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Extracted from Consolidated Report

This investigation was originally published as part of a larger consolidated report containing multiple investigations. View the consolidated PDF for the complete document.

Los Angeles County Grand Jury • 2016-2017

Make Invsetments that Transform Lives

Published: June 05, 2017 24 pages

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⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.

⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.

Findings 14 findings

Unfilled staff positions are fully funded.16 Unlike many County challenges, solving this problem does not rely necessarily on increasing the personnel budget of the DMEC.

In February 2017, the DMEC requested 56 new positions from the County. Since that time, the DMEC has been able to hire personnel to fill 26 positions. The recruitment and examination process is currently underway to fill all open positions.17

The DMEC is attempting to build a redundancy of employees because they typically operate with a 10% - 12% labor decrease due to personal leaves. With a small department of 220 employees in addition to the diverse, extensive, and expert-specific work, the net effect of a variable (daily) reduced permanent workforce is problematic.18

The DMEC has been operating without a permanent Chief Medical Examiner-Coroner for over a year.19

Backlog Problems: The CGJ committee found, in discussions with County staff and in reviewing media coverage,20 lack of sufficient personnel in the DMEC creates a backlog of investigations and autopsies. This causes potential heartache for families and frustration for staff. In January 2017, when the CGJ toured the DMEC, there were in excess of 450 bodies awaiting disposition. It is the opinion of the CGJ, backlogs may be perceived by the public as the most egregious result of personnel shortages in the DMEC.

Hiring Issues: The County’s hiring rules and procedures are created to implement a fair and transparent process. However, Civil Service Codes21 and complicated County hiring 16 Senior staff member at DMEC 17 Ibid 18 Ibid 19 Ibid 20 Los Angeles Daily News, Mike Reicher, April 21, 2016http://www.dailynews.com/genral-news/20160421/400- bodies-await-testing-at-backlogged-la-county-morgue 21Civil Service Codes https://www.municode.com/library/ca/los_angeles_county/codes/code_of_ordinances?nodeId=TIT5PE_APX1CISE RU 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 23 processes22 are particularly time-consuming and cumbersome for a small department of 220 people. Additionally, the hiring process can take up to 18 months. This includes formulating requirements, standards, examinations, interviews, background checks, and vetting.23 Included in this process is “Banding” which is the process whereby an applicant’s name is put in a “band” based on test scores. By County rules, the DMEC must interview and hire from the top “band” (or the banded applicants need to voluntarily withdraw) before candidates from the next “band” can be considered.24 It is the opinion of the CGJ, this is a highly restrictive and inefficient process for such specialized jobs within the DMEC. When these restrictions have caused hiring backlogs in specialty jobs in other County departments, “Alternative Banding” procedures have been instituted to fill critical shortages.25 Alternative Banding opens the levels of banding, resulting in a larger pool of candidates available for consideration.

Accreditation Issues: “An outside consultant’s report (Strategica, Inc.) completed in November 2016 found that the office was poised to lose its accreditation (with the National Association of Medical Examiners) because of a backlog in the toxicology lab, staffing vacancies, and a shortage of budgeted positions.”26 In part, the National Association of Medical Examiners (NAME) “promotes the highest practice of medical professional and ethical conduct; acts as a clearinghouse of relevant scientific information and administrative procedures and policy matters; and provides leadership and advocacy.”27 It is considered by many people we interviewed to be the standard-bearer of excellence and for the County to lose its accreditation would be regrettable.

Data Analysis: The County expressed concern for insufficient data analysis on the part of the DMEC to support the need to fill certain job vacancies.28 Historically, lack of maintaining sufficient data recognized by the County has disadvantaged the DMEC in successfully advancing its justification for more personnel. The outside consultant Strategica, Inc.’s report to the BOS did not agree with the DMEC in its assessment of how many personnel were needed.29 22 County Department of Human Resources http://hr.lacounty.gov/our-organization/ 23 Senior staff member at DMEC 24 Senior staff members at DHR and DMEC 25 Ibid. LA Times Local/LA Now, January 20, 2017, Matt Hamilton, http://www.latimes.com/local/lanow/la-me-ln- coroner-appointment-20170120-story.html 27 National Association of Medical Examiners Website https://netforum.avectra.com/eweb/StartPage.aspx?Site=NAME&WebCode=Home Senior staff member in CEO’s Office 29 Strategica Report to BOS re DMEC, December 1, 2016 “Workload Analysis of the Department of Medical Examiner-Coroner” including DMEC’s response to the recommendations in the report. http://file.lacounty.gov/SDSInter/bos/bc/1007230_ReporttoCEO-FINAL11-17-16.pdf 24 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT

This year’s CGJ was pleased to learn that since the 2015-2016 CGJ Final Report, the BOS and the CEO have committed ongoing time and resources to help ameliorate the personnel shortages in the DMEC through the formation of a Work Group.30

F10

The Work Group is comprised of staff from the DMEC, the CEO’s office, and the Department of Human Resources (DHR). Issues are reviewed in detail and solutions created where possible. Relevant staff members from other departments are brought into the Work Group when needed, i.e., Civil Service Commission and County Counsel. The Work Group has succeeded in creating an effective open dialogue between the three County departments (CEO’s Office, DHR, and the DMEC).31 Most importantly, the Work Group has the authority to solve problems and implement solutions, as issues are researched and understood.32 In discussions with staff of the three County departments, the following issues were presented to the CGJ committee members:  Due to “Surging” (the application of extensive temporary overtime) the DMEC is close to eliminating backlogs and attaining the industry standard of 90% of all investigations completed within 90 days from time of autopsy.33 However, this approach has resulted in 20,000 hours of overtime in twelve months.34  A new labor resource for DMEC has been instituted using students studying for a Masters of Social Work (MSW) degree. Students from the USC School of Social Work are utilized as interns to assist indigent families in crisis and help identify available social service resources. This time-consuming but vital service releases permanent staff to perform other duties.  A nurse intern program is also being explored by the Work Group which would introduce a new discipline in the DMEC: The nurse intern would work with the investigators’ unit and the doctors’ unit to read through medical records and request reports from hospitals, etc., helping both units. This activity is also time-consuming 30 Senior staff members of DMEC, CEO Office and DHR 31 Ibid. Ibid. National Association of Medical Examiners (NAME) “Inspection & Accreditation Checklist” https://netforum.avectra.com/public/temp/ClientImages/NAME/c43b8bca-ad7b-4a40-990b-7f45283a66ab.pdf 34 Pasadena Star News, April 18, 2017 Susan Abram “LA Coroner cuts body backlog, but request for more funding rejected”, http://www.pasadenastarnews.com/government-and-politics/20170417/la-county-coroner-cuts-body- backlog-but-request-for-more-funding-rejected 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 25 and requires certain expertise. If implemented, this nurse intern program also promises to relieve permanent staff to perform other duties.  Transitional Subsidized Employees (TSEs) from the County’s Department of Public Social Service (DPSS) are being utilized to assist in clerical work. The TSEs work for ten months and those eligible are encouraged to take the County examination for fulltime permanent employment with the DMEC. There have been some successful transitions into fulltime employment.  Due to the high media profile of the DMEC, the County established a new position of Public Information Officer (PIO) for the DMEC. The PIO will provide vital information to news organizations and the public for the myriad events occurring daily in the nation’s largest coroner’s office.

F11

There have been promising developments made in relation to hiring issues. “(The Work Group) has been very helpful in facilitating . . . issues with open positions. . . (the Work Group) helped prioritize and moved the process from 18 months to six to eight months.”35 It is the opinion of the CGJ that shortening the timeframe even more would remove unnecessary delays to more quickly bring staffing to required levels. Also, the DMEC created new test criteria, reviews, job analysis, and re-designed the exam process. The following information was learned from CGJ discussions with senior staff with the DMEC, CEO’s Office, and DHR:  The number of applicants, previously capped at 400, has been increased to 1000, thereby providing a larger pool of candidates.  Applicants are advised in more detail as to what constitutes an extensive background check, thereby giving applicants the opportunity to withdraw their applications before time and effort is put into an applicant who will not pass the background check.  A PowerPoint Presentation was designed by the DMEC and is given to prospective applicants, as well as scheduled possible “ride-alongs” and tours. These efforts are established to dispel the popular and misleading impression made by “CSI TV” (Crime Scene Investigation Television Series) that many applicants have of the work. Additionally, a strength and agility test was added so as to emphasize the physical strength and dexterity needed for lifting and moving bodies. Senior staff member at the DMEC 26 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT  Applicants can prefill applications enabling them to make submissions as soon as the job opening is posted.  Although the independent consultant’s report suggested combining different job functions to limit the need for more people, the DMEC was successful in explaining in its response to the report to the BOS, “to suggest that a criminalist could be an expert toxicologist on Mondays and Wednesdays, and then an expert microscopist and tool mark analyst on Tuesdays and Thursdays is not practical or realistic.”36  Unfortunately, the DMEC has had a “revolving door” of top people in the last few years.37 However, the DMEC just hired a new Chief of Labs who began work on April 17, 2017,38 and a national search for a permanent Chief Medical Examiner-Coroner is underway.  Each department in the County has a dedicated Human Resources Manager (HRM). Each HRM is classified based on his/her level of experience. The size of the County department determines the classification level of HRM. Currently, the DMEC, being a relatively small department by County standards, is eligible only for the lowest Level I HRM. The complexity and uniqueness of the skill set of the DMEC personnel requires hiring a HRM with more expertise and a higher level rating.

F12

The current provisional accreditation for the DMEC has been extended and will be reviewed later this year.39 If positions continue to be filled and the 90% / 90 days standard continues to be met, the staff expressed hope that the DMEC will be re-certified, or at the very least, have its certification extended.

F13

With the support of the Work Group, and the assistance of the CEO’s Office, the DMEC is implementing an Electronic Case Filing System (ECFS) to better gather and disseminate data. Phase I of this system is scheduled to be in place and operational by May 2017, at which time Phase II will commence.

F14

In the County’s 2017-2018 proposed budget, $57,000 less than the current fiscal year is recommended for the DMEC, which is $5 million less than the DMEC requested. While the new proposed budget is not in the realm of this investigation, the CGJ is concerned that the DMEC receive sufficient funding to resolve longstanding concerns. DMEC Response to Recommendations of the Independent Contractor, Strategica, Inc. December 1, 2016 http://file.lacounty.gov/SDSInter/bos/bc/1007230_ReporttoCEO-FINAL11-17-16.pdf 37 LA Times Section Local/LA Now, January 20, 2017, Matt Hamilton 38 Senior staff member CEO’s Office 39 Senior staff member at DMEC 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 27 V

Recommendations 6

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The BOS should commend the partners of the Work Group formed to ameliorate the myriad issues related to the DMEC. The three partners, DMEC, DHR, and the CEO, use open dialogue and effective problem-solving approaches in identifying issues. The Work Group has made significant progress in obtaining resources for the DMEC.
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The DHR should implement “Alternative Banding” for the DMEC to fill budgeted positions.
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The CEO should implement “Alternative Banding” for the DMEC to fill budgeted positions.
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The DHR should decrease the timeframe of the hiring of DMEC personnel, currently at six to eight months.
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The DHR should assign a Human Resources Manager to the DMEC with a higher classification level. VI REQUIRED RESPONSES California Penal Code Sections 933(c) and 933.05 require a written response to all recommendations contained in this report. Responses shall be made no later than ninety (90) days after the Civil Grand Jury publishes its report and files it with the Clerk of the Court. Responses shall be made in accord with Penal Code Sections 933.05 (a) and (b). All responses to the recommendations of the 2016-2017 Civil Grand Jury must be submitted on or before September 30, 2017, to: Presiding Judge Los Angeles County Superior Court Clara Shortridge Foltz Criminal Justice Center 210 West Temple Street Eleventh Floor-Room 11-506 Los Angeles, CA 90012 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 27 Responses are required from: Responding Agency Recommendations The County of Los Angeles Board of Supervisors 2.1 The County of Los Angeles Department of Human Resources 2.2, 2.4. 2.5 The County of Los Angeles Chief Executive Office 2.3 VII ACRONYMS BOS County of Los Angeles Board of Supervisors CEO Chief Executive Officer CGJ 2016-2017 Los Angeles County Civil Grand Jury CSC Civil Service Commission DHR Department of Human Resources DMEC Department of Medical Examiner-Coroner DPSS Department of Public Social Service ECFS Electronic Case Filing System HRM Human Resources Manager MSW Master of Social Work NAME National Association of Medical Examiners PIO Public Information Officer SORT Special Operations Response Team TSE Transitional Subsidized Employees VIII COMMITTEE MEMBERS Joanne D. Saliba Chair Regi Block Sharon Muravez 28 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT MENDING THE SAFETY NET Lucy Eisenberg Co-Chair Shelley Strohm Co-Chair Joyce Simily MENDING THE SAFETY NET Changes in the County’s Child Safety System I SUMMARY On May 24, 2013, an eight-year-old boy named Gabriel Fernandez died a tragic death in his home due to abuse and neglect. Gabriel’s problems were not unknown—there had been multiple calls and referrals to the County of Los Angeles Department of Children and Family Services (DCFS). But DCFS closed the case and a month later Gabriel was later found not breathing. His skull was cracked, three ribs were broken, his skin was bruised and burned and there were BB pellets in his lung and groin.1 Faced with the facts of Gabriel’s case and other tragic fatalities, the County of Los Angeles Board of Supervisors (BOS) decided to establish a Blue Ribbon Commission on Child Protection (BRCCP), which was assigned to review child protection failures and develop a plan for reform. The BRCCP worked for eight months, conducted 13 public hearings and interviewed more than 300 stakeholders. On April 18, 2014 it issued a lengthy report calling for a fundamental transformation of the current child protection departments and providing the BOS with “a roadmap for creating an integrated, effective child safety system.”2 The Los Angeles County Civil Grand Jury (CGJ) reviewed the BRCCP report and investigated some of the recommendations in the report with the goal of determining whether the child safety system has indeed been reformed and improved. Specific areas that have been reviewed include: the training and supervision of the Children’s Social Workers (CSWs), who are assigned to oversee children at risk; what is being done to increase the number of children who are placed in the care of relatives after being removed from their homes; efforts to provide medical examination for children in DCFS care; and the development of resources to provide housing and care to high risk children for whom no relative is found. II BACKGROUND Since the BRCCP issued its report in 2014, the DCFS has hired approximately 2,100 additional social workers to staff its 18 district offices. The CSWs currently have an average caseload of 23 children,3 and there is one Supervising Children’s Social Worker (SCSW) for every 6-7 CSWs. DCFS established a new “University” for training newly hired social workers. But the real responsibility for helping social workers work with parents and children lies on the shoulders of 1Melissa Etehad and Richard Winton, “Red Flags Were Everywhere,” Los Angeles Times, March 21, 2017 2Los Angeles County Blue Ribbon Commission on Child Protection, Executive Summary, p.2 3 A state-by-state study shows the standard case worker caseload to be significantly lower, at 12 per emergency responder and 15 for standard case workers. 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 29 the supervising social workers who may, or may not, accompany their social workers into the field, and who are responsible for monitoring their performance.4 When a child is removed from a home because of abuse and/or neglect, the first goal for placement is to find a relative to care for the child. In the last ten years, studies from Canada and Hawaii have provided strong support for the conclusion that placement with relatives should be the preferred choice when a child is removed from parental care. An article by retired Judge Leonard Edwards (Santa Clara County) quotes these and other studies which indicate that the best way to improve outcomes for abused and neglected children is to engage relatives early.5 The BOS moved to improve relative finding in Los Angeles County by passing a motion on May 31, 2016, instructing DCFS and the Los Angeles County Probation Department to establish a “Countywide Upfront Family Finding Protocol.” In response to the Board motion, a pilot project was established in two DCFS district offices, Glendora and Santa Fe Springs. The project began in November 2016, and is expected to finish in April or May 2017. Overseeing the health condition of children under DCFS care is the joint responsibility of DCFS and the Department of Mental Health (DMH), with services provided by the Department of Health Services (DHS). DHS, DCFS, and DMH run a countywide Medical Hub system that includes six Medical Hub clinics: the High Desert Health system; Olive View-UCLA Medical Center; the Los Angeles County-USC Medical Center (LAC+USC) Medical Center; the LAC+USC East San Gabriel Hub; the Martin Luther King, Jr. Ambulatory Care Center; and the Harbor-UCLA Medical Center. (Another service center is located at Children’s Hospital of Los Angeles, which is a non-public entity but is available to provide services to DCFS-supervised children.)6 The Hub clinics are responsible for providing an initial medical examination for all newly- detained children. State regulations require the initial medical examination to be performed after placement. Some of the Hubs are also staffed to conduct a forensic examination of a child when there are allegations of physical or sexual abuse. When a forensic examination is required it must be made within 72 hours of the time the child was taken into custody. (If allegations of physical abuse are made when a child is already in custody, the forensic examination must be made within 72 hours of the time the allegations were made.) The Hub at LAC+USC is part of the Violence Intervention Program (VIP), which was established by a physician at the USC Keck School of Medicine and has become a model for hundreds of programs around the world. The VIP program is housed on the campus of the Los Angeles County-USC Medical Center (LAC+USC). In addition to the services provided by the 4 The supervising social workers in turn are monitored by an assistant regional administrator who in turn reports to a regional administrator in each district office. The Bench, Summer 2016, p6. Interview with Hub management. The High Desert and the East San Gabriel Hubs do not currently conduct forensic examinations. 30 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT Hub, the VIP program provides medical care for children suffering from sexual assault and includes an LGBTQ clinic. The VIP program provides services 24/7, and also does screening for Fetal Alcohol syndrome, a condition that may result in abnormal appearance, low intelligence, behavioral problems, and trouble in school.
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The OCP should define and adopt measures of success for the performance of DCFS, and require quarterly reports from DCFS on its performance with respect to those measures. VI REQUIRED RESPONSES California Penal Code Sections 933(c) and 933.05 require a written response to all recommendations contained in this report. Responses shall be made no later than ninety (90) days after the Civil Grand Jury publishes its report and files it with the Clerk of the Court. Responses shall be made in accord with Penal Code Sections 933.05 (a) and (b). All responses to the recommendations of the 2016-2017 Civil Grand Jury must be submitted on or before September 30, 2017, to: 36 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT Presiding Judge Los Angeles County Superior Court Clara Shortridge Foltz Criminal Justice Center 210 West Temple Street, Eleventh Floor-Room 11-506 Los Angeles, CA 90012 Responses are required from: Responding Agency Recommendations County of Los Angeles Department of 3.1, 3.2, 3. 3, 3. 4, 3. 5, 3.6 Children and Family Services County of Los Angeles Office of Child 3.6 Protection VII ACRONYMS APT Accelerated Placement Team BRCCP Blue Ribbon Commission on Child Protection (BRCCP) CSW Children’s Social Worker DCFS Los Angeles County Department of Children and Family Services DHS Department of Health Services DMH Department of Mental Health LAC + USC Los Angeles County/ University of Southern California NREFM Non-Related Extended Family Members OCP Office of Child Protection SCSW Supervising Children’s Social Worker TSC Transitional Shelter Care VIP Violence Intervention Program VFM Voluntary Family Management VIII COMMITTEE MEMBERS Lucy Eisenberg Shelley Strohm Joyce Simily 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 37 THIS PAGE INTENTIONALLY LEFT BLANK 38 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT SCHOOLS OF THE FUTURE Gloria Garfinkel Co-Chair Thomas Kearney Co-Chair Hilda Dallal Marilyn Gelfand SCHOOLS OF THE FUTURE I SUMMARY The “Los Angeles County Strategic Plan for Economic Development (2016-2020)” recognizes the need to shift the educational focus. The plan’s introduction states: “Unlike the move from an agricultural economy to a manufacturing-based one 150 years ago, when a worker needed little training to move seamlessly from the field to a factory floor, moving from a production-based economy to an information-age one today requires much higher levels of skills and education.”1 The first goal within this plan focuses on preparing our students for the highly technical, knowledge-based careers of the future. This goal aligns with today’s world of product globalization, instant world-wide communication, entrepreneurship, and rapidly developing scientific advancements. The challenge will be implementing change within the public educational system, which has not historically been an institution to quickly implement change in curricula or teaching methodologies. The Civil Grand Jury (CGJ) decided to investigate current developments and trends in the field of public education. While the need for traditional schools remains firm, there are students who can certainly benefit from different learning models such as those highlighted in this report. In today’s society, our students need a deeper level of learning in order for them to remain competitive in the globalized market and enhance their career potential. Having a stronger knowledge and skills base will make Los Angeles County (“County”) a more desirable location for businesses and industries. Appropriate changes to our educational system will provide these requisite skills and knowledge and lead to greater opportunity for our children to succeed in the future. II BACKGROUND History of Public Education Formation of the “traditional” public educational system is credited to Horace Mann along with other educational reformers in the early nineteenth century2,3. They believed a free educational 1 [Online] Available: http://laedc.org/2016/01/04/2016‐2020‐l‐a‐county‐strategic‐plan‐for‐economic‐ development/ 2 Massachusetts Board of Education was created in 1837 with Horace Mann appointed as its secretary. Horace Mann started a biweekly journal, Common School Journal, in 1838 for teachers and lectured on education. 3 [Online] Available: http://www.biography.com/people/horace‐mann‐9397522 2016-2017 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 39