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Isabella Brooke Knightly and Austin Gamez-Knightly

Isabella Brooke Knightly and Austin Gamez-Knightly
In Memory of my Loving Husband, William F. Knightly Jr. Murdered by ILLEGAL Palliative Care at a Nashua, NH Hospital

Wednesday, December 9, 2009

Toddler's death a blow to family, child welfare guardians

Toddler's death a blow to family, child welfare guardians

BY JAMES BURGER, Californian staff writer
jburger@bakersfield.com | Saturday, Nov 28 2009 07:00 PM
Last Updated Saturday, Nov 28 2009 08:22 PM
Seventeen children died in Kern County in 2008 and 2009 as a result of abuse or neglect.

A new law allows the public to view details of those deaths.

While public attention often focuses on Child Protective Services when a child dies here, the reports show CPS shares no blame in most of the 17 fatal neglect or abuse cases.

Here's a breakdown:

* In six cases, CPS had not had any previous activity in the deceased child's life.

* In five cases, the agency had contact with the family but social workers did not make mistakes and did not have any indication children were in mortal danger.

* In three cases, CPS' involvement is not clear because final reports from law enforcement are pending.

But social workers did make mistakes in three cases where children died. And at least two social workers lost their jobs.

Fighting the abuse or neglect they do hear about is the daily life of Kern County social workers.

Those in the Emergency Response division -- the front-line team that investigates abuse reports -- carry an average load of 17 to 19 cases.

That caseload should be about 12 per social worker, according to the Child Welfare League of America.

But to get there, the Department of Human Services would have to hire 24 new social workers.

That, said Director Pat Cheadle, isn't going to happen with the state slashing funding each new fiscal year.

So those social workers are left to deal, as best they can, with an everlasting flow of new cases.

In 2008, according to DHS reports, workers investigated an average of 1,196 cases a month.

In 38 percent of those cases, the allegations of abuse or neglect were found to be true.

Cheadle said Senate Bill 39 allows her to tell the positive stories of her division's work too.

"They need to be recognized for the difficult job they have to do," she said.

The price on social workers is high, said Bethany Christman, who recently retired as assistant director of Child Protective Services.

"We have serious death threats that come up against staff. We've had staff that have had serious dog attacks," Christman said. "Many of them, the very next day, they're out there again."

Former Emergency Response training supervisor Howie Acosta, who lost his job in 2008 as part of a review of the death of Reanna Alderette, said social workers believe in what they do and fight on despite the dark truth that they can't save every child.

Social workers don't like to acknowledge that truth, Christman said, and when a child dies it's a blow to every social worker.

"Social workers feel they can save everybody," she said. "There are some you just can't prevent."

But Acosta said social workers continue their work because it would be worse not to have them on the streets.

"Because they are not super-human, some children will still fall through the cracks," he said. "But it's better to save some children than none at all."

- Staff writer James Burger
Images:

Alex Horvath
Alex Horvath / The Californian Pat Cheadle, director of the Kern County Department of Human Services. Juan Pilar is still haunted by a 2-year-old girl he never met.

Reanna Marie Alderette's battered body was found in her grandmother's home on June 1, 2008, amid piles of filth, dog feces and rotting food.

Pilar was supposed to be the cherub-faced toddler's guardian.

But he didn't find Alderette in time. It cost him his job at the Kern County Department of Human Services.

"I think about this every day," said the 35-year-old custodian-turned-social worker. "Even though I didn't see the kid, but I picture a little Hispanic girl."

Reanna's death and its aftermath offer a rare glimpse into how this county's child guardians grapple with the loss of someone they are tasked with protecting.

The information is based on reports that a new law has made public plus rare, candid interviews with the social workers involved and their bosses.

THE BEGINNING

Bakersfield Police Department burglary detectives discovered more than a burglary suspect when they tracked down Crispin Alderette at his home in November 2007.

They found Alderette and his girlfriend, Jessica Alvarez, living with their four children in conditions similar to those they'd find daughter Reanna's body in six months later.

Trash was everywhere and there was "practically no food or facilities to care for the children," police reports state.

A kitchen knife was hidden blade-up among piles of clothes. The toilet didn't work. Alvarez said the home was in disarray because Alderette had lost his job and they were being evicted.

Police told Alvarez the children could not stay there.

She begged them not to call Kern County Child Protective Services, reports state.

They didn't - at least not immediately.

Police gave the children to Alvarez's mother, Margo Vasquez, who had shown up during the arrest. She took them home.

Bakersfield police Detective Mary DeGeare said the detectives were trying to deal with a terrible situation and felt that Vasquez was truly eager to keep the children safe.


In hindsight, she said, the detectives might have been wise to check Vasquez’s home and background.


“They (trusted) that this was a better choice, to leave them with a seemingly caring grandmother,” DeGeare said.


Police instead made a referral to Child Protective Services several days later.

Juan Pilar was assigned that referral.

"UNABLE TO LOCATE"

Pilar was a fresh new recruit to CPS' emergency response team in late November 2007 when the referral landed in his computer in-box.

He had just graduated from college and been on the job for about six months.

Pilar needed to check that the children were safe and that the home was habitable and wrap up the referral within 30 days of his first contact with the children.

He didn't yet have the police report on the case. But he did have another experienced social worker with him.

They couldn't find the family.

Alvarez said that was because her boyfriend was in jail and she had moved in with her aunt.

When a social worker is unable to find a family, there is an "unable to locate" protocol the social worker must follow before a case can be closed.

Pilar visited the home three or four times. He left his card and literature about how the family could receive help.

He got no response.

So Pilar took his completed "unable-to-locate" protocol on the case to his boss for review.

BOUNCED BACK

Howard "Howie" Acosta, Pilar's training supervisor, was a popular and respected 16-year veteran social worker in emergency response in December 2007. He had helped write the "unable to locate" protocol for emergency response.

When Pilar came back to him with a completed "unable to locate" protocol, Acosta reviewed it and noticed the rookie had missed something. The police report noted the children had been placed at the Vasquez home.

Pilar would later say he missed it in the dense, unique verbiage of police reports.

"I don't remember seeing the address," Pilar said.

Acosta gave him the address and told Pilar to push harder on the case.

Then he gave Pilar an extra resource: a paternal great-grandmother who might have more information about the family's circumstances.

Pilar misunderstood Acosta's advice.

WRONG GRANDMOTHER

When Pilar started searching for the family again, he focused on the home of the great-grandmother Acosta had mentioned.

It was the wrong home.

Once again, Pilar completed an unable-to-locate protocol.

Once again he brought it back to Acosta.

And for a second time the pair miscommunicated.

Acosta asked Pilar if he had checked the grandmother's home. Pilar, thinking Acosta meant the great-grandmother's residence, answered that he had.

Pursuit of the apparently routine case had, by now, lingered well into the new year and Acosta said he knew he was going to have to explain the delay to his boss.

He closed the case in March without checking the final contacts Pilar had made.

That, Acosta said, was the mistake he'll have to live with for the rest of his life.

In June, Reanna Alderette was found dead in the Vasquez home.

TERMINATED

"My first thought was, 'What could I have done different?'" Pilar said. "Am I responsible?"

Department of Human Services Director Pat Cheadle, who had taken the top job less than a year before, had the same question about Pilar and Acosta.

"Initially my feelings were that the infraction was enough to take action alone," Cheadle said.

But her top brass in CPS wasn't sure, Cheadle said.

Cheadle ordered a review of the two employees' overall error rates to clear up the issue.

Acosta told his supervisors what they would find before they did the six-month audit: mistakes. A lot of mistakes.

Department figures show average social worker caseloads in emergency response hover around 50 percent higher than what is recommended by the Child Welfare League of America.

Acosta said mistakes are unavoidable.

As he remembers it, the audit found an average of 16.7 mistakes per month in his work.

Those errors included failing to check with other Department of Human Services divisions on referrals, missing interviews with extended family members and spelling errors, Acosta said.

None of the mistakes triggered a re-review of any of his other cases, he said.

But his employment was terminated.

When he appealed his firing to the Civil Service Commission, Acosta said, three other supervisors "fell on their swords" for him and admitted higher error rates than his.

The commission still voted down his appeal.

UNFORGIVABLE

Cheadle said Acosta's mistake on the Alderette case cost him his job.

In light of the heavy caseloads social workers face, Cheadle said, she has told her staff some errors are forgivable.

But there are unforgivable errors, too, she said.

Cheadle said she doesn't believe closing a case on an "unable to locate" protocol is justified if the social worker hasn't followed up on all the information they have about where the family might be.

Cheadle said this case was her first major child death incident as director of Human Services.

"Nothing before and nothing after that has risen to the same level as this case," Cheadle said.

Acosta said Cheadle, aware of the criticism her predecessor Beverly Beasley-Johnson suffered as a result of high-profile child death cases, completed an unfair review of his work in order to justify his termination.

"There's never been an audit like the one they did on me and they've never done one since," he said.

FALLOUT

Cheadle acknowledges that the impact of a popular department leader's termination has sent ripples through Child Protective Services.

"There's an impact to the entire organization. They're wondering, 'Could I be next?'" Cheadle said. "We tell them we can't compromise."

She sees her tough stance in this case as evidence everyone will be held accountable.

"It's not our intent to create an environment of fear," Cheadle said. "The unknown, sometimes, creates fear. When you start to remind staff that the ratio of major disciplinary actions to child deaths is minor, that fear goes down."

When the Child Welfare League of America was hired to audit the Department of Human Services' troubled Child Protective Services function under Beasley-Johnson, staff felt there was no accountability, Cheadle said.

Morale was low because some people were treated differently, she said.

Cheadle feels accountability has returned and that has "helped steady the organization."

Acosta said people are being disciplined because the system is too overloaded to work well.

"This isn't about people's incompetence," he said. "This about people not being superhuman."

NO CLOSURE

Juan Pilar never found out exactly how Reanna Alderette died.

Coroners ruled the case a homicide.

"On the autopsy it said blunt force trauma to the stomach" as if Reanna had been kicked or kneed, Jessica Alvarez said. "I wasn't there so I'm not sure."

She said she was still living with her aunt at the time.

Alvarez said her family told her Reanna vomited and died in her sleep.

No one has been charged with a crime in Reanna's death.

But Alvarez said their family is living with the price of her loss.

Her three other children, all boys, remain in the custody of the courts.

She goes to court next month in the hopes of earning the right to live with them again.

"It's been hell for me and my boyfriend," she said. "I miss my daughter."

Pilar, meanwhile, was allowed to resign from Kern County CPS.

He and his 11-year-old daughter have left Kern County and he has a new job as a social worker.

But the little girl he never met still lives in the back of his mind, making him question everything he does.

"It's still haunting me," he said.



THE CASES

Sadly, the deaths of 17 children in 2008 and 2009 can be summed up in numbers.

Three died in tragic accidents parental responsibility might have avoided.

One was smothered while sharing an adult's bed.

One drowned.

Details of two deaths remain a public mystery pending the release of law enforcement reports.

And the other 10 children were killed -- five reportedly by a parent's boyfriend or girlfriend, one by a parent and four by unknown hands.

All died because someone abused or neglected them.

Here are their stories, based on reports by police, social workers, coroner's officials and the media:

MURDER CASES

These children died, according to law enforcement and Child Protective Services investigations, because someone chose to end their lives.

Name: Kayli Bearden

Age: 2 years

Date of death: Aug. 26, 2008

Kayli died from blunt-force trauma to the skull. Father Matt Bearden had left his daughter with his girlfriend, Melissa Blanchard. Police reports say Blanchard admitted causing the trauma while he was gone. She's being tried on charges of second-degree murder and assault by a custodian.

Name: Guillermo Gonzalez

Age: 2 years

Date of death: Aug. 31, 2008

Josue Daniel Palma Herrera has been charged with first-degree murder of girlfriend Sabrina Romero's son, Guillermo, in Shafter. Guillermo died from head injuries. A trial for Herrera is scheduled to begin in January.

Name: Nadely Gutierrez

Age: 2 years

Date of death: Nov. 12, 2008

Nadely died from blunt-force trauma to the head. Her mother, Kassandra Bailey, and Bailey's boyfriend, Victor Morales, initially told police the child jumped from her bed and landed on her head while both adults were with her. Bailey later admitted she had been at work and been called home by Morales, who was watching Nadely. Morales had told her the child was Ill. Morales is awaiting trial on charges of second-degree murder and assault by a custodian. Bailey pleaded no contest in May to charges of being an accessory to a crime and served two days in jail.

Name: Kevin Michael King

Age: 5 years

Date of death: March 8, 2009

Kevin died from blunt-force trauma to his body that ruptured his heart and liver. Police reports say his adopted mother, Gloria Grayson, admitted to losing her temper with Kevin while he was eating dinner, grabbing him by the throat and shoving him down the hallway to the bathroom. Grayson later contacted 911 and Kevin was taken to the hospital, where he died. Grayson has been charged with second-degree murder and assault by a custodian and is scheduled to be tried by a jury in March.

Name: Ayonna Thompson

Age: 6 months

Date of death: Nov. 18, 2009

Ayonna died as a result of blows to her head delivered by Roman Ray Brand, her mother's boyfriend, because the child was crying and he was tired, Brand admitted to KBAK Channel 29. Brand is scheduled to be arraigned on second-degree murder and assault by a custodian charges Monday. Kern County Child Protective Services has not yet issued a report on this case under the rules of Senate Bill 39.

AN UNKNOWN HAND

These children were intentionally killed, according to law enforcement and Child Protective Services investigations. But police have have not arrested anyone.

Name: Anthony Angel De La Rosa

Age: 4 months

Date of death: March 30, 2008

Child Protective Services ruled the death was a result of abuse or neglect. The coroner's office ruled the cause of death unknown. The child's mother was at the store when the father said he checked the child and found him lying on a toy car. The father later said he threw the child up in the air, failed to catch him and the child landed on the television. Police checked the television and did not find that dust on the television had been disturbed. No arrest has been made, according to Child Protective Services.

Name: Isabella Tran

Age: 1 year

Date of death: May 28, 2008

Isabella died from blunt-force trauma to the head, delivered in an unknown manner. More information about this case was not available through Child Protective Services.

Name: Arianna Cuevas

Age: 3 months

Date of death: Dec. 8, 2008

Arianna was rushed to the hospital Dec. 4 after her mother, Claudia Cuevas, left her with a friend to go shopping. Cuevas returned to pick up her daughter after the babysitter called her and told her there was a problem with Arianna. Cuevas found her daughter in distress and called 911. The child died four days later at Children's Hospital of Central California in Madera. The coroner later ruled the child died of blunt-force trauma to the back of the head. The cause of those injuries remains a mystery and no suspects have been identified.

Name: Karlyn Audrey Mae Uribe

Age: 5 weeks

Date of death: Jan. 26, 2009

Karlyn died at Tehachapi Hospital in January. Kern County sheriff's investigators couldn't find enough evidence of foul play to convince the Kern County District Attorney's office to prosecute any of the three adults who were with the child around the time they believe she was injured.

Kern County Child Protective Services closed the case, pending a final report from the Kern County coroner's office. The coroner's office took its time with the case, calling in independent consultants from Stanford University to inspect Karlyn's remains and double-check opinions.

Nine months later, in September, the report came back stating that Karlyn was killed. She had four broken ribs and multiple hemorrhages on her brain that were inflicted within the hours that led up to her death. Sheriff's officials said they were aware of the injuries in the initial coroner's report and that there is still not enough evidence to charge anyone.

ACCIDENT AND NEGLECT

These deaths were terrible accidents, but CPS ruled the adults involved made serious judgment errors that resulted in the accident or complicated the situation after the fact.

Name: Maryonna Wooten

Age: 1 month

Date of death: July 12, 2008

Maryonna Wooten's mother left her child with the child's uncle Charles Wooten while she and others visited a party, police reports say. Wooten said he fell asleep, drunk, on his couch and woke up when a neighbor knocked at the door. When he turned around, Wooten said, he saw Maryonna bleeding on the couch and summoned medical help. "It was an accident, but there was some things we as a family could have done to prevent it," he told reporters. No charges have been brought in the case. The cause of death is undetermined. Reports say the soft part of the child's head was swollen and there was blood coming out of her nose.

Name: Carl Deloney

Age: 5 months

Date of death: Dec. 18, 2008

Carl was a foster child living with Oswaldo and Luz Peralta. He died while in the care of Oswaldo Peralta. Peralta tripped on a piece of carpet Dec. 15 while holding the child and attempting to throw Carl away from him so he would not fall on and crush the infant. Instead the child hit the floor head-first. The impact resulted in his death days later at Children's Hospital of Central California in Madera. The case was ruled neglect because Oswaldo Peralta called his wife before calling for medical help, and later lied to police about the causes of Carl's injuries.

Name: Ruben Soto Jr.

Age: 2 years

Date of death: May 27, 2009

Ruben Soto Jr. died when a single hollowpoint bullet from his father's Glock handgun hit him in the chest. The 2-year-old and his 3-year-old sister, Ariana, had found the weapon under their parents' mattress. Arianna pulled the weapon out and pulled the trigger. Ruben was hit and later died. Usually their father, Ruben Cirilo Soto, pulled the gun out from under the mattress each morning, locked it up and put it away on a high shelf in his closet. On May 27 he forgot to put away the weapon. After Ruben's death, Soto surrendered all of his weapons and moved to his father's home to get his family away from the rough neighborhood.

Name: Edward Shotwell

Age: 6 weeks

Date of death: July 26, 2009

No other information was available through Child Protective Services because completion of reports is still pending.

Name: Edgar Munoz

Age: 2 years

Date of death: Aug. 19, 2009

The young boy drowned. No other information was available through Child Protective Services reports, pending the release of a coroner’s report.


MISTAKES

Child Protective Services missed a step or two in their processes that could have made a difference in these cases. There is no way to know if the child would have lived if the social workers had not made the mistakes.

Name: Reanna Marie Alderette

Age: 2 years

Date of death: June 1, 2008

Reanna died at the home of her maternal grandparents, Margo and Cesar Vasquez. The cause of death was blunt-force trauma to the body. The child and her three siblings moved in with the Vasquezes after Bakersfield police found them living in filthy, unsafe conditions with their mother and father, Jessica Alvarez and Crispin Alderette, in November 2007 while looking for Alderette on unrelated burglary charges. Social workers failed to locate the children at their grandmother's home. The grandparents' home was in similar condition when Reanna died in June. There have been no arrests in Reanna's death.

Name: Alena Breann Garcia

Age: 2 months

Date of death: Feb. 20, 2009

Two-month-old Alena Garcia was smothered in February while sleeping with her mother, Brenda Plata, who had been using methamphetamine and marijuana, Child Protective Services officials said. Plata placed her daughter on her belly next to her in bed after an early morning feeding and then slept until noon, according to police reports. The child suffocated.

Social workers had counseled the mother repeatedly not to sleep with her newborn after the family was referred to Child Protective Services in late December. Social workers didn't have grounds to pull the children from the home in December, despite the fact the parents were drug users, CPS supervisors said. But workers also didn't promptly check the results of the drug tests the parents agreed to take in December. The results could have justified a follow-up investigation that could have revealed the risks to the child.

Plata was charged with three felony counts of willful cruelty to a child and pleaded no contest to one count. She served 115 days in jail.

Name: Guillermo Alvarez

Age: 2 years

Date of death: June 22, 2009

Guillermo died in June of blunt-force trauma to his body caused by blows that ruptured his spleen. His mother, Gina Serna, had been referred to Child Protective Services three times for neglect -- she had been a heavy drug user and left her children with other people for long stretches of time -- before her son died.

Department of Human Services officials acknowledged that social workers did not do the proper check-up of the mother's new home after the most recent referral and failed to check results of a drug test and assign the case the proper "substantiated" tag.

Kern County sheriff's deputies arrested her then-boyfriend, Joshuae Preston, 28, in Guillermo's death but charges were later dropped.

http://www.bakersfield.com/news/local/x1596957328/Toddlers-death-a-blow-to-family-child-welfare-guardians

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