Report 2013-110 Summary - April 2014

Child Welfare Services: The County Child Welfare Services Agencies We Reviewed Must Provide Better Protection for Abused and Neglected Children


Our audit of child welfare services (CWS) agencies in Butte, Orange, and San Francisco counties highlighted the following:


The three county child welfare services (CWS) agencies that we visited are not adequately ensuring that their decisions to remove or not remove children from homes are appropriate. Although the California Department of Social Services (Social Services) provides oversight of the CWS system, county CWS agencies administer the programs that are designed to protect children from ongoing abuse and neglect. When necessary for the protection of a child, county CWS agencies may remove a child from the home and place the child with relatives or in foster care. Before a CWS agency takes this step, state law and regulations require that it make efforts to keep the family together when services and other support make it safe to do so.

When a report of child maltreatment (referral) is received, county CWS agencies must determine how to respond. We visited the CWS agencies in Butte, Orange, and San Francisco counties and found that information contained in the initial intake documents was often inaccurate or incomplete. Although most of these errors ultimately proved inconsequential, a few ended up affecting decisions regarding the appropriate response to a referral. The three county CWS agencies have each adopted the use of standardized assessments that analyze safety and risk factors of families for which the agencies have received a referral, and the agencies also examine what services a family may need to allow the child to safely remain in or return to the home. Although these assessments are the principal mechanism by which these agencies document critical decisions regarding the child's safety, we found that some assessments were not prepared in a timely manner or were not prepared at all. We also found that the information used in these assessments was often incomplete and inconsistent. At times, this led to flawed evaluations of safety, risk, and needed services. Although we found a few instances where safety threats identified in assessments had no documented basis, most of the errors we found involved social workers leaving out key safety threats from assessments, which can lead to leaving children in unsafe situations.

When their initial attempts to make in-person contact with children and parents to investigate allegations of child maltreatment were unsuccessful, the county CWS agencies we visited did not consistently follow up in a reasonable time frame—sometimes waiting weeks before attempting to see the child again. Further, when social workers decided to leave a child in a home that presented a safety threat, they often did not establish a credible safety plan to mitigate that threat. In addition, social workers at times allowed the child to be placed or remain in a temporary living situation until safety concerns could be alleviated. In these instances, they often did not perform any history check on the temporary caregivers and, in a few instances, these individuals were later found to be unfit to supervise the child. When the county CWS agencies we visited did formally remove a child, they did not consistently perform required background checks before a subsequent placement.

We also found that required assessments used to determine the strengths and needs of a family, and to develop the corresponding case plan, were not always completed. In addition, assessments used to determine whether a child could be reunited with his or her family were frequently not performed in a timely manner and were sometimes not performed at all. Failing to complete this assessment could lead to social workers improperly assessing the potential danger of a child returning to the home, while late assessments indicate a child could be spending longer in out-of-home placement than necessary.

For each item we reviewed, we noted a frequent lack of documented supervisory review. For those instances when reviews were documented, it appeared at times that supervisory review occurred so late that it had little or no effect on the safety or risk decision. For instance, we found that approximately one-fourth of all safety and risk assessments received no supervisory review within 30 days of the completion of the assessment.

State laws and regulations provide county CWS agencies with broad discretion in determining when to involve law enforcement in investigations and in removing children from their homes. Their policies and practices regarding involvement of law enforcement in CWS efforts reflect this flexibility. Even so, we found instances where coordination and communication between local law enforcement and the county CWS agencies we visited could have been better.

To varying degrees, each of the three county CWS agencies we visited needs to improve its practices, as any deficiency in these practices increases the likelihood that a child will suffer further abuse and neglect. Even so, for most of the items we reviewed, the Orange County CWS agency, which was one of the earliest adopters of standardized assessments, appeared to perform better than the other two CWS agencies. Although all three aspire to models considered to encompass best practices in California, the Orange County CWS agency appears to have better developed its management processes designed to ensure compliance with requirements. In particular, for a number of years it has maintained designated policy development and quality assurance units that help provide clear communication to staff and ongoing feedback to management. The Butte County CWS agency recently developed a one-person quality assurance function, but neither this agency nor the San Francisco County CWS agency has personnel designated to update policies and procedures. Given the relationship we observed between the strength of management processes and county CWS agencies' performance, we believe Social Services—as the state agency responsible for overseeing the CWS system—should encourage and monitor, for a time, the establishment of the key management processes of policy development and quality assurance at all 58 counties.


To ensure that all required assessments are completed, the CWS agencies of Butte and San Francisco counties should develop and implement clear guidance regarding which assessments are required in different situations.

To improve the timeliness and accuracy of all required assessments, the CWS agencies of Butte, Orange, and San Francisco counties should ensure that their supervisors are reviewing assessments in a timely manner.

The CWS agencies of Butte, Orange, and San Francisco counties should ensure that social workers are making reasonable and timely efforts to make in-person contact with children who are allegedly being maltreated.

To help strengthen safety plans to effectively mitigate safety threats, the CWS agencies of Butte, Orange, and San Francisco counties should ensure that supervisors are reviewing and approving all safety plans.

To improve the timeliness of their supervisors' reviews:

To ensure that required safety plans are created, the CWS agencies of Butte, Orange, and San Francisco counties should have supervisors promptly review all safety assessments and verify that a written safety plan the responsible parties have signed accompanies any assessments designating the need for such a safety plan.

As part of their responsibility to help children remain safe at all points during the investigation of a referral, the CWS agencies of Butte, Orange, and San Francisco counties should do the following:

To ensure that they provide clear, up-to-date guidance to their social workers, the CWS agencies of Butte and San Francisco counties should designate specific personnel to stay informed of relevant practice changes and to ensure that corresponding updates are made to their policies and procedures.

To promote continued improvement in the CWS system, Social Services should encourage each county CWS agency to designate personnel to regularly update policies and procedures and perform quality assurance reviews. Further, Social Services should monitor the status of each county CWS agency's efforts.


Social Services and the three county CWS agencies we reviewed agreed with our findings and recommendations. Each outlined actions it plans to take in response to the recommendations.