ensure that CPS is meeting all mandated state and federal requirements. Examples of problem areas or areas that are not adding significant value to the CPS work include the following: Staff Meetings: Staff largely supports the staffing meeting process, feeling it gives additional input and perspective and helps improve outcomes for children and families. However, the process itself results in a large amount of paperwork and documentation. Staffing meetings usually require a staffing form to be filled out by the social worker, with case information (that is already in CWS/CMS) handwritten in on the form. After reviewing the case and deciding whether or not to staff, the supervisors fill in their determination, have the social worker copy the form, and then place a copy in the supervisors files and in the hard copy case file. Social workers are then required to update CWS/CMS with the information, but this does not always occur. Team Decision Making (TDM) Meetings: TDM meetings are not resulting in significant value to the division and have resulted in the division under-utilizing some social workers. Management has expressed the viewpoint that TDMs are part of the solution to CPS permanency and stability issuesTDMs are intended to stabilize or find the best placement for a child in out-of-home care. However, TDM meetings can take a large amount of staff time, requiring social workers and supervisors to travel from various office locations to attend the meetings. Staff reported frustration with this process when the purpose of the meeting is to discuss placement changes that have occurred in the past. CPS requires staff to hold TDMs prior to placement change. However, this does not always occur. Between January to June 2008, 61 of 444 TDM meetings (14 percent) occurred after CPS had moved the child to a new placement. Anecdotal reports from supervisors and staff indicated that the number of meetings held after placement changes has increased in recent months. Although CPS did not provide data for TDMs after June 2008, during our fieldwork we were able to observe one TDM meeting. This meeting was being held for a child whose placement change had occurred two weeks prior to the meeting. Furthermore, TDMs require the use of social workers who are not otherwise carrying cases. The nine social workers assigned to the TDM unit conducted a total of 713 TDM meetings during fiscal year 2007-08, or an average of 6.6 meetings per month per worker. This workload is far lower than the workload of any other program within the division. We note that TDMs are designed to bring together as a group various partners, including parents, foster parents, social workers, teachers, doctors, and community groups, in an effort to not only stabilize placement for the child, but to identify action plans that will result in maximizing services available to the child and his or her family. However, although the TDMs may result in bringing together various parties to work together to meet the childs needs for a few cases, they are not provided to all, or even a majority, of children. Further, CPS intent in implementing these meetingsto stabilize placement has not resulted in measurable changes or improvements. For example, as reported in Exhibit 2 in this report, the department has seen significant decreases in its performance related to the stability of children in foster care. This means that even with the TDMs, children are continuing to move from placement to placement with the consequent
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disruption to their lives. Further, the CPS internal reports show that in fiscal year 200708, the TDMs resulted in a placement disruption for almost 40 percent of the meetings held. Although studies have shown that other counties have achieved service improvements through the use of TDMs, it appears that CPS implementation of these meetings has not. Referral Investigation Notes: To compensate for past failures, the division has increased documentation requirements in the narrative section of CWS/CMS for social workers conducting investigations of abuse or neglect. Investigation narratives can exceed ten pages (single spaced) in length due to the number of items that are mandatory for social workers to describe in the notes. Emergency Response workers must address 29 items separately, some of which are documented in other areas of CWS/CMS. The division has not made efforts to find more efficient ways to document investigation findings (such as creating codes for the most frequently identified findings). Court Reports: Court reports can average 30 or more pages. Documentation requirements for court reports are not standardized and can depend on the preferences of the judge or referee within the Juvenile Court system. To ensure they are meeting the strictest requirements, staff create court reports using the most stringent standard (that is, by making the reports include more information than may be necessary) rather than by including only what is needed for that particular case. CPS executive management has not created formal agreements with the Juvenile Court to delineate social worker court report requirements. The CWS/CMS system has three templates available for social workers to use in creating court reports. Other counties use these templates to reduce work for social workersthe templates pull information from several fields in the CWS/CMS system to reduce the amount of manual entry social workers must make. CPS does not believe that the current templates meet their needs. However, it has not tried to work with the Court to define report requirements that could be used to modify existing templates. Consequently, social workers must spend large amounts of time putting these documents together. CPS executive managers reported that CPS and the Courts frequently revise the court report, as new laws and regulations are enacted. They believed that this effort signified that they have worked collaboratively together for system improvement. However, as stated above, in their efforts to work with the Courts, they have not sought to design a standard template for the reportsa template that is used successfully by many other counties in the state. While we acknowledge that there appears to be a large amount of contact and working relationships between the Courts and CPS, CPS still has opportunities for improvement to reduce social workers work loads. Case Assignment: Supervisors reported that they do not assign cases based on the complexity of cases. Rather, they assign cases based on the number of cases and rotation (next social worker due for assignment). CPS does not take into account the various levels of work that may be required depending on the nature of the case. This could result in some staff having a proportionately larger burden and amount of work they must provide when compared to their coworkers. Taken as a whole, the processes result in a division that places more emphasis and focus on documentation and desk-work activities than it does on meeting with children and families and performing out-of-office fieldwork. This does not result in the best services for children and families and does not ensure social workers can give the support to families that is needed to reunify or end CPS involvement safely and promptly.
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To illustrate this, our team conducted an on-line survey of CPS social workers and asked them to estimate the amount of time that they spend conducting a variety of activities. The team notes that the survey was based on responses by social workers and does not represent a statistical analysis nor is it a time and motion study showing actual time required to manage real cases. Nevertheless, the survey responses validated much of what we identified in the process maps and review of division guidelines Administrative requirements (related to documentation of case work) are such that the majority of work by social workers must be performed within the office rather than in the field. In Exhibits 26, 27, and 28, we present staff responses to the survey with estimates of time spent in the field versus time spent in the office. In all instances, staff estimated fieldwork to be about one-third or less of the hours they work. Exhibit 26Emergency Response Staffs Estimates of Time Spent on Various Work Activities
ExternalMeetings withOther Agencies,4.4 Admin(Travel, Training, Internal Meetings),11.7 Other, 6.0
Casework in field,31.2
Casework in office,46.7
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Exhibit 27Family Maintenance and Informal Supervision Staffs Estimates of Time Spent on Various Work Activities
ExternalMeetings withOther Agencies,7.3
Other,10.9
Admin(Travel, Training, Internal Meetings),18.8
Casework infield, 34.0
Exhibit 28Family Maintenance and Informal Supervision Staffs Estimates of Time Spent on Various Work Activities
ExternalMeetings withOther Agencies,4.9
Other,15.2
Admin(Travel, Training, Internal Meetings),11.2
Casework infield, 26.7
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We observed many activities in the processes that do not need to be performed by trained social workers. For example, social workers are responsible for making referrals for parents to enter treatment programs or parenting classes. Making these referrals requires social workers to identify the appropriate class, call to determine openings and availability, schedule the parent or guardian for the class, and then follow-up to ensure the parent complied with the plan. Many of these tasks could be shifted to clerical or administrative support, especially repetitive tasks requiring phone calls or paperwork related to class enrollment. Additionally, social workers who carry out court-ordered case plans are often required to transport children to supervised visits or to their schools of choice. It would be more cost-effective for a Family Services Worker (lowerlevel and lower-paid staff person) to perform this task, thereby freeing up social workers to provide value-added case work rather than transportation services.
Implementation of Prior Recommendations from External Reviews

In the prior section, we answered several questions related to CPS guidelines for its staff. In this section, we discuss prior evaluations and recommendations from external organizations and the divisions current efforts to address issues it has self-identified. Question: Has the division addressed the ongoing and recurring issues and recommendations included in the CPS Oversight Committees prior reports?
Answer: CPS has failed to address ongoing and recurring issues and recommendations by the CPS Oversight Committee.
The primary external reviewer of CPS for several years has been the CPS Oversight Committee. Since 1996, the CPS Oversight Committee has issued eight reports. The majority of the issues identified have continued to be reported from year to year, and continue to exist within the divisions current practices. Moreover, many of the CPS Oversight Committees recommendations have been mirrored in the six Sacramento County Grand Jury reports issued between fiscal years 1996-97 through 2007-08. A summary of the findings and recommendations that continue to exist in the present day is shown in Exhibit 29. Exhibit 29Prior Findings and Recommendations Related to Child Protective Services
Report Critical Case Investigation Committee Final Report (May 1996) Total Findings 43 Total Recommendations 35 Key Findings and Recommendations CPS gave primary attention to the parent rather than to children at risk. The DHHS and CPS failed to use resources in the most effective manner. Caseloads exceed numbers recommended by the Child Welfare League of America. Working environment for social workers with contact with families and children at risk is stress filled. Policies and procedures are inconsistent with verbal directives within the division. Continued
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Report Critical Case Investigation Committee Final Report (May 1996) Continued from prior page
Total Findings 43
Total Recommendations 35
The CPS Oversight Committee Report to Board of Supervisors (September 1997)
30
34
The CPS Oversight Committee Report on Foster Care (April 1999)
37
37
The CPS Oversight Committee Report on Implementation and Compliance with 1996 Report Recommendations, (May 2000)
72
72
Key Findings and Recommendations The Department needs to undertake a complete review of organizational structure, policies, and procedures. The Department needs to assess the risk to children more frequently and on an ongoing basis. CPS needs to assign a single case worker as the primary contact in each open case to manage and coordinate all services to the family. Termination of cases needs to have specific criteria, such as an assessment of ongoing risk factors and a child safety plan. CPS needs to create a method of interagency communication. Committee noted systematic problems including the need for policies and procedures, and personnel training. CPS needs training for social workers for risk assessment criteria. CPS needs to have a team approach to communication and coordination of agencies involved in case management. Staff managing high caseloads decrease their ability to spend sufficient time on each case and increases stress per social worker. High turnover affects morale within the division as well as relationships with clients. Because of the increased focus on protection of children, the number of children put into protective custody had increased dramatically. The Committee noted problems with inadequate foster care placements, unsuitable alternative placements, and inadequate training and support for foster parents. The Committee noted deficiencies in case management and face-to-face contacts and in providing assessments during child placement. CPS needs to implement system-wide coordination with state and local entities to ensure support for CPS and the foster care system. Caseloads continue to exceed state recommended limits. Workers have limited space and poor equipment. Work environment continues to be stress filled and crisis oriented. Social workers are not reassessing or updating risk assessments frequently or consistently. CPS has neglected the recommendation to coordinate efforts and hold parents and families accountable by reducing risk. CPS lacks a formal protocol or written policy for social workers partnering with other agencies to jointly manage cases and freely exchange information. Continued
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Report The CPS Oversight Committee Follow Up Report to Foster Care Report (November 2002) The CPS Oversight Committee 2005 Annual Report (March 2006)
Total Findings 54
Total Recommendations 59
19
19
The CPS Oversight Committee 2006 Annual Report (May 2007)
21
21
The CPS Oversight Committee 2008 Annual Report (September 2008)
Key Findings and Recommendations CPS has a continued need for additional foster homes to handle the increase in children needing placement. Foster care resources and services should be evaluated, updated, and utilized. Additional training is needed for foster-care parents. CPS staff continues to have problems using the SDM tool. In some instances, staff overrode the SDM results. CPS supervisors need training related to managing staff and mentoring. The Board needs to designate an outside agency to ensure the recommendations of the report are implemented. CPS has to reemphasize the mission to protect the child and to make child safety the number one priority. Social workers are not using the SDM tool with fidelity and some of the tools had inadequate information to assess risk. CPS continues to have problems with interagency collaboration. CPS needs a system of accountability to ensure supervision is taking place. Social workers need to corroborate and document statements by parents to assess the accuracy of these statements. CPS needs training on assessing infants, children with special needs, or those with physical disabilities. Supervisory personnel failed to provide adequate oversight, contributing to a potential risk of harm going undetected or potentially being exacerbated. CPS continues to have issues due to inadequate training and supervision. CPS has challenges collaborating with service providers and community partners that serve high-risk children and families.
Source: The CPS Oversight Committee reports, as noted.
As shown above, in reviewing these prior reports in correlation with our review of CPS current activities, organizational structure, and policies and procedures, we found that many of the findings identified by the committee in prior years continue to be findings for CPS today. CPS executive management has failed to implement effective solutions that adequately address the findings from prior years, resulting in the recurrence of these problems. The CPS Oversight Committee lacks the authority to compel CPS to implement the recommendations or to periodically report on their progress. The Board, which does have this power, has not required CPS to report on its status of addressing identified issues, either periodically or as part of its budget requests. CPS management has not disagreed with any of the findings in the CPS Oversight Committee reports, and in many instances has agreed that the problems exist and that they intend to find solutions. In fact, CPS management has implemented a large number of action steps to attempt to resolve deficiencies and findings. However, these actions have failed to result in substantive changes and improvements to service delivery. In general, it appears that most of
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managements solutions are short-term in nature or involve creating, but not necessarily implementing, new policies or procedures. In other cases, these solutions are quickly overridden by staff. Thus, given the repetitive nature of the CPS Oversight Committee findings and recommendations, it is apparent that the responses are not sufficient to address the identified problems. For example, in its list of actions taken in response to findings, CPS executive managers reported that they have ensured that SDM training is a core requirement for all social worker staff. They also state that they have provided staff with a laminated card that includes a list of safety factors to be used as a quick safety check while conducting investigations. However, as discussed earlier in this report, CPS data shows that social workers are not completing the SDM risk and safety assessments for all referrals for which they are required, or are not completing them timely. Furthermore, staff and supervisors reported that some social workers use the laminated cards in the field as replacements for the SDM assessments, rather than for their intended use as reminders. Moreover, CPS does not appear to be effectively tracking the implementation status of its action plan items. CPS action items do not contain timelines, responsible staff, start and end dates, or how it plans to measure the results of its actions. Therefore, not only does CPS lack data on the effectiveness of its actions, it also lacks a means to determine which recommendations staff have actually implemented. For example, in its list of actions taken, CPS managers reported that Emergency Response supervisors are completing qualitative reviews of 100 percent of the social workers documented assessments and interventions using a comprehensive quality assurance sheet for all closures and transfers. Our discussions with Emergency Response supervisors and social workers found, however, that supervisors are not completing these assessments. Rather, supervisors perform a high-level scan of case notes on closed cases as time permits. This issue is reinforced by our findings related to our review of case files pertaining to critical incidents, files which lacked documentation of the required assessments. Furthermore, as reported earlier, in one case, a supervisor did not review the case after the social worker closed it with an inappropriate determination that it was unfounded. Only after the childs death did the supervisor review the case and change the social workers finding to substantiated. In part, CPS problems with addressing issues stems from executive management (division managers and the deputy director) not functioning as strategic leaders within the division. Issues related to child fatalities in recent years have resulted in executive managers spending a large portion of their time reviewing cases and unit metricstasks better suited for program managers or supervisors. CPS executive managers stated that they have strategic plans, and provided us with the documents consisting of the DHHS strategic plan and the 2005 countywide System Improvement Plan (SIP). These plans have action items, responsible parties, and strategies for improvement. However, we do not see evidence of significant and measurable progress in achieving objectives. In many instances in its SIP, for instance, CPS has indicated that it is still working to implement the majority of the action items. Therefore, it does not appear to be an effective strategic plan to guide long-term improvements. Communication issues and staff resistance have also played a role in CPS failure to implement recommendations and make substantive changes within the organization. Staff and supervisors reported that they do not feel supported by CPS management. Survey responses and results of interviews revealed that many CPS staff feel that management agrees too readily when members of the public, press, or community groups blame social workers for critical incidents (throw workers under the bus was a frequent comment heard by our team). However, in attempting to make changes, managers at several levels reported having issues with overcoming staff resistance. Line staff stated that they did not believe the promotion process Page68
resulted in the most qualified candidates being hired into management positions, and therefore often questioned or worked against supervisors or managers directives. Line staff stated that would like management to conduct a review to identify the cause of problems rather than just immediately assessing blame on the social worker. Staff would also like to see management provide more public support and praise for the dedicated and hard-working staff in various bureaus, which relates to the survey response on whether the division recognizes employees who do well. Exhibit 30Response to Survey Question Do employees feel supported by management?
StronglyAgreeandAgree 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
EmergencyResponse FamilyMaintenanceand InformalSupervision FamilyReunification Intake AllRespondents 57.14% 53.06% 46.94% 42.86% 32.43% 28.57% 41.92%
67.57%
71.43%
58.08%
Source: The MGT survey of CPS employees, November/December 2008. CPS executive managers will need to address and remedy communication gaps at all levels if they are to successfully implement fixes to the system and improve outcomes for children and families. Furthermore, given the number of changes needed coupled with ongoing division requirements and increased workload, it may not be feasible for the executive managers to implement the changes without additional resources and assistance. Bringing in outside assistance with experience in a variety of child welfare models and operations may bring needed perspective to allow CPS to make the changes required to revamp the system rather than focusing on making adjustments to a broken system. Question: Is there an adequate management control system for measuring, reporting, and monitoring the programs policies and procedures?
Answer: Yes. However, the division has only recently begun to require the use of the system.
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CPS has a system to measure, report on, and monitor the progress of staff and compliance with required policies and procedures. However, until recently, management did not use this system to evaluate staff activities or to identify areas ripe for improvement. Consequently, as discussed in the prior section, many of managements actions to address issues have failed to remedy items of concern. Our survey of CPS staff and supervisors as well as focus group discussions found that many CPS employees reported that they felt that a lot of the responses to negative media or report findings were reactive and did not result in meaningful changes. Staff reported that they believed that these types of solutions often caused more problems than they solve. Staff and supervisors in interviews, focus groups, and survey responses, overwhelmingly reported that the division needs a consistent and comprehensive plan to research findings and recommendations and vet them with staff to consider and weigh possible solutions before making changes. This viewpoint is mirrored in the CPS Oversight Committees report recommendations. In part, as discussed in the prior section, our review indicates that managements failure to implement recommendations and fixes may be due to the fact that executive management is spending too much time on detailed reviews and day-to-day operations instead of working as the strategic leaders and guides of the divisions mission. Additionally, lacking a big picture focus means that managers may have terminated or reduced programs that were actually resulting in positive changes. For example, in response to heightened criticism, CPS executive managers established a QA unit in 2000 to perform random quality assurance reviews to ensure uniformity in service delivery and compliance with requirements. CPS QA unit performed a number of reviews on various bureaus and problem areas in 2006 and 2007. The QA unit noted deficiencies and then followed-up with several of the supervisors and staff as needed, leading to improvements in subsequent reviews. However, due to the amount of additional work required of the QA unit (tracking and providing training, for example), the QA units review efforts were reducedbetween June 2008 and January 2009, the QA unit did not perform any quarterly reviews of division activities. Given the improvements identified in subsequent reviews QA did in earlier years of formerly problem units or areas, it would be in CPS best interests to devote adequate resources to this unit to allow it to continue or increase its reviews. This focus could result in improvements in case management as well as improved outcomes for children and families due to better case and referral actions. Executive managers reported that in lieu of QA reviews, managers and supervisors are expected to conduct QA reviews of all high and very high-risk cases transferred from or closed within their units. However, our review of the seven child fatality cases found that this process was not consistently followed. Additionally, supervisors in focus groups reported that their workloads did not permit them to conduct extensive case reviews or to use the case review checklists provided in division guidelines (most reviews consisted of reading case notes and contact information). Furthermore, reviewing high and very high-risk cases will not ensure the division is protecting children from harm due to staffs ability to override the SDM risk determination (force the risk result to a lower risk level). In several of the fatality cases we reviewed, staff had assessed risk as low or moderate even though the factors present should have indicated a much higher risk level. Supervisors who are only reviewing high or very highrisk cases would be unaware of these over-ridden cases. The QA reviews are especially critical given a finding by both the CPS Oversight Committee in prior years and in our review. This finding is that there is no person or group responsible for monitoring cases and referrals as they move through the various handoffs and units within CPS. Supervisors are supposed to review cases as they assign them to their staff and as they
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transfer them out. However, the reality is that supervisors are overwhelmed and often do not spend sufficient time performing detailed reviews. As a result, supervisors miss opportunities to identify deficiencies in case or referral work and children may be left in risky situations. Examples of effects due to poor review practices are as follows: The January 2007 QA review of 77 high and very high-risk cases assigned to Emergency Response found that 34 (44 percent) had practice issues that could have a potential impact on child safety or risk. The practice issues included incorrect or conflicting information, missing contacts or interviews, staff failing to demonstrate an understanding of the difference between safety and support plans, and supervisors not completing sufficient reviews. Supervisors reported in focus group discussions that many cases that they inherit from other programs within the division are inappropriate (do not address the issues related to the familys situation) or are not functional. This condition is consistent with the QA units findings from July 2007, which found that five of 20 case plans reviewed had been established with missing or inappropriate components. The division does not have a process to follow-up on problem units or staff to ensure that identified problems with case plans are remedied in the future. In two of the seven child fatality cases we reviewed, supervisors failed to identify problems with the conclusions of a staff person assigned to investigate the referrals and who had a known history of not following procedures. Consequently, the staff person (same person on both cases) closed the referrals without providing needed services to the families. Had the referral disposition been made in compliance with SDM protocols, it is likely that the families would have been required to participate in voluntary or mandatory services, and thus may have reduced the chance of the children being killed. Additionally, in all seven fatality cases, there were serious deficiencies and questionable decisions made by social workers. In four of the seven cases, we believe that the childs outcome may have been improved (reduced the chance of death) had thesocial workers complied with required policies and procedures. The division has had access to a monitoring toolSafe Measuresfor several years that, for the most part, staff, supervisors, and managers have not used. The Safe Measures system provides a wealth of information at all levels (program, bureau, unit, or staff person) to allow supervisors and managers to identify performance and focus on areas of weakness. Among other information, Safe Measures provides information on case compliance, case plan status, the use of SDM tools, workload levels, compliance with state outcomes, and contacts with children and families. In recent months, the executive managers have begun issuing requirements to supervisors and managers for using Safe Measures, and usage reports indicate that supervisors and managers are increasing their use of this tool. This will ultimately assist the division in monitoring and targeting areas of improvement in the future.
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Review of Staff and Technology Resources

Questions: Is the division using the optimum amount of resources (staff, equipment, and facilities) in producing or delivering the appropriate quantity and quality of services in a timely manner? Does the agency have adequate resources for staff to provide optimal services?
Answer: CPS is not optimizing its service delivery due to technology and resource deficiencies that hamper staffs ability to properly manage cases and investigate referrals. The review team is unsure whether there are adequate numbers of staff within the division to handle workloads, because the current guidelines result in a great deal of duplication and non-value-added work.
As discussed earlier in this report, CPS workloads for case-carrying social workers have increased in several programs in the most recent year. For many staff, the case load levels are such that staff cannot fulfill all required activities. It would appear that given the number of cases and children served by CPS compared to expectations established by the state in funding child welfare services, CPS may need additional staff. However, determining the number of staff required by CPS and for which programs is difficult to estimate. This is because the inefficiencies in the current system contribute greatly to the amount of work social workers must perform. Bringing in more social workers without addressing process deficiencies and lack of clear guidelines could result in CPS paying for a larger number of staff who are not providing timely or compliant services to children and families. It could also increase costs to the County as social workers become frustrated with working in a broken system and leave. The County therefore needs to combine exploring ways to address issues with CPS lacking sufficient staff in conjunction with making system improvements to better retain existing staff. Moreover, our review found that CPS has a continuing problem with obtaining sufficient technology and resources for staff to effectively and efficiently perform their jobs. Although, the division provides cell phones for social workers to use while in the field, technology resources are lacking within the division. Social workers and supervisors do not have access to CWS/CMS, electronic case files or records, or e-mail while in the fieldCPS has been unable to obtain Blackberrys or personal digital assistants for any staff. CPS executive managers have been working to make improvements, however. For example, CPS recently refreshed its computer technology hardware within the offices. CPS has also obtained CWS/CMS tokens for Emergency Response and Court Services supervisors and all after-hours social workers and supervisors. These tokens allow staff to access the system via a broadband connection from their home without having to return to the office. CPS employees recognize the divisions effortsin response to a survey question on whether CPS provides adequate access to computers and technology, more than 87 percent of all respondents agreed or strongly agreed. Nevertheless, CPS needs to consider additional technology options. In prior years, CPS issued QuickPads to some social workers for use in the field. QuickPads are hardware that provides connectivity to electronic data (mobile computing). However, the hardware is now outdated. When the division updated its internal hardware system during the last fiscal year, the new system no longer supported the use of QuickPads. CPS managers are now reviewing options for out-of-office access, including purchasing additional tokens for staff to connect to CWS/CMS
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from home. CPS lacks any means for social workers to quickly access data while they are in the field or to electronically document case notes and findings. Therefore, social workers must perform critical review and assessment functions, such as the SDM assessments, when they return to the office. In a county self assessment released in March 2009, CPS reported that it only has 53 laptops for its social workers and supervisors to useless than 0.1 laptops per employee. In the same report, Sacramento County Probation Department noted that it had laptop computers in place for its Probation Officers to use while in the field. The Probation Officers in the Placement Division use the laptops to access the Probation Information Program and to input case notes while they are out in the field. CPS social workers could benefit greatly from similar technology and access. Additionally, in creating court reports, CPS requires social workers to submit the reports to transcriptionists. The purpose of this requirement is to ensure that court reports meet Juvenile Court formatting and content requirements. However, using transcriptionists rather than clerical support within the bureau or program has caused significant delays for some social workers in obtaining these required reports. To alleviate the delays, staff informed us that in some instances, social workers are typing their own reports. Staff cannot e-mail reports to transcriptionists due to network security. However, many staff have found a back-door way to download the reports and save them onto compact or floppy disks. The transcriptionists then get pre-typed reports that they format into the court style. This process, however, is an inefficient use of resources since transcriptionists are essentially receiving premium pay for formatting documents rather than for their specialized transcriptionist skills. Additionally, it represents a data security breach and increases the risk that confidential case data could be misplaced or misused. Staff and supervisors reported that due to the increasing number of court filings and cases, the division lacks sufficient transcription staff to meet program needs. In some instances, social workers have been held in contempt of court due to late filings of court reports. Although the division is looking at alternatives, such as text-to-speech computer programs, staff will continue to face sanctions and delays in obtaining required reports until CPS acquires additional technology. Moreover, as shown on Exhibit 31, some supervisors and social workers reported frustration with the process of obtaining vehicles. For liability reasons, social workers cannot transport children or parents in their own vehicles and must obtain a County vehicle for this purpose. There are 201 cars in the division, but only 108 are available for shared use by the divisions 470 social workers, however. This is because CPS assigns some of these cars permanently to Family Services Workers, and assigns other cars to specific bureaus of units. Staff are therefore limited by the amount of cars assigned to their unit or location. CPS administrative staff review vehicle use on a monthly basis and have a comprehensive tracking system that includes usage (miles driven), service history, and assignment. To obtain a vehicle, social workers must check in with the administrative or control clerk for their bureau or program. There is no electronic reservation system or electronic methodology to check for vehicles, and many clerks require social workers to check cars out in-person rather than via the phone or e-mail. If there are no vehicles available within a unit, social workers can rent cars from the County motor pool. However, the County motor pool has recently reduced its inventory of available vehicles as well as the locations it operates. To rent County vehicles, social workers must drive to either the Bradshaw or Downtown locations, leave their vehicles, check out a vehicle, drive to the home or location and transport the children and/or parents, then drive back to retrieve their vehicles. If they park downtown, they must also obtain a parking sticker in advance to pay for their parking. Depending on the time of day and area they are traveling to and from, social workers may end up spending extensive amounts of time Page73
commuting to and from the County motor pool locations, which is time that is not adding value to case work. Exhibit 31Response to Survey Question Does CPS Provide Adequate Access to Vehicles?
StronglyAgreeandAgree 70.0%
62.16%
50.00%
60.0%
51.02%
50.0% 40.0%
50.00% 46.43% 38.10% 32.43%
42.86% 34.23% 23.81%
30.0% 20.0% 10.0% 0.0%

EmergencyResponse FamilyMaintenanceand FamilyReunification InformalSupervision
Intake
AllRespondents
Source: The MGT survey of CPS employees, November/December 2008. Additionally, social workers expressed concern with the quality of the vehicles available to them. The divisions policy is to replace vehicles at 100,000 miles or ten years. Additionally, division policies are to ensure vehicles are serviced every 5,000 miles or six months, whichever comes first. Given the large geographic area and number of children served, cars are experiencing a high degree of wear and tear, resulting in shorter than expected life spans. Social workers reported feeling unsafe in cars and experiencing frequent breakdowns while in County vehicles. As shown in Exhibit 32, 40 percent of vehicles owned by CPS are more than nine years old. CPS workers drove almost 2 million miles in the vehicles in fiscal year 2007-08. Exhibit 32The Majority of CPS Vehicles are More than Five Years Old
Age of Vehicle 9 years or more 6 to 8 years 4 to 5 years 1 to 3 years TOTAL Number and Percent of Cars 82 40.2% 55 27.0% 5 2.5% 62 30.4% 204
Source: CPS Vehicle Mileage Reports
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Given the high usage and large geographic area, it may be beneficial for the CPS to consider contracting with the County for additional vehicles, using lower paid staff as runners to obtain vehicles for social workers at their field offices, or reviewing replacement policies related to vehicles to determine if the policy should be modified. Human Resources Issues and Issues with Staff Not Following Policies and Procedures As discussed earlier, the division has significant problems with its written guidelines, which are often confusing, contradictory, or duplicative. This environment makes it difficult for supervisors to properly discipline those employees who are not following required activities, particularly given the sheer number of guidelines that overlap and contradict each other. Staff and supervisors reported that they believe there is a large problem with the discipline taken for problem employees. As shown in Exhibit 33, our survey of staff found that in response to the statement that the division disciplines employees who perform poorly, 69 percent of employees disagreed or strongly disagreed. In contrast, employees were split on whether the division recognizes employees who perform well50.4 percent agreed or strongly agreed that the division did recognize employees who performed well, while 49.6 percent disagreed or strongly disagreed. Exhibit 33Response to Survey Question Does CPS Discipline Employees Who Perform Poorly?
StronglyAgreeandAgree 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
EmergencyResponse FamilyMaintenanceand FamilyReunification InformalSupervision Intake AllRespondents 26.53% 28.57% 29.73% 23.81% 30.77%
73.47% 71.43% 70.27%
76.19% 69.23%
Source: The MGT survey of CPS employees, November/December 2008. In managements defense, we note that taking disciplinary action can be a cumbersome process and require extensive documentation and monitoring by supervisors. Staff may believe that supervisors are failing to take action to discipline problem employees. Staff may also not be aware of all actions supervisors are taking, or of the time it takes to gather appropriate documentation pertaining to the identified deficiencies. Nevertheless, it appears that the division has problems external to the administrative process.
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In part, the problems with holding staff accountable to meeting division guidelines come from the poor guidelines in place. Supervisors are hard-pressed to discipline a staff person for failing to follow policies when the policies are outdated, contradictory, or confusing. Nonetheless, supervisors reported that they need more support from County Human Resources staff. There have been past occurrences where disciplinary actions have been overturned by the civil service commission review panel due to poor documentation and noncompliance with required human resources practices. Supervisors reported that the Human Resources unit has discouraged them from taking disciplinary actions in some instances, even in extreme cases such as when employees have been caught lying, stealing supplies meant for families or children, or falsifying case documents. In fact, two of the seven child fatality cases involved the same social worker, and CPS own review reported that this person had past problems with complying with policies and investigating referrals properly. Staff also believed there is particularly low morale within CPS staff throughout the organization. The low morale is partially attributable to the negative attention the division has received in recent months. However, we observed that the division has communication problems present at all levels within the organization. These communication problems appear to have resulted in dissatisfaction spreading throughout line staff ranks. Many staff responding to the survey complained about interactions with supervisors and managers. Some staff also reported that they had not received feedback on their performance (such as an employee evaluation) in several years. CPS executive managers agreed that they have experienced communication issues and issues with supervisor and manager skill levels. To correct this, executive managers and program managers attended a series of management classes in December 2008 and January 2009 designed to improve communication and supervision skills. They plan to roll this knowledge out to lower-level managers and supervisors in the upcoming year. Additionally, CPS executive managers said they are reviewing possible changes to the staff evaluation tool, with the goal of rolling out a new review form that will be mandatory for supervisors to use for all of their staff. This form will help to increase the supervisors communication with staff and provide staff with much-needed feedback related to their individual performance. Lack of Support from Other Agencies An area of concern is that CPS does not benefit from its relationships with community partners and other governmental agencies and gain synergy that could help improve service delivery to children and families served by CPS and these other entities. CPS has often entered into formal agreements with other agencies that outline expectations. CPS has MOUs with organizations such as the Departments of Mental Health, Alcohol and Drug, and Public Health, County and city law enforcement agencies, and many community-based organizations. However, in many instances, the MOUs are dated as far back as the 1990s and have not been reviewed or updated for current requirements or changes in laws and regulations. Further, as summarized in Exhibit 34, some CPS staff reported in the survey that they are not receiving support from external departments and organizations. CPS lacks a designated person responsible for maintaining and strengthening community linkages and partnerships with other governmental entities or not-for-profit organizations. In the past, CPS designated a staff person as the focal contact point for community relations. However, CPS executive managers reported that CPS staff were relying too heavily on this person to form all community linkages. Therefore, executive managers eliminated this position and required supervisors and managers to begin community outreach activities. The intention was to have those supervisors and managers who
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were familiar with and working in a specific area, be responsible for the community outreach in their area. However, the reality is that supervisors and managers who are already overloaded with other activities have not maintained or strengthened relationships with other organizations. Exhibit 34Response to Survey Question Do employees receive support from external departments or organizations?
StronglyAgreeorAgree 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
EmergencyResponse FamilyMaintenanceand FamilyReunification InformalSupervision Intake AllRespondents 46.94% 39.29% 38.10% 60.71% 48.65% 51.35% 55.38% 44.62%
StronglyDisagreeorDisagree
61.91% 53.06%
Source: The MGT survey of CPS employees, November/December 2008. Building on and strengthening partnerships with other organizations would allow CPS to build off the strengths of these groups and leverage their resources to help families and children in the community. This step could add a great deal of value given that prior collaborations, such as the Dependency Drug Court and the Early Intervention Drug Court, have proven to be successful and to have resulted in cost savings for the County and CPS. Partnering with external groups and organizations could allow Sacramento to focus on problem areas or types of risk factors that are leading to childrens entry into the child welfare system. This could ultimately reduce the workload for the division as a whole by diverting or preventing families from seeing their problems escalate to the point where CPS must intervene in their lives. Question: What strategies are needed for implementation of recommendations?
Answer: In this section we present our specific recommendations by theme. As discussed earlier in this report, CPS executive managers have made many attempts to implement action items to improve services and to address recommendations identified by their own internal reviews or by external review organizations. Efforts to make improvements include, improvements to training programs, the use of QA reviews in prior years, improvements to technology resources in CPS offices, and the mandatory use of Safe Measures data.
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Nonetheless, although CPS has made some efforts to improve its operations, it still has much to do to address the issues discussed in this report. Specifically, it will need to undertake a comprehensive plan of action to restructure its policies and procedures, reallocate staff based on identified needs and caseloads, train staff on the proper use of available resources and tools, and analyze technology and resource needs to ensure staff have the resources available to do their jobs. 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. Based on our review, it appears that the County needs to strongly consider bringing in external assistance to lead the change development efforts and to ensure that the action steps taken have clear, measurable goals. These steps will help the County oversee the efforts made by CPS to remedy the areas of concern. In implementing these recommendations, especially in light of the Countys current economic forecast, one question that the County may have is how to fund system improvements. We cannot fully answer this question since we did not review the divisions budget or costs except at a high level. However, we note that in looking at budget to actual figures for the previous year, it appears that CPS may have opportunities for fiscal savings that could free up funds that it could use to implement the recommendations. For example, the division could review its contracts with current service providers to determine whether it can gain efficiencies by re-negotiating terms or seeking competitive bids. We found a possible opportunity in its expenditures for security services. In fiscal year 2007-08, the division budgeted $245,683 for these services, but actually spent $1.1 million. Additionally, improving processes should decrease some of the divisions costs, again, freeing up resources for system improvements. For example, in fiscal year 2007-08, the division budgeted for $1 million in overtime, but actually incurred $3.7 million in overtime costs. Reallocating workload and improving system processes could reduce the time needed by social workers to carry out key activities, and thus could reduce the amount of overtime use by the division. Reducing turnover could result in additional savings. In fiscal year 2007-08, the departments actual expenses for eligibility exams exceeded budgeted amounts by over $251,000. Our specific recommendations for CPS are shown on the following pages.
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Theme
Recommendations: The County must hold CPS responsible for developing and implementing a comprehensive change management plan to allow it to correct identified deficiencies and to improve outcomes for children and families in the Sacramento area. The County should appoint a capacity development manager who will jointly (with the deputy director) develop and direct the change management plan. The capacity development manager preferably should be someone from outside CPS system, who has sufficient background and experience working in a number of counties and is familiar with best practices employed within California or other states. The capacity development manager should be placed organizationally at a peer level with CPS deputy director (that is, should not report directly to the deputy director, but should work in conjunction with the deputy director and her staff). The deputy director should be responsible for ensuring staff cooperation with the change management plan and capacity development manager and for assisting in implementing the action plan items. The change management plan should include, at a minimum, specific action steps, staff responsible for implementing the change, time lines, and performance measures. The capacity development manager should report directly and verbally, on a monthly basis, to the County Board. The capacity development manager should also provide formal written reports to the County Board every 90 days. These reports and the County Boards oversight should continue until CPS has fully implemented all action plan steps and has shown measurable improvement over a specified period (six months to one year) in its performance metrics and child and family outcomes. Should the County fail to make measurable improvement or if the capacity development manager is unable to implement recommendations, the County Board should escalate actions and its level of involvement to ensure the County makes sufficient efforts timely. The County should allocate sufficient resources, both to hire the capacity development manager, as well as to staff a change management team. This team should include a mix of staff with experience in child protection and welfare issues and operations and change management. Continued
Overarching
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Theme
Management and Oversight
Best Practices
Policies and Procedures
Recommendations: CPS should, within the next 12 months, begin the process to develop a comprehensive five-year strategic plan with associated performance measures. As part of this planning process, CPS should incorporate a philosophy shift to allow the division to become a child-focused and fieldwork-based operation, instead of using a documentationfocused and deskwork-based model. By moving the emphasis to obtaining resources and modifying processes to allow social workers to spend more time in the field working directly with families and children and providing frontend services, the division should be able to reduce the number of children placed into protective custody and foster care and reduce casework at the back-end. The strategic plan should also identify ways to improve community outreach and participation. CPS should ensure that it provides sufficient resources to QA staff (and does not reassign them to non-QA duties), to allow the staff to once again undertake meaningful QA reviews. The QA staff can provide independent analyses of cases and referrals and can alleviate some of the review workload from supervisors. The QA staff reports can be used by supervisors and managers to identify and focus on resolving problem areas, and to hold staff accountable for carrying out core activities in accordance with federal, state, and county requirements and best practices. From the top downwards, CPS needs to reemphasize and require staff to use the SDM assessment tools as designed and in accordance with best practices. CPS supervisors and managers need to hold staff accountable for using the tool and to take appropriate actions (additional training and supervision or employee discipline) if staff consistently fail to use the tool. Executive management needs to hold supervisors and managers responsible for ensuring they are monitoring staffs use of the tool. Executive management should also review QA reports to identify deficiencies in how staff or units use the tool and identify possible future training needs. As part of the change management activities, CPS should review all written guidelines (including policies, procedures, and program information notices) and identify and remove duplicated, redundant, or outdated instructions. In revising its written guidelines, CPS should make a clear delineation between policy (what the division should be doing) and procedure (how the division should be working), and should organize documentation based on major process flows. CPS should map and reengineer its core child welfare processes to increase efficiency. CPS should map current processes down to the activity level and systems/documentation used. CPS should review the maps to identify decision points, handoffs, and bottlenecks. CPS should then examine and reengineer its processes using the maps to eliminate redundant steps, reduce the use of paper documents, improve quality, and reduce case and referral times. CPS should then use the reengineered process maps as the basis for its procedural documents (publish the maps as part of CPS procedures). Core questions CPS should ask of each step in the process are: (a) Is this step required by federal or state laws and regulations or County policies issued by the Board?; (b) Does this step add value and help ensure children and family outcomes are optimized?; (c) Who should be performing this activity? Can clerical or administrative staff be leveraged to free social workers to perform more work in the field? Continued
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Theme Policies and Procedures
Recommendations: CPS should establish a knowledge management unit so it can review and update guidelines on an annual basis. This unit should use the results of QA reports, best practice research, and interaction with social workers to identify possible improvements or changes. This unit should also assist in training and developing staff to ensure they have a full understanding of required activities and any changes. CPS should place a higher emphasis on developing and strengthening community connections and linkages. CPS should appoint a manager-level person as the community partner outreach focal point. This staff person would be responsible for developing relationships and synergies with other governmental agencies and community-based organizations so CPS obtains the support it needs and leverages other agencies strengths to reduce workloads for CPS staff. CPS should form MOUs with the community-based organizations and other governmental entities to delineate expectations and roles for both CPS and the external agencies. Periodically, but at least annually, CPS should solicit feedback from external agencies on the quality of CPS staffs interaction with these entities, and should also, in turn, provide feedback to the agencies on how their staff have interacted with CPS. CPS should identify front-end work (voluntary training or programs for families and children) that it can offer in conjunction with external agencies and that has the possibility of reducing the number of cases coming into the child welfare system. CPS should allocate staff to research what other counties are doing to assist families in their communities and pilot best practice programs that will assist families and prevent them from entering the child welfare system. CPS should take measures to identify and focus on units with high turnover and vacancies and to improve staff morale. CPS should institute a leadership development program at the program manager level and above. This program should consist of one-on-one coaching sessions aimed at developing individual leadership skills, problem solving, and identifying means to enhance staff morale. If this program proves to be successful, CPS should consider rolling it out to the supervisor-level positions as well. CPS should create a social worker rotation schedule that would allow social workers to rotate into different programs on an ad-hoc or periodic basis. This environment would build the pool of social workers who are cross-trained on multiple programs, and would also allow CPS flexibility in moving resources to those units with excessive cases or referrals. CPS should ensure that supervisors and managers are performing annual performance evaluations of all their staff. These evaluations should include assessment of the staffs use of the SDM tool, evaluation of outcomes related to the cases staff have worked on, and any information provided from the QA unit based on their reviews. Continued
Community Outreach
Human Resources
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Theme
Human Resources
Excessive Caseloads
Recommendations: CPS should implement an employee recognition program to identify and recognize high-performing staff. This program can be as simple as a monthly or quarterly newsletter to all staff that focuses on highlighting unit or staff achievements and that also discusses best practices identified or used by these staff/units. CPS should work with the unions and the Countys Human Resources unit to identify appropriate remedies available for staff who are not performing required functions and who violate policies, laws, or regulations. CPS should train all supervisors and managers on the required activities needed when employees are not performing as required. Staff members who are not performing as required or who have violated policies, laws, or regulations, should be provided with the resources needed to address these issues (additional training, oneon-one counseling, etc.) as appropriate. CPS must also ensure that it takes appropriate measures for staff who consistently violate policies, laws, or regulations, or who have committed egregious acts that would qualify them for discipline (up to and including termination). The County Human Resources staff should make a concerted effort to assist CPS supervisors and managers in carrying out effective employee actions, including discipline, evaluations, and hiring. After implementing process and guideline improvement changes, CPS should reevaluate its workloads and staffing levels to determine whether it has sufficient staff to carry out required activities or whether it needs to request additional staff from the County. As part of the annual budget process, CPS needs to evaluate actual and forecasted workloads by staff and by unit and allocate social worker positions to programs, offices, and units based on actual data and expected changes to future workloads in the upcoming year. CPS must make staff aware that assignment to a program or unit can change depending on the divisions need and that they are not guaranteed that they remain in the same programs. CPS should review its paper-based documentation requirements for social workers to determine if there are options to using paper documents (better use of CWS/CMS or using administrative staff to complete documentation, for example). CPS should require supervisors and managers to actively monitor caseloads of their social workers and units. Executive managers should obtain usage reports from CWS/CMS and Safe Measures to identify those supervisors or managers who are not logging in and using the system reports to their fullest extent. Executive managers should provide additional training or coaching for those supervisors or managers not using the available reports. CPS should work with the Juvenile Court system to identify what documentation or items the court actually needs at various hearings. CPS should develop templates that align with Juvenile Court needs and train social workers on using these templates. These actions should ensure that court reports are more streamlined and direct and contain only that which is directly relevant and needed, while reducing report creation time frames for social workers. Continued
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Theme
Excessive Caseloads
Resources
Recommendations: CPS should conduct a time-management study (using the SB 2030 study performed in 2000 as a model, for example), to identify actual case or referral processing times for core program areas. CPS should use this information to identify the minimum and maximum caseloads that social workers can reasonably be expected to carry by program. CPS should then develop contingency plans to address excessive workloads, such as temporarily increasing staff through the use of retired annuitants or temporary staff or fast-tracking the closure of lower-risk cases and referrals. CPS should work with the state and information technology units to identify possible improvements to the Countys access to CWS/CMS. CPS should identify whether it is possible to provide more frequent updates so that managers have access to information in real time or have more current information that would allow them to better manage staff and allocate resources. CPS should determine whether it can increase its use of CWS/CMS and decrease its use of paper documentation or alternative data systems (such as the Immediate Response Information System). CPS should also work with the state and County to determine if there are ways to fast-track the purchase of technology required by social workers to effectively manage cases while in the field. CPS should work with the state and information technology units to identify possible technology solutions to provide better access for social workers while they are in the field. This includes reevaluating the use of QuickPads or identifying alternative methods for access to data tools and CWS/CMS. Additionally, if functional alternative technologies exist, such as the use of Dragon Naturally Speaking that can replace outdated modes (such as the use of transcriptionists), the division should prepare a budget request to obtain the resources needed to purchase these technology items. This budget request should include the savings available from eliminating positions as a result of the improved efficiencies. CPS should develop a computer-based vehicle booking system and should centralize this system based on location rather than on program. CPS should work with the County motor pool to identify ways to increase access to reliable vehicles for CPS staff.
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APPENDIXA
Appendix A
Appendix A Process Maps

Introduction
To obtain an understanding of how staff within CPS deliver services, we met with supervisors in a series of focus groups to map out core processes. After creating process maps, we met again with the supervisors to vet the maps and issues lists. For any areas of concern, we conducted additional procedures to verify these findings. The procedures ranged from subsequent data analyses, additional interviews with supervisors, social workers, and administrative staff, reviews of policies, and research on best practices. Attached for information purposes only are the maps that we created in our focus group sessions. We note that these maps represent many, but not all, of the processes performed by CPS staff. Additionally, we note that as opposed to a business process review mappingwhich seeks to capture in great detail all steps, systems, and people within processes used by an organizationour maps are often abbreviated and contain general references to more detailed descriptions in the project background section of this report.
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Child Protective Services Process Maps
Clerical, Admin, Executive Managers
Intake, Referral Investigation, Emergency Response
Hotline staff receive phone call or letter
Go To 1
On page 2
External Parties
Other CPS Units

Community member observes or learns about suspected child abuse or neglect.
Social Worker
Reporter calls in a report of suspected child abuse or neglect to hotline.
Mandated reporter?
NO
Reporter may remain anonymous.
Mandated reporter may not remain anonymous.
Mandated reporter files written report within 36 hours of verbal report.
Documents
(916) 875-KIDS or Sacramento County CPS 7001-A East Parkway, Suite 1000 Sacramento, CA, 95823
YES
Department of Justice Suspected Child Abuse Report Form SS 8572 (Hard-Copy)
Note: Although we say Emergency Response Social Worker in the investigation referral process maps, social workers in other programs can and often do conduct investigations of subsequent referrals. The same steps apply to these social workers.
1
From page 1
Clerical staff route referral (phone call or letter) to an intake social worker (SW)
From page 3
Go To 2
On page 3
Social Worker
Intake SW obtains all necessary identifying and present location information about child, parents, caregivers, and determines what happened/is happening.
Intake SW assesses degree of harm, vulnerability of the child due to age and/or disability, frequency of maltreatment, and recency.
Referral meets criteria for in-person response?
MARGINALLY
Intake SW completes 526 (Intake) form but does not mark the Info Only, Immediate Response or 10 Day box
Intake SW completes 526 (Intake) form and marks it as Informational Only Report. Meets with supervisor to obtain supervisor approval to close referral. Can also refer out to other agencies as needed.
End Process
NO
Other CPS Units
YES
External Parties
Go To 3
On page 3
Documents
Form 526 Informational Only Report Case closure notes
Clerical staff pick up forms and run history checks on WISH II System, AFDC, and CWS/ CMS databases
Clerical staff return results of screening and any existing files to Intake SW
Go to 6
On page 4
Social Worker
Intake SW puts the intake form in the red basket in the ER room
Go To 4
On page 2
Intake SW completes the response priority decision tree for type of abuse.
Immediate or 10Day Response?
10 DAY
From page 2
From page 2
Intake SW marks the 526 (Intake) form as 10 Day response and puts the form n the red basket in the ER room
Other CPS Units
IMMEDIATE
External Parties
Go to 5
On page 5
Documents
6
From page 3
Clerical staff pick up forms and run history checks on WISH II System, AFDC, and CWS/ CMS databases
Clerical staff return results of screening and any existing files to Intake SW
ER Control Clerk accesses CWS/ CMS and identifies cases needing to be assigned.
ER Control Clerk assigns case to ER social worker (ER SW) by zip code and rotation list.
ER Control Clerk forwards hard copy case file to the ER SW.
Go to 7
On page 5
Social Worker
Intake SW enters information into CWS/CMS and assigns case number.
Intake SW creates hard-copy case file and puts completed SDM printouts and Intake form 526 in file.
Intake SW gives the case file to the ER Control Clerk (CWS/CMS notifies clerk of need to assign case).
External Parties
Other CPS Units
Documents
Form 526 Informational Only Report and printouts of results of history checks
Hard Copy case file
5
From page 3
For Immediate Referrals: same process as below, except supervisor assigns case immediately to on-call SW. SW has two hours to make contact with family and child(ren). If SW cannot locate the family within this time frame, SW notifies supervisor and continues efforts to locate through other means (friends, family, school, hospitals, etc). Additionally, case is logged into the Immediate Response Information System (IRIS) and tracked by supervisor.
Social Worker
ER SW and his/her supervisor review assignment.
ER SW begins investigation of the referral.
From page 4
ER SW contacts the child and family as well as any relevant collateral contacts (school teachers, mandated reporters, doctors, witnesses, neighbors, etc).
ER SW reviews documents, pictures, files relevant to referral.
If not already done so, ER SW conducts a criminal records check of the parent(s), any adults living in the home, or any adults exhibiting dangerous behavior that may pose a risk to the child(ren).
Go to 8
On page 6
External Parties
Other CPS Units
The child and family as well as any relevant collateral contacts (school teachers, mandated reporters, doctors, witnesses, neighbors, etc) speak to ER SW.
Documents
From page 9
10
Social Worker
ER SW completes the safety and risk structured decision making tool (SDM).
Exigent circumstances exist?
YES
ER SW contacts law enforcement to remove child(ren) from the home.
ER SW contacts supervisor to alert them of removal of child(ren) from the home.
ER SW updates case plan and file and forwards case to supervisor for review.
ER Supervisor reviews and approves case plan and transfers case to Dependency Intake.
End Process for ER
From page 5
NO
Move to Dependency Intake Process
Other CPS Units
Go to 9
Go to 11
On page 11
On page 7
External Parties
Law enforcement removes child(ren) from the home.
Documents
SDM Safety Assessment SDM Risk Assessment
Social Worker
ER SW decides PC Warrant is appropriate and required?
YES
ER SW notifies supervisor to discuss obtaining PC Warrant.
From page 6
ER SW makes appointment with PC Warrant staffing group to discuss obtaining PC Warrant.
ER SW presents evidence and case information to support PC Warrant.
ER SW completes all fields on the CS 189 (Juvenile Court Warrant Data Sheet)
Go to 13
On page 8
YES NO
Other CPS Units
Go to 12
On page 9
Court Services supervisor attends PC Warrant staffing meeting.
Sufficient evidence to support PC warrant?
External Parties
County counsel attends PC Warrant staffing meeting.
NO
Documents
PC Warrant staffing form
CS 189 form Juvenile Court Warrant Data Sheet
Transcriptionist creates and returns typed CS 189, declaration, and PC warrant
Social Worker
13
ER SW prepares declaration in support of PC Warrant
ER SW submits CS 189 and written declaration to transcriptionist.
ER SW proofreads documents and signs declaration.
ER SW submits CS 189, declaration, and PC warrant to court liasion.
From page 7
Other CPS Units
Court liasion reviews warrant for completeness and accuracy.
Court liasion submits warrant to the Juvenile Court warrant clerk.
Go to 14
On page 9
Documents
External Parties
Written declaration
CS 189, written declaration, PC warrant
Social Worker
Go to 10
On page 6
12
From page 7
What is the allegation disposition type?
UNFOUNDED
ER SW staffs the case closure with ER supervisor, completes case notes and closes case in CWS/CMS.
End Process
Other CPS Units
SUBSTANTIATED 14
From page 8
INCONCLUSIVE Go to 15
On page 10
External Parties
Juvenile Court rules on the motion and grants the warrant.
Warrant clerk notifies ER SW that PC warrant is available to be served.
Go to 16
On Page 10
Documents
Social Worker
15
From page 9
ER SW staffs case closure with supervisor. If appropriate, ER SW offers referrals to family resource centers or community programs.
End Process
16
From page 9
ER staffs case with appropriate CPS unit (FM or IS). For the hand-tohand process, see FM/IS flowcharts.
ER SW has five business days to complete reports and case file documentation and to provide case file to next case worker.
End Process
Other CPS Units
Go to 17
To page 23
Documents
External Parties
10
From page 6
Court Services and Dependent Intake Process
11
Social Worker
Childrens Receiving Home (CRH) or Donner receives chlld(ren)
CRH or Donner staff notify the Dependent Intake social worker (DI SW)
DI SW conducts initial interview of the child(ren), performs body check, refers to urgent care services or for medical exam as necessary
DI SW investigates allegation or referral and does SDM(s)
File on PC?
Yes
Go to 19
On page 12
No
Other CPS Units
Other CPS units put child(ren) into PC
Go to 18
On page 12
External Parties
Law Enforcement, Public Health Nurse, Mental Health worker places child(ren) in protective custody (PC)
Probation Court orders child(ren) into PC
Child talks to DI SW
Talk to law enforcement
Talk to parents
Talk to collateral contacts (family members, teachers, doctors, etc).
Documents
Inventory form of childs possessions Case notes
Donner = SAFE: all kids less than 6 y/o, Medical Clearance, Receiving Home Childrens Receiving Home = Receiving Home: lot of teens
11
No
Social Worker
18
From page 11
Family needs services?
Yes
Staff with appropriate CPS program (FM, IS) (needs program manager approval)
Staff case closure with supervisor. Arrange for child(ren) to return home and close case
19
From page 11
Create referral or case in CWS/CMS or update case file if already in system.
Place child(ren) in initial Out-of-Home Placement (OHP)
Go to 20
To page 13
Other CPS Units
End Process
End Process
External Parties
Child(ren) is placed in OHP
Documents
Case closure staffing form Supervisors QA review of case closure
12
Control Clerk opens day list and assigns case based on workload and rotation
Control Clerk prints out list of assigned cases and day list
Control Clerk provides day list, list of assigned cases and the hard copy case files to the Administrative Assistant
Social Worker
20
From page 12
SW adds child(ren)s information to the day list
SW creates/updates case file and sends via black suitcase to Court Services control clerk
Go to 21
To page 14
Documents
External Parties
Other CPS Units
Day List Excel file stored on server
Hard Copy Case File
Day List Excel file stored on server List of assignments
13
21
Administrative Assistant provides case file and day list to supervisor
From page 13
Social Worker
SW Supervisor emails, phones, or meets in person with Court Services social worker to notify of assignment.
SW reviews case file and SDM(s)
SW continues to investigate and build information on case
SW creates or updates the risk and safety SDM on each case
Go to 22
To page 15
External Parties
Other CPS Units
Child talks to Intake DI
Talk to parents
Documents
14
(If petition already filed) petition shouldnt have been filed and case should be closed
Social Worker
22
From page 14
SW assesses the case to determine required services or outomes.
What actions need to be taken?
SW meets with supervisor or program manager to discuss case
SW updates CWS/CMS narrative
Supervisor reviews and approves case closure.
Program manager reviews and approves case closure.
SW returns child(ren) to the home. SW closes case and updates case notes. Refers family to community services or other agencies as appropriate.
Family maintenance or family reunification (needs petition) Go to 24

To page 17
Other CPS Units
Family maintenance (no petition)
End Process
External Parties
Go to 23
To page 16
Documents
15
Social Worker
23
From page 15
Discuss with program manager or supervisor to get permission to transfer case
SW schedules staffing meeting with other CPS unit supervisor
SW and supervisor meet in staffing meeting with other CPS supervisor and social worker
SW has five days to do case plan and get signatures
SW transfers case file to new CPS unit.
Go to 25
To page 23
Other CPS Units
Supervisor from other unit approves case transfer
Documents
External Parties
Staffing form
16
Transcriptionist creates and/or formats court report
Social Worker
24
From page 15
1 pm staffing everyday
SW and supervisor meet to discuss case and to verify need to file.
SW writes up petition and detention report
SW sends petition and detention report to transcriptionist
SW and supervisor read and approve the court reports
SW sends court report and petition to county counsel
Go to 26
To page 18
External Parties
Other CPS Units
County Attorneys
Documents
Detention Report (Court Report Min. 2 pages) ICWA; Paternity; Finding
17
Social Worker
SW completes or updates CWS/CMS and checklist with case information.
Supervisor reviews case narrative and reports.
Go to 27
To page 19
Other CPS Units External Parties
From page 17
26
County counsel reads and reviews court report or petition. If changes are needed, returns to DISW.
Court Services Officer files court report or petition.
Court schedules a detention hearing. Detention hearings can, and often are delayed or continued.
Court hears the case and approves or dismisses the petition.
If court approves dependency - see description of court hearings process in Introduction of this report - not documented here.
Documents
Case checklist
18
Social Worker
27
From page 18
SW attends court hearings as needed
SW continues working on case, including updating case plan, and continuing investigation.. Prepares required court reports.
Go to 28
To page 20
External Parties
Other CPS Units
Talk to parents
Ensure that court orders are complied with.
Documents
Court reports
Court orders include (but arent limited to) providing counseling to the family, ensuring parents are enrolled in or complying with drug or alcohol abuse counseling or treatment, ensuring child is attending school closest to original home, ensuring child remains in contact with family or friends, etc.
See also process for obtaining transcription services on page 8
19
Social Worker
28
From page 19
SW periodically meets with court officers, county counsel, parents, or external agencies and continues offering services.
SW updates CWS/ CMS with court decision and case notes.
Other CPS Units
No
Yes
External Parties
Court gives a continuance on the case?
No
Court holds hearings in accordance with state requirements (see Introduction for description)
Court hears the case evidence and reviews CSSW reports.
Court orders Family Reunification services?
Yes
Go to 29
To page 21
Documents
20
End Process for Court Services
Social Worker
29
SW and supervisor review case file and CWS/CMS reports.
SW schedules staffing meeting with Family Reunification (FR) SW FR supervisor.
SW and supervisor meet with FR supervisor to hand off case.
Note that during the CS process, the SW may concurrently meet with Permanency Placement staff to establish a permanency plan.
Other CPS Units
Case may go to FR even before the court has held the first juris dispo hearing.
Case is transferred to FRSW
Go to 30
To page 22
External Parties
Documents
Note that to id the FR supervisor and social worker, clerical staff notify the FR program manager. The program managers clerical staff assigns to the next unit using caseload levels.
Can do staffing over the phone, but prefer in person (track on paper)
21
Family Reunification Services
Social Worker
30
From page 21
SW reviews the case documents
SW continues to investigate and build information on case
SW creates or updates the risk and safety SDM on each case.
If there is no case plan, SW creates the case plan based on court orders and family needs.
SW makes referrals to services in line with court orders and case plan as needed.
If Court reports are due, SW prepares required reports and information see Court Services process.
External Parties
Other CPS Units
Talk to parents
Documents
Referral forms
Note: FR provides these services to children and families for a period that ranges from six-to-18 months, depending on the age of the child and case circumstances. These steps continue until either the court terminates FR services, the case transfers to another unit, such as Adoptions or Permanent Placement, or the child emancipates. For purposes of brevity since many steps are already included in other process maps in this section, we have only documented a sample of FR activities, since FR activities can encompass the same activiteis performed by Family Maintenance, Court Services, and Emergency Response, among others.
22
25
From page 16
IS or FM Control Clerk receives notification of case assignment
IS or FM Control Clerk makes assignment based on caseload, rotation, and geographic location (North vs South)
Go to 31
To page 24
Social Worker
Emergency Response identifies need for services and staffs case with Voluntary FM or IS (petition not filed)
Court Services identifies need for services and staffs case with Voluntary FM or IS (petition not filed)
FR unit steps case down to FM or IS
If possible, control clerk tries to find cultural specialist if requested and available to work on the case
Other CPS Units
17
Family Court orders family maintenance services for the family
Another county or state notifies CPS of need for FM or IS services when transferring a case
From page 10
Documents
External Parties
To staff with IS or FM, CPS units need to complete FM or IS staffing form. Form includes: Family History, Allegations, Services Provided
23
Social Worker
31
From page 23
FM or IS Control Clerk prints assignment list and IS or FM Staffing Form
FM or IS Control Clerk provides assignment list and IS or FM staffing form to supervisor
FM or IS Supervisor reviews form and CWS/CMS. Notifies social worker (SW) or assignment
FM or IS SW receives notification of case assignment and reviews CWS/CMS file and staffing form
FM or IS Supervisor arranges a face-toface meeting with prior CPS SW
Go to 32
To page 25
External Parties
Other CPS Units
Documents
Hard copy documents: Assignment list Staffing form Case file
24
Social Worker
From page 24
32
FM or IS SW meets with prior CPS SW to discuss case
FM or IS SW schedules a faceto-face meeting with family to transition case
FM or IS SW meets with family and prior case worker to hand off case
FM or IS SW and prior case worker jointly develop a case plan with the family
FM or IS SW and prior case worker jointly complete SDM family strengths and needs assessment (FSNA)
Other CPS Units
Prior case worker meets with FM or IS SW to discuss case
Prior case worker meets with IS or FM SW and family to hand off case
Prior case worker and FM or IS SW jointly develop a case plan with the family
Prior case worker and FM or IS SW jointly complete SDM family strengths and needs assessment (FSNA)
Prior case worker has 5 business days to prepare closing docs and complete case file
Go to 33
To page 26
External Parties
Family meets with prior case worker and FM or IS SW
Parents sign the case plan agreement form
Documents
Case plan agreement form
25
From page 27
35
Social Worker
33
FM or IS SW receives case file and updated case plan
As needed, FM or IS SW refers family to appropriate services (AOD, parenting classes, etc).
FM or IS SW meets periodically with child(ren), parents, caregivers, and collateral contacts
Go to 34
To page 27
From page 25
External Parties
Other CPS Units
Family receives referrals for appropriate services.
Child(ren) meets with and talks to FM or IS SW
Talk to parents
Ensure that court orders are complied with.
Documents
Note: FM and IS are required to meet twice monthly with family and see all children in person in the first 3 months. Both units are generally trying to meet more often than minimum required by law, however. FM and IS can also be required to meet more often based on need or court orders.
26
Social Worker
34
From page 26
FM or IS SW updates case plan as needed
FM or IS SW assesses case plan progress and completes SDM assessment every 90 days
Is family meeting goals/complying with case plan?
Yes
Has family made sufficient progress that case can be closed?
Yes
FM or IS SW staffs case closure with supervisor or program manager
Go to 37
To page 27
No
No Go to 35
To page 26
Other CPS Units
Go to 36
To page 29
Documents
External Parties
27
Social Worker
37
FM or IS SW schedule a team decision making meeting if child is in OHP and returning home
From page 27
FM or IS SW refers family to family resource centers or community based organizations as needed
FM or IS SW updates case file and CWS/CMS with notes and closes case
FM or IS Supervisor approves case closure
End Process
Documents
External Parties
Other CPS Units
Team Decision Making Meeting results in written action plan - not documented in CWS/ CMS
Most FM or IS cases are closed at the end of 6 months.
28
Yes
Social Worker
From page 27
36
FM or IS SW decides on appropriate action needed for family based on SDM assessment (risk and safety)
Is child(ren) at risk of harm by being in the home?
Yes
Is danger immediate and severe?
No
FM or IS staffs case with court services and county counsel to have PC Warrant petition filed
County counsel files petition and provides order to FM or IS SW to remove child(ren)
FM or IS SW places child(ren) in protective custody with the assistance of law enforcement and transports to CRH or Donner
No
Other CPS Units
Go to 38
To page 30
Go to 39
To page 30
External Parties
Abbreviated process - see Court Services section
Documents
29
Social Worker
39
From page 29
FM or IS SW staffs case with Court Services
FM or IS SW updates case file and CWS/CMS
Case is transferred to Court Services
End Process
38
From page 29
FM or IS decides on appropriate action to be taken with family and updates case plan accordingly
Go to 35
From page 29
External Parties
Other CPS Units
Note that FMs may do investigation if case is open and new referral comes in - see investigation process in the Emergency Response program maps.
Documents
30
APPENDIXB
Sacramento County Appendix B Child Protective Services Review
Appendix B Results of the Employee Survey

Introduction
To obtain an understanding of staff perceptions related to CPS operations, we conducted an online survey. The survey was activated on November 17, 2008 and closed on December 2, 2008. CPS executive managers communicated to all staff the availability of the survey, and also sent several reminders to the staff at our request. In total, we received 288 responses from the department staff. These responses represent approximately 29.4 percent of the divisions 981 employees. We summarized survey results as shown in the following pages. For issues that appeared to indicate problem areas, we conducted additional procedures to validate possible findings and recommendations for inclusion in our report. For those items that seemed to indicate weaknesses or obstacles for the division, we verified the survey results through our focus group discussions with supervisors, our review of CPS and University of California Berkeley-provided data, our review of child fatality cases, and our review of the divisions policies and procedures. We also interviewed staff who provided us with their direct contact information and who were willing to participate in follow-up discussions to obtain perspective on selected issues. In several sections of the report we presented staff responses to selected questions in the survey to illustrate examples of opportunities or challenges for CPS. In this section, for information purposes, we provide summary level graphs and response percentages for all questions asked on the survey. We note that because we communicated to staff that survey responses would be kept confidential, we are only providing summary data and are not providing the text comments given to us by the respondents. We also note that we requested staff to provide their program areas and gave them a list of options to choose from. However, we did not specifically define the category identified as Intake. Thus, it appears that staff in both the Intake unit of Emergency Response, who take incoming referrals of abuse or neglect, as well as Dependent Intake social workers, who process children taken into custody, responded in this category.
Page87
SurveyQuestionOne: Employeesfeelsupportedbymanagement.
80.00% 70.00% 67.57% 60.00% 57.14% 50.00% 53.06% 46.94% 40.00% 42.86% 41.92% 58.08%
71.43%
30.00%
32.43% 28.57%
20.00%
10.00%
0.00% EmergencyResponse FamilyMaintenanceand InformalSupervision FamilyReunification Intake AllRespondents
SurveyQuestionTwo: Employeesarekeptwellinformedbymanagement.
90.00% 80.00%
80.95%
70.00% 67.86% 60.00% 59.46% 50.00% 53.06% 46.93% 40.00% 40.54% 32.14% 40.77% 59.23%
30.00%
20.00% 19.05% 10.00%
SurveyQuestionThree: Employeesareprovidedwithadequatetraining.
90.00% 85.71% 80.00% 80.95%
70.00% 67.34% 60.00% 62.16% 64.62%
50.00%
40.00% 37.84% 30.00% 32.65% 35.38%
20.00% 19.05% 10.00% 14.29%
SurveyQuestionFour: TheDepartmentdisciplinesemployeeswhoperformpoorly.
80.00% 76.19% 70.00% 73.47% 71.43% 70.27% 69.23%
60.00%
50.00%
40.00%
30.00% 26.53% 20.00% 28.57% 29.73% 23.81%
30.77%
10.00%
SurveyQuestionFive: TheDepartmentrecognizesemployeeswhoperformwell.
80.00% 70.00% 67.57% 60.00%
71.43%
50.00%
53.57% 51.02% 48.98% 46.43% 50.38% 49.62%
40.00%
30.00%
32.43% 28.57%
20.00%
10.00%
SurveyQuestionSix: Employeesarecomfortableaskingtheirpeersforadvice.
120.00%
100.00% 97.96% 92.86% 80.00% 97.30% 90.47% 92.69%
60.00%
40.00%
20.00% 7.14% 2.04% 0.00% EmergencyResponse FamilyMaintenanceand InformalSupervision FamilyReunification Intake AllRespondents 2.70% 9.52% 7.31%
SurveyQuestionSeven: TheDepartmenthastoomanypolicies.
80.00% 70.00% 69.39% 60.00% 64.29% 64.86% 59.62% 50.00% 52.38% 47.62% 40.38% 40.00% 30.61% 30.00% 35.71% 35.14%
20.00%
10.00%
SurveyQuestionEight: Employeesreceivesupportfromexternaldepartmentsororganizations.
70.00% 61.91% 60.00% 53.06% 50.00% 46.94% 40.00% 39.29% 38.10% 30.00% 51.35% 48.65% 44.62% 60.71% 55.38%
20.00%
10.00%
SurveyQuestionNine: TheDepartmentprovidesadequateaccesstovehicles.
70.00% 62.16% 60.00%
50.00%
51.02% 42.86%
50.00% 46.43%
50.00%
40.00%
38.10% 34.23% 34 23%
30.00%
32.43%
20.00%
23.81%
10.00%
Responsesdonottotalto100percentdueto"notapplicable" responsesnotbeingshownhere.
SurveyQuestionTen: TheDepartmentprovidesadequateaccesstocellphones
120.00%
100.00% 96.43%
80.00%
83.67%
83.78% 76.54%
60.00%
47.62% 40.00%
20.00% 10.20% 0.00% EmergencyResponse FamilyMaintenanceand InformalSupervision FamilyReunification 8.11%
14.28% 6.15%
0.00%
Intake
AllRespondents
80.00%
SurveyQuestionEleven: TheDepartmentprovidesadequateaccesstoemailanddataawayfrom theoffice.
70.00% 67.86% 60.00% 63.27% 57.31% 50.00% 54.05% 47.62% 40.00% 32.14% 30.00% 24.48% 20.00% 23.81% 23.46% 37.84%
10.00%
120.00%
SurveyQuestionTwelve: TheDepartmentprovidesadequateaccesstocomputersand technology.
100.00% 96.43% 87.75% 80.00% 90.48% 86.49% 87.31%
60.00%
40.00%
20.00% 12.24% 3.57% 0.00% EmergencyResponse FamilyMaintenanceand InformalSupervision
13.51% 9.52%
10.77%
FamilyReunification
Intake
AllRespondents
100.00% 90.00%
SurveyQuestionThirteen: TheDepartmentprovidesadequateaccesstosuppliesforfamiliesand children(carseats,diapers,etc).
89.29% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% EmergencyResponse FamilyMaintenanceand InformalSupervision FamilyReunification Intake AllRespondents 18.36% 14.62% 7.14% 29.73% 33.33% 28.57% 73.47%
62.16% 57.69% 57 69%
SurveyQuestionFourteen: Rateoftheeffectivenessofcasehandoffs.
50.00% 46.93% 45.00% 43.24% 40.54% 40.00% 39.29% 35.00% 30.00% 25.00% 23.81% 20.00% 15.00% 10.00% 5.00% 0.00% EmergencyResponse FamilyMaintenanceand InformalSupervision FamilyReunification Intake AllRespondents 36.73% 32.14% 32.69% 32.31% 38.10%
VeryEffectiveandEffective VeryIneffectiveandIneffective
SurveyQuestionFifteen: Rateoftheeffectivenessofstaffingmeetings.
100.00% 90.00% 80.00% 70.00% 70.27% 60.00% 50.00% 40.00% 32.65% 30.00% 20.00% 10.00% 3.57% 0.00% EmergencyResponse FamilyMaintenanceand InformalSupervision FamilyReunification Intake AllRespondents 28.57% 24.32% 23.85% 65.30% 64.23%
92.86%
52.38%
SurveyQuestionSixteen: Rateoftheeffectivenessofcaseplans(detailandappropriateness).
70.00%
60.00% 59.46% 57.14% 50.00% 53.06%
40.00% 30.61% 30.00%
42.69%
28.57% 24.32%
28.57% 23.08%
20.00% 19.05% 10.00%
Intake PercentageofTimeSpentonVariousActivities
Casework infield,5.3 Other,16.8
ExternalMeetingswith OtherAgencies,1.4
Admin(Travel,Training, InternalMeetings),6.6
Casework inoffice,69.9
EmergencyResponse PercentageofTimeSpentonVariousActivities
ExternalMeetingswith OtherAgencies,4.4 Other,6.0
Admin(Travel,Training, InternalMeetings),11.7 Internal Meetings), 11.7
Casework infield,31.2 Casework in field, 31.2
FamilyMaintenanceandInformalSupervision PercentageofTimeSpentonVariousActivities
Other,10.9
External Meetingswith OtherAgencies, 7.3 Casework i fi ld 34 0 C k infield,34.0
FamilyReunification PercentageofTimeSpentonVariousActivities
Other,15.2
ExternalMeetingswith OtherAgencies,4.9 Casework infield,26.7

Review of The Sacramento County Child Protective Services Division MGT (Mar 2009)

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Review of The Sacramento County Child Protective Services Division MGT (Mar 2009)

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ReviewoftheSacramentoCounty y ChildProtectiveServicesDivision

Sacramento County Child Protective Services Review

Scope and Methodology

Sacramento County Child Protective Services Review

Overall Findings and Recommendations

Sacramento County Child Protective Services Review

Sacramento County Child Protective Services Review

Sacramento County Child Protective Services Review

Sacramento County Child Protective Services Review

Sacramento County Child Protective Services Review

Sacramento County Child Protective Services Review

Scope and Methodology

Sacramento County Child Protective Services Review

Sacramento County Child Protective Services Review

Sacramento County Child Protective Services Review

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

Child Welfare System in California and Sacramento County

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

SACRAMENTO COUNTY BOARD OF SUPERVISORS

SUPERIOR COURT OF CALIFORNIA SACRAMENTO COUNTY

Sacramento Child Protective Systems Oversight Committee

COUNTY EXECUTIVE COUNTYWIDE SERVICES AGENCY

Child Abuse Prevention Council of Sacramento Child Death Review Team

Sacramento County Juvenile Court

Sacramento County Department of Health and Human Services

Annually reviews child fatalities with CPS involvement.

Sacramento County Division of Child Protective Services (CPS)

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

Description of the Child Protective Services Process

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

Description of the Child Protective Services Staff

Administrative Services Officer Budgets

Program Managers (4) Permanency Services Adoptions Kinship Licensing

Program Managers (4) Family Reunification Court Services

Program Manager Quality Assurance Program Administration CWS/CMS

Communications and Media Officer Media Relations

Sacramento County Child Protective Services Review

Description of the Child Protective Services Processes

Clerical and Transcription Staff, 249.8 Social Worker Staff, 469.5

CWS/CMS Support Staff, 4.0

Social Worker and Family Services Supervisors, 102.8

Findings and Recommendations

Analysis of Sacramento Countys Provision of Child Welfare Services

Sacramento County Child Protective Services Review

Findings and Recommendations