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Los Angeles County Department of Children and Family Services
It Has Not Adequately Ensured the Health and Safety of All Children in Its Care

Report Number: 2018-126

Audit Results

The Department’s Failure to Meet Investigation Timelines Has Placed Children’s Safety at Risk

The department did not consistently start or complete its investigations of child abuse or neglect within required time frames during fiscal years 2013–14 through 2017–18. When the department receives an allegation of child abuse or neglect (referral) and determines that an in‑person response is necessary, state law requires it to conduct this response immediately or within 10 days, depending on the severity or circumstances of the alleged abuse or neglect.3 The department’s policy is even stricter, requiring that social workers begin these investigations within five business days. However, the department adhered to its required time frames in only 19 of the 30 referrals we reviewed.

Of the nine immediate‑response referrals that we reviewed, the department began six investigations within 24 hours. In the three investigations that it failed to begin within the required time frame, the department did attempt to make in‑person contact within the first 24 hours, but the social workers did not conduct continued follow‑up attempts, as department policy requires, after the initial contacts were unsuccessful. In fact, in one instance, the department made one contact attempt within 24 hours but then failed to make any further attempts for 151 days. Once the department made renewed attempts, it removed multiple children from their mother’s care after discovering she had been abusing illegal drugs. Throughout those five months, the department risked the health and safety of the children by leaving them in an unsafe situation. The department confirmed that the file does not indicate why the delay occurred, and the social worker responsible for the referral no longer works for the department.

Of the 21 referrals we reviewed that legally required a 10‑day response time, the department began 13 investigations within the department’s policy of five business days. Of the remaining eight referrals, the department complied with state requirements—making the in‑person contact within 10 days—in four instances. For three of the remaining four referrals, the social workers attempted contact before the initial in‑person meetings. In one instance, the social worker attempted four contacts in 19 days before succeeding, and in another instance, the social worker made six attempts in 28 days before successfully arranging an in‑person meeting. For the last referral, the social worker did not make a second attempt for 12 days; while this second attempt was successful, the time frame did not comply with the department’s policy to make additional attempts at least once each week until making contact or exhausting all possible resources.

When we reviewed departmentwide referral data, we found that the department’s response time for immediate investigations improved from 85 percent of investigations beginning on time in fiscal year 2013–14 to 88 percent in fiscal year 2017–18. However, its 10‑day response investigations lagged behind, decreasing from 76 percent to 73 percent during the same time period, as Table 2 indicates.

Table 2
The Department Has Not Consistently Opened Investigations Within Required Time Frames

2013–14 85% 76%
2014–15 84 73
2015–16 86 75
2016–17 87 74
2017–18 88 73

Source: Analysis of case and referral data.

We also found that the department did not consistently complete its investigations into child abuse or neglect within required time frames. State law generally requires counties to close an investigation of allegations within 30 days of the date that the social worker has an in‑person response with the child. Additionally, in 2017 Social Services clarified that if a social worker is not able to initiate an investigation within the first 10 days of a referral, the social worker must close the investigations within 40 days from the referral date. However, of the 30 investigations we reviewed, the department completed just nine investigations within the required time frames. In fact, we found six investigations that exceeded 90 days. One investigation lasted over 400 days, and throughout that period, the social worker visited the children only three times. In another instance, the department had only one visit with the family, and the social worker did not attempt subsequent in‑person visits, leaving the children in an unsafe situation. In fact, while that investigation was still open, law enforcement notified the department it had removed the children as a result of another allegation.

Completing investigations within the prescribed time safeguards the welfare of vulnerable children. We shared our findings with the department’s director (director), who indicated that some referrals are more complex—including sexual abuse and exploitation—and that 30 days is not always sufficient time to conduct a thorough investigation. He explained that he is planning to work with Social Services to extend the investigation completion time frame to ensure that social workers have sufficient time to conduct thorough investigations. The director also stated that the department is planning to incorporate how well social workers meet timelines into their performance appraisals. Further, the department implemented protocols in March 2019 to ensure that social workers close referrals on time, including providing a greater level of oversight when investigations exceed 30 days and establishing the expectation that regional offices will develop and monitor work plans to close referrals.

The Department’s Safety and Risk Assessments Have Often Been Late and Inaccurate

Late and inaccurate safety and risk assessments, along with the lack of an adequate mechanism to catch errors in a timely manner, weaken the department’s ability to mitigate risks to children’s safety. As we discuss in the Introduction, the department uses SDM tools to assess a child’s immediate safety and the need for services, such as placement in a safe location. According to Social Services, the accurate and timely use of the assessment tools is critical to the department’s ability to effectively monitor each child’s safety and well‑being. Social Services’ SDM policy manual requires the department to complete safety assessments and enter them in a database within 48 hours of meeting children in person for the first time.4

However, when we reviewed 30 safety assessments, we found that the department did not complete 25 within the required 48 hours. In one instance, the department took 112 days to complete the assessment because the assigned social worker was not able to meet the required time frames and the department had to reassign the case. In another instance, the social worker completed the safety assessment 50 days after the initial visit. The department confirmed that this delay was inappropriate but explained that some of the children living in the home were not available for the initial assessment. Nevertheless, the social worker could have performed an initial safety assessment and completed a follow‑up assessment if necessary.

Department policy requires social workers to complete a risk assessment within 30 days of starting an investigation, but the department did not do so for two of the 30 investigations we reviewed. In one instance, the social worker did not perform the risk assessment until 42 days after the referral—at which point the social worker determined that the child should be removed from the home. Completing the risk assessments on time is necessary to ensure that the department mitigates circumstances that may endanger children’s health and safety.

After we identified these issues with the cases we reviewed, we examined departmentwide data and found that although the department has made improvements in recent years, it has not consistently completed safety and risk assessments within required time frames. In fiscal year 2017–18, the department completed 18 percent of its safety assessments late and never finished 10 percent. In that same year, the department completed only 76 percent of its risk assessments on time, while it failed to complete 8 percent, as Table 3 shows. The director acknowledged these deficiencies, as well as the accuracy problems we describe below, and he indicated that a review the department commissioned found that some of the department’s social workers were not relying on the assessments as decision‑making tools but instead viewed them as an additional bureaucratic step. He noted that the department is addressing this issue by developing new training that he plans to roll out by July 2020.

Table 3
The Department Has Not Completed Safety and Risk Assessments Within Required Time Frames

2013–14 69% 20% 11% 65% 28% 7%
2014–15 66 23 11 65 28 7
2015–16 66 24 10 67 24 9
2016–17 68 22 10 72 20 8
2017–18 72 18 10 76 16 8

Source: Analysis of case, referral, and assessment data.

* Safety assessments assist the social worker in determining whether a child is likely to be in immediate danger of serious harm.

Risk assessments assist the social worker in identifying the likelihood that a family will have a subsequent referral of abuse or neglect.

We also determined that some of the department’s safety and risk assessments were inaccurate. In five of the 30 safety assessments we reviewed, social workers did not accurately identify safety threats. For example, children can have caregivers who do not live in the same household and to ensure social workers identify safety issues appropriately, they need to evaluate the household in which the allegations occurred. However, in two instances in our review, the social workers erroneously performed safety assessments on homes and caregivers who were not the subjects of allegations. In the other three instances, social workers filled out safety assessments without actually visiting the children’s homes, yet they inaccurately asserted that the homes were safe and without hazards.

Similarly, 12 of the 30 risk assessments we reviewed were not accurate. In these instances, social workers failed to consider important risk factors such as the age of a very young child or the results of previous department investigations. The social workers omitted this information from assessments even though the information was available to them in the case files. In one instance, the social worker failed to include the caregiver’s mental health history. Although the social worker did open a case, failing to include all necessary information weakens the usefulness of the risk assessment.

Supervisors could have identified and corrected many of these issues upon review of the assessments, but they did not. Even if they had, the supervisors’ reviews often happen long after the department has made decisions affecting children. The department does not have policies that require supervisors to approve assessments within specified time periods after social workers submit them; rather, the department’s policy is that supervisors review and approve safety and risk assessments before the department closes a referral investigation. Although we do not agree that this policy is sufficient, we reviewed 30 safety and 30 risk assessments for compliance with it. Of the 60 assessments we reviewed, supervisors approved 17 after the investigations were closed and never approved two others. In one instance, the supervisor took 125 days to review and approve the initial safety assessment.

We analyzed the department’s data to determine the number of days between when social workers submitted their safety and risk assessments and when supervisors reviewed and approved them. As Table 4 shows, supervisors did not approve 11 percent of safety assessments and 27 percent of risk assessments until after the referrals were closed. Further, supervisors never approved 4 percent of safety assessments and 6 percent of risk assessments.

Table 4
Supervisors Did Not Approve All Safety and Risk Assessments Before the Closure of Referrals
Fiscal Years 2013–14 Through 2017–18

Approved while the referral was open 85% 67%
Approved after the referral closed 11 27
Never approved 4 6

Source: Analysis of case, referral, and assessment data.

We asked the regional offices whether they had guidelines or expectations beyond department policies for supervisors’ approving assessments. The Santa Fe Springs and Van Nuys regional offices explained that supervisors should approve assessments within 48 hours of submission, while the Compton regional office indicated that it expects supervisors to complete their assessment reviews within five days of submission. However, these are not documented policies. The department acknowledged that it currently does not have departmentwide time frames for supervisor reviews but stated that it plans to include timelines in an upcoming policy revision. The department has several tools supervisors can use to track the timeliness of assessments, including SDM tracking reports and SDM email alerts that flag supervisors when assessments are completed. However, the director indicated that supervisors’ use of these tools has been optional. He stated that he plans to require that supervisors use them in the future.

Additional training could better prepare social workers to use SDM assessments appropriately. Social Services requires new social workers to receive SDM assessment training that includes an overview of the procedures for completing the assessments. However, the department confirmed that it does not require ongoing training and that in order to ensure that social workers properly use the assessment tools, it needs to provide additional training. The department plans to develop robust training for social workers, supervisors, and managers related to new SDM policies by July 2020. By providing annual training specific to SDM assessments, the department can better ensure that its social workers and supervisors respond to allegations and conduct assessments thoroughly and in a timely manner.

Finally, the department inappropriately excluded some risk assessments when deciding whether to open cases and provide the children and families involved with services. Risk assessments evaluate a family’s likelihood of being referred to the department again, using a rating scale of very high, high, moderate, or low. Department policy requires that social workers open cases only for investigations that have substantiated allegations—regardless of the level of risk. However, SDM guidelines note that the department should open a case for referrals with high or very‑high risk assessments, even if the investigation of the allegation is inconclusive. We identified three instances that had inconclusive allegations but high or very‑high risk assessments. Social workers did not open cases for these children. However, the department later received new allegations related to two of these closed investigations. Social Services has highlighted the importance of following all components of SDM guidelines, and the department confirmed that it is currently revising its policy manual to better conform to the SDM guidelines.

The Department Has Not Consistently Conducted Required Assessments When Placing Children With Relatives

Although state law requires the department to conduct certain assessments before placing children with relatives, the department did not consistently meet these requirements. As we discuss in the Introduction, state law and department policy establish a preference for out‑of‑home care with children’s relatives or nonrelative extended family members (relative placement). In situations requiring an immediate placement of a child, state law requires the department to conduct an abbreviated in‑home inspection and background checks of the relatives willing to care for the child and of any other adults living in the home. State law also specifies that the department must complete these tasks before placing the child. However, the department may expose children to risk because it does not consistently meet this requirement and does not hold its supervisors accountable for thorough review of relative placements.

Because cases may involve multiple placements for a child, the 30 cases we reviewed involved 65 placements. Of those 65 total placements, 22 involved the department placing children with relatives. The department did not conduct initial home inspections before completing six of these 22 relative placements. In one placement, the social worker did not conduct an in‑home inspection until nearly a month after placing the child. The department did not provide specifics about the in‑home inspection for this case, but it agreed that in‑home inspections generally should occur before placing a child with relatives. Further, in two of these six relative placements, the social workers did not note whether they inspected the homes during their in‑person visits. Although the department’s expectation is for social workers to document that they inspected each home, it was unable to determine why these two social workers failed to do so.

The department also did not document whether it completed all required initial background checks before 17 of the 22 relative placements. The department did not document one required check until we questioned it on the matter in December 2018—nearly 800 days after the child had been placed. Although the department confirmed that the adults living in the home later passed the background check, it was unable to determine why it had not been documented on time.

In addition to the abbreviated home inspection and background check, state law requires the department to conduct a full home environment assessment within five business days of each relative placement. The department’s Resource Family Approval Unit (approval unit) contracts with community‑based organizations to conduct these home environment assessments. However, in 16 of the 22 relative placements we reviewed, the department did not meet the five business day requirement. In fact, the department did not complete four of these home environment assessments until more than a month after the children had been placed with relatives.

The director stated that communication gaps between social workers and the community‑based organizations make it difficult to complete the home environment assessments within the five business day period. The department’s standard contract language with the community‑based organizations states that the department will conduct annual reviews of the organization’s performance, including its on‑time completion of home environment assessments. However, the department has not performed these reviews. Had the department done so, the community‑based organizations might have completed more home environment assessments on time.

To ensure the accuracy of the initial background check, state law also generally required the department—for most of the years we reviewed—to secure a fingerprint clearance check (live scan) for all adults in the home within 10 days of the initial background check.5 To comply with this requirement, the department has live scan technicians. However, the department did not conduct live scans within the required time frame for 10 of the 22 relative placements we reviewed. The approval unit’s division chief explained that the database that contains live scan requests and results is not connected to the database containing information about the department’s relative placements. As a result, the department has limited ability to determine whether it is performing live scans within the required timelines.

The Department Has Not Always Met State Requirements for Conducting Monthly Case Visits

The department did not consistently meet requirements for evaluating the well‑being of children in its care. As the Introduction explains, the law requires the department to perform ongoing case visits at least once a month for all children with active cases, and the majority of the ongoing visits must take place in the children’s homes. Social workers use these visits to verify the location of the children, monitor their safety, and gather information to assess the effectiveness of services provided. Before 2015 the law required that the department complete at least 90 percent of these monthly visits; it now requires that the department complete 95 percent of these visits and that the majority of visits occur in the home.

As Table 5 shows, the department complied with the previous 90 percent threshold and the requirement that the majority of visits take place in the child’s home. However, it did not meet the 95 percent requirement in the most recent year we reviewed. In fact, although social workers’ caseloads decreased, the department’s percentage of completed monthly visits also declined. We would have expected the percentage of monthly visits to increase with the reduction of social workers’ caseloads, but the director said that the decrease was likely due to an increase in the number of inexperienced staff who are less likely to meet time frames for ongoing case visits.

Table 5
The Department Generally Met Requirements for Monthly In-Person and In‑Home Visits

2013–14 95% 80%
2014–15 94 81
2015–16 95 81
2016–17 95 81
2017–18 93 79

Source: Analysis of case and referral data.

Although the department conducted approximately 80 percent of the required monthly visits in the children’s homes, our review of 30 cases found compliance issues in some cases. For example, for two of the 30 children, it conducted the majority of ongoing monthly visits in other locations. The department agreed that the majority of the ongoing monthly visits should take place in children’s homes, and it was not able to provide an explanation for why this did not occur for these two children.

We also noted that for eight of the 30 children whose cases we reviewed, the department did not comply with the requirement that it conduct no more than two consecutive visits outside of the home. These eight children had more than two consecutive visits at locations other than their homes. In fact, in one case the social worker did not visit the child at home for eight months. Although social workers regularly saw this child in their offices during these eight months, they could not evaluate the safety of the child’s placement during this time because they did not visit the child in his home. To ensure that its social workers comply with this requirement, the department indicated that it will have supervisors review the locations of ongoing case visits to ensure that it conducts no more than two consecutive visits outside of the home.

In our review of 30 cases, we also noted two different cases in which the social workers repeatedly used nearly identical narratives for multiple months to document ongoing visits. When we discussed these cases with the department, it agreed that the social workers’ entries for these ongoing visits were questionable. Because the department does not require documented supervisor review for these visits, it is unable to determine whether the social workers actually performed them. The department confirmed that it will conduct a review of these two social workers and take appropriate action for any falsification of contact documentation.

The department does not have a system in place to hold supervisors accountable for conducting thorough reviews of ongoing case visits. Although the department asserted that it expects supervisors to conduct monthly reviews of three to five cases from the social workers they supervise to ensure that those social workers are making monthly well‑being visits, the department does not have a policy requiring documentation of these reviews. Thus, it cannot ensure that supervisors conducted these reviews or hold them accountable if they do not meet its expectations. The department agreed that it would benefit from creating a policy that requires supervisors to not only review a sample of social workers’ ongoing monthly visits, but to also document the outcome of those reviews. It has recently created a form for supervisors to document these reviews.

The Department Has Not Always Conducted Reunification Assessments on Time

The department did not consistently conduct reunification assessments in a timely manner. Reunification assessments document caretakers’ behavioral progress and evaluate the risk associated with returning children to their homes. State law generally requires the department to review the status of every child who is in an out‑of‑home, nonpermanent placement every six months. Social Services also requires county CWS agencies to conduct reunification assessments every six months in alignment with the SDM policy manual. However, the department has not conducted reunification assessments within this time frame, and it confirmed that it does not have a policy reflecting these requirements. Rather, pursuant to department practice, its social workers generally conduct reunification assessments before semiannual court hearings, which may not occur every six months.

Of the 30 cases we reviewed, 27 required reunification assessments, yet the department completed an assessment for only one of these cases within the six‑month time frame. In addition, supervisors took more than a month to approve 14 reunification assessments and did not approve one at all. The department’s data for fiscal years 2013–14 through 2017–18 show that it failed to ensure that it performed reunification assessments within the six‑month time frame for 73 percent of its cases. Further, supervisors took more than 30 days to approve 13 percent of reunification assessments and never approved 8 percent. The department does not believe it must conduct reunification assessments every six months because court hearings—during which a court determines whether a child returns home or is permanently removed from parental custody—do not always occur every six months. The director stated that the department will attempt to work with Social Services and the SDM provider to update the SDM policy manual to allow the department to conduct reunification assessments before court hearings rather than every six months. Nevertheless, until this change in policy occurs, the department must comply with current requirements.

Although the SDM policy manual also states that a reunification assessment must occur no more than 65 days before a change in a child’s permanent living situation, the department did not consistently meet this requirement either. Of the 30 cases we reviewed, 20 resulted in changes to the children’s permanent living situations—including reunification with a parent or permanent placement with a relative or others. In 11 of these 20 cases, the department did not conduct reunification assessments within the 65‑day required time frame. In fact, in three of the cases, the last reunification assessments occurred more than a year before the changes in the children’s permanent living situations. From fiscal years 2013–14 to 2017–18, the department conducted reunification assessments within the 65‑day requirement in only 34 percent of cases that ended in reunification with parents or guardians. Not completing these assessments promptly could lead the department to inappropriately return a child to a parent or guardian.

The Department Has Missed Opportunities to Improve the Quality of Its Case Reviews

Although the department has processes to review the quality of its casework, it needs to enhance these reviews to ensure that it identifies problems with individual cases and that it uses the results of the reviews to improve its departmentwide practices and procedures. The department has established reviews to evaluate its casework and key outcomes, but as we note earlier, it has not improved its performance in many important areas. The department could improve the quality assurance processes it employs by increasing the number of individual cases it reviews and by widening the scope of these reviews to address the accuracy and timeliness of assessments, as well as the quality of supervisors’ reviews.

The Department Should Enhance Its Monitoring of Cases

The department’s efforts to improve the quality of its casework have not been sufficient. In our March 2012 audit titled Los Angeles County Department of Children and Family Services: Management Instability Hampered Efforts to Better Protect Children , Report 2011‑101.2, we noted that the department struggled to complete investigations of child abuse and neglect within required time frames and failed to perform all required assessments of homes and caregivers before placing children with relatives. Our current audit found that the department still needs to improve in these areas. Further, as we note earlier, we found numerous instances in which social workers performed inaccurate or incomplete assessments and supervisors failed to perform adequate reviews of those assessments. These findings indicate that the mechanisms the department uses to monitor and improve the quality of its casework need improvement.

The department uses two key performance evaluations to conduct systemwide reviews of its policies and procedures. The two evaluations are the Quality Service Review—which it must perform as the result of a 2011 court order—and the Child and Family Services Review, which state law requires. These reviews include analyses of outcomes related to children’s overall well‑being, including safety and stability in living arrangements. However, neither the Quality Service Review nor the Child and Family Service Review includes an analysis of the quality of supervisorial reviews. Only the Child and Family Service Review evaluates if social workers have accurately assessed all risk and safety concerns, and—as we discuss below—the number of cases involved in this review limits the department’s ability to identify trends in noncompliance with assessment policies at the regional, supervisor, and social worker level.

Although these evaluations allow the department to identify some trends and spot certain problems, they include a review of only a relatively small number of cases. Specifically, as part of the Quality Service Review, the department reviews 216 cases at least every 18 months, and in its Child and Family Service Review, it analyzes 25 cases every quarter. Reviewing a larger number of cases would allow the department to identify issues that are specific to individual regional offices or even specific supervisors, therefore allowing it to take action on both countywide and individual levels. In early 2019, the department completed a review of 1,000 cases and referrals, and it anticipates using the results to identify a need for broader reviews, policy or practice changes, and resource allocations.

The department stated that it plans to expand its existing quality improvement section, which would allow it to gain a comprehensive understanding of processes and to enhance its internal and external operations. According to the department, the expanded quality improvement section would conduct reviews of a greater number of cases, of the quality of assessments, and of supervisorial reviews. However, the department does not yet have a time frame for implementing this expansion.

The Department Has Not Ensured That Its Reviews of Child Deaths Have Resulted in Meaningful, Systemwide Improvements

Although the department conducts robust reviews of circumstances that result in the death of any child in the county—particularly if it had responsibility for the child at some point in time—it does not have a mechanism to ensure that it consistently implements recommendations resulting from these reviews, nor does it always place sufficient scrutiny on supervisors’ work. As Table 6 shows, more than 250 children died as a result of abuse or neglect in Los Angeles County from fiscal years 2013–14 through 2017–18, including 69 children who had prior contact with the department. Although not all of these children were receiving services from the department at the time of their deaths, the department conducts reviews of all the referrals, cases, and interventions it performed related to children who died from suspected or confirmed abuse or neglect.

Table 6
In Los Angeles County, More Than 250 Children Died From Abuse or Neglect

  2013–14 2014–15 2015–16 2016–17 2017–18 TOTALS
Children with prior CWS case history 13 18 18 11 9 69
Children without prior CWS case history 43 41 44 42 18 188
Totals 56 59 62 53 27 257

Source: Department report.

State law permits, but does not require, the department to conduct reviews of child deaths. To review child deaths in Los Angeles County, the department has a designated division, which the county counsel and board of supervisors direct. This division identifies when the social workers or supervisors have not complied with statutory requirements or department policy. Further, the division recommends, when appropriate, how the department may improve its procedures. As part of our review, we selected 10 child‑death review cases in which the children had previously been the subjects of departmental referrals or cases. The documentation we reviewed identified numerous errors of varying levels of severity in the department’s management of the cases, including insufficient documentation of interviews and background checks. Other documentation related to the deaths of children in Los Angeles County noted that social workers neglected to interview children apart from their parents, improperly completed safety or risk assessments, or failed to verify where the children’s parents were living.

Many of these reviews resulted in recommendations to improve the quality of the department’s casework. However, the department confirmed that it currently does not have a process to track the implementation or outcomes of these recommendations. The department stated that although it informs regional offices of findings and recommendations on a case‑by‑case basis, it does not have a method to track these concerns on either systematic or specific levels. For example, the department does not have a process to identify the most frequently occurring or persistent case‑management problems. The department informed us that it will implement a web‑based tracking system by September 2019 to assist it in identifying, monitoring, and ensuring implementation of the recommendations resulting from the child‑death reviews.

In addition, while child‑death reviews generally focus on social workers’ actions, they generally do not scrutinize supervisors’ decisions. Supervisorial review of referrals and cases is critical to ensuring that social workers’ investigations, assessments, and case management are on time, accurate, and professional. Because supervisors are responsible for the quality control of the referrals and cases their social workers oversee, the department should also closely examine the supervisors’ work. We reviewed documentation related to the deaths of 10 children in Los Angeles County and in five of these cases the documentation did not include any findings related to supervisors—even though the documentation highlighted errors or omissions that the supervisors should have identified as part of their reviews. Table 7 identifies the findings of these five child‑death reviews and the actions the department took to address the issues.

Table 7
The Department Has Not Consistently Scrutinized Supervisors or Taken Action to Correct Problems
Fiscal Years 2013–14 Through 2017–18

Poor investigation technique and documentation None None documented
Improper conclusions in assessments
Focus on compliance rather than mitigating safety factors
Improper documentation of in-person contacts None None documented
Inadequate safety plan None Findings shared with social worker and supervisor
Lack of consultation with supervisor regarding family’s noncompliance with safety plan
Lack of focus on underlying issues None None documented
Failure to communicate safety concerns with caretaker
Assessments not completed None Results provided to regional office
Insufficient documentation of home and in-person visits
Failure to fully investigate allegations

Source: Analysis of department documentation.

As the table shows, the documentation for three of these five cases also did not describe any actions the department took to mitigate the errors it identified. The department indicated that over the past year and a half, it has begun working more closely with regional offices to apprise them of child‑death report findings and recommendations. Nevertheless, we would have expected the department to consistently document such interactions and reviews of the supervisors’ work. This further illustrates the need for the department to create and implement a robust tracking system for findings and recommendations.

Although the Department Has Generally Met Its Targeted Caseloads for Social Workers, Its Supervisors Have Often Overseen More Social Workers Than Its Established Threshold

The department has generally met target caseloads for social workers, but it has failed to meet the threshold of supervisors overseeing no more than six social workers. The department acknowledges that high caseloads lead to poor outcomes, and as a result, it is working to improve its staffing levels to reduce caseloads for social workers and supervisors. The agreement between the department and the social worker union limits the caseloads to 35 cases a month for social workers and to 27 referrals a month for emergency response social workers. If the department exceeds those limits, the agreement limits it from suspending or discharging social workers who are performing poorly. Further, it cannot even prepare written warnings or reprimands on performance evaluations. To ensure that it does not exceed those limits and to allow social workers to dedicate themselves to their duties, the department has set target caseloads for social workers that are below the agreement’s levels. In 2018 the target caseloads were 19 cases a month for social workers and 16 referrals a month for emergency response social workers.

According to department staffing data, nearly 60 percent of regional offices met their lower target caseload goals in June 2018, and none exceeded the limits established in the union agreement. Nevertheless, some regional offices have a persistent need to add social workers to meet the department’s target caseloads. For example, throughout 2018, the Palmdale regional office needed a 1 percent to 16 percent increase in social worker staffing to attain its caseload goal. When it does not ensure that regional offices meet these caseload targets, the department risks delaying its response to allegations of child abuse and neglect, which could result in some children staying in abusive homes for longer periods. The department confirmed that at some regional offices, such as Palmdale, hiring and retaining social workers is more difficult, and it is proposing offering financial incentives for working at those locations.

Moreover, the department has not consistently met its required ratio of social workers to supervisors. According to its union agreement, supervisors may supervise up to six social workers. If the supervisor oversees more than six social workers for 30 consecutive days, the union contract limits the discipline that the department may impose on supervisors for poor performance. However, department data indicate that its supervisors are chronically exceeding that threshold. In fact, from May 2017 through October 2018, the average ratio of social workers to supervisors increased from 5.5 to 6.3. Some regional offices had even greater caseloads for supervisors. For example, from May 2017 through October 2018, the ratio of social workers to supervisors rose from 6.2 to 7.3 at the Palmdale regional office and from 6.1 to 6.6 at the Pomona office. During the month of October 2018, the average caseload for supervisors at 13 of the 19 regional offices exceeded the supervisor staffing limits, as Table 8 shows.

Table 8
The Department Has Not Consistently Met Its Required Ratio of Six Social Workers Per Supervisor
October 2018

Palmdale 7.3
Metro North 6.7
South County 6.6
Pomona 6.6
West San Fernando Valley 6.6
Wateridge North 6.5
Santa Clarita 6.5
Santa Fe Springs 6.4
Lancaster 6.3
Glendora 6.3
Vermont 6.2
Pasadena 6.1
West Los Angeles 6.1
Torrance 6
El Monte 6
Wateridge South 5.9
Van Nuys 5.8
Compton 5.8
Belvedere 5.6
Total 6.3

Source: Department report.

As we previously discuss, supervisors as a whole struggle to approve investigations and assessments accurately or in a timely manner. The department agrees that a smaller ratio of supervisors to staff would improve the quality of supervisors’ reviews of cases, and in August 2018, the department met with the board of supervisors and indicated that it would like to reduce the ratio of staff to supervisor to five‑to‑one. However, the department does not currently have a time frame for when this reduction would happen.

The Department Is Implementing a Process to Protect the Health and Safety of Youth Who Identify as LGBTQ

The department is taking steps to improve the conditions of youth in its care who identify as lesbian, gay, bisexual, transgender, and questioning (LGBTQ). A 2014 Los Angeles County study of youth over age 12 in foster care found that about 19 percent—1,400 out of 7,400—identified as LGBTQ. Moreover, the study found that 13 percent of youth who identify as LGBTQ reported poor treatment by the foster care system, compared to 6 percent of youth who do not identify as LGBTQ. A recent state law required Social Services to begin collecting voluntary information regarding the sexual orientation and gender identity of youth within its care no later than July 1, 2018, to guide policy decisions for improving its services to this group. Accordingly, Social Services updated its database to include LGBTQ fields and began requiring county agencies to collect this information.

A board of supervisors’ motion in January 2018 requested that the department evaluate and make recommendations for improving its support of youth who identify as LGBTQ. In response, the department developed a work plan to identify and improve the conditions of youth who identify as LGBTQ by increasing the data gathering it requires, training its workforce, and improving its communication about LGBTQ issues with other county agencies. The department expects to fully implement this plan—which includes various milestones—by December 2021. In April 2018, the department began to include LGBTQ‑related fields in its database. The department also indicated that it would develop a process to track whether a guardian has a negative perception of a child’s perceived LGBTQ status, regardless of whether the child identifies as such. Although the department is only beginning the process of improving the conditions of youth who identify as LGBTQ in its care, it appears to be taking reasonable steps to address the board of supervisors’ motion requesting it to better support these individuals.


To ensure that it protects children by completing investigations, assessments, home inspections, and background checks in a timely manner, the department should do the following by November 2019:

To ensure that its staff appropriately use SDM assessments to identify safety threats and risks, the department should incorporate SDM instructions into its policies and procedures by July 2019 and provide mandatory annual SDM training for applicable staff, supervisors, and other members of management by May 2020.

To ensure that supervisors review investigations, assessments, and other documentation on time, the department should, by November 2019, specify time frames by which each type of document should be reviewed. In doing so, the department should acknowledge the particular urgency of reviewing safety assessments and related safety plans, which are key to determining whether to leave a child in a home.

To improve the accuracy of its assessments, the department should require its supervisors to regularly review and evaluate assessments against available evidence and observations. It should implement this process by July 2019.

To improve the quality of supervisors’ reviews and to allow it to hold supervisors accountable, the department should, by May 2020, reduce the number of social workers assigned to each supervisor to at least the ratio specified in its union contract.

To strengthen and improve its quality control processes, the department should do the following by November 2019:

We conducted this audit under the authority vested in the California State Auditor by Government Code 8543 et seq. and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives specified in the Scope and Methodology section of the report. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Respectfully submitted,

California State Auditor

Date: May 21, 2019


3 Because Social Services uses 24 hours as its measure for immediate responses, we did the same in our evaluation of the timeliness of the department’s immediate‑response referrals. Go back to text

4 The department’s policy differs from the SDM manual in that it requires social workers to complete safety assessments within two business days. We evaluated the department’s compliance with the SDM policy manual requirement of 48 hours. Go back to text

5 Beginning January 1, 2018, the Legislature amended state law to require the department to conduct a live scan within five business days of a relative placement or 10 days of a initial background check, whichever comes first. This change impacted two of the 22 relative placements we reviewed. Go back to text

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